A group of researchers lead by Dr. Colin Espie at the University of Glasgow, Scotland, asked a daring question: Can CBT for chronic insomnia be delivered by an automated, media-rich web application? Such a web application would have the advantage of cost-effectively reaching millions of people. Savings in cost also come from rendering unnecessary millions of prescriptions for sleep aid pills. They concluded that CBT delivered using a media-rich web application with automated support and a community forum is effective in improving sleep and associated daytime functioning of adults with chronic insomnia.
These findings in no way suggest that web-application replaces proper assessment, diagnosis, management, and treatment monitoring by a qualified health care professional. The findings raise the interesting question of whether internet-based psychotherapy can be effective for psychiatric and psychological problems. In 2008, a group of researchers led by Dr. Azy Barak from the Universtiy of Haifa, Israel performed a meta-analysis (comprehensive critical review) of 64 scholarly articles published up to March 2006 involving over 9700 clients of online, internet-based psychotherapy to answer this very question. The authors determined and reported a relative value called “effect size” for each of the psychotherapeutic interventions described in these studies. Larger effect sizes indicate greater relative cumulative positive impact on the clients of these interventions.
According to these authors, internet-based psychotherapeutic interventions are not a new phenomenon but have been around for at least 15 years. Internet-based psychotherapy has multiple formats:
- Self-help web-based therapy (web-based therapy without human interactions)
- Online communication-based therapy, internet therapy (with therapist support)
- Synchronous delivery, therapy in real-time via the world wide web (chat)
- Asynchronous delivery, delays between therapeutic exchanges (email, forums)
- Therapeutic exchanges via instant typed messaging platforms
- Audio-only therapeutic exchanges (with or without telephone support)
- Therapeutic exchanges via video/webcam (with or without telephone support)
- Group therapy
- Individual therapy
- Cognitive behaviour therapy
- Behavior modification
Challenges of internet-based psychotherapy include confidentiality concerns, licensing laws, legal jurisdictions, professional insurance, special training requirements, and most importantly, lack of face-to-face visibility important for nonverbal communication, which is thought to be essential for the therapeutic exchanges. None of these concerns have stopped numerous professionals from utilizing this new mode of delivering therapy. The limit seems to be dependency on electricity and access to the World Wide Web.
Advantages of internet-based psychotherapy include better therapist availability, high acceptability by clients, greater variety of modes of communication, availability of anonymity should it be desired, psychoeducation enhancement by video technology, graphics, and interactivity. Evidence suggests that therapeutic bonding or working alliance is still achievable. Evidence also suggests that internet-based psychotherapy appears to be more or less effective as part of the treatment for a variety of psychological, psychiatric, and physical problems: chronic stress, loneliness, hazardous behaviour, body dissatisfaction, eating disorder, over-eating, binge drinking, pre-surgery anxiety, smoking, depression, post-traumatic stress, anxiety, panic, social phobia, agoraphobia, bed-wetting, insomnia, tinnitus, traumatic brain injury, chronic headache, and chronic back pain.
Dr. Azy Barak and his colleagues found the effect size of internet-based psychotherapy to be widely varied depending on problem targeted, type of therapy, age of clients, and mode of communication. The greatest improvement in clients of online psychotherapy appeared to be in those 19 to 39 years of age, and amongst sufferers of anxiety-spectrum disorders such as post-traumatic stress, generalized anxiety, and panic disorder (0.8 to 0.88). The smallest improvements were shown by clients of online psychotherapy for weight-loss, and by sufferers of physiological problems (eg. tinnitus, 0.27). Individual therapy appeared to be more effective than group therapy. Cognitive behaviour therapy aimed at changing thought and behaviour patterns had the largest effect size (0.83) followed by psycho-education (0.46), and behavioural modification (0.23). Communication involving audio exchanges had the largest effect size (0.91) compared to chat, email, webcam, or forum (0.53 to 0.34)
Web design also had an impact on effectiveness of internet-based psychotherapy. Interactive and closed websites (requiring sign-in) had slight advantage over static and open websites, respectively. Evidence also suggests that stand-alone websites have an edge over online supplements to a face-to-face treatment modality. Multi-channel communications may serve to distract the client’s focus and attention. Furthermore, clients who prefer anonymity would not be helped by communication channels that forcibly reduce their privacy.
Most importantly, Dr. Azy Barak and his colleagues found 14 studies comparing internet-based psychotherapy to face-to-face therapy and found no statistically significant difference between the effect sizes of these modalities.
Dr. Azy Barak and his colleagues concluded that, contrary to popular belief, psychotherapy can be delivered effectively via the internet for varied and distinct clinical complaints. Audio, graphics, interactivity of closed websites increase therapeutic efficacy. The authors were careful to put forth the disclaimer that only carefully pre-screened individuals should be recommended for internet-based psychotherapy.
This meta-analysis has clear limitations. This type of study can only provide a big-picture view of this treatment trend. It cannot give guidelines on specifics of who would benefit and who would not for specific clinical problems. The measurement of “effect size” blurs multiple outcome measures for each of the online psychotherapeutic interventions studied. Nevertheless, these results mean good news for patient/client access to innovative health care practices. If these findings continue to hold true, it means a future of readily available and ubiquitous access to affordable psychotherapy for all.
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Barak A, Hen L, Boniel-Nissim M, Shapira N. A comprehensive review and a meta-analysis of the effectiveness of Internet-based psychotherapeutic interventions. Journal of Technology in Human Services 2008; 26(2-4): 109-160. Read it here.
In the next blog entry, I will explore whether these findings continue to hold true.
The views expressed in these blogs are the author’s own and not necessarily reflective of those of Psychotherapy Matters. Copyright © 2015 PsychotherapyMatters.com