Cognitive Behaviour Therapy

ISSN: 1650-6073 (Print) 1651-2316 (Online) Journal homepage: http://www.tandfonline.com/loi/sbeh20

Internet-Based Exposure Treatment Versus One-

Session Exposure Treatment of Snake Phobia: A
Randomized Controlled Trial

Gerhard Andersson, Johan Waara, Ulf Jonsson, Fredrik Malmaeus, Per

Carlbring & Lars-Göran Öst

To cite this article: Gerhard Andersson, Johan Waara, Ulf Jonsson, Fredrik Malmaeus, Per
Carlbring & Lars-Göran Öst (2013) Internet-Based Exposure Treatment Versus One-Session
Exposure Treatment of Snake Phobia: A Randomized Controlled Trial, Cognitive Behaviour
Therapy, 42:4, 284-291, DOI: 10.1080/16506073.2013.844202

To link to this article: https://doi.org/10.1080/16506073.2013.844202

Published online: 18 Nov 2013.

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 Cognitive Behaviour Therapy, 2013
Vol. 42, No. 4, 284–291, http://dx.doi.org/10.1080/16506073.2013.844202

Internet-Based Exposure Treatment Versus

One-Session Exposure Treatment of Snake

Phobia: A Randomized Controlled Trial

Gerhard Andersson1,2, Johan Waara3, Ulf Jonsson2,4, Fredrik Malmaeus3,

Per Carlbring5 and Lars-Göran O¨ st2,5

1
Department of Behavioural Sciences and Learning, Linköping University, Linköping,
Downloaded by [Pontificia Universidad Catolica de Chile] at 11:21 28 November 2017

Sweden; 2Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden;

3
Department of Psychology, Uppsala University, Uppsala, Sweden; 4Department of
Neuroscience, Child and Adolescent Psychiatry, Uppsala University, Uppsala, Sweden;
5
Department of Psychology, Stockholm University, Stockholm, Sweden
Abstract. In this study, the authors compared guided Internet-delivered self-help with one-session
exposure treatment (OST) in a sample of snake phobic patients. A total of 30 patients were included
following a screening on the Internet and a structured clinical interview. The Internet treatment
consisted of four weekly text modules which were presented on a web page, a video in which exposure
was modelled, and support provided via Internet. The OST was delivered in a three-hour session
following a brief orientation session. The main outcome was the behavioural approach test (BAT),
and as secondary measures questionnaires measuring anxiety symptoms and depression were used.
Results showed that the groups did not differ at post-treatment or follow-up, with the exception of a
significant interaction for the BAT in favour of the OST. At post-treatment, 61.5% of the Internet
group and 84.6% of the OST group achieved a clinically significant improvement on the BAT. At
follow-up, the corresponding figures were 90% for the Internet group and 100% for the OST
group (completer sample). Within-group effect sizes for the Snake Phobia Questionnaire were large
(d ¼ 1.63 and d ¼ 2.31 for the Internet and OST groups, respectively, at post-treatment). It is
concluded that guided Internet-delivered exposure treatment is a potential treatment option in the
treatment of snake phobia, but that OST probably is better. Key words: snake phobia; Internet
treatment; one-session exposure treatment

Received 26 August 2013; Accepted 10 September 2013

Correspondence address: Gerhard Andersson, Department of Behavioural Sciences and Learning,

Linköping University, SE-581 83 Linköping, Sweden. Fax: þ 46 13 28 21 45. E-mail: Gerhard.
Andersson@liu.se

Introduction
Specific phobia is one of the most common
anxiety disorders, with an estimated lifetime
prevalence of 13.8% (Kessler, Petukhova,
Sampson, Zaslavsky, & Wittchen, 2012).
Among the specific phobias, animal phobias
are highly prevalent with a point prevalence of
7.9% (Fredrikson, Annas, Fischer, & Wik,
1996), and snakes are commonly feared
among the animal phobics. The therapy
found to be most effective and time efficient
for specific phobias is the one-session exposure
treatment (OST) developed by O¨ st (1989,
1997), with clinically significant improvement
rates often reaching up to 80% (Zlomke &
Davis, 2008). While OST should be regarded
as the treatment of choice for specific phobia,
there is lack of trained therapists who can and
are willing to provide OST, and in response
to this need, alternative ways to deliver
exposure treatments have been developed
(Emmelkamp, 2005). However, in a meta­
analysis by Wolitzky-Taylor, Horowitz,
Powers, and Telch (2008), in vivo exposure
was found to be better than other forms of

q 2013 Swedish Association for Behaviour Therapy

 VOL 42, NO 4, 2013 Internet-Based Exposure Treatment Versus One-Session Exposure Treatment of Snake Phobia 285

exposure, such as virtual reality treatment.
Unfortunately, attempts to provide detailed
instructions for patients so that they can
perform exposure at home (and together with
significant others) have often not been
effective enough (e.g., Hellström & Ost,
1995). For example, in a study on spider
phobia, the treatment was stepped up from
self-exposure to individual treatment (Ost,
Stridh, & Wolf, 1998), and the authors found
that only 27% of the participants reached a
clinically significant improvement after the
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small pilot study, and in the present study we
report findings from a very similar study in
which we focused on snake phobia.
The study reported here was conducted at
the same time as our previous spider phobia
¨ study, and followed similar procedures includ­
ing comparing guided Internet treatment
against OST. In contrast to the literature on
¨ spider phobia, there is much less published
work on snake phobia as a separate
group using OST (Zlomke & Davis, 2008),
and there is no study on guided Internet

first step of self-exposure. This was not
therapist-guided self-exposure, which may
have influenced the outcome.
Self-help treatments can be delivered with
therapist interaction from a distance, either by
telephone or with the help of modern
information technology such as the Internet
(Andersson, 2009; Carlbring & Andersson,
2006). An increasing number of studies
show that guided Internet-delivered self-
help cognitive behaviour therapy (CBT) can
be as effective as face-to-face CBT for a range
of conditions (Andersson, 2012; Cuijpers,
Donker, van Straten, & Andersson, 2010).
Even if factors such as therapist drift and
competence are probably less relevant in
guided Internet treatments than in face-to­
face treatments (e.g., Almlöv et al. [2011], but
see Paxling et al. [2013] for examples of how
therapists can influence the outcome), it is
clear that some form of guidance increases
adherence and often leads to better outcomes
than purely unguided self-help treatments
(Palmqvist, Carlbring, & Andersson, 2007).
To date, there have been numerous studies on
guided Internet treatment for anxiety dis­
orders such as social anxiety disorder, panic
disorder, and generalized anxiety disorder
(Andersson in press). However, much less has
been published on guided Internet treatment
for specific phobia. One exception is a study
on spider phobia by our group, in which we
found that OST was superior on the beha­
vioural approach test (BAT), where at post­
treatment, 46.2% of the Internet group and
85.7% of the OST group achieved a clinically
significant improvement (Andersson et al.,
2009). On other continuous measures such as
the Spider Phobia Questionnaire (Klorman,
Weerts, Hastings, Melamed, & Lang, 1974),
there were no statistically significant differ­
ences between the two groups. This was a
treatment. Thus, the aim of this study was to
replicate the study on spider phobia, but this
time with a sample of patients with snake
phobia. We expected improvements following
both OST and guided Internet treatment, but
with an advantage of OST. Since this was a
small pilot trial, we could not power the study
as a non-inferiority trial, but instead used OST
as a benchmark against which the more novel
Internet treatment was compared.
Method
Participants and procedure
Participants were recruited via local bulletin
boards, articles in local newspapers, and on
the Internet. The study website presented
information about the project and screening
questions which included background infor­
mation and questions from the Anxiety
Disorders Interview Schedule for DSM-IV
(Di Nardo, Brown, & Barlow, 1994), the
Structured Clinical Interview for DSM-IV
Diagnosis I (SCID-I; First, Gibbon, Spitzer, &
Williams, 1997), the self-rated version of
Montgomery A� sberg Depression Rating
Scale (Svanborg & A�sberg, 1994), and Beck
Anxiety Inventory (BAI; Beck, Epstein,
Brown, & Steer, 1988). A total of 104
applicants completed the online screening
questions. Of these, 34 were called to a
screening interview consisting of a section of
the SCID-I, mainly focusing on specific
phobia, and a BAT, which was adapted for
snake phobia (Kaloupek & Levis, 1983). The
reason for not including more participants for
interview was that the study was aimed to be a
pilot study and we had no capacity to include
more. Before the interview, pre-treatment
questionnaires were completed (see below).
In order to participate in the study, the
following criteria had to be fulfilled: (1) be
 286 Andersson, Waara, Jonsson, Malmaeus, Carlbring and Öst
between 18 and 65 years of age; (2) fulfilling
the DSM-IV criteria of specific phobia, snake
type; (3) being incapable of approaching and
touching snake during the behavioural test; (4)
have no other psychiatric problems requiring
immediate treatment; (5) no current depressive
episode for two weeks or longer the last
month; (6) access to the Internet at least two
times a week; and (7) agree to be randomized
to either of the conditions. A total of 30
participants met the inclusion criteria and
were randomized by an independent person to
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either OST or guided Internet treatment (using
a computerized randomization procedure).
However, two immediately dropped out (one
in each condition), and two completed the
treatment but did not provide follow-up data
(also one in each condition), leaving a total of
26 participants in the trial. Given the small
sample size, we made no attempt to impute the
missing data for the four missing cases. Mean
age of the included 26 participants was 27.2
years (SD ¼ 8.1; range: 19– 54 years), and a
majority (84.6%) were females. Most were
university students (54.0%), but 19.0% had 12
years of basic education only, and the
remaining 27% had graduated from univer­
sity. The four cases that were missing from the
final analyses did not differ systematically
from the completers.
Treatments
OST for specific phobia was delivered with a
brief orientation session and a three-hour
exposure treatment session following the
¨ (1997). There was
guidelines provided by Ost
a one-week interval between a first assessment
and information session and the OST. The
post-treatment interview was conducted one
week after the OST. There were four therapist
including two clinical psychology students in
their last year, one PhD student in clinical
psychology, and one licensed psychologist/
researcher. The four therapists were trained by
¨
Ost (during a one-day workshop), who also
provided supervision on two occasions for
three hours (supervision for another trial on
spider phobia was also provided during that
time; Andersson et al., 2009). All therapists
were required to have completed at least two
video-recorded pilot patients using the treat­
ment protocol. Briefly, the exposure session
gradually progress in collaboration between
the therapist and the patient, and catastrophic
COGNITIVE BEHAVIOUR THERAPY
cognitions are challenged during the exposures
(Zlomke & Davis, 2008). We used two corn
snakes (Pantherophis guttatus) that were
approximately 120 cm long. The snake that
had been involved in the BAT was not the one
used in the OST. At the start of the treatment
they were contained in an opaque plastic bowl
with sawdust. The exposure session was
videotaped and the participants were given
the video after the completion of the exposure.
They were also given a maintenance pro­
gramme and instructed to confront snakes in
order to maintain the treatment gains. For a
detailed description of OST see Ost¨ (2012).
The Internet treatment consisted of four
text modules which were presented on web
pages and as downloadable pdf files. Each
module was presented on a continuous basis
and each participant had a therapist who was
responsible for the treatment. E-mails were
used in the contact and the whole process was
password protected (Andersson, Carlbring,
Ljótsson, & Hedman, in press). In addition, an
instructional videotape was sent by post to the
participants in which exposure instructions
were illustrated. The duration of the treatment
was four weeks. Participants were contacted if
they failed to send in their homework assign­
ments. Briefly, the first module consisted of an
introduction and rationale, psychoeducation
regarding fear responses, and a description of
exposure treatment including point-by-point
instructions. As homework, participants were
instructed to formulate goals and to have a
friend or significant other to help them find
snakes to facilitate exposure. Moreover, they
had as homework to read a text about snakes,
look at three snake pictures on the website,
and finally watch the video that was sent to
them and illustrated the exposure principles.
The video lasted for 30 minutes and contained
a woman who presented the exposure prin­
ciples with herself as the patient, while
commenting on what occurred. Participants
were instructed not to interrupt the exposure
until the anxiety had decreased. When the
homework was reported the following week
the participant had to complete a brief set of
questions in order to be allowed to proceed to
the next module.
The second module included detailed
exposure instructions according to an unpub­
lished self-help manual by O¨ st. They were
encouraged to expose themselves to three
 VOL 42, NO 4, 2013 Internet-Based Exposure Treatment Versus One-Session Exposure Treatment of Snake Phobia
Internet
14
12
Behaviour Approach Test
10
8 including the 30-item Snake Phobia Ques­
6 et al., 1974), the 76-item Fear Survey
4 Schedule-III (FSS-III; Wolpe & Lang, 1964),
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2 Beck, Ward, Mendelson, Mock, & Erbaugh,
0 The outcome measures have good psycho­
Pre Post
Figure 1. Results on the behavioural approach test
for the Internet treatment and one-session exposure
treatment at pre-treatment, post-treatment, and
one-year follow-up.
additional pictures of snakes. They were also
instructed to seek out a pet store or a
herpetological society where they could see a
snake, approach it, and touch the glass of its
container. Reporting progress back to the
therapist was the homework assignment. In
the third module, the exposure was continued
with an emphasis on avoided situations and
cognitions. There were three additional snake
pictures for exposure, and instructions were
given on how to get to a zoo (Skansen in
Stockholm) where they could get access to a
snake and touch it. In the fourth module,
suggestions were given on how to expand and
repeat the exposure in real life such as visiting
an animal shop and watching a movie with
snakes. The fourth module also included a
maintenance programme. When needed, the
participants could rely on the supporting
person for assistance. However, it was
emphasized that the goal was to work and
do exposures independently. The contact with
the therapist was 25 minutes in total per client,
and on average the participants’ own estimate
of how much time they had devoted to the
treatment was 2.4 hours per week (total time
12 hours).
Outcome measures
The patients were assessed one week before
and one week after the treatment, and also at a
one-year follow-up. As the main outcome
287
Live
measure we used the BAT to assess the
patient’s avoidance and fear of live snakes
(Kaloupek & Levis, 1983). The test consists of
14 steps, scored 0 –14, ranging from not
entering the room (0 points) to holding the
snake for at least 20 s (14 points). A set of self-
report inventories were administered online,
tionnaire (SNAQ; Fredrikson, 1983; Klorman
the 21-item Beck Depression Inventory (BDI;
1961), and the 21-item BAI (Beck et al., 1988).
1-year fu metric properties and there are no indications
that Internet administration impairs these
properties negatively (e.g., Carlbring et al.,
2007).
Clinically significant improvement
Clinically significant improvement was
derived from the BAT. The change from pre-
to post-treatment had to be statistically
reliable, and the post-treatment score had to
be either within the range of a normal sample
or outside the range of the patient
group defined as M ^ 2 SD in the direction
of functionality (Jacobson & Truax, 1991).
Using data of Öst (1997), the cut-off score for
a normal range score was 10 and the change
had to be at least 2 points.
Results
As mentioned in the method section, two
participants did not provide data and two
dropped out, yielding a total sample of 26. At
the one-year follow-up, three participants
dropped out from the Internet treatment
condition and one from the OST. One
additional participant from the OST failed to
complete the online questionnaires measures.
The reason for not turning up was usually lack
of time or having moved from the region.
Behavioural approach test
Results from the BAT are presented in
Figure 1. Within-group effect sizes (pre to
post) for the BAT, using formula 3 in the
study by Dunlap, Cortina, Vaslow, and Burke
(1996), were large for both groups (d ¼ 1.81
for Internet treatment and d ¼ 3.07 for the
OST). Regarding the pre- to post-effects,
 288 Andersson, Waara, Jonsson, Malmaeus, Carlbring and Öst COGNITIVE BEHAVIOUR THERAPY

Table 1. Means (SD) for the self-report measures at pre-treatment, post-treatment, and one-year follow-
up for the Internet treatment (n ¼ 13) and the one-session treatment (OST; n ¼ 13)

Measures Group Pre-treatment Post-treatment One-year follow-up Effect size pre to post (d)
SNAQ Internet 24.2 (2.4) 10.7 (6.8) 10.8 (5.3) 1.63
OST 25.0 (3.3) 11.7 (6.5) 11.3 (5.4) 2.31
FSS-III Internet 135.2 (27.9) 122.5 (23.6) 126.4 (31.8) 0.46
OST 136.2 (13.5) 123.5 (21.2) 128.5 (29.0) 0.69
BDI Internet 3.6 (3.4) 2.1 (1.8) 5.7 (6.1) 0.49
OST 2.2 (2.0) 1.4 (2.0) 1.2 (1.2) 0.29
BAI Internet 5.5 (3.7) 4.5 (3.0) 3.9 (4.0) 0.31
OST 6.8 (3.3) 6.9 (4.4) 3.3 (2.1) 2 0.04
Downloaded by [Pontificia Universidad Catolica de Chile] at 11:21 28 November 2017

Note. Three cases are missing in the Internet treatment and two in the OST condition at one-year follow-
up. SNAQ, Snake Phobia Questionnaire; FSS-III, Fear Survey Schedule-III; BDI, Beck Depression Inventory;
BAI, Beck Anxiety Inventory.

there was a significant main effect of time
F(1, 24) ¼ 148.5, p , .001, and a significant
interaction F(1, 24) ¼ 5.40, p ¼ .03. The
between-group effect size at post-treatment
was d ¼ .65 in favour of the OST, and as seen
in Figure 1, this interaction is explained by the
larger improvement in the OST group. There
was further improvement from post-treatment
to one-year follow-up F (1, 20) ¼ 5.69,
p ¼ .03, but then there was no significant
interaction.
Results on the BAT were also analysed with
regards to clinically significant improvement.
This revealed that 61.5% (95% CI ¼ 30.9 –
92.1) of the Internet group showed clinically
significant improvement with the correspond­
ing figure being 84.6% (95% CI ¼ 61.9 – 100)
in the OST group. This difference was
not significant, x 2 (1) ¼ 1.8, p ¼ .18. At one-
year follow-up, the corresponding figures were
90% (95% CI ¼ 67.4 – 100) for the Internet
group and 100% for the OST group. The
difference between the groups was not
significant.
Self-report measures
Means and standard deviations for the self-
report measures are presented in Table 1.
As seen in the table, improvements were
found for the SNAQ with a main effect of time
F(1, 24) ¼ 91.3, p , .001, but no interaction
or main effect of group. There was no
deterioration between post-treatment and
one-year follow-up. For the FSS-III, we also
found pre to post main effect F(1, 24) ¼ 15.3,
p , .001, and again no interaction or post to
one-year changes. For the BDI, there was an
effect of time F(1, 24) ¼ 4.6, p ¼ .04, and no
interaction. The BAI showed no effects.
Discussion
The aim of this randomized trial was to
compare guided Internet-delivered self-
exposure against OST for snake phobia. In
line with the expectations, OST was found to
be a highly effective treatment, very much in
line with what a previous review of random­
ized controlled trials has found (Zlomke &
Davis, 2008). Thus, the within-group effect
sizes were large and the proportion of
participants showing a clinically significant
improvement on the BAT was high. While we
had no strong reasons to believe that persons
with snake phobia would respond differently
to OST than persons with spider phobia (for
which there is more evidence), this study adds
to the literature on OST by providing
group estimates of the effects of OST for
snake phobia. As this was our second report,
preceded by a trial on spider phobia
(Andersson et al., 2009), it is interesting to
note that the response to OST in this trial was
just as good or even better with 84.6%
responding to treatment at post-treatment
and as many as 100% at one-year follow-
up. Obviously these figures would not be as
impressive if dropouts from assessment were
considered, but still it is an indication that we
managed to deliver OST in an effective
manner. This is an interesting finding for
both this trial and the previous spider phobia
trial, as we had very little experience of
providing OST. However, the initial training
 VOL 42, NO 4, 2013 Internet-Based Exposure Treatment Versus One-Session Exposure Treatment of Snake Phobia
and supervision by the originator of the
treatment probably explains this, in addition
to the clear structure in the treatment manual.
OST is not an easy treatment to deliver, and
hence supervision and training is needed, but
it is also the case that the treatment was well
received and nobody declined treatment when
the exposure was performed.
The effects found for the Internet-delivered
self-exposure treatment were impressive as
well, in particular when compared to other
self-exposure treatments for specific phobia
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(Zlomke & Davis, 2008). Overall, this trial
suggested that OST was more effective than
self-administered Internet treatment, albeit
therapist-guided from a distance. In spite of
this, the Internet treatment tested in this study
was clearly effective, with large within-
group effect sizes (including a good response
rate of 61.5% at post-treatment and 90% at
one-year follow-up). As with the spider phobia
study, it is important to note that the Internet
treatment was self-administered exposure and
not a treatment delivered in front of a
computer or with the help of a virtual reality
equipment (e.g., Côté & Bouchard, 2008). Our
study adds to the growing literature on
Internet-delivered exposure treatments for
anxiety disorders, with promising findings
for panic disorder (e.g., Carlbring et al., 2006),
social anxiety disorder (e.g., Andersson et al.,
2006), generalized anxiety disorder (e.g.,
Paxling et al., 2011), obsessive-compulsive
disorder (Andersson et al., 2012) and severe
health anxiety (hypochondriasis; Hedman
et al., 2011). The technology used in the
Internet treatment was not advanced and was
mainly in the form of downloadable pdf files, a
video, and secure therapist – patient inter­
action within a contact management system.
Future studies could benefit from the use of
modern mobile smartphones, as they are
capable of providing film clips and can also
be used for fear ratings in the actual exposure
situations (Luxton, McCann, Bush, Mishkind,
& Reger, 2011). This study shares all of the
limitations of our previous spider phobia trial
(Andersson et al., 2009). For example, the
study was underpowered. It would also have
been informative to have treatment credibility
assessed for the two conditions, and this is
recommended in future trials. In addition,
another limitation specific for this study was
that we only used two snakes, and it was
289
inevitable that participants had been con­
fronted with either or both snakes at the one-
year follow-up (and during treatment for the
OST group). For the participants in the OST
group, this may have provided them with an
advantage when performing the BAT. On the
other hand, the participants in the Internet
treatment had to seek out other snakes for
exposure, which may be important for
generalization of treatment effects and also
an advantage in the BAT. While there were a
few additional dropouts at the one-year
follow-up, it is still interesting to note that
the treatment effects remained and even
improved from post-treatment to follow-
up on the BAT. In previous Internet studies
we have repeatedly found that effects are
maintained over time (e.g., Carlbring, Berg­
man Nordgren, Furmark, & Andersson,
2009), and since participants have access to
the treatment material after the treatment has
ended (i.e., saved the printouts of the
treatment manual), they have the possibility
to repeat the whole treatment in addition to
the booster instructions provided. Future
studies should be clearly focused on OST for
specific phobia, and also large-scale Internet
trials on specific phobia as the two existing
trials are far too small to draw any firm
conclusions regarding effects.
In conclusion, this study showed that the
OST was effective for specific phobia (for
snakes) and that guided Internet treatment
can be an alternative in cases where it is not
possible to set up OST for practical reasons.
Acknowledgement
This study was sponsored in part by a grant
from the Swedish Research Council.
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