Comparing Self-Help In Social Anxiety With Cognitive Behavior Therapy

Individual Project. 3-4 pages in length, typed, double-spaced. Please make sure your full name, the class number, and “Research Proposal 1” appear at the top of the page (nothing else). This proposal should be 3-4 pages in length (not including references). It should be in APA style. In general, this proposal should have two components: (1) A literature review of relevant research in an area that is of interest to you, summarized and leading to…(2) a research question you wish to ask and why you wish to ask it (based on the gaps in the literature you have reviewed). This will require you to do a brief literature review of a research area that is of interest to you that includes a comprehensive search of the literature on a topic of interest, using PubMed, PsycInfo, or Web of Science, acquiring and summarizing the literature using references where appropriate, explaining what is known in the area, describing your research question, and explaining why your research question addresses an issue that is unknown or unclear currently in the literature. (3) State in broad terms how you plan to ask and answer the question in research terms using all the knowledge you have learned in the course to date. Do NOT include an abstract. The plan is to discuss these in class if we have the time.

my topic: comparing self-help in social anxiety with cognitive behavior therapy

Andersson, G., Carlbring, P., Holmström, A., Sparthan, E., Furmark, T., Nilsson-Ihrfelt, E., … Ekselius, L. (2006). Internet-based self-help with therapist feedback and in vivo group exposure for social phobia: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 74(4), 677–686.
Internet-Based Self-Help With Therapist Feedback and In Vivo Group Exposure for Social Phobia: A Randomized Controlled Trial

Gerhard Andersson and Per Carlbring Linköping University

Annelie Holmström Karolinska Institute

Elisabeth Sparthan, Tomas Furmark, Elisabeth Nilsson-Ihrfelt, and Monica Buhrman

Uppsala University

Lisa Ekselius Uppsala University Hospital

Sixty-four individuals with social phobia (social anxiety disorder) were assigned to a multimodal cognitive–behavioral treatment package or to a waiting list control group. Treatment consisted of a 9-week, Internet-delivered, self-help program that was combined with 2 group exposure sessions in real life and minimal therapist contact via e-mail. Results were analyzed on an intention-to-treat basis, including all randomized participants. From pre- to posttest, treated participants in contrast to controls showed significant improvement on most measured dimensions (social anxiety scales, general anxiety and depression levels, quality of life). The overall within- and between-groups effect sizes were Cohen’s d � 0.87 and 0.70, respectively. Treatment gains were maintained at 1-year follow-up. The results from this study support the continued use and development of Internet-distributed, self-help programs for people diagnosed with social phobia.

Keywords: Internet treatment, social anxiety disorder, minimal therapist contact, clinical significance

Social phobia (also known as social anxiety disorder) is asso- ciated with substantial impairment in quality of life (Safren, Heim- berg, Brown, & Holle, 1997) and is highly prevalent (Furmark, 2002). As evidenced by several trials, there are effective psycho- social treatments for social phobia (Heimberg, 2001). However, far from all sufferers seek treatment (Baldwin & Buis, 2004). Barriers to accessing expert assistance include shortage of skilled thera- pists, long waiting lists, and costs. These barriers particularly disadvantage geographically isolated people, such as those in regional and rural areas where traveling time is an added burden. Another problem is that those with generalized social phobia may not seek therapy because of the fear or embarrassment associated

with help seeking (Newman, Erickson, Przeworski, & Dzus, 2003). Therefore, a major challenge is to increase the accessibility and affordability of evidence-based psychological treatments for social phobia.

Printed self-help manuals have been developed to assist people with mental health problems who are unwilling or unable to access professional assistance, although there has been little evaluation of their efficacy (Rosen, Glasgow, & Moore, 2003). A modern alter- native to printed self-help manuals is computers (Proudfoot, 2004). Computerized programs have been used for a number of years for assessment, diagnosis, and education (Gruber, Moran, Roth, & Taylor, 2001) but most controversial has been their use for psy- chological treatment (Proudfoot, 2004). Until recently, computer- mediated therapies have often been offered without any patient– therapist interaction (Marks, Shaw, & Parkin, 1998). There now seems to have been a shift toward individuals using the World Wide Web to administer self-help treatment instructions (Ritter- band et al., 2003) in conjunction with some sort of text-based human interaction (e.g., e-mail).

In an attempt to provide cost-effective treatments for common disorders, independent research groups have developed Internet- based cognitive–behavioral interventions for various conditions (Ritterband et al., 2003), including the anxiety disorders (Anders- son, Bergström, Carlbring, & Lindefors, 2005). A number of randomized controlled trials have been conducted, all suggesting that Internet-based treatment with minimal therapist contact via e-mail can be effective in treating various conditions (Carlbring & Andersson, 2006).

To our knowledge, the effect of Internet-based treatment for social phobia, in the present context defined as self-help assisted by e-mail support from a clinician, has not been evaluated in a

Gerhard Andersson and Per Carlbring, Department of Behavioural Sci- ences, Linköping University, Linköping, Sweden; Annelie Holmström, Department of Clinical Neuroscience, Section of Psychiatry, Karolinska Institute, Stockholm, Sweden; Elisabeth Sparthan, Tomas Furmark, Elisa- beth Nilsson-Ihrfelt, and Monica Buhrman, Department of Psychology, Uppsala University, Uppsala, Sweden; Lisa Ekselius, Departments of Neu- roscience and Psychiatry, Uppsala University Hospital, Uppsala, Sweden.

The study was funded in part by a grant from the Söderström Königska Foundation and the Swedish Research Council. We thank Fredrik Folke and Tomas Parling for conducting 19 Structured Clinical Interviews for DSM–IV (SCIDs) and Marie Söderberg for treating 5 Internet patients. We also thank members of the KLARA research group for their assistance in coding SCID protocols. Finally, we thank Ata Ghaderi and Johan Waara for being cotherapists during some of the group exposure sessions, and Johan Westöö for administrative help.

Correspondence concerning this article should be addressed to Gerhard Andersson, Department of Behavioural Sciences, Linköping University, SE-581 83 Linköping, Sweden. E-mail:

Journal of Consulting and Clinical Psychology Copyright 2006 by the American Psychological Association 2006, Vol. 74, No. 4, 677–686 0022-006X/06/$12.00 DOI: 10.1037/0022-006X.74.4.677


randomized controlled trial. There have been computer-based treatments for social phobia, such as virtual reality exposure (e.g., Harris, Kemmerling, & North, 2002); however, more comprehen- sive self-help materials have not been tested. Social phobia could hypothetically be suitable for Internet-based treatment, as the sense of anonymity is high on the Internet (Erwina, Turk, Heimberg, Frescoa, & Hantula, 2004). There has also recently been a move toward individual treatment of social phobia instead of group treatment, which has been the standard cognitive–behavioral treat- ment format (Clark et al., 2003; Stangier, Heidenreich, Peitz, Lauterbach, & Clark, 2003). However, as the empirical support for pure bibliotherapy for social phobia was lacking, we suspected that the Internet-based treatment may require in vivo exposure sessions to have maximum effect. Therefore, we devised a 9-week treat- ment of social phobia on the Internet, which was combined with two real-life group exposure sessions. The current state of knowl- edge suggested that the first step would be to compare the effects of this novel treatment approach with a waiting list control group, as the equivalence between Internet-based treatment, group-based cognitive–behavioral therapy (CBT), individual CBT, or pure self-help booklets based on CBT could not be assumed.


Recruitment and Selection

Participants were recruited by means of newspaper articles in national and regional papers, notices in health magazines, and an Internet link from the home page of the Swedish National Anxiety Association. This was done in the spring of the year 2003. The study protocol was approved by the ethics committee at Uppsala University (Uppsala, Sweden).

A Web page was created for the study, which included general infor- mation about CBT and its effects in treating social phobia, an outline of the study, and an application form. We achieved the first selection of partic- ipants by using a computerized screening interview that consisted of the Social Phobia Screening Questionnaire (SPSQ; Furmark et al., 1999), the self-rated version of the Montgomery Åsberg Depression Rating Scale (MADRS-S; Svanborg & Åsberg, 1994), and 10 additional questions regarding current and past treatment. Participants who fulfilled the inclu- sion criteria according to the initial computerized screening were called to a personal interview at the psychology department in which the Structured Clinical Interview for DSM–IV (SCID; First, Spitzer, Gibbon, & Williams, 1995) was used to confirm the social phobia diagnosis. Before coming to the interview, they were required to download, print out, sign, and post an informed consent form that should have…

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