By Associate Professor Britt Klein MAPS, Co-Director, National eTherapy Centre Faculty of Life and Social Sciences, Swinburne University

It is a professional imperative that psychologists continue to play an instrumental role in developing new ways of providing services that are accessible, safe and capable of enhancing self-care management practices. Mental and behavioural health promotion, prevention, treatment and management-oriented interventions that are delivered via the internet or other electronic technologies, with or without human support, are termed e-Interventions, with the most common type being web-based interventions¹. Although e-Interventions will not grow into the ‘sum of all things', nor lead to a paradigm shift in psychological practice, they will play an integral part in reshaping our healthcare landscape over the next decade.

Healthcare systems and their related practices are by nature conservative, steeped in tradition and slow to change, however the field of e-Interventions has developed a critical mass that can no longer be easily ignored. With the emergence of a supportive e-Intervention infrastructure (initiatives such as the Commonwealth Department of Health and Ageing's (DoHA) Telephone Counselling, Self Help and Web-based Support Programmes measure, the National Broadband Network, the National E-Health Transition Authority) and the overarching healthcare reform agenda, the time is ripe for a proliferation of e-Interventions for the prevention, treatment and management of ill health, as well as the promotion of mental wellbeing.

Although psychologists have, by and large, led the way in developing and/or evaluating hundreds of e-Interventions, many of these have originated within the halls of academia while in professional practice psychologists have been seemingly reluctant to embrace e-mental health technologies. Psychologists are, however, in a prime position to lead the safe dissemination of e-Interventions into the ‘real world' by integrating them within daily practice, by advocating and championing their availability - especially for hard to reach populations (e.g., rural/remote, stigmatised, prison) - and by lobbying government regarding funding mechanisms.

¹For a general discussion regarding the multiple terms used to label and to define internet-supported interventions see Barak, Klein & Proudfoot (2009).

Types of e-Interventions and their efficacy

e-Interventions have been applied to a vast selection of mental and physical health conditions spanning the health promotion, at risk/symptomatic and clinical spectrum. Results from hundreds of feasibility and evaluation trials firmly support their efficacy (e.g., Barak et al., 2008; Griffiths, Farrer & Christensen, in press; Marks, Kavanagh & Gega, 2007). The evidence is in and they do work!

Effective e-Interventions exist for depression, the anxiety disorders, alcohol and drug conditions, eating disorders and a variety of physical health conditions (e.g., insomnia, encopresis, diabetes, pain management, tinnitus), as well as the enhancement of wellbeing. The BEACON web portal (www.beacon.anu.edu.au), developed by the Centre of Mental Health Research at the Australian National University, is an invaluable ‘must visit' website for practitioners and consumers alike that lists and provides expert review and quality ratings of e-Interventions.

Model of behaviour change

Many e-Intervention programs are based on cognitive behavioural treatments as they lend themselves very well to an online format. However, more recently IPT and psychoanalytic approaches have been explored with initial promising results. It was only last year that a theoretical model of behaviour change for internet interventions was published (see Ritterband, Thorndike, Cox, Kovatchev & Gonder-Frederick, 2009).

The Ritterband et al. model is based on multiple theories/models (e.g., health belief model, social learning, web-based design), empirical evidence and clinical experience proposing that effective internet interventions result in behaviour change and symptom improvement through nine nonlinear steps/components. Users' individual characteristics (e.g., demographics, beliefs), influenced by their environment (e.g., family), affect the use of the intervention program. Intervention usage is also influenced by the website program characteristics (e.g., interactivity), adherence to the intervention, and the support provided to assist the user (e.g., email). From here, the model predicts that website use brings about behavioural change through various mechanisms (e.g., acquisition of knowledge). Actual changes in behaviour lead to symptom improvement and treatment maintenance occurs via relapse prevention activities. This model helps practitioners and researchers better understand how behaviour changes might occur through the use of e-Interventions.

For whom are e-Interventions most appropriate?

We are still in the early stages of understanding who can benefit most from e-Interventions and the Ritterband et al. model has provided an important framework from which to investigate this further. However, in general, individual characteristics - such as previous treatment experience, disorder type/symptom severity and chronicity, motivation to change, personality traits, self-management orientation, locus of control and learning styles - are most likely to play important and interacting roles in predicting/determining who will and won't do as well when using e-Interventions. Additionally, individual preferences for different e-Intervention features - such as whether it is self-help or human-supported, the program length, and whether it is text- or video/gaming-based - will also almost certainly influence adherence and outcome.

For crisis management and severe mental health problems (e.g., psychotic, highly suicidal, severely disabling depression), traditional face-to-face care will always be an obvious necessity. However, the preventative potential of appropriately developed websites for suicide risk, for example, may become a much needed and life-saving resource (Christensen & Griffiths, 2009).

In terms of what consumers want, recent surveying of Australians preferences for either face-to-face or e-mental health services (Cook & Klein, in preparation) found that 77 per cent of respondents preferred face-to-face services. However, it is important to note that only ten per cent of the sample reported that they would not use e-mental health services should they have a mental health condition. This suggests that the vast majority were willing to use e-Interventions.

The major concern levelled at e-Interventions is the belief that the therapeutic alliance will be compromised by employing remote methods with which to engage and interact. However, emerging evidence (e.g., Klein et al., 2009; Knaevelsrud & Maercker, 2006; Ritterband, Thorndike, Vasquez & Saylor, in press) demonstrates that consumers using e-Interventions rate the quality of their relationship and satisfaction with the e-Intervention as high and at similar rates to their face-to-face counterparts. Continued investigation of these issues is important.

Roles for psychologists

Psychologists can certainly play a central role in the development, use and dissemination of e-Interventions should they wish to embrace it.

Psychological practice

There are a variety of ways in which e-Interventions can be utilised within professional practice.

  1. Sole use of e-Interventions through establishment of an online clinic providing online counselling and/or prescription of e-Interventions and communication via email/skype/ telephone
  2. Offering either face-to-face treatment or an e-Intervention as the ‘low intensity' treatment modality alternative
  3. Offering a mixed service delivery model integrating both treatment modalities (e.g., provide a client with six face-to-face sessions and six e-Intervention sessions)
  4. Use of e-Interventions as adjuncts to supplement traditional face-to-face care

Another approach involves employing a stepped care model whereby e-Interventions may become the first major port of call for those with low level or mild mental health symptoms (Christensen, in press). If Medicare was able to provide rebates for ‘e' sessions/prescriptions, wide-ranging savings (personal, economic, societal) would undoubtedly ensue and so informing and lobbying government is essential.

Education/training and ethics

It is vital that psychologists lead the way in providing (and/or obtaining) e-Intervention education and training. One current initiative is the online training programs for e-Therapists and e-Supervisors within Anxiety Online at the National eTherapy Centre (NeTC) at Swinburne University (www.anxietyonline.org.au). These e-Training programs are currently open to psychologists who work at the NeTC (largely postgraduate provisionally registered psychology students on placement and their supervisors).

Equally as important, psychologists must continue to promote and adhere to high ethical standards when using e-Interventions. To further ensure the safe use of e-Interventions within psychological practice, periodic revision of the APS Ethical Guidelines for providing services and products on the internet is necessary due to the rapid rate of technological change. Psychologists can also draw upon DoHA's Quality Frameworks for Telephone Counselling and Internet-based Support Services (2009) for additional guidance regarding e-related service delivery standards.

Systemic coordination

On a broader systemic level, the creation of a National e-Mental Health Web Portal (Christensen et al., 2009) containing psychoeducational information, screening/assessment/decision support tools, consumer created e-mental health records, direct access to e-Interventions and referral pathways to traditional services is crucial. If in addition such a portal became firmly embedded within the broader healthcare system, enormous synergy would most certainly transpire.

Conclusion

Psychology has much to offer and to do in this exciting field of ‘e' and all are wholeheartedly encouraged to join in advocating and championing its widespread use. e-Interventions can significantly assist psychologists in their work to further advance the promotion of wellbeing and the prevention and alleviation of ill health during this new era of Australian healthcare reform.

The author can be contacted at bklein@swin.edu.au.

Acknowledgements
Utmost thanks go to our major e-Intervention funders/supporters: DoHA, Rotary, NH&MRC, beyondblue, and the ARC; and also to Assoc Prof Lee Ritterband for his timely comments. The pioneering ‘e' work of the late Professor Jeff Richards FAPS is also acknowledged.

Australian e-Interventions

Australia is at the forefront in the development and delivery of e-Interventions and already offers an array of self-help and human-supported health promotion, prevention/treatment programs/virtual clinics that are open directly to the public or accessible via research trials.

 

Organisation

Major programs and/or main website

e-Intervention descriptors

Australian National University - e-mental Health Research and Development (e-hub) at the Centre for Mental Health Research

www.ehub.anu.edu.au  

BEACON -
www.beacon.anu.edu.au

BluePages/BlueBoard - www.bluepages.anu.edu.au

e-couch -
www.ecouch.anu.edu.au

MoodGYM -
www.moodgym.anu.edu.au

Youth, adult, health promotion, education, prevention, treatment, self-help and human-supported e-Interventions, depression, anxiety, online portal to e-Interventions

beyondblue

www.beyondblue.org.au

Youth beyondblue -
www.youthbeyondblue.com/depression
-and-anxiety

e-mental health services listing -
www.beyondblue.org.au/index.aspx?link_id=107.1203 

Youth, adult, health promotion, education, treatment and prevention information, forum-based e-Intervention, mood disorders, anxiety disorders, e-mental health listing directory

depressionServices

www.depressionservices.org.au

Adult, treatment, human-supported e-Interventions, depression, wellbeing

Inspire Foundation

 

www.inspire.org.au

ReachOut Central -
http://roc.reachout.com.au/flash/
index.html

Youth, health promotion, education and prevention information, gaming and forum-based e-Interventions, depression, anxiety, wellbeing, drug and alcohol

Queensland University of Technology - School of Psychology and Counselling

OnTrack Programs - www.ontrack.org.au/Programs.do

Adult, education, prevention, treatment, self-help and human-supported e-Interventions, depression, alcohol

Swinburne University - eTherapy Unit and the National eTherapy Centre (NeTC)

 

www.swinburne.edu.au/lss/
swinpsyche/etherapy

Anxiety Online -
www.anxietyonline.org.au

eTherapy Unit programs - www.swinburne.edu.au/lss/
swinpsyche/etherapy/programs.html

Child, adult, health promotion, education, prevention, treatment, self help and human-supported e-Interventions, anxiety disorders, autism, wellbeing, physical health, online psychological assessment, virtual clinic

University of NSW - BlackDog Institute

 

www.blackdoginstitute.org.au

Bipolar Education Project - www.blackdoginstitute.org.au/public/
resources/bipolareducationprogram.cfm

Adult, health promotion, education, prevention, treatment, self-help e-Interventions, mood disorders

University of NSW - Clinical Research Unit for Anxiety and Depression (CRUfAD)

www.crufad.org

Virtual Clinic -
www.virtualclinic.org.au

Adult, education, prevention, treatment, self-help and human-supported e-Interventions, depression, anxiety disorders, virtual clinic

University of Queensland (and Griffith University for BRAVE-ONLINE)

BRAVE-ONLINE -
www.brave.psy.uq.edu.au

Online Anxiety Prevention Project - www2.psy.uq.edu.au/~jkweb/
register.html

Child/adolescent, prevention, treatment, human-supported e-Intervention, anxiety disorders, adult, prevention, self-help e-Intervention, anxiety

University of Tasmania - Faculty of Health Science

Fear drop - www.feardrop.com

Adult, treatment, self-help e-Intervention, specific phobia

 

References

Barak, A., Hen, L., Boniel-Nissim, M., & Shapira, N. (2008). A comprehensive review and a meta-analysis of the effectiveness of internet-based psychotherapeutic interventions. Journal of Technology and Human Services, 26, 109-160.

Barak, A., Klein, B., & Proudfoot, J. (2009). Defining internet-supported therapeutic interventions. Annals of Behavioral Medicine, 38, 4-17.

Christensen, H. (in press). Increasing access and effectiveness: Using the internet to deliver low intensity cognitive behaviour therapy. In Bennett-Levy, J et al. (Eds.). The Oxford Guide to low intensity CBT interventions. Oxford: Oxford University Press.

Christensen, H., & Griffiths, K. (2009). Submission to the inquiry into suicide in Australia. Available online: www.aph.gov.au/Senate/committee/clac_ctte/suicide/submissions/sub60.pdf

Christensen, H., Proudfoot, J., Andrews, G., Klein, B., Kavanagh, D., O'Neil, D., Woodward, A., Young, L., & Graham, K. (2009). E-mental health: A 2020 vision and strategy for Australia. Available online: www.ehub.anu.edu.au/workshop2009.php

Commonwealth Department of Health and Ageing. (2009). Quality Frameworks for Telephone Counselling and Internet-based Support Services. Available online: www.health.gov.au/internet/main/publishing.nsf/Content/DB24242029D642E6CA2575BD0001FCA2/$File/quatel.pdf

Cook, S., & Klein, B. (in preparation). ‘e' versus non ‘e' mental health users: Is there a difference?

Griffiths, K., Farrer, L., & Christensen, H. (in press). The efficacy of internet interventions for depression and anxiety disorders: A review of randomised controlled trials. Medical Journal of Australia.

Klein, B., Austin, D., Pier, C., Kiropoulos, L, Shandley, K, Mitchell, J., Gilson, K., & Ciechomski, L. (2009). Frequency of email therapist contact and internet-based treatment for panic disorder: Does it make a difference? Cognitive Behaviour Therapy, 38, 100-13.

Knaevelsrud, C., & Maercker, A. (2006). Does the quality of the working alliance predict treatment outcome in online psychotherapy for traumatized patients? Journal of Medical Internet Research, 8, e31.

Marks, I. M., Cavanagh, K., & Gega, L. (2007). Hands on help: Computer-aided psychotherapy. New York: Psychology Press.

Ritterband, L. M., Thorndike, F. P., Cox, D. J., Kovatchev, B., & Gonder-Frederick, L. (2009). A behavior change model for internet interventions. Annals of Behavioral Medicine, 38, 18-27.

Ritterband, L., Thorndike, F., Vasquez, D., & Saylor, D. (in press). Treatment credibility and satisfaction of internet interventions. In Bennett-Levy, J et al. (Eds.). The Oxford Guide to low intensity CBT interventions. Oxford: Oxford University Press.

InPsych February 2010