Internet-based trials and the creation of health consumers q Jenny Advocat * , Jo Lindsay Monash University, Clayton, Victoria, Australia article info Article history: Available online 18 November 2009 Keywords: Australia Randomised controlled trials Panic disorder Therapy culture Internet Health consumption Cognitive behavioural therapy (CBT) abstract In this paper we document the experience of participating in novel randomised controlled trials for panic disorder – where face-to-face and Internet delivery of cognitive behavioural therapy are compared. Our analysis is based on 18 months of observation and in-depth interviews with 10 trial participants and 8 trialists in Victoria, Australia. We argue that the participants are positioned as active health consumers and approach the trial as they would other self-help practices. High levels of individual responsibility are assumed of participants in these trials, which they accept by approaching the trials reflexively and searching for information and strategies they can employ while building their health literacy on panic disorder. Although the researchers set the parameters of the treatment and interaction, increasingly the participants choose the extent to which they will comply with their defined role. For the participants the trial is one of the ‘pick and mix’ options of available treatment and we suggest it is a compelling example of contemporary health consumption. Ó 2009 Elsevier Ltd. All rights reserved. Introduction In this paper we document the experience of participating in Internet-based mental health randomised controlled trials (RCTs) which has received very little attention in either biomedical or social science literatures. Broader shifts in mental health care intersect in these trials for the treatment of panic disorder, including the use of the Internet for health care provision, the rise of therapeutic culture and the consumer model of health. We describe the forms of subjectivity created in the trials so that participants see themselves as responsible consumers and the trials as one option amongst an array of others in the therapeutic marketplace. We begin by reviewing the literature on Internet-based RCTs for mental health problems. We then outline the development of treatment for panic disorder and discuss the broader social context of therapeutic culture and health care consumption which are key to understanding the trials and forms of subjectivity they foster. Internet-based randomized controlled trials for mental health problems With the increasing influence of evidence-based medicine, the RCT is considered the ‘‘gold standard’’ for providing the best evidence for treatment interventions for health conditions. RCTs for online treatment of mental health issues are rapidly developing but there is little research on participants’ perspectives on being in these trials. Randomised trials involve random allocation of participants to different treatment groups, one which receives the treatment under investigation and at least one other group who may receive the standard therapy or a placebo. The experimental therapy is statistically evaluated against the known treatment. There is little doubt that interest in RCTs is growing as reflected by the number of trials conducted around the world (National Insti- tutes of Health, 2006). The first Internet-based psychological research was conducted by Welch & Krantz in 1996 (Birnbaum, 2004). Since then there has been a great deal of research into the use of the Internet for the treatment of mental health problems in both psychology (Jerome & Zaylor, 2000; Reips, 2002) and other disciplines (Gackenbach, 1998). This literature examines a variety of aspects of Internet-based therapy. Research questions are often framed in terms of the therapists and how Internet-based approaches impact upon their practice, either in terms of time efficiency (Crone et al., 2004; Marks, Kenwright, McDonough, Wittaker, & Mataix-Cols, 2004) or cost effectiveness (Crone et al., 2004). There has been research on the effectiveness of the Internet for q We would like to acknowledge the Institute of Health Services Research at Monash University, Prof. Sally Green, the Australasian Cochrane Collaboration and an APA(I)scholarship which supported this research. We are grateful for the helpful comments of Alan Petersen, Mark Davis and Joshua Mullan. We also thank the researchers and participants for sharing their experiences with us and making this research possible. * Corresponding author. Monash University, School of Political and Social Inquiry, Building 11, Clayton Campus, Wellington Road, Clayton, Victoria 3800, Australia. Tel.: þ61 422506698. E-mail address: jenny.advocat@arts.monash.edu.au (J. Advocat). Contents lists available at ScienceDirect Social Science & Medicine journal homepage: www.elsevier.com/locate/socscimed 0277-9536/$ – see front matter Ó 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2009.10.051 Social Science & Medicine 70 (2010) 485–492