Abstract
The recent expansion in the literature around Internet-based cognitive behaviour therapy (CBT) raises a number of interesting questions. Will real as opposed to virtual clinicians retain any relevance? Does individualized case conceptualization add little or nothing over generic treatments? Will Internet-based treatments reach the disadvantaged, or just provide more choice to those who are already well-informed and savvy about health-care options?
Some of the initial questions about Internet-based treatment appear to have been satisfactorily addressed. For example, people undertaking Internet-based treatment are not less severely affected than those attending an outpatient clinic [1], and effects persist in the follow-up periods so far reported [2,3]. Other questions remain to be settled, such as effectiveness against psychological placebos as opposed to waiting list control, and longer follow-up periods.
A number of factors suggest a continuing role for the clinician. Firstly, studies consistently show lower drop-out rates from treatment when participants have some communication with a therapist [4]. But the clinician's role may extend beyond simply corresponding in cyberspace with programme participants, and recent reports suggest technicians may do as well or better in this regard anyway [5], since, although acceptability of computer-assisted treatment programmes has been reported as high [6], this is usually in studies where no alternative was presented. In the Andrews et al. study [7], half of those eligible preferred face-to-face treatment when given the choice. It is also interesting that the Internet-based treatment in Andrews et al. [7] and Titov et al. [8] is described as being based on an illustrated story of a young man who receives face-to-face help (from his aunt, who happens to be a clinical psychologist) to master his anxiety. Finally, severely unwell patients who are suicidal are usually excluded from Internet-based treatment, presumably for safety reasons [9,10], so they will need a real clinician.
Generic (non-individualized) treatments continue to do well, as least when presented in a manualized form by experienced or well-supervised therapists. A recent study of Internet-based treatment failed to find much superiority for weekly emails based on individualized case conceptualizations involving an average of 509 min of therapist time over a generic programme requiring an average of 53 min of therapist time [10]. The suggestion by Andrews and Titov [9] of a stepped-care model is consistent with the views of many authors that individualized case conceptualizations may be of particular benefit in complex cases.
It was reported in the first Australian National Survey of Mental Health and Wellbeing that only 44% of respondents meeting criteria for an anxiety disorder perceived any need for treatment [11]. Many respondents who did perceive a need for treatment did not seek help: 54.9% reported that they preferred to manage themselves and 49% either did not believe anything could help, did not know where to find help or were afraid to ask for it. Reported demographics suggest that currently offered Internet-based treatments are reaching a well-educated, older group of people [1,6]. Internet-based therapies do not (yet) appear to have met the challenge to engage younger, poorer and less well educated people in treatment.
Internet-based treatment is a young and exciting field of development and many of the questions raised are likely to be addressed in the near future.