Internet-based Interventions - Competencies

Overview

Rapid progress in technology has diversified the way behavior change methods such as psychotherapy or coaching are provided. The global movement to limit face-to-face contact caused by the COVID-19 pandemic has accelerated the provision of behavior change methods delivered via the internet. As an example, Cognitive Behavioral Therapy (CBT)  has been adapted in various ways. Therapy materials, video clips, and worksheets are provided online, and symptom questionnaires and self-assessments are used to monitor progress as usual but these may be collected and scored in different formats. Generally speaking, there are two types of remote CBT provision. First, clients practice CBT without the support of a therapist. Second, a therapist supports a client by using a remote method such as an online meeting, mail, chat, and telephone. VR has also been used to provide CBT (Maheu, Pulier, McMenamin, & Posen, 2012).

Terminology

Psychological services or interventions provided via the internet have been described in the literature with a variety of terms including "telepsychological services," "Digital mental health technology," "web-based," "Internet CBT," and "tele-CBT." Another complication is that internet-based interventions have sometimes been described as "telehealth" yet the term telehealth has been used in multiple ways, sometimes referring to the provision of psychological services specifically and sometimes referring more generally to both medical and behavioral health interventions. This proliferation of terms has been called “terminology chaos (Barak, 2013). Term reduction is required to evaluate the effectiveness and tasks of remote psychological services or interventions (Andersson, Titov, Dear, Rozental, & Carlbring, 2019). Here we use Internet CBT (ICBT) to represent all types of remote CBTs.

Benefits
Internet-based psychological interventions, including ICBT, have significant advantages over face-to-face psychological services or interventions in terms of time, effort, and costs. A client can choose a good therapist without considering distance, even in a different country (subject to country-specific laws and profession-specific regulations). Internet-based services can be delivered to people with mobility difficulties, such as severe physical disability. Remote delivery of services offers an advantage to clinical research as well since much more participants can be recruited beyond geographical barriers (Andersson, et al., 2019), which may lead to more diverse research samples.

Issues
Data security is crucial, especially when sensitive information is exchanged. Legal requirements for managing personal data are being developed in many countries, and ICBT guidelines are also being provided by the American Psychological Association (Joint Taskforce for the Development of Telepsychology Guidelines for Psychologists, 2013) and Canada (Johnson, 2014). Older persons who are not familiar with using a computer and smartphone and people living in unavailable areas or countries would not be able to benefit from ICBT. The gap in dissemination has widened. Finally, the acceptance of ICBT by insurance companies depends on their country (Andersson et al., 2019).

Current evidence base
Many studies have investigated the effectiveness of ICBT. Recent meta-analyses have shown that ICBT is more effective than no treatment, and therapist-supported ICBT is the same as face-to-face CBT (Cuijpers, Cristea, Karyotaki, Reijnders, & Huibers, 2016; Cuijpers et al., 2009; Spek et al., 2007). A study comparing ICBT with and without therapist support showed that ICBT with support was more effective than that without support for anxiety disorders and depressions (Andrews et al., 2018; Olthuis, Watt, Bailey, Hayden, & Stewart, 2016; Sijbrandij, Kunovski, & Cuijpers, 2016). However, it should be noted that the quality of the evidence was low to moderate (Olthuis et al., 2016).

Trindade et al. (2021) completed a systematic review and meta-analysis of online-based delivery of ACT specifically for chronic pain. Online ACT demonstrated more effectiveness (relative to control conditions) on outcome measures of pain interference, pain intensity, depression, anxiety, mindfulness, and psychological flexibility.

CBS therapies delivered via the internet
Regarding therapies under the rubric of contextual behavior science (CBS), there are some meta-analyses. Most of them focused on Acceptance and Commitment Therapy. The effectiveness or feasibility were reported for subjective wellbeing (Stenhoff, Steadman, Nevitt, Benson, & White, 2020), anxiety (Brown, Glendenning, Hoon, & John, 2016; Kelson, Rollin, Ridout, & Campbell, 2019), and depression (French, Golijani-Moghaddam, & Schröder, 2017; Thompson, Destree, Albertella, & Fontenelle, 2021; Trindade et al., 2021). Lakeman et al. (2022) and van Leeuwen et al. (2021) conducted systematic reviews of DBT provided by the Internet. Lakeman et al. (2022, p.11) reported “current research evidence does not support a permanent shift towards online or blended DBT. It is pivotal and timely to increase efforts to investigate the efficacy of online DBT, compared to standard face-to-face DBT.”

Competency measures

To date, there are limited measures of competency for internet-based interventions. There are several best practice guidelines for the use of telepsychology, which can be used for self-assessment of one's fidelity to the guidelines. For example, see Figure 1 from Maheu et al. (2021) describing telebehavioral health competencies:

These telepsychology guidelines typically describe ways of effectively delivering services via remote electronic means, and there are meant to apply to a range of psychological interventions spanning a variety of theoretical approaches (e.g., cognitive-behavioral, psychodynamic, humanistic). In a scoping review, McCord et al. (2020) distilled a set of guidelines.

Specific interventions, such as ACT, may have a set of competency measures. Generally, these competencies are not altered when the intervention is delivered remotely. Essentially, practitioners are expected to meet the competencies of telepsychology and the intervention-specific competencies at the same time. As McCord et al (2020) noted: in their discussion of telepsychology competence: 

"Most basically, a clinician must first be competent in his or her ability to effectively enact the content of the chosen treatment, regardless of the mode of communication (i.e., telepsychology vs. in‐person). No matter the means of transmitting the services, a provider must be extensively trained and prepared in treatments that they are offering to clients. This includes receiving proper supervision and feedback throughout the training process. For example, a psychologist conducting cognitive behavioral therapy over videoconferencing would not only need to be properly trained in this treatment but also be able to make proper adaptations to treatment based on any available best practices and clinical judgment. An example of an adaptation may be mailing worksheets or sending them over a secure file transfer electronically so that they client is able to follow along and participate in homework. (p. 1076)."

Recently, Weisenmuller & Luzier (2022) called for technology to be considered a core competency for psychologists to develop.

How is culture addressed In the competencies?

Some studies have attempted to adapt or modify ICBT programs developed in Western countries to culturally different countries. Patel et al. (2016) and Abuwalla (2017) adapted the CATCH-IT (Competent Adulthood Transition with Cognitive-Behavioral, Humanistic and Interpersonal Training program), which is an internet-based intervention targeting teens at risk for developing depression, to China and Arabian countries. Zemestani, Hosseini, Petersen, & Twohig (2022) reported internet-based ACT (iACT) in Iran was equally effective as ACT delivered in Western countries. Ramaiya et al.,（2017）provided DBT to persons in Nepal. They conducted the study with three phases. One was qualitative interviews with major Nepali mental health stakeholders, the second was an adaptation workshop with 15 Nepali counselors, and the third was a small-scale treatment pilot with eligible clients in one rural district. They concluded that while DBT concepts were the least comprehensible to clients, the high program completion rate suggested the utility of structured, skills-based treatment of DBT. A systematic review of DBT (Haft, O'Grady, Shaller, & Liu, 2022) revealed that most adaptations involved modifications to language, metaphors, methods, and context, and there was insufficient evidence to determine the effectiveness of culturally adapted DBT. Competency has usually been assessed in these studies by measuring fidelity to the specified intervention. Fidelity measures may include items that address the aim of successfully adapting the intervention to a different cultural context, but competency in doing so is rarely measured.

Willis et al. (2022) made recommendations for increasing the cultural responsivity of telepsychology (and mHealth) interventions, but they did not call for new directions in measures of competence.

How have competencies been operationalized in diverse practice settings and delivery modalities? 

Aside from resources on best-practices in delivering therapy through telehealth, no specific guidance was found. McCord et al. (2020) identified key variations in practice settings and delivery modalities for telepsychology, but called for an overall focus on competence and multicultural competence that did not vary across settings.

Materials / Assessments / Work Products

To date, no scale has been developed to measure therapist competency in ICBT. Several guidelines for the implementation of Internet-based telepsychology have been reported, and McCord et al. (2020) summarized them and proposed a practice model. One of the cube models summarizes considerations related to Internet-based psychotherapy (IBT). These are briefly summarized below.

Client appropriateness
Therapists should consider the client's history (e.g., repetitive crises and comfort-receiving telepsychology services). In particular, clients receiving telepsychology services, as opposed to in-person services, are in a situation where self-harm and other behaviors are difficult to control. It is also necessary
to consider the appropriateness of a client's literacy regarding technology.

Informed consents
Therapists should obtain informed consent about the risks, benefits, and alternatives to telepsychology services.

Professional boundaries
Therapists should maintain professional language through email and texting communications. They should clarify that these messages are for the client only and are not shared with others. Therapists should be mindful of the ubiquitous nature of social media and should maintain boundaries by not contacting clients through social media. Therapists should explain to clients their social media policy (e.g., not becoming friends on social media) at the start of the service.

Privacy and confidentiality
Therapists should develop policies regarding security issues (including the use of encryption, transmission, storage, and disposal). Therapists should clearly explain to clients that digital information such as telephone records, videos, and emails is protected and will not be shared outside the organization.

Managing outages and downtime,
Therapists should ensure that the system reliably provides services. At the same time, they should consider that it is inevitable that the system will fail and make plans for this.

Competent
Therapists should be competent in the interventions they provide, regardless of the mode in which the service is provided, for example, telepsychology vs. in-person. This includes receiving ongoing SV. Therapists delivering CBT through videoconferencing should also adapt their in-person interventions, for example, by sending worksheets to clients via secure file transfers.

Termination of services
Therapists should ask clients to assess their satisfaction and the quality of the services provided if the termination of services is deemed appropriate.

Dissemination and maintenance of competencies

Implementation of internet-based interventions has been studied (see e.g., Benavides-Vaello, Strode, & Sheeran, 2013; Jang-Jaccard, Nepal, Alem, & Li, 2014), and the adoption of best-practices has also been described, particularly in the context of the Covid-19 pandemic (Alqahtani et al., 2021; Dopp et al., 2020; Penney et al., 2021) Little is known about the maintenance of competencies specific to internet-based interventions.

References

Abuwalla, Z., Kadhem, Z., Gladstone, T., Mikhael, E., Bishay, A., & Van Voorhees, B. W. (2017). Proposed model for the cultural adaptation of an Internet-based depression prevention intervention (CATCH-IT) for Arab adolescents. International Journal of Adolescent Medicine and Health, 31(1), 20160147.

Alqahtani, M. M. J., Alkhamees, H. A., Alkhalaf, A. M., Alarjan, S. S., Alzahrani, H. S., AlSaad, G. F., ... & Alqahtani, K. M. M. (2021). Toward establishing telepsychology guideline. Turning the challenges of COVID-19 into opportunity. Ethics, Medicine and Public Health, 16, 100612.

Andersson, G., Titov, N., Dear, B. F., Rozental, A., & Carlbring, P. (2019). Internet‐delivered psychological treatments: from innovation to implementation. World Psychiatry, 18(1), 20-28.

Andrews, G., Basu, A., Cuijpers, P., Craske, M., McEvoy, P., English, C., & Newby, J. (2018). Computer therapy for the anxiety and depression disorders is effective, acceptable and practical health care: an updated meta-analysis. Journal of anxiety disorders, 55, 70-78.

Barak, A. (2013). Concepts, definitions, and applications: the terminology cha os of Internetsupported psychotherapeutic interventions. Paper presented at the 6th Meeting of the International Society for Research on Internet Interventions, Chicago.

Benavides-Vaello, S., Strode, A., & Sheeran, B. C. (2013). Using technology in the delivery of mental health and substance abuse treatment in rural communities: a review. The journal of behavioral health services & research, 40(1), 111-120.

Brown, M., Glendenning, A., Hoon, A. E., & John, A. (2016). Effectiveness of web-delivered acceptance and commitment therapy in relation to mental health and well-being: a systematic review and meta-analysis. Journal of medical Internet research, 18(8), e221.

Cuijpers, P., Cristea, I. A., Karyotaki, E., Reijnders, M., & Huibers, M. J. (2016). How effective are cognitive behavior therapies for major depression and anxiety disorders? A meta‐analytic update of the evidence. World Psychiatry, 15(3), 245-258.

Cuijpers, P., Marks, I. M., van Straten, A., Cavanagh, K., Gega, L., & Andersson, G. (2009). Computer‐aided psychotherapy for anxiety disorders: A meta‐analytic review. Cognitive Behaviour Therapy, 38(2), 66-82.

Dopp, A. R., Mapes, A. R., Wolkowicz, N. R., McCord, C. E., & Feldner, M. T. (2021). Incorporating telehealth into health service psychology training: A mixed-method study of student perspectives. Digital health, 7, 2055207620980222.

Joint Taskforce for the Development of Telepsychology Guidelines for Psychologists (2013). Guidelines for the practice of Telepsychology. The American psychologist, 68(9), 791-800.

French, K., Golijani-Moghaddam, N., & Schr?der, T. (2017). What is the evidence for the efficacy of self-help acceptance and commitment therapy? A systematic review and meta-analysis. Journal of Contextual Behavioral Science, 6(4), 360-374.

Haft, S. L., O'Grady, S. M., Shaller, E. A., & Liu, N. H. (2022). Cultural adaptations of dialectical behavior therapy: A systematic review. Journal of consulting and clinical psychology.

Jang-Jaccard, J., Nepal, S., Alem, L., & Li, J. (2014). Barriers for delivering telehealth in rural Australia: a review based on Australian trials and studies. Telemedicine and e-Health,?20(5), 496-504.

Johnson, G. R. (2014). Toward uniform competency standards in telepsychology: A proposed framework for Canadian psychologists. Canadian Psychology/Psychologie canadienne, 55(4), 291.

Kelson, J., Rollin, A., Ridout, B., & Campbell, A. (2019). Internet-delivered acceptance and commitment therapy for anxiety treatment: systematic review. Journal of medical Internet research, 21(1), e12530.

Lakeman, R., King, P., Hurley, J., Tranter, R., Leggett, A., Campbell, K., & Herrera, C. (2022). Towards online delivery of Dialectical Behaviour Therapy: A scoping review. International Journal of Mental Health Nursing, 31(4), 843-856.

Maheu, M. M., Pulier, M. L., McMenamin, J. P., & Posen, L. (2012). Future of telepsychology, telehealth, and various technologies in psychological research and practice. Professional psychology: Research and practice, 43(6), 613.

Maheu, M. M., Wright, S. D., Neufeld, J., Drude, K. P., Hilty, D. M., Baker, D. C., & Callan, J. E. (2021). Interprofessional telebehavioral health competencies framework: Implications for telepsychology. Professional Psychology: Research and Practice, 52(5), 439.

McCord, C., Bernhard, P., Walsh, M., Rosner, C., & Console, K. (2020). A consolidated model for telepsychology practice. Journal of Clinical Psychology, 76(6), 1060-1082.

Olthuis, J. V., Watt, M. C., Bailey, K., Hayden, J. A., & Stewart, S. H. (2016). Therapist‐supported Internet cognitive behavioural therapy for anxiety disorders in adults. Cochrane Database of Systematic Reviews(3).

Patel, U., Sobowale, K., Fan, J., Liu, N., Kuwabara, S., Lei, Z., . . . Van Voorhees, B. (2016). Cultural considerations for the adaptation of an Internet-based intervention for depression prevention in Mainland China. International Journal of Adolescent Medicine and Health, 29(5), 20150099.

Penney, E., Reynolds, J., Knott, V., & Green, H. (2022). Lessons from 2020: practical and clinical aspects of rapid telepsychology adoption in clinical psychology postgraduate programs. Australian Psychologist, 57(3), 161-166.

Ramaiya, M. K., Fiorillo, D., Regmi, U., Robins, C. J., & Kohrt, B. A. (2017). A cultural adaptation of dialectical behavior therapy in Nepal. Cognitive and Behavioral Practice, 24(4), 428-444.

Sijbrandij, M., Kunovski, I., & Cuijpers, P. (2016). Effectiveness of internet‐delivered cognitive behavioral therapy for posttraumatic stress disorder: A systematic review and meta‐analysis. Depression and anxiety, 33(9), 783-791.

Spek, V., Cuijpers, P., Nykl??ek, I., Riper, H., Keyzer, J., & Pop, V. (2007). Internet-based cognitive behaviour therapy for symptoms of depression and anxiety: a meta-analysis. Psychologicalmedicine, 37(3), 319-328.

Stenhoff, A., Steadman, L., Nevitt, S., Benson, L., & White, R. G. (2020). Acceptance and commitment therapy and subjective wellbeing: A systematic review and meta-analyses of randomised controlled trials in adults. Journal of Contextual Behavioral Science, 18, 256-272.

Thompson, E. M., Destree, L., Albertella, L., & Fontenelle, L. F. (2021). Internet-based acceptance and commitment therapy: a transdiagnostic systematic review and meta-analysis for mental health outcomes. Behavior therapy, 52(2), 492-507.

Trindade, I. A., Guiomar, R., Carvalho, S. A., Duarte, J., Lapa, T., Menezes, P., . . . Castilho, P. (2021). Efficacy of online-based acceptance and commitment therapy for chronic pain: A systematic review and meta-analysis. The Journal of Pain, 22(11), 1328-1342.

van Leeuwen, H., Sinnaeve, R., Witteveen, U., Van Daele, T., Ossewaarde, L., Egger, J. I., & van den Bosch, L. (2021). Reviewing the availability, efficacy and clinical utility of Telepsychology in dialectical behavior therapy (Tele-DBT). Borderline personality disorder and emotion dysregulation, 8(1), 1-15.

Weisenmuller, C. M., & Luzier, J. L. (2022). Technology is a core competency in professional psychology. Training and Education in Professional Psychology.

Willis, H. A., Gonzalez, J. C., Call, C. C., Quezada, D., Scholars for Elevating Equity and Diversity (SEED), & Galán, C. A. (2022). Culturally Responsive Telepsychology & mHealth Interventions for Racial-Ethnic Minoritized Youth: Research Gaps and Future Directions. Journal of Clinical Child & Adolescent Psychology, 51(6), 1053-1069.

Zemestani, M., Hosseini, M., Petersen, J. M., & Twohig, M. P. (2022). A pilot randomized controlled trial of culturally-adapted, telehealth group acceptance and commitment therapy for Iranian adolescent females reporting symptoms of anxiety. Journal of Contextual Behavioral Science, 25, 145-152.