Acta Psychiatr Scand 2005: 111: 272–285 Copyright
Blackwell Munksgaard 2005

All rights reserved

ACTA PSYCHIATRICA
DOI: 10.1111/j.1600-0447.2005.00499.x
SCANDINAVICA

Review article
A review of self-management interventions
for panic disorders, phobias and
obsessive-compulsive disorders
Barlow JH, Ellard DR, Hainsworth JM, Jones FR, Fisher A. A review J. H. Barlow, D. R. Ellard,
of self-management interventions for panic disorders, phobias and J. M. Hainsworth, F. R. Jones,
obsessive-compulsive disorders. A. Fisher
Acta Psychiatr Scand 2005: 111: 272–285.
Blackwell Munksgaard 2005. Interdisciplinary Research Centre in Health, School of
Health and Social Sciences, Coventry University,
Objective: To review current evidence for the clinical and cost- Coventry, UK
effectiveness of self-management interventions for panic disorder,
phobias and obsessive-compulsive disorder (OCD).
Method: Papers were identified through computerized searches of
databases for the years between 1995 and 2003, manual searches and
personal contacts. Only randomized-controlled trials were reviewed.
Results: Ten studies were identified (one OCD, five panic disorder,
four phobias). Effective self-management interventions included
cognitive-behavioural therapy (CBT) and exposure to the trigger
stimuli for phobias and panic disorders. All involved homework. There Key words: self-management; literature review; phobic
was evidence of effectiveness in terms of improved symptoms and disorders; panic disorder; obsessive-compulsive
psychological wellbeing when compared with standard care, waiting disorder
list or relaxation. Brief interventions and computer-based interventions Professor Julie Barlow, Interdisciplinary Research
were effective for most participants. In terms of quality, studies were Centre in Health, School of Health and Social Sciences,
mainly based on small samples, lacked long-term follow-up, and failed Coventry University, Priory Street, Coventry CV1 5FB,
to address cost-effectiveness. UK.
Conclusion: Despite the limitations of reviewed studies, there appears E-mail: j.barlow@coventry.ac.uk
to be sufficient evidence to warrant greater exploration of self-
management in these disorders. Accepted for publication December 7, 2004

tion, the provision of needs-led, accessible services

Introduction
Mental health conditions are common in the
general population. For example, in the UK
approximately a quarter of general practice con-
sultations are for mental health conditions. It is
estimated that 4.7% of adults experience general-
ized anxiety disorders (not including depression),
0.7% will develop a panic disorder, 1.9% experi-
ence phobias, and approximately 1.2% has an
obsessive-compulsive disorder (OCD) at any one
time (point prevalence) (1). However, the preval-
ence of mental health conditions such as OCD may
be under estimated, as people are often afraid to
seek help (2). Indeed, figures from the USA
National Comorbidity Survey estimated lifetime
prevalence for simple phobia as high as 13.3% (3).
The modernization agenda for mental health
services in the UK (4) emphasiszes health promo-
and the development of partnerships with users,
carers and the wider community. The recent emer-
gence of self-management approaches in the mental
health sector is consistent with the values under-
pinning this agenda. The emphasis is on individual
autonomy and the development of collaborative
approaches that aim to empower, or enable, the
users of mental health services to take an active role
in the management of their difficulties. This reflects
the notion that service users should be perceived as
experts in relation to their experience of illness or
disability and their needs. It also highlights the
importance of collaboration and inclusion.
The growing interest in mental health services
and research has occurred against a changing ethos
within service provision, with a gradual shift from
paternalistic approaches towards patient empow-
erment and increased recognition of the role that

272

patients themselves play in the daily management
of their conditions. The value of self-management
strategies for people with chronic conditions is now
widely accepted [e.g. Saving Lives: Our Healthier
Nation, White Paper, HMSO, (5)] and there is a
growing body of evidence to support the effective-
ness of self-management approaches in this field
(e.g. 6–9). Attention is now turning towards
exploration of similar developments in the field of
mental health.
Self-management
There is no universally accepted definition of Ôself-
managementÕ in the health arena. Indeed, the terms
Ôself-helpÕ, Ôself-careÕ and Ôself-managementÕ tend to
be used interchangeably. Collectivist approaches
reflect the mutual aid provided by self-help groups,
typically devoted to a specific diagnosis (e.g.
depression). Self-help groups are viewed as Ôsup-
plementary to professional assistanceÕ (10) and
typically play a supportive role rather than one of
providing instruction in new skills that can be used
in the management of a condition and its conse-
quences. Self-help groups and organizations grew
in popularity in the 1980s. Many such organiza-
tions are now beginning to respond to the educa-
tional needs of their members by providing more
structured support in the form of workshops,
seminars and interventions.
Individual approaches are reflected in terms of
self-care and self-management. A review of chronic
conditions (11) suggests that, in general, Ôself-careÕ
refers to preventative strategies (i.e. tasks per-
formed by healthy people at home), whilst Ôself-
managementÕ refers to the strategies used by people
with chronic conditions. Thus, self-management
refers to the individual’s ability to manage the
symptoms, treatment, physical and psychosocial
consequences and life style changes inherent in
living with a chronic condition. Efficacious self-
management encompasses ability to monitor one’s
condition and to affect the cognitive, behavioural
and emotional responses necessary to maintain a
satisfactory quality of life. A dynamic and con-
tinuous process of self-regulation is established,
with individuals working in partnership with rele-
vant health professionals (12). Lorig (13) defined
self-management in a similar way and outlined the
key differences between self-management and
patient education. She noted that Self-management
Interventions help the patient to manage life with
the disease, increase skills and self-confidence, are
patient-centred (e.g. derived from patientsÕ own
needs) and the course leader is a guide and model.
In contrast, patient education tries to change
Self-management review: phobias, PD and OCD
behaviours, increase knowledge, is based on what
the patient needs to know as perceived by health
professionals, and the course leader is a health
professional.
Several authors use the term Ôself-managementÕ
specifically in relation to mental health conditions.
For example, Pollack (14) considered in-patient self-
management of bipolar disorder, defining Ôself-
managementÕ as the daily activities an individual
must engage into control or decrease the impact of
disease on health status, which includes contending
with the psychosocial difficulties caused or intensi-
fied by the disorder. This definition is similar to that
used by Barlow (12) and the ideals postulated by
Lorig (13) in relation to chronic disease and was
adopted as an operational definition for our review.
We did not set out to provide a review of the
extensive literature on cognitive-behavioural ther-
apy (CBT) or exposure therapy or behavioural
treatment per se, rather we were interested in
finding studies that incorporated a self-manage-
ment ethos. It should be noted that the use of
professionally led, cognitive-behavioural interven-
tions appears more widespread in the field of
mental health compared with the field of chronic
disease. It is therefore important to distinguish
between therapeutic interventions that rely on the
presence of a professional, and self-management
interventions that can involve professionals but
also rely on the individual to practice self-manage-
ment techniques in their everyday lives. Central to
self-management is the promotion of control and
responsibility by the individual who then feels
confident in his or her own ability to manage
symptoms and the impact of symptoms on his or
her life. This approach differs from behavioural
treatment: use of the term ÔtreatmentÕ infers ther-
apist intervention and is not the same as interven-
tions that are informed by behavioural principles.
Aims of the study
The overall purpose of this study was to identify
and review current evidence for the clinical and
cost-effectiveness of self-management interventions
for panic disorder, phobias and OCD.
Material and methods
Study selection criteria
The review focused on evidence derived from
randomized-controlled trials (RCT) only between
the years 1995 and 2003. The rationale for this
decision is that RCTs provide the most reliable
evidence of effectiveness. Inclusion criteria for the
273
Barlow et al.
review process were: evaluation of a self-manage-
ment approach using RCT methodology. Exclusion
criteria were: non-RCT; bibiliotherapy with no
professional or paraprofessional input (e.g. self-
help manual); commentaries and editorials; opin-
ions, speeches, brief points of view or short com-
munications, including letters to the editor and
news sections; identification of self-management
behaviours; non-randomized, uncontrolled follow-
up studies; book reviews; scale development; meth-
odology articles; articles not available in English.
Search of the literature
Search terms were drawn from previous reviews in
the field of mental health, including a report
generated for the Department of Health (15), and
from those specified by the Cochrane Collabor-
ation. Search terms included combinations of key
words used to describe self-management and self-
help (self-help, self-care, self-management, self-
instruction, self-administration and self-technique).
Keywords for each condition were expanded to
include the terms, attack, reaction, symptom and
disorder. The following electronic databases were
searched for the years 1995 to April 2003: the
Cochrane Library comprising the Cochrane Data-
base of Systematic Reviews, the Cochrane-con-
trolled Trials Register (CCTR), the Database of
Abstracts of Reviews of Effectiveness (DARE), the
Health Technology Assessment (HTA) and NHS
Economic Evaluation (EED); the National
Research Register (NRR); PsycINFO; PubMed;
CINAHL; Index of Theses; Web of Science com-
prising the Index to Scientific and Technical Pro-
ceedings and Science Citation Index and EconLit.
Electronic database searches were supplemented
by examining the identified literature (particularly
reviews) for further references. In addition, perso-
nal communications were made with key experts,
authors and voluntary organizations.
Data extraction and tabulation
Papers were read and summarized by the research
team using a record sheet adapted from a previous
review (6). Inter-researcher reliability was addres-
sed at the initial selection of papers and review
stages through regular meetings of the review team
where discrepancies were discussed and a consen-
sus reached.
Studies meeting review criteria
It is important to note that none of the studies
identified in our searches could be considered ÔpureÕ
274
self-management interventions such as those devel-
oped for chronic disease (e.g. 7). However, studies
including an element of self-management ethos
were included in the review. For example, several
studies compared professionally led interventions
(e.g. full CBT) with self-directed or brief interven-
tions that were driven more by the patient and
delivered via computer or homework and the
practice of techniques in the home environment.
About 66 studies were identified in the prelim-
inary search. Fifty-six were excluded for the
following reasons: search terms identified physical
health problems with associated psychological
sequelae (e.g. chronic pain, cancer, brain injury,
myocardial infarction, cystitis, temporomandibular
joint disorder, multiple sclerosis and human immu-
nodeficiency virus); no clearly defined self-man-
agement component; attendance and participation
at self-help groups and meetings (e.g. alcoholics
anonymous); self-help groups in general; families/
carers/parents of people with mental health condi-
tions; teaching interventions to health-care profes-
sionals (e.g. medical students); intervention not
specified or described; non-randomized follow-up
studies; focused on expectations about and satis-
faction with interventions; impact of condition on
self-regulation (e.g. binge eating); counselling/psy-
chotherapy; examining systems or organizations;
commentaries/essays. A total of 10 papers met the
inclusion criteria and were reviewed (see Table 1
for a tabulated summary). None of the reviewed
papers reported effect sizes (ES). These were
calculated using mean scores at follow-up and
standard deviations reported in the reviewed
papers using the following formula:
ES ¼ ðX2
X1 Þ=SD
Where, X2 is the mean score at follow-up, X1 is the
mean score at baseline and SD is the standard
deviation at baseline. ES are presented in the
ÔOutcome Measures columnÕ of the summary tables
(Table 1).
Results
Panic disorder
Adults ranging in age from 16 to 60 years with a
Diagnostic Statistical Manual (DSM-IV) classifi-
cation of panic disorder or panic disorder with
agoraphobia were the target population in all five
studies. The interventions were delivered in the:
UK (n ¼ 1); Brazil (n ¼ 1); USA (n ¼ 1) and
Sweden (n ¼ 2) by clinical psychologists or psy-
chiatrists experienced in the use of CBT for anxiety
 Table 1. Summary of papers reviewed
Author/date/
country/condition Objectives and research design
Clark et al. (16)/ To examine the effects of brief
UK/panic cognitive therapy (BCT) for PD
disorder (PD) Randomized-controlled trial
(RCT): three groups
Blind treatment allocation
Group 1: Full cognitive therapy
(FCT)
Group 2: BCT
Group 3: Wait list control (no
therapy for 3 months and
then assigned to either FCT
or BCT)
Assessments: Pretherapy/
waiting list, post-therapy/
waiting list
Follow-up: 3-/12-month
post-therapy
Ito et al. (17)/ To compare self-exposure to
Brazil/PD with external, internal cues, and
agoraphobia their combination with a
control group in the treatment
of PD with agoraphobia
RCT: four groups
Group 1: Self-exposure to
external cues
Group 2: Self-exposure to
interoceptive cues (i.e.
repeated exposure to feared
bodily sensations)
Group 3: Self-exposure to both
external and interoceptive
cues
Group 4: Control group
Assessments: Baseline, 6, 10,
24 (3-month follow-up), 36
(6-month follow-up) and
62 weeks (1-year follow-up)
275
Sample description
43 participants randomly assigned. One
participant dropped out from group 1 after
one session to give (n ¼ 14) in each group
Criteria: 18–60 years of age; no previous
treatment with cognitive or exposure
therapy; no evidence of mental illness or
chronic illness
Recruitment via referrals from General
Practitioners (GPs). Psychiatrists and
psychologists
Participants: Mean age, 34 years (SD: 11.1);
mean duration of current episode of PD:
3.7 years (range: 0.5–27); 62% female
80 out-patients who had PD + agoraphobia
randomized at baseline to give n ¼ 21,
n ¼ 20, n ¼ 21 and n ¼ 18 in groups
1, 2, 3 and 4 respectively
75 participants included in analyses at
10 weeks
52 participants included in analyses at
62 weeks
Criteria: 18–65 years of age; absence of
suicidal intent, organic brain disease,
psychosis, substance use; no other
psychotherapy
Recruitment: Mostly self-referred following
article in lay press
Mean age 37 years (SD: 11); 83% Caucasian;
64% female; mean illness duration 7 years
(SD: 8)
34 participants had comorbid symptoms
(e.g. depression, anxiety, social and specific
phobias)
Intervention setting,
deliverer and content
Delivered on 1 : 1 basis by four clinical
psychologists experienced in the use of
cognitive- behavioural treatments for anxiety
FCT: Up to 12 · 1 h sessions in first 3 months.
Comprised cognitive techniques and
behavioural experiments designed to modify
misinterpretations of body sensations and
their maintenance
BCT: Modified version of full treatment. Five
sessions in 3 months. Comprised same
procedures as FCT together with introduction
of self-study modules
Both groups had up to two booster sessions
during the first 3 months of follow-up
Total therapy and booster time: FCT, 11.9 h;
BCT, 6.5 h
Interventions conducted on a 1 : 1 basis by four
psychiatrists and a psychologist experienced in
behaviour therapy for anxiety disorders
Groups 1, 2 and 3 had seven 60 min sessions
of self-exposure over 10 weeks and carried out
60 min of daily self-exposure homework
Explanation of panic and anxiety response given
in first session
Groups 2 and 3 taught breathing techniques
following interoceptive exposure exercises
Group 1: Sessions 1 and 2 comprised 45 min
of therapist-accompanied exposure to feared
external situations + 15 min homework
planning
Group 2: Sessions 1 and 2 comprised 45 min
of therapist-accompanied interoceptive
exposure exercises + 15 min homework
planning
Group 3: Sessions 1 and 2 comprised 30 min
of therapist-accompanied exposure to
feared external situations, 15 min of
therapist-accompanied interoceptive
exposure + breathing techniques, + 15 min
homework planning
Group 4: Session 1 informed that symptoms
could improve without treatment and put
on 10-week waiting list
Outcome measures
Treatment credibility, panic
attacks, general anxiety,
agoraphobic avoidance,
panic-related cognition and
depression were assessed
Panic-free classification: no
panic attacks recorded in
diary during previous 2 weeks
and panic-free rating by
assessor
Effect size (ES) range at
post-therapy:
Group 1: )3.15 to )0.92
Group 2: )3.30 to )1.02
Group 3: )0.74 to )0.03
Self-ratings: Fear questionnaire
(FQ) agoraphobic conditions
questionnaire. Diary of panic
frequency over 2 weeks; beck
depression inventory (BDI)
Assessor ratings: Hamilton
anxiety scale (HAS), clinical
global impression scale (CGI)
ES range at 12-month follow-up
Group 1: )4.04 to )0.68
Group 2: )3.29 to )0.63
Group 3: )3.96 to )0.74
Group 4: )0.48 to 0.01
Key results
Extensive use was made of
self-study modules
Use of between sessions
self-study modules reduces
amount of therapists time needed
without loss of effectiveness
BCT had low drop-out rate (0%)
BCT and FCT superior to wait list
group (all P < 0.005). No
significant difference between
BCT and FCT post-therapy (all
P > 0.35). Gains were
maintained at follow-up for
both groups
BCT required 6.5 h of therapist
time including booster sessions
Patients' initial expectation of
therapy success negatively
correlated with post-treatment
panic-anxiety
Cognitive measures at end of
treatment predicted panic-anxiety
at 12-month follow-up
Groups 1, 2 and 3 each improved
significantly more (P < 0.001)
than control group on all 10
outcome measures from weeks
0 to 10
These gains were mostly
maintained at 1-year follow-up
Gains included change in
cognitions (catastrophic thoughts
and misinterpretations related
to panics)
Rates of improvement on main
outcome measures averaged
60% at post-treatment and 77%
at follow-up
The three methods of
self-exposure were equally
effective in reducing panic and
agoraphobic symptoms in the
short- and long-term
Commentary
Need to see if results generalize to
naturalistic settings
Cost-effectiveness – a brief treatment
making extensive use of self-study
modules between sessions, reduced
therapist time without loss of
effectiveness
Need to examine in larger samples.
Unable to attribute success to specific
components of BCT.
Future studies could establish optimum
FCT/BCT programme scheduling, as
frequent sessions over a shorter
space of time may be beneficial
Important to aim for both symptom
elimination and cognitive change as
cognitive measures taken at the end
of therapy were significant predictors
of panic-anxiety 1 year on
Intent-to-treat analyses used.
Further research needs to examine
interoceptive exposure without
breathing retraining; role of group 1
exposure homework; participants with
PD without agoraphobia instructed in
self-exposure to external cues
(group 1 conditions)
Authors question sample size and
whether it was too small to detect
significant differences in treatments
between groups
20 participants left before week 4 and
were replaced
No cost-effectiveness data, but likely
to be a costly intervention with
psychiatrists as deliverers of a
seven session programme
Self-management review: phobias, PD and OCD
 Table 1. (Continued)
276
Author/date/
country/condition Objectives and research design
Carlbring et al. A controlled study of an
(20)/Sweden/PD Internet-delivered self-help
programme with minimal
therapist intervention by
e-mail
RCT: two groups
Group 1: Internet-delivered
self-help programme
Group 2: Waiting-list
Assessments: 2-week baseline
and post-treatment
Carlbring et al. A controlled study of an
(19)/Sweden/PD Internet-delivered cognitive-
behaviour therapy (CBT), self- were randomized into the two groups. 15
help programme with very
limited therapist input,
compared with applied
relaxation (AR)
RCT: two groups
Group 1: Internet-delivered
CBT programme
Group 2: AR
Assessment: 2-week baseline Intent-to-treat analyses used
and post-treatment
Sample description
500 participants screened using the self-
administered, diagnostic, Composite
International Diagnostic Interview –
shortened form (CIDI-sf). 41 fulfilled
inclusion criteria and randomized to
group 1 or 2
15 participants withdrew prior to
randomization. Following randomization,
four participants withdrew from group 1
and one from group 2
Criteria include: PD duration ‡1 year; aged
18–60 years; no other psychiatric disorder
requiring treatment; depression self-rating
on Montgomery
sberg Depression Rating
Scale (MADRS-SR) <21 and <4 on suicide
question
Recruitment via newspapers, health
magazines and Internet link for people
suffering from PD
All participants had access to a computer
and Internet
Participants: mean age 34 years (SD: 7.5);
29 female and 12 male; 64% on
psychoactive medication
Structured clinical interviews with 53 possible
participants, 22 fulfilling inclusion criteria
females, seven males (mean age 38 years,
SD: 8.6)
21 were excluded due to PD being result of;
social phobia (n ¼ 18), specific phobia
(n ¼ 2) and obsessive-compulsive disorder
(OCD) (n ¼ 1)
Five participants withdrew during study
(group 1, n ¼ 3 and group 2, n ¼ 2)
Inclusion criteria as on previous study (20)
All participants had access to a computer
with Internet connection
Intervention setting,
deliverer and content
Home-based individual approach with minimal
therapist contact (90 min per participant)
Group 1: Internet-delivered self-help programme
based on manual divided into six modules:
psychoeducation, breathing retraining,
cognitive restructuring, interoceptive
exposure, in vivo exposure and relapse
prevention
Treatment was reading assignments and
exercises plus e-mails with therapist over
7–12 weeks
Participants assessed via e-mail responses
to set module questions
Group 2: Offered self-help treatment
programme following post-test measures
Home-based individual approach with very
minimal therapist contact (30 min. per
participant including administration)
Group 1: Internet-delivered self-help
programme based on manual divided
into six modules: psychoeducation,
breathing retraining, cognitive restructuring,
interoceptive exposure, in vivo exposure
and relapse prevention
Treatment was reading assignments and
exercises plus e-mails with therapist for
which there was no time limit set
Participants assessed via e-mail responses to
set module question. Replies to participants
were standardized e-mails, sent within 7 days,
thus reducing therapist time
Group 2: Comprised a compact disc and an
adapted (computer-based) AR book that
participants had to work through
Treatment comprised nine modules:
1) Psychoeducation 2) Rational
3) Progressive muscle relaxation long version
4) Progressive muscle relaxation short version
5) Conditioned relaxation
6) Differential relaxation
7) Quick relaxation
8) AR
9) Relapse prevention
Participants assessed via e-mail responses to
set module question. Replies to participants
were standardized e-mails, sent within 7 days.
Text messages were used as reminders for some
in this group (n ¼ 5)
Outcome measures
Self-report measures used: Body
Sensations Questionnaire
(BSQ), Agoraphobic Cognitions
Questionnaire (ACQ), Mobility
Inventory for Agoraphobia (MI),
Beck Anxiety Inventory (BAI),
BDI, Quality of Life Inventory
(QOLI)
Panic diary and anxiety ratings
Treatment credibility scale
Evaluation of self-help
programme and advisory
service
ES range at post-treatment:
group 1 – )2.17 to )0.56,
group 2 – 0.35 to )0.03
Self-report measures used: BSQ,
ACQ, MI, BAI, BDI, QOLI
Panic diary and anxiety ratings
Treatment credibility scale
ES at post-treatment follow-up:
group 1 – )0.88 to )0.08,
group 2 – )2.00 to )0.92
Key results
No significant difference between
groups on any measures at
pretreatment
For the treatment group, all
measures except the MI showed
significant improvement
compared with waiting list group
Participants considered the service
to be personal. Lack of eye
contact was a plus factor
Almost all valued being able to
access service at home at time
of their own choice
No significant difference between
groups on any measures at
pretreatment
Post-treatment there was a
significant improvement in all
measures in both groups
Surprisingly the AR group had
the better overall effect when
compared with the CBT group
although not significantly
Almost all valued being able to
access service at home at time
of their own choice
Commentary
Intent-to-treat analyses
Long-term follow-up is needed – if
Barlow et al.
long-term benefit there may be
advantages over pharmacological
interventions
Comparative study of the reliability of
data volunteered via Internet and via
researcher/therapist is needed
Study relied entirely on participants'
own accounts of their difficulties and
self-report measures
Unclear whether participants met
Diagnostic Statistical Manual
(DSM-IV) criteria for PD. High
proportion of participants had
additional diagnoses
Addition of telephone contact and
improved visual materials might
improve efficacy
Cost of setting up Internet programme
estimated at $1000 and time invested
equivalent to 10 working days
The results suggest that
Internet-administered self-help plus
minimal therapist contact via e-mail is
an effective intervention. However,
due to the low power of the study
it is difficult to make gross assumptions
Interestingly, both treatments appeared
to benefit participants in this study,
but the study also highlights some of
the methodological problems with this
type of treatment
The lack of time constraints to complete
modules led to a laissez-faire attitude
Participants reported that the minimal
support given and the long wait for
replies was also de-motivating
Unlike the earlier study some
participants even suggested that they
felt `alone' and isolated due to the
lack of contact
This study highlights the need for more
therapist input per participant
(although less than live CBT)
The study also shows that a programme
of AR delivered via the Internet with
some minimal support may also be
effective and should be considered for
possible inclusion in the programme
 Murphy et al. To examine the effects of self-directed
(18)/USA/PD with in vivo exposure combined with
agoraphobia cognitive therapy, relaxation training,
(PDA) or therapist-assisted exposure in the
treatment of PDA
RCT: three groups
Group 1: cognitive therapy (CT) +
graded exposure (GE) + self-directed
in vivo exposure (SDE)
Group 2: relaxation training
(RT) + GE + SDE
Group 3: therapist-assisted GE + SDE
Pretreatment, 1-, 2- and 3-month
assessments during treatment,
post-treatment and 3-month
follow-up
Park et al. Two-year post-treatment follow-up of
(23)/UK/ RCT on self- and clinician-led
phobia/PDs exposure therapy for phobias
RCT: three groups
Group 1: Clinician-led self-exposure
(Ee)
Group 2: Self-exposure (e)
Group 3: Self-relaxation (r)
Assessments: Baseline, 8, 14 and
26 weeks after study entry; 2 years
post-treatment
277
89 participants with PDA
73 participants completed the
protocol
82% females, 18% males, mean
age 37 years, mean age at onset
26 years
Inclusion criteria: onset of disorder
age <40; duration of illness
>1 year; aged 18–65 years;
score higher than 3 on Global
Assessment of Severity Scale
Participants were excluded for
current alcohol or substance
abuse, organic brain syndrome,
OCD, or antisocial personality
Psychoactive medication was
withdrawn 2 weeks prior to
treatment
Drop-out rates (groups): CT (group 1)
– 17%, RT (group 2) – 25%, GE
(group 3) – 11%
68 (85%) of 80 psychiatric
out-patients completing 14 week
RCT (1992) followed up at 2-year
post-treatment
Group 1 (n ¼ 27)
Group 2 (n ¼ 26)
Group 3 (n ¼ 15)
Criteria: Disabling phobic disorder
of >1 year duration
Three types of phobia: agoraphobia
(n ¼ 16); social phobia (n ¼ 22)
and specific phobia (n ¼ 30)
Participants: mean age 35 years
(SD: 11); 37% male; mean duration
of phobia 18 years (SD: 11)
Three licensed, clinical psychologists
experienced in CBT
Clinic-based: four to five participants
per group
Graduated exposure (GE); Self-directed
graded exposure (SDE); Progressive
Deep-Muscle Relaxation Training (RT)
and CT
16 weeks of 2.5 h-sessions (two
sessions per week for first 3 weeks)
Group 1 (CT): 90 min in depth CT
followed by 90 min GE
Group 2 (GE): 90 min
therapist-assisted GE + 90 min of
group diary time and encouragement
to practice SDE
Group 3 (RT): 90 min for rehearsal
of RT (instructed to practice
20 min/day) followed by 90 min
GE + instructions and
encouragement to practice and
record SDE outings
During weeks 1–8, all three groups
received six, 60-min, individual
sessions with a clinician
Exposure homework comprising
individualized treatment targets,
was negotiated by each participant
with the therapist
Group 1 given extra 90-min session
in which clinician-accompanied live
exposure carried out
At week 14 exposure therapy offered
to participants who had not improved
after self-relaxation
At 2-years post-treatment, participants
invited to attend for assessment
Behavioural diary noting date, time, and
nature of in vivo exposure, and frequency,
duration and distance of outings
In vivo anxiety measured on Unit of
Disturbance Scale (SUDS)
Global Assessment of Severity Scale
Behavioural assessment using
Standardized Behavioural Avoidance
Course (S-BAC)
Phobic Anxiety and Avoidance Scale (PAA),
BDI, Dyadic Adjustment Scale
(DAS)
Self-rating questionnaire for severity of
panic attacks
The Subjective Symptom Scale
(agoraphobia, panic, depersonalization
and obsessions)
Self-rating of Severity (SRS)
The MI (phobias) and the Bodily
Sensations Questionnaire (anxiety)
ES range at 3-month follow-up
Group 1: )1.73 to )0.19, group 2: )1.09
to 0.13, group 3: )1.38 to 0.58
Target phobias (fear and avoidance
ratings)
FQ
BDI
Work, Home Management, Social and
Private Leisure Adjustment Scale (WSA)
At 2-years post-treatment, participants
rated above according to 1) satisfaction
with treatment during weeks 1–14 and
any subsequent treatment and 2)
treatment success
ES range at 2-year follow-up:
group 1 – )5.11 to )0.35,
group 2 – )6.83 to )0.35,
group 3 – )4.22 to )0.94
All three treatments were effective
in facilitating and maintaining
increases in client-directed
exposure to phobic stimuli
Few significant between group
differences on diary measures
Across all three-treatment groups
SDE was adopted and facilitated
decreases in vivo anxiety
2-year follow-up: Only self-rated
measures analysed; the three
types of phobia were pooled for
analysis of inter-treatment
differences; crossover participants
(r fi Ee/r fi e) pooled to boost
cell size
Groups 1 and 2 improved
significantly and remained stable
up to 2 years on nearly all
measures.
Most improvement occurred
between weeks 1 and 14
Compliance with self-exposure
homework during weeks 1–8
predicted greater improvement
at 2 years
Participants who crossed over from
relaxation to exposure therapy
showed significant improvement
on target fear, target avoidance,
global phobia severity and WSA
A co-therapist (relative or friend)
had been recruited during weeks
1–14 by 44% of participants in
group 1 and 35% in group 2 but
was not related to improvement
At 2 years, 33 participants (49%)
felt a need for further treatment
for their phobias
Considerable therapist input in these
interventions with all groups receiving
the same amount of therapist time
May explain limited between group
differences
SDE had a significant impact on anxiety
and appears to be an important
component of treatment for PDA.
However, because of the high levels of
therapist's time, the effectiveness of
SDE is not clear-cut
Anxiety management appears to be
essential to overall improvement.
Depressed mood and marital satisfaction
interfered with habituation to the
phobic stimuli
Future research needs to examine the
differential effects of SDE vs.
therapist-assisted exposure as well as
the underlying mechanism of SDE and
in vivo anxiety as predictors of
treatment outcome for PDA
The 9 h of clinician-accompanied
exposure given did not enhance
outcome at 2-year follow-up and may
have been confounded by large amount
of self-exposure homework
The three types of phobia were pooled
due to small sample size
Follow-up participants had only
self-ratings and were more improved
at 14 weeks than non-follow-up
participants
Not possible to draw conclusions:
long-term effects of relaxation as 10
of original relaxation participants had
crossover exposure therapy after
week 14
Some difficulty in drawing firm
conclusions for clinical practice
Self-management review: phobias, PD and OCD
 Table 1. (Continued)
278
Author/date/
country/condition Objectives and research design
Smith et al. A comparison of three
(21)/Australia/ treatment conditions using
spider phobia computer-delivered modelling
of exposure for spider phobia
RCT: three groups
Group 1: Relevant exposure
(to spiders) with feedback
(REF)
Group 2: Relevant exposure
(to spiders) with no feedback
(RENoF)
Group 3: Irrelevant exposure
(to lifts) with feedback (IEF)
Assessments: Pre- and
post-treatment
Follow-up: 6–12 months
Gilroy et al. Controlled comparison of
(22)/Australia/ computer-aided, vicarious
spider phobia exposure vs. live exposure
in the treatment of spider
phobia
RCT: three groups
Group 1: Computer-aided
vicarious exposure
Group 2: Therapist-delivered
live exposure
Group 3: Relaxation placebo
Assessments: Baseline,
post-treatment, 3-month
follow-up
Sample description
45 participants were randomly assigned
(n ¼ 15 in groups 1, 2 and 3 respectively)
38 participants completed 6–12-month
follow-up (n ¼ 12, n ¼ 14, n ¼ 12 in
groups 1, 2 and 3 respectively)
Criteria: At initial screening, participants
assessed on the National Adult Reading Test
(NART) and familiarity with a computer
mouse was tested
Recruitment via newspaper advertisement
Participants: mean age, 34.8 (SD: 11.57);
mean duration of phobia, 22.7 years
(SD: 10.0); 44 female
45 participants randomly assigned to one
of three treatment groups (n ¼ 15 in each
group)
Five non-completers (four from group 3 and
one from group 2) replaced with new
participants assigned to same treatment
groups
Criteria: Diagnosis of specific phobia using
the CIDI; minimum duration 1 year;
16–60 years of age; no history of affective
disorder or psychosis; female
Recruitment: Via newspaper advertisements
and public notices
Mean age 33.11 (SD: 10.85); 100%
Caucasian; 100% female
Intervention setting,
deliverer and content
Participants allocated to one of three versions of
a computer programme, each completing
3 · 40–45 min sessions every 2 weeks
Programmes comprised an introductory section
and interactive, animated scenario, modelling
self-exposure for spider or lift phobia [split
screen with anxiety thermometer (LHS) and
phobic `patient' in a specific situation (RHS)]
Group 1 (REF): Vignette refers to spider phobia
Exposure to range of anxiety-provoking
situations and anxiety thermometer present
Score rewards exposure behaviour
Group 2 (RENoF): No anxiety thermometer
Feedback score rewards neutral behaviours
(e.g. spider locations not visited or left when
faced with anxiety-provoking situation)
Group 3 (IEF): Vignette portrays lift phobia
Anxiety thermometer present and score rewards
exposure behaviour
Each participant completed a questionnaire
about specific homework activities related
to spider exposure, although no specific
instructions were given regarding homework
exercises
Assessments and interventions conducted
1 : 1 by a master's student in psychology
3 · 45 min sessions 2 weeks apart
Group 1: Computer programme using
point-and-click method to guide a screen
figure through a house and spider-related
scenarios. Therapist present for 5 min in
first session
Group 2: Instructed in exposure using five
pictorial representations of spiders and
hierarchical sequence of feared stimuli
using a live spider. Relaxation exercises
and modelling were not used in the
exposure sessions
Group 3: Audiotape of progressive muscle
relaxation used. No instructions for imaginal
exposure were given
No explicit exposure homework instructions
were given to any of the groups
Outcome measures
Two times Spider Questionnaires
(SPQ and SQ)
Phobic Targets (PT)
Work and Adjustment Rating
Scales (WARS)
Homework Questionnaire (HQ)
ES range at follow-up:
Group 1: )2.64 to )0.47
Group 2: )4.22 to )0.49
Group 3: )2.75 to )0.32
Pretreatment assessment: CIDI
National Adult Reading Test
(NART)
Post-treatment and 3-month
follow-up: FQ, Spider
Questionnaire (SQ), Phobic
Targets (PT), Work and
Adjustment Ratings Scales
(WARS)
Behavioural Assessment Test
(BAT) including Subjective Units
of Distress Scale (SUDS)
ES range at 3-month follow-up:
Group 1: )16.33 to )1.22,
group 2: )6.00 to )1.04,
group 3: )3.82 to )0.33
Key results
All groups showed significant
phobic improvement following
the treatment on SPQ, SQ, PT,
WARS
Outcome was not significantly
affected by either relevance of
exposure or the manipulation
of onscreen feedback
Participants' reports of
home-based exposure treatment
correlated positively with phobic
improvement
Computer-aided vicarious exposure
was an effective treatment for
spider phobia and comparable
with live exposure therapy in
significantly reducing phobic
symptoms
Computer and live exposure
treatments were more effective
than the relaxation placebo
treatment
Commentary
No intent-to-treat analysis
Comparable treatment effect in all
Barlow et al.
three groups, but small sample size
Addition of a behavioural avoidance
test would strengthen outcome
measures used
No cost-effectiveness
Assessment and treatment sessions
conducted by same therapist
Small sample size – may explain
lack of significant differences
between treatment groups
Homework instructions excluded
– may have diminished efficacy of
computer and live exposure
Only female participants included in
study
No cost-effectiveness
 Salaberria and To determine the added value
Echeburua of CBT to self-exposure
(24)/Spain/ in vivo for social phobia with
generalised longer term follow-up
social phobia Additionally, the therapeutic
impact of a self-help manual
was tested
Randomized-controlled design
with two treatment and one
waiting list control group
Three groups: i) self-exposure
in vivo (n ¼ 24),
ii) self-exposure in vivo
with CBT (n ¼ 24),
iii) waiting list control group
(n ¼ 23)
The manual was distributed
randomly in groups 1 and 2
(nested 2 · 2 factorial
design)
Assessments at baseline,
post-treatment, 1, 3, 6 and
12 months
Greist et al. To compare a computer-guided,
(25)/USA/OCD self-help, behaviour therapy
system (BT STEPS) or
clinician-guided, behaviour
therapy with systematic
relaxation as a control
RCT: three groups
Group 1: BT STEPS
Group 2: Clinician-guided
behaviour therapy
Group 3: Self-relaxation
Assessments: Baseline,
2, 6 and 10 weeks
Follow-up: 26 weeks
postbaseline
279
N ¼ 71 severely disabled social
phobics
(DSM-III-R) of ‡1 year; not suffer-
ing from
any other illness/serious beha-
vioural
disorder
Sample comprised volunteers and
patients
referred by mental health centres
Mean age ¼ 31 (SD: 8.3)
Male 52%
218 participants randomly assigned
(n ¼ 74, n ¼ 69, n ¼ 75 in
groups 1, 2
and 3 respectively)
183 participants at baseline (n ¼
57,
n ¼ 59, n ¼ 67 in groups 1, 2 and
3 system
respectively)
176 included in intent-to-treat ana-
lyses
(n ¼ 55, n ¼ 55 and n ¼ 66 in
groups
1, 2 and 3 respectively)
Criteria: ‡14 years of age; total
score
of ‡16 on YBOCS
Recruitment via radio, newspaper
advertisements and articles, cur-
rent
caseloads and referrals
Participants: mean age, 39 years
(SD: 12);
93% white, 58% male; mean OCD
duration 22 years (SD 12)
Group 1: group format, simulated
exposure and
practice of behaviour. At least two
exposures
per patient per session, homework
given
Group 2: CBT (identify and question
automatic
thoughts, restructure) and self-expo-
sure
Group format, homework given
Group size ¼ 4–8
Eight sessions on weekly basis, each
2–5 h
Group 3: received therapeutic aid after
6 months
Self-help manuals for anxiety given to
50%
of groups 1 and 2
Delivered in clinics using professionals
(clinical psychologist)
Conducted in eight North American
practice
sites on 1 : 1 basis by clinicians with
behaviour therapy expertise
2 weeks of assessment followed by
10 weeks treatment
BT STEPS: 9-step computer-driven
accessed by touchtone telephone
and a
self-paced workbook (topics include
exposure
and ritual prevention, homework
tasks)
Clinician-guided behaviour therapy: 11
weekly
1-h sessions; negotiate self-exposure
tasks
conducted for 60 min daily and
recorded in
diaries
Relaxation therapy: Progressive relax-
ation
exercises performed for 60 min daily
over
10 weeks and recorded in diaries.
Guided
by relaxation manual and audiotape
Structured individual interview:
ADIS-R interview schedule
Evaluation of social phobia:
SAD and FNE
Evaluation of other symptoms:
State-trait Anxiety Inventory
(STAI)
BDI
Scale of Adaptation
Evaluation of personality:
Self-esteem Scale
Rathus Assertiveness Scale
(Lengthy assessment)
Assessments done as interviews
limited with group meetings
Control group entered treatment
at 6 months
ES range at 6-month follow-up:
group 1 – )3.52 to )0.85,
group 2 – )3.32 to )0.54,
group 3 – )0.32 to 0.07
Primary outcome: Yale-Brown
Obsessive Compulsive Scale
(YBOCS)
Secondary: Patient and Clinical
Global Impressions (PGI and
CGI) scales
Self-rated Work and Social
Adjustment Scale (WSAS)
Comorbid depression –
self-rated HAM-D
Treatment expectations
questionnaire (TRT-X)
Satisfaction questionnaire (PSQ)
ES range at 26 weeks
postbaseline:
Group 1 – )1.30 to 0.004,
group 2 – )1.65 to )0.24,
group 3 – )0.92 to 0.04
64% of patients in groups 1 and 2
showed significant improvement
at 12 months
In general, groups 1 and 2 showed
improvements in all measures
compared with group 3
There was no difference between
groups 1 and 2
The self-help manual showed little
evidence of added value
At 10 weeks, mean change in
score on YBOCS significantly
greater in clinician-guided BT
than computer-guided
Both group 1 and group 2
significantly greater changes in
scores than group 3
On CGI, significantly greater
improvement for group 1 than
group 2 and both significantly
greater than group 3
Greater satisfaction with
either clinician-guided or
computer-guided BT than
with relaxation
Paper took at least 5 years to get
into print
The addition of CBT to self-exposure
did not confer any benefits, and
neither did the self-help manual
confer any benefits
No cost-effectiveness
Intent-to-treat analysis
Behaviour therapists may have
motivated more participants than
computer-guided BT to start
self-exposure homework
Suggest a `stepped-care' approach
to OCD
Potential effect of pre-enrolling
screening by clinician; contact with
clinicians to provide ratings during
treatment; did not compare
self-exposure guided by BT STEPS
workbook with BT STEPS workbook
+ computer-system; sample restricted
to those with extensive rituals
(mainly cleaning and checking)
At week 10, 22 BT STEPS
non-responders were changed to
clinician-guided BT and showed
subsequent improvement;
non-responders from clinician-guided
BT changed to BT STEPS did not
improve
No cost-effectiveness
Self-management review: phobias, PD and OCD
Barlow et al.
disorders. An intensive, individual approach was
adopted in two of the studies (16, 17), using
cognitive techniques, behavioural experiments,
self-exposure and completion of self-study modules
between sessions. Murphy et al. (18) used a group
approach comparing the effects of i) CBT + gra-
ded exposure + self-directed in vivo exposure; ii)
relaxation training + graded exposure + self-
directed in vivo exposure and iii) therapist-assisted
graded exposure + self-directed in vivo exposure,
in the treatment of panic disorder with agorapho-
bia. Each treatment group (n ¼ 4–5) was given a
considerable amount of therapist input (16 weeks
of 2.5 h sessions). In contrast, a home-based,
Internet-delivered, self-help programme had min-
imal therapist intervention via e-mail (19, 20).
Information about panic disorder was accessed
through the website, together with reading assign-
ments. All of these approaches rely on the use of
homework tasks and practice of techniques
designed to manage symptoms, either in the form
of diary keeping (e.g. monitoring panic symptoms)
or through behavioural experiments and self-
exposure.
Effectiveness
Outcome measures typically focused on the reduc-
tion of symptoms (e.g. frequency of panic attacks)
and change in panic-related cognitions, anxiety
and depression, and impact on quality of life.
Cognitive-behavioural therapy and self-exposure
were found to be effective and allowed individuals
to develop skills and coping strategies to use in the
self-management of panic disorder, with improve-
ments in panic frequency, panic-related cognitions,
agoraphobic avoidance, anxiety and depression
being maintained at follow-up (16, 17). However,
these studies were based on relatively small sample
sizes, which may have been insufficient to detect
significant differences in treatments between the
groups. For example, Clark et al. (16) compared
three groups with 14 participants in each at
baseline and Ito et al. (17) had a total of 52
participants across four groups at follow-up. The
precise intervention components that contributed
to improvement among participants remain to be
identified.
The cost-effectiveness of the interventions was
not addressed. However, Clark et al. (16) did refer
to the amount of therapist time required to deliver
the intervention. A brief therapy intervention,
making extensive use of self-study modules
between sessions, reduced the total therapy time
to 6.6 h (from 12 h), without loss of effectiveness.
In addition, no participants dropped out of this
280
group. Carlbring et al. (20) estimate the cost of
developing the Internet Programme to be $1000
with an additional investment in time of 10
working days. However, self-management inter-
ventions that require a high degree of motivation
and engagement may be less suitable for people
who are experiencing greater distress or a more
severe level of mental illness. Further research is
needed to determine who benefits most from
interventions involving parsimonious contact time
with professionals.
Phobias
The age range of participants in the self-manage-
ment interventions reviewed was 23–46 years. The
interventions were delivered in the UK (n ¼ 1),
Australia (n ¼ 2) and Spain (n ¼ 1). There were
gender differences in terms of type of phobia
studied, with a greater number of female partici-
pants presenting with spider phobia and a slightly
higher number of male participants presenting with
generalized social phobia.
Two studies for spider phobia report self-help/
self-management type components and both used
computer programmes as a means of delivery.
Smith et al. (21) compared three versions of
computer-delivered modelling for spider phobia:
i) exposure with feedback; ii) exposure with no
feedback and iii) irrelevant exposure to lifts.
Interestingly, outcomes were significant and similar
across all three groups, suggesting that self-man-
agement behaviours can be learned using condi-
tions other than the target phobia, the assumption
being that management techniques generalize to
other phobic stimuli. Gilroy et al. (22) compared
computer-aided, vicarious exposure for spider
phobia with therapist-led exposure and relaxation,
showing that exposure was more effective than
relaxation. No differences were found in the
effectiveness of computer-aided or therapist-led
exposure.
Two RCTs of self-management for phobias
evaluated the effectiveness of professionally led,
group programmes. In a 3-group study, Park et al.
(23) found no advantage of clinician-led exposure
over self-exposure among people with agorapho-
bia, social phobia and specific phobias at 2-year
follow-up. Participants in both exposure condi-
tions completed self-exposure homework. At
14 weeks, participants assigned to the self-relaxa-
tion group who had not improved (10 of 15) were
offered treatment by exposure. Salaberria and
Echeburua (24) conducted a 3-group study to
determine whether CBT enhanced outcomes of an
intervention based on self-exposure in vivo for

social phobia. They used a nested 2 · 2 factorial
design to test the impact of a self-help manual in
the self-exposure group and the self-exposure plus
CBT group. The addition of CBT did not confer
any additional benefits and neither did the self-help
manual.
Effectiveness
Outcome measures included those specific to the
phobia, evaluation of other symptoms such as
anxiety and depression, personality measures, and
adjustment to work and leisure.
None of the studies reviewed included analyses
of cost-effectiveness or did they use intent-to-treat
analyses, and all studies were based on relatively
small sample sizes. The addition of CBT and
provision of a self-help manual to self-exposure
therapy for people experiencing social phobia, did
not enhance benefits (24). Similarly, there were no
differences in outcomes between professionally led
exposure and either self-exposure or computer-
aided exposure. However, it was clear that expo-
sure was more effective than relaxation. These
findings suggest that it is the self-exposure in vivo
component that enables participants to manage
their phobic symptoms.
Obsessive-compulsive disorder
Adults aged 15–80 years meeting criteria for OCD
on the Yale-Brown Obsessive Compulsive Scale,
were the target population in the study conducted
by Greist et al. (25). The self-management
intervention was delivered in the USA on an
individual basis and comprised a computer-
guided, self-help, behaviour therapy system (BT
STEPS) accessed by touchtone telephone and a
self-paced workbook. There was e-mail contact
with a therapist. This home-based intervention
was compared with behavioural therapy conduc-
ted in practice settings by clinicians with expertise
in behaviour therapy, and relaxation using a
manual and tape.
Effectiveness
Outcome measures included reduction in symp-
toms, work and social adjustment and comorbid
depression. The design of this study had a number
of strengths including the sample size (n ¼ 176)
randomly assigned across three groups, the use of
intent-to-treat analyses and a structured, home-
based, self-management intervention. Both BT
STEPS and clinician-led, behaviour therapy were
significantly more effective than relaxation and
Self-management review: phobias, PD and OCD
received greater satisfaction ratings from partici-
pants. However, the clinician-led, behaviour ther-
apy was found to be more effective than BT
STEPS. It should be noted that the sample was
restricted to those with extensive rituals (mainly
cleaning and checking), who may not be expected
to have responses to this sort of treatment, and
therefore further evaluation is needed among
people with less severe OCD. After 10 weeks of
the intervention, participants in the BT STEPS
condition who were not responding to treatment
were changed to clinician-guided, behaviour ther-
apy and showed subsequent improvement. In
contrast, non-responders to clinician-guided, beha-
viour therapy did not improve after being changed
to BT STEPS. The model of using a less intensive
approach followed by referral to clinician-led
therapy appears useful in terms of making the
most effective use of resources. Although cost-
effectiveness was not directly assessed in this study,
reference was made to the cost-efficiency of com-
puter vs. clinician-guided care and the effectiveness
of the self-exposure component of behaviour
therapy in treating OCD.
Discussion
The studies reviewed were conducted in a range of
countries (Australia, Brazil, Spain, Sweden, the
UK and the USA) with no particular clustering in
any one place. Interventions targeted adults and
were typically delivered by professionals (e.g.
psychiatrists, psychologists, clinicians) in a clinical
setting or were home-based interventions delivered
via the Internet or computer programmes. How-
ever, the latter still involved contact time with
therapists. For example, the Internet-based pro-
gramme of Carlbring et al. (20) included 90 min of
e-mail contact with a therapist.
Interventions were either group-based, an indi-
vidualized approach, or a combination of both.
Group approaches typically comprised between 4
and 10 participants and were often supplemented
with written materials. Individual approaches typ-
ically comprised one-to-one sessions with a clini-
cian or were computer-based approaches with
support from a therapist. Individual approaches
included: one-to-one with clinician + homework
(e.g. diary, workbook, practice of self-exposure);
computer-programme + support from therapist
via e-mail, telephone or face-to-face; computer-
programme + workbook/manual; Internet +
e-mail access to therapist. Programmes included
specific homework tasks such as monitoring of
symptoms in a diary, self-exposure, or rehearsal of
coping strategies.
281
Barlow et al.
The interventions reviewed focused almost
exclusively on symptom reduction and control.
Few interventions addressed the consequences of
phobia, panic disorder or OCD on family and
social life, leisure activities or work. Interventions
for phobia were primarily based around exposure,
interventions for OCD were based on CBT, and
interventions for panic disorders combined CBT
with self-exposure.
Clinical effectiveness
Self-management interventions were found to be
effective when compared with control conditions
(e.g. routine care or waiting list) and relaxation
therapy. The exception was a comparison of an
Internet-delivered CBT programme with applied
relaxation delivered via a CD and a computer-
based programme for people with panic disorder.
No time limit was set for completion of the
programmes and both groups received standard-
ized e-mail feedback following completion of set
questions linked to each module. Both groups
improved in terms of reduction in symptoms and
psychological wellbeing (19). Participants reported
that the long wait for responses and minimal
support was ÔdemotivatingÕ. Indeed, some partici-
pants reported that they felt ÔaloneÕ and ÔisolatedÕ.
These results contrast markedly with an earlier
evaluation of the same Internet programme that set
a limit of 7–12 weeks for completion and had more
e-mail contact time with the therapist (19), sug-
gesting that there may be threshold below which
reduction in professional, contact time can have an
adverse influence.
The issue of contact time with therapists was
examined by Clark et al. (16), who found that brief
CBT (five sessions) combined with self-study
modules was just as effective as full CBT (12
sessions) in reducing the frequency of panic attacks
among people with panic disorder. The optimum
length of interventions for this group of patients
remains to be identified but there appears to be an
indication that shorter interventions may be effect-
ive for some patients. There is also some evidence
that Internet-based programmes for panic disorder
can be effective in reducing panic cognitions and
improving psychological wellbeing (20). Interest-
ingly, participants in this programme found the
lack of eye contact associated with the Internet to
be a plus factor. However, as noted above, care
needs to be taken in setting appropriate time limits
for completion of home-based programmes and
also in the provision of prompt feedback.
Various combinations of self-exposure combined
with breathing techniques were found to be equally
282
effective among people with panic disorder and
agoraphobia (17) in terms of reduction of panic
frequency and psychological wellbeing. Similarly,
Murphy et al. (18) found that self-directed expo-
sure combined with cognitive therapy, relaxation
training or therapist-assisted exposure were equally
effective for people with panic disorder and ago-
raphobia. All three groups received the same
amount of therapist time. However, the small
sample sizes of these studies may have hindered
detection of significant differences between the
intervention groups, thus results should be inter-
preted with caution and further investigation of the
precise techniques offering optimum effectiveness is
necessary.
Studies focusing on phobias (with or without
panic disorder) consistently show that exposure is
more effective than relaxation. Interestingly, Park
et al. (23) report that compliance with homework
predicted greater improvement at 2-year follow-up
emphasizing the importance of practising tech-
niques learned on interventions in the home
environment. One intriguing finding from a study
of a computer-based intervention for spider
phobia, was that participants who were given an
irrelevant exposure condition (i.e. to lifts)
improved just as much as those exposed to spiders
(21). This suggests that it may be possible to
develop a generic package for people with phobias
that would not need to include exposure to the
individual’s specific trigger stimuli. Computer-
based programmes appear to be just as effective
as the more costly, professionally led therapy for
people with phobias (e.g. 22, 24), although further
research is needed to identify those patients for
whom such approaches are appropriate.
Only one study was identified for OCD. How-
ever, results were in keeping with those for panic
disorder and phobias. Greist et al. (25) found that
a computer-guided programme (BT STEPS) was
more effective than a relaxation, control condition
but less effective than clinician-guided therapy.
After 10 weeks, non-responders to BT STEPS were
switched to clinician-guided therapy and showed
improvement. This study illustrates the potential
for a graded or staged approach whereby those
with less severe conditions, or, patients on a
waiting list could receive computer or Internet-
based programmes initially.
The notion of adopting a staged approach to
treatment may assist in overcoming the shortage of
trained CBT therapists. Equally, interventions
drawing on cognitive-behavioural principles that
do not require trained therapists for delivery may
widen the availability of interventions. There are a
number of computer-guided and interactive

multimedia programmes developed for the treat-
ment of anxiety and depression, schizophrenia and
dementia (26–30), as well as those reviewed here
for OCD, panic disorder and phobias. Kenwright
et al. (31) suggest that computer-aided, self-treat-
ment could provide an assured standard of treat-
ment that could operate with minimal support. In
addition, some people find it easier to discuss their
difficulties using an Ôanonymized processÕ (26) and
users can progress through each programme step at
their chosen pace. The caveats to this arising from
our review are that goals for self-completion of
modules need to be carefully set and prompt
feedback is essential in order to maintain motiva-
tion.
Cost-effectiveness
Little can be said about the cost-effectiveness of the
interventions reviewed as none of the studies
addressed this issue. It can be assumed that
group programmes are less costly than one-to-
one therapy and also that computer-based pro-
grammes are less costly in terms of therapistsÕ time
than group or individual interventions. The model
of referring patients to less intensive programmes
whilst on a waiting list or as a first stage of
treatment also requires examination in terms of
cost-effectiveness both in the short and longer
term.
Quality of studies
Some comment is needed regarding the quality of
studies reviewed. Although we focused exclusively
on RCTs as being the best available evidence, the
sample sizes of the studies reviewed were typically
small and authors did not report any power
calculations. A number of the studies may have
been underpowered and thus were not able to
detect differences between the interventions being
compared. Not all studies adopted an intent-to-
treat approach to analysis and longer term follow
ups (over 12 months) were rare.
Issues to be addressed
None of the studies reviewed provided a definition
of self-management either for mental health in
general or a specific mental health condition. The
working definitions we began with [i.e. (12, 14), see
Introduction] appear to have some relevance.
Barlow (12) refers to the individual’s ÔabilityÕ to
manage the symptoms, treatment and psychosocial
consequences of living with a chronic condition
whereas Pollack (14) refers to the Ôdaily activitiesÕ
Self-management review: phobias, PD and OCD
that an individual must engage into control or
decrease the impact of disease on health status,
including psychosocial difficulties resulting from or
intensified by the disorder. Barlow (12) includes the
need to monitor one’s condition, to effect cogni-
tive, behavioural and emotional responses, and the
notion of working in partnership with health
professionals. The latter was a key aspect of self-
management in the studies reviewed here, even
where contact was via e-mail. However, the diffi-
culties of distinguishing ÔpureÕ self-management
from interventions with a self-management com-
ponent are acknowledged.
Indeed, one reviewer of this paper pointed out
that the clinical and research literature on the
treatment of anxiety traditionally uses the term
Ôbehavioural treatmentÕ when in fact self-exposure
combined with homework tasks could be described
as Ôself-managementÕ. We hope this paper will
generate further debate and will encourage other
authors to provide definitions of their work on
topics such as self-management and self-help.
Few studies focused on the wider consequences
of living with enduring mental health conditions.
Rather, research focused almost exclusively on
immediate outcomes such as reduction in symp-
toms. For example, few interventions have
addressed entering the employment arena or how
to maintain employment after the onset of a mental
health condition. Furthermore, there do not
appear to be any generic self-management inter-
ventions that provide training in core skills, such as
how to improve communication with friends,
family and health professionals. Of interest was
the finding that exposure to an irrelevant stimuli
was proven to be effective in reducing symptoms in
spider phobia, suggesting that there may be some
value in developing a generic intervention that
provides training in strategies to manage or control
common symptoms such as anxiety.
All the studies reviewed targeted adults. There
appears to be a major gap in terms of provision for
children and young people. Furthermore, the small
sample sizes of most studies suggest that many of
the interventions require further investigation in
larger, more heterogeneous samples and with
longer term follow ups. Cost-effectiveness studies
will be essential if the value of self-management in
mental health is to be fully considered.
The issue of peer-led interventions is worthy of
consideration given the evidence for effectiveness in
chronic diseases such as arthritis (e.g. 7, 32). In the
UK, voluntary organizations appear to be leading
the way in relation to peer-led self-management
interventions in mental health thus mirroring the
situation that occurred in relation to chronic
283
Barlow et al.
diseases. Although there is no research evidence of
effectiveness for these interventions, the methods
used to develop such peer-led programmes are
firmly embedded in the concept of individuals as
experts living with the condition. Moreover, course
content has been developed from the views of
people with each specific mental health condition
(e.g. manic-depression). Indeed, it is the UK
voluntary organizations that are planning to
tackle self-management interventions for younger
adults (e.g. the STEADY programme developed by
the Manic-Depression Fellowship). Making
greater use of family support and training families
in providing appropriate support are also areas
worthy of further exploration in self-management
for mental health.
Although it is acknowledged that many inter-
ventions utilized cognitive-behavioural principles,
none of the studies reviewed made direct reference
to any theoretical framework for either the inter-
vention or research design. Theory can be useful in
providing guidelines for changing behaviour and in
determining outcome measures. For example, self-
efficacy theory (33) provides a clear blueprint for
increasing perceptions of control through mastery
experience, role modelling, persuasion and reinter-
pretation of physiological and affective states.
These strategies can be incorporated, either singly
or in combination, into self-management
interventions. Self-efficacy is often referred to as
ÔconfidenceÕ by lay people and in the context of
self-management refers to perceived ability to
control, or manage, various aspects of the condi-
tion and has proven to be a useful concept in
relation to evaluation of self-management pro-
grammes for chronic diseases (7, 32).
Finally, there remains a need to thoroughly
examine the optimum length of intervention for
each condition taking an account of symptom
severity and to determine how much professional
involvement is required in order to effect positive
change.
To conclude, this review has found evidence of
effectiveness of self-management style interven-
tions for panic disorders, phobias and OCD.
Effective interventions utilize cognitive-beha-
vioural principles with or without self-exposure.
The importance of providing appropriate and
responsive support and feedback as people work
through the programmes is clear. In addition,
evidence suggests that a staged approach whereby
people are referred initially to a less intensive
intervention is worthy of exploration. Computer-
based programmes may prove useful in this respect
and have the advantage of allowing people to work
through the intervention at their own pace. One
284
caveat is that realistic goal setting in terms of time
for completion of the programme appears to be
important. Studies based on larger, more hetero-
geneous samples are needed, as are cost-effective-
ness analyses of clinically effective interventions.
Other gaps relate to interventions for younger
people and increasing the use of peer-led interven-
tions. In conclusion, there is a growing body of
evidence supporting the use of self-management in
panic disorder, phobias and OCD. Despite the
limitations noted above, further developments of
interventions in this field are worthy of explora-
tion.
Acknowledgements
The review was supported by a grant awarded to Professor
Barlow from Gamian Europe. The authors extend their
grateful thanks to all authors and organizations that supplied
papers and information for the review.
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