Internet-delivered CBT (guided and self-guided)

1. Introduction

Version followed: therapist-guided internet-delivered CBT (ICBT) as described by Andersson, Titov, Dear, Rozental and Carlbring (2019, World Psychiatry); the Swedish scheduled-support model as run in the Käll, Andersson et al. (2023) trial; the MindSpot Clinic model (Wellbeing Course as published on mindspot.org.au, October 2026; risk procedures per Nielssen et al., 2015); the therapist-behaviour framework of the ICBT Therapist Rating Scale (Hadjistavropoulos et al., 2018, Online Therapy Unit, Saskatchewan, with MindSpot authors); and NHS Talking Therapies use of digitally enabled therapies as NICE describes it. Self-guided use is covered as a separate pathway. For NICE's early value assessments of named digitally enabled therapies, see guide 087.

ICBT is a delivery format, not a separate school of therapy. A structured CBT programme (text, video, audio, worksheets, quizzes) carries the treatment content, released as lessons or modules, usually one per week; the client works through it at home and does homework such as exposure or behavioural activation. In the guided form a clinician gives brief, mostly written, asynchronous support: feedback on homework, answers to questions, encouragement, and monitoring of symptoms and risk [source: Andersson et al., 2019]. Change is assumed to happen the way it does in CBT generally, through the client practising the programme's skills between contacts; the guide's job is to keep the client engaged, help them understand and apply the material, and keep them safe [source: Andersson et al., 2019; Hadjistavropoulos et al., 2018] [synthesis for the framing].

The psychotherapist can take three roles: (a) guide or therapist inside a service that runs its own programmes (MindSpot, an internet psychiatry clinic, an NHS Talking Therapies service using a commissioned platform); (b) prescriber or supervisor of a programme a client uses alongside your own work (THIS WAY UP is built to allow this [uncertain: clinician-prescribing procedures not verified]); (c) adviser to a client who uses a self-guided programme.

Status, as of October 2026 (check before relying on it; services change):

Australia: MindSpot runs free-to-user online assessment and courses; the Wellbeing Course is offered to Australian residents, with an option of weekly therapist support or contacting the service when needed [source: MindSpot Wellbeing Course page, Oct 2026]. THIS WAY UP is provided by St Vincent's Hospital Sydney with UNSW and CRUfAD as partners, states accreditation under the National Safety and Quality Digital Mental Health Standards, and is supported by Australian Government funding [source: THIS WAY UP site footer, Oct 2026].
Sweden: guided ICBT is delivered in routine regional care, including by an internet psychiatry unit with published routine-practice data [source: Andersson et al., 2019]; regional care uses the national 1177 platform for internet CBT [uncertain: not verified].
England: in NHS Talking Therapies for anxiety and depression, digitally enabled therapies are most commonly offered as low-intensity step 2 interventions, facilitated by a psychological wellbeing practitioner (PWP) who reviews progress, and may be offered at step 3 if they include the content of the relevant NICE guideline; each is delivered with regular practitioner or therapist support [source: NICE early value assessment, digitally enabled therapies for anxiety disorders, section 2, Oct 2026]. NICE lists Beating the Blues as no longer available to the NHS [source: same]. The NHS Talking Therapies manual page was last updated March 2024 [source: NHS England]. Full NICE detail: guide 087.
Regulatory classification (medical-device status, CE/UKCA, DTAC) differs by product and is not summarised here [uncertain: not verified per product]; see 087 for the NHS products NICE assessed.

Evidence status (attributed, brief). Andersson et al. (2019) report that guided ICBT is generally more effective than self-guided ICBT, that self-guided ICBT for depression showed a small effect against controls (g = 0.27), that clinician time averages about 10 minutes per client per week, and that routine-care services in several countries report large improvements, low deterioration and high satisfaction. In a Swedish trial for social anxiety disorder, scheduled support led to more modules completed (mean 7.1 of 9) than support on demand (5.8 of 9) [source: Käll et al., 2023].

2. Framework

Guided ICBT runs in five phases. Session counts below are what the named programmes publish; local services vary [source: as tagged].

Phase 0: Access and online screening. Goal: identify likely problems and immediate risk before any human contact. Format: online questionnaires. MindSpot uses a structured questionnaire plus K10, PHQ-9 and GAD-7, adding condition-specific measures (e.g. for social anxiety, panic, OCD, PTSD) where indicated, with suicide questions at the end that trigger an on-screen crisis alert [source: Nielssen et al., 2015]. Move on when screening is complete and any positive risk screen has been actioned.

Phase 1: Assessment, suitability, programme choice, consent. Goal: confirm the problem the programme treats, rule out what it cannot safely treat, pick the programme and support level, and obtain informed consent. Format: one telephone or video assessment (trials use structured diagnostic interviews by telephone, e.g. SCID-I [source: Käll et al., 2023]; routine services supplement online questionnaires with telephone interviews [source: Andersson et al., 2019]). Move on when: the presenting problem matches a programme, risk is manageable in a remote format with a safety plan, and the client has consented.

Phase 2: Active treatment. Goal: complete the programme's lessons and practise its skills. Published formats: MindSpot Wellbeing Course, 5 lessons over 8 weeks, at least about 4 hours a week of reading and practice, with optional weekly therapist support [source: MindSpot Wellbeing Course page]; Online Therapy Unit, an 8-week programme for anxiety and depression with a designated therapist answering by secure email [source: Soucy et al., 2019]; Swedish trial, 9 modules, one released per week, with therapist feedback on a fixed weekday when the next module opens [source: Käll et al., 2023]. Weekly measures are taken throughout (MindSpot PHQ-9 at each login [source: Nielssen et al., 2015]; disorder-specific weekly scale in the Swedish trial [source: Käll et al., 2023]). Clinician time is roughly 10 to 15 minutes per client per week [source: Andersson et al., 2019; Käll et al., 2023]. Move on when the last lesson is completed or the treatment window closes. Step out early when risk rises beyond the remote format, the client deteriorates, or a different problem emerges [synthesis].

Phase 3: Ending. Goal: post-treatment measurement, a written plan for staying well, and a decision on what next. MindSpot's final lesson covers staying well after the course [source: MindSpot Wellbeing Course page]. Format: final message and, where the service offers it, a closing call [synthesis].

Phase 4: Follow-up and stepping. Goal: check maintenance and route non-responders to more intensive care. Services in stepped care use ICBT as one step [source: Andersson et al., 2019]; follow-up timing is local [uncertain].

3. Guiding principles

The programme delivers the treatment; you support it. Your messages reinforce, clarify and apply programme content rather than adding a parallel therapy [source: Andersson et al., 2019]. Meaning: before you write, check which lesson the client is on and anchor your reply to it.
Guidance matters, but it can be brief. Guided ICBT generally does better than self-guided, and some support may be practical and technical [source: Andersson et al., 2019]. Meaning: aim for short, regular, specific contact, about 10 to 15 minutes per client per week.
Predictability beats availability. Scheduled support produced more module completion than support on demand [source: Käll et al., 2023]. Meaning: tell clients the exact day you will reply and keep to it.
Hold the homework. A lenient response to uncompleted homework was linked to less improvement in GAD [source: Andersson et al., 2019, summarising earlier work]. Meaning: notice and name missed practice warmly, and plan a concrete next attempt; do not simply move on.
Affirm. Affirming responses to client messages were linked to better outcomes in depression [source: Andersson et al., 2019]. Meaning: name specifically what the client did well.
Use the full set of guide behaviours. The ICBT Therapist Rating Scale names nine: builds rapport, seeks feedback, provides symptom feedback, provides psychoeducation, facilitates understanding, praises effort, encourages practice, clarifies administrative procedures, communicates effectively; symptom feedback and facilitating understanding were the ones most often missing [source: Hadjistavropoulos et al., 2018]. Meaning: check each message against the nine before sending.
Measure every week and use the numbers. Platforms administer symptom and risk questionnaires regularly [source: Andersson et al., 2019]. Meaning: comment on the client's scores in each message and act on rises.
Safety procedures are built in, not improvised. Positive risk answers trigger an on-screen alert, a therapist phone call, structured risk assessment, a safety plan or urgent referral, and supervisor involvement [source: Nielssen et al., 2015]. Meaning: know your service's triggers, out-of-hours limits and escalation route before your first client.
Text needs care. Communicates effectively is a rated behaviour [source: Hadjistavropoulos et al., 2018]. Meaning: short paragraphs, plain words, one clear task, warm close; reread for tone.
Stay within scope and say so. About one in eight client questions concern problems outside ICBT's scope [source: Soucy et al., 2019]. Meaning: acknowledge, signpost or arrange a call, and bring the client back to the programme.
Client choice of support level. MindSpot lets clients choose weekly support or contact as needed [source: MindSpot Wellbeing Course page]. Meaning: offer the choice, explain that regular contact tends to help completion, and respect the decision.
Privacy and security equal to banking. Encryption and two-factor login are standard; clinical notes and messages must be stored securely [source: Andersson et al., 2019]. Meaning: use only the platform's secure messaging, never ordinary email or text for clinical content.
Skill and specialisation help quality. Novice clinicians may achieve similar outcomes, but message quality was higher among therapists specialising in ICBT [source: Andersson et al., 2019; Hadjistavropoulos et al., 2018]. Meaning: get ICBT-specific training and have your messages audited in supervision.
Engagement is a clinical target. People who read at least three Wellbeing Course lessons are likely to improve, per MindSpot [source: MindSpot Wellbeing Course page]. Meaning: treat early non-login as a priority.

4. Intervention inventory

The inventory follows the client's path. Programme lesson content itself (CBT psychoeducation, thought challenging, managing physical symptoms, graded exposure, behavioural activation, relapse prevention) is delivered by the programme; your interventions are the ones below. MindSpot's Wellbeing Course lessons cover the cycle of symptoms, recognising and challenging unhelpful thoughts, managing physical symptoms, gradually facing avoided situations, and staying well [source: MindSpot Wellbeing Course page]. For the techniques themselves see the cognitive-behavioural therapy guides.

4.1 Online screening review

Purpose / when: Before the first contact, to form a working picture and catch risk. Every new client.
Steps: (1) Read the structured intake answers and every score (in MindSpot: K10, PHQ-9, GAD-7 and any condition-specific measure triggered [source: Nielssen et al., 2015]). (2) Check the suicide items first; if either is positive, the risk pathway (4.13) takes priority over everything else. (3) Note which disorder-specific scores are elevated, as these guide programme choice. (4) Note functional details: work, supports, current treatment, medicines (record only, do not advise), substance use. (5) List questions to ask in the assessment call [synthesis for steps 3 to 5].
Example language (illustrative): "Thanks for completing the questionnaires. I have read them, and in our call I would like to check a few things with you, starting with how you have been feeling about your safety."
Watch for: Score patterns that do not match the reported problem (e.g. very high distress with a mild description), missing items, signs of psychosis, mania, severe substance use or an eating disorder, which most transdiagnostic programmes do not treat [synthesis]. Working: you start the call already knowing your top three questions.

4.2 Assessment interview (telephone or video)

Purpose / when: To confirm diagnosis and suitability. Trials use a structured diagnostic interview by telephone (e.g. SCID-I) [source: Käll et al., 2023]; routine services supplement online measures with telephone interviews [source: Andersson et al., 2019].
Steps: (1) Confirm identity and a safe contact number and location, and agree what you will do if the call drops [synthesis]. (2) Explain the purpose and length. (3) Ask about the main problem, its course and impact. (4) Use the structured interview modules your service specifies; do not substitute your own unvalidated questions for a required instrument. (5) Ask directly about suicidal thoughts, plans, intent and past attempts using your service's risk form [source: Nielssen et al., 2015]. (6) Screen for exclusion problems (4.3). (7) Ask about reading ability, language, internet access, private space and time available (MindSpot asks for at least about four hours a week [source: MindSpot Wellbeing Course page]). (8) Summarise back and say what happens next.
Example language (illustrative): "This programme asks for about four hours a week of reading and practice. Looking at your week, where could that fit?" / "I ask everyone this: in the past two weeks, have you had thoughts that life isn't worth living?"
Watch for: Hesitancy about time or privacy at home, limited literacy, ambivalence about doing therapy alone, or the client expecting weekly talk sessions. Working: the client can describe in their own words what they will do each week.

4.3 Suitability decision

Purpose / when: At the end of assessment, to decide ICBT, a different step, or onward referral.
Steps: (1) Check the programme's published inclusion range (e.g. the Wellbeing Course is offered to Australian residents with low mood, depression, stress, social anxiety, panic or excessive worry, within its published adult age band [source: MindSpot Wellbeing Course page; the page shows both 25–65 and 26–65, uncertain]). (2) Apply published exclusions: MindSpot does not recommend the course for people who are currently suicidal, and strongly advises people with very severe symptoms to see a GP and a psychologist and/or psychiatrist [source: same]. (3) Apply your service's further exclusions, commonly psychosis, bipolar disorder in an active phase, severe substance dependence, and need for urgent care [synthesis; check local criteria]. (4) Consider readiness: time, privacy, device, literacy, language. (5) Decide with the client, and if ICBT is not right, make the referral rather than only signposting [synthesis].
Example language (illustrative): "From what you have told me, the course fits what you are dealing with. The main question is whether now is a workable time. What do you think?" / "I don't think an online course alone is the safest option right now, so I'd like to connect you with your GP and the local mental health team today."
Watch for: Pressure (from the client or the service) to enrol someone whose risk or complexity exceeds a remote format. MindSpot sets no minimum score for enrolment [source: Nielssen et al., 2015], so mild cases are eligible. Working: you can name the reason for the decision in one sentence in the notes.

4.4 Programme choice

Purpose / when: After suitability, to match a programme to the client.
Steps: (1) Choose disorder-specific or transdiagnostic. MindSpot offers a transdiagnostic Wellbeing Course, Wellbeing Plus for older adults, and courses for PTSD and OCD, with choice depending on age and symptom pattern [source: Nielssen et al., 2015]; later MindSpot course listings include further courses (e.g. an Indigenous Wellbeing Course) [uncertain: not verified]. (2) In England, choose among products the local NHS Talking Therapies service commissions, at step 2 or step 3 according to the NICE-recommended content they include [source: NICE EVA section 2]; NICE's product list is in 087. (3) Consider format needs: reading load (some programmes are about 150 pages of text [source: Andersson et al., 2019]), audio or video, language, accessibility. (4) Consider the support level the client wants (4.7). (5) Record the programme and version.
Example language (illustrative): "There are two options. One course works on worry, low mood and panic together; the other focuses only on social anxiety. Your social fears seem to be the main driver, so I'd suggest the specific one. How does that sound?"
Watch for: A comorbid picture where a transdiagnostic course fits better than chasing the loudest diagnosis [synthesis]. Working: the client agrees the programme addresses what they most want to change.

4.5 Informed consent and treatment agreement

Purpose / when: Before any lesson opens.
Steps: Cover in plain words and record agreement: (1) what the programme is and that most work is self-directed; (2) your role, the support schedule, the reply day and expected response time; (3) that contact is mainly written and asynchronous, and what counts as urgent; (4) that you will phone if safety is a concern even if the client chose written contact only, as MindSpot's terms of use state [source: Nielssen et al., 2015]; (5) service hours (MindSpot staffs 8 am to 8 pm Monday to Saturday [source: Nielssen et al., 2015]) and what to do outside them; (6) weekly questionnaires and what you do with the scores; (7) data storage, who can see messages, security measures [source: Andersson et al., 2019, on encryption and two-factor login]; (8) right to stop and how to return; (9) that the programme does not replace GP or prescriber care, and permission to contact the GP if risk arises [synthesis for 1–3, 6, 8, 9].
Example language (illustrative): "Messages here are not monitored around the clock. If you feel unsafe, don't wait for my reply. Call emergency services or the crisis line on the urgent-help page." / "If your answers ever tell me you might not be safe, I will phone you, even though we mostly write."
Watch for: Clients who assume the message box is a crisis channel; concerns about shared devices or someone else reading messages. Working: the client can tell you the reply day and the out-of-hours plan.

4.6 Welcome message and onboarding

Purpose / when: At the start of treatment, to set up the relationship and the routine. In the Swedish scheduled-support model, the personal clinician sends the introductory message [source: Käll et al., 2023].
Steps: (1) Introduce yourself by name and role. (2) Restate the reply day and what you will comment on. (3) Explain how to open the first lesson and complete the weekly questionnaire. (4) Suggest a fixed weekly time slot for lessons and a daily time for practice [synthesis]. (5) Point to the urgent-help page. (6) Ask one easy question to invite a reply (seeks feedback) [source for rapport and seeking feedback as guide behaviours: Hadjistavropoulos et al., 2018].
Example language (illustrative): "Hi Sam, I'm Alex, a psychologist, and I'll be your guide for the next eight weeks. Each Tuesday I'll read what you've written and your weekly scores and reply. A good first step is Lesson 1 and the short questionnaire. When in your week might you sit down with it?"
Watch for: No login within the first week, which needs early follow-up (4.12) [synthesis]. Working: first lesson started and a reply received.

4.7 Setting the support level and schedule

Purpose / when: At enrolment and whenever engagement changes.
Steps: (1) Explain the options your service offers: scheduled weekly support, or contact when needed (both offered by MindSpot [source: MindSpot Wellbeing Course page]). (2) Share that scheduled support led to more module completion than support on demand in a Swedish trial [source: Käll et al., 2023]. (3) Fix the weekday and keep it; in that trial feedback came on the same weekday the next module unlocked [source: same]. (4) Budget about 10 to 15 minutes per client per week for reading and replying [source: Andersson et al., 2019; Käll et al., 2023]. (5) Block clinician time on set days to monitor activity and respond [source: Käll et al., 2023].
Example language (illustrative): "Some people like a weekly check-in from me; others prefer to get in touch only when they need to. People who have regular contact tend to get further through the course. Which would suit you?"
Watch for: On-demand clients who never ask (in the trial, mean messages under one per client [source: Käll et al., 2023]). Working: messages sent and answered on the agreed day.

4.8 The weekly written feedback message

Purpose / when: The core guide intervention, sent on the scheduled day each week [source: Käll et al., 2023]. In the Swedish model clients summarise each module in their weekly message to the clinician, and the clinician gives feedback on the exercises [source: same].
Steps: Before writing, read the client's summary, homework entries, quiz results, login activity and weekly scores (about 2–3 minutes). Then build the message around the nine ICBT Therapist Rating Scale behaviours [source: Hadjistavropoulos et al., 2018; ordering and wording are synthesis]: (1) Builds rapport: greet by name, reflect one thing they said. (2) Provides symptom feedback: state this week's score and its direction compared with the start. (3) Praises effort: name a specific action they took. (4) Facilitates understanding: check or restate the lesson's key idea in their terms. (5) Provides psychoeducation: add a short explanation where they misunderstood or asked. (6) Encourages practice: set one concrete practice task for the coming week, linked to the next lesson. (7) Clarifies administrative procedures: when the next lesson opens, deadlines, next reply day. (8) Seeks feedback: ask one question. (9) Communicates effectively: short paragraphs, plain words, no jargon, warm sign-off. Keep it to a few short paragraphs.
Example language (illustrative): "Hi Priya, thanks for your summary of Lesson 2. Your worry score dropped from 15 to 12 this week, which is a real shift. I noticed you caught the thought 'I'll be fired' and wrote down the evidence against it; that is exactly the skill. One thing to try this week: do the same exercise once a day, even for a small worry. Lesson 3 opens on Tuesday and I'll write again then. How did it feel to write the evidence down?"
Watch for: Messages that only praise and skip symptom feedback and understanding, which were the most often missing behaviours [source: Hadjistavropoulos et al., 2018]; messages that drift into a separate therapy; tone that reads as cold or as scolding. Working: the client replies, completes the set task, and scores move.

4.9 Answering client questions

Purpose / when: Whenever a client writes with a question. In one programme clients sent about six messages over 8 weeks, fewer than two with questions [source: Soucy et al., 2019].
Steps: (1) Classify the question using the categories found in that study: understanding and applying the material (about 47%), clarifying the therapeutic process (about 23%), technical problems (about 18%), problems outside the programme's scope (about 12%) [source: Soucy et al., 2019]. (2) Material questions: answer briefly, give a personal example of the technique applied to their situation, point to the lesson section. (3) Process questions: explain how the programme works and what to expect. (4) Technical: solve or pass to technical support (4.16). (5) Out-of-scope: acknowledge, signpost or offer a call, and if it bears on risk or suitability, review (4.13, 4.19) [synthesis for steps 2 to 5].
Example language (illustrative): "Good question. 'Facing it gradually' means starting with the step you rated about 30 out of 100, not the hardest one. For you that might be..." / "The relationship worry you mention is important, and the course doesn't cover it well. Would a short call help to think about where you could get support for that?"
Watch for: Repeated reassurance-seeking questions in anxiety, where answering can maintain the problem [synthesis]. Working: the client applies the answer in the next homework.

4.10 Homework review and accountability

Purpose / when: Each week, especially when homework was not done. A lenient response to uncompleted homework was linked to less improvement in GAD [source: Andersson et al., 2019].
Steps: (1) Check what was assigned and what was logged. (2) If done: praise specifically and ask what they learned. (3) If not done: name it neutrally, ask what got in the way, problem-solve one obstacle, shrink the task if needed, and agree when it will happen. (4) Do not unlock or encourage the next lesson's harder tasks as a way to skip practice (e.g. exposure steps) [synthesis for 2 to 4].
Example language (illustrative): "I noticed the exposure log for this week is empty. That's common at this stage, and I'd like to understand what got in the way. Was it time, or did the first step feel too big?"
Watch for: Shame and withdrawal after a missed week; clients reporting practice they did not do. Working: the next week's log has entries.

4.11 Weekly symptom monitoring and measurement feedback

Purpose / when: Every week, to track progress and risk. MindSpot administers the PHQ-9 at each login [source: Nielssen et al., 2015]; the Swedish social-anxiety trial used a weekly disorder-specific self-report scale [source: Käll et al., 2023].
Steps: (1) Check scores before each message. (2) Graph or note the trend since baseline. (3) Report the number and direction to the client in plain words (symptom feedback). (4) If scores are flat after several lessons or rising, review with the client and in supervision (4.19). (5) Check risk items and automated alerts every working day, not only on reply day [synthesis].
Example language (illustrative): "Your mood score has been steady at 14 for three weeks. Courses often work slowly at first, but I'd like to look at this with you. Which parts are you finding hardest to put into practice?"
Watch for: Reliable deterioration; risk items; clients completing measures without lessons. Working: scores falling, and the client using the graph to notice progress.

4.12 Re-engagement after inactivity

Purpose / when: When a client has not logged in, sent a message, or completed the weekly measure by the expected day. Module completion was linked to symptom reduction in the on-demand group of the Swedish trial [source: Käll et al., 2023]; MindSpot reports that people reading at least three lessons are likely to improve [source: MindSpot Wellbeing Course page].
Steps: [synthesis throughout] (1) Send a short, warm reminder on the scheduled day. (2) If no response, send a second reminder offering a smaller step (read one page, do the questionnaire). (3) If still no response, phone if your service allows, or send a closing-the-loop message offering a pause or return. (4) If the last scores showed risk, inactivity is treated as a risk event (4.14), not an engagement problem.
Example language (illustrative): "Hi Tom, I haven't seen you on the course this week. Life gets busy and that's fine. Even ten minutes on Lesson 3 would keep things moving. Is anything getting in the way that I can help with?"
Watch for: Silent dropout after early deterioration; client embarrassment. Working: the client logs back in.

4.13 Risk response at screening and assessment

Purpose / when: When a screening or assessment answer indicates suicidal thoughts, plans or intent. Procedures below are MindSpot's as published [source: Nielssen et al., 2015].
Steps: (1) Anyone answering yes to the suicide questions sees an on-screen alert with crisis and emergency contacts. (2) A therapist phones as soon as practicable, including clients who chose email-only contact. (3) Complete a structured risk assessment covering suicidal thoughts and behaviour, risk factors, past attempts, access to lethal means and imminence of any plan, using the service's risk form. (4) Write a crisis summary report recording risk and protective factors, actions taken and outcomes. (5) If the client cannot guarantee safety for at least 24 hours, or you judge risk imminent, refer urgently to the local mental health crisis team or emergency services. (6) If risk is not imminent, complete a safety plan naming at least three people or services the client will contact if things worsen, give crisis-line contacts, and include the plan in the written assessment report. (7) If the client cannot be reached or will not engage and risk is high, MindSpot has used police welfare checks and, once, an ambulance. (8) The shift supervisor and senior clinicians are alerted to every risk assessment, check the report, and confirm safety plans. Lethal-means counselling covers safe storage and removal only [synthesis].
Example language (illustrative): "I'm calling because of your answers about not wanting to be here. I'm glad you were honest. Can we talk about how things are right now and how to keep you safe?" / "Who are three people or services you could contact if these thoughts get stronger?"
Watch for: Clients who disengage when called; clients giving no address; out-of-hours disclosures. MindSpot reported most urgent referrals arose at assessment rather than during treatment [source: Nielssen et al., 2015]. Working: a written safety plan, the client reachable, and a clear decision documented and countersigned.

4.14 Risk triggers during treatment

Purpose / when: Any time during treatment. MindSpot triggers a risk assessment when the weekly PHQ-9 shows suicidal intent or plan, a rise of more than five points, or a total above its preset cut-off of 20; automated alerts go to the therapist and senior staff, followed by attempts to contact [source: Nielssen et al., 2015].
Steps: (1) Know your platform's alert rules and who receives them. (2) Respond the same working day by phone. (3) Repeat the structured assessment (4.13) and update the safety plan. (4) Decide whether to continue, pause, add support, or step up, and inform the GP with consent or as your service's duty-of-care policy allows [synthesis for 4]. (5) Document and inform the supervisor. (6) In your next written message, refer to the call and the plan.
Example language (illustrative): "Your score went up quite a bit this week, and I wanted to check in by phone rather than write."
Watch for: Alerts landing outside service hours; scores rising in clients who have stopped doing lessons. Working: risk reviewed within the service's standard and the client's plan updated.

4.15 Moderating peer forums

Purpose / when: Where the programme has a forum. The Swedish trial ran separate anonymous forums, monitored by study staff for safety [source: Käll et al., 2023].
Steps: [synthesis] (1) Set and post rules (no clinical advice, no method details of self-harm, respect, anonymity). (2) Check posts on set days. (3) Remove unsafe posts and contact the poster privately through the risk pathway. (4) Do not use forum content in a client's feedback without their consent.
Example language (illustrative): "I've removed your post because it included details we keep out of the forum for everyone's safety. I'd like to call you today to see how you are."
Watch for: Comparisons that discourage, misinformation, contagion. Working: supportive posts, safety rules respected.

4.16 Technical and administrative support

Purpose / when: Login, access, lesson locking, measure problems. Technical problems made up about 18% of client questions [source: Soucy et al., 2019], and practical and technical support alone may be sufficient for some clients [source: Andersson et al., 2019].
Steps: (1) Fix simple issues yourself (where to click, when lessons unlock). (2) Pass account or security issues to the platform team. (3) Confirm when solved. (4) Note recurring issues for the service [synthesis].
Example language (illustrative): "Lesson 4 unlocks a week after you finish Lesson 3, so it should appear on Thursday."
Watch for: Technical complaints that mask low motivation or avoidance [synthesis]. Working: access restored and lesson completed.

4.17 Collaborative care with the GP and prescriber

Purpose / when: At enrolment, when risk rises, and at ending. MindSpot recommends discussing participation with a GP and refers to GPs and community mental health teams in crises [source: MindSpot Wellbeing Course page; Nielssen et al., 2015].
Steps: (1) Record the GP and any prescriber and current medicines (as reported). (2) With consent, send a brief note at start and end of treatment [synthesis]. (3) If the client reports side effects, wishes to change medication, or has questions about it, route them to the prescriber; never advise starting, stopping or changing a medicine. (4) Send the risk summary to the GP or crisis team as your service's procedure states.
Example language (illustrative): "That's a question for your GP, since they prescribed it. Would it help to write down what you've noticed so you can take it to the appointment?"
Watch for: Clients using the course instead of needed medical review. Working: the GP knows, and the client has the appointment.

4.18 Data privacy and security conversation

Purpose / when: At consent and when the client raises worries. Platforms use security similar to internet banking, including encrypted data traffic and two-factor login, and must store messages and clinical notes securely; health-data privacy law is changing quickly [source: Andersson et al., 2019].
Steps: (1) Explain where data are held, who can see messages (guide, supervisor, technical staff under confidentiality), and how long records are kept, using your service's privacy notice [synthesis]. (2) Advise a private device or account, logging out, and not saving passwords on shared devices [synthesis]. (3) Use only the platform's secure channel for clinical content. (4) For products you prescribe, check data-protection and clinical-safety documentation (in England, products NICE assessed and their requirements are summarised in 087) [uncertain: product-level compliance not verified]. (5) Ask about anyone who might read their device, including in cases of domestic abuse, and adjust (e.g. notifications off) [synthesis].
Example language (illustrative): "Your messages to me sit in the secure system, not ordinary email. Is there anyone at home who might see your phone or computer that we should plan around?"
Watch for: Coercive partners, workplace devices, young people on family accounts. Working: the client knows the risks and has a plan.

4.19 Mid-course review and stepping

Purpose / when: When scores do not move, risk rises, or a new problem appears.
Steps: [synthesis] (1) Arrange a call. (2) Review completion, practice and scores together. (3) Consider: continuing with more support, switching programme, adding sessions, or stepping up to face-to-face or specialist care; ICBT is used as one step in stepped care [source: Andersson et al., 2019]. (4) Agree the plan and inform the GP if stepping up.
Example language (illustrative): "We are halfway and the numbers haven't shifted much. Let's look at what's working and decide together whether to carry on, add some calls, or move to something more intensive."
Watch for: Continuing by default. Working: a documented decision with a reason.

4.20 Ending: final message, staying-well plan, post-treatment measures

Purpose / when: At the final lesson or end of the treatment window. MindSpot's Wellbeing Course ends with a lesson on staying well after the course [source: MindSpot Wellbeing Course page]; trials take post-treatment measures [source: Käll et al., 2023].
Steps: (1) Ask the client to complete the final measures. (2) Feed back the change from baseline in numbers and words. (3) Help them write a personal staying-well plan from the final lesson: early warning signs, the skills that helped most, a practice routine, people and services to contact [synthesis on contents]. (4) Remind them how long they can access the material [uncertain: varies by service]. (5) Agree next steps: discharge, follow-up measure, or step-up referral. (6) Send a closing message and, with consent, a GP letter.
Example language (illustrative): "You started at 18 on the mood measure and you're now at 7. That change came from what you did each week. Which two skills would you want to keep using?"
Watch for: Partial responders who need more; fear of losing support. Working: a written plan the client can name.

4.21 Self-guided use: recommending and safety-netting

Purpose / when: When a client prefers to work alone, for mild problems, waiting-list periods, or relapse prevention. Self-guided ICBT for depression showed small effects (g = 0.27) and is generally less effective than guided ICBT; some self-guided programmes with administrative contact still produced clinically significant improvement [source: Andersson et al., 2019]. MoodGYM is an example of a publicly available self-guided programme [source: same]; MindSpot also allows clients to skip weekly support [source: MindSpot Wellbeing Course page].
Steps: (1) Screen for risk and severity first; self-guided use without monitoring suits mild to moderate problems [synthesis]. (2) Choose a programme from a reputable provider with published evidence, a privacy notice and a visible crisis page [synthesis]. (3) Agree a reading and practice routine. (4) Offer a check-in point (e.g. after two weeks) and a repeat measure. (5) Give a clear safety net: when to contact you, the GP or crisis services. (6) If you support it within your own sessions, review the lessons the client did at the start of each session [synthesis].
Example language (illustrative): "This course is self-paced. Let's agree to look at how it's going in two weeks. If your mood drops or you start thinking about harming yourself, contact me or your GP straight away, or the crisis line if it's urgent."
Watch for: Early stopping, which is common without guidance (unguided dropout around 31% in early programmes [source: Andersson et al., 2019]). Working: lessons completed and scores improving at check-in.

4.22 Using a programme alongside your own therapy (blended or prescribed)

Purpose / when: When you want a programme to carry psychoeducation and skills practice between your sessions. Stakeholders prefer blended over stand-alone ICBT, especially for moderate to severe depression [source: Andersson et al., 2019]. THIS WAY UP offers clinician access to its programmes [uncertain: registration and monitoring steps not verified].
Steps: [synthesis] (1) Pick lessons that match your formulation. (2) Assign one lesson per week and agree what the client will bring to session. (3) Review the lesson and homework at the start of each session. (4) Use the platform's measures as your outcome monitoring. (5) Agree who responds to alerts between sessions.
Example language (illustrative): "Before next week, could you do Lesson 2 on thoughts and bring one example you worked through? We'll start there."
Watch for: Duplicated or contradictory content; nobody responsible for alerts. Working: sessions build on the lessons.

4.23 Supporting digitally enabled therapy at NHS Talking Therapies step 2 or 3

Purpose / when: In England, when a service offers a commissioned digitally enabled therapy. These are most commonly step 2 low-intensity interventions facilitated by a PWP who reviews progress, and can be step 3 if they include the content of the relevant NICE guideline; some products administer NHS Talking Therapies outcome measures and export them to the service's records, and some have built-in risk alerts and crisis signposting [source: NICE EVA section 2]. See 087.
Steps: (1) Follow the service's protocol for which product, which step and how many review contacts [uncertain: contact schedule not specified by NICE page]. (2) Review the product's measures before each contact. (3) Confirm how product risk alerts reach the service and who acts on them. (4) Step up per local criteria.
Example language (illustrative): "I'll review your progress in the programme with you every couple of weeks and look at your questionnaire scores before each review."
Watch for: Assuming the product's crisis signposting replaces your service's risk procedure [synthesis]. Working: reviews happen on schedule and measures are recorded.

4.24 Supervision and message fidelity audit

Purpose / when: Ongoing. The ICBT Therapist Rating Scale was developed for research and clinical training; message quality was higher when therapists specialised in ICBT [source: Hadjistavropoulos et al., 2018]. MindSpot therapists, mostly registered psychologists, receive competency-based training in risk assessment and crisis contact, and senior staff support every risk assessment in real time [source: Nielssen et al., 2015].
Steps: (1) Each month, pick a sample of your messages. (2) Rate each against the nine behaviours as present or absent and adequate or not. (3) Discuss gaps in supervision, especially symptom feedback and facilitating understanding. (4) Review every risk case with a senior clinician. [synthesis for 1 to 3 procedure]
Example language (illustrative, supervision): "In these five messages I praised effort every time but only gave score feedback twice. I'll add a line on scores each week."
Watch for: Drift into long, unfocused messages. Working: audit ratings stable and high.

5. Handling problems

Most responses below are practical synthesis from the principles and procedures above; source tags show where a published programme addresses the point.

Non-login in the first week. Early activity predicts benefit (MindSpot: at least three lessons read [source: MindSpot Wellbeing Course page]). Response: reminder on day of schedule, second smaller-step reminder, then a call [synthesis]. Check whether a technical or privacy barrier is the cause.
Gradual dropout mid-course. Completion is lower in guided ICBT than face-to-face CBT (65.1% vs 84.7% full completers in depression) [source: Andersson et al., 2019]. Response: name the pattern, offer a pause with a return date, shorten tasks, or a call; if the client wants to stop, close well with a staying-well summary and an open door [synthesis].
Homework not done, week after week. Response: avoid leniency [source: Andersson et al., 2019]; explore the obstacle (time, fear, not understanding), break the task down, link it to the client's goal, and if exposure is being avoided, review the hierarchy together by phone [synthesis].
Client wants more contact than the model offers. Response: explain the schedule and why regular brief contact helps; offer a call if the service allows; if needs exceed guided ICBT, step up (4.19) [synthesis].
Excessive messaging or reassurance-seeking. Response: reply on the scheduled day only (except risk), answer the core question once, and frame reassurance-seeking as a pattern to work on with the programme's skills [synthesis].
Rupture in text (client feels criticised or ignored). Text loses tone. Response: acknowledge promptly, apologise for the impact, clarify intent, ask how they would like feedback; offer a call to repair [synthesis]. Rapport-building and seeking feedback are rated guide behaviours [source: Hadjistavropoulos et al., 2018].
Overwhelm by reading load or content. Some programmes run to about 150 pages [source: Andersson et al., 2019]. Response: suggest audio or video versions where offered, reading one section a day, focusing on the core exercise, and extending the timeline if the service permits [synthesis].
Misunderstanding the material. Facilitating understanding was one of the behaviours most often missing from messages [source: Hadjistavropoulos et al., 2018]. Response: ask the client to describe the skill in their words, correct gently, give a worked example from their own life [synthesis].
Problems outside the programme's scope (relationships, grief, trauma not covered, practical crises) were about 12% of questions [source: Soucy et al., 2019]. Response: acknowledge, signpost, and reassess suitability if the issue dominates [synthesis].
Deterioration or rising risk. Response: follow the alert and risk pathway (4.13, 4.14) the same working day; never handle risk by message alone [source: Nielssen et al., 2015].
Out-of-hours risk disclosure in a message. Services are not staffed around the clock (MindSpot: 8 am to 8 pm Monday to Saturday [source: Nielssen et al., 2015]). Response: make sure the consent, welcome message and every page show urgent-help contacts; on reading the message, act at once under the risk pathway; review whether auto-replies point to crisis services [synthesis].
Client unreachable after a risk alert. Response: repeated attempts by phone, then the emergency contact or GP per consent, and welfare check by police in high-risk cases as MindSpot has done [source: Nielssen et al., 2015]; document each step and involve the senior clinician.
New or emerging severe condition (psychosis, mania, severe eating disorder, substance dependence). Response: pause the course, assess by phone, refer to GP and specialist services [synthesis; MindSpot advises severe cases to see a GP and psychologist and/or psychiatrist, source: MindSpot Wellbeing Course page].
Medication questions or side effects. Response: route to the prescriber; no advice on starting, stopping or changing (4.17).
Privacy fears or shared devices. Response: plan as in 4.18; consider whether telephone or face-to-face care is safer [synthesis].
Literacy, language or disability barriers. Response: check accessibility features, translated or culturally adapted courses (e.g. an Indigenous Wellbeing Course is listed by MindSpot [uncertain: content not verified]), or offer another format [synthesis].
Age outside the programme's range. Published adult courses have defined age bands (Wellbeing Course for adults within its published band; MindSpot supports younger people to reach appropriate care [source: MindSpot Wellbeing Course page; Nielssen et al., 2015]). Response: refer to a youth-specific service or programme [synthesis].
Self-guided user who stalls. Response: offer a guided version or a check-in session; if they return to you with low scores, reassess rather than restarting the same course [synthesis].
Product withdrawn or changed by the provider. NICE notes Beating the Blues is no longer available to the NHS [source: NICE EVA section 2]. Response: before prescribing, check the product is current and supported; plan continuity of care and data access if a product closes [synthesis].
Therapist workload and message drift. Response: protect scheduled time, use the nine-behaviour checklist, keep messages brief, audit monthly (4.24) [synthesis].

Sources

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