For young people with anxiety disorders, cognitive behavioral therapy can offer real improvement. Reviews of its effectiveness show that CBT can stop clinical-level anxiety in half to two-thirds of participants. Offer CBT to every adolescent with anxiety problems, and we can expect at least half these young people to become symptom free. Simple, right?

Wrong – for three reasons. First is the near-impossibility of providing the funding and specialist time (around three hours a week) to offer CBT to every young person who needs it. The high cost of therapy and a lack of trained therapists leads to notoriously long waiting lists. Second, even if CBT could be made available to all, it is unlikely the vast majority those of who need it would take it up. Only a mere 25 percent of adolescents with clinical-level anxiety disorders seek out any professional help.

Third, the way in which provision is offered often runs into practical and emotional barriers. Time constraints and travel difficulties prevent some from attending therapy sessions. The perceived stigma of attending CBT prevents others – especially adolescents, who tend to prize privacy and confidentiality. As a result, while there is an effective treatment available in theory, in reality it has been able only to scratch the surface of need.

Not engaging with the majority of those who need it means that CBT has fallen short of its promise, argue a team of Australian researchers. Reporting on the results of a recent trial, the authors outline how a change in the delivery of CBT – from face-to-face treatment to interactive web-based delivery – might result in more young people engaging with the intervention, a reduction in costs, and subsequently an increase in reach.

The team, led by psychologist Susan Spence at Griffith University, put this new web mode of delivery through its paces alongside traditional CBT in a randomized control trial (RCT). Australian adolescents with clinical anxiety were assigned to web CBT, traditional in-person CBT, or to a control group. The content, length, and number of sessions in the internet program were designed to replicate traditional CBT as closely as possible. The sessions included the standard CBT anxiety management techniques such as relaxation training, recognition of the physical symptoms of anxiety, and strategies for coping and problem solving. Sessions were completed by both adolescents and their parents, and gave teens a chance to apply CBT techniques to their own anxiety-provoking situations. Homework was set after every session and feedback was provided at the start of new ones.

Spence and colleagues claim that CBT was relatively straightforward to adapt for online delivery. The web-based version of CBT was not completely automated; each family had a qualified therapist to monitor progress and provide individual feedback. Therapist contact was also used to cover shortfalls in the online model. One particular challenge was creating an “exposure hierarchy” of the anxiety-causing stimulus. To get around this, telephone contact was given with a trained therapist for 15 minutes following this session.

The trial’s results were startlingly positive. When the program was complete after 12 weeks, both the web-based and traditional CBT groups showed significant improvement over the waiting list control group, both on the primary diagnosis of anxiety disorder, and on other secondary anxiety disorders. Perhaps more important, there was no significant difference between the effectiveness of the traditional CBT and the web-based delivery. Furthermore, no difference was also found between the two different modes of delivery at either six- or 12-month follow-up, when around 80% of both treatment groups were free from clinical anxiety.

But what about user satisfaction? If the web-based version of the intervention is to be successful, then users should feel as comfortable with it as with traditional CBT. The trial found that adolescents were just as satisfied with web-based CBT as with face-to-face therapy. However, parents – who are often the ones who initiate therapy for their teens – felt more comfortable with traditional CBT.

The headline finding of Spence and colleagues’ study is the comparative effectiveness of this “lighter touch” version of CBT. While no cost-benefit analysis has been conducted yet, five to ten minutes of therapist time per week for web-based CBT compared to 180 minutes for traditional face-to-face delivery implies significant potential for financial savings. The authors conclude: “Online CBT may represent one way in which a greater number of clinically anxious young people can be helped effectively than can be achieved solely through clinic-based interventions.”

Reference:
Spence, S.H., Donovan, C.L., March, S., Prosser, S., Gamble, A., Anderson, R.E., & Kenardy, J. (2011). A Randomized Controlled Trail of Online Versus Clinic-Based CBT for Adolescent Anxiety. Journal of Consulting and Clinical Psychology, 79 (5), 629-642.