Professional Psychology: Research and Practice
2003, Vol. 34, No. 5, 527–534
Copyright 2003 by the American Psychological Association, Inc.
0735-7028/03/$12.00 DOI: 10.1037/0735-7028.34.5.527
Internet Interventions: In Review, In Use, and Into the Future
Lee M. Ritterband, Linda A. Gonder-Frederick, Daniel J. Cox, Allan D. Clifton,
Rebecca W. West, and Stephen M. Borowitz
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
University of Virginia Health System
The provision of health care over the Internet is a rapidly evolving and potentially beneficial means of
delivering treatment otherwise unsought or unobtainable. Internet interventions are typically behavioral
treatments operationalized and transformed for Web delivery with the goal of symptom improvement.
The literature on the feasibility and utility of Internet interventions is limited, and there are even fewer
outcome study findings. This article reviews empirically tested Internet interventions and provides an
overview of the issues in developing and/or using them in clinical practice. Future directions and
implications are also addressed. Although Internet interventions will not likely replace face-to-face care,
there is little doubt that they will grow in importance as a powerful component of successful psychobehavioral treatment.
information (see Crutsinger, 2000; Employment Policy Foundation, 2001; Pew Research Center, 2002; Rabasca, 2000). This new
field of Internet interventions is only going to grow and expand.
The benefits are vast, as there is the potential for greater numbers
of people to receive more services than ever before. However, to
meet this potential, Internet interventions, like any other treatment,
must first demonstrate feasibility and efficacy through rigorous
scientific testing. In this article we present a critical examination of
the current state of the available literature focused on the development and testing of these types of interventions. In addition,
issues that should be addressed when constructing Internet interventions are enumerated, followed by a discussion of possible
future directions and implications for research and clinical
practice.
With the advancement of computer technologies over the
past 20 years, a flood of new ways to communicate, provide, and
deliver psychological treatments has emerged. The Internet has the
ability to reach people all over the world and provide highly
specialized psychological interventions otherwise not sought or
obtainable. There is a new but growing literature on the use of the
Internet as a means of delivering treatment. These Internet treatments are typically focused on behavioral issues, with the goal of
instituting behavior change and subsequent symptom improvement. They are usually self-paced, interactive, and tailored to the
user, and they make use of the multimedia format offered by the
Internet. Individuals with computer and Internet access who use
these treatments may also overcome many of the barriers to
obtaining traditional care because they can seek such treatments at
any time, any place, and often at significantly reduced cost.
Clearly, people are using computers and the Internet in greater
frequency and with the specific purpose of obtaining mental health
Researchers are beginning to apply the Web as a way to have an
impact on patient behaviors by reducing negative physical and
LEE M. RITTERBAND received his PhD in clinical psychology and doctoral
minor in computer science from the University of South Florida in 1998.
He is an assistant professor at the Center for Behavioral Medicine Research
at the University of Virginia Health System in Charlottesville, VA. His
research interests focus on the development of Internet treatment interventions for various health psychology issues.
LINDA A. GONDER-FREDERICK received her PhD in health psychology from
the University of Virginia in 1985 and her PhD in clinical psychology
from the University of Virginia in 1994. She is an associate professor in
the Department of Psychiatric Medicine at the University of Virginia
and clinical director of the Behavioral Medicine Center. Her research
interests include behavioral and psychological aspects of Type 1 diabetes
in adults and children, including the development of psychobehavioral
interventions.
DANIEL J. COX received his PhD in clinical psychology from the University
of Louisville in 1977. He holds a diplomat in clinical psychology and is a
professor in the Departments of Psychiatric Medicine and Internal Medicine at the University of Virginia. He is also the director of the Center for
Behavioral Medicine Research. His primary areas of research involve
behavioral medicine aspects of Type 1 diabetes, pediatric encopresis, and
attention-deficit/hyperactivity disorder.
ALLAN D. CLIFTON received his MA in clinical psychology in 1999 from
the University of Virginia, where he is currently a doctoral candidate. He
will be attending clinical internship at Western Psychiatric Institute and
Clinic in Pittsburgh, PA. His research interests focus on interpersonal
aspects of adaptive and maladaptive personality traits.
REBECCA W. WEST received her JD from the University of Richmond
School of Law in 1983. She is the executive director of the Piedmont
Liability Trust as well as an assistant professor of general medicine at the
University of Virginia School of Medicine, where she lectures on law and
medicine. She has lectured and published often on legal issues in medicine.
STEPHEN M. BOROWITZ received his MD from Rush Medical College in
Chicago in 1980. He is a professor of pediatrics and health evaluation
sciences as well as the assistant chief information officer at the University
of Virginia Health System. His research interests focus on childhood
constipation and encopresis and the use of information technology in the
delivery of health care and health education.
CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Lee M.
Ritterband, University of Virginia Health System, Department of Psychiatric Medicine, Center for Behavioral Medicine Research, P.O. Box
800223, Charlottesville, Virginia 22908. E-mail: leer@virginia.edu
Internet Education and Interventions
527
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RITTERBAND ET AL.
psychological symptoms. Patient health-related information Web
sites, Web-based treatment interventions (WBTIs), and hybrid
treatment interventions (HTIs) have all been created for this purpose. People are using the information they find on the Internet to
become better informed (Pew Research Center, 2002), although
the link between such improved knowledge/awareness and actual
behavioral change has not been demonstrated. Nonetheless, most
of the available studies examining online interventions have shown
that this treatment approach is, at the very least, feasible.
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Health-Related Information Web Sites for Patients
Over 100,000 static health information Web sites have been
constructed that deliver basic information on various problems and
disorders (Kolata, 2000). Huge amounts of money have been
invested into some of the more well-known and widely used
patient information sites (e.g., WebMD.com, drkoop.com,
Mayohealth.org, FDA.gov, and NIH.gov). A large number of
people report that information from the Web has affected their
health-care-related decisions (Pew Research Center, 2002). The
provision of health-related information has the potential to change
the health care market by making consumers more knowledgeable.
Although major investments have been made to provide health
information on the Internet, little research has been conducted as to
the efficacy of health-related information on the Web. Since 1995,
the Children’s Medical Center at the University of Virginia has
maintained a series of Web-based patient education information
sites about common pediatric problems directed at parents and
children (Borowitz & Borowitz, 2000; Borowitz & Ritterband,
2001). Between January 1, 1998, and April 30, 2000, these tutorials received more than 650,000 successful page requests from
more than 100,000 distinct hosts, and over 4,000 completed feedback forms were received. More than 90% of respondents found
that the information helped them understand why children develop
some of their health problems and felt that the information helped
them care for a child suffering from a particular health problem.
More than 85% of respondents rated this as a “very good” way to
teach people about health problems.
These results further support the fact that many people are
searching the Internet for information about common healthrelated problems. In addition, information sites can provide parents
and families with useful and accurate information and help address
questions and concerns. However, although these patient
education/health-related Web sites can be very helpful, the ultimate achievement is to deliver comprehensive, personalized, engaging, and empirically validated treatments that could be quickly
and easily distributed over the Internet.
Web-Based Treatment Interventions (WBTIs)
Although WBTIs are a few years away from being a truly
comprehensive treatment option, mainly due to issues of bandwidth, a thorough literature search revealed that some researchers
are beginning to test the feasibility and effectiveness of delivering
this form of treatment intervention over the Internet. Identified
studies for inclusion in this review are empirically tested, randomly assigned Internet interventions in which a treatment had
been developed and operationalized specifically for Web delivery.
Tested Internet interventions (see Table 1) include those for smoking cessation (Schneider, Walter, & O’Donnell, 1990), weight loss
(Tate, Wing, & Winett, 2001; Winett et al., 1999), headaches
(Ström, Pettersson, & Andersson, 2000), body image (Celio et al.,
2000; Winzelberg et al., 2000), posttraumatic stress and pathological grief (Lange, van de Ven, Schrieken, & Emmelkamp, 2001),
physical activity (McKay, King, Eakin, Seeley, & Glasgow, 2001),
panic disorder (Klein & Richards, 2001), tinnitus (Andersson,
Strömgren, Ström, & Lyttkens, 2002), diabetes management
(McKay, Glasgow, Feil, Boles, & Barrera, 2002), and pediatric
encopresis (Ritterband et al., 2003). These studies all focus on
behavioral medicine/health psychology issues, which seem to be
more adaptable to Internet interventions (Childress & Asamen,
1998) because of the availability of highly structured treatment
approaches to many problems.
Generally, these studies provide support for the notion that
Internet interventions can be feasible and effective. These studies
also demonstrate that some behaviorally related psychological
treatments can be operationalized, transformed, and transported to
the user via the Internet. To test efficacy, most of these studies
used some form of a nontreatment control group rather than a
face-to-face treatment group for the identified disorder. This decision makes sense given that the first step in verifying the applicability of this form of intervention is to make sure that it works
rather than to hold it up to the “gold standard” of face-to-face
treatments. Subsequent generations of clinical trials will need to
incorporate face-to-face treatment interventions as one of the experimental conditions. However, it should not be necessary for
Internet interventions to prove more effective than face-to-face
treatments but rather to provide close to equivalent benefits and
outcome results. As the many advantages of Internet interventions,
especially accessibility, become increasingly clear, people who
might not otherwise have obtained treatment may do so. These and
future studies in this area are not meant to imply that face-to-face
treatment should be replaced; rather, they are meant to provide an
alternative or adjunctive component to already well-established
and highly effective interventions.
Web-based treatment interventions offer an opportunity for psychologists to provide specific behavioral treatments, tailored to
individuals who prefer or need to seek help from their own homes.
The technology is now available and will be more readily accessible with high-speed bandwidth, which should be widely accessible in the near future. Although the current sparse literature
examining this area may have limitations, these studies represent
the pioneering efforts to develop what will likely become a major
force in the delivery of psychological treatments. However, many
of these interventions do not take advantage of the full capabilities
of the Internet. Currently, Internet interventions tend to be limited
in their graphical elements and other potentially engaging factors
(i.e., audio, animation, interactivity) and can certainly be improved
with new development software for Web applications. There is a
significant need for more diverse and comprehensive interventions, but the time and effort to operationalize an intervention is
considerable. Although these new interventions are developed,
current applications must overcome the difficulties of delivering
their often large-file-sized programs over phone lines. A compromise that has been created is a hybrid approach.
INTERNET INTERVENTIONS
529
Table 1
Empirically Tested Internet Interventions
Target behaviors/
symptoms
Subjects (N)
Schneider, Walter, &
O’Donnell, 1990
Smoking cessation
1,158 adults
Internet intervention with smoking
diaries vs. outline of behavioral
strategies.
Trends of greater cessation at 1, 3, and 6
months for Internet group.
Winett et al., 1999
Improve teenage
girls’ health
behaviors
180 high
school
females
Semester of Internet intervention
focusing on weight loss, healthy
eating, and health behaviors vs.
standard high school health class
with similar content.
Internet group had significant improvements
in many health-related behaviors.
Celio et al., 2000
Body image
satisfaction and
eating attitudes
76 women
Psychoeducational Internet program vs.
same content delivered in a class vs.
wait-list control.
Internet group had fewer weight and shape
concerns and better eating attitudes at
posttreatment. Risk factors for eating
disorders reduced at 4-month follow-up.
Ström, Pettersson, &
Andersson, 2000
Headaches
45 adults
Internet intervention focused on applied
relaxation and problem-solving
techniques vs. wait-list control.
After 6-week program, Internet intervention
group experienced significantly fewer and
less severe headaches.
Winzelberg et al.,
2000
Body image
satisfaction
60 women
Psychoeducational Internet program vs.
control condition.
After 8-week program and at 3-month
follow-up, Internet group had greater
satisfaction with their body and less desire
for “thinness.”
Klein & Richards,
2001
Panic
22 adults
Internet intervention containing
psychoeducational components and
techniques to reduce panic vs. selfmonitoring control group.
Internet subjects had reduced panic-related
symptoms.
Lange, van de Ven,
Schrieken, &
Emmelkamp, 2001
Posttraumatic stress
and pathological
grief
25 college
students
Internet intervention utilizing 5 weeks
of writing assignments vs. wait-list
control.
80% of experimental group demonstrated
clinically significant improvement in
symptoms of trauma and general
psychopathology posttreatment.
McKay, King, Eakin,
Seeley, &
Glasgow, 2001
Physical activity
78 patients
with
Type 2
diabetes
Internet physical activity intervention
vs. information-only control.
Both groups increased activity levels, but no
significant differences between groups.
Those in Internet group who more often
used program did significantly better.
Tate, Wing, &
Winett, 2001
Weight loss
91 adults
Behavior weight loss Internet program
with e-mail consultation vs.
education about weight loss and
access to information-based Web
sites.
Internet behavior therapy led to significantly
more weight loss at 3 and 6 months.
Andersson,
Strömgren, Ström,
& Lyttkens, 2002
Tinnitus
117 adults
Internet cognitive–behavioral
intervention for tinnitus vs. wait-list
control.
After 6-week program, Internet group
experienced significantly greater
improvements in several measures of
anxiety, depression, and other tinnitusrelated distress vs. controls.
McKay, Glasgow,
Feil, Boles, &
Barrera, 2002
Diabetes selfmanagement
133 patients
with
Type 2
diabetes
Internet-based diabetes support program
on diet, mental health, and
physiologic outcomes vs.
information-only control.
Both groups improved, but no significant
differences between groups.
Ritterband et al.,
2003
Pediatric encopresis
24 children
Psychoeducational and interactive
behavioral Internet intervention vs.
no intervention.
Significant improvements for children in
Internet condition on no. of accidents, no.
of bowel movements in the toilet/week,
and increased trips to the bathroom
without a parental prompt.
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Study
a
All studies used random assignment as part of their design.
Designa
Results
RITTERBAND ET AL.
530
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Hybrid Treatment Interventions (HTIs)
HTIs address the problem of limited bandwidth by providing
highly engaging interventions without losing the critical Internet
connection. All the large files are stored either on a CD-ROM or
a hard disk drive. The computer still connects to the Internet to
transfer small bits of information back and forth from the utilized
server. In this way, all the benefits of the Web can still be
maintained, including the ability to update information, exchange
information, collect data, monitor user activity in real time, provide feedback, and prompt behavior change, without losing the
ability to have large data files, such as extensive graphic and audio
files. The disadvantage is that the large files must be furnished to
the user in order to receive the intervention. This typically means
providing a CD-ROM to the user through regular mail or in person.
An example of an HTI is the “U-CAN-POOP-TOO” Web site
developed by our research group at the University of Virginia and
supported by the National Institutes of Health. The goal in designing this program was to deliver a child-focused, entertaining, and
engaging site that would provide all the necessary behavioral and
medical components of Enhanced Toilet Training (Cox, Borowitz,
Kovatchev, & Ling, 1998) to successfully treat pediatric encopresis. This HTI encompasses hundreds of pages of content, with
numerous illustrations, interactive components, animated tutorials,
and reinforcing quizzes.
In order to validate this intervention, we placed a computer in
the homes of half the subjects and provided Internet access to the
Web site. The large graphic and animation files were put on the
hard drive in order to reduce long wait times when progressing
through the program. All subjects continued to receive care from
their primary care physician. Children who received the Web
intervention in addition to care by their primary care physician
decreased their accidents by 93%, increased their number of bowel
movements (BMs) in the toilet each week by 152%, and increased
their trips to the bathroom without a parental prompt by 109%. The
control children decreased their accidents by 31%, but they also
decreased their number of BMs in the toilet each week by 16% and
their trips to the bathroom without a parental prompt by 37%
(Ritterband et al., 2003). These results are equivalent to those
found in tests of a face-to-face behavioral intervention for pediatric
encopresis (Cox et al., 1998).
This hybrid example allowed for the assessment of (a) the
feasibility of this type of treatment intervention, (b) the usability/
acceptability of such a system to patients, and (c) the effectiveness
of such a system for delivering the necessary information, promoting behavior change, and ameliorating symptoms. Further studies
of this kind are necessary to establish the validity of this type of
intervention. Eventually, as more high-speed connections become
available, the HTI model can be discarded, and the WBTI model
will be the standard.
Developing and Using Internet Interventions
Developing Internet interventions is an arduous, sometimes
tedious, and always time-intensive process. It necessitates an interdisciplinary approach, requiring a team of diverse professionals,
including clinicians and other health care providers to provide
content; computer and Web programmers to build essential applications; Web designers to create the Web structure; Web graphic
artists to create still and animated images; database developers to
integrate a mechanism to store and retrieve data; health informatics
evaluators to evaluate user interface issues and outcomes; and
behaviorists to incorporate behavior change concepts into the
system. Other potential members of the team may include business/financial advisors to ensure proper marketing, management,
and sales; videographers to create video; audio engineers to integrate Web audio; psychometricians to certify appropriate scale
integration; tech support personnel to provide user support; costanalysis specialists to determine savings; linguists/translators to
provide readability testing and translation; disability experts to
oversee usability issues; and health educators to make certain the
content is structured in such a way that the majority of users will
find it helpful.
Obviously, only a small number of psychologists would be
likely to want or to have the resources to be able to create an
Internet intervention. However, many clinicians may want to utilize this form of treatment within their own clinical practice. The
most plausible reason for this is to supplement skills that could be
addressed with an adjunctive Internet intervention. For example, a
clinician who feels comfortable treating depression and anxiety
may not have the training to implement the behavioral components
for treating insomnia, which commonly co-occurs with these disorders. An Internet intervention for insomnia with demonstrated
effectiveness could very easily be used as a component of faceto-face treatment, allowing the clinician to target this specific
issue.
A brief summary of the steps involved in developing Internet
interventions may be helpful in conveying the underlying process
of this type of approach. It may also instill an appreciation for the
efforts that go into creating these programs. Also, a greater understanding of these systems will help clinicians recognize how to
best integrate them into their own practice.
A number of factors must be considered when creating an
Internet intervention (see Figure 1). First, the disorder must be
identified and the treatment should be translatable (Step 1). This
means that the intervention is structured such that it can be delivered using the Internet. Typically, the treatment is highly structured and can be at least semi-self-guided. It is also important to
determine the effectiveness of the intervention to be transformed
(Step 2). An effective face-to-face intervention is the gold standard
by which an Internet intervention will ultimately be compared.
Once the treatment is identified and determined to be effective, it
must be operationalized completely (Step 3). To operationalize a
treatment, one must identify all critical aspects of the intervention,
including specific treatment techniques and procedures.
There are numerous legal and ethical issues that must be considered when developing an Internet intervention (Step 4). These
include issues of privacy, confidentiality, data validity, potential
misuse of Internet interventions by professionals, equality of Internet access, and credentialing issues (see Humphreys, Winzelberg, & Klaw, 2000; Jerome et al., 2000; Koocher & Morray,
2000; Sampson, Kolodinsky, & Greeno, 1997; Winker et al., 2000;
Winzelberg et al., 2000). Examining these issues in depth is
beyond the scope of this article, but each issue should be carefully
considered before creating and/or utilizing an Internet intervention
in a clinical practice. Many of these same ethical and legal issues
need to be considered when incorporating an Internet intervention
as an adjunctive component of treatment.
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INTERNET INTERVENTIONS
Figure 1.
531
Development of Internet interventions.
The multimedia aspect of the Internet should be used in creating
the intervention (Step 5). Without using Internet components such
as audio, graphics, animation, and video, the intervention is little
more than a self-help book that can be read online. These elements
help make the intervention engaging and should increase motivation to use and complete the treatment program. Interactivity is
another key component that will likely enrich the intervention and
keep users connected. Personalization allows the user to receive
more individually tailored content, helping to focus the intervention specifically to the user (Step 6). Personalization may be as
simple as using the name of the user when presenting certain
content or as sophisticated as the system identifying specific
treatment areas the individual user may need to address. It is
critical that users receive some feedback regarding their progress
within the treatment (Step 7). These feedback loops may allow
users to track specific elements of the treatment and may even
provide information to be used with their clinician if the system is
an adjunctive component of treatment.
Several technical issues must also be addressed when constructing the Internet program (Step 8). It needs to be determined
whether a fully Web-based or hybrid treatment intervention would
be most appropriate. All issues of Internet delivery, including type
of browser or self-contained application, type of database, and
programming languages to use, must be resolved. Also, issues of
cross-platform compatibility (e.g., making sure the program will
work on a PC and a Macintosh), as well as hardware issues
(providing minimum requirements, such as amount of machine
memory and hard drive space needed) and software issues (identifying necessary browser, plug-ins, and software incompatibility
issues), should be considered. Most of these issues are usually
decided on the basis of the needs of the target audience.
Finally, once the program is developed, testing of the application must be conducted (Step 9). There are several steps to testing
the Internet intervention. Early tests may include focus groups, in
which individuals are invited to view the program and provide
feedback regarding its use. The intervention will also need to be
pilot tested with a small group of patients in order to determine
issues of feasibility, usability, and possibly early determinations of
efficacy. Finally, a large clinical trial will need to be conducted in
order to demonstrate effectiveness. Revisions will likely need to be
incorporated into the program on the basis of users’ feedback, so
a loop between Step 9 and Step 8 will occur.
Future Directions and Implications
Computers and the Internet have become important tools used in
the field of psychology (for other reviews, see Barak, 1999;
Laszlo, Esterman, & Zabko, 1999; Smith & Senior, 2001; Stamm,
1998). However, many clinical and research issues need to be
addressed to further solidify as well as broaden their place in the
discipline.
Clinical Directions
It is likely that there are many other Internet interventions
currently in various stages of development and evaluation. Some
are computer treatments that are in the process of being transformed to Internet interventions, including computer-based health
information and support systems for patients with life-threatening
illnesses (such as for patients who are HIV positive and for those
with breast cancer; Gustafson et al., 1999, 2001), phobias (Kenwright, Liness, & Marks, 2001), fears of public speaking (Botella
et al., 2000), and marital therapy (Jerome et al., 2000). Additional
treatments need to be developed and examined for their efficacy in
order to establish Internet interventions as a viable treatment
alternative and to support generalizability. Some issues, such as
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532
RITTERBAND ET AL.
sexual dysfunctions, may be particularly suited to an Internet
intervention, because many people may be uncomfortable seeking
face-to-face help for such concerns. Internet interventions for other
issues, such as insomnia, may provide help to those who do not
believe their problem warrants a doctor’s visit but who would
follow a treatment plan on their own.
Internet interventions can help reduce many of the traditional
barriers inherent in the current mental health care deliverance
model, including unavailability of skilled professionals, long lag
time for dissemination of information, length of treatment, costs
and inconvenience of treatment, and unwillingness to seek treatment. With the use of the Internet, professionals or patients can
gather information whenever they wish, and the treatments can be
presented in great detail through the use of the written word as well
as through such visuals as pictures, movies, and animated graphics
to enhance the understanding of a disorder. Patients are likely to
feel empowered by being able to digest the information at their
own pace and to better use it to enhance treatment efficacy. Also,
the cost of obtaining access to this information, already minimal,
continues to decline every day. Finally, this mode of treatment
deliverance may be much more appealing to some patients, increasing their willingness to participate and follow the
recommendations.
Even though Internet interventions may help overcome many
barriers to mental health care treatment, some critical issues still
need to be addressed and resolved, including problems of selfassessment and diagnosis, dissemination of information and treatments, establishment of a financial model, and compliance. There
are potential significant negative consequences to individuals assessing and diagnosing themselves, including misdiagnosis and
improper treatment selection.
Internet interventions are not meant to replace face-to-face treatment but rather to provide an alternative for individuals who might
otherwise choose not to receive treatment (e.g., because of embarrassment) or who might be unable to obtain treatment (e.g., because of location) or to find appropriate treatment (e.g., because no
provider is available). However, it is difficult to disseminate information about these interventions and make individuals aware of
them. New ways of broadcasting this type of treatment are needed
so that people may know and take advantage of them.
A financial model must be established so that individuals can
purchase treatments, insurance companies pay for treatments, and
providers charge for development and usage of treatments. Without some financial framework, these interventions will not survive
regardless of how effective they are found to be. However, before
individuals should be charged for these services, research must be
conducted to prove their effectiveness.
Compliance is a problem for traditional approaches and for
Internet interventions. Although people reported enjoying the “UCAN-POOP-TOO” program, it was still difficult to maintain compliance. Subjects were instructed to access the program at least
once a week; however, some subjects needed numerous phone
calls to remind and encourage them to return to the site and
complete the program. In the body image studies conducted at
Stanford University (Winzelberg et al., 2000), subjects typically
completed less than two thirds of the program, and compliance
progressively declined each week of the intervention. Suggestions
have been made for improving compliance, including stressing the
importance of following through with treatment recommendations
at the beginning of the program, utilizing various “motivational
components” built into the program, and providing reinforcement
for cooperation and program completion.
Research Directions
It is vital that methodologically sound clinical studies be conducted to ensure the efficacy of Internet interventions. A few early
studies show promising outcomes; however, although it appears
that the feasibility of this form of treatment approach is possible,
the development of additional Internet treatments and adequate
clinical trials are necessary to establish Internet interventions as a
viable treatment option.
Many of the areas identified in the Clinical Directions section of
this article need to be examined by means of scientific measures.
Issues of assessment and diagnosis, cost-effectiveness, and compliance all need to be explored. Compliance, in particular, is an
area in which Internet interventions may make a significant difference. Patient compliance is said to increase when patients’
satisfaction with the communication of the health-related information increases (Ley, 1982). Research is necessary to determine
whether computer and Internet components, such as audio, video,
graphics/animation, and interaction, will improve compliance. It
may be that through the use of Internet interventions, treatment
programs can be made to be more engaging, thus increasing an
individual’s motivation to continue working. Internet interventions
and other computer treatments can include personalized and pertinent information, quizzes, case reports, and games to make the
programs more enticing, but the impact of all of these needs to be
assessed. Internet treatment programs can also utilize the power of
e-mail (e.g., individuals could be sent an e-mail with a hyperlinked
Web address to access the Web program more easily). This may
also serve as a behavioral prompt that might improve compliance.
However, it is also possible that compliance may be even more
problematic with computer/Internet treatment programs because of
limited supervision, but no research as of yet has focused on this
important question.
There is also a need for more basic research examining components of the Internet and, specifically, the Web and its ability to
elicit behavioral changes. Some researchers have questioned
whether changing various elements within a computer program,
such as adding color, sound, and video, would improve or hinder
outcome (Sproull, Subramani, Kiesler, & Walker, 1996). Similar
inquiries need to be addressed with respect to the Web. These basic
research questions will help shape a model or framework for
developing WBTIs. Although it might be tempting to use business
models already developed for creating engaging and “sticky” Web
sites (i.e., those Web sites that keep users at the site and draw them
back for future visits), it is important to note that these models do
not address the most critical component of Internet interventions:
behavior change. A theoretical model for this type of approach is
necessary so that additional Internet interventions can be
developed.
Future Possibilities
In addition to the developments already presented, the future
promises even greater technologies and applications for psychology. Web-based treatment interventions, as well as enhanced
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INTERNET INTERVENTIONS
videoconferencing and other bandwidth-intensive approaches, will
likely flourish as increased and improved Internet access becomes
more prevalent. Wireless technology is also rapidly improving,
and consumer products with wireless capabilities are becoming
more available. Some users already have cellular phones and
hand-held computers with wireless Internet access. These products
will become even more widely available and easier to use over the
coming years. These wireless products will allow individuals to
track and share information with their health care professions in
real time, ease data input, reduce data-entry errors, and, we hope,
improve compliance.
In addition to wireless technologies, older technologies such as
the telephone will be better able to interface with some of the
newer technologies, including the Internet (see Ritterband et al.,
2001). For example, Internet applications can be created to call
patients on a regular basis to track progress and symptom relief
and prompt for recommended behaviors. This information can be
stored on a Web server database that can be accessed by the
individual and the health care professional. Patient care and patients’ perceptions of care will likely improve with this type of
technology.
Gaming consoles and future personal digital assistants already
have Internet capabilities, and treatment-based software could be
created for use on these platforms. Children may be more interested in receiving treatments if they are presented in an engaging
and entertaining way. Hand-held computers can be carried anywhere, which could improve the collection of symptom information and provide reminders of treatment components to improve
compliance. This information could be wirelessly transmitted to
the user’s health care professional, who could help expedite treatment goals.
Implications
It is unlikely that Internet interventions will replace face-to-face
psychotherapy; however, this technology may be helpful in the
treatment of some psychological problems that might otherwise go
untreated. It is also possible that such interventions may enhance
traditional therapy as an adjunctive component. These new possibilities usher in a whole new platform from which mental health,
and health care in general, can be conducted. Clinicians will have
to be trained to understand, create, and use these forms of treatment. In time, advances in technology will escalate and push
health care to use its power to improve care to the benefit of all.
The following are some of the implications of the issues and the
research presented in this article:
1. Additional clinical treatment interventions need to be operationalized and transformed into Internet interventions for greater
patient consumption.
2. These interventions must be empirically validated through
well-designed clinical research studies.
3. Studies of all components of Internet interventions are necessary to establish and improve feasibility, usability, and efficacy.
4. Psychologists need to accept that technology is changing the
world. This means that multidisciplinary teams will likely include
a rather unusual set of people to provide new treatment
interventions.
5. New definitions of treatment must be created that embrace
533
the use of new technologies and encompass the use of the Internet
in their deliverance.
6. Costs to create and test Internet interventions are significant
and should not be underestimated when considering the development of a new program.
7. Psychologists need to understand and accept that there are
numerous ethical and legal issues relevant to providing new ways
to deliver health care and that it takes time before these issues can
be appropriately managed.
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Received June 11, 2002
Revision received May 15, 2003
Accepted May 22, 2003 䡲
Professional Psychology: Research and Practice
2003, Vol. 34, No. 5, 527–534
Copyright 2003 by the American Psychological Association, Inc.
0735-7028/03/$12.00 DOI: 10.1037/0735-7028.34.5.527
Internet Interventions: In Review, In Use, and Into the Future
Lee M. Ritterband, Linda A. Gonder-Frederick, Daniel J. Cox, Allan D. Clifton,
Rebecca W. West, and Stephen M. Borowitz
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
University of Virginia Health System
The provision of health care over the Internet is a rapidly evolving and potentially beneficial means of
delivering treatment otherwise unsought or unobtainable. Internet interventions are typically behavioral
treatments operationalized and transformed for Web delivery with the goal of symptom improvement.
The literature on the feasibility and utility of Internet interventions is limited, and there are even fewer
outcome study findings. This article reviews empirically tested Internet interventions and provides an
overview of the issues in developing and/or using them in clinical practice. Future directions and
implications are also addressed. Although Internet interventions will not likely replace face-to-face care,
there is little doubt that they will grow in importance as a powerful component of successful psychobehavioral treatment.
information (see Crutsinger, 2000; Employment Policy Foundation, 2001; Pew Research Center, 2002; Rabasca, 2000). This new
field of Internet interventions is only going to grow and expand.
The benefits are vast, as there is the potential for greater numbers
of people to receive more services than ever before. However, to
meet this potential, Internet interventions, like any other treatment,
must first demonstrate feasibility and efficacy through rigorous
scientific testing. In this article we present a critical examination of
the current state of the available literature focused on the development and testing of these types of interventions. In addition,
issues that should be addressed when constructing Internet interventions are enumerated, followed by a discussion of possible
future directions and implications for research and clinical
practice.
With the advancement of computer technologies over the
past 20 years, a flood of new ways to communicate, provide, and
deliver psychological treatments has emerged. The Internet has the
ability to reach people all over the world and provide highly
specialized psychological interventions otherwise not sought or
obtainable. There is a new but growing literature on the use of the
Internet as a means of delivering treatment. These Internet treatments are typically focused on behavioral issues, with the goal of
instituting behavior change and subsequent symptom improvement. They are usually self-paced, interactive, and tailored to the
user, and they make use of the multimedia format offered by the
Internet. Individuals with computer and Internet access who use
these treatments may also overcome many of the barriers to
obtaining traditional care because they can seek such treatments at
any time, any place, and often at significantly reduced cost.
Clearly, people are using computers and the Internet in greater
frequency and with the specific purpose of obtaining mental health
Researchers are beginning to apply the Web as a way to have an
impact on patient behaviors by reducing negative physical and
LEE M. RITTERBAND received his PhD in clinical psychology and doctoral
minor in computer science from the University of South Florida in 1998.
He is an assistant professor at the Center for Behavioral Medicine Research
at the University of Virginia Health System in Charlottesville, VA. His
research interests focus on the development of Internet treatment interventions for various health psychology issues.
LINDA A. GONDER-FREDERICK received her PhD in health psychology from
the University of Virginia in 1985 and her PhD in clinical psychology
from the University of Virginia in 1994. She is an associate professor in
the Department of Psychiatric Medicine at the University of Virginia
and clinical director of the Behavioral Medicine Center. Her research
interests include behavioral and psychological aspects of Type 1 diabetes
in adults and children, including the development of psychobehavioral
interventions.
DANIEL J. COX received his PhD in clinical psychology from the University
of Louisville in 1977. He holds a diplomat in clinical psychology and is a
professor in the Departments of Psychiatric Medicine and Internal Medicine at the University of Virginia. He is also the director of the Center for
Behavioral Medicine Research. His primary areas of research involve
behavioral medicine aspects of Type 1 diabetes, pediatric encopresis, and
attention-deficit/hyperactivity disorder.
ALLAN D. CLIFTON received his MA in clinical psychology in 1999 from
the University of Virginia, where he is currently a doctoral candidate. He
will be attending clinical internship at Western Psychiatric Institute and
Clinic in Pittsburgh, PA. His research interests focus on interpersonal
aspects of adaptive and maladaptive personality traits.
REBECCA W. WEST received her JD from the University of Richmond
School of Law in 1983. She is the executive director of the Piedmont
Liability Trust as well as an assistant professor of general medicine at the
University of Virginia School of Medicine, where she lectures on law and
medicine. She has lectured and published often on legal issues in medicine.
STEPHEN M. BOROWITZ received his MD from Rush Medical College in
Chicago in 1980. He is a professor of pediatrics and health evaluation
sciences as well as the assistant chief information officer at the University
of Virginia Health System. His research interests focus on childhood
constipation and encopresis and the use of information technology in the
delivery of health care and health education.
CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Lee M.
Ritterband, University of Virginia Health System, Department of Psychiatric Medicine, Center for Behavioral Medicine Research, P.O. Box
800223, Charlottesville, Virginia 22908. E-mail: leer@virginia.edu
Internet Education and Interventions
527
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RITTERBAND ET AL.
psychological symptoms. Patient health-related information Web
sites, Web-based treatment interventions (WBTIs), and hybrid
treatment interventions (HTIs) have all been created for this purpose. People are using the information they find on the Internet to
become better informed (Pew Research Center, 2002), although
the link between such improved knowledge/awareness and actual
behavioral change has not been demonstrated. Nonetheless, most
of the available studies examining online interventions have shown
that this treatment approach is, at the very least, feasible.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Health-Related Information Web Sites for Patients
Over 100,000 static health information Web sites have been
constructed that deliver basic information on various problems and
disorders (Kolata, 2000). Huge amounts of money have been
invested into some of the more well-known and widely used
patient information sites (e.g., WebMD.com, drkoop.com,
Mayohealth.org, FDA.gov, and NIH.gov). A large number of
people report that information from the Web has affected their
health-care-related decisions (Pew Research Center, 2002). The
provision of health-related information has the potential to change
the health care market by making consumers more knowledgeable.
Although major investments have been made to provide health
information on the Internet, little research has been conducted as to
the efficacy of health-related information on the Web. Since 1995,
the Children’s Medical Center at the University of Virginia has
maintained a series of Web-based patient education information
sites about common pediatric problems directed at parents and
children (Borowitz & Borowitz, 2000; Borowitz & Ritterband,
2001). Between January 1, 1998, and April 30, 2000, these tutorials received more than 650,000 successful page requests from
more than 100,000 distinct hosts, and over 4,000 completed feedback forms were received. More than 90% of respondents found
that the information helped them understand why children develop
some of their health problems and felt that the information helped
them care for a child suffering from a particular health problem.
More than 85% of respondents rated this as a “very good” way to
teach people about health problems.
These results further support the fact that many people are
searching the Internet for information about common healthrelated problems. In addition, information sites can provide parents
and families with useful and accurate information and help address
questions and concerns. However, although these patient
education/health-related Web sites can be very helpful, the ultimate achievement is to deliver comprehensive, personalized, engaging, and empirically validated treatments that could be quickly
and easily distributed over the Internet.
Web-Based Treatment Interventions (WBTIs)
Although WBTIs are a few years away from being a truly
comprehensive treatment option, mainly due to issues of bandwidth, a thorough literature search revealed that some researchers
are beginning to test the feasibility and effectiveness of delivering
this form of treatment intervention over the Internet. Identified
studies for inclusion in this review are empirically tested, randomly assigned Internet interventions in which a treatment had
been developed and operationalized specifically for Web delivery.
Tested Internet interventions (see Table 1) include those for smoking cessation (Schneider, Walter, & O’Donnell, 1990), weight loss
(Tate, Wing, & Winett, 2001; Winett et al., 1999), headaches
(Ström, Pettersson, & Andersson, 2000), body image (Celio et al.,
2000; Winzelberg et al., 2000), posttraumatic stress and pathological grief (Lange, van de Ven, Schrieken, & Emmelkamp, 2001),
physical activity (McKay, King, Eakin, Seeley, & Glasgow, 2001),
panic disorder (Klein & Richards, 2001), tinnitus (Andersson,
Strömgren, Ström, & Lyttkens, 2002), diabetes management
(McKay, Glasgow, Feil, Boles, & Barrera, 2002), and pediatric
encopresis (Ritterband et al., 2003). These studies all focus on
behavioral medicine/health psychology issues, which seem to be
more adaptable to Internet interventions (Childress & Asamen,
1998) because of the availability of highly structured treatment
approaches to many problems.
Generally, these studies provide support for the notion that
Internet interventions can be feasible and effective. These studies
also demonstrate that some behaviorally related psychological
treatments can be operationalized, transformed, and transported to
the user via the Internet. To test efficacy, most of these studies
used some form of a nontreatment control group rather than a
face-to-face treatment group for the identified disorder. This decision makes sense given that the first step in verifying the applicability of this form of intervention is to make sure that it works
rather than to hold it up to the “gold standard” of face-to-face
treatments. Subsequent generations of clinical trials will need to
incorporate face-to-face treatment interventions as one of the experimental conditions. However, it should not be necessary for
Internet interventions to prove more effective than face-to-face
treatments but rather to provide close to equivalent benefits and
outcome results. As the many advantages of Internet interventions,
especially accessibility, become increasingly clear, people who
might not otherwise have obtained treatment may do so. These and
future studies in this area are not meant to imply that face-to-face
treatment should be replaced; rather, they are meant to provide an
alternative or adjunctive component to already well-established
and highly effective interventions.
Web-based treatment interventions offer an opportunity for psychologists to provide specific behavioral treatments, tailored to
individuals who prefer or need to seek help from their own homes.
The technology is now available and will be more readily accessible with high-speed bandwidth, which should be widely accessible in the near future. Although the current sparse literature
examining this area may have limitations, these studies represent
the pioneering efforts to develop what will likely become a major
force in the delivery of psychological treatments. However, many
of these interventions do not take advantage of the full capabilities
of the Internet. Currently, Internet interventions tend to be limited
in their graphical elements and other potentially engaging factors
(i.e., audio, animation, interactivity) and can certainly be improved
with new development software for Web applications. There is a
significant need for more diverse and comprehensive interventions, but the time and effort to operationalize an intervention is
considerable. Although these new interventions are developed,
current applications must overcome the difficulties of delivering
their often large-file-sized programs over phone lines. A compromise that has been created is a hybrid approach.
INTERNET INTERVENTIONS
529
Table 1
Empirically Tested Internet Interventions
Target behaviors/
symptoms
Subjects (N)
Schneider, Walter, &
O’Donnell, 1990
Smoking cessation
1,158 adults
Internet intervention with smoking
diaries vs. outline of behavioral
strategies.
Trends of greater cessation at 1, 3, and 6
months for Internet group.
Winett et al., 1999
Improve teenage
girls’ health
behaviors
180 high
school
females
Semester of Internet intervention
focusing on weight loss, healthy
eating, and health behaviors vs.
standard high school health class
with similar content.
Internet group had significant improvements
in many health-related behaviors.
Celio et al., 2000
Body image
satisfaction and
eating attitudes
76 women
Psychoeducational Internet program vs.
same content delivered in a class vs.
wait-list control.
Internet group had fewer weight and shape
concerns and better eating attitudes at
posttreatment. Risk factors for eating
disorders reduced at 4-month follow-up.
Ström, Pettersson, &
Andersson, 2000
Headaches
45 adults
Internet intervention focused on applied
relaxation and problem-solving
techniques vs. wait-list control.
After 6-week program, Internet intervention
group experienced significantly fewer and
less severe headaches.
Winzelberg et al.,
2000
Body image
satisfaction
60 women
Psychoeducational Internet program vs.
control condition.
After 8-week program and at 3-month
follow-up, Internet group had greater
satisfaction with their body and less desire
for “thinness.”
Klein & Richards,
2001
Panic
22 adults
Internet intervention containing
psychoeducational components and
techniques to reduce panic vs. selfmonitoring control group.
Internet subjects had reduced panic-related
symptoms.
Lange, van de Ven,
Schrieken, &
Emmelkamp, 2001
Posttraumatic stress
and pathological
grief
25 college
students
Internet intervention utilizing 5 weeks
of writing assignments vs. wait-list
control.
80% of experimental group demonstrated
clinically significant improvement in
symptoms of trauma and general
psychopathology posttreatment.
McKay, King, Eakin,
Seeley, &
Glasgow, 2001
Physical activity
78 patients
with
Type 2
diabetes
Internet physical activity intervention
vs. information-only control.
Both groups increased activity levels, but no
significant differences between groups.
Those in Internet group who more often
used program did significantly better.
Tate, Wing, &
Winett, 2001
Weight loss
91 adults
Behavior weight loss Internet program
with e-mail consultation vs.
education about weight loss and
access to information-based Web
sites.
Internet behavior therapy led to significantly
more weight loss at 3 and 6 months.
Andersson,
Strömgren, Ström,
& Lyttkens, 2002
Tinnitus
117 adults
Internet cognitive–behavioral
intervention for tinnitus vs. wait-list
control.
After 6-week program, Internet group
experienced significantly greater
improvements in several measures of
anxiety, depression, and other tinnitusrelated distress vs. controls.
McKay, Glasgow,
Feil, Boles, &
Barrera, 2002
Diabetes selfmanagement
133 patients
with
Type 2
diabetes
Internet-based diabetes support program
on diet, mental health, and
physiologic outcomes vs.
information-only control.
Both groups improved, but no significant
differences between groups.
Ritterband et al.,
2003
Pediatric encopresis
24 children
Psychoeducational and interactive
behavioral Internet intervention vs.
no intervention.
Significant improvements for children in
Internet condition on no. of accidents, no.
of bowel movements in the toilet/week,
and increased trips to the bathroom
without a parental prompt.
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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Study
a
All studies used random assignment as part of their design.
Designa
Results
RITTERBAND ET AL.
530
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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Hybrid Treatment Interventions (HTIs)
HTIs address the problem of limited bandwidth by providing
highly engaging interventions without losing the critical Internet
connection. All the large files are stored either on a CD-ROM or
a hard disk drive. The computer still connects to the Internet to
transfer small bits of information back and forth from the utilized
server. In this way, all the benefits of the Web can still be
maintained, including the ability to update information, exchange
information, collect data, monitor user activity in real time, provide feedback, and prompt behavior change, without losing the
ability to have large data files, such as extensive graphic and audio
files. The disadvantage is that the large files must be furnished to
the user in order to receive the intervention. This typically means
providing a CD-ROM to the user through regular mail or in person.
An example of an HTI is the “U-CAN-POOP-TOO” Web site
developed by our research group at the University of Virginia and
supported by the National Institutes of Health. The goal in designing this program was to deliver a child-focused, entertaining, and
engaging site that would provide all the necessary behavioral and
medical components of Enhanced Toilet Training (Cox, Borowitz,
Kovatchev, & Ling, 1998) to successfully treat pediatric encopresis. This HTI encompasses hundreds of pages of content, with
numerous illustrations, interactive components, animated tutorials,
and reinforcing quizzes.
In order to validate this intervention, we placed a computer in
the homes of half the subjects and provided Internet access to the
Web site. The large graphic and animation files were put on the
hard drive in order to reduce long wait times when progressing
through the program. All subjects continued to receive care from
their primary care physician. Children who received the Web
intervention in addition to care by their primary care physician
decreased their accidents by 93%, increased their number of bowel
movements (BMs) in the toilet each week by 152%, and increased
their trips to the bathroom without a parental prompt by 109%. The
control children decreased their accidents by 31%, but they also
decreased their number of BMs in the toilet each week by 16% and
their trips to the bathroom without a parental prompt by 37%
(Ritterband et al., 2003). These results are equivalent to those
found in tests of a face-to-face behavioral intervention for pediatric
encopresis (Cox et al., 1998).
This hybrid example allowed for the assessment of (a) the
feasibility of this type of treatment intervention, (b) the usability/
acceptability of such a system to patients, and (c) the effectiveness
of such a system for delivering the necessary information, promoting behavior change, and ameliorating symptoms. Further studies
of this kind are necessary to establish the validity of this type of
intervention. Eventually, as more high-speed connections become
available, the HTI model can be discarded, and the WBTI model
will be the standard.
Developing and Using Internet Interventions
Developing Internet interventions is an arduous, sometimes
tedious, and always time-intensive process. It necessitates an interdisciplinary approach, requiring a team of diverse professionals,
including clinicians and other health care providers to provide
content; computer and Web programmers to build essential applications; Web designers to create the Web structure; Web graphic
artists to create still and animated images; database developers to
integrate a mechanism to store and retrieve data; health informatics
evaluators to evaluate user interface issues and outcomes; and
behaviorists to incorporate behavior change concepts into the
system. Other potential members of the team may include business/financial advisors to ensure proper marketing, management,
and sales; videographers to create video; audio engineers to integrate Web audio; psychometricians to certify appropriate scale
integration; tech support personnel to provide user support; costanalysis specialists to determine savings; linguists/translators to
provide readability testing and translation; disability experts to
oversee usability issues; and health educators to make certain the
content is structured in such a way that the majority of users will
find it helpful.
Obviously, only a small number of psychologists would be
likely to want or to have the resources to be able to create an
Internet intervention. However, many clinicians may want to utilize this form of treatment within their own clinical practice. The
most plausible reason for this is to supplement skills that could be
addressed with an adjunctive Internet intervention. For example, a
clinician who feels comfortable treating depression and anxiety
may not have the training to implement the behavioral components
for treating insomnia, which commonly co-occurs with these disorders. An Internet intervention for insomnia with demonstrated
effectiveness could very easily be used as a component of faceto-face treatment, allowing the clinician to target this specific
issue.
A brief summary of the steps involved in developing Internet
interventions may be helpful in conveying the underlying process
of this type of approach. It may also instill an appreciation for the
efforts that go into creating these programs. Also, a greater understanding of these systems will help clinicians recognize how to
best integrate them into their own practice.
A number of factors must be considered when creating an
Internet intervention (see Figure 1). First, the disorder must be
identified and the treatment should be translatable (Step 1). This
means that the intervention is structured such that it can be delivered using the Internet. Typically, the treatment is highly structured and can be at least semi-self-guided. It is also important to
determine the effectiveness of the intervention to be transformed
(Step 2). An effective face-to-face intervention is the gold standard
by which an Internet intervention will ultimately be compared.
Once the treatment is identified and determined to be effective, it
must be operationalized completely (Step 3). To operationalize a
treatment, one must identify all critical aspects of the intervention,
including specific treatment techniques and procedures.
There are numerous legal and ethical issues that must be considered when developing an Internet intervention (Step 4). These
include issues of privacy, confidentiality, data validity, potential
misuse of Internet interventions by professionals, equality of Internet access, and credentialing issues (see Humphreys, Winzelberg, & Klaw, 2000; Jerome et al., 2000; Koocher & Morray,
2000; Sampson, Kolodinsky, & Greeno, 1997; Winker et al., 2000;
Winzelberg et al., 2000). Examining these issues in depth is
beyond the scope of this article, but each issue should be carefully
considered before creating and/or utilizing an Internet intervention
in a clinical practice. Many of these same ethical and legal issues
need to be considered when incorporating an Internet intervention
as an adjunctive component of treatment.
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INTERNET INTERVENTIONS
Figure 1.
531
Development of Internet interventions.
The multimedia aspect of the Internet should be used in creating
the intervention (Step 5). Without using Internet components such
as audio, graphics, animation, and video, the intervention is little
more than a self-help book that can be read online. These elements
help make the intervention engaging and should increase motivation to use and complete the treatment program. Interactivity is
another key component that will likely enrich the intervention and
keep users connected. Personalization allows the user to receive
more individually tailored content, helping to focus the intervention specifically to the user (Step 6). Personalization may be as
simple as using the name of the user when presenting certain
content or as sophisticated as the system identifying specific
treatment areas the individual user may need to address. It is
critical that users receive some feedback regarding their progress
within the treatment (Step 7). These feedback loops may allow
users to track specific elements of the treatment and may even
provide information to be used with their clinician if the system is
an adjunctive component of treatment.
Several technical issues must also be addressed when constructing the Internet program (Step 8). It needs to be determined
whether a fully Web-based or hybrid treatment intervention would
be most appropriate. All issues of Internet delivery, including type
of browser or self-contained application, type of database, and
programming languages to use, must be resolved. Also, issues of
cross-platform compatibility (e.g., making sure the program will
work on a PC and a Macintosh), as well as hardware issues
(providing minimum requirements, such as amount of machine
memory and hard drive space needed) and software issues (identifying necessary browser, plug-ins, and software incompatibility
issues), should be considered. Most of these issues are usually
decided on the basis of the needs of the target audience.
Finally, once the program is developed, testing of the application must be conducted (Step 9). There are several steps to testing
the Internet intervention. Early tests may include focus groups, in
which individuals are invited to view the program and provide
feedback regarding its use. The intervention will also need to be
pilot tested with a small group of patients in order to determine
issues of feasibility, usability, and possibly early determinations of
efficacy. Finally, a large clinical trial will need to be conducted in
order to demonstrate effectiveness. Revisions will likely need to be
incorporated into the program on the basis of users’ feedback, so
a loop between Step 9 and Step 8 will occur.
Future Directions and Implications
Computers and the Internet have become important tools used in
the field of psychology (for other reviews, see Barak, 1999;
Laszlo, Esterman, & Zabko, 1999; Smith & Senior, 2001; Stamm,
1998). However, many clinical and research issues need to be
addressed to further solidify as well as broaden their place in the
discipline.
Clinical Directions
It is likely that there are many other Internet interventions
currently in various stages of development and evaluation. Some
are computer treatments that are in the process of being transformed to Internet interventions, including computer-based health
information and support systems for patients with life-threatening
illnesses (such as for patients who are HIV positive and for those
with breast cancer; Gustafson et al., 1999, 2001), phobias (Kenwright, Liness, & Marks, 2001), fears of public speaking (Botella
et al., 2000), and marital therapy (Jerome et al., 2000). Additional
treatments need to be developed and examined for their efficacy in
order to establish Internet interventions as a viable treatment
alternative and to support generalizability. Some issues, such as
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532
RITTERBAND ET AL.
sexual dysfunctions, may be particularly suited to an Internet
intervention, because many people may be uncomfortable seeking
face-to-face help for such concerns. Internet interventions for other
issues, such as insomnia, may provide help to those who do not
believe their problem warrants a doctor’s visit but who would
follow a treatment plan on their own.
Internet interventions can help reduce many of the traditional
barriers inherent in the current mental health care deliverance
model, including unavailability of skilled professionals, long lag
time for dissemination of information, length of treatment, costs
and inconvenience of treatment, and unwillingness to seek treatment. With the use of the Internet, professionals or patients can
gather information whenever they wish, and the treatments can be
presented in great detail through the use of the written word as well
as through such visuals as pictures, movies, and animated graphics
to enhance the understanding of a disorder. Patients are likely to
feel empowered by being able to digest the information at their
own pace and to better use it to enhance treatment efficacy. Also,
the cost of obtaining access to this information, already minimal,
continues to decline every day. Finally, this mode of treatment
deliverance may be much more appealing to some patients, increasing their willingness to participate and follow the
recommendations.
Even though Internet interventions may help overcome many
barriers to mental health care treatment, some critical issues still
need to be addressed and resolved, including problems of selfassessment and diagnosis, dissemination of information and treatments, establishment of a financial model, and compliance. There
are potential significant negative consequences to individuals assessing and diagnosing themselves, including misdiagnosis and
improper treatment selection.
Internet interventions are not meant to replace face-to-face treatment but rather to provide an alternative for individuals who might
otherwise choose not to receive treatment (e.g., because of embarrassment) or who might be unable to obtain treatment (e.g., because of location) or to find appropriate treatment (e.g., because no
provider is available). However, it is difficult to disseminate information about these interventions and make individuals aware of
them. New ways of broadcasting this type of treatment are needed
so that people may know and take advantage of them.
A financial model must be established so that individuals can
purchase treatments, insurance companies pay for treatments, and
providers charge for development and usage of treatments. Without some financial framework, these interventions will not survive
regardless of how effective they are found to be. However, before
individuals should be charged for these services, research must be
conducted to prove their effectiveness.
Compliance is a problem for traditional approaches and for
Internet interventions. Although people reported enjoying the “UCAN-POOP-TOO” program, it was still difficult to maintain compliance. Subjects were instructed to access the program at least
once a week; however, some subjects needed numerous phone
calls to remind and encourage them to return to the site and
complete the program. In the body image studies conducted at
Stanford University (Winzelberg et al., 2000), subjects typically
completed less than two thirds of the program, and compliance
progressively declined each week of the intervention. Suggestions
have been made for improving compliance, including stressing the
importance of following through with treatment recommendations
at the beginning of the program, utilizing various “motivational
components” built into the program, and providing reinforcement
for cooperation and program completion.
Research Directions
It is vital that methodologically sound clinical studies be conducted to ensure the efficacy of Internet interventions. A few early
studies show promising outcomes; however, although it appears
that the feasibility of this form of treatment approach is possible,
the development of additional Internet treatments and adequate
clinical trials are necessary to establish Internet interventions as a
viable treatment option.
Many of the areas identified in the Clinical Directions section of
this article need to be examined by means of scientific measures.
Issues of assessment and diagnosis, cost-effectiveness, and compliance all need to be explored. Compliance, in particular, is an
area in which Internet interventions may make a significant difference. Patient compliance is said to increase when patients’
satisfaction with the communication of the health-related information increases (Ley, 1982). Research is necessary to determine
whether computer and Internet components, such as audio, video,
graphics/animation, and interaction, will improve compliance. It
may be that through the use of Internet interventions, treatment
programs can be made to be more engaging, thus increasing an
individual’s motivation to continue working. Internet interventions
and other computer treatments can include personalized and pertinent information, quizzes, case reports, and games to make the
programs more enticing, but the impact of all of these needs to be
assessed. Internet treatment programs can also utilize the power of
e-mail (e.g., individuals could be sent an e-mail with a hyperlinked
Web address to access the Web program more easily). This may
also serve as a behavioral prompt that might improve compliance.
However, it is also possible that compliance may be even more
problematic with computer/Internet treatment programs because of
limited supervision, but no research as of yet has focused on this
important question.
There is also a need for more basic research examining components of the Internet and, specifically, the Web and its ability to
elicit behavioral changes. Some researchers have questioned
whether changing various elements within a computer program,
such as adding color, sound, and video, would improve or hinder
outcome (Sproull, Subramani, Kiesler, & Walker, 1996). Similar
inquiries need to be addressed with respect to the Web. These basic
research questions will help shape a model or framework for
developing WBTIs. Although it might be tempting to use business
models already developed for creating engaging and “sticky” Web
sites (i.e., those Web sites that keep users at the site and draw them
back for future visits), it is important to note that these models do
not address the most critical component of Internet interventions:
behavior change. A theoretical model for this type of approach is
necessary so that additional Internet interventions can be
developed.
Future Possibilities
In addition to the developments already presented, the future
promises even greater technologies and applications for psychology. Web-based treatment interventions, as well as enhanced
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INTERNET INTERVENTIONS
videoconferencing and other bandwidth-intensive approaches, will
likely flourish as increased and improved Internet access becomes
more prevalent. Wireless technology is also rapidly improving,
and consumer products with wireless capabilities are becoming
more available. Some users already have cellular phones and
hand-held computers with wireless Internet access. These products
will become even more widely available and easier to use over the
coming years. These wireless products will allow individuals to
track and share information with their health care professions in
real time, ease data input, reduce data-entry errors, and, we hope,
improve compliance.
In addition to wireless technologies, older technologies such as
the telephone will be better able to interface with some of the
newer technologies, including the Internet (see Ritterband et al.,
2001). For example, Internet applications can be created to call
patients on a regular basis to track progress and symptom relief
and prompt for recommended behaviors. This information can be
stored on a Web server database that can be accessed by the
individual and the health care professional. Patient care and patients’ perceptions of care will likely improve with this type of
technology.
Gaming consoles and future personal digital assistants already
have Internet capabilities, and treatment-based software could be
created for use on these platforms. Children may be more interested in receiving treatments if they are presented in an engaging
and entertaining way. Hand-held computers can be carried anywhere, which could improve the collection of symptom information and provide reminders of treatment components to improve
compliance. This information could be wirelessly transmitted to
the user’s health care professional, who could help expedite treatment goals.
Implications
It is unlikely that Internet interventions will replace face-to-face
psychotherapy; however, this technology may be helpful in the
treatment of some psychological problems that might otherwise go
untreated. It is also possible that such interventions may enhance
traditional therapy as an adjunctive component. These new possibilities usher in a whole new platform from which mental health,
and health care in general, can be conducted. Clinicians will have
to be trained to understand, create, and use these forms of treatment. In time, advances in technology will escalate and push
health care to use its power to improve care to the benefit of all.
The following are some of the implications of the issues and the
research presented in this article:
1. Additional clinical treatment interventions need to be operationalized and transformed into Internet interventions for greater
patient consumption.
2. These interventions must be empirically validated through
well-designed clinical research studies.
3. Studies of all components of Internet interventions are necessary to establish and improve feasibility, usability, and efficacy.
4. Psychologists need to accept that technology is changing the
world. This means that multidisciplinary teams will likely include
a rather unusual set of people to provide new treatment
interventions.
5. New definitions of treatment must be created that embrace
533
the use of new technologies and encompass the use of the Internet
in their deliverance.
6. Costs to create and test Internet interventions are significant
and should not be underestimated when considering the development of a new program.
7. Psychologists need to understand and accept that there are
numerous ethical and legal issues relevant to providing new ways
to deliver health care and that it takes time before these issues can
be appropriately managed.
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Received June 11, 2002
Revision received May 15, 2003
Accepted May 22, 2003 䡲
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