Cognitive Behaviour Therapy
ISSN: 1650-6073 (Print) 1651-2316 (Online) Journal homepage: http://www.tandfonline.com/loi/sbeh20
Therapists' Experiences of Conducting Cognitive Behavioural Therapy Online vis-à-vis Face-to-Face Jonas Bengtsson, Steven Nordin & Per Carlbring To cite this article: Jonas Bengtsson, Steven Nordin & Per Carlbring (2015): Therapists' Experiences of Conducting Cognitive Behavioural Therapy Online vis-à-vis Face-to-Face, Cognitive Behaviour Therapy, DOI: 10.1080/16506073.2015.1053408 To link to this article: http://dx.doi.org/10.1080/16506073.2015.1053408
Published online: 19 Jun 2015.
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Date: 05 November 2015, At: 18:25
Cognitive Behaviour Therapy, 2015 http://dx.doi.org/10.1080/16506073.2015.1053408
Therapists’ Experiences of Conducting Cognitive Behavioural Therapy Online vis-a`-vis Face-to-Face Jonas Bengtsson1, Steven Nordin1 and Per Carlbring2 Department of Psychology, Umea˚ University, Umea˚, Sweden; 2Department of Psychology, Stockholm University, Stockholm, Sweden
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Abstract. This study has explored therapists’ experiences of conducting cognitive behavioural therapy (CBT) online and face-to-face. Eleven therapists partook in semi-structured interviews, which were thematically analysed using an abductive approach. The results indicate that the therapists viewed face-to-face therapy as a stronger experience than Internet-based CBT (ICBT), and the latter as being more manualised, but providing more work-time control. Several participants also thought that working alliance may be achieved faster and more easily in face-to-face therapy, and might worsen with fewer modalities of communication. Clinical implications in need of investigation are whether working with ICBT might buffer therapist exhaustion, and whether this therapy form can be improved by becoming less manual dependant in order to be easier to individualise. Key words: Internet-based treatment; ehealth; therapists; qualitative; interview; Internet CBT; ICBT. Received 18 March 2015; Accepted 12 May 2015 Correspondence address: Jonas Bengtsson, Department of Psychology, Umea˚ University, Umea˚, Sweden. Email: [email protected]
Introduction Research on Internet-based cognitive behavioural therapy (ICBT) with therapist support has been proven effective against many different psychiatric disorders, such as depression, anxiety disorders, stress and sleeping difficulties (Andersson, Carlbring, Ljo´tsson, & Hedman, 2013). However, there are still knowledge gaps to fill. A recent Cochrane review argues that too few studies have been conducted to directly compare Internet-based treatment with face-to-face therapy (Olthuis, Watt, & Stewart, 2011). The research that so far has compared the two therapy modalities has shown no significant differences in efficacy (Andersson, Cuijpers, Carlbring, Riper, & Hedman, 2014). However, most of this research has been carried out from a quantitative standpoint, and has thus provided limited in-depth understanding for the differences. The few qualitative studies that do exist show far more complex differences, such as clients experiencing the same aspect in treatment in completely different ways (Bendelin et al., 2011; Olsson q 2015 Swedish Association for Behaviour Therapy
Halmetoja, Malmquist, Carlbring, & Andersson, 2014). This study aims to fill some of the abovementioned knowledge gaps. This was done by comparing ICBT to face-to-face therapy, adopting an explorative and qualitative stance. A therapist perspective was taken since this has rarely been done in research concerning ICBT (Montero-Marı´ n et al., 2013). Since working alliance has been shown to be a factor in treatment outcome (Bergman Nordgren, Carlbring, Linna, & Andersson, 2013; Dolemeyer, Klinitzke, Steinig, Wagner, & Kersting, 2013; Preschl, Maercker, & Wagner, 2011; Wagner, Brand, Schulz, & Knaevelsrud, 2012), special focus was given to this aspect. According to Rogers (1957), good working alliance requires that the therapist has an unconditionally positive regard for the client and that the therapist conveys empathy, warmth and congruency towards the client. The two more ample reviews on working alliance in ICBT to date (Klasen, Knaevelsrud, & Bo¨ttche, 2013; Sucala et al., 2012) arrive at very similar conclusions. First, that
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creating a working alliance online is possible and can be equal to the alliance in face-to-face therapy. Second, both studies showed support for working alliance affecting the treatment outcome. Sucala et al. (2012) and Cook and Doyle (2002) found evidence that the more the modalities of communication used (for example, mail, chat or video chat), the stronger the working alliance being perceived by the client. Research done from the therapist’s viewpoint gives a different perspective. Sucala, Schnur, Brackman, Constantino, and Montgomery (2013) examined clinicians’ thoughts about creating a working alliance online. Even though they thought it was possible, the therapists highlighted that the working alliance was more important in face-to-face therapy. The participants conveyed that they had difficulties assessing the clients’ emotions and communicating warmth and empathy over the Internet. Calero-Elvira, Santacreu, de la Torre, Purrin˜os, and Shih (2014) reported that working alliance might be equivalent in both forms of therapy from a client’s perspective, but that therapists experienced the established working alliance as better in face-to-face than online. To recapitulate, the purpose of this study was thus to explore therapists’ experiences of conducting face-to-face and Internet-based guided CBT, with special focus on how they experience their contact with the clients. By comparing and contrasting these experiences, the study aimed at identifying potential strengths and weaknesses in each modality of therapy, particularly in the area of working alliance.
Method
face-to-face. They had 1 to 10 years of experience with ICBT, except for one therapist who had finished two treatments when interviewed. All participants had at least three years of experience with face-to-face therapy. The participants had worked with both therapy modalities to a varying extent. This extent reached from working full-time face-to-face and occasionally online through research projects, to a full-time employment working with ICBT and earlier experience with face-to-face therapy only from education or early work days. Among themselves, the participants had treated a number of psychiatric disorders with ICBT, including different forms of anxiety, depression, panic disorder, sleeping difficulties, Irritable Bowel Syndrome, Obsessive Compulsive Disorder, pain, eating disorders and tinnitus. The participants had treated all of the abovementioned disorders face-to-face, but also stress, burnout, bipolar disorder, overweight, various personality disorders, Post-Traumatic Stress Disorder and Attention Deficit Hyperactive Disorder.
Data collection Each interview lasted about 30 to 50 min that followed a semi-structured interview guide in accordance with the method of abductive thematic analysis. The interview was recorded to be transcribed later on. The data collection was concluded when the last two interviews provided no new themes or perspectives. Thus, saturation in the data was achieved. A pilot interview guide was tested with two junior Internet therapists and revised two times. All participants gave their written informed consent, and the procedure followed stipulated Swedish ethical research guidelines (Swedish Research Council, 2002).
Participants Twenty-one psychotherapists were contacted with information on this study and asked to participate. Out of these eight declined and two were excluded for reasons concerning time and resources. Lastly, 11 therapists were recruited for semi-structured interviews. This group consisted of five men and six women, varying in age between 31 and 48 years (M ¼ 37, SD ¼ 5.88). Ten were licensed psychologists, and one was a social worker and licensed psychotherapist. All participants had worked with both CBT both online and
Analysis The interviews were transcribed verbatim by the first author and two outside transcribers. The thematic analysis (Braun & Clarke, 2006) of the data commenced parallel with the transcription of the other interviews, and was conducted by the first author. First, the raw data were read through several times to obtain familiarisation and a holistic view. Second, all the interviews were coded, and a number of quotes were collected under each code. Third, these codes where gathered under overarching
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themes. The entire data-set and codes were reviewed as to find everything that could potentially fit under each theme, and to make sure the themes would still reflect the data. Finally, these themes where refined and defined as clearly as possible, and quotes from the raw data were selected to show the relationship with the themes in this presentation.
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Results The analysis revealed four large themes, each with two to three subthemes. The four larger themes were named “Manual-based ICBT or individually tailored face-to-face therapy”, “Face-to-face therapy as a stronger experience than online therapy”, “ICBT and work-time control” and “Working alliance”. These can be found in Appendix 1, and presented more in detail below (Table 1).
Manual-based ICBT and individually tailored face-to-face therapy? The participants’ reported sometimes having difficulties in achieving structure and focus in face-to-face therapy. In contrast, they experienced that ICBT made it easier to achieve such focus, sometimes attributed to the manual or structure of the therapy. The manual is clearer and easier to follow when you have it in text form, which the patient reads. ( . . . ) You focus on what you really have agreed to focus on. If it is depression—or whatever it is—and not get stuck on all the little things which can pop up in a conversation between . . . between people. (#2)
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Having the treatment material and communication fixed in writing seemed to make it clearer and more available for both the therapist and the client. The manual was also often seen as a safety measure for the therapists, and made them feel secure and believe in the treatment and that they provided evidence-based material that would yield results. The manual also made the therapy difficult to adapt to the individual. However, some argued that they had the opportunity to adapt their answers and interventions to the client even via the Internet. A few therapists remarked that some of the clients needed a more caring therapy style where the client was allowed to “float away as they pleased”. When you work with complete treatment packages (in ICBT), then it becomes a little bit ‘one size fits all’. Then it does not fit anyone really well. ( . . . ) I want several different sizes, so that I can find you a slimmed suit that fits you. (#5)
Contrasting this opinion on ICBT, face-toface therapy was described as providing flexibility. This meant a larger opportunity to tailor the therapy to the client. They described it as having more “tools” to work with, meaning the direct feedback, the option to ask direct follow-up questions, body language, voice and tone as well as subconscious communication. There is great room to individualise each treatment, and that does not exist in internet therapy in the same way ( . . . ) Uh, so that you can really bury yourself in a case and think a
Table 1. Themes and subthemes emerging from the data-set. Theme Face-to-face therapy is a stronger experience than ICBT Manualised ICBT or individually tailored face-to-face therapy ICBT and work-time control Working alliance
Sub-theme Face-to-face therapy is more reinforcing than ICBT (35 statements). Face-to-face therapy brings more focus to the therapist (25 statements). Face-to-face therapy is more demanding than ICBT (31 statements). ICBT is manualised and more focused than face-to-face therapy (67 statements). Face-to-face therapy is easier to adapt to the client than ICBT (62 statements). Face-to-face therapy is dependent on time and space (10 statements). ICBT offers more flexible work-time (39 statements). Working alliance is possible in ICBT (25 statements). Advantages of creating a working alliance face-to-face (30 statements). Working alliance differs in both therapy forms (13 statements).
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little more and, uh, shape it after a specific patient. And it does not have to be diagnosespecific either. It can be, like . . . yes, compulsion or depression in a mix, like that, yeah? (#3).
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You can look each other in the eye and validate in another way, because you see, maybe, that they are feeling bad, even though it would not have emerged through what they say or what they write for example. Uh, so you can catch things in another way. You do not have . . . you have access to body language and such. So that is an advantage. You can also . . . another advantage is that the treatment becomes more adaptable. (#2)
According to some, this opened face-to-face therapy for addressing broader problems as well as more unspecified ones, compared with ICBT. It was assumed that ICBT offered a broader range of competence and with several different areas at the same time.
Face-to-face therapy is a stronger experience than ICBT Face-to-face therapy is a, well, more, both more rewarding and more punishing in some way, it is like a strong, a stronger experience (than ICBT). When it is going well and going forwards for the patients, then you become happier, and when it does not go as well or when it goes badly with, with the patient work, then you become frustrated and self-critical. Meanwhile, in internet therapy, you might be more lukewarm all the time. (#11)
As expressed above, some therapists described face-to-face therapy as a ‘stronger’ experience than ICBT. They expressed that they felt ‘more reinforced’ as therapists by face-to-face therapy. This reinforcement came from the direct feedback they got from their clients, because they could see how their interventions were received. (ICBT) is not as reinforcing for the therapist as it is to meet a person face-to-face. ( . . . ) There are some reinforcing aspects missing, which exists in face-to-face. ( . . . ) You do not really see how (your interventions) affects the person in the moment. (#4)
Some therapists reported that they experienced that ICBT lacked the “wow-moments” or “breakthroughs” of face-to-face therapy. It should be noted that all therapists found ICBT a working and satisfactory treatment form, though some found the experience inferior to face-to-face therapy. Lastly, some
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of the participants talked about how they perceived the working alliance as stronger in face-to-face therapy. This will be elaborated upon under the headline “Working alliance”. Several therapists discussed how ICBT gives the clients more of the responsibilities for their own treatment. This seemed to coincide with a larger focus being brought onto the therapists’ work in face-to-face therapy. The increased focus on the therapists could make them feel “helpful” and better about their work. There is more focus on me, that is also . . . uh, could actually be a disadvantage in livetherapy, that there is less focus on the therapy. Progress is also attributed more to me as therapist than to the therapy itself and what the patient does. (#10)
Contrasting this, a picture of face-to-face therapy as more demanding for the therapists also emerged. First, face-to-face was described as “frustrating”, “exhausting” and lacking appropriate rewards for effort. Second, several of the participants also reported a more strained work load in face-to-face, due to administrative work, such as booking and rebooking sessions as well as handling cancellations. Several of them also reported that more time in the actual therapy sessions was spent on themes not concerning the treatment goals. One therapist noted, however, that this belief could be a result of “heavier cases” and different clients in face-to-face therapy, and thus not only from the modality itself. I think that is has been both, well, fun and occasionally also very, like, demanding. ( . . . ) You feel very much less burdened by (ICBT) than in regular outpatient care. It does not get as, like . . . heavy in the moment, as it can get when you are sitting with someone who become like that really sad or really angry or dissatisfied or—you become protected by the screen in some way. (#7)
As displayed above, the participants often remarked that ICBT provides weaker reinforcement. Thus, some of the participants pursued alternative forms of reinforcement when working in ICBT. They could, for example, get their reinforcement by acknowledging their clients’’ gradual achievements. Another possibility is to share achieved progress with their colleagues. However, the weaker experience of ICBT could also be seen as something positive.
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I think it is good that you, you are protected and you will last a little longer and you do not get tired and you will not, like, you will not be negatively impacted. Uh, you do not get run down. I think you will last longer as an internet therapist. (#7)
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ICBT and work-time control A recurring theme in the data centred on the flexibility of work-time in ICBT. Face-to-face therapy was depicted as compartmentalised and dependent on a certain time and place to function. A few therapists also mentioned that these tasks could often become disarrayed with cancelled therapy sessions, meetings and full schedules. You are usually completely dependent on time and space. Uh, you got to have a certain venue, got to be at a certain place. The patient and you have to be there on a certain time. Uh, it is . . . uh . . . and that is like technical for the both of you. ( . . . ) uh, but in internet ther- or face-to-facetherapy there are cancelled appointments and you mess up the patients schedule, and the likes. (#8) Yeah, well, the only disadvantage that I have experienced—which is not inconsiderable—is that you are very booked up in time. You have your appointments, where you are very booked up, and those you have to make and follow very carefully in that way. So for me it fits extremely well with the internet therapy where I can decide when I want to do what. And rearrange a day if I want. Swap the order of things. (#1)
As shown above, many therapists mentioned work-time flexibility in ICBT. For example, they could decide not only when and how fast they would do their work, but also where to do it. In short, the participants experienced that therapy conducted over the Internet became unbound by time and space. Another work-time advantage concerning ICBT that emerged from the data was that the participants perceived it as being unaffected by illness (either their own or their children’s), emergencies or meetings at the work place. For some it even meant that colleagues could take over their clients for them if needed. The technical solutions often did much of the work for the therapists, for example reminding clients to do their homework or to write to their therapists. This flexibility in time made it possible for several of the therapists to do other work on the side of their ICBT, such as research or
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face-to-face therapy. Many of them also mentioned that this made it possible for them to work with many more clients at one given time than would face-to-face.
Working alliance Several therapists reported that creating a working alliance was definitely a possibility in both media. Some therapists had had misconceptions that it would be hard to create a working alliance online, but found it easier than expected. A misgiving I had when I started working here, that, that how are you going to, like, get a personal relationship, uh, with patients that you never meet? ( . . . ) There can be very personal meetings even over the net. ( . . . ) I have seen very, very good, fantastic alliances, even with patients over, over the internet surprisingly good. (#6)
However, even though almost all therapists maintained and emphasised that creating a working alliance over the Internet is possible, they also stated that it might be done easier and faster in face-to-face therapy. A few speculated that this was because of the broader spectrum of communication available in face-to-face therapy. It is very different in the live contact, but generally it might take longer to get that personal (contact in ICBT) maybe, even if I think it comes with time anyway. So it is seldom you can get that immediate thing, like, that you can get with some (clients) live. (#2) In some way maybe it is easier (to create a working alliance), that is, when you are sitting in the room, because you have access to the body in some way. And then you have gestures and like . . . yes, but, facial expressions and gaze and the likes. You do not have that (in ICBT). (#7)
However, opinions on whether the quality of the working alliance in both forms of therapy could be compared were diverse. Several stated that the two media were different in this respect. Some argued that the working alliance usually was “stronger” and “richer” in face-to-face therapy. However, most of them still maintained that this did not make the ICBT working alliance inferior. You can say that . . . you have . . . a contact with these people that is of another quality, you, you . . .
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uh . . . it is probably a notch . . . better, or no, not better, but it is a notch . . . a notch richer. (#3) It becomes another, yes, it becomes like another type of alliance, but at the same time it becomes a different alliance. It might be equally good, but it is not really the same. (#5)
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One therapist argued that this discrepancy in working alliance was because he had worked with both therapy forms and was therefore able to compare them. I experience that you get a stronger alliance in face-to-face, but at the same time I know (laughs) that there are studies that show that it is not always that big a difference when you assess it, so it is simply relative, that . . . we who go for both parts, we might experience a greater difference than patients who only experience the one. (#11)
Others, in contrast, speculated that it was rather the clients that differed. A few participants even thought that ICBT and writing as communication create better working alliances than face-to-face therapy when dealing with clients with social phobia, because ICBT is less “charged” and threatening than face-toface therapy. Finally, two participants experienced that adolescents open themselves up more in ICBT. I think that many times, for some patients, it can be an advantage that you have not . . . met live because it feels a little more threatening and revealing to sit face-to-face and tell someone things that are shameful, anxious. (#6) I rather think that ( . . . ) clients have opened themselves more (in ICBT) than what you can do in the room ( . . . ) It could be because they are adolescents, but also that you, that sometimes it can be easier when you express something in writing instead of sitting together with a person you do not know so well in a room. That . . . if you write you, you do not see the person in front of you so that, uh . . . that you dare to expose yourself a little more. (#10)
Discussion As shown by the results, several of the participants viewed ICBT as focused, structured, evidence-based, clear and safe. This was often attributed to the treatment manual. Contrasting this view, face-to-face therapy was depicted as easier to individualise, providing more “tools” to work with and opening up for working with broader,
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unspecified or multiple problems. This contrast taps into a larger debate about whether psychotherapy in general benefits more from being manual based or tailored to fit the individual (Linden & Golier, 2008). The results of this study have two major similarities with the advantages that Wilson (1996) finds with manual-based treatments. First, the manual helps the therapist achieve a clearer focus in the therapy. He argues that this is partly because of the demarcation in time that a manual-based treatment requires. Second, that a manual makes it easier to maintain a certain quality in the treatment, keeping it evidence based and researchable. The disadvantages of manual use stipulated by Wilson (1996) also have parallels to the participants’ views. He writes that treatment manuals for specific disorders are not always applicable since these disorders vary in their symptoms and causes. Therefore, a manual might miss differences and focus on treating conditions that might be irrelevant for the specific client. Wilson (1996) also supports the notion from the participants that less manualbased face-to-face therapy might be better suited for working with broader, more unspecified and multiple problems, and that ICBT is not suitable for everyone. Lastly, Wilson (1996) argues that it might be necessary to assess the client’s problems in person. Since the therapists reported it more difficult to “read” the client over the Internet, this seems to be a valid point, and important for the recruitment of clients in ICBT. It also gives support to the praxis of blended therapy, where the client and therapist have a few introductory sessions face-to-face, and then continue working online if it suits the clients’ needs. However, it should be argued that the dichotomy of manual-based and individualised treatments is not an absolute. There exist many highly manualised face-to-face treatments, which allow several advantages of manualisation to actually be achieved face-toface. However, with a few exceptions (e.g. Carlbring et al., 2011), more flexible forms of ICBT do not yet seem to exist to the same extent. This suggests a few alternative routes for the future of the latter therapy form. First, ICBT could remain manualised. This means that ICBT would stay unsuitable for certain problems and clients. Second, another
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option is to facilitate individualisation in ICBT. This can be done either by merging more face-to-face elements into ICBT, making it more of a blended therapy (van der Vaart et al., 2014), or as Wilson (1996) suggests, allow the treatment manual to become more individualised. According to Svartvatten et al. (in press), this can be done by timing the intervention, using multiple techniques and using the manual more flexibly. Some participants found face-to-face therapy exhausting due to the stronger emotional experience, frustration and more administrative work. This theme might be related to a major problem in Swedish healthcare. Healthcare workers, such as psychologists, continue to be one of the groups with the largest amount of sick leave in Sweden, mostly on account of stress reactions or depressive episodes (Fo¨rsa¨kringskassan, 2011). The therapists’ experiences of emotional exhaustion and a heavier work load in face-toface therapy fit well with this pattern. In contrast, many participants described ICBT as providing a less exhausting experience, which might even protect the therapist from exhaustion. Generalisable research is needed to verify this, but this study gives several affirming indications. These assumptions are also in line with previous research done by Reynolds, Stiles, Bailer, and Hughes (2013), who measured lower levels of arousal in both therapists and clients in ICBT as opposed to face-to-face therapy. They hypothesise that the online environment is more comfortable and less threatening (p. 375) than its face-to-face counterpart, and speculate that this is because of the time delay in the communication. Even though this study focuses on the therapists and Reynolds et al. (2013) on the clients, there are similarities. For example, the time delay in Internet communication mentioned by Reynolds et al. (2013) and the direct feedback of face-to-face therapy reported as a reason in this study can very well be seen as two sides of the same coin. This study also supports Reynolds et al. (2013) posed implications, such as ICBT being suitable for clients (or perhaps even therapists) with anxiety disorders or social phobia. The increased work-time control in ICBT reported by the participants might also play a part in this. The effects of work-time control are positive, according to Nijp, Beckers,
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Geurts, Tucker, and Kompier (2012). Their review shows that it has positive effects on work – non-work balance, as well as job satisfaction and job performance. More importantly, work-time control also has a positive effect on health and well-being, including stress, burnout, depression, anxiety and sick leave (Nijp et al., 2012). Considering that the work-time control described by the participants in this study does have the effects that Nijp et al. (2012) suggest, maybe ICBT can work as a first step for exhausted therapists returning to work, or as a buffer for therapists on the verge of burnout? As stated, better targeted research is needed to answer whether a relation exists between ICBT, work-time control and positive health effects, but the results of this study indicate that such an assumption is not farfetched. The results of this study can both corroborate and challenge existing research. Most importantly, the participants’ views that creating a working alliance in ICBT is possible—despite prejudices that it would not be possible—has been confirmed by the previously mentioned reviews by Klasen et al. (2013) and Sucala et al. (2012). Sucala et al. (2013) and Calero-Elvira et al. (2014) suggest that therapists experience it as stronger and better in face-to-face than over the Internet, which is also a theme in these results. The working alliance and the therapist’s work were also seen as less important than the client’s own work in ICBT by both the participants in this study and those in the study by Sucala et al. (2013). As stated earlier, some participants thought the relationship was equivalent in both modalities. Indeed, other research examined in the two reviews by Klasen et al. (2013) and Sucala et al. (2012) do not find any significant difference from the client’s point of view. One possible explanation is the relative difference discussed by one of the participants, where he commented that maybe the therapists experience working alliance as better face-to-face since they have experience of both. On the other hand, clients usually only have experience from one treatment form, and therefore the different working alliances might be assessed as the same. Should this be the case, it may very well explain the findings of Sucala et al. (2013) and Calero-Elvira et al. (2014).
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The results from this study suggest that whereas more modalities of communication are available, working alliance might be created more easily and faster, and provide a stronger experience for the therapist. This is supported by Sucala et al. (2013), who argue that clinicians experienced that negative impact on the working alliance is related to fewer modalities of communication (mail, chat, video chat) accessible. The participants of this study point out that fewer means of communication also mean that the assessment, and more importantly suicide assessment, of the client becomes more difficult. Along with Sucala et al. (2013), we would like to suggest more research on how working alliance is affected by more or fewer means of communication. Interestingly, in one study by Lindner et al. (2014), therapist guidance by telephone appears to be equal to therapist guidance by e-mail with regard to working alliance and treatment outcome. This study faces a number of limitations, mainly with the selection of participants. The partaking therapists were still active Internet therapists, which may imply that they enjoyed and saw advantages with ICBT. Future studies might instead also recruit Internet therapists who are not as pleased with their experiences in order to broaden the diversity of opinions. In spite of this limitation, disadvantages and advantages of both therapies have been highlighted and neither should be overlooked. Related to the above limitation is the fact that there are very few ICBT projects active in Sweden at date. Therapists working in several of these projects were approached concerning participation in the study. Since eight therapists declined to participate and two were excluded due to limited time and resources, the conclusive sample chosen for this study had to be based on availability. Thus, the Internet Psychiatry Unit in Stockholm was over represented among the participants of this study. This means that some of the similarities in the data might stem from the participants’ sharing workplace, as well as all of them working in an urban environment. Another liable limitation emerged from the data itself, namely that the participants speculated as to whether different clients were attracted to face-to-face therapy and ICBT. This has consequences for the validity of the results, in that the differences expressed
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by the participants might not derive from working with different modalities of therapy, but rather with different people. To generalise these results, more quantitative studies can be of use. For example, a design in which therapists’ level of stress, burnout and work –family conflict is correlated or compared with respect to work face-to-face versus ICBT can further clarify whether worktime control is a factor in ICBT that determines these variables. Another suggestion is to focus on a relative difference in working alliance between Internet and face-toface therapy in more fields (Jasper et al., 2014). This might answer the question of whether working alliance actually becomes stronger with the non-verbal communication provided by face-to-face therapy and what part, if any, it actually plays in ICBT. This study can with benefit be replicated in other contexts or redesigned to differentiate the data collected here. Other questions could also be asked regarding differences in, for example, credibility, expectancy and projected adherence of ICBT and face-to-face therapy. With time and resources, maybe a study with joint therapist and client perspective might be preferable, to examine the reciprocal relationship between the two. At the current, there is a deficit in research on ICBT that takes a qualitative stance (Rozental, Boettcher, Andersson, Schmidt, & Carlbring, 2015), that compare ICBT to face-to-face-therapy (Andersson et al., 2014) and that examines the therapist point of view (Friesen, Hadjistavropoulos, & Pugh, 2014). That is why this study has aimed to explore therapists’ experiences of conducting CBT online and face-to-face. To conclude, the results showed that the therapists viewed faceto-face therapy as a stronger experience than ICBT, and the latter as more manualised and providing more work-time control. They also showed that working alliance may be easier and faster created in face-to-face therapy. Clinical implications are that ICBT might buffer therapist exhaustion and that it might have to become less manual dependant in order to be easier to individualise.
Disclosure statement No potential conflict of interest was reported by the authors.
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Funding The current study was made possible in part by a grant from the Swedish Research Council (2011 – 2913).
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viour therapy. Internet Interventions, 1, 41 – 48. doi:10.1016/j.invent.2014.04.001 Jasper, K., Weise, C., Conrad, I., Andersson, G., Hiller, W., & Kleinsta¨uber, M. (2014). The working alliance in a randomized controlled trial comparing Internet-based self-help and face-to-face cognitive behavior therapy for chronic tinnitus. Internet Interventions, 1, 49 – 57. doi:10.1016/j.invent.2014.04.002 Klasen, M., Knaevelsrud, C., & Bo¨ttche, M. (2013). Die therapeutische beziehung in internetbasierten therapieverfahren. Der Nervenarzt, 84, 823– 831. doi:10.1007/s00115-012-3659-6 Linden, M., & Golier, J. (2008). Challenges in the implementation of manualized psychotherapy in combat-related PTSD. CNS Spectrum, 13, 872– 880. Lindner, P., Olsson, E., Johnsson, A., Dahlin, M., Andersson, G., & Carlbring, P. (2014). The impact of telephone versus e-mail therapist guidance on treatment outcomes, therapeutic alliance and treatment engagement in internetdelivered CBT for depression: A randomised pilot trial. Internet Interventions, 1, 182–187. doi:10.1016/j.invent.2014.09.001 Montero-Marı´ n, J., Carrasco, J.M., Roca, M., Serrano-Blanco, A., Gili, M., Mayoral, F., & Garcı´ a-Campayo, J. (2013). Expectations, experiences and attitudes of patients and primary care health professionals regarding online psychotherapeutic interventions for depression: Protocol for a qualitative study. BMC Psychiatry, 13, 64. Nijp, H.H., Beckers, D.G.J., Geurts, S.A.E., Tucker, P., & Kompier, M.A.J. (2012). Systematic review on the association between employee worktime control and work – nonwork balance, health and well-being, and job-related outcomes. Scandinavian Journal of Work, Environment & Health, 38, 299–313. doi:10.5271/sjweh.3307 Olsson Halmetoja, C., Malmquist, A., Carlbring, P., & Andersson, G. (2014). Experiences of internet-delivered cognitive behavior therapy for social anxiety disorder four years later: a qualitative study. Internet Interventions, 1, 158– 163. doi:10.1016/j.invent.2014.08.001 Olthuis, J., Watt, M., & Stewart, S. (2011). Therapist-delivered distance cognitive behavioural therapy for anxiety disorders in adults. The Cochrane Library, (3). Retrieved from http://onlinelibrary.wiley.com/doi/10.1002/ 14651858.CD009028/full Preschl, B., Maercker, A., & Wagner, B. (2011). The working alliance in a randomized controlled trial comparing online with face-to-face cognitive-behavioral therapy for depression. BMC Psychiatry, 11, 189. Reynolds, D.J., Stiles, W.B., Bailer, J., & Hughes, M.R. (2013). Impact of exchanges and clienttherapist alliance in online-text psychotherapy. Cyberpsychology, Behavior, And Social Networking, 16, 370– 377. doi:10.1089/cyber.2012. 0195
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Rogers, C. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21, 95 – 103. doi:10.1037/h0045357 Rozental, A., Boettcher, J., Andersson, G., Schmidt, B., & Carlbring, P. (2015). Negative effects of internet interventions: a qualitative content analysis of patients’ experiences with treatments delivered online. Cognitive Behavioural Therapy, 44, 223– 236. doi: 10.1080/ 16506073.2015.1008033 Sucala, M., Schnur, J.B., Brackman, E.H., Constantino, M.J., & Montgomery, G.H. (2013). Clinicians’ attitudes toward therapeutic alliance in E-therapy. The Journal of General Psychology, 140, 282– 293. doi:10.1080/00221309.2013. 830590 Sucala, M., Schnur, J.B., Constantino, M.J., Miller, S.J., Brackman, E.H., & Montgomery, G.H. (2012). The therapeutic relationship in e-therapy for mental health: A systematic review. Journal of Medical Internet Research, 14(4). doi:10.2196/jmir.2084 Svartvatten, N., Segerlund, M., Dennhag, I., Andersson, G., & Carlbring, P. (2015). A
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Therapists' Experiences of Conducting Cognitive Behavioural Therapy Online vis-à-vis Face-to-Face Jonas Bengtsson, Steven Nordin & Per Carlbring To cite this article: Jonas Bengtsson, Steven Nordin & Per Carlbring (2015): Therapists' Experiences of Conducting Cognitive Behavioural Therapy Online vis-à-vis Face-to-Face, Cognitive Behaviour Therapy, DOI: 10.1080/16506073.2015.1053408 To link to this article: http://dx.doi.org/10.1080/16506073.2015.1053408
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Cognitive Behaviour Therapy, 2015 http://dx.doi.org/10.1080/16506073.2015.1053408
Therapists’ Experiences of Conducting Cognitive Behavioural Therapy Online vis-a`-vis Face-to-Face Jonas Bengtsson1, Steven Nordin1 and Per Carlbring2 Department of Psychology, Umea˚ University, Umea˚, Sweden; 2Department of Psychology, Stockholm University, Stockholm, Sweden
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Abstract. This study has explored therapists’ experiences of conducting cognitive behavioural therapy (CBT) online and face-to-face. Eleven therapists partook in semi-structured interviews, which were thematically analysed using an abductive approach. The results indicate that the therapists viewed face-to-face therapy as a stronger experience than Internet-based CBT (ICBT), and the latter as being more manualised, but providing more work-time control. Several participants also thought that working alliance may be achieved faster and more easily in face-to-face therapy, and might worsen with fewer modalities of communication. Clinical implications in need of investigation are whether working with ICBT might buffer therapist exhaustion, and whether this therapy form can be improved by becoming less manual dependant in order to be easier to individualise. Key words: Internet-based treatment; ehealth; therapists; qualitative; interview; Internet CBT; ICBT. Received 18 March 2015; Accepted 12 May 2015 Correspondence address: Jonas Bengtsson, Department of Psychology, Umea˚ University, Umea˚, Sweden. Email: [email protected]
Introduction Research on Internet-based cognitive behavioural therapy (ICBT) with therapist support has been proven effective against many different psychiatric disorders, such as depression, anxiety disorders, stress and sleeping difficulties (Andersson, Carlbring, Ljo´tsson, & Hedman, 2013). However, there are still knowledge gaps to fill. A recent Cochrane review argues that too few studies have been conducted to directly compare Internet-based treatment with face-to-face therapy (Olthuis, Watt, & Stewart, 2011). The research that so far has compared the two therapy modalities has shown no significant differences in efficacy (Andersson, Cuijpers, Carlbring, Riper, & Hedman, 2014). However, most of this research has been carried out from a quantitative standpoint, and has thus provided limited in-depth understanding for the differences. The few qualitative studies that do exist show far more complex differences, such as clients experiencing the same aspect in treatment in completely different ways (Bendelin et al., 2011; Olsson q 2015 Swedish Association for Behaviour Therapy
Halmetoja, Malmquist, Carlbring, & Andersson, 2014). This study aims to fill some of the abovementioned knowledge gaps. This was done by comparing ICBT to face-to-face therapy, adopting an explorative and qualitative stance. A therapist perspective was taken since this has rarely been done in research concerning ICBT (Montero-Marı´ n et al., 2013). Since working alliance has been shown to be a factor in treatment outcome (Bergman Nordgren, Carlbring, Linna, & Andersson, 2013; Dolemeyer, Klinitzke, Steinig, Wagner, & Kersting, 2013; Preschl, Maercker, & Wagner, 2011; Wagner, Brand, Schulz, & Knaevelsrud, 2012), special focus was given to this aspect. According to Rogers (1957), good working alliance requires that the therapist has an unconditionally positive regard for the client and that the therapist conveys empathy, warmth and congruency towards the client. The two more ample reviews on working alliance in ICBT to date (Klasen, Knaevelsrud, & Bo¨ttche, 2013; Sucala et al., 2012) arrive at very similar conclusions. First, that
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creating a working alliance online is possible and can be equal to the alliance in face-to-face therapy. Second, both studies showed support for working alliance affecting the treatment outcome. Sucala et al. (2012) and Cook and Doyle (2002) found evidence that the more the modalities of communication used (for example, mail, chat or video chat), the stronger the working alliance being perceived by the client. Research done from the therapist’s viewpoint gives a different perspective. Sucala, Schnur, Brackman, Constantino, and Montgomery (2013) examined clinicians’ thoughts about creating a working alliance online. Even though they thought it was possible, the therapists highlighted that the working alliance was more important in face-to-face therapy. The participants conveyed that they had difficulties assessing the clients’ emotions and communicating warmth and empathy over the Internet. Calero-Elvira, Santacreu, de la Torre, Purrin˜os, and Shih (2014) reported that working alliance might be equivalent in both forms of therapy from a client’s perspective, but that therapists experienced the established working alliance as better in face-to-face than online. To recapitulate, the purpose of this study was thus to explore therapists’ experiences of conducting face-to-face and Internet-based guided CBT, with special focus on how they experience their contact with the clients. By comparing and contrasting these experiences, the study aimed at identifying potential strengths and weaknesses in each modality of therapy, particularly in the area of working alliance.
Method
face-to-face. They had 1 to 10 years of experience with ICBT, except for one therapist who had finished two treatments when interviewed. All participants had at least three years of experience with face-to-face therapy. The participants had worked with both therapy modalities to a varying extent. This extent reached from working full-time face-to-face and occasionally online through research projects, to a full-time employment working with ICBT and earlier experience with face-to-face therapy only from education or early work days. Among themselves, the participants had treated a number of psychiatric disorders with ICBT, including different forms of anxiety, depression, panic disorder, sleeping difficulties, Irritable Bowel Syndrome, Obsessive Compulsive Disorder, pain, eating disorders and tinnitus. The participants had treated all of the abovementioned disorders face-to-face, but also stress, burnout, bipolar disorder, overweight, various personality disorders, Post-Traumatic Stress Disorder and Attention Deficit Hyperactive Disorder.
Data collection Each interview lasted about 30 to 50 min that followed a semi-structured interview guide in accordance with the method of abductive thematic analysis. The interview was recorded to be transcribed later on. The data collection was concluded when the last two interviews provided no new themes or perspectives. Thus, saturation in the data was achieved. A pilot interview guide was tested with two junior Internet therapists and revised two times. All participants gave their written informed consent, and the procedure followed stipulated Swedish ethical research guidelines (Swedish Research Council, 2002).
Participants Twenty-one psychotherapists were contacted with information on this study and asked to participate. Out of these eight declined and two were excluded for reasons concerning time and resources. Lastly, 11 therapists were recruited for semi-structured interviews. This group consisted of five men and six women, varying in age between 31 and 48 years (M ¼ 37, SD ¼ 5.88). Ten were licensed psychologists, and one was a social worker and licensed psychotherapist. All participants had worked with both CBT both online and
Analysis The interviews were transcribed verbatim by the first author and two outside transcribers. The thematic analysis (Braun & Clarke, 2006) of the data commenced parallel with the transcription of the other interviews, and was conducted by the first author. First, the raw data were read through several times to obtain familiarisation and a holistic view. Second, all the interviews were coded, and a number of quotes were collected under each code. Third, these codes where gathered under overarching
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themes. The entire data-set and codes were reviewed as to find everything that could potentially fit under each theme, and to make sure the themes would still reflect the data. Finally, these themes where refined and defined as clearly as possible, and quotes from the raw data were selected to show the relationship with the themes in this presentation.
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Results The analysis revealed four large themes, each with two to three subthemes. The four larger themes were named “Manual-based ICBT or individually tailored face-to-face therapy”, “Face-to-face therapy as a stronger experience than online therapy”, “ICBT and work-time control” and “Working alliance”. These can be found in Appendix 1, and presented more in detail below (Table 1).
Manual-based ICBT and individually tailored face-to-face therapy? The participants’ reported sometimes having difficulties in achieving structure and focus in face-to-face therapy. In contrast, they experienced that ICBT made it easier to achieve such focus, sometimes attributed to the manual or structure of the therapy. The manual is clearer and easier to follow when you have it in text form, which the patient reads. ( . . . ) You focus on what you really have agreed to focus on. If it is depression—or whatever it is—and not get stuck on all the little things which can pop up in a conversation between . . . between people. (#2)
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Having the treatment material and communication fixed in writing seemed to make it clearer and more available for both the therapist and the client. The manual was also often seen as a safety measure for the therapists, and made them feel secure and believe in the treatment and that they provided evidence-based material that would yield results. The manual also made the therapy difficult to adapt to the individual. However, some argued that they had the opportunity to adapt their answers and interventions to the client even via the Internet. A few therapists remarked that some of the clients needed a more caring therapy style where the client was allowed to “float away as they pleased”. When you work with complete treatment packages (in ICBT), then it becomes a little bit ‘one size fits all’. Then it does not fit anyone really well. ( . . . ) I want several different sizes, so that I can find you a slimmed suit that fits you. (#5)
Contrasting this opinion on ICBT, face-toface therapy was described as providing flexibility. This meant a larger opportunity to tailor the therapy to the client. They described it as having more “tools” to work with, meaning the direct feedback, the option to ask direct follow-up questions, body language, voice and tone as well as subconscious communication. There is great room to individualise each treatment, and that does not exist in internet therapy in the same way ( . . . ) Uh, so that you can really bury yourself in a case and think a
Table 1. Themes and subthemes emerging from the data-set. Theme Face-to-face therapy is a stronger experience than ICBT Manualised ICBT or individually tailored face-to-face therapy ICBT and work-time control Working alliance
Sub-theme Face-to-face therapy is more reinforcing than ICBT (35 statements). Face-to-face therapy brings more focus to the therapist (25 statements). Face-to-face therapy is more demanding than ICBT (31 statements). ICBT is manualised and more focused than face-to-face therapy (67 statements). Face-to-face therapy is easier to adapt to the client than ICBT (62 statements). Face-to-face therapy is dependent on time and space (10 statements). ICBT offers more flexible work-time (39 statements). Working alliance is possible in ICBT (25 statements). Advantages of creating a working alliance face-to-face (30 statements). Working alliance differs in both therapy forms (13 statements).
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little more and, uh, shape it after a specific patient. And it does not have to be diagnosespecific either. It can be, like . . . yes, compulsion or depression in a mix, like that, yeah? (#3).
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You can look each other in the eye and validate in another way, because you see, maybe, that they are feeling bad, even though it would not have emerged through what they say or what they write for example. Uh, so you can catch things in another way. You do not have . . . you have access to body language and such. So that is an advantage. You can also . . . another advantage is that the treatment becomes more adaptable. (#2)
According to some, this opened face-to-face therapy for addressing broader problems as well as more unspecified ones, compared with ICBT. It was assumed that ICBT offered a broader range of competence and with several different areas at the same time.
Face-to-face therapy is a stronger experience than ICBT Face-to-face therapy is a, well, more, both more rewarding and more punishing in some way, it is like a strong, a stronger experience (than ICBT). When it is going well and going forwards for the patients, then you become happier, and when it does not go as well or when it goes badly with, with the patient work, then you become frustrated and self-critical. Meanwhile, in internet therapy, you might be more lukewarm all the time. (#11)
As expressed above, some therapists described face-to-face therapy as a ‘stronger’ experience than ICBT. They expressed that they felt ‘more reinforced’ as therapists by face-to-face therapy. This reinforcement came from the direct feedback they got from their clients, because they could see how their interventions were received. (ICBT) is not as reinforcing for the therapist as it is to meet a person face-to-face. ( . . . ) There are some reinforcing aspects missing, which exists in face-to-face. ( . . . ) You do not really see how (your interventions) affects the person in the moment. (#4)
Some therapists reported that they experienced that ICBT lacked the “wow-moments” or “breakthroughs” of face-to-face therapy. It should be noted that all therapists found ICBT a working and satisfactory treatment form, though some found the experience inferior to face-to-face therapy. Lastly, some
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of the participants talked about how they perceived the working alliance as stronger in face-to-face therapy. This will be elaborated upon under the headline “Working alliance”. Several therapists discussed how ICBT gives the clients more of the responsibilities for their own treatment. This seemed to coincide with a larger focus being brought onto the therapists’ work in face-to-face therapy. The increased focus on the therapists could make them feel “helpful” and better about their work. There is more focus on me, that is also . . . uh, could actually be a disadvantage in livetherapy, that there is less focus on the therapy. Progress is also attributed more to me as therapist than to the therapy itself and what the patient does. (#10)
Contrasting this, a picture of face-to-face therapy as more demanding for the therapists also emerged. First, face-to-face was described as “frustrating”, “exhausting” and lacking appropriate rewards for effort. Second, several of the participants also reported a more strained work load in face-to-face, due to administrative work, such as booking and rebooking sessions as well as handling cancellations. Several of them also reported that more time in the actual therapy sessions was spent on themes not concerning the treatment goals. One therapist noted, however, that this belief could be a result of “heavier cases” and different clients in face-to-face therapy, and thus not only from the modality itself. I think that is has been both, well, fun and occasionally also very, like, demanding. ( . . . ) You feel very much less burdened by (ICBT) than in regular outpatient care. It does not get as, like . . . heavy in the moment, as it can get when you are sitting with someone who become like that really sad or really angry or dissatisfied or—you become protected by the screen in some way. (#7)
As displayed above, the participants often remarked that ICBT provides weaker reinforcement. Thus, some of the participants pursued alternative forms of reinforcement when working in ICBT. They could, for example, get their reinforcement by acknowledging their clients’’ gradual achievements. Another possibility is to share achieved progress with their colleagues. However, the weaker experience of ICBT could also be seen as something positive.
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I think it is good that you, you are protected and you will last a little longer and you do not get tired and you will not, like, you will not be negatively impacted. Uh, you do not get run down. I think you will last longer as an internet therapist. (#7)
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ICBT and work-time control A recurring theme in the data centred on the flexibility of work-time in ICBT. Face-to-face therapy was depicted as compartmentalised and dependent on a certain time and place to function. A few therapists also mentioned that these tasks could often become disarrayed with cancelled therapy sessions, meetings and full schedules. You are usually completely dependent on time and space. Uh, you got to have a certain venue, got to be at a certain place. The patient and you have to be there on a certain time. Uh, it is . . . uh . . . and that is like technical for the both of you. ( . . . ) uh, but in internet ther- or face-to-facetherapy there are cancelled appointments and you mess up the patients schedule, and the likes. (#8) Yeah, well, the only disadvantage that I have experienced—which is not inconsiderable—is that you are very booked up in time. You have your appointments, where you are very booked up, and those you have to make and follow very carefully in that way. So for me it fits extremely well with the internet therapy where I can decide when I want to do what. And rearrange a day if I want. Swap the order of things. (#1)
As shown above, many therapists mentioned work-time flexibility in ICBT. For example, they could decide not only when and how fast they would do their work, but also where to do it. In short, the participants experienced that therapy conducted over the Internet became unbound by time and space. Another work-time advantage concerning ICBT that emerged from the data was that the participants perceived it as being unaffected by illness (either their own or their children’s), emergencies or meetings at the work place. For some it even meant that colleagues could take over their clients for them if needed. The technical solutions often did much of the work for the therapists, for example reminding clients to do their homework or to write to their therapists. This flexibility in time made it possible for several of the therapists to do other work on the side of their ICBT, such as research or
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face-to-face therapy. Many of them also mentioned that this made it possible for them to work with many more clients at one given time than would face-to-face.
Working alliance Several therapists reported that creating a working alliance was definitely a possibility in both media. Some therapists had had misconceptions that it would be hard to create a working alliance online, but found it easier than expected. A misgiving I had when I started working here, that, that how are you going to, like, get a personal relationship, uh, with patients that you never meet? ( . . . ) There can be very personal meetings even over the net. ( . . . ) I have seen very, very good, fantastic alliances, even with patients over, over the internet surprisingly good. (#6)
However, even though almost all therapists maintained and emphasised that creating a working alliance over the Internet is possible, they also stated that it might be done easier and faster in face-to-face therapy. A few speculated that this was because of the broader spectrum of communication available in face-to-face therapy. It is very different in the live contact, but generally it might take longer to get that personal (contact in ICBT) maybe, even if I think it comes with time anyway. So it is seldom you can get that immediate thing, like, that you can get with some (clients) live. (#2) In some way maybe it is easier (to create a working alliance), that is, when you are sitting in the room, because you have access to the body in some way. And then you have gestures and like . . . yes, but, facial expressions and gaze and the likes. You do not have that (in ICBT). (#7)
However, opinions on whether the quality of the working alliance in both forms of therapy could be compared were diverse. Several stated that the two media were different in this respect. Some argued that the working alliance usually was “stronger” and “richer” in face-to-face therapy. However, most of them still maintained that this did not make the ICBT working alliance inferior. You can say that . . . you have . . . a contact with these people that is of another quality, you, you . . .
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uh . . . it is probably a notch . . . better, or no, not better, but it is a notch . . . a notch richer. (#3) It becomes another, yes, it becomes like another type of alliance, but at the same time it becomes a different alliance. It might be equally good, but it is not really the same. (#5)
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One therapist argued that this discrepancy in working alliance was because he had worked with both therapy forms and was therefore able to compare them. I experience that you get a stronger alliance in face-to-face, but at the same time I know (laughs) that there are studies that show that it is not always that big a difference when you assess it, so it is simply relative, that . . . we who go for both parts, we might experience a greater difference than patients who only experience the one. (#11)
Others, in contrast, speculated that it was rather the clients that differed. A few participants even thought that ICBT and writing as communication create better working alliances than face-to-face therapy when dealing with clients with social phobia, because ICBT is less “charged” and threatening than face-toface therapy. Finally, two participants experienced that adolescents open themselves up more in ICBT. I think that many times, for some patients, it can be an advantage that you have not . . . met live because it feels a little more threatening and revealing to sit face-to-face and tell someone things that are shameful, anxious. (#6) I rather think that ( . . . ) clients have opened themselves more (in ICBT) than what you can do in the room ( . . . ) It could be because they are adolescents, but also that you, that sometimes it can be easier when you express something in writing instead of sitting together with a person you do not know so well in a room. That . . . if you write you, you do not see the person in front of you so that, uh . . . that you dare to expose yourself a little more. (#10)
Discussion As shown by the results, several of the participants viewed ICBT as focused, structured, evidence-based, clear and safe. This was often attributed to the treatment manual. Contrasting this view, face-to-face therapy was depicted as easier to individualise, providing more “tools” to work with and opening up for working with broader,
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unspecified or multiple problems. This contrast taps into a larger debate about whether psychotherapy in general benefits more from being manual based or tailored to fit the individual (Linden & Golier, 2008). The results of this study have two major similarities with the advantages that Wilson (1996) finds with manual-based treatments. First, the manual helps the therapist achieve a clearer focus in the therapy. He argues that this is partly because of the demarcation in time that a manual-based treatment requires. Second, that a manual makes it easier to maintain a certain quality in the treatment, keeping it evidence based and researchable. The disadvantages of manual use stipulated by Wilson (1996) also have parallels to the participants’ views. He writes that treatment manuals for specific disorders are not always applicable since these disorders vary in their symptoms and causes. Therefore, a manual might miss differences and focus on treating conditions that might be irrelevant for the specific client. Wilson (1996) also supports the notion from the participants that less manualbased face-to-face therapy might be better suited for working with broader, more unspecified and multiple problems, and that ICBT is not suitable for everyone. Lastly, Wilson (1996) argues that it might be necessary to assess the client’s problems in person. Since the therapists reported it more difficult to “read” the client over the Internet, this seems to be a valid point, and important for the recruitment of clients in ICBT. It also gives support to the praxis of blended therapy, where the client and therapist have a few introductory sessions face-to-face, and then continue working online if it suits the clients’ needs. However, it should be argued that the dichotomy of manual-based and individualised treatments is not an absolute. There exist many highly manualised face-to-face treatments, which allow several advantages of manualisation to actually be achieved face-toface. However, with a few exceptions (e.g. Carlbring et al., 2011), more flexible forms of ICBT do not yet seem to exist to the same extent. This suggests a few alternative routes for the future of the latter therapy form. First, ICBT could remain manualised. This means that ICBT would stay unsuitable for certain problems and clients. Second, another
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option is to facilitate individualisation in ICBT. This can be done either by merging more face-to-face elements into ICBT, making it more of a blended therapy (van der Vaart et al., 2014), or as Wilson (1996) suggests, allow the treatment manual to become more individualised. According to Svartvatten et al. (in press), this can be done by timing the intervention, using multiple techniques and using the manual more flexibly. Some participants found face-to-face therapy exhausting due to the stronger emotional experience, frustration and more administrative work. This theme might be related to a major problem in Swedish healthcare. Healthcare workers, such as psychologists, continue to be one of the groups with the largest amount of sick leave in Sweden, mostly on account of stress reactions or depressive episodes (Fo¨rsa¨kringskassan, 2011). The therapists’ experiences of emotional exhaustion and a heavier work load in face-toface therapy fit well with this pattern. In contrast, many participants described ICBT as providing a less exhausting experience, which might even protect the therapist from exhaustion. Generalisable research is needed to verify this, but this study gives several affirming indications. These assumptions are also in line with previous research done by Reynolds, Stiles, Bailer, and Hughes (2013), who measured lower levels of arousal in both therapists and clients in ICBT as opposed to face-to-face therapy. They hypothesise that the online environment is more comfortable and less threatening (p. 375) than its face-to-face counterpart, and speculate that this is because of the time delay in the communication. Even though this study focuses on the therapists and Reynolds et al. (2013) on the clients, there are similarities. For example, the time delay in Internet communication mentioned by Reynolds et al. (2013) and the direct feedback of face-to-face therapy reported as a reason in this study can very well be seen as two sides of the same coin. This study also supports Reynolds et al. (2013) posed implications, such as ICBT being suitable for clients (or perhaps even therapists) with anxiety disorders or social phobia. The increased work-time control in ICBT reported by the participants might also play a part in this. The effects of work-time control are positive, according to Nijp, Beckers,
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Geurts, Tucker, and Kompier (2012). Their review shows that it has positive effects on work – non-work balance, as well as job satisfaction and job performance. More importantly, work-time control also has a positive effect on health and well-being, including stress, burnout, depression, anxiety and sick leave (Nijp et al., 2012). Considering that the work-time control described by the participants in this study does have the effects that Nijp et al. (2012) suggest, maybe ICBT can work as a first step for exhausted therapists returning to work, or as a buffer for therapists on the verge of burnout? As stated, better targeted research is needed to answer whether a relation exists between ICBT, work-time control and positive health effects, but the results of this study indicate that such an assumption is not farfetched. The results of this study can both corroborate and challenge existing research. Most importantly, the participants’ views that creating a working alliance in ICBT is possible—despite prejudices that it would not be possible—has been confirmed by the previously mentioned reviews by Klasen et al. (2013) and Sucala et al. (2012). Sucala et al. (2013) and Calero-Elvira et al. (2014) suggest that therapists experience it as stronger and better in face-to-face than over the Internet, which is also a theme in these results. The working alliance and the therapist’s work were also seen as less important than the client’s own work in ICBT by both the participants in this study and those in the study by Sucala et al. (2013). As stated earlier, some participants thought the relationship was equivalent in both modalities. Indeed, other research examined in the two reviews by Klasen et al. (2013) and Sucala et al. (2012) do not find any significant difference from the client’s point of view. One possible explanation is the relative difference discussed by one of the participants, where he commented that maybe the therapists experience working alliance as better face-to-face since they have experience of both. On the other hand, clients usually only have experience from one treatment form, and therefore the different working alliances might be assessed as the same. Should this be the case, it may very well explain the findings of Sucala et al. (2013) and Calero-Elvira et al. (2014).
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The results from this study suggest that whereas more modalities of communication are available, working alliance might be created more easily and faster, and provide a stronger experience for the therapist. This is supported by Sucala et al. (2013), who argue that clinicians experienced that negative impact on the working alliance is related to fewer modalities of communication (mail, chat, video chat) accessible. The participants of this study point out that fewer means of communication also mean that the assessment, and more importantly suicide assessment, of the client becomes more difficult. Along with Sucala et al. (2013), we would like to suggest more research on how working alliance is affected by more or fewer means of communication. Interestingly, in one study by Lindner et al. (2014), therapist guidance by telephone appears to be equal to therapist guidance by e-mail with regard to working alliance and treatment outcome. This study faces a number of limitations, mainly with the selection of participants. The partaking therapists were still active Internet therapists, which may imply that they enjoyed and saw advantages with ICBT. Future studies might instead also recruit Internet therapists who are not as pleased with their experiences in order to broaden the diversity of opinions. In spite of this limitation, disadvantages and advantages of both therapies have been highlighted and neither should be overlooked. Related to the above limitation is the fact that there are very few ICBT projects active in Sweden at date. Therapists working in several of these projects were approached concerning participation in the study. Since eight therapists declined to participate and two were excluded due to limited time and resources, the conclusive sample chosen for this study had to be based on availability. Thus, the Internet Psychiatry Unit in Stockholm was over represented among the participants of this study. This means that some of the similarities in the data might stem from the participants’ sharing workplace, as well as all of them working in an urban environment. Another liable limitation emerged from the data itself, namely that the participants speculated as to whether different clients were attracted to face-to-face therapy and ICBT. This has consequences for the validity of the results, in that the differences expressed
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by the participants might not derive from working with different modalities of therapy, but rather with different people. To generalise these results, more quantitative studies can be of use. For example, a design in which therapists’ level of stress, burnout and work –family conflict is correlated or compared with respect to work face-to-face versus ICBT can further clarify whether worktime control is a factor in ICBT that determines these variables. Another suggestion is to focus on a relative difference in working alliance between Internet and face-toface therapy in more fields (Jasper et al., 2014). This might answer the question of whether working alliance actually becomes stronger with the non-verbal communication provided by face-to-face therapy and what part, if any, it actually plays in ICBT. This study can with benefit be replicated in other contexts or redesigned to differentiate the data collected here. Other questions could also be asked regarding differences in, for example, credibility, expectancy and projected adherence of ICBT and face-to-face therapy. With time and resources, maybe a study with joint therapist and client perspective might be preferable, to examine the reciprocal relationship between the two. At the current, there is a deficit in research on ICBT that takes a qualitative stance (Rozental, Boettcher, Andersson, Schmidt, & Carlbring, 2015), that compare ICBT to face-to-face-therapy (Andersson et al., 2014) and that examines the therapist point of view (Friesen, Hadjistavropoulos, & Pugh, 2014). That is why this study has aimed to explore therapists’ experiences of conducting CBT online and face-to-face. To conclude, the results showed that the therapists viewed faceto-face therapy as a stronger experience than ICBT, and the latter as more manualised and providing more work-time control. They also showed that working alliance may be easier and faster created in face-to-face therapy. Clinical implications are that ICBT might buffer therapist exhaustion and that it might have to become less manual dependant in order to be easier to individualise.
Disclosure statement No potential conflict of interest was reported by the authors.
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Cognitive behavioural therapy
Funding The current study was made possible in part by a grant from the Swedish Research Council (2011 – 2913).
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