The Efficacy and Effectiveness of Online CBT - Jeroen Ruwaard

5.4. Discussion 101Our results imply that face-to-face sessions are an optional ingredient of onlineCBT. Past trials of internet-based CBT for bulimic symptoms included face-to-facesessions (Ljotsson et al., 2007; Sánchez-Ortiz et al., 2010; Fernandez-Aranda et al.,2009; Nevonen et al., 2007; Robinson & Serfaty, 2008), which limits conclusionsabout the effects of online treatment per se, and may restrict the results of these trialsto those clients who are not deterred by face-to-face contact. These limitations donot apply to this trial, since the study did not involve any face-to-face contact. Ourresults suggest that face-to-face sessions may be an optional ingredient of online CBT.In the study of Sánchez-Ortiz and colleagues, face-to-face contact was replaced withtelephone contact when participants preferred not to meet face to face (Sánchez-Ortizet al., 2010). If existing online programs, which currently require face-to-face sessions,are adapted along similar lines, the uptake of these programs might increase.In the online CBT group, improvements at post-test remained stable up to one-yearafter treatment. However, in the bibliotherapy group, participants strongly improvedafter the end of treatment, which resulted in non-significant differences betweenthe two experimental conditions at follow-up. Since the bibliotherapy did not haveeffects at post-test, it is likely that bibliotherapy had an indirect delayed effect; thebibliotherapy might have stimulated participants to seek additional treatment at alater stage. The fact that 31% of the participants in the bibliotherapy group startedadditional treatment before post-test, supports this reasoning. Our results suggest thatbibliotherapy increases the probability of recovery by promoting positive attitudestowards treatment in a considerable portion of patients.5.4.1 LimitationsFirst, results of the long-term follow-up should be interpreted with caution. Studyattrition at follow-up was high. Participants, who experienced a more favourable longtermoutcome, may have been more inclined to respond to the follow-up invitations.Also, no data were available with regard to additional treatment between post-testand the long-term follow-up. This is a serious omission, since these data could haveprovided more support for our post-hoc hypothesis about the effect of additionaltreatment at follow-up.