CYBERPSYCHOLOGY, BEHAVIOR, AND SOCIAL NETWORKING

Volume 13, Number 4, 2010

ª Mary Ann Liebert, Inc.
DOI: 10.1089=cyber.2009.0224

An Internet-Based Self-Help Treatment

for Fear of Public Speaking: A Controlled Trial
Downloaded from online.liebertpub.com by Ucsf Library University of California San Francisco on 01/14/15. For personal use only.

C. Botella, Ph.D.,1,2 M.J. Gallego, Ph.D.,1 A. Garcia-Palacios, Ph.D.,1,2 V. Guillen, Ph.D.,3

R.M. Baños, Ph.D.,2,4 S. Quero, Ph.D.,1,2 and M. Alcañiz, Ph.D.2,5

Abstract
Cyberpsychology, Behavior, and Social Networking 2010.13:407-421.

This study offers data about the efficacy of ‘‘Talk to Me,’’ an Internet-based telepsychology program for the
treatment of fear of public speaking that includes the most active components in cognitive-behavior therapy
(CBT) for social phobia (exposure and cognitive therapies). One hundred twenty-seven participants with social
phobia were randomly assigned to three experimental conditions: (a) an Internet-based self-administered pro-
gram; (b) the same program applied by a therapist; (c) a waiting-list control group. Results showed that both
treatment conditions were equally efficacious. In addition, Talk to Me and the same treatment applied by a
therapist were more efficacious than the waiting-list condition. Treatment gains were maintained at 1-year
follow-up. The results from this study support the utility of Internet-delivered CBT programs in order to reach a
higher number of people who could benefit from CBT. Internet-delivered CBT programs could also play a
valuable role in the dissemination of CBT.

Introduction The treatment of choice for social phobia is cognitive-

S ocial phobia, or social anxiety disorder, is a common
anxiety disorder.1 The clinical features of social phobia
include a wide number of situations, from specific fears such as
speaking, eating, or writing in public to more generalized fears
that appear in all or almost all social situations. This disorder
is very prevalent and chronic in adult populations,2–5 and it
can cause severe impairment in several life areas.6–9 Social
fears may extend to a broad range of situations but could also
be limited to specific settings. Heimberg et al.10 distinguished
three different social phobia subtypes: (a) generalized social
phobia: the fear of most social situations; (b) nongeneralized
social phobia: the fear of several social situations wherein the
person reports no problems in at least one social area; and (c)
discrete (or specific) social phobia: the fear of a limited number
of social situations (such as fear of public speaking).
Public speaking is the single most commonly feared situa-
tion reported in both community and university samples,11–15
with prevalence estimates from 20%11,14 to 34%.15 Although
not everyone with social phobia is afraid of speaking in public,
in this work, we focus on this discrete social phobia, which is a
high prevalent disorder.
behavior therapy (CBT) that combines exposure and cogni-
tive therapies.16,17 Despite the demonstrated efficacy of
CBT, fewer than 50% of people with social phobia receive
psychological treatment for it.18–20 A possible reason for
not seeking treatment is because people feel ashamed to do
so.21,22 Furthermore, many who receive treatment do not re-
ceive effective interventions.23 This may be due to mental
health practitioners’ difficulties with disseminating CBT.24
Apart from dissemination issues, CBT has other limitations,
including high cost and time investments, both of which
prevent many clients from receiving suitable treatment.
Therefore, one important challenge is to design new ways to
deliver CBT that are more cost effective.25
Self-help procedures could be an alternative method for
applying CBT, as they could both increase the number of
individuals able to be treated and reduce the contact time
between client and therapist.22,26–31 Approximately 80% of
psychotherapists recommend the use of self-help procedures
as an adjunct to psychotherapy.32 Glasgow and Rosen26,27
and Rosen33 reviewed the use of self-help procedures in be-
havior therapy and concluded that these procedures could be
effective for several disorders.

1
Universitat Jaume I, Castellon, Spain.
2
CIBER Fisiopatologia Obesidad y Nutrición (CB06=03), Instituto Carlos III, Spain.
3
Centro Clı́nico PREVI, Valencia, Spain.
4
Universidad de Valencia, Valencia, Spain.
5
Instituto de Bioingenierı́a y Tecnologı́a Orientada al Ser Humano, Universidad Politécnica de Valencia, Camino de Vera, Valencia, Spain.

407
 408
Several meta-analyses have been conducted supporting
the efficacy of self-help programs. The effect sizes estimated
for these treatments have been variable but relatively
large.28,30,34–37 Menchola et al.31 conducted a meta-analysis
controlling a number of limitations present in previous meta-
analyses. This review explored the efficacy of relatively pure
forms of self-help treatments for clinical samples suffering
Downloaded from online.liebertpub.com by Ucsf Library University of California San Francisco on 01/14/15. For personal use only.
depression or anxiety with minimal contact; it focused on
pretreatment and posttreatment assessments and periodic
contact to monitor progress. The results indicated that self-
help programs were more effective than control conditions
and placebo interventions. On the other hand, they produced
significantly lower levels of improvement than did therapist-
directed individual interventions. These authors concluded
that self-help procedures are valuable clinical tools that
clearly have a significant effect on anxiety and depression.
However, therapist-administered programs should be re-
commended in cases in which symptoms are clinically sig-
Cyberpsychology, Behavior, and Social Networking 2010.13:407-421.
nificant. Self-help programs remain both a useful therapeutic
component as an adjunct to traditional therapy and a valu-
able treatment option when no other interventions are
available, as the National Institutes of Health recommends.38
Also, several concerns have been raised about self-help
procedures.27,28,33 One is that the client usually has all of the
self-help information at his or her disposal (as opposed to a
system wherein each step in the program must be suitably
completed before advancing to the next step). This is one of
the main issues that guided the design of the self-help pro-
gram that we present in this work; the program does not
allow advancing to the next step until the previous one has
been completed.
New technologies can help to improve the delivery of CBT.
A number of computer-delivered programs have already
become important tools in the health system, such as Beating
the Blues, a program for depression and anxiety developed
by Marks and his team.39–41 Furthermore, the utility of tele-
psychology in the field of psychological disorders has been
acknowledged by authors in the field of CBT.32,42,43 Internet-
based programs are another method for reducing the contact
time between therapist and client. The main advantage is that
online therapy can reach people who might not otherwise
seek therapy (for instance, disabled people or those who live
in remote areas). In recent years, several studies have dem-
onstrated the efficacy of Internet-based programs on a variety
of problems,44,45 including eating disorders,46–48 posttrau-
matic stress and pathological grief,49,50 panic disorders,51
depression,52–54 severe headaches,55 tinnitus,39 insomnia,56
stress,57 and chronic pain.58
Regarding Internet treatment for social phobia, studies
comprise two groups according to the classification of Glas-
gow and Rosen:26 (a) Internet-based self-help programs with
therapist contact (by phone, e-mail, or infrequent meetings)
and (b) Internet-based self-help programs without therapist
contact in which the entire treatment is delivered over the
Internet. Andersson et al.59 conducted a controlled random-
ized study in which an Internet-based self-help program with
therapist contact via e-mail combined with two group expo-
sure sessions was more effective in treating social phobia than
was a waiting-list control. A limitation of this study is the
uncertainty over which treatment component was responsi-
ble for the outcomes given that the self-help procedure was
combined with two in vivo exposure sessions.
BOTELLA ET AL.
Because of the disadvantages in this study, Carlbring
et al.44 developed another one in which they administered the
same program including weekly therapist contact via e-mail;
however, the study did not include the group in vivo expo-
sure sessions. The results showed that participants improved
significantly from pretest to posttest and that these gains
were maintained at 6-month follow-up. The most relevant
limitation is that this study is an open trial without a control
condition.
Another related study, conducted by Carlbring et al.,60
focused on improving treatment adherence by adding short
weekly telephone calls. The study was a controlled ran-
domized trial in which their 9-week Internet-based self-help
program plus weekly phone calls was compared with a
waiting-list control group. The results showed that this
treatment was effective in treating social phobia and in im-
proving program adherence. Moreover, this improvement
was maintained after 1 year. A limitation of this study is that
the authors administered the clinical interview over the
telephone and the assessment was only based on self-report
measures. Another is that the participants were selected from
individuals who were interested in an Internet-based self-
help program, which is a biased selection method. Finally,
they did not include a comparison face-to-face treatment.
There is only one report of a telepsychology program that
is completely delivered over the Internet.61 This Internet-
based self-help program for the treatment of fear of public
speaking is called Talk to Me. The program uses videos of real
audiences (using the streaming technique) that simulate so-
cial situations using actors. One of the main features of this
program is the continuous assessment of the progress of the
user. The program presents the progressive treatment steps
only when the user is ready, with the goal of ensuring suitable
evolution throughout the process and avoiding therapeutic
failures. This program has shown preliminary efficacy in two
studies, a case study,62 and one single case series.63,64 These
studies showed that Talk to Me could be an effective therapy
for treating fear of public speaking. The aim of the present
work is to offer controlled data about the efficacy of Talk to
Me by comparing it with the same program applied face to
face by a therapist and a waiting-list control group. In addi-
tion to self-report measures, a behavioral avoidance test is
included. Both short-term and long-term efficacy data (1-year
follow-up) are presented.
Method
Recruitment and selection
The study was carried out at the Emotional Disorders Clinic
of the Universitat Jaume I and the University of Valencia.
Participants were recruited using advertisements on the uni-
versity campuses for a free psychological treatment for fear of
public speaking. The participants could contact the clinic via
phone or e-mail to obtain more information about the treat-
ment and the study. The selection of participants was achieved
by a face-to-face screening in which the psychologist assessed
the inclusion criteria described in the measures section.
To be included in the study, participants had to meet the
following criteria: (a) fulfill the DSM-IV-TR1 criteria for social
phobia; (b) be afraid of giving a public speech (measured by a
behavioral avoidance test); (c) be at least 18 years old; (d)
suffer the problem at least 1 year; (e) undergo no other psy-
 INTERNET SELF-HELP THERAPY
chological treatment during the study; (f) have social phobia
as a primary diagnosis if other disorders were present; (g) not
have a primary diagnosis of major depression; and (h) not be
diagnosed for substance abuse or dependence, psychosis, or
mental retardation.
Two assessment sessions were carried out by an experi-
enced psychologist to confirm the diagnosis of the participants
Downloaded from online.liebertpub.com by Ucsf Library University of California San Francisco on 01/14/15. For personal use only.
who fulfilled the inclusion criteria according to the initial
screening. In addition, half of the participants were reassessed
by independent assessors at pretreatment and at posttreatment
to confirm the diagnostic; because the diagnostic was identical
in all cases, we did not continue with this independent inter-
view with the second half of participants. After assessment, the
participants voluntarily signed the consent form.
Of the 176 people interested in the study, 152 were
screened. Seventeen of the 152 people who completed the
first interview were excluded because they did not meet
the inclusion=exclusion criteria (8 did not fulfill the DSM-
Cyberpsychology, Behavior, and Social Networking 2010.13:407-421.
IV-TR criteria for social phobia, 1 had mental retardation, 1
suffered from major depression, 3 were diagnosed for sub-
stance abuse, and 4 were undergoing another psychological
treatment), and 8 withdrew from the study before being as-
signed to an experimental condition.
Measures
Consent form. Participants read and signed a consent
form in which they accepted to participate in the research
project.
Admission interview.65 This interview was used in our
clinic to find out if the participants met the inclusion=
exclusion criteria. Apart from that, the instrument is used for
the differential diagnosis with other anxiety disorders.
Diagnostic interview. We used an adaptation of the An-
xiety Disorders Interview Schedule (ADIS-IV)66 from the so-
cial phobia section. This interview assessed social phobia
criteria from DSM-IV-TR,1 including the level of fear and
avoidance in different social situations, the severity of the
problem, and how long the participant had suffered from it.
Target behaviors.67 Participants rated the level of fear
and avoidance they had in several social situations on a scale
of 0 to 10 (0, no fear at all, I never avoid; 10, severe fear, I always
avoid). Each social situation corresponded to a different sce-
nario of the program. This measure was very important be-
cause it constructed a hierarchy for each participant while
conducting the exposure task. In addition, participants rated
their degree of belief in catastrophic thoughts related to the
target behaviors on a scale ranging from 0, I do not believe the
thought at all, to 10, the thought is totally true. In the data an-
alyses, we included the main target behavior chosen by the
participant. Avoidance related to the main target behavior
was also rated after each treatment session. In the self-applied
condition, the system asked the participant to rate avoidance.
In the therapist-applied condition, the therapist asked the
participant to do so.
Brief version of the Fear of Negative Evaluation Scale
(BFNE).68 This instrument assesses apprehension about
being negatively evaluated by others. It is composed of 12
items, which are rated on a scale of 1, not at all characteristic of
409
me, to 5, extremely characteristic of me. This questionnaire has a
high internal consistency (a ¼ 0.90–0.91) and a good test–
retest reliability at 4 weeks (r ¼ 0.75).68 We validated this
questionnaire in a clinical Spanish population and confirmed
the high internal consistency (a ¼ 0.90).69
Social Avoidance and Distress Scale (SAD).70 This
questionnaire measures distress and avoidance related to
social situations. It consists of 28 items rated as true or false.
This scale has excellent internal consistency (a ¼ 0.94) and
test–retest reliability (r ¼ 0.68).
Fear of Public Speaking Questionnaire (FPSQ). This
questionnaire was adapted from the instrument by Bados
called ‘‘Concern Regarding Speaking in Public.’’71 The FPSQ
measures the presence and intensity of several anxiety
symptoms when participants have to speak in public or they
think about the possibility of having to do so. It contains eight
items rated on a scale of 1 to 10 (1, I completely agree; 10, I
completely disagree). This measure has been validated in
Spanish populations and has shown good psychometric
properties, including a test–retest reliability of 0.92.71
Self-Statements During Public Speaking (SSPS).72 This
measure assesses self-statements and levels of discomfort
while someone is speaking in public. It contains 10 items
rated from 1, I completely disagree, to 5, I completely agree. This
instrument has two subscales: positive self-statements sub-
scale (SSPS-P) and negative self-statements subscale (SSPS-N).
Both subscales have excellent internal consistency (SSPS-P,
a ¼ 0.80; SSPS-N, a ¼ 0.86) and test–retest reliability (SSPS-P,
r ¼ 0.78; SSPS-N, r ¼ 0.80).72
Impromptu speech task.73 This is a behavioral assess-
ment test for socially anxious people that consists of an im-
promptu public speech in front of three people. The
participant chooses three general topics at random from a list.
The participant then has 3 minutes to prepare the speech and
must speak from 3 to 10 minutes. The participant reports his
or her level of fear during the task, and the therapist also
assesses it on a scale of 0, no fear at all, to 10, severe fear). The
participant and the therapist also assess the participant’s
performance on a scale of 1, very bad, to 7, excellent). Our
research group adapted this measure for Spanish.74
Clinician global impression, adapted from Guy.75 The
therapist assesses the global severity of the participant on a
6-point scale: 1, normal, 2, slightly disturbed, 3, moderately dis-
turbed, 4, quite disturbed, 5, severely disturbed, and 6, very seri-
ously disturbed.
Maladjustment Scale (MS).76 This questionnaire assesses
the level of impairment that the problem is causing in dif-
ferent areas of life (work, social, and global impairment) us-
ing 5-point scales (0, not impaired, 5, severely impaired). This
scale showed a high internal consistency (a ¼ 0.94).
Short form of Depression Inventory (BDI-13).77 This in-
strument measures depression and is composed of 13 items;
each item consists of four alternative statements graded from
0 to 3. The correlation between this version and the original
Depression Inventory78 was high (r ¼ 0.97). The cutoff scores
 410 BOTELLA ET AL.

are 0 to 4, no depression; 5 to 7, mild depression; 8 to 15, moderate
depression; and 16 or more, severe depression. We used a ver-
sion adapted for Spanish by Conde and Franch.79
Apparatus and software
The hardware used was a Pentium II (400 Hz, 256 MB of
Downloaded from online.liebertpub.com by Ucsf Library University of California San Francisco on 01/14/15. For personal use only.
an Internet-based self-administered treatment program for
fear of public speaking (n ¼ 62), (b) the same program applied
by a therapist face to face (n ¼ 36), and (c) a waiting-list
control group (n ¼ 29). As Figure 1 shows, the proportion of
participants assigned to the self-administered condition was
higher than in the other two groups (the ratio was 2:1) pri-
marily because another Internet-based treatment for so-

RAM, and 64 MB graphics card). Participants needed a

cial phobia also had a higher attrition rate (38%) than
monitor, a mouse, a keyboard, and a speaker. A modem for
therapist-administered treatments.80 After randomization,
Internet access was also necessary. For the presentation of
50 people (39.37%) voluntarily withdrew during the course of
many of the stimuli, we used the XML format. XML (eX-
the study. Attrition rate for the self-administered (SA) con-
tensible Markup Language) is a standard set by the World
dition was 51.61% (n ¼ 32), 38.89% (n ¼ 14) for the therapist-
Wide Web Consortium. XML allows expressing the entities
administered (TA) condition, and 13.79% (n ¼ 4) for the
composing the information in a structured, hierarchical way.
waiting-list (WL) control group. The most common reasons
Talk to Me incorporates video streaming, which makes it
for dropping out were having other more important obliga-
possible to watch and hear videos via the Internet in real time.
tions like university exams and having not enough time to
The requirements for the user are an Internet connection
dedicate to the treatment. Some participants also dropped out
and Microsoft Windows 98 or Microsoft Windows XP with
because they had doubts about the efficacy of the program,
Windows Media Player and Internet Explorer 5 or 6.
Cyberpsychology, Behavior, and Social Networking 2010.13:407-421.

and some because they felt better after a few sessions. We

Procedure
One hundred twenty-seven participants were randomly
assigned to one of the following experimental conditions: (a)
have postbaseline data of 35 of the 50 dropouts.
Participants allocated to the self-administered condition
were given a period of 2 months to complete the treatment,
which they could self-apply anywhere at any time. The par-

Assessed for eligibility

(n = 152)

Excluded (n = 25)

Not meeting inclusion criteria

(n = 17)
Refused to participate
(n = 0)
Other reasons
Randomized (n = 8)
(n = 127)

Internet-based Therapist- Waiting-list

treatment applied treatment control group
(n = 62) (n = 36) (n = 29)

Dropouts Dropouts Dropouts

(n = 32) (n = 14) (n = 4)

Posttreatment Posttreatment Posttreatment

assessment assessment assessment
(n = 30) (n = 22) (n = 25)

Lost to
follow-up Lost to
(n = 10) follow-up
(n = 3)
1-year 1-year No follow-up
follow-up follow-up assessment of
(n = 20) (n = 19) control group

FIG. 1. Participants’ progress through the trial: CONSORT diagram. More participants were assigned to the Internet-based
condition than to the other two groups; the ratio was 2:1
 INTERNET SELF-HELP THERAPY 411

Table 1. Diagnosis of Participants Using DSM-IV-TR Criteria for Social Phobia and Heimberg et al.
Criteria to Establish the Social Phobia Subtype at Pretest, Posttest and 1-Year Follow-up

Pretest % Posttest % Follow-up %

SA No SP 0 0 18 60 11 55
Specific SP 7 3.33 10 33.33 8 40
Nongeneralized SP 15 50 1 3.33 1 5
Downloaded from online.liebertpub.com by Ucsf Library University of California San Francisco on 01/14/15. For personal use only.

Generalized SP 8 26.67 1 3.33 0 0

TA No SP 0 0 14 63.64 14 73.68
Specific SP 9 40.91 6 27.27 3 15.79
Nongeneralized SP 7 31.82 2 9.09 2 10.53
Generalized SP 6 27.27 0 0 0 0
WL No SP 0 0 0 0 — —
Specific SP 13 52 14 56 — —
Nongeneralized SP 9 36 7 28 — —
Generalized SP 3 12 4 16 — —

SA, self-administered; TA, therapist administered; WL, waiting list; SP, social phobia.
Cyberpsychology, Behavior, and Social Networking 2010.13:407-421.

ticipants who did not have Internet access at home could self-
apply the treatment at the university in a room where they
had access from 8 a.m. until 10 p.m. Participants in the self-
administered condition did not have any contact with the
psychologist during the treatment, although they could
e-mail or telephone her if they had any problem with the
system. Regarding the therapist condition, participants had
two weekly sessions until the completion of the treatment,
which lasted 2 months. Those in the treatment conditions
were assessed at posttreatment (SA: n ¼ 30; TA: n ¼ 22) and at
a 12-month follow-up (SA: n ¼ 20; TA: n ¼ 19). Those in the
waiting-list control group were assessed when they asked for
help and 1 month afterwards (n ¼ 25) when they had the
chance to be treated.
The participants’ diagnosis is shown in Table 1. The more
prevalent diagnosis in the SA condition was nongeneralized
social phobia, while specific social phobia was more preva-
lent in the TA condition and the control group. Demographic
data are reported in Table 2.
Treatment
Both treatment groups received the therapy explained be-
low. The control group remained on a waiting list and did not
receive treatment during that time. The treatments were CBT
programs with the following components: education, cogni-
tive therapy, and exposure. We chose the most effective
components in CBT programs for social phobia following the
Task Force on Promotion and Dissemination of Psychological
procedures,25 last updated in 1998.81
Internet-based treatment. Talk to Me includes three
protocols: (a) an assessment protocol that assesses the par-
ticipant’s problem, including impairment, severity, and the
degree of fear and avoidance related to public speaking sit-
uations; the key assessment instruments of Talk to Me are
marked with an asterisk in the measures section; (b) a treat-
ment protocol structured in separate blocks reflecting the
participant’s progress, which helps prevent him or her from

Table 2. Participant Demographic Characteristics (n ¼ 77)

SA TA WL n (%)

Gender
Females 23 (76.7) 18 (81.8) 20 (80) 61 (79.2)
Male 7 (23.3) 4 (18.2) 5 (0) 16 (20.8)
Age
M (SD) 24.9 (6.41) 25.9 (6.61) 22.5 (3.44) 24.40 (5.78)
Range 18–41 18–48 18–34 18–48
Marital Status
Married=living together 5 (16.7) 2 (9.1) 0 7 (9.1)
Divorced 0 0 1 (4) 1 (1.3)
Single 25 (83.3) 20 (90.9) 24 (96) 69 (89.6)
Educational level
Elementary 0 1 (4.5) 0 1 (1.3)
High school 2 (6.7) 0 1 (4) 3 (3.9)
University degree 28 (93.3) 21 (95.5) 24 (96) 73 (94.8)

SA, self-administered; TA, therapist administered; WL, waiting list.

 412
skipping any step in the treatment; and (c) a control protocol
that assesses the treatment effectiveness at its conclusion and
at every intermediate step.
Treatment starts when the assessment is completed. Talk to
Me is a self-administered CBT for fear of public speaking
comprising education, cognitive restructuring, and exposure.
The educational component provides information about
Downloaded from online.liebertpub.com by Ucsf Library University of California San Francisco on 01/14/15. For personal use only.
the nature and physiological characteristics of anxiety, fear,
and phobias. The cognitive restructuring component teaches
users to identify and challenge negative thoughts related to
public speaking. The most important component is exposure,
which is explained in more detail shortly. After each block of
information is completed, the program presents questions
designed to ensure that the participant understands the in-
formation. If the participant does not answer them correctly,
he or she cannot progress to the next step and must read the
information again.
In the session before exposure, Talk to Me asks users to
Cyberpsychology, Behavior, and Social Networking 2010.13:407-421.
prepare a speech for the next session. The users choose
appropriate themes for specific scenarios, and the pro-
gram gives advice on adapting a theme for different situa-
tions.
The program is composed of five scenarios. Each scenario
incorporates a real videotaped audience in different public
speaking situations: classroom, oral exam, work meeting, and
group of friends. The various audiences behave in different
ways: listeners adopt positive (e.g., nodding), negative (e.g.,
appearing to be impatient), or neutral roles.
After the user prepares a speech, the program organizes a
hierarchy of public speaking scenarios that were created
during the initial assessment. The scenarios are presented
according to levels of fear, progressing from those less feared
to those more feared. The users confront situations of in-
creasing difficulty when they overcome the different scenar-
ios (demonstrated when the level of anxiety decreases at least
2 points). If the users’ anxiety does not decrease during the
scenario, they must repeat the exposure.
Before beginning exposure, Talk to Me reminds users of the
purpose of exposure, instructs them not to rely on safety or
avoidance behaviors, and recommends that they ‘‘stay in the
moment.’’ Another important instruction is to challenge
negative automatic thoughts related to the situation. In ad-
dition, the program reminds users to focus their attention on
positive (e.g., an audience member who is taking notes) or
neutral events rather than on negative events (e.g., an audi-
ence member who is not paying attention).
Talk to Me inquires about the degree of fear and avoidance
related to each scenario before and after every exposure ses-
sion. Users rate their degree of fear every 5 minutes, and the
program shows a graphic after the exposure with the evolu-
tion of their fear response.
Talk to Me provides different advice to users depending
on their level of fear upon finishing the exposure. If their
level of fear has diminished fewer than 2 points from the
beginning, the program recommends continuing the expo-
sure. When their level of fear has diminished 2 or more
points, Talk to Me presents them with a new situation. In
both cases, the system encourages the users to continue
working diligently to overcome their fear and congratulates
them for their effort. Talk to Me recommends that the users
enter the program and follow its instruction in the same way
that they complete daily homework assignments (for more
BOTELLA ET AL.
detailed information about Talk to Me, see Botella et al.62
and Botella et al.64).
Therapist-administered treatment program. Participants
in the live therapy condition received therapy once or twice
a week, depending on their availability. Treatment included
individual sessions lasting 45 to 60 minutes. This treatment
featured the same components as Talk to Me: education,
cognitive therapy, and exposure. However, an experienced
therapist rather than a computer administered the treatment.
The therapist presented the same treatment steps as the self-
help program. Regarding the length of the therapy, it de-
pended on the measure called target behaviors (adapted
from Marks and Mathews67), that is, the level of avoidance
and fear related to main situations they feared. The partici-
pants completed the treatment when they overcame each
social situation they feared. This was equal in the self-ad-
ministered condition.
Results
Dropout data
Fifty participants withdrew after randomization. We cal-
culated analyses of variance (ANOVAs) using whether or not
the participant dropped out as dependent variable and the
three experimental conditions as factors. We found significant
differences in the dropouts between conditions, F(2, 124) ¼
1.41, p < 0.005, and post hoc Tukey comparisons indicated
only significant differences between the waiting-list and the
self-administered treatment groups (lower bound ¼ 0.13,
upper bound ¼ 0.73, p < 0.005).
We have postbaseline data of 35 of the 50 dropouts. Those
35 participants went through at least one therapy session. In
each therapy session in both treatment conditions, partici-
pants rated the level of avoidance regarding the main target
behavior related to fear of public speaking. In the self-
administered condition, the program asked the user to rate
the level of avoidance related to the main target behavior at
the end of each therapy session. This was done by the ther-
apist in the therapist-administered condition. We used the
last rating as a postbaseline for those participants. We agree
with Marks et al.39 that where postbaseline data were not
available, carrying their pretherapy data forward assuming
that none had progressed could distract the results; because
of that, we included the last rating of the participants in one of
the main outcome measures: avoidance. In the 15 cases where
the postbaseline data were unavailable because they dropped
out right after randomization, baseline data were carried
forward to the posttreatment assessment.
Replacing missing values with the last observation available
of the full sample did not alter the good results of one of the
main outcome measure, avoidance. ANOVAs indicated a
significant time effect, F(1, 123) ¼ 70.33, p < 0.0001; a significant
group effect, F(2, 123) ¼ 3.93, p < 0.05; and a significant inter-
action effect, F(2, 123) ¼ 9.31, p < 0.0001. Post hoc Tukey
comparisons revealed a significant difference between the
self-applied program and the waiting-list condition (lower
bound ¼ 0.084, upper bound ¼ 2.51, p < 0.05). The differences
were also significant between the therapist-applied program
and the waiting list (lower bound ¼ 0.069, upper bound ¼ 2.77,
p < 0.05). There were no differences between the self-
administered and the therapist-administered conditions.
 INTERNET SELF-HELP THERAPY 413

Table 3. Means and Standard Deviations of the Variables Related to Social Phobia

Pretest Posttest FU-12

M SD M SD M SD

Fear (TB) SA 8.60 1.43 5.00 1.84 4.15 2.52

TA 8.95 1.21 4.82 2.04 4.05 2.15
Downloaded from online.liebertpub.com by Ucsf Library University of California San Francisco on 01/14/15. For personal use only.

WL 8.24 1.69 8.04 1.21

Avoidance (TB) SA 8.57 2.03 2.97 2.22 2.65 2.48
TA 7.95 2.66 3.36 2.40 2.89 2.62
WL 8.08 1.93 7.48 2.02
Belief (TB) SA 7.68 1.68 3.60 2.18 2.61 2.00
TA 7.64 2.04 3.59 2.09 2.89 2.09
WL 7.16 1.60 7.32 1.68
BFNE SA 42.80 9.32 39.88 10.80 34.00 7.80
TA 44.14 8.97 40.18 11.24 37.00 8.72
WL 44.42 9.99 45.33 8.63
SAD SA 12.17 6.86 7.67 5.81 5.83 5.27
Cyberpsychology, Behavior, and Social Networking 2010.13:407-421.

TA 11.66 6.35 8.29 5.14 5.28 4.44

WL 12.71 7.50 11.28 7.45
FPSQ SA 53.27 14.34 39.70 15.45 33.43 15.44
TA 50.45 11.86 39.32 12.97 34.61 18.52
WL 56.64 14.48 56.80 13.72
SSPS-P SA 13.23 5.37 15.55 5.10 16.41 5.26
TA 11.62 6.12 17.10 4.13 14.24 5.85
WL 13.13 5.20 13.83 4.66
SSPS-N SA 8.78 4.99 5.30 4.17 3.11 4.38
TA 11.45 6.38 5.15 5.72 4.29 4.51
WL 11.39 4.55 9.56 4.96
Anxiety (IST) P SA 6.83 2.25 4.17 2.33 2.83 2.33
TA 5.64 1.94 3.50 1.95 2.75 2.26
WL 5.95 2.44 5.85 1.84
Anxiety (IST) T SA 7.88 1.19 5.04 1.60 3.00 1.31
TA 7.23 1.38 4.73 1.28 2.63 1.85
WL 7.16 1.98 6.37 1.30
Performance (IST) P SA 3.35 1.11 4.17 0.98 4.50 0.90
TA 3.31 1.02 4.64 0.95 5.00 0.74
WL 3.20 1.06 4.00 1.26
Performance (IST) T SA 3.38 1.17 5.25 0.98 5.88 0.99
TA 3.41 1.40 5.50 0.91 5.63 0.74
WL 3.37 1.34 3.74 1.19

TB, target behavior; BFNE, brief version of the Fear of Negative Evaluation Scale; SAD, Social Avoidance and Distress Scale; FPSQ, Fear of
Public Speaking Questionnaire; SSPS-P, Self-Statements during Public Speaking–Positive subscale; SSPS-N, Self-Statements during Public
Speaking–Negative subscale; IST, impromptu speech task; P, participant; T, therapist; SA, self-administered; TA, therapist administered;
WL, waiting list.

Pretreatment comparisons Measures directly related to social phobia

Repeated ANOVAs and chi-squared tests for the depen-
dent variables at pretreatment were applied. Results did not
show differences among the three groups at the pretreatment
for any of the demographic and clinical variables.
Pretreatment and posttreatment comparisons
among the three experimental conditions
Tables 3 and 4 present means and standard deviations of
the different conditions at pretreatment, posttreatment, and
12-month follow-up. Table 5 displays the ANOVA results.
Table 6 offers the post hoc comparisons related to the inter-
action effects.
Multivariant analyses of the variance (MANOVAs) were
calculated for three different groups of dependent variables
that were significantly correlated: target behavior variables
(fear, avoidance, and belief in catastrophic thought), im-
promptu speech task variables (level of fear during the task
and performance assessed by the participant and the thera-
pist), and questionnaires related to social phobia (BFNE,
SAD, FPSQ, SSPS-P, and SSPS-N). Experimental condition
was used as an independent variable.
MANOVA for the target behavior variables revealed a
significant group effect, Wilks’s l ¼ 0.71, F(6, 134) ¼ 4.15,
p < 0.005. The time effect assessed was significant, Wilks’s
l ¼ 0.20, F(3, 67) ¼ 87.77, p < 0.001. Finally, MANOVA
 414 BOTELLA ET AL.

Table 4. Means and Standard Deviations of Measures of Maladjustment, Clinician Impression,

and General Psychopathology at Pretreatment, Posttreatment, and 12-Month Follow-up

Pretest Posttest FU-12

M SD M SD M SD

Social impairment SA 2.30 1.50 1.32 1.16 1.19 1.01

Downloaded from online.liebertpub.com by Ucsf Library University of California San Francisco on 01/14/15. For personal use only.

TA 2.68 1.53 1.77 1.24 1.13 1.20

WL 1.98 1.57 2.20 1.53
Work impairment SA 3.12 1.34 1.32 1.16 1.43 1.24
TA 3.00 1.24 1.77 1.24 0.97 0.89
WL 2.86 1.26 2.20 1.53
Global impairment SA 2.77 1.29 1.48 1.30 1.45 1.67
TA 2.70 1.32 2.02 1.17 1.00 0.91
WL 2.46 1.39 2.56 1.22
Clinician global impression SA 3.60 1.10 1.07 1.26 0.95 1.20
TA 3.36 1.43 0.91 1.19 0.79 1.36
WL 3.12 1.67 3.04 1.17
Cyberpsychology, Behavior, and Social Networking 2010.13:407-421.

BDI SA 5.07 0.96 2.79 3.33 2.81 BDI

TA 3.52 3.06 2.48 2.62 2.72
WL 5.04 4.39 4.21 3.21

BDI, Beck Depression Inventory; SA, self-administered; TA, therapist administered; WL, waiting list.

revealed a significant interaction effect, Wilks’s l ¼ 0.34, F(6,
134) ¼ 16.08, p < 0.001. Repeated ANOVAs revealed that
group effects were significant for the three variables fear,
avoidance, and belief in catastrophic thought as well as for
the time effect and interaction effect. Post hoc Tukey com-
parisons related to the interaction effect revealed that the SA
and TA conditions did not differ in any of these measures and
that participants in both treatments improved significantly
more than participants in the WL condition.
Regarding impromptu speech task variables, there was a
significant group effect, Wilks’s l ¼ 0.74, F(8, 116) ¼ 2.38,
p < 0.05; a significant time effect, Wilks’s l ¼ 0.28, F(4,
58) ¼ 37.31, p < 0.001; and a significant interaction effect,
Wilks’s l ¼ 0.51, F(8, 116) ¼ 5.80, p < 0.001. ANOVAs re-
vealed a significant group effect only for performance in the
impromptu speech task assessed by both the participant and
the therapist. The time effect was significant for all measures,
and the interaction effect was significant for all measures
except performance assessed by the participant. Post hoc
Tukey comparisons related to the interaction effect revealed
that the SA and TA conditions did not differ in any of these
measures and that participants in both treatments improved

Table 5. Repeated Measures ANOVA among the Experimental Conditions in Different Measures
from Pretest to Posttest

Group effect Moment effect Interaction effect

Measure F p Zp2 PO F p Zp2 PO F p Zp2 PO

Fear (TB) 8.76 0.000*** 0.19 0.97 143.37 0.000*** 0.66 1 30.73 0.000*** 0.45 1
Avoidance (TB) 10.57 0.000*** 0.22 0.99 166.18 0.000*** 0.69 1 30.02 0.000*** 0.46 1
Belief (CO) 9.34 0.000*** 0.21 0.97 99.66 0.000*** 0.59 1 28.69 0.000*** 0.45 1
BFNE 0.97 0.967 0.03 0.21 8.37 0.005*** 0.11 0.81 4.63 0.013* 0.12 1
SAD 0.65 0.653 0.02 0.15 29.08 0.000*** 0.31 1 1.35 0.267 0.04 0.28
FPSQ 6.95 0.002** 0.16 0.92 26.22 0.000*** 0.26 1 7.23 0.001** 0.16 0.93
SSPS-P 0.29 0.753 0.01 0.09 24.80 0.000*** 0.28 1 6.04 0.004** 0.16 0.87
SSPS-N 2.77 0.071 0.09 0.53 44.23 0.000*** 0.43 1 4.79 0.012* 0.14 0.78
Anxiety (IST) P 3.05 0.055 0.09 0.57 32.96 0.000*** 0.35 1 7.30 0.001*** 0.19 0.91
Anxiety (IST) T 2.17 0.123 0.07 0.43 102.67 0.000*** 0.62 1 9.38 0.000*** 0.23 0.97
Performance (IST) P 3.01 0.039* 0.10 0.62 27.81 0.000*** 0.31 1 .04 0.960 0.08 0.06
Performance (IST) T 0.50 0.010* 0.14 0.79 77.99 0.000*** 0.56 1 10.26 0.000*** 0.25 0.98
Social impairment 0.76 0.470 0.02 0.18 12.85 0.001** 0.15 0.94 6.35 0.003** 0.15 0.89
Work impairment 0.61 0.547 0.02 0.15 48.95 0.000*** 0.09 0.67 3.80 0.027* 0.40 1
Global impairment 0.83 0.441 0.02 0.19 18.51 0.000*** 0.20 0.99 8.25 0.001** 0.18 0.96
Clinician global impression 4.92 0.010* 0.12 0.79 214.01 0.000*** 0.74 1 48.97 0.000*** 0.57 1

TB, target behavior; BFNE, brief version of the Fear of Negative Evaluation Scale; SAD, Social Avoidance and Distress Scale; FPSQ, Fear of
Public Speaking Questionnaire; SSPS, Self-Statements during Public Speaking; IST, impromptu speech task; P, participant; T, therapist; BDI,
Beck Depression Inventory.
*p < 0.05; **p < 0.01; ***p < 0.001.
 INTERNET SELF-HELP THERAPY 415

Table 6. ANOVA from Pretest to Posttest; Condition by Time Interactions Post Hoc Analysis

Differences between Inferior limit Superior limit p<

Fear (TB) SA & WL
4.64 2.16 0.001

TA & WL
5.28
2.60 0.001
Avoidance (TB) SA & WL
6.57
3.43 0.001
TA & WL
5.69
2.29 0.001
Downloaded from online.liebertpub.com by Ucsf Library University of California San Francisco on 01/14/15. For personal use only.

Belief (TB) SA & WL
5.77
2.71 0.001

TS & WL
5.78
2.63 0.001
BFNE TA & WL
8.96
0.79 0.05
FPSQ SA & WL
22.73
4.72 0.005
TA & WL
21.02
1.57 0.05
SSPS-P TA & SA
6.97
0.08 0.05
TA & WL
8.81
1.53 0.005
SSPS-N TA & WL 1.44 8.27 0.005
Anxiety (IST) P SA & WL 4.23
0.87 0.005
TA & WL
3.73
0.34 0.05
Anxiety (IST) P SA & WL
3.24
0.85 0.001
TA & WL
2.93
0.49 0.005
Cyberpsychology, Behavior, and Social Networking 2010.13:407-421.

Performance (IST) P TA & WL 0.02 1.33 0.05

Performance (IST) T SA & WL 0.54 2.47 0.005
TA & WL 0.74 2.71 0.001
Social impairment SA & WL
2.08
0.33 0.005
TA & WL
2.08
0.18 0.05
Work impairment SA & WL
0.21
0.15 0.05
Global impairment SA & WL
2.20
0.57 0.001
Clinician global impression SA & WL
3.10
1.80 0.001
TA & WL
3.08
1.71 0.001

TB, target behavior; BFNE, brief version of the Fear of Negative Evaluation Scale; SAD, Social Avoidance and Distress Scale; FPSQ, Fear of
Public Speaking Questionnaire; SSPS, Self-Statements during Public Speaking; IST, impromptu speech task; P, participant; T, therapist.

significantly more than participants in the WL condition.
However, regarding the variable performance in the IST as-
sessed by the participant, there were only significant differ-
ences between the WL and TA conditions (see Table 6).
MANOVA for the questionnaires related to social phobia
did not reveal a significant group effect. There was a signif-
icant time effect, Wilks’s l ¼ 0.44, F(5, 48) ¼ 12.41, p < 0.001);
and a significant interaction effect, Wilks’s l ¼ 0.65, F(10,
96) ¼ 2.35, p < 0.05). ANOVAs revealed a significant group
effect only for FPSQ; a significant time effect for all measures;
and a significant interaction effect for all measures but the
SAD. Post hoc Tukey comparisons related to the interaction
effect revealed that the SA and TA conditions did not differ
and that participants in both treatments improved signifi-
cantly more than participants in the WL condition in the
majority of measures except BFNE and SSPS-N; in these
cases, there were significant differences only between the WL
and TA conditions (see Table 6).
Impairment measures and clinician global impression
Impairment in work and social areas, as well as global
impairment, were measured. The clinician also rated the
perceived impairment and severity of the participant (clini-
cian global impression).
MANOVA did not reveal significant group differences.
However, there was a significant time effect, Wilks’s l ¼ 0.23,
F(4, 71) ¼ 58.80, p < 0.001, and interaction effect, Wilks’s
l ¼ 0.39, F(8, 142) ¼ 10.59, p < 0.001).
ANOVAs showed a significant group effect in the clinician
global impression, although it was not significant for work,
social, and global impairment. However, time effects and
condition by time interactions were significant for all these
measures. Post hoc Tukey comparisons indicated that the
waiting-list group significantly differed from the treatment
groups in social impairment and clinician global impression
(Table 6). With regard to work and global impairment, there
were significant differences only between the SA and WL
conditions.
General psychopathology measures
The mean scores in the BDI were not clinically significant at
pretest, which means that our sample did not present clini-
cally significant depressive symptoms. Therefore, BDI scores
were not included in the analyses.
Follow-up comparisons for the two
treatment conditions
MANOVAs were applied using as dependent variables
groups of related measures, as done when calculating pretest
to posttest comparisons. The analyses were conducted from
posttest to 1-year follow-up for both treatment conditions.
ANOVAs were also applied for every dependent variable
between posttest and 1-year follow-up.
Measures directly related to social phobia
MANOVA for the target behavior variables did not reveal
a significant group, time, or interaction effect. Likewise,
ANOVAs did not show a significant group, time, or interac-
tion effect in any of the target behavior (see Table 7).
MANOVA for the impromptu speech task variables
revealed a significant time effect, Wilks’s l ¼ 0.28, F(4,
 416 BOTELLA ET AL.

Table 7. Repeated Measures ANOVA among the Experimental Conditions in Different Measures
from Posttest to 1-Year Follow-up

Group effect Moment effect Interaction effect

Measure F p Zp2 PO F p Zp2 PO F p Zp2 PO

Fear (TB) 0.05 0.834 0.00 0.05 4.03 0.052 0.10 0.50 0.11 0.918 0.00 0.05
Downloaded from online.liebertpub.com by Ucsf Library University of California San Francisco on 01/14/15. For personal use only.

Avoidance (TB) 0.00 0.968 0.00 0.05 1.85 0.182 0.05 0.26 0.31 0.583 0.01 0.08
Belief (CO) 0.02 0.893 0.00 0.05 3.70 0.063 0.10 0.46 0.34 0.562 0.01 0.09
BFNE 0.58 0.453 0.02 0.11 9.52 0.004** 0.22 0.85 0.39 0.539 0.01 0.09
SAD 0.09 0.769 0.00 0.06 15.42 0.000*** 0.31 0.97 3.48 0.071 0.09 0.44
FPSQ 0.23 0.637 0.01 0.08 4.06 0.051 0.10 0.50 0.15 0.698 0.15 0.07
PSSEQ 0.00 0.972 0.00 0.05 1.24 0.274 0.03 0.19 0.55 0.464 0.02 0.11
SSPS-P 0.22 0.643 0.01 0.07 1.89 0.178 0.06 0.27 3.28 0.080 0.09 0.42
SSPS-N 0.37 0.549 0.01 0.09 1.31 0.260 0.04 0.20 0.22 0.646 0.01 0.07
Anxiety (IST) P 0.76 0.392 0.03 0.13 2.15 0.16 0.09 0.29 4.06 0.056 0.16 0.49
Anxiety (IST) T 0.01 0.924 0.00 0.05 11.46 0.004** 0.45 0.88 0.29 0.594 0.30 0.09
Performance (IST) P 4.31 0.050 0.16 0.51 0.27 0.610 0.01 0.08 0.27 0.610 0.01 0.08
Performance (IST) T 0.32 0.579 0.02 0.08 5.44 0.035* 0.28 0.58 0.11 0.744 0.01 0.06
Social impairment 0.39 0.537 0.01 0.09 5.71 0.022* 0.13 0.64 2.36 0.133 0.06 0.32
Cyberpsychology, Behavior, and Social Networking 2010.13:407-421.

Work impairment 0.00 0.998 0.00 0.05 2.46 0.125 0.06 0.33 3.94 0.055 0.09 0.49
Global impairment 0.00 0.979 0.00 0.05 2.72 0.107 0.07 0.36 3.86 0.057 0.09 0.48
Clinician global impression 0.42 0.521 0.01 0.10 0.40 0.532 0.01 0.09 0.13 0.722 0.01 0.06

TB, target behavior; BFNE, brief version of the Fear of Negative Evaluation Scale; SAD, Social Avoidance and Distress Scale; FPSQ, Fear of
Public Speaking Questionnaire; SSPS, Self-Statements during Public Speaking; IST, impromptu speech task; P, participant; T, therapist.
*p < 0.05; **p < 0.01; ***p < 0.001.

11) ¼ 7.24, p < 0.005, although we did not identify a signifi-
cant group or interaction effect. Repeated ANOVA measures
revealed that the time effect was significant for the anxiety
reported by the participants and assessed by the therapist in
the IST and performance assessed by the therapist in the IST.
Regarding questionnaires related to social phobia, we
identified a significant time effect, Wilks’s l ¼ 0.36, F(5,
19) ¼ 6.77, p < 0.005, although we did not find a group or
interaction effect. ANOVAs revealed a significant time effect
only for the BFNE and the SAD; they did not reveal a group
or interaction effect.
Impairment measures and clinician global impression
We carried out a MANOVA for the impairment-related
variables (work, social, and global impairment) and clinician
global impression. In this analysis, we did not find a group,
time, or interaction effect. ANOVAs did not show a signifi-
cant group or interaction effect; they showed a significant
time effect only for the social impairment.
Diagnosis
We also used the Heimberg et al.10 criteria to determine
the social phobia subtype at pretest, posttest, and 1-year
follow-up. Table 1 shows that both treatment groups im-
proved their diagnosis after the treatment and at 1-year
follow-up. In the SA group, 60% at posttest and 55% at
follow-up no longer met the social phobia criteria. In the TA
group, 63.64% at posttest and 73.68% at follow-up no longer
met social phobia criteria. These changes did not occur in the
control condition.
Discussion
Present findings support the idea that it is possible to ef-
fectively use procedures such as Talk to Me, which are en-
tirely self-administered via the Internet, for the treatment of
the discrete social phobia of fear of public speaking. The data
showed significant differences from pretreatment to post-
treatment in important measures of fear of public speaking in
both treatment conditions (self-administered and therapist-
administered) as compared to a waiting-list control group.
The results achieved by Talk to Me were similar to those
achieved when the same program was applied by a therapist.
Regarding measures directly related to fear of public
speaking, there were statistically significant differences in
fear, avoidance, and belief in catastrophic thoughts related to
target behavior and in self-report questionnaires measuring
fear of public speaking (FPSQ), positive verbalizations
related to social phobia (SSPS-P), anxiety in the speech task
(IST) assessed by the participant and the therapist, and per-
formance assessed by the therapist. Regarding fear of nega-
tive evaluation (BFNE), negative verbalizations (SSPS-N),
and performance in the IST assessed by the participant, post
hoc analyses revealed significant differences only between
therapist-administered and waiting-list conditions. However,
scores in BFNE and SSPS-N at posttest were similar in both
treatments and were similar to those of a normal population.
This was noted in the other measures as well; the scores at
posttest and follow-up were similar to those of normal
populations.
Regarding the impairment measures and clinical global
impressions, both treatment condition scores significantly
decreased at posttreatment compared with the WL group.
However, for work and global impairment, there were sig-
nificant differences only between the SA condition and the
WL condition. This may be due to participants having to
make an extra effort to self-apply the treatment, which could
have fostered self-efficacy.
An outstanding result was that the outcomes achieved
in both treatment conditions were maintained at 12-month
follow-up. Therefore, the treatments were shown to be
 INTERNET SELF-HELP THERAPY
effective in the short and long term. The only significant
difference between both treatment groups was in the per-
formance assessed by the participant, in which case the TA
group improved more than the SA group.
Another important result is the changes in diagnosis after
treatment completion. In the SA group, 60% at posttest and
55% at follow-up no longer met social phobia criteria. In the
Downloaded from online.liebertpub.com by Ucsf Library University of California San Francisco on 01/14/15. For personal use only.
TA group, 63.64% at posttest and 73.68% at follow-up no
longer met social phobia criteria. Although the TA treatment
produced higher percentage changes than the SA program, it
is significant that a program administered without a therapist
assisted 50% of participants in overcoming the social phobia
criteria.
A relevant question is to what degree telepsychology is
accepted as a new way of applying therapy. Results regard-
ing this issue have been reported elsewhere82 and are sum-
marized here. Participants in both treatment groups reported
a high satisfaction with the treatment and thought that the
Cyberpsychology, Behavior, and Social Networking 2010.13:407-421.
treatment was logical and useful for their problem and for
other problems. There was a statistically significant difference
only between the treatment conditions. Participants in the TA
group considered the program slightly more aversive than
the participants in the SA condition. This result seems logical
given that the presence of a therapist during exposure could
be an aversive element for an individual with social phobia. It
is worth considering this phenomenon; for some social pho-
bics, it may be less threatening to interact with a program
such as Talk to Me that enables exposure to occur in isolation.
From this starting point, individuals could more comfortably
progress to more anxiogenic stimuli, such as the presence of a
therapist or other people. The results suggest that programs
like Talk to Me could increase the motivation and willingness
of people to begin an exposure program.
In short, Talk to Me, a self-help, completely Internet-
delivered program, presented a similar efficacy to the same
treatment applied by a therapist, and both treatment condi-
tions were more efficacious than a waiting-list control group.
Furthermore, treatment gains were maintained at the 12-
month follow-up. These findings support the preliminary
data found in a case study62 and one single case series.64
This study offers similar results to those done in the field of
Internet-based treatments for social phobia.59,80 There are
several differences between our study and the ones con-
ducted by Andersson’s team. Our program is totally self-
administered by the participant, whereas the Andersson
program established minimal contact with a therapist in the
open trial (but included two in vivo exposure sessions in the
controlled trial, or two 3-hour group sessions with two
therapists). Also, all of the participants in Andersson’s study
(including the waiting-list condition) participated in an online
discussion. The authors acknowledged that this could have
affected the waiting-list condition given that 37.5% of those
participants achieved a clinically significant change. If the
online discussion affected the waiting-list condition, it is
possible that this also affected the treatment group. In this
case, the online discussion could be considered another active
ingredient of the program. Furthermore, Andersson et al.59
advertised an Internet-administered self-help program,
which is a biased selection method; our treatment was offered
without specifying that it was delivered via the Internet.
Furthermore, Andersson et al. used only self-report instru-
ments, whereas we also included a behavioral avoidance test;
417
finally, their study did not include a comparison face-to-face
treatment, whereas ours did.
An important issue in this line of research is the adherence
and attrition rates in the programs. In our study, the SA
group had a higher dropout rate (51.61%) than other studies
in the area of Internet-based treatments and social pho-
bia.59,60,80 This could be a threat to the internal validity of the
study. Currently, we are working to decrease the dropout
rate in order to achieve the same rates obtained by the CBT
programs for social phobia administered by therapists, which
are approximately 18% for cognitive therapy plus exposure,
16.4% for exposure only, and 12.2 % for cognitive therapy
only.83 One method of diminishing the number of dropouts
could be incorporating new technologies such as e-mail, text
messages, or telephone calls to encourage participants to
enter the program and motivate them to continue until
treatment completion.
Andersson et al.59 applied an Internet-delivered program
that was combined with two group exposure sessions and
minimal therapist contact via e-mail; the attrition rate was
very low in that case (6.25%). Carlbring et al.80 used an In-
ternet-based treatment for social phobia plus contact with the
participants via e-mail, and 38% of the participants failed to
finish the whole treatment within 9 weeks. The same research
group tried to improve treatment adherence through weekly
telephone calls, and the attrition rate decreased to 7%.60
Therefore, at least for social phobia, maintaining contact with
the client face to face or by new technologies appears to be a
good strategy to decrease dropout rates. It may be more ef-
fective to use the telephone rather than e-mail, but other
methods, such as text messages through the cell phone, might
have comparable effects.
Another approach to reducing attrition is to increase the
amount of time participants are allowed to work with the
treatment materials and procedures. Andersson et al.59 ex-
plored this area with different results. They indicated that
most participants in their study reported needing more time
than given to complete each treatment module. However,
they also stated that increasing the amount of time could have
limitations.51 One possible alternative is to reduce the infor-
mation included in each module and increase the number of
modules in order to allow participants more time in which to
practice in vivo exposure. We think it is important to consider
ways of customizing treatment for each individual. Maybe it
is not a question of less or more treatment time but of how
much treatment each individual needs. Finally, participants
could receive a benefit for completing the program; for in-
stance, those on a waiting list could be treated by a therapist
when they finish the program. This would be very useful in
the public mental health system, where waiting lists are often
long.
The attrition rate for the TA treatment condition in our
study was also high (38.89%) and far from the attrition rates
reported in Taylor.83 One possible explanation is that the
therapist had instructions to follow the exact steps as in Talk
to Me and to avoid giving additional indications. Perhaps this
made the behavior of the therapist excessively rigid and less
like what a therapist would do in a traditional face-to-face
treatment. These results indicate that work is needed in order
to reduce the dropout rates and that dropout rates are related
to the type and quality of care therapists give to clients. We
believe this is an important line of research to follow in the
 418
future: on one hand, designing and testing different ways to
support and encourage participants throughout the thera-
peutic process and, on the other hand, making these support
strategies available using new technologies.
In our study, there are several methodological weaknesses
related to the sample. The participants were young; the mean
age of the sample was 24.40 years. Most participants were
Downloaded from online.liebertpub.com by Ucsf Library University of California San Francisco on 01/14/15. For personal use only.
female (79.22%). And in parallel with other Internet-based
treatment studies,59,84 the level of education of the sample
was higher than that of the general population. Another
limitation is that we do not know which component or
components were the most efficacious, given that all partici-
pants received the same program. It would be instructive to
investigate this issue in future studies. We note that the same
therapist applied the treatment to all participants in the
therapist-administered condition. Finally, although many
participants conducted the treatment in their houses, some
conducted it at the university because they did not have In-
Cyberpsychology, Behavior, and Social Networking 2010.13:407-421.
ternet connection in their homes. It is important to indicate
the threats to internal validity that may be present, such as
regression to the mean. This type of error occurs when par-
ticipants are selected on the basis of extreme scores (one far
away from the mean) during a test. Improvements at the end
of the program might be due to regression toward the mean
and not due to treatment efficacy. However, in our study, we
incorporated different kinds of measures to explore changes in
key features of social phobia, including a performance test. We
also included measures rated by clinicians and not only by the
participants. Also, the scores at posttest and follow-up in many
variables were similar to those of normal populations; that
is, the participants achieved not only a statistically significant
change but also a clinically significant improvement.
Results from the last meta-analysis conducted by Mench-
ola et al.31 indicated that although self-help can be a useful
clinical tool for treating simple psychological problems, self-
help without therapist contact could be insufficient for more
severe disorders such as depression or anxiety. This may limit
who can benefit from self-help procedures. Rapee et al.85
randomized severe social phobics to a pure bibliotherapy
condition, an augmented self-help condition by therapist as-
sistance, a standard group treatment, and a waiting-list con-
trol group. These authors did not find significant differences
between the self-help augmented condition and the standard
group therapy. Regarding the pure bibliotherapy group,
these conditions showed limited efficacy for severe social
phobia. However, even in severe cases, self-help could be
useful for enhancing personal self-efficacy. Self-help proce-
dures could be very valuable to people who live in remote
areas or for whom it is difficult to access traditional face-to-
face treatments (e.g., incarcerated people, hospital inpatients).
Related to this is the question of the feasibility of applying a
self-help program via the Internet. The combination of new
technologies with self-help materials appears to be a promising
alternative to other treatments and can help overcome some of
the problems related to the delivery of effective treatments in
mental health. Self-help telepsychology programs offer a series
of advantages: (a) They are less time-consuming than contact
with a mental health professional. (b) They significantly reduce
travel time, reaching individuals who live in remote areas. (c)
The scheduling flexibility (available any time during the week,
on holidays, and day or night) makes it easier to reach a higher
number of people. (d) Receiving treatment at home assures a
BOTELLA ET AL.
high degree of confidentiality and minimizes the stigma re-
lated to receiving mental health care.86 Of course, the needs of
each client may be different. Each individual requires different
components and could therefore choose different components
and work on them at his or her own pace. Self-help tele-
psychology programs can be understood as a complement to
already available treatment programs. At the very least, In-
ternet treatments can reach many people who would otherwise
be unable to access other treatment alternatives. Regarding
this point, we would like to address the issue of dissemination
of evidence-based treatments. In recent years, the applicability
of standardized and manualized evidence-based treatments to
everyday clinical practice has been questioned.87,88 In the case
of social phobia, it has been demonstrated that the treatment
effects achieved in well-controlled studies such as randomized
controlled trials are generalizable to the clinical population
who seek help.24 New technologies, such as interactive Web
sites, could help solve the problem of treatment dissemination
and could also help clinicians learn more about these treatment
programs and to get training via the Internet.89
As we mentioned in a former study,64 it is important to
highlight ethical concerns regarding the use of the Internet for
delivering psychological treatments. Several authors have
remarked upon ethical issues such as the necessity of using
well-protected passwords when using the Internet, the dan-
ger of hackers, the risk of using real identities, the need for
safe methods to protect confidentiality, and the importance of
eliminating participants’ biographical information from the
databases.48,50 We addressed these issues in our program: we
protected confidentiality by using passwords chosen for each
participant that nobody else knew, and we protected assess-
ment data by restricting access to them to the researchers.
There are several related subjects of interest for future re-
search. First, it is important to improve adherence and to
solve the problem of attrition. This is linked to delimiting how
much contact is needed with the therapist and which type of
contact is best (telephone, e-mail, chat, SMS, etc.). Second, it is
necessary to compare the Internet self-administered program
with CBT programs. Third, future studies must include a
higher number of participants, which is easily done with the
Internet, in order to study who benefits from the program and
who does not. Fourth, a central research question is how to
conduct exposure more effectively; for example, programs
could give detailed instructions for conducting self-exposure
or could conduct exposure supported by a cotherapist. Fi-
nally, in order to study which is the best way to apply ex-
posure, we must explore whether it would be convenient to
conduct an initial exposure session with a therapist (via
webcam or chat) followed by self-help; it may be that the
session with the therapist is unnecessary.
In summary, the combination of new technologies and self-
help procedures could be a useful clinical tool for the treat-
ment of discrete social phobia. We believe this combination
could also be useful for the treatment of other psychological
disorders, and we encourage research in this area.
Acknowledgments
The research presented in this article was funded in part by
Ministerio de Educación y Ciencia. Spain. PROYECTOS
CONSOLIDER-C (SEJ2006-14301=PSIC), by Programa de
Acciones Integradas con Sudáfrica (HS2006-0001), and by
 INTERNET SELF-HELP THERAPY
Universitat Jaume I–Fundació Caixa Castelló (P1 1A2005-06).
CIBER Fisiopatologı́a de la Obesidad y Nutrición is an ini-
tiative of ISCIII.
Disclosure Statement
No competing financial interests exist.
Downloaded from online.liebertpub.com by Ucsf Library University of California San Francisco on 01/14/15. For personal use only.
References
1. American Psychiatric Association (APA). (2000) Diagnostic
and statistical manual of mental disorder, 5th ed. Washington,
DC: APA.
2. Andrews G, Henderson S, Hall W. Prevalence, comorbidity,
disability, and service utilisation: an overview of the Aus-
tralian national mental health survey. British Journal of
Psychiatry 2001; 178:145–53.
3. Furmark T. Social phobia: overview of community surveys.
Acta Psychiatrica Scandinavica 2002; 105:84–93.
4. Jenkins R, Lewis G, Bebbington P, et al. The National Psy-
Cyberpsychology, Behavior, and Social Networking 2010.13:407-421.
chiatric Morbidity Surveys of Great Britain –initial findings
form the household survey. Psychological Medicine 1997;
27:775–89.
5. Narrow WE, Rae DS, Robins LN, et al. Revised prevalence
estimates of mental disorders in the Unites States. Archives
of General Psychiatry 2002; 59:115–23.
6. Mendlowicz MV, Stein MB. Quality of life in individuals
with anxiety disorders. American Journal of Psychiatry 2000;
157:669–82.
7. Rapee RM. (1995) Descriptive psychopathology of social
phobia. In Heimberg RG, Liebowitz MR, Hope DA, et al.,
eds. Social phobia: diagnosis, assessment and treatment. New
York: Guilford Press, pp. 41–66.
8. Safren SA, Heimberg RG, Juster HR. Clients’ expectancies
and their relationship to pretreatment symptomatology and
outcome of cognitive-behavioral group treatment for social
phobia. Journal of Consulting & Clinical Psychology 1997;
65:694–8
9. Schneier FR, Heckelman LR, Garfinkel R, et al. Functional
impairment in social phobia. Journal of Clinical Psychiatry
1994; 55:322–31.
10. Heimberg RG, Holt CS, Schneier FR, et al. The issue of
subtypes in the diagnosis of social phobia. Journal of Anxi-
ety Disorders 1993; 7:249–69.
11. Cho Y, Won H. Cognitive assessment of social anxiety: a
study on the development and validation of the social in-
teraction self-efficacy scale. Issues in Psychological Research
1997; 4:397–434.
12. Holt CS, Heimberg RG, Hope DA, et al. Situational domains
of social phobia. Journal of Anxiety Disorders 1992; 6:
63–77.
13. Mannuzza S, Schneier FR, Chapman TF, et al. Generalized
social phobia: reliability and validity. Archives of General
Psychiatry 1995; 52:230–7.
14. Pollard CA, Henderson JF. Four types of social phobia in a
community sample. Journal of Nervous & Mental Disease
1988; 176:440–5.
15. Stein MB, Walter JR, Forde DR. Public speaking fears in a
community sample: prevalence, impact on functioning, and
diagnostic classification. Archives of General Psychiatry
1996; 53:169–74.
16. Barlow DH, Raffa SD, Cohen EM. (2002) Psychosocial treat-
ments for panic disorder, phobias, and generalized anxiety
disorder. In Nathan PE, Gorman MJ, eds. A guide to treatments
that works, 2nd ed. New York: Oxford University Press.
419
17. Rodebaugh TL, Holaway RM, Heimberg RG. The treatment
of social anxiety disorder. Clinical Psychology Review 2004;
24:883–908.
18. Andrews G, Issakidis C, Carter G. The short fall in mental
health service utilisation. British Journal of Psychiatry 2001;
179:417–25.
19. Bebbington P, Meltzer H, Brugha T, et al. Unequal access
and unmet need: neurotic disorders and the use of primary
care services. Psychological Medicine 2000; 30:1359–68.
20. Bebbington P, Brugha T, Meltzer H, et al. Neurotic disorders
and the receipt of psychiatric treatment. Psychological
Medicine 2000; 30:1369–76.
21. King SA, Poulos ST. Using the Internet to treat generalized
social phobia and avoidant personality disorder. Cyberpsy-
chology & Behavior 1998; 1:29–36.
22. Newman MG, Erickson T, Prezeworski A, et al. Self-help and
minimal-contact therapies for anxiety disorders: Is human
contact necessary for therapeutic efficacy? Journal of Clinical
Psychology 2003; 59:251–74.
23. Issakidis C, Andrews G. Service utilization for anxiety in
an Australian community sample. Social Psychiatry &
Psychiatric Epidemiology 2002; 37:153–63.
24. Gaston JE., Abbott MJ., Rapee RM, et al. Do empirically
supported treatments generalize to private practice? A
benchmark study of a cognitive-behavioural group treat-
ment programme for social phobia. British Journal of Clin-
ical Psychology 2006; 45:33–48.
25. American Psychological Association Task Force on Psycho-
logical Intervention Guidelines. (1995) Template for devel-
oping guidelines: Interventions for mental disorders and
psychological aspects of physical disorders. Washington,
DC: American Psychological Association.
26. Glasgow R, Rosen G. Behavioral bibliotherapy: a review of
self-help behavior therapy manuals. Psychological Bulletin
1978; 85:1–23.
27. Glasgow R, Rosen G. Self-help behavior therapy manuals:
Recent development and clinical usage. Clinical Behavior
Therapy Review 1982; 1:1–20.
28. Gould RA, Clum GA. A meta-analysis of self-help treatment
approaches. Clinical Psychology Review 1993; 13:169–86.
29. Mains JA, Scogin. The effectiveness of self-administered
treatments: a practice-friendly review of the research. Journal
of Clinical Psychology 2003; 59:237–46.
30. Marrs RW. A meta-analysis of bibliotherapy studies.
American Journal of Community Psychology 1995; 6:
843–70.
31. Menchola M, Arkowitz HS, Burke BL. Efficacy of self-
administered treatments for depression and anxiety. Pro-
fessional Psychology: Research & Practice 2007; 38:421–9.
32. Norcross JC, Santrock JW, Campbell, LF, et al. (2003)
Authoritative guide to self-help resources in mental health. Rev.
ed. New York: Guilford Press.
33. Rosen GM. Self-help treatment books and the commer-
cialization of psychotherapy. American Psychologist 1987;
42:46–51.
34. Cuijpers P. Bibliotherapy in unipolar depression: a meta-
analysis. Journal of Behavior Therapy & Experimental Psy-
chiatry 1997; 28:139–47.
35. den Boer PC, Wiersma D, Van den Bosch RJ. Why is self-
help neglected in the treatment of emotional disorders? A
meta analysis. Psychological Medicine 2004; 34:959–71.
36. Scogin F, Jamison C, Davis N. Two-year follow-up of
bibliotherapy for depression in older adults. Journal of
Consulting & Clinical Psychology 1990; 58:665–7.
 420
37. Wampold BE, Mondin GW, Moody M, et al. A meta-analysis
of outcome studies comparing bona fide psychotherapies:
empirically, ‘‘all must have prizes.’’ Psychological Bulletin
1997; 122:203–15.
38. Walker JR, Ross CA, Norton GR. (1991) A final word:
pragmatic considerations for the practitioner. In Walker
JR, Norton GR, Ross CA, University of Manitoba Dept.
Downloaded from online.liebertpub.com by Ucsf Library University of California San Francisco on 01/14/15. For personal use only.
of Psychiatry, eds. Panic disorder and agoraphobia: a compre-
hensive guide for the practitioner. Pacific Grove, CA: Brooks=
Cole.
39. Marks IM., Kenwright M, McDonough M, et al. Computer-
guided self-help for panic=phobic disorder cut per-patient
time with a clinician: a randomised controlled trial. Psy-
chological Medicine 2003; 34:9–17.
40. McCrone P, Knapp M, Proudfoot J, et al. Cost-effectiveness
of computerized cognitive-behavioural therapy for anxiety
and depression in primary care: randomised controlled trial.
British Journal of Psychiatry 2004; 185:55–62.
41. Proudfoot J, Ryden C, Everitt B, et al. Clinical efficacy of
Cyberpsychology, Behavior, and Social Networking 2010.13:407-421.
computerised cognitive behavioural therapy for anxiety and
depression in primary care. British Journal of Psychiatry
2004; 185:46–54.
42. Barlow D. Psychological treatments. American Psychologist
2004; 59:869–78.
43. Norcoss JC, Hedges M. The face of 2010: a Delphi Poll on the
future of psychotherapy. Professional Psychology: Research
& Practice 2002; 33:316–22.
44. Carlbring P, Andersson G. Internet and psychological
treatment. How well can they be combined? Computers in
Human Behavior 2006; 22:545–53.
45. Ritterband LM, Gonder-Frederick LA, Cox DJ, et al. Internet
interventions: in review, in use and into the future. Profes-
sional Psychology: Research & Practice 2003; 34:527–34.
46. Robinson PH, Serfaty MA. The use of e-mail in the identi-
fication of bulimia nervosa and its treatment. European
Eating Disorders Review 2001; 9:182–93.
47. Celio AA, Winzelberg AJ, Wilfley DE, et al. Reducing risk
factors for eating disorders: comparison of an Internet and a
classroom-delivered psychoeducational program. Journal of
Consulting & Clinical Psychology 2000; 68:650–7.
48. Winzelberg AJ, Eppstein D, Eldredge KL, et al. Effectiveness
of an Internet-based program for reducing risk factors for
eating disorders. Journal of Consulting & Clinical Psychol-
ogy 2000; 68:346–50.
49. Lange A, Rietdijk D, Hudcovicova M, et al. Interapy: a
controlled randomized trial of the standardized treatment
of posttraumatic stress through the Internet. Journal of
Consulting & Clinical Psychology 2003; 71:901–9.
50. Lange A, Schrieken B, van de Ven JP, et al. ‘‘Interapy’’: the
effects of a short protocolled treatment of posttraumatic
stress and pathological grief through the Internet. Beha-
vioural and Cognitive Psychotherapy 2000; 28:175–92.
51. Carlbring P, Ekselius L, Andersson G. Treatment of panic
disorder via the Internet: a randomized trial of CBT vs. ap-
plied relaxation. Journal of Behavior Therapy & Experi-
mental Psychiatry 2003; 34:129–40.
52. Andersson G, Bergström J, Holländare F, et al. Internet-
based self-help for depression: a randomised controlled trial.
British Journal of Psychiatry 2005; 187:456–61.
53. Berström J, Hollander F, Carlbring P, et al. Treatment of de-
pression via the Internet: a randomized trial of a self-help
programme. Journal of Telemedicine & Telecare 2003; 9:85.
54. Spek V, Cuijpers P, Nyklicek I, et al. Internet-based cog-
nitive behaviour therapy for symptoms of depression and
BOTELLA ET AL.
anxiety: a meta-analysis. Psychological Medicine 2007; 37:
319–28.
55. Ström L, Pettersson R, Andersson G. A controlled trial of
self-help treatment of recurrent headache conducted via the
Internet. Journal of Consulting & Clinical Psychology 2000;
68:722–727.
56. Ström L, Pettersson R, Andersson G. Internet-based treat-
ment for insomnia: a controlled evaluation. Journal of Con-
sulting and Clinical Psychology 2004; 72:113–20.
57. Zetteqvist K, Maanmies J, Ström L, et al. Randomized con-
trolled trial of Internet-based stress management. Cognitive
Behaviour Therapy 2003; 32:151–60.
58. Buhrman M, Faltenhag S, Ström L, et al. Controlled trial of
Internet-based treatment with telephone support for chronic
back pain. Pain 2004; 111:368–77.
59. Andersson G, Carlbring P, Holmström A, et al. Internet-
based self-help with therapist feedback and in-vivo group
exposure for social phobia: a randomised controlled
trial. Journal of Consulting & Clinical Psychology 2006; 74:
677–86.
60. Carlbring P, Gunnarsdóttir M, Hedensjö L, et al. Treatment
of social phobia: randomised trial of internet-delivered
cognitive-behavioural therapy with telephone support.
British Journal of Psychiatry: Journal of Mental Science 2007;
190:123–8.
61. Botella C, Baños RM, Guillén V, et al. Telepsychology: public
speaking fear treatment on the Internet. CyberPsychology &
Behavior 2000; 3:959–68.
62. Botella C, Hofmann SG, Moscovitz DA. A self-applied
Internet-based intervention for fear of public speaking.
Journal of Clinical Psychology 2004; 60:1–10.
63. Guillén V. Miedo a hablar en público: un tratamiento auto-
aplicado en Internet. Master thesis, Universidad de Valencia.
Spain, 2001.
64. Botella C, Guillén V, Baños RM, et al. Telepsychology and
self-help: the treatment of fear of public speaking. Cognitive
& Behavioral Practice 2007; 14:46–57.
65. Botella C. Admission Interview of the Universitat Jaume I
Emotional Disorder Clinic. Unpublished manuscript, 1988.
66. Brown TA, DiNardo P, Barlow DH. (1994) Anxiety disorders
interview schedule for DSM-IV (ADS-IV) adult and lifetime
version. Clinician manual. San Antonio, TX: Psychological
Corporation.
67. Marks IM, Matthews AM. Brief standard self-rating for pho-
bic patients. Behaviour Research & Therapy 1979; 17:263–7.
68. Leary MR. A brief version of the Fear of Negative Evaluation
Scale. Personality & Social Psychology Bulletin 1983; 9:371–5.
69. Gallego MG, Botella C, Quero S, et al. Propiedades psico-
métricas de la Escala de Miedo a la Evaluación Negativa
versión breve (BFNE) en muestra clı́nica. Revista de Psico-
patologı́a y Psicologı́a Clı́nica 2007; 12:163–76.
70. Watson D, Friend R. Measurement of social evaluative
anxiety. Journal of Consulting & Clinical Psychology 1969;
33:448–57.
71. Bados A. Análisis de componentes de un tratamiento
cognitivo-somático-conductual del miedo a hablar en púb-
lico. Doctoral dissertation, Universidad de Barcelona, 1986.
72. Hofmann SG, DiBartolo PM. An instrument to assess self-
statements during public speaking: scale development and
preliminary psychometric properties. Behavior Therapy
2000; 31:499–515.
73. Beidel DC, Turner SM, Jacob RG, et al. Assessment of social
phobia: Reliability of an impromptu speech task. Journal of
Anxiety Disorders 1989; 3:149–58.
 INTERNET SELF-HELP THERAPY
74. Gallardo M. Delimitación de subtipos clı́nicos en fobia so-
cial. Doctoral dissertation, Universidad de Valencia, 2001.
75. Guy W. (1976) ECDEU. Assessment manual for psychopharma-
cology revised. NIMH Publ. DHEW Publ. No. (Adm) 76–338.
76. Echeburúa E, Corral P, Fernández-Montalvo J. Escala de
inadaptación: Propiedades psicométricas en contextos clı́n-
icos. Análisis en contextos clı́nicos. Análisis y Modificación
Downloaded from online.liebertpub.com by Ucsf Library University of California San Francisco on 01/14/15. For personal use only.
de Conducta 2000; 26:325–338.
77. Beck AT, Rial WY, Richels K. Short form of depression
inventory (cross-validation). Psychological Reports 1974; 34:
1184–6.
78. Beck S, Ward C, Mendelson M, et al. An inventory for
measuring depression. Archives of General Psychiatry 1961;
4:561–71.
79. Conde V, Franch JI. (1984) Escalas de evaluación comporta-
mental para la cuantificación de la sintomatologı́a psicopatológica
en los trastornos angustiosos y depresivos. Madrid: Laboratorios
Upjohn.
80. Carlbring P, Furmark T, Steczkó J, et al. An open study of
Cyberpsychology, Behavior, and Social Networking 2010.13:407-421.
Internet-based bibliotherapy with minimal therapist contact
via e-mail for social phobia. Clinical Psychology 2006; 10:30–8.
81. Woody SR, Sanderson WC. Manuals for empirically sup-
ported treatments: 1998 update. Clinical Psychologist 1998;
51:17–21.
82. Botella C, Gallego MJ, Garcı́a-Palacios A, et al. The accept-
ability of an internet-based self-help treatment for fear of
public speaking. British Journal of Guidance & Counselling
2008; 37:297–311.
83. Taylor S. Meta-analysis of cognitive-behavioral treatments
for social phobia. Journal of Behavior Therapy & Experi-
mental Psychiatry 1996; 27:1–9.
421
84. Carlbring P, Westling BE, Ljungstrand P, et al. Treatment of
panic disorder via the Internet: a randomized trial of a self-
help program. Behavior Therapy 2001; 32:751–64.
85. Rapee RM, Abbott MJ, Baillie AJ, et al. Treatment of social
phobia through pure self-help and therapist-augmented self-
help. British Journal of Psychiatry 2007; 191:246–52.
86. Bachofen M, Nakagawa A, Marks IM, et al. Home self-
assessment and self-treatment of obsessive-compulsive dis-
order using a manual and a computer-conducted telephone
interview: replication of a UK-US Study. Journal of Clinical
Psychiatry 1999; 8:545–9.
87. Garfield SL. Some problems with ‘‘validated’’ forms of
psychotherapy. Clinical Psychology: Science & Practice 1996;
3:218–29.
88. Havik OE, VandenBos GR. Limitations of manualised psy-
chotherapy for everyday clinical practice. Clinical Psychol-
ogy: Science & Practice 1996; 3:264–7.
89. Weingardt KR. The role of instructional design and tech-
nology in the dissemination of empirically supported,
manual-based therapies. Clinical Psychology: Science &
Practice 2004; 11:313–31.
Address correspondence to:
Dr. Azucena Garcia-Palacios
Dpt. Psicologia Basica, Clinica y Psicobiologia
Universitat Jaume I
Avda Vicent Sos Baynat s=n
12071 Castellon
Spain
E-mail: azucena@psb.uji.es
 Cyberpsychology, Behavior, and Social Networking 2010.13:407-421.
Downloaded from online.liebertpub.com by Ucsf Library University of California San Francisco on 01/14/15. For personal use only.