The Effect of Shame on Patients With Social Anxiety Disorder in Internet-Based Cognitive Behavioral Therapy: Randomized Controlled Trial

BACKGROUND: 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. OBJECTIVE: This study aimed to investigate the role shame played in the ICBT treatment process for participants with SAD. METHODS: 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). RESULTS: 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(96)=2.317; P=.02) and gender (β=−.33; SE 0.002; t(77)=−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). CONCLUSIONS: 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. TRIAL REGISTRATION: Chinese Clinical Trial Registry ChiCTR1900021952; http://www.chictr.org.cn/showproj.aspx?proj=36977