Wen Xu, Gou Mengke, Chen Huijing, Kishimoto Tomoko, Qian Mingyi, Margraf Jürgen, Berger Thomas
Department of Clinical Psychology and Psychotherapy, Ruhr University Bochum, Bochum, Germany.
School of Psychological and Cognitive Science, Peking University, Beijing, China.
JMIR Ment Health. 2024 Jun 27;11:e50535. doi: 10.2196/50535.
Social anxiety disorder (SAD) is one of the most prevalent psychological disorders and generally co-occurs with elevated shame levels. Previous shame-specific interventions could significantly improve outcomes in social anxiety treatments. Recent review suggests that integrating a more direct shame intervention could potentially increase the effectiveness of cognitive behavioral therapy. Web-based cognitive behavioral therapy (WCBT) has proven efficacy, sustaining benefits for 6 months to 4 years. Previous evidence indicated that shame predicted the reduction of social anxiety and mediated between engagements in exposure and changes in social anxiety during WCBT.
This study aimed to design a shame intervention component through a longitudinal study and conduct a randomized controlled trial to investigate the effectiveness of a shame intervention component in reducing social anxiety symptoms and shame experience in a clinical sample of people with SAD.
The development of a shame intervention component was informed by cognitive behavioral principles and insights from longitudinal data that measured the Experience of Shame Scale (ESS), the Coping Styles Questionnaire, and the Social Interaction Anxiety Scale (SIAS) in 153 participants. The psychoeducation, cognitive construct, and exposure sections were tailored to focus more on shame-related problem-solving and self-blame. A total of 1220 participants were recruited to complete questionnaires, including the ESS, the SIAS, the Social Phobia Scale (SPS), and diagnostic interviews. Following a 2-round screening process, 201 participants with SAD were randomly assigned into a shame WCBT group, a normal WCBT group, and a waiting group. After the 8-week WCBT intervention, the participants were asked to complete posttest evaluations, including the ESS, SIAS and SPS.
Participants in the shame WCBT group experienced significant reductions in shame levels after the intervention (ESS: P<.001; ηp2=0.22), and the reduction was greater in the shame intervention group compared to normal WCBT (P<.001; mean deviation -12.50). Participants in both the shame WCBT and normal WCBT groups experienced significant reductions in social anxiety symptoms (SIAS: P<.001; ηp2=0.32; SPS: P<.001; ηp2=0.19) compared to the waiting group after intervention. Furthermore, in the experience of social interaction anxiety (SIAS), the shame WCBT group showed a higher reduction compared to the normal WCBT group (P<.001; mean deviation -9.58). Problem-solving (SE 0.049, 95% CI 0.025-0.217) and self-blame (SE 0.082, 95% CI 0.024-0.339) mediated the effect between ESS and SIAS.
This is the first study to design and incorporate a shame intervention component in WCBT and to validate its efficacy via a randomized controlled trial. The shame WCBT group showed a significant reduction in both shame and social anxiety after treatment compared to the normal WCBT and waiting groups. Problem-solving and self-blame mediated the effect of shame on social anxiety. In conclusion, this study supports previous findings that a direct shame-specific intervention component could enhance the efficacy of WCBT.
社交焦虑障碍（SAD）是最常见的心理障碍之一，通常与较高的羞耻感同时出现。以往针对羞耻感的特定干预措施可显著改善社交焦虑治疗的效果。近期综述表明，整合更直接的羞耻感干预措施可能会提高认知行为疗法的有效性。基于网络的认知行为疗法（WCBT）已被证明具有疗效，其益处可持续6个月至4年。先前的证据表明，羞耻感可预测社交焦虑的减轻，并在WCBT期间暴露环节的参与度与社交焦虑的变化之间起中介作用。
本研究旨在通过纵向研究设计一个羞耻感干预组件，并进行随机对照试验，以调查羞耻感干预组件在减少SAD临床样本中社交焦虑症状和羞耻感体验方面的有效性。
羞耻感干预组件的开发基于认知行为原则以及对153名参与者进行纵向数据测量的结果，这些数据包括羞耻感体验量表（ESS）、应对方式问卷和社交互动焦虑量表（SIAS）。心理教育、认知构建和暴露部分经过调整，更侧重于与羞耻感相关的问题解决和自责。共招募了1220名参与者完成问卷，包括ESS、SIAS、社交恐惧症量表（SPS）和诊断访谈。经过两轮筛选过程，201名SAD患者被随机分为羞耻感WCBT组、普通WCBT组和等待组。在进行8周的WCBT干预后，要求参与者完成包括ESS、SIAS和SPS在内的后测评估。
羞耻感WCBT组的参与者在干预后羞耻感水平显著降低（ESS：P<.001；ηp2 = 0.22），与普通WCBT组相比，羞耻感干预组的降低幅度更大（P<.001；平均偏差 -12.50）。与干预后的等待组相比，羞耻感WCBT组和普通WCBT组的参与者社交焦虑症状均显著降低（SIAS：P<.001；ηp2 = 0.32；SPS：P<.001；ηp2 = 0.19）。此外，在社交互动焦虑（SIAS）体验方面，羞耻感WCBT组的降低幅度高于普通WCBT组（P<.001；平均偏差 -9.58）。问题解决（SE 0.049，95% CI 0.025 - 0.217）和自责（SE 0.082，95% CI 0.024 - 0.339）介导了ESS与SIAS之间的效应。
这是第一项在WCBT中设计并纳入羞耻感干预组件，并通过随机对照试验验证其疗效的研究。与普通WCBT组和等待组相比，羞耻感WCBT组在治疗后羞耻感和社交焦虑均显著降低。问题解决和自责介导了羞耻感对社交焦虑的影响。总之，本研究支持先前的发现，即直接针对羞耻感的特定干预组件可提高WCBT的疗效。
