Chapter 4 Information Technology and the Changing Role of Practice

Gerhard Andersson, PhD

Department of Behavioral Sciences and Learning, Linköping University, and Karolinska Institute

Psychotherapy has gradually changed from a mainly individual face-to-face practice to various alternative forms of treatment delivery. Examples include group treatment, information materials, class-based interventions, unguided prevention programs, and guided self-help programs using either books or computerized interventions based on different platforms (e.g., computers, via the Internet, and smartphones). Not all of these changes in the practitioner’s role are recent, nor have they been caused by modern information technology, but my focus in this chapter is on those that have been.

Although controversy about group and class-based interventions remains (Morrison, 2001), the changes produced by these methods have been with the field for some time, these methods are already part of regular practice, and they have empirical support with at least some conditions (Cuijpers, van Straten, & Warmerdam, 2008; White, Keenan, & Brooks, 1992). The same is true with some forms of information technology as well, such as using a text-based intervention in the form of books and leaflets as a stand-alone treatment, often referred to as bibliotherapy (Keeley, Williams, & Shapiro, 2002). Some newer forms of intervention, such as seeking out web-based information material or online support groups, fall outside of the scope of this chapter (G. Andersson, 2014) because they are rarely integrated with practice per se. In this chapter I will instead comment on the changes in the role of practice in which modern information technology has been introduced to complement and sometimes even replace traditional formats of service delivery.

Internet-Based Treatments with No Clinician Contact

There are many Internet-based self-help programs that are automated and involve no contact with a human being. These programs can have different purposes, ranging from prevention to early intervention in a stepped-care process (Nordgreen et al., 2016) to full psychological treatment.

Treatments with no contact with a clinician are often presented under a name other than “treatment,” and they tend to target specific symptoms rather than mental health disorders and syndromes (Leykin, Muñoz, Contreras, & Latham, 2014). This may partly be the result of legal restrictions in some countries and professional and ethical regulations. For example, in the United States it isn’t possible for a clinician to treat a person via the Internet if the person lives in a state in which the clinician is not licensed.

Magnitude of need and lack of face-to-face services are motivators for the creation of self-guided programs (Muñoz, 2010), but such programs face problems, such as the fact that many who register fail to complete the interventions (Christensen, Griffiths, Groves, & Korten, 2006). Automated reminders and other programmed ways to foster adherence may boost treatments with no human support. Recent studies suggest that this form of augmented, unguided Internet treatment can be effective, with fewer dropouts than in previous studies (Titov et al., 2013).

The level of human involvement tends to be higher when online interventions are used as part of the health care system. Online interventions often automatically include at least some human support, such as a prescribing primary-care clinician or research staff member who sees a research participant for assessment (Ritterband et al., 2009). The level of human involvement can increase when clinicians are part of the process of supportive engagement.

Internet-Based Treatments with Clinician Support

Internet-based treatments with some form of clinician support have emerged as an evidence-based approach to deliver psychological treatments for several conditions, including anxiety (Olthuis, Watt, Bailey, Hayden, & Stewart, 2015), depression, and somatic disorders (G. Andersson, 2014). These programs are often full-scale treatments that span five to fifteen weeks and include many of the components of face-to-face interventions. Several features of guided Internet treatments are likely to influence how psychological treatments will be practiced in the future.

First, guided Internet-based treatments generally include online assessment procedures. Many researchers and clinicians see value in the repeated assessment of outcome during treatment (Lambert, 2015), but this is often not possible in clinical practice given time constraints, and the administration and coding involved with questionnaires. Modern information technology can facilitate outcome monitoring. Clinicians can administer self-report questionnaires with maintained psychometric properties via the Internet (Van Ballegooijen, Riper, Cuijpers, van Oppen, & Smit, 2016), and with the help of mobile phones they can collect data in real time from clients (Luxton, McCann, Bush, Mishkind, & Reger, 2011). This is useful not only in research but also in regular treatment. For example, smartphones can be used instead of paper and pencil to collect distress ratings during exposure therapy. Gustafson and colleagues (2014) used a smartphone app to support the treatment of drug abuse. Yet another possibility is to use video chat when interviewing clients. Of course, this requires secure online solutions, making ordinary programs for social media less suitable, even if clinicians increasingly use common systems such as Skype (Armfield, Gray, & Smith, 2012).

Second, how guided Internet-based treatments are scheduled and the content they use (for a recent review of Internet versions of evidence-based treatment, see G. Andersson, Carlbring, & Lindefors, 2016) are also likely to influence future psychological practice. Overall, the scheduling of online programs tends to mimic face-to-face scheduling, and these programs provide weekly homework assignments. Moreover, the treatments have a total length similar to that of face-to-face manuals. The content of online treatment programs varies, but most are based on cognitive behavioral therapy (CBT) (G. Andersson, 2014); others are informed by interpersonal psychotherapy (Dagöö et al., 2014) or psychodynamic psychotherapy (Johansson, Frederick, & Andersson, 2013) and so on.

While many treatment programs have been derived from evidence-based protocols for specific disorders, such as panic disorder and depression, evidence-based treatments tend to overlap across disorders and problems, and it is important to give end users freedom regarding treatment preferences. Two different and partly overlapping solutions to this dilemma have been developed.

A focus on transdiagnostic mechanisms is the first solution. Examples are Barlow’s unified protocol for mood and anxiety disorders (Barlow, Allen, & Choate, 2004) and acceptance and commitment therapy’s focus on psychological flexibility across different forms of mental and behavioral health (Hayes, Strosahl, & Wilson, 2012). Titov, Andrews, Johnston, Robinson, and Spence (2010) have developed and tested a transdiagnostic Internet treatment for anxiety and depression, with good results. Researchers have tested other transdiagnostic approaches, such as mindfulness (Boettcher et al., 2014), affect-focused psychodynamic treatment (Johansson, Björklund, et al., 2013), and acceptance and commitment therapy (Levin, Pistorello, Hayes, Seeley, & Levin, 2015), using the Internet format. In addition, researchers have used the Internet to test generic treatments, such as applied relaxation, and for specific disorders, such as social anxiety disorder (Carlbring, Ekselius, & Andersson, 2003).

Without additional tailoring, even transdiagnostic approaches are not capable of handling client preferences, and case-formulated treatments, which clinicians often favor, are not possible if treatment content is more or less fixed. One exception is the transdiagnostic approach by Titov and colleagues (2011), which offers clients material in addition to that of the fixed program. Similarly, the program described by Levin and colleagues (2015) provides for “flavors” of acceptance and commitment therapy to fit the client problem area.

Another approach to giving end users freedom regarding treatment preferences, developed by our research group in Sweden, consists of tailoring Internet treatment according to a diagnostic interview; a case formulation; and, to some extent, client preferences (Carlbring et al., 2010). In practice, tailoring might consist of set modules and flexible modules. A client may be prescribed a ten-week program consisting of psychoeducation (fixed), tailored modules based on case presentation and preferences (for example, modules on social anxiety and stress management), and then a fixed ending (relapse prevention). This transdiagnostic approach can address comorbidity for cases in which problems, such as insomnia, relationship issues, and psychiatric conditions (e.g., generalized anxiety), coexist. Evidence to date suggests that tailored Internet treatment probably is as effective as disorder-specific treatments (Berger, Boettcher, & Caspar, 2014), and in one study on depression, tailored treatment was found to be superior to standard Internet treatment for more severe cases (Johansson et al., 2012).

An advantage of treatment programs delivered via the Internet is that they can go beyond text to include audio files, animations, videos, chat rooms, texting, automated reminders, and other technological solutions that, in principle, can guide the client through a behavior change process in a seamless manner that would be difficult to fully replicate in face-to-face therapy. Text is still a major part of most interventions, and many people are used to processing text, but in most programs different presentation formats are mixed with, for example, an introductory video from a therapist, text-based instructions and psychoeducation, interactive homework instructions, and pictures to illustrate concepts. Indeed, researchers have developed treatments that use illustrations extensively; for example, there is a depression treatment in manga format (Imamura et al., 2014), and programs from Australia use pictures drawn by former artists at Disney (Mewton, Sachdev, & Andrews, 2013).

Another strength of Internet-based therapy is that it can be modified to fit people who speak different languages and have different cultural backgrounds. Figure 1 presents an example. It’s a screenshot of a treatment study for depression used in a trial with people speaking the Kurdish language Sorani. The depression manual was originally written in Swedish, as you can see from the video’s title. The figure shows that Internet interventions can easily be translated and adapted for use in other languages. In a similar way, Internet-based therapy can change program examples, names, or photos to fit cultural expectations (e.g., a picture showing a man and a woman shaking hands can be changed to two women shaking hands for an Internet protocol presented in Farsi).

The third feature of guided Internet-based treatments likely to affect future psychology practices is the role of the clinician. Most reviews and meta-analyses have found that clinical support boosts treatment outcomes for online programs and reduces dropout (Baumeister, Reichler, Munzinger, & Lin, 2014), but more work is needed regarding the role and training of therapists guiding Internet-based treatments (G. Andersson, 2014). However, support may be differentially associated with outcome; for example, depression treatments may be more dependent on support (Johansson & Andersson, 2012), and some other conditions potentially require less clinical support (Berger et al., 2011). Both clinicians and clients may prefer to have some form of clinical contact, but the amount and form of support needed is not yet known empirically. It may be that on-demand support, similar to help lines, could be sufficient for some clients (Rheker, Andersson, & Weise, 2015). Other clients may need scheduled support and tailored reminders. A challenge for future research will be to identify outcome moderators that will help clinicians decide what form of support a client needs.

Overall, the effects of Internet-based treatments challenge the assumption that a therapeutic alliance is a necessary feature behind effective psychosocial treatments (Horvath, del Re, Fluckiger, & Symonds, 2011). Several studies (e.g., Sucala et al., 2012) have looked at the therapeutic alliance between the client and the online therapist, and in most, clients have rated the alliance as high (using measures such as the working alliance inventory), but these ratings have rarely correlated with outcome.

Are We Ready to Implement Internet Treatment?

In this chapter I focus on guided Internet-based treatment because the evidence base is large for a range of problems and clinical conditions (G. Andersson, 2014). However, there are barriers to clinicians incorporating modern information technology in daily clinical practice. First, clients may not view Internet treatment as a firsthand treatment (Mohr et al., 2010), even if some surveys suggest that clients may be more positive than clinicians (Gun, Titov, & Andrews, 2011; Wootton, Titov, Dear, Spence, & Kemp, 2011). Second, attitudes may differ depending on target group; for example, clinicians may be less willing to use Internet treatment with younger clients (Vigerland et al., 2014).

Third, providers may fear that Internet treatments will come to be regarded as being equally effective as face-to-face treatments. Direct comparative studies suggest that this may be the case when it comes to guided Internet treatments (G. Andersson, Cuijpers, Carlbring, Riper, & Hedman, 2014), with the caveat that no treatment is likely to be suitable for all clients and outcomes may vary across clinicians. From a clinical point of view, it is highly likely (given the overall equivalence in studies) that there are some clients and some clinicians for whom face-to-face treatment is superior, but there are also clients and clinicians for whom Internet treatment is more effective. Unfortunately, the literature on predictors of outcome does not send a clear message, as there are few consistent findings on what works for whom.

Fourth, clinicians are concerned about whether they can trust the findings from efficacy studies in which participants are recruited via advertisements. Given the rapid speed of research on guided Internet treatments (with the help of technology), there are now several effectiveness studies (those that are clinically representative, with ordinary clients seen in regular settings and not recruited via advertisements) showing that such treatments (so far, without exception, those based on CBT) work well when delivered in regular care (G. Andersson & Hedman, 2013), with some recent studies performed with very large samples (e.g., ~2,000 clients; Titov et al., 2015). Finally, ethical concerns and restrictions may also limit the reach of Internet treatments (Dever Fitzgerald, Hunter, Hadjistavropoulos, & Koocher, 2010), as may service delivery models and funding.

In sum, in spite of the fast-growing empirical support for guided Internet treatments, changes in the structure of practice are slow. There are examples of established Internet-treatment facilities (e.g., one has been treating tinnitus distress in Uppsala, Sweden, since 1999; Kaldo et al., 2013) and implementations in countries such as Australia, the Netherlands, Germany, and Norway, but many treatment programs are not used yet in regular care.

Guided Self-Help As an Adjunct to Standard Therapy

Self-help books have already penetrated therapy practices and found use within them. Given the large number of self-help books available on the market, some of which have been supported by controlled treatment trials, it is not surprising that many clinicians use and recommend them. One study on CBT therapists in the United Kingdom found that 88.7 percent of therapists used self-help materials, mostly as a supplement to individual therapy (Keeley et al., 2002). A similar survey found that only 1 percent of practicing clinicians used computerized interventions as an alternative to face-to-face services (Whitfield & Williams, 2004), but the blending of face-to-face services and modern information technology is a recent development likely to change how therapists and clinicians practice.

An example of this blending is an online support system for CBT in which all the paperwork (for example, homework assignments, diaries, questionnaires, information material) exists online, but the system is used to complement face-to-face sessions rather than as a replacement (Månsson, Ruiz, Gervind, Dahlin, & Andersson, 2013). An online support system of this kind builds on earlier technological developments, such as the CD-ROM support system for general practice clinicians (Roy-Byrne et al., 2010). Another approach is to use the online treatment program as a base and to complement it with face-to-face meetings (Van der Vaart et al., 2014). A recent depression study in Norway, conducted in general practice, successfully used that approach based on the online MoodGYM program (Høifødt et al., 2013).

With the spread of modern mobile phones (i.e., smartphones), additional opportunities have emerged for blended practice. Practitioners can use the technology in the way they use self-help books, recommending it to clients with the hope of making intervention more effective and efficient. In one recent project, a smartphone app was developed to support behavioral activation. The app was blended with four face-to-face sessions and was tested—against a full behavioral activation arm consisting of ten face-to-face sessions under supervision—in a randomized trial with eighty-eight clients with diagnosed depression (Ly et al., 2015). Results showed no difference between the two treatments and large within-group effects for both treatments.

Trials such as this show that we have now reached a stage at which regular face-to-face services will need to learn how to incorporate modern information technology on empirical grounds. It seems inevitable that Internet-supported interventions using different platforms, such as computers, smartphones, and tablets, will become more common. The blending of these interventions into regular clinical care can occur from two perspectives: regular services, such as evidence-based psychological treatment, can use technology as an adjunct to regular face-to-face sessions, or online treatment programs, smartphone apps, and other devices can be supported by clinicians. Many trials and clinical applications of Internet interventions have used both styles of blending over the years. What is not yet clear is how clinicians are going to adjust their roles to make use of technological developments.

Ongoing and Future Developments

In light of the rapid spread of modern information technology across the world, it is clear that the practice of psychological assessment and treatment will change. It is hard to predict exactly how. In this section I will comment on a few possible scenarios and make observations about the current state of affairs.

First, it seems likely that some Internet-based interventions will emerge that can only be conveniently done in computerized forms, driving their early adoption. Attention modification training, which moved from being mostly laboratory based (Amir et al., 2009) to online delivery, is such an example. Its development shows both promise and risks, since promising findings from laboratory research have not been replicated in programs delivered via the Internet (Boettcher, Berger, & Renneberg, 2012; Carlbring et al., 2012), and paradoxical results have been reported (Boettcher et al., 2013; Kuckertz et al., 2014). However, additional examples seem sure to emerge (especially given point three below).

Second, specific treatment components (e.g., mindfulness and physical exercise) that are sometimes embedded in evidence-based psychological treatments have also been delivered over the Internet in controlled trials. Mindfulness components have been part of treatment protocols in studies on Internet-delivered acceptance-oriented treatments (Hesser et al., 2012). In a study on depression, a physical exercise program was delivered via the Internet with promising results (Ström et al., 2013), again showing that Internet delivery can be a feasible way to test the effects of interventions. There have also been controlled trials on mindfulness (Boettcher et al., 2014; Morledge et al., 2013) and problem solving as treatment components delivered as stand-alone interventions via the Internet (Van Straten, Cuijpers, & Smits, 2008). As these specific components are better developed, their linkage to new forms of functional analysis and program development seem likely, especially if the process-oriented approach in the present volume begins to provide more focus on moderation and processes of change. It is worth noting that Internet studies allow for larger samples and thus can facilitate dismantling studies in which the effects of specific components are isolated.

Third, we are now in the position where it is likely that new interventions will be tested directly in Internet trials rather than first being developed and tested in regular face-to-face trials. One such example is a treatment of procrastination (Rozental, Forsell, Svensson, Andersson, & Carlbring, 2015). The change of focus from psychiatric syndromes to the problems people have and the processes that foster them seems likely to increase Internet trials. This overall trend may narrow the focus of Internet interventions to problem areas (an example is the treatment of perfectionism; Arpin-Cribbie, Irvine, & Ritvo, 2012). It also may broaden the range of problem areas—from mild to moderate psychiatric conditions, where there are now few conditions for which no programs exist (G. Andersson, 2014); to somatic health problems, such as chronic pain; to general health problems, such as stress and insomnia (G. Andersson, 2014).

Fourth, on the process front, Internet treatment research can be a testing ground for new ideas regarding the processes that moderate or mediate treatment outcome. Again, given the larger samples of participants in Internet trials, it is easier to get sufficient statistical power to test outcome predictors but also mediators of outcome in process research (Ljótsson et al., 2013). A large controlled study of two hundred people suffering from social anxiety disorder found that knowledge about social anxiety and confidence in that knowledge increased following treatment (G. Andersson, Carlbring, & Furmark, on behalf of the SOFIE Research Group, 2012). This example in CBT psychoeducation is important, but few studies have investigated what clients actually learn from their therapies, and knowledge acquisition deserves to be studied more as it is an important goal of most psychosocial interventions (Harvey et al., 2014).

Another example of research (Bricker, Wyszynski, Comstock, & Heffner, 2013) done in association with Internet trials had participants accept the physical, cognitive, and emotional cues to smoke. This study attributed 80 percent of the increased level of smoking cessation at follow-up to an acceptance and commitment therapy website and Smokefree.gov, the smoking-cessation website developed by the National Cancer Institute. A study done by Månsson and colleagues (2015), on brain mechanisms as outcomes and predictors of outcome, is yet another example of an Internet-associated trial. Other studies (e.g., E. Andersson et al., 2013) have investigated genetic markers of outcome, but this research has not yet generated any strong findings.

A fifth and final area of interest is the provision of training, supervision, and education via the Internet. There are few studies on online education in CBT (Rakovshik et al., 2013) and even fewer for online supervision. However, university education has changed dramatically, and an increasing number of education programs across the world use modern information technology. Online supervision is probably common even if there are restrictions regarding security and very little research regarding its efficacy. There is a need for systematic research on how we can use the Internet to increase access to education in evidence-based psychological treatments.

Concluding Remarks

In this chapter I gave several examples of how clinical practice might change due to the introduction of modern information technology in society. In a short time researchers have conducted a large number of Internet-based studies, and it is now common for new treatments targeting new populations to be tested directly with Internet research and not just time-consuming studies with face-to-face sessions. But there are also challenges with Internet-based interventions. Diagnostic procedures and case formulations are generally based on human interaction between clinicians and clients. To date, for Internet treatments these therapy procedures have often been done either in clinic or via telephone. There is a need to improve online screening and diagnostic procedures but also to implement other tests, such as cognitive testing, for online delivery. In this chapter I did not discuss cost-effectiveness and the potential cost savings with Internet interventions (Donker et al., 2015), but it is worth adding that Internet-intervention costs are less than face-to-face services and, perhaps more importantly, clients can be reached more easily and earlier with Internet treatment, which may reduce suffering.

Clinicians being trained today grew up in the Internet era, and they may be better prepared than more senior peers to embrace the bold new world that looms on the horizon. The opportunities are great, but it seems likely that practice changes will proceed gradually. This may be a good thing, as the pace appears to be encouraging the field to begin the change process by blending the best of face-to-face and modern information technology, creating a solid foundation for the additional and perhaps more professionally challenging steps likely to be taken in the future.

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