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By Professor Gerhard Andersson, Professor of Clinical Psychology, Linköping University, Sweden

For those involved in cognitive behavioural therapy (CBT) it is well known that at least some of the intervention methods can be delivered in different ways, and sometimes even without a clinician present. One alternative is self-help, which has a long history with Miller (1964) making a call to bring psychology to the people. Using self-help in conjunction with CBT has been especially fruitful, and it has been observed that a majority of CBT clinicians (88 per cent) use and recommend self-help books in their practice (Keeley, Williams, & Shapiro, 2002). However, my impression is that self-help often is neglected in psychotherapy research, in spite of the substantial empirical support for some psychological conditions such as moderate depression. In fact, Den Boer, Wiersma and Van Den Bosch (2004) summarised the literature in a meta-analysis and found an average effect size of Cohen's d=.84 in comparison with waiting list, d=.76 at follow-up, and d=-.03 in comparison with other therapy forms. Since these figures are surprisingly similar to what we find in traditional face-to-face therapy, it can at least be stated that self-help should be considered for some of our cases. However, the authors of this meta-analysis went further asking: "Do psychiatrists underestimate the value of the acquisition of knowledge by patients? Do psychiatrists and psychotherapists overestimate the importance of the therapeutic relationship and their own level of experience?".

While the outcome of 'self-help' research looks promising, it is important to clarify that in most cases a more proper term would be 'minimal contact intervention'. In fact, in many studies and clinical applications self-help is often combined with some form of contact (for example telephone). When it comes to internet-based interventions this is relevant as well, as most protocols involve therapist interaction in the form of email exchanges. There are however some promising applications in which therapist input has been minimal or even absent (with the exception of severe cases in need of immediate help).

Computers have been around for a while and so has the use of computers in psychological treatment. One of the pioneers in this field is Professor Isaac Marks in London (Marks, Shaw, & Parkin, 1998). Although the result from computer-administered CBT is very promising (Proudfoot, 2004), the approach has not yet reached full-scale clinical application, and is rarely used by clinicians. Yet, with the advent of the internet the use of computers for psychological treatment might become more common as it is likely to reach a wider group of people.

Remember the days when we did not have the internet? As you all know, the internet is an expanding network of computers that has dramatically changed access to information and spread of information worldwide. It has become a regular part of many people's lives, and this is not the least reflected in the use of the internet in seeking health care advice and assistance. In fact, health care information is often said to be one of the most retrieved types of information on the worldwide web. I guess that most psychologists have more or less been influenced by the new information technology, although there are differences regarding how much the internet has changed daily clinical practice.

One potential way to present self-help material in a structured manner is via the internet. Providing treatment via the internet has advantages over self-help books in that advice can be given on a continuous basis without delay. In comparison with ordinary treatment it can be cost effective, and it also makes the treatment available to people living far from the specialist centre. The approach usually involves therapist interaction either via email or supplemented with telephone calls, and so far most treatment applications have been based on CBT principles. The main difference from previous self-help studies is that in internet-based self-help treatment all material is provided via web pages.

My own introduction into this field started when two MSc students knocked on my door in 1998 and asked if I could supervise their theses. First, I must admit that the idea sounded a bit strange, but after giving it a second thought the notion that self-help for headache could be presented via the internet seemed to be a good one. This resulted in our first clinical trial on headache, which was published a few years later (Ström, Pettersson, & Andersson, 2000). The results were very promising, although we had a problem with dropout from that trial. Later we conducted a trial on insomnia, again with good outcome (Ström, Pettersson, & Andersson, 2004). The headache study has been replicated in the United States (Devineni & Blanchard, 2005), and we did a small trial in which we compared our internet program with or without telephone support (Andersson, Lundström, & Ström, 2003). Surprisingly, the addition of telephone support did not add much to the effects or dropout rate in that trial. Internet treatment has been applied in other health psychology areas, and we have done one trial on chronic pain (Buhrman, Fältenhag, Ström, & Andersson, 2004), and other research groups have conducted studies on cancer (Winzelberg et al., 2003), childhood encropresis (Ritterband et al., 2003), and obesity (Tate, Wing, & Winett, 2001), just to give a few examples.

Our most extensive clinical experience from delivering internet treatment comes from the work on distressing tinnitus (ringing or buzzing in the ears), as this program was immediately transferred into clinical practice at the audiology department in Uppsala where I worked then. The first randomised trial (Andersson, Strömgren, Ström, & Lyttkens, 2002) showed good outcome although with substantial dropout, but in later studies we have had less dropout. After the controlled trial we did an effectiveness study to see if the treatment would work in regular clinical practice (Kaldo-Sandström, Larsen, & Andersson, 2004), and more recently we have compared group treatment in vivo with the internet program. Results showed few differences, suggesting that internet treatment can replace group treatment (at least for some patients).

Yet another student knocked on my door in the late 90's and this resulted in a very successful program for panic disorder. Following the first randomised trial (Carlbring, Westling, Ljungstrand, Ekselius, & Andersson, 2001), we compared the CBT program with applied relaxation (Carlbring, Ekselius, & Andersson, 2003), and later individual face-to-face CBT was compared with the internet program (Carlbring et al., 2005). Again, we found no difference between internet treatment and live treatment. Internet treatment has now received more interest and this requires that we conduct better trials in line with the evidence-based movement. Recently, we completed a controlled trial with internet treatment plus telephone support (Carlbring et al., in press). This time we made sure that we had blind telephone interviews (structured psychiatric assessement) after the treament, in addition to the self-report inventories.

When we started the panic research we were unaware of the fact that simultaneously in Australia a similar project had begun, led by the late Professor Jeff Richards. Professor Richards was one of the pioneers in the field and he contributed immensely to its progression. He and his group published a series of good internet trials on panic disorder (Klein & Richards, 2000; Klein, Richards, & Austin, in press; Richards & Alvarenga, 2002). He will be greatly missed, not the least because of the collaboration we started and his role in the International Society for Research on Internet Interventions, which was founded in Sweden in 2004 .

The application of internet treatment is not restricted to panic disorder, and there are studies on social phobia (Carlbring, Steczkó, Furmark, Ekselius, & Andersson, 2005) and symptoms of post traumatic stress (Lange, van de Ven, & Schrieken, 2003). There are also studies on other anxiety disorders not yet available but in progress (e.g., specific phobia).

Given the empirical support for self-help in the treatment for depression it is not surprising to find that internet treatment has been applied for mild to moderate depression with good results. We have done one trial in Sweden (Andersson et al., 2005), and there are other studies, in particular the excellent research in Australia by Christensen and co-workers (e.g., Christensen, Griffiths, & Jorm, 2004).

I would like to briefly describe what a typical participant might experience in one of our panic trials (or in clinic for that matter). As in all proper psychological treatment, the patient will go through assessment, including web-based questionnaires and most likely an interview either directly with a therapist or via telephone. This is done to establish that panic disorder is the most likely diagnosis. Once the assessment has been completed, the participant is given a code to get access to the first module in the panic program. Overall, the treatment is presented in text modules (chapters) of approximately 25 pages each. We begin the treatment and the first module with a proper description of panic disorder and anxiety in general. This is often referred to as psychoeducation in CBT. The participant is then asked to respond to a few queries, and correct responses are required in order to obtain the password for the next module. Of course, this is not a test in the strict sense, since the participant will have the chance to respond several times if wrong answers are given on the website. The second module also contains information and psychoeducation (Clark's panic circle), but in the third module breathing retraining and a hyperventilation test are presented. The middle modules are devoted to cognitive restructuring and interoceptive exposure. The last module includes relapse prevention and assertiveness training. As the reader might recognise, these are all well-known methods in CBT for panic disorder. However, given the treatment format the educational aspects are perhaps even more crucial. All homework assignments given in association with each module require that the participant applies the methods in real life. A common misunderstanding about internet treatment is that the treatment is conducted directly over the internet, but this is not true as exposure exercises have to include in vivo practice. As improvement is the overall goal, all that can be done to facilitate this is included. For example, the participant is encouraged to use a coach (e.g., spouse or close friend) in the treatment, and in some studies net-based discussion groups are used actively in the treatment.

The interaction between the participant and the responsible therapist can be intense sometimes, although it is common that email exchanges are used less frequently, apart from progress report and feedback. However, it is often good for the participant to know that each message will be answered within 24 hours (typical deadline in studies), and this is far quicker than in regular therapy (unless mobile phones are used as in dialectical behaviour therapy).

Although, we have had comments from a few participants that they have felt alone, opposite reactions are often reported, such as the positive experiences of being cared for while in treatment and that there have been many advantages with getting the treatment from a distance. One additional advantage mentioned is that the participant can access the treatment outside of office hours, which means that the treatment is less likely to interfere with ordinary life.

Where are we heading now? Since this novel treatment approach has turned out to be promising, there are numerous questions left unanswered. We need to consider differential access to the internet (which I assume is relevant in Australia too), computer security, and that the treatment approach must sit safely among practitioners who might be less comfortable with computers and self-help. We need to remind ourselves that the internet-based treatment is just one of many ways to use information technology in health care, and that it so far is best to regard it as a complement rather than as a replacement. Future research will need to target stepped care approaches, since the most cost-effective first-line treatment very well could be internet-based self-help, whereas for the more hard-to-treat cases intense treatment face-to-face might be implicated. In our search for significant predictors of outcome we have found very little, including some preliminary data on the lack of a role of therapeutic alliance. Of course this needs to be pursued further, as there very well might be more specific predictors of treatment outcome that are separate from the predictors of common psychotherapy outcome. My sincere hope is that internet treatment will blend in with clinical practice (and general practice), and that the work started by Professor Richards will continue.

References

Andersson, G., Bergström, J., Holländare, F., Carlbring, P., Kaldo, V., & Ekselius, L. (2005). Internet-based self-help for depression: a randomised controlled trial. British Journal of Psychiatry, 187, 456-461.

Andersson, G., Lundström, P., & Ström, L. (2003). Internet-based treatment of headache. Does telephone contact add anything? Headache, 43, 353-361.

Andersson, G., Strömgren, T., Ström, L., & Lyttkens, L. (2002). Randomised controlled trial of internet-based cognitive behavior therapy for distress associated with tinnitus. Psychosomatic Medicine, 64, 810-816.

Buhrman, M., Fältenhag, S., Ström, L., & Andersson, G. (2004). Controlled trial of Internet-based treatment with telephone support for chronic back pain. Pain, 111, 368-377.

Carlbring, P., Ekselius, L., & Andersson, G. (2003). Treatment of panic disorder via the Internet: A randomised trial of CBT vs. applied relaxation. Journal of Behavior Therapy and Experimental Psychiatry, 34, 129-140.

Carlbring, P., Bohman, S., Brunt, S., Buhrman, M., Westling, B. E., Ekselius, L., & Andersson, G. (In press). Remote treatment of panic disorder: A randomized trial of Internet-based cognitive behavioral therapy supplemented with telephone calls. American Journal of Psychiatry.

Carlbring, P., Nilsson-Ihrfelt, E., Waara, J., Kollenstam, C., Buhrman, M., Kaldo, V., Söderberg, M., Ekselius, L., & Andersson, G. (2005). Treatment of panic disorder: Live therapy vs. self-help via Internet. Behaviour Research and Therapy, 43, 1321-1333.

Carlbring, P., Steczkó, J., Furmark, T., Ekselius, L., & Andersson, G. (2005). An open study of Internet-based bibliotherapy with minimal therapist contact via email for social phobia. Clinical Psychologist, 10, 30-38.

Carlbring, P., Westling, B. E., Ljungstrand, P., Ekselius, L., & Andersson, G. (2001). Treatment of panic disorder via the Internet- a randomized trial of a self-help program. Behavior Therapy, 32, 751-764.

Christensen, H., Griffiths, K. M., & Jorm, A. (2004). Delivering interventions for depression by using the internet: randomised controlled trial. British Medical Journal, 328, 265-268.

Den Boer, P. C. A. M., Wiersma, D., & Van Den Bosch, R. J. (2004). Why is self-help neglected in the treatment of emotional disorders? A meta-analysis. Psychological Medicine, 34, 959-971.

Devineni, T., & Blanchard, E. B. (2005). A randomized controlled trial of an internet-based treatment for chronic headache. Behaviour Research and Therapy, 43, 277-292.

Kaldo-Sandström, V., Larsen, H. C., & Andersson, G. (2004). Internet-based cognitive-behavioral self-help treatment of tinnitus: Clinical effectiveness and predictors of outcome. American Journal of Audiology, 13, 185-192.

Keeley, H., Williams, C., & Shapiro, D. A. (2002). A United Kingdom survey of accredited cognitive behaviour therapists' attitudes towards and use of structured self-help materials. Behavioural and Cognitive Psychotherapy, 30, 193-203.

Klein, B., & Richards, J. C. (2000). A brief Internet-based treatment for panic disorder. Behavioural and Cognitive Psychotherapy, 29, 113-117.

Klein, B., Richards, J. C., & Austin, D. W. (In press). Efficacy of internet therapy for panic disorder. Journal of Behavior Therapy and Experimental Psychiatry.

Richards, J. C., & Alvarenga, M. E. (2002). Extention and replication of an Internet-based treatment program for panic disorder. Cognitive Behaviour Therapy, 31, 41-47.

Lange, A., van de Ven, J.-P., & Schrieken, B. (2003). Interapy: Treatment of post-traumatic stress through the Internet. Cognitive Behaviour Therapy, 32, 110-124.

Marks, I., Shaw, S., & Parkin, R. (1998). Computer-assisted treatments of mental health problems. Clinical Psychology: Science and Practice, 5, 51-170.

Miller, G. A. (1964). Psychology as a means of promoting human welfare. American Psychologist, 24, 1063-1075.

Proudfoot, J. G. (2004). Computer-based treatment for anxiety and depression: is it feasible? Is it effective? Neuroscience and Biobehavioral Reviews, 28, 353-363.

Ritterband, L. M., Cox, D. J., Walker, L. S., Kovatchev, B., McKnight, L., & Patel, K. (2003). An Internet intervention as adjunctive therapy for pediatric encopresis. Journal of Consulting and Clinical Psychology, 71, 910-917.

Ström, L., Pettersson, R., & Andersson, G. (2000). A controlled trial of self-help treatment of recurrent headache conducted via the internet. Journal of Consulting and Clinical Psychology, 68, 722-727.

Ström, L., Pettersson, R., & Andersson, G. (2004). Internet-based treatment for insomnia: A controlled evaluation. Journal of Consulting and Clinical Psychology, 72, 113-120.

Tate, D. F., Wing, R. R., & Winett, R. A. (2001). Using Internet technology to deliver a behavioral weight loss program. Journal of the American Medical Association, 285, 1172-1177.

Winzelberg, A. J., Classen, C., Alpers, G. W., Roberts, H., Koopman, C., Adams, R. E., et al. (2003). Evaluation of an internet support group for women with primary breast cancer. Cancer, 97, 1164-1173.

Professor Gerhard Andersson can be contacted by email at geran@ibv.liu.se.