Does Internet-Based Psychotherapy Work?

Computer-based psychotherapy is on the rise, with many seeing it as a way for patients to access the therapy they need in a speedy and cost-effective manner. An increasing number of practitioners are offering computer-based Cognitive Behavioural Therapy for a range of conditions, including depression, anxiety disorders, and Post-Traumatic Stress Disorder.

Computer-based what?

In computer-based psychotherapy, patients talk to a therapist over the internet, who then assigns individual activities or exercises. Depending on the nature of the therapy, these exercises may vary.

There are also interactive computer programs designed to help sufferers of anxiety, Obsessive-Compulsive Disorder, phobias, and panic disorder.

But isn't all psychotherapy pretty much the same?

No.

There are several different types, and they may suit different conditions. Common types include:

Computer-based Cognitive Behavioural Therapy

Computer-based CBT works in the same way as face-to-face CBT, to change the way you think about things, and altering maladaptive behaviours into healthier ones. In Computer-based CBT, you may be asked to write logs of your negative emotions and their triggers between sessions.

CBT is used for a wide range of conditions, from anxiety to eating disorders.

Mindfulness training

In mindfulness training, participants are taught how to be calm and aware. They may be led through a series of training modules, and asked to perform mindfulness exercises several times a week between sessions.

Mindfulness training can be used for anxiety disorders if CBT is found ineffective.

But does any of this work?

In recent years, there have been a number of comparative studies, which have compared computer-based interventions with face-to-face therapy.

Computer-based CBT and Depression

In 2014, Wagner and colleagues tested 62 adults with depression. 32 had computer-based CBT and 30 had face-to-face psychotherapy. When treatment ended, both groups showed significant improvement in symptoms.

However, it's worth noting that - while the computer-based group was still seeing the benefit three months later - the face-to-face group had already started to suffer worsening symptoms of depression by that time.

Computer-based CBT and PTSD

A 2003 experiment by Lange and colleagues found that 69 patients with Post-Traumatic Stress Disorder benefitted significantly from computer-based CBT, rather than waiting for a face-to-face appointment.

Furthermore, more than 50% of participants showed long-term change and significant improvement.

Computer-based CBT and Panic Disorder

A 2010 study by Bergström and colleagues placed 113 patients with panic disorder into two groups. 53 had computer-based CBT, while 60 had traditional group-based CBT. 9 patients dropped out immediately (3 from the computer-based group, and six from the group-based group).

After research concluded, the rates at which Panic Disorder were relieved were roughly equal (60% for the computer-based group; 63% for the group based group). However, at the follow-up six-months later, the percentage of participants now free of Panic Disorder was substantially different (70% for the computer-based group; 59% for the group-based group).

Computer-based CBT and Generalised Anxiety Disorder

In a 2011 study, Paxling and colleagues randomised participants into two groups. One (the trial group of 44) had computer-based CBT. The other (the control-group of 45) waited for a face-to-face appointment. Of the participants who completed the computer-based CBT (13.6% didn't), almost all aspects of the participants' lives considerably improved (except quality of life).

This improvement was maintained (and, in some cases, improved) at one-year and three-year follow-ups.

Possible Benefits and Weaknesses of Computer-Based Psychotherapy

There's little doubt that computer-based psychotherapy does have the potential to benefit a wide range of conditions. However, opinion is split over the benefits and limitations of it as a therapy:

Benefits of Computer-Based Psychotherapy

Computer technology has made the administration of psychological testing quick and efficient. The responses of patients cannot be influenced in any way and marking is entirely objective, making the results more valid.

Computer-based psychotherapy is also less-expensive, improving access to psychotherapy for the most vulnerable members of society.

Computer-based psychotherapy could be used in a therapist's office to provide a working framework for specialist, co-morbid conditions (such as a computer-based program for depression to be used by an eating disorder specialist, as the two are often found together). Many clinicians have only specialist training in a few areas, this could help extend the therapist's knowledge and help address multiple issues.

Computer-based psychotherapy could be used to monitor patients who live quite far from the therapist's office or hospital to monitor them for signs of relapse or deterioration.

People might be more willing to try computer-based psychotherapy, due to the anonymity it affords. Additionally, in mild to moderate cases, computer-based psychotherapy could be an effective treatment, preventing a disorder becoming severe.

Limitations of Computer-Based Psychotherapy

Although every attempt will be made to keep details safe, no system is completely secure. This could leave patients (especially those engaged in illegal behaviours) vulnerable to targeting by criminal gangs.

Following through with advice may carry risks (to contact an estranged child, or to cut-off contact with friends whom are linked with drug abuse). Another risk is that patients could be advised to quit drugs too quickly, and have dangerous withdrawal symptoms, including seizures, without any close personal contact. Dangerous advice is more likely to be given by peer-supported-therapy.

Computer-based therapy is linked with a higher attrition rate (the number of people who don't complete therapy) than other kinds of therapy (an average increased attrition rate of 7 to 2). Attrition rates as high as 66% (for children with anxiety disorder) have been reported, while other figures of around 25% have been noted (for adults with anxiety or affective disorders). The anonymity is thought to be a contributory factor in the high attrition-rate.

If someone doesn't complete therapy, or it fails to help them, there is a risk the patient may not seek out other forms of help and support that may be more effective.

There is a risk that relying on unverified patient self-reports (when patients often want to please their doctor by showing improvement) may lead to an inaccurate view of the progress made, skewing the available data on computer-based psychotherapy. In face-to-face therapy, the therapist is able to make their own judgments by observing the patient's affect (their posture, their expression, their tone of voice, whether the patient meets their eye) while asking the same questions, forming a more balanced opinion.

Additionally, in automated computer programs, many patients find it difficult to engage. This is because, when depressed or anxious, patients find it difficult to repeatedly log-in. A study at the University of York found that a quarter of patients with depression dropped-out of the study. It was also not found to be more beneficial for those who did complete: 44% of those in the face-to-face therapy group were still depressed, as opposed to 49% using a free online program and 50% using a paid online program.

So, is it any good or isn't it?

There are some positive early signs that computer-based psychotherapy may provide lasting benefit to some patients. However, the early promise is tempered by concerns.

And, if computer-based psychotherapy isn't suitable for you, don't despair.

The right treatment is out there.