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To cCBT or not cCBT, that is the question

We overheard a Practitioner saying recently that cCBT is much like that well know brand of yeast extract. You either love it, or you hate it (they went on to say how much they hated it). The strong reaction cCBT provoked struck a chord for us here at The CBT Resource. We have been thinking about this a lot recently, not least due to the NICE review of cCBT packages that is taking place at the moment.

We thought it made an interesting topic for our next blog!

  • Is cCBT a good option for services?

  • How can you engage and support people to get the most from it and not drop out?

  • What qualities does the person supporting cCBT need?

cCBT is an approach that is championed by leaders in the field as a way of meeting the ever increasing demand for CBT. Professor Issac Marks was one of the first pioneers to recognise the benefits that cCBT could offer to help with the problem; and even published a review book with colleagues back in 2007. A decade on, even with the launch of the IAPT programme in England, the supply and demand problem still exists. Services are now working towards 25% access rate. This is a welcome and fantastic move forwards. Even with that new target though, it still means that 75% of people in need, that could benefit, may still not have access.

Will we ever reach a time where there isn't a supply versus demand problem? where we have sufficient practitioners to meet 100% of need? Even if we did, would it be the right thing for everyone? would they make use of it? how would they want to access help?

Many people may not want to fit in with traditional treatment delivery models. They may struggle to fit in with available service appointments due to competing demands in their work or home life. We are also constantly reminded how much time we are all spending on the internet and using social media sites these days. For some people, online cCBT may offer the perfect option for them to be able to access help. It is discrete, can be personalised and accessed whenever and wherever the person wants to. One person sat on a train could be using a cCBT platform for their treatment and another sat watching a film, or listening to music, and no one would know the difference. It fits in with modern life and modern ways of accessing information. At a recent dinner party we were at, we asked the people sat at the table, 'if you needed help with a problem with your mood, where would you go first?' not one person said their GP or a family member would be their very first point of call. The internet via their phone or tablet would be. The reason? It is quick and accessible, you don't have to wait to get the information you want, when you want it. It is confidential and private.

As we speak, NICE are undertaking a review of cCBT packages for anxiety disorders and depression. It is an interesting move forwards that has not happened for written self-help, with many being prescribed or given out without review or supporting evidence. There are a large number of cCBT platforms available now; much like the CBT self-help books that line the shelves in most clinical offices, libraries and bookshops these days. How do you choose which is the option right for your Patient or Service? We know Clinician choice often leads to biased decision making, based on what they themselves prefer, rather than on the evidence or what would suit an individual Patient.

Our view is cCBT can be a very positive and useful option to meet unmet need. It is another way of offering evidence based treatment in a way people want to access it. When the right package is paired with the right person great results can occur, especially when they have the right support to motivate and encourage them to use it. There is a great literature out there of qualitative and quantitative research supporting cCBT. Just like any other form of self-help CBT, a platform must be engaging to the person, be readable, interactive, follow an evidence based approach and encourage the person to put their skills they will learn from it into action in their daily life.

A criticism of cCBT can be the drop out rate, with problems with adherence to treatment. However, depending on the study, drop out rates vary considerably and adherence depends on a range of factors, such as the person being engaged in the approach in the first place and knowing what to expect and feeling motivated and supported to use it. Just like a new book, when you get it you are motivated to read it. It is all too easy though for life to get in the way. To let it sit gathering dust on the table, then to not even notice it is there anymore; or get placed on a shelf or in a drawer remaining unread in a tidy up session later down the line. Getting access and staying motivated to use a cCBT platform is no different. Both book and computerised CBT options work best with someone to encourage and motivate the person to access it and encourage them to put into action the skills they have learned. For some, a cCBT package may be all that is needed. For others, the package may let a bit of light in and build the persons confidence in seeking further support from the service.

What about the person providing the support for cCBT though? do they impact on drop-out or outcomes? It is often quoted that the level of hope of improvement we have for our patients and how much we believe in the approach we are offering, translates into how well they then do (or don't!) respond and recover. Research has shown this to be the case. So, if we don't believe in an approach, be it a particular resource or delivery method, what are the consequences of this on our Patients? Studies have shown that clinicians who have specific training in cCBT and how to provide support, have higher levels of expectancy for their Patients that the approach can work for them. Their Patients also get better outcomes! So training in cCBT and how to support it is essential (and is not covered in any depth in most CBT practitioner and PWP training courses).

People are of course individuals and there may be no one format of CBT or indeed cCBT package that suits everyone. With cCBT, knowing what the package looks like, how to log in and what it will involve, really helps people to engage in it. Helping the person see the flexibility of cCBT and when and where they can use it, can help the person to visualise how it may work for them as an option.

cCBT is a way of reaching out to many more people. It offers a flexibility and reach that cannot be replicated in any other way. It can be bright, up to date and engaging. It is there whenever someone needs it and unlike a book, won't be gathering dust on a shelf. So, if cCBT is like that brand of well known yeast paste, well, we would have to say we are on the love side for all the benefits it can offer!