Efficacy of Short-Term CBT for Internet and Computer Game Addiction

 Wölfling, K., Müller, K. W., Dreier, M., Ruckes, C., Deuster, O., Batra, A., Mann, K., Musalek, M., Schuster, A., Lemenager, T., Hanke, S., & Beutel, M. E. (2019). Efficacy of short-term treatment of internet and computer game addiction. JAMA Psychiatry, 76 (10), 1018. https://doi.org/10.1001/jamapsychiatry.2019.1676 

Summary by: Vali Ibrahimi

Introduction

The article by Wölfling et al. (2019) starts off by discussing internet and computer game addiction in relation to the diagnostic frameworks of the DSM-5 and ICD-11. While internet gaming disorder was included in the DSM-5 as a condition for further study, gaming disorder was recognized as a disorder in the ICD-11. Wölfling et al. (2019) discuss the broader concept of Internet Addiction (IA), which includes several different subtypes. The authors note a higher prevalence of gaming-related IA in men, as well as an estimated prevalence rate of 3% to 6% for IA, alongside associated psychosocial impairment and comorbidity.

CBT has been suggested as a suitable treatment option for targeting dysfunctional cognitions, coping strategies, motivation, and the development of alternative activities, but previous research has shown considerable methodological limitations. To address this gap, Wölfling et al. (2019) developed the Short-term Treatment of Internet and Computer game Addiction (STICA), a manualized CBT program that combines individual and group therapy and had shown promising effects in a pilot study. Wölfling et al. (2019) designed a multicenter, randomized, observer-blind clinical trial to test the efficacy of STICA on remission and related outcomes in men with IA.

Methodology

The multicenter randomized controlled trial (RCT) was conducted in four outpatient clinics in Germany and Austria. Men aged 17–55 who had met the criteria for IA within the past six months, based on clinician-rated AICA-C and self-report AICA-S assessments, were eligible to participate. Participants were randomly assigned in a 1:1 ratio using computer-generated lists to either the STICA or wait-list control (WLC) group. Independent clinicians assessing the outcomes were blinded to treatment allocation.

STICA consisted of 15 weekly group sessions lasting 100 minutes, along with up to eight individual sessions of 60 minutes over approximately four months. The sessions were conducted by CBT therapists who had received training and regular supervision to ensure treatment fidelity. Assessments occurred at baseline (T0), mid-treatment (2 months, T1), post-treatment (4 months, T2), and a 6-month follow-up for the STICA group only (T3).

The primary endpoint was remission of IA at T2, defined as an AICA-S score of less than 7. Secondary endpoints included IA symptom severity, time spent online, psychosocial functioning, and depressive symptoms. The sample-size planning targeted 192 participants, based on pilot remission rates and an assumed 20% remission rate for the WLC group, but recruitment ultimately yielded an analyzed sample of 143 participants.

Results

Of the 149 initially randomized men, six withdrew from participation, leaving 143 participants in the analyzed sample, with 72 in the STICA group and 71 in the WLC group.

At post-treatment, remission (as measured by AICA-S) was higher in the STICA group (69.4%) compared to the WLC group (23.9%), with an adjusted odds ratio (OR) of 10.10 (95% CI, 3.69–27.65). Secondary outcome analyses also favored the STICA group, with larger reductions in self-reported IA symptoms (d = 1.19) and weekday time spent online (d = 0.88), as well as improved psychosocial functioning (GAF, d = 0.64).

Depressive symptoms improved in both groups, but the time × treatment interaction was not statistically significant. At the 6-month follow-up, 80.6% of the 36 contacted STICA participants scored below the cutoff for IA. However, only half of the original STICA group participated in this follow-up assessment. Clinician-rated outcomes measured by AICA-C also favored the STICA group, with a large effect size (d = 0.80).

Completion rates were 65.3% for STICA and 74.6% for the WLC group, with lack of adherence and missed sessions among the most common reasons for dropout.

Discussion

Wölfling et al. (2019) conclude that this is the first multicenter, observer-blind RCT to demonstrate that a manualized CBT program can achieve markedly higher remission rates and improvements in psychosocial functioning among men with IA compared to a wait-list control. The improvements reported by participants were also supported by clinician-rated assessments.

The authors also note small improvements in the WLC group, which may have been related to repeated assessment contacts and expectations of future treatment. These findings highlight the need for controlled study designs and suggest that previous pre-post studies may have overestimated treatment effects.

The study's limitations include a smaller sample size than the originally planned 192 participants, reliance on self-report measures for the primary endpoint rather than clinician-rated assessments, and male-only eligibility, which limits the generalizability of the findings to women. Furthermore, exclusion criteria based on certain comorbid mental disorders reduce the representativeness of the sample. The absence of a WLC group at the 6-month follow-up, along with the high loss to follow-up in the STICA group, also limits conclusions about the long-term effectiveness of the treatment.

Finally, Wölfling et al. (2019) recommend that future studies prioritize participant retention, include active treatment comparators, examine the potential benefits of combining CBT with pharmacological treatment, and test the effectiveness of STICA in women as well.

The Effectiveness of Schema Therapy in Individuals Who Committed Crimes

Sousa, M., Gouveia, C., Cunha, O., & de Castro Rodrigues, A. (2024). The Effectiveness of Schema Therapy in Individuals Who Committed Crimes: A Systematic Review. Trauma, Violence & Abuse, 25(5), 3631–3642. https://doi.org/10.1177/15248380241254082 

Summary by: Joelle Shadi Fawaz Haddadin

Studies have shown that schema therapy is a promising therapeutic approach in several areas of psychology, including forensic psychology. In this paper, I will be reviewing a comprehensive systematic review conducted in 2024 by Sousa and colleagues, which assessed whether schema therapy is effective in reducing psychological symptoms as well as risk factors associated with criminal behavior among offenders. Out of an initial pool of 886 papers, the review identified 15 studies that met the inclusion criteria and analyzed their findings. The studies were found across multiple databases and were conducted in a variety of countries, with predominantly male participant pool.

Now, one may ask what sets schema therapy apart from the traditional Cognitive Behavioral Therapy (CBT) we are used to using in such cases. Well, schema therapy focuses on deeper underlying issues by exploring the emotional and developmental patterns that individuals develop, known as early maladaptive schemas (EMSs). In turn, this approach can help address the effects of traumatic experiences, impulsivity, and deeply ingrained personality patterns that may contribute to offending behavior.

The findings of the reviewed studies showed generally positive results. Offenders who received schema therapy often demonstrated reductions in early maladaptive schemas and maladaptive schema modes, as well as decreases in factors associated with criminal behavior, such as anger, paranoia, and cognitive distortions. Some studies also reported improvements in symptoms linked to personality disorders, including antisocial personality disorder and psychopathic traits, which is consistent with the theoretical literature on schema therapy.

Moreover, schema therapy didn't only reduce negative traits within these individuals but also helped develop some positive ones. For instance, studies observed improvements in emotional regulation, self-esteem, and interpersonal functioning. Additionally, one prominent example of the noticeable difference after intervention was seen in research conducted by Bernstein and colleagues, where offenders receiving schema therapy advanced more rapidly through forensic rehabilitation milestones compared to those receiving treatment as usual (TAU). Case studies included in the review also showed reductions in certain violence risk factors and improvements in interpersonal functioning, even within high-risk offender populations.

Schema therapy was also found to be promising in the form of schema therapy-based programs. The CONTIGO program, intended for intimate partner violence offenders, had a recidivism rate of 15.4% among participants who completed the program. However, this finding alone does not prove that the program prevented reoffending. Similarly, Portugal's Growing Pro-Social (GPS) program reduced anger, cognitive distortions, and early maladaptive schemas, with improvements maintained at a 12-month follow-up.

Nonetheless, the results weren't unanimous across all studies, and the review had some limitations that should be taken into consideration. The studies didn't all have the same research quality. Some used methodologically stronger randomized controlled trials, while others consisted of smaller samples and less consistent treatment protocols. One study found no significant improvements in most of the outcomes measured after treatment. Furthermore, several studies examined the same intervention program, and almost all participants were male, which limits how broadly the findings can be generalized. Hence, it would be beneficial for the field as a whole to conduct more high-quality trials and track long-term outcomes like recidivism.

Overall, this systematic review provides promising evidence for the effectiveness of schema therapy among offenders. By addressing deeply rooted maladaptive schemas and emotional and developmental patterns, this approach may help reduce personality disorder symptoms and risk factors associated with criminal behavior while improving emotion regulation. However, its effectiveness in preventing recidivism still needs further investigation.

This study offers only a glimpse into the potential effects of schema therapy on offenders, and more robust, larger-scale research is needed to confirm the results found in these studies. These findings suggest that schema therapy could not only help offenders manage their behavior but also support longer-term psychological change and potentially contribute to improvements in correctional rehabilitation programs.

How Effective Is Digital CBT-I for Improving Sleep and Mood?

 Lin, W., Li, N., Yang, L., & Zhang, Y. (2023). The efficacy of digital cognitive behavioral therapy for insomnia and depression: A systematic review and meta-analysis of randomized controlled trials. PeerJ, 11, Article e16137. https://doi.org/10.7717/peerj.16137

Summary by: Cecilia Gutierrez Zepeda

Insomnia and depression often occur together, creating a cycle that can be difficult to break. People who struggle to fall asleep or stay asleep are more likely to experience low mood, and those experiencing depression often report ongoing sleep problems. Cognitive Behavioral Therapy for Insomnia (CBT-I) is one of the most effective treatments available for insomnia, but accessing it can be a challenge. There are not enough trained clinicians, and therapy can be expensive or inconvenient for many people.

To address this gap, researchers have developed digital CBT-I, which delivers similar therapeutic strategies through online platforms or apps. But how well does digital CBT-I work, especially for people who also experience symptoms of depression? That is the question Lin and colleagues (2023) set out to answer in their systematic review and meta-analysis.

The study focused on the effectiveness of digital CBT-I in improving two major outcomes: insomnia severity and depressive symptoms.

The authors examined studies that directly compared digital CBT-I to a control condition, such as a waitlist group, a placebo intervention, or treatment as usual without specific sleep treatment. They also wanted to see not only whether symptoms improved right after completing digital CBT-I, but also whether improvements lasted over time.

The researchers searched several major scientific databases, including PubMed, Embase, the Cochrane Library, and Web of Science. They looked for randomized controlled trials (RCTs), which are among the strongest research designs for testing whether a treatment works.

To be included in the analysis, each study had to meet several criteria:

• The participants had to be adults with insomnia and depressive symptoms.

• The intervention needed to be a digital or online form of CBT-I.

• The study needed to measure both insomnia and depressive symptoms.

• The design had to randomly assign participants to digital CBT-I or a control group.

After screening the results, the researchers included seven RCTs involving several thousand participants. They used a statistical method called random-effects meta-analysis, which allows researchers to combine results from different studies while accounting for differences among them. The researchers then calculated standardized mean differences (SMDs) to show how much the treatment improved insomnia and depression compared to the control groups.

The main findings were that, overall, digital CBT-I showed meaningful improvements in both insomnia and depressive symptoms. Participants who received digital CBT-I reported significantly lower insomnia severity at the end of treatment compared to participants in control groups. This effect was large in size (SMD = −0.85). When researchers examined follow-up periods ranging from six weeks to six months, these improvements remained substantial (SMD = −0.71). This suggests that the benefits were not limited to the immediate treatment period.

In addition, the researchers found that digital CBT-I led to moderate improvements in depressive symptoms on the Patient Health Questionnaire (PHQ). The benefits appeared immediately after treatment (SMD = −0.47) and were also present at follow-up (SMD = −0.42), although the effect sizes were smaller than those for insomnia. However, results based on another depression measure (HADS) did not reach statistical significance. This suggests that targeting sleep through CBT-I may also have positive effects on mood, even when depression is not the primary focus of treatment.

One notable strength of this meta-analysis is that it combined results from multiple studies, providing a broader picture of the effectiveness of digital CBT-I. The study also included only randomized controlled trials, which strengthens the reliability of the findings. Another strength is that the authors examined both immediate and follow-up outcomes, offering a more complete picture of how digital CBT-I works over time. Examining both sleep and depressive symptoms also highlights how treatments for one condition can influence another connected area of mental health.

Despite the promising findings, the authors noted several limitations. Only seven studies met the inclusion criteria, which means more research is needed to confirm and expand the findings. There was also variation in the interventions. Some digital CBT-I programs were fully automated, while others included some level of human support. The length and structure of the programs differed too, making it harder to determine which features were most effective. Moreover, the studies showed considerable variation in their effect sizes, a sign of heterogeneity, particularly for insomnia outcomes. Follow-up periods were also relatively short, and not all studies included follow-up assessments. This makes it difficult to determine how long the improvements last beyond the periods studied.

Future studies could examine several important questions. Longer follow-up periods would help researchers understand how durable the benefits of digital CBT-I truly are. Studies that examine program engagement and adherence could also clarify how usage patterns influence treatment success. Furthermore, future research might focus on combining digital CBT-I with other therapeutic approaches or personalizing digital interventions based on specific user characteristics.

This study provides encouraging evidence that digital CBT-I is a promising option for people struggling with sleep problems and that it may provide additional benefits for mood. Digital tools have the potential to reach more people than traditional therapy formats, especially those who lack access to in-person services.

By demonstrating that digital CBT-I can reduce insomnia severity and may also improve depressive symptoms, this research supports the growing role of digital mental health interventions in healthcare systems around the world.

Gamifying CBT: Can Smartphone Games Reduce Depression?

Lukas, C. A., Eskofier, B., & Berking, M. (2021). A Gamified Smartphone-Based Intervention for Depression: Randomized Controlled Pilot Trial. JMIR mental health, 8(7), e16643. https://doi.org/10.2196/16643   

Summary by: Farah Hamdan

Depression is one of the most common mental health challenges worldwide. Many people who suffer from depression could benefit from therapy but never receive it. Cognitive Behavioral Therapy (CBT) is highly effective, but traditional face-to-face sessions are not always accessible, affordable, or engaging. In recent years, digital interventions have offered a new path: CBT delivered through smartphone apps. A pilot study by Lukas, Eskofier, and Berking (2021) explored an innovative solution: MT-Phoenix, a gamified smartphone-based intervention combining CBT with a game-based cognitive bias modification tool called approach-avoidance modification training (AAMT). The idea was simple but clever: to make CBT-based exercises more interactive and game-like, motivating users to challenge negative thinking patterns.

How Does the App Work?

MT-Phoenix includes 13 CBT modules covering topics like functional thinking, problem-solving, self-care, and gratitude. Ten of these modules feature mini-games where participants interact with statements or images. Examples of the mini-games include swiping negative thoughts away and pulling functional ones closer, drawing gestures like check marks or crosses, and navigating a maze to reach positive thoughts. After each module, users complete short real-world behavioral tasks, such as writing down three positive events, going for a walk, or performing a small act of self-care. By combining gamified cognitive training with practical behavioral exercises, the app seeks to bridge the gap between learning and real-life application which is a core principle of CBT.

The Study

The pilot trial included 77 participants with elevated depressive symptoms (PHQ-9 ≥ 5). They were randomly assigned to either use MT-Phoenix for 14 days or be placed on a waiting list. The primary outcome was depressive symptoms measured by the PHQ-9, while secondary measures included the German General Depression Scale (ADS) and well-being (WHO-5). Engagement metrics like modules completed, days of app use, and performance in the mini-games were also tracked.

Results

Participants who started using MT-Phoenix used the app for an average of 6.4 out of 14 days, completing nearly six modules. Compared to the waitlist group, the intervention group showed significantly greater reductions in depressive symptoms, with large effect sizes on the PHQ-9 (d = 1.02) and ADS (d = 1.41). There was also a significant improvement in well-being (WHO-5, d = 0.91). These effects were maintained at a 3-month follow-up. Users who engaged with the app also completed around 26 behavioral tasks on average and performed very well in the mini-games, with an average error rate of only 2.4%. However, engagement was not universal, as 13 out of 40 participants in the intervention group never started using the app, indicating that even gamified interventions cannot guarantee full participation.

Strengths and Limitations

MT-Phoenix is pretty innovative, as it mixes CBT with gamified bias training and showed promising results in reducing depressive symptoms while encouraging user engagement. The study used multiple measures and even checked in at 3 months, which makes the findings more encouraging.

Of course, there are some downsides. The study only had 77 participants, used a waitlist control instead of another app or therapy, and only iOS users could join. Also, participants were included based on their depressive symptom scores rather than a clinical diagnosis. Plus, we don't know which part of the app, whether the CBT modules, mini-games, or behavioral tasks, was actually responsible for the improvements. The study also did not compare the gamified app with a non-gamified version, so we cannot be sure how much gamification itself contributed to engagement. Still, the findings suggest that gamified digital CBT could be an effective approach, although more research is needed.

Conclusion

From my perspective, MT-Phoenix is exciting because it seems both promising and engaging. But gamification alone doesn't solve engagement problems, as some people never even started the app. This shows that motivation, onboarding, and maybe some personal support are still important. Apps like this could be useful for people with milder depressive symptoms or as a boost to regular therapy, although these possibilities need further research. Future studies should test bigger, more diverse groups and figure out which parts of the app are the most effective.

Overall, MT-Phoenix is a cool step forward in digital mental health. By combining CBT with game-like tasks, it shows potential for reducing depressive symptoms while making psychological interventions more engaging and accessible. There's still work to do, but it's exciting to see therapy and technology coming together in such a creative way.

Effectiveness of Predominantly Group Schema Therapy and Combined Individual and Group Schema Therapy for Borderline Personality Disorder

Arntz, A., Jacob, G. A., Lee, C. W., Brand-de Wilde, O. M., Fassbinder, E., Harper, R. P., Lavender, A., Lockwood, G., Malogiannis, I. A., Ruths, F. A., Schweiger, U., Shaw, I. A., Zarbock, G., & Farrell, J. M. (2022). Effectiveness of predominantly group schema therapy and combined individual and group schema therapy for borderline personality disorder: A randomized clinical trial. JAMA Psychiatry, 79(4), 287–299. https://doi.org/10.1001/jamapsychiatry.2022.0010

Summary by: Zeynep Ersoy

A person with Borderline Personality Disorder (BPD) often experiences difficulties with emotion regulation, impulsivity, and interpersonal relationships. Therefore, schema therapy has emerged as a promising treatment. Yet, despite growing evidence, an important clinical question remains: What is the most effective way to deliver schema therapy to individuals with BPD? The randomized clinical trial conducted by Arntz et al. (2022) offers a decisive answer. In this study, three different treatments were compared: predominantly group schema therapy (PGST), combined individual and group schema therapy (IGST), and treatment as usual (TAU). The treatment-as-usual condition most frequently consisted of dialectical behavior therapy, but other psychological treatments were also used. Another feature that makes this study important is that it was conducted at 15 different locations across five countries, involving 495 participants: Germany, the Netherlands, Greece, Australia, and the UK. This multinational design strengthens the generalizability of the findings. The study examined whether BPD severity decreased and investigated the longer-term effects of the interventions.

First, the most significant finding was the difference in effectiveness between the treatment methods. IGST stood out compared to the other treatment groups. It produced a large effect size compared to TAU (Cohen's d = 1.14) and significantly outperformed PGST (d = 0.84), whereas PGST did not differ significantly from TAU. This suggests that patients with BPD may benefit particularly from IGST and that several factors could contribute to this. Schema therapy is beneficial for BPD treatment because it works with early maladaptive schemas and attachment needs. One possible explanation for the difference between IGST and PGST is the greater emphasis on individual therapy in IGST, which allows therapists to work more deeply with childhood trauma, attachment injuries, and shame-related schema modes. These topics can be too sensitive or overwhelming to address in a group setting. On the other hand, group sessions can reflect the real-world relational difficulties that characterize BPD by providing opportunities to explore interpersonal patterns and receive feedback from peers. As a result, the combination of group and individual schema therapy appears to be a promising treatment method for BPD.

In addition to the effectiveness of these treatments, another important point is treatment retention. Treatment dropout can be a major barrier to successful BPD treatment, but the IGST condition demonstrated the highest retention rates over the two-year treatment period. Higher retention may increase the likelihood of sustained therapeutic gains. In addition, improvements in BPD severity continued during the follow-up period, suggesting that the benefits of treatment may extend beyond the therapy itself. This could indicate that patients were able to apply what they had learned even after treatment ended. Another important finding was that IGST was more effective than TAU in reducing suicidality and suicide attempts, which further highlights the clinical importance of this treatment.

Finally, there are also limitations to this study. Group schema therapy was generally delivered by therapists with limited experience in this specific group format. Also, some individual schema therapists were using this method for the first time. Therefore, in future research, it could be important to control for therapists' experience and investigate how training and supervision influence treatment outcomes. Another limitation is that treatment as usual was not standardized across the different locations, making direct comparisons more difficult. Although several psychological treatments were used as treatment as usual, IGST showed greater improvements than TAU. Testing these approaches in a multinational sample and examining not only short-term but also longer-term effects are important strengths of the study.

Ultimately, this study has significant clinical implications. Professionals seeking to use schema therapy in the treatment of BPD may benefit from combining group dynamics with individual therapy. Integrating both approaches can offer longer-term benefits. Focusing on emotional depth while also taking advantage of interpersonal interactions and feedback can produce encouraging results for people with BPD.

In conclusion, Arntz et al. (2022) provide evidence that combined individual and group schema therapy is a highly effective and clinically meaningful way to deliver schema therapy for borderline personality disorder. IGST emerges as a promising model for addressing both the intrapersonal and interpersonal dimensions of BPD. Its strong results, high retention rates, and sustained improvements make it an important treatment option and suggest that it may be the preferred format of schema therapy for treating BPD.

Beyond Exposure: A New Path to Treating OCD Without Fear

Wolf, N., van Oppen, P., Hoogendoorn, A. W., van den Heuvel, O. A., van Megen, H. J. G. M., Broekhuizen, A., Kampman, M., Cath, D. C., Schruers, K. R. J., van Es, S. M., Opdam, T., van Balkom, A. J. L. M., & Visser, H. A. D. (2024). Inference-based cognitive behavioral therapy versus cognitive behavioral therapy for obsessive-compulsive disorder: A multisite randomized controlled non-inferiority trial. Psychotherapy and Psychosomatics, 93(6), 397–411. https://doi.org/10.1159/000541508

Summary by: Levente Szovák Brack

For clinicians and patients, the treatment of Obsessive-Compulsive Disorder (OCD) can be very difficult because the nature of treatment often involves exposure to highly anxiety-provoking stimuli related to the obsessions of the patient which is how the current “gold standard”: Cognitive Behavioural Therapy (CBT) with Exposure and Response Prevention (ERP) essentially works. While it is effective, it can be extremely difficult. It requires the patients to deliberately expose themselves to their fears and at the same time resist the urge to perform compulsions which generates significant anxiety and distress.

This intense anxiety may contribute to approximately 15% of OCD patients refusing treatment or dropping out before completing it. This leaves a room for another approach to helping those with OCD that does not require patients to face their fears so aggressively. The recent randomized controlled trial by Wolf et al. (2024) suggests that Inference-Based Cognitive Behavioural Therapy (I-CBT) could be a viable alternative for OCD patients, potentially including those unwilling or unable to complete ERP therapy due to the anxiety and distress it can cause.

In standard ERP, the goal is habituation which means getting the patient used to the trigger so the anxiety decreases over time. In contrast, I-CBT focuses on the time before anxiety spikes described as “inferential confusion”. According to the I-CBT method, OCD is not just a fear problem, it is a reasoning problem. Patients confuse "possibility" (e.g., “It’s possible there are germs on this handle”) with reality (e.g., “There are germs on this handle”).

I-CBT aims to help patients identify the flawed reasoning behind their obsessions and fears, trust their common sense, and resolve their doubts logically, making the compulsion unnecessary. The main crucial difference between I-CBT and ERP is that I-CBT does not have an exposure complement. This means there is no deliberate activation of the fear/obsession and the patient learns to tolerate anxiety and trust reality.

This study recruited 197 participants with moderate-to-severe OCD, as measured by the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), and randomly assigned them to receive 20 sessions of either standard CBT (with ERP) or I-CBT. The main question was “Is I-CBT as effective as standard CBT? (Non-inferiority)".

The results showed that both treatments were highly effective. Participants in both the CBT and I-CBT groups saw statistically significant improvement in their OCD symptoms, as measured by the Y-BOCS. These improvements were long lasting at both 6-month and 12-month follow-ups.

The non-inferiority cut-off point was 2 points. At post-treatment, CBT improved OCD symptoms by 10.02 points on the Y-BOCS, while I-CBT improved symptoms by 7.97 points. The difference between the two groups was 2.05 points in favour of traditional CBT with ERP. However, the 95% confidence interval for this difference ranged from −0.11 to 4.22 points, exceeding the non-inferiority margin of 2 points. Therefore, I-CBT could not be conclusively considered non-inferior to CBT. At the same time, the difference between the treatments was not statistically significant (p = 0.06), meaning that CBT's superiority was not established either. Therefore, the results were inconclusive. I-CBT still showed a large effect size however and was also significantly more tolerable at mid and post treatment compared to CBT showing it is still a valid and viable option.

A limitation is that the CBT therapists had an average of 7.5 years of experience while the I-CBT therapists had just 0.9 years on average experience with I-CBT as most of them were trained in the technique specifically for this study. A future study where experience is more equal in both may yield different results.

The findings of Wolf et al. (2024) suggest that deliberately confronting feared situations is not the only way to reduce OCD symptoms and severity.

While standard CBT with ERP will remain a strong therapy, it is not a perfect technique for all OCD sufferers. For those who are hesitant to start the therapy because they are terrified of exposure exercises, I-CBT offers an effective alternative.

Cognitive-Behavioral treatment and antidepressants combined with virtual reality exposure for patients with chronic agoraphobia

Peñate Castro, W., Roca Sánchez, M. J., Pitti González, C. T., Bethencourt, J. M., de la Fuente Portero, J. A., & Gracia Marco, R. (2014). Cognitive-behavioral treatment and antidepressants combined with virtual reality exposure for patients with chronic agoraphobia. International Journal of Clinical and Health Psychology, 14(1), 9–17. https://doi.org/10.1016/S1697-2600(14)70032-8

Summary by: Alba Basholi

The Exposure Dilemma 

Cognitive Behavioral Therapy (CBT) in combination with in vivo exposure—which means confronting feared situations directly in real life—is considered by many as the best possible treatment for agoraphobia. But this "best treatment" also has a problem: the therapy itself is often very scary. A lot of patients feel so overwhelmed by the idea of being exposed to real-world stimuli that they either refuse to take the treatment or drop out very early. This problem has been magnified in cases of "chronic" patients—those who have been in agony for several years and might have already tried exposure a few times unsuccessfully. 

In 2014, Peñate Castro and his colleagues studied this dilemma in therapy by using Virtual Reality Exposure Therapy (VRET) as a test case. They suggested that VRET would not act as a replacement for real-world exposure; instead, it would be a vital intermediate that would not only improve adherence but also long-term outcomes for stubborn patients. 

Targeting the "Chronic" Sufferer 

The clinical trial was carried out with the utmost care, and it was mainly directed towards a difficult-to-treat population: long-term agoraphobic patients. They had been in distress for an average time of 11.46 years, with some cases lasting for as long as 30 years. To be on the safe side and for the sake of scientific rigor, the study accounted for drug variables; every participant was treated with antidepressants that had been proven effective against anxiety (Paroxetine or Venlafaxine). 

Out of 80, the subjects were assigned randomly to one of the three groups as follows: 

• CBT + Medication: They took part in the CBT with in vivo exposure, where they confronted the actual environments along with the therapists. 
• VRET + Medication: The patients were those who received the significant approach combined with a Virtual Reality system to confront the phobic scenarios (e.g., airports, squares, elevators) gradually and subsequently to the real-life exposure. 
• Medication Only: They received only medications and no psychological intervention during the study. 

A Crisis of Adherence in Standard CBT 

About clinical efficacy, the research validated that the treatment through medication alone is not enough for this group of patients. The "Medication Only" group did not have any remarkable symptom improvement between pre-treatment and post-treatment; rather, some anxiety scores slightly went up. 

The two therapy groups were compared to the drug-only group, and statistically significantly, the two therapy groups were better off. However, there was a marked difference over time, and that difference was in favor of the VRET group. At the six-month follow-up, the VRET group achieved "clinical improvement" (50% reduction in scores) for most variables, including fear and avoidance. Above all, VRET patients had a very big score decrease on the "Agoraphobia Inventory - Alone" scale, which reflects a patient`s greater ability to attend the feared places without a safety partner—a main characteristic of independence. 

The "Intermediate Step" 

The authors consider VRET to be an effective treatment because it serves as an "intermediate procedure.” A virtual simulation can be a very small but very important first step for a patient who has not used elevators for ten years. The patient boosts his self-efficacy and confronts fear in a safe environment by mastering the virtual analogue. This "scaffolding" guarantees that when they finally confront the real world, they are armed with confidence, not fear, which leads to fewer dropouts and creates a path for permanent recovery.