Client engagement in psychotherapeutic treatment and associations with client characteristics, therapist characteristics, and treatment factors

Primary care team perspectives on approaches to engaging patients in treatment for opioid use disorder

INTRODUCTION

Engagement is a critical component of successful treatment for opioid use disorder (OUD). However, rates of patient engagement in OUD treatment, especially in outpatient settings, are variable and often low. Little is known about the specific strategies members of primary care teams use to initiate and encourage ongoing participation in OUD treatment. In a national cohort of primary care clinics in the U.S., we explored the perspectives of primary care team members on the meaning of and approaches to OUD treatment engagement.

METHODS

We conducted semi-structured interviews with 35 providers from multidisciplinary primary care teams in an existing national cohort of 13 clinics across seven states. Teams were delivering OUD treatment via the Collaborative Care Model, a model that combines primary care providers (PCP), behavioral health care managers (BHCM) and consulting psychiatric providers (CPP) in a structured way to provide patient-centered, team-based, and measurement-based care. Interview participants included 14 PCPs, 13 BHCMs, and 8 CPPs. Interviews asked open-ended questions about provider experiences and practices that aided or hindered patient engagement in OUD treatment. Interview transcripts were double-coded by trained qualitative researchers and analyzed using a combination of deductive and inductive approaches to identify themes.

RESULTS

Two themes emerged that describe provider perspectives on the meaning of engagement: 1) qualifying engagement by the volume of contact with patients, and 2) the need for more multidimensional measures of engagement. Six themes emerged that characterized provider engagement practices: 1) creating an environment of disclosure, 2) normalizing OUD treatment, 3) offering gentle but persistent outreach, 4) providing human connection and encouragement, 5) tailoring treatment to patient needs, and 6) avoiding stigmatizing responses. Analysis identified multiple replicable strategies that providers used to support these engagement practices.

CONCLUSIONS

Providers consistently apply a range of strategies when trying to engage patients in OUD treatment. Specific engagement strategies used embodied compassion and pragmatism, hallmarks of patient-centered care. Further research is needed to understand the impact of scaling engagement approaches across all care settings.

Working alliance and its link to guidance in an internet-based intervention for depressive disorders: a secondary analysis of a randomized controlled trial

Background

Guided Internet-based interventions (IBIs) are typically found to be more effective than unguided ones, but the reasons behind this are not well understood. The therapist-client working alliance, crucial in face-to-face psychotherapy, is also increasingly recognized as an important factor in IBIs. This study examines trajectories of the working alliance and its relationship to therapeutic guidance through a secondary analysis of a randomized controlled trial (RCT) on Selfapy, a 12-week IBI based on cognitive behavioral therapy for depressive disorders. The trial compared a therapist-guided version (with weekly calls) to an unguided version (n = 301, mean age 37 years, 83% female, mean BDI-II = 30.09).

Methods

Based on an intention-to-treat approach, this study investigates within- and between-group differences in the quality of the working alliance, assessed with the WAI-SR questionnaire at mid- and post-treatment via repeated measures ANOVA. Furthermore, correlations and mediation analyses were conducted to explore the relationship between the working alliance and outcomes, as well as adherence parameters.

Results

Findings indicate that the IBI was successful in fostering a robust working alliance in both intervention groups, with similar ratings at mid-treatment but significantly higher ratings in the guided group at post-treatment (Cohen's d = -0.38). Post-treatment working alliance scores were positively linked to symptom reduction at post-treatment (guided: r = .25, unguided r = .15) and follow-up (guided: r = .25, unguided: r = .17). In the unguided group, the association was primarily driven by the subscale task. Serial mediation analysis indicated that the relationship between guidance and outcomes at follow-up was mediated by working alliance (b = 0.59; 95% CI: 0.14, 1.22) and a link between working alliance and adherence (b = 0.15; 95% CI: 0.04, 0.34).

Conclusions

Considering limitations like using a questionnaire developed for face-to-face therapy, findings support the importance of the working alliance in guided IBIs, while also providing new insights into its role and formation in unguided IBIs. The potential benefits of a strong working alliance, notably by improving adherence, may prove crucial for integrating guided as well as unguided IBIs into routine use, indicating the need for additional research in this context.

Clinical Trial Registration

https://tinyurl.com/2p9h5hnx, German Clinical Trials Register DRKS00017191.

Investigating Determinants of Client Psychotherapy Preference: An Analog Study

Increased emphasis has been placed on elucidating the contribution of client variables, such as treatment preference, to optimize evidence-based practice. This analog study sought to better understand variables associated with treatment preference using a convenience sample of college students (n = 54) who read brief descriptions of three interventions for negative thoughts-defusion, noticing, and restructuring. They rated each on acceptability and practicality and completed measures of cognitive fusion, emotional distress, and experiential avoidance as possible moderating variables. Restructuring was overwhelmingly preferred and rated as more acceptable than the two alternatives by both the overall sample and a distressed subsample. Preference for defusion or noticing was not predicted by ratings of acceptability or practicality but by elevated levels of cognitive fusion and emotional distress consistent with a compensation model. Limitations of the study and its implications for further research on psychotherapy preference and its integration within evidence-based practice are discussed.

An exploration of organizational climate in community-based opiate prescribing services; a mixed methods study

INTRODUCTION

Assessing the internal dynamics of organizations has been shown to provide information that can help planners and policymakers improve service delivery. A good organizational climate, which in this study incorporates mission clarity, team cohesion, staff autonomy, communication, levels of stress, and openness to change has been shown to be of particular importance. Still, there is a dearth of evidence in this area, and while relationships between organizational factors have been identified, little is known about the mechanisms that might underpin these relationships, and there is little understanding of how to address deficits once they are identified. The objective of this study was to identify relationships between program factors that influence organizational climate and to explore which mechanisms might underpin these relationships.

METHODS

This paper reports on a cross-sectional, concurrent, mixed-methods study design, across twelve discrete community-based prescribing service providers (organizations) in Ireland. Data was obtained using a staff survey [n = 132] which utilized measurements of organizational readiness to change and one-to-one interviews [n = 12]. Quantitative data was analyzed using multivariate linear regression modeling which assessed relationships between variables, while interviews were analyzed using an abductive approach, both types of data were synthesized at the interpretation stage.

RESULTS

A range of interdependent factors were considered to affect the climate of organizations. Surveys identified that specific types of resources, such as physical infrastructure, training, and staffing resources were important for supporting a good organizational climate, while programs with greater needs had a poorer climate. Opportunities for professional growth, the skill sets of staff, and having access to e-communication were also significant. Interviewees reported that rigid organizational hierarchies and bureaucracy, philosophical views of addiction, stress, and staff turnover were influenced by the provision of fewer resources. Interdependent factors such as leadership, supervision, staff relationships, and collective training, also thought to be influenced by resources, were considered to positively influence programs. Resources were not the only challenge identified, and practices within programs and how existing resources are used were also thought to contribute both positively and negatively to the internal dynamics of services.

CONCLUSION

Key findings in this study identified that the organization of effective services is influenced by a range of specific factors, some of which can be addressed without additional resources. Overall, staff views of organizations can provide us with valuable information to support service improvement. Using a mixed methods approach can not only identify where relationships between organizational variables exist but can also help us to understand the mechanisms that underpin these relationships and, importantly, how to address deficits once they are identified. In order to improve how substance misuse services work, the need for a long-term systemic approach to program development, which incorporates some of the findings from this study, is required.

Therapist's warmth and competence increased positive outcome expectations and alliance in an analogue experiment

Objective: The quality of the therapeutic alliance, treatment motivation, outcome expectations (OE), and specific health behaviour predicts psychotherapy success. Therapists should be able to improve these factors to optimize outcomes. This study investigated the therapist's interpersonal behaviour to optimize alliance, motivation, OE, and health behaviour. Method: A stressed study sample (N = 465) completed an online analogue experiment. We gave participants positive information about psychotherapy effectiveness and varied the therapist's interpersonal behaviour along the dimensions of warmth and competence.Results: High (vs. low) competence and high (vs. low) warmth increased alliance, OE, and help-seeking scores, while high (vs. low) competence increased motivation to do psychotherapy. We found no effects on health behaviour.Conclusion: In contrast to previous correlational analyses, our experimental study supports the causal role of the therapist's warmth and competence and its impact on alliance, motivation, and OE. We discuss approaches for future studies and clinical implications.

Therapeutic Content of Mobile Phone Applications for Substance Use Disorders: An Umbrella Review

Mobile phone applications (MPAs) for substance use disorder (SUD) treatment are increasingly used by patients. Although pilot studies have shown promising results, multiple previous systematic reviews noted insufficient evidence for MPA use in SUD treatment-many of the previously published reviews evaluated different trials. Subsequently, we aimed to conduct an umbrella review of previously published reviews investigating the efficacy of MPAs for SUD treatment, excluding nicotine/tobacco because umbrella reviews have been done in this population and the nicotine/tobacco MPA approach often differs from SUD-focused MPAs. No previous reviews have included a statistical meta-analysis of clinical trials to quantify an estimated overall effect. Seven reviews met inclusion criteria, and 17 unique studies with available data were taken from those reviews for the meta-analysis. Overall, reviews reported a lack of evidence for recommending MPAs for SUD treatment. However, MPA-delivered recovery support services, cognitive behavioral therapy, and contingency management were identified across multiple reviews as having promising evidence for SUD treatment. Hedges g effect size for an MPA reduction in substance use-related outcomes relative to the control arm was insignificant (0.137; 95% CI, -0.056 to 0.330; P=.16). In subgroup analysis, contingency management (1.29; 95% CI, 1.088-1.482; τ 2=0; k=2) and cognitive behavioral therapy (0.02; 95% CI, 0.001-0.030; τ 2=0; k=2) were significant. Although contingency management's effect was large, both trials were small (samples of 40 and 30). This review includes an adapted framework for the American Psychiatric Association's MPA guidelines that clinicians can implement to review MPAs critically with patients.

Subjective Experience and Perceived Benefits in Clients with Schizophrenia Following Participation in Metacognition Reflection and Insight Therapy (MERIT)

Schizophrenia spectrum disorders involve disturbances in the experience of the self, which are related to limited metacognitive ability. The aim of metacognition-based therapies is to improve metacognitive ability and, subsequently, self-management and recovery. Adding to the quantitative findings from a trial on the effectiveness of Metacognition Reflection and Insight Therapy (MERIT), in the current study, we report on a qualitative assessment of MERIT's subjective perceived contribution. Twenty-seven patients with schizophrenia were interviewed after completing MERIT. Content analysis based on grounded theory was conducted by two independent raters. Most participants were satisfied with the therapy and reported improvement mainly in self-experience domains. The main contributors to perceived improvement pertained to the intervention process (e.g., therapeutic alliance and therapist interventions) as well as to the patient being an active agent of change. Perceived outcomes are particularly important among this cohort, as they often cope with limited metacognitive abilities, expressed by challenges in reflecting on themselves and others. The current study supports MERIT as a treatment that enhances positive outcomes for people with schizophrenia.

Modified Approaches to Treating Anxiety for Children With Visual-Spatial Problems: A Strengths-Based Perspective

Anxiety disorders are common and impairing1 and affect as many as 30% of youth with2 and without3 neurodevelopmental disorders. Nonverbal learning disability (NVLD) is an understudied neurodevelopmental disorder with an estimated prevalence of 3% in North American children and adolescents.4 Although definitions of NVLD vary, all include a core deficit of difficulty with visual-spatial processing. Importantly, anxiety is also a common psychiatric comorbidity for youth with NVLD, affecting roughly one-third of these youth.4,5 In youth with neurodevelopmental disorders, treatment is often sought or received for comorbid conditions (eg, anxiety, attention-deficit/hyperactivity disorder) or associated impairments, rather than for the symptoms or core deficits of the neurodevelopmental disorder itself.6 Considerable work has examined the adaptation of anxiety disorder treatments for children with attention-deficit/hyperactivity disorder7 and autism.8 Comparatively little work has explored treatment approaches for children with NVLD. Given the overlap of anxiety symptoms and visual-spatial problems in NVLD,9,10 herein we consider how these cognitive problems might interfere with patients' abilities to engage with common treatment approaches.

Predictors of homework engagement in group CBT for social anxiety: client beliefs about homework, its consequences, group cohesion, and working alliance

OBJECTIVE

Group cognitive behaviour therapy (CBT) for social anxiety disorder (SAD) is effective, but little data exist on generic relational components of the therapeutic process, such as group cohesion and therapy alliance, and central CBT-specific components such as homework engagement, beliefs, and perceived consequences. The aim of this study was to investigate the relationships between homework, group cohesion, and working alliance during group CBT for social anxiety disorder.

METHOD

Participants (N = 105) with SAD engaged in 12 sessions of group CBT. Measures of homework, working alliance, and group cohesion were completed at multiple points throughout treatment. Random-intercept cross-lagged panel models were used to evaluate the prospective relationships between measures.

RESULTS

Prospective relationships between the homework outcomes did not vary throughout the treatment period, with the only significant relationships seen between the random intercepts ("trait" levels). Homework beliefs were a significant negative predictor of future group cohesion, but only in mid- to late-treatment. Homework consequences and working alliance were significantly and positively predictive of each other throughout therapy.

CONCLUSION

Early homework engagement is associated with higher engagement throughout therapy. Working alliance and homework engagement are important to bolster early in group CBT.Trial registration: Australian New Zealand Clinical Trials Registry identifier: ACTRN12616000579493..

Therapist competence, homework engagement, and client characteristics in CBT for youth depression: A study of mediation and moderation in a community-based trial

OBJECTIVE

Prior studies of Cognitive Behavioral Therapy (CBT) have focused on the quantity and quality of clients' homework completion and only rarely have considered the role of therapist competence.

METHODS

The present study examined (a) therapist competence across the entire process of integrating homework into CBT, including the review, design, and planning of tasks; (b) homework engagement, including client appraisals of the difficulty and obstacles encountered in task completion using the Homework Rating Scale - Revised (HRS-II); (c) pre-post symptom reduction as the index of outcome; and (d) considered client factors such as suicide risk in a community-based trial for adolescent depression. Trained independent observers assessed therapist competence and engagement with homework at two consecutive sessions of CBT for N = 80 young people (Mage = 19.61, SD = 2.60).

RESULTS

Significant complementary mediation effects were obtained; there was an indirect mediation effect of HRS-II Beliefs (b = 1.03, SE B = 0.42, 95% BCa CI [0.35, 2.03]) and HRS-II Perceived Consequences on the Competence-Engagement relationship (b = 0.85, SE B = 0.31, 95% BCa CI [0.39, 1.61]). High levels of suicidal ideation were also shown to moderate this relationship.

CONCLUSIONS

The present findings contribute to the growing body of CBT process research designed to examine the complex interrelationships of client and therapist variables, in a manner that reflects the actual process of therapy, and advances beyond studies of isolated predictors of symptom change.

Massed cognitive processing therapy for combat-related posttraumatic stress disorder: Study design and methodology of a non-inferiority randomized controlled trial

BACKGROUND

Posttraumatic stress disorder (PTSD) is prevalent among military personnel. Cognitive processing therapy (CPT) is identified as one of the most effective treatments for PTSD, although smaller effects have been found in military populations. High rates of dropout from treatment may contribute to reduced efficacy, and military personnel may face unique barriers to treatment completion. One method of improving efficacy may be to reduce dropout by decreasing the time required to receive a full dose of treatment. This paper describes the design and methodology of the first randomized clinical trial testing whether CPT delivered in an intensive format is non-inferior to standard delivery of CPT.

METHOD

Participants are 140 active duty service members randomized to receive CPT in a 5-day combined group and individual intensive outpatient format (MCPT) or standard CPT (delivered individually twice weekly over 6 weeks). Participants are assessed at baseline, and 1 month, 4 months, and 1 year following the conclusion of the therapy. Reduction in PTSD symptomatology is the primary outcome of interest. Secondary outcomes include comorbid psychological symptoms, health, and functioning. A secondary objective is to examine predictors of treatment outcome to determine which service members benefit most from which treatment modality.

CONCLUSION

If determined to be non-inferior, MCPT would provide an efficient and accessible modality of evidence-based PTSD treatment. This therapy format would improve access to care by reducing the amount of time required for treatment and improving symptoms and functioning more rapidly, thereby minimizing interference with work-related activities and disruption to the mission.

Associated factors of nurse-sensitive patient outcomes: A multicentred cross-sectional study in psychiatric inpatient hospitals

WHAT IS ALREADY KNOWN?: The nurse-patient relationship in mental health care is an important focus of mental health nursing theories and research. There is limited evidence about which factors influence nurse-sensitive patient outcomes of the nurse-patient relationship. This hinders the development, planning, delivering, and quality assurance of the nurse-patient relationship in nursing practice and nursing education. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: To our best knowledge, this is the first study to examine associations between nurse-sensitive patient outcomes of the nurse-patient relationship and a range of patient characteristics and relationship-contextual factors. In this study, we found that gender, age, hospital characteristics, nurse availability when needed, nurse contact, and nurse stimulation were associated with the scores on the nurse-sensitive patient outcome scale. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Having insight into the factors associated with nurse-sensitive patient outcomes of the nurse-patient relationship can help nurses, nursing students, nursing management and also patients to enhance the nurse-patient relationship, trying to influence outcomes of nursing care. ABSTRACT: Introduction The lack of evidence on patient characteristics and relational-contextual factors influencing nurse-sensitive patient outcomes of a nurse-patient relationship is a possible threat to the quality and education of the nurse-patient relationship. Aim To measure nurse-sensitive patient outcomes of the nurse-patient relationship and to explore the associations between nurse-sensitive patient outcomes and a range of patient characteristics and relational-contextual factors. Method In a multicenter cross-sectional study, 340 inpatients from 30 units in five psychiatric hospitals completed the Mental Health Nurse-Sensitive Patient Outcome Scale. Descriptive, univariate and Linear Mixed Model analyses were conducted. Results Overall, patient-reported outcomes were moderate to good. Female participants, nurse availability when needed, more nurse contact and nurse stimulation were associated with higher outcomes. Age differences were observed for some of the outcomes. Outcomes also varied across hospitals but were not related to the number of times patients were hospitalized or to their current length of stay in the hospital. Discussion The results may help nurses to become more sensitive and responsive to factors associated with nurse-sensitive patient outcomes of the nurse-patient relationship. Implications The nurse-sensitive results can support nurses in designing future nurse-patient relationships.

User Engagement Clusters of an 8-Week Digital Mental Health Intervention Guided by a Relational Agent (Woebot): Exploratory Study

BACKGROUND

With the proliferation of digital mental health interventions (DMHIs) guided by relational agents, little is known about the behavioral, cognitive, and affective engagement components associated with symptom improvement over time. Obtaining a better understanding could lend clues about recommended use for particular subgroups of the population, the potency of different intervention components, and the mechanisms underlying the intervention's success.

OBJECTIVE

This exploratory study applied clustering techniques to a range of engagement indicators, which were mapped to the intervention's active components and the connect, attend, participate, and enact (CAPE) model, to examine the prevalence and characterization of each identified cluster among users of a relational agent-guided DMHI.

METHODS

We invited adults aged 18 years or older who were interested in using digital support to help with mood management or stress reduction through social media to participate in an 8-week DMHI guided by a natural language processing-supported relational agent, Woebot. Users completed assessments of affective and cognitive engagement, working alliance as measured by goal and task working alliance subscale scores, and enactment (ie, application of therapeutic recommendations in real-world settings). The app passively collected data on behavioral engagement (ie, utilization). We applied agglomerative hierarchical clustering analysis to the engagement indicators to identify the number of clusters that provided the best fit to the data collected, characterized the clusters, and then examined associations with baseline demographic and clinical characteristics as well as mental health outcomes at week 8.

RESULTS

Exploratory analyses (n=202) supported 3 clusters: (1) "typical utilizers" (n=81, 40%), who had intermediate levels of behavioral engagement; (2) "early utilizers" (n=58, 29%), who had the nominally highest levels of behavioral engagement in week 1; and (3) "efficient engagers" (n=63, 31%), who had significantly higher levels of affective and cognitive engagement but the lowest level of behavioral engagement. With respect to mental health baseline and outcome measures, efficient engagers had significantly higher levels of baseline resilience (P<.001) and greater declines in depressive symptoms (P=.01) and stress (P=.01) from baseline to week 8 compared to typical utilizers. Significant differences across clusters were found by age, gender identity, race and ethnicity, sexual orientation, education, and insurance coverage. The main analytic findings remained robust in sensitivity analyses.

CONCLUSIONS

There were 3 distinct engagement clusters found, each with distinct baseline demographic and clinical traits and mental health outcomes. Additional research is needed to inform fine-grained recommendations regarding optimal engagement and to determine the best sequence of particular intervention components with known potency. The findings represent an important first step in disentangling the complex interplay between different affective, cognitive, and behavioral engagement indicators and outcomes associated with use of a DMHI incorporating a natural language processing-supported relational agent.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05672745; https://classic.clinicaltrials.gov/ct2/show/NCT05672745.

The benefits and challenges of virtual SMART recovery mutual-help groups: Participant and facilitator perspectives

BACKGROUND

COVID-19 prompted widespread transition of face-to-face mutual-help groups to virtual delivery. Current understanding of the experience of virtual mutual-help groups is limited to 12-step approaches or asynchronous groups (e.g., forums). This paper explores participant and facilitator perspectives regarding the benefits and challenges of accessing SMART Recovery mutual-help groups virtually via videoconference.

METHODS

A self-selected convenience sample of participants (n = 29) and facilitators (n = 15) from SMART Recovery mutual-help groups in Australia were enrolled. Participants and facilitators were sampled to reflect experience of virtual groups delivered via videoconference ('online'), face-to-face groups ('face-to-face') or both types of groups ('both'). Telephone qualitative interviews were conducted using a semi-structured interview guide. Interviews were audio-recorded, transcribed, and analysed using iterative categorisation.

RESULTS

Participant and facilitators discussed their experience across eight interconnected themes benefits were typically discussed with regard to the (1) availability, (2) ease of access and (3) value add of the chat feature in online groups. Challenges largely pertained to (1) in-group engagement, (2) group size, (3) non-verbal cues, (4) social interaction and (5) technology problems. The impact of these challenges on participant and facilitator experience varied, and neither modality was consistently identified as superior.

CONCLUSIONS

SMART Recovery mutual-help groups provided participants with another option for accessing mutual-help and appealed to different people under different circumstances. Depending on the needs and preferences of the individual, online SMART Recovery mutual-help groups may help to mitigate a range of barriers to help seeking and may also engage people otherwise unable or reluctant to engage in treatment. To inform training, practice and policy, improved understanding of the individual and contextual factors that enhance participant engagement, experience and outcomes is needed.

Process mining to discover patterns in patient outcomes in a Psychological Therapies Service

In the mental health sector, Psychological Therapies face numerous challenges including ambiguities over the client and service factors that are linked to unfavourable outcomes. Better understanding of these factors can contribute to effective and efficient use of resources within the Service. In this study, process mining was applied to data from the Northern Health and Social Care Trust Psychological Therapies Service (NHSCT PTS). The aim was to explore how psychological distress severity pre-therapy and attendance factors relate to outcomes and how clinicians can use that information to improve the service. Data included therapy episodes (N = 2,933) from the NHSCT PTS for adults with a range of mental health difficulties. Data were analysed using Define-Measure-Analyse model with process mining. Results found that around 11% of clients had pre-therapy psychological distress scores below the clinical cut-off and thus these individuals were unlikely to significantly improve. Clients with fewer cancelled or missed appointments were more likely to significantly improve post-therapy. Pre-therapy psychological distress scores could be a useful factor to consider at assessment for estimating therapy duration, as those with higher scores typically require more sessions. This study concludes that process mining is useful in health services such as NHSCT PTS to provide information to inform caseload planning, service management and resource allocation, with the potential to improve client's health outcomes.

Feasibility and preliminary results of a call centre delivered continuing care intervention following residential alcohol and other drug treatment

INTRODUCTION

To help reduce relapse rates following alcohol and other drug (AOD) treatment, continuing care interventions have been recommended. Previous continuing care interventions have incorporated telephone and face-to-face sessions to help promote participant engagement. The study was conducted as a randomised controlled feasibility study and examined a call centre delivered continuing care intervention for people leaving residential rehabilitation services.

METHODS

Participants were attending AOD residential treatment services in NSW, Australia (N = 154). Participants were randomised to either 12- or 4-sessions of continuing care. Follow up assessments were completed at 6-months. The primary outcomes were demand and implementation. Secondary outcomes were AOD use, mental health and physical health at 6-months.

RESULTS

Interest in continuing care was high, with 93% of participants approached reporting an interest in being involved. Of the participants who completed the consent and baseline procedures, 29% of people were contacted post residential treatment and randomised. For those people randomised, the average number of sessions completed was 2.78 (SD = 1.65) for the 4-session arm and 4.81 (SD = 4.46) for the 12-session arm. Fidelity to the treatment manual was high. Both treatment arms showed higher complete abstinence at 6-months compared to baseline (12-session OR 28.57 [2.3, 353.8]; 4-session OR 28.11 [3.6, 221.2]).

DISCUSSION AND CONCLUSIONS

A major challenge associated with the call centre approach was re-engaging participants once they left the residential facility and delivering the planned dose of treatment. Further work is required to promote greater uptake of these protocols once people leave residential treatment.

Measuring Engagement with Mental Health and Behavior Change Interventions: an Integrative Review of Methods and Instruments

BACKGROUND

Engagement is a complex construct consisting of behavioral, cognitive, and affective dimensions, making engagement a difficult construct to measure. This integrative review aims to (1) present a multidisciplinary overview of measurement methods that are currently used to measure engagement with adult mental health and behavior change interventions, delivered in-person, blended, or digitally, and (2) provide a set of recommendations and considerations for researchers wishing to study engagement.

METHODS

We used an integrative approach and identified original studies and reviews on engagement with mental health or behavior change interventions that were delivered in-person, digitally, or blended.

RESULTS

Forty articles were analyzed in this review. Common methods to assess engagement were through objective usage data, questionnaire-based data, and qualitative data, with objective usage data being used most frequently. Based on the synthesis of engagement measures, we advise researchers to (1) predefine the operationalization of engagement for their specific research context, (2) measure behavioral, cognitive, and affective dimensions of engagement in all cases, and (3) measure engagement over time.

CONCLUSIONS

Current literature shows a bias towards behavioral measures of engagement in research, as most studies measured engagement exclusively through objective usage data, without including cognitive and affective measures of engagement. We hope that our recommendations will help to reduce this bias and to steer engagement research towards an integrated approach.

Keeping children and youth in trauma treatment: Examination of an alliance building dropout management program

Evidence-based treatments exist to address traumatic stress related symptoms for children, however dropout from trauma-focused treatment remains a concern. This study examined use of an alliance building dropout management program for a group of children ages 3-17 who received an evidence-based trauma-focused treatment. Logistic regression analysis was conducted to examine the relationships between child gender, race, ethnicity, age, guardianship, externalizing behaviors, participation in a dropout management program and the dose of treatment received. The final model was significant and participation in the dropout management program as well as a child's placement in foster care were significant individual correlates with full completion of treatment. Use of an Alliance Building Dropout Management program may help decrease overall dropout over and above the contribution of other variables known to impact treatment completion.

Leveraging observational data to identify in-session patient and therapist predictors of cognitive processing therapy response and completion

Cognitive processing therapy (CPT) is an evidence-based treatment for posttraumatic stress disorder (PTSD), but little is known about in-session process variables that predict symptom reduction and treatment completion during CPT. Examining potentially malleable factors that may promote or impede recovery can inform care delivery and enhance outcomes. The current study used observational ratings of CPT session recordings to examine in-session patient and therapist factors in cognitive, affective, and interpersonal domains to identify their relative contributions to predicting symptom outcomes and treatment completion. Participants were 70 adult survivors of interpersonal violence who received CPT. Predictors of better posttreatment PTSD outcomes included less patient fear, β = .32, and less patient avoidance of engaging with the therapist, β = .35. When using the last available PTSD score, less fear, β = .23, and avoidance, β = .28, continued to predict better outcomes, and more patient cognitive flexibility emerged as a stronger predictor of outcome, β = -.33. Predictors of a higher likelihood of treatment completion included more therapist use of Socratic dialogue, OR = 6.75, and less therapist encouragement of patient affect, OR = 0.11. Patient sadness and anger and therapist expression of empathy did not predict symptom outcomes or treatment completion versus dropout. The results highlight the importance of patients' cognitions, emotions, and engagement with their therapist in CPT as well as the role of therapist behaviors in patient completion of treatment.

Building partnerships in education through a story-tool based intervention: Parental involvement experiences among families with Roma backgrounds

Introduction

School educators are likely to explain the poor educational trajectories of students with Roma backgrounds related to the lack of parental support and interest in children’s education. Aiming to understand further the patterns of Roma group’s parental involvement in children’s school life and their engagement experiences in school-related activities, the current research set an intervention supported by a culturally sensitive story-tool.

Method

Grounded in the intervention-based research framework, 12 participants (i.e., mothers) from different Portuguese Roma groups participated in this study. Data was collected through interviews conducted pre-and postintervention. Eight weekly sessions were delivered in the school context, using a story-tool and hands- on activities to generate culturally significant meanings regarding attitudes, beliefs, and values toward children’s educational trajectories.

Results

Through the lens of acculturation theory, data analysis provided important findings under two overarching topics: patterns of parental involvement in children’s school life and participants’ engagement in the intervention program.

Discussion

Data show the distinct ways Roma parents participate in children’s education and the relevance of mainstream contexts providing an atmosphere likely to build collaborative relationships with parents to overcome barriers to parental involvement.

A thematic analysis of barriers and facilitators to participant engagement in group exposure and response prevention therapy for obsessive-compulsive disorder

Exposure and response prevention (ERP) is the gold standard in the treatment of the obsessive-compulsive disorder (OCD). It can be delivered effectively using an individual or group therapy format. Nonetheless, a sizeable proportion of people diagnosed with OCD do not experience OCD symptom remission following ERP. Research suggests that participant engagement with ERP tasks predicts therapy outcomes but there is little consistent evidence across studies on what predicts engagement. A recent meta-analysis of participant engagement in cognitive-behavioral therapy for OCD found that group ERP had a comparatively lower dropout rate than individual ERP. Little is known about participant perceptions of ERP to guide an understanding of how the group therapy format may affect participant engagement. This study conducted a qualitative exploration of what helps or hinders participants' engagement in group ERP. It involved thematic analysis of semi-structured interview data collected at a 6-month follow-up from 15 adults with OCD who took part in group ERP. The study identified five main themes that captured participants' perceived facilitators and barriers to engagement in therapy: 'Group processes', 'Understanding how to overcome OCD', 'Personal relevance', 'Personal circumstances', and 'Attitudes towards ERP', which captured dynamically inter-related barriers and facilitators at the level of the client, therapist, therapy and social environment. Each theme and associated sub-themes are discussed in turn, followed by a consideration of the study's limitations and implications.

Which therapist perceptions best predict client outcomes? A naturalistic examination

Examining associations between therapists' perceptions of therapy sessions and client-reported outcomes in naturalistic settings (real-life therapy settings) can provide valuable guidance for the assessment, treatment, and monitoring of clients. This study included data of 1334 sessions from 127 clients (86 individual and 41 couple cases) and 15 therapists, collected at a therapy training center. Clients reported their personal functioning and individual symptoms before each session. Therapists rated clients' participation, receptivity, session progress, goal progress, and therapeutic alliance at the end of each therapy session. Multilevel Structural Equation Modeling analyses revealed that therapist-rated client participation and goal progress predicted better personal functioning, beyond clients' previous personal functioning scores. In contrast, none of therapist-rated session variables predicted clients' individual symptoms, beyond previous symptom scores. Power analyses suggested sufficient statistical power to detect small effect sizes. Findings of the current study have clinical implications for treatment planning and progress monitoring.

Effective – and tolerable: Acceptance and Side Effects of Intensified Exposure for Anxiety Disorders

Despite striking empirical support, exposure-based treatments for anxiety disorders are underutilized. This is partially due to clinicians' concerns that patients may reject exposure or experience severe side effects, particularly in intensive forms of exposure. We examined acceptance and side effects of two randomly assigned variants of prediction error-based exposure treatment differing in temporal density (1 vs. 3 sessions/week) in 681 patients with panic disorder, agoraphobia, social anxiety disorder, and multiple specific phobias. Treatment acceptance included treatment satisfaction and credibility, engagement (i.e., homework completion), and tolerability (i.e., side effects, dropout, and perceived treatment burden). Side effects were measured with the Inventory for the Balanced Assessment of Negative Effects of Psychotherapy (INEP). We found treatment satisfaction, credibility, and engagement to be equally high in both variants of exposure-based treatment, despite higher treatment burden (β = 0.25) and stronger side effects (β = 0.15) in intensified treatment. 94.1% of patients reported positive effects in the INEP. 42.2% reported side effects, with treatment stigma (16.6%), low mood (14.8%) and the experience to depend on the therapist (10.9%) being the most frequently reported. The mean intensity of side effects was low. We conclude that prediction error-based exposure treatment is well accepted by patients with different anxiety disorders and that patients also tolerate temporally intensified treatment, despite higher perceived treatment burden and stronger side effects. Clinicians should be aware of the most frequent side effects to take appropriate countermeasures. In sum, temporal intensification appears to be an acceptable strategy to achieve faster symptom reduction, given patients' well-informed consent.

A spotlight on avoidance coping to manage fear of recurrence among breast cancer survivors in an eHealth intervention

Background

Fear of recurrence (FoR) is prevalent among breast cancer survivors (BCS) and may be exacerbated by avoidance coping. This study examined BCS with avoidance coping and their engagement in a FoR eHealth intervention (FoRtitude).

Methods

BCS (N = 196) with elevated FoR participated in FoRtitude. Patient-reported measures assessed avoidance coping with FoR and baseline emotional and behavioral health. Intervention engagement was measured quantitatively (e.g., website logins, telecoaching attendance) and qualitatively (i.e., telecoaching notes).

Results

38 BCS (19%) endorsed avoidance coping, which was associated with more severe post-traumatic anxiety-related symptoms and worse global mental health (ps < .05), but not anxiety (p = .19), depression (p = .11), physical health (p = .12), alcohol consumption (p = .85), or physical activity (p = .39). Avoidance coping was not associated with engagement levels (ps > .05) but did characterize engagement-related motivators and barriers.

Conclusions

Avoidance coping was not a barrier to FoRtitude engagement. eHealth delivery is a promising modality for engaging survivors with avoidance coping in FoR interventions.

Divergent experiences of U.S. veterans who did and did not complete trauma-focused therapies for PTSD: A national qualitative study of treatment dropout

Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT) are first-line treatments for posttraumatic stress disorder (PTSD) and have been disseminated throughout the U.S. Veterans Health Administration. Treatment non-completion is common and lessens clinical effectiveness; however, prior work has failed to identify factors consistently associated with non-completion. Semi-structured interviews were conducted with a national sample of veterans who recently completed (n = 60) or did not complete (n = 66) PE or CPT. Non-completer interviews focused on factors that contributed to veterans' decisions to drop out and efforts undertaken to complete PE/CPT. Completer interviews focused on challenges faced in completing treatment and facilitators of completion. Transcripts were coded using a mixed deductive/inductive approach; constant comparison was used to identify differences between completers and non-completers. Completers and non-completers differed in the extent of treatment-specific therapist support received, therapists' flexibility in treatment delivery, the type of encouragement offered by the care team and social supports, their interpretation of symptom worsening, the perceived impact of treatment on functioning, and the impact of stressors on their treatment engagement. Treatment-specific therapist support, more patient-centered and flexible treatment delivery, leveraging the full care team, and addressing functional concerns are potential targets for PE and CPT engagement interventions.

Predictors of Disengagement and Symptom Improvement Among Adults With Depression Enrolled in Talkspace, a Technology-Mediated Psychotherapy Platform: Naturalistic Observational Study

BACKGROUND

Depression is a common psychiatric condition with an estimated lifetime prevalence for major depression of 16.6% in the US adult population and is effectively treated through psychotherapy. The widespread availability of the internet and personal devices such as smartphones are changing the landscape of delivery of psychotherapy; however, little is known about whether and for whom this type of therapy is beneficial, and whether having synchronous video-based sessions provides additional benefits to clients above and beyond messaging-based therapy.

OBJECTIVE

This study examined the outcomes associated with the use of a digital platform (Talkspace) for technology-mediated psychotherapy. We examined the duration of client engagement in therapy and client depression score trajectories over 16 weeks. We explored the association of client characteristics, therapist characteristics, and service plan type with time-to-disengagement and trajectories of change in depression scores.

METHODS

This naturalistic observational study assessed data collected routinely by the platform between January 2016 and January 2018 and examined psychotherapy outcomes among a large representative sample of adult clients with clinically significant depression. Treatment disengagement was defined as a lack of client-initiated communication for more than 4 weeks. Clients completed the Patient Health Questionnaire-8 item (PHQ-8) at intake and every 3 weeks via an in-app survey. Cox regression analysis was used to examine the time until and predictors of disengagement. Changes in depression scores and predictors of change over time were examined using mixed-effects regression.

RESULTS

The study included 5890 clients and 1271 therapists. Client scores on the PHQ-8 declined over time, with the average client improving from a score of 15 to below the clinical cutoff of 10 by week 6. At the same time point, 37% of clients had disengaged from the therapy. When combined into a final Cox regression model, those who were more likely to disengage were clients aged 18 to 25 years versus those aged ≥50 years (odds ratio [OR] 0.82, 95% CI 0.74-0.9; P<.001), had higher education (OR 1.14, 95% CI 1.06-1.22; P<.001), had been in therapy before (OR 1.09, 95% CI 1.02-1.17; P=.01), and were living with a partner but unmarried versus single (OR 1.14, 95% CI 1.02-1.27; P=.02). Having a therapist with >10 years of experience was related to lower odds of disengagement (OR 0.87, 95% CI 0.8-0.94; P=.01). When combined into a final regression model predicting improvement in depression scores over time, clients showing more improvement were those with an associate's degree or higher (linear estimate=-0.07, P=.002) and higher intake PHQ-8 scores (estimate=3.73, P<.001). There were no differences based on the plan type.

CONCLUSIONS

Our findings add to the growing literature showing the benefits of technology-mediated psychotherapy over a relatively brief period (16 weeks).

Can chatbots help to motivate smoking cessation? A study on the effectiveness of motivational interviewing on engagement and therapeutic alliance

Background

Cigarette smoking poses a major threat to public health. While cessation support provided by healthcare professionals is effective, its use remains low. Chatbots have the potential to serve as a useful addition. The objective of this study is to explore the possibility of using a motivational interviewing style chatbot to enhance engagement, therapeutic alliance, and perceived empathy in the context of smoking cessation.

Methods

A preregistered web-based experiment was conducted in which smokers (n = 153) were randomly assigned to either the motivational interviewing (MI)-style chatbot condition (n = 78) or the neutral chatbot condition (n = 75) and interacted with the chatbot in two sessions. In the assessment session, typical intake questions in smoking cessation interventions were administered by the chatbot, such as smoking history, nicotine dependence level, and intention to quit. In the feedback session, the chatbot provided personalized normative feedback and discussed with participants potential reasons to quit. Engagement with the chatbot, therapeutic alliance, and perceived empathy were the primary outcomes and were assessed after both sessions. Secondary outcomes were motivation to quit and perceived communication competence and were assessed after the two sessions.

Results

No significant effects of the experimental manipulation (MI-style or neutral chatbot) were found on engagement, therapeutic alliance, or perceived empathy. A significant increase in therapeutic alliance over two sessions emerged in both conditions, with participants reporting significantly increased motivation to quit. The chatbot was perceived as highly competent, and communication competence was positively associated with engagement, therapeutic alliance, and perceived empathy.

Conclusion

The results of this preregistered study suggest that talking with a chatbot about smoking cessation can help to motivate smokers to quit and that the effect of conversation has the potential to build up over time. We did not find support for an extra motivating effect of the MI-style chatbot, for which we discuss possible reasons. These findings highlight the promise of using chatbots to motivate smoking cessation. Implications for future research are discussed.

Working together: An investigation of the impact of working alliance and cohesion on group psychotherapy attendance

OBJECTIVES

Group psychotherapy holds considerable potential for cost-effective treatment delivery. However, issues with client attendance can compromise the efficacy of such treatments. To date, client specific factors are amongst the most researched predictors of attendance in psychotherapy, with much less of a focus given to process factors, particularly in the group therapy context. This study aimed to determine which process factors influenced attendance in the context of a group therapy programme for adults with anxiety. It was hypothesized that (1) the working alliance and group cohesion would be moderately correlated, (2) both the working alliance and group cohesion would explain unique variance in session attendance, and (3) the working alliance would act as a moderator for attendance, when group cohesion was low.

DESIGN

The study utilized a within participants design.

METHODS

Participants were 91 adults (aged 18-74 years) who took part in a 9-week, transdiagnostic cognitive behavioural group therapy programme for the treatment of anxiety disorders.

RESULTS

Working alliance and group cohesion were significantly, but only moderately correlated (rs ranging .41 to .55). Together, working alliance and group cohesion significantly predicted total session attendance (17.70% variance explained). Working alliance did not moderate the relationship between group cohesion and session attendance.

CONCLUSIONS

The importance of individual and group processes in influencing group therapy engagement is highlighted, including the role of fostering bonds within the group and between clients and therapists.

PRACTITIONER POINTS

A complex array of process factors has been argued to influence treatment outcomes in group therapy The quality of the relationship between group therapy clients, as well as the relationship between a client and the therapist, predict session attendance. The quality of the relationship between the client and the therapist may be the most important predictor of session attendance. Therapists should foster positive relationships between each client and the therapist in group therapy, as well as assisting each client to foster positive relationships with other group members.

Acceptability and effectiveness of CBT and psychologically based interventions for emergency department attenders with medical complaints: a systematic literature review

This systematic literature review surveyed the evidence for the acceptability and effectiveness of CBT and psychologically based interventions for emergency department (ED) attenders with physical health complaints as their primary concern, in light of over-burdened EDs and the existing evidence base for psychological interventions in other medical settings. The review protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO; CRD42018087860). A systematic search of three databases (APAPsychNet, Cochrane and PubMed) was performed to identify psychological treatment studies targeting physical health problems presenting in the ED, with broad inclusion criteria to capture a coherent understanding of the current knowledge base. A total of 2606 potential studies for inclusion were identified; 45 proceeded to full review. Twenty papers met the full inclusion. Included studies covered four clinical areas: trauma/PTSD-prevention, panic attacks, non-cardiac chest-pain and miscellaneous. A narrative description of findings reflected positive outcomes across all groups, but this was not consistent across any group. Few studies measured ED attendance (20%) or satisfaction/acceptability (10%). The majority of studies (90%) were underpinned by a cognitive behavioural framework, consistent with the current evidence base as applied to the management of medical conditions. Findings suggest there is some evidence that interventions in the ED are effective and acceptable to patients, but interpretation of findings is limited by the mixed quality of designs and risk of bias.

Key learning aims

(1)

Early Treatment Change in Perpetrators of Sexual Versus Non-Sexual Violence

The purpose of this study is to assess treatment change at both a group and individual level in a sample of 81 Dutch male patients who received mandated care for either violent (non-sexual) behavior or sexual violent behavior. Psychiatric nurses rated patients' social skills, insight, hostility, physical violence with the BEST-Index every 6 months over the course of 2 years after patients were admitted to hospital. Mixed analysis of covariances and the reliable change index indicated that patients, irrespective of offense type, showed treatment change over time with exception of physical violence. This study shows that general treatment may be useful in the first 18 month for risk factors common to different types of offenses, but that specialized treatment is needed to establish further change.

Therapeutic engagement in robot-assisted psychological interventions: A systematic review

PURPOSE

Therapeutic engagement is a key component of psychological interventions. Robot-assisted psychological interventions appear to have therapeutic benefits for service users that are challenging to engage. However, engagement with robots in robot-assisted psychological interventions is not well understood. The aim of this systematic review is to evaluate the quality of therapeutic engagement in robot-assisted psychological interventions (PROSPERO: 122437).

METHODS

Scopus, Web of Science, PsycInfo and Medline were searched until 15 January 2021 for studies which quantitatively evaluated therapeutic engagement in robot-assisted psychological interventions. The Effective Public Health Practice Project (EPHPP) quality assessment tool was used to assess methodological dimensions of studies.

RESULTS

3647 studies were identified through database searching. Thirty studies (N = 1462), published between 2004 and 2020, and from 14 countries, were included. Robots were typically toy animals or humanoids and were used to provide support and improve wellbeing through social interaction. Studies primarily tested robots on older adults with dementia and children with autism and indicated positive therapeutic engagement. Twelve studies included a control group. EPHPP ratings were 'strong' (N = 1), 'moderate' (N = 10) and 'weak' (N = 19).

CONCLUSIONS

Therapeutic engagement between service users and robots is generally positive. Methodological limitations of studies, such as small sample sizes, and lack of control groups and longitudinal data, mean that the field is in early stages of its development and conclusions should be drawn with caution. There are important practical and ethical implications for policymakers to consider, such as responsible clinical practice and how service users may understand the therapeutic relationship with robots.

Premature termination of the unified protocol for the transdiagnostic treatment of emotional disorders: The role of ambivalence towards change

Ambivalence towards change is an expected, recurrent process in psychological change. However, the prolonged experience of ambivalence in psychotherapy contributes to client disengagement, which could result in treatment dropout. Considering the negative effects of premature termination of therapy and the convenience of the identification of clients who are at risk of dropping out before achieving good-outcome, the current study explored the predictive power of ambivalence for premature therapy termination using a multilevel time-backwards model (i.e., considering the session of the dropout as session zero and then modelling what occurred from the dropout until session 1). Participants included a total of 96 psychotherapy clients (38 dropouts) treated in a university-based clinic following the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders. Multilevel modelling using a time-backwards model to analyse dropout data provided evidence of the predictive power of ambivalence evolution throughout treatment on the decision to prematurely discontinue treatment (p < .0001; R² _adj  = .29). Specifically, good-outcome dropouts presented a decreasing ambivalence trend throughout treatment, whereas poor-outcome dropouts tended to experience the same levels of ambivalence before deciding to drop out (time × dropout; β₁₁  = .64, p = .014). Additionally, poor-outcome dropouts presented higher levels of ambivalence (β₀₁  = 9.92, p < .0001) in the last session. The results suggest that the pattern of client ambivalence towards change is a predictor of premature termination of therapy. Implications for clinical and research contexts are discussed.

Opening Up: Clients' Inner Struggles in the Initial Phase of Therapy

Objective

To explore how clients in clinical settings experience the process of opening up and sharing their inner experiences in the initial phase of therapy.

Methods

Two psychotherapy sessions of clients (N = 11) were videotaped and followed by interviews. Interpersonal process recall was used to obtain in-depth descriptions of clients’ immediate experiences in session. A follow-up interview was conducted 3 months later. The interviews were analyzed using thematic analysis.

Results

The data revealed how and why clients distanced themselves from inner experiences in the initial phase of therapy. The overarching theme was “Holding back and struggling to open up,” which included four subthemes: (a) fearing the intensity and consequences of negative emotions; (b) experiences of being incapable and bodily stuck; (c) being insecure about one’s worthiness and right to share inner experiences with the therapist; and (d) struggling with feeling disloyal to loved ones.

Conclusion

The participants held back because they feared different consequences of opening up. A range of concerns led participants to distance themselves from their inner experiences and/or to refrain from openly talking about them to the therapist. Concerns related to appropriate interpersonal conduct as client were especially important. This knowledge is highly relevant to clinicians when building safety for psychotherapeutic work.

Engagement with smartphone-delivered behavioural activation interventions: a study of the MoodMission smartphone application

BACKGROUND

Despite increased research interest in smartphone mental health applications (MHapps), few studies have examined user engagement and its determinants. MoodMission is a MHapp that targets low mood and anxiety via evidence-based techniques including behavioural activation (BA).

AIMS

The present study aimed to investigate (i) whether BA interventions delivered with visual psychoeducation had greater engagement than BA interventions delivered with solely written psychoeducation, (ii) whether BA interventions targeting mastery would have greater engagement than those targeting pleasure, and (iii) the relationship between level of engagement and MHapp benefit.

METHOD

Participants downloaded MoodMission and completed activities and within-app evaluations over a 30-day period. Data from 238 MoodMission users were analysed via multi-level modelling and linear regression.

RESULTS

The average number of app-based activities completed was 5.46 and the average self-reported engagement level was in the low to moderate range. As hypothesized, higher levels of engagement significantly predicted more positive activity appraisal.

CONCLUSIONS

The results suggest that BA technique beliefs are involved in MHapp engagement and future research examining user appraisals of techniques is warranted.

Program factors influencing parents' engagement in a friendship-making intervention for youth with disabilities

PURPOSE

The aim was to examine parents' experiences of engagement in a friendship-making intervention for youth with physical and developmental disabilities.

METHOD

This mixed methods study used a convergent parallel design where quantitative and qualitative data were collected concurrently, analyzed independently, and then merged into an overall interpretation. Four parents completed the Pediatric Rehabilitation Intervention Measure of Engagement-Parent version at four points during the 8-week program. They also took part in post-intervention interviews about their engagement-related experiences, including their involvement, interest, and confidence in the parent sessions.

RESULTS

Parents' engagement experiences were captured in four themes involving the person-intervention fit: the relevance of program content, the usefulness of the content, their behavioral involvement in planning and group discussions, and seeing youth experience success. The themes corroborated the quantitative measurement of engagement and illustrated and elaborated on how program factors influenced engagement.

CONCLUSIONS

This study indicates the value of including a parent component in a youth friendship-making intervention, and points to the importance of considering relevance, usefulness, behavioral involvement, and success in designing these sessions. The four themes reflect important program factors that may be broadly relevant to the design of group-based interventions for parents of youth with disabilities.IMPLICATIONS FOR REHABILITATIONThe findings indicate the value of including a parent component in youth interventions.Parents are engaged when they feel programs are relevant and useful, are behaviorally involved, and see youth experience success-these factors should be considered in optimal program design.It is important to optimize parent engagement by personalizing content, such as by providing choices and options to increase relevance and decrease burden.Transparent communication about program content and the benefits experienced by other parents will help new parents be more fully informed about what to expect.

Attention Problems and Comorbid Symptoms following Child Sexual Abuse

Treatment utilization following child sexual abuse (CSA) is essential in combatting the various negative consequences of CSA. Youth may present to treatment for CSA with symptoms that cut across multiple diagnostic presentations that impact their ability to successfully engage in treatment. In particular, children who have difficulties with attention may have unique treatment needs following CSA. The purpose of this study was to examine how attention problems interplay with comorbid symptoms and how these clinical presentations impact treatment outcomes for youth who have been sexually abused. Participants included 323 families presenting to treatment for CSA. Youth were 7 to 19 years old, 78.5% female, and 76.6% identified as Caucasian/White. Results indicated that 22.9% of the youth presented with clinically elevated attention problems as collected through parent-report of the Child Behavior Checklist (CBCL). Results demonstrated that child survivors of CSA who presented with attention problems self-reported more psychological concerns (e.g., symptoms of depression, anxiety, and post-traumatic stress). At post-treatment, attention problems, interpersonal problems, and thought problems were significantly reduced for youth initially presenting with attention problems. Further implications for treatment following CSA and unique needs for youth with attention problems are discussed.

Participant perspectives on the acceptability and effectiveness of mindfulness-based cognitive behaviour therapy approaches for obsessive compulsive disorder

Cognitive behavioural therapy (CBT) which includes Exposure and Response (ERP) is a highly effective, gold standard treatment for Obsessive-Compulsive Disorder (OCD). Nonetheless, not all patients with OCD significantly benefit from CBT. This has generated interest in the potential benefits of Mindfulness-Based Interventions (MBIs), either integrated with CBT, to enhance engagement with ERP tasks, or delivered as a stand-alone, first-line or therapy to augment CBT. This paper reports on two qualitative studies that involved a thematic analysis of interview data with participants in a 10-week Mindfulness-Based ERP (MB-ERP) course (study 1) and a 9-week Mindfulness-Based Cognitive Therapy course adapted for OCD (MBCT-OCD) (study 2). Whilst MB-ERP integrated a mindfulness component into a standard ERP protocol, MBCT-OCD adapted the psychoeducational components of the standard MBCT for depression protocol to suit OCD, but without explicit ERP tasks. Three common main themes emerged across MB-ERP and MBCT-OCD: 'satisfaction with course features', 'acceptability of key therapeutic tasks 'and 'using mindfulness to respond differently to OCD'. Sub-themes identified under the first two main themes were mostly unique to MB-ERP or MBCT-OCD, with the exception of '(struggles with) developing a mindfulness practice routine' whilst most of the sub-themes under the last main theme were shared across MB-ERP and MBCT-OCD participants. Findings suggested that participants generally perceived both MBIs as acceptable and potentially beneficial treatments for OCD, in line with theorised mechanisms of change.

A Paradigm Shift in Batterer Intervention Programming: A Need to Address Unresolved Trauma

Intimate partner violence (IPV) is a significant public health problem affecting women, men, and children across the United States. Batterer intervention programs (BIPs) serve as the primary intervention for men who use violence, employing three primary modalities: psychoeducation, cognitive-behavioral therapy (CBT), and other forms of group therapy such as alcohol or drug treatment. However, research indicates that program effectiveness of the primary BIP modalities is limited, due, in part, to the theoretical underpinnings guiding intervention such as learned behavior (psychoeducation), patriarchy as the root cause (Duluth model), and "dysfunctional" thinking (CBT). Considering the mental, physical, and economic toll of IPV on families and the limited effectiveness of current intervention approaches, an assessment of the strengths and weaknesses of current modalities and an incorporation of the latest science addressing violence prevention and cessation are paramount. This article draws upon existing theories of trauma and the etiologies of violence perpetration and proposes an alternative model of care for men with IPV histories. Experiences of childhood adversity and trauma have well-established associations with a range of negative sequelae, including neurological, cognitive, behavioral, physical, and emotional outcomes. Childhood trauma is also associated with later violence and IPV perpetration. Thus, incorporating trauma-informed care principles and trauma interventions into programming for IPV perpetrators warrants further investigation. Practice and policy implications of a trauma interventions for men with IPV histories, as well as areas for future research, are discussed.

Advancing the Assessment of Mindfulness-Based Meditation Practice: Psychometric Evaluation of the Mindfulness Adherence Questionnaire

Background

Mindfulness-based meditation practice (MBP) can be assessed in terms of time spent (quantity) or skill acquisition (quality), but these components have rarely been delineated in adherence measures. Individuals may also engage in MBP through everyday life (informal practice) and dedicate specific time for MBP (formal practice).

Method

The Mindfulness Adherence Questionnaire, a scale designed to assess quantity and quality of formal and informal MBP was evaluated. Study 1 used a cross-sectional design to examine internal reliability and construct validity (N = 282). Study 2 examined test–retest reliability and sensitivity (N = 55) during a 4-week mindfulness intervention.

Results

A nested-factor model showed adequate fit: MAQ items loaded on both the general factor (Practice) and specific factors (Formal and Informal). Discriminant validity analyses revealed the MAQ captured MBP adherence distinct from trait mindfulness. Quality of both formal and informal mindfulness practice was more strongly associated with higher levels of trait mindfulness than quantity. Changes in MAQ Quantity scores were observed over time.

Conclusions

The MAQ is reliable and has a meaningful scale structure, may usefully distinguish both quality versus quantity and formal versus informal MBP, and is sensitive to variations in MBP and does not solely measure trait mindfulness.

Resilience Protective Factors Checklist (RPFC): Buffering Childhood Adversity and Promoting Positive Outcomes

While research tends to focus on understanding risk factors associated with adverse childhood and adolescent experiences, there is growing empirical support within the field of human services to also focus on strengths and protective factors that bolster resilience in life. This study investigated the psychometrics of the Resilience Protective Factors Checklist (RPFC), which is a questionnaire that assists in the identification of protective factors empirically linked to resilience and positive outcomes. In addition, associations between protective factors, childhood adversity, and quality of life outcomes were examined. Participants were undergraduate college students (n = 1,256). The results revealed good psychometric properties for the RPFC and the factor analysis supported the resilience structural model of three interrelated areas of protective factors - Individual, Family, and Community influences. All three areas of protection were positively correlated with all four domains of positive life outcomes (physical health, psychological health, social relationships, and a healthy environment) and negatively correlated with adverse childhood experiences. RPFC's individual protective factors positively predicted physical health and psychological health outcomes, while the community protective factors positively predicted environmental health outcomes. In addition, the RPFC's family protective factors moderated the path between adverse childhood experiences and social relationships. That is, for individuals who have experienced more adverse childhood experiences, those with higher levels of RPFC family protective factors had positive social relationship outcomes, while those with lower levels of family protective factors had negative social relationship outcomes. These findings lend support for the utilization of assessment measures for identifying and promoting protective factors that can buffer life adversity and heighten resilient positive outcomes.

Assessing Adherence, Competence and Differentiation in a Stepped-Wedge Randomised Clinical Trial of a Complex Behaviour Change Intervention

BACKGROUND

A key challenge in behavioural medicine is developing interventions that can be delivered adequately (i.e., with fidelity) within real-world consultations. Accordingly, clinical trials should (but tend not to) report what is actually delivered (adherence), how well (competence) and the distinction between intervention and comparator conditions (differentiation).

PURPOSE

To address this important clinical and research priority, we apply best practice guidelines to evaluate fidelity within a real-world, stepped-wedge evaluation of "EAT: Eating As Treatment", a new dietitian delivered health behaviour change intervention designed to reduce malnutrition in head and neck cancer (HNC) patients undergoing radiotherapy.

METHODS

Dietitians (n = 18) from five Australian hospitals delivered a period of routine care and following a randomly determined order each site received training and began delivering the EAT Intervention. A 20% random stratified sample of audio-recorded consultations (control n = 196; intervention n = 194) was coded by trained, independent, raters using a study specific checklist and the Behaviour Change Counselling Inventory. Intervention adherence and competence were examined relative to apriori benchmarks. Differentiation was examined by comparing control and intervention sessions (adherence, competence, non-specific factors, and dose), via multiple linear regression, logistic regression, or mixed-models.

RESULTS

Achievement of adherence benchmarks varied. The majority of sessions attained competence. Post-training consultations were clearly distinct from routine care regarding motivational and behavioural, but not generic, skills.

CONCLUSIONS

Although what level of fidelity is "good enough" remains an important research question, findings support the real-world feasibility of integrating EAT into dietetic consultations with HNC patients and provide a foundation for interpreting treatment effects.

Adherence to e-mental health among youth: Considerations for intervention development and research design

E-mental health programmes have great potential to provide young people with access to mental health support. However, it is commonly reported that adherence to these programmes is low. Low adherence can be problematic, particularly if young people do not receive the full benefits of a programme. In a research trial setting, non-adherence to treatment recommendations can prevent researchers from drawing strong conclusions about effectiveness. Although adherence has been recognised as an issue in need of attention, many of the reviews available are focused on adults and lack clear direction towards what strategies to employ. This paper presents a broad review of the adherence literature, focusing on factors associated with improving adherence to e-mental health among youth. Our view on the key elements to improve adherence identified from the existing literature are presented, and key recommendations for e-mental health intervention design are provided. These include: developing and communicating adherence guidelines based on individuals’ needs and symptom severity, including customisable features to provide a tailored experience and promote a sense of agency, including engagement checks and adopting a user-centred approach by utilising strategies such as co-design. This paper provides guidance to intervention designers and researchers by outlining recommendations and considerations for intervention development and research design.