CBT in the Age of the Internet
Hear from expert in digital mental health, Heather Hadjistavropoulos, about the advantages and disadvantages of internet-delivered CBT (iCBT).
In practice, there is significant variability in how iCBT is delivered to clients. Common to all iCBT programs is offering cognitive behavioral treatment materials online via lessons typically spread over a few months. Sometimes these lessons are delivered in a standardized order and other times clients or therapists choose the order of the lessons based on client concerns.
The nature of lessons differs considerably across iCBT programs in terms of content. For example, lessons may focus on only one disorder versus multiple disorders, or focus on cognitive versus behavioral content. They may also differ by the number of lessons provided, the length between lessons and whether support is offered (that is, self-directed versus supported).
Moreover, who provides support (for example, coach versus registered professional) and what form that support takes (phone calls, secure emails, video calls, in-person sessions, and so on) also differ. There is also variability in the extent to which iCBT programs use technology to assist clients, such as symptom monitoring and automated messages.
Reviews of iCBT research have found that iCBT can address diverse mental health concerns, such as anxiety and mood disorders, adjustment to chronic health conditions and alcohol problems. In general, the research literature shows comparability between iCBT and face-to-face therapy.
More information is available at the following links:
https://doi.org/10.1177/0706743719839381
https://doi.org/10.1080/16506073.2017.1401115
There is considerable research to suggest that guided support – whether delivered by a therapist or coach – improves the efficacy of iCBT. Nevertheless, there is growing research that does not find differences between iCBT which is self-guided and iCBT which is therapist-guided. Researchers have been trying to understand when therapist support is needed, when it is not and what amount of support is required.
A recent meta-analysis found that symptom severity may be related to whether therapist support is needed. For example, in the case of moderate to severe depression, there is strong evidence that outcomes are better when therapist support is available than when clients work on iCBT without guidance. In other research, our group has explored whether there is a benefit to offering more therapist support. We found that iCBT outcomes were similar, whether clients received once-weekly support or a one-business-day response to client emails, or once-weekly versus twice-weekly support.
One thing that complicates this area of research is that not all clients actually use therapist support. That is, when therapist support is offered, some clients continue to focus primarily on the review of the materials and limit their interactions with therapists, diluting the impact of therapist support. When we explored client preference for therapist support, we found as many as 25 percent of clients prefer optional therapist support, where therapist support is only offered when the client requests it.
More information is available at the following links:
https://doi.org/10.1016/j.invent.2014.08.003
https://doi.org/10.1001/jamapsychiatry.2020.4364
https://doi.org/10.1016/j.invent.2020.100347
iCBT has similarities with self-help literature but is also distinct. Similar to self-help literature, iCBT involves presenting clients with text to describe cognitive behavioral strategies. Unlike self-help literature, there is more material offered in iCBT to complement the text including images, audio and video which is designed to make iCBT engaging and thus more effective.
Moreover, iCBT programs are different from self-help in that they typically employ technology to facilitate change such as automated emails, time delays to open materials, symptom monitoring and progress bars. One review has found evidence that self-guided iCBT interventions that are designed more persuasively (for example, self-monitoring, reminders and rewards) are more effective in treating depression.
Interestingly, research shows that clients report an alliance with iCBT program materials, indicating that they feel understood by the program materials and that the program meets their needs. Of note, when iCBT is offered with some form of therapist assistance, even when this contact is brief, client ratings of the therapeutic alliance are strong and similar to alliance ratings reported in face-to-face therapy.
More information is available at the following links:
https://doi.org/10.1002/wps.20610
https://doi.org/10.1080/10503307.2015.1119908
Most research on iCBT has focused on individuals with anxiety and mood disorders. In these studies, individuals are often screened out of iCBT and referred to face-to-face therapy if they are at risk of suicide, have severe problems with alcohol or drugs, or have severe mental health problems such as schizophrenia and bipolar disorder. That said, it is important to continue to conduct research on iCBT with individuals suffering from more severe disorders and explore opportunities to offer iCBT to clients with more severe mental health concerns.
There is research to suggest, for example, that iCBT for suicide prevention is associated with reduced suicidal ideation. Moreover, recent research on iCBT freely available in Australia showed that enrolling in iCBT was associated with reduced suicide risk. There are also studies supporting the use of iCBT as an add-on treatment to care as usual for individuals with psychosis.
More information is available at the following links:
https://doi.org/10.1177/0706743719839381
https://doi.org/10.1001/jamanetworkopen.2020.3933
https://doi.org/10.1080/10508422.2019.1684295
There are iCBT programs for insomnia, which represents an important direction given the prevalence of insomnia and the considerable negative impacts of the condition. Reviews of this literature show that iCBT is effective for improving insomnia in adults with evidence to suggest it improves many different outcomes such as insomnia severity, subjective sleep quality and total time asleep.
Importantly, treating insomnia also results in improvements in depression. Outcomes of iCBT for insomnia are found to be maintained over time. It also seems that iCBT outcomes are better among iCBT programs of longer duration and when personal support is offered.
More information is available at the following links:
There is wide variability in what clients want from their therapist in iCBT. In one study, we explored emails sent to therapists who sought iCBT for depression or anxiety and coded statements into various categories. We found that 40 percent of statements concerned building an alliance with the therapist (for example, expressed an emotional tie to the therapist or to the iCBT program) and 25 percent of statements related to describing their personal patterns and problem behaviors. However, it is important to note that the frequency of statements seems to vary across iCBT programs. In another study, these same statements were less frequent.
In other research examining iCBT among individuals with symptoms of depression and anxiety, we explored questions that clients asked their therapists. During an eight-week treatment period, we found that clients sent an average of six emails to their therapist. In these six emails, only two questions were asked. Most commonly, questions were about how to apply cognitive behavioral techniques to their unique situation. In other cases, however, the questions were to clarify the nature of therapy itself or to help with technical challenges. Still other times, clients wanted help with problems outside the scope of iCBT.
More information is available at the following links:
https://doi.org/10.1016/j.invent.2018.01.006
There are many barriers to making iCBT widely accessible. First of all, many clients are unaware of this option for care or do not understand what is involved. One frequent assumption is that iCBT involves a client and therapist meeting online face-to-face, not realizing that the main component of iCBT is the delivery of treatment materials online. Another issue is that if clients are aware of iCBT, they may assume it is less effective than face-to-face therapy and not seek it out.
Clients may also have concerns about the security of the information they share in iCBT, limiting how much clients interact with therapists. Internet access poses a barrier for others, although some programs can develop a workaround for this problem. For example, some programs allow clients to download materials that limit the required time online and offer phone calls instead of email exchanges with therapists.
Knowledge deficits can also be a barrier to accessing iCBT, including discomfort navigating technology and reading and writing required for many iCBT programs. iCBT programs can also vary in terms of how user-friendly they are, which may make iCBT less accessible (for example, difficulties creating a user account). In some parts of the world, cost represents another barrier, with some programs only available for a fee and not included in freely available mental health services.