(p. 269) Using different communication channels to support internet interventions
Internet interventions can take many different forms, but usually delegate at least some therapy decisions to the computer and are delivered using the world wide web. There is no firm distinction between different approaches, but most internet treatments to date use text and can therefore be regarded as a modern extension of bibliotherapy. However, in addition to text, internet interventions commonly include pictures and video to illustrate therapy components. Interactive features are also common such as automated responses to homework assignments. With the emergence of internet-based mental health interventions, it has become increasingly clear that guidance and support from a clinician leads to better outcomes than automated interventions without any clinician assistance (Spek et al. 2007). In this chapter we will discuss different ways of providing this support. We will cover different channels to communicate with clients including face-to-face, live groups, email, SMS, online discussion groups and telephone support. (For use of these communication channels as primary modes of delivery for low intensity CBT; see Lovell, Chapter 27; Shapiro and Bauer, Chapter 28; Titov, Chapter 29). While interactive web pages often are included in online interventions we do not consider that to be a ‘different channel’ as it is usually embedded in the treatment program. Moreover, we will not consider telemedicine and the use of video-conferencing (such as Skype).
During the last decade a number of trials have been reported testing the effects of internet-based mental health interventions. The meta-analysis by Spek et al. (2007) showed that internet interventions without clinician support had a small effect, whereas intervention studies in which support was given had a much larger effect (four times larger). Another issue concerns dropout rates which tend to increase dramatically without any guidance and are extremely high in open access programs (Christensen et al. 2006).
Communication is not a one-way phenomenon, but involves at least two people. However, an author of a book might communicate at least one-way with a reader, but will most often not be able to check how the book is understood. Many of the evidence-based mental health interventions have used primarily text-based treatment, which has been referred to as ‘net-bibliotherapy’. The literature on bibliotherapy mirrors the findings from the internet research with a clear advantage of guided bibliotherapy over unguided (p. 270) (Hirai and Clum 2006). However, in guided bibliotherapy the most common way to provide support has been by the telephone. To confuse things even further, there is a separate literature on telephone administered psychotherapy, but as the main intervention is the telephone calls and not the online text or book, we will not discuss it here (see Lovell, Chapter 27, on phone-based support).
To conclude, a range of communication support channels are used alone or together to treat mental health problems. Broadly categorized there are interventions in which the ‘other supporting channels’ are only used to provide support and feedback. This includes the guided internet therapy used by our own research group (Andersson et al. 2008a; Andersson, 2009), where the guidance is mainly provided using email correspondence. This format is widely used in research, for example in Australia (Klein et al. 2006) and the Netherlands (Lange et al. 2003). It also includes the literature on telephone-assisted bibliotherapy.
The second category is the interventions in which the ‘other supporting channel’ is the main intervention. This includes email therapy, video-conferencing, and pure telephone therapy. In this latter category structured learning material might exist, but not to the extent of a full treatment program. Finally, it should be mentioned that there are internet-based mental health interventions that are brief and perhaps more aimed at prevention. These are often much shorter than face-to-face treatments and tend to be presented without any guidance.
Given the lack of any clear definitions and a range of old and new technologies, we identify several challenges from research and clinical practice.
First, we identify a challenge in using mainly text in correspondence with clients and in treatment programs. Overall, this has been useful and in our research so far we have found little evidence that reading skills and intellectual capacity overall has any major impact on the outcome of guided internet-based mental health interventions (Andersson et al. 2008b). However, this experience is based on research trials with participants mainly recruited via advertisements. If internet-based mental health interventions are to be used in ordinary clinical settings, we need to pay attention to language problems (e.g. not having English as native language), and consider alternative modes of communicating and presenting information. Moreover, there is little research done to test if text material and the text-based email correspondence are properly understood.
The second challenge concerns finding ways to increase adherence to treatment protocols.
In research trials, support has been given in different ways, including email and telephone. A relatively underused option is to take advantage of online discussion groups. While we have so far seen little use in research of video-conferencing such as web cameras with Skype, this is likely to be included in the future. Another way to potentially increase (p. 271) adherence is to use closed online discussion groups in which clients encourage and give feedback to each other. To our knowledge, there is no consensus or any systematic knowledge regarding which format for support is best. Could automatic reminders working with an online treatment protocol be enough? When it comes to live support, we are left with the question of whether text only, voice only or voice and a face produces the best adherence. In addition, combined formats of support, such as check-up calls over the telephone and feedback on homework assignments via e-mail have been used in research with direct comparisons of their effects. Some studies suggest that adherence increases with telephone support, but that it does not necessarily increase treatment effectiveness.
Provider of support
We now turn to a related question, namely ‘who should provide the support?’ If the support is not prepared in advance (automated) there will be room for individual differences as different support persons or therapists will differ in their behaviour. For example, we differ in the way we talk, write and, while practically no research has been done in this field, there are indications that a therapeutic alliance can be formed in internet-based interventions even if all of the correspondence occurs via email. When it comes to telephone guidance, many of the aspects of traditional face-to-face therapy will be present and if web camera is used the situation will even more approximate the regular therapy session. If we agree that different providers of support can differ in their skills, the next question is how and if these support persons should be trained? For example, most internet-based mental health interventions have been derived from cognitive behavioural therapy, and an obvious question then becomes if the support person needs to be trained in CBT or perhaps even should have experience of face-to-face CBT? A related issue concerns supervision. Is it needed?
Our last challenge has to do with security. Information technology should be safe and all communication with clients should take this into consideration. Preferably, encryption and other security measures should seamlessly be built into all applications. This is an ethical issue as well. For example, using online support groups as part of the treatment can potentially be useful, but introduces confidentiality issues not only restricted to the dyad of client-support person. Moreover, while the online communication can be confined within a closed IT environment, we can never control client behaviours totally and in contrast to face-to-face therapies, almost all correspondence can be copied and saved in separate files. These could then potentially be accessed by family members. Although unlikely, other people could gain access to that person’s computer using malware.
Alternatives to text and translations of treatments
There are several potential solutions to the problem of using text in treatment and correspondence. Language problems could be solved by translating the program text into different languages. This has been done with some internet-based mental health intervention (p. 272) systems such as Moodgym (Christensen et al. 2004), Interapy (Lange et al. 2003); the tinnitus and panic treatments, which have been developed in Sweden and translated into English and Norwegian, respectively, and tested in pilot trials. We believe that it is important to test translated protocols at least in open trials, as cultural issues could make a difference when a program is transferred.
In one of our trials, we focused on older adults and it became apparent that at least some of these clients might need adjusted text (font), and facilitated procedures due to less experience with technology. While little has been written about the use of videos and lecture style presentation in internet-based mental health interventions, they exist and it is possible to present downloadable audio files where the text material is read. We have already commented on the usefulness of telephones, but in addition to that, SMS has been used most commonly as reminders or as a way to collect brief symptom ratings. Surprisingly, we know very little about how well internet programs and the correspondence is understood by client. We have collected preliminary data suggesting that knowledge about social anxiety increases following internet treatment, but we have not yet investigated how the correspondence between the support person and client is understood by the client.
Fostering adherence to treatment has been an important challenge since the early trials, and is still a problem in some unguided interventions. As mentioned, support is often needed in internet interventions, but as yet we do not know what kind of support and how much is best for what client. It is indeed the case that some clients prefer anonymity and no contact with a clinician, but overall support generates better results and adherence to the treatment (see Cavanagh, Chapter 21). How much can be delegated to the computer without any professional assistance is still the subject of much debate. Even if we acknowledge the importance of face-to-face support, the format is yet not clear. Web cameras or later equivalents will potentially be used more, and in particular when it comes to diagnosis of mental health problems, questionnaires are not enough. We have found that a first online screening can be complemented with a semi-structured telephone interview, using a stepped-care approach to diagnosis. However, for some conditions, telephone might not be enough. We have used online discussion groups and while they are appreciated in some groups, it is yet unclear if they enhance adherence and treatment effects. While adolescents use the internet frequently, there is little to suggest that they are more suitable for internet-based mental health interventions, and the evidence points more in a direction of combining live sessions with the internet treatment program (Spence et al. 2006). We hesitate to draw any early conclusions about the role of different support formats, as the technology develops rapidly and information technology becomes integrated increasingly in health care overall.
Who gives the support?
The third challenge concerning who should provide the online support has not been answered empirically. For us it appears to be a safe conclusion that the support person (p. 273) (e.g. non-psychologist) should at least be ‘psychologically minded’. In most of our research, students at the later stages of their clinical training (MSc level) have been involved as student therapists with excellent results. Preliminary data do not show that different internet therapists produce different client outcomes. However, with the expansion of internet-based mental health interventions, training and supervision will most likely be required when the format is disseminated (see Austin et al., Chapter 49). This might be of particular importance when the support person does not have background knowledge about CBT.
Solutions for the security issues are likely to differ between different contexts. We have developed a secure client contact system, which shares many features of other similar secure systems (e.g. internet banking). This system is preferable to email contact where patients’ regular email addresses are used. Indeed, clinicians who practice online counselling by means of email therapy should consider more secure alternatives. It is very likely that we will see secure web systems designed for clinicians in the near future. As at least some internet treatment programs are delivered in regular health care settings, they should not conflict with local IT standards, and at least in Sweden electronic file systems (patient records) are increasingly used by hospitals. When it comes to activities outside of the closed computer environment, we recommend careful information about the risks of leaving sensitive information on a computer. Apart from the IT security, there are also risks when clients develop severe problems along the way, for example, suicidal ideation. The first step is identifying this by weekly monitoring of key questions. Once a case is identified, utilize clinical experts close at hand (e.g. psychiatrist) and also ensure that you can contact the client by telephone especially if the client has an anxiety and/or mood disorder.
Take home messages
◆ It is now generally established that guided internet-based mental health interventions work effectively. The format of the support can vary, but mostly involves e-mail or brief telephone calls
◆ Adherence to internet-based mental health interventions can be poor, but is increased by the guidance of a support person when evaluated via randomized control trials. However, is not yet established in research if frequency of contact and individualization makes a difference. It is also not clear if text-based interactions are as good as face-to-face or telephone support
◆ Little is known regarding the expertise of the support person. Most research to date has used CBT protocols and in many studies psychology students under supervision have been support persons/therapists (p. 274)
◆ All practitioners of internet-based mental health interventions need to consider confidentiality and security issues. Although security can be obtained to some extent, it can never be totally achieved as clients, at least in standard applications, can copy and paste correspondence to other documents in their computers.
Andersson, G. (2009). Using the internet to provide cognitive behaviour therapy. Behaviour Research and Therapy, 47, 175–80.Find this resource:
Andersson, G., Bergström, J., Buhrman, M. et al. (2008a). Development of a new approach to guided self-help via the internet: the Swedish experience. Journal of Technology in Human Services, 26, 161–81.Find this resource:
Spek, V., Cuijpers, P., Nyklicek, I., Riper, H., Keyzer, J. and Pop, V. (2007). Internet-based cognitive behaviour therapy for symptoms of depression and anxiety: a meta-analysis. Psychological Medicine, 37, 319–28.Find this resource:
Andersson, G., Carlbring, P., and Grimlund, A. (2008b). Predicting treatment outcome in internet versus face to face treatment of panic disorder. Computers in Human Behavior, 24, 1790–801.Find this resource:
Christensen, H., Griffiths, K., Groves, C. and Korten, A. (2006). Free range users and one hit wonders: community users of an internet-based cognitive behaviour therapy program. Australian and New Zealand Journal of Psychiatry, 40, 59–62.Find this resource:
Christensen, H., Griffiths, K. M., and Jorm, A. (2004). Delivering interventions for depression by using the internet: randomised controlled trial. British Medical Journal, 328, 265–8.Find this resource:
Hirai, M. and Clum, G.A. (2006). A meta-analytic study of self-help interventions for anxiety problems. Behavior Therapy, 37, 99–111.Find this resource:
Klein, B., Richards, J.C. and Austin, D.W. (2006). Efficacy of internet therapy for panic disorder. Journal of Behavior Therapy and Experimental Psychiatry, 37, 213–18.Find this resource:
Lange, A., van de Ven, J.-P. and Schrieken, B. (2003). Interapy: treatment of post-traumatic stress through the Internet. Cognitive Behaviour Therapy, 32, 110–24.Find this resource:
Spence, S.H., Holmes, J.M., March, S., and Lipp, O.V. (2006). The feasibility and outcome of clinic plus internet delivery of cognitive-behavior therapy for childhood anxiety. Journal of Consulting and Clinical Psychology, 74, 614–21.Find this resource: