Thread: CBT Online?
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Unread October 20th, 2011, 03:26 PM
James Pretzer James Pretzer is offline
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Default Cautions re CBT Online

There is increasing evidence that CBT can be provided effectively over the Internet. This can be done either by a therapist conducting CBT over a video, audio, or text link or by a web site that provides CBT with minimal therapist involvement. For example, Spence, et al (2011) compared online vs clinic delivery of CBT in the treatment of anxiety disorders in adolescents. They found that both approaches were quite effective. 78-80.6% of participants no longer met criteria for an anxiety disorder at 12-month follow-up and both treatments were rated highly by both the adolescents and their parents.

Online provision of CBT has a number of important advantages. It makes CBT available to residents of underserved areas, eliminates the hassle and expense of traveling to the therapist's office, avoids the perceived stigma of attending therapy, may take less therapist time, may reduce the cost of treatment, etc.

Does this mean we should start doing CBT online? Here are a few issues that come to mind:
  1. There are many ways in which CBT can be provided online. I could do conventional one-on-one CBT over a video, audio, or text link, I could provide a web site that is essentially an online self-help book, I could provide a web site that is much more interactive that a self-help book but which involves very little therapist involvement, I could facilitate an online support group, I could set up an unmoderated self-help book, etc. It seems clear that any of these can be done effectively (or ineffectively) but I don't think we know which approaches will work best for which purposes. Also, I'm not sure we know how to tell if we're doing a good job of providing CBT online (without systematically collecting outcome data) or what the risks are.
  2. Speaking of risks, one of the big issues in providing services online is how to deal with emergencies. If I'm providing services in person and a client has a crisis I can deal with the crisis in person, I can contact family members if necessary, and I'm familiar with the professionals, agencies, and emergency services in my area if additional resources are needed. If I'm providing services online and an individual in Timbuktu has a crisis, becomes suicidal, or has a psychotic break, how do I deal with that? Unless I thought ahead and obtained contact information in advance, I may not know how to contact them if they aren't online, I won't know how to reach family members, I may not even know what part of the world they're in or how to contact local emergency services if necessary. (This isn't just a hypothetical problem, I have first-hand knowledge of two serious emergency situations that were very difficult to handle online)
  3. Where do I need to be licensed if I live in one state and the person receiving CBT resides in another state? Many state licensing boards are of the opinion that I need to be licensed in the state where the individual receiving services resides. This is impractical, but if I violate the various licensing boards' regulations, I could find myself in serious trouble. Suppose I'm not doing one-on-one therapy but am providing CBT in some other format, does that mean I don't need to be licensed? My bet is that a number of licensing boards would object to my providing professional services in their state without being licensed there.
  4. Suppose I do something like an online self-help book where I'm not providing professional services and therefore don't need to be licensed… If I'm not providing professional services does my professional liability insurance cover me if I get sued? It would be a real problem to get sued and discover that you're uninsured.
  5. How do I get paid for the time, energy, and expense that I put into providing CBT online? Can I bill insurance companies as though I'm providing CBT face-to-face or do they consider that insurance fraud? Can I sell enough ad space on my web site to cover the costs and provide me with a paycheck? Can I get enough people to pay out of pocket for the services I'm providing? Or have I just adopted an expensive hobby?

Don't get me wrong. I'm very interested in providing CBT online and I'm convinced that it has a lot of potential. However, I'm also convinced that it is important to stop and think rather than just plunging in. Well-intended individuals could easily find themselves in serious difficulty if they don't consider the practical, legal, and ethical complexities that are involved in providing CBT online.
Spence, S.H., et al (2011). A randomized controlled trial of online versus clinic-based CBT for adolescent anxiety. Journal of Consulting and Clinical Psychology, 79, 629-642.
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