Internet CBT

At a glance

Compared with waiting

Much better than waiting. Combining 37 trials, the difference was large.

Compared with other treatments

In UK and Swedish trials, guided programmes did about as well as face-to-face individual or group therapy. Against other active treatments overall, the advantage was small.

Does it last

In a Swedish follow-up of 80 people, gains were still there five years later.

What it takes

Several weeks of online lessons and practice, plus short messages or calls with a therapist. Access depends on your country.

What it is

Internet CBT is cognitive behavioural therapy delivered through a website or app. CBT is talking therapy that works on how you think and what you do. You work through lessons, videos and worksheets, and do exercises in real life between them.

There are two kinds:

• Guided: a therapist reads your work and replies by message or short calls, usually for a few minutes a week.
• Unguided: you work on your own, with no therapist.

For many people with social anxiety, online is easier to start. You don’t have to phone anyone or sit in a waiting room.

What the evidence shows

• It helps much more than waiting. A study that combined 37 trials found a large difference between internet CBT and waiting. Against active treatments, it still came out a little ahead.
• It matches face-to-face therapy.
  • In a UK trial of 102 people, internet cognitive therapy for social anxiety (iCT-SAD) worked about as well as face-to-face sessions. It used 6.45 hours of therapist time instead of 15.8.
  • In a Swedish trial, internet CBT was no worse than group CBT.
  • A review across many conditions found guided internet CBT and face-to-face CBT about equal. Only 3 of those trials were in social anxiety.
• It lasts. In a five-year follow-up in Sweden, 80 people treated with internet CBT kept their gains.
• It works in different countries. An Australian trial of 105 people found a large difference between a six-lesson guided course and waiting. A trial in Hong Kong found iCT-SAD worked there with little change to the programme. A UK trial in teenagers aged 14 to 18 also found good results.
• Guidance helps. Trials of guided programmes give the best results. In a Swedish trial of internet psychodynamic therapy, the guided version beat the unguided one. A study of messages from an online forum found that people who wrote about motivation and seeing good results improved more.
• A book can do part of the job. In another Swedish trial, both a self-help book and guided internet CBT beat waiting.

What the trials have not answered

• Most trials took place in Sweden, Australia, the Netherlands, Germany and the UK. They mostly recruited through adverts, and most volunteers were educated adults. Results may differ elsewhere.
• No trial has compared commercial online platforms with each other.

Where to find a tested programme

Access is country-specific. These are examples with trial evidence behind them:

• England: internet cognitive therapy for social anxiety (iCT-SAD), developed in Oxford, is used in some NHS Talking Therapies services. Adults in England can refer themselves to NHS Talking Therapies and ask if they offer it.
• Australia: THIS WAY UP, run by St Vincent’s Hospital Sydney, offers a six-module social anxiety course. It can be done on your own for a fee, or free with a referral from a registered clinician. The service says it has been tested in its own research trials.

Elsewhere, ask your doctor or a local anxiety clinic. When you look at any programme, ask:

1. Has this programme, or the one it is based on, been tested in a trial for social anxiety?
2. Is it CBT made for social anxiety, with exposure and behavioural experiments?
3. Does a real therapist check in with me?

If no guided option is available, a good CBT self-help book is a tested alternative.