Invited essay
Using the Internet to provide cognitive behaviour therapy

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Abstract

A new treatment form has emerged that merges cognitive behaviour therapy with the Internet. By delivering treatment components, mainly in the form of texts presented via web pages, and provide ongoing support using e-mail promising outcomes can be achieved. The literature on this novel form of treatment has grown rapidly over recent years with several controlled trials in the field of anxiety disorders, mood disorders and behavioural medicine. For some of the conditions for which Internet-delivered CBT has been tested, independent replications have shown large effect sizes, for example in the treatment of social anxiety disorder. In some studies, Internet-delivered treatment can achieve similar outcomes as in face-to-face CBT, but the literature thus far is restricted mainly to efficacy trials. This article provides a brief summary of the evidence, comments on the role of the therapist and for which patient and therapist this is suitable. Areas of future research and exploration are identified.

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)

  • L.A. Kiropoulos et al.

    Is internet-based CBT for panic disorder and agoraphobia as effective as face-to-face CBT?

    Journal of Anxiety Disorders

    (2008)
  • B. Klein et al.

    Efficacy of internet therapy for panic disorder

    Journal of Behavior Therapy and Experimental Psychiatry

    (2006)
  • B. Ljótsson et al.

    Remote treatment of bulimia nervosa and binge eating disorder: a randomized trial of Internet-assisted cognitive behavioural therapy

    Behaviour Research and Therapy

    (2007)
  • L. Mora et al.

    Psychologist treatment recommendations for Internet-based therapeutic interventions

    Computers in Human Behavior

    (2008)
  • L.-G. Öst et al.

    Applied relaxation vs cognitive behaviour therapy in the treatment of panic disorder

    Behaviour Research and Therapy

    (1995)
  • J.W. Pennebaker

    Putting stress into words: health, linguistic, and therapeutic implications

    Behaviour Research and Therapy

    (1993)
  • V. Spek et al.

    Predictors of outcome of group and internet-based cognitive behavior therapy

    Journal of Affective Disorders

    (2008)
  • Almlöv, J., Carlbring, P., Källqvist, K., Paxling, B., Cuijpers, P., Andersson, G. (2008). Therapist effects in guided...
  • G. Andersson

    Internet based cognitive behavioral self-help for depression

    Expert Review of Neurotherapeutics

    (2006)
  • G. Andersson et al.

    Development of a new approach to guided self-help via the Internet. The Swedish experience

    Journal of Technology in Human Services

    (2008)
  • G. Andersson et al.

    Internet-based self-help for depression: a randomised controlled trial

    British Journal of Psychiatry

    (2005)
  • G. Andersson et al.

    Delivering CBT for mild to moderate depression via the Internet. Predicting outcome at 6-months follow-up

    Verhaltenstherapie

    (2004)
  • G. Andersson et al.

    Internet-based self-help with therapist feedback and in-vivo group exposure for social phobia: a randomized controlled trial

    Journal of Consulting and Clinical Psychology

    (2006)
  • G. Andersson et al.

    Pros and cons of online cognitive-behavioural therapy

    British Journal of Psychiatry

    (2008)
  • G. Andersson et al.

    Internet-based treatment of headache. Does telephone contact add anything?

    Headache

    (2003)
  • G. Andersson et al.

    A primer for the assessment, diagnosis and delivery of Internet interventions for (mainly) panic disorder. Lessons learned from our research groups

    Clinical Psychologist

    (2008)
  • A. Barak et al.

    A comprehensive review and a meta-analysis of the effectiveness of Internet-based psychotherapeutic interventions

    Journal of Technology in Human Services

    (2008)
  • D.H. Barlow

    Anxiety and its Disorders

    (2002)
  • Berger, T., Hohl, E., & Caspar, F. (2008). Internet-based treatment for social phobia: a randomized controlled trial....
  • Bergström, J., Andersson, G., Karlsson, A., Andreewitch, S., Rück, C., Carlbring, P., et al. (2009). An open study of...
  • T. Buchanan

    Internet-based questionnaire assessment: appropriate use in clinical contexts

    Cognitive Behaviour Therapy

    (2003)
  • P. Carlbring et al.

    Remote treatment of panic disorder: a randomized trial of Internet-based cognitive behavioral therapy supplemented with telephone calls

    American Journal of Psychiatry

    (2006)
  • P. Carlbring et al.

    Treatment of social phobia: randomized trial of internet delivered cognitive behaviour therapy and telephone support

    British Journal of Psychiatry

    (2007)
  • P. Carlbring et al.

    Randomized trial of Internet-delivered self-help with telephone support for pathological gamblers

    Journal of Consulting and Clinical Psychology

    (2008)
  • H. Christensen et al.

    Delivering interventions for depression by using the internet: randomised controlled trial

    British Medical Journal

    (2004)
  • H. Christensen et al.

    Online randomized trial of brief and full cognitive behaviour therapy for depression

    Psychological Medicine

    (2006)
  • D.M. Clark et al.

    Brief cognitive therapy for panic disorder: a randomized controlled trial

    Journal of Consulting and Clinical Psychology

    (1999)
  • G. Clarke et al.

    Overcoming depression on the Internet (ODIN) (2): a randomized trial of an self-help depression skills intervention program with reminders

    Journal of Medical Internet Research

    (2005)
  • G. Clarke et al.

    Overcoming depression on the Internet (ODIN): a randomized controlled trial of an Internet depression skills intervention program

    Journal of Medical Internet Research

    (2002)
  • J.E. Cook et al.

    Working alliance in online therapy as compared to face-to-face therapy: preliminary results

    Cyberpsychology & Behavior

    (2002)
  • Cited by (0)

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