Intended for healthcare professionals


Therapist guided internet delivered cognitive behavioural therapy

BMJ 2014; 348 doi: (Published 10 March 2014) Cite this as: BMJ 2014;348:g1977
  1. Erik Hedman, postdoctoral researcher
  1. 1Department of Clinical Neuroscience, Karolinska Institutet, SE-171 77 Stockholm, Sweden
  1. kire.hedman{at}

Can be highly effective and is used to increase access to psychological treatment

There are two main forms of internet delivered cognitive behavioural therapy—fully automated open access programmes without therapist contact and programmes guided by a therapist, which are conducted in a context similar to that of regular healthcare. This editorial focuses on therapy that is guided by a therapist, with scheduling that mirrors face to face treatment.1

Because the mechanisms for improvement are the same for internet delivered cognitive behavioural therapy as for face to face therapy, the patient should be exposed to the same interventions. So, if exposure to a feared object—such as snakes in patients with a phobia about snakes—is important in face to face therapy, then it is equally important in internet delivered therapy. In essence, internet delivered therapy is not a new treatment in itself but rather a new framework for providing psychological treatments.

The patient accesses the treatment through a personal account in a secure internet based treatment platform. The most important elements of the treatment are modules, often eight to 15, whose content reflects that of sessions in face to face therapy and provides patients with the information needed to change their behaviour. The modules mainly consist of text but can also include images and audio and video files. Throughout the treatment, the patient has contact with an identified therapist who provides guidance on how to apply the interventions to the patient’s symptoms. Contact is provided mainly through a messaging system in non-real time, which resembles email. On average, therapists spend about 10 minutes on each patient per week,2 which is about a quarter of the time spent in face to face therapy. Evidence suggests that therapist contact, as compared with unguided internet-delivered therapy, is associated with larger treatment effects.3 Because the module content is relatively inflexible, diagnostic assessment before the treatment starts is at least as important as in face to face therapy.

There are several advantages of internet delivered cognitive behavioural therapy. Firstly, and perhaps most importantly, it can drastically increase accessibility to effective treatment. In most countries common barriers to conventional cognitive behavioural therapy include lack of therapists but also stigma and difficulty in taking time off from work to attend therapy.4 5 Internet delivered therapy avoids these problems because each therapist can treat up to 80 patients simultaneously and the lack of face to face appointments means that geographical separation is not a problem.

A second advantage is that internet delivered therapy provides an excellent framework for testing the relative effects of treatment components because large scale trials can be conducted with limited resources. For example, in a recent randomised controlled trial that tested internet delivered exposure therapy against stress management for irritable bowel syndrome, all 195 patients could be treated simultaneously by only six therapists.6 Finally, because internet delivered cognitive behavioural therapy saves time, limited therapist resources can be devoted to those patients who require intensive face to face treatments.

For what problems does internet delivered cognitive behavioural therapy work and how effective is it? A recent systematic review showed that therapist guided internet delivered therapy has been evaluated for 25 clinical disorders in at least 103 randomised trials since 2000.7 Internet delivered therapy has been developed for most common psychiatric disorders, such as anxiety disorders and depression, but applications also include functional disorders such as tinnitus, irritable bowel syndrome, chronic pain, and sexual dysfunction. The disorders for which the therapy currently has strong empirical support are depression, social anxiety disorder, and panic disorder.7 A meta-analysis of 13 randomised trials, mostly of these three disorders, which compared internet delivered cognitive behavioural therapy with face to face therapy, found that the between group effect across all studies was g=−0.01 (95% confidence interval −0.13 to 0.12).8 This suggests no significant difference between the two treatment approaches and that the effect of the intervention type is likely to be small. Because there were relatively few studies, the results should be interpreted with caution, but they suggest that internet delivered therapy could be as effective as face to face therapy for some of the most common psychiatric disorders. Studies of the long term effect of internet delivered therapy show that treatment effects can last up to five years after the completion of therapy.9

Internet delivered cognitive behavioural therapy has been implemented as part of regular healthcare in the Netherlands10 and Australia.11 In Stockholm, Sweden, the ICBT Clinic has treated more than 3000 patients with depression, social anxiety disorder, or panic disorder with internet delivered therapy in the context of regular psychiatric care, which is subsidised by a national health system. Therapy is integrated within a regular outpatient clinic at a university hospital and patients receive care on the same terms as patients within conventional psychiatric care. Patients can self refer, and treatments are provided by licensed psychologists, with psychiatrists conducting diagnostic assessments before and after treatment. Studies suggest that internet delivered therapy provided in this routine setting can be as effective as in published randomised trials.12

Although internet delivered cognitive behavioural therapy has been generally well studied, several important challenges remain. These include testing treatments against face to face therapy in non-inferiority trials, developing and testing treatments for children and adolescents, and, not least, ensuring that treatments have strong empirical support.

In summary, internet delivered cognitive behavioural therapy can be effective for common psychiatric disorders, is a useful adjunct to face to face treatment, and has the potential to substantially increase accessibility to effective psychological treatment.


Cite this as: BMJ 2014;348:g1977


  • Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: None.

  • Provenance and peer review: Commissioned; not externally peer reviewed.


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