**5.1. Workplace interventions using iCBT**

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

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

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

The following examples serve to illustrate the flexibility and adaptability of iCBT in various settings. The examples also show some real-world benefits of this mode of delivering

acknowledged her progress and encouraged her to keep going.

that she had succeeded in facing her anxieties.

**5. Service delivery examples**

interventions.

treatment.

230 Cognitive Behavioral Therapy and Clinical Applications

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 productivity while attending work when sick).

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 for seeking and accessing treatments.

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 collected to assess the overall effect.

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.

#### **5.2. ICBT in IAPT services**

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 procedures.

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 of demand and the lack of trained clinicians. Therefore, iCBT is considered as a supportive tool implemented as a prequel to high-intensity therapy at step 3, for individuals with depression and anxiety disorders. In this particular case, a therapeutic package is offered to those eligible for step 3 that includes iCBT before commencing face-to-face or group treatment. Individuals using iCBT are informed that they can withdraw from the treatment at any point and still avail of other services. Service users are monitored weekly, and any deterioration in their symptoms is attended to. If an appointment for face-to-face therapy becomes available, they are then offered to begin this high-intensity treatment.

be signed up for the iCBT intervention in a supported or unsupported modality. Primary Care Physicians (PCP) could create a referral in the patient management system and this could be managed by care advocates in the system, to onboard the service user to the iCBT platform. The platform content can be explored independently by the service user on either a smartphone or computer and their progress can be reviewed at pre-determined intervals set by the healthcare provider. Where technology allows, service user risk is routinely monitored, and alerts can be generated when a specific risk is flagged, which can then be escalated appropri-

Internet-Delivered Cognitive Behaviour Therapy http://dx.doi.org/10.5772/intechopen.71412 233

In many US and UK behavioural health services, CBT is the treatment of choice and is typically delivered face-to-face for a period of between 12 and 16 sessions, depending on the presenting problem. Many of these health services face the continuous challenge of meeting the demands with a lack of trained resources to see people face-to-face. Recently, such services are investigating the utility of incorporating iCBT in innovative ways. In some cases, an implementation is a blended approach, where services now deliver a model of care that includes both face-to-face and internet-delivered CBT. This can be achieved in many different formats, for instance where service users are assessed and after that complete their first faceto-face session with their CBT therapist. After that, the service user has access to the iCBT platform where they are encouraged to access the intervention in the time between the sessions. In this model, the sessions are spaced at intervals of every two or even 3 weeks. The intention is that the service user receives both face-to-face support, but also has access to content and tools

between sessions that enable and support their trajectory through their therapy.

could have significant implications for service development and delivery.

will be critical to support large-scale adoption of iCBT in practice.

This model of implementing a blended service has the advantage of increasing throughput of service users, embracing the benefits of early intervention to treatment, and preventing dropout from long waiting lists. In these ways, successfully implementing a blended care model

The efficacy of iCBT in addressing the symptoms of depression and anxiety disorders has been presented. However, more effectiveness studies conducted in various settings are needed to examine the potential barriers and find appropriate solutions for successfully implementing iCBT. It would seem reasonable to understand that achieving solutions for implementation

Another issue which merits further study is the effect of mechanisms of change, that is, the underlying factors that aid the efficacy of the interventions. Understanding these mechanisms further will allow for the adaptation of the content to the specific needs of each service user, improving the provision of these treatments in a more efficient way (determining precisely what works and for whom). Indeed, to date, little has been achieved in understanding the relative contribution of mechanisms of change to specific outcomes in iCBT [19]. Further, studies with

ately within service frameworks.

**6. Future directions**

**5.4. Blended delivery using of iCBT**

Service users are given immediate access to the platform so that they can start their treatment while being supported by their clinician. Each week throughout the intervention, service users complete a minimum data set, as per the national requirements regarding IAPT services, which includes the care provided to each service user and his/her clinical progress. The clinician reviews these assessments and the progress of the service user on a weekly basis. In this sense, the clinicians are not only expected to review the progress of the service users, but also to keep service users adhered to the intervention by acknowledging the efforts that the service users are taking, and by encouraging them to logon to the platform and practice the exercises. Once the service user finishes with the interventions, they can follow some potential trajectories in the treatment pathway. Firstly, the service user may recover and therefore get discharged from the service. Secondly, the service user might continue needing high-intensity therapy and consequently, would take up face-to-face or group therapy. Finally, it may be the case that the service user would prefer to continue with other low-intensity treatments (i.e., bibliotherapy). In sum, iCBT at stage 3 is expected to reduce the burden of the waiting lists by providing a treatment at the time the service users are waiting to start with the high-intensity therapy.

#### **5.3. Primary care using iCBT in US health systems**

In the US, healthcare systems are service bodies that provide physical and mental healthcare to large populations with diverse and changing needs of some primary, secondary and tertiary settings. They are also known as accountable care organisations (ACOs), which consists of one or several care providers uniting to provide mapped-out models of care under a predefined and limited budget.

Healthcare commission solutions are innovative, cost-effective, and evidence-based with proven clinical outcomes. Where users of healthcare services enter a treatment pathway principally through primary care, iCBT can be an efficient first step for those that present with mild to moderate mental health difficulties. Service users frequently present with depression and anxiety to primary care clinics, and physicians generally refer service users to face-to-face treatment services, which often have long waiting lists. Deploying an iCBT intervention into primary care can address these difficulties without the need for a referral to higher intensity face-to-face services, allowing for a form of treatment which is more efficient in its use of resources.

In considering the successful implementation of an iCBT intervention in primary care, the service user pathway is important. When service users present for routine assessment, they can be administered either the 9 or 4 item version of the Patient Health Questionnaire to assess symptom severity. If the service user is within a clinical range of symptoms, they can be signed up for the iCBT intervention in a supported or unsupported modality. Primary Care Physicians (PCP) could create a referral in the patient management system and this could be managed by care advocates in the system, to onboard the service user to the iCBT platform. The platform content can be explored independently by the service user on either a smartphone or computer and their progress can be reviewed at pre-determined intervals set by the healthcare provider. Where technology allows, service user risk is routinely monitored, and alerts can be generated when a specific risk is flagged, which can then be escalated appropriately within service frameworks.
