**3. How does internet-delivered cognitive behaviour therapy function?**

Throughout this chapter, we use the generic term 'service user' to include patients, clients, or other types of users of iCBT in different settings. Likewise, we use 'supporter' as a category to include clinicians, para-professionals, healthcare workers, nurse practitioners, peer mentors, technicians, and volunteers who may be providing support to service users of iCBT interventions in different settings.

Service users can avail internet-delivered CBT in several ways, the two most common methods being through self-sign-up or via an invitation from a supporter. Self sign-up to iCBT occurs where the service user acquires access automatically through a website of a particular provider organisation (e.g., healthcare, employer, and educational) without the need for a formal triage or assessment. One example of this would be an employee having access to an internet-delivered stress management intervention as part of his/her employee assistance intranet. In contrast, an invitation from a supporter can be generated from the platform to a service user. In some cases, supporter sign-up involves an initial assessment of psychopathology and suitability for an iCBT intervention (e.g., in a mental health service setting or a university counselling clinic setting). For the purpose what follows, the treatment pathway within a mental health service organisation will be used to illustrate how iCBT functions.

The science in this area is rapidly expanding with trials conducted in countries including Ireland [5], Switzerland [14], Germany [20], Australia [21], England [11], Canada [22], and the USA [23]. Besides, while most of the work has been with adults, there is some work with adolescents [24]. Recent avenues for research in iCBT for depression have included the cultural adaptation of interventions [25] and tailoring interventions to more appropriately meet the

A similar picture of clinical efficacy for the anxiety disorders is established with trials for panic disorder, social anxiety disorder (SAD), generalised anxiety disorder, specific phobias, and severe health anxiety. The most recent review contributing to our understanding of the efficacy of iCBT for anxiety disorders is a Cochrane review on therapist-supported iCBT for

The review [27] consisted of eight trials for panic disorder with or without agoraphobia and showed significant post-treatment and follow-up effects for iCBT for panic compared to waiting list controls. Some of these trials included a direct comparison with face-to-face treatment and demonstrated comparable outcomes. The evidence for panic disorder treatment delivered online is therefore good, although the diversity of trials and interventions is limited. Eleven trials of iCBT for social anxiety disorder (SAD) treatment were included in the review. Several different groups have researched treatment protocols for SAD and demonstrated large post-treatment and follow-up results, with effects being maintained up to 5-years [28]. What is also interesting is the comparison of iCBT for SAD with face-to-face treatment, and

similar to panic disorder there is some good evidence to show similar outcomes [29].

**3. How does internet-delivered cognitive behaviour therapy function?**

Throughout this chapter, we use the generic term 'service user' to include patients, clients, or other types of users of iCBT in different settings. Likewise, we use 'supporter' as a category to include clinicians, para-professionals, healthcare workers, nurse practitioners, peer mentors, technicians, and volunteers who may be providing support to service users of iCBT interven-

Due to strict eligibility criteria, the Cochrane review included only a small proportion (four studies) of the available literature on generalised anxiety disorder (GAD). Another recent systematic review and meta-analysis of internet-delivered interventions for GAD considered a total of 17 studies and included 11 in a meta-analysis, where the treatment intervention delivered in 9 of the 11 studies was cognitive behaviour therapy [30]. Three of these studies are disorder specific, with interventions that directly addressed GAD [31–33]. The remaining six studies were transdiagnostic, treating either multiple anxiety disorders [34–36] or anxiety disorders and depression [21, 37]. The review concluded that across the studies there were significant improvements for internet-delivered interventions for GAD compared to waiting list controls. Preliminary research has emerged that supports the use of iCBT in the treatment of severe health anxiety and specific phobias, but more studies are needed to establish this method in

needs of individual users [26].

226 Cognitive Behavioral Therapy and Clinical Applications

treating these disorders [38–41].

tions in different settings.

anxiety disorders that included 30 studies [27].

Post clinical assessment, a service user can be identified as suitable and be requiring an iCBT intervention. They provide their e-mail address to their supporter (clinician in this setting), who then invites them through their supporter account on the platform to use the intervention. An e-mail is posted to the service user that provides them with some preliminary information about the platform and a definite URL/web link that directs them to the sign-up process. The service user will then be prompted to create a unique username and password. As with all online utilities associated with potentially sensitive information, users should be required to create a password that is composed of upper and lowercase letters, numbers and special characters. Once the service user has completed the necessary sign-up steps, they will gain access to their intervention.

In a supported mode of treatment, service users are expected to log-in to their account several times throughout the prescribed course. The supporter is supposed to review the service users' progress at regular, pre-determined intervals. These core expectations should be presented to the service user from the outset, along with other goals that may be of importance to the service providing the iCBT intervention. Support to iCBT is provided in one of two modalities:

Synchronously: where both the service user and supporter are online at the same time, and the review is conducted over video conferencing or live chat.

Asynchronously: where the service user and supporter are online at different times to engage with the programme content and providing a review, respectively. This type of contact takes the form of either e-mail or post-session review on the iCBT platform.

As with all psychological treatments, service user reported outcomes are an important aspect of iCBT. Incorporating an assessment protocol for treatment can provide a supporter with further insight into the progress of the service user. For example, a series of measures on depression, anxiety, or other related constructs could be applied at baseline, at the intervals corresponding to the date of review set by the supporter and subsequent discharge. Administering the measures through an iCBT platform would allow supporters to gauge the improvement (or deterioration) of the service user over the course of their use of the intervention, where the information is presented in an easy-to-interpret manner. Assessments conducted in this way facilitate the assessment of risk during the intervention and automated alerts can be established to inform supporters to take appropriate action.

In general, an iCBT intervention will consist of modules that reflect the active ingredients of a CBT protocol, such as behavioural activation, cognitive restructuring, problem-solving, and self-monitoring for instance. Usually, the modules are designed to be administered on a weekly basis. These modules can be presented in either a prescriptive or non-prescriptive fashion. A prescriptive intervention will require service users to go through modules in a specific order, where certain items unlock depending on the service user's progress, while a nonprescriptive intervention will allow the service user to access the modules in any order they choose. The core skills and strategies of a CBT intervention will also be incorporated through the various interactive activities that help the service user learn new concepts and skills and apply their new learning. For example, service users should be able to know about the relationship between their thoughts, feelings, and behaviours, and later apply this through an interactive activity that helps them to create their own thought-feeling-behaviour cycles. Furthermore, the pedagogy of iCBT typically includes personal stories or clinically informed vignettes of fictitious service users. These are presented with a specific symptomatology, or they may also illustrate how to apply specific CBT skills as a way of providing examples that facilitate the integration of the content. Users can return to prior modules and review specific content if they feel the need to do so. Once the user finishes with the intervention, they are assessed to determine whether the intervention has been effective or if they require further assistance.

draft of the content map, a beta version of the intervention is designed online, which is then administered to users for acceptability and usability testing. This will provide an insight into the needs and experiences of the target populations. Once all feedback has been gathered and applied, the intervention can then be implemented into service provider settings and research

Internet-Delivered Cognitive Behaviour Therapy http://dx.doi.org/10.5772/intechopen.71412 229

Karen is a 35-year-old divorcee with two children in shared custody with her ex-husband. She has a degree in chemistry, and she works in a ceramic company as a full-time laboratory

Two years ago, Karen suffered a sudden panic attack for the first time when she was in a shopping centre with a friend. She went to the emergency room because she thought she was about to suffer a heart attack. The doctor told her that it was anxiety and that her heart was fine, so she was prescribed anxiolytics by the doctor on duty. Medication resulted in a reduction of her symptoms, and she got better quite quickly. However, she developed a fear of suffering more panic attacks, so she started to avoid specific activities such as taking public transport or attending school meetings, as she was worried about the possibility of suffering high levels of anxiety and not being able to escape from those situations without other people noticing. Over time, she started to develop higher levels of awareness of interoceptive symptoms, and Karen started noticing the beats of her heart while she was in bed, along with other ordinary signs that she believed were dangerous, so she decided to avoid other activities, such as

Despite the burden of these limitations, Karen continued with her routine, and it was not until 1 year later, when she suffered another panic attack while attending a family event, that she decided to take matters into her own hands. She went again to the emergency room, and she was given medication and seen by the psychiatrist on duty. It was explained to her that she most likely had an anxiety disorder and that she needed to receive psychological therapy. Therefore, she made an appointment with her GP, who after a brief assessment, decided to refer her to specialised care. Karen was then enrolled on a waiting list which took 1 month for the first screening with the psychologist, given that it was not a severe condition. However, during that month,

can be conducted to establish its efficacy and effectiveness.

3. Deliver the intervention on robust, engaging, secure, and responsive technologies.

4. Be service user-centric and involve users in the development and testing. 5. Undergo research and evaluation to support its efficacy and effectiveness.

1. Include evidence-based and empirically supported content. 2. Incorporate subject matter experts' (SMEs) clinical expertise.

6. Deliver effective clinical outcomes for service users [42].

Key points in developing an iCBT intervention:

assistant. She lives in a small village with her two children.

**4. Case presentation**

drinking coffee and working out.

#### **3.1. The process of developing an iCBT programme**

Before deployment to service users, an iCBT intervention will go through several rounds of research, development, and testing by an interdisciplinary group of psychologists, software developers, and user experience (UX) designers.

These individuals are involved in the researching and writing of the psychoeducational/interventional content on the iCBT platform, where the content requires validation and they may lead to research trials to establish the efficacy of the intervention.

User experience (UX) designers:

When designing an iCBT platform, a critical component is the user experience and acceptability, where the display of content is unappealing, or a therapeutic tool is poorly designed, the service user will not interact with it. UX designers work to create a user-friendly and appealing experience for any service user.

Software developers:

This group takes what psychologists and UX designers create, and implement it online. Another side to this role is coding the entire platform, as well as ensuring that everything is working as intended, such as any data collection measures and the functionality of tools.

Initially, a review of the literature is conducted on the treatment protocols for the disorder the iCBT intervention intends to target. From this, a content map is developed; this document details the structure of the iCBT programme, the content of the modules, as well as the therapeutic goals and intended user objectives for service users. The preliminary content map is circulated to subject matter experts in the field for further feedback and critique. With the final

Psychologists:

draft of the content map, a beta version of the intervention is designed online, which is then administered to users for acceptability and usability testing. This will provide an insight into the needs and experiences of the target populations. Once all feedback has been gathered and applied, the intervention can then be implemented into service provider settings and research can be conducted to establish its efficacy and effectiveness.

Key points in developing an iCBT intervention:

