Cognitive and behavioural self-help bibliotherapy

1. Introduction

Version followed: guided self-help as NICE CG113 (generalised anxiety and panic, rec. 1.2.13–1.2.17) specifies it; the session structure and skills from the English low-intensity training materials Reach Out (Richards & Whyte, 3rd ed., 2011) and their supervisor materials (Richards et al., 2010); books chosen from the Reading Well for mental health (Books on Prescription) list; and the two classic texts the method grew from, David Burns's Feeling Good: The New Mood Therapy (1980; revised 1999) and Peter Lewinsohn's Control Your Depression (revised edition, Touchstone e-book 2010). Where these differ, the differences are named in the text.

Cognitive and behavioural self-help bibliotherapy means the client works through a structured book (or an e-book or audiobook version) based on CBT, with a small, planned amount of contact from a clinician. NICE describes it as more than handing someone something to read. The material is evidence-based and written for this purpose, and a practitioner introduces it, monitors progress and reviews the outcome [source: GPnotebook summary of NICE definition; NICE CG113 1.2.14]. The idea of change is borrowed from the books themselves. The client learns and practises CBT skills between contacts: recording and scheduling activity, recording and testing thoughts, relaxation, and problem-solving. Clinician contact keeps them engaged, corrects misunderstandings, checks risk and measures progress, and moves them to more intensive care if they do not improve [source: Reach Out 3rd ed.; NICE CG113]. Burns says he wrote Feeling Good so his own clients could read it between sessions, so less session time went on teaching the basic concepts [source: Feeling Good Podcast ep. 139].

This is a way of delivering CBT, not an arts therapy. No profession or credential specific to self-help bibliotherapy is described in the sources [uncertain: PWP registration routes]. In England it is usually delivered in NHS Talking Therapies by Psychological Wellbeing Practitioners, who work under weekly case-management supervision [source: Reach Out supervisor materials]. The PWP curriculum, now published by Health Education England, is not drawn on here [uncertain]. A qualified psychotherapist can deliver it within their existing registration or accreditation (for example HCPC, BABCP, BACP or UKCP) [synthesis; these bodies' requirements were not checked]. Whoever delivers it needs training in CBT-based low-intensity work, routine outcome measurement and risk assessment, and needs regular supervision. NICE CG113 1.2.16 requires regular high-quality supervision and routine outcome measures [source: NICE CG113]. Reading Well itself needs no clinician. Anyone can borrow the books from a public library for free, without a referral [source: LGA case study]. Physical safety concerns are minimal: reading posture and screen time [synthesis].

Related guides. Guide 138 (Clinical and developmental bibliotherapy) covers guided reading of fiction and poetry with discussion, including the interactive four-step model. Guide 140 (Affective fiction-based bibliotherapy, Shechtman) covers the affective, fiction-based form, which its author contrasts with the cognitive, instructional form described here.

2. Framework

The framework comes from CG113 and Reach Out. The phases below are the sequence those sources describe. Grouping them into phases is my own synthesis.

Phase 0: Access route (optional, no clinician). Reading Well titles can be borrowed free from public libraries in England and Wales. GPs, social prescribers and other professionals can signpost people to them, including while people wait for an appointment [source: LGA case study; Reading Well booklist]. The booklist tells readers to contact their GP or a health professional if a book isn't helping, and lists crisis lines [source: Reading Well booklist].

Phase 1: Assessment and engagement (one longer contact, usually face to face).

• Goals: a patient-centred assessment ending in a problem statement, the patient's own goals and treatment options.
• Also at this contact: risk assessment, baseline outcome measures, information about the problem and the options, and a shared decision about whether to use guided self-help and which material [source: Reach Out pp. 9–15, 22–25].
• Materials are handed over in person before any telephone work starts [source: Reach Out p. 19].
• To move on: the problem suits low-intensity CBT, the risk is manageable at this step, the patient chooses guided self-help, and a book or format matches their reading level and language [source: NICE CG113 1.2.12, 1.2.14, 1.2.17; Reach Out].

Phase 2: Supported self-help (the core).

• NICE CG113 1.2.14: a trained practitioner supports the programme, usually in 5 to 7 sessions of 20 to 30 minutes, weekly or fortnightly, face to face or by telephone.
• An older NICE definition, as GPnotebook summarises it, says "usually no more than three contacts". This guide follows the CG113 version.
• Non-facilitated self-help is a lighter variant. The client works through the material for at least 6 weeks, with occasional contacts of 5 minutes or less [source: NICE CG113 1.2.13].
• Each follow-up contact is short unless the person has deteriorated markedly [source: Reach Out p. 16].
• At every contact: review the problem statement and risk, take routine measures, review the information given, any medication and the self-help work, and agree the next step [source: Reach Out pp. 17–18].
• In NICE NG222 (2022), guided self-help is listed first among the options for less severe depression: try the least intrusive option first unless the person prefers something else [source: NICE decision aid, 2022]. The full NG222 text is not drawn on here, and its session parameters for depression are [uncertain].

Phase 3: Review, step up or end.

• Step up to high-intensity psychological therapy or medication when there is marked functional impairment, or no adequate response at this step [source: NICE CG113 1.2.17].
• Consider specialist referral when there is risk of self-harm or suicide, significant comorbidity, self-neglect, or no response to more intensive treatment [source: NICE CG113 1.2.37].
• In case-management supervision, every patient is reviewed at least every four weeks. Patients above a set risk or symptom-score threshold are reviewed sooner. The materials give 15 or more on PHQ-9 or GAD-7 as an example threshold [source: Reach Out supervisor materials pp. 14, 16].
• No fixed number of sessions without improvement is published as a step-up trigger. Teams set their own [uncertain].
• Ending: offer relapse-prevention information and a plan for setbacks [source: Reach Out p. 23]. Burns reports that readers who had setbacks often recovered by re-reading the sections that had helped them [source: Feeling Good Podcast ep. 139].

Lewinsohn's group lineage. Lewinsohn's behavioural approach was also delivered as a structured group course. The adolescent version (CWD-A) runs 16 two-hour sessions, twice a week for 8 weeks, for up to 10 adolescents, with an optional 9-session parent group [source: NHS Education for Scotland, CWD-A page]. That is a separate group programme, not guided self-help.

3. Guiding principles

• Least intrusive effective option first. Start with self-help unless the person prefers otherwise, or severity or risk rules it out [source: NICE CG113 1.2.1; NICE decision aid 2022].
• Guidance is more than handing over a book. Plan contacts that introduce the material, monitor progress and review outcomes [source: GPnotebook/NICE definition].
• Patient-centred and collaborative. Negotiate what, how, where, when and with whom. The patient decides [source: Reach Out pp. 24–25].
• Match the material to the person. Use CBT-based material at the right reading level, or in an alternative format or the person's preferred language where possible [source: NICE CG113 1.2.13–1.2.14, 1.2.22].
• Stay within the low-intensity role. Support the book's method; do not drift into full therapy. The supervisor materials call this "medium-intensity creep" [source: Reach Out supervisor materials pp. 11, 24].
• Measure every time and share the scores. Take session measures and ask the patient how the score fits their experience [source: Reach Out p. 12].
• Check risk at every contact, not only at assessment [source: Reach Out pp. 14, 16].
• Follow up assertively. Low mood and low energy cause missed appointments. Keep contact rather than discharging people who do not attend [source: Reach Out p. 19].
• Supervision is part of the method. Discuss caseloads weekly. Discuss risk and non-improvement cases routinely [source: Reach Out supervisor materials; NICE CG113 1.2.16].
• Practise the skills, don't just read. Change comes from repeatedly doing the exercises between contacts [source: Reach Out p. 33].
• Step up promptly. Self-help is the first step, not a ceiling [source: NICE CG113 1.2.17].

4. Intervention inventory

The sources fall into two groups. The scheme sources (NICE, Reach Out, Reading Well) describe the delivery procedure, which is items 4.1–4.8 and 4.14–4.17. The book sources describe the skills that the client learns from the book, which is items 4.9–4.13. The full texts of Burns's and Lewinsohn's books are not drawn on here. Their exercises are described only at the level the sources allow, and the exercises themselves are not reproduced.

4.1 Patient-centred assessment interview

• Purpose: decide whether guided self-help fits, and build the shared problem statement that guides which book is chosen [source: Reach Out pp. 9–15].
• Steps:
  1. Open with a general open question, then narrow to specific open questions, then closed ones to clarify. Reach Out calls this funnelling.
  2. Map the main problem with the "4 Ws": what, where, with whom, when. Then cover triggers; physical, behavioural and cognitive features; and the impact on work, home, social life and leisure.
  3. Ask about other important issues: past episodes and treatment, medication, alcohol and drug use.
  4. Do the risk assessment (4.2) and take baseline measures (4.3).
  5. Summarise a problem statement in the patient's words, agree goals with them, and set out the options.
• Example language (illustrative): "Tell me what's been happening for you lately." "When it's at its worst, where are you and who's around?" "Let me check I've understood it, in your words…"
• Watch for:
  • severity, impairment or risk beyond step 2;
  • problems a CBT book doesn't target, such as psychosis or active substance dependence [synthesis];
  • signs that literacy, sight, cognition or language may get in the way of reading (see 4.16).

4.2 Risk assessment and review at each contact

• Purpose: keep a low-contact method safe [source: Reach Out pp. 14, 16, 18].
• Steps:
  1. At assessment, ask about thoughts of suicide and their intent, any plans, any actions or preparations, and access to means.
  2. Ask what stops the person acting (protective factors), whether they pose any risk to others, and whether they are neglecting themselves or anyone who depends on them.
  3. Record the risk level and the plan, and agree what the person will do in a crisis. Give them the urgent and crisis contacts.
  4. At each later contact, feed back the previous assessment, ask whether it still holds, and re-assess fully if anything has changed.
  5. Discuss anyone above the service's risk threshold in supervision [source: Reach Out supervisor materials p. 14].
  6. On access to means, discuss safe storage and removal only [synthesis].
• Example language (illustrative): "Last time you told me you'd had fleeting thoughts that life wasn't worth living, but no plans. Is that still how it is, or has anything changed?"
• Watch for:
  • new plans, preparations, hopelessness, or a sudden rise in the depression score;
  • risk to children or other dependants. Any of these means a same-day discussion with a supervisor and moving the person out of self-help [synthesis consistent with NICE CG113 1.2.37].

4.3 Routine outcome measurement

• Purpose: track change session by session and inform decisions about stepping up [source: Reach Out p. 12; NICE CG113 1.2.16].
• Steps:
  1. At every contact, use the depression and anxiety measures in the service's minimum data set. In Reach Out these are PHQ-9 and GAD-7. Use a functional impairment measure (WSAS) and a broader measure (CORE) at the first and last contacts, and occasionally in between.
  2. Read the items out in order, score them quickly and feed the result back.
  3. Ask how the score fits the person's experience.
  4. Give the person spare copies of the forms for telephone contacts.
  • Use the licensed or official versions; the items are not reproduced here.
• Example language (illustrative): "Your score's come down from 17 to 12 since we started. Does that match how the last fortnight has felt?"
• Watch for:
  • flat or rising scores, which call for a supervision review (see 4.15);
  • a single question on self-harm scoring above zero, which needs a direct risk check [synthesis].

4.4 Information giving and rationale

• Purpose: give the person enough understanding to make an informed choice, and introduce the CBT model that the book will build on [source: Reach Out pp. 22–24].
• Steps:
  1. Cover five areas:
     • what the practitioner will do;
     • the condition;
     • medication;
     • psychological treatments;
     • other options.
  2. Pitch the information to what the person already knows.
  3. Back it up with something written. This matters especially where literacy or language is a barrier, and it also covers the leaflet about the practitioner's role.
  4. For depression, explain the vicious circle of low mood, withdrawal and avoidance. That circle is the rationale for behavioural work [source: Reach Out pp. 27–28].
• Example language (illustrative): "The book teaches the same skills a therapist would. My job is to help you put them into practice and keep an eye on how it's going."
• Watch for: the person hearing "read a book" as being fobbed off. Explain how the guidance works and how stepping up works [synthesis].

4.5 Shared decision and choosing the book

• Purpose: match the material to the problem, the person's preferences and their reading access [source: Reach Out pp. 24–25; NICE CG113 1.2.12–1.2.14].
• Steps:
  1. Offer the step-2 options: non-facilitated self-help, guided self-help, a psychoeducational group, or computerised CBT where the service has it. Go with the person's preference.
  2. Choose the material from the problem statement:
     • The Reading Well mental health list maps problems to books. For depression it includes, for example, Overcoming Depression (Gilbert), Mind Over Mood (Greenberger & Padesky), An Introduction to Coping with Depression (Brosan & Hogan) and Manage Your Mood (Veale & Willson). For anxiety it includes Overcoming Anxiety (Kennerley), Overcoming Worry and GAD (Meares & Freeston) and Overcoming Panic (Manicavasagar & Silove). For OCD it includes Break Free from OCD (Challacombe, Bream Oldfield & Salkovskis). There are also books on low self-esteem, social anxiety, health anxiety, anger, binge eating and sleep [source: Reading Well booklist].
     • Burns matches his own titles to problems. Feeling Good is for mild to severe depression, The Feeling Good Handbook for depression and anxiety, and When Panic Attacks for anxiety disorders [source: Feeling Good Podcast ep. 139].
     • Feeling Good was not on the Reading Well list opened. Using it is the clinician's choice, outside that scheme [uncertain].
     • Lewinsohn's book suits a reader who prefers a behavioural self-change programme [synthesis based on publisher description].
  3. Check the format: print, e-book or audiobook, and the reading level. Reading Well titles come in several formats and reading levels [source: LGA case study]. Ask about the person's preferred language [source: NICE CG113 1.2.22].
  4. Agree what, how, where, when and who: the format and pace of contacts, and whether a family member will be involved.
  5. Make sure the person has the book in hand, from a library loan or a purchase, before contacts start.
• Example language (illustrative): "There are a couple of books that fit what you've described. Have a look at the first chapter of each and tell me which one sounds like you."
• Watch for:
  • long, dense books given to someone with low concentration. Start with a shorter introductory title from the same list [synthesis].
  • If a medication decision comes up, respect the person's choice and suggest a GP appointment when they stop or decline medication [source: Reach Out p. 24].

4.6 Setting up support contacts

• Purpose: provide the structured guidance that makes this guided rather than pure self-help [source: NICE CG113 1.2.14; Reach Out pp. 19–22].
• Steps:
  1. Plan 5–7 contacts of 20–30 minutes, weekly or fortnightly.
  2. Do the first contact face to face. Later contacts can be by telephone. Offer face to face to anyone uncomfortable on the phone or with a clinical reason for meeting in person.
  3. Agree the call times, which number to use, who may answer, and what happens if a call is missed.
  4. Use a telephone-working checklist: confirm identity, check privacy, have the materials and measures to hand, and confirm the next contact.
  5. For the lighter non-facilitated variant, plan at least 6 weeks with occasional contacts of 5 minutes or less [source: NICE CG113 1.2.13].
• Example language (illustrative): "I'll ring you at 10 on Tuesday for about twenty minutes. Have the book and your diary nearby. If I can't get through, I'll try again at 2."
• Watch for: contacts drifting into long, unstructured conversations [source: Reach Out supervisor materials pp. 11, 24].

4.7 Follow-up support session (the standard contact)

• Purpose: review progress and solve problems with the self-help work [source: Reach Out pp. 16–18].
• Steps:
  1. Set the agenda and re-state the problem statement.
  2. Review risk.
  3. Take and feed back the measures.
  4. Review the information given before and any medication: whether it is being taken, side effects and the person's views.
  5. Review the self-help work: which chapter or exercise they did, what happened, and what got in the way.
  6. Make shared decisions: carry on, repeat a section, move to the next skill, or change the support or the step.
  7. Close with a summary and the agreed next steps, including the specific reading and exercises.
  • Keep the session short unless the person has deteriorated markedly.
  • Leave worksheet and diary planning until near the end.
• Example language (illustrative): "Let's look at your activity diary from this week. What went to plan, and where did it get stuck?"
• Watch for: reading without doing the exercises. Ask to see the worksheets, not just whether the chapter was read [synthesis].

4.8 Medication check within support

• Purpose: low-intensity practitioners support adherence and safety but do not prescribe [source: Reach Out pp. 24, 36; Reach Out supervisor materials p. 39].
• Steps:
  1. Ask about adherence, side effects and the person's views on their medication.
  2. If dangerous side effects seem possible, the low-intensity procedure is to:
     • advise temporary discontinuation;
     • inform the GP;
     • strongly advise an urgent GP appointment;
     • tell the supervisor as soon as possible.
  3. Pass on the general advice to continue antidepressants after remission, and direct questions about duration to the prescriber [source: Reach Out p. 37].
  • Doses are not discussed here.
• Watch for: people under 30 who have just started an SSRI or SNRI. NICE asks for monitoring of suicidal thinking in this group [source: NICE CG113 1.2.30].

4.9 Supporting behavioural activation from the book

• Purpose: for depression with withdrawal and avoidance. This is the behavioural core that Lewinsohn's approach shares with the low-intensity method [source: Reach Out C1 pp. 27–31; Simon & Schuster description of Control Your Depression].
• Steps (Reach Out sequence, paraphrased):
  1. Go over the book's rationale: being less active means fewer rewarding experiences, which lowers mood further.
  2. The client lists three kinds of activity they have dropped or avoided: routine, pleasurable and necessary.
  3. They sort the list from easiest to hardest, keeping a mix of the three kinds.
  4. They schedule a few small, specific activities from the easier end into a diary, saying what, when, where and with whom.
  5. They do the activities and record what happened.
  6. At the next contact, review the diary, work through any obstacles, and step up the difficulty.
• Example language (illustrative): "Rather than 'sort the house', let's pick something you can tick off: wash up after breakfast on Wednesday."
• Watch for:
  • plans that are too big or too vague;
  • only necessary tasks scheduled, with nothing pleasurable;
  • all-or-nothing reviews of the week.
  • Signs it is working: more activities done and the mood measure starting to fall [synthesis].

4.10 Supporting thought recording and cognitive restructuring from the book

• Purpose: for depression and anxiety driven by negative appraisals. It is the core of Feeling Good, and Control Your Depression also covers it, under the heading of changing self-defeating thinking [source: Reach Out C2 pp. 32–35; Wikipedia on Feeling Good; Simon & Schuster description].
• Steps (Reach Out sequence, paraphrased):
  1. The client notices a shift in mood and writes down the situation, the emotion and the thoughts. They pick out the thought most linked to the emotion (the "hot thought") and rate how strong the emotion is and how much they believe the thought, each from 0 to 100.
  2. They gather evidence for and against the hot thought, using guiding questions.
  3. They write a more balanced thought, then re-rate their belief in the original thought and their mood.
  4. They repeat this over several weeks. Change usually takes practice.
  • With Feeling Good, the client uses the book's own catalogue of thinking errors and its written exercises. Use the book's forms; do not reproduce them [source: Wikipedia on Feeling Good]. The detailed exercises in the book are not drawn on here [uncertain].
• Example language (illustrative): "Which of the thoughts in that column hit hardest? How much did you believe it at the time, from nought to a hundred?"
• Watch for:
  • Balanced thoughts that are just positive slogans and have no effect on the belief rating.
  • People with severe depression may find written cognitive work too hard at first. Start with behavioural work [synthesis].

4.11 Supporting a Lewinsohn-style self-change programme

• Purpose: a structured self-change plan for depression, in which readers pick out their own problem areas and build a personal programme [source: Simon & Schuster description].
• Content as sources give it:
  • The publisher says the book: explains depression; has readers identify their problem areas (dealing with other people, tension, troublesome thoughts, dissatisfaction at work or at home); helps them build a personal plan; teaches relaxation, social skills and ways to change self-defeating thinking; and covers judging progress, maintaining gains and deciding whether more help is needed.
  • The group course descended from this work, the adolescent CWD-A, teaches: mood monitoring, social skills, pleasant activities, relaxation, constructive thinking, communication, negotiation and problem-solving, and life planning and maintaining gains [source: NHS Education for Scotland, CWD-A page].
  • The chapter order, monitoring forms and self-reward procedures in the adult book are not drawn on here [uncertain].
• Steps for the guide [synthesis]:
  1. Help the reader pick the one or two problem areas the book points them towards.
  2. Agree a daily mood rating, so they can see how mood links to activity.
  3. Take one skill at a time, in the book's order. Give each skill a week or two, with a specific practice plan.
  4. At each contact, compare the mood record with the practice record.
  5. Near the end, use the book's section on maintaining gains to plan for setbacks.
• Example language (illustrative): "Looking at your mood ratings next to your diary, what do you notice about the days that went better?"
• Watch for:
  • Relaxation exercises unsettling people with trauma or panic. Offer an eyes-open option and let them stop at any time [synthesis].
  • Social-skills practice needs a safe, low-stakes first target [synthesis].

4.12 Feeling Good as between-session reading within therapy

• Purpose: Burns's original use. Assigned reading speeds up therapy and frees session time from teaching concepts [source: Feeling Good Podcast ep. 139].
• Steps [synthesis on structure]:
  1. Assign specific chapters that match what the session is working on.
  2. Ask the client to do the written exercises, not just read.
  3. Start the next session by reviewing what they read and what they tried.
  4. Use the book's vocabulary in session so the reading and the therapy reinforce each other.
  • The page does not describe a fixed chapter-by-chapter protocol [uncertain].
• Example language (illustrative): "Before next week, could you read the chapter on how thoughts drive feelings and try one written exercise on Thursday's argument?"
• Watch for: the client using the book to label their own thinking harshly ("I'm distorting again"). Reframe it as noticing, not failing [synthesis].

4.13 Waiting-list bibliotherapy with weekly monitoring

• Purpose: offer active help during a wait for treatment. This was the design of the Scogin studies [source: Feeling Good Podcast ep. 139; Smith et al. 1997 abstract].
• Procedure as Burns reports it:
  • Moderately to severely depressed adults waiting four weeks were given either Feeling Good or a Lewinsohn behavioural book, and were encouraged to read it.
  • A research assistant contacted every participant weekly and gave them a depression measure.
  • Burns reports that about two-thirds improved, one-third did not, and gains lasted up to three years.
  • The follow-up study (Smith, Floyd, Scogin & Jamison, 1997) followed up participants of a 1995 cognitive bibliotherapy trial (Jamison & Scogin) using the Hamilton and Beck depression measures, and reports that gains were maintained.
  • Wikipedia's account says the 1989 study involved older adults with mild to moderate depression. Burns describes the 1995 sample as moderately to severely depressed.
  • Burns names the behavioural book Up from Depression. The book named alongside Feeling Good in this guide is Control Your Depression. The original papers are not drawn on here [uncertain].
• Clinical steps [synthesis]:
  1. While the person waits, give them a matched book.
  2. Make a brief weekly check-in with a measure and a risk check.
  3. Make sure they know the plan if they get worse.
  4. When treatment starts, review what helped.
• Watch for: a deteriorating score or new risk during the wait. That means bringing treatment forward, not just continuing the book [synthesis].

4.14 Signposting to Reading Well, or non-facilitated self-help

• Purpose: the lightest step, for mild problems or as a supplement [source: LGA case study; Reading Well booklist; NICE CG113 1.2.13].
• Steps:
  1. Name the specific title, using the printed or digital Reading Well leaflets.
  2. Explain that library membership and borrowing are free and confidential, and that titles can be reserved.
  3. Point out the crisis numbers listed on the scheme materials.
  4. Arrange a review.
  • Other agencies need The Reading Agency's permission to reuse the list itself [source: Reading Well booklist].
• Example language (illustrative): "Your library has this one free. If it isn't helping after a few weeks, come back to me or your GP."
• Watch for: signposting used as a substitute for assessment when risk or severity is unclear [synthesis].

4.15 Case-management supervision and stepping up

• Purpose: catch non-improvement and risk across a large, low-contact caseload [source: Reach Out supervisor materials pp. 11–14, 16; NICE CG113 1.2.16–1.2.17, 1.2.37].
• Steps:
  1. Hold timetabled case-management supervision at least weekly, with skills supervision at least fortnightly.
  2. Cases to present:
     • new patients;
     • every patient at least four-weekly;
     • anyone above the risk or score threshold;
     • anyone overdue for contact;
     • anyone the practitioner is unsure about.
  3. For each case, present the current scores, the trend and the risk, along with the options: another low-intensity option, or stepping up to high-intensity therapy or medication.
  4. The supervisor records, signs and dates the agreed action.
  5. Step up when there is marked impairment or an inadequate response. Refer to specialist services for complex risk or comorbidity.
• Example language (illustrative), to the client: "Your scores haven't shifted over four sessions, and that tells us you need something more than the book. I'd like to refer you on for a course of CBT with a therapist."
• Watch for: stepping up framed as the client's failure. Frame it as information about fit [synthesis].

4.16 Access adaptations: literacy, language, sensory and cognitive needs

• Purpose: make reading-based treatment usable for everyone [source: NICE CG113 1.1.1–1.1.2, 1.2.13–1.2.14, 1.2.22; Reach Out p. 22; LGA case study].
• Steps:
  1. Ask about reading tactfully. Offer audiobook, e-book (with adjustable text size and text-to-speech) or simpler titles. Reading Well offers several formats and reading levels.
  2. Provide written support material, especially where literacy or language is a barrier.
  3. Use the person's preferred language where possible. Use a professional interpreter for contacts, not family [synthesis].
  4. For a mild learning disability or cognitive impairment, keep the same intervention but change the delivery or length, for example shorter sections and more contacts. For moderate or severe impairment, consult a specialist.
  5. For sight loss, use audio and large print. Bookshare lists an accessible edition of Control Your Depression, which is not drawn on here [uncertain].
• Example language (illustrative): "Some people prefer to listen to these books rather than read them. Would audio suit you better?"
• Watch for:
  • exercises not done because of hidden literacy problems;
  • forms the person cannot complete. Fill them in together during the call [synthesis].

4.17 Ending and relapse prevention

• Purpose: keep the gains [source: Reach Out p. 23; Simon & Schuster description; Feeling Good Podcast ep. 139].
• Steps:
  1. Review the measures against the person's goals.
  2. Use the book's section on maintaining gains, or the service's relapse-prevention pack, to list early warning signs and the skills that helped most.
  3. Mark the most helpful chapters to re-read if setbacks come. Burns reports that readers did this.
  4. Agree how to get back into the service.
• Example language (illustrative): "Which pages would you turn to first if the old pattern started creeping back?"
• Watch for: ending while scores are still in the clinical range without discussing stepping up [synthesis].

4.18 Children and young people

• Purpose: Reading Well has collections for children aged 7–11 and for teens [source: LGA case study]. The guided structure above was written for adults, and adapting it to young people is [synthesis].
• Steps [synthesis]:
  1. Get consent from the young person and, where the law requires it, from a parent or carer. Get the child's assent.
  2. Choose a title from the age-matched list.
  3. Agree what the parent or carer's role will be.
  4. Keep contacts shorter.
  5. Follow local safeguarding procedures and mandatory reporting duties for any disclosure.
  • For adolescent depression needing a structured group, the CWD-A course is delivered by trained mental health professionals, with an optional parent group [source: NHS Education for Scotland, CWD-A page].
• Watch for: self-harm risk. Young people with risk need a specialist child and adolescent mental health assessment, not self-help alone [synthesis].

5. Handling problems

Only the guidance on missed contacts, medication safety, risk review and stepping up comes from the sources. Everything else in this section is my own synthesis, marked [synthesis].

• Missed contacts and dropping out.
  • Low mood and low energy lead to missed appointments. Reach Out says to keep contact assertively rather than recording "did not attend" or discharging [source: Reach Out p. 19].
  • Try again at the agreed backup time, then send a letter or text offering a new slot.
  • Before discharging anyone who has gone quiet, check whether the last known risk calls for a welfare contact [synthesis].
• Reads but does not practise.
  • Shrink the task to one exercise a week.
  • Do the first worksheet together on the call.
  • Ask for a photo or a read-out of what they wrote [synthesis].
• Does not read at all.
  • Find out why:
    • concentration;
    • literacy (see 4.16);
    • the book doesn't fit;
    • not believing it can help.
  • Respond to the reason: switch to audio, an introductory title or a different book on the Reading Well list, or another step-2 option such as a group or computerised CBT [source: NICE CG113 1.2.12; synthesis].
• Feels fobbed off by "just a book".
  • Explain how the support, measurement and stepping-up rules work.
  • Respect a preference for a different option at the same step [source: NICE CG113 1.2.12; NICE decision aid 2022].
• Reading makes things worse.
  • For example: self-blame over thinking errors, distress at case examples, or worry stirred up by symptom descriptions.
  • Point them back to the chapters that are useful now, normalise the reaction, and move behavioural work ahead of cognitive work.
  • If distress keeps rising, stop the book and review the step [synthesis].
• Overwhelm on exposure or relaxation exercises in the anxiety books.
  • Grade the task down.
  • Make sure the person knows that stopping is allowed.
  • Panic or trauma responses need step-3 care with a therapist present [synthesis].
• Scores rise or new risk appears.
  • Re-assess risk fully the same day and discuss with your supervisor.
  • Step up or refer to specialist or crisis services [source: Reach Out pp. 16, 18; supervisor materials p. 14; NICE CG113 1.2.37].
  • Give the crisis contacts again. The Reading Well materials list NHS 111, Samaritans and Mind [source: Reading Well booklist].
  • When discussing means, talk about safe storage and removal only [synthesis].
• Stuck: flat scores across several contacts.
  • Raise it at the next case-management review, and consider another low-intensity option or stepping up [source: Reach Out supervisor materials p. 14; NICE CG113 1.2.17].
  • Check for things that self-help cannot address, such as hidden alcohol misuse, interpersonal crises, comorbid PTSD or social problems [synthesis].
• Wants more than the role allows.
  • Stay within the low-intensity frame and step up if more is needed. Do not quietly extend into longer or deeper sessions [source: Reach Out supervisor materials pp. 11, 24].
• Ruptures.
  • Repair openly: "It sounds like last week's call felt rushed. Let's sort out what would work better" (illustrative).
  • Offer face-to-face contact if the phone is getting in the way [source: Reach Out pp. 19–22 on mode choice; synthesis].
• Medication problems.
  • Respect the person's choices.
  • For suspected dangerous side effects, follow the procedure in 4.8 [source: Reach Out p. 24, 36].
• Disability, language or cultural mismatch with the book's examples.
  • Change the format or language.
  • Talk through how the examples translate to the person's own life.
  • Choose a title that better fits their culture where one exists [source: NICE CG113 1.2.22, 1.3.2; synthesis].
• Private material on the page.
  • Diaries can reveal abuse, intent or risk to children. Act on these under safeguarding procedures.
  • Remind clients where their worksheets are stored and who might see them, for example a book returned to the library with notes in it [synthesis].

Sources

Sources

• Reach Out 3rd edition: National Programme Student Materials (Richards & Whyte, 2011)
• Reach Out: National Programme Supervisor Materials (Richards, Chellingsworth, Hope, Turpin & Whyte, 2010)
• NICE CG113 Generalised anxiety disorder and panic disorder in adults: 1 Guidance
• NICE: Depression in adults – discussing first-line treatments for less severe depression (decision aid, 2022, hosted by NHS Lothian)
• GPnotebook: Guided self-help
• Reading Well for mental health booklist (Dorset Council copy)
• Local Government Association: Books on prescription – how reading can support health outcomes (2026)
• Feeling Good Podcast ep. 139: Can a self-help book really help? (Burns & Barovsky, 2019)
• Simon & Schuster UK: Control Your Depression, Rev'd Ed
• Wikipedia: Feeling Good: The New Mood Therapy
• Smith, Floyd, Scogin & Jamison (1997) Three-year follow-up of bibliotherapy for depression – repository record
• NHS Education for Scotland Early Intervention Framework: Adolescent Coping with Depression Course (CWD-A)

Further reading (full texts not drawn on unless listed above)

• Burns, D. D. (1980; revised 1999). Feeling Good: The New Mood Therapy. William Morrow (1980).
• Lewinsohn, P. (2010 e-book of the revised edition). Control Your Depression. Touchstone. Co-authors and the date of the first edition were not verified [uncertain].
• Smith, N. M., Floyd, M. R., Scogin, F., & Jamison, C. S. (1997). Three-year follow-up of bibliotherapy for depression. Journal of Consulting and Clinical Psychology, 65(2), 324–327. doi:10.1037/0022-006X.65.2.324
• Jamison, C., & Scogin, F. (1995). Outcome of cognitive bibliotherapy with depressed adults. Cited in Smith et al. (1997) and by Burns. Not drawn on here [uncertain].
• Scogin, F., Jamison, C., & Gochneaur, K. (1989). Comparative efficacy of cognitive and behavioral bibliotherapy for mildly and moderately depressed older adults. Cited by Wikipedia. Not drawn on here [uncertain].