Integrating self-help materials into mental health practice

Objective of program

There are few guidelines for professionals on how to use mental health self-help resources effectively.14,15 This article describes a program that was developed to aid health professionals in integrating self-help materials into their mental health practices.

Description of program

The program was initiated as part of a larger demonstration project, the Rural Mental Health Project, in a rural Newfoundland community. The aim of the program was to increase rural health care providers’ capacity to respond to mental health needs.16 The community had a population of about 3000 people, with a catchment of 10 000. Two social workers served the catchment area, but there were no psychiatrists or psychologists.

In order to address the most commonly seen mental health issues, local health professionals, including family physicians, nurses, social workers, and guidance counselors, were asked to identify the most pressing mental health needs in their community. The issues they identified, such as depression, parenting issues, marital or relationship problems, and addictions, were similar to those generally brought to family physicians’ offices. A resource library of about 100 print, audiotape, and videotape materials on these topics was purchased for the community. Funding for the resources was provided by the provincial government’s Department of Community Services. All the materials were prescreened in order to ensure high quality: print materials were either evidence-based or recommended by experts,6 while audiotape and videotape materials were evaluated using the DISCERN criteria.17 (A catalogue of the library may be obtained from the corresponding author.)

The resource library was housed at the local health centre, which had a part-time librarian who was also the community librarian. Health professionals who had participated in the Rural Mental Health Project were invited to a videoconference where they were introduced to the materials and given guidelines on how to integrate self-help into their practices most effectively. Some participants also engaged in an informal journal club, in which they gave brief synopses of the materials they thought would be useful in their practices.

Evaluation

The librarian tracked the use of the library over a 14-month period, noting which resources were borrowed, by whom, and for how long. Fifty-nine percent of the materials were checked out during this period. Parenting resources were the most popular, including materials on child discipline, living in a stepfamily, and helping shy children. Next were resources for depression, followed by materials on addictions, death and dying, learning disabilities, attention deficit hyperactivity disorder, and anxiety. Although there were fewer videotapes and audiotapes in the resource library, proportionally they were borrowed more often than print resources.

Health professionals, including physicians, social workers, nurses, nurse practitioners, and guidance counselors, used the library most frequently, accounting for 61% of the borrowed resources. Those who attended the initial training session were the most likely to recommend resources to their patients. A quarter of the resources were checked out by community members, and 14% were borrowed by staff and administrators in the health centre and teachers and principals from local schools. By the end of the 14 months, a kind of snowball effect had developed, with the most popular materials circulating among community members.

The primary author conducted follow-up interviews with 4 participants: the resource librarian and 3 health professionals who had accessed the resources frequently—a family physician, a guidance counselor, and a nurse. The interviews were about half an hour in length; they were audiotaped and transcribed, and a thematic analysis of the transcripts was carried out.

Participants believed that the anonymity of a self-help library was an asset for a rural community, as there is still a stigma in rural communities about mental health issues and they had to be cautious about raising “touchy subjects” when “everyone knows everything about everything.” The librarian noted that, while resources about topics such as sexual problems and divorce were not checked out, they were often taken off the shelves, presumably having been read in the library. The librarian played a pivotal role in publicizing and recommending the resources; often people would ask for guidance regarding a particular problem, such as grief, and she would suggest appropriate materials.

From the interviews with the health professionals, it was apparent that they viewed the resources as a way to supplement their mental health practice and reduce demands on their time. They usually either referred patients to the library or recommended relevant resources: “I usually suggest books to parents …. If it is very accessible, they’ll take it and read it, but who has time to go and search.” Occasionally the health professionals had follow-up discussions with patients regarding the resources, but generally left their patients to work independently and did not attempt to integrate self-help into treatment plans. They stated that it was critical that the materials had been prescreened, because they did not have time to review materials themselves: “Sometimes I feel bad recommending books I haven’t read, but if they come from [the] Rural Mental Health Project, I figure that someone has looked at them, that they must be okay.” The health professionals also used the resources for themselves in order to increase their knowledge in a particular area, to provide training for paraprofessionals, and for personal reasons.

Improving the program

Based on our experience and the successes of the UK programs, we plan to implement some changes to our program:

• Each health professional will be given a “prescription pad” with a list of the resources, as well as an annotated bibliography that briefly describes each resource and for whom it would be most helpful.

• As lack of motivation can affect success, we will provide training for the professionals in how to use the Stages of Change model, which helps to identify patients’ readiness to change.21 This assessment can be done fairly easily by either the professionals or the patients.22

• In order to ensure that patients are receiving the appropriate level of support, a stepped-care model will be adopted.23 With this approach, the professional starts with the simplest, least intrusive intervention and only progresses to more intensive treatment if necessary. This model has been used in the treatment of depression, panic disorder, alcohol abuse, hypertension, and anxiety. The steps will be as follows:

  • - The professional will first assess the severity of the mental health problem.

  • - If the problem is mild to moderate and the patient appears ready to make changes, relevant self-help resources will be recommended.

  • - The professional will follow up with the patient after about 4 weeks to assess the effectiveness of the resources.

  • - If the problem has not been alleviated, the professional will assess whether this is related to motivation or environmental factors, such as lack of time, whether other self-help materials might be more appropriate, and whether more intensive treatment, such as psychotherapy or medication, is appropriate.

Conclusion

Mental health issues are an increasing focus of family physicians’ practices. A self-help approach, where family physicians refer patients to a library of high-quality mental health resources, can help meet the demand for such care. This strategy is an efficient way for family physicians to address mild to moderate mental health problems, particularly if care is framed within a stepped-care model of practice. Although we need more evidence to support the effectiveness of self-help in a family medicine context, this method offers a great deal of promise.