The Efficacy and Effectiveness of Online CBT - Jeroen Ruwaard
The Efficacy and Effectiveness of Online CBT - Jeroen Ruwaard The Efficacy and Effectiveness of Online CBT - Jeroen Ruwaard
120 Chapter 6. Online CBT in Routine Clinical Practicecould not be affected by a selection of well-responding patients. Fourth, patients weretreated by a large number of relatively inexperienced therapists. Since we found littlevariance between the therapists in terms of treatment outcome, we concur with Wilson,who argued that “the capacity to train a diverse group of therapists to a criterion levelof competence so that they can reliably administer a treatment protocol [. . . ]] canbe seen as a significant advance in the dissemination of effective treatment” (Wilson,1998). Fifth, the therapeutic procedures and outcome measures in the study wereidentical to those used in the controlled trials. In both contexts, the same computerizedtreatment manuals were used. Hence, treatment integrity was guaranteed in bothcontexts. Sixth, there was no face-to-face contact at all. This considerably enhancesthe flexibility of the online treatment, since it provides the possibility to treat patientswho live at distant locations. Paradoxically, this positive aspect could also be seenas a potential weakness, as will become clear in our subsequent discussion of thelimitations of the study.A first limitations of our study is that patient screening was conducted onlineand by telephone, without a structured clinical interview. The clinic made use ofdimensional screening through validated self-report instruments for which normtables have been established. This did not allow for formal DSM-IV diagnoses, butcompared well with the DSM-IV categories by using the cut-off scores of the scales.Since there are indications that telephone interviews and face-to-face interviews yieldcomparable results (Cacciola, Alterman, Rutherford, McKay, & May, 1999), the clinicat present makes use of structured diagnostic interviews in telephone contacts duringthe screening, in addition to the dimensional screening. Second, we recall that ahigh percentage of the patients did not complete the long-term follow-up measures(65%). Although available data suggest that effects maintain up to one year aftertreatment, these results should be interpreted with caution. It would have been usefulif we would have sent short questionnaires to non-responders, to assess whether therewere any differences between responders and non-responders. Third, a considerablepercentage of the applicants (40%) withdrew, during or even prior to the screening.While pre-treatment withdrawal rates are often not reported, research shows thathigh withdrawal rates are common, in both online and offline research (Issakidis &Andrews, 2004; Melville, Casey, & Kavanagh, 2010). It is a challenge to improve these
6.3. Discussion 121figures, but our data do not permit valid assessment of the reasons for and effects ofpre-treatment withdrawal. The withdrawal might be caused by the ease with whichone can apply for online therapy. This may result in impulsive applications (we foundsome indications that applicants, who started the screening without a referral, wereless likely to start treatment). A second possibility is that patients withdraw fromonline treatment because they are unwilling to relinquish their anonymity (Lange &Ruwaard, 2010).6.3.3 Clinical utilityThe protocols that are used in this routine practice comprise a strong mix of cognitivebehavioral procedures and techniques that enhance patient motivation and the patienttherapistrelation. One particular advantage of the therapy format is that therapistsdo not have to respond immediately when patients post their homework. Due to theasynchronous communication, therapists have time to reflect on the best possiblefeedback and the best explanation of new homework assignments. If needed, they mayeven discuss a case with colleagues. In addition, the Interapy protocols provide helpfiles, which the therapists may consult to find motivating phrases for their feedback.All these aspects make this a highly usable treatment for clinical practice.The study shows how computer-mediated treatment can save time by freeingtherapists of repetitive tasks such as the administration and scoring of outcomequestionnaires. In a computerized environment, these tasks can be easily automated.Online treatment is highly dependent on regulatory approval, professional codesof ethics and jurisdiction regulations, which vary considerably from country to country.But even when such barriers have been overcome, financial hurdles may still exist.When the Interapy clinic was founded, in 2001, costs of face-to-face treatment werefully reimbursed by Dutch public health insurance, while costs of online treatmentwere not. In effect, access to online treatment was limited due to a financial barrier.This changed in 2005, when health regulatory bodies recognized the online services ofthe clinic as reimbursable healthcare, under condition of a GP-referral for psychotherapy.Without this recognition, further implementation of online CBT would not havebeen feasible.
- Page 78 and 79: 70 Chapter 4. Online CBT of Panic S
- Page 80 and 81: 72 Chapter 4. Online CBT of Panic S
- Page 82 and 83: 74 Chapter 4. Online CBT of Panic S
- Page 84 and 85: 76 Chapter 4. Online CBT of Panic S
- Page 86 and 87: 78 Chapter 4. Online CBT of Panic S
- Page 88 and 89: 80 Chapter 4. Online CBT of Panic S
- Page 90 and 91: 82 Chapter 4. Online CBT of Panic S
- Page 92 and 93: Ruwaard, J., Lange, A., Broeksteeg,
- Page 94 and 95: 86 Chapter 5. Online CBT of Bulimic
- Page 96 and 97: 88 Chapter 5. Online CBT of Bulimic
- Page 98 and 99: 90 Chapter 5. Online CBT of Bulimic
- Page 100 and 101: 92 Chapter 5. Online CBT of Bulimic
- Page 102 and 103: 94 Chapter 5. Online CBT of Bulimic
- Page 104 and 105: 96 Chapter 5. Online CBT of Bulimic
- Page 106 and 107: 98 Chapter 5. Online CBT of Bulimic
- Page 108 and 109: 100 Chapter 5. Online CBT of Bulimi
- Page 110 and 111: 102 Chapter 5. Online CBT of Bulimi
- Page 112 and 113: Ruwaard, J., Lange, A., Schrieken,
- Page 114 and 115: 106 Chapter 6. Online CBT in Routin
- Page 116 and 117: 108 Chapter 6. Online CBT in Routin
- Page 118 and 119: 110 Chapter 6. Online CBT in Routin
- Page 120 and 121: 112 Chapter 6. Online CBT in Routin
- Page 122 and 123: 114 Chapter 6. Online CBT in Routin
- Page 124 and 125: 116 Chapter 6. Online CBT in Routin
- Page 126 and 127: 118 Chapter 6. Online CBT in Routin
- Page 130 and 131: 122 Chapter 6. Online CBT in Routin
- Page 133 and 134: Chapter 7General DiscussionPrevious
- Page 135 and 136: 7.1. Key Findings 1277.1.2 The effe
- Page 137 and 138: 7.1. Key Findings 129Work−related
- Page 139 and 140: 7.2. Strengths and limitations 1317
- Page 141 and 142: 7.2. Strengths and limitations 133s
- Page 143 and 144: 7.3. Implications for clinical prac
- Page 145 and 146: 7.4. Suggestions for future researc
- Page 147: 7.5. Conclusion 139Post-treatment b
- Page 150 and 151: 142 Summaryof the introduction prov
- Page 152 and 153: 144 Summarythat face-to-face contac
- Page 154 and 155: 146 Summarycomplex, routine practic
- Page 157 and 158: SamenvattingIn 1997 ontwikkelden on
- Page 159 and 160: Samenvatting 151startten direct met
- Page 161 and 162: Samenvatting 153up-metingen suggere
- Page 163 and 164: Samenvatting 155ongeveer gelijk zou
- Page 165 and 166: ReferencesAben, I., Verhey, F., Lou
- Page 167 and 168: References 159Bickel, R. (2007). Mu
- Page 169 and 170: References 161apy Research, 1(2), 8
- Page 171 and 172: References 163Hay, P. P., Bacaltchu
- Page 173 and 174: References 165for bulimia nervosa:
- Page 175 and 176: References 167Mond, J. M., Hay, P.
- Page 177 and 178: References 169(2003). The developme
6.3. Discussion 121figures, but our data do not permit valid assessment <strong>of</strong> the reasons for <strong>and</strong> effects <strong>of</strong>pre-treatment withdrawal. <strong>The</strong> withdrawal might be caused by the ease with whichone can apply for online therapy. This may result in impulsive applications (we foundsome indications that applicants, who started the screening without a referral, wereless likely to start treatment). A second possibility is that patients withdraw fromonline treatment because they are unwilling to relinquish their anonymity (Lange &<strong>Ruwaard</strong>, 2010).6.3.3 Clinical utility<strong>The</strong> protocols that are used in this routine practice comprise a strong mix <strong>of</strong> cognitivebehavioral procedures <strong>and</strong> techniques that enhance patient motivation <strong>and</strong> the patienttherapistrelation. One particular advantage <strong>of</strong> the therapy format is that therapistsdo not have to respond immediately when patients post their homework. Due to theasynchronous communication, therapists have time to reflect on the best possiblefeedback <strong>and</strong> the best explanation <strong>of</strong> new homework assignments. If needed, they mayeven discuss a case with colleagues. In addition, the Interapy protocols provide helpfiles, which the therapists may consult to find motivating phrases for their feedback.All these aspects make this a highly usable treatment for clinical practice.<strong>The</strong> study shows how computer-mediated treatment can save time by freeingtherapists <strong>of</strong> repetitive tasks such as the administration <strong>and</strong> scoring <strong>of</strong> outcomequestionnaires. In a computerized environment, these tasks can be easily automated.<strong>Online</strong> treatment is highly dependent on regulatory approval, pr<strong>of</strong>essional codes<strong>of</strong> ethics <strong>and</strong> jurisdiction regulations, which vary considerably from country to country.But even when such barriers have been overcome, financial hurdles may still exist.When the Interapy clinic was founded, in 2001, costs <strong>of</strong> face-to-face treatment werefully reimbursed by Dutch public health insurance, while costs <strong>of</strong> online treatmentwere not. In effect, access to online treatment was limited due to a financial barrier.This changed in 2005, when health regulatory bodies recognized the online services <strong>of</strong>the clinic as reimbursable healthcare, under condition <strong>of</strong> a GP-referral for psychotherapy.Without this recognition, further implementation <strong>of</strong> online <strong>CBT</strong> would not havebeen feasible.
Change language