Skip to main content

Social phobia and evasiveness: trial protocol for a randomized controlled feasibility and superiority trial of the effect of Modified Collaborative Assessment vs. standard assessment on patients’ readiness for psychotherapy (CO-ASSM-RCT)



Evasive personality disorder (AvPD) and social phobia (SP) have substantial costs for patients and their families and great economic costs to the society. While psychotherapy can be an efficacious treatment, many patients drop out during treatment. Increased knowledge on how to decrease dropout from psychotherapy is warranted, including how to increase a patient’s readiness for psychotherapy.


We describe a randomized controlled feasibility and superiority trial of 42 individuals with a clinical diagnosis of either SP or AvPD, who are to initiate psychotherapeutic treatment in Danish outpatient mental health services. They will be randomized in a 1:1 ratio to either assessment-as-usual and receive no further assessment or to a Modified Collaborative Assessment (MCA) provided as a pre-treatment intervention before psychotherapy initiation. MCA will include a battery of psychological tests designed to thoroughly assess the patients’ psychopathology. The tests are administered in collaboration with the patient, including detailed oral and written feedback. We hypothesize that the intervention is feasible regarding patient’s acceptance and adherence. We further hypothesize that patients randomized to MCA will reach higher levels of readiness for psychotherapy as assessed with the University of Rhode Island Change Assessment Scale (URICA).


This protocol assesses the feasibility, efficacy, acceptability, and safety of an intervention aimed at changing the readiness for participation in psychotherapy of patients with SP and AvPD. Results from this feasibility study could guide the development of future large-scale trials of MCA and procedures for MCA treatment fidelity assessment.

Trial registration


Peer Review reports


Introduction and rationale

Anxiety disorders represent an important public health concern in the Western world [1, 2]. Estimates from a large European epidemiological survey suggest that 14% of the European population will meet the criteria for an anxiety disorder within their lifetime [3]. These disorders are often associated with a chronic, debilitating course for the affected individual as well as high socio-economic costs [4,5,6]. Anxiety disorders are among the leading causes of the global disease burden and the annual costs in Europe alone reached 74 billion Euros in 2010 [7, 8]. Continuous efforts to improve treatment programs for anxiety pathology are imperative.

Social phobia (SP) is the most common among the anxiety disorders. The fear of being observed or negatively evaluated by other people is a prominent characteristic of individuals with social phobia. This fear leads the individual to avoid performance or social situations (e.g., speaking or eating in front of others, making acquaintances, and meeting authorities), or enter such situations with substantial discomfort [9]. This evasiveness severely impacts the social functioning and quality of life of affected individuals [10, 11].

Similarly, avoidant personality disorder (AvPD) is characterized by a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, which result in marked evasiveness and avoidance of social interactions. AvPD patients perceive themselves as unwanted and isolated from others [9]. The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) [12], recognizes a considerable overlap between AvPD and SP. Although the relationship between the disorders is a matter of debate [13], the dominant conceptualization is that the two disorders represent a spectrum, differing from each other only in severity (the severity continuum hypothesis [14]). In the upcoming revision of the International Classification of Diseases, tenth edition (ICD-10), AvPD will be removed as an independent diagnosis [15], which further supports the severity continuum hypothesis. Similar to the anxiety disorders, AvPD is associated with profound impairment in daily life for the affected individual, as well as high socio-economic costs [16]. Hence, the present study protocol relevantly focuses on SP and social evasiveness.

Danish outpatient mental health services provide time-restricted, standardized, interdisciplinary treatment programs for social phobia and AvPD. Following national clinical practice guidelines, the treatment programs offer evidence-based cognitive-behavioral therapy for social phobia and mentalization-based therapy for AvPD.

The content and format in the standardized treatment programs for moderate-severe SP and AvPD are regulated in accordance with the Danish Health Authority guidelines. The treatment program for SP consists of diagnostic assessment (1–3 consultations), medical consultations (1–2 consultation), and group therapy with two therapists (14 sessions (120 min)), relatives’ support (1 session), and network consultation (1 session) [17]. Correspondingly, the standardized outpatient treatment program for AvPD includes up to 78 h of clinician time consisting of clinical assessment (2 h), medical consultations (1–2 consultations), group therapy with two therapists (30 sessions (120 min)), and network consultation (1–2 sessions) [18].

However, despite a solid evidence base for the efficacy of cognitive-behavioral therapy for social phobia, recent meta-analytic data suggest that only 45% of patients suffering from social phobia remit from their principal diagnosis after treatment and patients with social phobia have a worse outcome than patients with other anxiety disorders [19]. The evidence-based psychological treatment for avoidant personality is limited in terms of number and quality of studies and the remission rates vary substantially from 40 to 80% [20].

Data from a recently finalized multicenter randomized controlled trial [21] investigating the relative efficacy of group diagnosis-specific versus transdiagnostic cognitive-behavioral therapy for anxiety disorders or depression supports the meta-analytic findings on social phobia. In this trial, 291 patients with anxiety disorders or depression received standardized treatment programs from three Danish mental health services, and the results suggested that only half of the patients no longer met diagnostic criteria for their principal diagnosis by the end of treatment [22]. No data exists on the efficacy of the standardized programs for AvPD.

Modified collaborative assessment

Psychiatric assessment usually aims to establish a diagnosis and plan the treatment, but it is not considered part of the treatment proper. We wish to alter this perspective by the introduction and exploration of a modification of Collaborative Assessment that we have chosen to name Modified Collaborative Assessment (MCA).

MCA takes off from Collaborative Assessment and Therapeutic Assessment (C/TA) [23,24,25]. These terms are used to describe a family of semi-structured, brief therapeutic interventions, in which a therapist administers a large battery of standardized diagnostic and psychological tests in collaboration with a patient and delivers feedback in a manner that is useful and enriching—and therefore therapeutic—for the patient.

C/TA has been explored in several controlled trials with adults and has been shown to increase a range of process variables related to therapy outcomes. This includes self-esteem [26,27,28,29], compliance with treatment recommendations [30], therapeutic alliance with subsequent therapist [31, 32], and satisfaction with treatment [33], as well as decreased anxiety symptoms [34, 35] and levels of self-criticism [34]. In addition, Poston and Hanson [36] published a meta-analysis on 17 published C/TA studies, which found favorable effects of this intervention in terms of overall effectiveness when compared to assessment as usual.

We wish to apply a modification of C/TA, where the intervention is shorter, is slightly more structured, and requires less psychiatric expertise (i.e., it can be carried out by trainee doctors and psychologists), which we therefore expect to be more feasible in the trial as well as in later implementation.

Like C/TA, MCA will include the administration of standardized diagnostic instruments, but in contrast to C/TA, we will only include a smaller selection of tests in order to secure feasibility. The battery of tests will be specifically designed to gather information on psychopathology which a brief clinical interview might not detect, such as symptoms of previously undetected developmental disorders or incipient psychosis. We have compiled a battery of tests with this focus because we find it most suitable for application in the Mental Health Service. The present study is further designed to establish diagnosis adhering to the current diagnostic systems (ICD-10 and DSM-5), but we expect it would also be applicable if the Mental Health Service introduced the dimensional [37, 38] model of psychopathology, since the current MCA also includes a thorough personality assessment according to the DSM-5 alternative model of personality pathology.

MCA emphasizes respect for the patients as “experts on themselves.” The assessor will, in collaboration with the patient, formulate a list of therapeutic questions which the patient would like to “ask the psychological tests.” This will help guide the patient and assessor’s collaborative quest to learn more about the patient’s problems and personal resources. The results of the assessment and the answers to the therapeutic questions will be communicated, respectfully, to the patient both orally and in writing. It will further be communicated to the patient’s future therapist in writing. In this manner, it should be possible to formulate personally relevant problems for later psychotherapy. The MCA assessor recognizes that diagnostic assessment is an interpersonal event and that the relationship between assessor and patient is paramount both in relation to the validity of the result and the patient’s further treatment [25].

In short, MCA is a brief, individualized, and person-centered assessment of psychopathology, where assessment, psychotherapy, and psychoeducation are integrated into a novel intervention, all carried out in collaboration with the patient.

Readiness for psychotherapy

The fundamental role of patients’ readiness for psychotherapy change (or client motivation) in the outcome of therapy is widely recognized [39]. The overall concept refers to the intentional aspect of change, the internal drive preceding behavioral change before the initiation of therapy, and the ongoing engagement throughout therapy [40]. Theoretically, the concept is most profoundly described as a core component in the “stage of change” dimension of the so-called Transtheoretical Model of behavioral change set forward by Prochaska and DiClemente [41]. In the “stage of change” dimension, patients are assumed to vary in their overall readiness to change, being on different levels ranging from “pre-contemplation” to being ambivalent about change (“contemplation”), having intentions to change (“preparation”), starting changes (“action”), and consolidating changes (“maintenance”).

Studies have consistently found patients’ readiness to change to be an important factor in predicting and moderating their psychotherapy outcomes [42]. Regarding anxiety disorders, research indicates that patients’ readiness to change reduces symptoms and improves other process variables, such as working alliance and adherence to treatment [43]. However, data suggests that up to 80% of patients are not ready for change (to pursue treatment goals) when they enter treatment and possess ambivalence about therapy [44].

We expect that MCA will increase patients’ readiness for psychotherapy, as assessed by the University of Rhode Island’s Change Assessment Scale (URICA) (contemplation subscale) and the Readiness for Psychotherapy Index (RPI), and will increase engagement in psychotherapy as measured by attendance. We expect that more than one mechanism of action is at play: (a) the patient will develop a relationship with the MCA accessor and the outpatient clinic during the course of MCA, which will carry over to the therapeutic relationship with the psychotherapist; (b) due to the structural MCA format, the patient will be confident that her problems are seen and understood; (c) the patient will understand herself, her problems, and personal strengths and will be able to work more effectively on these in therapy; and (d) the therapists will have a greater knowledge of the patient’s problems based on the summaries from the MCA.


The study objectives are to (1) explore the feasibility of MCA as an intervention through rates of recruitment of screened patients, patience’s adherence to MCA or Assessment As Usual (AAU), patient satisfaction ratings, and patient and therapist/clinician evaluations; (2) compare the effect of MCA versus AAU on levels of readiness for psychotherapy in patients referred to group therapy for social phobia or AvPD at end-of-intervention (T1) (main outcome) and after 1-month follow-up (T2); (3) compare the effect of MCA vs AAU on diagnoses (number of diagnostic revisions) and treatment offered (number of patients offered other or additional treatment) in patients referred to group therapy for social phobia or AvPD, as well as adherence to group therapy within the first 4 weeks; and (4) develop a fidelity checklist for the MCA intervention.

We hypothesize that MCA is feasible regarding acceptance and adherence in patients with social phobia or AvPD and is superior to AAU in increasing contemplation score (URICA, see below) at the end of intervention (T1). (2) In addition to this, patients offered MCA have higher service satisfaction ratings (CSQ) than those offered AAU prior to psychotherapy onset, and user evaluation scores of MCA (purpose-made) are positive (more than 3 on a 1–5 Likert Scale).



The present protocol is based on reporting guidelines from the SPIRIT guideline for Standard Protocol Items for Clinical Trials [45] adapted as recommended when reporting protocols of feasibility trials [46]. The study is designed in order to inform and evaluate the feasibility of a possible future, full-scale RCT of MCA versus AAU. We will evaluate the feasibility of the interventions in terms of clinician resources and patient’s acceptability and adherence to the intervention and comparator, selected based on recommendations for the conduct of feasibility trials [47,48,49].

In addition to these feasibility outcomes, we will assess outcomes regarding readiness for change, symptoms, and regarding self-esteem and self-efficacy. Data are gathered from patients through a number of questionnaires delivered by the RedCap © webmodule prior to randomization (T0), at the end of MCA (T1) and after 4 weeks of psychotherapy (T2)—the absolute time depends on clinical logistics and timing of group therapy onset.

Trial design

A two-armed, parallel randomized controlled feasibility and superiority trial comparing the effect of pre-treatment MCA with AAU.

A CONSORT diagram is provided in Fig. 1. A diagram of the proposed study and the outcome assessment is provided in Fig. 2. The trial data collection and randomization, stratified by gender, will be carried out in the web-based data management system REDCap ( Self-ratings will also be collected on the web-based REDCap platform.

Fig. 1
figure 1

CONSORT 2010 flow diagram

Fig. 2
figure 2

Flow diagram of the intervention


The setting of the study is Psychiatry South in Region Zealand, which is a rural region with several medium-sized cities, according to Danish standards. Three of these cities have psychiatric outpatient clinics (Maribo, Slagelse, and Naestved), which carry out psychotherapeutic treatment of patients with emotional disorders too serious to be managed by family doctors and primary sector psychologists and psychiatrists. Patients are typically referred by general practitioners, when they have failed to respond to one or two different treatments (medication and/or psychotherapy). The services in these clinics are covered by Danish public health insurance and involve both psychotherapy and psychopharmacological treatment (see also the “Introduction and rationale” section).

Participants and eligibility criteria

We aim to include 42 patients who satisfy the inclusion criteria: (1) a patient with a tentative ICD-10 diagnosis of either SP or AvPD, (2) who is going to be offered treatment in the aforementioned clinics, (3) is 18–65 years of age, (4) has given written consent to participate, and (5) has sufficient knowledge of the Danish language.

Patients will be excluded if (1) the risk of suicide is high or moderate according to the investigator, (2) they have alcohol or drug dependency, and (3) they have a co-occurring eating disorder with BMI < 18 or psychotic illness.


In the first consultation at the psychiatric clinic, clinicians will evaluate if the patient is eligible for psychotherapeutic treatment and stipulate a clinical diagnosis. If patients are eligible for treatment in the clinic, they will be invited to an information meeting with the first author, where they will be provided with information about the project. Following this, they can give informed consent to participate.

Randomization and blinding

Patients will be randomized 1:1 to either the MCA or AAU on an individual level. Allocation to experimental intervention or comparison intervention will be computer-generated using the software REDCap © [50].

Due to the nature of the intervention, neither participants nor the researcher who will administer the intervention can be blinded to allocation. However, data will be re-coded for concealment and analyzed without access to information about allocation. The conclusion will be written prior to unblinding.

Experimental intervention

The MCA, as described in the “Introduction and rationale” section, will include the possible administration of the following nine assessment instruments:

Present State Examination (PSE)

PSE is a semi-structured interview that seeks to provide an objective evaluation of symptoms associated with mental disorders. It consists of 140 items and is scored on a 3-point or 4-point scale [51].

Structured Clinical Interview for DSM-5 (SCID-5)

SCID-5PD is a semi-structured interview guide for evaluation of the 10 DSM-5 Personality Disorders.

The Examination of Anomalous Self-Experience (EASE)

EASE is a semi-structured checklist for clinical-phenomenological exploration of experiential disturbances. Scores are summed up in a global score, with five sub-scores: Cognition and stream of consciousness, Self-awareness and presence, Bodily experiences, Demarcation/transitivism, and Existential reorientation [52].

The Screen for Cognitive Impairment in Psychiatry (SCIP)

SCIP is a neuropsychological test for quick and objective quantification of cognitive function in patients with psychiatric disorders. The Danish translation has demonstrated validity for the detection of objective cognitive impairment [53]. It assesses verbal learning and memory, delayed memory, working memory, word mobilization, and processing speed [54].

Autism Diagnostic Observation Schedule (ADOS-2)

ADOS-2, module 4 [55], is a semi-structured and standardized observation of communication, social interaction, and creative use of materials used to assess autism spectrum disorder pathology.

Wechsler Adult Intelligence Scale—Fourth Edition (WAIS-IV)

The WAIS is an IQ test designed to measure intelligence and cognitive ability in adults and older adolescents [56].

Conners’ Adult ADHD Rating Scales (CAARS)

The CAARS is a test developed to diagnose attention problems, such as ADHD and ADD. It provides both Self-Report and Observer Report Forms, permitting multimodal assessment of adults with attention problems [57].

Level of Personality Functioning—Brief Form 2.0 (LPFS-BF)

LPFS-BF is a brief 12-item self-report inventory developed to assess levels of personality functioning, as defined in the alternative model for personality disorders in DSM-5 Section III. It measures impairment in personality functioning within the domains of self-functioning and interpersonal functioning [58].

Personality Inventory for DSM-5, 36-item version (PID-36)

The PID-36 is an abbreviated version of the originally 100-item version of the Personality Inventory for DSM-5 (PID-5), which was developed to measure the pathological trait specifiers listed in the alternative model for personality disorders in DSM-5 Section III [59].

The instruments will be administered by the first author. No other clinicians or therapists will see the included patients in this period of time. Materials from the medical record and from the full MCA will be presented for case supervision with a senior psychiatrist, with the option of getting an additional opinion from another senior consultant in case of diagnostic uncertainty. This procedure is included in order to ensure solid diagnostic verification or alteration. Therapists and teams are informed of the results of the MCA, in order for them to use the extra information about the patient in the following psychotherapeutic intervention, which will be administered after completion of the primary endpoint.

Comparison intervention

Patients allocated to the control group will receive AAU, which is the standard assessment that patients receive in the clinic, administered as follows: the patients are referred to the clinic by a family doctor or a private practice psychiatrist. On intake to the clinic, they will receive a diagnostic interview with either a medical doctor or a psychologist which can be supplemented with specific psychological tests, (e.g., SCID-5) when personality disorders are suspected, depending on the current resources and competencies in the clinics and following request from the head of treatment. Supplementary assessment is indicated roughly in one case out of ten. Otherwise, AAU patients are on the waitlist for the group therapy and are not followed by any therapist. Following the end of the MCA intervention, MCA patients might also wait a short while for group therapy, not seeing any psychotherapist in that interval. As all participants start group therapy, they will have a designated contact person, but only one preparatory individual therapy session before entering the specific treatment group.

Intervention fidelity

The intervention will be carried out by the first author, a resident in psychiatry. He has received training and supervision on the assessment battery from national experts in the field. The intervention will be supervised by the third author, who is trained in therapeutic assessment. Audio or video recordings of MCA consultations will be used for supervision purposes and to secure intervention fidelity.

Outcomes’ objective 1: Feasibility

  • Acceptability: The feasibility criterion for acceptability in patients is supported if 25% of patients who are found eligible for inclusion and who have received formal information (information meeting with the first author) about the trial agree to participate in the trial.

  • Satisfaction: The feasibility criterion for satisfaction in patients is supported if the mean CSQ-8 score is ≥ 3 (see below for description of instrument).

  • Adherence: The feasibility criteria for adherence in patients is supported if 75% complete the MCA intervention (attend all MCA sessions including feedback-session).

  • Time spent on the intervention: We evaluate the resources used to complete the study by recording the time spent in direct contact with the patient used to complete the MCA intervention [48].

  • Evaluation of the Intervention Questionnaire (EQ)

  • Adverse events

Outcomes’ objective 2: Trial outcomes

See Table 1 for a table of measurements.

Table 1 Table of measurements CO-ASSM-RCT

Primary outcome

University of Rhode Island Change Assessment Scale (URICA)

URICA is a 32-item self-report measure including 4 subscales, designed to quantify the patient’s motivation for change: The four subscales are Pre-contemplation, Contemplation, Action, and Maintenance [60]. We will utilize the Contemplation score as our primary outcome.

Secondary outcomes

The Liebowitz Social Anxiety Scale-Self-Report (LSAS)

The self-administered 24-item LSAS-SR [60], which is highly correlated with the clinician-administered version [61], includes questions pertaining to social interaction and performance situations. The LSAS-SR has shown to have good convergent, discriminant validity, and reliability [62].

Rosenberg Self-Esteem Scale (RSES)

The RSES is a 10-item measure of self-esteem that includes five positive items and five negative items which are reverse-scored [63]. In general, the RSES has demonstrated good convergent validity and good test–retest reliability, and in similar populations of adults with social phobia, the RSES has demonstrated high internal consistency [64].

General Self-Efficacy Scale (GSES)

The GSES is a 10-item psychometric scale that is designed to assess optimistic self-beliefs to cope with a variety of difficult demands in life. In contrast to other scales that were designed to assess optimism, this one explicitly refers to personal agency, i.e., the belief that one’s actions are responsible for successful outcomes [65, 66].

Exploratory outcomes

Readiness for Psychotherapy Index

The RPI is a 42-item self-report measure that uses a 5-point Likert scale to assess 7 dimensions of readiness for psychotherapy: level of distress, desire for change, willingness to work in therapy, recognition of problems as psychological, willingness to discuss personal matters, willingness to endure discomfort in therapy, and responsibility for change [67]. The questionnaire will be translated and validated for use in a Danish mental health service population as part of the present study.

National Patient-Reported Outcome Measures (PROM)-Psychiatry

The Danish National PROM is a 19-item self-report measure covering patients’ own views on their mental and physical health and level of general well-being [68]. It includes the WHO Well-Being Index (WHO-5), the Work and Social Adjustment Scale (WSAS) [69], and general items from the SF36.

Data from Electronic Health Records (EHR)

We will monitor the number of no-shows and the number of diagnostic re-classifications by accessing the included patients’ EHR.

User evaluations

Client Satisfaction Questionnaire (CSQ-8)

The CSQ-8 is a self-report questionnaire, constructed to measure satisfaction with services received by individuals and families [70].

Evaluation of the Intervention Questionnaire (EQ)

This questionnaire focusing on the patient’s and therapist’s evaluation of the intervention, which is purpose-made for the current study, will be distributed at the end of the intervention. Items will be constructed as Likert Scale feedback forms consisting of a list of statements about different aspects of the course of the intervention. Response possibilities are five categories ranging from “very much in agreement” to “not at all.”

Adverse effects

We expect no serious risks or adverse effects to the included patients. We monitor for adverse events, in particular suicidal behavior/ideation, and will check for this at every visit to the clinic. If a patient is admitted during participation in the study, a senior consultant (RB) will decide whether the patient can continue to participate.

Patient and public involvement

We will establish a user panel who will help interpret the findings of the study, and we will include the feedback in our reporting of the findings of the present study, and in the preparations for a possible full-scale phase-3 study of the intervention. The user panel will include five patients recruited from the clinics and they will meet two times throughout the study. They will be users of the Danish MHS but not participants in this trial.

Statistical considerations

As the primary objective of the present trial is to test feasibility, a formal power calculation is not required. However, the present trial also wishes to examine MCA versus AAU, and we present the following power calculation for the primary outcome: readiness for change. Sample size calculation is based on figures in Dozois et al. [71] of patients with panic/anxiety, where the primary outcome “Contemplation stage score” in readiness for change was mean 37.3 (SD 1.9) for CBT responders and mean 34.4 (std 3.4) for non-responders, i.e., with significance level 5% and power 90%. This yields a total sample of 36 with 18 patients in each arm. We strive for 42 patients to account for attrition around 15%. We find it feasible to include the 42 patients since 64 patients are offered treatment packages annually (40 SP and 24 AvPD).

A detailed statistical analysis plan will be published on prior to data processing initiation. Briefly, we expect to report descriptive data such as data for the feasibility criterion as percentages, means, and variation as standard deviation. Outcomes will be analyzed as continuous and categorical measures (i.e., responder status and new diagnosis, see below). All statistical analyses will be performed as intention-to-treat analyses (ITT); however, main outcomes will also be analyzed for completers only for sensitivity reasons. Missing data will be handled by the use of multiple imputations. The pre- to post-treatment effects of the MCU or AAU will be determined utilizing a series of repeated measures analyses of variance (rmANOVAs). Analysis will be based on masked data (recoded data for concealment of allocation). Conclusions of the main outcomes will be formulated prior to unmasking the data. Statistical calculations will be performed prior to unblinding. All statistical calculations will be performed in R and RStudio [72].

Dissemination policy

The results of the present study will be disseminated by the Psychiatric Research Unit social media account and website. We will also seek to publish it through high-impact international peer-reviewed journals and present it at conferences for clinicians, commissioners, and researchers working in the mental health field. Both negative and positive findings will be published. The trial is registered at (Nr 2,021,001). Although steps will be taken to avoid it, protocol deviations may happen. Protocol deviations that occur after the start of trial recruitment will be communicated at and detailed in publications.

Trial status

The trial began recruitment in October 2021, and the last participant is expected to be included in January 2023. The experimental intervention ran from November 2021 to April 2023.


The current study will be the first RCT investigating MCA in a mental health service setting. It will be a feasibility study and will test the study hypothesis in a small clinical sample. If the present study is successful, it may be followed up by other, larger clinical studies on MCA. The study will contribute to sparse existing research concerning the impact of clinical assessment; it will provide important new knowledge about the effects of routine and systematic patient-centered clinical assessment and generate effect size measures for future power calculations. It will also generate data regarding patients’ readiness for psychotherapy, and the percentage of patients who are wrongly diagnosed in a prototypical Danish public psychotherapeutic healthcare clinic.

We believe that the intervention will have a positive effect on the included patients. However, there is a risk that the patients receiving MCA may not benefit from the excess assessment but that the treatment will instead increase dropout due to the patient becoming overwhelmed. There is also a possibility of the patients becoming upset or disappointed due to the new knowledge they receive about themselves. Ultimately, the MCA may yield an unexpected diagnosis which could severely change the way the patient sees herself and the way society in general sees the patient. Many of these problems may, however, also occur in AAU. We will evaluate this by comparison of dropout from MCA and AAU.

If the current project documents the feasibility of the approach, further studies should examine the incremental value of MCA on patient outcome in terms of treatment completion or number of treatment sessions attended, and cost-effectiveness.

By the end of the present project, we will be able to decide whether the results are sufficiently promising to pursue a full trial (phase III) [73]. For that purpose, the study output also encompasses the development of a MCA protocol for clinicians and an adjoining fidelity instrument.

Availability of data and materials

The datasets generated by the planned study will not be publicly available due to the rules of the Danish Data Protection Agency but will be available from the corresponding author, after publication, on reasonable request and following a signed confidentiality agreement with PI and the Danish Data Protection Agency Region Zealand.


  1. Whiteford HA, Degenhardt L, Rehm J, et al. Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010. Lancet. 2013;382(9904):1575–86 (2010).

    Article  PubMed  Google Scholar 

  2. Flachs EM, E.L., Koch MB, et al., Sygdomsbyrden i Danmark - sygdomme., ed. Sundhedstyrelsen. 2015, Copenhagen, Denmark.: Statens Institut for Folkesundhed.

  3. Alonso J, A.M., Bernert S, et al., Prevalence of mental disorders in Europe: results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project. Acta Psychiatr Scand Suppl. 2004(420):21–27., 2004.

  4. Comer JS, Blanco C, Hasin DS, et al. Health-related quality of life across the anxiety disorders: results from the national epidemiologic survey on alcohol and related conditions (NESARC). J Clin Psychiatry. 2011;72(1):43–5 2011.

    Article  PubMed  Google Scholar 

  5. Kessler RC, Petukhova M, Sampson NA, Zaslavsky AM, Wittchen HU. Twelve-month and lifetime prevalence and life- time morbid risk of anxiety and mood disorders in the United States. Int J Methods Psychiatr Res. 2012;21(3):169–84 2012.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Hendriks SM, Spijker J, Licht CM, et al. Long-term disability in anxiety disorders. BMC Psychiatry. 2016;16:248 2016.

    Article  PubMed  PubMed Central  Google Scholar 

  7. D., M.C.a.L., Projections of global mortality and burden of disease from. to 2030. PLoS Med. 2002;3(11):e4422006.

    Google Scholar 

  8. Gustavsson A, Svensson M, Jacobi F, et al. Cost of disorders of the brain in Europe 2010. Eur Neuropsychopharmacol. 2011;21(10):718–79 2011.

    Article  CAS  PubMed  Google Scholar 

  9. (WHO), W.H.O., The ICD-10 Classification and Statistical Manual of Mental Disorders., Geneva: WHO.

  10. Gómez-Ortiz O, Romera EM, Jiménez-Castillejo R, Ortega-Ruiza R, García-López L. Parenting practices and adolescent social anxiety: a direct or indirect relationship? Int J Clin Health Psychol. 2019;19:124–33 2019.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Olivares-Olivares P, O.-G.P.a.O.J., Role of social skills training in adolescents with social anxiety disorder. International Journal of Clinical and Health Psychology. 2019;19:41–48. , 2019.

  12. Association, A.P., The Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Fifth Edition 2013. 2013: American Psychiatric Publishing; 5th edition.

  13. Frandsen F, Simonsen S, Poulsen SB, Sørensen P, Lau ME. Social phobia and Avoidant Personality Disorder from an interpersonal perspective. Psychol Psychother. 2020;93(1):88–104.

    Article  PubMed  Google Scholar 

  14. Chambless DL, Fydrich T, Rodebaugh TL. Generalized social phobia and avoidant personality disorder: meaningful distinction or useless duplication? Depress Anxiety. 2008;25(1):8–19.

    Article  PubMed  Google Scholar 

  15. (WHO), W.H.O., ICD-11. International Classification of Diseases 11th Revision. 2019.

  16. Isomura K, Boman M, Rück C, Serlachius E, Larsson H, Lichtenstein P, Mataix-Cols D. Population-based, multi-generational family clustering study of social anxiety disorder and avoidant personality disorder. Psychol Med. 2015;45(8):1581–9 2015.

    Article  CAS  PubMed  Google Scholar 

  17. Regioner, D. Pakkeforløb for angst. 2017 [cited May 28th, 2021.

  18. Regioner, D. Pakkeforløb for evasiv personlighedsforstyrrelse. 2017 [cited Maj 28th, 2021.

  19. Springer KS, Levy HC, Tolin DF. Remission in CBT for adult anxiety disorders: a meta-analysis. Clin Psychol Rev. 2018;61:1–8.

    Article  PubMed  Google Scholar 

  20. Weinbrecht A, Schulze L, Boettcher J, et al. Avoidant personality disorder: a current review. Curr Psychiatry Rep. 2016;18(29):2016.

    Google Scholar 

  21. Arnfred SM, A.R., Hvenegaard M, Poulsen S, Bach B, Arendt M, Rosenberg NK and Reinholt N, Transdiagnostic group CBT vs. standard group CBT for depression, social anxiety disorder and agoraphobia/panic disorder: study protocol for a pragmatic, multicenter non-inferiority randomized controlled trial. BMC Psychiatry volume 17, Article number: 37 (2017), 2017.

  22. Reinholt N, H.M., Christensen AB, Eskildsen A, Hjorthøj C, Poulsen S, Arendt MB, Rosenberg NK, Gryesten JR, Aharoni RN, Alrø AJ, Christensen CW and Arnfred SM., Transdiagnostic versus diagnosis-specific group cognitive behavioral therapy for anxiety disorders and depression: a randomized controlled trial. Psychother Psychosom . 2021 Jun 10;1–14., 2021.

  23. Finn, S.E., Manual for using the MMPI–2 as a therapeutic intervention. 1996, Minneapolis, MN: University of Minnesota Press.

  24. Finn, S.E., In our clients’ shoes: Theory and techniques of Therapeutic Assessment. Mahwah. NJ: Erlbaum; 2007.

    Google Scholar 

  25. Finn, S.E., Fischer, C. T., Handler, L. (Eds.). Collaborative/therapeutic assessment: a casebook and guide. 2012: John Wiley Sons Inc.

  26. Aldea MA, Rice KG, Gormley B, Rojas A. Telling perfectionists about their perfectionism: effects of providing feedback on emotional reactivity and psychological symptoms. Behav Res Ther. 2010;48(12):1194–203.

    Article  PubMed  Google Scholar 

  27. P., N.M.a.G., Therapeutic effects of providing MMPI-2 test feedback to clients at a university counseling service: a collaborative approach. Psychological Assessment, 9(2), 122–131.

  28. Finn, S.E.a.T.M.E., Therapeutic effects of providing MMPI-2 test feedback to college students awaiting therapy. Psychological Assessment 4(3):278–287, 1992.

  29. Allen A, M.M., Tubman J, Frazier L and Luis Escovar, The effects of assessment feedback on rapport-building and self-enhancement processes. Journal of Mental Health Counseling (2003) 25 (3): 165–182., 2003.

  30. Ackerman SJ, et al. Interaction of therapeutic process and alliance during psychological assessment. J Pers Assess. 2000;75(1):82–109.

    Article  CAS  PubMed  Google Scholar 

  31. Hilsenroth MJ, A.S., Clemence AJ, Strassle CG. and Handler L., Hilsenroth, Mark J, Ackerman, S. J., Clemence, A. J., Strassle, C. G., & Handler, L. Psychotherapy: theory, research, practice, training, 39(4), 309–323., 2002.

  32. Hilsenroth M, Peters E, Ackerman S. The development of therapeutic alliance during psychological assessment: patient and therapist perspectives across treatment. J Pers Assess. 2004;83:332–44.

    Article  PubMed  Google Scholar 

  33. J., L., Collaborative assessment, supportive psychotherapy or treatment as usual: an analysis of ultra-brief individualized intervention for psychiatric inpatients. Santa Barbara. CA: University of California; 2009.

    Google Scholar 

  34. Aschieri F, Smith JD. The effectiveness of therapeutic assessment with an adult client: a single-case study using a time-series design. J Pers Assess. 2012;94(1):1–11.

    Article  PubMed  Google Scholar 

  35. Smith JD, George C. Therapeutic assessment case study: treatment of a woman diagnosed with metastatic cancer and attachment trauma. J Pers Assess. 2012;94(4):331–44.

    Article  PubMed  Google Scholar 

  36. WE, P.J.a.H., Meta-analysis of psychological assessment as a therapeutic intervention. Psychological Assessment 2010, Vol. 22, No. 2, 203–212, 2010.

  37. Kotov R, Krueger RF, Watson D. A paradigm shift in psychiatric classification: the Hierarchical Taxonomy Of Psychopathology (HiTOP). World Psychiatry. 2018;17(1):24–5 2018.

    Article  PubMed  PubMed Central  Google Scholar 

  38. LJ, C.C.a.S., Maximizing the applied value of structural models of psychopathology: introduction to a special issue of Personality and Mental Health. Personal Ment Health. 2020 Feb;14(1):3–8., 2020.

  39. Vogel PA, H.B., Stiles TC and Götestam KG, Treatment motivation, treatment expectancy, and helping alliance as predictors of outcome in cognitive behavioral treatment of OCD. Journal of Behavior Therapy and Experimental Psychiatry, 37(3), 247–255., 2006.

  40. CC, P.J.a.D., The transtheoretical approach. In: Norcross JC, Goldfried MR, editors. Handbook of psychotherapy integration. 2. pp. 147–171. 2005, New York, NY: Oxford Press.

  41. CC., P.J.a.D., The transtheoretical approach: crossing the traditional boundaries of therapy. . 1984, Homewood, IL: Dow-Jones/Irwin.

  42. Krebs P, N.J., Nicholson JM, Prochaska JO., Stages of change and psychotherapy outcomes: a review and meta-analysis. J. Clin. Psychol. 2018;74:1964–1979., 2018.

  43. PJ., M.I.a.N., The efficacy of incorporating motivational interviewing to cognitive behavior therapy for anxiety disorders: a review and meta-analysis. Clinical Psychology Review, 62, 1–10., 2018.

  44. Prochaska J, N.C., and DiClemente C., Applying the stages of change. Psychotherapy in Australia, 19(2), 10, 2013.

  45. Chan AW, Tetzlaff JM, Altman DG, Laupacis A, Gøtzsche PC, Krleža-Jerić K, et al. SPIRIT 2013 statement: defining standard protocol items for clinical trials. Chin J Evid Based Med. 2013;13(12):1501–7 2013.

    Google Scholar 

  46. Eldridge SM, Chan CL, Campbell MJ, Bond CM, Hopewell S, Thabane L, et al. CONSORT 2010 statement: extension to randomised pilot and feasibility trials. Pilot Feasibility Stud. 2016;2(1):1–32 2016.

    Article  Google Scholar 

  47. Craig P, D.P., Macintyre S, Mitchie S, Nazareth I, Petticrew M., Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ. 2008;337(7676):979–83., 2008.

  48. Thabane L, Ma J, Chu R, Cheng J, Ismaila A, Rios LP, Robson R, Thabane M, Giangregorio L, Goldsmith CH. A tutorial on pilot studies: the what, why and how. BMC Med Res Methodol. 2010;6(10):1. 2010.

    Article  Google Scholar 

  49. G., T.L.a.L., A guide to the reporting of protocols of pilot and feasibility trials. Pilot Feasibility Stud. 2019 Feb 28;5:37., 2019.

  50. Harris PA, T.R., Thielke R, Payne J, Gonzalez N and Conde JG., Research electronic data capture (REDCap) – a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009 Apr;42(2):377–81., 2009.

  51. O., M., Present State Examination (PSE). 2018.

  52. Parnas J, M.P., Kircher T, Thalbitzer J, Jansson L, Handest P and Zahavi D., EASE: Examination of Anomalous Self-Experience. Psychopathology. Sep-Oct 2005;38(5):236–58.

  53. Ott CV, Bjertrup AJ, Jensen JH, Ullum H, Sjælland R, Purdon SE, Vieta E, Kessing LV, Miskowiak KW. Screening for cognitive dysfunction in unipolar depression: validation and evaluation of objective and subjective tools. J Affect Disord. 2016;190:607–15 2015.

    Article  PubMed  Google Scholar 

  54. Svendsen AM, Kessing LV, Munkholm K, Vinberg M, Miskowiak KW. Is there an association between subjective and objective measures of cognitive function in patients with affective disorders? Nord J Psychiatry. 2012;66(4):248–53 2012.

    Article  PubMed  Google Scholar 

  55. M., L.C.a.R., (ADOS™-2) Autism Diagnostic Observation Schedule™, Second Edition. 2012, Torrance, CA: Western Psychological Services.

  56. Wechsler, D., Wechsler Adult Intelligence Scale (4th ed.). 2008, San Antonio, TX: Psychological Corporation.

  57. Conners CK, E.D.a.S.E., Conners’ Adult ADHD Rating Scales–Self-Report: Long Version. North Tonawanda. NY: Multi-Health Systems; 1998.

    Google Scholar 

  58. Hutsebaut J, Feenstra DJ, Kamphuis JH. Development and Preliminary Psychometric Evaluation of a Brief Self-Report Questionnaire for the Assessment of the DSM-5 level of Personality Functioning Scale: The LPFS Brief Form (LPFS-BF). Personal Disord. 2016;7(2):192–7 2016.

    Article  PubMed  Google Scholar 

  59. Association, A.P., The Personality Inventory DSM-5 (PID-5) Self-Report Form (full version). 2013.

  60. SO., D.C.a.H., Stages of change profiles in alcoholism treatment. Journal of Substance Abuse, 2, 217–235., 1990.

  61. Baker SL, Heinrichs N, Kim HJ, Hoffman SG. The Liebowitz Social Anxiety Scale as a self-report instrument: a preliminary psychometric analysis. Behav Res Ther. 2002;40:1087–98 2002.

    Article  Google Scholar 

  62. Fresco DM, Coles ME, Heimberg RG, Liebowitz MR, Hami S, Stein MB, Goetz D. The Liebowitz Social Anxiety Scale: a comparison of the psychometric properties of self-report and clinician-administered formats. Psychol Med. 2001;31:1025–35 2001.

    Article  CAS  PubMed  Google Scholar 

  63. M., R., Society and the adolescent self-image. Princeton. NJ: Princeton University; 1965.

    Google Scholar 

  64. Kuo JR, G.P., Werner K, Heimberg RG and Gross JJ., Childhood trauma and current psychological functioning in adults with social anxiety disorder. Journal of Anxiety Disorders. 2011; 25:467– 473., 2011.

  65. M., S.R.a.J., Generalized Self-Efficacy scale. In J. Weinman, S. Wright, & M. Johnston, Measures in health psychology: a user’s portfolio. Causal and control beliefs (pp. 35–37). 1995, Windsor, England: NFER-NELSON.

  66. Scholz U, G.r.-D.a.B., Sud S and Schwarzer R, Is general self-efficacy a universal construct? Psychometric findings from 25 countries. European Journal of Psychological Assessment, 18(3), 242–251., 2002.

  67. W, J.A.a.P., Development of the Readiness for Psychotherapy Index. The Journal of nervous and mental disease 197(6):427–33, 2009.

  68. S., K., Evaluering af PRO-Psykiatri - Baseret på erfaringer fra Psykiatrien i Region Nordjylland. Psykiatrien i Region Nordjylland. 2020.

  69. Mundt JC, M.I.e.a., The Work and Social Adjustment Scale: a simple measure of impairment in functioning. Br. J. Psychiatry 180: 461–4., 2002.

  70. K, A.C.a.G., The Client Satisfaction Questionnaire-8 and the Service Satisfaction Questionnaire-30. In M. E. Maruish (Ed.), The use of psychological testing for treatment planning and outcomes assessment (pp. 402–420). 1994, Hillsdale: Lawrence Erlbaum Associates.

  71. Dozois D, Westra HA, Collins K, Fung Tak. Stages of change in anxiety: Psychometric properties of the University of Rhode Island Change Assessment (URICA) scale. Behav Res Ther. 2004;42(6):711–29 2004.

    Article  PubMed  Google Scholar 

  72. Team, R., RStudio: integrated development for R. Boston: RStudio, Inc.; 2019.

  73. Gitlin LN. Introducing a new intervention: an overview of research phases and common challenges. Am J Occup Ther. 2013;67(2):177–84 2013.

    Article  PubMed  PubMed Central  Google Scholar 

Download references


The authors wish to thank Trygfonden and AP Møllers Lægefond for their financial contribution to the study.


Open access funding provided by Royal Library, Copenhagen University Library. The study has received funding from Psychiatry South, Region Zealand Mental Health Service (2.128.560 DKK), which is allocated to the PhD’s salary, and the Region Zealand PhD Tuition og Annuum fond (180.000 DKK) which is allocated to the tuition fee to the University of Copenhagen and the PhD student’s annum funds. SA is affiliated with Region Zealand Mental Health Service, where she is employed. Furthermore, the study has received competitive funding from Trygfonden (997.259 DKR) and the AP Møllers Lægefond (50.000 DKR), which will cover the running costs of the study.

Author information

Authors and Affiliations



SMA is the principal investigator and manager on the executive level as well as the head academic supervisor. SMA conceptualized the study and ORH was responsible for writing the first manuscript draft, which was supplemented with substantial input from NR and KD. All authors have discussed, reviewed, and approved the manuscript.

Corresponding author

Correspondence to Oliver Rumle Hovmand.

Ethics declarations

Ethics approval and consent to participate

The protocol was approved by Ethics Committee Region Zealand (Registration number: SJ-924) and Region Zealand Data Protection Agency (Registration number: REG-050–2021) and has thus undergone full external peer review and lives up to the European Union’s rules of data security.

All participants will give written informed consent following the National Danish Ethics Committee’s guidelines and will do so prior to randomization and intervention allocation.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Hovmand, O.R., Reinholt, N., Dichmann, K. et al. Social phobia and evasiveness: trial protocol for a randomized controlled feasibility and superiority trial of the effect of Modified Collaborative Assessment vs. standard assessment on patients’ readiness for psychotherapy (CO-ASSM-RCT). Pilot Feasibility Stud 9, 102 (2023).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: