درمان هراس اجتماعی مبتنی بر اینترنت: کارآزمایی تصادفی کنترل شده در مقایسه با کارآزمایی غیرهدایت شونده با دو نوع از خودیاری هدایت شده
|کد مقاله||سال انتشار||مقاله انگلیسی||ترجمه فارسی||تعداد کلمات|
|33909||2011||12 صفحه PDF||سفارش دهید||11525 کلمه|
Publisher : Elsevier - Science Direct (الزویر - ساینس دایرکت)
Journal : Behaviour Research and Therapy, Volume 49, Issue 3, March 2011, Pages 158–169
Internet-based self-help for social phobia with minimal therapist support via email have shown efficacy in several controlled trials by independent research teams. The role and necessity of therapist guidance is, however, still largely unclear. The present study compared the benefits of a 10-week web-based unguided self-help treatment for social phobia with the same intervention complemented with minimal, although weekly, therapist support via email. Further, a third treatment arm was included, in which the level of support was flexibly stepped up, from no support to email or telephone contact, on demand of the participants. Eighty-one individuals meeting diagnostic criteria for social phobia were randomly assigned to one of the three conditions. Primary outcome measures were self-report measures of symptoms of social phobia. Secondary outcome measures included symptoms of depression, interpersonal problems, and general symptomatology. Measures were taken at baseline, post-treatment, and at 6-month follow-up. Data from a telephone-administered diagnostic interview conducted at post-treatment were also included. Results showed significant symptom reductions in all three treatment groups with large effect sizes for primary social phobia measures (Cohen’s d = 1.47) and for secondary outcome measures (d = 1.16). No substantial and significant between-groups effects were found on any of the measures (Cohen’s d = 00–.36). Moreover, no difference between the three conditions was found regarding diagnosis-free status, clinically significant change, dropout rates, or adherence measures such as lessons or exercises completed. These findings indicate that Internet-delivered treatment for social phobia is a promising treatment option, whether no support is provided or with two different types of therapist guidance.
Internet-based therapeutic interventions have developed rapidly over the last decade. A growing body of evidence suggests that this new treatment form can lead to significant and enduring improvements in a variety of mental disorders (Barak et al., 2008 and Spek et al., 2007). Particularly for the treatment of anxiety disorders, independent replications have consistently shown promising results for social phobia (Andersson et al., 2006, Berger et al., 2009a, Botella et al., 2010, Carlbring et al., 2006a, Carlbring et al., 2006b, Carlbring et al., 2007, Titov et al., 2008c and Titov et al., 2008b), panic disorder (Carlbring et al., 2006a, Carlbring et al., 2003, Carlbring et al., 2006b, Klein and Richards, 2001 and Klein et al., 2006), post-traumatic stress disorder (Hirai and Clum, 2005, Knaevelsrud and Maercker, 2007, Lange et al., 2001 and Lange et al., 2003), and generalized anxiety disorder (Robinson et al., 2010). In the majority of these studies, a guided self-help approach has been used, in which the presentation of a web-based self-help program is combined with minimal but regular therapist contact. For anxiety disorders, this treatment format has proven to be efficacious regardless of whether it is delivered via the Internet (i.e., with a web-based self-help program and additional therapist support via email) or with more traditional means of communication (i.e., with a self-help book and additional phone calls from a therapist) which was recently confirmed in a meta-analysis (Cuijpers, Donker, van Straten, & Andersson, 2010). The Internet, however, is a medium of communication and information that seems ideally suited to easily deliver and disseminate guided self-help. Together with other advantages such as the possibility to reach people who would otherwise not find help (e.g., because of a shortage of skilled therapists, long waiting lists, or the fact the people live in more rural areas), this may partly explain the fast expansion of Internet-delivered treatments. Because Internet treatments are also associated with reduced costs and a lower level of fear of seeking help, they may be especially advantageous for disorders such as social phobia, which are characterized by a combination of high prevalence and low treatment seeking rates (Kessler, 2003 and Newman et al., 2003). Social phobia (also known as social anxiety disorder) is a highly disabling disorder (Kessler, 2003 and Mendlowicz and Stein, 2000). However, it can be treated effectively with psychotherapeutic interventions such as cognitive behavior therapy (CBT; Heimberg, 2001). In addition, as indicated above and now evidenced by several studies, with Internet-delivered guided self-help programs based on CBT. In the latter case, large between-group effect sizes against no treatment controls have been reported on social anxiety measures (Andersson et al., 2006, Berger et al., 2009a, Berger et al., 2009b, Carlbring et al., 2006a, Carlbring et al., 2006b, Carlbring et al., 2007, Furmark et al., 2009, Titov et al., 2008a, Titov et al., 2008b and Titov et al., 2008c). Long-term effects up to 30 months post-treatment have also been established (Berger et al., 2010 and Carlbring et al., 2009). Regarding Internet-based treatments for social phobia, however, there are challenges, such as the fact that there is just one small effectiveness study in which an Internet-based treatment for social phobia was tested in a more regular clinical setting (Aydos, Titov, & Andrews, 2009). The present study deals with another challenge which concerns the role of the therapist and the question about whether guidance is needed. Since therapist support in guided self-help approaches is associated with costs and also a somewhat limited availability of the treatment (even if costs are reduced and the availability increased compared with face-to-face therapy), the importance and necessity of the support given by a therapist deserves particular attention. Results from a meta-analysis by Spek et al. (2007) suggested that self-help programs including support are more effective than programs without support. This was also found in a meta-analysis on Internet-based depression treatments (Andersson & Cuijpers, 2009). Moreover, in interventions without support, the dropout rates are considerably higher than in interventions with support (Spek et al., 2007). However, the differences between the guided and unguided treatments may also be related to other factors. Variables such as more or less intense screening procedures before participants gain access to treatment, or the length and comprehensiveness of a self-help program are systematically confounded with whether support is added or not (Nordin, Carlbring, Cuijpers, & Andersson, 2010). In addition, the need for a therapist could be more pronounced in some disorders (e.g., depression) than in others (e.g. anxiety disorders, Andersson, 2009). Recent direct experimental comparisons between guided and unguided treatments for social phobia have provided mixed results. Whereas in a study by Rapee, Abbott, Baillie, and Gaston (2007), pure self-help delivered in the form of printed material (bibliotherapy) was significantly inferior to the same intervention augmented with five group sessions with a therapist, Botella et al. (2010) reported equivalently good outcomes for an entirely self-administered Internet-based self-help treatment and the same intervention provided by a therapist. In a series of studies on an Internet-based program for social phobia, Titov, Andrews, Choi, Schwencke, and Mahoney (2008a) first found significant differences between a guided and an unguided condition with only small within-group effect sizes for the unguided program (Cohen’s d = .33). After enhancing the web-based self-help program and after adding a clinician-moderated online discussion forum, the same group reported large within-group effect sizes for the self-guided program on social anxiety measures (Cohen’s d = 1.56; Titov et al., 2009 and Titov et al., 2009). Although a clinician was actively involved in this study by reading and responding to messages on the forum, the time spent by the clinician was substantially reduced in comparison to a guided self-help approach. It remains to be seen whether the moderation of the forum by a clinician is necessary. Furmark et al. (2009) found comparable effects for an Internet-based guided self-help program and the same self-help program delivered in the form of bibliotherapy with no therapist support but with access to an online discussion forum. Thus, sharing experiences and giving and receiving feedback and support from other participants in discussion forums may compensate the lack of therapist support to some degree ( Berger & Caspar, 2008). The present study extends our work on an Internet-based treatment program for social phobia which has shown to be efficacious compared to a wait-list control group when provided with weekly therapist contacts via email (Berger et al., 2009a and Berger et al., 2010). The aim of this study was to compare the respective efficacy of three treatment conditions: 1) Unguided pure Internet-based self-help with no contact with a therapist or the study team during treatment; 2) Guided Internet-based self-help which included access to the same self-help program but with weekly scheduled email feedback by a therapist and the possibility to ask questions via email; 3) Internet-based self-help (same as condition 1) with the possibility to step up to (a) Email-guided Internet-based self-help (same as condition 2) or (b) Telephone-guided Internet-based self-help. In this third condition, participants were able to ask for additional weekly email or telephone contact with a therapist at several points in the self-help program and/or by clicking on a link in an email participants would automatically receive if they did not use the self-help guide for more than seven days. We included this third condition because it can be assumed that not every participant needs additional therapist support, and if support is needed, not every participant needs the same level of support. Ideally, pre-treatment characteristics could be used to match patients with the optimal level of support, but since empirical decision rules are lacking, we decided to test a model in which patients could step-up the level of support on their own initiative. In contrast to the two other treatment conditions, this stepped care model also represents an attempt to maximize the efficiency of resource allocation (Haaga, 2000). A combination of a lower cost pure self-help intervention with a more costly guided self-help intervention provided for those insufficiently helped by the self-guided version could result in the most cost-effective treatment option.