Invited essayUsing the Internet to provide cognitive behaviour therapy
Introduction
Defining Internet-delivered interventions can be problematic as there are different conceptualisations and viewpoints. A first distinction relates to the Internet itself, as it can be a way to communicate with a physical person on the other side of the connection (e.g., e-mail), a way to present information in a more or less one way direction (information web pages), or a platform for more interactive programs which do not require any input from a clinician. Finally, Internet interventions can be a little bit of all this. In some ways this resembles the problems when trying to define psychotherapy, even within cognitive behaviour therapy (CBT), as we are dealing with different techniques and delivery approaches. All of these may have an impact on the manner in which the therapy works. For example, the differences between individual and group CBT can be substantial, and different change processes could be involved (Morrison, 2001). In our research program in Sweden we have developed an approach to Internet-delivered CBT which is distinct in the sense that it involves therapist contact, albeit minimised, and that it is not heavily computerised in terms of interactive programmes requiring no therapist input. According to Marks, Cavanagh, and Gega (2007), computerised interventions should delegate at least some therapy decisions to the computer, but in the approach I will present in this paper this is not necessarily the case as the Internet very well can be used without any automatic, computer generated decision making. When describing our approach Marks et al. referred to the Swedish model as “Net-bibliosystem CBT”, but that does not fully catch the essence of the approach. In a paper by our group we instead proposed the following definition of guided Internet-delivered treatment:
… a therapy that is based on self-help books, guided by an identified therapist which gives feedback and answers to questions, with a scheduling that mirrors face-to-face treatment, and which also can include interactive online features such as queries to obtain passwords in order to get access to treatment modules (Andersson, Bergström et al., 2008 p. 164)
As seen from this definition we used the term self-help, which may cause some confusion. In research it is often the case that self-help refers to treatments that are delivered with minimal input from a clinician (Watkins & Clum, 2008). That approach is different from purely self-administered self-help. Guided Internet-delivered treatment is an approach which combines the advantages of structured self-help materials, presented in an accessible fashion via the Internet, with the important role played by an identified therapist who provide support, encouragement and occasionally direct therapeutic activities via e-mail (Postel, de Haan, & De Jong, 2008). As will be seen in this review there are strong reasons to assume that it is premature to leave out the therapist when moving to the new format of Internet-delivered CBT. For example, if Internet delivery is regarded as mainly one way to decrease therapist time, this follows a long-standing tradition in CBT when treatments are shortened without compromising the efficacy (e.g., Clark et al., 1999, Öst, 1997).
The present review will describe and comment on how CBT has the potential to reach more people by using the Internet. The focus will not be to describe all studies that have now been conducted (see Barak, Hen, Boniel-Nissim, & Shapira, 2008), but rather to give examples of trials and consider questions regarding therapist factors and dissemination issues. Indeed, systematic reviews of the literature on Internet-delivered CBT show that moderate to strong effects are observed at posttreatment (e.g., Cuijpers et al., 2008a, Spek et al., 2007).
Section snippets
Anxiety disorders
Among the first conditions to be systematically studied in self-help research and later on in research on Internet-delivered CBT are the anxiety disorders. Many people never seek help or do it after years of suffering (Clark, 1999).
Mood disorders
Depression represents one of the major challenges for maintenance of public health (Ebmeier, Donaghey, & Steele, 2006). At least in a mild to moderate form, depression tends to respond well to most forms of psychotherapy (Cuijpers, van Straten, Andersson, & van Oppen, 2008b). This includes self-help interventions (Cuijpers, 1997), and several trials on Internet-delivered CBT have been conducted by different research groups (Andersson, 2006). Our own experience in using a guided
Other health problems
There are several other conditions for which guided Internet-delivered CBT has been tested (Cuijpers et al., 2008a). In our research group we have conducted controlled trials on tinnitus (Kaldo et al., 2008), headache (Andersson, Lundström, & Ström, 2003), insomnia (Ström, Pettersson, & Andersson, 2004), and chronic pain (Buhrman, Fältenhag, Ström, & Andersson, 2004). Other targets of Internet-based intervention have included pathological gambling (Carlbring & Smit, 2008), eating disorders (
The Internet and the therapist
Emerging evidence across trials clearly suggests that the computer cannot totally replace human contact, even if it can be minimised. In fact, we found a correlation of rho = 0.75 (p < 0.005) between the amount of therapist contact in minutes and the between group effect size in 15 trials dealing with psychiatric conditions (Palmqvist, Carlbring, & Andersson, 2007). It is possible that there is a cut-off point below which smaller effects and more dropouts are seen. Indeed, this is especially clear
For whom is Internet-based treatment suitable?
Some obvious limitations relate to comprehension of text materials and computer expertise. In many studies, patients who lack these characteristics are excluded. It does not have to be this way however, as multimedia presentations (e.g., video and audio files online), and simplified language can be used to handle these obstacles. Another limitation relates to comorbidity and the mere fact that an evidence-based treatment, with its research base coming from standard individual therapy, does not
Future challenges
It is not difficult to identify future challenges regarding Internet-delivered CBT. Methodological problems are one. High attrition in some studies is one example. Lack of proper diagnoses in many trials is another. It is also difficult to grasp the content of the self-help materials used, and the content of treatment programs and compliance with the treatment could be described better. Another issue has to do with costs of developing and implementing the interventions, for example describing
Acknowledgements
Co-workers in my research group and former students are thanked as well as international colleagues in the International Society for Research on Internet Interventions (http://www.isrii.org). Finally, my research has been supported by the Swedish Council for Working and Life Research, Swedish Cancer Foundation, and the Swedish Research Council.
References (80)
- et al.
Predicting treatment outcome in Internet versus face to face treatment of panic disorder
Computers in Human Behavior
(2008) - et al.
The Liebowitz Social Anxiety Scale as a self-report instrument: a preliminary psychometric analysis
Behaviour Research and Therapy
(2002) - et al.
Controlled trial of Internet-based treatment with telephone support for chronic back pain
Pain
(2004) - et al.
Treatment of panic disorder via the Internet: a randomized trial of CBT vs. applied relaxation
Journal of Behavior Therapy and Experimental Psychiatry
(2003) - et al.
Treatment of panic disorder: live therapy vs. self-help via Internet
Behaviour Research and Therapy
(2005) - et al.
Treatment of panic disorder via the Internet – a randomized trial of a self-help program
Behavior Therapy
(2001) Anxiety disorders: why they persist and how to treat them
Behaviour Research and Therapy
(1999)Bibliotherapy in unipolar depression: a meta-analysis
Journal of Behavior Therapy and Experimental Psychiatry
(1997)- et al.
Recent developments and current controversies in depression
Lancet
(2006) - et al.
Internet versus group cognitive-behavioral treatment of distress associated with tinnitus. A randomised controlled trial
Behavior Therapy
(2008)