Internet-Based Psychotherapy Treatments

Research on Internet-based psychotherapy treatments for depression, anxiety disorders and other conditions has grown rapidly during the past 15 years, and the evidence shows that some forms of Internet-based treatments often result in similar outcomes as traditional face-to-face psychotherapy.

Surveys report lifetime prevalence rates of mental disorders of up to 47.4%, but only a small proportion of individuals in need receive treatment (Kessler et al., 2009).

One solution to the many challenges mental health care is facing is the use of new technology such as the Internet. Internet-based interventions can be delivered to large populations and they can be used flexibly and accessed easily.

Internet-based treatments can be distinguished depending on whether the Internet is used to communicate and/or to deliver information. There are:

(a) Web-based unguided self-help programs using the Internet as a delivery medium,

(b) Internet-based guided self-help approaches, in which the presentation of a Web-based self-help program is combined with regular contact with a therapist or a trained supporter, and

(c) Internet-based therapies such as e-mail, chat or videoconference-based therapies, in which the Internet is only used for communication purposes.

Internet interventions that include therapist contact can further be divided into those that involve real-time (synchronous; e.g. face-to-face, chat, video, telephone) or delayed (asynchronous; e.g. e-mail) interaction with patients.

Treatment Models for Internet-based Psychotherapy

Most Internet-based psychotherapy treatments are based on cognitive-behavioural models (Andersson, 2009), but other approaches such as psychodynamic, interpersonal and eclectic (or integrative) treatments have also been evaluated (Andersson et al., 2012b; Donker et al., 2013; Meyer et al., 2009).

A recent development is the use of transdiagnostic and tailored treatments that address the problem of high comorbidity rates in patients with common mental disorders (e.g. Titov et al., 2011; Johansson et al., 2012; Berger, Böttcher, & Caspar, 2014). While transdiagnostic treatments target common elements of several disorders, Internet-based tailored treatments do not use the same protocol for all patients but individually tailor the self-help material to the symptom profile of a patient.

Most of the growing body of evidence comes from studies evaluating guided self-help treatments in which the main component of the intervention is a Web-based self-help program. Such programs are typically arranged into a series of lessons or modules that include exercises and homework assignments.

While patients work through the program, therapists assist and support patients. The amount of contact between patients and therapists and the time therapists spend working with patients varies between studies. However, the majority of interventions only involve minimal guidance via e-mail, which requires considerably less time than face-to-face psychotherapy. Often, minimal guidance consists of a weekly feedback to patients on their behavior and progress in the self-help program. It is mainly aimed to motivate and reinforce the patients’ independent work with the self-help guide and to provide patients with a time structure that corresponds to the weekly scheduling of face-to-face therapy.

Efficacy of Internet-based Guided Self-help Treatments

Independent replications have shown moderate to large effect sizes for Internet treatments in comparison with control groups for the efficacy of Internet-based guided self-help treatments for anxiety disorders and depression (Hedman, Ljótsson, & Lindefors, 2012.). Moreover, in some direct experimental comparisons between Internet-based treatments and face-to-face therapy, no differences have been found between the two approaches (e.g. Andersson et al., 2013; Hedman et al., 2011).

An important limitation of the evidence is that most of the studies were efficacy trials conducted in university-based research settings with participants recruited from the community. However, in a recent review, four controlled trials and eight open studies conducted under clinically representative conditions were identified showing that the promising effects of Internet-based guided self-help treatments can also be observed when the treatment is transferred to regular clinical settings (Andersson & Hedman, 2013).

The Importance of Therapist Contact

The available evidence clearly suggests a superiority of guided versus unguided self-help treatments (Richards & Richardson, 2012; Spek et al., 2007). The main problems of unguided Web-based programs are the usually low adherence to treatment and the high drop-out rates. There are exceptions in studies on unguided treatments in which contact with a clinician was established before the treatment started (i.e. during a diagnostic interview; Berger et al., 2011).

A recent systematic review of Internet interventions for depression concluded that any contact with a clinician, including contact before treatment, may improve outcomes (Johansson & Andersson, 2012).

There are other advantages of guided over unguided treatments such as the fact that clinicians may assist patients to access other services that may be required such as crisis services or other forms of treatments (e.g. face-to-face psychotherapy; Andersson & Titov, 2014).

Establishing an alliance: Can therapeutic rapport be built over the Internet?

There are several studies investigating the therapeutic alliance in Internet psychotherapy interventions. Self-reported patient ratings on the working alliance are high across several studies, indicating that Internet-based treatments tend to generate a strong therapeutic alliance. However, results on the association of the working alliance and outcome are less consistent: There are some studies in which the online alliance predicted outcome (e.g. Wagner, Brand, Schulz, & Knaevelsrud, 2012) and others in which no relationship was found (e.g. Andersson et al., 2012a).

Responding to crises and maintaining confidentiality

How do therapists respond to crises such as suicidal ideation or threats? It can be challenging to adequately and immediately deal with crisis from a distance and in a time delayed communication environment (e.g. e-mail). Most studies have excluded suicidal patients. In addition, many research groups develop an emergency plan with all participants in which locally available treatment alternatives and emergency services for crisis situations are identified.

Another common concern is the confidentiality of communications and client records. Even if most providers of Internet-based treatments use encryption solutions, Internet-based communication is never completely secure.

Possible Negative Side Effects

While research on negative effects is also scarce in psychotherapy research in general, it is almost inexistent in Internet interventions. An exception is a recent study on negative side effects of an Internet-based intervention for social anxiety disorder (Boettcher et al., 2014). In this study 19 (14%) out of 133 participants reported negative effects that they related to the treatment, with the emergence of new symptoms as the most commonly reported side effect, followed by the deterioration of symptoms. Although the majority of the described side effects had only a temporary negative effect on participants’ well-being in this study, negative effects need to be taken seriously and they should be studied systematically in the future.

Challenges and Future Directions in Researching Internet Psychotherapy Interventions

Some of the most important issues are:

(a) for whom and how Internet treatments work

(b) how Internet treatments can and should be disseminated and implemented into regular healthcare

(c) how Internet interventions can best be combined with face-to-face treatments

Regarding characteristics of patients who are likely to benefit from Internet-based treatments, the few predictors of treatment outcome identified in some studies should be validated in future research (Nordgreen et al., 2012).

An interesting finding of our research group is that online activity and time spent in the self-help part of the treatment during the first week of treatment was significantly associated with treatment outcome (Berger et al., 2011).

Stepped-care Approach

A stepped care approach in which patients are assigned to increasingly intensive treatments (e.g. patients may start with an Internet intervention and then move on to face-to-face therapy if the Internet treatment does not show satisfactory effects) is one possibility to combine Internet interventions with face-to-face treatments. However, research on stepped care models is still scarce and there are several questions and problems related to this idea (Andersson & Titov, 2014).

Combining Internet-based Psychotherapy Treatment and Face-to-Face Therapy

Blending internet-based treatment with traditional face-to-face therapy has gained in popularity (see e.g., www.ecompared.eu). It is likely that therapists are getting more and more used to providing some interventions online, while still having face-to-face therapy sessions. However, more research is needed on how Internet interventions can best be blended with traditional forms of care.

Summary and Implications

In conclusion, there is now extensive evidence that Internet interventions work for common mental disorders such as anxiety disorders and depression.

Internet-based psychotherapy interventions represent a promising complement to face-to-face therapy that have the potential to improve access to evidence-based psychological treatments.

Research on Internet interventions is moving on at a high speed, while the dissemination and sustained implementation of Internet interventions into regular care is still in its infancy.

Present and future research should therefore move on from a legitimation phase (Do Internet-based psychotherapy treatments work?) to a prescriptive, process and implementation phase (For whom are Internet interventions indicated? How do they work? How should Internet interventions best be implemented into regular care and combined with traditional forms of care?).