Internet-Delivered Cognitive Behavioral Therapy for Anxiety

Introduction

Online mental health interventions have evolved significantly in the last three decades.¹ While modern information technology has progressed considerably, so has the burden related to anxiety² (e.g., increased worldwide prevalence following COVID-19³, increased global wealth gap⁴) and its consequential functional impairment. The multifactorial etiology of anxiety (e.g., genetic vulnerability, environmental factors) combined with its high incidence, co-morbidity, and early age of onset display a unique, but impairing, presentation resulting in the most common mental health disorder in the world.⁵ Cognitive-behavioral therapy (CBT) is an effective first-line treatment for anxiety disorders across the lifespan, considered as the “gold-standard” psychotherapy.^6–8 While CBT has been adapted to address the heterogeneity in anxiety pathology, all protocols share the foundational premise that anxiety is maintained by maladaptive cognitions that are related to emotional distress and challenging behaviors.⁷ Resultant CBT protocols include skills-based cognitive, behavioral, and emotional techniques to reduce symptoms and improve functioning. In a review of meta-analyses, CBT demonstrated medium to large effect sizes across adult anxiety symptomatology (e.g., social anxiety, generalized anxiety disorder, panic disorder, specific phobias).^6–7 Similar findings were demonstrated within pediatric populations.⁸

Despite its strong evidence, there is a significant research-to-practice gap. Factors such as limited access to CBT-trained clinicians and therapists, direct and indirect treatment costs, low fidelity in practice, and provider interest are amongst barriers to both treatment dissemination and implementation.⁷ However, with the advent of online mental health interventions, treatment delivery formats such as Internet-delivered CBT (iCBT) present a promising treatment avenue.

iCBT refers to CBT delivered via the Internet through a computer or mobile device.^9–14 iCBT differs from traditional, face-to-face treatment in that it is often low intensity (either therapist guided or self-paced) and helps overcome conventional disadvantages such as cost inefficiency and limited follow up. Several studies suggest numerous benefits of iCBT, including high accessibility, confidentiality, and quick feedback.¹⁰ Combined with idiosyncratic clinical factors such as individual and family characteristics, symptom severity, socioeconomic status (SES), and access to care, iCBT presents a favorable treatment alternative for patients. Moreover, the worldwide disruption related to the COVID-19 pandemic resulted in increased demand for telehealth and digital mental health interventions, and iCBT aptly filled the gap.^3,11–12 Several studies suggest that iCBT may be a promising alternative as it demonstrates outcomes similar to that of standard CBT.^12–14 However, iCBT for anxiety exhibits several limitations (e.g., treatment adherence, limited opportunities for the therapeutic alliance and ethical concerns).¹⁴

iCBT for anxiety presents a unique arena of research and practice. The current chapter presents an overview of iCBT for anxiety, associated evidence base, and application. We first start with by reviewing the history of iCBT and its evolution into mainstream mental health. We then provide a review of iCBT anxiety procedures and its varying delivery formats. Advantages and limitations are then discussed, followed by a review of the evidence-base across the lifespan. Further, both cultural and ethical considerations are presented. The chapter concludes with a review of key points and future directions.

Discussion

The Evolution and Development of iCBT

While computer-based psychotherapeutic interventions have been around for some time, its evolution to modern-day iCBT has undergone several iterations.¹⁴ From its revolving terminology (including, but not limited to, computer-assisted psychotherapy, e-therapy, web-based therapy, digital mental health intervention) to its advancement in the last decade, iCBT for anxiety can be best described as a product of its time. The field has witnessed a recent increase in iCBT delivery largely due to the COVID-19 pandemic and its lasting effects on the way in which individuals interact with one another through virtual platforms. However, this recent upsurge in the provision of iCBT can be better understood by examining the history of this intervention, as it demonstrated both efficacy and effectiveness years before the practices of social distancing.

Historical Background and Emergence of iCBT

The history of iCBT dates back prior to the modern Internet age. Its background can be best described in two sequential phases: (1) the prominence and use of CBT as an evidence-based intervention and its hand in guided self-help treatment and (2) the introduction of computerized psychological treatment.¹⁴ Given the structured nature of CBT, the framework is a popular approach for guided self-help treatments such as bibliotherapy. Bibliotherapy refers to the use of a self-help book to help patients manage unhelpful thoughts and challenging emotions.¹⁵ As such, guided self-help books often get credit for opening the door for iCBT programs.^15–18 This is due to the parallels between the early versions of iCBT and bibliotherapy, with similar characteristics such as e-mail support and information presented via text and visual aids.¹⁸

From there, bibliotherapy and guided self-help treatments transitioned to digital platforms via computerized psychological treatments.¹⁹ These CBT-based treatments were delivered on a computer via an offline program (i.e., CD-ROM)¹⁴ and were comprised of many of the same elements as bibliotherapy. Computerized psychological treatments demonstrate a significant evidence-base in its own right (e.g., computerized CBT [CCBT], evidencing support in several meta-analyses).^{14–15, 18–19} As access to the Internet became more commonplace, computerized psychological treatments were made available online, ultimately transitioning to iCBT. Presently, many iCBT programs are delivered through online programs and apps made available for download on smartphone devices, tablets and computers.¹⁷

iCBT Treatment Procedures and Delivery Formats

While numerous iCBT models exist, all have four key features: an online treatment platform, secure assessment procedures embedded within the treatment platform, scheduled service delivery, and treatment content drawn from established manualized CBT protocols with text, visual, and audio aids.²⁰ The online platform is often encrypted to secure sensitive information, often requiring a form of password protection or two-factor authentication. Therapist communication (if any) is also protected to ensure patient confidentiality. Self-reported assessment procedures are often integrated into the treatment platform to assess symptoms at baseline, monitor progress over time, and examine outcomes.^{17, 20}

Like traditional face-to-face CBT, iCBT models follow a time-limited sequence where sessions (often referred to as “modules”) range from 5–15 weeks and are designed to be delivered on a weekly basis.²⁰ Treatment typically begins with a psychoeducation module and ends with relapse prevention and termination. The modules in between consist of treatment material for the specific condition with accompanying video and audio aids, illustrative examples, and homework assignments. iCBT for anxiety^21–22 consists of modules that reflect the active ingredients in a conventional CBT for anxiety protocol: self-monitoring, relaxation, hierarchy development, cognitive restructuring, and exposure (Figure 1).²² Some protocols may include optional or supplemental modules to support treatment for comorbid presentations, such as autism.²³

Figure 1.

CBT Framework for Anxiety (data from James et al.²²)

Delivery formats

Generally, iCBT can be delivered via an unguided or guided format. Unguided iCBT is entirely self-directed where patients are provided with the online intervention platform and guide themselves through the program. Guided iCBT (or therapist-assisted iCBT) refers to iCBT with dedicated communication and support from the patients’ therapist, either synchronously or asynchronously.¹⁹ The role of an iCBT therapist may include any combination of the following: conducting weekly check ins via secure email, offering feedback on hierarchy development and exposure tasks, offering guidance on homework assignments, questionnaires or surveys, answer, providing motivation, and ensuring patient follow up.¹⁹

Among guided formats, the level of guidance varies widely in the literature. Matsumoto et al.²⁸ describe three levels of therapist guidance: full assistance via real-time videoconferencing, minimal assistance (i.e., feedback, email communication), and no assistance. Similarly, Harrer and colleagues²⁵ characterize guided iCBT with reminders and feedback, whereas Andersson et al.²⁶ describes any level of human support in iCBT treatment as guided iCBT.

Early studies found guided iCBT interventions for anxiety were more effective than unguided.^{10, 27} However, the overall empirical base supporting that claim is mixed. Several clinical trials comparing the two delivery formats indicate that guided iCBT was noninferior to unguided iCBT.^27–28 A recent meta-analyses identified differences in the maintenance of treatment outcomes, where guided iCBT was found to be more effective in the short-term, but not the long-term.²⁷ Overall, both guided and unguided iCBT models have demonstrated similar outcomes.

Benefits of iCBT

Accessibility and cost-effectiveness

iCBT offers several benefits for both patients and mental healthcare providers. First, digital delivery of treatment allows clinicians to access populations that are often difficult to reach. Despite recent developments that have increased access to mental healthcare, many areas in the United States do not have sufficient access to mental health services (e.g., rural areas, low SES communities).²⁹ Such limited access places many individuals in situations in which appropriate levels of care require traveling further away, which presents additional time and financial barriers. iCBT presents a viable alternative for individuals to access care that might otherwise go unutilized.

Second, common barriers to receiving services includes transportation, availability, and cost.²⁹ iCBT may address these issues. Medical expenses related to anxiety disorders place a significant economic burden on the American healthcare system. iCBT presents a promising alternative for treatment in that it requires less therapist time and is more readily accessible (i.e., online access at any time). Several studies indicate the cost-effectiveness of the intervention, where iCBT offered a societal saving of $144 per patient relative to waitlist controls.³⁰ Moreover, iCBT generates a societal gain (being more clinically efficacious at a lower societal cost) for panic disorder,³¹ health anxiety,³² and anxiety disorders broadly.³³

Third, iCBT programs can serve as a mechanism for relapse prevention in which a patient engages with a referred iCBT program upon completion of face-to-face treatment.⁴⁵ Having access to iCBT may help maintain their treatment progress, without the immediate need to reengage in more traditional psychotherapy.

Limitations of iCBT

Technological barriers and access disparities

Although iCBT may reduce certain barriers (e.g., cost, availability, stigma), there may be inequities of access for others.^34–36 Given the Internet mode of delivery, there may be “digital divide” such that iCBT may be more acceptable to younger populations given their familiarity with technology.^35(p35) Participation in iCBT may require familiarity with computer use, digital literacy skills, and proficient typing abilities. Ultimately, these factors point to the social determinants of access to iCBT and illustrate how economic and social inequities may preclude certain populations from accessing, and benefiting from iCBT (e.g., individuals with low computer and digital literacy, no access to a computer or the Internet, low SES).^34–36

Therapeutic alliance and rapport in iCBT

The therapeutic alliance is a core component to psychotherapy and associated with improved treatment outcomes.³⁷ Recent studies have demonstrated varying levels of association between treatment outcomes and therapeutic alliance within iCBT.³⁸ For example, despite limited data, several studies suggest that iCBT presents a suitable environment for an effective therapeutic alliance between therapist and client.^38–39 However, future research is required in the area (e.g., identifying predictors that may improve therapeutic alliance and whether the semblance of therapeutic alliance can be achieved without therapist contact). Potential areas to investigate include the impact of increased therapist/client communication, individualized modules, and therapist credibility on therapeutic alliance.

Dealing with crisis situations and emergencies in iCBT

In more traditional settings, when a patient encounters a crisis (e.g., endorses suicidal ideation or self-harming behaviors) clinicians have a set protocol to follow. It is equally important to establish crisis situations within iCBT. Literature suggests that an effective safety protocol can begin with preventative steps for each patient (e.g., providing a document or list of resources during intake sessions) as well as regular monitoring of self-report measures conducted throughout the duration of treatment.⁴⁰

Thanks to technological advancements, iCBT programs have demonstrated the ability to provide notifications to clinicians and patients themselves if an individual endorses elevated or significant levels of distress.^40–41 Such alerts can then allow clinicians to implement their clinic or organization’s safety protocols effectively and immediately or prompt the patient to engage with crisis resources that they have been provided. For iCBT programs that are more self-help oriented and patient-driven, it is beneficial to incorporate direct links to emergency resources in addition to a means to connect with a provider as necessary.

A Review of iCBT Efficacy

Current studies – adults

The evidence base for iCBT for anxiety in adults is strong.^{6, 10, 20 , 24, 28, 31, 33, 42} Several systematic reviews and meta-analyses indicate that iCBT for anxiety disorders is superior to waitlist and active control conditions (e.g., treatment as usual).^{6, 11, 17, 27} For example, in a review of 22 RCTs, results indicated that iCBT for internalizing problems demonstrated a number needed to treat (NTT) of two.⁴³ These findings are consistent throughout adulthood, in that iCBT demonstrates efficacious from anxious emerging adults⁴⁴ to older adults experiencing anxiety symptomatology.⁴²

Factors that influence iCBT outcomes.

Several factors may influence iCBT treatment outcomes. Regarding iCBT for anxiety, previous studies with adult populations have demonstrated that increased treatment adherence (i.e., completion of program modules/assignments) is associated with improved treatment outcomes.^{37, 40} However, full treatment rates are relatively low (ranging from 16%⁹ to around 50%).^42,43 Although these findings are relatively mixed, factors such as symptom severity and chronicity, treatment length, and therapist support have been identified as potential predictors of treatment adherence.^32,49 Treatment credibility was also found to be a predictor of both outcome and treatment adherence in iCBT for severe health anxiety.³²

While it is important to understand factors that may impact treatment response in iCBT, it is equally important to recognize factors that do not. Research has also demonstrated that some factors, such as age and gender do not affect symptom improvement rates.^{32, 42, 46, 48} However, this research is relatively mixed, as other studies have found that higher age decreases response^48,57 or that higher age is positively associated with response.⁴⁶

Current studies – children and adolescents

There is a modest evidence base on iCBT for pediatric anxiety, where several RCTs suggest moderate efficacy.^50–59 In comparison to non-therapeutic and waitlist conditions, iCBT treatment has shown to be more effective than waitlist control groups across several trials.^53–50 .See Waite P, et al.⁶⁰for exception.

iCBT programs also demonstrated efficacy when compared to traditional CBT delivered treatments,⁵⁵ as well as other therapeutic treatment options such as psychoeducation and supportive therapy.^58,61 Many RCTs report that iCBT treatment responders endorse moderate to high remission rates,^57,62 with Spence and colleauges⁵⁶ reporting remission in 78% of the iCBT treatment group. Several studies suggest that reductions in anxiety symptoms were sustained over time.^{53–57, 59, 62} Higher treatment efficacy was recorded overall when utilizing clinician- or caregiver- reported outcomes measures, in comparison to examining youth-reported outcome measures.⁵⁰ However, more research is required to identify and evaluate the specific mechanisms of iCBT for anxious youth, particularly within routine care.⁵¹

When considering implementing iCBT with youth, it is also important to consider developmental factors that may impact treatment engagement and adherence. For example, while iCBT presents as a favorable approach to treatment due to its flexible nature, iCBT may not be suitable for younger children without significant parent/caregiver involvement. Moreover, children significantly at-risk for suicide or self-harming behaviors, those with complex life situations (e.g., unstable home environment), patients with history of disengaging from treatment, or those with cognitive impairments that impact comprehension of intervention content, may not be suitable for iCBT.⁴⁰

Cultural Considerations for iCBT for anxiety

Importance of cultural considerations

Given the increased reach and accessibility of iCBT, it is important to discuss cultural considerations and adaptations to maximize treatment effects. Although the evidence base for iCBT is strong, it is equally imperative to refrain from applying a one-size fits all approach to treatment application as most RCTs draw from mainly majority-group samples (i.e., middle-to high income White and European Americans).⁶³

Literature suggests that culturally adapted treatments are often more effective for minoritized populations.⁶⁴ For example, cultural differences in anxiety symptom presentation and expression play a role in how an individual defines psychopathology, self-monitors symptoms, and understands symptom severity.^64–65 Acknowledging cultural differences not only acknowledges the diverse manifestations of mental health conditions, but also fosters a sense of cultural humility in the delivery of online treatment.

Culturally-adapted iCBT for anxiety

By recognizing and respecting the cultural context of users, culturally adapted iCBT may enhance relevance and engagement, ultimately leading to improved treatment outcomes⁶⁶. iCBT can be tailored on the large-scale during intervention development, or individually through clinician-patient collaboration.^66–69 In guided iCBT, therapists can consider patient cultural factors during goal-setting and treatment planning. This collaborative approach fosters a sense of empowerment and inclusivity, acknowledging the unique factors influencing mental health within various cultures.⁶⁶ Moreover, by recognizing the importance of cultural perspectives in goal-setting, iCBT practitioners can tailor treatment plans to address culturally specific stressors, coping mechanisms, and resilience factors.

In the context of iCBT anxiety treatments, individually tailored treatments have shown to be effective in increasing treatment retention, reduced symptom severity, and quality of life.^67–68 The same effect has been observed for culturally tailored iCBT programs, with one RCT reporting increased engagement for those in the culturally tailored treatment group in comparison to the typical treatment group.⁶⁹ It is important to note, however, that this treatment protocol was adapted by stakeholders on a large-scale, rather than based on individual patient perspectives. While the treatment remained effective, this approach may minimize the individuals’ unique experiences and preferences drawn from their associated cultures. Evidence suggests that a more collaborative working relationship between the therapist and patient when delivering tailored iCBT avails greater treatment outcomes.⁶⁸

Ethical and Privacy Considerations in iCBT

Ethical and privacy considerations are critical in the landscape of iCBT, requiring a vigilant approach to uphold user trust and maintain professional integrity. It is imperative that practitioners follow ethical best practices to support patient confidentiality. Principal themes present in the literature include trust and therapeutic alliance, privacy and confidentiality in the context of iCBT, beneficence and the uncertainty of new treatment modalities, nonmaleficence and limitations to client safety, justice an enhanced access, respect for autonomy and informed consent, and professional and legal issues.^70–71 Table 1 presents an overview of these themes and applied examples.

Table 1.

Principal ethical considerations in iCBT for anxiety disorders (data from the Canadian Agency for Drugs and Technologies in Health)⁷²

Themes	Examples
Trust and therapeutic alliance	- Therapists should only render guided iCBT services if therapist is able sustain a therapeutic alliance.
Privacy and confidentiality	- Utilize a secure user environment that encrypts therapist-client communications.
Beneficence and uncertainty of new treatments	- Therapists must weigh risks and advantages for utilizing iCBT with each client to act in their best interest.
Nonmaleficence and limitations to client safety	- Therapists must take all necessary steps to limit risks to client safety as to do no harm (e.g., assess their capacity to accurately screen and manage patient distress through an iCBT intervention).
Justice	- The enhanced access of iCBT helps reduce barriers, however it is important that therapists attend to additional social determinants that may arise with iCBT (e.g., access to Internet, using culturally adapted treatments).
Respect for autonomy and informed consent	- The independence that iCBT offers helps promote patient autonomy, however it is important for therapists to provide informed consent on iCBT risks and benefits.
Professional and legal issues	- Therapists should only deliver iCBT services if they are competent in rendering internet -delivered treatments.

Addressing potential ethical dilemmas and boundary issues with iCBT demands a proactive and thoughtful approach from mental health practitioners. The virtual nature of iCBT can blur traditional therapeutic boundaries, necessitating clear guidelines for online conduct and communication outside of scheduled sessions.^71–72 Therapists must navigate the challenge of maintaining a professional yet empathetic stance in a digital environment. Ethical considerations extend to the use of technology, ensuring secure data handling, encryption, and compliance with privacy regulations to protect user confidentiality.^71–72 Regular training and supervision are essential to equip practitioners with the tools to identify and navigate emerging ethical challenges within iCBT.

Summary

iCBT for anxiety has demonstrated both efficacy and effectiveness across the lifespan. With the increased demand for evidence-based anxiety treatment, iCBT has the potential to enhance accessibility, ease costs, and support flexible treatment options (notably for those facing geographical constraints, time limitations, or mobility issues).^{40, 51} Tech-savvy individuals comfortable with online platforms and digital tools may find iCBT particularly effective, as it offers the convenience of accessing therapy from virtually anywhere. Moreover, iCBT can be a valuable resource for self-motivated individuals who actively engage with therapy materials and exercises. However, iCBT may be less suitable for individuals with unreliable Internet access, require increased therapist support, and are in acute crisis situations where immediate intervention and in-person support are crucial. Treatment enhancing methods such as cultural adaptations and upholding ethical standards are essential features of the intervention. Future research should focus on conducting clinical trials with diverse populations, assessing the impact of therapist support, moderators and mediators of treatment outcomes, common co-occurring diagnoses, and increasing intervention infrastructure to support exposure therapy (a critical feature of CBT anxiety treatment).

Key Points.

• Internet-delivered CBT (iCBT) is an efficacious anxiety treatment for adults and demonstrates moderate efficacy for children.

• iCBT demonstrates several benefits such as cost-effectiveness, increased accessibility.

• It is important to consider elements to support effectiveness, such as guided therapist support, cultural adaptations, and safeguarding privacy and confidentiality.

Clinics Care Points:

• Internet-delivered cognitive behavior therapy (iCBT) for anxiety has evolved significantly over the last three decades and is a cost-effective and accessible evidence-based treatment for anxiety across the lifespan.

• Although there is support for iCBT across varying delivery formats (eg, unguided versus therapistguided), it is important to consider potential limitations such as technological barriers, therapist rapport building, and crisis management for patients.

• ICBT boasts strong evidentiary support with adults, however treatment adherence rates are relatively low. Treatment enhancing factors such as individually tailoring treatment may be helpful to address this. Further, iCBT for pediatric anxiety demonstrates modest support, but may not be suitable for young children without parental support or high-risk youth.

• Given its online format, it is imperative for practitioners to vigilantly uphold key ethical standards (ie,confidentiality, nonmaleficence, etc.) to protect patient welfare.

Synopsis.

Internet-delivered cognitive behavioral therapy (iCBT) for anxiety is an innovative and efficacious treatment for anxiety disorders across the lifespan. iCBT differs from traditional, therapist-led treatment in that it is low intensity, cost-effective, and increases treatment accessibility. iCBT boasts empirical support for both adults and children, however, application considerations and privacy concerns remain. Research has evaluated treatment enhancers such as therapist support and cultural adaptations to support intervention effectiveness. The current chapter presents an overview of the development, efficacy, and limitations of iCBT for anxiety across the lifespan while reviewing implementation considerations.