The measurement and management of stress related difficulties in primary care

A major assumption that lies behind public policy towards mental health provision is that individuals with psychological problems will seek help. Moreover, the assumption that follows from this is that their needs will be assessed and appropriate resources will be made available. Often this does not occur. The reasons that people who seek help fail to find appropriate treatment relate to the culture of service provision, the identification of distress, and the accessibility of therapy.

This thesis aims to investigate an approach which targets the above issues by focusing on the utility of assisted self-help for mild anxiety and depression in a primary care setting. The approach differs from both current clinical practice and traditional self-help in two distinct ways:

1. The provision of information and coping skills is blended into the assessment process. An assessment tool, the Buffers, Pressures and Symptom Profile (BPSP), was designed and validated specifically for this approach (Chapters 2 and 3).

2. The bibliotherapy process was designed specifically for people with mild anxiety and depression.

There was good evidence of the utility of Assisted Bibliotherapy at a number of levels. The efficacy of the approach was enhanced through the support of the project worker. In an anxiety study, reported in Chapter 8, symptom reduction was strongly related to active participation in the programme. In a low mood study, reported in Chapter 9, this association was less clear. This discrepancy was addressed both in terms of the adequacy of the rating materials and the natural course of low mood. As well as significantly reducing levels of distress, changes were also evident in areas that were not directly targeted by the approach. There were significant concomitant changes in the perception of stress related issues that were not the primary focus of the Assisted Bibliotherapy materials.

The data from cases that were unable to benefit from the approach were examined together with 'improvers', in order to consider whether pre-treatment variables could predict a clients potential to benefit from varying levels of assisted self-help. This would allow for more objective guidance toward the appropriate 'dose' and level of therapy.

The Assisted Bibliotherapy approach promoted cognitive and behavioural mastery of symptoms through a repertoire of adaptive responses in a good proportion of cases.