attacking anxiety: a naturalistic study of a multimedia self-help program

Attacking Anxiety: A Naturalistic Studyof a Multimedia Self-Help Program

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Arthur E. Finch and Michael J. LambertBrigham Young University

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George (Jeb) BrownHuman Affairs International

The effects of a commercial multimedia self-help program (Attacking Anx-iety) were evaluated by examining the outcome of 176 individuals whoparticipated in the treatment. Results suggested that 62 individuals suf-fering from anxiety achieved clinically significant improvement. An addi-tional 40 achieved reliable change, despite the fact that these individualshad suffered from anxiety-based problems for years prior to their partici-pation. Only one participant experienced negative change. These resultsare discussed in relation to the growing literature on self-help interventionsand the limitations imposed by the naturalistic nature of the investigation.© 2000 John Wiley & Sons, Inc. J Clin Psychol 56: 11–21, 2000.

Anxiety is a common component of numerous psychological disorders and is frequentlymanifest as the predominant difficulty in a client’s life. Those who suffer specificallyfrom anxiety-based disorders such as generalized anxiety disorder, agoraphobia, and panicdisorder, represent a unique set of clients who are frequently very treatable yet may,ironically, remain unlikely to seek professional psychological assistance due directly tothe presenting symptoms themselves; i.e., afflicted individuals may have unusual diffi-culty leaving the house, driving the car, or otherwise establishing contact with a therapist.In addition, individuals suffering from panic disorders may form intensive therapeuticattachments and experience elevated concerns about being alone, losing the relationship,or abandonment, all signs of overdependence on the therapist, which may result in relapse

Correspondence concerning this article should be addressed to Michael J. Lamberg, Ph.D., Dept. of Psychology& Clinical Psychology, Brigham Young University, 248 Taylor Building, PO Box 28626, Provo, UT 28626.

JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 56(1), 11–21 (2000)© 2000 John Wiley & Sons, Inc. CCC 0021-9762/00/010011-11

following the conclusion of treatment (Holden, O’Brien, Barlow, Stetson, & Infantino,1983).

As multimedia technology continues to become increasingly available to generalconsumers, self-help techniques in psychology are becoming more sophisticated and encom-passing. It is more than likely that any given household will own a television, videocassette recorder, audio cassette player, and compact disc player, not to mention the largeproportion of homes with at least one personal computer, opening the door to interactivemultimedia and virtual reality as treatment delivery tools. Therapists have begun to tapinto these resources as a means of expanding both primary as well as supplementaltreatment delivery by using audio tapes, compact discs, video tapes, and computer pro-grams along with the more traditional manuals and books typically associated withbibliotherapy.

During the 1970s there was an explosion in the growth of self-help treatment pro-grams largely driven by behavioral therapists translating their treatments into writtenself-help manuals and materials. In fact, by 1987 Rosen (1987) was able to identify over150 published self-help programs written from a behavioral perspective alone. Thesebasic behavioral techniques along with cognitive-behavioral, Gestalt, rational-emotive,transactional-analysis, and hypnotic treatment models continue to make up the bulk ofthe self-help treatment programs available to consumers today. These treatments cover awide range of dysfunction including specific phobias, generalized anxiety, social phobia,panic disorder, agoraphobia, depression, sexual anxiety and dysfunction, obsessive-compulsive disorder, smoking cessation, weight loss and control, parental distress, devi-ant child behaviors, test-taking anxiety, dating anxiety, and substance abuse (Gould &Clum, 1993).

Surveys have found that clinicians and interns frequently prescribe self-help pro-grams to their patients. This is most commonly done as a supplement to regular outpatienttherapy sessions. Most patients subjectively indicate that they are well pleased with theresults of these adjunct therapeutic techniques and cite them as playing a significant rolein the containment of pathological symptoms (Starker, 1988). Unfortunately, there is nota great deal of empirical research attempting to better understand how well these thera-pies are working or the actual curative elements of self-administered therapies (Marrs,1995).

A review of past literature indicates that the most outspoken critic of self-help ther-apies, as well as the lack of validating research on the subject, has been Gerald Rosen.Rosen has been continually concerned about the ethical violations of self-help programspromoted by commercial interests, making incredible promises about potential gains with-out supporting clinical research to substantiate these claims (Rosen, 1987). Rosen was soconcerned about this unregulated commercialism that he was even responsible for orga-nizing the “Golden Fleece Awards for Do-it-Yourself Psychotherapies,” a satirical awardpresented at the American Psychological Association (1989) annual meetings.

In spite of positive responses from many practitioners and consumers, concerns canstill be raised about the tendency of persons with psychological disorders to obsessivelydevour self-help systems, fully investing themselves into the dream that this treatmentwill be the one that saves them, frequently leaving them demoralized and hopeless whenexpected gains are not met. In addition there is some concern that each new self-helpsystem contributes to the “pop-culture” of psychology by promoting self-diagnosis, whichmay lead a client in the wrong direction for life improvement, or worse, by preventing theaccurate treatment and diagnosis of other pathologies, which are swept under the rug witheach new wave of “do-it-yourself” therapies. Ogles, Lambert, and Craig (1991), forexample, found that the treatment effect of bibliotherapy for depression was reduced in

12 Journal of Clinical Psychology, January 2000

proportion to the number of self-help books that a person had read prior to the book understudy.

Ultimately researchers, clinicians, and administrators want to know, “Do self-helpresources work?” The answer is a qualified yes. In a 1993 meta-analysis Gould and Clumfound that self-help treatments were capable of establishing an effect size of .76, repre-senting a strong treatment effect nearly identical to therapist-applied treatments (a find-ing based largely on behavioral interventions cited in the bulk of the literature reviewed).In addition to this significant effect size, Gould and Clum also discovered that there wereno significant differences between end-of-treatment and follow-up effect sizes, suggest-ing that patients were capable of maintaining therapeutic gains from self-administeredtreatments. Gould and Clum also reported that self-help techniques are most effective inthe realm of social-skills training and fear reduction where the focus is on discrete phe-nomenon. In addition, evidence from this meta-analysis indicated a benefit for personswith depression, headaches, insomnia, and parent-child conflicts. The least effective treat-ment areas were directed at habit-based difficulties such as smoking, drinking, poor diet,and lack of exercise. One final finding of importance in this particular meta-analysis wasthat when basic bibliotherapy was combined with other self-help formats such as audiotapes, the effect sizes nearly doubled. Gould and Clum indicate that caution be used ininterpreting these immense gains since they are based on a limited number of studies. Themagnitude of this improvement, however, indicates a need for more empirical researchinto the impact that multifaceted self-help treatment delivery mechanisms may provide.

In perhaps the most comprehensive meta-analysis in the this area, Marrs (1995) alsoconcluded that there is a significant positive effect size for those individuals who employedself-help bibliotherapy. He also found that this effect size was not significantly differentfrom therapist-administered treatments nor were there significant differences betweenformats in maintenance of gains as established by follow-up interviews and testing. Marrs’smeta-analysis reached the same ultimate conclusion of Gould and Clum in establishingthat self-help bibliotherapies were more effective for assertion training, anxiety, and sex-ual dysfunction, than they were for the habit-driven domains of weight loss, impulsecontrol, and studying difficulties.

The purpose of the present study was to evaluate the effectiveness of a popularself-help program for the treatment of anxiety disorders currently being marketed by theMidwest Center for Stress and Anxiety, Inc. under the title “Attacking Anxiety.” Adver-tisements are presented on television at the rate of five to six times per month with anestimated viewing audience of hundreds of thousands per year. This is a widely viewedand widely used program for which outcome has never been studied. As an initial step inthis evaluation, a naturalistic study of participants who ordered this program wasundertaken.

Method

Subjects

The sample for this study was composed of 176 individuals who purchased the AttackingAnxiety program through word of mouth, infomercials, or other promotional techniques;actively participated in the treatment regimen; and completed and returned at least twoadministrations of the Outcome Questionnaire-45 (OQ-45) at two- and four-, or two- andsix-week intervals. Subjects were also asked to complete a descriptive survey composedof questions regarding basic demographics, previous treatment history, and the impactanxiety has had on their lives.

Attacking Anxiety 13

This subject pool had a mean age of 43.70 years (SD5 12.25) ranging from 16 to 83years of age. Twenty-eight percent of the sample was male and 72% was female. Educa-tional experiences for these subjects included 5% who had not graduated from high school,26% high school graduates, 30% with some college, 28% with an undergraduate degree,and 10% with graduate degrees.

The typical length of time participants reported suffering from anxiety prior to usingthe program was five to ten years, with 35% of this sample reporting suffering for overtwenty years. Forty percent of the participants in this study estimated that they had vis-ited an emergency room for anxiety-related problems at least once in the last two years;45% of subjects reported visiting a doctor at least 10 times in the last two years; and 50%of subjects reported missing, on average, 10 days of work over the last two years. All ofthese medical visits were attributed directly to their anxiety problems. Subjects wereasked questions directly regarding their condition such as, “How long have you sufferedfrom anxiety problems?” and, “ In the past year, how many days of work have you misseddue to your condition?” A more detailed description of utilized services past and presentis found in Table 1.

Measures

The OQ-45 is a self-report instrument designed for repeated measurement of client progressthrough the course of therapy, termination, and follow-up. It was developed to assessthree domains of a client’s current psychological functioning: (1) Symptom Distress,which emphasizes symptoms from the most frequently diagnosed mental disorders and isheavily loaded with items that measure depression and anxiety, including items for thedetection of substance abuse; (2) Interpersonal Relations, which includes items that assessproblems with friendships, family life, and marriage, particularly elements of isolation,feelings of inadequacy, withdrawal, or conflict; (3) Social Role Performance, which gaugesthe patient’s level of dissatisfaction, conflict, or distress in his/her employment, familyroles, and leisure life. In addition to these three specific domains, the OQ-45 attempts tomeasure positive feelings and life satisfaction. The OQ-45 has excellent psychometricproperties. Internal consistency and test-retest reliability estimates range from .70 to .93and .78 to .84 respectively as derived from a normative samples (N 5 3001) collected

Table 1Utilization of Treatment Services Past andPresent for Anxiety Sufferers

Service utilizing % Utilizing % Nonutilizing

Doctor in past 78 22Doctor in present 41 59Psychiatrist in past 60 40Psychiatrist in present 27 73Therapist in past 67 33Therapist in present 32 67Chiropractor in past 80 20Chiropractor in present 11 89Other treatments in past 72 28Other treatments in present 12 88


from sites in seven different states. Criterion-validity studies reveal high correlationswith extant measures of anxiety, depression, interpersonal functioning, and social adjust-ment. Construct-validity studies measuring sensitivity to change in patients undergoingoutpatient psychotherapy in samples from a university training clinic, employee-assistance programs, and managed-care settings all produced highly significant pretest/posttest differences on all scales of the OQ-45 (Lambert, Hansen, Umphress, Lunnen,Okiishi, Burlingame, Huefner, & Reisinger, 1996; Burlingame, Lambert, Reisinger, Neff,& Mosier, 1995; Lambert, Burlingame, Umphress, Hansen, Vermeersch, Clouse, & Yan-char1996; Umphress, Lambert, Smart, Barlow, & Clouse, 1997; Wells, Burlingame, Lam-bert, Hoag, & Hope, 1996).

Treatment

Attacking Anxiety is a self-help treatment program for anxiety based on a course of audiocassettes, video tapes, and optional bibliotherapeutic interventions. The basic program aspurchased by a typical consumer consists of sixteen tapes focusing on cognitive restruc-turing and exposure, one tape designed to train individuals in deep muscle relaxation, onevideo containing two taped training sessions from conferences, and written informationregarding various bibliotherapy resources also available through the Midwestern Center.

The treatment model is based around the understanding that anxiety is a motivationaldrive state which patients can be trained to identify, attend to, and subsequently intervenewith. Through relaxation training, cognitive restructuring, mental imagery, and positiveaffirmation, clients are trained to identify intrinsically motivated anxiety cues brought onby mentally imaged exposure to anxiety producing stimuli, and then using the relaxation,cognition, and affirming skills to eliminate the anxiety.

Procedure

When each subject received their Attacking Anxiety program in the mail, enclosed was apacket with a basic demographic survey, a questionnaire regarding their experience withanxiety and previous treatment attempts, and several copies of the OQ-45 with instruc-tions to complete one and mail it in every two weeks. There were no initial OQ-45 scoresestablished prior to initiating treatment. A total of 176 (out of approximately 500 towhom packets were sent) subjects completed and returned at least two administrations ofthe OQ-45. These 176 subjects were then separated into two groups; those who hadreturned OQ-45s at two- and four-week intervals, and those who returned OQ-45s at two-and six-week intervals. Of these 176 subjects 144 were common to both groups leavingnine subjects unique to the two- and four-week group and 23 subjects unique to the two-and six-week group.

Results

Initial and post-test scores for the group that returned completed OQ-45s at two- andfour-week intervals were analyzed using a pairedt test. Results indicate that the initialand post-test score means (n5 153) were significantly different (1-tailedp , .0001); seeTable 2. Effect sizes were calculated for the difference between the initial and post-testscores expressed in initial-test standard deviation units by using the formula recom-mended by Smith, Glass, and Miller (1980):

d-stat5upre 2 upost

Spre


This yielded a treatment effect size of .75 standard-deviation-units improvement betweenthe second and fourth weeks of implementing the Attacking Anxiety system.

Initial and post-test scores for the group that returned completed OQ-45s at two- andsix-week intervals were also analyzed using a pairedt test. Results indicated that theinitial and post-test score means (n 5 167) were significantly different (1-tailedp ,.0001). Effect sizes were again calculated for the difference between the two- and six-week initial and post-test scores expressed in initial-test standard deviation units as 1.08initial-test standard deviation units.

In addition to group change from initial testing to post-testing, each participant wasclassified into one of four categories—“recovered,” “improved,” “unchanged,” or“deteriorated,”—following Jacobson and Truax’s (1991) criteria for clinically significantimprovement as applied specifically to the OQ-45 by Kadera, Lambert, and Andrews(1996). These methods include (1) movement of a patient’s total OQ-45 score from thedysfunctional range into the functional range (as determined by an OQ-45 total scorecutoff of 63), and (2) a minimum magnitude of change specified by a reliable changeindex (RCI) to ensure that such a change is statistically reliable (RCI for the OQ-45 is adifference of 15 points between pre- and post-test total scores). For a complete discussionof this specific application of the RCI as it applies to the OQ-45 please see Lambert,Hansen, Umphress, Lunnen, Okiishi, Burlingame, Huefner, & Reisinger (1996).

With regard to the current study, individuals were considered “recovered” if theybegan treatment with a total score on the OQ-45 of 63 or more and moved below thiscutoff point over the course of treatment with an initial-to-post-test difference magnitudeof at least 15 points. Subjects were classified “improved” if they began treatment with atotal OQ-45 score less than 63 and produced an initial-to-post-test difference magnitudeof 15 points or greater, or if they began treatment with a total OQ-45 score greater than 63and produced an initial-to-post-test difference magnitude of at least 15 points, but did notmove below the cutoff point of 63. Participants were considered “unchanged” if theybegan treatment with a total OQ-45 score greater than or less than 63 but did not producean initial-to-post-test difference magnitude of at least 15 points. Finally, subjects wereconsidered “deteriorated” if their OQ-45 total score increased by more than 15 pointsbetween their initial and post-test.

Of the 167 patients who returned complete information, 159 began treatment in thedysfunctional range (OQ-45 total score of 63 or greater). When the aforementioned cri-teria for statistically significant change were applied to the data for this study, it wasestablished that 24% of participants could be classified as “recovered,” and 37% of sub-jects could be categorized as “improved.” Thirty-nine percent of persons in the currentstudy did not demonstrate reliable change one way or the other. In general, these partici-

Table 2Descriptive Statistics for Outcome Questionnaire-45 Repeated Measures

OutcomeQuestionnaire Total Mean

StandardDeviation

Standard Errorof Mean t d

2 Sessions 89.16 16.58 1.284 Sessions 77.68 14.61 1.18 *13.00 *0.756 Sessions 71.28 14.80 1.15 **16.36 **1.08

* t andd scores for comparison between 2 and 4 sessions** t andd scores for comparison between 2 and 6 sessions


pants appeared to begin treatment with more extensive histories of disturbance and moreimpaired functioning than persons who achieved a better outcome (see Tables 3 and 4).Only one participant in this study fulfilled criteria to be considered “deteriorated,” but nodemographic information was available for this subject, making it difficult to interpretthe meaning of the submitted scores.

In order to explore the characteristics of those participants who improved and thosewho did not, subjects were listed by category of improvement for basic demographicvariables, length of time suffered, and service utilization (past and current experienceswith various treatments (e.g., medications, therapy, hospitalizations, and so forth). Aninitial analysis of the data indicated that the distributions of these groups were skewed tosuch a degree that a nonparametric analysis would provide the most reliable statisticalresults. A Kruskal-Wallace nonparametric one-way ANOVA was run across the threecategories and established that the three classifications “recovered,” “improved,” and“unchanged” were significantly different statistically depending upon how much educa-tion a subject had received. In order to better understand these differences, a series of

Table 3Demographics, Service Utilization, and Lost Productivity by Percentfor Outcome Classification Categories

Category

Unchanged39%

(N 5 64)

Improved37%

(N 5 62)

Recovered24%

(N 5 40)

Age 46 (11.78) 42 (13.02) 43 (11.80)Sex:

Males 31% 31% 18%Females 69% 68% 82%

Education (more than high school) 81% 61% 58%Time suffered (5 years or more) 45% 60% 50%Emergency room visits (31/2 years) 9% 10% 15%Physician visits (61/2 years) 39% 42% 48%Missed days work (111/2 years) 17% 16% 10%

Table 4Utilization of Services Past and Present by Category of Improvement

ServiceUnchanged

(%)Improved

(%)Recovered

(%)

Doctor in past 70 66 80Doctor in present 34 29 50Psychiatrist in past 64 57 45Psychiatrist in present 31 26 16Therapist in past 67 58 63Therapist in present 31 27 30Chiropractor in past 17 16 20Chiropractor in present 13 10 8Other treatments in past 20 34 25Other treatments in present 14 11 10


Wilcoxon Rank SumW tests were run across each variable for pairings of “unchanged”and “improved,” “improved” and “recovered,” and “unchanged” and “recovered.” Thesecomparisons indicate that the “unchanged” and “improved” groups differed significantlyfor both age and education, indicating that the older a subject was, or the more educationhe or she had achieved, the less likely this treatment was to work. It was also discoveredthat there were no significantly different variables for the pairing of the “improved” and“recovered” groups, and that there was a significant difference between the “unchanged”and “recovered” groups on education, again indicating that the more education a patientin this sample had obtained, the less likely this treatment was to work.

Discussion

Limitations

The primary limitation of this study is the fact that it is a naturalistic study, which imme-diately precludes random selection and assignment, the use of control group compari-sons, assessment of treatment compliance, causal inferences, and other features of morerigorous experimental designs. These limitations also make it impossible to identify thisself-help program as the single causal factor responsible for the measured change, sinceparticipants may have continued to use prescribed medications or concurrently partici-pated in other forms of therapeutic treatment.

This sample is self-selected on two levels. First participants are composed of a groupof individuals who chose to purchase this self-help program. Second, the final analysiswas performed on only one third of the original population due to attrition for unknownreasons. No efforts have been made at this point to establish why some individuals choseto comply and others did not, or to understand what characteristics make this participantsample unique or similar to other groups.

A final limitation was the use of only one self-report instrument. The OQ-45 isintended to make multiple assessments of the level of subjective psychological distress ina given individual’s life in an effort to track treatment-related progress. The OQ-45 is notmeant to act as a diagnostic tool and is therefore not capable of identifying whether or notany of the subjects would fulfill the requirements for a diagnosis of anxiety.

These limitations also serve to illustrate why a naturalistic study of this program wasundertaken as an initial step rather than a series of clinical trials. This study was initiatedwith the hope that it would provide some understanding of the experience that a typicalcompliant respondent to a self-help program such as this might have. As such it wasdeemed important to minimize the level of interference and involvement from investiga-tors, hence the use of one short self-report measure. For the purposes of this study areliable diagnosis is not of primary importance. It is far more important that people arepurchasing these aids because they believe that they are experiencing symptoms relatedto anxiety. Not only did participants in this case believe that they were anxious, most alsoreported that over a six-week period during which they used the Attacking Anxiety pro-gram they experienced a subjective reduction in the psychological distress in their lives.

This study is only intended to provide an unobtrusive glimpse at the individuals whochoose to purchase a self-help anxiety treatment plan and the progress that these partici-pants believe they are making in relieving psychological distress in their lives. This studyis not intended to identify this self-help program as the causal factor in the reduction ofpsychological distress, nor is it intended to be generalized to other client populations. Itis hoped that the results of this study will begin to provide the insight needed to developa series of clinical trials which can experimentally examine the efficacy of this and otherself-help programs in relieving symptoms of anxiety.


Summary

This study was able to identify effect sizes between two and six sessions of 1.08 standarddeviation units, suggesting that this treatment helped move people toward more effectivefunctioning. In fact, 61% of these subjects were classified within the “improved” or“recovered” range, suggesting that a sizable number of persons who have suffered diffi-culties with anxiety, in some cases for years, showed substantial improvement while onlyone individual reported deteriorating. However, the group mean for the post-test OQ-45total score (77.68) was still well within the dysfunctional range, with nearly 40% ofpersons not showing a substantial benefit.

Group comparisons indicate that this program is most effective for younger individ-uals with less education (no more than one to two years of college). Individuals who wereless successful with this program were more educated and older than more successfulparticipants, suggesting that higher levels of academic achievement and length of timesuffering from anxiety (as a correlate of age) may make an individual an unlikely ben-eficiary in this self-help treatment program. This is an unexpected finding as psychother-apy outcome research often suggests better outcome for more educated participants(Garfield, 1994).

It is recognized that this was a progressively self-selected population with perhapsunique characteristics. It is difficult to generalize the results to all people who may orderthe program. However, studies such as this are also extremely important in that theyprovide an intimate actuarial glimpse at the type of individual who experiences successwith a program such as this and may eventually suggest possible contra-indications forthose individuals who do not. This information may then be used to calibrate treatmentmethods to better serve the target populations with an enlightened understanding of thetherapeutic intricacies surrounding these individuals who may otherwise continue to livewithin the confines of varied anxiety states.

The most common difficulty cited with regard to self-help efficacy is the differinglevels of individual motivation found among consumers of these programs. The researchstrongly affirms that those who gain the strongest benefits are motivated individuals whoare following through with practice, assigned tasks, and consistent use of programmedmaterials. Those who fail to see gains from self-administered therapy are typically lowerin motivation and do not follow through with regular application of suggested techniques,a problem that consistent therapy sessions may be more likely to control (Gould & Clum,1993). Consistent with this observation, anecdotal reports of program users suggestedthat the frequent use of the treatment package is the best predictor of who will profit (D.Bassett, personal communication, 1998). Consumers of Attacking Anxiety would be welladvised to listen to the material repeatedly. A single exposure is not likely to result indramatic benefits.

The analysis of change provided by the self-report instrument (OQ-45) employed inthe current study suggests that a sizable number of individuals who availed themselves ofa self-help program and provided feedback about their progress showed positive treatmenteffects. As a group they manifested change that is similar to that found in other self-helpprograms (Gould & Clum, 1993), and professional treatment (Lambert & Bergin, 1994).

While no control group was employed in this naturalistic study, the majority of indi-viduals in this study had experienced anxiety for long periods of time (5–10 years) priorto initiating treatment with Attacking Anxiety and yet found relief. They also reportedimportant reductions in medical utilization and increases in work attendance.

Many additional questions remain to be answered as to which forms of self-helpresources are most effective for a given disorder, and which therapeutic modality maxi-


mizes these specific benefits. Throughout the current literature these questions are beingasked. Unfortunately the unsystematic approach to this research is in many cases leadingto contradictory results and unnecessary replication, due to the massive variation in researchtechniques, populations, and operational constructs. Marrs (1995), following Rosen’s(1987) suggestion, concludes, “Perhaps the American Psychological Association shoulddevelop a set of guidelines for development of self-help materials analogous to those forpsychological test materials. This might not only help assure the quality of such materialsbut could spur on the research that is badly needed in this area.”

Additional research on this specific program as well as other similar systems needsto make use of well-designed experiments. Such research needs to use the principles ofrandom subject and control selection in order to allow for causal inference and refining ofthis treatment modality. Research should also include the use of multiple measures tobetter establish diagnosis and provide a richer understanding of the specific psychologi-cal stressors that are motivating individuals to pursue self-help anxiety treatments. Fur-ther research should also combine self-help therapies, such as Attacking Anxiety, withregular treatment by a therapist in order to better establish the most effective means ofhelping individuals suffering from anxiety disorders.

The fact that a program such as this is associated with treatment effects as high as1.08 standard deviation units suggests that self-help materials can help individuals whosuffer from anxiety disorders. This indicates that research needs to focus not only on theefficacy of treatments but also on the characteristics of those for whom these techniquesdid not work. Such assessments could begin with following up on those who begin self-help programs but do not finish them, and establishing the reasons that they were unsuc-cessful. Eventually this information can lead to refined treatment modes capable ofaddressing the needs of this very distressed but highly treatable population.

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attacking anxiety: a naturalistic study of a multimedia self-help program

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