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Internet-delivered cognitive behavior therapy (ICBT) has been found to be effective for treating alcohol misuse in research trials, but it is not available as part of routine care in Canada. Recent recommendations in the literature highlight the importance of integrating perspectives from both patient and health care stakeholders when ICBT is being implemented in routine practice settings.
This study aimed to gain an understanding of how ICBT is perceived as a treatment option for alcohol misuse by interviewing diverse stakeholders. Specifically, the objectives were to (1) learn about the perceived advantages and disadvantages of ICBT for alcohol misuse and (2) elicit recommendations to inform implementation efforts in routine practice.
A total of 30 participants representing six stakeholder groups (ie, patients, family members, academic experts, frontline managers, service providers, and health care decision makers) participated in semistructured interviews. To be included in the study, stakeholders had to reside in Saskatchewan, Canada, and have personal or professional experience with alcohol misuse. Interviews were transcribed verbatim, anonymized, and analyzed using thematic analysis.
Stakeholders identified numerous advantages of ICBT for alcohol misuse (eg, accessibility, convenience, privacy, relevance to technology-based culture, and fit with stepped care) and several disadvantages (eg, lack of internet access and technological literacy, isolation, less accountability, and unfamiliarity with ICBT). Stakeholders also provided valuable insight into factors to consider when implementing ICBT for alcohol misuse in routine practice. In terms of intervention design, stakeholders recommended a 6- to 8-week guided program that uses Web-based advertising, point-of-sale marketing, and large-scale captive audiences to recruit participants. With regard to treatment content, stakeholders recommended that the program focus on harm reduction rather than abstinence; be evidence based; appeal to the diverse residents of Saskatchewan; and use language that is simple, encouraging, and nonjudgmental. Finally, in terms of population characteristics, stakeholders felt that several features of the alcohol misuse population, such as psychiatric comorbidity, readiness for change, and stigma, should be considered when developing an ICBT program for alcohol misuse.
Stakeholders’ insights will help maximize the acceptability, appropriateness, and adoption of ICBT for alcohol misuse and in turn contribute to implementation success. The methodology and findings from this study could be of benefit to others who are seeking to implement ICBT in routine practice.
Alcohol misuse, defined as alcohol consumption that causes harm to the drinker, others, or society, is prevalent among Canadian adults, affecting 8% of individuals aged 15 years or older; this is higher than the world average of 5.1% [
Internet-delivered cognitive behavior therapy (ICBT) has emerged as an effective form of treatment that increases access to services by overcoming many barriers associated with face-to-face intervention [
Despite the mounting evidence supporting the efficacy of ICBT for alcohol misuse, it has yet to be implemented in routine care in Canada. Previous research has outlined numerous outcomes that should be addressed when implementing an intervention in a new setting [
Considering acceptability, adoption, and appropriateness before implementation serves several purposes. First, it allows researchers to incorporate stakeholder feedback directly into the development of the ICBT program. Second, it ensures the intervention is patient oriented, ie, the intervention is “closely connected to the primary needs of the patients it is meant to serve” [
The purpose of this study was to interview diverse stakeholders who had personal or professional experience with alcohol misuse to gain a comprehensive understanding of how ICBT is perceived as a treatment option for alcohol misuse. Specifically, our objectives were to (1) learn about the perceived advantages and disadvantages of ICBT for alcohol misuse and (2) elicit recommendations to inform implementation efforts.
This study was conducted in Saskatchewan, a landlocked province in Western Canada with a population of 1,098,352 [
In Saskatchewan and across Canada, medical and mental health care are publicly funded and financed by the government through taxation [
Of the more than 1000 clients who were screened for ICBT for depression and anxiety in the past year, approximately 20% self-reported alcohol misuse problems, suggesting that there is a need for ICBT for alcohol misuse in Saskatchewan. This anecdotal finding is supported by recent Census data, which suggest that 21.9% of people aged 12 years or older in Saskatchewan report engaging in heavy drinking at least once a month, compared with the Canadian average of 19.5% [
Participants for this study were individuals from six stakeholder groups: patients (ie, individuals with direct lived experience), family members (ie, individuals with indirect lived experience), academic experts (ie, individuals who teach about or conduct research on alcohol misuse), frontline managers (ie, individuals who manage service providers), service providers (ie, individuals who work directly with patients), and health care decision makers (ie, individuals involved with government policy related to alcohol misuse). To be included in the study, stakeholders had to reside in Saskatchewan and have personal or professional knowledge of alcohol misuse. Our goal was to recruit numerous stakeholders from each group who could provide diverse perspectives on the topic of alcohol misuse. For example, we wanted stakeholders who could represent the perspectives of the urban and rural population and individuals with knowledge of different cultural perspectives. A priori, we hypothesized that a sample size of 20 to 30 stakeholders would be sufficient; however, we intended to continue conducting interviews until we were confident in the saturation of the data [
This study obtained approval from the institutional research ethics board. Interested participants were invited to take part in a semistructured interview with research staff members from the Online Therapy Unit in person or via telephone. Individual interviews were chosen over focus groups to maximize scheduling convenience for the stakeholders and because the stakeholders resided in geographically diverse locations across the province. One staff member (AW) was chosen to conduct interviews because of familiarity with alcohol misuse literature, whereas the other staff member (ST) was chosen because of experience in conducting qualitative interviews. The interview was comprised of 15 questions that provided insight into the acceptability, adoption, and appropriateness of ICBT for alcohol misuse in Saskatchewan (see
A total of 30 stakeholders were interviewed between October 2018 and January 2019. The participants who were interviewed represented a number of stakeholder groups (see
Number of stakeholders by group (N=30).
Stakeholder type | Interviewed, n |
Patients | 7 |
Family members | 3 |
Health care decision makers | 7 |
Frontline managers | 6 |
Service providers | 4 |
Academic experts | 3 |
Interview transcripts were transcribed verbatim, anonymized, and entered into QSR International’s NVivo 12 qualitative analysis software [
Stakeholders from all groups (eg, patients, family members, academic experts, frontline managers, service providers, and health care decision makers) resoundingly endorsed the implementation of ICBT for alcohol misuse in Saskatchewan. Moreover, they provided a wealth of information to be considered when developing an ICBT program for alcohol misuse. The results are discussed below, and illustrative stakeholder quotes are provided to enhance reader understanding.
When discussing the immense need for ICBT for alcohol misuse in Saskatchewan, stakeholders highlighted some perceived advantages and disadvantages of an ICBT approach to the treatment of alcohol misuse. The advantages and disadvantages are described in
Perceived advantages of internet-delivered cognitive behavior therapy for alcohol misuse. ICBT: internet-delivered cognitive behavior therapy.
Advantages | Description | Example quote |
Accessibility | ICBT allows clients with alcohol use who live in rural and remote locations to access care that is otherwise limited. | “For people who are in the rural areas I think it [ICBT for alcohol misuse] is hugely advantageous, because getting an addictions counselor in rural areas can be really challenging.” [Stakeholder #12, Patient] |
Convenience | ICBT allows clients who are limited by cost, transportation, or time constraints to access care. | “There are individuals that have obligations with work or parenting where they are not able to necessarily attend programming during some of the traditional hours that they’re offered or even outside of traditional hours, right? So being able to access a program in their home is definitely a need.” [Stakeholder #6, Frontline Manager] |
Privacy | ICBT allows clients to participate in treatment from a private location, which reduces the chances of experiencing stigma related to alcohol misuse. | “[ICBT for alcohol misuse] is more private, it's not like they have to walk into a public meeting and say “Hi, I'm an alcoholic.” That can be very intimidating.” [Stakeholder #24, Family Member] |
Relevance to technology-based culture | ICBT is congruent with today’s technology-based culture. | “Our world is living in that direction [toward technology], so it would make sense to have a service [like ICBT] that's delivered in a way that lots of people can access. Technology is just part of life.” [Stakeholder #3, Service Provider] |
Fit with stepped care | ICBT fits within a stepped-care model, wherein clients with less severe alcohol misuse can use ICBT, leaving more intensive in-person services for those with more severe alcohol misuse. | “[ICBT] is really the starting part of a step-care approach so that not everybody needs to go to addiction services. Sometimes it’s just a matter of gathering information for themselves or for others and I think it could potentially have a role in prevention. It could potentially have an impact on wait times too |
Perceived disadvantages of internet-delivered cognitive behavior therapy for alcohol misuse. ICBT: internet-delivered cognitive behavior therapy.
Disadvantages | Description | Example quote |
Requires internet access and technological literacy. ICBT: internet-delivered cognitive behavior therapy. | ICBT requires clients to have access to the internet and the knowledge and ability to use a computer, tablet, or mobile phone, which may prohibit some individuals from participating. | “A lot of individuals don’t have access to Internet. Oftentimes we see a population who are disadvantaged so they may not have a stable house where they can access a computer to access online ICBT. They may not have access to a phone where they can get it on their mobile.” [Stakeholder #2, Health Care Decision Maker] |
May foster isolation | ICBT may reinforce isolation that can be associated with alcohol misuse by allowing clients to engage in treatment without leaving home. | “It [addiction] is about disconnection; disconnection with ourselves, disconnection with others. How do you make it [an ICBT program for alcohol misuse] in a way that is not allowing clients to further isolate?” [Stakeholder #25, Academic Expert] |
Less accountability | The Web-based nature of ICBT could allow clients to be less accountable for their actions than they would be if they had face-to-face meetings with their service provider or peers. | “It’s easier not to be accountable to a computer than it is to an addiction counsellor or an AA group.” [Stakeholder #28, Health Care Decision Maker] |
Unfamiliarity with ICBT | Clients might not be aware that ICBT is an available treatment option for alcohol misuse. | "Unfamiliarity with this whole resource [ICBT] could be one [disadvantage].” [Stakeholder #15, Frontline Manager] |
Stakeholders provided valuable insight into factors to consider when implementing ICBT for alcohol misuse in Saskatchewan. Three themes emerged from the analysis: (1) intervention design, (2) treatment content, and (3) population considerations (
Factors to consider when implementing internet-delivered cognitive behavior therapy for alcohol misuse.
The majority of stakeholders suggested that a guided ICBT program would be beneficial because it would allow for greater support, increase accountability, and provide clients with someone to connect with. In terms of the best method of guidance, stakeholders felt that offering email support in combination with telephone follow-ups would be important. However, several stakeholders indicated that it might be helpful for clients to be able to choose the level and type of support that fits their needs (ie, guided vs self-guided, email vs telephone contact). When discussing the value of guidance, one stakeholder explained:
I think it [guided ICBT] is a happy medium between having to go see a therapist and having to do it all on your own.
When stakeholders were asked about the ideal length of treatment, responses ranged from 6 to 12 weeks. The majority of stakeholders suggested a 6- to 8-week time frame. Some recommended a longer treatment length of 10 to 12 weeks, but other stakeholders expressed concern that clients would be less likely to commit to a longer treatment period. A number of stakeholders suggested that the length of treatment may need to be altered depending on a number of factors (eg, interest and alcohol misuse severity).
Stakeholders felt that advertising to potential clients on the Web using social media and Web advertisements would be most effective. The value of recruiting via social media was described by one stakeholder who commented:
[Facebook] is where everyone is going these days; that’s where you're guaranteed to get the best reach. Facebook is really targeted these days in that you can select people who live in Regina who are between the ages of 14 and 35 who enjoy drinking [...] you can target ads to every single group [related to alcohol], so you can pick out exactly who you need and who's going to be successful in your program just with one click of a button.
Several additional strategies were also recommended, including point-of-sale advertising (ie, advertisements in places where alcohol is sold or consumed such as liquor stores, restaurants, bars, and sporting events) and media advertising (eg, newspaper and radio). With regard to referrals, stakeholders recommended creating a professional referral network to increase coordination of care among alcohol misuse service providers. Specifically, they suggested the exchange of information and referrals with counselors, physicians, community health clinics, social workers, and public education or advocacy groups.
A few stakeholders discussed abstinence and harm reduction approaches to the treatment of alcohol misuse. Stakeholders generally held the perspective that harm reduction was a more appropriate approach, particularly for people who are drinking at mild-to-moderate levels. However, there was also recognition that clients can choose abstinence within a harm reduction model if their goal was to eliminate alcohol consumption altogether. One stakeholder explained:
I think that [the idea of abstinence] turns people off, the idea that you can’t have something anymore, then that... You know, you almost want it even more because you can’t have it.
A number of stakeholders emphasized the importance of including evidence-based information and skills in the ICBT program. They underscored the value of teaching clients what constitutes alcohol misuse and about the low-risk drinking guidelines. They also recommended providing education about the effects of alcohol, especially the physical effects and how to deal with withdrawal. They suggested using language such as
People often don’t know how to moderate their drinking. They don’t understand what a standard drink is. There is a need for [education] about that.
Stakeholders spoke of the importance of gaining the trust of potential clients by delivering content that demonstrates understanding and sensitivity to the diversity that exists among individuals with alcohol misuse in terms of culture, age, and socioeconomic status. Stakeholders indicated that content such as photos, wording, and case stories must be relatable and relevant to individuals from various cultures. Stakeholders also spoke of alcohol misuse as a cross-generational issue and recommended that the content appeal to adults across the life span. Stakeholders finally recommended that the program content be sensitive to socioeconomic diversity, as people struggling with alcohol misuse are likely to range from those who live in poverty to those who are wealthy. This point was illustrated by one stakeholder who commented:
We [individuals with alcohol misuse] come from all walks of life. I mean, you could be a doctor, you could be a janitor, you could be a 16-year old kid, you could be a 90-year old grandmother. It could be anybody... like I said, it’s all walks of life so it [alcohol misuse] crosses all boundaries.
All stakeholders spoke to the importance language and messaging would play, not only in drawing potential clients to the Online Therapy Unit website but also in keeping them engaged once participating in the program. Stakeholders advised against language or information that is confrontational, difficult to understand, and stigmatizing or has the potential to trigger feelings of hopelessness. Instead, stakeholders spoke of the need to use encouraging, nonjudgmental, and simple language. One stakeholder explained the importance of removing stigmatizing language:
I would say if you’re looking to hook in people who are moderate drinkers, I would avoid the term “alcoholic,” because I think some people would look at that and think, “Well, I’m not an alcoholic, I’m not a drunk, that’s not me.”
The majority of stakeholders highlighted the challenge of providing treatment for alcohol misuse in the context of comorbid conditions. Many spoke of the strong connection between alcohol misuse and other mental health conditions, such as anxiety, depression, and trauma. It was suggested that an ICBT program for alcohol misuse take into account and possibly even address comorbid psychiatric conditions. One stakeholder described the link between alcohol misuse and mental illness:
The drinking is just a symptom of deeper emotional issues and so a lot of people aren’t aware of that in the beginning part of their journey, they think alcohol is the problem, not the fact that they have years of trauma.
The vast majority of stakeholders described the impact of drinking culture on alcohol consumption. They explained that alcohol consumption is typically considered an acceptable, normal activity that goes hand in hand with the day-to-day social activities. Thus, they warned that reducing or eliminating alcohol consumption might contribute to feelings of social isolation. They stressed the importance of the ICBT program acknowledging societal drinking culture and preparing clients for reducing their alcohol consumption within this context.
Several professional stakeholders described the importance of the ICBT program considering potential clients’ readiness to change their drinking behavior. Relatedly, a number of patients and family members discussed denial or lack of recognition of a drinking problem as a reality for some individuals with alcohol misuse. Stakeholders indicated that it may be valuable to conduct an assessment and provide feedback to allow potential clients to understand their level of alcohol misuse and its negative effects; they suggested this may reduce ambivalence about following through with an ICBT program. The importance of addressing readiness for change was described by one stakeholder who stated:
That level of motivation to want to change, sometimes that’s just not there, so I think getting an accurate assessment of where they are in that stages of change model would be helpful, but even within that, we know that it’s cyclical and people can revert back to contemplation or pre-contemplation where that motivation to follow through on a program like this just isn’t there.
Several stakeholders talked about the shame and stigma associated with alcohol misuse being a significant barrier to seeking help. In particular, a number of patients and family members spoke of the feeling of not wanting anyone to know they had a problem because if that had become known it may have had negative consequences. Stakeholders suggested the ICBT program be aware of the enormous stigma faced by individuals with alcohol misuse.
Stakeholders spoke of the importance of recognizing the variety of stressors that can be experienced by individuals who misuse alcohol. They noted that alcohol consumption can be not only a source of stress but also a way of coping with stress. One stakeholder discussed stress as a social determinant of health:
It’s important to acknowledge the social determinants of health that have led to or support that abuse. [...] You'd have to talk about what's your housing situation, where are living, do you have a job, etc. [...] Because if you're an alcoholic who lives at home with a family and you have a job, you're in a much, much different situation than someone who's living in a shelter.
This study aimed to interview stakeholders who had personal or professional experience with alcohol misuse to understand their perceptions of ICBT as a treatment option for alcohol misuse in routine practice. Along with a resounding endorsement for implementation, stakeholders shared their perceptions about the advantages and disadvantages of using ICBT to treat alcohol misuse and made numerous recommendations related to intervention design, intervention content, and the population being treated.
The perceived advantages and disadvantages identified by stakeholders were consistent with previous ICBT research [
In contrast, the perceived disadvantages of ICBT for alcohol misuse—requires internet access and technological literacy, may foster isolation, less accountability, and unfamiliarity with ICBT—represent areas to be acknowledged and mitigated as implementation proceeds. Perhaps the most addressable disadvantage is unfamiliarity with ICBT. When implementing ICBT for alcohol misuse in routine practice, significant effort can be made to inform potential clients and referral sources about the nature and availability of the treatment. Other disadvantages might be mitigated by incorporating certain features into the ICBT program for alcohol misuse; eg, guided ICBT likely has greater potential to lessen clients’ isolation and improve accountability compared with a self-guided approach. In addition, designing a program that is downloadable and can be accessed through a variety of technological devices (eg, computer, tablet, or mobile phone) may benefit those without a home computer or a consistent internet connection.
In terms of intervention design, stakeholders indicated that a guided program with both email and telephone correspondence would be preferable as it would allow for greater support, increased accountability, and human connection. This suggestion is supported by two previous studies that found guided ICBT programs for alcohol misuse to be both more engaging and more effective than self-guided ICBT [
This study has several important strengths. First, to our knowledge, this is the first study related to implementation of ICBT for alcohol misuse in routine care. It should be stated that the advantages and disadvantages identified in the stakeholder interviews were in line with what has been previously identified in the literature on internet interventions [
Despite its strengths, this study also has several limitations. First, although we expect the findings of this study to be largely applicable to other geographic locations, the inclusion of stakeholders exclusively from Saskatchewan may hamper generalizations to other geographical contexts. Second, with regard to the sample, there may be a selection bias as some stakeholders may have had initial favorable attitudes toward ICBT. For example, 8 out of 30 stakeholders (27%) had professional or personal experience with other ICBT courses being offered by the Online Therapy Unit. Relatedly, the use of snowball sampling increases the risk that stakeholders referred like-minded individuals to participate. In terms of the interview guide, it is conceivable that the semistructured nature of the interview influenced the stakeholders’ responses. Specific interview questions may have implicitly encouraged stakeholders to speak to certain topics and not to others. Moreover, the choice to conduct individual interviews rather than focus groups could be regarded as a limitation, as a focus group format could have resulted in broader discussion, enhancing the richness of the results. Finally, as with all qualitative research, it is possible that the researchers’ knowledge and previous experience with ICBT and the treatment of alcohol misuse implicitly influenced how the interview content was interpreted. As described by Braun and Clarke [
The recognizable next step is to move forward with the development and implementation of ICBT for alcohol misuse in routine practice. This will include continuing to assess acceptability, appropriateness, and adoption once the intervention is implemented. Moreover, other implementation outcomes such as feasibility, fidelity, and implementation cost can be measured in addition to service outcomes (eg, effectiveness, efficiency, and timeliness) and client outcomes (eg, satisfaction, functioning, and symptomatology). Attempts should be made to replicate the findings from this study among stakeholders in other geographical locations and practice settings. We encourage researchers interested in implementing ICBT for alcohol misuse (or any other condition) to use our interview guide and analytic procedure as a model. Finally, as ICBT becomes more common in routine care, there is likely to be ongoing value in taking a patient-oriented approach, whereby patient partners are engaged in all aspects of program development and evaluation. Past research suggests that adopting a patient-oriented approach ensures treatment is tailored to the needs of the clients it is meant to serve, which can improve satisfaction and patient outcomes [
Conducting semistructured interviews with 30 stakeholders who had personal or professional experience with alcohol misuse provided valuable insights that will inform the development of an ICBT program for alcohol misuse in routine practice. In terms of intervention design, stakeholders recommended a 6- to 8-week guided program. With regard to treatment goals, stakeholders recommended that the program focus on harm reduction rather than abstinence. In terms of population characteristics, stakeholders believed that several features of the alcohol misuse population, such as psychiatric comorbidity and readiness for change, should be taken into account when developing an ICBT program for alcohol misuse. The feedback provided by stakeholders will be used to bolster acceptability, appropriateness, and adoption and in turn contribute to implementation success. The methodology and findings from this study can serve as an example to others who are seeking to deliver ICBT in routine practice.
Interview guide.
internet-delivered cognitive behavior therapy
This study was supported by funds from the Saskatchewan Ministry of Health. The authors would like to thank the stakeholders who participated for their valuable insights.
None declared.