CBT via the Internet: Can It Be Effective?

In a recent study in the Netherlands, Web-based treatment was most effective for those with binge eating disorder.

Reprinted from Eating Disorders Review
September/October Volume 26, Number 5
©2015 IAEDP

A team of Dutch investigators led by Elke D ter Huurne, from the Nijmegan Institute, Nijmegan, Netherlands, has reported that their Web-based cognitive behavior therapy (CBT) approach improved eating disorder psychopathology among participants in a randomized controlled study (J Med Internet Res. 2015; 17: e152). [See also “Update,” in this issue.]

The participants were self-recruited users of the Dutch website, Look at Your Eating, an open-access Internet site that offers psychoeducational content about eating disorders and a forum for peer support. Participants were females at least 18 years of age, with a DSM-IV diagnosis of BN, BED, or EDNOS who had access to the Internet; written referral from a Dutch general practitioner was required. Candidates were ruled out if they were severely underweight, suicidal, or had received psychological or pharmaceutical treatment for any eating disorder within the past 6 months. One-hundred and eight participants were randomized to the web-based CBT program and 106 to the wait-listed group. 

The program’s design

The web-based CBT intervention used a software program developed by a team that includes a psychologist, addiction specialist, psychotherapist, psychiatrist, dietician, as well as registered nurses and social workers, a software development team, and patients and members of a Dutch organization for people with eating disorders. 

Seventeen therapists with either a bachelor’s degree in nursing or social work or a master’s degree in psychology participated in the study. Prior to working with the CBT program, all therapists had 3 months of specialized training, including one day focusing on eating disorders and two days of training in theoretical information and practice-oriented assignments related to the Internet program. They also learned technical aspects of using the intervention, and on CBT and Motivational Interviewing (MI) techniques. 

Study therapists were trained to work with patients with severe eating problems, relapse, or suicidal ideation, and given guidelines for when to contact the individual’s primary care physician. As a further safeguard, all messages from the therapists were checked retrospectively by a multidisciplinary team, and all patient files were regularly checked by the coaches of the Web-based intervention. These coaches were available daily for consultation and advice. 

The CBT intervention included a structured two-part program with at least 21 patient contacts and 10 assignments on a secure Web-based application, according to the authors. These occurred twice weekly, typically for about 20 minutes. Phase 1 analyzed the participants’ eating attitudes and behaviors, while the second part focused on behavior change. 

During the online sessions, participants were instructed about completing homework assignments and registering eating behaviors daily in their online food diaries. They could leave messages in private files, and the therapist always responded within 3 working days. The therapist’s messages were personalized to the individual but also often contained other information and hyperlinks to information on the website, and were based in CBT and MI approaches. When a participant hadn’t responded within 4 weeks, she was considered to have dropped from the study. 

Wait-listed controls 

The control group members each received 7 supportive emails sent by a therapist during the waiting period. These messages included information about the program, as well as details about when participants could begin participating in the intervention, the aim of the supportive messages, and what to do in case they needed urgent help. Further emails described the website, the online forum, and provided basic psychoeducation.

Outcome was primarily measured with the Eating Disorder Examination-Questionnaire. Secondary measures included the Body Attitude Test, the Maudsley Addiction Profile-Health Symptom Scale, and the Rosenberg Self-Esteem Scale.

Results: CBT intervention was more effective

Ninety-four percent of the participants completed the study. Those in the web-based CBT group improved significantly more on eating disorder psychopathology than did those in the wait-listed control group, with lower EDE-Q subscale scores after treatment. The group with BED had the most significantly positive results in changes in eating disorder psychopathology, body dissatisfaction, and mental health. 

The authors noted that during the intervention or wait-listing period, several women in both groups had other sources of support, for example from friends or family or through a self-help program. Some of the women also had in-person contacts with a professional such as a therapist, dietician, or family physician. In all cases this was more common among women in the wait-listed group than in the CBT group. However, this additional support did not seem to provide much treatment value; for the control group, face-to-face contact with a professional improved only one area: body dissatisfaction.

Satisfaction with the program

Overall, participants were satisfied with the Web-based intervention and with their therapists. Most participants evaluated the intervention as rather (46%) or very (35%) useful, particularly for its positive effect upon eating behavior. Notably (for an internet-delivered intervention), one of the components most highly rated by participants was the support of the therapists. The study demonstrates the acceptability of such interventions (satisfaction and treatment retention were high) and adds to the growing literature in this regard.