Making and Keeping the Connection: Improving Consumer Attitudes and Engagement in E-Mental Health Interventions

Abstract

E-mental health services are internet-based treatment options for mental
illness. Potential benefits of e-mental health interventions include increased
cost effectiveness, enhanced dissemination of evidence based treatments, and
decreased burden on existing healthcare systems (Griffiths, Farrer, & Christensen,
2007). E-mental health services may also overcome various barriers to care
such as stigma, accessibility, and socioeconomic status. Despite these benefits,
consumer uptake and engagement in e-mental health services remains less than
optimal. Available research indicates that consumer attitudes toward e-mental
health services are problematic (Klein & Cook, 2010) but may be improved by the
provision of information about the services (Casey, Joy & Clough, 2013). Research
also suggests that the medium by which this information is delivered may have
a significant influence on the efficacy of such interventions (Casey et al., 2013).
Similarly, client engagement in e-mental health services is less than optimal,
with a weighted average of 31% of clients prematurely ceasing involvement in
psychological interventions delivered via the internet (Melville, Casey & Kavanagh,
2010). The current chapter will provide a review and discussion of consumer
attitudes toward e-mental health services, as well as the efficacy and use of
strategies to improve attitudes and enhance engagement. Recommendations for
future research and clinical practice are also provided.

Full text

Leanne M. Casey, Bonnie A. Clough
8 Making and Keeping the Connection:
Improving Consumer Attitudes and
Engagement in E-Mental Health Interventions
Abstract: E-mental health services are internet-based treatment options for mental
illness. Potential benefits of e-mental health interventions include increased
cost effectiveness, enhanced dissemination of evidence based treatments, and
decreased burden on existing healthcare systems (Griffiths, Farrer, & Christensen,
2007). E-mental health services may also overcome various barriers to care
such as stigma, accessibility, and socioeconomic status. Despite these benefits,
consumer uptake and engagement in e-mental health services remains less than
optimal. Available research indicates that consumer attitudes toward e-mental
health services are problematic (Klein & Cook, 2010) but may be improved by the
provision of information about the services (Casey, Joy & Clough, 2013). Research
also suggests that the medium by which this information is delivered may have
a significant influence on the efficacy of such interventions (Casey et al., 2013).
Similarly, client engagement in e-mental health services is less than optimal,
with a weighted average of 31% of clients prematurely ceasing involvement in
psychological interventions delivered via the internet (Melville, Casey & Kavanagh,
2010). The current chapter will provide a review and discussion of consumer
attitudes toward e-mental health services, as well as the efficacy and use of
strategies to improve attitudes and enhance engagement. Recommendations for
future research and clinical practice are also provided.
E-mental health refers to mental health interventions which are delivered via the
internet and encompasses a broad range of service types, including those with and
without human interaction (Klein & Cook, 2010; Griffiths, Farrer, & Christensen,
2007). Potential benefits of e-mental health interventions include increased
cost effectiveness, enhanced dissemination of evidence based treatments, and
decreased burden on existing healthcare systems (Barak, Hen, Boniel-Nissim, &
Shapira, 2008)). Within the broad category of e-mental health, there are several
types of treatment available.
Information websites provide content regarding diagnosis, symptoms, causes,
and treatments for mental health problems (Barak, Klein, & Proudfoot, 2009).
These websites are predominantly text based, although interactive elements
and multimedia are often included (Barak et al., 2009). For example, Griffiths
and colleagues (Griffiths, Christensen, Jorm, Evans &Groves, 2004) developed
an information website on depression (BluePages) and found that participants
© 2016 Leanne M. Casey, Bonnie A. Clough
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Making and Keeping the Connection 91
accessing this site reduced their level of personal stigma experienced in regard to
depression.
Interventions can also be delivered through internet programs without
therapist assistance. Internet programs without therapist assistance are usually
presented in a range of self-guided modules, and usually based upon a particular
psychological approach (Rickwood, 2010). For example, Casey and colleagues
developed an Internet-based treatment program for pathological gambling
(Casey, Oei & Raylu, 2010). Known as Improving the Odds, this program provided
a fully automated version of Internet-based Cognitive Behaviour Therapy (I-CBT)
for pathological gambling which was delivered in six modules. When compared
to both active treatment and waitlist control conditions, I-CBT was associated
with stronger reductions in gambling related behaviour and achieved similar
effect sizes to those observed in therapist-administered face to face treatment of
pathological gambling.
Another form of e-mental health service is internet programs with therapist
assistance, which provide structured psychological programs with the support of
a health professional. This support can take many forms, including reminders and
personalised feedback (Barak et al., 2009). For example, Berger, Hohl, and Caspar
(2009) reported that combining I-CBT with therapist contact via email resulted
in significant reductions in social anxiety, which was maintained six months
after the intervention. Online counselling is also an effective treatment option,
as King et al. (2009) demonstrated in their examination of online counselling to
treat substance abuse.. Participants in this study were outpatients at an addiction
treatment centre (N = 37) who were randomly assigned to receive counselling
via internet video conferencing, or face-to-face sessions. After the six-week
intervention, there were no significant differences between the groups in terms of
program adherence or drug use.
In summary, e-mental health services appear to be a promising medium to
administer treatment. In an extensive meta-analysis, Barak, et al., (2008) analysed
92 studies utilising e-mental health interventions. Overall, e-mental health services
were found to effectively reduce symptoms across a range of conditions, with an
effect size of 0.53. Notably, in the 14 studies directly comparing e-mental services
with face-to-face treatments, there were no significant differences in treatment
efficacy. Despite this evidence that e-mental health services can be effective, there
has been relatively little examination of how well consumers engage with these
services (Hordern, Georgiou, Whetton, & Progmet, 2011). Client engagement forms
part of the broader concept of adherence to the therapeutic process (Clough &
Casey, 2011). Two key issues in client engagement associated with e-mental health
services are the rates of uptake (i.e., clients entering the service) and dropout (i.e.,
people ceasing the service).
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92 Making and Keeping the Connection
8.1 Uptake of E-mental Health Services
A number of studies indicate that uptake rates of e-mental health services can be
relatively low. In one study, participants were recruited to a guided online CBT
program for depression from 11 participating general practitioners, who first identified
eligible patients from his or her personal files, then sent out the study information
packs (Woodford, Farrand, Bessant, & Williams, 2011). Only seven participants were
recruited over eight months from 1,606 study packages sent out. In another study on
the evaluation of the effectiveness of an online treatment program for depression, out
of 12,051 study packages sent out to eligible depressed and non-depressed individuals
only 255 people were recruited (Clarke et al., 2005). However, there are a number
of limitations in the studies finding low-uptake of computer and online treatment
programs for mental health conditions. A number of studies in this area have
neglected to publish their recruitment methods and treatment uptake rates as well
as there being insufficient trials conducted in routine settings (Bennett & Glasgow,
2009). Reported studies vary considerably on recruitment methods: participants are
either self-selected, or specifically selected by health-care practitioners, and it is
possible that the reluctance to take up treatment could be related to reluctance to be
involved in a clinical trial and not the medium of treatment itself (Kaltenthaler et al.,
2008). Despite these limitations, there is a growing consensus that participation in
online treatment program is less than optimal.
8.2 Consumer Satisfaction with E-mental Health Services
Paradoxically, e-mental health services are well accepted by consumers who have
actually participated in e-mental health treatments. Research has shown high
satisfaction rates amongst users who have completed, or are participating in, an
online treatment program. Titov and colleagues investigated therapist assisted
internet-based treatment for depression (Titov, Andrews, Johnston, Schwencke, &
Choi, 2009). Treatment involved an eight to ten week program consisting of online
lessons, homework, an online discussion forum, and email communication with
a therapist. Immediately following the completion of treatment, the participants
completed measures which assessed their opinions about the face-to-face and
e-mental health treatment options. These measures included rating e-mental health
treatment on several dimensions. In terms of preference and efficacy, no significant
differences were found between endorsements for e-mental health and face-to-
face services. Immediately after participation, the treatment was rated as logical
(9/10) and effective (8/10), and participants reported that they would be confident
recommending the treatment to others (9/10). At six months follow up, there was no
change in the rating of treatment efficacy, and only slight reductions in ratings of logic
(8/10) and confidence in recommending the treatment (8/10). In a study that directly
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Attitudes to E-mental Health Services 93
compared behavioural treatment delivered via an internet-based program with
therapist assistance to or face-to-face therapy Kiropoulos and colleagues reported
that after 12 weeks of treatment for panic disorder, both treatment conditions were
rated as equally satisfying and credible at the conclusion of treatment and achieved
significant improvements in panic frequency, depression, and stress (Kiropoulos et
al., 2008). Although the face-to-face group reported more enjoyment during therapist
interactions, there was no significant difference in the degree of therapeutic alliance
achieved.
8.3 Attitudes to E-mental Health Services
Attitudes of potential consumers of e-mental health services generally remain
problematic. A consistent finding across the literature is that face-to-face services
are preferred in comparison to e-mental health services. Tsan & Day (2007) analysed
attitudes towards counselling delivered via face-to-face treatment, online instant
messaging, internet microphone, email or internet video conferencing in a sample of
college students (N = 176). Eighty-seven per cent of the sample reported a preference
for face-to-face treatment. Similarly, Horgan and Sweeney (2010) reported that in a
sample of university students aged between 18 and 24 years (N = 922), e-mental health
services were the preferred treatment format for only 20.6 per cent of the sample.
Opinions and experiences with e-mental health services have also been assessed
by Neal, Campbell, Williams, Liu, & Nussbaumer (2011) who conducted an online
study of Canadians aged between 18 and 25 years of age (N = 1308). In this study,
participants were asked about their opinions and experience in regards to online-
mental health treatment. Sixty-eight per cent of the sample indicated that they would
not consider contacting a psychologist online, and only 17 per cent reported that they
would use a self-directed online program if they needed help.
Attitudes regarding the helpfulness of mental health services have also been
examined by Leach and colleagues in a study that assessed the perceived helpfulness
of treatments delivered via a website, book or health educator (Leach, Christensen,
Griffiths, Jorm, & Mackinnon, 2007). Although over half of the sample (N = 3998)
stated that a website would be useful, it was rated as the least helpful treatment
option. In a study of university students (N = 330) in the United Kingdom, participants
were provided with a description of a traumatic event, resulting post traumatic stress
disorder symptoms, and 14 potential treatment options (Tarrier, Liversidge, & Gregg,
2006). Participants rated the treatments on several dimensions, and ranked them
according to their suitability for treating post traumatic stress disorder. Information
was also gathered about prior knowledge of the services, and whether the prior
knowledge was positive or negative. Notably, only 8.2 per cent of the sample were
familiar with computer-based therapy, and 6.6 per cent with e-therapy. These findings
contrasted with knowledge of face-to-face treatments such as cognitive therapy (43.5
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94 Making and Keeping the Connection
per cent), group therapy (63.8 per cent), and family therapy (47 per cent). Additionally,
the e-mental health services were amongst the least endorsed treatments, ranking 12th
and 13th out of the 14 services. Carper, McHugh and Barlow (2011) gave information
about various forms of computer based psychological treatment (e.g., email-based
psychotherapy) to patients seeking treatment for an anxiety or a related disorder.
These patients were asked to rank the various forms of computer based psychological
treatment and to answer a questionnaire about their perceptions of computerized
therapy. Overall, the patients’ perceptions of computer based psychological therapy
were found to be neutral to slightly negative and they reported low intentions of
utilising computer based psychological therapy in the future. Analysis of individual
items revealed that participants did, however, report that computer-based treatment
had advantages such as reduced cost, being easier to access, and flexibility in meeting
individual needs. This finding is similar to other studies in which participants
reported perceiving advantages to internet-based treatment but expressed an overall
preference for face-to-face treatment (Mohr et al., 2010).
One explanation for the lack of interest in internet-based treatment is the general
lack of information that potential consumers may have about this treatment modality.
There is certainly evidence that knowledge about treatment is associated with
treatment preferences. For instance, primary care patients (N = 1187) with depressive
symptoms responded to a telephone survey regarding their preferences for treatment
and their knowledge about treatment (Dwight-Johnson, Sherbourne, Liao & Wells,
2000). The survey revealed that patients with greater knowledge about antidepressant
medication were more likely than those without knowledge to desire active treatment
for depression (medication, individual counselling or group counselling). Counselling
was the most preferred treatment among participants who reported preferring active
treatment over no treatment. Patients reporting a preference for counselling also
reported having a greater knowledge about counselling than patients who did not
prefer counselling.
The provision of information regarding treatment outcomes has also been shown
to have a positive impact on hopefulness about treatment outcomes and psychotherapy
treatment uptake rates (Woodhead, Ivan & Emery, 2012). In this study, participants
(N = 50) aged over 60 years with depressive symptoms, who were recommended to
receive psychotherapy were also given information about the outcomes achieved
by older adults in psychotherapy, (i.e., 80% remained depression free 3 years
after psychotherapy). Participants then rated how important they perceived the
information to be and were given the opportunity to receive psychotherapy. Weak,
but significant, positive correlations were found between participants who elected to
initiate treatment and the participants’ ratings of how important they perceived the
information to be (Spearman’s r = 0.30, p = 0.04). That is, participants who elected to
initiate treatment reported that they perceived the information regarding treatment
outcomes to be important.
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Providing Information to Improve Attitudes 95
Unfortunately, potential consumers of e-mental health services appear to have
relatively little information about these services. Carper et al. (2011) found that the
observability of computer based psychological treatment was rated as very low, with
potential consumers reporting that they did not often see treatment being used in this
format and were unfamiliar with it. This finding may indicate that there is a need to
better understand an internet-based treatment in order to feel confident accessing
treatment in this modality. Thus, it is possible that the provision of more detailed
information may enhance the likelihood of engaging in internet-based treatment.
The possibility that additional information regarding internet-based treatment
may increase utilisation of this treatment medium is supported by an Australian
online survey (Klein and Cook, 2010). Participants (N = 218) were asked whether they
would prefer to use face-to-face treatment or internet-based treatment if they were
experiencing a mental health problem. In line with previous research, the majority of
participants (77.1%) reported a preference for face-to-face treatment. However, only
9.6% of participants reported that they would not use e-mental health services. So,
while the majority of participants indicated a preference for face-to-face treatment,
only a small number of participants indicated that they would not use internet-
based treatment. In attempting to clarify this finding, the researchers examined the
concerns raised by participants in regard to internet-based health services. Fifty-four
percent of participants indicated a need to know more about internet-based health
services, suggesting a lack of information about these type of services may underlie
the reluctance to access treatment offered through this medium.
8.4 Providing Information to Improve Attitudes
Despite a lack of awareness about e-mental health services, research indicates
that individuals are receptive to gaining more information about these treatment
options. Furthermore, there is preliminary evidence that knowledge and familiarity
may enhance attitudes towards services. A number of studies have investigated the
impact of providing information to improve attitudes towards mental health services,
although most of this has been conducted with regard to services provided face to
face. The American Psychological Association conducted a national media campaign
to increase usage of psychological services (Farberman, 1997). This campaign
provided consumers with information about psychological services and their
potential benefits. It resulted in a marked increase in enquiries from states in which
the campaign had been implemented. Esters, Cooker, and Ittenbach (1988) delivered
a school based intervention to adolescents between 13 and 17 years of age (N = 40).
The treatment group in this study viewed a video presentation about mental illness,
local help sources, and the qualifications of mental health professionals. The control
group attended their normal classes, and did not watch the video presentation. In
comparison to the control group, participants in the intervention group reported a
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96 Making and Keeping the Connection
significant increase in mental health knowledge as well as significantly attitudes
towards help seeking. These findings were maintained at a 12 week follow up, and
indicate that education can influence attitudes about mental illness.
Sharp, Hargrove, Johnson, & Deal (2006) examined the impact of an informational
intervention upon the help seeking attitudes of American university students (N =
123). All participants watched a 40 minute lecture and slide show presentation. In
the intervention group, the topics addressed in the presentation were psychological
disorders, the therapeutic process, and the role of mental health professionals.
Participants in the control group watched a presentation on astronomy. Participants
were also provided with the contact details of their local mental health services.
Attitudes towards help seeking and opinions about mental illness were significantly
more improved for participants in the intervention group and were maintained
at four weeks following the study. Sawamura, Ito, Koyama, Tajima and Higuchi
(2010) provided 122 psychiatric clinic outpatients who met criteria for a depressive
disorder with either treatment as usual or treatment with the provision of an
additional educational leaflet. The educational leaflet included information about
depressive disorders, available treatments, and strategies for coping with stress.
Participants were asked to indicate their attitudes and beliefs about depression and
antidepressants at their first and third visit. Participants who received the educational
leaflet demonstrated significantly improved attitudes and beliefs about depression
and antidepressant treatment at their third visit, whereas the attitudes and beliefs of
participants who did not receive the leaflet did not change.
Nicholas, Oliver, Lee, and O’Brien (2004) examined the impact of informational
intervention about e-mental health services in secondary schools with participants
aged 13 to 18 years (N = 243). The topic of the intervention was ‘Reach Out’, an
e-mental health service for young people in Australia. Interactive presentations
were used to promote Reach Out as a place where young people could seek help
for a variety of personal problems. Following the presentation, 70% of participants
reported that the intervention had taught them where they could seek help if they
were experiencing difficulties and 45% of participants visited the Reach Out website
following the presentation. Notably, six months after the presentation, 63 per cent
of participants reported that they would use the Reach Out website in the future if
they needed help. Although the interpretation of these findings is constrained by the
absence of a control group, this study suggests that information may enhance help
seeking intentions and awareness of e-mental health services.
An important issue to consider is the type of information that may improve the
attitudes of potential utilisers of these treatments (Sawamura et al, 2010). Young (2 005)
asked clients (N =48) taking part in an online treatment program for internet addiction
about their decision to access online counselling. Of these clients 71% reported that
the convenience and flexibility offered by online treatment was an important factor
and 52% reported that understanding the credentials of the counsellor was also an
important factor. Bradley (2010) explored what features of an internet-based self-
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Providing Information to Improve Attitudes 97
help program for psychological distress would encourage adolescents to seek help.
Adolescents reported an online treatment program that was credible, offered privacy,
convenience, and accessibility was the most appealing.
Providing information about issues of privacy and confidentiality may be
particularly important to users of e-mental health services. A survey of internet
users (N = 7014) in America compared the internet usage patterns of participants
who reported experiencing a stigmatised illness, such as depression, to those who
reported other health related conditions, such as back pain (Berger, Wagner & Baker,
2005). The survey revealed that participants who reported a stigmatised illness
were significantly more likely to access the internet for health information and to
communicate with clinicians on the internet about their condition than participants
who did not report having a stigmatised illness
Providing information about the efficacy of treatment programs may also be
important, although again much of this evidence comes from research into improving
attitudes toward face to face psychological interventions. Interviews with employees
of a manufacturing plant (N =984) revealed that the likelihood of accessing an
employee assistance program providing psychological treatment for drinking
problems was directly increased by their belief in the efficacy of the program (Delaney,
Grube & Ames, 1998). Ahmed & Westra (2009) provided participants demonstrating
a high fear of negative evaluation with a rationale about CBT for the treatment of
social anxiety. Participants’ expectancies for improvements in their anxiety and
their perceived helpfulness of exposure to information about treatment efficacy
were measured before and after being exposed to the information. Participants’
perceptions of the helpfulness of treatment and their expectations for anxiety change
significantly improved following the presentation of a rationale for therapy. Mitchell
and Gordon (2007) found that a sample of university students rated a computerised
CBT treatment for depression as less credible, unlikely to help improve depression,
and also reported that they were unlikely to use it. However, after their participants
were exposed to a sample demonstration of the treatment, increases were found
in credibility, expectation for improvement, and perceived likelihood of using the
treatment in the future.
It is evident that an association exists between treatment preferences and
consumers knowledge or understanding of available treatments. Therefore, providing
information regarding the outcomes and process of e-mental health services may
increase their perceived likelihood of uptake. Casey, Joy & Clough (2013) directly
tested this possibility in a randomised control study by investigating the relationship
between knowledge of e-mental health services and attitudes toward e-mental health
services. The attitudes examined were the perceived helpfulness of e-mental health
services and the likelihood of using the services. Participants (N = 217) were randomly
assigned to one of three conditions: provision of e-mental health information by
means of film; provision of e-mental health information by text; or provision of no
e-mental health information. Main effects were found for type of e-mental health
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98 Making and Keeping the Connection
service and for both perceived helpfulness and likelihood of future use. Participants
perceived online programs without therapist assistance as being significantly less
helpful, and reported reduced likelihood of engaging these programs when compared
to other e-mental health services. There was also a main effect for type of information
intervention, in that the text group reported higher likelihood of e-mental health use
in the future, whereas there were no effects for the film group. Results indicated that
participants perceive important differences between types of e-mental health services,
and that a brief text intervention can improve attitudes toward these services.
Finally, provision of information may also be important for clinicians, with
research suggesting that particularly in rural areas health professionals play an
important role in the referral of clients to treatment pathways (Griffiths & Christensen,
2007). However, research suggests that professional opinions of e-mental health
programs remain largely unfavourable (Tarrier et al., 2006), although more research
is needed in this area.
8.5 Adherence and Dropout from E-mental Health services
Researchers vary considerably in their use of the terms to describe clients
ceasing treatment. “Premature termination”, “attrition” and “dropout” are used
interchangeably in the literature to indicate clients who terminate before the
completion of treatment. High attrition rates are common for e-mental health services
and are thought to be due to the low intensity and unstructured nature of many online
treatment programs (Bennett & Glasgow, 2009). However, attrition rates are found
to be similar to traditional face-to-face therapy when online treatment programs
are combined with therapist support (Kaltenthaler et al, 2008; Melville, Casey, &
Kavanagh, 2010; Proudfoot, 2004). In a comprehensive review of the literature
(1990 to 2009) on the extent of dropout from internet-based treatment programs
for psychological disorders, a weighted mean of 31% was found for dropout rates
(Melville et al., 2010). Within e-mental health, client engagement includes not only
initial uptake of services but also participation in therapeutic modules and activities
(i.e., adherence), and completion of a therapeutic program. Research investigating
strategies to minimize client dropout in e-mental health services is currently limited,
as is research investigating ways of enhancing client adherence to these programs.
8.6 Adherence
Client adherence during a psychological program is an important predictor of treatment
outcome. This relationship is particularly true when considering self help or unguided
programs (Rapee, Abbott, Baillie, & Gaston, 2007). Nordgreen and colleagues (2012)
examined patient adherence in guided and unguided e-mental health treatment for
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Dropout 99
social phobia. Results indicated greater adherence for guided compared to unguided
treatment. For the unguided self-help group, higher participant ratings of treatment
credibility were associated with greater treatment adherence. This effect was not
found for the guided group, suggesting that client perceptions of treatment credibility
may be of particular importance for programs with reduced or no therapist contact.
The efficacy of internet delivered therapy with therapist telephone support was
examined by Carlbring et al (2007). Participants in the treatment group were found
to have high adherence to the social anxiety program, with 93% of participants
completing all modules of the program. However, as the study did not contain a
comparison treatment group, a direct comparison of the unique contribution of the
telephone support was not possible. Although patient adherence was found to be
significantly greater (93% vs. 62%) when compared to participants from a previous
study (Andersson et al., 2006) that completed the same e-therapy program without
telephone support. These results indicate that client engagement during e-mental
health programs may be increased by the addition of minimal therapist support and
contact during the program.
8.7 Dropout
Although Melville et al (2010) failed to find consistent associations between the
various client, contextual, and treatment related variables among participants who
dropped out of e-mental health programs, there is some evidence that dropout may
be lower among those clients with more favourable treatment expectations and
perceptions of credibility prior to treatment commencing (Cavanagh et al., 2009).
This finding further supports the importance of interventions providing information
not only to increase uptake but also to potentially reduce dropout once clients have
started programs. Similarly, minimal therapist contact either by phone or email may
be an important strategy for increasing client adherence to treatment modules, and
promoting greater program completion (Andersson et al., 2006; Carlbring et al.,
2007). Such therapist contact might also be beneficial for the recovery of participants
who dropout of treatment prematurely.
Alternatively, it may be worth considering how this form of contact can be
built into e-mental health services. Melville, Casey, and Kavanagh (in preparation)
randomised those participants who dropped out of an online treatment program for
pathological gambling to receive either an automated treatment recovery intervention
or no intervention. Those in the treatment recovery group were automatically emailed
following dropout from the program, with the email inviting them to a return to
treatment intervention. The return to treatment intervention was an online program,
which explored participant reasons for discontinuing treatment, and provided
problem solving and motivational strategies for continuing treatment. At the end of
the return to treatment intervention, participants were then asked if they would like
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to resume their work in the original e-therapy program. Participants in the control
condition also received an email upon dropout from the e-therapy program. This
email acknowledged their withdrawal from the program and offered participants
the option to return to treatment, but did not offer the recovery intervention. Results
indicated significant support for this approach to reducing dropout, with 32% of those
participants in the treatment recovery condition returning to treatment compared to
9% in the control condition. Interventions such as this, which require minimal or no
therapist input, could substantially improve client engagement and reduce dropout
in e-mental health programs.
8.8 Summary
The effectiveness of e-mental health therapies is dependent on client engagement with
these services. These engagement behaviours can include initial uptake of services,
engagement with activities and modules, and completion of programs. A range of
efficacious e-mental health programs now exist, however ongoing difficulties with
client engagement in these services remain. Recent research suggests that uptake of
services can be improved through educational interventions, which may be important
for both health professionals and consumers.
These educational interventions may also be beneficial in improving client
perceptions of credibility and effectiveness of e-mental health interventions,
particularly for those programs with minimal or no therapist contact. Improving
client attitudes and understanding of e-mental health programs has been found to
have beneficial effects for engagement with therapeutic content, as well as reducing
dropout. Client engagement with e-mental health programs would also likely improve
with the integration of dropout recovery programs, such as those used by Melville et
al. (in preparation).
Despite the ongoing difficulties with client engagement currently observed in
e-mental health programs, the difficulties reported are similar to those observed in
face-to-face treatment programs. Ongoing difficulties exist in traditional therapy
modalities with regards to help seeking behaviours and uptake of services, engagement
during therapy and homework adherence, as well as the completion of treatment
programs. A considerable amount of research has been conducted in these areas
with various therapeutic strategies (e.g., motivational, session contracting, dropout
recovery) found to enhance client engagement in these areas. As of yet, research in
the use of these engagement interventions is limited with regards to e-mental health
interventions. Future research should explore the integration of these strategies with
the aim of increasing client engagement and thereby the effectiveness of e-mental
health programs.
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Downloaded from PubFactory at 08/22/2016 01:51:00AM
via University of Southern Queensland

References 101
References
Ahmed, M., & Westra, H. A. (2009). Impact of a treatment rationale on expectancy and engagement
in cognitive behavioural therapy for social anxiety. Cognitive Therapy and Research, 33,
314-322.
Andersson, G., Carlbring, P., Holmstrom, A., Sparthan, E., Furmark, T., Nilsson-Ihrfelt, E., . . .
Ekselius, L. (2006). Internet-based self-help with therapist feedback and in vivo group exposure
for social phobia: A randomized controlled trial. [Article]. Journal of Consulting and Clinical
Psychology, 74(4), 677-686. doi: 10.1037/0022-006x.74.4.677
Barak, A., Hen, L., Boniel-Nissim, M., & Shapira, N. a. (2008). A comprehensive review and a
meta-analysis of the effectiveness of Internet-based psychotherapeutic interventions.
Journal of Technology in Human Services, 26(2-4), 109-160. doi: http://dx.doi.
org/10.1080/15228830802094429
Barak, A., Klein, B., & Proudfoot, J. G. (2009). Defining Internet-supported therapeutic interventions.
Annals of Behavioral Medicine, 38(1), 4-17.
Bennett, G. G., & Glasgow, R. E. (2009). The delivery of public health interventions via the Internet:
actualizing their potential. Annu Rev Public Health, 30, 273-292.
Berger, M., Wagner, T. H., & Baker, L. C. (2005). Internet use and stigmatized illness. Social Science
& Medicine, 61(8), 1821-1827. doi: DOI: 10.1016/j.socscimed.2005.03.025
Carlbring, P., Gunnarsdottir, M., Hedensjo, L., Andersson, G., Ekselius, L., & Furmark, T. (2007).
Treatment of social phobia: randomised trial of internet-delivered cognitive-behavioural therapy
with telephone support. [Article]. British Journal of Psychiatry, 190, 123-128. doi: 10.1192/bjp.
bp.105.020107
Carper, M., McHugh, R., & Barlow, D. (2011). The Dissemination of Computer-Based Psychological
Treatment: A Preliminary Analysis of Patient and Clinician Perceptions. Administration and
Policy in Mental Health and Mental Health Services Research., doi: 10.1007/s10488-011-0377-5.
Casey, L. M., Joy, A., & Clough, B. A. (2013). The impact of information on attitudes toward E-mental
health services. Cyberpsychology, Behavior, and Social Networking, 16(8), 593-598.
Cavanagh, K., Shapiro, D. A., Van Den Berg, S., Swain, S., Barkham, M., & Proudfoot, J. (2009).
The acceptability of computer-aided cognitive behavioural therapy: a pragmatic study.
[; Research Support, Non-U.S. Gov’t]. Cognitive behaviour therapy, 38(4), 235-246. doi:
10.1080/16506070802561256
Clarke, G., Eubanks, D., Reid, E., Kelleher, C., O’Connor, E., DeBar, L. L., . . . Gullion, C. (2005).
Overcoming depression on the Internet (ODIN) (2): A randomized trial of a self-help depression
skills program with reminders. [Article]. Journal of Medical Internet Research, 7(2). doi: e16
10.2196/jmir.7.2.e16
Clough, B. A., & Casey, L. M. (2011). Technological Adjuncts to Increase Adherence to Therapy: A
Review. Clinical Psychology Review, 31, 697-710.
Delaney, W., Grube, J. W., & Ames, G. M. (1998). Predicting likelihood of seeking help through the
employee assistance program among salaried and union hourly employees. Addiction, 93(3),
399-410.
Dwight-Johnson, M., Sherbourne, C. D., Liao, D., & Wells, K. B. (2000). Treatment preferences among
depressed primary care patients. Journal of General Internal Medicine, 15(8), 527-534.
Esters, I. G., Cooker, P. G., & Ittenbach, R. F. (1998). Effects of a unit of instruction in mental
health on rural adolescents’ conceptions of mental illness and attitudes about seeking help.
Adolescence, 33(130), 469-469-476.
Farberman, R. K. (1997). Public attitudes about psychologists and mental health care: Research
to guide the American Psychological Association public education campaign. Professional
Psychology: Research and Practice, 28(2), 128-136. doi: 10.1037/0735-7028.28.2.128
Giuseppe Riva, Brenda K. Wiederhold and Pietro Cipresso - 9783110473780
Downloaded from PubFactory at 08/22/2016 01:51:00AM
via University of Southern Queensland

102 Making and Keeping the Connection
Griffiths, K., Farrer, L., & Christensen, H. (2007). Clickety-click: E-mental health train on track.
Australasian Psychiatry, 15(2), 100-108.
Griffiths, K. M., & Christensen, H. (2007). Internet-based mental health programs: A powerful tool
in the rural medical kit. Australian Journal of Rural Health, 15(2), 81-87. doi: 10.1111/j.1440-
1584.2007.00859.x
Hordern, A., Georgiou, A., Whetton, S., & Progmet, M. (2011). Consumer eHealth-an overview of
the research evidence and the implications for future policy. Health Information Management
Journal, 40(2), 6-14.
Horgan, Á., & Sweeney, J. (2010). Young students’ use of the Internet for mental health information
and support. Journal of Psychiatric and Mental Health Nursing, 17(2), 117-123. doi:
10.1111/j.1365-2850.2009.01497.x
Kaltenthaler, E., Sutcliffe, P., Parry, G., Beverley, C., Rees, A., & Ferriter, M. (2008). The acceptability
to patients of computerized cognitive behaviour therapy for depression: a systematic review.
Psychological Medicine, 38, 1521-1530.
King, V. L., Stoller, K. B., Kidorf, M., Kindbom, K., Hursh, S., Brady, T., & Bronner, R. K. (2009).
Assessing the effectiveness of an Internet-based videoconferencing platform for delivering
intensified substance abuse counseling Journal of Substance Abuse Treatment, 36, 331-338.
Kiropoulos, L. A., Klein, B., Austin, D. W., Gilson, K., Pier, C., Mitchell, J., & Ciechomski, L. (2008). Is
internet-based CBT for panic disorder and agoraphobia as effective as face-to-face CBT? Journal
of Anxiety Disorders, 22, 1273-1284.
Klein, B., & Cook, S. (2010). Preferences for e-mental health services amongst an online Australian
sample. Electronic Journal of Applied Psychology, 6, 28-39.
Leach, L. S., Christensen, H., Griffiths, K. M., Jorm, A. F., & Mackinnon, A. J. (2007). Websites as a
mode of delivering mental health information: Perceptions from the Australian public. Social
Psychiatry and Psychiatric Epidemiology, 42, 167-172.
Melville, K. M., Casey, L. M., & Kavanagh, D. J. (2010). Dropout from Internet-based treatment
for psychological disorders. British Journal of Clinical Psychology, 49, 455-471. doi:
10.1348/014466509x472138
Melville, K. M., Casey, L. M., & Kavanagh, D. J. (in preparation). Evaluation of a Program to Recover
Dropouts from Internet-based Psychological Treatment
Mitchell, N., & Gordon, P. K. (2007). Attitudes towards computerized CBT for depression amongst a
student population. [Article]. Behavioural and Cognitive Psychotherapy, 35(4), 421-430. doi:
10.1017/s1352465807003700
Mohr, D. C., Ho, J., Duffecy, J., Baron, K. G., Lehman, K. A., Jin, L., & Reifler, D. (2010). Perceived
barriers to psychological treatments and their relationship to depression. Journal of Clinical
Psychology, 66(4), 394-409. doi: 10.1002/jclp.20659
Neal, D. M., Campbell, A. J., Williams, L. Y., Liu, Y., & Nussbaumer, D. (2011). “I did not realize so
many options are available”: Cognitive authority, emerging adults, and e-mental health. Library
& Information Science Research, 33(1), 25-33. doi: DOI: 10.1016/j.lisr.2010.07.015
Nicholas, J., Oliver, K., Lee, K., & O’Brien, M. (2004). Help-seeking behaviour and the Internet: An
investigation among Australian adolescents Australian e-Journal for the Advancement of Mental
Health, 3, 1-7.
Nordgreen, T., Havik, O. E., Öst, L. G., Furmark, T., Carlbring, P., & Andersson, G. (2012). Outcome
predictors in guided and unguided self-help for social anxiety disorder. Behaviour Research
and Therapy, 50(1), 13-21. doi: http://dx.doi.org/10.1016/j.brat.2011.10.009
Proudfoot, J. G. (2004). Computer-based treatment for anxiety and depression: is it feasible?
Is it effective? Neuroscience & Biobehavioral Reviews, 28(3), 353-363. doi: 10.1016/j.
neubiorev.2004.03.008
Rapee, R. M., Abbott, M. J., Baillie, A. J., & Gaston, J. E. (2007). Treatment of social phobia through
pure self-help and therapist-augmented self-help. British Journal of Psychiatry, 191(3), 246-252.
Giuseppe Riva, Brenda K. Wiederhold and Pietro Cipresso - 9783110473780
Downloaded from PubFactory at 08/22/2016 01:51:00AM
via University of Southern Queensland

References 103
Rickwood, D. (2010). Promoting youth mental health through computer-mediated communication.
International Journal of Mental Health Promotion 12(3), 32-44.
Sawamura, K., Ito, H., Koyama, A., Tajima, M., & Higuchi, T. (2010). The effect of an educational
leaflet on depressive patients’ attitudes toward treatment. Psychiatry Research, 177(1), 184-187.
Sharp, W., Hargrove, D. S., Johnson, L., & Deal, W. P. (2006). Mental Health Education: An Evaluation
of a Classroom Based Strategy to Modify Help Seeking for Mental Health Problems. Journal of
College Student Development, 47(4), 419-438.
Tarrier, N., Liversidge, T., & Gregg, L. (2006). The acceptability and preference for the psychological
treatment of PTSD. Behaviour Research and Therapy, 44(11), 1643-1656.
Titov, N., Andrews, G., Johnston, L., Schwencke, G., & Choi, I. (2009). Shyness programme: Longer
term benefits, cost-effectiveness, and acceptability. Australian and New Zealand Journal of
Psychiatry, 43(1), 36-44.
Tsan, J. Y., & Day, S. X. (2007). Personality and gender as predictors of online counseling use. Journal
of Technology in Human Services, 25(3), 39-55.
Woodhead, E. L., Ivan, L. I., & Emery, E. E. (2012). An exploratory study of inducing positive
expectancies for psychotherapy. Aging and Mental Health, 16(2), 162-166.
Giuseppe Riva, Brenda K. Wiederhold and Pietro Cipresso - 9783110473780
Downloaded from PubFactory at 08/22/2016 01:51:00AM
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