Cognitive behavioral therapy (CBT) has for a long time been applied to treat psychological disorders that stem from human beings’ thoughts, changing some aspects of their behaviors. The article Internet-based cognitive behavioral therapy for adolescents with anxiety disorders: A feasibility study by Stjernekler et al., (2018) explores the efficacy of internet based CBT (ICBT) as an intervention to anxiety among adolescents. ICBT aspects of physical CBT, but is delivered online by a professional. Citing from several past studies, the authors state that the number of adolescents who seek professional help for psychological disorders remain low. This is due to reasons such as privacy concerns, societal stigmatization, waiting time, costs, fear of rejection by friends, self-reliance, among others (Stjernekler et al., 2018). Some of the advantages of ICBT compared to physical CBT sessions include elimination of travel time and cost, flexibility, increased anonymity, greater accessibility, and overall reduced costs. The study implements the recently developed Chilled Out program to adolescents from Denmark.
In their 2018 journal article Long-term effectiveness of cognitive behavioral therapy for youth with anxiety disorders, Kodal et al. investigates, not only the efficacy of CBT on youths with anxiety, but its effectiveness on a long-term basis. While many studies have dedicated to examining the efficacy of CBT on individuals with anxiety, few of them perform follow-up strategies to determine whether the patients maintain the achieved results. The authors insist that it is only by following up for at least two years after treatment, that researcher can conclude effectiveness. (Kodal et al., 2018). Additionally, following up prevents an occurrence of sequelae and relapse. Furthermore, the study acknowledges that a majority of efficacy studies for the same research are conducted in university clinics, which presents variations of results, in a community clinic setting. Among the hypotheses is that adolescent patients will maintain long-term effectiveness of CBT on anxiety, but on lower levels than those of a university clinic setting. The research also aims at comparing two variations of CBT; group (GCBT) and individual (ICBT), and assumes a maintenance of high efficacy rates in both. Lastly, the study considers the long-term effectiveness of CBT on different types of anxiety namely separation anxiety disorder (SAD), social anxiety disorder (SOP), and generalized anxiety disorder (GAD). The authors predict that efficacy rates of SOP would be lower than the rest.
. Stjernekler et al. realizes the trend in using ICBT and examines whether it is as effective as face-to-face CBT. Kodal et al. on the other hand, follows up on previously treated patients who report short-term effectiveness of CBT on their anxiety, to ascertain whether the outcomes remain constant even on a long-term basis. Additionally, the first study occurs at a university clinic setting and generalizes on anxiety as a single disorder, while the latter is at a community health clinic, exploring variations of anxiety disorder.
Research Methods
Seeing the applied intervention does not involve physical meetings, Stjernekler et al. used telephone interviews and email questionnaires. This study was first of its kind in Denmark, thus a small participant population of six adolescents from a university clinic, ranging from 13 to 17 years. For participants to be conducted eligible, they had to fall within the above age range, satisfy the DSM-IV signs and symptoms of depression, can write and read Danish, and have all-time access to a computer with internet connection. Participants who met this criteria, but had additional psychological disorders, substance dependence, primary PTSD, extreme conduct issues, intellectual disability or suicidal thoughts were excluded. In addition, they were asked not to be another anxiety treatment method and if taking drugs for the same, continue with the dose without making any alterations. Families of the identified participants then signed a consent form, and received materials that explained about the entire process. Assessments were done in three phases; before applying ICBT, after, and a follow-up at three months. In the pre-assessment, participants interacted with their assigned therapists, and inquired about the overall process. The eight module assessment was completed within twelve weeks, each with assigned practice activities. Professionals conducted a telephone interview once a week to check progress, offer support and motivation to the participants. Analysis of results were done on the basis of evident change in symptoms and diagnosis of anxiety and extent to which the disorder impacted their lives and family.
Unlike Stjernekler et al., Kodal et al conducted their study at a community health setting, with a large population and took four years. An initial Randomized Control Trial (RCT), which investigated the effectiveness of GCBT and ICBT was conducted on a total of 179 adolescents with anxiety, with an age range of 8-15 years. The only inclusion criterion was a positive diagnosis of either or all of the three types of anxiety. Exclusion was based on factors like mental retardation, severe conduct issues, psychotic, and pervasive development disorder. However, after the RCT, 40 participants opted out of a long-term follow up, which left the present study with 139 participants from several mental health clinics. Participants took several assessments all meant to test for their anxiety symptoms, while comparing results of GCBT with ICBT. Data was collected through questionnaires and, sometimes, phone interviews to assess progress. Measure tools were used to determine the extent of anxiety symptoms, as well as short feelings and moods throughout the study. In addition, parents of participants were part of the assessment by participating in several meetings per week. Analysis of results was meant to prove the stated hypothesis.
Summary of Results
The study by Stjernekler et al. (2018) reported a significant improvement from anxiety signs and symptoms among the five participants (one adolescent dropped out of the research). Both the parents and adolescents were pleased with the outcome and suggested the intervention for peers suffering from anxiety. Among the five, two reported an entire a complete elimination of anxiety symptoms, while the rest no longer experienced secondary diagnostic measures of anxiety (Stjernekler et al., 2018). However, a majority of self-report assessment were disparate with those of their parents, indicating a limitation. In comparison with face-to-face CBT, adolescents espoused the primary assumptions that ICBT was associated with less embarrassment, flexibility, anonymity, and maximum savings. Furthermore, the adolescents unanimously agreed that the program was easy to use on a computer, validating the need to develop interventions that are in line with the digital age. In brevity, ICBT is an effective and efficient intervention for adolescents with anxiety disorder.
Similarly, results of the second study supported a majority of its hypothesis. First, there was an improvement from anxiety symptoms in a majority of the participants. Long-term follow up indicated the same, with some improving from previous short-term assessment. Second, both GCBT and ICBT used as variables in this research provided equivalent results, which espouses previous studies. Third, participants with SOP recovered at a lower rate compared to those with SAD and GAD, as hypothesized. In addition to this, improvement progress for youths with SOP seemed to deteriorate over time, until long-term follow up. However, the hypothesis that this long-term follow up study would present significantly lower results than other efficacy studies did not stand, and all outcomes fell within ranges of previous experiments. In summary of these results, CBT is an effective intervention for anxiety, and its results persist for a long time. Also, from the results, it is evident that patients with SOP require more attention as compared to GAD and SAD, because it has specific features that vary from the rest.
Critique of the Studies
Being a trial test, Stjernekler et al. (2018) paves way for more studies seeking to improve the Chilled Out program. In this case, the authors assert that the study helped in the addition of features, such as extending the period required for intervention. Furthermore, the study incorporates ICBT, which could be a significant step in intervention programs for the youth. However, this study has few participants, almost unsatisfactory to make conclusions on the overall program using their outcomes. Thus, generalizing this study to apply it in a larger population is difficult, and there is need for future studies with a larger population. In addition, ICBT poses challenges like lack of follow up, patients are at risk of laxity, and the unavailability of face-to-face meetings, which serve as reinforcements.
The second study is the largest of its kind to investigate CBT’s effectiveness on youths with anxiety, and especially of mixed type, drawing participants from a community clinic. current study features notable strengths. All the major processes of the study were conducted by qualified clinicians who have worked in respective clinics for a considerable period, implying that they are familiar with the patients. In addition, the minimal missing data and high participation rates increases the strengths of the study. It would, therefore, be right to generalize these findings to other settings with the same problems. However, the research does not provide any information regarding cases of relapse, seeing that it explores long-term follow-ups.
Synthesis of Findings
The articles are similar in that they both examine the effectiveness of CBT as a treatment for anxiety disorder. The participants involved in both studies are adolescents of almost the same age range. Additionally, both articles concluded that, indeed, CBT is an effective intervention for anxiety disorder among young people, and participants asserted that they are likely to suggest to their peers. Furthermore, the researches successfully fulfilled their primary aims and the outcomes supported all, but one, hypotheses. Finally, both articles report studies that are first of their kind and, thus, providing useful literature for future studies.
However, the study by Stjernekler et al. explores CBT in a different form than that of Kodal et al. In the first article, CBT is conducted over the internet, while the latter involves face-face therapy sessions with qualified clinicians. The first study has only six participants, which might seem unsatisfactory for a study of that nature, while the second had 139 participants, allowing generalization of results. Just like most studies of this kind, Stjernekler et al. conducted their study at a university clinic setting, while Kodal et al. carried out their research at community clinic, improving the efficacy results. It is also worth noting that besides investigating the effectiveness of CBT, Kodal et al. involves a lot of variables, such as variants of anxiety disorders and modes of delivering CBT in their study. Stjernekler et al., on the other hand have only one independent and dependent variable.
Recommendations for Future Research
The above studies provide insightful literature to scholars examining almost similar questions. First, in a similar research, authors should extend the period of delivering ICBT on participants to allow them sufficient time to understand successfully complete the modules without feeling rushed. Second, future studies on ICBT should include more participants to ensure that the outcomes are satisfactory for generalization across a larger population. Finally, similar works should use a community clinic setting to examine whether there will be any differences in results. Similarly, studying the long-term effectiveness of CBT may investigate both the efficacy and cases of relapse among adolescents with anxiety disorder. Furthermore, to make causal conclusions regarding long-term CBT on anxiety, future research may include control groups and study the differences between this and the experimental group.
Conclusion
The articles Internet-based cognitive behavioral therapy for adolescents with anxiety disorders: A feasibility study and Long-term effectiveness of cognitive behavioral therapy for youth with anxiety disorders conclude that CBT is an effective treatment for anxiety in adolescents. While there are major differences between aspects of these studies, their findings make significant contributions to the field of psychology. The first study can be improved by having more participants, while the latter should include information on relapse cases. On the learning theory, Ormrod (2016) explains that behaviorists concordantly believe that learning processes are best studied by focusing on a stimuli and response, and involves behavioral alterations. Similarly, treating anxiety using CBT involves changing individual behaviors that happen in situations likely to trigger anxiety, and focusses on therapy, along with the observation of outcomes.
References
Kodal, A., Fjermestad, K., Bjelland, I., Gjestad, R., Öst, L. G., Bjaastad, J. F., ... " Wergeland, G. J. (2018). Long-term effectiveness of cognitive behavioral therapy for youth with anxiety disorders. Journal of anxiety disorders, 53, 58-67.
Ormrod, J. E. (2016). Human learning (7th ed.). Upper Saddle River, New Jersey: Pearson/ Merrill Prentice Hall.
Stjerneklar, S., Hougaard, E., Nielsen, A. D., Gaardsvig, M. M., " Thastum, M. (2018). Internet-based cognitive behavioral therapy for adolescents with anxiety disorders: A feasibility study. Internet Interventions, 11, 30-40.
