Introduction
Depression is a common mental disorder worldwide with more than 350 million people affected. Although there are known, effective treatments for depression, fewer than half of those affected in the world receive such treatments. While only a third of the adult population in the UK who have diagnosable depression receive some form of treatment (Department of Health, 2007), the majority of people who seek help are cared for by their general practitioner (GP) instead of a specialist (National Health Service Centre for Reviews and Dissemination, 2002). But, psychological therapies are increasingly preferred by patients (McHugh et al. Reference McHugh, Whitton, Peckham, Welge and Otto2013). Moreover, empirical evidence suggests that patients who are able ‘to exercise control over their healthcare decisions may experience improved outcomes’ (Winter & Barber, Reference Winter and Barber2013, p. 1049).
Against this background, the UK government's Improving Access to Psychological Therapies (IAPT, n.d.) programme was developed to instigate an increase in the provision of evidence-based psychological therapies, mainly aimed at treating anxiety and depression in primary care. Within the NHS, treatment for anxiety and depression follows the stepped care approach, which is ‘a flexible model of healthcare delivery in which patients can begin their treatment with a low intensity intervention requiring only limited practitioner support such as guided self-help’ (Kenicer et al. Reference Kenicer, McClay and Williams2012, p. 1).
Unfortunately, the observation made at the beginning of this century that many patients are not offered psychological treatment, is still relevant (Proudfoot et al. Reference Proudfoot, Ryden, Everitt, Shapiro, Goldberg, Mann, Tylee, Marks and Gray2004). In particular, treatment such as CBT is often not available to patients because of therapist shortages (Du et al. Reference Du, Quayle and Macleod2013). Therefore, the need for alternatives to one-to-one therapeutic treatment delivery has been underlined.
This study aims to analyse one of the most recent treatment options for depression offered within the NHS, i.e. computerized cognitive behavioural therapy (cCBT). The NHS currently offers cCBT via stand-alone computer-based or web-based programmes which meet criteria set out by NICE (2009). We chose to evaluate ‘Beating the Blues (BtB)’, which is ‘one of the most commonly used cCBT programmes in the UK’ (Koeser et al. Reference Koeser, Dobbin, Ross and McCrone2013, p. 307). Furthermore, although the NICE (2009) guidance recommends cCBT programmes ‘for people with persistent subthreshold depressive symptoms or mild to moderate depression’ and does not specifically endorse BtB, BtB is the only ‘cCBT programme with an RCT evidence base within the United Kingdom’ (Rhodes & Grant, Reference Rhodes and Grant2012, p. 4).
BtB is a software package which aims at treating patients with mild to moderate depression or anxiety (the latter condition will not be discussed further in this paper). BtB provides standardized treatment via the computer, thereby allowing patients to work at their own pace and take responsibility for their own improvement Proudfoot et al. Reference Proudfoot, Swain, Widmer, Watkins, Goldberg, Marks, Mann and Gray(2003b). BtB consists of eight 1-hour sessions, usually completed once weekly (Proudfoot et al. Reference Proudfoot, Swain, Widmer, Watkins, Goldberg, Marks, Mann and Gray2003b ) and mainly consisting of psycho-education, assessment of current problems, action plans and goals, change techniques, and homework. Throughout the sessions, video-recorded case studies which depict individuals modelling depressive symptoms and applying change techniques are available to the patient, as a means for them to learn about their symptoms and how to manage them with CBT techniques (Proudfoot, Reference Proudfoot2004). After each session the patient and their GP each receives a progress report. In the final session, relapse prevention strategies are introduced to equip the patient with skills to recognize when depression may be recurring, and how to cope with it in an efficient manner. Once a patient is diagnosed with mild to moderate depression by their GP and has agreed to do BtB, the only contact a patient receives during the treatment is with a practice nurse or a secretary who provides assistance with the package; they do not offer any support on clinical issues (Proudfoot et al. Reference Proudfoot, Goldberg, Mann, Everitt, Marks and Gray2003a , Reference Proudfoot, Ryden, Everitt, Shapiro, Goldberg, Mann, Tylee, Marks and Gray2004). While BtB does not include therapist guidance, there are other cCBT packages that do (Høifødt et al. Reference Høifødt, Lillevoll, Griffiths, Wilsgaard, Eisemann, Waterloo and Kolstrup2013).
In several studies, the efficacy of cCBT has been shown to be superior to treatment as usual (Foroushani et al. Reference Foroushani, Schneider and Assareh2011; but see De Graaf et al. Reference De Graaf, Gerhards, Arntz, Riper, Metsemakers, Evers, Severens, Widdershoven and Huibers2009 and Gilbody et al. Reference Gilbody, Littlewood, Hewitt, Brierley, Tharmanathan, Araya, Barkham, Bower, Cooper, Gask, Kessler, Lester, Lovell, Parry, Richards, Andersen, Brabyn, Knowles, Shepherd, Tallon and White2015) and on level with therapist-led CBT (Foroushani et al. Reference Foroushani, Schneider and Assareh2011). A few studies have used qualitative method to examine patients’ attitudes towards cCBT (e.g. Beattie et al. Reference Beattie, Shaw, Kaur and Kessler2009; Gerhards et al. Reference Gerhards, De Graaf, Jacobs, Severens, Huibers, Arntz, Riper, Widdershoven, Metsemakers and Evers2010). The findings suggest that subgroups of people with depression find cCBT to be an acceptable treatment method as it allows for improved access, managing time constraints, and the potential for anonymity; barriers include a lack of non-verbal cues, delayed responses, and the need for a sufficient level of computer literacy. Researchers have pointed out that it is important to understand ‘factors that might have affected healthcare professionals and therapists in advocating cCBT … since their attitudes and perceptions towards cCBT may have a direct impact on the uptake of cCBT and subsequent adherence rates by patients’ (Du et al. Reference Du, Quayle and Macleod2013, p. 217). According to a survey study of therapists’ attitudes towards cCBT, published in 2004, the majority of respondents saw cCBT as a useful treatment approach for mild to moderate problems (Whitfield & Williams, Reference Whitfield and Williams2004).
Although a number of quantitative studies have been conducted to examine the effectiveness of cCBT, there is limited qualitative research. In particular, to our knowledge, cognitive behavioural therapists’ views on cCBT have not been explored qualitatively. This study aims to use qualitative methods to explore the views of cCBT in cognitive behavioural therapists who treat people for depression. In particular, the study aims to examine therapists’ thoughts about (1) how cCBT fits into the stepped care approach to treating depression, (2) whether cCBT can provide a suitable alternative to face-to-face CBT, and (3) what are cCBT's main strengths and weaknesses.
Method
Design
A qualitative, paper-based study of views on cCBT treatment for depression was conducted using data collected from cognitive behavioural therapists accredited by the British Association for Behavioural and Cognitive Psychotherapies (BABCP) using a questionnaire format. The purpose of the study was to check participants’ understanding and ability to answer the questions and highlight areas of confusion in order to amend problems with the questionnaire before issuing a large-scale survey.
Participants
To be considered for this study, therapists had to meet the following criteria: listed as an already accredited member of BABCP (those listed as provisional members were not contacted); listed as practising CBT; a contact email address present on their BABCP profile; their BABCP profile needed to specify that they treat those suffering from depression.
Therapists in this sample were obtained via the BABCP website using the ‘Find a Therapist’ function, then the ‘Geographical Search’ option. All therapists within a certain geographical area (e.g. Greater Manchester) who met the inclusion criteria were contacted and invited to complete the questionnaire. The geographical areas from which therapists were contacted were chosen at random, but were limited to only areas in England as guidelines can differ in Scotland, Wales and Ireland. The geographical areas selected were: Derbyshire, Nottinghamshire, Greater Manchester, Northumberland and Bristol.
Therapists were contacted via email, and of the >100 accredited therapists contacted, 12 therapists replied. Age ranged between 46 and 61 years, average age was 52 years. Eight therapists were female and four were male. All participants were white British. Participants were not selected on the basis of how much experience they had, nor were they asked if they had had previous positive or negative experiences with cCBT. Thus, rather than asking about personal experience, focus in this study was on general attitude. In this study, the mean age was higher compared to the large-scale randomized controlled CoBalT trial by Nicola Wiles and colleagues (mean age was 39 years; Wiles et al. Reference Wiles, Thomas, Abel, Ridgway, Turner, Campbell, Garland, Hollinghurst, Jerrom, Kessler, Kuyken, Morrison, Turner, Williams, Peters and Lewis2013).
The questionnaire
Qualitative data was collected with a questionnaire containing open questions that focused on participants’ views and experiences of BTB or other cCBT computer programs for depression. A few sample questions are ‘Do you think the standardized style of “Beating the Blues” is appropriate for treating a unique and varied illness like depression?’ and ‘The “mood diary” is used to log the emotions of a patient while they use “Beating the Blues”. Do you believe dwelling on negative thoughts in this way would be a helpful or harmful experience when discussing emotions with a therapist is not part of the treatment?’
Analysis
Anonymity was assured by using a unique identifier (e.g. ID1) that was chosen by participants at the same time as their consent was collected. For this study, we used thematic analysis (Braun & Clarke, Reference Braun and Clarke2006) which is an ‘abbreviated’ approach to grounded theory (Willig, Reference Willig2001) as compared to the ‘full’ approach of Glaser & Strauss (Reference Glaser and Strauss1967). Thus, while the ‘full’ grounded theory approach builds on an iterative process of data collection, coding, analysis and planning to allow for building theory grounded in the data, the abbreviated version of grounded theory works with the original data only. Participants’ responses to the open questions in the questionnaire were analysed applying the six-phase model proposed by Braun & Clarke (Reference Braun and Clarke2006): (1) reading and rereading the data, noting down initial ideas; (2) initial coding of interesting features of the data; (3) collating codes into potential themes; (4) reviewing the themes and checking them against the initial coded extracts; (5) continued refining of themes and the way in which they explain the analysis, allowing for themes to be labelled; (6) selecting extracts which illustrated the themes. Having such a small sample allowed for all opinions to be debated by the two authors. Both authors independently of each other formulated themes and selected quotes that were thought (1) to capture the gist of the themes, and (2) to demonstrate differing views between participants. Following detailed discussions, the final themes and quotes were agreed.
Results
Three major themes emerged in the participants’ responses: (1) the standardized nature of cCBT is suitable for depression, (2) the importance of the therapeutic relationship in CBT and cCBT, and (3) the pros and cons with cCBT as an alternative to CBT. The themes will be presented in detail below.
The standardized nature of cCBT is suitable for depression
The majority of participants reported that, in their view, the standardized nature of cCBT is not a problem when treating depression.
Yes [the standardized nature of cCBT is appropriate for treating depression] – [but] it does depend on the person and their problem but I think it can be helpful to a certain extent. (ID1)
In addition, several therapists emphasized that patient motivation for treatment is particularly important in cCBT, and cCBT is useful only to those who are highly motivated for computerized therapy.
Probably okay for . . . patients [who] are well motivated to use the prograM and carry out suggested homework. (ID6)
Many of the therapists also pointed out that while in CBT, the therapist has the opportunity to ‘encourage patients to believe they can manage their mood differently in the future’ (ID8), this is not an option in cCBT. Therefore, the therapists suggested that cCBT should be used as an initial step to orientate and motivate patients for psychological treatment before they start face-to-face CBT. However, even at this stage there is a risk that the patient may feel that cCBT is not helpful.
cCBT may or may not help while patients are waiting for therapy, i.e. psychoeducation and socialization, etc. (ID5)
Majority of therapists who participated in the study outlined the manner in which they deliver CBT. In doing so, they explained that a fair number of elements in CBT have been incorporated into cCBT while other elements are less common. The elements that participants feel are integral to successful face-to-face CBT and are incorporated in the software include: cognitive restructuring of unhelpful core beliefs and thoughts, relapse prevention techniques, and demonstrations of how to manage moods in the future. But, other features in CBT were thought to be more difficult or even impossible to incorporate into cCBT. For example, interaction with the therapist, non-verbal communication, mutual formulation of a treatment plan, mindfulness training, monitoring recurrent depression, and improving the patient's understanding of why they have not been able to improve on their own.
cCBT cannot provide some of the things that CBT centres around [for example] … mindfulness for recurrent depression. (ID1)
70–80% of communication is through body language, and a computer cannot give you that. (ID9)
The problem with cCBT is poor [patient] motivation, and there is no real monitoring of risks. (ID11)
The importance of the therapeutic relationship in CBT and cCBT
Therapists underlined that the alliance is the core element of any psychotherapy and that recovery is not possible without it. The therapist's capacity to listen empathically is crucial, together with ‘a willingness to listen and “be human”’ (ID8) and ‘using the core conditions of warmth, empathy, genuineness, respect, non-judgemental attitude’ (ID2). Thus, many of the therapists expressed concern that unguided cCBT may not be clinically effective.
An essential part of CBT of course is the therapeutic relationship, or for any other therapy for that matter . . . BtB does not provide these features. (ID10)
A couple of the participants alluded to the importance of showing the patient that they are more than just ‘another name on your list’. One therapist questioned whether unguided cCBT can make a patient feel that they are an important person in their own right.
Computerized CBT seems so impersonal – patients must feel like numbers. (ID7)
In contrast, other therapists argued that the absence of a therapeutic relationship in BtB is not a problem as the educative approach in this treatment approach is appropriate for patients with a mild level of depression.
No [the self-help nature of BtB is not detrimental to treatment] – there is a significant amount of psychoeducation and health education in BtB. (ID3)
Several participants mentioned that there will always be some patients who feel more comfortable to communicate with a computer. In addition, one participant suggested that although a computer is unable to show empathy, some patients may take comfort from the fact that a software package to treat depression has been put in place.
I think the existence of a program for self-help may be [seen as] a kind of empathy because the patient will realize that they are not alone and others have had a similar problem. Someone has cared enough about the problem that they have designed a computer program to help them. (ID3)
A few participants suggested that adequately trained practitioners can provide the necessary level of support to people with mild depression as they can review progress, risks and software-related problems.
My understanding is that PWPs [psychological wellbeing practitioners] should help set up patient/s at the start of the session and then do a quick review of risk, progress, user problems, etc. (ID8)
However, the therapists pointed out that there are moments in the therapy which might be difficult for PWPs to manage. For example, when a patient has identified their negative thought patterns, how would they be able to cope with this realization without having the option of communicating with a therapist?
They feel even worse because they realize some of the problem is to do with their inner world. They then blame themselves. (ID12)
Pros and cons with cCBT as an alternative to CBT
Despite having certain issues, all participants agreed that cCBT is a viable complement to CBT which is required due to the high costs of CBT together with a continued rising demand for it.
I do not believe it is an alternative [to CBT], I believe it is something that could be considered along with bibliotherapy, psychoeducation courses, CBT group therapy and individual therapy. (ID6)
Majority of participants reported that they believed that cCBT should be used on step one only, with patients without comorbidity, and only when the patient has expressed that they would like to do cCBT.
[whether cCBT can be successful] depends on the individual and whether the case is mild, moderate or severe. (ID4)
BtB could provide psychoeducation while people are on waiting lists – to get the ball rolling. (ID12)
Give patients the choice [to do BtB] at the first step – if they have mild depression. (ID4)
Discussion
This research set out to explore the views on cCBT among a self-selected group of accredited CBT therapists and three key themes were identified: (1) the standardized nature of cCBT for depression, (2) the importance of the therapeutic relationship in CBT and cCBT, and (3) the pros and cons with cCBT as an alternative to CBT.
The participants reported that they viewed cCBT to be well suited for treating depression, but only when the patient presents with mild depression. Thus, the therapists appeared to disagree with the recommendation in NICE guidelines (2009) that cCBT is an adequate treatment for patients with moderate as well as mild depression. However, our results concur with a review of the literature on barriers to uptake of computer-based therapies, where practitioners were less positive about computer-based therapies than were patients (Waller & Gilbody, Reference Waller and Gilbody2009). In similar, a national survey of accredited CBT therapists’ attitudes towards CBT self-help showed that the CBT therapists generally saw self-help interventions as useful when supplementing or continuing one-to-one work with an accredited CBT practitioner; however, only a relatively small percentage (10.6%) recommended cCBT to their patients (MacLeod et al. Reference MacLeod, Martinez and Williams2009).
Several of the accredited therapists in this study emphasized that patient motivation is a crucial factor in cCBT without therapist guidance because the patient in this type of treatment does not receive regular support from a therapist. The issue of patient motivation in cCBT has been widely discussed (e.g. Powell et al. Reference Powell, Hamborg, Stallard, Burls, McSorley, Bennett, Griffiths and Christensen2012; Graham et al. Reference Graham, Cha, Papandonatos, Cobb, Mushro, Fang, Niaura and Abrams2013; Wilhelmsen et al. Reference Wilhelmsen, Lillevoll, Risør, Høifødt, Johansen, Waterloo, Eisemann and Kolstrup2013) and, in some studies, patient motivation has been linked to attrition (Christensen et al. Reference Christensen, Griffiths and Farrer2009; Melville et al. Reference Melville, Casey and Kavanagh2010; Wilhelmsen et al. Reference Wilhelmsen, Lillevoll, Risør, Høifødt, Johansen, Waterloo, Eisemann and Kolstrup2013). In turn, this finding may reflect research results which indicate that a substantial number of patients allocated to cCBT do not start their treatment (e.g. Waller & Gilbody, Reference Waller and Gilbody2009). Moreover, it is safe to suggest that patients’ motivation for treatment is related to their understanding of the treatment (Calkins et al. Reference Calkins, Davis, Reiley, Phillips, Pineo, Delbanco and Iezzoni1997; Meyer et al. Reference Meyer, Pilkonis, Krupnik, Egan, Simmens and Sotsky2002; Makaryus & Friedman, Reference Makaryus and Friedman2005).
Some of the views expressed by the practitioners who participated in this study showed that they agreed on aspects of the NICE recommendations as well as research reports, e.g. that professional support during cCBT enhances outcome (Kaltenthaler et al. Reference Kaltenthaler, Brazier, De Nigris, Tumur, Ferriter, Beverley, Parry, Rooney and Sutcliffe2006; NICE, 2009; Newman et al. Reference Newman, Szkodny, Llera and Przeworski2011).
At other times, participants expressed views that are in conflict with the evidence-based viewpoint; for example, participants suggested that cCBT should be only for mild symptoms while NICE (2009) as well as researchers (e.g. Pittaway et al. Reference Pittaway, Cupitt, Palmer, Arowobusoye, Milne, Holttum, Pezet and Patrick2009) have suggested that cCBT is beneficial for adults with both mild and moderate depression. Second, in contrast to the evidence base, some participants purported that psychoeducation but not guidance should be viewed as a critically important feature in any cCBT package. In contrast, research has found that the effect of psychoeducation is ‘clinically negligent’ but guidance is associated with greater effectiveness (Gellatly et al. Reference Gellatly, Bower, Hennessy, Richards, Gilbody and Lovell2007). Also contrary to research findings (Ormrod et al. Reference Ormrod, Kennedy, Scott and Cavanagh2010; Anderson et al. Reference Anderson, Spence, Donovan, March, Prosser and Kenardy2012; Barazzone et al. Reference Barazzone, Cavanagh and Richards2012), participants expressed concern that a cCBT package does not allow the development of a therapeutic relationship.
Since the present study has a questionnaire format with open questions, the researchers were prevented from using follow-up questions to explore further what were the therapists’ reasons and rationale for taking their stance. However, the results seem to suggest that the implementation of evidence-based practice and policy remain a challenge in clinical practice. In particular, in the discussion of the gap between research findings and CBT practice, two sets of barriers to dissemination of research findings have been identified (Shafran et al. Reference Shafran, Clark, Fairburn, Arntz, Barlow, Ehlers, Freeston, Garety, Hollon, Ost, Salkovskis, Williams and Wilson2009, p. 903). The first set includes ‘commonly held beliefs among clinicians’ about, e.g. the limited relevance of research trials to clinical practice and the importance of common factors (the therapist is more important for treatment outcome than the specific treatment protocol). The second set includes ‘gaps in our knowledge about treatments, their delivery and training modes’. Shafran et al. presented eight recommendations to facilitate the utilization of empirically supported CBT protocols in routine practice, for example that practitioners should have easy access to treatment guidelines and manuals which state how the clinical trials address comorbidity, and they should have easy access to training in diagnostic assessments and routine outcome measures.
The participants in the present study pointed out a number of benefits of cCBT such as low costs, which will lead to expansion in treatment availability, flexibility, which means that patients can access the treatment program at a time and place that is convenient for them, and, cCBT was also thought to offer privacy. These advantageous features were also reported in previous studies (Kenwright et al. Reference Kenwright, Marks, Graham, Franses and Mataix-Cols2005; Griffiths & Christensen, Reference Griffiths and Christensen2007; Beattie et al. Reference Beattie, Shaw, Kaur and Kessler2009; Green & Iverson, Reference Green and Iverson2009; Gerhards et al. Reference Gerhards, Abma, Arntz, de Graaf, Evers, Huibers and Widdershoven2011). In summary, cCBT provides people who suffer from depression with the opportunity to access psychological treatment delivered over the Internet in the privacy of their own home which allows them to avoid ‘long waiting lists, increase convenience and confidentiality, and lessen stigma’ (Marks et al. Reference Marks, Cavanagh and Gega2007, p. 473).
While the majority of participants suggested that professional support would not be required in cCBT delivered to patients with mild depression, other studies have found that the addition of support to cCBT may be a way of improving adherence (Palmqvist et al. Reference Palmqvist, Carlbring and Andersson2007; Spek et al. Reference Spek, Cuijpers, Nyklicek, Riper, Keyzer and Pop2007, but see Murray et al. Reference Murray, Schmidt, Pombo-Carril, Grover, Alenya, Treasure and Williams2007). A couple of the participants in our study suggested that an ‘informed support worker’ could review progress, monitor risks and help solve problems with the software. This finding lends support to previous research which found that support from lay people (Angermeyer et al. Reference Angermeyer, Matschinger and Riedel-Heller2001; Oliver et al. Reference Oliver, Pearson, Coe and Gunnel2005) and technicians (Titov et al. Reference Titov, Andrews and Perminder2010) are commonly seen among people with mental health problems engaged in computerized treatment. Indeed, this could be because the therapy is accessed via a computer program, and therefore the support that the patient needs requires less skills than in face-to-face therapies. Moreover, as suggested in one study (Gerhards et al. Reference Gerhards, Abma, Arntz, de Graaf, Evers, Huibers and Widdershoven2011, p. 124), adding (professional) support might endanger the appealing aspects of cCBT including ‘accessibility, low costs, and independence on availability of healthcare professionals’.
Several participants in this study emphasized the importance of offering patients the choice of what type of treatment they wish to undergo. Since an estimated two thirds of the adult population in the UK who have a diagnosable depression are hidden, and thus do not receive any treatment (Department of Health, 2007), it seems fair to suggest that we do not know what type of treatment and support, if any, these people wish to undergo. A related issue is whether people in general have sufficient knowledge about CBT to allow them to choose, e.g. between face-to-face and cCBT. However, the increasing distribution of knowledge about CBT treatment over the Internet and via software programs is likely to lead to a growing knowledge and understanding of CBT in the general population.
As this research used qualitative method to examine a small self-selected sample, there are a number of methodological concerns that need to be highlighted. An important limitation is the small sample size. More than 100 BABCP-accredited therapists were approached; however, only 12 chose to complete the questionnaire. In addition, the average age (52.25 years) of the therapists who participated in the study is perhaps not representative of the population, and younger therapists may have different views on computerized forms of therapy. Furthermore, therapists were contacted by email which again may have limited the number of therapists who were made aware of the study. Finally, participants were recruited using BABCP's online CBT Register, which inadvertently excluded therapists who opt out of the register. A future study involving accredited practitioners should attain the whole contact list of practitioners from BABCP.
In agreement with many qualitative researchers, we believe that it is important for qualitative researchers to demonstrate quality in their research (e.g. Yardley & Moss-Morris, Reference Yardley and Moss-Morris2009, but see, for example Buchanan, Reference Buchanan1992). Despite this general agreement, there is no consensus on how quality in qualitative research should be evaluated (see, e.g. Hefferon & Gil-Rodriguez, Reference Hefferon and Gil-Rodriguez2011). In this study, we made use of guidelines summarized by Golafshani (Reference Golafshani2003) who concluded that ‘Reliability and validity are conceptualized as trustworthiness, rigor and quality in qualitative paradigm’ (p. 604). In our study, we added a third criterion, impact and importance (Yardley, Reference Yardley2000, Reference Yardley and Smith2008). Our evaluation of the development of the study design and questionnaire as well as the data collection and analysis showed that these procedures were undertaken in a systematic and rigorous manner. Thus, the study's trustworthiness, or the extent to which the findings could present a true picture of the phenomenon under study, suggested that the findings had a good quality. A future study could confirm the findings’ credibility by triangulating the findings from this study using, e.g. focus groups or interviews. However, the rigor and quality of the study was limited by the usage of a questionnaire with open-ended questions, which most likely lowered the degree to which the participants were able to fully disclose their views on cCBT. On the other hand, the questionnaire format removed biases that pervade many other qualitative data collection methods, for example, the interviewer–interviewee relationship in the individual interview.
In conclusion, the accredited therapists that took part in this study agreed that cCBT is a useful complement to face-to-face therapy as more patients can be provided with therapy at a lower cost while maintaining treatment benefit. However, some of the views that the participants expressed, for example that a therapeutic relationship cannot be formed in cCBT, are incorrect from an evidence-based viewpoint. This finding suggests that more work is needed to improve the implementation of evidence-based practice and policy, i.e. to implement evidence-based treatment protocols. Nevertheless, the possibility of standardizing aspects of CBT with software programs offers a strategy for increasing the availability of CBT. Challenges ahead for clinical practitioners and researchers lie in ascertaining for which patients in which settings cCBT is beneficial and adding appropriate support (i.e. laymen/technician, therapist support) to patients who undergo unguided cCBT.
Main points
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• Participants in the study saw that cCBT for individuals with depression is an important alternative to face-to-face CBT.
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• In line with current empirical research, several participants emphasized the critical importance of patients’ motivation for being able to engage in cCBT.
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• Some participants thought that an important limitation with cCBT is that it can only be used successfully for individuals with mild depression. This assumption goes against NICE guidelines and accumulating evidence which suggests that cCBT can be used to treat people with both mild and moderate depression.
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• Other participants expressed concern that it is not feasible to create a therapeutic relationship in cCBT; however, a number of studies have suggested that aspects of a relationship is present in cCBT (Ormrod et al. Reference Ormrod, Kennedy, Scott and Cavanagh2010; Anderson et al. Reference Anderson, Spence, Donovan, March, Prosser and Kenardy2012).
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• CBT therapists and researchers are facing the task to improve the knowledge and evidence on what patient groups can benefit from CCBT.
Acknowledgements
The authors thank the accredited cognitive behavioral therapists who made this project possible. This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Declaration of Interest
None.
Ethical standards
The study was approved by the Social Sciences School Research Ethics Committee (SREC), Nottingham Trent University, before it was conducted.
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.
Learning objectives
After reading this paper the reader will be able to:
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(1) Understand how a group of therapists view cCBT.
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(2) Appreciate the need for innovations in CBT delivery formats (e.g. internet-based, computerized) and treatments based on CBT principles delivered by health professionals other than psychotherapists.
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(3) Appreciate strength and limitations of cCBT as a treatment for patients with depression.
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