“Talk to me”: A Self-applied Telepsychology Programme for Treatment of Fear of Public Speaking. Botella C. eHealth week 2010 (Barcelona: CCIB Convention Centre; 2010)

1. Improving Mental Health Care: an
Internet Delivered Program for the
Treatment of Social Phobia
C. Botella
Director of the Clinical Psychology Area
Universitat Jaume I (Spain)

2. Who we are
PSYCHOLOGY TECHNOLOGY
ITC applications in
Psychology

3. INTRODUCTION
Mental Disorders
CBT

4. INTRODUCTION
 Social Anxiety Disorder (SAD) has a high prevalence
between 7% and 13% (Furmark, 2002; Andrews,
Henderson & Hall, 2001; Kessler, Berglund, Demler, Jin &
Walters, 2005).
 SAD is usually associated to school phobia, separation
anxiety, and shyness.
 If it’s not correctly treated, the development of the disorder
can be chronic and produce important problems in the life of
the person.

5. INTRODUCTION
 Currently we have evidence based psychological
treatments (EBT) for SAD. Nevertheless:
- less of the 50% of people receive a correct treatment
- the cost and the time that require the treatment
- the lack of well prepared professionals.
- many patients decide do to not seek for help
That is, efficacious psychological treatments are not
available for both, practitioners and patients.

6. NEW WAYS OF DELIVERY CBT
One important challenge is to design new and more
cost-effective ways of delivering CBT
Reducing the contact between the patient and the
therapist by using self-help procedures
Using new technologies:
 Computer-aided treatments
 Virtual reality
 The Internet

7. INTERNET-BASED THERAPY
 Internet-based programs have been successfully applied to
the treatment of Social Phobia:
 Botella et., (2000, 2004)
 Anderson, et al., (2005, 2006)
 Carlbring, et al., (2006, 2007)
 Titov et al., (2008)
 Berger, Hohl, & Caspar (2009)

8. SELF-HELP AND THE INTERNET
 However, there are only 2 telepsychology programs in which the whole
treatment is self-administered:
“TALK TO ME” “WITHOUT FEAR”
 Fear of Public Speaking  Small Animal Phobia
 The feared scenarios are real  The feared scenarios consist of
videotaped audiences. a virtual environment.
 Its efficacy has been proven in:  Its efficacy has been proven in:
 a case study (Botella, Quero
 a case study (Botella, et al., in press),
Hoffmann & Moscovitch, 2004)  a series of 12 cases
 a series of 12 cases (Botella, (Botella, Quero et al., in
Guillén et al., 2007) press).
 In this presentation we will focus on TALK TO ME

9. Objective
 To compare the efficacy of a self-administered internet-
based program for the treatment of Social Phobia versus
the same program applied by the therapist.

10. Method: Sample
SOCIAL PHOBIA
 77 participants
 16 male (20.8%) and 61 female (79.2%)
 Mean age was 24.40 (SD=5.78) ranging from 18 to 48
 Educational level:
 73 university students (94.8%)
 3 went to high school (3.9%)
 1 went to primary school (1.3%)

11. Method: Sample
 Diagnosis:
 All participants met DSM-IV (APA, 1994, 2002) criteria for Social
Phobia.
 Exclusion criteria:
 Current alcohol or drug dependence
 Being in treatment for the same psychological problems
 Primary diagnosis of major depression
 Psychotic disorder
Subtype of social phobia:
 Specific social phobia: 29 participants (37.7%)
 Non generalized social phobia: 31 participants (40.3%)
 Generalized social phobia: 17 participants (22.1%)

12. Method: Design
 Between-group design
 Participants were randomly assigned to one of the
following experimental conditions:
Experimental Conditions
1. Therapist Administered (N=22)
2. Self-administered (N=30)
3. Waiting List (N=25)

13. Method: Measures
 Anxiety Disorders Interview Schedule for Social
Phobia (ADIS-IV; Brown, DiNardo, & Barlow, 1994)
 Target behaviours: Fear, Avoidance, and Belief in
the negative thought
 Brief version of the Fear of Negative Evaluation Scale
(BFNE; Leary, 1983)
 Social Avoidance and Distress Scale (SAD; Watson &
Friend, 1969)
 Fear of Public Speaking Questionnaire (FPSQ; Bados,
1986).

14. Method: system description
“Talk to Me”: a CBT Program Treatment
 Psychoeducation
 Cognitive restructuring
 Exposure:
Scenarios
• The oral presentation in front of a class
• The oral test
• The job interview
• The oral presentation at work
• The conference
• The wedding
Modulators: gender, number of people
 Relapse prevention

15. Method: system description
Trust and rapport
 “Talk to Me” introduces itself and states that its role is to
assess, guide and offer help
The program has an assistant: Dr. Net

16. Method: system description
Assessment

17. Method: system description
“Talk to Me”: a CBT Program Treatment
Treatment components:
1.-Psychoeducation

18. Method: system description
“Talk to Me”: a CBT Program Treatment
Treatment components:
2.-Cognitive Therapy

19. Method: system description
Treatment components: Exposure “The class”

20. Method: system description
Treatment components: Exposure “The Conference”

21. Method: system description
Treatment components: Exposure “The oral test”

22. Method: system description
Treatment components: Exposure “Project Presentation”

23. Method: system description
 The program has “barriers” between different parts of the
treatment: It is allowed to progress to the next task “only” if
the present task has been overcome.
 “Talk to Me” assesses the patient at pre-treatment, during
the treatment and after the treatment.

24. Talk to Me Target Behaviours
FEAR AVOIDANCE
9
9
8 8
7 7
6 6
5 5
4 4
3 3
2 2
1 1
0
0
pre post 12-month
pre post 12-month
follow-up
follow-up
Therapist Self-applied Waiting List
Therapist Self-applied Waiting List
F(2,76)=30.73 p<0.001 F(2,76)= 30.02 p<0.001
BELIEF IN CATASTROPHIC THOUGHT
10
8
6
F(2,76)= 28.69
4
2
p<0.001
0
pre post 12-month
follow-up
Therapist Self-applied Waiting List

25. Talk to Me Self-report questionnaires
Social Avoidance and Distress Fear of Public Speaking
Scale Questionnaire
50 60
40 50
40
30
30
20
20
10
10
0 0
pre post 12 months pre post follow up 12
follow-up
months
Therapist Self-applied Waiting List
Therapist Self-applied Waiting List
F(2,76)= 4.63 F(2,76)= 7.23
p<0.05 p<0.01

26. Talk to Me Self-report questionnaires
Brief version of the Fear of Negative Evaluation Scale
14
12
10
8
6
4
2
0
pre post follow up 12
months
Therapist Self-applied Waiting List
F(2,76)= 1.35
p=0.267

27. Conclusions
• Results offer support of the effectiveness of the Internet-
administered self-help program for the treatment of social
phobia.
• “Talk to me” was as effective as the same program applied
by a therapist.
• The treatment conditions were more effective than a waiting
list control group.
• The treatment program was effective not only at short-term
(post-test), but also at long-term (12-month follow-up).

28. Conclusions
Counseling/motivation Self-help therapy
3D environments Multimedia stimuli

29. The future
TELEPSYCHOLOGY AND MENTAL HEALTH:
 Reduction of costs
 Feared situations more available
 Higher control over feared context
 Possibility of overlearning
 Confidentiality and privacy
 A less aversive experience than in vivo exposure
New technologies, in this case the Internet, can allow a higher
number of people to have access to health programs and
resources:
- at home
- choosing the moment they prefer
- at their own pace

30. The future
CAN ICTs HELP TO IMPROVE QUALITY
OF LIFE AND WELLBEING?

31. The Butler project
Assistance and care Therapy
Social inclusion Leisure
A CONSOLIDER action project

32. THERAPEUTIC APPLICATION
The Butler project: Tools included
Virtual Reality
Environments
-Induction of joyful mood state
-Relaxation
Book of life
My memories:
– Images
–Sounds

33. THERAPEUTIC APPLICATION
2 Virtual environments to induce positive mood:
Therapeutic benefits
“Going to a relaxing place”
“Going to a joyful place”
They allow to induce positive
mood states (relax, joy)
The individual can learn useful
techniques to reduce negative
emotional mood states Relaxing sun rise
(relaxation, mindfulness…)

34. LUDIC APPLICATION
Butler: Tools included
“Write a letter” “Talk to someone” “Meet new people”
The access to communication using ICTs helps to::
- Promote social support, by helping to maintain the already present relationships (family,
friends, grandchildren…)
- Promote new relationships with other users of the Butler net.

36. ETIOBE: A CIBER action
• According to the International
Obesity TaskForce (EASO,
2002) governments should act
against childhood obesity ,
improving the evidence for
treatments.
• ETIOBE is an intelligent e-
therapy system (e-TI) for the
treatment of obesity,

37. ETIOBE is composed by 3 applications:
• Clinical support system (CSS)
• Home support system (HSS)
• Mobile support system (MSS)
Home support
system Clinical support
system
Mobile support
system

38. ETIOBE

39. The OPTIMI project
OPTIMI: Online Predictive Tools
for Intervention in Mental Illness
- Challenge 5: Towards Sustainable and Personalised Healthcare
- Objective ICT-2009.5.1: Personal Health Systems
 Mental Health care represents a third of the health care to
all EU nations.
 Depression and Stress related disorders are the most
common mental illnesses.

40. The OPTIMI concept
 Prevention of Depression and suicide is one of the
five points central focus points in the European Pact
for Mental Health and Wellbeing.
 OPTIMI: prediction, prevention
• is based on a PROACTIVE approach to
mental health and pretends lower costs and
higher levels of life quality

41. The OPTIMI project
CCBT Treatment
Beating the Blues
• Existing commercial software
approved by NICE
• Will be modified code and
content with OPTIMI
ETIOBE
• Existing e-therapy
treatment under trials in
Spain (schools, pediatric
services hospital , eating
disorder clinics)
• Will be modified code and
content with OPTIMI

42. The OPTIMI project

43. FUTURE PERSPECTIVES
This is the beginning of a new era in the
psychological treatments field: the evidence-
based CBT programs delivered using the
Internet.
At the present moment it is possible to
conclude that Internet-delivered CBT is useful
for the treatment of different disorders (at least
for some patients

44. FUTURE PERSPECTIVES
The prediction seems to be that the
Internet has come, and is going to stay,
and grow, and improve, more and
more in the coming years, helping us
to improve health care.