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Publicação semestral da Federação Brasileira de Terapias Cognitivas (FBTC)

Vol. 12 nº 1 - Jan. / Jun.  de 2016

DOI: 10.5935/1808-5687.20160009

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Páginas 57 a 61

Self-guided internet-based psychological interventions: An interview with Dr. Thomas Berger

Intervenções auto-guiadas baseadas na internet: Uma entrevista com o Dr. Thomas Berger

Autores: Rodrigo T. Lopes1; Thomas Berger2

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Keywords: Cognitive-behavioral therapy, internet, state-of-the-art review, online therapy, e-mental health.

Palavras-Chave: terapia cognitivo-comportamental, terapia online, panorama, intervenção assíncrona baseada na internet.

Abstract:
The internet is an established form of human communication increasingly present in our daily lives. There is solid evidence showing the efficacy of synchronous and asynchronous internet based interventions for psychological and health problems, also when compared to face-to-face interventions. Despite some isolated efforts, research on long distance interventions in Brazil is sparse. On the other hand, the Federal Council of Psychology allows limited internet-based interventions, not only in experimental settings. Dr. Thomas Berger, from the University of Bern, Switzerland, studies the theme of online delivered interventions since 2005 and has developed several interventions, mainly asynchronous, for the online setting. In this interview, he talks about treatment efficacy, therapeutic relationship, research issues and how European and specifically Swiss psychologists are using this format of psychological care.

Resumo:
A internet constitui uma forma de comunicação humana cada vez mais indispensável e cotidiana. Há sólidas evidências mostrando a eficácia das intervenções síncronas e assíncronas via internet para diversos problemas psicológicos e de saúde, inclusive quando comparadas com intervenções face-a-face. Apesar de alguns esforços isolados, a pesquisa acerca das intervenções psicológicas a distância no Brasil encontra-se esparsa. Por outro lado, a mediação da internet por psicólogos já foi regulamentada pelo Conselho Federal de Psicologia (CFP), que permite intervenções a distância limitadas, não só com finalidades experimentais. O professor doutor Thomas Berger, da Universidade de Berna na Suíça, se dedica à prática e ao estudo dos tratamentos mediados pela internet desde 2005 e tem desenvolvido várias intervenções psicológicas online, a maioria assíncrona. Nessa entrevista ele fala da eficácia dos tratamentos via internet, da relação terapêutica, da pesquisa sobre o tema e como os psicólogos europeus e suíços especificamente estão usando esse formato de atendimento psicológico.

Self-administered internet-based psychological interventions: an interview with Dr. Thomas Berger

Human communication increasingly mediated by technology and affects our daily lives. It is no wonder that psychotherapy, as a form of human relationship, would also be affected by technology. There is a strong body of evidence showing the efficacy of psychological interventions for psychological and health problems and disorders based on communication technologies, such as the internet (eg., Cuijpers, Donker, van Straten, Li, & Andersson, 2010). The efficacy of these interventions is comparable to face-to-face interventions for the same problems.Although research on this topic has been carried out extensively in some countries (Andersson, Hesser, Hummerdal, Bergman-Nordgren, & Carlbring, 2013; Berger et al., 2011; Berger & Andersson, 2013; Spek et al., 2007), the research in Brazil is in its infancy (Pieta & Gomes, 2014). On the other hand, the use of the internet by psychologists have been regulated by the Federal Council of Psychology through the resolution 011/2012 (Conselho Federal de Psicologia, 2012) and it is believed to be growing exponentially (Pieta & Gomes, 2014). Brazilian psychologists are allowed to use internet as a tool for intervention in experimental settings and as long as it is focused, brief and informative interventions.

Dr. Thomas Berger, from the University of Bern, Switzerland, studies the theme of online delivered interventions since 2005. He has recently been distinguished with an Early Career Award by the Society of Psychotherapy Research for his contribution of the field. Besides having published several important papers about internet interventions, Dr. Berger has developed and adapted several interventions for the online setting. He is a board member the European Society for Internet Interventions (ESRII) and is member of the editorial board of important journals in this field such Internet Interventions.

RL: Can you tell us a bit about your professional background? Can you remember what caught your attention in in the internet-based format of CBT?

TB: During my CBT psychotherapy training, I worked as a therapist in a study investigating the efficacy of face-to-face CBT for patients suffering from social anxiety disorder. Especially during the psychoeducational part of this treatment, I often had the impression that patients were not able to concentrate entirely on the content of what was being said during therapy. Due to their disorder, patients were nervous in this face-to-face setting, concentrating on their own behavior, and not on the content of the session. Thus, I thought it were better to realize the educational part of the treatment in another way. This was in 2005 and together with Eleonore Hohl and Franz Caspar, we started to develop an internet-based platform to treat social phobia. This platform included a self-help part consisting of several self-help modules with quite a lot of psychoeducational material and CBT exercises, but it also included a secured message system through which a therapist assisted and supported patients while they worked their way through the self-help platform.This kind of treatment is termed guided selfhelp treatment and most studies in the field of internet-based treatments have been conducted with such an approach. We were surprised by the promising results we received in our pilot studies, so that we decided to go on with this work and received research funding. Moreover, we were not the only ones at the time in that field of research, as a Swedish and an Australian group started even earlier. In 2009, I went to Sweden to dedicate my post-doctoral studies in one of the leading research groups in this field (with Dr. Gerhard Andersson, Linköping University).

RL: Can you tell us what type of work you do at the moment? Is it more research? Do you also have an online practice?

TB: I would define myself as a researcher, but borders between research and practice are not clear-cut. Essentially, my team and I are developing internet-based treatment programs and then doing studies with varying research questions. For instance, we are presently testing whether peer support through an online forum increases the efficacy of an internet-based selfhelp treatment; whether such a treatment can also be delivered through a smartphone app; or how internet-based treatment can be combined with conventional face-to-face psychotherapy. I do not have an online practice, but of course we treat clients with diagnosed mental disorders in our studies conducted at the University of Bern.

RL: In Brazil we have very strict guidelines about when internet-based interventions can be used. For instance, it is only allowed in experimental settings, in short-term and problem focused interventions. Can you tell us a bit about the Swiss environment for the internet based interventions? Is the regular professional allowed to deliver the online format of self-guided cognitive-behavioral therapy (iCBT)? Is it something that clinicians actually use in their daily practice? Is it normally well accepted by the clients?

TB: In general and internationally, internet-based interventions are not well implemented into regular health care settings yet, with some exceptions such as Sweden, the Netherlands or Australia. Thus, iCBT has been heavily researched during the last few years but it is not yet disseminated on a large scale. In Switzerland, regular professionals are allowed to deliver treatments via the internet. However, iCBT is not paid by Swiss health insurances. There are therapists offering internet-based therapy for self-payers but the situation is very scattered so that it is difficult to keep an overview. The question regarding the acceptance of internet-based interventions by clients is not easy to answer because we let patients decide which format they prefer. In our studies, we only include participants for which an internet-based intervention is at least an acceptable option. We do not know much about patient preferences in Switzerland, but in a recent Swedish study, patients preferred internet treatment over group treatment. Another observation is that acceptance and preferences change during the course of a treatment depending on whether the treatment works or not.

RL: What types of internet-based psychological interventions are available today?

TB: On the one hand, there are approaches in which the internet is used to communicate with a physical person on the other side of the connection such as online therapy via chat, email or videoconferencing. On the other hand, there are interventions that use the internet to provide information and interactive self-help programs which do not require any input from a clinician. As mentioned above, a combination of these two possibilities is often observed: In the so-called guided selfhelp approaches, the presentation of a web-based self-help program is combined with minimal but regular therapist contact (often via e-mail). Furthermore, during the last years, there was in increased interest in treatments combining web-based technologies with traditional face-to-face therapy. However, research on these blended approaches is still scarce.

RL: I have the impression that most internet-based interventions come from CBT. Is that really the case? If so, why do you think it happens? Are CBT interventions more suited to be "translated" to online settings?

TB: Indeed, most interventions evaluated in this field are based on CBT. However, there have been recent studies showing that psychodynamic, affect phobia treatment or interpersonal psychotherapy work well for depression and anxiety. It is also important to note that there are various forms of CBT. For instance, there are several studies on Acceptance and Commitment Therapy (ACT) over the internet. CBT may be specially suited to be delivered via internet because of its directive approach with many psychoeducational elements and homework assignments, but as mentioned above, there are also other options now.

RL: Which disorders or problems have been treated successfully with iCBT? Are there disorders more suitable to be treated with this psychotherapeutic format than others?

TB: Today, there are studies with promising results for all common mental disorders such as anxiety, mood, eating and sleep disorders. But there are also successful treatments for behavioral medicine problems such as tinnitus, irritable bowel syndrome or chronic pain. At this point, there is no definite answer to the question for which disorders internet-based treatments are especially suited or especially not suited. There are conditions such as social anxiety disorder for which more than 22 randomized controlled trials indicate good results, comparable to the results of face-to-face treatments. There are other disorders such as borderline personality disorder or severe psychiatric conditions such as schizophrenia and bipolar disorder for which two years ago, internet-based solutions would have been judged as inappropriate. Nowadays, there are several groups working on internet-based interventions for these patient populations.

RL: It seems that the intervention delivered over the internet has a special interest of clients with social anxiety problems.Why is this the case? And isn’t a sort of a paradox to treat a problem of social interaction through a media with some "anti-social traits"?

TB: Indeed, social anxiety disorder is one of the most researched disorders in the field of internet-based treatments. I agree that it is not obvious that internet interventions should work for patients with social anxiety disorder. It has been found that persons with social phobia do use the internet extensively, and it could be argued that these treatments reinforce their avoidance of contact with people. On the other hand, the programs are based on CBT and they include exposure to real life situations. In our studies, we encourage users to test reality explicitly in real-life situations they would usually avoid. Our experience is that many people with social anxiety manage to seek outside exposure with the guidance of an internet-based intervention. In addition, the perceived safety of their familiar environment in front of the computer might facilitate the necessary learning phase in CBT.

RL: Is there a client profile who will benefit best if treated over the internet?

TB: Unfortunately, there is no clear-cut answer to this question either. Until recently, the majority of studies have focused on establishing ICBT as an efficacious treatment and there are only a few studies on predictors and moderators of outcome at the present moment. In addition, potential predictors of outcome have usually not been found consistently across studies, but these inconsistent findings are also known from research on face-to-face psychotherapies. There are several studies showing that positive patient expectations are associated with better outcome. A finding of our group is that online activity in the self-help program early in the treatment is predictive of outcome. Thus, monitoring of the online behavior of the participants can be important and easily done in online approaches. However, the literature on predictors of outcome is still too limited to draw firm conclusions.

RL: Are there any counter-indications?

TB: Patients with suicidal tendencies are usually excluded from treatment, as the therapist has no means to react adequately from a distance.

RL: Have there been studies comparing the efficacy of the internet-based and face-to-face interventions?

TB: Yes, as a matter of fact, a recent systematic review and meta-analysis identified 13 studies directly comparing guided iCBT with face-to-face treatment, and there are some more studies when including other internet-based treatment formats than guided iCBT. The studies are on social anxiety disorder, panic disorder, depression, specific phobia, body dissatisfaction, tinnitus or sexual dysfunction.

RL: What are the conclusions they reach?

TB: The meta-analysis, and also other studies, clearly indicate that iCBT and face-to-face treatments produce equivalent overall effects. However, the number of direct comparisons is still small and there are many disorders for which iCBT has not been compared to face-to-face treatment at all.

RL: Clinicians who see clients via internet often report that most people who seek online treatments, given the choice, will prefer to use text messages over real time voice or image sharing. Do you also see that in your practice?

TB: In one of our recent studies, participants were able to choose between a regular text-based email contact or weekly telephone calls with their therapists. Only 2 out of 27 participants chose the phone calls.

RL: Do you have an explanation for this?

TB: Some of the participants indicated time reasons for not choosing the phone call option, as phone calls need to be scheduled and emails can be read and written at all times. Others said that the written feedback satisfied all needs. I remember one participant telling us that he kept the participation secret from his family members and weekly telephone contact without informing the family would have been a problem. Thus, greater convenience of asynchronous text-based communication seems to be important.

RL: It is well shown in the literature of psychotherapy research the strong correlation between the quality of the therapeutic alliance and clinical outcome. Is there a difference in how the therapeutic alliance happens in internet-based treatments and how do you think this might affect the results?

TB: We do not know much about qualitative differences between the therapeutic alliance in internet-based treatments when compared to conventional face-to-face treatments. However, there is already quite a lot of quantitative research showing that alliance ratings of clients are fairly high in internet-based treatments, comparable to ratings in face-toface treatments. Thus, clients tend to trust and appreciate their online therapists. Probably, this is not such a surprising fact if we consider how many people find their intimate partners and build all sorts of relationships over the internet nowadays. However, it is not very clear yet whether the alliance makes so much difference for the final outcome.There are studies that find an association between the alliance and outcome, and others that do not. Our own results indicate that there are differences between different clients in how important the alliance is for the outcome.

RL: What are the areas that are lacking research at this point?

TB: Given that the efficacy of internet-based treatments has been demonstrated repeatedly, research is now facing new challenges. Some of the issues are for whom and how internet-based interventions work best, how these interventions should and can be implemented into regular practice, and how they should complement and be combined with face-to-face treatments. Presently, there is a lot of discussion going on regarding blended treatments, the combination of face-toface and online interventions. However, there are almost no studies on this issue with some notable exceptions (see www.ecompared.eu). Other issues are what role the therapist contact plays in internet interventions, whether smartphone-delivered treatments can add something to the existing approaches, how treatment adherence can be improved especially unguided selfhelp interventions, and finally whether internet-based treatments also work for other groups such as children or older people.

RL: How do you visualize the impact of the internet on the clinical practice of the regular psychotherapist?

TB: I believe that it will become quite normal for therapists to provide some elements of the treatment online.The dissemination of blended treatments, where we see our patients in our practice but also have treatment and communication over the internet, is quite a realistic scenario for the near future.


REFERENCES

Andersson, G., Hesser, H., Hummerdal, D., Bergman-Nordgren, L., & Carlbring, P. (2013). A 3.5-year follow-up of Internet-delivered cognitive behavior therapy for major depression. Journal of Mental Health, 22(2), 155–164. http://doi.org/10.3109/09638237.2011.608747

Berger, T., & Andersson, G. (2013). Internet-Based Treatments - Experiences from Sweden: An Interview with Gerhard Andersson. Verhaltenstherapie, 23(3), 211–214. http://doi.org/10.1159/000188079

Berger, T., Caspar, F., Richardson, R., Kneubühler, B., Sutter, D., & Andersson, G. (2011). Internet-based treatment of social phobia: A randomized controlled trial comparing unguided with two types of guided self-help. Behaviour Research and Therapy, 49(3), 158-169. http://doi.org/10.1016/j.brat.2010.12.007

Conselho Federal de Psicologia. (2012). Resolução CFP N° 011/2012: Regulamenta os serviços psicológicos realizados por meios tecnológicos de comunicação a distância, o atendimento psicoterapêutico em caráter experimental e revoga a Resolução CFP N.o 12/2005. Conselho Federal de Psicologia. Retrieved from http://site.cfp.org.br/wpcontent/uploads/2012/07/Resoluxo_CFP_nx_011-12.pdf

Cuijpers, P., Donker, T., van Straten, A., Li, J., & Andersson, G. (2010). Is guided self-help as effective as face-to-face psychotherapy for depression and anxiety disorders? A systematic review and meta-analysis of comparative outcome studies. Psychological Medicine, 40(12), 1943-1957. http://doi.org/10.1017/S0033291710000772

Pieta, M. A. M., & Gomes, W. B. (2014). Psicoterapia Pela Internet: Viável ou Inviável? Psicologia: Ciência E Profissão, 34(1), 18-31.

Spek, V., Cuijpers, P., Nyklíček, I., Riper, H., Keyzer, J., & Pop, V. (2007). Internet-based cognitive behaviour therapy for symptoms of depression and anxiety: a meta-analysis. Psychological Medicine, 37(03), 319. http://doi.org/10.1017/S0033291706008944










1. Doutor em Psicologia Clínica, Universidade do Minho, Portugal - (Professor adjunto do Programa de Pós-graduação em Psicologia Universidade Católica de Petrópolis, RJ, Brasil) - AdHoc - MG - Brasil
2. Doutor em Psicologia Clínica, Universidade de Freiburg, Alemanha - (Professor adjunto do Departamento de Psicologia Clínica e Psicoterapia, Universidade de Berna, Suíça)

Correspondence:
Universidade Católica de Petropólis - Centro de Ciências da Saúde - Mestrado em Psicologia.
Rua Benjamin Constant, 213, Centro
Petrópolis, RJ, Brazil. Caixa Postal 90.944, CEP: 25610-130.

This paper was submitted to the RBTC SGP (Management Publications System) on May 4, 2016. cod. 426.
Article accepted on November 26, 2016.
 
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