Swinburne University of Technology - Melbourne Australia

Cognitive therapy just a click away

Story by Karin Derkley

Through graphics, animation, audio and video, a patient is guided through an internetbased psychological treatment. He or she is given the option to choose a male or female online presenter, to access video materials by former sufferers or watch a professor discussing treatment options and techniques relevant to the condition.

The concept is 'e-therapy', and although it may sound futuristic, its use could become more widespread with the Federal Government's decision to fund a national e-therapy centre.

Using the internet to deliver therapy is something that Swinburne University of Technology's e-Therapy Unit co-directors Dr Britt Klein and Dr David Austin have been striving towards for some time.

Both have actively sought to persuade the mental health service community that etherapy is a safe and effective form of mental health treatment. And for good reason: the success rate has been as good as best-practice, traditional 'face-to-face' counselling sessions, while it offers convenience and cost benefits.

Dr Austin says until recently most people did not believe the internet could be used to effectively treat clinical psychological disorders such as anxiety and depression.

A decade ago, Dr Klein and the late Professor Jeffrey Richards used the internet as a means of delivering therapy by evaluating an internet-based mental health intervention program for panic at the University of Ballarat.

Now, following that decade of research, Dr Klein and Dr Austin have demonstrated that e-therapy services can be as effective as face-to-face therapy at treating many highprevalence mental health disorders.

That success has been recognised with funding of $1.65 million from the Australian Government Department of Health and Ageing to establish the National e-Therapy Centre for Anxiety Disorders (NetCAD) at Swinburne's

Hawthorn campus. (The centre will be run by the university's e-Therapy Unit, which itself forms part of Swinburne's PsyCHE Research Centre and which aims to find efficient and effective ways of disseminating psychological treatments to the community.)

NetCAD will provide a suite of internetbased clinical treatment programs for anxiety disorders to the Australian public.

A department spokesperson says the government is pleased to be working with Swinburne on the project. "This innovation will be particularly helpful for people in rural and remote areas who face some barriers in accessing face-to-face services."

The project is in line with the Australian Government's Telephone Counselling, Self Help and Web-Based Support Programmes initiative, which aims to increase access to mental health services by supplementing face-to-face treatments with online and telephone interventions.

All of Swinburne's online anxiety disorder treatment programs will be based on cognitive behavioural therapy (CBT) principles, which seek to address problematic behaviours by recognising and modifying the thinking that causes them. However, these programs will differ from other currently accessible online programs in that they offer both automated self-help and therapistassisted versions, Dr Austin says. "People will therefore always have the option to have a therapist assigned to them during the treatment program who will guide and support them during the program via email."

The research has also shown that although patients want support, its frequency does not appear to be a factor in gauging the program's value, Dr Klein says.

"We have demonstrated that patients do just as well with the program regardless if they are contacted once a week by their therapist, or as often as every day over the course of the program," he says.

Dr Austin says that although program modules incorporate text and multi-media elements, it is not the content so much as the activities and tools within the programs that constitute treatment. Working through the activities in each module can take several hours each week, which is where the behaviour modification takes place.

Users complete an initial screening questionnaire to determine if they are at risk, and if so, they will then be invited to complete an online clinical assessment that will identify the presence of any psychological condition.

Depending on the results, the system will then recommend that the individual either works through the automated selfhelp program or therapist-assisted version of the program, although individuals always have the final say. Costs to have a therapist guide and support them through the program will be $120 for the 12 weeks, and the self-help automated version will be free of charge. Drs Klein and Austin hope that the therapist-assisted programs will be widely used, especially as they are proving to be just as effective and acceptable as face-to-face treatment, more cost efficient and convenient.

The effectiveness of the programs has been confirmed by rigorous evaluation and randomised controlled clinical trials. About 70 to 90 per cent of people who worked their way through the Panic Online program, for example, were alleviated of their clinical panic disorder - around the same as the success rate of best-practice face-to-face CBT treatment.

It is this kind of success that has seen the Panic Online program recognised in the refereed journal Psychological Medicine as the world's most effective internet-based treatment program for a mental health disorder.

Although the programs have a particular value to those in remote and isolated communities for whom a visit to a clinical psychologist is out of the question, Dr Klein and Dr Austin say there are many others in the community who can benefit from the accessibility and relative anonymity of the service. "Low mental health literacy and stigma are also barriers as to why some people do not seek out mental health assistance" Dr Klein says.

"Men, for instance, can find it more difficult to visit a psychologist than women. Other issues, such as the severity of someone's mental health disorder or the presence of a co-occurring chronic physical health condition can also prevent people from leaving their home and accessing traditional face-to-face treatment," she says.

"These programs could also reach specific, hard-to-reach populations, such as people in prisons, where the prevalence of mental health disorders are disproportionately higher in comparison to the general community."

By its very nature, the e-therapy service means people can work through their treatment in the privacy of their own home, at their own convenience and in their own time. Dr Austin says it is much less threatening doing it via the internet. "Online, people are freer to reflect on things without feeling they are being judged. They don't have to look anyone in the eye and tell them their problems."

Others likely to take up the programs will be general practitioners, especially in regional and rural areas, who carry the burden of dealing with mentally ill patients with little support or training in psychological treatment.

"The availability of the program means that GPs will be able to refer their patients to the online program and then follow up with them if necessary during the program," Dr Austin says.

Despite the programs' documented success in treating patients with anxiety disorders, until now benefits have been restricted to research participants. Once the research had been completed the programs were relegated to the 'bottom drawer' because of a lack of funding.

"They've all just been sitting here doing nothing because we haven't had the means to take them to the wider Australian public," says Dr Austin. With the government grant, the specialised centre will open next year and will help facilitate the development of other programs in both health and mental health areas.

In the meantime, Dr Klein, Dr Austin and colleagues are conducting a research study into their online post-traumatic stress disorder treatment program (PTSD Online) funded by the Australian Rotary Health Research Fund. They are seeking people over the age of 17 who have post-traumatic stress disorder. Preliminary results have demonstrated that PTSD Online is effective in treating the disorder.

More information: www.ptsd-online.org www.swinburne.edu.au/lss/swinpsyche/etherapy