Shyness 3: Randomized Controlled Trial of Guided Versus Unguided Internet-Based CBT for Social Phobia
Abstract
Objective: In two previous randomized controlled trials Titov et al. demonstrated significant benefit from an Internet- and email-based treatment programme for social phobia. The present study (Shyness 3) explores whether participants are able to complete this programme independently. Method: A total of 98 individuals with social phobia were randomly assigned to a clinician-assisted computerized cognitive behavioural treatment (CaCCBT) group, a self-guided computerized CBT (CCBT) group, or to a waitlist control group. CaCCBT group participants completed the usual Shyness programme consisting of six online lessons, cognitive behavioural homework assignments, email contact with a therapist, and participation in an online discussion forum. CCBT group participants accessed the same resources except for therapist emails. An intention-to-treat model was used for data analyses. Results: A total of 77% of CaCCBT and 33% of CCBT group participants completed all lessons. Significant differences were found after treatment between CaCCBT and control groups (mean between-groups effect size (ES) for the social phobia measures = 1.04), and between the CaCCBT and CCBT groups (mean between-groups ES for the social phobia measures = 0.66). No significant differences were found after treatment between the CCBT and control groups (mean between-groups ES for the social phobia measures = 0.38). CCBT participants, however, who completed the six lessons made good progress (mean within-group ES for the social phobia measures = 0.62). Quantitative and qualitative data indicate that both the CaCCBT and CCBT procedures were acceptable to participants. Conclusions: The reliability of this Internet-based treatment programme for social phobia has been confirmed. The therapist-guided condition was superior to the self-guided condition, but a subgroup of participants still benefited considerably from the latter. These data confirm that self-guided education or treatment programmes for common anxiety disorders can result in significant improvements.
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The number of modules completed was found to correlate with outcomes in interventions that targeted cigarette smoking, depression, and anxiety disorders.
“The number of modules completed was found to correlate with outcomes in interventions that targeted cigarette smoking [42,46,47], depression [45,48-51], and anxiety disorders [52-57].”
From A Systematic Review of the Impact of Adherence on the Effectiveness of e-Therapies (2011) · cites this paper as [53]
In Titov et al.'s study, it was unclear whether the facilitated bulletin board or the email support provided the additional therapist guidance.
“What was unclear from the study was the extent to which it was the facilitated bulletin board or the email support that successfully provided the additional therapist guidance.”
Other studies that included online discussion groups as part of an online intervention failed to report usage data, to differentiate usage of the groups across treatment groups, or to analyse the impact of the discussion groups on study outcomes.
“Other studies have included online discussion groups as part of an online intervention (for example: [27, 29, 30]), but failed to either report usage data, differentiate the usage of the groups across the treatment groups, or analyse the impact of the discussion groups on the study outcomes.”
Eighteen studies state that encouraging adherence is a task for the counselor.
“it is remarkable that 18 state that encouraging adherence is a task for the counselor [45-62]”
From Persuasive System Design Does Matter: a Systematic Review of Adherence to Web-based Interventions (2012) · cites this paper as [54]
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“Guidance in a study by Titov and colleagues [46] was provided by clinicians who, in contrast to the volunteers in the current study, may have provided clinical input and support.”
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Barnett, P., Goulding, L., Casetta, C., Jordan, H., Sheridan-Rains, L., Steare, T., Williams, J., Wood, L., Gaughran, F., & Johnson, S. (2021) · Journal of Medical Internet Research · doi:10.2196/26492 · Cited by 136 · see citing works
Goldin, P. R., Lee, I., Ziv, M., Jazaieri, H., Heimberg, R. G., & Gross, J. J. (2014) · Behaviour Research and Therapy · doi:10.1016/j.brat.2014.02.005 · Cited by 130 · see citing works
Coull, G., & Morris, P. G. (2011) · Psychological Medicine · doi:10.1017/s0033291711000900 · Cited by 126 · see citing works
A 5-Year Follow-up of Internet-Based Cognitive Behavior Therapy for Social Anxiety Disorder
Hedman‐Lagerlöf, E., Furmark, T., Carlbring, P., Ljótsson, B., Rück, C., Lindefors, N., & Andersson, G. (2011) · Journal of Medical Internet Research · doi:10.2196/jmir.1776 · Cited by 123 · see citing works
“In recent years, Internet-based cognitive behavior therapy (CBT) has demonstrated efficacy in several randomized controlled trials [4-9].”
BackgroundThe promise and pitfalls of the internet for cognitive behavioral therapy
Andersson, G. (2010) · BMC Medicine · doi:10.1186/1741-7015-8-82 · Cited by 114 · see citing works
“There may be room for large-scale open access programs, in particular intelligent systems which may be able to mimic what the online therapist is doing and thereby secure that effects are obtained [40].”
BackgroundMak, W. W., Tong, A. C., Yip, S. Y., Lui, W. W., Chio, F. H., Chan, A. T., & Wong, C. C. (2018) · JMIR Mental Health · doi:10.2196/mental.8597 · Cited by 123 · see citing works
“Previous studies comparing guided versus unguided self-help approaches have reported higher adherence rate in guided interventions [75,76].”
Hedman, E., Andersson, E., Ljótsson, B., Andersson, G., Andersson, E., Schalling, M., Lindefors, N., & Rück, C. (2012) · Acta Psychiatrica Scandinavica · doi:10.1111/j.1600-0447.2012.01834.x · Cited by 114 · see citing works
Klein, B., Meyer, D., Austin, D. W., & Kyrios, M. (2011) · Journal of Medical Internet Research · doi:10.2196/jmir.1918 · Cited by 118 · see citing works
“e-Therapy programs can be broadly categorized as being self-help or therapist-assisted, and hundreds have been evaluated across a range of mental health disorders and symptoms, including panic disorder (eg, [13,14], SAD (eg, [15]), PTSD and symptoms (eg, [8,16,17]), anxiety prevention (eg, [18,19]), depression and dep…”
BackgroundMayo-Wilson, E., & Montgomery, P. (2013) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd005330.pub4 · Cited by 112 · see citing works
Randomized Controlled Trial of Web-Based Treatment of Social Phobia Without Clinician Guidance
Titov, N., Andrews, G., Choi, I., Schwencke, G., & Johnston, L. (2009) · Australian & New Zealand Journal of Psychiatry · doi:10.1080/00048670903179160 · Cited by 122 · see citing works
“The findings are a logical extension of a previous trial [6].”
BackgroundMethodResultSelf-citationGhawadra, S. F., Abdullah, K. L., Choo, W. Y., Danaee, M., & Phang, C. K. (2020) · Journal of Nursing Management · doi:10.1111/jonm.13049 · Cited by 122 · see citing works
Wildeboer, G., Kelders, S. M., & van Gemert-Pijnen, J. E. W. C. (2016) · International Journal of Medical Informatics · doi:10.1016/j.ijmedinf.2016.04.005 · Cited by 98 · see citing works
Titov, N., Andrews, G., Schwencke, G., Solley, K., Johnston, L., & Robinson, E. (2009) · Australian & New Zealand Journal of Psychiatry · doi:10.1080/00048670903179228 · Cited by 112 · see citing works
“A subsequent RCT explored outcomes in a self-guided version of the Shyness programme without any email or clinician reminders [15].”
BackgroundSelf-citationKleiboer, A. M., Donker, T., Seekles, W., van Straten, A., Riper, H. M., & Cuijpers, P. J. (2015) · Behaviour Research and Therapy · doi:10.1016/j.brat.2015.06.013 · Cited by 109 · see citing works
Lancee, J., van den Bout, J., Sorbi, M. J., & van Straten, A. (2013) · Behaviour Research and Therapy · doi:10.1016/j.brat.2013.09.004 · Cited by 104 · see citing works
Titov, N., Andrews, G., Kemp, A., & Robinson, E. (2010) · PLoS ONE · doi:10.1371/journal.pone.0010885 · Cited by 97 · see citing works
Self-citationTitov, N., Andrews, G., Schwencke, G., Robinson, E., Peters, L., & Spence, J. (2010) · Australian & New Zealand Journal of Psychiatry · doi:10.3109/00048674.2010.493859 · Cited by 98 · see citing works
Self-citationEl Alaoui, S., Ljótsson, B., Hedman, E., Kaldo, V., Andersson, E., Rück, C., Andersson, G., & Lindefors, N. (2015) · PLOS ONE · doi:10.1371/journal.pone.0124258 · Cited by 98 · see citing works
“On the other hand, in a study where effectiveness and adherence was compared between guided and unguided ICBT for SAD, it was found that therapist guidance increased the likelihood of completing the treatment and that treatment effects were similar among those who completed the treatment regardless of whether they had…”
BackgroundMak, W. W., Chio, F. H., Chan, A. T., Lui, W. W., & Wu, E. K. (2017) · Journal of Medical Internet Research · doi:10.2196/jmir.6737 · Cited by 94 · see citing works
“Previous research has shown that (1) guided self-help has higher completion rates than unguided self-help [38], (2) programs with weekly telephone reminders are more efficacious than those without [39], and (3) technician-assisted telephone or email support for Internet-based interventions is as efficacious as clinici…”
Outcome predictors in guided and unguided self-help for social anxiety disorder
Nordgreen, T., Havik, O. E., Öst, L. G., Furmark, T., Carlbring, P., & Andersson, G. (2012) · Behaviour Research and Therapy · doi:10.1016/j.brat.2011.10.009 · Cited by 87 · see citing works
“(Farvolden, Denisoff, Selby, Bagby, & Rudy, 2005; Titov et al., 2008).”
BackgroundResultComputer-Assisted Cognitive-Behavior Therapy and Mobile Apps for Depression and Anxiety
Wright, J. H., Mishkind, M., Eells, T. D., & Chan, S. R. (2019) · Current Psychiatry Reports · doi:10.1007/s11920-019-1031-2 · Cited by 93 · see citing works
Newby, J. M., Mewton, L. R., Williams, A. D., & Andrews, G. (2014) · Journal of Affective Disorders · doi:10.1016/j.jad.2014.04.037 · Cited by 91 · see citing works
Self-citationKählke, F., Berger, T., Schulz, A., Baumeister, H., Berking, M., Auerbach, R. P., Bruffaerts, R., Cuijpers, P. J., Kessler, R. C., & Ebert, D. D. (2019) · International Journal of Methods in Psychiatric Research · doi:10.1002/mpr.1766 · Cited by 90 · see citing works
Shyness programme: Longer term benefits, cost-effectiveness, and acceptability
Titov, N., Andrews, G., Johnston, L., Schwencke, G., & Choi, I. (2009) · Australian & New Zealand Journal of Psychiatry · doi:10.1080/00048670802534424 · Cited by 88 · see citing works
Self-citationSteinert, C., Stadter, K., Stark, R., & Leichsenring, F. (2017) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.2032 · Cited by 83 · see citing works
Sunderland, M., Mahoney, A. E. J., & Andrews, G. (2012) · Journal of Psychopathology and Behavioral Assessment · doi:10.1007/s10862-012-9276-7 · Cited by 80 · see citing works
Self-citationTitov, N., Dear, B. F., Johnston, L., McEvoy, P. M., Wootton, B., Terides, M. D., Gandy, M., Fogliati, V., Kayrouz, R., & Rapee, R. M. (2014) · PLoS ONE · doi:10.1371/journal.pone.0089591 · Cited by 81 · see citing works
Self-citationProudfoot, J. G., Jayawant, A., Whitton, A. E., Parker, G. B., Manicavasagar, V. L., Smith, M., & Nicholas, J. (2012) · BMC Psychiatry · doi:10.1186/1471-244x-12-196 · Cited by 82 · see citing works
“Such interventions are typically offered as stand-alone programs or with support from mental health professionals, with evidence indicating superior outcomes, greater compliance and decreased rates of attrition in supported, compared to unsupported programs [36-38].”
BackgroundLungu, A., Jun, J. J., Azarmanesh, O., Leykin, Y., & Chen, C. E.-J. (2020) · Journal of Medical Internet Research · doi:10.2196/18723 · Cited by 75 · see citing works
Hedman, E., El Alaoui, S., Lindefors, N., Andersson, E., Rück, C., Ghaderi, A., Kaldo, V., Lekander, M., Andersson, G., & Ljótsson, B. (2014) · Behaviour Research and Therapy · doi:10.1016/j.brat.2014.05.010 · Cited by 79 · see citing works
Social Phobia (Social Anxiety Disorder)
Andersson, G., & Carlbring, P. (2010) · Springer eBooks · doi:10.1007/978-1-4419-6510-3_6 · Cited by 79 · see citing works
Ngan, H. Y., Chong, Y. Y., & Chien, W. T. (2021) · Diabetic Medicine · doi:10.1111/dme.14525 · Cited by 77 · see citing works
Shim, M., Mahaffey, B., Bleidistel, M., & Gonzalez, A. (2017) · Clinical Psychology Review · doi:10.1016/j.cpr.2017.09.003 · Cited by 72 · see citing works
“For example, Titov et al (2008) examined the effect of CCBT for social phobia and found that the average therapist time needed in the therapist-guided condition was less than 3 hours during the 10-week program (Titov et al., 2008).”
BackgroundResultLintvedt, O., Griffiths, K. M., Eisemann, M. R., & Waterloo, K. K. (2013) · Journal of Medical Internet Research · doi:10.2196/jmir.2422 · Cited by 74 · see citing works
“The deterioration in the control group is not unusual over a short time [78], but over a longer time period, one would expect improvements.”
BackgroundDigital Technologies in the Treatment of Anxiety: Recent Innovations and Future Directions
Firth, J., Torous, J., Carney, R., Newby, J., Cosco, T. D., Christensen, H., & Sarris, J. (2018) · Current Psychiatry Reports · doi:10.1007/s11920-018-0910-2 · Cited by 70 · see citing works
Internet-Delivered Cognitive Therapy for Social Anxiety Disorder: A Development Pilot Series
Stott, R., Wild, J., Grey, N., Liness, S., Warnock-Parkes, E., Commins, S., Readings, J., Bremner, G., Woodward, E., Ehlers, A., et al. (2013) · Behavioural and Cognitive Psychotherapy · doi:10.1017/s1352465813000404 · Cited by 61 · see citing works
“…2012; Berger, Hohl and Caspar, 2009; Carlbring et al., 2007; Furmark et al., 2009; Hedman et al., 2011; Titov, Andrews, Schwencke, Drobny and Einstein, 2008; Titov, Andrews and Schwencke, 2008; Titov, Andrews, Choi, Schwencke and Mahoney, 2008; Titov, Andrews, Johnston, Robinson and Spence, 2010).”
Internet-Based Interventions for Social Anxiety Disorder - an Overview
Boettcher, J., Carlbring, P., Renneberg, B., & Berger, T. (2013) · Verhaltenstherapie · doi:10.1159/000354747 · Cited by 67 · see citing works
“In a fourth program, the comparison of guided and unguided selfhelp favored the guided approach [Titov et al., 2008c].”
BackgroundInfluentialDistance-delivered interventions for PTSD: A systematic review and meta-analysis
Olthuis, J. V., Wozney, L., Asmundson, G. J. G., Cramm, H., Lingley-Pottie, P., & McGrath, P. J. (2016) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2016.09.010 · Cited by 64 · see citing works
Mewton, L., Smith, J., Rossouw, P., & Andrews, G. (2014) · Psychology Research and Behavior Management · doi:10.2147/prbm.s40879 · Cited by 57 · see citing works
Self-citationBoettcher, J., Berger, T., & Renneberg, B. (2012) · Behavioural and Cognitive Psychotherapy · doi:10.1017/s1352465812000501 · Cited by 61 · see citing works
Romijn, G., Batelaan, N., Kok, R., Koning, J., van Balkom, A., Titov, N., & Riper, H. (2019) · Journal of Medical Internet Research · doi:10.2196/11706 · Cited by 52 · see citing works
“When a general measure of anxiety was not available, we used a measure for specific anxiety symptoms (see Multimedia Appendix 2 [39-49] for the order of rating scales and Multimedia Appendix 3 [7,27-31,50-85] for the outcome measures we used for all studies).”
MethodSelf-citationInternet Treatment for Social Phobia Reduces Comorbidity
Titov, N., Gibson, M., Andrews, G., & McEvoy, P. (2009) · Australian & New Zealand Journal of Psychiatry · doi:10.1080/00048670903001992 · Cited by 58 · see citing works
“Data on 211 participants in three randomized controlled trials (RCTs) of the Shyness programme were reanalysed [5 7].”
BackgroundResultSelf-citationSchulz, A., Stolz, T., Vincent, A., Krieger, T., Andersson, G., & Berger, T. (2016) · Behaviour Research and Therapy · doi:10.1016/j.brat.2016.07.001 · Cited by 59 · see citing works
An Online Recovery Plan Program: Can Peer Coaching Increase Participation?
Simon, G. E., Ludman, E. J., Goodale, L. C., Dykstra, D. M., Stone, E., Cutsogeorge, D., Operskalski, B., Savarino, J., & Pabiniak, C. (2011) · Psychiatric Services · doi:10.1176/ps.62.6.pss6206_0666 · Cited by 62 · see citing works
“Our findings regarding the positive effect of coaching on participation are similar to those seen with other online interventions for mental health treatment (10,12).”
Williams, A. D., O'Moore, K., Mason, E., & Andrews, G. (2014) · Internet Interventions · doi:10.1016/j.invent.2014.11.001 · Cited by 53 · see citing works
Self-citationDraper, C., & O’Donohue, W. (2010) · Springer eBooks · doi:10.1007/978-1-4419-6510-3 · Cited by 54 · see citing works
Johansen, M. A., Henriksen, E. K. K., Horsch, A., Schuster, T., & Berntsen, G. (2012) · Journal of Medical Internet Research · doi:10.2196/jmir.2214 · Cited by 54 · see citing works
“We suggest not focusing so much on symptom and its synonyms as search words, since they were lacking in many of these studies, but to include specific search strings such as Interapy [85,86], Internet-based therapy [86,87], Internet-based treatment [86,88-91], and online therapeutic relationship [86].”
BackgroundAcceptability of Digital Mental Health Interventions for Depression and Anxiety: Systematic Review
Lau, C. K. Y., Saad, A., Camara, B., Rahman, D., & Bolea-Alamanac, B. (2024) · Journal of Medical Internet Research · doi:10.2196/52609 · Cited by 51 · see citing works
Psychometric validation of the Dysexecutive Questionnaire (DEX)
Shaw, S., Oei, T. P. S., & Sawang, S. (2015) · Psychological Assessment · doi:10.1037/a0038195 · Cited by 50 · see citing works
Mahoney, A., Elders, A., Li, I., David, C., Haskelberg, H., Guiney, H., & Millard, M. (2021) · Internet Interventions · doi:10.1016/j.invent.2021.100439 · Cited by 52 · see citing works
“…treatment adherence associated with guided iCBT is similar to that of face-to-face CBT (van Ballegooijen et al., 2014), some studies have shown that adherence to self-guided iCBT courses is lower than adherence to guided iCBT courses (Berger et al., 2011a; Berger et al., 2011b; Titov et al., 2008).”
Self-citationEffectiveness of computerised cognitive behaviour therapy for anxiety disorders in secondary care
Bell, C. J., Colhoun, H. C., Carter, F. A., & Frampton, C. M. (2012) · Australian & New Zealand Journal of Psychiatry · doi:10.1177/0004867412437345 · Cited by 50 · see citing works
“In comparison with other studies, particularly those of self-referred participants, there were high rates of psychotropic medication use (59% in comparison with 21–34% (Titov et al., 2008b)) and previous mental health treatment (71% in comparison with 30–40% (Titov et al., 2008b)).”
BackgroundResultInfluentialAydos, L., Titov, N., & Andrews, G. (2009) · Australasian Psychiatry · doi:10.1080/10398560903284943 · Cited by 49 · see citing works
Patient Expectations in Internet-Based Self-Help for Social Anxiety
Boettcher, J., Renneberg, B., & Berger, T. (2013) · Cognitive Behaviour Therapy · doi:10.1080/16506073.2012.759615 · Cited by 47 · see citing works
AL-Asadi, A. M., Klein, B., & Meyer, D. (2014) · Journal of Medical Internet Research · doi:10.2196/jmir.3513 · Cited by 40 · see citing works
“7 reported for other self-help online programs [36,47,48].”
Cougle, J., Wilver, N. L., Day, T. N., Summers, B. J., Okey, S. A., & Carlton, C. N. (2020) · The Behavior Therapist · doi:10.1016/j.beth.2019.05.009 · Cited by 42 · see citing works
McCall, H. C., Hadjistavropoulos, H. D., & Sundström, C. (2021) · Journal of Medical Internet Research · doi:10.2196/26939 · Cited by 39 · see citing works
“[89] a For the purpose of this table, n was calculated as the number of participants assigned to the intervention identified in each row plus the number of participants assigned to the control condition (ie, excluding participants assigned to use other interventions). b Study duration expressed in…”
MethodInternet-Based Course for the Management of Stress for Junior High Schools
van Vliet, H., & Andrews, G. (2009) · Australian & New Zealand Journal of Psychiatry · doi:10.1080/00048670902721145 · Cited by 40 · see citing works
Self-citation
- Authors
- Titov, N., Andrews, G., Choi, I., Schwencke, G., & Mahoney, A.
- Affiliations
- UNSW Sydney (AU)
- St Vincent's Hospital Sydney (AU)
- Corresponding author
- Titov, Nickolai
- Venue
- Australian & New Zealand Journal of Psychiatry
- Publisher
- SAGE Publications
- Published
- 2008-01-01
- Volume
- 42
- Issue
- 12
- Pages
- 1030-1040
- ISSN
- 0004-8674 (ISSN-L)
- 1440-1614
- OpenAlex
- W2003524081
- Cited by
- 221
- References
- 40
- Citations by year
- 2026: 2 · 2025: 7 · 2024: 10 · 2023: 7 · 2022: 6 · 2021: 14 · 2020: 7 · 2019: 9 · 2018: 10 · 2017: 9 · 2016: 16 · 2015: 15 · 2014: 22 · 2013: 16 · 2012: 22
- FWCI
- 21.13
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Australian & New Zealand Journal of Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Social Sciences › Psychology › Clinical Psychology › Psychological Treatments and Assessments
- Keywords
- social anxiety disorder, internet-based cognitive behavioral therapy, self-guided treatment, online forums, treatment completion, treatment acceptability
- MeSH terms
- Adolescent, Adult, Female, Humans, Male, Middle Aged, Outcome and Process Assessment, Health Care, Phobic Disorders, Psychometrics, Self Care, Shyness, Therapy, Computer-Assisted, Cognitive Behavioral Therapy, Internet, Electronic Mail, Young Adult
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