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Social Anxiety Disorder in Second Life

Erica Yuen's masters thesis defense on the use of Second Life to treat Social Anxiety Disorder at Drexel University.

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Cognitive Behavioral Therapy for Social Anxiety Disorder in Second Life Master’s Defense Meeting September 29, 2009 Presented by Erica Yuen
Social Anxiety Disorder (SAD) ,[object Object],[object Object]
Social Anxiety Disorder (SAD) ,[object Object],[object Object],[object Object],[object Object]
Treatment of SAD ,[object Object],[object Object],[object Object],[object Object],[object Object]
Treatment of SAD ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Barriers to receiving CBT ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

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Social Anxiety Disorder in Second Life

  • 1. Cognitive Behavioral Therapy for Social Anxiety Disorder in Second Life Master’s Defense Meeting September 29, 2009 Presented by Erica Yuen
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Editor's Notes

  1. - Will give a brief 15 minute overview of the project and then answer questions
  2. Excessive fears of being embarrassed and negatively evaluated by other people in social situations 2 subtypes: specific SAD – fear of performance situations such as public speaking, generalized SAD – fear of most social situations ranging from public speaking, group conversations, individuals conversations, initiating and maintaining conversations, dating, speaking with authority figures, etc. Costs: Decreased quality of life, social relationships, life satisfaction, occupational advancement, and financial independence; increased
  3. - Literature identifies the Lifetime prevalence rate as between 5-12%, and the 12 month prevalence rate as between 2 or 7% Bimodal pattern of onset Unremitting course, SAD does tend to remit without treatment Mean age for first receiving treatment make sure to go through this stuff really quickly. and of course don't read from slides -- the audience can see this stuff. So here, for example, just say something like "So as you can see, social anxiety disorder is very common, has an early onset, and follows a chronic and unremitting course.
  4. CBT is a general treatment category targeting changes in behavior and /or cognitions. Some examples of CBT components are…. Empirical research has found that exposure is the most important component in the tx of CBT. Exposure for SAD generally involves creating a fear hierarchy, which is a rank ordered list of feared social situations. Those social situations are then systematically confronted, both in session and for homework anxiety levels begin to decrease in the feared situations client also learns that it is possible to function and engage successfully in anxiety-provoking situation
  5. Several CBT protocols supported by research exist. What they all have in common is that exposure is the main treatment component Exposure exercises are done in session, with the clients participating in social interactions with confederates – these exposures are also referred to as roleplays Literature shows that the addition of cognitive restructuring to exposure does not lead to additional benefits over exposure alone for SAD Research doesn’t yet exist to show whether the addition of acceptance-based components, such as mindfulness meditation, leads to additional benefits over exposure alone. Research shows that individual and group therapy are equally effective And that there are high rates of relapse for pharmacological treatments when the medication is discontinued.
  6. Over 80% of individuals with SAD do not receive any treatment. Compare this with: GAD – 50%; Depression – 40% Commonly reported reasons for not seeking treatment….. Many of those in treatment do not receive empirically supported CBT interventions ABCT (association for behavioral and cognitive therapies) Therapist survey – 168 out of over 2000 clinicians treat SAD All but 1 of those therapists live in a metropolitan area; 1 lives in a micropolitan area Academy of Cognitive Therapy referral directory of certified cognitive therapists. Of all 457 therapists listed, only 14 of them, which is .03%, live in a nonmetropolitan area. Individuals in many parts of the country have limited access to CBT, especially in nonmetropolitan areas
  7. Metropolitan areas (dark green) are urban areas with a population of 50,000 or more, and includes nearby counties. Micropolitan areas (light green) are urban areas with a population of 10,000 or more, but less than 50,000, and includes nearby counties.
  8. Broadband internet connection, meaning Cable, DSL, or wireless, is becoming increasing more common in the United States and other countries. broadband internet connection in the home has been adopted by 60% of suburban residents (up from 49% in 2007), 38% of rural residents (up from 31% in 2007), and 57% of urban residents (up from 52% in 2007). Only 10% of Americans reported using the slower dial-up internet connection. dfs Research supports the effective of internet based self help interventions, which can increase the availability of CBT to those who do not have access to a CBT therapist or who are unwilling to see a therapist in person. Typical intervention would involve the client downloading and reading self-help modules and then having limited contact with a therapist through email and/or phone. Major disadvantage is the limited therapist interaction, no live conversations, and no in-session exposures where the clients can practice social interactions with others. internet-based therapy to be more effective than a wait list control for SAD (Andersson et al., 2006) Tillfors and colleagues (2008) found that internet-based therapy supplemented by a limited number of in-person group exposure sessions was not more effective than internet-based therapy alone Internet-based therapy was found to be equally effective as in-person CBT for panic disorder with and without agoraphobia (Carlbring et al., 2005) Adherance - This study added weekly telephone calls, which resulted in a considerably higher proportion of participants finishing the entire treatment package within the 9-week time frame, compared with a previous study (Andersson et al, 2006) conducted without telephone support (93% v. 62%). *****Research has shown internet-based therapy is more effective than WLC for SAD
  9. A number of studies have been conducted supporting the effectiveness of telephone therapy for a variety of difficulties including: OCD, depression, disability, smoking cessation, and alcohol dependence Disadvantages: May be more difficult for therapist and client to communication without seeing each other and exchanging nonverbal communication. Limited opportunities for in-session exposure exercises No opportunity for the client to be exposed to visual cues that produce SAD Having look at people’s facial expressions and body language Having their own facial expressions and body language observed by others
  10. CBT programs use VRT for in-session exposure exercises VR is an intermediate step to real-life exposure A major disadvantage of using VRT is that the exposure opportunities are limited to the scenarios specifically programmed into the software package. Another major disadvantage of VRT is the high cost of building and obtaining the equipment. Klinger and colleagues (Klinger et al., 2005) reported significant improvements for socially anxious participants (with both generalized and specific subtypes) who received 12 weeks of VRT that included the following scenarios: delivering a speech during a meeting, making small talk at a dinner party, walking down a street while being observed, conversing with a friend, telling a waiter there is a mistake with the bill, and being assertive with people who are criticizing the participant or blocking an exit. No statistically significant differences were found in the efficacy of treatment between the VRT condition and the group CBT condition which consisted of real-life in vivo exposure exercises integrated with cognitive therapy.
  11. These disadvantages were also relevant to a study we recently conducted for my masters thesis on delivering CBT for SAD through an online virtual environment called Second Life. Users create avatars to represent themselves and then control their avatar’s movements inside a virtual world. Therapy took place in a virtual therapy room. Therapist and client meet for 12 weekly 1-hr long sessions and were able to speak to each other in real-time, like on the telephone In-session exposures were conducted in virtual environments such as bars, conference rooms, offices, and houses. Results: significant improvements in social anxiety, depression, quality of life, and disability. Effect sizes were comparable to previously reported effects sizes for in-person CBT for SAD. Disadvantages – technical issues, communication difficulties (can’t see client), uncomfortable feelings. May have affected treatment outcome. In-session exposures – no exposure to anxiety provoking stimuli of facial expressions or body language of other people, or knowing that their own faces and body language were being observed. Therapists could not provide feedback to clients on nonverbal communication skills.
  12. - 12 one-hour sessions of individual weekly therapy - Assessments at pre-treatment, mid-treatment, and post-treatment
  13. Recruited across the United States US territories? No?
  14. Take the online QP after SCID interview but before orientation meeting in Second Life? Recruitment: http://www.socialanxietysupport.com/ , http://www.socialphobiaworld.com , forums on the Second Life website Readings (30-60 minutes): psychoeducational material – the nature of social anxiety, how common it is, the evolutionary function of embarrassment, how social anxiety is maintained (such as through avoidance or attachment to inflexible beliefs) Quiz – about 12 questions
  15. Confederate role players in therapy room or outside of therapy room Examples of common simulated exposures are for clients to: initiate and maintain individual or group conversations, give a speech to an audience, assert an opinion, conduct a meeting, and tell a personal story. The role players and client will also have the capability to control their avatar’s movements, body language, and facial expressions. In-session exposures may also occur inside Second Life with non-confederates. For example, the in-session exposure may consist of the client and therapist traveling to a dance club or shopping mall inside Second Life and initiating conversation with a stranger. Out-of-session exposure exercises in the real world will be given as homework assignments. When possible, out-of-session e Learn to become more accepting of anxiety Increase willingness to experience anxiety during exposure exercises, in order to live a meaningful live and accomplish their goals Learn to focus attention on the present moment and current social situation (instead of getting lost in anxiety thoughts and rumination) Mindfulness – is being aware of things going on externally and internally in the present moment, and doing so in an accepting nonjudgmental manner
  16. Very similar to existing SATP procedures
  17. SPAI- how anxious you feel in certain social situations. Ex) I feel anxious when in a large gathering with strangers (1-7 likert scale) LSAS – equal parts fear & avoidance in specific social situations FINE – How often worry about fear of negative evaluation.
  18. Both intent-to-treat (ITT) and completer-only analyses were conducted, and results were equivalent. In order to be conservative and to save space, only the ITT results are reported, other than in Table 3, which displays descriptive statistics for all outcome variables. The two participants who dropped out of treatment (after sessions 3 and 9, respectively) completed post-treatment questionnaires at the time of discontinuation. The Shapiro-Wilk test for normality found normal distributions in pre- to post-treatment difference scores for all measures. Because this is a pilot study to explore if implementing CBT using Second Life is even feasible, we are mindful of balancing concerns over Type I error with those regarding Type II error. Therefore, we elected not to adjust alpha to control for experiment-wise error. A power analysis program, G*power (Mayr, Erdfelder, Buchner, & Faul, 2007), calculated a power of .93 for a large effect size (Cohen’s d = 1.00) at α = .05 and n =14 for a paired samples t test. However, power is very low for the correlation analyses, due to small sample size.
  19. The dropout rate was 14% with 12 out of 14 participants completing treatment.
  20. Therapists reported moderate to severe technical problems for 39% of sessions (see Tables 8 and 9). Inability to transmit or receive sound through the headset was the most commonly reported technical problem (in 21% of sessions), on the client, therapist, or role player’s end; sometimes the microphone settings or headset volume was not adjusted properly, and other times the reason for difficulty was unknown. In 17% of sessions, poor sound quality was experienced, with voices garbled or cutting out in the middle of conversation, or “echoing” which is when one hears the sound of his or her own voice back through the headset. Due to technical difficulties with sound in Second Life, therapists reported instead using the telephone for all or part of the time in 27% of sessions; in one-third of those telephone sessions, therapists reported difficulties with the phone connection (unclear sound, losing connection, etc.). In 6% of sessions, clients experienced hardware or internet connection problems, such as being disconnected from Second Life, having a slow internet connection, having their computer freeze, etc. The greatest impact of all these technical difficulties included wasted time (ranging from a few minutes to 30 minutes), interrupted flow of the session, and difficulty in hearing what the other party was saying.
  21. Clinical significance was also examined by comparing the participants’ SPAI-SP scores at post-treatment with a cutoff point for clinically significant change, as suggested by Jacobson & Truax (1991), where the cutoff score equals the midpoint between the mean of the functional population and the mean of the dysfunctional population. To calculate the cutoff point, the values used were: Dysfunction population (adults with SAD): mean SPAI-SP score = 124.5; SD = 30.9 (Baker et al., 2002) Functional population (adults without SAD): mean SPAI-SP score = 78.49; SD = 26.43 (Osman et al., 1996) The calculated cutoff score on the SPAI-SP is therefore 101.5. All participants had pre-treatment SPAI-SP scores above the cut-off score, and 6 participants (43%) achieved a SPAI-SP score lower than the cutoff point at post-treatment. However, a more stringent test requiring a drop into the “normal range” and a 95% confidence that the amount of improvement exceeds zero ( > 46.71 SPAI points, according to Jacobson & Truax’s formula), indicated that only three clients (29%) achieved clinically significant change.
  22. Clinical significance was also examined by comparing the participants’ SPAI-SP scores at post-treatment with a cutoff point for clinically significant change, as suggested by Jacobson & Truax (1991), where the cutoff score equals the midpoint between the mean of the functional population and the mean of the dysfunctional population. To calculate the cutoff point, the values used were: Dysfunction population (adults with SAD): mean SPAI-SP score = 124.5; SD = 30.9 (Baker et al., 2002) Functional population (adults without SAD): mean SPAI-SP score = 78.49; SD = 26.43 (Osman et al., 1996) The calculated cutoff score on the SPAI-SP is therefore 101.5. All participants had pre-treatment SPAI-SP scores above the cut-off score, and 6 participants (43%) achieved a SPAI-SP score lower than the cutoff point at post-treatment. However, a more stringent test requiring a drop into the “normal range” and a 95% confidence that the amount of improvement exceeds zero ( > 46.71 SPAI points, according to Jacobson & Truax’s formula), indicated that only three clients (29%) achieved clinically significant change.
  23. Due to small sample size, power was very low for correlation analyses; therefore, these analyses are exploratory. Partial correlations were conducted between pre- to mid-treatment residual gain of hypothesized process variables and mid- to post-treatment residual gain in social anxiety level, controlling for pre- to mid-treatment residual gain in social anxiety level. No significant results were found, possibly due to low power (see Table 10 ).   Correlations were also conducted between pre- to post-treatment residual gain in hypothesized process variables and pre- to post-treatment residual gain in social anxiety symptoms. An increase in PHLMS-Acceptance residual gain scores was significantly associated with a decrease in Brief-FNE scores ( r =-.541, p =.046). Although other correlations were non-significant (see Table 11), possibly due to low power, many of the effect sizes were moderate. A pattern can be seen between pre- to post-treatment increases in acceptance, psychological flexibility, and defusion associated with pre-to post-treatment reductions in social anxiety (SPAI-SP, LSAS-Total, Brief FNE). The opposite can be observed with awareness; pre- to post-treatment increase in awareness is associated with pre- to post-treatment increase in social anxiety.   See table 10: I don’t think I can draw consistent conclusions from these results, even when taking into account effect size. The directions of the relationships are all over the place.   So, is this different than examining whether t2 process var predicts t3 outcome var, controlling for t1 process, t1 outcome and t2 outcome vars?   Not sure I understand the above comment.
  24. Correlations between baseline levels of theorized moderators of treatment (mindfulness, defusion, psychological flexibility) and residual change in social anxiety symptoms did not reach significance (see Table 6); however, due to small sample size, power was very low for correlation analyses. There was a trend for the association between higher baseline PHLMS-Acceptance scores and greater reduction in LSAS-Total scores ( r =-.472, p =.088), and for the association between higher baseline AAQ-II scores and greater reduction in LSAS-Total scores ( r =-.486, p =.078). Furthermore, there was an overall pattern of higher baseline levels of theorized moderators (acceptance, defusion, and psychological flexibility, but not awareness) moderately correlated with better treatment outcome.   Did you try a RM anova with time and moderator as IVs, and interaction effect being the one of interest? That seems more straightforward, and maybe more powerful.   I conducted the above analysis and did not find significant interactions.
  25. - Clients and therapists viewed this treatment modality as both acceptable and feasible, with some caveats. - Satisfied with treatment and therapist - Receiving treatment through Second Life was easy - Dropout rate no higher than rates for in-person treatment of SAD - However, technical problems were commonly encountered: improper settings for headset use, disruption in sound quality when using headsets, and poor telephone connection. The impact of these technical difficulties included wasted time (ranging from a few minutes to 30 minutes), disruption to the flow of the session, and difficulty hearing what the other party was saying. Particularly time-consuming was setting up role-plays whereby the confederate role-players commonly experienced technical difficulties. The time devoted to solving the technical difficulties resulted in less time available for in-session discussion and role-plays. Proper training Advancing technology Significant pre to post treatment improvements in social anxiety symptoms, depression, disability, and quality of life. Clinical significance, measured by clinician-rated improvement and effect sizes appear comparable to other studies delivering in-person tx for SAD. Davison and colleagues (2004) reported an ITT treatment response rate of 51.7% for CCBT, defined as having a CGI Improvement score of 1 or 2 (very much improved, or much improved, respectively). Heimberg and colleagues (1998) reported an ITT treatment response rate of 58% for CBGT, using similar criteria of having a rating of 1 or 2 (markedly or moderately improved) on the Social Phobia Disorders Severity and Change Form. Using the same criteria as Davison and colleagues (2004) , ITT treatment response rate for the current study was a comparable 57%.  Significant pre- to post-treatment changes were found in acceptance, defusion, and psychological flexibility; however, awareness (a component of mindfulness), did not change significantly from pre- to post-treatment. This suggests that change in awareness may not be necessary in the treatment of SAD with ABBT. Cardaciotto and colleagues (2008) found that higher levels of acceptance (a second component of mindfulness) is associated with less anxiety and depression, but that awareness is not always correlated with baseline psychopathology. Furthermore, in some cases, increasing awareness of internal experiences may actually increase psychopathology (Ayduk, Mischel, & Downey, 2002; Mor & Winquist, 2002; Nolen-Hoeksema, 1991), and greater self-focused attention is associated with higher levels of social anxiety (Perowne & Mansell, 2003). The current study found pre- to post-treatment increase in awareness to be associated to pre- to post-treatment increase in social anxiety, which supports the theory that increasing awareness may not be helpful in the treatment of SAD. The analyses did not find pre- to mid-treatment changes in hypothesized process variables (acceptance, awareness, defusion, psychological flexibility) to be consistently or significantly associated with mid- to post-treatment improvements in social anxiety symptoms. However power was very low in these correlational analyses due to small sample size. Furthermore, this analytical approach is problematic in that change in social anxiety may occur more immediately after change in the hypothesized process variables. In order to examine this possibility, session-by-session analyses of the relationship between mediators and outcome variables are needed. Results did find that pre-to post-treatment increase in acceptance was significantly associated with pre- to post-treatment decreased fear of negative evaluation, which is congruent with the growing literature finding that acceptance mediates treatment outcome in acceptance and commitment therapy (S. C. Hayes, Levin, Yadavaia, & Vilardaga, November 2007; S. C. Hayes et al., 2006). A pattern of moderate to high effect sizes were found in the correlation analyses between pre- to post-treatment residual gain in hypothesized process variables (acceptance, defusion, and psychological flexibility) and pre- to post-treatment residual gain in social anxiety level. Further research is needed to explore the roles of acceptance, defusion, and psychology flexibility as mechanisms of change in acceptance-based CBT. If these variables do mediate treatment outcome, then adjusting treatment protocol to emphasize increasing acceptance, defusion, and psychological flexibility may result in better outcomes. The analyses did not find significant results for moderators of treatment outcome, possibly due to low power; however, a trend was discovered for higher baseline acceptance, psychological flexibility, and defusion scores to be associated with greater reductions in social anxiety. This trend suggests that ABBT may work better for individuals who are initially higher in acceptance and psychological flexibility. Recent research suggests that acceptance-based interventions may be more effective for individuals with higher levels of baseline acceptance, and that control-based interventions may be more effective for individuals with lower levels of baseline acceptance (Blacker et al., 2009; Yuen et al., 2008). Choosing a treatment approach based on a specific client’s initial strengths or proclivities may therefore enhance treatment outcome. For example, a client with an initial tendency toward acceptance may adopt the acceptance-based strategies more easily than a client with a greater initial tendency toward cognitive control. Additional research needs to be conducted in this area in order to draw more definitive conclusions. A major strength of this study is that it explored remote treatment delivery through an easily accessible and free application that could be downloaded and installed on a personal computer, and allowed the long-distance delivery of state-of-the-art treatment to individuals with SAD. The majority of clients reported that setting up and using Second Life was easy to learn. Participants had the convenience of receiving treatment through Second Life while located in their own homes. Furthermore, a few of the participants occasionally received treatment while located at their work office, or at a hotel because they were traveling. Remote treatment in general also saves individuals the time and monetary cost of traveling to and from a therapy office. A major disadvantage to the treatment delivered through Second Life was that therapists and clients could not actually see each other; although each person’s avatar could be seen, the person’s actual face could not be viewed. The absence of the ability to see the other party’s face was most critical. Therapists and several clients anecdotally reported difficulties in communication and comfort level due to the lack of reciprocal visual feedback. Several clients reported feeling uncomfortable with revealing personal details to a therapist whose face they could not see. On the clients’ end, it is possible that the lack of visual feedback may result in feelings of disconnection from the treatment or therapist, thereby harming the working alliance. Therapists reported that conducting therapy was difficult without being able to view and interpret the clients’ body language and facial expressions. For example, when there were moments of silence in the conversation, the therapists were unable to view the clients’ facial expression to interpret whether they were confused, thinking, crying, etc., or whether a technical problem was the cause of the silence. Furthermore, therapists were unable to know whether the clients’ attention was focused fully on the therapy, or if they were simultaneously engaged in another task. In-session exposure exercises through Second Life were also limited in that the client was not exposed to real-life faces and body language from their conversation partners. For example, the client could not practice coping with anxious thoughts that result from interpretation of others’ facial expressions. The client was also unable to practice certain nonverbal social skills during in-session exposures. Therefore, therapists were unable to evaluate and provide feedback to the participants about their nonverbal social skills, such as eye contact, posture, and facial expression. In general, most clients reported feeling anxious during role-plays, which is necessary for exposure exercises to be effective. However a number of clients reported that being unable to see real-life people made the role-plays feel less realistic, and thus they were somewhat less engaged than they might have been otherwise. Despite the commonly encountered technical and communication difficulties, significant improvements in social anxiety, depression, disability, and quality of life did occur. Delivering CBT for SAD through the online medium of Second Life appears to be both efficacious and feasible. Most individuals with SAD do not receive treatment; those who do receive treatment may not receive an empirically supported exposure-based treatment. The distribution of CBT therapists is highly concentrated around metropolitan areas, leaving a notable portion of the country without convenient access to a therapist specializing in the empirically supported treatment for SAD. Anecdotally, several participants in the current study reported living in an area where access to therapists was difficult. Remote interventions, such as through Second Life, could potentially make exposure-based CBT available to individuals who otherwise would not have access to a competent CBT therapist, and to individuals unwilling to seek in-person treatment due to the severity of their social anxiety. Participants in the Second Life study had higher baseline social anxiety symptoms (see Table 13) compared to other studies which only enrolled individuals with generalized SAD (Dalrymple & Herbert, 2007; Davidson et al., 2004), as well as studies which enrolled individuals with a mixture of generalized and non-generalized SAD (Heimberg et al., 1998; Otto et al., 2000). This suggests that individuals with more severe symptoms may be more willing to seek treatment online than in person. A number of individuals with social anxiety do not seek treatment because they fear social interactions. Seeking treatment may involve making a phone call to set up the initial appointment, leaving their home and traveling to the therapist’s office, sitting in the waiting area (possibly with other patients), and then speaking to the therapist who is initially a stranger. This process may appear overwhelming for individuals with severe symptoms whereby the very nature of their disorder leads them to stay inside their homes for the majority of the time in order to avoid observation by others. Remote treatment removes some of these barriers, because individuals with SAD may be more willing to speak to a therapist from inside the security of their own home. Due to the visual limitations of Second Life, it is possible that delivering treatment through remote videoconferencing may provide additional benefits over using Second Life. Videoconferencing involves real-time video and audio transmission over the internet between two or more individuals located in different physical locations. A major advantage of videoconferencing therapy is that it allows for the exchange of non-verbal communication between client and therapist. Non-verbal communication may enhance the therapeutic relationship, allowing the therapist to observe whether the client is confused or preparing to say something during moments of silence, and provide opportunity for the therapist to assess the client’s social skills. Another major advantage of videoconferencing therapy is the opportunity to conduct exposure exercises whereby the clients can see the confederate role-players and vice versa. Viewing the role players’ facial expressions is anxiety-provoking social stimuli for the clients, which is conducive for the exposure exercises. The clients can be exposed to both friendly and unfriendly real-life facial expressions as they practice coping with anxiety during social interactions. Knowing that their own facial expressions and body language are being observed by others may induce additional anxiety in the clients during the exposure exercises. Furthermore, the therapist can provide feedback on eye contact, posture, and facial expressions, and clients would have the opportunity to practice these nonverbal social skills. However, it is possible that that clients with more severe SAD may be unwilling to communicate through videoconferencing, but willing to receive treatment through Second Life or telephone. A pilot study delivering ABBT through videoconferencing is currently being developed by the SATP. As technology advances and becomes increasingly more accessible to the public, additional opportunities for remote treatment will emerge. For example, treatment delivery through mobile handheld videoconferencing devices may one day be a viable option, allowing clients to receive therapy in any location within a wi-fi or cellular network. These technological advances may be an important key to increasing dissemination of empirically supported treatments to those in need.
  26. - Clients and therapists viewed this treatment modality as both acceptable and feasible, with some caveats. - Satisfied with treatment and therapist - Receiving treatment through Second Life was easy - Dropout rate no higher than rates for in-person treatment of SAD - However, technical problems were commonly encountered: improper settings for headset use, disruption in sound quality when using headsets, and poor telephone connection. The impact of these technical difficulties included wasted time (ranging from a few minutes to 30 minutes), disruption to the flow of the session, and difficulty hearing what the other party was saying. Particularly time-consuming was setting up role-plays whereby the confederate role-players commonly experienced technical difficulties. The time devoted to solving the technical difficulties resulted in less time available for in-session discussion and role-plays. Proper training Advancing technology Significant pre to post treatment improvements in social anxiety symptoms, depression, disability, and quality of life. Clinical significance, measured by clinician-rated improvement and effect sizes appear comparable to other studies delivering in-person tx for SAD. Davison and colleagues (2004) reported an ITT treatment response rate of 51.7% for CCBT, defined as having a CGI Improvement score of 1 or 2 (very much improved, or much improved, respectively). Heimberg and colleagues (1998) reported an ITT treatment response rate of 58% for CBGT, using similar criteria of having a rating of 1 or 2 (markedly or moderately improved) on the Social Phobia Disorders Severity and Change Form. Using the same criteria as Davison and colleagues (2004) , ITT treatment response rate for the current study was a comparable 57%.  Significant pre- to post-treatment changes were found in acceptance, defusion, and psychological flexibility; however, awareness (a component of mindfulness), did not change significantly from pre- to post-treatment. This suggests that change in awareness may not be necessary in the treatment of SAD with ABBT. Cardaciotto and colleagues (2008) found that higher levels of acceptance (a second component of mindfulness) is associated with less anxiety and depression, but that awareness is not always correlated with baseline psychopathology. Furthermore, in some cases, increasing awareness of internal experiences may actually increase psychopathology (Ayduk, Mischel, & Downey, 2002; Mor & Winquist, 2002; Nolen-Hoeksema, 1991), and greater self-focused attention is associated with higher levels of social anxiety (Perowne & Mansell, 2003). The current study found pre- to post-treatment increase in awareness to be associated to pre- to post-treatment increase in social anxiety, which supports the theory that increasing awareness may not be helpful in the treatment of SAD. The analyses did not find pre- to mid-treatment changes in hypothesized process variables (acceptance, awareness, defusion, psychological flexibility) to be consistently or significantly associated with mid- to post-treatment improvements in social anxiety symptoms. However power was very low in these correlational analyses due to small sample size. Furthermore, this analytical approach is problematic in that change in social anxiety may occur more immediately after change in the hypothesized process variables. In order to examine this possibility, session-by-session analyses of the relationship between mediators and outcome variables are needed. Results did find that pre-to post-treatment increase in acceptance was significantly associated with pre- to post-treatment decreased fear of negative evaluation, which is congruent with the growing literature finding that acceptance mediates treatment outcome in acceptance and commitment therapy (S. C. Hayes, Levin, Yadavaia, & Vilardaga, November 2007; S. C. Hayes et al., 2006). A pattern of moderate to high effect sizes were found in the correlation analyses between pre- to post-treatment residual gain in hypothesized process variables (acceptance, defusion, and psychological flexibility) and pre- to post-treatment residual gain in social anxiety level. Further research is needed to explore the roles of acceptance, defusion, and psychology flexibility as mechanisms of change in acceptance-based CBT. If these variables do mediate treatment outcome, then adjusting treatment protocol to emphasize increasing acceptance, defusion, and psychological flexibility may result in better outcomes. The analyses did not find significant results for moderators of treatment outcome, possibly due to low power; however, a trend was discovered for higher baseline acceptance, psychological flexibility, and defusion scores to be associated with greater reductions in social anxiety. This trend suggests that ABBT may work better for individuals who are initially higher in acceptance and psychological flexibility. Recent research suggests that acceptance-based interventions may be more effective for individuals with higher levels of baseline acceptance, and that control-based interventions may be more effective for individuals with lower levels of baseline acceptance (Blacker et al., 2009; Yuen et al., 2008). Choosing a treatment approach based on a specific client’s initial strengths or proclivities may therefore enhance treatment outcome. For example, a client with an initial tendency toward acceptance may adopt the acceptance-based strategies more easily than a client with a greater initial tendency toward cognitive control. Additional research needs to be conducted in this area in order to draw more definitive conclusions. A major strength of this study is that it explored remote treatment delivery through an easily accessible and free application that could be downloaded and installed on a personal computer, and allowed the long-distance delivery of state-of-the-art treatment to individuals with SAD. The majority of clients reported that setting up and using Second Life was easy to learn. Participants had the convenience of receiving treatment through Second Life while located in their own homes. Furthermore, a few of the participants occasionally received treatment while located at their work office, or at a hotel because they were traveling. Remote treatment in general also saves individuals the time and monetary cost of traveling to and from a therapy office. A major disadvantage to the treatment delivered through Second Life was that therapists and clients could not actually see each other; although each person’s avatar could be seen, the person’s actual face could not be viewed. The absence of the ability to see the other party’s face was most critical. Therapists and several clients anecdotally reported difficulties in communication and comfort level due to the lack of reciprocal visual feedback. Several clients reported feeling uncomfortable with revealing personal details to a therapist whose face they could not see. On the clients’ end, it is possible that the lack of visual feedback may result in feelings of disconnection from the treatment or therapist, thereby harming the working alliance. Therapists reported that conducting therapy was difficult without being able to view and interpret the clients’ body language and facial expressions. For example, when there were moments of silence in the conversation, the therapists were unable to view the clients’ facial expression to interpret whether they were confused, thinking, crying, etc., or whether a technical problem was the cause of the silence. Furthermore, therapists were unable to know whether the clients’ attention was focused fully on the therapy, or if they were simultaneously engaged in another task. In-session exposure exercises through Second Life were also limited in that the client was not exposed to real-life faces and body language from their conversation partners. For example, the client could not practice coping with anxious thoughts that result from interpretation of others’ facial expressions. The client was also unable to practice certain nonverbal social skills during in-session exposures. Therefore, therapists were unable to evaluate and provide feedback to the participants about their nonverbal social skills, such as eye contact, posture, and facial expression. In general, most clients reported feeling anxious during role-plays, which is necessary for exposure exercises to be effective. However a number of clients reported that being unable to see real-life people made the role-plays feel less realistic, and thus they were somewhat less engaged than they might have been otherwise. Despite the commonly encountered technical and communication difficulties, significant improvements in social anxiety, depression, disability, and quality of life did occur. Delivering CBT for SAD through the online medium of Second Life appears to be both efficacious and feasible. Most individuals with SAD do not receive treatment; those who do receive treatment may not receive an empirically supported exposure-based treatment. The distribution of CBT therapists is highly concentrated around metropolitan areas, leaving a notable portion of the country without convenient access to a therapist specializing in the empirically supported treatment for SAD. Anecdotally, several participants in the current study reported living in an area where access to therapists was difficult. Remote interventions, such as through Second Life, could potentially make exposure-based CBT available to individuals who otherwise would not have access to a competent CBT therapist, and to individuals unwilling to seek in-person treatment due to the severity of their social anxiety. Participants in the Second Life study had higher baseline social anxiety symptoms (see Table 13) compared to other studies which only enrolled individuals with generalized SAD (Dalrymple & Herbert, 2007; Davidson et al., 2004), as well as studies which enrolled individuals with a mixture of generalized and non-generalized SAD (Heimberg et al., 1998; Otto et al., 2000). This suggests that individuals with more severe symptoms may be more willing to seek treatment online than in person. A number of individuals with social anxiety do not seek treatment because they fear social interactions. Seeking treatment may involve making a phone call to set up the initial appointment, leaving their home and traveling to the therapist’s office, sitting in the waiting area (possibly with other patients), and then speaking to the therapist who is initially a stranger. This process may appear overwhelming for individuals with severe symptoms whereby the very nature of their disorder leads them to stay inside their homes for the majority of the time in order to avoid observation by others. Remote treatment removes some of these barriers, because individuals with SAD may be more willing to speak to a therapist from inside the security of their own home. Due to the visual limitations of Second Life, it is possible that delivering treatment through remote videoconferencing may provide additional benefits over using Second Life. Videoconferencing involves real-time video and audio transmission over the internet between two or more individuals located in different physical locations. A major advantage of videoconferencing therapy is that it allows for the exchange of non-verbal communication between client and therapist. Non-verbal communication may enhance the therapeutic relationship, allowing the therapist to observe whether the client is confused or preparing to say something during moments of silence, and provide opportunity for the therapist to assess the client’s social skills. Another major advantage of videoconferencing therapy is the opportunity to conduct exposure exercises whereby the clients can see the confederate role-players and vice versa. Viewing the role players’ facial expressions is anxiety-provoking social stimuli for the clients, which is conducive for the exposure exercises. The clients can be exposed to both friendly and unfriendly real-life facial expressions as they practice coping with anxiety during social interactions. Knowing that their own facial expressions and body language are being observed by others may induce additional anxiety in the clients during the exposure exercises. Furthermore, the therapist can provide feedback on eye contact, posture, and facial expressions, and clients would have the opportunity to practice these nonverbal social skills. However, it is possible that that clients with more severe SAD may be unwilling to communicate through videoconferencing, but willing to receive treatment through Second Life or telephone. A pilot study delivering ABBT through videoconferencing is currently being developed by the SATP. As technology advances and becomes increasingly more accessible to the public, additional opportunities for remote treatment will emerge. For example, treatment delivery through mobile handheld videoconferencing devices may one day be a viable option, allowing clients to receive therapy in any location within a wi-fi or cellular network. These technological advances may be an important key to increasing dissemination of empirically supported treatments to those in need.
  27. - Clients and therapists viewed this treatment modality as both acceptable and feasible, with some caveats. - Satisfied with treatment and therapist - Receiving treatment through Second Life was easy - Dropout rate no higher than rates for in-person treatment of SAD - However, technical problems were commonly encountered: improper settings for headset use, disruption in sound quality when using headsets, and poor telephone connection. The impact of these technical difficulties included wasted time (ranging from a few minutes to 30 minutes), disruption to the flow of the session, and difficulty hearing what the other party was saying. Particularly time-consuming was setting up role-plays whereby the confederate role-players commonly experienced technical difficulties. The time devoted to solving the technical difficulties resulted in less time available for in-session discussion and role-plays. Proper training Advancing technology Significant pre to post treatment improvements in social anxiety symptoms, depression, disability, and quality of life. Clinical significance, measured by clinician-rated improvement and effect sizes appear comparable to other studies delivering in-person tx for SAD. Davison and colleagues (2004) reported an ITT treatment response rate of 51.7% for CCBT, defined as having a CGI Improvement score of 1 or 2 (very much improved, or much improved, respectively). Heimberg and colleagues (1998) reported an ITT treatment response rate of 58% for CBGT, using similar criteria of having a rating of 1 or 2 (markedly or moderately improved) on the Social Phobia Disorders Severity and Change Form. Using the same criteria as Davison and colleagues (2004) , ITT treatment response rate for the current study was a comparable 57%.  Significant pre- to post-treatment changes were found in acceptance, defusion, and psychological flexibility; however, awareness (a component of mindfulness), did not change significantly from pre- to post-treatment. This suggests that change in awareness may not be necessary in the treatment of SAD with ABBT. Cardaciotto and colleagues (2008) found that higher levels of acceptance (a second component of mindfulness) is associated with less anxiety and depression, but that awareness is not always correlated with baseline psychopathology. Furthermore, in some cases, increasing awareness of internal experiences may actually increase psychopathology (Ayduk, Mischel, & Downey, 2002; Mor & Winquist, 2002; Nolen-Hoeksema, 1991), and greater self-focused attention is associated with higher levels of social anxiety (Perowne & Mansell, 2003). The current study found pre- to post-treatment increase in awareness to be associated to pre- to post-treatment increase in social anxiety, which supports the theory that increasing awareness may not be helpful in the treatment of SAD. The analyses did not find pre- to mid-treatment changes in hypothesized process variables (acceptance, awareness, defusion, psychological flexibility) to be consistently or significantly associated with mid- to post-treatment improvements in social anxiety symptoms. However power was very low in these correlational analyses due to small sample size. Furthermore, this analytical approach is problematic in that change in social anxiety may occur more immediately after change in the hypothesized process variables. In order to examine this possibility, session-by-session analyses of the relationship between mediators and outcome variables are needed. Results did find that pre-to post-treatment increase in acceptance was significantly associated with pre- to post-treatment decreased fear of negative evaluation, which is congruent with the growing literature finding that acceptance mediates treatment outcome in acceptance and commitment therapy (S. C. Hayes, Levin, Yadavaia, & Vilardaga, November 2007; S. C. Hayes et al., 2006). A pattern of moderate to high effect sizes were found in the correlation analyses between pre- to post-treatment residual gain in hypothesized process variables (acceptance, defusion, and psychological flexibility) and pre- to post-treatment residual gain in social anxiety level. Further research is needed to explore the roles of acceptance, defusion, and psychology flexibility as mechanisms of change in acceptance-based CBT. If these variables do mediate treatment outcome, then adjusting treatment protocol to emphasize increasing acceptance, defusion, and psychological flexibility may result in better outcomes. The analyses did not find significant results for moderators of treatment outcome, possibly due to low power; however, a trend was discovered for higher baseline acceptance, psychological flexibility, and defusion scores to be associated with greater reductions in social anxiety. This trend suggests that ABBT may work better for individuals who are initially higher in acceptance and psychological flexibility. Recent research suggests that acceptance-based interventions may be more effective for individuals with higher levels of baseline acceptance, and that control-based interventions may be more effective for individuals with lower levels of baseline acceptance (Blacker et al., 2009; Yuen et al., 2008). Choosing a treatment approach based on a specific client’s initial strengths or proclivities may therefore enhance treatment outcome. For example, a client with an initial tendency toward acceptance may adopt the acceptance-based strategies more easily than a client with a greater initial tendency toward cognitive control. Additional research needs to be conducted in this area in order to draw more definitive conclusions. A major strength of this study is that it explored remote treatment delivery through an easily accessible and free application that could be downloaded and installed on a personal computer, and allowed the long-distance delivery of state-of-the-art treatment to individuals with SAD. The majority of clients reported that setting up and using Second Life was easy to learn. Participants had the convenience of receiving treatment through Second Life while located in their own homes. Furthermore, a few of the participants occasionally received treatment while located at their work office, or at a hotel because they were traveling. Remote treatment in general also saves individuals the time and monetary cost of traveling to and from a therapy office. A major disadvantage to the treatment delivered through Second Life was that therapists and clients could not actually see each other; although each person’s avatar could be seen, the person’s actual face could not be viewed. The absence of the ability to see the other party’s face was most critical. Therapists and several clients anecdotally reported difficulties in communication and comfort level due to the lack of reciprocal visual feedback. Several clients reported feeling uncomfortable with revealing personal details to a therapist whose face they could not see. On the clients’ end, it is possible that the lack of visual feedback may result in feelings of disconnection from the treatment or therapist, thereby harming the working alliance. Therapists reported that conducting therapy was difficult without being able to view and interpret the clients’ body language and facial expressions. For example, when there were moments of silence in the conversation, the therapists were unable to view the clients’ facial expression to interpret whether they were confused, thinking, crying, etc., or whether a technical problem was the cause of the silence. Furthermore, therapists were unable to know whether the clients’ attention was focused fully on the therapy, or if they were simultaneously engaged in another task. In-session exposure exercises through Second Life were also limited in that the client was not exposed to real-life faces and body language from their conversation partners. For example, the client could not practice coping with anxious thoughts that result from interpretation of others’ facial expressions. The client was also unable to practice certain nonverbal social skills during in-session exposures. Therefore, therapists were unable to evaluate and provide feedback to the participants about their nonverbal social skills, such as eye contact, posture, and facial expression. In general, most clients reported feeling anxious during role-plays, which is necessary for exposure exercises to be effective. However a number of clients reported that being unable to see real-life people made the role-plays feel less realistic, and thus they were somewhat less engaged than they might have been otherwise. Despite the commonly encountered technical and communication difficulties, significant improvements in social anxiety, depression, disability, and quality of life did occur. Delivering CBT for SAD through the online medium of Second Life appears to be both efficacious and feasible. Most individuals with SAD do not receive treatment; those who do receive treatment may not receive an empirically supported exposure-based treatment. The distribution of CBT therapists is highly concentrated around metropolitan areas, leaving a notable portion of the country without convenient access to a therapist specializing in the empirically supported treatment for SAD. Anecdotally, several participants in the current study reported living in an area where access to therapists was difficult. Remote interventions, such as through Second Life, could potentially make exposure-based CBT available to individuals who otherwise would not have access to a competent CBT therapist, and to individuals unwilling to seek in-person treatment due to the severity of their social anxiety. Participants in the Second Life study had higher baseline social anxiety symptoms (see Table 13) compared to other studies which only enrolled individuals with generalized SAD (Dalrymple & Herbert, 2007; Davidson et al., 2004), as well as studies which enrolled individuals with a mixture of generalized and non-generalized SAD (Heimberg et al., 1998; Otto et al., 2000). This suggests that individuals with more severe symptoms may be more willing to seek treatment online than in person. A number of individuals with social anxiety do not seek treatment because they fear social interactions. Seeking treatment may involve making a phone call to set up the initial appointment, leaving their home and traveling to the therapist’s office, sitting in the waiting area (possibly with other patients), and then speaking to the therapist who is initially a stranger. This process may appear overwhelming for individuals with severe symptoms whereby the very nature of their disorder leads them to stay inside their homes for the majority of the time in order to avoid observation by others. Remote treatment removes some of these barriers, because individuals with SAD may be more willing to speak to a therapist from inside the security of their own home. Due to the visual limitations of Second Life, it is possible that delivering treatment through remote videoconferencing may provide additional benefits over using Second Life. Videoconferencing involves real-time video and audio transmission over the internet between two or more individuals located in different physical locations. A major advantage of videoconferencing therapy is that it allows for the exchange of non-verbal communication between client and therapist. Non-verbal communication may enhance the therapeutic relationship, allowing the therapist to observe whether the client is confused or preparing to say something during moments of silence, and provide opportunity for the therapist to assess the client’s social skills. Another major advantage of videoconferencing therapy is the opportunity to conduct exposure exercises whereby the clients can see the confederate role-players and vice versa. Viewing the role players’ facial expressions is anxiety-provoking social stimuli for the clients, which is conducive for the exposure exercises. The clients can be exposed to both friendly and unfriendly real-life facial expressions as they practice coping with anxiety during social interactions. Knowing that their own facial expressions and body language are being observed by others may induce additional anxiety in the clients during the exposure exercises. Furthermore, the therapist can provide feedback on eye contact, posture, and facial expressions, and clients would have the opportunity to practice these nonverbal social skills. However, it is possible that that clients with more severe SAD may be unwilling to communicate through videoconferencing, but willing to receive treatment through Second Life or telephone. A pilot study delivering ABBT through videoconferencing is currently being developed by the SATP. As technology advances and becomes increasingly more accessible to the public, additional opportunities for remote treatment will emerge. For example, treatment delivery through mobile handheld videoconferencing devices may one day be a viable option, allowing clients to receive therapy in any location within a wi-fi or cellular network. These technological advances may be an important key to increasing dissemination of empirically supported treatments to those in need.