The University of Sydney, Australia
Citation
Monaghan, S. & Blaszczynski, A. (2009). Internet-based intervnetions for the treatment of problem gambling . Toronto: Centre for Addiction and Mental Health.

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Contact Information
Sally Monaghan
School of Psychology
Brennan MacCallum Building A(18)
The University of Sydney NSW 2006
Australia sallym@psych.usyd.edu.au
Tel: +514 803 3665 (Canada) +612 9969 8039 (Australia)
Prof. Alex Blaszczynski
School of Psychology
Brennan MacCallum Building A(18)
The University of Sydney NSW 2006
Australia alexb@psych.usyd.edu.au
Tel: +612 9036 7227
Acknowledgments
We thank the Centre for Addiction and Mental Health for their support of our research efforts and their generous funding of this project. We also thank all the researchers and treatment providers who are involved in Internet therapy programs for problem gambling for sharing information and data about these services to be included in this report, particularly when published studies were not currently available.

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Table of Contents
Executive Summary ...................................................................................................... 5
Introduction - background and rationale ................................................................... 9
Section 1 : ...................................................................................................................... 12
Current treatment utilization .................................................................................... 12
Internet interventions ................................................................................................. 13
Internet therapy .......................................................................................................... 14
Online interventions .................................................................................................... 14
Registration ............................................................................................................... 15
Tailored normative feedback .................................................................................... 16
Tailored content ........................................................................................................ 17
Screening and brief interventions ............................................................................. 19
Behavioural tools ...................................................................................................... 20
Interactive exercises.................................................................................................. 20
Motivational phases .................................................................................................. 21
Online support groups and forums............................................................................ 21
Contact schedules...................................................................................................... 23
Social networking and Web 2.0 applications............................................................ 24
Implementation issues for Internet therapy and online interventions ................... 25
Internet accessibility ................................................................................................. 25
Acceptability ............................................................................................................. 26
Promotion and advertising of services...................................................................... 27
Attrition..................................................................................................................... 29
Usability.................................................................................................................... 32
Utilisation.................................................................................................................. 33
Service Delivery Considerations............................................................................... 34
Fee-based services .................................................................................................... 36
Cost effectiveness ..................................................................................................... 36
Section 1 summary ...................................................................................................... 38
Section 2 ....................................................................................................................... 40
Internet therapy .......................................................................................................... 40
Problem drinking ...................................................................................................... 41
Tobacco use .............................................................................................................. 42
Substance abuse ........................................................................................................ 44
Group therapy ........................................................................................................... 46
Internet therapy for problem gambling .................................................................... 47
Sweden...................................................................................................................... 47
Norway...................................................................................................................... 48
Finland ...................................................................................................................... 50
Germany.................................................................................................................... 50
United Kingdom........................................................................................................ 52
Australia.................................................................................................................... 53

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Canada....................................................................................................................... 55
United States of America .......................................................................................... 57
Online interventions .................................................................................................... 57
Online interventions for addictions ........................................................................... 57
Problem drinking ...................................................................................................... 57
Smoking cessation .................................................................................................... 62
Substance abuse ........................................................................................................ 67
Online interventions for problem gambling ............................................................. 69
Tailored feedback...................................................................................................... 69
Online support groups............................................................................................... 70
Characteristics of clients seeking online assistance ................................................. 76
Problem drinking ...................................................................................................... 76
Smoking cessation .................................................................................................... 78
Client suitability for online interventions for problem gambling .......................... 79
Women...................................................................................................................... 79
Men ........................................................................................................................... 80
Youth......................................................................................................................... 81
Older adults............................................................................................................... 83
Minorities.................................................................................................................. 84
Section three ................................................................................................................ 84
Recommendations and necessary components of Internet therapy and online interventions for problem gambling .......................................................................... 84
References .................................................................................................................... 90

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Executive Summary
The past twenty years has seen increases in gambling availability and opportunities due to changes in regulations and technological developments. Coupled with an expansion of social acceptance of gambling and its prominence in popular media and advertising, the potential negative consequences of gambling have also been increasingly recognised by key stakeholders. The personal and social costs of problem gambling to individuals, families and societies is enormous, however, the vast majority of problem gamblers do not seek treatment suggesting that current treatment options do not meet the needs of a large proportion of gamblers who need help. Individuals are increasingly turning to the
Internet to seek help for a large variety of personal problems and Internet therapy and online self-help interventions have emerged as potentially effective forms of treatment for mental health and addiction disorders. Benefits of Internet-based interventions include increased availability, convenience and accessibility, privacy and anonymity, relevance, scalability and reduce costs for treatment providers and clients. Preliminary evidence shows that Internet therapy and online interventions are more effective than no treatment and as effective as face-to-face therapy for a large range of mental health disorders, including treatment of addictions and problem gambling. The implementation of Internet treatment directly corresponds with the Ontario Government’s recently announced mental health and addictions strategy, which aims to reach out to previously untreated populations using innovative methods that are proactive and ongoing to provide high quality, effective, integrated, culturally competent, person-directed services and support for Ontarians with mental illnesses and additions.
Internet therapy involves the delivery of a formal, structured, evidence-based treatment program to individuals diagnosed with a specific disorder utilising Internet-based technology. Typical programs run over a period of six to eight weeks and clients previously assessed to ensure suitability complete one online module per week. Modules are often based on cognitive behavioural therapy and motivational enhancement therapy principles and include readings (which may be presented using a variety of multimedia tools), interactive exercises including short answer questions, quizzes and selfassessments, and behavioural tools such as self-monitoring diaries, goal setting and relapse prevention techniques. Clients typically exchange emails with their therapist once per week to discuss progress and issues although contact can also occur through live chat, video conferencing or telephones. Following the completion of therapy clients may be contacted for follow-up sessions to ensure the gains made in therapy are maintained.
Online interventions are similar to the structure of Internet therapy with the exception that clients work through all modules individually without therapist contact. Clients typically register with a program to enable an assessment for needs and suitability and allow them to track their progress and receive automated contacts, for example emails with daily tips, help, advice or support at predetermined difficult periods. Completion of self-assessment allows clients to receive automated tailored normative feedback which demonstrates the extent to which their behaviour is typical (or in excess) of individuals of their age, gender, culture and nationality. Tailored feedback may also suggest the most suitable course of action for an individual, for example, the completion of an online intervention program. The treatment components of online interventions are similar to those in Internet therapy. Importantly, online interventions must use information gathered

6 during assessment to individually tailor program material to ensure that it is culturally and personally relevant for each client. This is essential to increase the effectiveness of the intervention offered and client motivation to work through a relevant treatment plan.
Online interventions may also include online forums and support groups to enable clients to ask questions, seek and provide support and discuss relevant issues with individuals facing similar difficulties. Clients may also have the option to contact therapists through email or a forum to seek clarification or support where necessary. Online interventions may be used as an adjunct to individual or group therapy, as a method of relapse prevention, or during a waiting period prior to the commencement of face-to-face therapy.
As Internet-based treatment options have been developed and implemented relatively recently there are many outstanding issues that require consideration. Although highspeed Internet access is increasingly widely available, some populations may still experience difficulty in accessing online treatment options, for example problem gamblers experiencing financial difficulties. Furthermore, the extent to which Internet treatment is acceptable is largely unknown, although evidence suggests that youth and adults are increasingly comfortable seeking help online. If launched, Internet-based treatments must be appropriately marketed to ensure all potential clients are aware of the services and its benefits. This may require the use of novel marketing techniques in addition to traditional and Internet media campaigns. Furthermore, it is essential that treatment providers including all health providers and telephone counsellors are aware of the intervention should they wish to refer clients to this. As with traditional therapy, online interventions may experience difficulties retaining clients. Client attrition may be caused by a lack of interest and motivation, time restrictions or difficulties in completing programs and modifying behaviours. Attrition for online interventions may be higher than in traditional therapy due to the low entry barriers, however, in contrast to face-toface therapy, failing to complete treatment may not cause shame and embarrassment and clients may be much more likely to access the online program again when they are ready to make life changes. To reduce attrition, research is required to enhance the usability and utilisation of Internet-based treatments and to determine which components are most effective and popular. Online feedback should be constantly sought and programs can be modified at any stage to increase effectiveness. Further considerations include training staff to be comfortable with online communication and suitable client assessment to ensure the provision of an appropriate level of care. However, despite initial start-up costs and funding for training and research, Internet-based interventions are expected to be highly cost effective due to reduced overheads and scalability to reach a large number of clients without increasing costs. Furthermore, as this new form of treatment appears to reach those who would not otherwise seek formal help, this may reduce social costs associated with problem gambling.
Internet-based treatment options are a newly developed phenomenon and the importance of treating problem gambling has also gained prominence in recent times, resulting in a lack of empirical research on Internet therapy and online interventions for the treatment of problem gambling. However, research from the field of addiction has traditionally guided problem gambling treatments and can be evaluated to determine the most suitable

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Internet-based treatment options for problem gambling. Evaluations of existing online treatments for problem drinking, tobacco use and substance abuse are incredibly useful in demonstrating which components of online interventions are used, ways in which to increase uptake, usability and reduce attrition, research and evaluation techniques and importantly effective therapeutic components. Furthermore, Internet therapy and online interventions for problem gambling have recently commenced in several countries internationally and while research is still being conducted, the experiences of these programs can be used to guide the creation of a suitable online intervention for implementation in Canada. It is also important to examine the characteristics of clients seeking help online, in comparison to those accessing traditional support services and consider techniques to increase client suitability for online interventions. As there is no existing “gold-standard” for Internet-based treatments, treatment providers can choose how they wish to structure their program, for example, what components should be included, how access should be facilitated and what populations should be targeted.
Based on a thorough and systematic evaluation of existing research and Internet-based treatment options for addictions and problem gambling, a series of recommendations have been made to guide the development of online interventions in Ontario, some of which are presented here:
•
Self-conducted assessments should be an initial component of all online interventions to assist individuals in evaluating their need for further help.
•
Registration is an important component of an online intervention as it allows users to keep track of progress, return to point last visited, and progress systematically through a program.
•
Tailored normative feedback should be automated and immediate and should provide a detailed, easy to comprehend report as relevant as possible to the individual.
•
The content of a treatment program should be tailored as specifically to the individual client as possible.
•
All therapeutic content should be based on empirically-validated therapeutic techniques where possible.
•
Programs should include a range of therapeutic techniques to suit a broad range of clients.
•
Online interventions may include automated contacts with the program, for example daily or weekly emails with tips, reminders of useful tools, progress reports, success stories.
•
In addition to cognitive-behavioural techniques, motivational interviewing components should be incorporated to any online treatment program.
•
Online forums may be an important component of any online intervention as this enables clients to discuss relevant issues with other individuals who can identify with similar difficulties.
•
Sites should include the professional qualification and affiliations for websites and therapists to establish site credibility.
•
Contact information must be provided for clients to contact a site administrator or technical support through email, telephone and physical address.

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•
Research is an essential component of Internet-based treatment and should be a key component of any program implementation.
See Section 3 of the report for a complete bulleted list of recommendations.
It is essential that any Internet therapy or online intervention program be based on empirical evidence where possible and that research be an integral component of any intervention developed and implemented. This is crucial to determine the effectiveness of online interventions, whether components require modification, to gather feedback from clients and ensure that the online program is successful in assisting those experiencing gambling-related problems. Internet-based treatment options are not intended to replace traditional services, but such interventions may be an extremely useful addition for individuals who have accessed existing treatments and for those unwilling or unable to access traditional treatment options. Online interventions may be utilised by those at-risk of gambling-related problems to prevent the development of pathological gambling and have the capacity to reach a large number of individuals to provide brief screening and interventions and more in-depth therapy where necessary. Internet-based treatment may be a highly cost-effective and beneficial treatment for problem gambling.

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Introduction - background and rationale
Addictive behaviours result in economic burden, health costs, and social strain for communities in addition to personal and emotional distress caused to both individuals and families. In the fields of medicine and mental health, addiction refers to a syndrome characterised by impaired control over a behaviour leading to significant harm (West,
2006). Although debate continues as to its precise definition, traditionally addiction is considered a state where there is a dependence on a particular substance for normal functioning. Dependence can be physical, manifested by the development of tolerance and physiological withdrawal effects in the absence of the substance, or psychological, where an individual requires the substance to function and feel comfortable. However, in common usage addiction , often used interchangeably with dependence (West, 2006), has come to refer to a persistent inability to control behaviours that provide short term pleasure despite associated negative consequences. More recently, the concept has been broadened to include a range of non-substance appetitive behaviours such as problem gambling, compulsive Internet use, and excessive computer/video gaming. As the
Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR: American
Psychiatric Association, 2000) is currently under revision, debate centres on the validity of classifying non-substance ‘behavioural addictions’ as a subcategory of dependence as opposed to impulse control disorders.
Untreated addictions have significant personal and social costs, particularly when left untreated. In 2002 the overall social cost of substance abuse in Canada, measured in terms of burden on health care services and law enforcement, and loss of workplace and domestic productivity resulting from premature death and disability, was estimated to be
CAD$39.8 billion (Canadian Centre on Substance Abuse, 2003). Smoking causes cancer and is one of the leading causes of preventable death in the world (WHO Report on the
Global Tobacco Epidemic, 2008). Yet, results of the 2008 Canadian Tobacco Use
Monitoring Survey (CTUMS) revealed that 18% of Canadians aged 15 or more were active smokers, with higher rates (27%) found among Canadians aged 20 to 24 (Canadian
Cancer Society, 2009). According to Farvolden, Cunningham, and Selby (2009), 70% of smokers state that they want to quit, and 35% attempt to quit each year, but less than 5% actually succeed.
Excessive alcohol use/abuse is associated with a variety of physical, mental, and social problems (Klingemann & Gmel, 2001). Despite the myriad of problems associated with alcohol abuse and dependence, only one-third of those experiencing alcohol problems ever seek treatment, suggesting serious accessibility or motivational issues (Cunningham
& Bresin, 2004). Although fewer Canadians die from illicit drug use than from alcohol or tobacco, deaths tend to involve younger people resulting in a significant impact in terms of years of life lost. In 2002, Canada illicit drug use account for an estimated 0.2% of all deaths and 352,121 days of acute care in hospital with associated costs of approximately
CAD$8.2 billion (Canadian Centre on Substance Abuse, 2003).
With respect to gambling, studies indicate 2-5% of adults in Ontario experience problem or pathological gambling with only 6% seeking formal help; 3% of therapeutic modalities being either online or print-based self-help manuals (Suurvali, Hodgins, Toneatto, &

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Cunningham, 2008). In addition to personal experiences related to increased psychological, physical and interpersonal difficulties, annual costs associated with problem and pathological gambling range from CAD$20,000 to $56,000 encompassing loss of employment, judicial and rehabilitation costs (Andresen, 2006).
The Ontario Government recently released its 10-year mental health and addictions strategic plan which aims to integrate people with addictions into communities, and to incorporate addiction services, including substance use and problem gambling, into general health service facilities (Ontario Ministry of Health and Long-term Care, 2009).
One specific aim is to reach previously untreated populations using ongoing proactive innovative programs and methods to “provide high quality, effective, integrated, culturally competent, person-directed services and support for Ontarians with mild to complex mental illnesses and/or addictions” (Ontario Ministry of Health and Long-term
Care, 2009, p.9). The report held the view that individuals must be active partners in their own recovery and that the system should make every effort to provide innovative, evidence-based opportunities to assist in recovery.
Since the first network linking of computers in 1969, the Internet has grown exponentially to represent a fundamental form of everyday social and commercial communication. The reduction in hardware and software computer costs coupled with technological advances that integrate wireless, phone and computer capabilities within the one device, has contributed significantly to the widespread community penetration of computer-based products, particularly among the younger generation. The importance of the Internet is evidenced by the extensive utilisation of interactive websites and email communication by businesses, governments and industry at a global level.
Given its inherent features and capabilities for communication and the dissemination of information, individuals are increasingly turning to the Internet as a medium through which to obtain information and guidance in dealing with their addictions. For example, reports estimate that, annually, over 10 million Americans search the Internet for information and support to quit smoking (Fox, 2005; Madden, 2006). Accordingly, health professionals are increasingly recognizing the educational and therapeutic potential of the Internet; availability and ease of access, capacity to deliver support and encouragement from therapists and/or peers at an interactive level, and the provision of educational material. One additional advantage of the Internet that should not be underestimated relates to its ability to offer mental health services to segments of the population that otherwise would not be able to access facilities; for example, community members residing in rural and remote regions, those with limited physical mobility or transport, and those reluctant to seek face-to-face due to social anxiety or embarrassment.
Internet-based interventions include any treatment option that engages clients through online resources, websites, and web-based methods of communication and can be incorporated into each stage of a stepped care model to fill treatment gaps. Barak, Klein, and Proudfoot (2009) offer a useful definition of Internet or, as these authors describe it, web-based interventions: “ a primarily self-guided intervention program that is executed by means of a prescriptive online program operated through a website and used by

11 consumers seeking health- and mental- health related assistance. The intervention program itself attempts to create positive change and or improve/enhance knowledge, awareness, and understudying via the provision of sound health-related material and use of interactive web-based components.”
As noted by Barak, Klein, and Proudfoot (2009) terminology describing Internet interventions remains imprecise with common terms including web-based therapy, e-
Therapy, cyber-therapy, eHealth, e-Interventions, computer-mediated interventions, and online therapy/counselling. However, the core components of Internet-based therapy involve some level of interaction between client and therapist through the medium of the
Internet. It incorporates the use of structured, web-based treatment programs that may or may not be supplemented by direct therapist involvement (Abbott, Klein, & Ciechomski,
2008). The therapist-client interaction most frequently occurs via time-delayed or asynchronous communication, such as email, but might extends to simultaneous communication (synchronous), such as online chat-based exchanges, instant messaging, and video conferencing (Skype). In some instances, Internet therapy is also complemented by telephone support from therapist with the bulk of client work undertaken online.
A useful framework suggested by Barak, Klein, and Proudfoot (2009) is to categorize
Internet interventions into three broad grouping:
1.
Web-based education interventions: designed to provide consumers with health related information about disorders, e.g., symptoms, course, diagnosis and available treatment.
2.
Self-guided web-based therapeutic interventions: designed to promote cognitive, behavioural and emotional changes by instructing consumers to follow a modularized and structured evidence-based program.
3.
Human-supported web-based therapeutic interventions: As above but incorporating a therapist to provide additional support, guidance and feedback, either on a synchronous or asynchronous basis.
Thus, Internet therapy or online interventions can be seen to facilitate recovery through self-guided options that include various components and emphases on education, tailored normative feedback, interactive web-based exercises and peer-support interactions such as chat rooms or forums that may or may not be additionally moderated by an expert or therapist. The value of these approaches is that they are cost-effective, do not require face-to-face communication with trained therapists, and can provide individual and group services to a wide range of clients.
As the Internet is a medium through clinicians are increasingly utilizing to deliver selfguided and interactive treatment programs, the purpose of the current review is to evaluate the use of, and existing evidence for the effectiveness of, Internet therapy for addictive behaviours in general, and specifically the efficacy and effectiveness of Internet therapy for problem gambling. For purposes of this report the term ‘addiction’ is used in a more inclusive way than that traditionally applied to substance-based addictions
(alcohol, tobacco and illicit substance use) by extending it to include problem and

12 pathological gambling as a behavioural addiction. As Internet treatment services have recently emerged as a treatment options, with relatively few published studies, the rationale for this definition is to increase the available evidence-based studies that can be included in a review.
Despite its potential, treatment providers and regulators have legitimate concerns regarding the overall efficacy of Internet-based interventions for addictions, legal and ethical concerns, cost and feasibility of programs, and the extent to which individuals would actually utilize technology-based services.
In the absence of a comprehensive review of Internet-based therapy or online interventions for addictions, this paper aims to systematically evaluate the current literature on the topic with a particular focus on problem and pathological gambling. For each Internet therapy program or online intervention directed to substance and nonsubstance related behaviours, we will examine evidence supporting its positive outcomes and comparability to established effective face-to-face therapy. The review will also discuss whether each therapeutic modality is unique to the disorder under review or generalisable to other Internet-based addictions.
In section one of this report, aspects related to the structural and ecological features of the
Internet influencing its use will be discussed followed by section two which reviews the empirical evidence base supporting Internet therapy.
Section 1:
Current treatment utilization
Studies have demonstrated the effectiveness of a range of interventions in the management of addictive disorders. To be effective, however, those with addictive disorders must enter and complete therapy. Unfortunately, the data shows that approximately 90% of pathological gamblers do not enter formal treatment (Ladouceur et al., 2001; Petry & Armentano, 1999; Productivity Commission, 1999, 2009), or typically seek help in response to a significant life crisis (Clarke, Abbott, DeSouza, & Bellringer,
2007). This low uptake rate is compounded by the relatively high attrition rate ranging between 17-76% depending on the treatment modality (Westphal, 2006). While some may recover without specialist treatment, and others benefit from brief contact, high attrition rates suggest that existing treatment options are either not attractive to clients or do not fully meet their needs (McLellan, 2006). Given that this population is characterised by low treatment acceptance and high remittance rates, Internet-based therapy and online self-help and peer-support programs represent a potentially ideal medium to increase service uptake and retention.
Avoidance or inability to access treatment may be related to internal factors or external barriers. Internal factors include subjective feelings of pride, shame, social anxiety and problem denial (Clark et al., 2007), and also a lack of understanding of treatment processes and reluctance to obtain professional help due to previous negative experiences
(Clark et al., 2007). The privacy and anonymity offered by Internet interventions act to

13 increase help-seeking amongst those dealing with perceived stigma, shame and guilt.
Clients are more motivated to make inquiries related to seeking Internet-based therapy compared to face-to-face interventions since anonymity is preserved given that there is no direct contact or appointment required in the first instance. This allows individuals to investigate treatment options at various stages of change (Prochaska & DiClemente,
1982; 1992) without experiencing shame or guilt that may be associated with missing assessment sessions or dropping out of therapy.
Individuals may also not access treatment due to external barriers such as difficulties attending sessions caused by geographical distance, absence of local expertise and resources, time commitment, and competing work/domestic demands. The availability and convenience of accessing Internet interventions at leisure from home at any time of day/night eliminates these barriers. The Internet provides an opportunity for individuals to explore and compare available resources at their own pace without the need to interact with others or feel obligated or pressured to enrol in a program.
Importantly, Internet therapy is particularly relevant for youth and Internet gamblers; two groups identified as being at greater risk for developing substance use and gamblingrelated problems (Delfabbro & Thrupp, 2003; Hardoon, Derevensky, & Gupta, 2002;
Kessler, et al., 2005; Monaghan, 2008; Veldhuizen, Urbanoski, & Cairney, 2007; Vega et al., 2002; Williams & Wood, 2007; Wood & Williams, 2009). Youth are generally highly familiar with technology (Monaghan, 2008) and therefore have a greater capacity to respond by seeking help through this format.
In summary, the potential to attract and retain a individuals suffering addictions into treatment who otherwise would be reluctant or unable to so do represents one of the primary benefits of this form of therapeutic endeavour. However, apart from its form of delivery, it is important to examine more closely the format and content of Internet interventions.
Internet interventions
Behavioural and cognitive-behavioural therapies (CBT) have been shown to be effective in the treatment of addictive disorders (Barbor et al., 2003; Finney & Moos, 1998) and problem gambling (Ladouceur et al., 2001; Ladouceur et al., 2003; Oakley-Browne,
Adams, & Mobberley, 2000; Sylvain, Ladouceur, & Boisvert, 1997), with these approaches appearing to be easily transferable into therapist or self-guided Internet-based programs. In addition, the cost-effectiveness of Internet interventions compares favourably with face-to-face interventions (Crone et al., 2004; Klein, Richards, & Austin,
2006; Mihalopoulos et al., 2005; Rabius, Pike, Wiatrek, & McAlister, 2008; Saitz et al.,
2004; Smit, Riper, Kramer, Conijn, & Cuijpers, 2006).
As noted earlier, important factors differentiate the various therapeutic applications available online. Firstly, the method employed is particularly significant; that is, whether it includes communication between a client and a trained therapist (referred to as Internet therapy for purposes of this report), or involves self-help (referred to as online

14 interventions ). An additional category involves peer-support via online communication channels, which shall be referred to as peer-support online interventions .
Internet therapy
Internet therapy commonly includes a mixture of bibliotherapy and email therapy designed to foster a guided self-help approach with minimal therapist contact. The most commonly used therapeutic model is CBT as this psychological treatment has been frequently translated into self-help formats with good empirical support (den Boer,
Wiersma, & Van den Bosch, 2004). It is also increasingly the most widely disseminated form of psychological treatment (Norcross, Karpiak, & Santoro, 2005), including its application in problem gambling (Ladouceur et al., 2001; Petry et al., 2006). There is also a growing body of evidence to support the effectiveness of face-to-face and telephone brief interventions for addictions with results showing that brief interventions are more effective than no counselling (Babor, 1994; Bien, Miller, & Tonigan, 1993; Hodgins,
Currie, & el-Guebaly, 2001; Hodgins, Currie, el-Guebaly, & Peden, 2004; Petry &
Armentano, 1999).
In Internet therapy, clinician input is markedly reduced compared to face-to-face treatment, with feedback delivered, and decision-trees determined, by the computer. For example, automatically generated tailored feedback can be given for completed online exercises and new modules may be opened subject to completion of prior work. In a review of all Swedish trials of online therapy, Andersson et al. (2008) concluded that
Internet therapy saved as much as 50-80% of therapist time. However, time spent by the client is not reduced; in fact Internet therapy may be more time consuming for clients than traditional therapy, as texts are used in homework assignments and clients continuously report progress and obtain feedback if exercises fail. Clinicians generally correspond with clients at set-points (e.g., weekly) via email, chat or other means of online communication to provide feedback, answer questions and assess client progress.
However, one important element to consider is the fact that Internet-intervention can be delivered in “real time” (synchronously) or be delayed (asynchronously). Synchronous communication includes instant messaging (IM), chat, and webcam video conferencing while the more popular asynchronous communication includes email, forums and bulletin boards.
Online interventions
In contrast to Internet therapy, online interventions are used for those who wish to deal with their problem without the involvement of direct (synchronous or asynchronous) therapist assistance. Online interventions include email announcement lists, online peersupport forums, interactive self-help exercises, automated personalised normative feedback, educational information and behavioural tools. The development of automated interventions may help expand access to treatment; because they do not require trained therapists, online interventions can be scaled upwards to serve large numbers of people
(Lieberman & Huang, 2008).

15
Online interventions vary greatly in form. In this section we will examine some common features and discuss evidence supporting their effectiveness. It should be highlighted that some of these features and components are also common to Internet therapy.
Online interventions all feature an introduction or home page providing information on the organisation maintaining the site allowing users to easily navigate sites and finding components they wish to use. Commonly, a set of screening items are displayed on initial access to a site to allow potential users to evaluate their behaviour (e.g., drinking, smoking, drug use or gambling) to see if it may be problematic. In this context, it is important to establish the reliability and validity of such screening measure and to ensure that the automated feedback is easily and accurately comprehendible to the user. At this stage normative feedback may also be provided (explained in further detail below).
Following these initial steps the user is generally prompted to register. Some sites then require users to move through the content in a systematic manner based on a planned program, whilst others allow users to pick and choose which components will be most useful to them. Ideally, the content of an online intervention should evolve over time based on user feedback and evaluation (Cunningham, 2007). This will enable components and tools to be refined and implemented to increase the usability and effectiveness of the intervention.
Registration
While registration is not always required, it has several advantages; registration allows continuity in a participant’s use of the site and enables transition through a set of programmed instructions. For example, a registered user can track which modules have been completed and record data and scores on monitoring forms (e.g., behavioural diaries). Registration may also encourage serious participation on forums and reduce spam. The disadvantage of registration is that raises concerns about privacy and anonymity. Website organizers should take steps to address these concerns for the user, that is, provide clear information on security and privacy policies, levels of threat to confidentiality, and access by third parties. Privacy may be protected by using an email address as opposed to a personal identifier, or registration under an alias. Once a user has registered, on login they can be directed to the last page accessed and enter further information to track their progress. It is helpful for clients to be able to track progress to obtain reinforcement as to their accomplishments, view and work towards goals, and continue to build their motivation for change.
The provision of personal contact details with registration can be considered an important element for Internet therapy where the potential for suicidality in a client exists and the therapist is required to exercise duty of care by informing local mental health crisis teams. Problems accessing appropriate services may arise, however, if the client and therapist are located in regionally or internationally different jurisdictions, and the therapist not knowledgeable with services or service contact details.
Registration may not be required to permit visitors to browse certain web pages of a site.
This would enable potential participants to examine tools offered and view posts on

16 forums to see if interventions offered would be suitable for them. This procedure may increase recruitment while decreasing attrition rates by maximising the likelihood that interest and motivation to participate will be captured and enhanced.
Tailored normative feedback
Research in health care has increasingly shown that personalising information or tailoring messages for individuals can be more effective than presenting generic information in respect to engaging individuals, building self-efficacy and improving health behaviours
(Bandura, 1998; Kreuter, Caburnay, Chen, & Donlin, 2004; Kreuter & Wray, 2003;
Marcus et al., 2005; Smeets, Brug, & de Vries, 2008; Williams-Piehota, Schneider,
Pizarro, Mowad, & Salovey, 2003). The tailored feedback technique is one of the core elements of motivational interviewing (Miller & Rollnick, 1991).This process combines large repositories of varying health messages with individual-level participant data to provide highly individualised health messaging to the individual (Kreuter & Wray, 2003).
Tailoring can be performed on any number of individual characteristics (e.g., age, gender, geographic location, self-efficacy, readiness) and has been shown to outperform traditional, static health information strategies across a wide range of outcomes (Bennett
& Glasglow, 2009). Compared to generic information, tailored information is more likely to be read, remembered and viewed as personally relevant (Brug, Campbell, & van
Assema, 1999; Dijkstra & De Vries, 1999). Moreover, it, commands greater attention, is processed more intensively, contains less redundant information, and is perceived more positively by health consumers (Brug, Oenema, & Campbell, 2003).
Fundamental to tailored feedback material is normative feedback that compares participant’s behaviour to that of others of the same age, sex, and country of origin. It is important to note that personalised feedback must be relevant and as specific as possible; therefore, an accurate normative database must be accessible/available to guarantee that culturally appropriate feedback is given. Normative feedback directs the individual’s attention to their own characteristics or behaviours needing to be addressed, improved, or changed. Studies suggest that incorporating social norms information into feedback interventions helps decrease problematic behaviour, such as alcohol consumption and smoking, given that individuals often underestimate their own and overestimate the consumption of others (Bewich, Trusler, Barkham, Hill, Cahill, & Mulhern, 2008; Etter
& Perneger, 2001). Feedback enhances awareness of the consequences of behaviours and how personal behaviours may be excessive in comparison to others of similar social or demographic backgrounds (Bewich et al., 2008; Etter & Perneger, 2001). As many gamblers also hold the normative fallacy that others gamble as much or more than they do (Larimer & Neighbors, 2003), personalised feedback interventions designed to correct these normative misperceptions are expected to result in reductions in problem gambling behaviours (Cunningham, Hodgins, Toneatto, Rai, & Cordingley, 2009). Although personalised feedback interventions have traditionally been given in person or over the telephone, Internet interventions can easily take information provided by the user and tailor a personalised response.
In addition to tailoring specific feedback and recommendations based on expert assessment of the individual’s needs or characteristics related to the target behaviours,

17 messages should also be personalised. Personalisation refers to the inclusion of specific and personally relevant identifiable information (e.g., names, age, and specific behaviours) gathered during the assessment process. This helps increase the perceived meaningfulness of the message by creating the impression that the message was designed specifically for the individual (Hawkins, Kreuter, Resnicow, Fishbein, & Dijkstra, 2008).
Importantly, online tailored feedback may inform potential clients when they may benefit from more intensive online or face-to-face therapy. It is essential that online programs attempt to ensure that clients are receiving the most appropriate level of care. For example, Hodgins (2005) noted that a large number of volunteers for self-help programs for problem gambling had significant gambling problems: in a proportion, the severity or concurrent comorbid disorders may make them unsuitable for online self-guided interventions. Tailored feedback should be able to refer clients to more intensive treatment options where necessary based on information gathered during assessment.
Internet-based automated personalised feedback can be readily accessed by a large number of individuals in developed countries, provide immediate feedback, are anonymous, and can be delivered cost-effectively over the often extended period clients may require assistance making and sustaining behavioural change. In principle, they are likely to have a role in supporting individuals who need less help than can be provided by a trained therapist, but who can potentially benefit from structured advice. It may be useful to provide personalised feedback for users regardless of whether they register to use a site’s program as this feedback has been found to motivate change in problem drinkers and in problem gamblers, whether they return for treatment or not (Cunningham,
Sdao-Jarvie, Koski-Jannes, & Breslin, 2001; Wood & Williams, 2009).
Tailored content
In addition to normative feedback, tailored interventions can ensure that users receive customised intervention programs to enable them to access the most relevant and appropriate information and tools. Based on a users’ response to questionnaires (which can be administered repeatedly), individuals may be directed to access motivational information to help them decide to change behaviours, or be directed to coping strategies if they have already taken action to modify their behaviour. There is growing evidence for the positive use of tailoring in behavioural health interventions (see Lustria, Cortese,
Noar, & Glueckauf, 2009). Tailored interventions evoke favourable perceptions from individuals and allows very personal and direct content presentation based on elements such as likes/dislikes, needs, and current behaviours (Lustria et al., 2009). Emerging evidence further supports the use of tailored messages in Internet interventions for behavioural change including addictive behaviours such as alcohol and tobacco consumption (Bewich et al., 2008; Swartz, Noell, Schroeder, & Ary, 2006; Tate,
Jackvony, & Wing, 2006). For example, an online smoking intervention provided physically active individuals information about the negative consequences of smoking on sports performance, in contrast to non-physically active individuals who received messages that focused more on general negative physical consequences of smoking (i.e. coughing and dizziness) (Dijkstra, 2005). Tailored content is particularly important for online interventions for problem gamblers due to the considerable differences between

18 types of gamblers including most problematic form of gambling (electronic gaming machines, sports wagering, Internet gambling etc.) and reasons for gambling (e.g., blocking emotions, risk-taking and sensation-seeking, etc.).
Research has found that that tailored web-based programs are more efficacious than nontailored sites (e.g., Etter, 2005; Etter & Pernerger, 2001; Severson, Gordon, Danaher, &
Akers, 2008; Strecher, Shiffman, & West, 2005; Swartz et al., 2006). Personalising interventions may greatly increase the extent to which participants use programs as they do not have to determine themselves as to which tools would be most useful. Participants may be able to choose the frequency by which they are contacted with reminders (e.g., daily or weekly emails that prompt them to stay on track and providing additional support). Programs may also block access to irrelevant information or features to increase the relevance of the program and reduce distractions.
The presentation of online interventions can also tailored specifically to an individual; audiovisual material can be manipulated so that clients are presented with videos and audio files giving information and instructions in whichever gender, age, accent, and language the client prefers. For example, a US-based online smoking cessation site “1-2-
3 Smokefree” consisted of 13 separate versions, included 12 demographically and one multicultural targeted versions (Swartz et al., 2006). The targeted versions were based on user sex, age (over or under 40), and race/ethnicity (white, African American, or
Hispanic) with users assigned to the multicultural version if they did not fit a targeted demographic. Video content was also matched demographically as it was considered important that the models viewed by users appeared to be “people like them”. Compared to a control condition, the intervention demonstrated short-term efficacy in terms of smoking cessation (Swartz et al., 2006).
Although more research is needed on the use of tailoring for Internet interventions, there is some evidence that more tailoring is better than less. In a randomised trial to test a web-based smoking cessation intervention in a sample of 1,866 smokers, Strecher et al.
(2008) tested different combinations of psychosocial and communication components.
Abstinence was related to high-tailored success stories and high personalised message source components. There was also an effect for receiving all three high-depth tailoring factors (success stories, outcome expectations, and efficacy expectations) with smoking abstinence achieved by 40% of participants receiving this intervention component combination. This is consistent with Noar, Benac and Harris’ (2007) meta-analysis of tailored interventions which emphasised that multiple points of contact (e.g., repeated assessment and contact with experts) may be important to foster feedback that is dynamically tailored to participant’s current stage of change, attitudes, needs, and so forth. Similarly Severson et al. (2008) found significantly higher quit rates and user satisfaction for an interactive, tailored tobacco cessation site compared to a traditional linear, static site.
An important area for future research is to investigate precisely what elements are most important to tailor feedback to increase program utilisation and effectiveness. Bandura
(1998) proposes that tailoring is best achieved through the assessment of a combination

19 of determinants (e.g., risk factors, needs, or psychological factors) governing health behaviours. This is consistent with findings from Noar et al.’s (2007) meta-analysis which found that tailoring using a combination of several concepts and criteria was common, and additionally that those interventions including behaviour, demographics and theoretical frameworks were most efficacious. The key is to determine which are the strongest determinants affecting the targeted behaviour. Measuring these key determinants and providing activities within the tailored intervention to support skill development should be an important design consideration that may affect the efficacy of online interventions (Lustria et al., 2009).
Screening and brief interventions
Screening and brief intervention represents a considerable advance in the treatment of addictions. Such screening typically involves opportunistic administration by a physician or nurse of a brief screening questionnaire and, for those who screen positive, provision of 5 to 10 minutes of advice or motivational therapy. Brief interventions have been shown to be effective for problem gambling. For example, CBT-based self-help books coupled with telephone-based therapist support have demonstrated effectiveness in reducing problem gambling (Hodgins et al., 2001; Hodgins et al., 2004). Brief advice has also been shown to produce favourable results in comparison to CBT and motivational enhancement therapy for problem gamblers (Weinstock, Petry, & Ledgerwood, 2009). A review of 36 randomised controlled trials has shown that screening and brief intervention programs typically reduce hazardous drinking for 12 months or longer (Moyer, Finney,
Swearingen, & Vergun, 2002). The US Preventive Services Task Force (2004) recommends its implementation in primary health care, and screening and brief intervention is a central component in the treatment manual of the National Institute on
Alcohol Abuse and Alcoholism (Pettinati et al., 2004).
Despite the apparent success of screening and brief interventions, obstacles to widespread implementation of this practice include the scarcity of practitioner time and reluctance of physicians and patients to discuss addictions in the context of general medical consultations (Kypri, Langley, Saunders, Cashell-Smith, & Herbison, 2008). Internetbased methods may overcome these obstacles and online screening and brief interventions can be developed for use in primary care and placed free of charge on appropriate websites. As described above, personalized feedback is very powerful for producing motivational and behavioural change. An example of a screening and brief intervention for problem gambling would include an appropriate screening questionnaire; for example, the widely-used Problem Gambling Severity Index (PGSI) of the Canadian
Problem Gambling Index (Ferris & Wynne, 2001) with additional questions gathering demographic information for comparative purposes. This can be complemented by the inclusion of questions reflecting the individual’s perception of their gambling behaviour, actual gambling behaviour and readiness for change. Feedback may consist of risk status, a summary of recent gambling behaviour, a comparison with the gambling behaviour of their peers (based on country, gender and age). Corrections to irrational beliefs and tailored motivational enhancement statements may be included as well as direction to appropriate resources, for example, an online intervention or therapy program.

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Behavioural tools
Online interventions frequently contain features that allow registered users to track progress by logging/monitoring behaviours. These diaries allow participants to track the patterns of behaviour and identify times and situations where they have most difficulty controlling consumption (Cunningham, 2007). An interactive diary can provide relevant updates, for example, how many days a participant has not gambled, how much money saved, and what they have done in their free time. This tool can be highly effective in promoting ongoing motivation for change. Episode diaries can collect a range of relevant information; for example day and time of gambling, people they were gambling with, where they were gambling, how much money and how long they gambled for, costs, thoughts, feelings and actions associated with gambling. The diary can include an integrated analysis to produce descriptive summaries of these variables over varying time periods. These can be presented in several ways and multiple episodes can be compared to allow the user to reflect on and analyse behaviour to identify gambling patterns. This may help identify risky situations or times at which they were successfully able to exercise control. Users should be directed to record their behaviour at certain intervals
(e.g., daily or weekly) during a program so progress can be tracked.
Often accompanying this feature is a section in which participants write down their goal.
In the case of problem gambling, for example, participants may choose whether they wish to cease gambling altogether, cease on some forms, or simply moderate or reduce their gambling. It is important that such sections are provided in a manner that best informs and guides individuals in setting goals. Furthermore, flexibility is needed to allow participants to update goals once achieved, or to changes these if found unsuitable
(e.g., attempts at moderation were unsuccessful so abstinence is required). These features may assist individuals ambivalent in their motivation to change. Some sites may encourage individuals to make a public pledge of their goal, for example to friends and family and on online forums (Cunningham, 2007). To further reinforce the effects of behavioural tools, features can be added to remind participants of their behavioural goals.
For example, participants in online smoking cessation programs received two computertailored, personalised counselling letters within a two-month period following an extensive online assessment process (Etter, 2005).
Interactive exercises
Educational information designed to increase motivation and promote cognitive and behavioural change can be presented in an interactive manner to increase it’s relevance to participants and make it more meaningful. For example, a site may contain exercises that allow the participant to evaluate the costs and benefits of changing, and also, to identify ways to deal with urges and temptations to gamble. Multimedia CBT programs that include video, audio, graphics, and checklists have been shown to have better outcomes in comparison to computer programs that predominantly use CBT written text (e.g.,
Bowers, Stuart, MacFarlane, & Gorman, 1993).
Interactive exercises can include quizzes or other self-assessment features that enable users to test their knowledge of the relevant information contained within a module. This may be a useful method for individuals to gauge the success of educational components.

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Furthermore, these assessments may be made required components of the site that block more advanced modules from being accessed prematurely. By setting a program based on a series of linear modules a client may work at their own pace with automatic assessment of when they are ready for the next level of the intervention.
Motivational phases
Internet-based programs are able to offer distinct segments of treatment to clients concordant with their level of motivation and readiness to change. These segments may be chosen automatically based on responses to readiness to change screening questionnaires or chosen selectively by clients depending on which aspect of the program’s material they wish to use.
In developing an online problem drinking intervention, “Down Your Drink”, Linke,
McCambridge, Khadjesari, Wallace, and Murray (2008) included three levels with different types of material and associated exercises and tasks based on Prochaska and
DiClemente’s (1982, 1992) stages of change theory. Phase 1 (It’s Up to You) was designed to help users reach decisions about whether and how to change their drinking.
This phase invites users to consider whether the program is right for them, introduces an online drinking record, simple educational material and exercises about costs and benefits of drinking. Participants then assess their current behaviour and its effects including normative feedback. Focus is directed to the dilemmas faced when making a decision to alter drinking behaviour and possible barriers to change, this includes setting goals.
Finally users are encouraged to take an overview of their situation and guides users in setting out a detailed plan for change.
Phase 2 of Linke et al. (2008) program, “Making the Change”, begins with a plan for support through the first few days of planned change including a behavioural analysis to identify risk factors. Educational material on coping strategies is provided including exercises for the user to identify their own sources of support. Users are directed to identify and develop skills and capacities to enable them to adhere to plans and achieve set goals. A key tool is a drinking episode diary that assists individuals in monitoring and analysing behaviours. Additional CBT strategies and educational exercises are included as in standard treatment formats (e.g., self-efficacy, stimulus-control strategies, and cognitive approaches).
Phase 3, “Keeping on Track”, is designed for those who have attempted to change behaviours and want support in maintaining change and avoiding relapse. Concepts introduced in this phase include dependence, cravings, and lapses. Users can rate their level of control and reflect on progress. Topics include a focus on the wider situation including high risk situations, assertiveness, sleep problems, relationships and other life issues.
Such programs provide a good illustration of how therapists could assess levels of change and offer interventions that are appropriately matched.
Online support groups and forums

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Online support groups began in the 1990s and have become a mass social phenomenon whereby individuals, separated by geographical, cultural, racial, and age barriers can support one another by uniting over a shared issue or difficulty. Online support groups operate through various Internet applications, including email lists and chat rooms with forums emerging as the most popular format. Asynchronous online forums allow participants to send messages when convenient and provide easy access, opportunity for archival search, use of emoticons and links, and friendly design (Meier, 2005).
Users of online forums take advantage of the group as a durable and accountable resource through which they may transmit and obtain information, provide and receive emotional support, socialise and form interpersonal relationships, and experience comradeship with others sharing similar types of distress, thereby helping to reduce perceived isolation and sense of uniqueness (Bane, Haymaker, & Zinchuk, 2005). Importantly, a support group is not the same as a therapy group as there are no treatment protocols or structures designed to provide therapeutic change: discussions are led by the group, not a therapist and simply aim to provide relief and improved feelings; there are no time limits; and members can enter and leave as they wish and choose their level of participation. Online support groups are not intended to substitute for psychological treatment or therapy; however, they may be useful in augmenting therapy or in assisting those not ready for therapy, need minimal support, or those recovered to prevent relapse.
Barak, Boniel-Nissim, and Suler (2008) argue that online support groups contribute to a participants’ sense of personal empowerment and well-being, and as such, may be positive supplements to professional treatment. These authors argue this is produced in part by online disinhibition effects (Suler, 2004a; Suler, 2004b) which increases honesty and self-disclosure fostering interpersonal intimacy and group bonding. Disinhibition is increased through the anonymity provided by masked online identities which serves to increase group cohesion and trust through knowledge that what happens in the group stays in the group (Christopherson, 2007). The reduction of status symbols, ability to remain ‘invisible’ and delayed reaction to messages posted adds to this phenomenon.
Barak et al. (2008) also contend that personal empowerment may emerge from “the act of writing itself, which enables emotional outlet and a sense of cognitive order; from emotions relief and catharsis; from receiving and providing necessary informational from interpersonal interactions and the formation of relationships, thereby reducing isolation; and finally from acquiring self-confidence and reassurance, which allowed better decision-making and behavioural transformation.” (Barak et al., 2008, p.1872).
A proportion of support groups discuss coping strategies; receiving information and guidance from individuals who have endured similar difficulties is more significant and easily accepted than receiving similar information from professionals. By sharing coping strategies, group members can increase confidence in their ability to feel better and use experiences to help others. Participation in an online support group may also reduce feelings of loneliness and social isolation, a feature particularly relevant to individuals who may experience stigma associated with certain disorders and consequently reluctant to seek help. The advantage of the Internet in bringing together individuals with similar difficulties is that it provides a communal, safe and non-judgmental location for

23 individuals who may use this experience to increase empowerment that may lead to seeking formal treatment without feelings of shame and guilt.
Importantly, given the large number of available online support groups, well-organised groups should be conducted by accredited and publically recognised organisations with sensible and non-ideological positions to provide maximum assistance to participants. A trained therapist should monitor online forums and answer questions where necessary to ensure that information/advice offered is valid (evidence driven) and accurate (free from bias or ideology) and that participation is positive and helpful for members. This would act to prevent group members unintentionally promoting misinformation or maladaptive beliefs; an aspect of particular importance for some groups, for example problem gamblers characterised by high levels of irrational beliefs. However, online peer-support groups may also take steps to “self-correct” posted content; for example, if one member posts erroneous information, several others can post corrections. This form of peer-based learning and communicating might again be more powerful than being corrected by an
“expert”.
Evidence from online interventions suggests that participation in social support forums is significantly associated with treatment success for smoking cessation sites (Cobb,
Graham, Bock, Papandonatos, & Abrams, 2005; Severson et al., 2008). However, research also indicates that these forums are under utilised by participants; for example online tobacco cessation studies have found that between 12% and 38% of participants make posts on peer-support forums (Severson et al, 2008; Stoddard, Augustson, &
Moser, 2008). Such low levels of utilisation reduce the possible effectiveness of online forums since posts should ideally be answered within a few hours to enable meaningful exchanges and encourage further posting. Online support groups may be more effective amongst those who have made behavioural changes (e.g., quit gambling, smoking or drinking) than those attempting to quit, and hence should be included in later stages of online interventions for clients working on maintenance and relapse prevention. Further research is needed to investigate ways in which to increase the utilisation of support groups and determine how to maximise the effectiveness of this online tool.
Contact schedules
To enhance effective communication, users should link website to email addresses with possible downloads to PDAs or mobile phone platforms for greater portability. Different levels of contact are possible and these should be tailored to the individual client to provide appropriate timing and content of information. Examples of possible additional contacts include newsletters with feature articles about addiction, success stories and seasonally relevant tips (e.g., how to cope during the holidays). Users may wish to receive daily reminders, tips, or enter specific dates (e.g., pay days, anniversaries) that they may need additional support. Program daily updates can be sent to users, or users can be directed to particular exercises. Clients who have completed the program may wish to receive reminder or booster emails that direct them back to particular components of the online treatment intervention. Users should be able to modify these contact points at any stage in their program.

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In addition to automatic downloads and reminders, clients must also be provided with ways in which to contact appropriate professionals associated with the site. Importantly, an online intervention must provide the physical location where the server is based and at minimum, a telephone number and email address for the administrator. These details are important to ensure the credibility and legitimacy of the site; client contact inquiries should be answered as soon as possible. Clients may need to contact an administrator to seek assistance in running programs and for technical support. Additionally, a client may request further assistance and accordingly should be offered the opportunity to be directed to local or alternative treatment options. Links to other resources and telephone helpline numbers are useful, but not sufficient; clients must be able to contact a point person who is affiliated with the online intervention.
Aside from administrative and technical support, online interventions may also provide clients with a forum to contact a trained therapist or expert. This is not expected to provide the same level of therapist care as Internet therapy, but clients may have brief questions or benefit from minor therapist feedback. For example, therapists may participate in chats at a designated time period, participate in online forums or respond to email questions.
Social networking and Web 2.0 applications
The Internet is increasingly used as a medium for social connection between friends.
Social networking sites allow individuals to find connections with individuals with whom they have lost contact, do not often see, or who share mutual friends or interests. Initially popular with youth, social networking sites such as My Space and Facebook are increasingly used by a wider range of people, with recent extension directed toward professionals (LinkedIn), brief updates (Twitter), music, video (YouTube), photo (Flickr) and file sharing sites and virtual communities (Second Life). Currently social networking sites are not heavily used for psychotherapeutic interventions; however, interest groups and organisations are increasingly using these sites to reach new audiences.
The term Web 2.0
refers to the second generation of web development and designs that facilitates information sharing, interoperability, user-centered design and collaboration on the World Wide Web. The advent of Web 2.0 has led to the development and evolution of web-based communities, hosted services, and web applications. The importance of online interventions involving Web 2.0 approaches is highlighted by the speed at which commercial business are adopting this practice. The efficacy of the Web 2.0 approach in attracting, retaining and engaging end users has been well demonstrated by virtually all major media, social networking and e-commerce sites incorporating these features.
Many virtual therapy clinics already exist in cyberspace reflecting society’s changing attitude to therapy in the face of the new emergent technologies. Of concern, the proliferation of clinics has occurred in the absence of regulatory, ethical and procedural guidelines leaving prospective clients exposed to potentially ineffective and unethical practices. While online interventions need to develop strategies to increase recruitment and prevent attrition, use of Web 2.0 principles is advisable to maximize the potential for interventions to remain current and provide the best available services.

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There is very little empirical evidence on the use of social networking for therapeutic purposes. Eysenbach et al.’s 2004 review of “virtual communities” and electronic support groups found little evidence that participation in peer-to-peer social networking communities was associated with change in health outcomes. Social networking may be more useful for some interventions than others, particularly those such as smoking cessation, physical activity promotion and weight loss, where peer support has been established as effective. For example, a smoking cessation intervention could allow participants to post their cigarette use in real time and share them with friends and family members to review, so that encouragement can be provided. Similarly, individuals dealing with cravings could get immediate feedback from friends and family as well as other recovering and recovered individuals to assist them in maintaining abstinence.
In addition to providing an intervention via a social networking, these sites may be used to market online interventions by engaging a wide variety of individuals in their own online communities. The advent of Web 2.0 presents a variety of important developments that should be considered as a means to reach and engage potential participants and modify programs based on user feedback.
3-D virtual worlds
One application of Web 2.0 is represented by three-dimensional (3-D) virtual worlds
(e.g., Second Life), which are computer-based simulated environments characterised by the simultaneous presence of multiple users who inhabit and interact via avatars within the same simulated space. These virtual worlds appear similar to real worlds and have increased dramatically in popularity with over 15 million accounts registered in 2008.
Several medical and health education projects have been launched on Second Life including the Nutrition Game that simulates choices a user can make in various restaurants and informs the player about the health impacts of those choices. Other examples include The HealthInfo Island funded by the US National Library of Medicine to provide consumer health information services, and the Second Life Virtual
Hallucinations Lab (Yellowlees & Cook, 2006) that aims to educate people about schizophrenic hallucinations.
The provision of interventions for real-world conditions using of 3-D virtual is based on several components; the use of advanced simulations to transform health guidelines and information into experiences that are more meaningful, and the use of hybrid virtual social interaction aimed at extending the sense of community and social support (Gorini,
Gaggioli, Vigna, & Riva, 2008). Although virtual worlds may represent a potential method of delivery for online interventions there is currently little evidence to support the effectiveness of this and few existing examples for the treatment of mental health and addictive disorders.
Implementation issues for Internet therapy and online interventions
Internet accessibility

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Recent estimates indicate that 84.3% of Canadians have Internet access. In 2003, Canada ranked fourth worldwide in terms of the proportion of households with broadband access
(Internet World Stats, 2008).
Although Internet access is increasing amongst the general population, the extent to which target populations can access the Internet will determine demand for Internet therapy. One Canadian study found that 45% of Internet users resided in rural areas
(Brethour, 2001) demonstrating that those who may not be able to easily access face-toface services are likely to benefit from online therapy. Addictions are often associated with factors that may reduce access to the Internet such as unemployment, low socioeconomic status, and current psychiatric disorders. An analysis employing general
Ontario population data collected in 2002 and 2004 found some disparities in Internet access based on substance abuse status (Cunningham, Selby, Kypri, & Humphreys,
2006). Of drinkers, smokers, cocaine, and cannabis users, only smoking was clearly associated with limited Internet access. Among problem drinkers, Internet access was surprisingly high with 88% of Ontario adult problem drinkers reporting access to the
Internet in 2005, and 81% having access from their homes. Given that problem gambling is often comorbid with substance abuse and alcohol use, these results may imply that problem gamblers also have regular access to the Internet, although given the financial difficulties often associated with problem gambling this requires further research.
Nevertheless, it is important to recognise that Internet therapy and online interventions may not be suitable for all individuals with addictions. Individuals who do not have access to the Internet on a regular basis may also have more severe problems and more comorbid difficulties requiring face-to-face treatment. Given the nature of gambling, severe pathological gamblers may not have sufficient funds to maintain Internet ISP subscriptions. If so, it may mean that it is those with less severe difficulties who access and benefit from online interventions and Internet therapy. Consequently, it may be necessary to provide suitable clients with the technology and connections necessary for
Internet therapy or interventions for a temporary period of time to enable them to complete the program. This has been done for some online addiction interventions but remains a resource issue for therapists.
Acceptability
Despite the significant problems associated with problem gambling and other addictions, individuals appear to be markedly reluctant to seek treatment for these disorders. Barriers to help seeking include a desire to quit unaided, fear of stigma, perception of traditional treatments as unhelpful and a lack of motivation to attend all sessions or inability due to geographical, mobility or transport difficulties, or other commitments (e.g., work, childcare). Emerging research demonstrates the growing support for online therapeutic support. Internet-based therapy and online interventions may be preferable to traditional forms of support due to the advantages of privacy, anonymity, accessibility and convenience. For example, of 1,257 current drinkers in a telephone survey of Ontario residents, 16% reported interest in receiving ‘a telephone call from a therapist to help them evaluate their drinking’, 26% in receiving a self-help book, and 39% in ‘a

27 computerized summary comparing their drinking to that of other Canadians’ (Koski-
Jannes & Cunningham, 2001, p.91).
Youth have additional barriers to help-seeking, particularly for mental health issues
(Owens et al., 2002). These include both structural barriers such as time, costs, and travel, and personal barriers such as being overwhelmed by unfamiliar problems, lack of confidence in seeking help, or not recognizing the extent of their problem. There is also evidence that adolescents often prefer to seek help from informal sources, such as family and friends, rather than formal support such as school counsellors and mental health professionals (King et al., 2006). Focus group studies conducted at a New Zealand university, suggested that student hazardous drinkers would be unwilling to discuss their drinking with a doctor, nurse, counsellor or psychologist, unless the discussion was selfinitiated (Kypri, 2002). Students were interested in receiving personalised assessment of their drinking, but were highly sensitive to being judged by health professionals. Given the failure of traditional treatment programs to recruit clients in need of help, application of Internet based interventions for adolescents and young adults may overcome accessibility barriers to treatment.
In an online survey of a random sample of 1,564 university students, Kypri et al. (2003) found significantly greater support (82%) among hazardous drinkers for online interventions than for health education seminars (40%) or practitioner-delivered interventions (58%). Results demonstrated a significant unwillingness to seek professional help and perceived stigma associated with this amongst university students.
Similar positive results were found in an evaluation of an online smoking cessation program for young adults (Escoffrey, McCormick, & Bateman, 2004) and Internet-based counselling services for general mental health amongst college students (Lintveldt,
Sorensen, Ostvik, Verplanken, & Wang, 2008; Skarsvag, 2004), indicating Internet-based therapy programs reach a wider population who would otherwise not seek traditional services.
Analysis of daily use patterns for an online problem drinking intervention found that 61% of the hits occurred between 9.00am and 6.00pm with about 39% occurring between
6.00pm and 9.00pm (Linke et al., 2007). This supports the notion that users access sites at their convenience including a substantial proportion accessing sites outside of traditional working hours.
Promotion and advertising of services
Health agencies are motivated to promote effective treatment program that can demonstrate a reduction in treatment cost and reduce long-term serious health effects through higher acceptance rates. For example, among International Business Machine
(IBM) employees (n=131,592) during the annual health benefits enrolment period 8,688 smokers were identified. Of these, 6,235 participated in the online smoking-cessation initiative, and 1,713 (28.5% of smokers) ultimately chose to utilise the QuitNet Internet interventions (Graham, Cobb, Raymond, Sill, & Young, 2007). In another example, the
Project Quit intervention sent letters to current smokers in two large health systems (more than 750,000 total) resulting in 7% (n=2,260) of patients visiting intervention sites, and

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4% (n=1,273) being eligible and enrolling in a tailored Internet smoking-cessation intervention (McClure et al., 2006). The authors concluded that smokers were interested in receiving online smoking cessation support, even though they had access to other forms of treatment through their health insurance, and that proactive mailings were an effective method for recruiting smokers compared to advertising the program in quarterly newsletters. Similarly, Strecher et al. (2008) recruited study participants through two health maintenance organisations (HMOs) allowing them to reach potential participants, regardless of their stage of readiness. An Editorial from the office of the American
Journal of Preventative Medicine argued that this recruitment method has external validity because it reflects how the intervention would likely be disseminated in a healthcare organisation (Norman, 2008).
In an investigation of the effects of incentives and recruitment for online health program
(encouraging increased vegetable consumption), 12,289 subjects were mailed a letter of invitation containing various incentives (Alexander et al., 2008). A small prepaid incentive (US$5) proved effective, reaching rates equal or higher than general massmailing recruitment. Declaring a ‘retention incentive’ (US$10-20) amount in the recruitment letter led to a greater retention rate (defined as those who completed a mailed follow-up survey 3 months after enrolment). The per-subject recruitment and retention costs ($30 and $65 respectively) were relatively cost effective, considering expenses saved by eliminating telephone contact and the costs of follow-up, data entry, and survey mailing. Those who enrolled were more likely to be older, women, white or other ethnicity (as opposed to African-American), married or cohabitating with a partner, better educated, have a higher household income, be “very comfortable” with Internet use and have relatively good personal health.
An evaluation of participant recruitment strategies for an online smokeless tobacco cessation program (ChewFree.com) compared the effectiveness of thematic promotional
“releases” to print and broadcast media, Google advertisements, placement of a link on other websites, limited purchase of paid advertising, direct mailings to smokeless tobacco users and targeted mailings to health care and tobacco control professionals (Gordon,
Akers, Severson, Danager, & Boles, 2006). Results indicated that the combined recruitment activities resulted in more than 23,500 unique hits on the website over 15 months yielding 2,523 eligible users who completed the registration process and enrolled in the study. Self-reports revealed that at least 1,276 (50.6%) of participants were recruited through media coverage (including newspaper articles, radio interviews and television stories), 874 (34.6%) from Google ads or via search engines or links on another website, and 373 (14.8%) from all other methods combined. Paid advertising (newspaper ads) and direct mailings (3,000 from purchased lists and 1,120 participants from a previous study) were relatively unsuccessful resulting in only 0.3% and 1.6% of total participants respectively. Mailings and presentations to health care professionals and tobacco control activists also appeared to be relatively unsuccessful with only 5% of participants reporting they had heard about the intervention through health care professionals or employers (Gordon et al., 2006).

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Individuals recruited through the media as opposed to the Internet were older and had used tobacco for longer, were less likely to have a college education, less likely to have made a quit attempt in the last year, and had lower perceived readiness to quit. This indicated that the Internet may be an important medium for recruiting motivated individuals who are more likely to succeed in their quit attempts. Online marketing also appeared to have a long-term impact as even without active promotions on Google, the
ChewFree website was still accessed by interested smokefree tobacco users at a rate approximately one-third of that found during the active recruitment period. The study suggests that multiple methods of recruitment need to be employed to reach target populations. For example, less media coverage of the site was found in tobaccoproducing states resulting in less publicity and fewer participants recruited from media coverage.
Results from Gordon et al. (2006) suggest that purely online methods of recruitment are not sufficient to recruit sufficient participants. Similarly, a 6-month analysis of registrants
(n=1,319) of an online drinking intervention (Down Your Drink) found that 34.5% found the site directly thought a search engine, 18.2% were directed from another website and
26% learned about the site from a newspaper or magazine; none reported seeing the leaflets sent to general practitioners (GPs) (Linke, Brown, & Wallace, 2004). Etter (2005) reported that approximately 2% of 50,00 monthly visitors to the French language Stop-
Tabac site actually utilised the site’s smoking-cessation interventions aptly demonstrating the vast number of visitors to a site required to acquire registered participants. However,
Cobb et al. (2005) reported that as of 2004, 2,400 individuals browsed the free version of the QuitNet intervention daily, with over 240,000 individuals referred annually via
Google searches. These mixed results indicate that online recruitment strategies play an important role, but these may be insufficient in targeting all those who may benefit from online interventions.
One advantage of online interventions is that potential users can be reached relatively easily by mass emails containing hyperlinks that take users to registration websites. This dramatically reduces the effort needed by potential clients as they are already online and can easily investigate the intervention. Online programs should have a clear and useful homepage containing all the necessary program information for potential clients including screening and brief interventions.
The evidence currently suggests that even though utilisation rates for online interventions are low at present, there is huge potential for continued growth. Furthermore, there is some evidence that while recruitment rates for online interventions may be low, Internet treatment recruitment rates may be greater than for face-to-face therapy. In one study supplemental online services were provided to outpatients at a substance abuse centre in
Cleveland and although 87% of clients participated regularly in online services only 30% of the same clients showed up for their first outpatient appointment (Alemi, Haack et al.,
1996).
Attrition

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Despite the potential advantages of Internet interventions in terms of increased accessibility and treatment uptake, relatively high attrition rates are expected and have been found amongst Internet interventions. Addiction treatment programs are often characterised by high attrition rates; for example, even after individuals undergo an initial assessment or take some other initial step toward treatment entry for alcohol or substance abuse, the likelihood that they will actually enter treatment or attend even one therapy session is often less than 50% (Donovan, Rosengren, Downey, Cox, & Sloan, 2001;
Doumas, Blasey, & Thacker, 2005). As online interventions may have significantly lower barriers to entry than traditional face-to-face therapy programs, attrition rates may be higher due to the larger volume of individuals attempting to access treatment. Although further research is required to determine factors to increase retention, as mentioned above, intrinsic feature of Internet interventions including convenience and accessibility may enhance retention rates in comparison to face-to-face therapy.
One possible reason for attrition in Internet interventions may be similar to that for traditional therapy, that is, individuals may simply lose interest and motivation irrespective of the type or modality of treatment received. Therefore, the fact that most online interventions have a low barrier to entry, low intensity and not highly structured may result in individual variations in the degree of web site utilisation. Although interventions may be marketed as easy to integrate into exiting lifestyles and represent an anonymous and private way to seek help, if site content is not continually salient, participant interest may wane. High-drop out rates have been seen in many studies of
Internet-based intervention (Wangberg, Bergmo, & Johnsen, 2008). A pilot study of
Down Your Drink, a 6-week online intervention for excessive drinkers found that of
1,319 registrations during a 6-month study, 61.8% completed week 1, and only 6.0% stayed with the program until the end (Linke et al., 2004). The completion rates of the program declined weekly with 32.3% completing week 2, 20% week 3, 13.6% week, 4 and 10.2% completing week 5. However, a further analysis of the first 10,000 site users over a 27 month period commencing from the launch date in September 2003, found
16.5% completed the whole six weeks (Linke, Murray, Butler, & Wallace, 2007). This may suggest that the program increased in effectiveness over time based on participant use or feedback, that internet therapy increased in acceptability or that participants required more than one attempt before completing the intervention. Since a dose-response relationship for the use of Internet interventions has been found (An et al., 2006; Cobb et al., 2005; Eysenbach, 2002; Graham et al., 2007; Japuntich et al., 2006; Steele,
Mummerey, & Dwyer, 2007), efforts should be directed toward increasing maintaining interest and compliance to increase the efficacy of such interventions.
Given the low barrier for online registration, many participants may register without considering implications and with no real intent of treatment follow through. Analysis of participation in an online problem drinking program found that the largest program attritions were found between weeks one and two indicating that many of these individuals were simply curious about the program but did not intend to or were not ready to change their behaviours (Linke et al., 2004; Linke et al., 2007). These results highlight the need for motivational enhancement strategies to be given immediately following the commencement of online treatment.

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Data based on drop-outs rates at subsequent points in the course of treatment suggested reasons were varied with clients dropping out because changing drinking habits was too difficult with others stating that the program was time-consuming and too challenging
(Linke et al., 2004). A comparison of treatment completers with those who completed only the first week found that completers were less at risk of alcohol dependency and harm from alcohol use at the time of entry compared to those who subsequently dropped out, although they were still at considerable risk of harm (Linke et al., 2007). In contrast, it is also possible that participants may disengage from a program after successful behavioural change. In one trial of a web-based smoking cessation program (Strecher et al., 2005) the number of cessation program pages opened was not a good predictor of 12week cessation. However, a later trial of the same intervention found an average 18% increase in likelihood of quitting smoking for every web section opened (Strecher et al.,
2008).
In an empirical investigation of attrition for an online smoking cessation program,
Strecher et al. (2008) found that participants who were younger, male, or had less formal education were more likely to disengage from programs, particularly when sections were delivered sequentially over time. The authors opined that programming that was more specific to the needs of these subgroups may reduce attrition. Analysis also showed that highly tailored messages related to self-efficacy and coping strategies for cessation may have promoted greater interim success or confidence, resulting in better program engagement. More personalised and highly tailored messages were perceived as personally relevant, which in term influenced longitudinal program engagement.
Although attrition rates for online interventions appear to be lower than would be desirable, there are still benefits for participants who do not complete the intervention as directed. Namely, they may decide they are not ready for the intervention, but have a relatively positive experience and be willing to return when they are at a more appropriate stage of change. In contrast to face-to-face therapy, the anonymous nature of online interventions means that there is no shame or guilt in failing to complete a course of treatment that may prevent an individual from attempting multiple times to seek treatment. There is evidence that, in contrast to face-to-face interventions, individuals who fail to complete follow-up assessments for Internet interventions may still derive as much intervention benefit as those who do not (Couper, 2005). Furthermore, the nature of online interventions without therapist support mean that costs are unaffected by the number of users so high drop-out rates do not increase the cost of providing treatment for those who do complete online programs.
Several methods have been trialled in an attempt to increase online treatment adherence:
•
Responsive and prompt provision of therapist assistance – Trials of Internet therapy programs for anxiety have found attrition rates are lowest when clients are able to access support relatively quickly and easily (Richards, Klein, & Carlbring,
2003).
•
Telephone calls – In a Swedish trial of guided online self-help for panic disorder, the addition of weekly telephone calls from a therapist improved adherence to the

32 treatment protocol and resulted in treatment outcomes equivalent to live treatment
(Carlbring, Bohman, et al., 2006).
•
Focus on broader life – Providing a broader focus on life is consistent with audience/customer focus strategies that appear to increase web site loyalty and return visits (Gehrke & Turban, 1999). An online smoking cessation site for college students increased sustained intervention by transforming the program into an online college life magazine (An et al., 2006).
•
Inclusion of motivation enhancement exercise – Some successful Internet treatments, such as a Swedish online problem gambling therapy program
(Carlbring & Smit, 2008), include motivational enhancement exercises that are specifically targeted to a client’s stage of readiness for change. This may be an important component of online interventions to encourage potential clients to complete the program.
•
Involvement of peers – Involvement of peers and peer leaders in health education interventions has been used in many different settings to increase engagement with and perceived relevance of intervention messages (An et al., 2006; Mellanby,
Rees, & Tripp, 2000; Williams & Perry, 1998). This may involve encouraging clients to discuss their treatment and goals with friends and family, or participation in online peer- and expert-support forums.
•
Using a linear structure (i.e., setting a task order as opposed to allowing clients to choose the order they complete exercises/tools) to simplify completion of weekly tasks (An et al., 2006; Tillman, 2003). This may be particularly useful for clients who have low involvement in an online program, such as first time users who are not trying to change their behaviour, (Lederer, Maupin, Sena, & Shuang, 1998).
•
Reduce time requirements – although Internet therapy programs may be run on a time line (e.g., one module completed each week), reducing time requirements for some participants may increase treatment completion rates. For example, in a
Swedish online problem gambling treatment program, after the designated eightweek time frame all modules were opened for clients to access for a period of six months (Carlbring & Smit, 2008). This resulted in treatment completion rates increasing from 50% at the end of eight weeks to 68% at six months.
•
Focus on educational rather than behavioural change – One reason a large proportion of individuals dealing with addictions do not seek treatment is that they do not perceive a need for such an intervention. An online alcohol intervention recruited non-treatment seekers by presenting itself as a nonthreatening evaluation and information site (Lieberman & Huang, 2008). Problem drinkers engaged with the interactive site and expressed concern about the harm of alcohol use indicating significant ambivalence and thus the potential role for
Internet applications designed to increase motivation for change.
•
Use of rewards – Small financial incentives or prizes or non-financial rewards such as entertainment, vouchers or public recognition might influence participation (An et al., 2006).
Usability
Retaining clients is notoriously difficult for Internet sites as the Internet culture supports clicking rapidly though sites without looking closely at the material contained within

33
(Linke et al., 2004). The majority of health information seekers begin searches without a clear plan (Fox & Rainie, 2002) and have low frustration tolerance for difficulties encountered on sites (Kalin, 1999), as alternative sites can be easily accessed. Thus, the effectiveness of online interventions are impacted by the quality of sites and in many cases this translates into issues related to the usability rather than the site’s content quality (Bock et al., 2004; Stoddard, Augustson, & Mabry, 2006). Usability refers to the quality of a user’s experience with a site, for example, the ease with which a user is able to learn about and use an intervention and its effectiveness in helping them achieve their goal of behavioural change as well as overall satisfaction with an online intervention
(Stoddard et al., 2006). Websites with low usability lose a substantial proportion of visiting users (Kalin, 1999) reducing program effectiveness.
Stoddard and colleagues argue that all online interventions should be evaluated for usability in terms of successful treatment completions and subjective user satisfaction.
Usability may be reduced when tasks take too long, either due to technical difficulties such as poor download speed, broken links or poorly designed navigation. Site layout should also be carefully considered to increase usability. A benefit of online interactions with clients is that feedback can be elicited and sites can be updated based on feedback.
For example, based on client feedback, an online smoking cessation site changed labels and information location, moved key information to more prominent locations, added information that users reported wanting and significantly changed the layout of the home page to match typical visual search patterns (Stoddard et al., 2006). Changes made nearly doubled the success rate of users as well as improving customer satisfaction.
Utilisation
Website utilisation is one of the more consistent predictors of positive outcomes.
Research in which diverse interactive sites for smoking cessation were compared found that the sites that obtained the highest number of visits produced the highest rates of smoking cessation at 4 months following registration (Pike, Rabius, McAlister, & Geiger,
2007). However, website utilisation tends to drop exponentially after the initial weeks of intervention participation (Hurling et al., 2007). More research is needed to determine what factors are associated with sustained program utilisation. The use of reminders
(postcards, emails, telephone calls) has had some success in improving outcomes (Clarke et al., 2005; Ritterband et al., 2005) while additional strategies may include the use of incentive programs (e.g., raffles, point systems, and giveaways), self-monitoring systems, managing participant expectations prior to trial enrolment, increasing accessibility and ease of use of site and providing personal contact and positive feedback (Eysenbach,
2005; Munoz et al., 2006).
A consistent finding in the evaluation of online addiction interventions is the positive association between website utilisation and success in quitting (An, Schillo et al., 2008;
Saul et al., 2007; Pike et al., 2007). In an online smoking cessation self-guided intervention, the use of tailored emails and website content increased adherence up to five months into the program compared to a non-tailored program (Wangberg et al., 2008).
Similarly, compared with a linear, static site, an interactive, tailored tobacco cessation site was utilised significantly more, with participants visiting more often and staying on

34 the site for longer (Severson et al., 2008). Another method of increasing adherence involves the use of mobile text messages (SMS) to prompt users to visit intervention sites; users can be reached regardless of time and location and without requirements for login.
In an Australian study, use of an online smoking cessation program, QuitCoach, increased in response to greater volumes of anti-smoking advertisements on television
(Balmford, Borland, Li, & Ferretter, 2009). Usage was also highest earlier in the week
(Monday and Tuesday), and decreased to a third of that level by Saturday. This may suggest that content should be updated early in the week and during high volume periods.
Use of therapist contact, as in Internet therapy, may increase program utilisation and completion; however, this needs to be balanced against the risk of reducing enrolment rates and costs.
Service Delivery Considerations
There are several issues relevant to discuss when outlining an online treatment approach.
Therapist requirements
Although many aspects of online interventions may be handled by a layperson, such as encouragement and emotional support via email, other components require proper specialist training and expertise. For Internet therapy it is essential that appropriately trained and accredited therapists are involved to maintain standards and effectiveness of therapeutic interventions. Furthermore, in addition to having the clinical skills and expertise to deliver the therapeutic program, therapists must be able to communicate well via email and be trained to pick up nuances in client’s writing (including style, timing, words chosen, etc.).
Client requirements
Certain requirements are necessary for clients to successfully participate in online interventions. Firstly, language skills are essential as much of the information is presented in text form. Sound files may be used, but most interventions require clients to be able to read, follow instructions, and communicate via text. Clients should also be able to handle the basics of computers and typing.
It is also essential that clients have accessed to appropriate computers with Internet connections. The use of out-of-date equipment may cause problems with slowed response and download times. For example, King et al. (2009) found, in their trial of Internet therapy for substance abusers where eligibility for participation was based on selfreported access to computers with Internet connections, that over time it became apparent most participants with computer problems had obsolete equipment with insufficient memory. This was subsequently detected and addressed prior to commencement of treatment resulting in this becoming less of an issue. This highlights the importance of identifying the presence of appropriate equipment prior to therapy. In the same study
(King et al., 2009) it was found that most participants had very little computer knowledge or experience at the outset. Thus for some, initial program downloads and technical

35 assistance needed to access the website became time consuming or participants had to engage family, friends or program support staff to assist them. Despite these initial difficulties, therapists reported that the technology was easy to learn and use without hindering the flow of therapy indicating that lack of technological understanding is not a substantive barrier to participation in Internet therapy programs.
For those without computer and Internet access, computers may be provided at low cost based on donations of computers from businesses following equipment upgrades, or from members of the community. Technical support should be readily available over the phone to assist those unfamiliar with computer and Internet technology.
Technological requirements
Although technological developments occur rapidly, online intervention website complexity should remain at the same level of public familiarity to avoid confusion. This involves maintaining web interactions as technically simple as possible while still incorporating the useful advances in Internet technology. For example, plug-in programs may not be as preferable as plain text, simple pictures and downloadable PDF files.
Although greater multimedia and interactivity may increase intervention utilisation and retention rates, it is important to balance these considerations against the technological capacity of clients. The advantage of using mainly text, downloadable as PDF files, is that new programs can easily be constructed and updates made without effort. However, web design is becoming increasingly user-friendly and requires less programming expertise and this is expected to enable implementation of more interactive features (e.g., automatic feedback on questionnaire answers and tailored programs based on responses given) coinciding with increased broadband access amongst Internet users.
Given their potential for low costs, scalability, adaptability, and effectiveness, Internet interventions may be appropriate for dissemination to a range of settings (e.g., municipalities, community organisations, treatment providers, employers). However, each of these settings varies considerably according to their resources, expertises, interests and ability to implement Internet interventions independently.
Several important factors should be considered in developing an online intervention. The targeted population and volume of use must be carefully considered. Most online intervention sites are hosted on shared servers, a low-cost, easily administered solution that is appropriate for a low volume of traffic. However, sites that intend to provide a larger scale intervention require different technology (e.g., multiple servers, application servers, search databases, session databases, and redundant storage systems). An inverse association likely exists between population size and the marginal costs of intervention implementation (Bennett & Glasglow, 2009). Consequently, there is a need to understand resource needs and how to effectively apply systems to smaller settings (e.g., rural areas, community health centres, and small municipalities). Smaller settings may be unable to make the infrastructure investments necessary to support high-quality Internet interventions so strategies are needed to overcome any resource constraints. One possibility would be to develop a federally or provincially supported, market competitive,

36
Internet intervention infrastructure that could be leveraged to disseminate interventions to interested parties.
Fee-based services
Most online interventions are available free-of-charge, others have optional fee-forservice features (e.g., QuitNet) and others charge a fee for service (e.g., Drinker’s Checkup; Hester, Squires, & Delaney, 2007). Some Internet-based interventions must charge a fee to maintain operations; however, a clear advantage of making online interventions available at no costs is the removal of potential barriers to access due to low income
(Cunningham, 2007). Alternatively, a minimal fee might increase the perceived worth of the online intervention to the user and increase utilisation rates and hence program effectiveness.
Cost effectiveness
Although few cost effectiveness studies have been conducted, it appears that Internetbased therapy and online interventions are cost-effective compared to traditional therapy, in-person assessment and brief interventions, and print-based materials. One randomised trial found telephone counselling provided by the American Cancer Society cost
US$1,300 per long-term quitter (McAlister, Rabius, Geiger, Glynn, Huang, & Todd,
2004), well below the health-related costs of tobacco use of US$3,991 per smoker per year estimated by the Centers for Disease Control and Prevention (2002). Internet service provides even greater potential for cost-efficacy.
Internet therapy is cheaper than traditional face-to-face therapy due to reduced costs of office space, secretarial support and related overheads. This enables therapists to set up less costly services. Additionally, more clients within geographical regions are able to access therapy online due to reduced costs involved with travelling to sessions. High quality and high speed Internet access and necessary technology (computers, webcams, etc) are becoming more affordable and increasingly accessible to the public through educational institutes, cafes and libraries. This reduces the potential technology-divide that limits online therapy to those who can afford the necessary technology equipment
Internet therapy typically involves less therapist time than traditional therapy, especially if asynchronous communication methods (e.g., email) are used. Self-guided online therapeutic programs can be established that are accessed by clients and provide automated information, exercises and feedback. Once these programs are established they can be easily updated and modified based on participant feedback or program evaluation.
This is much easier then reprinting materials. Online interventions that do not include therapist support are cost-effective as they provide services to a large number of people and costs do not increase with usage rates.
Overall, preliminary research into the delivery of Internet therapy in Australia tends to support the assertion that Internet therapy is less expensive compared to face-to-face therapy (Klein et al., 2006; Mihalopoulos et al., 2005), with costs estimated to be between one third and one sixth less than other psychological treatments (Crone et al.,
2004). Interventions can be updated centrally (at the host site) relatively easily in

37 response to new knowledge, client feedback or research data, avoiding costs associated with printing new handbooks or materials. Setting aside initial capital set-up costs,
Internet-based interventions are potentially more cost-efficient compared to face-to-face and print-based interventions.
Data from one web-based alcohol screening and brief intervention suggested that the website creation and maintenance cost approximately US$9,500 and advertising
US$9,000 (Saitz et al., 2004). A randomised controlled trial of Internet interventions for smoking cessation found that in a relatively short time (eight months), more than 6,000 users enrolled through the link posted on the regularly published American Cancer
Society website (Rabius et al., 2008). Service was provided with no costs other than those associated with the establishment of website links and targeted, relatively static, site posting. Approximately four days of programming at a cost of less than US$2,000 allowed approximately 5,000 additional users for scalable services from five tailored, interactive service providers (Rabius et al., 2008). This contrasts with the much large cost of serving new clients via telephone or face-to-face counselling.
Considering the cost of traditional treatment and the costs of untreated addiction-related problems on individuals and society in terms of lost productivity, health care, unemployment, public housing and crime, the intervention is very cost effective.
Researchers estimate the annual
$20,000 cost associated with a compulsive gambler ranges from to $56,000, including loss of work, and court and treatment costs ( Andresen,
2006).
In a randomised controlled trial of a smokeless tobacco online intervention, different recruitment methods were tested for effectiveness (Gordon et al., 2006). The most successful method of recruitment was use of traditional media, which cost US$116,336 for materials, postage, labour, and fax broadcast costs. Excluding the initial cost of obtaining a database of addresses and fax numbers, the average cost was US$92 per recruited participant. Internet marketing through the use of Google ads cost US$3,425, which yielded 9,155 clicks on the advertisement and approximately 511 recruited participants. At a charge of 37 cents per click, the cost per participant was about
US$6.70. Direct mailings to previous study participants and health care professionals cost
US$4,679 and resulted in few participants with a cost of at least US$36 per participant.
Newspaper advertisements were similarly ineffective and cost US$115 per participant
(total US$805). The most cost ineffective method of recruitment was direct mailings to individuals based on purchased lists which cost US$4,181 or US$597 per participant.
In considering the cost of interventions, various expenses have to be considered and weighed against one another:
• Research and development costs of treatment programs
• Internet intervention costs: time cost of online visitors, costs of accessing the
Internet, and cost of hosting Internet sites
• Direct medical costs for patients utilising traditional addiction treatments: consultation by general practitioners, hospitalisation, out-patient visits to addiction clinics, use of prescription drugs

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• Direct non-medical costs for patients utilising traditional addiction treatments: costs of travelling, parking, time costs
• Indirect non-medical costs of patients requiring addition therapy: days of work lost, cutback on work or non-productive work, domestic losses
In an analysis of the effectiveness of a Dutch online problem drinking program with an online information brochure, the online treatment produced greater clinical outcomes in terms of success rates and comparisons after 12 months (Smit et al., 2006). Furthermore, a comparison of the economic costs over the same timeframe found that the online program resulted in lower direct medical and direct and indirect non-medical costs. The authors concluded that investment in the online program is more than balanced by cost offsets and in terms of cost-effectiveness. The online intervention had a high probability of being more acceptable than the online information brochure at different levels of client and health-providers willingness-to-pay. Given that a substantial proportion of the costoffsets include the higher per capita productivity levels amongst the online treatment group, employers may benefit from providing or facilitating access to Internet interventions. The savings also occur in the health service sector as well as client’s outof-pockets costs being lower demonstrating additional benefits from the online intervention.
An early trial of a counsellor-facilitated online therapy group for recovering pregnant cocaine users (Alemi, et al., 1996) did not compare the cost of online and face-to-face groups, but reported data indicating that online patients had fewer associated medical costs. The clients participating in face-to-face support groups had lower group attendance rates and higher utilisation of health services (42% to 164% more office and clinical visits for mental and physical health) than the online group. Furthermore, by delivering services online, more patients can be served by a single clinical than would be possible in face to face settings.
Section 1 summary
Given low treatment uptake rates amongst individuals with addictive disorders, including problem gambling, Internet therapy and online interventions represent important new methods of providing necessary assistance. Internet therapy involves the completion of a specified program using online readings, exercises and tools with support and counselling provided by email, chat, or video-conferencing. In contrast, online interventions are a form of self-help whereby participants engage tools, readings, exercises, forums and other activities online without direct contact with a therapist. Both treatment modalities offer significant advantages to traditional face-to-face therapy in terms of increased accessibility and convenience of accessing assistance and help, lower costs and travel required, anonymity and privacy, and immediate access to a network of individuals facing similar problems and help professionals.
Online interventions and Internet therapy are made up of multiple components that can be used interchangeably depending on the treatment program offered. Such interventions commonly require participants to register using anonymous screen names to enable

39 individuals to track progress and maintain continuity throughout the treatment process.
An important component is the use of tailored normative feedback. This involves the provision of detailed information comparing behaviour to that of other individuals of the same age, nationality, gender and culture to provide a context for their excessive behaviours. In addition to tailoring feedback, website content should also be tailored to individuals as much as possible using age, gender, culture and problem variations as well as directing individuals to the most relevant treatment components based on their current motivation and level of readiness for change. Tailoring increases treatment relevance, adherence and effectiveness.
Online interventions may include interactive tools such as self-monitoring, goal setting, situation risk analysis, response to potential triggers and relapse prevention. Similarly, educational material may be presented in an interactive manner with the use of audio and video, quizzes with automated feedback and interactive text. Participants may also use online forums to seek and provide support, help and advice and interact with individuals facing similar problems. Online interventions may communicate with registered participants through the use of emails, SMS messages, telephone calls and regular mail to increase treatment effectiveness and support.
Online interventions and Internet therapy represent new treatment modalities and although some research has been conducted and trials are underway, many issues still require consideration. One significant advantage of using the Internet to reach clients is that Internet access is widely and cheaply available in Canada through homes, workplaces or public areas (e.g., Internet cafes and libraries). This reduces travel requirements and restrictions on office hours as well as reaching those unable to access help due to geographical barriers or unwillingness to attend a treatment clinic. However, although research indicates that individuals who use alcohol and substances have access to the Internet, given the financial difficulties often associated with problem gambling research is required to determine if this is a suitable method for reaching those with severe gambling problems. Similarly, further research is required to determine if online interventions and Internet therapy are deemed an acceptable treatment modality for addictive disorders, although preliminary evidence suggests that youth and young adults are increasingly comfortable seeking help online. Consideration should be given to the optimal means of marketing online services to reduce associated costs and reach a maximum number of potential users with a mix of online and traditional media sources advised as well as employers and HMOs.
Despite the potential benefits of the Internet in reducing attrition due to increased convenience, accessibility and privacy, online interventions appear to have high levels of attrition. As barriers to entry are relatively low this may reflect individuals seeking information and testing out services before they are ready to commit to change and may not necessarily represent treatment failure. However, further research is required to determine methods to increase participant retention and program completion. Therapists and clients must be familiar with online methods of communication including writing and reading online and using email and instant messaging. Online programs should assess the most appropriate level of care needed and direct patients to more intensive therapy where

40 necessary; however, Internet therapy and online interventions appear to represent an efficacious and cost-effective method of delivering much needed assistance to a large number of individuals.
Section 2
This section reviews the empirical literature supporting the effective use of the Internet as a medium through which treatment interventions are offered. As noted by Barak, Klein and Proudfoot (2009), the provision of therapy via the Internet is proliferating despite encountering opposition mainly on ethical and legal grounds. In the context of its potential benefits, it is important to establish the extent to which outcomes using this modality are comparable or better than those achieved using tradition methods.
Internet therapy
A meta-analysis of the effectiveness of Internet-based psychotherapeutic interventions
(Barak, Hen, Boniel-Nissim, & Shapira, 2008) reviewed 92 studies revealing that, on average, such interventions have a medium effect size of 0.53. The type of disorder treated appears important with those more psychological in nature (i.e. dealing with emotions, thoughts, and behaviours) better suited than those primarily physiological or somatic (e.g., weight loss). Smoking cessation had an effect size of 0.62 while treatments for problem drinking were slightly less effective with an effect size of 0.48; however, more participants were included in the smoking cessation studies (n=5,460) than drinking interventions (n=35).
The review (Barak et al., 2008) found that the effects of Internet-based interventions persists post-treatment, as should be expected of effective treatment intervention. An analysis of the psychotherapeutic approach used found that CBT was much more effective than psychoeducational or behavioural interventions, the latter being the least suited to online treatment. Examination of the age of clients found that youth (18 and under) and the oldest adults (40 and above) appear to benefit less than young (19-24) and older (25-39) adults. The increasing familiarity of youth and young adults with the
Internet, online resources and communication (cohort effect) may change these results based on studies published prior to 2006. The authors refer to more recent studies of
Internet-based therapy for older adults and children that show stronger therapeutic effects
(Barak et al., 2008).
In an examination of Internet therapy compared to self-help online interventions, no significant differences were found in effectiveness (Barak et al., 2008). However, this finding does not mean that both approaches are as effective in treating similar individuals and/or similar problems. Clients seek different treatment modalities depending on their problems, its severity, needs, preferences and a multitude of other factors. Therefore, the absence of a meaningful difference may represent self-selection biases to an intervention.
In contrast to these findings, a meta-analysis showed that Internet-based cognitivebehavioural therapy interventions for anxiety and depression were more effective with, as compared to those without, direct therapist involvement (Spek, Cuijpers et al., 2007).

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Individual therapy was found to be more effective than group therapy for both Internet therapy and online interventions (Barak et al., 2008). In regards to the type of modality of
Internet therapy, email and chat rooms were much more effective than forum and webcam interventions. Results suggest that Internet-based self-help interventions are most effective when provided on interactive websites that may be accessed only by prescreened authorised patients. Email reminders for clients also contribute to the success of therapeutic interventions. Among the 92 studies included in the analysis (Barak et al.,
2008), 14 directly compared Internet-based with face-to-face traditional treatments of the same disorder, with participants randomly assigned to each treatment mode. There were no statistically significant differences in the effect size of either modality. This result is consistent with those reached by other meta-analyses (Lambert & Ogles, 2004). Barak et al. concluded that “Internet based therapy on the average is as effective or nearly as effective as face-to-face therapy.” (Barak et al., 2008, p.30).
In a direct comparison of clients who received Internet and face-to-face counselling
(Murphy et al., 2009), Global Assessment of Function scores of online clients were found to be significantly higher than those of face-to-face clients but no significant differences were found in the amount of client change. The authors concluded that the two modalities were not different in their ability to bring about change suggesting that Internet therapy is equivalent in impact to face-to-face work. Furthermore, results of a client satisfaction survey found that online counsellors were equally effective in establishing the essential components of a working counselling relationship including therapeutic alliance.
Studies have found benefits of computerised therapies over other forms of treatment.
Wright et al. (2005) compared the efficacy of computer-assisted cognitive therapy against standard cognitive therapy and a control group without treatment for outpatients with non-psychotic major depressive disorder. In the computer-assisted condition, patients saw the therapist face-to-face for a reduced period of time (25 minutes vs. 50 minutes in the standard condition) and then worked alone on the computer program. Improvement in depression in both active conditions was maintained at 3- and 6-month follow-up assessments. Computer-assisted cognitive therapy showed more robust effects, relative to the wait-list, than standard cognitive therapy in reducing measures of cognitive distortions and in improving knowledge about cognitive therapy. These results indicate that while therapist contact is important, therapist time can be reduced with patients learning cognitive skills equally if not more effectively through interactive, multimedia electronic formats.
Problem drinking
Several Internet therapy programs targeting excessive drinking are now available.
In May 2006, the Australian based Turning Point Alcohol and Drug Centre launched www.CounsellingOnline.org.au, a pilot 24/7 alcohol and drug web-based counselling program utilising one-to-one access to professional alcohol and drug counsellors using live (synchronous) chat technology (Swan & Tyssen, 2009). After 13 months of service delivery, 2,004 sessions of online counselling were provided to clients, more than double

42 the number of traditional sessions delivered in one of the state’s larges specialist alcohol and drug services (Swan & Tyssen, 2009).
CounsellingOnline demonstrated a high rate of clients successfully connecting with counsellors (77.7%) and low rates of attrition (22.3%). The low wait time to connect to a counsellor (average 1:33 min) likely contributed to the high capture rate. Nearly twothirds (63%) of all online sessions were delivered outside standard business hours. Of these, 39% of contacts occurred during evening/overnight periods and 24% over weekend periods. Clients were more likely to be female (68.3%), consistent with data from the state telephone helpline but in contrast alcohol and drug services were clients are more likely to be male. Furthermore, online clients were younger than telephone and face-toface clients and twice as likely to be aged less than 24 years. The majority of online clients were employed with the rates of employment and study among online clients significantly higher than those seeking telephone or face-to-face help. Likewise, unemployment rates were significantly lower amongst the online clients.
Drugs of concern more frequently identified by CounsellingOnline clients included alcohol (37.5%), cannabis (17.4%), and amphetamines (14.5%). Clients reported accessing online services for reasons of privacy (62%) and service anonymously (78.6%);
39% reported no prior treatment seeking behaviours. Clients generally reported that the online service was very easy or easy to use (83.7%) and experienced no difficulties using the service (73.3%). However, this data may be biased as it was only collected from those who successfully reached a counsellor.
Internet therapy has been successfully used to help 30 court-involved parents in New
Jersey with alcohol problems, 83% of who were Black (Haack, Burda-Cohee, Alemi,
Harge, & Nemes, 2005). Parents charged with child abuse and neglect were randomly assigned to face-to-face treatment or online counselling plus participation in an electronic support group. The online intervention involved frequent, almost daily, online motivational interviewing, home monitoring to assess risk of relapse, and peer-support through electronic discussion groups. Clients also received telephone calls from counsellors if they were at high risk for relapse and were occasionally invited to access face-to-face sessions with a counsellor. Preliminary results suggested that the webassistance correlated with increased participation in face-to-face meetings (Haack et al.,
2005).
Tobacco use
To encourage smoking cessation amongst employees, Okayama University in Japan initiated a group therapy program consisting of a smoking cessation class, nicotine patch therapy and online support via email (Hotta et al., 2007). Participants received general information about smoking cessation by email newsletters sent for the first 35 days (one to three a day). Additionally, participants wrote and sent emails anonymously to the mailing list (that included all participants and health professionals) with questions or comments, and all members of the mailing list could respond to these emails. Participants were also asked to attend face-to-face discussion meetings 1 week, 2 weeks, 1 month, 6 months and 12 months after initiation of smoking cessation. In a trial of the program

43
(Hotta et al., 2007), 101 employees (20% of total smokers) enrolled and a total of 658 personal emails were voluntarily sent by each participant and health professional to the mailing list, the majority of which (83%) originated in the first month of the program.
The content of emails varied and included self introduction and queries about controlling nicotine cravings from new participants, advice and practical skills from health professionals and methods of stress management and encouragement from senior participants. At 12 month follow-up, 53% of participants (n=94) sustained cessation for a year. Sending email messages within the first week of the program was a significant factor affecting long-term smoking cessation. Employee position played a role with 1year cessation rates significantly higher for academic (78%) and administrative (55%) staff in comparison to technical staff (6%). The authors propose that this may have been attributed to the fact that technical staff were unable to read and write email messages during the day because of the rush of business. If so, this suggests that email support may be most effective for individuals (and employees) who devote most of their time to desk work with Internet access.
The Free & Clear Quit for Life program is associated with the popular interactive online
QuitNet program based in the US (Zbilkowski, Hapgood, Smucker, Barnwell, & McAfee,
2008). The Quit for Life program is available to participants through employer assistance or health plans. Participants enrol in the program directly by phone or online. Once registered, participants receive up to five proactive phone counselling sessions, access to the interactive website and printed self-help materials.
The counselling calls are designed to provide practical expert support to help clients develop problem-solving and coping skills, secure social support, and design a plan for successful cessation and long-term abstinence. Calls are scheduled at a time convenient to the caller and at relapse-sensitive intervals. Participants can also call a helpline for support at any time. During each call counsellors encourages participants to use the online program and information gathered from websites.
The online component of the program contains interactive tools and tailored content based on the participants’ readiness to quit, as well as active discussion forums and interactions with other members and experts. The program maintains continually tailoring; for example, once a participant reports quitting the website content shifts to a focus on relapse prevention.
An analysis of the treatment program found that participants used phone counselling more than online services and used discussion forums less often than they logged in to the site (Zbilkowski et al., 2008). However, utilisation rates were much higher for those participants who engaged in phone or web services at least once. Women were significantly more likely than men to utilise online discussion forums and complete a greater number of calls. Older callers were significantly more likely to complete more calls and log into the website than younger callers. Moderate smokers logged into the website significantly more often than light or heavy smokers. Participants eligible for the program through their employer were more likely to log in than those eligible for

44 treatment though their insurance plan. The program was rated as satisfactory by 92% of respondents and 41% abstained from tobacco use for 30 days or more. Those who logged in to the site more than five times were significantly more likely to be satisfied with their experience and to have abstained from tobacco for 30 days or more compared to those who never logged in. Those who participated in more phone calls and utilised the website more were more likely to have successfully ceased tobacco use. Specifically, for each additional call the odds of quitting increased by 56%, whereas for each additional log-in, the odds of quitting increased by 14%.
Substance abuse
Little research has been conducted evaluating the use of online therapy or interventions for substance abuse. The low treatment uptake and retention rates amongst this population suggest Internet therapy may be a useful therapeutic modality. Individuals with substance use problems are known to benefit from therapy and the effects of pharmacotherapy have been shown to be strengthened when combined with psychotherapy (Carroll et al., 2004; Fiellin, Kleber, Trumble-Hejduk, McLellan, &
Kosten, 2004). For example, although participation in substance abuse counselling has been found to be significantly related to retention in buprenorphine treatment, fewer than
50% of patients who initiate buprernorphine treatment in outpatient general medical settings report ever attending counselling (Alford et al., 2007; Stein, Cioe, & Friedmann,
2005). When barriers to treatment are comprehensively addressed, a successful treatment programs will increase rate of treatment completion, increase length of stay, decrease use of substances, reduce mental health symptoms, improve employment, improve selfreported health status, and reduce HIV risk (Ashley, Marsden, & Brady, 2003).
In an early study in the 1990s, Alemi et al. found that repeated use of online services was positively correlated with retention in substance abuse treatment (Alemi, Stephens,
Llorens, & Orris, 1995; Alemi, Stephens, Sabiers, & Arendt, 1993). Clients who accessed online services were more likely to participate in treatment, access community-based treatment and participate in self-care, such as attending self-help meetings.
The Substance Abuse Treatment Centres (SATC) in the Netherlands has provided two evidence-based online treatment programs since 2003: CBT and motivational enhancement training (MET). These programs have led to the development of online interventions for alcohol, cannabis, cocaine and tobacco users, and for pathological gamblers. A trial is currently underway that aims to compare two online treatment programs for problem drinkers (1) an anonymous, online non-counsellor involved, fully automated self-guided treatment program (self-help), and (2) a real-time online, nonanonymous counsellor-guided therapy program for problem drinkers (therapy) (Blankers,
Koeter, & Schippers, 2009). The self-help program has been shown to be highly attractive and promising in its effects (Blankers et al., 2007). However, participants reported that they missed the opportunity to interact with a counsellor on a regular basis.
The online therapy program uses weekly online exercises and guided interventions augmented by individual, private real-time chats with the therapist. Each chat lasts approximately 40 minutes during which feedback on homework is provided and the client

45 is motivated to enhance their attempt to stop or reduce drinking. A research project is currently underway to evaluate the effectiveness of this program.
An exploratory study was conducted to determine whether telephone or Internet-based substance abuse counselling would be feasible and acceptable alternatives to traditional face-to-face counselling in a sample of low-income buprenorphine maintenance patients
(Gandhi, Welsh, Bennett, Carreno, & Himelhoch, 2009). The study found that all participants (n=24) had a home (land-line) phone or cell phone while 58% had both.
Online therapy appeared to be feasible as 42% had a computer, and 90% of these had
Internet access, and 70%, an email account. The majority (59%) indicated a preference for non-office-based counselling, 57% preferred phone only, 7% Internet only, and 36% either phone or Internet. Ninety-two percent of participants said that they would be willing or very willing to receive counselling over the phone, while 55% were willing to do so over the Internet. Even among those who did not have a computer, Internet access, or an email account, many expressed willingness to receive counselling via the Internet
(50%, 57%, and 53% respectively). Although this study is limited by the small sample size, willingness to participate, and overrepresentation of older patients, women, and
African Americans it indicates that substance abuse clients may be willing and able to accept Internet counselling.
In an effort to increase treatment attendance amongst substance users, 37 patients were randomly assigned to on-site (Baltimore) group therapy or an Internet-based videoconferencing platform ( e-Getgoing ) (King et al., 2009). Patients in both groups received a manual-guided relapse control program conducted by the same group leaders.
Patients were scheduled to attend two relapse control group counselling sessions (in addition to one individual counselling session at the clinic) and were followed for six weeks. In the online condition the group leader could verify the identity of all participants in the group, whereas participants could only see the video of the group leader and not one another. Approximately one to four participants attended the online group therapy sessions at one time in comparison to five to ten participants who attended the on-site therapy session.
No differences were found between groups on counselling adherence, drug use or treatment completion. Participants in both conditions reported high and comparable satisfaction with their treatment. All of the participants in the Internet therapy condition reported a strong preference for this delivery condition, listing the greater convenience and privacy with this service condition, along with the novel and fun experience as reasons for this preference. Furthermore, despite clients’ lack of familiarity with the technology, therapists reported that this was easy to learn and did not hinder the flow of therapy.
A German site, Quit the Shit , provides Internet therapy for cannabis addicted youth
(Tossmann, 2009). Launched in 2004, the program requires individuals to register and make appointments for a chat-based interview before completing a 50-day online diary.
Each week participant receives detailed feedback from the therapist team via email with the team available for chats if necessary. At the completion of the program participants

46 again completed a chat-based interview with the therapist. An anonymous questionnaire completed during registration (n=206) found that the majority of participants were young males (74% male, mean ages = 25) with relatively high levels of education and cannabis use; 95% were addicted to cannabis. Approximately 90% of individuals who completed the interview entered the program, but less than half (44%) completed the program.
Completers were found to have achieved higher levels of abstinence (33%) compared to non-treatment controls (5%). Program completion was associated with significantly fewer days of consumption and grams of cannabis consumed (a strong effect), moderately reduced anxiety, small decreases in depression scores and small increases in life satisfaction. Although more research is needed, Quit the Shit , appears to be an effective intervention to help cannabis users to control cannabis consumption and to address consumption-related problems.
Group therapy
Internet therapy may also be delivered in a group format using an online chat room.
Differentiated from online peer-support groups by the presence of a therapist, online chat groups create new opportunities for the prevention and treatment of mental health problems. This method serves people with limited mobility, time restrictions and limited access to mental health services, and those living in remote areas, lacking access to appropriate therapists, or other patients with similar problems to allow the formation of a therapeutic group. Although Barak et al. (2008) found that group therapy was less effective than individual Internet therapy, in some circumstances produced positive treatment outcomes. Internet group therapy appeared to be more appropriate during bridging periods, for example prior to the beginning of individual treatment or as a supplement for individual treatment.
A German team initiated an Internet therapy aftercare group for patients discharged from an inpatient psychiatric service on the basis that patients were facing similar challenges and stresses and could support each other, reinforce positive developments and counteract negative ones (Golkaramnay, Bauer, Haug, Wolf, & Kordy, 2007). Additionally, patients were familiar with group therapy as a result of their inpatient treatment, aftercare was cost effective, met needs of those who could not travel to face-to-face sessions, reduced waiting lists and overcame patient fears of starting with a new therapist. An analysis found that, compared to those who did not participate in aftercare, participants found the chat groups helpful and were generally better off at 12 months follow-up with more favourable psychological and physiological health. Comparisons found no substantial differences in group processes between traditional inpatient face-to-face groups and online chat groups (Huag, Sedway, & Kordy, 2008).
In another study (Alemi, et al., 1996), the impact of electronic self-help groups on 53 pregnant women recovering from cocaine use was examined. One group had access to online services and was provided with an online support group, the other group was provided with only an in-person support group. Both groups were monitored and facilitated by a counsellor. Bi-weekly participation rates for the online support group over four months ranged from 54% to 79%; in contrast the participation rate in the face-to-face group ranged from 0% to 20% clearly demonstrating that clients found the online

47 participation to be easier and more convenient. Analysis of comments made by clients online found that 67% were intended to provide emotional support to other clients while remaining comments were task oriented. The more clients used online services, the more they felt a sense of solidarity with each other (Alemi et al., 1996), indicating that online groups behaved as if they were face-to-face.
Despite the benefits shown for group Internet therapy, certain factors require consideration. This form of treatment requires all participants to have access to a computer and the Internet, preferably in a private setting where they will not be disturbed for the duration of the session. Although Internet access is increasing and libraries and
Internet cafes provide access for those without home or office computers, certain populations may have difficulties accessing the Internet, for example those completing inpatient care for an addiction who may also experience financial and housing difficulties. Furthermore, online group therapy may be more successful for those with personal group therapy familiarity. For example, clients who have completed in-patient or face-to-face group therapy may benefit from on going outpatient therapy offered online particularly if they experience difficulties attending sessions due to geographical, travel, or time constraints.
Internet therapy for problem gambling
Sweden
The only published randomised controlled trial to evaluate the effectiveness of Internet therapy for problem gambling (to the authors’ knowledge) was conducted in Sweden based on slutaspela.nu
( Stop Playing ) (Carlbring, 2005; Carlbring & Smit, 2008).
Participants were current pathological gamblers (n=66), not presenting with severe comorbid depression. The majority of participants reported problems with Internet poker
(38%) or electronic gaming machines (34%) and the sample consisted of mostly males
(86%) with gambling debts (71%). Participants were randomly allocated to either a waitlist control or an eight-week Internet based cognitive behaviour therapy program with minimal therapist contact via email and weekly telephone calls of less than 15 minutes.
The program was time effective as the average time spent on each participant, including phone conversations, email and administration was four hours.
Treatment was based on established CBT techniques, as described in self-help books
(Hodgins, 2002; Ladouceur & Lachance, 2006). The text was divided into eight modules; the first four modules included motivational interviewing techniques to assist individuals in making a decision about their gambling. Participants were instructed to answer openended questions evoking talk of change and were encouraged to ask for input from relatives on different aspects of their gambling. In addition, the first four modules included a time line follow-back and mapping of reasons for gambling. The last four modules consisted of the actual treatment. The client completed one module each week which included reading and completed exercises, providing answers to essay-style questions via email, and posting comments on an online bulletin board. Feedback on homework assignments was usually given within 24 hours. Once weekly, a telephone call was made by the therapists to each participant with the purpose of providing positive feedback and encouragement as well as to answer any questions of the participant about

48 modules. Each conversation lasted approximately 15 minutes and the therapist decided whether the client was ready to move to the next module.
Half the participants completed all eight modules within the intended eight-week period.
After this time, participants were given open access to the rest of the program; at sixmonth follow-up, 68% of participants had completed the entire program. One month following the completion of the program gambling-related problems, anxiety and depression were significantly reduced in the experimental group and quality of life had significantly improved. Anxiety and depression remained low in the treatment group at 6,
18, and 36 month follow-ups. Clinical interviews were conducted over the telephone at
18 and 36 months and found that the majority of participants had made moderate (17.6%,
11.8%) or large improvements (50.5%, 61.8%) demonstrating the long-term maintenance of treatment effects.
The effect sizes in this study were lower at post-treatment than those reported in a metaanalysis of problem gambling treatments by Pallesen et al. (2005) (cited by Carlbring &
Smit, 2008; d = 2.01 vs. 0.83). However, this may be an effect of measurement problems with the higher effect sizes sometimes being based on a single item or on scales without adequate psychometric properties. Nonetheless, Carlbring and Smit (2008) reported higher effect sizes at the 18- and 36-month follow-ups compared with the mean of the 29 studies included in Palleson et al.’s metal analysis ( d = 1.96 and 1.98 vs. 1.59). However, these effect sizes should be interpreted with caution as they included different outcomes measures. The authors acknowledged that the results of this study were limited by the lack of a follow-up control group (waitlist participants had received treatment by this stage) and the possibility of spontaneous recovery or other extraneous factors that may have boosted results to overestimate the true impacts of treatment. Nonetheless, this study provides support for the use of Internet-based, therapist guided self-help for treating pathological gamblers who are not severely depressed. The treatment is free of charge and open to all Swedish citizens.
In September, 2009 the Swedish research trial was completed and funding was stopped for the treatment program. However, in November, 2009 funding was reinstated and clinicians were able to complete “booster” sessions with clients, continue new intake and collect follow-up data. This decision from the Swedish Government and National
Institute for Public Health was seen as groundbreaking and broke a trend in focusing on research recognising the success and impact of online treatment for problem gambling.
Norway
The geographic landscape of Norway means many citizens live far from treatment options, and perceived stigma prevents many individuals from seeking help for gambling problems. To overcome these barriers, an online treatment program for problem gambling was launched in November 2007. Funded by the Norwegian Ministry of Health and run by Innlandet Hospital Trust, the program aimed to reach out to groups of problem gamblers not accessing treatment, such as Internet gamblers, and offer greater flexibility in treatment including reduced time and monetary commitment.

49
The gambling treatment program is run from the site www.spillbehandling.no (Distance based therapy for problem gamblers in Norway) and offers a free structured therapy program for problem gambling. All communication between clients and therapists is conducted through the Internet and telephone and the treatment lasts for approximately three months. Client assignments provide the structure and content for the telephone meetings, and all assignments are based on CBT principles. There are a total of nine assignments that need to be completed, in addition to the various screenings: Symptom
Checklist Revised (SCL 90-R; Derogatis, 1977), Gamblers Beliefs Questionnaire (GBQ;
Steenbergh, Meyers, May, & Whelan, 2002) and South Oaks Gambling Screen Revised
(SOGS-R; Abbott & Volberg, 1992). The assignments are sent once a week through an online account that each client opens on registration. The assignments focus on topics within gambling behaviour and how to deal with the negative consequences/challenges caused by gambling. The clients also access an online discussion forum to communicate with each other.
The nine assignments consist of:
Motivation / goals
Readiness to change (the stages)
Analyzing gambling situations
High-risk situations / identifying automatic erroneous thoughts
Flashcard & notebook (self-help tools used in treatment)
Financial situation and challenges
Relationship, trust/honesty
When the program was initially launched, clients were required to have a GP referral.
However, in March 2009 intake procedures were modified to allow clients to contact the therapists and program coordinators directly through the website.
The site received 400-600 hits per month between December 2007 and June 2008.
Between November 2007 and November 2009, 90 clients had signed up for treatment.
This included 41 clients referred by their doctor and 49 signed up through the website since March 2009. The majority of participants were males (77 men, 13 women) and ages ranged from 19-59 years with a mean age of 35.8 years. The average SOGS-R rating was
11.6. Online gambling was the most commonly cited presenting problem, with online casinos (slot machines) followed by online poker being the highest represented forms of gambling although sports betting (both on and offline) and horserace betting were also represented as main problems.
To date, 38 clients completed the treatment program, 24 completed a follow-up conversation after 6 months. The majority of clients claimed to have reached their goals and maintained abstinence from gambling resulting in significant improvements in their quality of life. As of November 2009, 15 clients were in treatment with 8 waiting to commence, 18 elected not to start, and 11 dropped out after a few weeks. In addition to self-report measures, repeated SCL 90-R and GBQ measures indicated a positive change in all symptoms including depression, anxiety and concentration. The GBQ retest revealed fewer erroneous thoughts regarding gambling behaviour. Some clients continued

50 to gamble after completing the program, but described their behaviour as more controlled and less compared to before treatment. Most clients who dropped out quit early, that is, before completing half the program. Some clients reported that they had reached their goals, describing no more urges to gamble and therefore wished to leave the program.
The remainder did not provide an explanation for quitting.
Clients reported positive feedback and satisfaction with the combination of written email assignments and telephone calls. The program is intended to offer a complete treatment, although it may also be used in addition to other forms of therapy including group therapy or Gamblers Anonymous (GA). Follow-up phone calls are made at three and six months after treatment to check in with clients. A report describing the program did not refer to problems with technical issues, and it appeared to be successful in reaching clients living in areas without outpatient treatment (Eidem, 2008). However, difficulties included problems reaching clients for telephone sessions, clients skipping appointments or not completing assignments, and including clients who lived outside Norway. Clients have also reported that online therapy is in very close proximity to online gambling sites, which may be a temptation.
Finland
Similar to online gambling treatment programs operating in Norway and Sweden, Finland offers online therapy for problem gamblers. Initially begun for alcohol, drug and mental health problems, the use of Internet-based protocols is designed to empower clients to use their own resources and take advantage of the strength of the written word. Additionally, the online program aims to overcome shame and stigma associated with face-to-face therapy, and to lower the threshold for help seeking. Päihdelinkki (AddictionLink ) offers a full-service addiction site for Finland including peer support and discussion, self-help resources and professional support and counselling. Founded in 1996, the site is accessed by approximately 40,000 individual visitors a month (Peltoniemi & Bothas, 2007). For example, in May 2006, 6,179 individuals took the online gambling test and 7,597 individuals used the online discussion forums. Approximately 12% of counselling provided by the site is for problem gambling, which included individuals seeking help for their own gambling problems and concerned significant others seeking help relating to another’s gambling. Further outcome research regarding this site is expected to be available in 2009.
Germany
In December 2007, the Federal Centre for Health Education in Germany launched the personal counselling program Check dein Spiel ( Check Your Gambling ). It is part of www.spielen-mit-verantwortung.de, the website of the Federal Centre for Health
Education dealing with problem gambling. Besides personalised counselling the site offers an automated self-test on problem gambling, a search option for local help options and various other relevant information.
The counselling program is aimed at pathological gamblers who want to cease gambling.
Therefore, the goal is to reach abstinence within a timeframe of four weeks. Participation is free of charge and anonymous. Compared to traditional institutions for addiction help,

51 it is regarded as a low-threshold help offer. Therefore, it is also aimed at gamblers who had not yet been in contact with local addiction help institutions. The consulting is based on the behavioural principles of self regulation and self control (Kanfer, 1986) as well as on the concepts of motivational interviewing (Miller & Rollnick, 1999) and solutionfocused therapy (de Shazer, 1988).
The counselling program consists of four parts:
1.
Registration
2.
Initial counselling chat
3.
Program participation (four weeks)
4.
Concluding counselling chat
(1) During registration, several of the participants’ characteristics are elicited in an online questionnaire. These include socio-demographics, recent gambling behaviour, gamblingrelated cognitions, level of debts and other gambling related problems. Client records can be accessed by the counselling team.
(2) The initial chat talk is conducted by a member of the counselling team of Check dein
Spiel (approx. 50 min.). Each counsellor has a university degree in psychology and psychotherapeutic education. Generally, each participant is guided through the whole program by the same counsellor. The goals of the initial chat talk are to establish a trusting relationship, to evaluate the psychosocial situation of the client, and to work out goals and first coping strategies.
(3) After the initial chat, clients’ accounts are activated. One main feature of the personalized client’s area is an online-diary about the gambling behaviour. The diary is kept for the duration of the program and contains several questions dealing with gambling, for example, reasons for (not) gambling, related cognitions or the strategies used not to gamble. Moreover, several working modules can be activated individually.
Those deal with relapse prevention, improvement of life quality, re-establishing a daily structure, elaborating the advantages and disadvantages of gambling and creating an understanding and overview of any debt. Each week, clients receive a detailed feedback from the counsellor based on their work.
(4) After four weeks, clients and counsellors meet again for a concluding online chat
(approx. 30 min). Program participation is reviewed and discussed, which control strategies were found to be effective, and next steps to be taken in the process of behavioural change. In this regard, other possible means of professional help are highlighted, for example, local addiction counselling or debt counselling.
Between September 2007 and September 2009, 197 participants registered to use the program, a rate of approximately 12-15 per month. Of these, the majority were male
(87%) with a mean age of 34 years (SD=9.3) and were seeking professional help for the first time (64%). At registration the mean number of days gambling in the last 30 days was 13.6 (SD=9.0), and 5% appeared to have significant problems with gambling (PGSI scores of 3-7) while 95% appeared to be pathological gamblers (PGSI scores of more

52 than 7). The most commonly reported form of problem gambling were machines in amusement arcades and restaurants (76%), followed by machines in casinos (31%),
Internet casinos (25%), sports betting online (18%) and online-poker (16%).
Of the 197 participants, 66% completed the whole four week program. In a follow-up questionnaire at the completion of the program (n=75), the majority of respondents indicated that keeping a gambling diary, feedback from counsellors during the program and online chats with counsellors prior to and after the program were significantly helpful.
United Kingdom
GamAid (www.gamblingtherapy.org) is an online service that provides clients with available links and information, allows clients to talk to online advisors (during the hours of service), or to request information to be sent via email, mobile phone, or post. GamAid aims to assist clients reduce gambling behaviour but is not intended as a traditional treatment service because advisors communicate with clients to provide reassurance and give advice rather than act as counsellors.
Launched in November 2004, (forum and support group followed in June 2005) services offered include online advice and support for individuals, online support groups, a forum, and a database of resources. The first point of contact is the Helpline, where an individual is connected to an advisor anonymously, with webcam visual contact (one-way) but communicate by means of typing. Online support groups are run at various times providing live chat with others, facilitated by a therapist. A 24 hour forum is also available and email advice (reply within 24 hours) can be used, with multilingual services available (spanning 22 countries). Online counselling services are available with British
Association of Counsellors and Psychotherapists (BACP) accredited counsellor; however there is normally a charge for this service.
In comparison to existing phone line services, in the first three months of operation
GamAid was able to respond to approximately 20% more ‘calls’ (Farrel-Roberts, 2005).
In this period, 20,889 individuals visited the site (although this included repeat visitors),
4,422 clients talked to an advisor, 1,072 talked to a counsellor, 744 sent emails and 10% were less than 18 years of age. The majority of clients were from the UK although a significant proportion was from the US, with Canada also represented in a minority.
In an evaluation of GamAid , 80 clients completed a series of online questionnaire over a nine week period (Wood & Griffiths, 2007). The response rate was 19.4%, with significantly more females responding. Accordingly, results should be interpreted with caution as it is difficult to ascertain whether this service was more appealing to females, or whether females were more likely to respond to the survey. As the sample was selfselected this may present a biased evaluation of the service. Respondents were aged between 14 and 64 years (M=36, SD=11) and mostly Caucasian (86%). Of those seeking help for a gambling problem, Internet gambling was the preferred form of gambling for the majority of these (28%), followed by bookmakers (18%). Internet gamblers utilised
GamAid service more than any other comparable U.K. service, indicating (in contrast to

53
Wood & Williams, 2009) that this may be an appropriate mode of support for this group.
This is an important point given the higher prevalence of problem gambling amongst
Internet gamblers (Focal Research Consultants, 2008; Volberg, Nysse-Carris, & Gerstein,
2006; Wood, Williams, & Lawton, 2007).
When asked their reason for accessing the site, 65% of participants reported experiencing gambling problems, 26% wanted help for a friend or relative and 9% sought help, guidance and advice on specific issues (e.g., recovering gamblers seeking additional support or reassurance from spouses of problem gamblers in treatment). When asked how useful GamAid was, the vast majority agreed or strongly agreed that:
•
•
GamAid provided a useful service (86%)
•
Helped participants consider their options (84%)
•
Helped the participant be more confident to seek other help (80%)
•
Helped the participant decide what to do next (71%) and
Made the participant feel more positive about the future (63%)
Additionally, the majority of participants agreed or strongly agreed that the GamAid advisor contacted online understood their needs (85%) and was supportive (88%). The questionnaire also elicited qualitative feedback that indicated clients appreciated the immediate availability of the service and assistance provided, that it was faster and cheaper than phone calls, and that they did not have to directly talk to a counsellor.
Due to the cross-sectional nature of the study (Wood & Griffiths, 2007), brief time period and small, non-representative sample, this study did not provide any data on the effectiveness of GamAid services in reducing problematic gambling behaviour. The evaluation study did suggest that GamAid successfully assisted individuals to consider options, feel more confident about seeking help, and provided useful information of local help, referrals and additional information. GamAid offers an international service that is free-of-charge and most of those who had used other services reported that they preferred
GamAid because of the ease of accessing online help and more comfort talking online than by phone or face-to-face interactions. Technical problems were reported with the site including difficulties reading screens and security blocks placed by corporate and university systems preventing GamAid access. Overall, the brief evaluation found that
GamAid appears to provide a useful service, particularly for online gamblers and women, catering for individuals around the world.
Australia
Improving the Odds (http://www.improvingtheodds.com.au/) was an Internet-based treatment program developed to assist problem gamblers. The program was based at
Griffiths University in Queensland and available to Australian residents only. Before commencing treatment, all clients were required to meet DSM-IV criteria for pathological gambling as assessed by an online checklist. Participants in the Improving the Odds program completed sessions online and were provided with automated feedback on their progress.

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The program used CBT techniques and involved participation in six weekly sessions online. The focus was on learning skills and strategies to assist individuals to control their gambling behaviour and urges. A research study was planned to examine effectiveness with results expected to be available in 2009; however, since November 2009, the site appears to have been taken off the web with no information available explaining the cessation of this service.
In September 2009, Gambling Help Online (www.gamblinghelponline.org.au) was launched in Australia, jointly funded by all states and territories to provide 24/7 live counselling, email support and a range of self-help options. The site was launched relatively quickly given the seven month timeframe from inception to going live in response to funding requirements. Much of the content appears informed by practice wisdom gained in the delivery of CounsellingOnline (drug and alcohol online counselling), a program that was also developed and provided by telephone services at
Turning Point (the service provider of Gambling Help Online ) for the past five years.
Initial access to online counselling required each client to complete a pre-screening demographics form, PGSI or a family screen. This allowed counsellors to spend less time on assessment and focus more on rapport development. The treatment model for live counselling is a combination of motivational interviewing, cognitive therapy and cognitive-behavioural therapy. This is supported by a strong internal focus on dealing with the gambling rather than just the cause/consequences. Counsellors must be eligible for Australian Psychological Society, Australian Association for Social Workers or
Psychotherapy and Counselling Federation of Australia membership, have completed brief training specialising in cognitive therapy for problem gambling.
Clients are offered two options:
1) Live counselling available 24/7 providing immediate feedback. It functions similarly to instant messaging within a confidential environment. The client can see when the counsellor is typing and vice versa. Sessions are approximately 50-90 minutes, which is longer than drug and alcohol live online sessions that usually last approximately 45 minutes, and Gamcare in the UK, that lasts approximately 30 minutes. The gambling support takes longer than drug and alcohol clients as cases tend to be more complex and counselling is offered as compared to information and referral services provided by
Gamcare . Clinical guidelines outline a basic structure of engagement - assessment - intervention - summary/referral. With the amount of content on the website, counsellors can direct clients to appropriate information. This has proven useful in speeding up the session as the amount of content that can be covered online is estimated to be about a third of an oral session. A team of six front line gambling counsellors act as first contact with overflow to second tier (drug/alcohol/gambling) counsellors during weekends and overnights.
2) Email-based counselling with clients offered several emails a week for approximately six weeks with a 24 hour response time. Six weeks is allocated as a reasonable amount of time for preparation for change or referral, but flexibility is possible in the duration of

55 email support. For example, the telephone counselling programs run by Turning Point use a six weeks policy but most clients use the service for longer periods.
Focus groups were run in Queensland, New South Wales and Tasmania to develop the site name and logo. The website developers also constructed an additional site, www.problemgambling.vic.gov.au for the Victorian Government containing the capacity for users to leave feedback on public pages. This resulted in complications with many people requesting help in a non-moderated environment (posts are filtered but not responded to on this site), and indicates a need for moderated \ online forums for gambling in Australia.
Gambling Help Online is currently functioning well with more than 40 registered clients in the first month and over 1,000 visitors in the absence of promotional advertising. In the first six weeks of service delivery the site provided around 100 live counselling sessions and around 30 email support requests. As of November 2009, there were approximately eight clients currently accessing regular email supports. While some clients have accepted referrals to face-to-face services many have elected to register and return to the site. It appears that the service is effectively reaching the target group of those that would not otherwise access services.
Challenges faced by the service include:
•
Establishing an empirically-supported gold-standard outline for a single session or brief therapy using cognitive therapy focusing on gambling
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Translating existing therapeutic models into online support using emails. Email protocols are under development and the service has implemented an activelearning approach. Findings to date indicate that mirroring the client word length in the initial email is important as well as the language used
•
Assessing motivation which is somewhat difficult as clients tend to use the first email to express frustrations rather than directly request support
An evaluation of the site is planned by the Commonwealth Government, but not yet started.
Canada
A pilot project was conducted by the International Centre for Youth Gambling Problems and High-Risk Behaviors at McGill University to provide online help for adolescents and young adults with gambling problems throughout Canada. The Centre developed an online platform operated by psychology graduate students (supervised by psychologists) offering individual and group chats for approximately 28 hours per week. The online chat software was encrypted to provide security to individuals.
Topics included focused upon included:
•
•
Understanding the motivations for gambling
•
Analysis of gambling episodes
Establishing a baseline of gambling behaviour and encouraging a decrease in gambling

56
•
Addressing cognitive distortions
•
Establishing the underlying causes of stress and anxiety
•
Evaluating and improving coping abilities
•
Rebuilding healthy interpersonal relationships
•
Restructuring free time
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Fostering effective money management skills
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Relapse prevention
The creative website design team sought consultation with developmental psychologists, gambling and media experts and graphic designers. The website was field tested on adolescents for its attractiveness and appeal. The separate teen and young adult (aimed at college-aged youth) sites were widely promoted through schools, universities, health care providers, and popular media (including youth magazines and television shows) across
Canada. Staff training included the development of a comprehensive and detailed training manual that was revised based on student feedback.
From January through June, 2007 the site had 2,161 different visitors, 4,102 visits, and
1,031,893 hits. In total, from inception (November 2005) through the end of June 2007 the site has received 1,999,778 hits. Although the website received a large number of visitors and hits, and strong endorsement from the clinical and educational community, the number of adolescents engaged in this service was minimal (as indeed is the case for other treatment modalities). Upon completion of the pilot project funding was not continued and the websites are no longer operational. The chief reason cited for the project termination was a lack of clients to warrant service continuation.
Although the pilot project described above was not successful, lessons from the development of online smoking cessation and hazardous drinking sites aimed at adolescents and young adults may aid in the development of a more effective youthoriented online problem gambling intervention. In an evaluation of an online smoking cessation site, focus groups with college students indicated that a lack of time and interest discouraged use of social support features (Escoffrey et al., 2004). However, other interventions with demonstrated effectiveness have incorporated peer-support into a wider program (An, Klatt et al., 2008). Alternative, apparently successful, components include tailored feedback directing clients to relevant information and resources, interactive exercises and quizzes with automatic feedback, email reminders and prompts, email communication with therapists and content and formatting relevant to a youth audience (whether adolescent or young adult).
Due to the apparent reluctance of youth to recognise the seriousness of their gamblingrelated problems, an important component of an online gambling treatment for youth may be an Internet-based assessment with automatic, personalised normative feedback.
Receiving feedback on how their gambling behaviour compares with that of their peers may encourage adolescents and young adults to consider taking steps to modify their gambling involvement. Furthermore, recruitment strategies can be used to encourage all youth to complete online assessments and these can be actively encouraged or mandated within schools and universities and by health care providers.

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United States of America
The Problem Gamblers Help Network of West Virginia has announced plans to launch a free online-chat service with gambling counsellors by the end of December, 2009. The network aims to encourage young gamblers who are familiar with Internet-based communication to seek help. The network, which currently runs the 1-800-GAMBLER helpline plans to use existing counsellors to chat with clients to provide referrals to appropriate services as opposed to offering counselling online.
Online interventions
Positive outcomes in randomised controlled trials of Internet interventions for public health have been reported across a wide range of clinical outcomes including asthma management, care giving stress, breast cancer coping, chronic pain, congestive heart failure symptom monitoring, diabetes self-management, falls prevention, headache management, multiple risk-behaviour change, cardiac rehabilitation, HIV prevention, medical decision making, cognitive stimulation in Alzheimer’s, mental health disorders, dietary change/physical activity, organ donation, paediatric encopresis, prostate screening, sexually transmitted disease prevention, stress management, tinnitus distress and weight loss (see Bennett & Glasgow, 2009).
According to a meta-analysis that reviewed 40 well-designed outcome studies, online self-help treatments appears to be more effective than no treatment at all and just as effective in most cases as treatment administered by therapists (Scogin, Bynum, Stevens,
& Calhoon, 1990). Furthermore, online interventions appear to be more effective than traditional self-help programs. Klein (2002) found that individuals spent less time in
Internet-based CBT for panic disorder compared to a print-based self-help manual condition. This study also found that education levels were more likely to influence treatment outcomes of the print self-help materials compared to the Internet-based program, suggesting that Internet interventions may be more broadly used than printbased self-help programs.
Online interventions for addictions
Problem drinking
There is an urgent need to improve online intervention programs offered for problem drinking. Following an extensive search (Toll et al., 2003), only five of 68 alcohol treatment-related sites provided online treatment. Seventy percent of treatment sites applied 12-step facilitation, and only 4% focused on motivation strategies. Few sites provided references (13%) or outcome data (7%) on the treatments recommended. In a qualitative review, Copeland and Martin (2004) identified five published papers on
Internet-based interventions for problem drinking, but only one controlled trial. In another literature review, Kypri, Sitharthan, Cunningham, Kavanagh, and Dean (2005) identified nine acceptability studies, together with seven efficacy trials.

58
A more recent systematic review of the best available evidence on the effectiveness of web-based interventions aimed at decreasing alcohol consumption was conducted by
Bewick et al. (2008). These authors analysed the results of papers published before May
2006. Similar to previous studies, the review provided inconsistent evidence on the effectiveness of online interventions. Interpretation of data was constrained by methodological weaknesses such as the absence of control groups and outcome measures.
These results highlight the need for legislators to consider regulating website offering health or mental health advice and/or treatment to ensure that high standards of quality of care and appropriate empirically-based programs are provided.
Another recent meta-analysis of the effectiveness of online brief, single-session personalised-feedback interventions to reduce problem drinking without therapeutic guidance found this to be a viable and probably cost-effective option for student and the general population (Riper, van Straten et al., 2009). Furthermore, where web-based personalised feedback alone was compared to web-based feedback with additional selfhelp materials, results were found to favour the combined intervention (Cunningham,
Humphreys, Koski-Jones, & Cordingley, 2005).
There is also evidence that online and computer-based interventions appear to outperform face-to-face therapy. White (2006) found more favourable results for written and computer-based personalised feedback interventions than for face-to-face individual or group interventions; Walters and Neighbors (2005) found similar results.
A 6-week online drinking program based in the UK ( Down Your Drink ) found that those who completed the program had significantly reduced alcohol dependency and alcoholrelated harm compared to baseline scores (Linke et al., 2007). Mental health symptoms were also significantly improved including reduced risk of harm to self and others and improvement in subjective well-being and daily functioning. The program was based on the stages of change model and contained components common in brief interventions including Motivational Enhancement Therapy, CBT, and relapse prevention. The program included an automated drinking diary and consumption calculator, online quizzes, interactive behavioural analysis of drinking situations and emails or textmessages sent to mobile phones with reminders and controlled-drinking trips. The site was also associated with an online forum where users of the program could exchange personal messages about their experience with the program and obtain peer support for their efforts in reducing their drinking. Women, users with a partner, and users without children were more likely to complete the program.
Drinking Less (http://www.minderdrinken.nl) is an evidence-based online interactive self-help intervention without therapeutic guidance based in the Netherlands. The program is designed to curb problem drinking among the adult general population (Riper,
Kramer et al., 2009) and is based on motivational, cognitive-behavioural and self-control training principles that aim to reduce alcohol consumption rather than promoting abstinence. The program consists of 3 components; five 25 minute long television episodes following two real life participants and their coach; a 5-chapter course manual corresponding to the television episodes; and the online drinking program. In a research

59 trial participants were mailed a DVD of the television episodes, the course manual and given access information for the web component. Participants are encouraged to complete the course in 6 weeks but, given the self-help nature of the intervention they may use it for as long as they feel is necessary.
Six- and twelve-month follow-up data revealed significant improvements in terms of drinking outcomes compared to a waiting-list control group indicating the online program can be used effectively to help adults in the broad community (Riper, 2009). While 91% of participants completed the program, the website was used by only 18% of participants and drop-out rates were high with 59% not completing the online program at the sixmonth follow-up. Data analysis found that one in 16 site visitors started the program,
90% of program participants were seeking help for the first time and estimates indicated that the program reaches 2-25% of problem drinkers in the Dutch population. A new online visual screener is being developed to make the program more accessible to lower socio-economic groups and individuals from various cultural and ethnic backgrounds.
The screener will include pictures, audio and text-based questions for drinking, mood and anxiety to increase comprehension and increase questions comprehension and accuracy of responses.
An online drinking program was tested with 857 employees from a northern California company who were invited to participate in a 20-minute online intervention (Westrup et al., 2003). A total of 229 participants were randomly assigned to receive limited feedback or more comprehensive feedback related to their alcohol risk and stress and coping indices. The majority (82%) of participants completed all phases of the study and at 90day follow-up, 8% reported improvements in alcohol consumption, 29% experienced benefits in stress reduction, and 30% indicated positive changes in coping. Similarly to other findings, the majority (77%) of those who completed the study were women.
A brief Internet assessment and feedback program was launched in Finland targeting problem drinking (Koski-Jannes, Cunningham, Tolonen, & Bothas, 2007) that provided users with personalised normative feedback on their consumption of alcohol. The service was very popular with 22,536 tests completed over a seven month period out of a population of approximately 5 million Finnish speakers. Responses showed that the large majority of users were well above the limit of problem drinking indicating that the service was being used by the intended population. Feedback found 93% of participants reported the test and personalised feedback to be useful and the service appeared to be more appealing to women. Follow-up measures showed a significant reduction in levels of problem drinking, number of drinks consumed and negative consequences of drinking.
Problem drinking Internet interventions for young adults
Due to their propensity to drink to excess (Hingson, Heeren, Winter, & Wechsler, 2005;
Karam, Kypri, & Mariana, 2007) and their accessibility and knowledge of Internet technology (Escoffrey et al., 2005), college students have been targeted for online alcohol interventions.

60
In an online survey of a random sample of 1,564 university students (82% response),
Kypri, Saunders, and Gallagher (2003) found significantly greater support (82%) among hazardous drinkers for online interventions than for health education seminars (40%) or practitioner-delivered interventions (58%). A pilot randomised controlled trial of
Internet-based screening and brief intervention for New Zealand university students found significant reductions of 20% to 30% in hazardous drinking levels (Kypri et al.,
2004). In a further trial, university students who were identified as hazardous or harmful drinkers received a single web-based motivational intervention or additional web-based motivational interventions one and six months (Kypri et al., 2008). Participants reported statistically significantly less alcohol consumption and fewer problems at six and 12 month follow-ups compared to the control group, but the provision of up to two additional sessions did not increase the efficacy of the intervention. The treatment effects were of modest effect size but were of the same order as those for screening and brief intervention delivered face-to-face.
Chiauzzi et al. (2005) compared an interactive website with personalised feedback to an education-only website. The interactive website included access to reference materials, tailored motivational feedback about high-risk drinking, ask-an-expert services, peer stories, and emergency information among other resources. Participants (students who reported binge drinking in the last week, n=265) worked through four weekly 20-minute sessions. Results showed both groups made meaningful reductions in their drinking and reported significantly fewer negative consequences. Students rated the experimental intervention significantly higher in areas of content and message delivery than the education-only online group. Furthermore, the experimental intervention resulted in positive findings for three subgroups: women, persistent heavy drinkers and those with low-motivation to change at the outset of the intervention. These findings are significant in that they demonstrate the usefulness of a harm-reduction approach amongst a typically hard-to-reach population of heavy drinking young adults.
Another set of online alcohol interventions were evaluated by Walters, Hester, Chiauzzi,
& Miller (2005). First-year university students (n=138) were randomly assigned to receive online personalised feedback or online personalised feedback, a workbook, and a
50-minute face-to-face workshop. At 4-week follow up, both groups reported significant reductions in drinking. In a second trial, 190 first-year students were randomly assigned to receive the workbook and face-to-face group or a CD-ROM application containing reference information and role-playing scenarios. Half the students in each condition also received the online personalised feedback. At 4-week follow-up, there was a marked reduction in drinking among participants who received both the workshop and book and online personalised feedback.
Brief online interventions also appear to be effective in reducing hazardous drinking amongst young adults. Neighbors et al. (2009) reported results of a trial of Internet-based personalised feedback interventions specifically targeting 21 st
birthday heavy drinking.
Participants completed an online screen and received normative information with feedback on their intended drinking behaviour two days before their 21 st
birthday as well as protective behavioural strategies (e.g., avoiding drinking games, limiting the number

61 of drinks, avoiding drinks that contain multiple shots). Results showed the intervention to be effective at reducing estimated blood alcohol concentration, although it was still on average above the legal limit of .08.The intervention was particularly effective in reducing estimated drinking amongst participants who had intentions to drink heavily.
Support was found for the use of normative feedback especially normative perceptions of
21 st
birthday peer drinking. In contrast, no support was found for protective behavioural strategies. Importantly, results did not indicate that those with lower drinking intentions increased their drinking in response to feedback that other youth planned to drink comparatively more indicating that normative feedback is unlikely to be harmful. This research supports the use of specific event-based interventions for youth people that may be applied to other high risk behaviours, for example gambling interventions could target youth at the time of March Madness, sports playoffs and the Super Bowl, times that are associated with increases in youth gambling.
A trial of an Internet alcohol reduction intervention for college students found that students who completed a brief online screen for problem drinking and received personalised feedback found it easy to use, personally relevant and would recommend it to friends (Hallett, Matcock, Kypri, Howat, & McManus, 2009). The intervention prompted help-seeking behaviour with 30% of participants accessing additional information on support services through the website.
Despite the positive impacts of online interventions targeting youth, Wang and Etter
(2004) found a low proportion and low rate of return among respondents less than 20 years at a multi-lingual internationally-targeted smoking cessation online site. This may indicate that to be successful for youth, online interventions must be specifically tailored for this age group.
Online support groups for problem drinking
An online support group for problem drinkers (www.alcoholhelpcenter.net) provides a forum for the discussion of drinking. Visitors can view the content, however, only registered users can make postings and trained professional staff moderates all support group content (Cunningham, van Mierlo, & Fournier, 2008). Content analysis of postings made in the first 10 months of operation identified common themes. During this time
32% of the 155 registered members had posted at least one message and of 64 messages posted, 30% were posted by the support staff (Farvolden et al., 2009). Prominent themes included statements of encouragement, support and individual coping and success strategies (Cunningham et al., 2008). Also common were questions and answers about the support group and statements describing what motivated change and hopes and fears for the future. Other content included introductions to new group members, greetings, success stories, and discussion of difficulties.
The study also found that several members were highly active and dominated discussions, and that when they left the group, postings decreased. The authors hypothesised that this effect may decrease as the group grows in size. Due to the small size of the group moderators often prompted and participated in discussions, greeting

62 new users and providing high quality advice for members. Cunningham et al. (2008) concluded that although there is little evidence indicating that anonymous Internet-based support groups serve as a substitute for proven methods of treating alcohol abuse, expertmoderated and anonymous online social support may be a useful tool for problem drinkers who do not have access to, or do not access traditional face-to-face interventions.
Moderation Management is an alcohol self-help organisation motivated to target nondependent problem drinking and allow moderate drinking goals that offers face-to-face and Internet-based meetings. An evaluation study (Humphreys & Klaw, 2001) found that significantly more online-only members were female and appeared to have significantly greater alcohol-related problems and drinking severity. Those who accessed the online groups had higher levels of education but were less likely to attend face-to-face meetings.
Participants indicated that they accessed the online self-help groups due to the ease of accessibility, convenience of being able to access groups when they wanted (e.g., outside of work hours), increased privacy, lack of face-to-face meetings in their area, and greater comfort with writing rather than speaking in front of a group. A gender comparison found that women were more likely than men to endorse accessing the group due to greater ease at expressing feelings and experiences in writing compared to speaking in a group, and wanting to access the group at any time of day.
Smoking cessation
Internet interventions may represent a highly effective medium to assist a large number of individuals in quitting smoking. Estimates suggest that over eight million Americans search online each year for information on how to stop smoking (Fox, 2005). However, an early review of the websites available to assist with smoking cessation found that most sites were of mediocre quality and the highest quality websites attracted few visitors
(Bock et al., 2004; Etter, 2006). The majority (>77%) of websites did not provide direct guidance or assistance in quitting and those that did generally failed to adhere to components of treatment recommended by national guidelines (Bock et al., 2004). A more recent study (Bock, Graham, Whitely, & Stoddard, 2008) of web-assisted interventions for smoking cessation revealed that, similar to prior studies (Bock et al.,
2004; Etter, 2006), individuals searching for help for smoking cessation would experience difficulty finding appropriate websites. There was a notable lack of personalised feedback, interactive features, and a failure to provide follow-up contact.
These findings highlight the urgent need for qualified organisations to provide highquality websites offering personalised feedback, interactive features, practical counselling and Internet-based therapist contact. These sites should be prominently advertised and organised so they are easily reachable through basic Internet searches. The provision of a high-quality website by a recognised and accredited organisation may vastly improve the usage and effectiveness of online smoking cessation interventions.
Furthermore, research is needed to determine methods to increase usage of online interventions and reduce attrition rates. While a large number of potential clients may reach an online smoking cessation program, steep declines are typically seen in continued participation, which limits exposure to and the potential effectiveness of online

63 interventions (Eysenbach, 2002). A study by Lenert reported that site users completed only an average of two of eight smoking cessation modules (Lenert et al., 2003). Feil reported a higher number of return visits for women than men, although 10% of participants accounted for 79% of the total site visits, suggesting limited site use by the majority of clients (Feil, Noell, Lichtenstein, Boles, & McKay, 2003).
One of the oldest online substance abuse intervention programs is QuitNet
(http://www.quitnet.org). Launched in 1995, the site claims to attract over 3,000 visitors per day and have around 23,000 registered members from 160 countries (Copeland &
Martin, 2004; Saul et al., 2007). It provides advice on smoking cessation and personalised interactions which provide feedback on annual amounts smoked and the associated costs in terms of money spent and impact on life expectancy. Once a user has stopped smoking the site provides ongoing monitoring and feedback including noting of
“anniversaries” such as one month and six months since the last cigarette.
In addition to educational information and individualised assistance in formulating plans for smoking cessation, the site also offers a range of online forums enabling users to communicate with and support each other through the processes of quitting and avoiding relapse. Approximately 2,000 messages per day are posted in public forums with thousands more exchanged privately (An, Schillo et al., 2008). In addition, online counsellors answer individual questions and website staff moderate forums and host chat sessions (Saul et al. 2007). The QuitNet website has an “open” design that is intended to give users easy access to all site features. Access to the general “quit” services are free but there is an option for a paid “premium membership” which entitles users to additional features. The site is well managed, well published and attractive to users.
Several studies have examined the efficacy of QuitNet . An uncontrolled evaluation study at 12-months for smokers recruited from a workplace population found that participation resulted in quit rates that ranged from 13% to 43% (based on actual follow-up data and intent-to-quit analysis) (Graham et al., 2007). Higher website utilisation was associated with better cessation outcomes, even after for controlling for baseline motivation.
A study of self-selected participants (n=607) who registered for the Internet-based tobacco cessation program during a 2.5 month period in 2004 found that of 471 respondents at 6 months, 17% had not smoked in the past 7 days resulting in a quit rate of
13.2% (Saul et al., 2007). The authors argued that the Internet-based program has a greater impact than telephone quitlines and produces better outcome rates than those expected for unassisted quit attempts. An analysis of site usage examined the utilisation of different tools offered to users (n=607) (An, Schillo et al., 2008). Use of informational resources was more common than passive or active engagement with the online community. Nearly 80% of participants used the interactive quit planning tools at least once and nearly two-thirds used these more than four times. Over half the participants viewed informational resources and the interactive diagnostic tools were used by 45% of participants. Only 5% of participants posted one or more questions to the expertmoderated forums. Passive engagement with the online community (i.e. reading discussion boards) was more common (38%) than active engagement (i.e. posting

64 messages) (24%). There was a positive association between self-reported 30-day abstinence and use of general information resources, interactive quit planning tools, counsellor services, active community engagement, and one-to-one messaging. Neither passive community engagement nor use of the interactive diagnostic tools was significantly associated with abstinence. Neither demographic data nor smoking-related data significantly predicted abstinence although utilisation of interactive quit planning tools was. Results suggest that treatment program operators may have to redesign sites and programs to place more emphasis on and encourage use of community and expert forums to take advantage of the potential benefits of these features.
A French-based smoking cessation website (http://www.Stop-tabac.ch), launched in
1996, is available in five languages. In addition to educational information, forums, referral contacts, and a range of interactive tests, the site includes an assessment and very thorough personalised feedback report (Copeland & Martin, 2004). The report includes objective feedback about smoking rates, costs involved, perceived risks, high risk situations, and a range of cognitive and behavioural strategies tailored to the requirements of the individual. Users are required to register so progress over time can be incorporated into subsequent feedback reports. The intervention has empirical support for its effectiveness and is estimated to produce one ex-smoker for every 28 participants (Etter
& Perneger, 2001). Between June 1998 and March, 201, 18,361 people from 112 countries used the program (Wang & Etter, 2004). When compared to the distribution of smokers in the general population in seven countries, smokers in the action stage (11%) were overrepresented among the online program users; furthermore those in the action stage of change were most likely to return to the site (Wang & Etter, 2004). This indicated that the website is successful in attracting and retaining smokers who are ready and motivated to quit.
In a randomised controlled trial, Etter (2005) compared this original site with a shorter modified program that provided more information on nicotine replacement and nicotine dependence. Abstinence rates at follow-up were higher for those in the original program than those in the modified program.
Online self-help programs do not appear to be sufficiently effective on their own.
Interactive tailored elements of web-based interventions appear to be important in increasing positive outcomes. An evaluation of a web-based cessation program for smokeless tobacco users (http://www.ChewFree.com) found an interactive, tailored website was significantly more effective than a more linear, text-based website in a randomised trial with 2,523 participants (Severson et al., 2008). The basic site presented the intervention material in a static, textual format characteristic of many informational websites including a text-guide for quitting, a resources and links section, all with printable material. The enhanced site included a guided, interactive program to help each user create a tailored plan for quitting and preventing relapse, streaming video, a broader range of printable resources, links to other sites and a peer-support forum and ‘Ask an
Expert’ forum. Participants in this condition were also forwarded up to three tailored emails based on predefined schedules. Compared with the basic site, quit rates for participants in the enhanced condition were significantly higher at each assessment point

65 consistent with other research reporting that tailored web-based programs are more efficacious than non-tailored sites (e.g., Etter & Perneger, 2001; Strecher et al., 2005;
Swartz et al., 2006). Ratings of overall satisfaction and ease of use were also significantly higher in the enhanced condition.
Happy Ending , based in Norway, is a fully automated and digitally delivered smoking cessation intervention (Brendryen & Kraft, 2008). Until week 11, the intervention has multiple daily contacts and is highly intensive, but from week 11 onwards the intervention switches to a markedly lower intensity. At the start of the intervention, the user receives an email early in the morning each day for six weeks with instructions on how to open that day’s page. The client is also contacted via cell phone and receives one pre-recorded audio message and up to three text messages throughout the day. Each evening the client receives a proactive call that asks whether or not they have been smoking and this may trigger a relapse prevention intervention via pre-recorded audio message relating to the specific number of lapses reported. If the user does not log onto the program or answer the evening call, they receive a reminder call and up to two reminder text messages. A craving helpline is also available 24 hours a day from day 15
(cessation day).
In a randomised controlled trial, 400 participants were allocated to the Happy Ending online intervention or a control condition (44-page self-help booklet received in the mail) and both groups received free nicotine replacement products that could be used if desired and ordered via email (Brendryen & Kraft, 2008) To a large extent subjects in the online condition adhered to the intended program, however few clients called the craving helpline. In total 45 (out of 197) participants discontinued the online intervention, half of whom did so in the first six weeks, but the majority completed assessment surveys.
Program satisfaction was high with 93% reporting the program to be ‘helpful’ or ‘very helpful’. Seven-day abstinence (at 1, 3, 6, and 12 months) was significantly higher in the treatment (22%) than control group (13%), and the treatment effect was not mediated by nicotine replacement therapy adherence indicating the psychological support provided by the program was successful. The online intervention resulted in improved levels of postcessation self-efficacy among both current smokers and non-smokers.
The Australian-based QuitCoach (http://www.quitcoach.org.au) is a tailored, Internetdelivered smoking cessation advice program, designed to replicate many of the core features of in-person multi-session cessation counselling (Balmford et al., 2009). It provides detailed cognitive-behavioural support and advice on the use of pharmacotherapy, tailored to answers users provide in an online assessment. It is designed to be used on multiple occasions, guiding the user through the process of smoking cessation in the manner of a life coach.
Smoking cessation Internet interventions for young adults
Similar to positive attitudes found amongst young adults for online versus face-to-face interventions for problem drinking (Kypri et al., 2003), young adults appear to have positive attitudes towards online smoking cessation programs (Escoffrey et al., 2004). A trial of an Internet-based smoking cessation program amongst young adults found

66 participants were more engaged in the program activities, rated their treatment more favourably and had quit for more consecutive days at 3- and 6-month follow-ups compared to participants who received an in-person counselling session and traditional print-based self-help materials (Abroms, Windsor, Simons & Morton, 2008). The online intervention was introduced in an in-person session and consisted of a self-help kit, but was augmented by 10-12 counselling emails tailored to the individual participant.
Participants were encouraged to reply by email to their counsellors with questions and comments, and to update their counsellors on their cessation progress. Emails were sent weekly for the first month and then monthly for the following five months. Additional emails were sent around the participant’s quit date.
Although all participants received the same cognitive and behavioural techniques from the self-help guide and in-person session, those in the online condition were more likely to have adopted these and have made a quit attempt. The majority of participants (92%) read “most” or “all” or their emails indicating that this is an appropriate medium to communicate with young adults. Another online smoking cessation program incorporated content of general interest to young adults, weekly reminder emails, interactive quizzes with tailored feedback, behavioural monitoring, peer-support via weekly emails from peer coaches, and weekly incentives ($10 gift card) (An, Schillo et al., 2008). Compared to a control group, participants had increased short-term abstinence rates. Although longterm quit rates were not found, given that this study included participants who had no immediate plans to quit, an emphasis on taking breaks from smoking may encourage quitting attempts in the future.
Online support groups for smoking cessation
Social support has been found to be effective in helping tobacco users quit (Coppotelli &
Orleans, 1985; Gulliver, Hughes, Solomon, & Dey, 1995; Ockene, Benfari, Nuttall,
Hurwitz, & Ockene, 1982); however, it is unclear how effective online social support is for smoking cessation. Burri, Baujar, and Etter (2006) conducted a qualitative analysis of the content of an online support group for smokers. They concluded that the support group was mainly used as a source of support and encouragement during the initial phases of quitting. Practical information and tips for quitting were less common. A free
Internet-based smoking Intervention, StopSmokingCenter.net
provides registered users with personalised feedback and interventions and offers peer support through a moderated support group (Farvolden et al., 2009). Analysis of the dataset gathered from the site between November 2004 and May 2007 allowed the comparison of registered members who actively participated in the online support group and those who did not. Of the 16,764 registered members, 14,202 did not post anything in the support group and
2,562 made at least one post. Posters were more likely to be slightly older (40.4 vs. 38.6 years old), have smoked for longer (21.6 vs. 19.5 years) smoke more cigarettes per day
(22.1 vs. 20.3) and be female (70.1% vs. 64.6%). The authors do not state whether these differences were statistically significant.
Reporting on a smoking cessation website ( QuitNet ) with online social support, Cobb et al. (2005) found that 3-month maintained quitting rates among visitors were highly related to how many times chat rooms were visited. Use of the online social support,

67 which included threaded forums, internal emails and chat-rooms, was associated with more than three times greater cessation and with more than four times greater likelihood of continuous abstinence for more than 2 months. Social support mediated the relationship between intensity of use and 7-day point prevalence abstinence, suggesting that active involvement in a support community is a key ingredient to quitting smoking.
In another interactive tobacco cessation site that included a peer-support and ‘Ask an
Expert’ forum, significantly higher quit rates were found compared to a static site
(Severson et al., 2008). A substantial proportion of participants (38%) posted to the peersupport forum, but only 5% posted on the expert forum, although others may have
“lurked” on both sites. No data was collected on the relationship between use of social support elements and treatment effectiveness, but these results suggest that online support may need greater promotion within online interventions to maximise the utility and subsequent benefits of this treatment component.
In contrast, Stoddard et al. (2008) found that the addition of a bulletin board to an online smoking cessation intervention did not have an impact on quit rates. Few participants
(12%) utilised the bulletin board to view or post a message limiting the ability to analyse the impact of this element. The authors posited that the low use rates may be due to an observer effect (participants knew they were in a research study and posts may be analysed) or to slow response rates (typically a few days after the post was made).
Furthermore, other research has shown that former smokers are significantly more likely to become active members of an online support community than those who are planning a quit attempt (Etter, 2005). Finally, to be successful, bulletin board communities may require a much larger number of members than was possible in a limited research trial.
Substance abuse
There are very few online interventions designed to assist individuals control or reduce their use of illicit substances. Websites have been launched by various governments and organisations in an attempt to provide individuals with information about the use of illicit drugs and tips and strategies for reducing use and assisting those who have substance abuse problems. In Canada a cannabis website (www.WhatsWithWeed.ca) focuses on young adults, takes a harm reduction perspective, and assists participant in making informed choices about their cannabis use (Cunningham & van Mierlo, 2009). Available on this site is the Check Your Cannabis Screener in which participants answer questions about their cannabis use and receive personalised feedback with normative data and an indication of the severity of their cannabis use. The goal of the screen is to allow participants to evaluate their own cannabis use in a non-judgemental setting and with a harm-reduction perspective. The screen collects demographic information (age, sex, country of origin), asks questions about frequency of cannabis use in the last 12 months, amount of money spent on cannabis and screens for alcohol, smoking and substance abuse.
Upon completing the screener participants are provided with a report including a pie chart and summary that compares the participant’s cannabis use to others of the same age and sex. The report includes a summary of the amount of money spent on cannabis and

68 the individuals’ severity of substance use and an interpretation of what this means. In the first 12 months of use the screener was used by 986 individuals, of which 59% (n=580) were taking the test for themselves. The majority were male (73%) and resided in Canada and indicated moderate risk of cannabis severity (70%) as compared to high risk (24%) or low risk (6%). No information has been provided on the impact of the screen on young adults, but linking the screen with the cannabis website was more effective than listing it on a standalone site.
Eureka – A Second Life island for addiction prevention and treatment
A team based in Italy are in the process of creating a Second Life island for addiction prevention and treatment termed, Eureka (Gorini et al., 2008). Eureka is a virtual immersive environment organised around three different but interconnected areas: the
Learning area, the Community area, and the Experience area. The goal of the Learning area is to use motivation provided by virtual worlds to teach users about how to improve their living habits. The Learning area is organized around different learning areas, both without and with teachers (classes). In this area, users learn how to manage daily choices and activities, acquire general and specific information about addiction, and get the information needed to succeed, with daily tips and expert ideas. The goal of the
Community area is to use the strength of virtual communities to provide real-life insights aimed at improving living habits. The Community area is organized around different zones in which users discuss and share experiences among themselves with or without the supervision of an expert (physician, psychologist, nutritionist, etc). In the Learning and Community areas, users enjoy support and guidance, learn how to make wise choices and live healthily, and benefit from the exchange of practical experiences and tips from other users. The goal of the Experience area is to use the feeling of presence provided by the virtual experience to practice both emotional and relational management and general decision-making and problem-solving skills. This area includes different zones, presenting critical situations related to the maintenance and relapse mechanisms (Stores,
Pub, Gaming venues, etc). Each of these environments is experienced only under supervision.
In all three areas, the user is helped to develop specific strategies for avoiding and/or coping with their problems. After the experience, the coach explores the patient’s understanding of what happened in the virtual experience and the specific reactions— emotional and behavioral—to the different situations experienced. If needed, new strategies for coping with the situations are presented and discussed. In all three areas, type and intensity of care will vary depending on the type of intervention (e.g., prevention vs. treatment).
The authors argued that compared with other Internet therapeutic applications, 3-D virtual worlds provide users with a more immersive and socially interactive experience.
In addition, these provide a feeling of embodiment that has the potential to facilitate clinical communication processes and positively influence group interaction and cohesiveness in group-based therapies. However, there is no research to date examining the impact or effectiveness of this form of therapy for mental health or addictions. There is also no infrastructure existing to support the application of clinical settings to virtual

69 worlds. An organisation would have to make arrangements to ensure all ethical procedures including confidentiality were upheld while providing appropriate clinical care that may involve obtaining clients’ identity and locations. It may be difficult to prevent external interferences and protect privacy in such an intervention.
Additionally, the vast majority of virtual worlds have high subscription costs that may be too expensive for private therapists of non-profit organisations. For example, in February
2008, the price for an island in second life was US$1,675 plus a US$295 monthly fee
(Gorini et al., 2008). Furthermore, setting up a private area on second life requires specific expertise that may increase the expense for an organisation that does not already employee an experienced computer programmer. Without further evidence to support the effectiveness of 3-D virtual interventions, the technical, ethical and economic issues make such an intervention a less valid opportunity than other forms of online treatment.
Online interventions for problem gambling
Tailored feedback
Few online interventions exist for problem gambling, but some evidence supports its potential effectiveness. In a study conducted with a sample of international gamblers recruited online, participants were provided with automated personalised feedback on their gambling behaviour (Wood & Williams, 2009). The majority of participants
(65.2%) reported that the interactive feedback (how normative their gambling behaviour was, projection of yearly expenditures, explanations of why certain beliefs held were gambling fallacies, risk of becoming a problem gambler, current score on PGSI, etc.) was
‘somewhat’ or ‘very useful’, with this percentage being significantly higher for problem gamblers (70.6%). Furthermore, 33.5% of problem gamblers reported that they expected their gambling behaviour would decrease subsequent to receiving the feedback. This suggests that online interventions providing personalised feedback and educational information could have a potential impact on reducing problem gambling as well as beneficial effects for non-problem gamblers.
A personalised feedback intervention for problem gamblers in which participants were mailed summaries based on a battery of assessment instruments found these individuals reported spending less money on gambling than control subjects at 3-month follow-up
(Cunningham et al., 2009). The feedback materials included a brief statement of the purpose of the report (“help to give you a picture of your gambling and let you know how your gambling compares with other Canadians”) then provided a summary of gambling behaviour with a comparison of how this compared to other Canadians of their sex
(Cunningham et al., 2009, p220-221). A graph was also included to visually demonstrate where their gambling fits in comparison with other Canadians. Feedback was also given on CPGI score along with an interpretation of what it meant and a list of the actual problems the participant indicated.
The next section included a description of irrational beliefs endorsed and a summary of cognitive errors. Finally, feedback included a list of techniques individuals could use to lower the risk associated with their gambling. Almost all (96%) recipients who responded to the 3-month follow-up survey felt that the feedback materials should be made available

70 to other people who wanted to modify or evaluate their gambling. The most positively endorsed element was the feedback on their PGSI score and the other elements were also positively evaluated in terms of usefulness. Although these results are from a pilot study they suggest that brief screening and feedback interventions could be very useful for gamblers and problem gamblers and suggest a full research evaluation is merited.
An online version of the intervention is now available (www.CheckYourGambling.net).
The assessment is short and can be completed in five minutes with the feedback brief taking 10 to 20 minutes to read. It offers an online screen in English or French that allows individuals to check how their own gambling behaviour compares to that of individuals similar to themselves. The screen includes five pages and takes approximately five to ten minutes to complete. Questions include frequency of betting on different forms of gambling, typical gambling expenditure, irrational thinking or behaviour strategies and the individuals’ thoughts and feelings about their gambling. These questions generate a report that immediately summarises information provided and reports where they are in comparison to others from their country. They are also told their problem gambling index score outlining levels of risk for being a problem gambler. The report includes accurate information about irrational beliefs and behaviours and tips on how to gamble in a responsible, low risk manner. The aim of the online screen is to assist individuals in assessing their own behaviour and being aware of whether they may need to alter their gambling or seek additional help or treatment.
A strength of the site is that it offers private, anonymous feedback in an objective and non-judgmental manner and encourages self-awareness and reflection. This intervention has not been empirically tested, so the impact on individuals is unknown; however, given support from prior trials (Cunningham et al., 2009; Wood & Williams, 2009), this intervention may yield positive benefits for problem gamblers although further research is needed to investigate the efficacy of this intervention.
Online support groups
A search conducted in February 2009, for gambling support groups online through the popular search engine ‘Google.ca’ found 13 currently active groups devoted to the topic of problem gambling. Most of these groups are open only to members, although the majority are anonymous and free to join. Several offer multi-lingual services including email and chat-based counselling to individuals located around the world. One site,
GamblingTherapy.org
, reports that thousands of clients have used the services, and other forums receive hundreds of posts on forums/bulletin boards each month. This sample search reveals only the easily found gambling support groups and related traffic online.
Of concern, many sites did not list adequate contact information or provide information about the facilitators. Two sites had notices indicating that the server was due to close and the sites would be terminated unless appropriate action was taken. This search revealed that appropriate online help for gambling is difficult to find and locating a qualified group facilitator and counsellor online may be difficult for potential clients.
This situation could be remedied by credible websites of organisations such as the Centre for Addiction and Mental Health (CAMH) including advice for individuals looking for online support groups and therapy for problem gambling and links to credible sites.

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It is important to note that Internet-based support groups (including bulletin boards and chat sites) are not intended as treatment interventions, but rather serve as an adjunct support service where peers can seek and provide advice for others impacted by problem gambling. Very few studies have been conducted to study the impact of online support groups for problem gambling making it difficult to evaluate the efficacy of these forums for assisting gamblers and concerned significant others. However, the research that is available indicates that Internet forums may be useful and beneficial, particularly for those who would not otherwise seek help for example due to fear of stigma, discomfort in face-to-face situations (Cooper, 2004; McGowan, 2003a; Wood & Wood, 2009).
Gender specific forums
McGowan (2003a) examined a women-only online newsgroups-style forum for problem gambling issues designed as an adjunct to face-to-face support groups. The forum aimed to provide relevant information and facilitate mutual support to assist the processes of recovery in the tradition of GA. Posts on the discussion forums follow the GA tradition of sharing personal stories and common themes included: losing control, loss of material goods and experience of legal consequences, and feelings of shame and self-loathing.
Posts also indicated the women’s appreciation of hearing others’ stories and realising that they are not alone resulting in the construction of an online women’s only community that shared their experiences of suffering and offered empathic acceptance. A third category of themes concerned social and moral reconciliation in the process of recovery from problem gambling including the positive consequences of staying with the GA program.
In addition to posts by problem gamblers, the online forum provided space for professional perspectives where therapists and other experts regularly posted articles about problem gambling and the therapeutic processes. Although the group included a space for professional opinion (which was written in a narrative style in contrast to academic discourses), this is a departure from the tradition of GA, and some embedded references to experts indicated an undercurrent of distrust remains, with a preference for mutual support. Additional benefits of the group included the needs met by genderspecific support groups and ability to write and communicate in a highly expressive and emotionally demonstrative style that is reportedly missing in men-dominated GA groups.
The evaluation of this online group for female problem gamblers indicated that members derived significant benefits from the online community and these benefits were directly related to aspects of the Internet including narrative/written communication, dislike of male-dominated face-to-face meetings, accessibility, and convenience and immediacy.
GAweb
In an exploratory study (Cooper, 2004), a 41-item survey was completed by 50 pathological gamblers recruited from GAweb , a peer-support group, that was available from 1986 to 2001. Participants had a mean age of 43 years, were generally welleducated, evenly divided by gender (52% male) and the majority were married or in a common-law relationship, employed and resided in large urban centres in America.

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Overall, 80% of participants reported attendance at some form of face-to-face intervention at some stage in their lives (GA and/or treatment). Despite this, 78% reported that they had avoided going to a face-to-face self-help group or treatment on occasions, for a range of reasons related to stigma, concerns about confidentiality, unwillingness to make a commitment, discomfort about personal disclosure and inconvenience.
The majority or respondents stated that their exposure to GAweb had :
•
•
Increased the likelihood that they would continue returning to that website (86%)
Increased the likelihood that they would seek out additional forms of Internet selfhelp (76%)
•
Increased the likelihood that they would attend face-to-face GA meetings (78%)
•
Increased the likelihood they would seek face-to-face treatment services (50%)
The majority also reported that the opportunity to engage in lurking behaviour
(anonymously reading the postings of others without detection) increased the likelihood of their disclosing gambling problems both online and in face-to-face meetings and treatment. The site appeared to be helpful given that 70% of respondents indicated that
GAweb made a difference to their gambling behaviour. Positive factors included the ease and immediacy of access regardless of geography or weather, and anonymous nature of the site that increased their levels of honesty. Many also reported that they were helped through the online archives of previous postings that were always available. For 20% of the sample, GAweb was the only means of help used to deal with gambling problems.
This may suggest that for some, online forums may be the only support they are able, or willing, to receive, while for others it is a useful adjunct to treatment interventions.
However, as this study utilised a self-selecting sample it is difficult to make generalised conclusions about other problem gamblers who seek help online.
U.K. Internet forums for problem gambling
A recent study examined two U.K. online forums designed to support people with gambling problems and others affected by problem gambling (e.g., partners, relatives and friends) (Wood & Wood, 2009). The two forums examined were the GamCare forum and the Gambling Therapy forum, both of which have been operating for several years through organisations that provide numerous other forms of support services. At the time when the study was conducted, there were approximately 8,000 registered members across both forums, around half of those classified as “active” in that they had logged in at least once in the last six months.
A content analysis of sixty posts identified that the forums served a variety of purposes including:
•
Forum members providing advice or information to another member (38% of posts)
•
A supportive statement (37% of posts)
•
Personal stories (25% of posts)
•
Requests for help and answers to specific questions (24% of posts)
•
Personal statements (10% of posts)

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•
Introductions by new members (8% of posts)
Online interviews were conducted with 19 self-selected participants (10 female), 17 of whom had or were experiencing gambling problems, and two who were married to someone with a gambling problem. Analysis of discussions revealed several significant perceived benefits of the online forum including:
•
•
Feeling less along through shared personal experiences
•
A sense of community and friendship providing a means of mutual support
Assistance with self-discovery and insight through reading others posts and the process of writing their own thoughts down
•
Increased feelings of accountability to themselves and other forum members through regular posts
•
Being reminded of how bad things can get through reading other’s posts, deterring potential relapses and assisting with resisting urges
•
Learning about problem gambling and different strategies for dealing with problems
•
Convenience and accessibility, particular for those who were either geographically remote or who could not attend other services because of commitments such as child care
These themes were used to construct an online questionnaire that was completed by 121 participants (53 male; 52 female 16 unknown) aged between 18 and 61 years (M = 41;
SD = 11). Participants were mostly white in ethnic origin (96%), two-thirds were from the U.K., with other participants from the U.S. (14%), Australia (11%), Canada (7%),
Sweden (1%) and Finland (1%). The majority of participants (62%) found one of the forums by searching for help on the Internet, with others referred via gambling websites
(15%), websites for problem gambling (10%), a friend or relative (6%), telephone helpline (3%), from a professional (3%) or from a sign on a gambling machine (1%).
Most participants had been a member of one of the forums for several months (40%), or for a year or more (31%). Half the participants reported that they used one of the forums every day, and 39% reported using a forum a few times a week. There was no significant association between gender and frequency of forum use.
Most participants accessed one of the forums because they were personally experiencing some kind of gambling problem (67%), because they were no longer experiencing gambling problems and wanted some support (17%), or because they were seeking help for a partner, relative or friend (16%). Females were more likely to be seeking help regarding other’s gambling problems and males were more likely to be seeking support as recovered gamblers. The majority of participants (58%) reported having contacted another support service at some stage in the past. This was most likely to be a face-toface support group (30%), a telephone helpline (17%), a doctor (9%) or residential treatment (3%). For those who had used other services previously, the online forum was used due to a preference for help online (56%), additional help (48%), convenience and accessibility (17%), dissatisfaction with previous services (15%) and a desire for a second option (9%). Almost half of participants reported it would be either fairly difficult

74 or extremely difficult to get alternative help (49%) indicating that the online forum is reaching a group of individuals who would not otherwise receive help.
Specific reasons for using the Internet-based forums included the ease of access (80%) and constant accessibility (70%), ability to talk to others in the same situation as themselves (73%), anonymity (49%), and a dislike of discussing gambling issues on the phone (27%) or face-to-face (21%). Participants were very positive about the efficacy of the forums in helping them with their problems. The vast majority of participants found the following features either somewhat useful or very useful:
•
•
Being anonymous (90%)
•
Writing a continuous personal diary (57%)
•
Telling their own story (88%)
•
Asking for help from other members (81%)
•
Getting professional advice (56%)
•
Reading other people’s stories (98%)
•
Having 24 hour, seven days per week access to the forum (97%)
•
Having a specific section to discuss non-gambling issues (40%)
•
Discussing Gamblers Anonymous matters (42%), and
Writing responses to other forum members (87%).
There were no significant gender differences in relation to the utility of any of the forum features.
As with previous studies, interpretation of these results requires caution due to the small, self-selected sample utilised. However, until more extensive studies are completed they provide useful insight into the use and benefits of Internet-based support groups for problem gambling.
GamTalk
GamTalk was launched in October, 2008 as a nation-wide free online support service for anyone with gambling issues in Canada. Initially sponsored by the Nova Scotia Gaming
Corporation, GamTalk provides opportunities for people who wish to discuss their own personal gambling issues, concerns about a friend or relative, or swap advice on how to gamble safely and in moderation. Modelled after similar forums that exist in the U.K., the service offers anonymous forums that are all facilitated by a moderator and an online live chat section. The various forums include:
•
•
An introduction section where new members can introduce themselves
•
Chatroom feedback
•
My Story – where members can tell their story
•
Overcoming Problems – members discuss difficulties and strategies for recovery
Progress Diary – members record their progress and share their thoughts, feelings, and experiences
•
GA Talk – for specific GA issues
•
Family and friends – for concerned significant others

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•
Strategies to hep avoid developing problems – for those who don’t want to quit gambling but need assistance on staying in control
•
The lounge – for non-gambling related topics
•
Feedback and suggestions
•
A forum in French
As of December 2009, GamTalk (www.gamtalk.org) had 569 members, an increase from
234 members in March 2009, largely as a result of Google advertisements in the form of sponsored links to particular searches (Wood, 2009). Analysis of known IP locations
(60%) shows that the majority of members are Canadian (53%) with members also from the US (30%), the Netherlands (7%), the UK (4%) and other countries. Of Canadian members, 29% are based in Ontario, 24% in Alberta, 20% in the Atlantic Provinces, 8% in British Columbia and Manitoba, 7% in Saskatchewan and 4% in Quebec. The various forums have resulted in 294 unique discussion threads and 2,277 posts. Approximately
150 different visitors who may or may not be members are logged each day ant there are approximately 3,000 unique visitors each month, with members reportedly lurking first before making a post. The site also lists other resources including helpline numbers, other support services, and other international online forums for gambling issues. The site also includes contact details in the form of an email address, allowing members to contact the facilitator directly with concerns or issues.
To date only preliminary research has been conducted to examine the usefulness of the site for problem gamblers. An online survey for all GamTalk users was completed by 55 participants (79% female). The majority of respondents reported initially visiting the site for help with problem gambling (56%) although respondents also indicated they wanted to ask questions (32%), help with quitting (24%), and for another person (15%).
Advantageous features of the site included being able to talk to people in a similar situation (65%), remain anonymous (62%), easy access (56%), not face-to-face (35%), dislike of phone calls (32%) and nothing else available locally (29%). Respondents indicated that they use GamTalk most commonly to read posts but also sometimes make posts about their thoughts and experiences, ask questions, offer advice and record progress. Just over half (53%) of participants had contacted alternate gambling support services and a significant proportion indicated they occasionally or regularly saw a faceto-face counsellor (33%), used telecounselling (11%), another forum (11%), a support group (6%) or a doctor (6%). Of these participants (n=29) the majority indicated they used GamTalk for extra support (62%), as they preferred online support (33%), it was difficult to access other services (17%), they didn’t have the time (17%), were not satisfied with other help (11%) or other services cost too much (6%) or raised child care issues (6%). Participant responses to questions indicated that using the site may increase their likelihood of using another support service (54%) or talking about their gambling issues with others (48%) and that they felt somewhat more informed about their own gambling behaviour (64%), gambling issues (79%) and other support services (79%).
Participants also ‘strongly’ or ‘mostly’ agreed that GamTalk:
•
•
Provides a helpful community to talk to (76%)
•
Made them feel less alone (72%)
Gave them hope for a better future (53%)

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•
Helped them gain better control of their gambling behaviour (39%)
•
Enabled them to talk about gambling issues (39%)
•
Helped organise their thoughts (48%)
•
Reminds them of how bad things can get (70%)
This research provides some preliminary evidence that users gain benefits from the
GamTalk site, however the use of a small, self-selected sample means that results may not be generalisable. Further systematic, empirical research would provide valuable information regarding what elements of this service assist gamblers in their recovery without seeking formal treatment.
Characteristics of clients seeking online assistance
Little is known about the characteristics of individuals who use online interventions for addictions including whether they are broadly representative of the population affected by addictions and whether they differ from those who seek traditional forms of treatment.
It is important to understand the population online interventions are reaching and whether this method is reaching individuals who would not otherwise receive help.
A study was undertaken by Hall and Tidwell (2003) to describe the users of online interventions for substance abuse (including nicotine) and alcoholism. A total of 928 surveys completed by active users of online interventions for addictions were analysed.
Overall, twice as many women (66%) as men (34%) responded to the survey indicating that women are more likely to complete online surveys, a finding consistent with other research suggesting women are more likely than men to use online interventions (e.g.,
Postel, DeJong, & DeHann, 2005; Westrup et al., 2003). Participants primarily resided in the U.S., however, Canada, and 18 other countries were also represented, including 12 non English speaking countries. The average age of users was 46 years and participants ranged from teenagers to seniors although 70% were aged between 36 and 55. Users were predominantly White (91%). More than 97% report program affiliations with only one or two online recovery programs (e.g., Alcoholics Anonymous or Narcotics Anonymous).
There was a great deal of variety in time spend using online interventions, with about one-third reporting a year or less of time online in recovery programs, about one-third reporting one to four years and about one third reporting four years or more.
Problem drinking
A study of online interventions for problem drinking found that individuals who used web-based alcohol interventions were more likely to be female, more highly educated and likely to be employed, and older than patients in face-to-face treatment (Postel et al.,
2005). These findings may relate to the increased stigma that women experience related to alcohol problems and their discomfort with traditional male-dominated treatment groups, and hence their preference for the confidentiality and anonymity offered online
(Finfgeld-Connett, 2006). In addition, women may be more likely to use online interventions for the convenience and accessibility as they tend to be more ‘time-poor’ than men due to struggles with domestic and child-rearing demands.

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In contrast to these findings, Linke et al. (2004) found that of 1,319 registrants of a website offering a 6-week program for problem drinking, the majority were male (56%).
Similarly, Saitz et al. (2004) found that 66% of members of a site offering an online alcohol intervention were male. However, Saitz et al. (2004) noted that whereas men are five times more likely than women to present for hazardous drinking in primary care settings (Fiellin, Reid, & O’Connor, 2000), in the online sample the prevalence of male hazardous drinkers was only between one and two times that of females. Furthermore, the proportion of women drinking hazardous weekly amounts was higher than for men.
These results suggest that online interventions may be particularly useful for women who otherwise might not have hazardous drinking identified or assessed, although more research is requiring the impact of online interventions based on gender.
Researchers have suggested that online interventions have greater potential than traditional treatment to reach more elderly individuals, particularly as familiarity with
Internet technology increases (Postel et al., 2005). However, Saitz et al. (2004) found that the majority of registrants for an online intervention for problem drinking were aged
18-24 years (30%) or 25-34 years (33%), with few (1%) 65 or older. A meta-analysis of online brief personalised feedback interventions for problem drinking found that these programs appear to be more readily accepted by both young and mature risky drinkers, as the unobtrusive nature of the intervention allays feats of stigmatisation and violation of privacy (Riper, van Straten et al., 2009).
Internet-based problem drinking interventions appear to be successful in targeting an appropriate population of heavy drinkers. In an evaluation of nearly 40,000 users of a brief online drinking intervention, 90% reported drinking hazardous amounts, 88% reported binge drinking, and 55% reported typically exceeding weekly risky drinking limits (Saitz et al., 2004). Similarly, Riper, Kramer et al. (2009) found that 95% (n=360) of participants who completed an online drinking intervention had excessively high weekly alcohol intake and/or were experiencing alcohol-related problems. Furthermore,
83.6% of users had never sought professional help for their alcohol problems (Riper,
Kramer et al., 2009). Similarly, based on the responses of participants who completed a
6-week online problem drinking intervention and returned the feedback questionnaire,
74% (n=27) stated that they had never sought help for their drinking previously and 90%
(n=34) had not received any additional help other than the online intervention (Linke et al., 2004). These findings indicate that online interventions are successfully reaching a population who need assistance, but have not previously sought formal treatment.
Evidence also exists that online alcohol treatment has the potential to reach underserved groups, such as minorities and marginalised individuals. (Finfgeld-Connett, 2006). Linke et al. (2004) found that clients accessed the site either from home (57%) or work (38%) although they were not frequent Internet users with 91% reporting they used the Internet for less than 1 hour per day and had never previously sought health advice online. This feedback indicates that the online problem drinking program was not restricted to those familiar with Internet technology or who accessed the Internet at a high rate. In contrast, a study of users of an online smoking cessation program in the Netherlands found more than two-thirds were highly educated and four-fifths were in paid employment (Riper et

78 al., 2009a). As such individuals typically have high rates of Internet use this suggests that online interventions may be helpful for a wide range of individuals regardless of other
Internet use.
In an investigation of which client characteristics predict better outcome from an online problem drinking intervention, Riper et al. (2008) found that, of those who had received prior help for alcohol problems, women and more highly educated individuals appeared slightly more likely to derive benefits from the intervention but there were no clear predictive factors. These results indicate that online interventions are well suited for a heterogeneous group of individuals and could be offered at the general population level.
Furthermore, these results suggest that Internet-based self-help may be particularly attractive for problem drinkers with greater fears of stigmatisation, including women and more highly educated people, population segments that might otherwise be difficult to reach with traditional treatments (Riper et al., 2008).
In a survey of members of an Internet-based problem drinking site, Moderation
Management (Humphreys & Klaw, 2001), participants reported choosing to seek help online for a variety of reasons including: easy access to a computer (69%); ability to access the program at any time (38%); finding it easier to write about feelings and experiences than to speak about them in front of a group (25%; females=35%, males=13%); and online participation being easier to attend than meetings (23%).
Smoking cessation
In an investigation of smokers, Stoddard and Augustson (2006) found that smokers using the Internet tended to be younger, employed, more educated, and more affluent than
American smokers who did not use the Internet. Internet-connected smokers also reported less psychological distress, fewer barriers to healthcare, and a greater interest in quitting smoking. The latter difference points to the importance of emphasising information about preparation for quitting as well as reinforcing messages to support smokers in their decision to quit using online cessation programs. No differences were found between male and female smokers in respect to their Internet access suggesting that results from studies showing females are more likely to access online smoking interventions (Cobb et al., 2005; Fox, 2005) are not related to accessibility but more likely to be related to a higher interest in assistance with tobacco cessation (Stoddard & Augustson, 2006).
In a comparison of users of an Australian smoking cessation site (QuitCoach), a smoking cessation hotline (Quitline), and smokers, online interventions were typically used by current smokers with higher than average levels of nicotine dependence, although less addicted than those who sought help from the Quitline service. Younger smokers were more likely to use the QuitCoach, particularly those aged 25-44 years, as were female smokers, and QuitCoach users were more likely to report previous quit attempts than smokers in general. The authors concluded that given the reduced prominence of the online intervention, the site is attracting those more likely to seek help and those with greater need. Furthermore, smokers with no recent quitting experiences were relatively

79 more likely to seek out the site before actively planning to quit, presumably to help them make a decision as to whether to try and find out what they might expect.
Client suitability for online interventions for problem gambling
Women
Despite population data that suggest men and women are equally likely to gamble, men are more likely to seek treatment for problem gambling (Crisp et al., 2000). For example, an evaluation of problem gambling treatment in Ontario found that men constituted a greater proportion (66%) of clients seeking help for gambling problems than women
(34%) (Rush & Urbanoski, 2004). There are a number of reasons explaining these findings. Females seeking assistance from health or welfare professionals are less likely to be routinely assessed for gambling problems (Downing, 1991; Mark & Lesieur, 1992).
The paucity of women in treatment may also imply that existing programs fail to take into account needs and issues that are predominantly of concern to women, such as child care, sexual assault and domestic violence. Women who enter treatment programs designed for men may find that program staff do not have the expertise or resources to deal with problems that are specific to their gender (Reed, 1985). An investigation of the gender specific treatment needs of problem gamblers found that traditional programs originally designed for men should be modified to suit the needs of female problem gamblers, for example by being provided in gender neutral settings with a greater emphasis placed on supportive counselling (Crisp et al., 2000). Data from problem gambling helplines suggests that women are more likely to seek help than men, but are less likely to utilise treatment interventions (Bellringer, Pulford, Abbott, DeSouza, &
Clarke, 2008), indicating that women recognise the need for treatment, but these needs are not satisfactorily met by existing.
Although the number of women seeking help for problem gambling is increasing, 12-step support groups have predominantly involved middle-age men (McGowan, 2003a).
Conventional 12-step support groups are not perceived as ‘woman friendly’ and are criticised for failing to acknowledge gendered aspects of addiction and recovery, as well as reinforcing stereotypical ideas and practices concerning women (Doyal, 1995;
Harrison, 1997; Kast, 1990 as cited in McGowan, 2003a). The experience of maledominated dynamics in GA groups has prompted many women not only to seek out, but actively create alternatives such as women-specific support groups both online and offline (McGowan, 2003b). As with face-to-face therapy, Internet support groups and group therapy also appear to be subject to gender-bias based on a review of relevant literature suggesting that online interactions are not gender neutral (McGowan, 2003a).
However, online groups do allow individuals to gather from various locations for a specific purpose, for example, creating a women’s support group or online therapy group for problem gambling would be entirely possible. Indeed, a study of an online support group/newsletter, Women Helping Women (www.femalegamblers.info), for women problem gamblers revealed that this is a valid and useful approach for participants
(McGowan, 2003a).
The advantages of online therapy and support groups for women cited by participants included:

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•
Being able to identify with the stories of others and related to other members of the group
•
Overcoming the shame, guilt, and embarrassment associated with face-to-face meetings
•
Lack of guilt over missing meetings due to a lack of alternative child-care arrangements
•
Empathy, understanding and group support
•
Anonymity, safety and security
•
Equality in numbers
•
Empowerment through dialogue between women and the choice and actions of making changes (Freestone, 2008)
A Pew Internet Project survey between January and June in 2005 indicated that women slightly outnumbered men in the U.S. Internet population (Pew Internet & American life
Project, 2005). While various measures suggest that men are slightly more engaged with their Internet use than women, at the same time women are closing the gap. In particular, compared with men, women are more likely to use the Internet to send and receive email, look for health and medical information, and use emails and websites to discuss and get support for health or personal problems. Furthermore, women appear to use the Internet in a richer and more engaging way. They are more likely than men to use emails for communication and feel satisfied with the role of email in their lives, especially when it comes to nurturing relationships. The study showed that more women (43%), than men
(33%), said that communicating by email has improved relationships with family members (Pew Internet & American life Project, 2005). Additionally, more women than men stated that the email brought them closer to their family and friends, and that they have learned more about their family and friends. These results indicate that online textbased communication appears to satisfy deep, emotional needs for women and that this is an appropriate mode of communication for personal thoughts and feelings, perhaps more so than face-to-face interaction.
Men
While men are more likely to engage in treatment for problem gambling than women
(Rush & Urbanoski, 2004) numerous authors have described the characteristics associated with interest and successful engagement in traditional psychotherapy, including being emotionally expressive, vulnerable, intimate, as being in contrast with the values of the male culture and norms (Good, Gilbert, & Scher, 1990; Kelly & Hall, 1992;
O’Neil, 1981a, 1981b; Robertson & Fitzgerald, 1992; Rochlen, 2001; Wilcox & Forrest,
1992). Overall, men of varied nationalities, ethnicities, racial backgrounds, and ages seek professional help to a lesser extent than women (Addis & Mahalik, 2003). In a study addressing men’s perception of different theoretical approaches to counselling, Rochlen and O’Brien (2002) found men preferred a more directive approach over a more contextual, emotional oriented approach. Although research on gender differences in treatment are limited, data from the BreakEven problem gambling intervention based in
Victoria, Australia suggest that when gender differences in treatment-seeking are controlled for, men are less likely to complete treatment than women (Crisp et al., 2000).

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The atmosphere and conditions of Internet therapy may not encompass the levels of expressiveness and vulnerability involved with face-to-face counselling that men may find off-putting. One study showed that whereas women generally show more interest in traditional counselling than men, attitudes towards Internet counselling show no such gender differences (Rochlen, Beretvas, & Zach, 2004). Further research showed that men with self-described discomfort expressing emotions demonstrated a preference for online counselling as opposed to face-to-face therapy (Rochlen, Land, & Wong, 2004).
Evidence of this relationship supports the cited benefit of Internet therapy as appealing to populations who are uncomfortable with verbal expression and as such, less likely to seek therapy. Further support for the effectiveness of Internet therapy for men comes from a study directly comparing the effectiveness of Internet-based CBT and face-to-face group
CBT for sub-threshold depression (Spek, Nyklicek, Cuijpers, & Pop, 2007). Significantly fewer men dropped out of the Internet-based treatment (7%) than the group treatment
(23%). Although the authors do not indicate a reason for this difference, together with previous results it may suggest that Internet-based CBT may be more suitable for men than group therapy due to the anonymity and reduced discomfort with expressing emotions in public.
Youth
Although typically seen as an adult pursuit, increasing numbers of adolescents and young adults are engaging in gambling and experiencing gambling-related problems. Studies from Australia, Canada, the US and UK that have assessed the rate of problem gambling among adolescents (aged 12-17 years) have found rates of problem gambling typically 2-
3 times that found in adults (Delfabbro & Thrupp, 2003; Derevensky & Gupta, 2004;
Ipsos MORI, 2009; Shaffer & Hall, 2001). Young adults aged 18-24 also appear to have significantly more gambling-related problems than any other adult age cohort (Delfabbro,
2008; Derevensky, 2009; Welte, Barnes, Wieczorek, Tidwell, & Parker, 2001). Gambling amongst youth is particularly disconcerting as young gamblers are more likely to engage in alcohol and drug use and abuse/dependence, develop significant psychiatric problems including pathological gambling, substance use and mood disorders (Lynch,
Maciejewski, & Potenza, 2004).
Young people have specific barriers when it comes to accessing mental health services
(Owens et al., 2002). These include both structural barriers of time, costs, and travel, and personal barriers such as being overwhelmed with unfamiliar issues. Because of these and other obstacles, the majority of adolescents who require services do not receive them.
There is also evidence that adolescents prefer to seek help from informal sources, such as family and friends, than formal supports, including school counsellors and mental health professionals (King et al., 2006). Research indicates that the Internet is rapidly becoming a major source of health information for adolescents (Gray, Klein, Noyce, Sesselberg, &
Cantrill, 2005). Preliminary research indicates that adolescents regard the Internet as appealing because it is an accessible and anonymous method of seeking help (Gray et al.,
2005; Nicholas, Oliver, Lee & O’Brien, 2004).
High rates of Internet use amongst young adults and college students (Pew Internet and
American Life Project, 2002), have prompted the trial of several online interventions for

82 smoking and alcohol use. There are several reasons that make online interventions advantageous in seeking to treat high-risk behaviours amongst youth. Firstly, the confidentiality and nonjudgmental quality of the Internet may increase the potential for youth to divulge personally relevant information, which may facilitate knowledge, attitude or behavioural changes (Chiauzzi et al., 2005). Compared with paper-and-pencil questionnaires, computerized programs for young people increase self-disclosure in sensitive areas, such as risky sexual behaviour, excessive alcohol use, marijuana use, and family problems (Paperny, Ayono, Lehman, Hammar, & Risser, 1990; Turner et al.,
1998). The anonymity and accessibility of the Internet may allay young people’s concerns about seeking help, especially their fears about being personally identifiable
(Gould, Munfakh, Lubell, Kleinman, & Parker, 2002; Skinner, Biscope, & Poland, 2003), which is particularly important for interventions for illegal activities such as underage gambling.
A further advantage of online interventions is the ability to assess a large and vulnerable population in a cost-effective and confidential manner and provide relevant resources to those in need. For those without Internet access in their homes, websites can be easily accessed from computers in schools, colleges, libraries and Internet cafes. Adolescents and young adults can complete online screening questionnaires in private and at their convenience and receive automatic and personalised feedback to determine their need for further intervention and be directed to relevant resources. There is evidence that brief online feedback that sets an individuals’ gambling behaviour against social norms is perceived as being useful for non-problem and problem gamblers and may encourage behavioural change (Wood & Williams, 2009). Although youth may be sceptical about discussing high-risk and illegal behaviours with a health practitioner, parent, or other adult, they are interested in how their behaviour compares with that of their peers
(Doumas, McKinley, & Book, 2009). Online feedback interventions appeal to this curiosity while reducing apprehension associated with talking to a professional.
Furthermore, research indicates that youth respond better to electronic feedback than to in-person feedback regarding high-risk behaviours such as drinking (Kypri et al., 2003;
Larimer & Cronce, 2002; Saunders, Kypri, Walters, Laforge, & Larimer, 2004).
Internet interventions can be tailored to be relevant for the individual accessing it, providing customised information, exercises and support based on their reported problems, age, gender, stage of readiness and needs. This is particularly useful for problem gambling interventions given the variety of forms (e.g., electronic gaming machines, sports wagering, online gambling) and reasons for gambling (e.g., risk-taking, boredom, social pressure, emotional escape). Tailoring program content is more likely to be read, remembered, and viewed as personally relevant (Brug et al., 1999; Dijkstra & De
Vries, 1999), which may ultimately increase program utilisation and effectiveness.
Internet-based interventions also enable users to control their learning environment, move at their own pace, and receive information on demand (Cheiten & Walters, 1995). This may encourage youth to access the interventions at a time convenient to them and when they are at the appropriate stage of readiness for change. The convenience of online programs allows youth to access therapeutic support from experts or peers at any time if

83 they need advice, counselling, or have any questions. Online programs overcome barriers to traditional treatment including geographical isolation, inability to attend individual or group sessions due to timing, transport or conflicting commitments, fears of stigmatisation and/or privacy concerns.
Older adults
A significant majority of older adults participate in gambling and subsequently experience problem gambling. In a survey of 1,500 adults over 60 taken from a study of
5,000 adults in Ontario, 74% of older adults had participated in some type of gambling activity in the past 12 months (Wiebe, Single, Falkowski-Ham, & Mun, 2005). Although the vast majority of the sample did not experience any gambling-related problems, 2.1% had moderate or severe problems. Problem gamblers were more likely to have low incomes and be single adults aged between 60 and 65. A study of older adults in Quebec found rates of problem gambling (1.2%) were comparable to those reported elsewhere in
Canada and the US for senior citizens, but that the at-risk gambling rate (1.6%) was significantly higher than the current one for the general population of the overall
Province of Quebec (Phillippe & Vallerand, 2007).
While Internet use continues to be populated largely by younger generations, larger percentages of older generations use online facilities more than previously, according to the Pew Research Center’s Internet and the American Life Project survey for 2006 to
2008 (Pew Internet & American life Project, 2009). The biggest increase in Internet use since 2005 can be seen in the 70-75 year-old age group. While 26% of adults aged 70-75 were online in 2005, 45% of that age group is currently active online. Email is the most popular activity by older adults, with 74% of Internet users aged 64 and older sending and receiving emails. Compared with teens and Generation Y (ages 18-32), older generations use the Internet less for socialising and entertainment and more as a tool for information searches, emailing, and buying products. In particular, older Internet users are significantly more likely than younger generations to look online for health information. Health questions drive Internet users aged 73 and older to the Internet just as frequently as they drive Generation Y users, outpacing teens by a significant margin.
Since 2005, broadband Internet access has increased dramatically in the U.S. across all age groups, but older groups are still largely unconnected to high-speed Internet, with only 16% of adults aged 73 and above having broadband access at home.
A randomised controlled trial was conducted with individuals (n=301) aged 50 to 75 with sub-threshold depression to evaluate the effectiveness of self-help Internet cognitive behavioural therapy (Spek, Nyklicek et al., 2007). Many participants reported not seeking help through the regular health-care system because they were very concerned about being stigmatized. Results demonstrated that there were no significant differences between the Internet intervention and group therapy and that both treatments were significantly more effective than the waiting list control. The completion rate for the
Internet-based intervention was only 50% as compared to 95% for the group course. The authors attributed this to a lack of social interaction and support although there was little active effort to increase active participation in the online condition. The main reason given for not completing treatment was lack of time. Participants on average completed

84
78% of the 8 Internet modules and 98% of the 10 group sessions. These findings suggest that older adults can benefit from Internet-based interventions and such treatment options may increase treatment seeking amongst individuals who would not otherwise seek help.
Minorities
Ethnic minorities are often underrepresented in problem gambling treatment agencies
(Raylu & Oei, 2004). Shame has been found to be a major factor in preventing some ethnic minorities (e.g., the Chinese) from accessing problem gambling treatment services
(Raylu & Oei, 2004). A number of other cultural factors may also explain low presentation rates; these include different inclination to seek assistance, negative attitudes towards treatment, treatment available not being sensitive enough to attract ethnic minority problem gamblers, limited knowledge of the availability of services, stigma associated with problem gambling, insufficient social and financial resources to support treatment entry and behavioural change, negative experiences with the immigration process and language problems (Oei & Raylu 2007; Raylu & Oei, 2400). Furthermore, a number of cultures (e.g., the Chinese) are more likely to rely on self-help techniques than professional assistance (Oei & Raylu, 2007; Raylu & Oei, 2004). Therefore, online treatment may be more suitable for ethnic minorities with gambling problems, particularly because they are more confidential than other treatments.
Section three
Recommendations and necessary components of Internet therapy and online interventions for problem gambling
The available data to date suggests that certain components of Internet therapy and online interventions are essential in the assessment, implementation and evaluation. The following recommendations are offered for consideration.
Assessment
•
Self-conducted assessments should be an initial component of all online interventions to assist individuals in evaluating their need for further help.
•
Assessments should be based on empirically-validated tools and provide automated feedback that is easily comprehended. Feedback should indicate an individual’s level of risk and steps to be taken to reduce potential harm; for example, direct clients to an online treatment program or other local services (telephone helpline or face-to-face treatment).
•
If possible, assessments should attempt to screen for individuals who need more intense help than can be provided online, for example, by asking about suicidal ideation, severe, ongoing depression, and psychosis.
•
Assessments may be conducted online using an automated tool, using email or chat, or through telephone or face-to-face interview.
•
Assessment with detailed normative feedback may act as a stand-alone intervention or be part of a more comprehensive online treatment.
Registration

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•
Registration is an important component of an online intervention as it allows users to keep track of progress, return to point last visited, and progress systematically through a program.
•
Registration can maintain anonymity and privacy by requiring users to register with an anonymous email address and username (e.g., hotmail or yahoo account) or provide actual identifying information including address and point of contact in case of emergency.
•
Registered accounts may be deactivated after a certain period of inactivity to protect privacy.
•
As part of the registration process, an explanation should be provided to participants of the research purposes for which their data will be used. This should clarify that anonymity will be maintained and all research is aimed at improving the services provided by the site. They should be given the contact details of a researcher, whom they can contact at any stage over their use of the site. Registration completion can then be taken as informed consent provided that research projects have been approved by an appropriate institutional ethics review board.
Tailored normative feedback
•
Tailored normative feedback following assessment may be a stand-alone intervention or the first stage of a more comprehensive intervention.
•
Feedback should be automated and immediate and should provide a detailed, easy to comprehend report as relevant as possible to the individual. For example, data should be matched to the individual’s gender, age range, culture, and nationality. Feedback may be specific to the form of gambling identified, address irrational thoughts identified and key negative consequences. Feedback should direct clients to a range of options based on their level of risk to enable individual choice for an appropriate response (e.g., more information, online treatment, face-to-face treatment).
•
Feedback may be stored to enable repeat assessments at different stages of treatment with a comparison of progress.
Tailored content
•
The content of a treatment program should be tailored as specifically to the individual client as possible. Following assessment, the client should be directed to the most appropriate content based on their gender, culture, and age, level of problem gambling, motivation for change, previous treatment and most problematic form of gambling. This will maximise the effectiveness of the treatment and reduce attrition by increasing the relevance to the client.
•
Written information, audio and video material may all be tailored.
•
Tailoring can be accomplished by a closed design whereby clients can only access sections of the site that the automated program allows. This design may require multiple versions of the program to be developed and run simultaneously.
Alternatively, clients may be able to access the entire program but are directed via personalised messages to the most appropriate sections and tools available on the site.
Program content

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•
All therapeutic content should be based on empirically-validated therapeutic techniques where possible.
•
Content should be technologically sophisticated to take advantage of interactive features and engage users without preventing use by those who lack technology capacity. For example, a site can be offered as a plain HTML site as well as an interactive site, for example using Java capabilities
•
Material should be presented in audio and visual formats as well as written form.
•
Programs must be Mac and PC compatible and work may be done to develop a site that has PDA compatibility.
•
Programs should include a range of therapeutic techniques to suit a broad range of clients. For example, information should be provided in written form (with an option to print the information easily) as well as using audio and video tools. Clients should be able to complete assignments, quizzes and short assessments that test the knowledge learned and provide automated, immediate feedback.
•
Clients should also complete writing exercises. The process of writing is an important element of Internet therapy and online interventions. This process helps clients understand themselves and their own experiences in a clear and organised way, which increases empowerment and control over actions and decisions (Barak et al., 2008).
Writing may be completed for the clients to keep themselves or to be emailed to a therapist or posted on an online forum. The increased sense of anonymity provided by sending emails to a therapist or writing posts in an online support group increases honesty and self-disclosure, which in turn solicits guidance and feedback from the therapist or support groups members that can aid in recovery and enhanced personal well-being.
Program contacts
•
Online interventions may include automated contacts with the program, for example daily or weekly emails with tips, reminders of useful tools, progress reports, success stories.
•
Contacts may also be personalised, for example weekly emails from a designated counsellor to provide feedback on progress and answer any questions.
•
Email may be the preferred contact method for clients. SMS messages to cellular phones may also be useful if technological capacity exists.
•
Clients should be able to modify account settings, for example the number of email or
SMS contacts received, indicate whether they are willing to complete progress or follow-up questionnaires and be notified of new features.
Motivational phases
•
In addition to cognitive-behavioural techniques, motivational interviewing components should be incorporated to any online treatment program. This is particularly important for those who have not reached the action phase of change
(Prochaska & DiClemente, 1992) or are not ready to cease or reduce gambling.
•
Motivational components should be included in the beginning of all online treatment programs to assist individuals in starting and completing the program.
Online forums

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•
Online forums may be an important component of any online intervention as this enables clients to discuss relevant issues with other individuals who can identify with similar difficulties.
•
Online forums should be viewed as a support mechanism and adjunct to therapy, but not as a form of treatment.
•
Users must register on a site before they are able to make posts on forums to protect users, respect the forum and reduce spam.
•
Members should be encouraged to create anonymous nicknames and not to post any personally identifiable information.
•
Registration must also involve explicit agreement with a user agreement. Key features of a user agreement (based on the user agreement of the Ontario-based
AlcoholHelpCenter.net; Cunningham, van Mierlo, & Fournier, 2008) include, but are not limited to: (1) members agree to only post messages that are directly related to the gambling or problem gambling; (2) an agreement to treat other members respectfully and avoid profanity; (3) the acceptance of a “three-strike” rule in the rare case of user agreement infractions.
Contacts
•
Sites should include the professional qualification and affiliations for websites and therapists to establish site credibility.
•
Contact information must be provided for clients to contact a site administrator through email, telephone and physical address.
•
Help should be available for technical inquiries to assist individuals with creating an account and installing any relevant programs.
•
Professional help may also be provided through email or forum contacts with a psychologist or counsellor.
•
Clients must be provided with information of where to access help in case of an emergency and if more intensive care is required including details of a telephone helpline or directions to local services.
Research
•
Research is an essential component of online therapy and interventions given the lack of empirical evidence on their effectiveness.
•
The most successful research will be planned prior to creating and launching a site as the appropriate measurement tools and data collection procedures can be built into the program.
•
Brief measurement tools can be built into a program, for example, screeners that are repeated at certain stages of therapy.
•
The nature of online interventions enables all data to be collected, stored and analysed appropriately to evaluate the effectiveness of the program.
•
Computerised text analysis enhances the ability to evaluate the treatment. All sessions, completed tools and measures, and emails are transcribed, recorded and create a database of text which can be analysed. From this, keywords can be identified and linked with concepts and outcomes allowing words and terms that lead to change to be recognized and incorporated into the treatment. Treatment outcome

88 and compliance can also be easily tracked, again allowing treatment to be modified and improved where possible.
•
As research results become available programs can be modified immediately.
•
Direct feedback can also be sought from clients through questionnaires placed on the site or emailed to clients. Feedback options can be integrated using Web 2.0 features, for example, seeking comments at various points on the site. Such feedback can be analysed and immediately used where appropriate to modify the program.
Conclusion
Individuals dealing with addictions including tobacco use, problem drinking, substance abuse and problem gambling appear to be willing to use the Internet to seek therapy or online treatment. Furthermore, some governments, organisations and treatment providers have already begun to expend financial resources on such services. To reduce problems associated with individuals accessing unregulated and unethically conducted Internet treatment sites, there is a need for health care providers and reputable organisations to provide useful, evidence-based sites that provide appropriate treatment information in an easily accessible manner. Ideally individuals should make decisions to use Internet therapy or online interventions based upon informative research data. In addition, government and organisational funding decisions should also be informed by research evidence. Unfortunately, the best evidence regarding treatment efficacy comes from randomised controlled trials, and in this area such trials are hard to find. Given the newness of the Internet as a treatment delivery option, there is limited evidence to support the effectiveness of online therapeutic programs for addictions. Furthermore, research trials of Internet-based programs are often limited by self-report, and in some cases do not have sufficient control groups or random allocation. Recruitment methods for research trials may also not reflect real world participation in online programs.
However, the evidence that is available suggests that both Internet therapy and online automated, tailored interventions may be very successful in assisting those who would not otherwise seek treatment in controlling their addictions and related problems.
There are many key advantages of providing online treatment options for problem gambling and addictions. Seeking professional help online allows clients to maintain privacy and anonymity, thus reducing fears of stigma, shame and guilt that may act as a barrier to treatment. Clients may still provide identifying information if necessary, and retain a sense of perceived anonymity without damaging therapist rapport and treatment success. The Internet is highly accessible allowing clients to access help at a place and time that is convenient to them regardless of geographical isolation or time commitments and constraints. Many treatment components can be completed at any time without the need to pre-commit to a particular appointment time increasing the likelihood of clients accessing services. Programs can be created to fit with a stepped-care model of therapy as clients can access appropriate help regardless of their stage of change or previous interaction with help services. Clients can use online programs when considering seeking help, while waiting for help services to be available, as an adjunct to face-to-face therapy, or following therapy for relapse prevention and ongoing maintenance and support. The anonymous nature of online care enables clients to test the service and come back at any stage or time without experience shame or guilt at previous failed attempts. Online

89 programs can be tailored to suit the individual client thus increasing effectiveness and reducing attrition. Importantly, Internet interventions can be easily modified based on client feedback and research findings, enabling programs to increase in effectiveness as they progress.
Given the high number of problem gamblers who do not ever seek professional support,
Internet therapy and online interventions may provide an important role by making treatment accessible to those who would not otherwise seek help. Programs can be created at various levels of intensity and be modified for placement where most effective for the target population. More research is required to identify potential clients and society’s response to an online problem gambling treatment, how best to launch and market such a service and essentially, to monitor and evaluate a program to measure and increase effectiveness. Internet treatment may provide a cost-effective, brief intervention that fits into a stepped-care mental health program to provide effective help for those who require assistance with their gambling problems or addictions.

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