The Efficacy and Effectiveness of Online CBT - Jeroen Ruwaard

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30 Chapter 2. Online CBT of Work-Related Stressstress (Lange, van de Ven, & Schrieken, 2003), in which effects also proved to bestable. We may conclude that participants, who complete this type of Internet-drivenCBT, have a high chance to not relapse, and may even enjoy further improvements.These results are compelling, as the further improvements were not explained by anyadditional treatment, which some participants had sought in this three year period.2.4.3 LimitationsSeveral aspects of this study limit the generalizability of the results. We will discussthe self-selection of the participants, the different time-frame between measurementsin the experimental groups, and the dropout and attrition at follow-up.Self-selection most clearly manifested itself in the high educational level of the participants.The high educational level is probably due to the fact that most participantswere recruited through an article in a quality newspaper that is favoured by the welleducated. Yet, high education seems to be rather typical of people who participatein Internet-based therapy (Andersson et al., 2006; Carlbring et al., 2001). Until therelation between education and Internet therapy is better understood, caution shouldbe exercised in generalising the present results to less well-educated populations.Participants in the treatment condition were posttested when they completedtreatment. We expected them to complete treatment within the planned 7 weeks,but the average treatment took substantially longer (16 weeks). Consequently, theexperimental group, on average, was posttested several weeks after the control condition.Therefore, the between-effects may have been confounded by (uncontrolled)effects of the mere passage of time. However, if present, this effect was probably small.Exploratory analyses did not reveal a significant effect of treatment duration on theoutcome variables. Nevertheless, to avoid such interpretative issues in our currentstudies, we now multiply the protocol time by 1.5 to estimate the actual length oftreatment.During the study, a considerable number of participants dropped out. Although theobserved dropout rate of 21% is common in online therapy (Wantland et al., 2004), itis disconcerting that most dropout occurred in the treatment group. No significantpredictors of dropout were found, and many dropouts did not provide a reason forterminating their participation. However, therapists noticed that participants often
2.4. Discussion 31experienced problems in combining work and treatment demands. Perhaps some ofthe exercises required too much time for some participants or were otherwise toodemanding. Thus, the treatment may have presented a practical burden in terms oftime and effort that was not experienced by control group participants.Finally, the observed long-term reduction of complaints is promising, but wasuncontrolled, and suffered considerable attrition. The long-term follow-up needsreplication.2.4.4 E-mail versus websiteIn this study, the website was used only for basic psycho-education and recruitment.Communication between clients and therapists took place though e-mails. At present,the treatment is delivered completely through a structured, database-driven website.This has several advantages over e-mail exchanges. Privacy is ensured by transparentencryption techniques and login procedures. Further, therapists and clients nowuse a graphical interface to access treatment elements, which enhances access tothe treatment dossier and process overview. Furthermore, the website providesreal-time calculation of results and multimedia interfaces that support and facilitatethe execution of the exercises. Preliminary (unpublished) findings suggest that thewebsite-driven manual decreases the number of dropouts to a mere 15%, and that itenhances the improvement rates. It would be interesting to directly test the results ofan e-mail versus website-driven treatment protocol for chronic stress.2.4.5 Client-therapist relation and treatment integrityKnaevelsrud and Maercker (2006) and Spek et al. (2007) observed that positiverelationships between therapists and clients are quite feasible in Internet-driventherapy. This observation is supported by the positive evaluation of our participants oftheir therapists. Yet, this study does not permit conclusions regarding the effect ofworking alliance or the amount of therapist involvement in Internet-driven treatment.Given that some studies investigating Internet-based self-help with minimal therapistcontact report reasonable results (e.g. Carlbring, Furmark, Steckzó, Ekselius, &Andersson, 2006), future research should focus explicitly on the role of the therapist:
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Chapter 7General DiscussionPrevious
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7.1. Key Findings 1277.1.2 The effe
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7.1. Key Findings 129Work−related
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7.2. Strengths and limitations 1317
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7.2. Strengths and limitations 133s
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7.3. Implications for clinical prac
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7.4. Suggestions for future researc
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7.5. Conclusion 139Post-treatment b
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142 Summaryof the introduction prov
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144 Summarythat face-to-face contac
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146 Summarycomplex, routine practic
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SamenvattingIn 1997 ontwikkelden on
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Samenvatting 151startten direct met
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Samenvatting 153up-metingen suggere
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Samenvatting 155ongeveer gelijk zou
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ReferencesAben, I., Verhey, F., Lou
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References 159Bickel, R. (2007). Mu
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References 161apy Research, 1(2), 8
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References 163Hay, P. P., Bacaltchu
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References 165for bulimia nervosa:
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References 167Mond, J. M., Hay, P.
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References 169(2003). The developme
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References 171of change in psycholo
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DankwoordAlleen mijn naam staat op
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Dankwoord 175en Janneke Broeksteeg
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178 Curriculum VitaeLange, A., & Ru
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The Efficacy and Effectiveness of Online CBT - Jeroen Ruwaard

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