**4. Case presentation**

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

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

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

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

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

designers work to create a user-friendly and appealing experience for any service user.

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

assistance.

Psychologists:

of the intervention.

Software developers:

User experience (UX) designers:

measures and the functionality of tools.

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

228 Cognitive Behavioral Therapy and Clinical Applications

developers, and user experience (UX) designers.

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

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 drinking coffee and working out.

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, the panic attacks became more frequent and intense. Innocuous situations such as watching TV or washing the dishes could trigger an attack, and they even occurred in the middle of the night. After being screened by the psychologist, Karen was diagnosed with Panic Disorder and Agoraphobia, meeting all the criteria of the DSM-V, and she also obtained a clinically significant score on the Panic Disorder Severity Scale. She made an appointment for further face-to-face therapy; however, factors such as the distance to the service, the difficulty to fit her work schedule with the schedule of the service, and not least the care of her children, prevented her from attending regularly. Given this situation, the psychologist offered her the possibility of being enrolled in a supported iCBT programme that had proven to be effective for this disorder. Karen always enjoyed independent learning, therefore, she felt more enthusiastic about the online treatment. Furthermore, the possibility of accessing the programme at any time and in any location, allowed her to juggle taking care of her children, her work and receiving psychological treatment.

**5.1. Workplace interventions using iCBT**

productivity while attending work when sick).

for seeking and accessing treatments.

lected to assess the overall effect.

**5.2. ICBT in IAPT services**

procedures.

Within a workplace environment, it is known that depression and anxiety are detrimental not only to individual's wellbeing and quality of life but also to employers and companies, through accumulated absenteeism (absence from work due to illness) and presenteeism (lost

Internet-Delivered Cognitive Behaviour Therapy http://dx.doi.org/10.5772/intechopen.71412 231

iCBT has already been tested in the workplace environment and produced positive results for some outcome measures, including distress, anxiety, sleep, and productivity. Employees can be made aware of the tools available to them for stress, depression, and anxiety related to their work. However, within the employee space, it can be difficult to access face-to-face counselling and therapy due to stigma, fears about confidentiality, and potential judgement from peers. Using an internet-delivered intervention helps to overcome some of the barriers

Employees can, for instance, access a unique webpage where they may complete some screening measures to establish levels of symptoms and after that directed to appropriate content. As individuals progress through the intervention, clinical staff provides support and feedback through the online reviews. Measures of symptomology and productivity can be col-

iCBT in the workplace enjoys the same advantages as in other services including increased access, for example, in companies with several locations wherein the support could come from a central location. Anonymity when accessing the program tackles the barrier associated with stigma, and constant availability allows the worker to access the program at suitable times. Lastly, service users can also return to the information and content for months after the intervention ends.

The UK National Health Service (NHS) Improving Access to Psychological Therapies (IAPT) programme is a five-step approach aimed to facilitate access to psychological care for individuals with depression and anxiety disorders. It endeavours to alleviate the burden and reduce the costs associated with these conditions. Specifically, IAPT follows an escalated treatment pathway depending on the severity of service users. Step 1 includes watchful waiting by general practitioners; step 2 offers low-intensity interventions (i.e., iCBT, bibliotherapy) for service users with mild to moderate conditions; step 3 includes high-intensity treatment (i.e., face-to-face); step 4 offers specialist mental health care; and step 5 provides in-patient

As mentioned, iCBT recommended as a low-intensity intervention for service users with mild to moderate symptoms (step 2). These interventions are aimed to provide evidence-based treatments that reduce therapist time [43]. They are supported by Psychological Wellbeing Practitioners, who are graduate psychologists with training in delivering low-intensity interventions, and support is offered through electronic communication means or by telephone. However, at step 3, some IAPT providers may struggle with waiting lists, given the high levels

In the morning, she received an e-mail to create an account on the platform, and once she logged in, she received a message from her supporter. The treatment comprised eight modules that she could complete on a weekly basis and the supporter would give her feedback on her progress at the end of every week. In treatment, she benefitted a lot from knowing the rationale of the panic attacks and knowing the anxiety curve, since she learned through this that anxiety was not dangerous. Moreover, the personal stories included in the programme made her feel that she was not alone and she identified with the stories. Every week she was encouraged to do homework tasks, and she shared the activities with her supporter, who acknowledged her progress and encouraged her to keep going.

She found the CBT techniques very useful and practiced these when she began to negatively interpret her physical sensations, allowing her to address these negative thoughts, and to reduce her worrying. She practiced these techniques for some weeks, and she reviewed the content to ensure she was applying them correctly. For Karen, the most beneficial part of the iCBT intervention was the exposure component. She was able to identify which physical feelings produced her fear and she rated them by intensity. She developed a graded exposure hierarchy and started practicing these exercises each day. She was very pleased with herself, when, after a few weeks of treatment she looked at the mood chart and realised that her symptoms had decreased and that she was feeling much better. Once she finished the modules, she made an appointment with the psychologist for the post-treatment assessment, at which point Karen's symptoms had reduced to asymptomatic ranges. Karen was delighted that she had succeeded in facing her anxieties.
