Wang Haoyu, Zhao Qingxue, Mu Wenting, Rodriguez Marcus, Qian Mingyi, Berger Thomas
School of Psychological and Cognitive Sciences, Peking University, Beijing, China.
School of Psychological and Cognitive Sciences, Beijing Key Laboratory for Behavior and Mental Health, Peking University, Beijing, China.
JMIR Ment Health. 2020 Jul 20;7(7):e15797. doi: 10.2196/15797.
Prior research has demonstrated the efficacy of internet-based cognitive behavioral therapy (ICBT) for social anxiety disorder (SAD). However, it is unclear how shame influences the efficacy of this treatment.
This study aimed to investigate the role shame played in the ICBT treatment process for participants with SAD.
A total of 104 Chinese participants (73 females; age: mean 24.92, SD 4.59 years) were randomly assigned to self-help ICBT, guided ICBT, or wait list control groups. For the guided ICBT group, half of the participants were assigned to the group at a time due to resource constraints. This led to a time difference among the three groups. Participants were assessed before and immediately after the intervention using the Social Interaction Anxiety Scale (SIAS), Social Phobia Scale (SPS), and Experience of Shame Scale (ESS).
Participants' social anxiety symptoms (self-help: differences between pre- and posttreatment SIAS=-12.71; Cohen d=1.01; 95% CI 9.08 to 16.32; P<.001 and differences between pre- and posttreatment SPS=11.13; Cohen d=0.89; 95% CI 6.98 to 15.28; P<.001; guided: SIAS=19.45; Cohen d=1.20; 95% CI 14.67 to 24.24; P<.001 and SPS=13.45; Cohen d=0.96; 95% CI 8.26 to 18.64; P<.001) and shame proneness (self-help: differences between pre- and posttreatment ESS=7.34; Cohen d=0.75; 95% CI 3.99 to 10.69; P<.001 and guided: differences between pre- and posttreatment ESS=9.97; Cohen d=0.88; 95% CI 5.36 to 14.57; P<.001) in both the self-help and guided ICBT groups reduced significantly after treatment, with no significant differences between the two intervention groups. Across all the ICBT sessions, the only significant predictors of reductions in shame proneness were the average number of words participants wrote in the exposure module (β=.222; SE 0.175; t=2.317; P=.02) and gender (β=-.33; SE 0.002; t=-3.13; P=.002). We also found a mediation effect, wherein reductions in shame fully mediated the relationship between the average number of words participants wrote in the exposure module and reductions in social anxiety symptoms (SIAS: β=-.0049; SE 0.0016; 95% CI -0.0085 to -0.0019 and SPS: β=-.0039; SE 0.0015; 95% CI -0.0075 to -0.0012).
The findings of this study suggest that participants' engagement in the exposure module in ICBT alleviates social anxiety symptoms by reducing the levels of shame proneness. Our study provides a new perspective for understanding the role of shame in the treatment of social anxiety. The possible mechanisms of the mediation effect and clinical implications are discussed.
Chinese Clinical Trial Registry ChiCTR1900021952; http://www.chictr.org.cn/showproj.aspx?proj=36977.
先前的研究已经证明基于互联网的认知行为疗法（ICBT）对社交焦虑障碍（SAD）有效。然而，尚不清楚羞耻感如何影响这种治疗的效果。
本研究旨在探讨羞耻感在SAD患者的ICBT治疗过程中所起的作用。
总共104名中国参与者（73名女性；年龄：平均24.92岁，标准差4.59岁）被随机分配到自助ICBT组、引导式ICBT组或等待列表对照组。由于资源限制，引导式ICBT组的参与者每次有一半被分配到该组。这导致三组之间存在时间差异。在干预前和干预后立即使用社交互动焦虑量表（SIAS）、社交恐惧症量表（SPS）和羞耻感体验量表（ESS）对参与者进行评估。
自助ICBT组和引导式ICBT组参与者的社交焦虑症状（自助组：治疗前和治疗后SIAS的差异=-12.71；Cohen d=1.01；95% CI 9.08至16.32；P<.001，治疗前和治疗后SPS的差异=11.13；Cohen d=0.89；95% CI 6.98至15.28；P<.001；引导式组：SIAS=19.45；Cohen d=1.20；95% CI 14.67至24.24；P<.001，SPS=13.45；Cohen d=0.96；95% CI 8.26至18.64；P<.001）和羞耻倾向（自助组：治疗前和治疗后ESS的差异=7.34；Cohen d=0.75；95% CI 3.99至10.69；P<.001，引导式组：治疗前和治疗后ESS的差异=9.97；Cohen d=0.88；95% CI 5.36至14.57；P<.001）在治疗后均显著降低，两个干预组之间无显著差异。在所有ICBT疗程中，表示羞耻倾向降低的唯一显著预测因素是参与者在暴露模块中所写的平均单词数（β=.222；标准误0.175；t=2.317；P=.02）和性别（β=-.33；标准误0.002；t=-3.13；P=.002）。我们还发现了一种中介效应，即羞耻感的降低完全中介了参与者在暴露模块中所写的平均单词数与社交焦虑症状降低之间的关系（SIAS：β=-.0049；标准误0.0016；95% CI -0.0085至-0.0019，SPS：β=-.0039；标准误0.0015；95% CI -0.0075至-0.0012）。
本研究结果表明，ICBT中参与者参与暴露模块通过降低羞耻倾向水平减轻了社交焦虑症状。我们的研究为理解羞耻感在社交焦虑治疗中的作用提供了一个新视角。讨论了中介效应的可能机制和临床意义。
中国临床试验注册中心ChiCTR1900021952；http://www.chictr.org.cn/showproj.aspx?proj=36977 。
