Article Critique

PSYC 433 - LAB

Navdeep Vining 10126327

Running head: LIVE VERSUS INTERNET SELF-HELP THERAPY

The article Treatment of panic disorder: live therapy vs self-help via the Internet by
Carlbring, Nilsson-Ihrfelt, Waara, Kollenstam, Buhrman, Kaldo, Soderberg, Ekselius
&Andersson (2005) was based upon a study to compare two different methods for the treatment
of Panic Disorder. The study conducted a randomized trial in which they compared the results of
live therapy and self-help internet via the Internet. The authors used past research to hypothesize
that online self-help therapy would be significantly effective, similar to live cognitive behavior
therapy. The randomized trial was conducted comparing 10 individuals live weekly sessions
versus 10-module self-help program on the internet. The live therapy was solely done through
online modules and feedback through email whereas the live therapy involved weekly sessions
with direct communication and increased feedback.
Carlbring et al (2005) recruited participants through Swedish newspapers and the Swedish
national website from a waiting list of people who were interested in being a part of online selfhelp treatment for Panic Disorder. The participants had to meet certain criteria to be able to be a
part of the study such as completing a total of 7 questionnaires/inventories (Body Sensations
Questionnaire, Beck Anxiety inventory, Beck Depression inventory, quality of life inventory,
mobility inventory, Agoraphobic Cognitions questionnaire, meet DSM-IV criteria for Panic
disorder)
After this phase, they were brought in to conduct an in person SCID interview to confirm the
diagnosis, which was done by an independent psychologist blind to the treatment condition. The
study got approval from the ethics committee at the Uppsala University in Sweden. The authors
of the study concluded that the results of the study provided proficient evidence to prove that
internet based self-programs are equally as effective as live therapy and declared the need for
continued use and development of the IT self-help programs for the future.

Running head: LIVE VERSUS INTERNET SELF-HELP THERAPY

This study contained many issues and problems that can be lead to questioning the results and
conclusions made by the authors.
First of all, the abstract in the article contained no information about the participants in terms
of size, demographics and recruitment. There should have been a brief sentence about the
participants in the abstract to make it stronger.
The introduction built a great rationale with relevant scientific background that established
a foundation for the study and the authors listed many different previous studies that related
directly to internet therapy and its effectiveness. However, the introduction combined with
abstract state no clear hypothesis. After reading the abstract and introduction thoroughly a couple
times it was possible to get an idea of what the hypothesis is but it was not clearly stated for the
reader which was frustrating and should be improved for future studies. The introduction
efficiently explains the absence of control trials because of previous separate control trials done
for both self-help and live therapy treatments (resulted in no improvement).
The second huge issue with the article was the sample pf participants. The participants were
selected from individuals who had an interest and preference in an internet administered selfhelp program therefore it is very likely that selection biases were present to create responses in
favor of the IT treatment. The selection biases worked to lower the internal validity of the study.
The recruitment process of participants included a severe amount of cuts and criteria that at the
end captures a small unrealistic sample. Out of the 427 who completed the computer interview
only 49 participants were used for the study. Out of the 49 participants, 3 from each of IT and
LIVE group dropped out of the study but their treatment scores were still used in the statistical
analysis for the results. It is inefficient and threatening to the results to include information from
the dropouts towards the effectiveness of the treatments. The many reasons for exclusions early

Running head: LIVE VERSUS INTERNET SELF-HELP THERAPY

on in the recruitment do not resemble the realistic image of individuals with panic disorder
because the process excluded people who showed symptoms of social phobia, post-traumatic
stress disorder, generalized anxiety disorder and individuals with higher depression total. The
exclusions fail to consider that in reality individuals with one disorder most likely are comorbid
with another one.
Panic Disorder is highly known to be associated with anxiety and social phobia, so excluding
comorbid individuals form the sample actually works to decrease the generalizability and
external validity of the results. Furthermore, the majority of participants in both LIVE and IT
treatments were female (LIVE = 75%, IT=68%) and all participants were Caucasian except for
one Latin American immigrant. The over recruitment of Caucasian women, makes the results of
the studies less applicable to men and other nationalities. This decreases the external validity of
the study and limits the authors ability to generalize the results to a broader population in the
real world.
One strength of the recruitment process of the participants was the reliability of the
questionnaires/inventories given to the participants. The questions in the computerized interview
were adapted according to the participants previous answer. All of the questionnaires had high
test retest reliability scores and the internal consistency of the subject sample was also high,
which made the questionnaires used in the study highly reliable.

The participants in the study reported the pace of the study to be too high and this was clearly
seen in the IT group as only 28% of the individuals completed all their modules within the 10
weeks, whereas 88% of individuals finished all modules in the LIVE group. It is greatly
problematic that even though most of the IT group did not even complete all the modules, they

Running head: LIVE VERSUS INTERNET SELF-HELP THERAPY

still reported higher treatment effects during the post treatment and follow up findings.
One strength of internet based self-help therapy is that it gives the opportunity to treat
people who would normally not seek treatment. However, in this study the authors only recruited
individuals who show interest in the program and they aim to exclude individual with social
phobia and agoraphobia. The SCID interviews could have induced self-selection bias for the
treatment applications. Another great weakness is that a high number of panic disorder patients
do not ask for professional help, therefore, once again there is a limit to the extent of
generalizability towards the projected population.
The quality of communication was a huge factor when comparing the LIVE and IT therapy.
The exclusive way of communication with the IT therapy was emails and the study states that the
same emails would be reused and often the replies were very similar to one another. The mean
time spent on each participant was 150 mins (administration and emails). LIVE therapy received
10 weekly individual sessions that lasted 45-60 mins each. Participants read module handouts
and listened to their recorded sessions afterwards to consolidate learning. Compared to IT
therapy the LIVE therapy program had more feedback, direct communication and active learning
and improvement.
The authors of this article claimed that IT therapy can be equally effective as LIVE therapy,
however, it is surrounded by many probable biases and permits low generalizability to larger
population. The authors kept on referring to the study to be generalizable and significant
however, they should not able to claim so with all the problems and inconsistencies within the
study.

Running head: LIVE VERSUS INTERNET SELF-HELP THERAPY

Discussion
Panic Disorder is associated with a substantial impairment in the quality of everyday life
activities. It hinders the individuals from interacting with others, going out in public and just
living their lives. Only about 25% of individuals with panic disorder actually go to seek out any
kind of treatment. (Lidren, Watkins, Gould, Clum, Asterino, & Tulloch, 1994). This study does
not attempt to include individuals who dont seek treatment and do not aim to distribute the IT
treatment to them. For future studies it would be beneficial to recruit individuals not interested in
the treatment to lower the biases and increase the generalizability. The IT therapy has the
potential to be used as a power tool to increase accessibility of therapy to individuals. Patients
could start their treatment from home instead of having to go to a clinic and being judged by
people in society.
Every country is different in their technological awareness and growth, so conducting the IT
therapy in different countries with would let psychologists know of the differences in treatments
and if different cultures and societies would respond to the treatment contrarily or similarly.
A future study could look at strengthening the IT self-help program by making sure majority
of the modules are finished and work to increase the credibility of the treatment. By including a
diverse (gender and nationality) population sample a future study can be generalized to the
broader public. Furthermore, a study is needed to examine the combination of panic disorder
and psychotropic medication/comorbid individuals to foresee the effects the live therapy would
have on these individuals who would work to represent the realistic world population for patients
with panic disorder.
There should also be distinction between the severity of the panic disorder and what effects
the IT therapy would have on the individual compared to the LIVE therapy.

Running head: LIVE VERSUS INTERNET SELF-HELP THERAPY

Lastly, having better communication among the IT therapy would strengthen the treatment and
help individuals better reflect and improve on their condition. Having more interacting emails
and maybe including phone calls in the process could help the program to connect more
efficiently with the patients.
Overall, the direction of ideas for this study are remarkable as people all around the world are
becoming increasingly dependent on technology for their everyday needs. Therefore, it isnt
surprising that IT therapy is a rising study model to treat panic disorder. This study was efficient
in making readers think about the benefits of having an Internet self-help program for people
suffering with panic disorders. The study did have several issues with internal validity, external
validity, and generalizability which can be fixed with the proper recruitment and further work
with the therapy.

Running head: LIVE VERSUS INTERNET SELF-HELP THERAPY

References
Carlbring, P., Nilsson-Ihrfelt, E., Waara, J., Kollenstam, C., Buhrman, M., Kaldo, V., &
Andersson, G. (2005). Treatment of panic disorder: live therapy vs. self-help via the Internet.
Behaviour research and therapy, 43(10), 1321-1333.
Carlbring, P., Brunt, S., Bohman, S., Austin, D., Richards, J., st, L. G., & Andersson, G.
(2007). Internet vs. paper and pencil administration of questionnaires commonly used in
panic/agoraphobia research. Computers in Human Behavior, 23(3), 1421-1434.
Lidren, D. M., Watkins, P. L., Gould, R. A., Clum, G. A., Asterino, M., & Tulloch, H. L. (1994).
A comparison of bibliotherapy and group therapy in the treatment of panic disorder. Journal of
consulting and clinical psychology, 62(4), 865.