How Good is Internet-based Cognitive Behavioral Therapy (iCBT)?
Image: Western by Leroy Skalstad (CC0)
Synopsis: Internet-based Cognitive Behavioral Therapy (iCBT) is a computerized version of Cognitive Behavioral Therapy (CBT) that is delivered over the internet. This article addresses hard questions critics have about iCBT, research supporting its benefit, the impact it can have in communities and who can benefit from the treatment.
BY LEN LANTZ, MD / 12.8.20; No. 42 / 9 min read
Disclaimer: Yes, I am a physician, but I’m not your doctor, and this article does not create a doctor-patient relationship. This article is for educational purposes and should not be seen as medical advice. You should consult with your physician before you rely on this information. This post might also contain affiliate links. Please click this LINK for the full disclaimer.
What is CBT?
Cognitive Behavioral Therapy (CBT) is arguably one of the most effective forms of face-to-face psychotherapy. It is time-limited, focuses on skills-building and works to rebalance thoughts. Most of the time that a person experiences an emotion, such as happiness or anxiety, a thought preceded and triggered the emotion. Chronic unwanted emotions that are out of proportion to situations are usually caused by recurring unbalanced thoughts. CBT works to re-balance or replace the unbalanced thoughts and results in a person having emotional responses that are more in tune with their life circumstances. This often leads to a substantial reduction in excessive sadness, anxiety and anger. For more information on CBT, please check out my article, “Cognitive Behavioral Therapy (CBT) – the Most Effective Therapy?”.
What is iCBT?
Researchers have been looking for ways to utilize early limited-access computers to assist in behavioral therapies since the 1980s (Burnett, et al. Journal of Consulting and Clinical Psychology. 1985; Baer L, et al. Journal of Behavior Therapy and Experimental Psychiatry. 1988). According to Dr. John Greist who began researching computer-based CBT in 1981, national psychiatric leadership initially resisted researchers studying computer-based CBT. Dr. Greist, one of the authors of the Thrive study described below, reported that “Paulette Selmi’s original mini-computer-administered cognitive behavior therapy (cCBT) program was studied in a 1983 RCT and had a large effect size (1.37) equivalent to that of an excellent clinician (1.26) when compared to a wait-list control. The result was so resisted by psychoanalytic reviewers of the American Journal of Psychiatry that it was not published there until 1990 [Selmi, et al. American Journal of Psychiatry. 1990] – after enough reviewers had retired or died."
As the internet has expanded, these expensive computer-based therapies have given way to low-cost Internet-based Cognitive Behavioral Therapy (iCBT), as a means to increase accessibility to computer-assisted therapies and decrease costs. There are different forms of iCBT that use the same strategies as conventional CBT and may involve interaction with a trained therapist or be entirely automated. iCBT might involve many activities such as watching videos, reading about helpful strategies, doing thought-balancing exercises, engaging in stress-reduction activities and tracking progress.
Is the goal of iCBT to replace therapists?
No. iCBT is intended to complement, support and augment available high-quality CBT. Unfortunately, many people who want and could be helped by CBT are not able to find it in their communities, to attend therapy sessions when therapists are available or to afford the cost of therapy. However, it is worthwhile to consider where internet-based psychotherapies might leave psychotherapists in the future. With the rise of artificial intelligence (AI), some have expressed concern that there is a movement to remove the human component from psychotherapy and accelerate humanity toward a computerized or AI-dominated dystopian future. Computers replacing humans is a legitimate concern, however, a critical component of many forms of psychotherapy is the expression of empathy - human empathy - from therapists toward patients. It is also important to note that iCBT is only possible due to the more formulaic approaches found in Behavior Therapy and Cognitive Behavioral Therapy. Internet-based therapy for other forms of psychotherapy would be much more difficult to accomplish.
When CBT is researched, the therapists must follow a manual. This potentially restricts the therapists to such a degree that they might feel like they have been turned into a robot to deliver the therapy. Many therapists I know who are highly skilled in CBT do not use a manual or follow the approaches rigidly but instead use an approach that blends several different forms of evidence-based psychotherapy. It can be very difficult in some communities - especially smaller communities - to find a therapist willing to follow a pure CBT protocol in therapy. So, if most therapists are not open to adhering strictly to CBT protocols, why not delegate that work to a computer?
Even though AI is becoming increasingly advanced, humans nearly always want and need help from other humans when going through difficult times. Therefore, internet-based therapies are more likely to continue supplementing the existing psychotherapy workforce rather than replace it.
Is iCBT self-help, a therapeutic intervention or psychotherapy?
The self-help movement stretches back well over 100 years to the writer James Allen, best known for his book As a Man Thinketh, and predecessors. Self-help interventions may or may not be science-based and have rarely been approved in a research-caliber, peer-reviewed process. For example, a currently popular self-help guru, Tony Robbins, has many self-help products. While he may have helped many people, what he offers is not considered to be psychotherapy nor is it considered to be a science-based therapeutic intervention.
In contrast, several science-based researchers have developed evidence-based psychotherapy approaches and later gone on to write books for the general public on these approaches. Their self-help books were essentially a pre-internet way of getting their helpful ideas, strategies and exercises out to the masses. Below are some examples of researchers, their psychotherapy approaches and their books for the layperson.
Interestingly, Dr. Burns’ book Feeling Good has been found in several studies to have a significant, positive impact as bibliotherapy (McKendree-Smith, et al. Journal of Clinical Psychology. 2003). While bibliotherapy can be very helpful and could reach the level of becoming a science-based therapeutic intervention, it is not considered to be psychotherapy.
So, is iCBT a therapeutic intervention or self-help? iCBT falls into a bit of a grey area. A computer does not replace a therapist. iCBT certainly is therapeutic and can be considered a treatment or an intervention, but without the human therapist, it is hard to argue that it is psychotherapy. To perform psychotherapy, therapists have to achieve a significant amount of education and training and be certified and licensed to deliver the treatment. iCBT without a therapist is a computer program that is following a protocol. At the same time, the efficacy of iCBT is far more scientifically proven than typical self-help strategies.
With the wealth of research proving its efficacy, I would conclude that iCBT is categorized somewhere between psychotherapy and a science-based therapeutic intervention. With the involvement of a CBT therapist, enthusiasts could easily reason that iCBT is psychotherapy. However, minus the human element of a CBT therapist, critics could argue that iCBT is a science-based therapeutic intervention, not a form of psychotherapy. Whatever we call it, iCBT is helpful to many who use it.
Research on the efficacy of iCBT
As there is value in learning and practicing the strategies of conventional CBT, it should come as no surprise that iCBT also has been shown to help many conditions. There is a large number of research articles (Andrews, et al. Journal of Anxiety Disorders. 2018) showing the efficacy of iCBT with a therapist and/or self-guided iCBT in the following conditions:
Anxiety disorders: In a large review of 37 studies on the use of iCBT for anxiety disorders, it was found that “iCBT was found to be commensurate with face-to-face cognitive behavioral therapy whether delivered individually or in group format” (Mewton, et al. Psychology Research and Behavior Management. 2014)
Posttraumatic Stress Disorder (PTSD) (Spence, et al. Journal of Affective Disorders. 2014)
Obsessive-Compulsive Disorder (OCD) (Andersson, et al. Psychological Medicine. 2012)
Panic Disorder (Hedman, et al. Acta Psychiatrica Scandinavica. 2013)
Social Anxiety Disorder (Alaoui, et al. Journal of Consulting and Clinical Psychology. 2015)
Generalized Anxiety Disorder (Hobbs, et al. Journal of Anxiety Disorders. 2017)
Specific Phobia (Vigerland, et al. Cognitive Behaviour Therapy. 2013)
Suicidality: A 2020 meta-analysis of iCBT showed “significantly reduced suicidal ideation compared with controls following intervention in all 6 trials” and that “considering their high scalability, iCBT interventions have the potential to reduce suicide mortality” (Büscher, et al. JAMA Network Open. 2020).
Depression: In a meta-analysis of 13 studies of self-guided iCBT compared to controls, the iCBT treatment was found to be significantly more effective in treating depression (Karyotaki, et al. JAMA Psychiatry. 2017).
Insomnia: A meta-analysis of 14 studies found strong evidence that iCBT for insomnia (ICBT-i) is effective and lasting (Ye, et al. BMJ Open. 2016).
Who says that iCBT is even needed?
Not every person who wants help is interested in or able to participate in face-to-face CBT. There are several potential barriers with face-to-face CBT (whether in-person or by video) that can be more easily addressed with iCBT:
The value of iCBT has been demonstrated in the large rural state of Montana. Montana has had one of the highest suicide rates in the US for decades. Montana is an enormous, rural-frontier state with a population of 1 million people. One of the strategies Montana has been researching at the Center for Mental Health Research and Recovery (CMHRR) to lower its high suicide rate is the use of iCBT. You can learn more about Thrive for Montana by clicking this LINK (I have no financial affiliations with CMHRR, Thrive or Waypoint Health).
The Thrive study in Montana utilized self-guided iCBT with no therapist contact and showed substantial improvements within 8 weeks in depression, anxiety, functioning, resilience and suicidal thinking, with benefits at 8 weeks persisting or increasing at 12-month follow-up (Schure, McCrory, Tuchscherer Franklin, Greist, Striegel Weissman. Journal of Medical Internet Research. 2020). The magnitude of improvement in depression symptom severity with Thrive was double that found with antidepressant medications in short-term trials (Hengartner, et al. PLOS One. 2020). The research findings have been so robust that the State of Montana, through the Department of Health and Human Services (DPHHS), is currently paying for Montanans to have access to Thrive iCBT for free! I believe that this is a very wise, high-yield expenditure of state tax dollars.
A story about doing iCBT in rural America
“Joe” was a 39-year-old Native American man who lived on his ranch in an American Indian nation - what people often call a reservation. While life could be hard in Indian Country, it was his home and he didn’t want to live anywhere else. He had experienced his share of ups and downs in life and he felt that he had struggled off and on with depression since a year after high school when his mom died. Not only did her loss hit him hard, he felt like he was alone in watching out for his relatives, several of whom were struggling just to get by.
He went through a divorce last year, and his depression took hold as badly as when his mom died, and it wasn’t getting any better. Last week, he talked to his primary care doctor at Indian Health Services (IHS), who said he could meet with a therapist by video, and Joe just laughed. “C’mon, Doc!” he said, “It won’t work. You know the internet sucks on the Rez. The fastest speeds we have are in town here and even that’s slow. And it takes me 40 minutes to get here from the ranch. Besides, I gotta work! I don’t waste daylight.”
Joe figured he would just have to give his depression more time to get better, but last night he had a crisis. He’d thought about suicide a lot over the past year, but last night he was actually planning to do it. Some type of self-preservation impulse must have kicked in because he called his aunt Sarah in desperation. She came over to the ranch immediately but she also called the Tribal Police. He was surprised that he wasn’t bothered that she called the police. The Tribal Police recommended that he be evaluated by a mental health professional in the ER, but Joe refused. He was concerned he could be hospitalized and then who would look after his animals? Sarah offered to stay at his house with him through the night to make sure he was safe. The whole situation seemed a little surreal to Joe. The Tribal Police looked unhappy that he wouldn’t go to the ER, but it was because they were genuinely concerned for him.
Before the Tribal Police left, they asked him to go see his primary care doctor the next morning and they gave him a business card with a website address on it. The officer said, “Joe, this is a tool for dealing with your depression. It can help you with suicidal thoughts, too. It’s like online therapy without the therapist, called iCBT, and you can work at your own pace. It works with slow internet speeds and it’s free because the Tribe and the State are paying for it. You should check it out.”
Joe was a little stunned. The cops were actually nice. Sarah was really helpful, and she stayed the night at his house to make sure he was safe. By morning, the crisis felt like it was over. After he got up, he made some coffee and switched on the computer. As far as he could tell, the iCBT website looked like it was going to work, despite his slow internet speeds at the ranch. He watched the first video which, even though it was slow to download, eventually played and gave him a little bit of hope. When he went to see his doctor at IHS later that morning, he showed his doctor the card he received from Tribal Police and said, “Doc, maybe you can share this with some of the folks you see. I think it might just work for me.”
Considering iCBT for yourself or a loved one
iCBT is helping many people across the country, especially those who have trouble accessing a CBT therapist. Individuals who have already had a course of psychotherapy and want to brush up their skills can find it helpful. iCBT also can help men and women who are simply not willing to go to therapy but know they need help. Cost is less of a barrier with iCBT and it can help people who currently are not connected to a therapist. If traditional styles of therapy are not the right fit or there are too many obstacles to doing traditional therapy, iCBT might be the right solution.
For further reading, check out:
Len’s article, “Finding Quality Psychotherapy – Moving Beyond Talk Therapy”
Len’s article, “Cognitive Behavioral Therapy (CBT) – the Most Effective Therapy?”
Mind Over Mood, Second Edition: Change How You Feel by Changing the Way You Think by Drs. Dennis, Greenberger and Padesky (See Len’s Book Review)
Feeling Good by Dr. Burns (See Len’s Book Review)
A Guide to Rational Living by Drs. Ellis and Harper (See Len’s Book Review)
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