قابلیت استفاده و ابزار برنامه خودیاری شناختی رفتاری کامپیوتری برای اضطراب صحبت های عمومی

This study describes the use of a cognitive-behavioral computer-administered self-help program with minimal therapist contact for public speaking anxiety. Participants (N = 10) with social phobia, as measured by a structured clinical interview, completed the self-help program in an open clinical trial. The program was delivered via a CD-ROM during individual sessions at an outpatient clinic, including 4 sessions of psychoeducation/cognitive therapy and 4 sessions of exposure therapy using a virtual audience presented on a computer screen. A therapist was available in another room to answer questions and to debrief for up to 10 minutes after each session. Participants completed standardized self-report questionnaires assessing social anxiety at pretreatment, posttreatment, and 3-month follow-up. Participants also completed measures of computer usability. Results showed decreases on all self-report measures of social anxiety from pre- to posttreatment, which were maintained at follow-up (n = 8). Participants also reported that they were satisfied with treatment, that they felt improved after treatment, and that the computer program was user-friendly. This study provides preliminary evidence that a computer-administered cognitive-behavioral-based program that includes minimal therapist contact may reduce public speaking anxiety and suggests that further research with a controlled design is needed.

Computerized self-help programs are a popular alternative and supplement to psychotherapy and offer several advantages for consumers, including increased availability, convenience, and cost-effectiveness (Mains and Scogin, 2003 and Tate and Zabinski, 2004). A recent poll of psychologists predicted that computerized therapies and self-help techniques will substantially increase in the next 10 years (Norcross, Hedges, & Prochaska, 2002). However, the commercialization and dissemination of unproven self-help materials has prompted concerns by many (Finch et al., 2000, Marrs, 1995, McKendree-Smith et al., 2003, Rosen, 1987 and Scogin, 2003). The empirical literature examining the effectiveness of computer-assisted self-help programs is limited, though findings to date are encouraging. Studies have demonstrated good compliance with treatment and have found no differences in dropout rates and equal levels of satisfaction between traditional and technology-administered approaches (Ghosh and Marks, 1987, Ghosh et al., 1988, Newman et al., 1997a and Newman et al., 1997b). Self-help programs vary widely with regard to concomitant contact with a therapist. Glasgow and Rosen (1978) characterized self-help programs as either self-administered (therapist contact for assessment at most), predominantly self-help (therapist contact for check-ins, teaching clients how to use self-help program), minimal contact (active involvement of therapist, though less than in traditional therapy), and predominantly therapist-administered (self-help is used to augment regular therapy sessions) and concluded that minimal-contact therapies have been most successful for the greatest variety of anxiety disorders. The current study examined a “predominantly self-help” program. Next, we present a rationale for the potential benefit of computerized self-help programs that target social anxiety, review the data on computerized self-help programs for anxiety disorders, particularly social anxiety, and present data from an open clinical trial testing the usability and utility of a self-help program for public speaking anxiety. The development of effective self-help programs for social anxiety is important because social anxiety (especially public speaking anxiety) is quite common and the vast majority of people do not receive treatment. Data from a community sample suggest that 34% of individuals have substantial public speaking fears and that these fears are associated with lower income, decreased likelihood of achieving post-secondary education, and increased likelihood of unemployment (Stein, Walker, & Forde, 1994). Social phobia has the third lowest rate of treatment among the major mental disorders, following drug and alcohol use disorders, and between 72% and 95% of individuals with social phobia report that they have never received mental health treatment (Robins and Reiger, 1991 and Schneier et al., 1992). Socially phobic individuals participating in National Anxiety Disorders Screening Day indicated that the most common barriers to treatment were uncertainty over where to go for treatment, financial barriers, and fear of what others might think (Olfson et al., 2000). Usable and effective self-help programs for social anxiety have the potential to address some of these barriers. For example, self-administered, predominantly self-help, or minimal contact programs may represent a treatment option that minimizes embarrassment and that is less costly. A handful of studies have examined computerized self-help programs as applied to anxiety disorders. One group of researchers tested the use of computer-aided self-help programs—viewed as “clinician extenders,” not “clinician replacers”—for both depression and anxiety within the framework of a primary care clinic (Gega et al., 2004 and Marks et al., 2003). Results showed that program completers reported clinical improvement and feeling “fairly satisfied” with treatment. Two studies have examined the use of Internet-delivered self-help programs for panic disorder and found that the self-help program was as effective as therapist-administered treatment for many patients (Carlbring et al., 2003 and Carlbring et al., 2001). However, results from another study suggested that self-help treatments for panic disorder are no more effective than a wait-list control condition when they are used without therapist contact to monitor progress and treatment compliance (Febbraro, Clum, Roodman, & Wright, 1999). There are very few published studies describing the use of computerized self-help programs for social anxiety. One study compared CBT group therapy led by a therapist supplemented with or without palmtop computer-assisted therapy. The palmtop computer was used to facilitate effective between-session exposure homework. Gruber, Moran, Roth, and Taylor (2001) found that the addition of the palmtop computer to 8 sessions of group therapy was comparable to 12 sessions of group therapy without computer assistance at follow-up. Another study adapted a computer program developed to treat generalized anxiety disorder (GAD) for use among individuals with social anxiety (Przewski & Newman, 2004). The role of the computer during treatment included relaxation training, imagery retraining, cognitive restructuring, and imaginal desensitization, in which the client imagined coping with an anxiety-provoking situation in an adaptive way. In a case study of a socially phobic college student, the researchers reported success with this program as measured by compliance with homework, enthusiasm about the incorporation of a computer into treatment, and no longer meeting criteria for social anxiety. While the previous studies have examined computerized self-help in conjunction with some therapist contact, one group of researchers designed a program for public speaking anxiety that is completely self-administered and delivered over the Internet (Botella et al., 2000). The “Talk to Me” treatment protocol includes structured modules for psychoeducation, cognitive restructuring, exposure, and homework assignments. The exposure sessions include recordings of various social situations that are presented on the computer. A case report described the successful six-session treatment of an individual with generalized social phobia as indicated by the client’s rating of satisfaction with treatment, utility of treatment, as well as decreased ratings of fear and avoidance of the exposure scenarios at posttreatment and follow-up (Botella, Hofmann, & Moscovitch, 2004). In summary, although several computer-assisted self-help programs have been developed using cognitive-behavioral techniques, few programs have directly targeted social phobia and been evaluated. Given the prevalence of social phobia and public speaking anxiety, its impact on quality of life, and the low rates of treatment among those who suffer, further research of such programs seems warranted. The current study describes the use and utility of a self-help program to address pubic speaking anxiety. As detailed below, the program includes many of the traditional cognitive-behavioral approaches to anxiety, such as providing a treatment rationale, psychoeducation, and cognitive restructuring. In this way it is very similar to the Botella program, although this program currently cannot be delivered over the Internet. A relatively unique aspect of the program includes the use of a Webcam with playback to challenge cognitions. This self-help program also differs from other programs that use a virtual audience for exposure (Anderson, Zimand, Hodges, & Rothbaum, 2005) in that the exposure is not conducted by a therapist and a head-mounted display is not used. Instead, the participant guides herself through exposure by viewing an audience on a computer monitor. This paper presents preliminary data regarding the program’s usability (as measured by the user-friendliness of the software, primarily) and utility (as measured by changes in measures of public speaking anxiety) among a clinical sample within an open clinical trial at posttreatment and 3-month follow-up.

In summary, results from this open clinical trial suggest that participants in the study found the computerized self-help program both usable and useful. Participants’ ratings of usability were very positive. Furthermore, only one participant sought technical assistance on one occasion during the use of the program. This is important given the fact that there were some aspects of the program that could have been confusing. For example, perhaps the most difficult aspect of the program to navigate was in Session 4: participants were asked to record themselves using a Webcam, play back that recording, and make assessments about their own beliefs (e.g., about the visibility of their anxiety). With one exception during one session, participants were able to complete this task without therapist assistance. During the exposure sessions, participants were asked to “program” the virtual audience to respond in a certain way, based on their hierarchy (e.g., small audience looking encouraging versus large audience looking bored). Again, this is a task that can be difficult psychologically (e.g., an anxiety hierarchy is usually developed with a therapist) but could also be difficult technologically. However, participants did not seem to have difficulty using the virtual audience for exposure. Not only were participants able to use the program, they seemed to benefit from it as well. Group data indicate decreases in social anxiety at posttreatment and follow-up relative to pretreatment with large effect sizes across measures, and the majority of participants reported satisfaction with treatment and feeling improved. Based on our a priori definition of treatment response, half of the participants were categorized as “treatment responders.” Although the small sample size precludes analysis of predictors of treatment response, there are several possibilities. For example, more participants may have responded to treatment had they had increased contact with the therapist or had they been able to use the program on their own terms (e.g., utilized more exposure sessions). Although the data regarding usability and utility are positive, the conclusions are quite preliminary and subject to multiple interpretations. An uncontrolled trial is vulnerable to multiple threats to internal validity such as regression to the mean, spontaneous remission, placebo effects, historical effects, and maturational effects (Cook & Campbell, 1979). A controlled study would generate greater confidence that treatment indeed had an effect. Other specific limitations of the current study include the lack of a behavioral avoidance test and the lack of reassessment of diagnostic status at follow-up which would provide more context about the meaningfulness of change for the participants. The research testing computerized self-help programs is in its infancy and there is much work to be done. There is considerable variability in the literature about the effect of traditional bibliotherapy, with some studies reporting moderate to large effect sizes (e.g., Marrs, 1995 and Scogin et al., 1990) and others reporting no significant effect (e.g., Febbraro et al. 1999). For this study, we asked participants to complete the program at a clinic, and although the psychologist did not conduct therapy, she was available to answer questions. This is quite a different context than a person using a self-help program in his or her home without any assistance from or access to a therapist. Research suggests that self-help treatments that include contact with a therapist result in better effect sizes than those that do not (Scogin, Bynum, Stephens, & Calhoon, 1990). Using Glasgow and Rosen’s (1978) categories, a recent review noted that self-help programs appeared to be more effective when conducted in the lab than at home (Newman, Erickson, Przeworski, & Dzus, 2003). More research is needed to understand under what conditions computerized self-help programs are effective. Researchers have stressed the importance of considering ethical issues related to self-help programs in general (Rosen, 1987) and new technologies in particular (Anderson, Jacobs & Rothbaum, 2004). There are several ethical issues to consider with regard to self-help programs for social anxiety. For example, when conducting self-guided exposure therapy, it is imperative that the person stays in the feared situation until anxiety habituates; otherwise, the program could actually sensitize them to anxiety. For individuals with social anxiety, there is a concern that the use of a self-help program may perpetuate social isolation. Finally, because socially anxious people also may experience comorbid depression, a program should not contribute to a feeling of hopelessness, and it should not undermine a sense of mastery (e.g., “I can’t even figure out this program”). These concerns were addressed in this study via in-person diagnostic assessment and ongoing contact with a therapist (albeit minimal). However, one of the potential advantages of self-help programs is to reach people who would not otherwise receive therapy. Thus, future studies must evaluate self-help programs in a more naturalistic setting, including gathering data that provide information on these ethical concerns. Clearly, there is a wealth of research to be done to determine what types of computerized self-help programs work in which contexts for what types of problems and for whom. A sample of other questions to be answered include: What is considered satisfactory improvement from a self-help program? What are the best ways to transmit CBT concepts? Does the public prefer computer-based self-help compared to self-help books? Does using computer technology increase understanding, compliance, use, and effectiveness? Are computerized self-help programs cost-effective? Another issue for future research is measuring how “real” a computer-based exposure needs to be to achieve therapeutic response. When a person is engaged in in-vivo exposure, it is generally presumed that direct exposure to the feared stimulus provides the context for habituation and a therapeutic response. Virtual reality researchers have developed the concept of presence to measure how “real” a virtual exposure feels to participants. With increasing efforts to administer exposure via a computer, it will be important for future research to test the relation between presence and response to treatment. This study used an unpublished measure with unknown psychometric properties (ImQ) as an indicator of presence, and thus does not advance our knowledge on this important topic. This study examined whether or not individuals with public speaking anxiety can benefit from a computer-based program with minimal contact with a therapist in a relatively controlled setting. Such “predominantly self-help” programs may increase access to treatment by reducing suffers’ fear of embarrassment because treatment is not conducted in a group. These types of programs also have the potential advantage of reducing cost by reducing face-to-face therapist time. However, self-help programs that do not include contact with a therapist would seem to have a better likelihood of overcoming barriers to treatment. For example, a computerized self-help program that is delivered over the Internet would not require a person to seek out a mental health professional. So, paralleling the call for both efficacy and effectiveness research in traditional clinical research on traditional therapy, research for computerized self-help programs needs to continue to be done in controlled environments (as in the current study), and in the “real world,” to determine whether or not people gain benefits from computerized self-programs at home without contact with or accountability to a therapist.