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Review by expert Adam C. Powell, Ph.D.

Pros:

  • Demonstrated clinical efficacy
  • Highly structured
  • Easy to use

Cons:

  • Costly
  • Use of British English may be distracting to some users
  • Requires a high-quality broadband connection

Description

FearFighter is a comprehensive cognitive behavioral therapy (CBT) and exposure therapy program intended to help people manage anxiety, phobias, and panic over the course of nine sessions. Each session contains video-based training and activities for users to complete. Some sessions ask people to complete a battery of psychometric assessments (Work and Social Adjustment Questionnaire, Patient Health Questionnaire, General Anxiety Disorder Questionnaire, Phobia Scale) in order to chart their progress.

FearFighter takes users on a nine week journey whose purpose is improving anxiety management. Users are encouraged to find a helper to assist them in certain parts of the journey. As users go through the journey, they watch videos of four actors who describe their own efforts to manage their anxieties and phobias. The program begins by teaching users about anxiety disorders, recognizing safety behaviors, and practicing anxiety management techniques. Users are then asked to challenge their negative thoughts with alternatives, create a list of goals for overcoming their fears, and finally, to embark upon exposure therapy with the assistance of their helper. The program concludes with sessions evaluating the user’s progress with exposure therapy.

Ease of Use and User Experience

FearFighter has a relatively linear interface and is very easy to use. It prompts users to provide information about their current status (through the psychometric assessments), negative thoughts, and goals for overcoming their fears. User responses are recorded in the system, and then shown through the course of the program whenever users are prompted to build upon their prior responses. Progression through the site seemed very logical, and it was easy to move both backwards and forwards through the content.

As the site uses videos to deliver content, a high-quality broadband connection is necessary for the best user experience. When the site was used on a 5 Megabit broadband connection in a developing country, there were periodic delays in the experience as the videos loaded. When the site was used on a 30 Megabit broadband connection in the United States, it performed smoothly.

User Interface

The site is accessible on both computers and mobile devices. CCBT makes the somewhat contradictory claim that it is testing compatibility with mobile devices running iOS 9, Android, and Windows 10, but that iPhones and iPads are fully supported. For the purposes of testing, a laptop running Windows 8, a desktop computer running Windows 10, and an iPhone 6S running iOS 9.3 were used. The site performed properly on all three platforms. FearFighter is rather platform agnostic, as it is intended to be used through a web browser.

The content on FearFighter consists of a combination of videos, radio buttons for answering assessment questions, and textboxes for inputting information about fears. While users are offered the ability to choose which actor scenario videos that they watch, and the order in which they watch actor scenarios, the user interface is otherwise entirely linear.

Appropriateness of Content

The content is appropriate for people whose anxieties are preventing them from accomplishing things that they wish to accomplish. The four actors who are followed throughout the course of the program each are facing extreme anxieties or phobias. The program follows a woman with social phobia who is uncomfortable speaking and eating in front of others, a man with agoraphobia with panic attacks who fears having panic attacks in public settings such as shopping centers, a woman with agoraphobia who fears shopping at the supermarket alone, and a man with a specific phobia who fears riding in lifts (elevators). Each of the people are initially unable to complete the task related to their fear, and then use exposure therapy to progressively work towards overcoming their respective fears. While this may be helpful for someone whose anxiety is preventing them from accomplishing something, it is less helpful for people who experience anxiety in specific situations, but are able to accomplish necessary tasks in spite of their anxiety.

American users may be distracted by the use of British English throughout the content of the program. All of the people included in the program speak British English. This became particularly distracting when one of the actors discussed his fear of lifts (elevators) throughout the program. The use of British terminology may make it harder for some users to imagine that the people featured are everyday people speaking to them as peers. Keeping with the British theme, when users click the “Help” button on the site, they see a box which refers users to two help services in the United Kingdom to meet immediate needs – The National Health Service 111 Service and The Samaritans. No helplines based in the United States are listed.

Appropriateness of Feedback

The feedback provided is based upon the nature of the subscription that the user has purchased for the program. The Silver (£129) and Platinum (£179) editions of the program do not include support. (The Platinum edition contains a bundle of cognitive behavioral therapy programs all produced by CCBT, the creators of FearFighter.) Silver and Platinum users are encouraged to find someone they trust to serve as a helper throughout the program. Feedback is additionally provided by the site itself, which charts progress on the battery of psychometric assessments which it periodically has users complete. Emails are sent at the end of each step to congratulate users on their progress. The Gold (£229) edition of FearFighter includes the same content as the Silver and Platinum editions, but additionally offers telephone support and 60 minutes of coaching. Thus, a greater degree of feedback and support is available to users willing to pay for it.

Cognitive Challenge

The program is intended to provide an emotional challenge, rather than a cognitive challenge. Users are taught anxiety management techniques, asked to identify a fear, and then to work with a helper towards overcoming it through exposure therapy. Users are likely to find the exposure therapy portion of the program to be the most challenging component, as it asks them to place themselves in situations that they have identified as anxiety provoking.

Ease of Account Management

Upon paying the program registration fee, users are sent a username and password selected by the company. There is not an obvious means for managing the account within the FearFighter website. However, the main portal housing all the CCBT programs offers users a means for editing their password and specifying their names. The software does not require the user to specify a name in order to function, although it is not anonymous, as billing information must be provided to obtain access.

Scientific Basis

FearFighter has been reviewed and endorsed by the National Institute for Health and Care Excellence (NICE), a government institution in the United Kingdom which is internationally known for its evaluation of healthcare interventions. At the time of writing, FearFighter was the only computerized cognitive behavioral therapy (CBT) tool for panic and phobia to have received NICE’s endorsement. NICE reviewed two randomized controlled trials and two non-randomized trials in making its determination about FearFighter, and found the program to be both efficacious and cost-effective.[i] FearFighter has been shown to be cost-effective relative to clinician-led exposure therapy[ii], as effective as clinician-guided exposure therapy while utilizing less clinician time[iii], feasible to use in a rural area[iv], and associated with user satisfaction[v]. FearFighter has also been shown to be an efficient and effective tool to use when educating medical students[vi] and nurses[vii] about exposure therapy.

Qualitative Review of Program Efficacy

FearFighter is likely to be quite effective in people with extreme anxieties and phobias who have the courage to face their fears through exposure therapy. It takes users through a logical process of learning about CBT, setting exposure goals, and then working with a helper to engage in exposure therapy. The process is modeled by four actors who share their experiences through the journey. FearFighter may be less appropriate for people unlikely to benefit from exposure therapy due to having milder anxieties or phobias and for people unwilling to participate in exposure therapy.

Estimate of Efficacy Relative to Similar Products

There is more research supporting FearFighter than other tools in its class. At least fifteen scientific studies on FearFighter have been conducted.[viii] Likewise, it has the endorsement of NICE. FearFighter is likely to be most effective from people facing anxiety or phobias which can potentially be mitigated by exposure therapy. People with more mild anxiety or phobias may benefit more from other tools which take a cognitive behavioral therapy (CBT) approach that is less focused on exposure therapy.

Cost

£129 with no live support or coaching; £179 with no live support or coaching if bundled with other tools; £229 with 60 minutes of coaching and clinician support. As of 4/16/16, $1.42 = £1. Thus, the price ranges from $183.21 to $325.23. The price in dollars will fluctuate with the exchange rate and some credit cards may impose fees (often 3%) for purchases made in foreign currency.


[i] Computerised cognitive behaviour therapy for depression and anxiety: NICE technology appraisal guidance [TA97]. National Institute for Health and Care Excellence. https://www.nice.org.uk/guidance/ta97/chapter/4-evidence-and-interpretation February 22, 2006. Accessed April 16, 2016.

[ii] Mccrone P, Marks IM, Mataix-cols D, Kenwright M, Mcdonough M. Computer-aided self-exposure therapy for phobia/panic disorder: a pilot economic evaluation. Cogn Behav Ther. 2009;38(2):91-9.

[iii] Marks IM, Kenwright M, Mcdonough M, Whittaker M, Mataix-cols D. Saving clinicians’ time by delegating routine aspects of therapy to a computer: a randomized controlled trial in phobia/panic disorder. Psychol Med. 2004;34(1):9-17.

[iv] Hayward L, MacGregor AD, Peck DF, Wilkes P. The feasibility and effectiveness of computer-guided CBT (FearFighter) in a rural area. Behavioural and Cognitive Psychotherapy. 2007 Jul 1;35(04):409-19.

[v] Macgregor AD, Hayward L, Peck DF, Wilkes P. Empirically grounded clinical interventions clients’ and referrers’ perceptions of computer-guided CBT (FearFighter). Behav Cogn Psychother. 2009;37(1):1-9.

[vi] McDonough M, Marks IM. Teaching medical students exposure therapy for phobia/panic–randomized, controlled comparison of face‐to‐face tutorial in small groups vs. solo computer instruction. Medical Education. 2002 May 1;36(5):412-7.

[vii] Gega L, Norman IJ, Marks IM. Computer-aided vs. tutor-delivered teaching of exposure therapy for phobia/panic: randomized controlled trial with pre-registration nursing students. International Journal of Nursing Studies. 2007 Mar 31;44(3):397-405.

[viii] Research –  FearFighter. CCBT Ltd. http://fearfighter.cbtprogram.com/about-ccbt/research/ Accessed April 16, 2016.


Review date: April 2016

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