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Test anxiety is widespread and associated with poor performance in academic examinations. The Internet, not well-proven for the treatment of anxiety, should be able to deliver highly accessible Cognitive Behavior Therapy (CBT). This study sought to test the hypothesis that CBT, available on the Internet, could reduce test anxiety. Ninety university students were randomly allocated to CBT or a control program, both on the Internet. Before and after treatment, the participants completed the Test Anxiety Inventory (TAI), an Anxiety Hierarchy Questionnaire (AHQ), the Exam Problem-Solving Inventory (EPSI), the General Self-Efficacy Scale (GSES) and the Heim reasoning tests (AH) as a measure of test performance. Of the CBT and control groups 28% and 35%, respectively, withdrew. According to the TAI, 53% of the CBT group showed a reliable and clinically significant improvement with treatment but only 29% of the control group exhibited such a change. On the AHQ, 67% of the CBT group and 36% of the control group showed a clinically significant improvement, more than two standard deviations above the mean of the baseline, a change in favour of CBT. Both groups improved on the GSES, in state anxiety during exams retrospectively assessed, and on the AH tests. The improvement on the AH tests was probably a practice effect and not a reflection of a change in capacity for academic testing. This study thus supports use of CBT on the Internet for the treatment of test anxiety.

Test anxiety is experienced throughout the world and in all socio-economic groups; it is more common in females and is the most common and most persistent fear in young people. It affects between 25% and 30% of students including those with learning difficulties (McDonald, 2001, Wachelka and Katz, 1999 and Zeidner, 1998). Avoidance by students of exams is rarely practicable (Zeidner, 1998). Those with high test anxiety perform more poorly than others (Hembree, 1988) but it is not clear if this is the cause or effect of test anxiety (Cassady and Johnson, 2002, Hembree, 1988 and Seipp, 1991). If test anxiety does contribute to poor performance, because many organisations employ tests, the outcome of testing could affect the life-long destiny of candidates. Nevertheless, whatever the causal relationship is, many students believe that anxiety does impair test-taking (Hong & Karstensson, 2002). Test anxiety has been regarded ubiquitously as a continuous variable rather than a discrete diagnostic category, present or absent (Zeidner, 1998). “Test anxiety” therefore applies to extreme anxiety on that dimension. Reviewed by Zeidner (1998), test anxiety was first seen as excessive arousal which interfered with the performance of tests although moderate anxiety could enhance effectiveness. The remedy for excessive arousal has been relaxation training. Test anxiety was then identified as a situation-specific trait in students evident in a variety of situations in which they were being evaluated. The corresponding treatment has been systematic desensitisation. Morris and Liebert (1969) distinguished worry, a cognitive component, from emotionality, evident as autonomic arousal, and concluded that only worry interfered with task performance. It does so by diverting attention to self-deprecating thoughts which provoke autonomic arousal. Corresponding treatment has consisted of attention training. Highly anxious students are also deficient in skills for studying and taking tests according to Kirkland and Hollandsworth (1979). Those students who believe this and who are aware of impaired performance become anxious accordingly. Self-efficacy theory (Jones & Petruzzi, 1995) has a similar perspective. Cognitive approaches have emphasised dysfunctional beliefs in students such as the need, suggested by rational emotive therapy, to strive for perfection which they find unattainable (Zeidner, 1998). Alternatively they believe that they compare unfavourably with their peers under whose scrutiny they think they fall (Beck, Emery, & Greenberg, 1996). Treatments corresponding to all these perspectives have been successful in reducing test anxiety but cognitive therapy plus skills training or emotion-focussed components have worked best (Ergene, 2003 and Vagg and Spielberger, 1995). The simplest hypothesis would therefore suggest that the most effective treatment should include all these approaches as components in “multimodal treatment” (Zeidner, 1998). However, this would require a unifying theory to support the hypothesis that several such components would have an additive effect (Zeidner, 1998). There has been one attempt at such a theory, that by Spielberger and Vagg (1995). They proposed that differences in trait anxiety interact with situational factors such as the student's perception of the test's difficulty, skills in studying and taking tests and the importance of the exam to determine the extent to which an exam is seen as threatening. This will influence arousal, contribute to difficulties in information processing, cause task irrelevant behaviour, produce a decrement in performance and corresponding self-derogatory cognitions. However, a test of this theory would require structural path analysis (Zeidner, 1998) which has not been done and so corresponding treatments have not been tested. Moreover, there appear to have been no multimodal treatments, of more than two modules, which have included cognitive therapy. Therefore, the present study adopted the simplest and widespread assumption (Zeidner, 1998) that several treatments, shown separately to have treated test anxiety successfully (Ergene, 2003), would be more effective if all, rather than one or two, were included in a multimodal package of Cognitive Behaviour Therapy (CBT). So widespread is test anxiety, there is a considerable need for effective short treatments. However, the opportunity for treatment is severely limited by cost, the scarcity of therapists and inaccessibility for people who are in full-time learning, long hours of work, night-shift working or in distant communities dependent on tele-learning. Computer-based treatment may be one solution. CBT is well suited to this because of its well-defined procedures (Bloom, 1992). Computer-administered CBT on CDs has been tested for several anxiety disorders (Kaltenhaler, Parry, & Beverley, 2004) but the National Institute for Health and Clinical Excellence (NICE, 2002) concluded that the evidence (Kaltenhaler et al., 2002), although promising, was not strong enough to recommend this for clinical practice. However, NICE has this under review and they would consider the latest study by Marks, Kenwright, McDonough, Whittaker, and Mataix-Cols (2004). They have shown that self-exposure therapy presented mainly by a computer was no less successful in treating phobias and panic disorders than a similar programme conducted by a therapist alone. However, 43% of computer-aided clients dropped out of treatment. That study is typical in that very few studies have included a credible procedure delivered by computer with which to compare the computerised treatment. They seek rather to show that the latter is no less effective than clinician-delivered therapy. The Internet is another means of delivering programs via a computer. The studies of computer-aided treatment noted above would encourage research on the use of the Internet to treat anxiety disorders. Furthermore, that medium could provide advantages over CDs. Programs could be more accessible, more readily modified by authors. Access by users could be monitored; they could try before buying. Lange, Schrieken, van de Ven, Bredeweg, and Emmelkamp (2000) and Richards and Alvarenga (2002), with therapists aided by the Internet, found improvements in measures of anxiety but neither study had a control group. Klein and Richards (2001) provided 11 participants suffering from panic disorder (PD) with information which was delivered by the Internet and introduced by a therapist. All of several measures of anxiety and panic declined after a week's treatment unlike those in a similar group who only monitored their symptoms. Carlbring, Westling, Ljungstrand, Ekselius, and Andersson (2001) compared a CBT Internet program of six modules, based on published self-help manuals, with a waiting list control. Twenty-six of 41 PD participants completed the trial. On all but one of eight self-report inventories and five of seven variables in a diary, they improved to a greater extent than the controls. Most of these improvements were clinically significant but no effect size or comparison with face-to-face therapy was reported. This program was repeated by Carlbring, Ekselius, and Andersson (2003) and compared with applied relaxation instructions both delivered by the Internet in a sample of 22 participants divided into two groups. Both improved on most of the self-report measures and diary records but there was no difference between treatments. The moderate effect sizes were similar in both groups. Kenardy, Mc-Cafferty, and Rose (2003) found that an Internet program based on published self-help manuals for panic reduced scores on self-report of anxiety in 43 participants selected to be high in anxiety sensitivity. Although this improvement was greater than in a waiting list control group, there was no significant effect on anxiety sensitivity, contrary to prediction. Schneider, Mataix-Cols, Marks, and Bachofen (2005) have recently reported that Internet-delivered CBT plus telephone support was effective in treating phobias with or without panic, whether or not the treatment included exposure. Most recently, Carlbring et al. (2005) compared Internet-delivered CBT with treatment provided by therapists in vivo to 49 participants with PD with or without agoraphobia. The only contact with a therapist in the Internet group was provided by e-mail. No behavioural data were reported but responses to questionnaires showed significant improvements with large effect sizes in both groups. The authors claim that the Internet group improved as much as the in vivo therapy participants but they provide few results to support this. Therefore, although anxiety has been reduced in several studies using the Internet in comparison with other approaches, none has compared treatment with a placebo program delivered by the Internet. The Internet can generate influential expectations which might spuriously inflate the effect of programs (Richards, Klein, & Calbring, 2003). So much trust in web sites can be placed by users that ethical debate has ensued (Briggs et al., 2002 and Fisher and Fried, 2003). Placebo programs delivered on the Internet (Zeidner, 1998) should be included, therefore, to evaluate the efficacy of CBT in this medium. No study has done this. Moreover, as noted above, there has been insufficient use of placebo-controlled trials of computerised treatment to pre-empt such a comparison for Internet-delivered treatment. Computerised packages for test anxiety (Buglione, Devito, & Mulloy, 1990) have consisted mainly of systematic desensitisation and, although there are many relevant Internet sites (e.g. University of South Australia, 2001), these provide information, not treatment. Therefore, Internet programs cannot yet be recommended for test anxiety. The present study therefore compared two programs on the Internet: CBT and a placebo package presenting similar procedures. We were to measure test anxiety by the Test Anxiety Inventory (TAI) (Spielberger, 1980) and our own Anxiety Hierarchy Questionnaire (AHQ) before and after treatment in groups of participants allocated to each program. We expected that anxiety on both measures would be less after each intervention than before but the decline in anxiety would be greater in the group who had received CBT than in the controls. We expected that there would be corresponding changes in the participants’ confidence about succeeding in exams and about their ability to overcome exam-related problems. Test anxiety may impair performance of intellectual tasks. Therefore, we expected that a test of cognitive functioning, administered before and after the interventions, would show a greater improvement in the CBT group than in the controls. Previous research (Zeidner, 1998) using the TAI (Spielberger, 1980), the most widely used measure, suggested that, with a power of 0.80 and α=0.05α=0.05, we would require 25 participants in each group to reject the null hypothesis.

We have shown that our CBT program, introduced by a therapist but delivered by the Internet and used freely by University students, can reduce test anxiety substantially according to statistical effect sizes, can effect a reliable and clinical significant improvement in more than half a sample of test anxious students and as effectively as face-to-face therapy, according to effect sizes compared with other studies. It would be less expensive of therapists’ time and more accessible to students than therapist-delivered therapy. It would be important, therefore, to determine the effectiveness of our program for other groups including less able students for whom test anxiety is most disruptive. There are probably many Internet programs of questionable value in health care (Briggs et al., 2002). Therefore, we believe that evidence-based programs such as ours, with clear guidance about their use, should have the approval of a professional organisation before being made available on the Internet to the public.