روانشناسی از راه دور و خودیاری: درمان هراس از سخنرانی عمومی

This work presents a self-help, Internet-based telepsychology program for the treatment of public speaking fears. The system is comprised of 3 parts: The assessment protocol gives the patient information about his or her problem (i.e., amount of interference it creates in his or her life, severity, degree of fear and avoidance). The system also includes a structured treatment protocol, organized into separate blocks, reflecting the patient’s progress. This ensures that the patient does not skip any steps in the treatment (something quite common in traditional self-help manuals), which provides more control over the process. The treatment protocol is a cognitive-behavioral program that provides exposure to the feared situation using videos of real audiences. Finally, the control protocol assesses treatment efficacy, not only at closure, but also at every intermediate step. Efficacy data from 12 social phobia patients are presented from pretreatment to posttreatment and at 1-month follow-up. These preliminary data support the efficacy of our telepsychology program for the treatment of fear of public speaking. This is a preliminary work in a promising research path that examines the possibility of using the Internet for the treatment of psychological disorders.

Social phobia is one of the most prevalent mental disorders (Magee, Eaton, Wittchen, McGonagle, & Kessler, 1996), and many people suffering from social phobia do not seek treatment (Schneier, Johnson, Hornig, Liebowitz, & Weissman, 1992). Cho, Smits, and Telch (2004) refer to fear of public speaking as the most feared situation among the general population, with an estimated prevalence ranging from 20% (Cho and Won, 1997 and Pollard and Henderson, 1988) to 34% (Stein, Walter, & Forde, 1996). The clinical features of social phobia include a wide number of situations, from specific fears such as speaking, eating, or writing in public, to more generalized fears that appear in all or almost all social situations. Heimberg, Holt, Schneier, Spitzer, and Liebowitz (1993) identified three social phobia subtypes: generalized social phobia, which includes individuals with fear across almost all domains of social situations; nongeneralized social phobia, which includes individuals who fear multiple social situations but who report no problems in at least one social domain; and finally, discrete (or specific) social phobia, which includes individuals with fear in only one or two circumscribed social situations (such as writing in public or public speaking). In this work we present a novel program for the treatment of a specific social phobia, the fear of public speaking. There have been very important advances in recent years in the development of effective treatments for anxiety disorders, including social phobias. Although there are well-established programs for the treatment of these disorders (Barlow, Raffa, & Cohen, 2002), there are still limitations on the availability of these treatments. For example, mental health practitioners encounter difficulties in the application of empirically validated programs (Barlow, Levitt, & Bufka, 1999). High costs and time investments prevent many patients from receiving suitable treatment. These limitations reduce the possibility of offering the programs to all of the individuals who suffer from mental disorders. Therefore, one of the challenges in the study of psychological treatments is to design new, more cost-effective methods of treatment delivery. The key goal of this research is to shorten the face-to-face contact with the therapist without reducing the effectiveness of the treatment (Botella & García-Palacios, 1996). One of the lines of research addressing this has been the reduction of contact between patient and therapist by means of self-help procedures (for instance, Clark et al., 1995, Côté et al., 1994, Gould and Clum, 1995, Gould et al., 1993, Hecker et al., 1996 and Lidren et al., 1994). Self-help material can be defined as any media (written, taped, etc.) whose content is a treatment program (or a part of a treatment program) that can be self-administered by the patient alone or with the guidance of a therapist (Glasgow & Rosen, 1978). Glasgow and Rosen, 1978 and Glasgow and Rosen, 1982 reviewed the use of self-help procedures in behavior therapy manuals and concluded that these procedures could be effective. Though optimistic with regard to the use of self-help manuals in treating several psychological problems (phobias, obesity, sexual disorders, assertiveness, behavior problems in children, tobacco addiction, etc.), they emphasized the necessity of carrying out empirical studies before offering a self-help program to the general public. Rosen (1987) highlighted the increasing availability of self-help materials and stressed the importance of carrying out rigorous studies to test the effectiveness of such programs. He also noticed that an incorrect application of self-help procedures could exacerbate psychological problems. For example, a patient could incorrectly diagnose his or her problem and self-administer an inappropriate treatment. Or, a patient could misunderstand instructions and administer a treatment incorrectly. Any of these mistakes could lead to a failure. Ultimately, the patient’s misunderstanding of the program could lead to his or her decreased confidence in psychological treatments in general. In a more recent work on this subject, Gould and Clum (1993), after a review of self-help programs, reported several general conclusions about the effectiveness of self-help procedures. Their conclusions were optimistic and highlighted the importance of conducting research studies in this field. In addition to the concerns raised by these authors, another important characteristic of most self-help procedures is that the patient has all the self-help information at his or her disposal (as opposed to a system that makes sure that each step in the program has been suitably completed before advancing to the next step). This is one of the main issues that guided the design of the self-help program that we present in this work, a program that does not allow going to the next step until the previous has been completed. In summary, self-help procedures could be an alternative way of applying therapy and could increase the number of individuals who can be treated, reducing costly face-to-face therapy time. Of course, it is essential to test the programs thoroughly before offering them to the public. Previously, we contributed to this line of research with the design and testing of a reduced treatment for panic disorder supported by self-help. The results were similar to those achieved by a standard program (Botella & García-Palacios, 1999). Advances achieved in this field would signal an important step in increasing the availability of effective treatments, one of the main recommendations of the National Institutes of Health (Walker, Ross, & Norton, 1991). Another method of reducing contact between therapists and patients is telehealth. Telehealth is the term chosen by the Standing Committee of Family and Community Affairs (1997) to refer to the “provision of long-distance health services.” The main features of telehealth systems are (a) the geographical distance between the service and the user and (b) the use of telecommunication technologies that facilitate the interaction ( Banshur, 1995). In the wide field of telehealth, disciplines such as telemedicine, telepsychology, and telepsychiatry have emerged. The technologies used by these disciplines include videoconference, phone, computer, Internet, fax, radio, and television. Telepsychology and telepsychiatry have been defined as “the use of telecommunication technologies to put patients in contact with the mental health practitioners with the aim of providing a suitable diagnosis, education, treatment, consultations, communication and storage of the patients’ records, research data, and other activities related to the provision of mental health care” ( Brown, 1998). One of the first works in the field of telemedicine involved the use of long-distance communication between a medicine department and a state hospital to carry out consultations between the two centers (see Baer, Cukor, & Coyle, 1997). As a result of this experience, interest in this field has been increasing, supported by advances in telecommunication technologies. There are already some respectable, established programs that have become important tools in the health system, such as the Adelaide telepsychiatry system in Southern Australia (Kalucy, 1998) and the Beating the Blues program for depression and anxiety developed by Marks and his team (Marks et al., 2003, McCrone et al., 2004 and Proudfoot et al., 2004). Acknowledging the utility of telepsychology in the field of psychological disorders, Barlow stated: Well-written self-help manuals, Internet resources, and telehealth programs containing up-to-date, easy-to-follow psychological treatments seem effective in reducing impairment for individuals with less severe manifestations of pathology (see Norcross et al., 2003, for an excellent compendium). Telehealth procedures typically refer to intervention and assessment using electronic communication such as telephone or Internet technologies. The President’s New Freedom Commission on Mental Health in 2003 strongly encouraged continued development in the area of health technology and telehealth to facilitate contact with untold numbers of individuals unable to access a mental health professional.” (Barlow, 2004, p. 874)