Other Challenges

Additional concerns related to the use of BITs include (a) the potential of a BIT reinforcing an issue that it was initially designed to address and solve (e.g., social isolation) and (b) BITs not being a comparable substitute to the face-to-face interactions between patients and care providers (Griffiths et al., 2006). While BITs may allow for cost-effective methods for providing behavioral support to groups of individuals who normally would experience difficulty in accessing this support, the act of providing a low-cost intervention may in fact increase their feelings of isolation as the employment of a low-cost treatment option may reinforce the “low priority” of these individuals with regards to health and social services (Griffiths et al., 2006). As an example, those suffering from a stigmatizing mental health issue who are assigned to a Web-based intervention rather than a face-to-face intervention may psychologically feel as if they are “unworthy” of participating in a traditional intervention or that they are “not worth the time or effort” to medical personnel. This may force the group to feel even more marginalized and reinforce the stigmas they experience.

In addition, although BITs can increase access to behavioral therapies and treatments, such interventions may lack the personable attributes and the nuances of face-to-face interactions with physicians and study personnel. In effect, BITs may not provide the same personalized touch afforded by face-to-face interactions. This is not to imply that face-to-face interactions are always preferred, as there can be a great amount of discomfort experienced among patients in face-to-face situations, which can be potentially reduced through the use of a BIT (Bennett & Glasgow, 2009). However, there are cases wherein BITs have been shown to have less potent effects on patients compared to face-to-face interactions. An example is found in a study conducted by Mohr et al. (2012) comparing face-to-face cognitive behavioral therapy versus telephone-based therapy with individuals suffering from depression. The findings indicated that, while the telephone-based therapy was associated with lower attrition and patients saw comparable improvement in depression when compared to the face-to-face group, over time the group that received face-to-face therapy reported lower depression than the telephone group. It is important to recognize that Internet-based contact may be providing something different than face-to-face contact, and researchers should seek to assess these potentially different effects. However, some studies, such as those looking at online therapy effects on pain and headaches, find that online modalities are comparable to face-to-face interactions (Cuijpers, van Straten, & Andersson, 2008), highlighting the fact that continued research is needed in this area.

Some final considerations for researchers using BITs include access, usability, and privacy. Although BITs have the potential to deliver behavioral interventions to populations that may typically have difficulty accessing these interventions, as noted not all populations have access to these technologies. As pervasive as computer and smartphone technologies have become in daily life, there are pockets of people (such as those with lower socioeconomic status) who cannot afford these technologies; in addition, there are pockets of people (such as those in rural areas) who may not have Internet connectivity strong enough to support more complex multimedia interventions. Researchers and therapists must take this into account when potentially assigning clients/patients/study participants to a BIT treatment. Usability of the technology (and the need for training of targeted populations) must also be ascertained, as a lack of technical knowledge and experience can inhibit the effectiveness of the BIT (e.g., an older adult with very little Internet experience may become frustrated with navigating an online treatment for depression, which may lessen the treatment’s efficacy). In addition, as with face-to-face interactions, steps must be taken to assure participant privacy and confidentiality when using BITs; an example may be to require a specific login so that only patients may access the BIT and to have any patient data that is collected through the BIT be stored on a secure server. Finally, the development of technology-based interventions necessitates the inclusion of technical personnel on the research team. These individuals may not be familiar with behavioral intervention research or the target populations; thus, it is extremely important that they receive training in the goals and objectives of the intervention, the study timeline and constraints, and the characteristics of the target population.

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