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Saxler E, Schindler T, Philipsen A, Schulze M, Lux S. Therapeutic alliance in individual adult psychotherapy: a systematic review of conceptualizations and measures for face-to-face- and online-psychotherapy. Front Psychol 2024; 15:1293851. [PMID: 38993343 PMCID: PMC11238262 DOI: 10.3389/fpsyg.2024.1293851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 06/17/2024] [Indexed: 07/13/2024] Open
Abstract
Background The therapeutic alliance (TA) is a robust and pantheoretical predictor of treatment outcome in Face-to-Face- (F2F-) and Online-psychotherapy (Online-PT). Many authors have proposed several conceptualizations of TA, which are oftentimes operationalized. The resulting diversity of conceptualizations and measures is presented in this review. Methods We performed a three-parted literature search for self-report-instruments of TA in individual, voluntary F2F-PT with adults (1. utilization of past reviews, 2. systematic literature search yielding 5,205 articles, 3. reference lists). Analogously, we conducted a systematic literature search for instruments of TA in the Online-setting (yielding 200 articles). Additionally, we analyzed the content of the instruments qualitatively. Results A current overview of 48 instruments for measuring TA (46 for F2F-PT, 2 for Online-PT) including their conceptual backgrounds, characteristics and main content aspects is presented. Most instruments (n = 24) operationalize one or more theoretical conceptualizations of TA. Other instruments are adaptation/syntheses of existing measures (n = 14), based on literature searches (n = 3) or on an empirical survey (n = 3) and two instruments provide no conceptual background information. The content of the instruments mainly focused on the following aspects: 1. Self-disclosure and authenticity; 2. Agreement; 3. Active participation, motivation and compliance; 4. Trust and secure attachment; and 5. Considering needs/abilities/wishes of the patient. Additionally, a narrative review of various approaches to conceptualize TA is presented and linked to respective corresponding instruments. Discussion The broad variety of conceptualizations and measures of TA makes coherent research on TA difficult. There are conceptual challenges such as the role of attachment style in TA that remain to be clarified. The current conceptualizations and measures do not incorporate the practical experience and expertise of psychotherapists and patients sufficiently. A metatheoretical conceptualization and measure of TA based on an empirical survey of psychotherapists and patients could address these issues.
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Affiliation(s)
- Eva Saxler
- Deutsches Zentrum für Neurodegnerative Erkrankungen, University Clinic of Bonn, Bonn, Germany
| | - Theresa Schindler
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Alexandra Philipsen
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Marcel Schulze
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Silke Lux
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
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Doukani A, Quartagno M, Sera F, Free C, Kakuma R, Riper H, Kleiboer A, Cerga-Pashoja A, van Schaik A, Botella C, Berger T, Chevreul K, Matynia M, Krieger T, Hazo JB, Draisma S, Titzler I, Topooco N, Mathiasen K, Vernmark K, Urech A, Maj A, Andersson G, Berking M, Baños RM, Araya R. Comparison of the Working Alliance in Blended Cognitive Behavioral Therapy and Treatment as Usual for Depression in Europe: Secondary Data Analysis of the E-COMPARED Randomized Controlled Trial. J Med Internet Res 2024; 26:e47515. [PMID: 38819882 PMCID: PMC11179025 DOI: 10.2196/47515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 02/09/2024] [Accepted: 02/11/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND Increasing interest has centered on the psychotherapeutic working alliance as a means of understanding clinical change in digital mental health interventions in recent years. However, little is understood about how and to what extent a digital mental health program can have an impact on the working alliance and clinical outcomes in a blended (therapist plus digital program) cognitive behavioral therapy (bCBT) intervention for depression. OBJECTIVE This study aimed to test the difference in working alliance scores between bCBT and treatment as usual (TAU), examine the association between working alliance and depression severity scores in both arms, and test for an interaction between system usability and working alliance with regard to the association between working alliance and depression scores in bCBT at 3-month assessments. METHODS We conducted a secondary data analysis of the E-COMPARED (European Comparative Effectiveness Research on Blended Depression Treatment versus Treatment-as-usual) trial, which compared bCBT with TAU across 9 European countries. Data were collected in primary care and specialized services between April 2015 and December 2017. Eligible participants aged 18 years or older and diagnosed with major depressive disorder were randomized to either bCBT (n=476) or TAU (n=467). bCBT consisted of 6-20 sessions of bCBT (involving face-to-face sessions with a therapist and an internet-based program). TAU consisted of usual care for depression. The main outcomes were scores of the working alliance (Working Alliance Inventory-Short Revised-Client [WAI-SR-C]) and depressive symptoms (Patient Health Questionnaire-9 [PHQ-9]) at 3 months after randomization. Other variables included system usability scores (System Usability Scale-Client [SUS-C]) at 3 months and baseline demographic information. Data from baseline and 3-month assessments were analyzed using linear regression models that adjusted for a set of baseline variables. RESULTS Of the 945 included participants, 644 (68.2%) were female, and the mean age was 38.96 years (IQR 38). bCBT was associated with higher composite WAI-SR-C scores compared to TAU (B=5.67, 95% CI 4.48-6.86). There was an inverse association between WAI-SR-C and PHQ-9 in bCBT (B=-0.12, 95% CI -0.17 to -0.06) and TAU (B=-0.06, 95% CI -0.11 to -0.02), in which as WAI-SR-C scores increased, PHQ-9 scores decreased. Finally, there was a significant interaction between SUS-C and WAI-SR-C with regard to an inverse association between higher WAI-SR-C scores and lower PHQ-9 scores in bCBT (b=-0.030, 95% CI -0.05 to -0.01; P=.005). CONCLUSIONS To our knowledge, this is the first study to show that bCBT may enhance the client working alliance when compared to evidence-based routine care for depression that services reported offering. The working alliance in bCBT was also associated with clinical improvements that appear to be enhanced by good program usability. Our findings add further weight to the view that the addition of internet-delivered CBT to face-to-face CBT may positively augment experiences of the working alliance. TRIAL REGISTRATION ClinicalTrials.gov NCT02542891, https://clinicaltrials.gov/study/NCT02542891; German Clinical Trials Register DRKS00006866, https://drks.de/search/en/trial/DRKS00006866; Netherlands Trials Register NTR4962, https://www.onderzoekmetmensen.nl/en/trial/25452; ClinicalTrials.Gov NCT02389660, https://clinicaltrials.gov/study/NCT02389660; ClinicalTrials.gov NCT02361684, https://clinicaltrials.gov/study/NCT02361684; ClinicalTrials.gov NCT02449447, https://clinicaltrials.gov/study/NCT02449447; ClinicalTrials.gov NCT02410616, https://clinicaltrials.gov/study/NCT02410616; ISRCTN Registry ISRCTN12388725, https://www.isrctn.com/ISRCTN12388725?q=ISRCTN12388725&filters=&sort=&offset=1&totalResults=1&page=1&pageSize=10; ClinicalTrials.gov NCT02796573, https://classic.clinicaltrials.gov/ct2/show/NCT02796573. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.1186/s13063-016-1511-1.
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Affiliation(s)
- Asmae Doukani
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Matteo Quartagno
- Medical Research Council Clinical Trials Unit, University College London, London, United Kingdom
| | - Francesco Sera
- Department of Statistics, Computer Science and Applications "G. Parenti", University of Florence, Florance, Italy
| | - Caroline Free
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Ritsuko Kakuma
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Heleen Riper
- Department of Psychiatry, Amsterdam University Medial Centre, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Annet Kleiboer
- Department Clinical, Neuro, and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Amsterdam Public Health Institute, Amsterdam, Netherlands
| | - Arlinda Cerga-Pashoja
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Anneke van Schaik
- Department of Psychiatry, Amsterdam University Medial Centre, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Academic Department for Depressive Disorders, Dutch Mental Health Care, Amsterdam, Netherlands
| | - Cristina Botella
- Department of Basic Psychology, Clinical and Psychobiology, Universitat Jaume I, Castellón de la Plana, Spain
- Centro de Investigación Biomédica en Red Fisiopatología Obesidad y Nutrición, Instituto Carlos III, Madrid, Spain
| | - Thomas Berger
- Department of Clinical Psychology and Psychotherapy, University of Bern, Bern, Switzerland
| | - Karine Chevreul
- Unité de Recherche Clinique in Health Economics, Assistance Publique-Hôpitaux de Paris, Paris, France
- Health Economics Research Unit, Inserm, University of Paris, Paris, France
| | - Maria Matynia
- Faculty of Psychology, SWPS University, Warsaw, Poland
| | - Tobias Krieger
- Department of Clinical Psychology and Psychotherapy, University of Bern, Bern, Switzerland
| | - Jean-Baptiste Hazo
- Unité de Recherche Clinique in Health Economics, Assistance Publique-Hôpitaux de Paris, Paris, France
- Health Economics Research Unit, Inserm, University of Paris, Paris, France
| | - Stasja Draisma
- Department on Aging, Netherlands Institute of Mental Health and Addiction (Trimbos Institute), Utrecht, Netherlands
| | - Ingrid Titzler
- Department of Clinical Psychology and Psychotherapy, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Naira Topooco
- Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden
| | - Kim Mathiasen
- Department of Clinical Medicine, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Centre for Digital Psychiatry, Mental Health Services of Southern Denmark, Odense, Denmark
| | - Kristofer Vernmark
- Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden
| | - Antoine Urech
- Department of Clinical Psychology and Psychotherapy, University of Bern, Bern, Switzerland
- Department of Neurology, Inselspital Bern, Bern University Hospital, Bern, Switzerland
| | - Anna Maj
- Faculty of Psychology, SWPS University, Warsaw, Poland
| | - Gerhard Andersson
- Department of Behavioral Sciences and Learning, Linköping University, Linköping, Sweden
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Matthias Berking
- Department of Clinical Psychology and Psychotherapy, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Rosa María Baños
- Centro de Investigación Biomédica en Red Fisiopatología Obesidad y Nutrición, Instituto Carlos III, Madrid, Spain
- Department of Personality, Evaluation and Psychological Treatments, Universidad de Valencia, Valencia, Spain
| | - Ricardo Araya
- Department of Health Service and Population Research, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom
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Nissling L, Weineland S, Vernmark K, Radvogin E, Engström AK, Schmidt S, Nieto Granberg E, Larsson E, Hursti T. Effectiveness of and processes related to internet-delivered acceptance and commitment therapy for adolescents with anxiety disorders: a randomized controlled trial. RESEARCH IN PSYCHOTHERAPY (MILANO) 2023; 26:681. [PMID: 37401474 PMCID: PMC10481424 DOI: 10.4081/ripppo.2023.681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 06/02/2023] [Indexed: 07/05/2023]
Abstract
Early access to evidence-based help is crucial for adolescents with anxiety disorders. Internet-delivered acceptance and commitment therapy (iACT) may offer adolescents increased access to care and more flexibility in engaging with treatment when and how they prefer. Process-based therapies, such as ACT, focus on theoretically derived and empirically tested key mechanisms in treatment that enable change. This study aimed to investigate the effectiveness of iACT for adolescents with anxiety disorders. The study also assessed the relationship between psychological flexibility and treatment outcomes and the relationship between participating adolescents' and therapists' perceived alliance and treatment outcomes. This was a randomized controlled trial comparing a 10-week intervention group with a wait-list control group. The 52 participants, aged 15 to 19, were recruited from all over Sweden. The treatment was effective in increasing quality of life and psychological flexibility, with moderate between-group effect sizes based on observed values. Changes in psychological flexibility was associated with changes in anxiety symptoms. The results further showed a statistically significant between-group difference in post-treatment diagnoses. No significant time per group interaction was found for anxiety symptoms, as both groups improved. Working alliance was rated as high by both participating adolescents and therapists but showed no significant relationship with treatment outcomes. Participants found the treatment an acceptable intervention. This study shows promising results for iACT in treating adolescents with anxiety disorders. The results suggest the model of psychological flexibility as an important process of change in treatment outcomes. Future research should validate these findings in larger samples and clinical contexts.
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Affiliation(s)
- Linnea Nissling
- Department of Psychology, Faculty of Social Sciences, University of Gothenburg; Research, Development, Education and Innovation, Primary Health Care, Västra Götaland Region; General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg.
| | - Sandra Weineland
- Department of Psychology, Faculty of Social Sciences, University of Gothenburg; Research, Development, Education and Innovation, Primary Health Care, Västra Götaland Region; General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg.
| | - Kristofer Vernmark
- Department of Behavioural Sciences and Learning (IBL), University of Linköping.
| | - Ella Radvogin
- Department of Behavioural Sciences and Learning (IBL), University of Linköping.
| | - Anna-Karin Engström
- Department of Psychology, Faculty of Social Sciences, University of Uppsala.
| | - Sara Schmidt
- Department of Psychology, Faculty of Social Sciences, University of Uppsala.
| | - Eva Nieto Granberg
- Department of Psychology, Faculty of Social Sciences, University of Uppsala.
| | - Elin Larsson
- Department of Psychology, Faculty of Social Sciences, University of Uppsala.
| | - Timo Hursti
- Department of Psychology, Faculty of Social Sciences, University of Uppsala.
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Darcy A, Beaudette A, Chiauzzi E, Daniels J, Goodwin K, Mariano TY, Wicks P, Robinson A. Anatomy of a Woebot® (WB001): agent guided CBT for women with postpartum depression. Expert Rev Med Devices 2023; 20:1035-1049. [PMID: 37938145 DOI: 10.1080/17434440.2023.2280686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 11/03/2023] [Indexed: 11/09/2023]
Abstract
INTRODUCTION Postpartum depression (PPD) is common, persistent, and stigmatized. There are insufficient trained professionals to deliver appropriate screening, diagnosis, and treatment. AREAS COVERED WB001 is a Software as a Medical Device (SaMD) based Agent-Guided Cognitive-Behavioral Therapy (AGCBT) program for the treatment of PPD, for which Breakthrough Device Designation was recently granted by the US Food and Drug Administration. WB001 combines therapeutic alliance, human-centered design, machine learning techniques, and established principles from CBT and interpersonal therapy (IPT). We introduce AGCBT as a new model of service delivery, whilst describing Woebot, the agent technology that enables guidance through the replication of some elements of human relationships. The profile describes the device's design principles, enabling technology, risk handling, and efficacy data in PPD. EXPERT OPINION WB001 is a dynamic and personalized tool with which patients may establish a therapeutic bond. Woebot is designed to augment (rather than replace) human healthcare providers, unlocking the therapeutic potency associated with guidance, whilst retaining the scalability and agency that characterizes self-help approaches. WB001 has the potential to improve both the quality and the scalability of care through providing support to patients on waiting lists, in between clinical encounters, and enabling automation of measurement-based-care.
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Affiliation(s)
| | | | | | | | | | - Timothy Y Mariano
- Woebot Health, San Francisco, CA, USA
- RR&D Center for Neurorestoration and Neurotechnology, VA Providence Healthcare System, Providence, RI, USA
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, RI, USA
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Alavi N, Moghimi E, Stephenson C, Gutierrez G, Jagayat J, Kumar A, Shao Y, Miller S, Yee CS, Stefatos A, Gholamzadehmir M, Abbaspour Z, Shirazi A, Gizzarelli T, Khan F, Patel C, Patel A, Yang M, Omrani M. Comparison of online and in-person cognitive behavioral therapy in individuals diagnosed with major depressive disorder: a non-randomized controlled trial. Front Psychiatry 2023; 14:1113956. [PMID: 37187863 PMCID: PMC10175610 DOI: 10.3389/fpsyt.2023.1113956] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 04/10/2023] [Indexed: 05/17/2023] Open
Abstract
Objective The increased prevalence of major depressive disorder (MDD) amid the COVID-19 pandemic has resulted in substantial growth in online mental health care delivery. Compared to its in-person counterpart, online cognitive behavioral therapy (e-CBT) is a time-flexible and cost-effective method of improving MDD symptoms. However, how its efficacy compares to in-person CBT is yet to be explored. Therefore, the current study compared the efficacy of a therapist-supported, electronically delivered e-CBT program to in-person therapy in individuals diagnosed with MDD. Methods Participants (n = 108) diagnosed with MDD selected either a 12 week in-person CBT or an asynchronous therapist-supported e-CBT program. E-CBT participants (n = 55) completed weekly interactive online modules delivered through a secure cloud-based online platform (Online Psychotherapy Tool; OPTT). These modules were followed by homework in which participants received personalized feedback from a trained therapist. Participants in the in-person CBT group (n = 53) discussed sessions and homework with their therapists during one-hour weekly meetings. Program efficacy was evaluated using clinically validated symptomatology and quality of life questionnaires. Results Both treatments yielded significant improvements in depressive symptoms and quality of life from baseline to post-treatment. Participants who opted for in-person therapy presented significantly higher baseline symptomatology scores than the e-CBT group. However, both treatments demonstrated comparable significant improvements in depressive symptoms and quality of life from baseline to post-treatment. e-CBT seems to afford higher participant compliance as dropouts in the e-CBT group completed more sessions on average than those in the in-person CBT group. Conclusion The findings support e-CBT with therapist guidance as a suitable option to treat MDD. Future studies should investigate how treatment accessibility is related to program completion rates in the e-CBT vs. in-person group. Clinical Trial Registration ClinicalTrials.Gov Protocol Registration and Results System (NCT04478058); clinicaltrials.gov/ct2/show/NCT04478058.
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Affiliation(s)
- Nazanin Alavi
- Department of Psychiatry, Queen’s University, Kingston, ON, Canada
- Centre for Neuroscience Studies, Queen’s University, Kingston, ON, Canada
- OPTT Inc., Toronto, ON, Canada
- *Correspondence: Nazanin Alavi,
| | - Elnaz Moghimi
- Department of Psychiatry, Queen’s University, Kingston, ON, Canada
| | | | - Gilmar Gutierrez
- Department of Psychiatry, Queen’s University, Kingston, ON, Canada
| | - Jasleen Jagayat
- Centre for Neuroscience Studies, Queen’s University, Kingston, ON, Canada
| | - Anchan Kumar
- Department of Psychiatry, Queen’s University, Kingston, ON, Canada
| | - Yijia Shao
- Department of Psychology, University of Toronto, Toronto, ON, Canada
| | - Shadé Miller
- Department of Psychiatry, Queen’s University, Kingston, ON, Canada
| | - Caitlin S. Yee
- Department of Psychiatry, Queen’s University, Kingston, ON, Canada
| | - Anthi Stefatos
- Department of Psychiatry, Queen’s University, Kingston, ON, Canada
| | | | - Zara Abbaspour
- Department of Psychiatry, Queen’s University, Kingston, ON, Canada
| | | | - Tessa Gizzarelli
- Department of Psychiatry, Queen’s University, Kingston, ON, Canada
| | - Ferwa Khan
- Department of Psychiatry, Queen’s University, Kingston, ON, Canada
| | - Charmy Patel
- Department of Psychiatry, Queen’s University, Kingston, ON, Canada
| | - Archana Patel
- Department of Psychiatry, Queen’s University, Kingston, ON, Canada
| | - Megan Yang
- Department of Psychiatry, Queen’s University, Kingston, ON, Canada
| | - Mohsen Omrani
- Department of Psychiatry, Queen’s University, Kingston, ON, Canada
- OPTT Inc., Toronto, ON, Canada
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Păsărelu CR, David D, Dobrean A, Noje A, Roxana Ș, Predescu E. ADHDCoach-a virtual clinic for parents of children with ADHD: Development and usability study. Digit Health 2023; 9:20552076231161963. [PMID: 36923370 PMCID: PMC10009016 DOI: 10.1177/20552076231161963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 02/17/2023] [Indexed: 03/12/2023] Open
Abstract
Attention-deficit/ hyperactivity disorder (ADHD) is one of the most common mental health problems in childhood. Despite the fact that evidence-based treatments exist, behavioral parent training programs are the gold standard in the care of children with ADHD, a significant percentage of parents of children with ADHD do not access such interventions. Internet-delivered interventions are effective for a range of mental health problems, however, there is limited research conducted on the efficacy of such interventions in the treatment of ADHD. Objective: The aim of this study is to present the development and feasibility of an Internet-delivered intervention for parents of children with ADHD. Methods: The intervention was based on Behavioral Parent Training and Rational Emotive Behavior Therapy. Participants were mental health specialists (N = 16) and parents of children diagnosed with ADHD (N = 24). Results: Our results indicated high usability and parental satisfaction with the intervention. Conclusion: In conclusion, an Internet-delivered intervention addressed to parents of children diagnosed with ADHD is a promising approach. Future research should investigate the efficacy of this Internet-delivered intervention in a randomized controlled trial.
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Affiliation(s)
- Costina-Ruxandra Păsărelu
- Department of Clinical Psychology and Psychotherapy, Babeș-Bolyai University, Cluj-Napoca, Romania.,The International Institute for the Advanced Studies of Psychotherapy and Applied Mental Health, Babeș-Bolyai University, Cluj-Napoca, Romania
| | - Daniel David
- Department of Clinical Psychology and Psychotherapy, Babeș-Bolyai University, Cluj-Napoca, Romania.,The International Institute for the Advanced Studies of Psychotherapy and Applied Mental Health, Babeș-Bolyai University, Cluj-Napoca, Romania
| | - Anca Dobrean
- Department of Clinical Psychology and Psychotherapy, Babeș-Bolyai University, Cluj-Napoca, Romania.,The International Institute for the Advanced Studies of Psychotherapy and Applied Mental Health, Babeș-Bolyai University, Cluj-Napoca, Romania
| | - Alexandru Noje
- Department of Neuroscience, Iuliu Hațieganu University of Medicine and Pharmacology, Cluj Napoca, Romania
| | - Șipoș Roxana
- Department of Neuroscience, Iuliu Hațieganu University of Medicine and Pharmacology, Cluj Napoca, Romania
| | - Elena Predescu
- Department of Neuroscience, Iuliu Hațieganu University of Medicine and Pharmacology, Cluj Napoca, Romania
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Greenwood KE, Gurnani M, Ward T, Vogel E, Vella C, McGourty A, Robertson S, Sacadura C, Hardy A, Rus‐Calafell M, Collett N, Emsley R, Freeman D, Fowler D, Kuipers E, Bebbington P, Dunn G, Michelson D, Garety P. The service user experience of SlowMo therapy: A co-produced thematic analysis of service users' subjective experience. Psychol Psychother 2022; 95:680-700. [PMID: 35445520 PMCID: PMC9873386 DOI: 10.1111/papt.12393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 03/18/2022] [Indexed: 01/27/2023]
Abstract
OBJECTIVES SlowMo is the first blended digital therapy for paranoia, showing significant small-moderate reductions in paranoia in a recent large-scale randomized controlled trial (RCT). This study explored the subjective service-user experience of the SlowMo therapy content and design; the experience of the blended therapy approach, including the triangle of the therapeutic alliance; and the experience of the digital aspects of the intervention. DESIGN Qualitative co-produced sub-study of an RCT. METHODS Participants were 22 adult service users with schizophrenia-spectrum psychosis and persistent distressing paranoia, who completed at least one SlowMo therapy session and a 24-week follow-up, at one of 3 sites in Oxford, London, and Sussex, UK. They were interviewed by peer researchers, using a topic guide co-produced by the Patient and Public Involvement (PPI) team. The transcribed data were analysed thematically. Multiple coding and triangulation, and lay peer researcher validation were used to reach a consensus on the final theme structure. RESULTS Six core themes were identified: (i) starting the SlowMo journey; (ii) the central role of the supportive therapist; (iii) slowing things down; (iv) value and learning from social connections; (v) approaches and challenges of technology; and (vi) improvements in paranoia and well-being. CONCLUSIONS For these service users, slowing down for a moment was helpful, and integrated into thinking over time. Learning from social connections reflected reduced isolation, and enhanced learning through videos, vignettes, and peers. The central role of the supportive therapist and the triangle of alliance between service user, therapist, and digital platform were effective in promoting positive therapeutic outcomes.
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Affiliation(s)
- Kathryn E. Greenwood
- School of PsychologyUniversity of SussexBrightonUK,Sussex Partnership NHS Foundation TrustWorthingUK
| | | | - Tom Ward
- Department of PsychologyInstitute of Psychiatry, Psychology and NeuroscienceKing’s College LondonLondonUK,South London and Maudsley NHS Foundation TrustLondonUK
| | - Evelin Vogel
- Sussex Partnership NHS Foundation TrustWorthingUK
| | - Claire Vella
- Sussex Partnership NHS Foundation TrustWorthingUK
| | | | | | | | - Amy Hardy
- Department of PsychologyInstitute of Psychiatry, Psychology and NeuroscienceKing’s College LondonLondonUK,South London and Maudsley NHS Foundation TrustLondonUK
| | | | | | - Richard Emsley
- Department of Biostatistics and Health InformaticsInstitute of Psychiatry, Psychology and NeuroscienceKing’s College LondonLondonUK
| | - Daniel Freeman
- Oxford Health NHS Foundation TrustOxfordUK,Department of PsychiatryOxford UniversityOxfordUK
| | - David Fowler
- School of PsychologyUniversity of SussexBrightonUK,Sussex Partnership NHS Foundation TrustWorthingUK
| | - Elizabeth Kuipers
- Department of PsychologyInstitute of Psychiatry, Psychology and NeuroscienceKing’s College LondonLondonUK,South London and Maudsley NHS Foundation TrustLondonUK
| | | | - Graham Dunn
- Centre for BiostatisticsSchool of Health SciencesManchester Academic Health Science CentreThe University of ManchesterManchesterUK
| | | | - Philippa Garety
- Department of PsychologyInstitute of Psychiatry, Psychology and NeuroscienceKing’s College LondonLondonUK,South London and Maudsley NHS Foundation TrustLondonUK
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Doukani A, Free C, Araya R, Michelson D, Cerga-Pashoja A, Kakuma R. Practitioners' experience of the working alliance in a blended cognitive-behavioural therapy intervention for depression: qualitative study of barriers and facilitators. BJPsych Open 2022; 8:e142. [PMID: 35876079 PMCID: PMC9344874 DOI: 10.1192/bjo.2022.546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Digital technologies have been widely acknowledged as a potentially useful resource for increasing mental healthcare access. The working alliance is a key influence on outcomes in conventional psychotherapy, but little is known about therapists' experiences of forming an effective working alliance in blended interventions that involve in-person psychotherapy and a digital programme. AIMS To investigate psychological well-being practitioners' (PWPs') experiences of the working alliance in a trial of blended cognitive-behavioural therapy (b-CBT) for depression. Trial registration ISRCTN12388725. METHOD Semi-structured qualitative interviews were conducted with 13 PWPs who delivered b-CBT in a two-arm, non-inferiority randomised controlled trial investigating the effectiveness of b-CBT compared with face-to-face CBT. Thematic analysis was used to analyse the data. RESULTS Participants reported four facilitating factors when building and maintaining a working alliance in b-CBT: having more time to deliver treatment, access to a wider toolkit, capacity to tailor components of b-CBT and receiving appropriate training and support. Participants also identified four barriers to building and maintaining a working alliance: time and resource constraints, usability challenges, limited flexibility to tailor the digital programme to patients' needs and lack of confidence in delivering b-CBT. CONCLUSIONS Our study is the first specifically to investigate practitioners' perceived facilitators and barriers to forming a working alliance in b-CBT for depression. Findings suggest that PWPs' experiences of the working alliance can be improved by: accounting for the time required to deliver b-CBT in service workflows to reduce time pressures; increasing opportunities to tailor the digital programme through offering transdiagnostic tools and adaptable features; and providing appropriate b-CBT training and technical support.
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Affiliation(s)
- Asmae Doukani
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Caroline Free
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Ricardo Araya
- Health Service and Population Research Department, King's College London, UK
| | | | - Arlinda Cerga-Pashoja
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Ritsuko Kakuma
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
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9
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Blending Internet-based and tele group treatment: Acceptability, effects, and mechanisms of change of cognitive behavioral treatment for depression. Internet Interv 2022; 29:100551. [PMID: 35722084 PMCID: PMC9204733 DOI: 10.1016/j.invent.2022.100551] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 05/23/2022] [Accepted: 05/30/2022] [Indexed: 11/20/2022] Open
Abstract
The current COV-19 pandemic increases the need for remote treatment. Among several provision strategies, tele groups have been tested as an efficient option. Still, the number of studies is comparably low, with a clear lack of studies investigating supposed treatment mechanisms. Sixty-one mildly to moderately depressed participants from Salzburg, Bavaria, and Upper Austria were randomized to the intervention or a waiting list control group (RCT). The seven-week treatment comprised preparatory online modules, followed by personalized feedback and a subsequent tele group session. Large treatment effects were observed for depression (CES-D: d = 0.99, p < .001; PHQ-9: d = 0.87, p = .002), together with large effects for cognitive behavioral skills (cognitive style, and behavioral activation, d = 0.88-0.97). Changes in skills mediated treatment outcomes for CES-D and PHQ-9, suggesting comparable mechanisms as in face-to-face therapy. Two typical moderators, therapeutic alliance, and group cohesion, however, failed to predict outcome (p = .289), or only exhibited statistical tendencies (p = .049 to .071). Client satisfaction, system usability, and treatment adherence were high. Blending Internet-based and tele group interventions offers additional options for low-threshold care that is less dependent on population density, commuting distances, or constraints due to the current COV-19 crisis. Results indicate that the blended intervention is clinically effective by fostering core CBT skills. While findings suggest the notion that working alliance and group cohesion can be established online, their relevancy for outcomes of blended treatment needs to be further investigated.
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10
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Lungu A, Wickham RE, Chen SY, Jun JJ, Leykin Y, Chen CEJ. Component analysis of a synchronous and asynchronous blended care CBT intervention for symptoms of depression and anxiety: Pragmatic retrospective study. Internet Interv 2022; 28:100536. [PMID: 35433277 PMCID: PMC9011163 DOI: 10.1016/j.invent.2022.100536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 11/04/2021] [Accepted: 04/04/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Depression and anxiety are leading causes of disability worldwide. Though effective treatments exist, depression and anxiety remain undertreated. Blended care psychotherapy, combining the scalability of online interventions with the personalization and engagement of a live therapist, is a promising approach for increasing access to evidence-based care. OBJECTIVES To evaluate the effectiveness and individual contribution of two components - i) digital tools and ii) video-based therapist-led sessions - in a blended care CBT-based intervention under real world conditions. METHODS A retrospective cohort design was used to analyze N = 1372 US-based individuals who enrolled in blended care psychotherapy. Of these, at baseline, 761 participants had depression symptoms in the clinical range (based on PHQ-9), and 1254 had anxiety symptoms in the clinical range (based on GAD-7). Participants had access to the program as a mental health benefit offered by their employer. The CBT-based blended care psychotherapy program consisted of regular video sessions with therapists, complemented by digital lessons and digital exercises assigned by the clinician and completed in between sessions. Depression and anxiety levels and clients' treatment engagement were tracked throughout treatment. A 3-level individual growth curve model incorporating time-varying covariates was utilized to examine symptom trajectories of PHQ-9 scores (for those with clinical range of depression at baseline) and GAD-7 scores (for those with clinical range of anxiety at baseline). RESULTS On average, individuals exhibited a significant decline in depression and anxiety symptoms during the initial weeks of treatment (P < .001), and a continued decline over subsequent weeks at a slower rate (P < .001). Engaging in a therapy session in a week was associated with lower GAD-7 (b = -0.81) and PHQ-9 (b = -1.01) scores in the same week, as well as lower GAD-7 (b = -0.58) and PHQ-9 (b = -0.58) scores the following week (all P < .01). Similarly, engaging with digital lessons was independently associated with lower GAD-7 (b = -0.19) and PHQ-9 (b = -0.18) scores during the same week, and lower GAD-7 (b = -0.25) and PHQ-9 (b = -0.27) the following week (all P < .01). CONCLUSIONS Therapist-led video sessions and digital lessons had separate contributions to improvements in symptoms of depression and anxiety over the course of treatment. Future research should investigate whether clients' characteristics are related to differential effects of therapist-led and digital components of care.
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Affiliation(s)
- Anita Lungu
- Lyra Health, 287 Lorton Ave, Burlingame, CA 94010, USA,Corresponding author.
| | - Robert E. Wickham
- Department of Psychological Sciences, Northern Arizona University, Flagstaff, AZ, 86011
| | - Shih-Yin Chen
- Lyra Health, 287 Lorton Ave, Burlingame, CA 94010, USA
| | - Janie J. Jun
- Lyra Health, 287 Lorton Ave, Burlingame, CA 94010, USA
| | - Yan Leykin
- Palo Alto University, Department of Psychology, Palo Alto, CA 94304, USA
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Darcy A, Beaudette A, Chiauzzi E, Daniels J, Goodwin K, Mariano TY, Wicks P, Robinson A. Anatomy of a Woebot® (WB001): agent guided CBT for women with postpartum depression. Expert Rev Med Devices 2022; 19:287-301. [PMID: 35748029 DOI: 10.1080/17434440.2022.2075726] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 05/05/2022] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Postpartum Depression (PPD) is common, persistent, and stigmatized. There are insufficient trained professionals to deliver appropriate screening, diagnosis, and treatment. AREAS COVERED WB001 is a Software as a Medical Device (SaMD) based Agent-Guided Cognitive Behavioral Therapy (AGCBT) program for the treatment of PPD, for which Breakthrough Device Designation was recently granted by the US Food and Drug Administration. WB001 combines therapeutic alliance, human-centered design, machine learning techniques, and established principles from CBT and interpersonal therapy (IPT). We introduce AGCBT as a new model of service delivery, whilst describing Woebot, the agent technology that enables guidance through the replication of some elements of human relationships. The profile describes the device's design principles, enabling technology, risk handling, and efficacy data in PPD. EXPERT OPINION WB001 is a dynamic and personalized tool with which patients may establish a therapeutic bond. Woebot is designed to augment (rather than replace) human healthcare providers, unlocking the therapeutic potency associated with guidance, whilst retaining the scalability and agency that characterizes self-help approaches. WB001 has the potential to improve both the quality and the scalability of care through providing support to patients on waiting lists, in between clinical encounters, and enabling automation of measurement-based care.
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12
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Schlieter H, Marsch LA, Whitehouse D, Otto L, Londral AR, Teepe GW, Benedict M, Ollier J, Ulmer T, Gasser N, Ultsch S, Wollschlaeger B, Kowatsch T. Scale-up of Digital Innovations in Health Care: Expert Commentary on Enablers and Barriers. J Med Internet Res 2022; 24:e24582. [PMID: 35275065 PMCID: PMC8956989 DOI: 10.2196/24582] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 02/17/2021] [Accepted: 12/28/2021] [Indexed: 12/13/2022] Open
Abstract
Health care delivery is undergoing a rapid change from traditional processes toward the use of digital health interventions and personalized medicine. This movement has been accelerated by the COVID-19 crisis as a response to the need to guarantee access to health care services while reducing the risk of contagion. Digital health scale-up is now also vital to achieve population-wide impact: it will only accomplish sustainable effects if and when deployed into regular health care delivery services. The question of how sustainable digital health scale-up can be successfully achieved has, however, not yet been sufficiently resolved. This paper identifies and discusses enablers and barriers for scaling up digital health innovations. The results discussed in this paper were gathered by scientists and representatives of public bodies as well as patient organizations at an international workshop on scaling up digital health innovations. Results are explored in the context of prior research and implications for future work in achieving large-scale implementations that will benefit the population as a whole.
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Affiliation(s)
- Hannes Schlieter
- Research Group Digital Health, Faculty of Business and Economics, Technische Universität Dresden, Dresden, Germany
| | - Lisa A Marsch
- Center for Technology and Behavioral Health, Geisel School of Medicine, Dartmouth College, Lebanon, NH, United States
| | | | - Lena Otto
- Research Group Digital Health, Faculty of Business and Economics, Technische Universität Dresden, Dresden, Germany
| | - Ana Rita Londral
- Value for Health CoLAB, NOVA Medical School, Nova University of Lisbon, Lisbon, Portugal.,Comprehensive Health Research Center, NOVA Medical School, Nova University of Lisbon, Lisbon, Portugal
| | - Gisbert Wilhelm Teepe
- Centre for Digital Health Interventions, Department of Management, Technology and Economics, ETH Zurich, Zurich, Switzerland
| | - Martin Benedict
- Research Group Digital Health, Faculty of Business and Economics, Technische Universität Dresden, Dresden, Germany
| | - Joseph Ollier
- Centre for Digital Health Interventions, Department of Management, Technology and Economics, ETH Zurich, Zurich, Switzerland
| | - Tom Ulmer
- Institute of Information and Process Management, Eastern Switzerland University of Applied Sciences, St. Gallen, Switzerland
| | | | - Sabine Ultsch
- Centre for Digital Health Interventions, Institute of Technology Management, University of St. Gallen, St. Gallen, Switzerland
| | - Bastian Wollschlaeger
- Research Group Digital Health, Faculty of Business and Economics, Technische Universität Dresden, Dresden, Germany
| | - Tobias Kowatsch
- Centre for Digital Health Interventions, Department of Management, Technology and Economics, ETH Zurich, Zurich, Switzerland.,Centre for Digital Health Interventions, Institute of Technology Management, University of St. Gallen, St. Gallen, Switzerland
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13
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Mathiasen K, Andersen TE, Lichtenstein MB, Ehlers LH, Riper H, Kleiboer A, Roessler KK. Clinical Effectiveness of Blended CBT Compared vs Face-to-Face CBT for adult depression: a Randomised Controlled Non-Inferiority Trial (Preprint). J Med Internet Res 2022; 24:e36577. [PMID: 36069798 PMCID: PMC9543221 DOI: 10.2196/36577] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 03/02/2022] [Accepted: 06/15/2022] [Indexed: 11/13/2022] Open
Abstract
Background Internet-based cognitive behavioral therapy (iCBT) has been demonstrated to be cost- and clinically effective. There is a need, however, for increased therapist contact for some patient groups. Combining iCBT with traditional face-to-face (FtF) consultations in a blended format may produce a new treatment format (B-CBT) with multiple benefits from both traditional CBT and iCBT, such as individual adaptation, lower costs than traditional therapy, wide geographical and temporal availability, and possibly lower threshold to implementation. Objective The primary aim of this study is to compare directly the clinical effectiveness of B-CBT with FtF-CBT for adult major depressive disorder. Methods A 2-arm randomized controlled noninferiority trial compared B-CBT for adult depression with treatment as usual (TAU). The trial was researcher blinded (unblinded for participants and clinicians). B-CBT comprised 6 sessions of FtF-CBT alternated with 6-8 web-based CBT self-help modules. TAU comprised 12 sessions of FtF-CBT. All participants were aged 18 or older and met the diagnostic criteria for major depressive disorder and were recruited via a national iCBT clinic. The primary outcome was change in depression severity on the 9-item Patient Health Questionnaire (PHQ-9). Secondary analyses included client satisfaction (8-item Client Satisfaction Questionnaire [CSQ-8]), patient expectancy (Credibility and Expectancy Questionnaire [CEQ]), and working (Working Alliance Inventory [WAI] and Technical Alliance Inventory [TAI]). The primary outcome was analyzed by a mixed effects model including all available data from baseline, weekly measures, 3-, 6, and 12-month follow-up. Results A total of 76 individuals were randomized, with 38 allocated to each treatment group. Age ranged from 18 to 71 years (SD 13.96) with 56 (74%) females. Attrition rate was 20% (n=15), which was less in the FtF-CBT group (n=6, 16%) than in the B-CBT group (n=9, 24%). As many as 53 (70%) completed 9 or more sessions almost equally distributed between the groups (nFtF-CBT=27, 71%; nB-CBT=26, 68%). PHQ-9 reduced 11.38 points in the FtF-CBT group and 8.10 in the B-CBT group. At 6 months, the mean difference was a mere 0.17 points. The primary analyses confirmed large and significant within-group reductions in both groups (FtF-CBT: β=–.03; standard error [SE] 0.00; P<.001 and B-CBT: β=–.02; SE 0.00; P<.001). A small but significant interaction effect was observed between groups (β=.01; SE 0.00; P=.03). Employment status influenced the outcome differently between groups, where the B-CBT group was seen to profit more from not being full-time employed than the FtF group. Conclusions With large within-group effects in both treatment arms, the study demonstrated feasibility of B-CBT in Denmark. At 6 months’ follow-up, there appeared to be no difference between the 2 treatment formats, with a small but nonsignificant difference at 12 months. The study seems to demonstrate that B-CBT is capable of producing treatment effects that are close to FtF-CBT and that completion rates and satisfaction rates were comparable between groups. However, the study was limited by small sample size and should be interpreted with caution. Trial Registration ClinicalTrials.gov NCT02796573; https://clinicaltrials.gov/ct2/show/NCT02796573 International Registered Report Identifier (IRRID) RR2-10.1186/s12888-016-1140-y
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Affiliation(s)
- Kim Mathiasen
- Research Unit for Telepsychiatry and E-Mental Health, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Tonny E Andersen
- Department of Psychology, University of Southern Denmark, Odense, Denmark
| | - Mia Beck Lichtenstein
- Research Unit for Telepsychiatry and E-Mental Health, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Lars Holger Ehlers
- Danish Center for Healthcare Improvements, Aalborg University, Aalborg, Denmark
- Nordic Institute of Health Economics, Aarhus, Denmark
| | - Heleen Riper
- Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Annet Kleiboer
- Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Kirsten K Roessler
- Department of Psychology, University of Southern Denmark, Odense, Denmark
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14
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Okeke FC, Onyishi CN, Nwankwor PP, Ekwueme SC. A blended rational emotive occupational health coaching for job-stress among teachers of children with special education needs. Internet Interv 2021; 26:100482. [PMID: 34824983 PMCID: PMC8604685 DOI: 10.1016/j.invent.2021.100482] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 11/01/2021] [Accepted: 11/10/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND/OBJECTIVES Heightened stress tends to undermine both teachers' efficacy and students' outcomes. Managing job stress in teachers of children with special education needs is continually recommended due to the increased demands for the teachers to adapt curriculum content, learning materials and learning environments for learning. This study investigated the efficacy of blended Rational Emotive Occupational Health Coaching in reducing occupational stress among teachers of children with special needs in Abia State, Nigeria. METHOD The current study adopted a group-randomized waitlist control trial design with pretest, post-test and follow-up assessments. Participants (N = 83) included teachers of children with special education needs in inclusive and specialized schools. The bREOHC group was exposed to intersession face-to-face and online REOC program weekly for twelve (12) weeks. Data were collected using Single Item Stress Questionnaire (SISQ), Teachers' Stress Inventory and Participants' Satisfaction questionnaire (PSQ). Data collected at baseline; post-test as well as follow-up 1 and 2 evaluations were analyzed using mean, standard deviation, t-test statistics, repeated measures ANOVA and bar charts. RESULTS Results revealed that the mean perceived stress, stress symptoms and the total teachers' stress score of the bREOHC group at post-test and follow up assessments reduced significantly, compared to the waitlisted group. Participants also reported high level of satisfaction with the therapy and procedures. CONCLUSION From the findings of this study, we conclude that blended REOHC is efficacious in occupational stress management among teachers of children with special education needs.
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Affiliation(s)
| | - Charity N. Onyishi
- Department of Educational Foundations, University of Nigeria, Nsukka, Nigeria
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15
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Békés V, Aafjes-van Doorn K, Zilcha-Mano S, Prout T, Hoffman L. Psychotherapists' acceptance of telepsychotherapy during the COVID-19 pandemic: A machine learning approach. Clin Psychol Psychother 2021; 28:1403-1415. [PMID: 34723404 PMCID: PMC8652775 DOI: 10.1002/cpp.2682] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 10/17/2021] [Accepted: 10/26/2021] [Indexed: 11/12/2022]
Abstract
Objective This study aimed to develop predictive models of three aspects of psychotherapists' acceptance of telepsychotherapy (TPT) during the COVID‐19 pandemic, attitudes towards TPT technology, concerns about using TPT technology and intention to use TPT technology in the future. Method Therapists (n = 795) responded to a survey about their TPT experiences during the pandemic, including quality of the therapeutic relationship, professional self‐doubt, vicarious trauma and TPT acceptance. Regression decision tree machine learning analyses were used to build prediction models for each of three aspects of TPT acceptance in a training subset of the data and subsequently tested in the remaining subset of the total sample. Results Attitudes towards TPT were most positive for therapists who reported a neutral or strong online working alliance with their patients, especially if they experienced little professional self‐doubt and were younger than 40 years old. Therapists who were most concerned about TPT were those who reported higher levels of professional self‐doubt, particularly if they also reported vicarious trauma experiences. Therapists who reported low working alliance with their patients were least likely to use TPT in the future. Performance metrics for the decision trees indicated that these three models held up well in an out‐of‐sample dataset. Conclusions Therapists' professional self‐doubt and the quality of their working alliance with their online patients appear to be the most pertinent factors associated with therapists' acceptance of TPT technology during COVID‐19 and should be addressed in future training and research.
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Affiliation(s)
- Vera Békés
- Ferkauf Graduate School of Psychology, Yeshiva University, New York, New York, USA
| | | | | | - Tracy Prout
- Ferkauf Graduate School of Psychology, Yeshiva University, New York, New York, USA
| | - Leon Hoffman
- New York Psychoanalytic Institute, New York, New York, USA
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16
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Long Term Outcomes of Blended CBT Compared to Face-to-Face CBT and Treatment as Usual for Adolescents with Depressive Disorders: Analyses at 12 Months Post-Treatment. SOCIAL SCIENCES 2021. [DOI: 10.3390/socsci10100373] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Depression is a major problem in youth mental health and identified as the leading cause of disability worldwide. There is ample research on the acute effects of treatment, with estimated small-to-moderate effect sizes. However, there is a lack of research on long-term outcomes. A total of 129 adolescents with clinical depression (82.2% female), aged 13–22 (M = 16.60, SD = 2.03), received blended CBT, face-to-face CBT or treatment as usual. Data were collected at 12 months after the intervention and compared between treatment conditions. Clinical diagnosis, depressive symptoms, suicide risk, internalizing symptoms and externalizing symptoms decreased significantly over time, from baseline to the 12-month follow-up, and also from post-treatment to the 12-month follow-up in all three conditions. Changes were not significantly different between conditions. At the long-term, improvements following the treatment continued. Due to the large amount of missing data and use of history control condition, our findings need to be interpreted with caution. However, we consider these findings as a clinical imperative. More evidence might contribute to convincing adolescents to start with therapy, knowing it has lasting effects. Further, especially for adolescents for whom it is not possible to receive face-to-face treatment, blended treatment might be a valuable alternative. Our findings might contribute to the implementation of blended CBT.
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17
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Obiweluozo PE, Dike IC, Ogba FN, Elom CO, Orabueze FO, Okoye-Ugwu S, Ani CKC, Onu AO, Ukaogo V, Obayi LN, Abonyi SE, Onu J, Omenma ZO, Okoro ID, Eze A, Igu NCN, Onuigbo LN, Umeano EC, Onyishi CN. Stress in teachers of children with neuro-developmental disorders: Effect of blended rational emotive behavioral therapy. Sci Prog 2021; 104:368504211050278. [PMID: 34783626 PMCID: PMC10402289 DOI: 10.1177/00368504211050278] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND/OBJECTIVES Neuro-developmental disorders impose a wide range of learning barriers on learners, increasing stress among their teachers. Evidence attests to the heightened stress among teachers teaching children with such conditions. This study tested the efficacy of blended Rational Emotive Behavior Therapy in reducing job stress among teachers of children with neuro-developmental disorders in Abia State, Nigeria. METHOD The current study adopted a group-randomized waitlist control trial design with pretest, post-test, and follow-up assessments. Participants (N = 83) included teachers of children with neuro-developmental disorders in inclusive and specialized schools. The blended Rational Emotive Behavior Therapy group participated in a 2 h intersession face-to-face and online Rational Emotive Behavior Therapy (REBT) program weekly for 12 weeks. Data were collected using the Single Item Stress Questionnaire, Teachers' Stress Inventory, and Participants' Satisfaction questionnaire. The waitlisted group also received a blended Rational Emotive Behavior Therapy intervention after all data collection. Data collected at baseline; post-test as well as follow-up 1 and 2 evaluations were analyzed using mean, standard deviation, t-test statistics, repeated measures analysis of variance, and charts. RESULTS Results revealed that the mean perceived stress, stress symptoms, and the total teachers' stress score of the blended Rational Emotive Behavior Therapy group at post-test and follow-up assessments reduced significantly, compared to the waitlisted group. Participants also reported a high level of satisfaction with the therapy and procedures. CONCLUSION From the findings of this study, we conclude that blended Rational Emotive Behaviour Therapy is efficacious in occupational stress management among teachers of children with neuro-developmental disorders.
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Affiliation(s)
- Patience E Obiweluozo
- Department of Educational Foundations, Faculty of Education, University of Nigeria Nigeria
| | - Ibiwari C Dike
- Department of Educational Foundations, Faculty of Education, University of Nigeria Nigeria
| | - Francisca N Ogba
- Department of Educational Administration, Alex Ekwueme Federal University, Ndufu Alike Ikwo Ebonyi State, Nigeria
| | - Chinyere O Elom
- Department of Educational Administration, Alex Ekwueme Federal University, Ndufu Alike Ikwo Ebonyi State, Nigeria
| | | | - Stella Okoye-Ugwu
- Department of English and Literary Studies, University of Nigeria, Nigeria
| | - Casmir KC Ani
- Department of Philosophy, University of Nigeria, Nigeria
| | - Augustine O Onu
- Department of Sociology and Anthropology, University of Nigeria, Nigeria
| | - Victor Ukaogo
- Department of History and International Studies, University of Nigeria, Nigeria
| | | | - Sunday E Abonyi
- Department of Social Work, University of Ilorin, Ilorin, Nigeria
| | | | - Zippora O Omenma
- Department of Social Science Education, University of Nigeria, Nigeria
| | | | - Angela Eze
- Department of Educational Administration, Alex Ekwueme Federal University, Ndufu Alike Ikwo Ebonyi State, Nigeria
| | - Ntasiobi CN Igu
- Department of Educational Administration, Alex Ekwueme Federal University, Ndufu Alike Ikwo Ebonyi State, Nigeria
| | - Liziana N Onuigbo
- Department of Educational Foundations, Faculty of Education, University of Nigeria Nigeria
| | - Elsie C Umeano
- Department of Educational Foundations, Faculty of Education, University of Nigeria Nigeria
| | - Charity N Onyishi
- Department of Social Science Education, University of Nigeria, Nigeria
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Khan S, Shapka JD, Domene JF. Counsellors’ experiences of online therapy. BRITISH JOURNAL OF GUIDANCE & COUNSELLING 2021. [DOI: 10.1080/03069885.2021.1885009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Shereen Khan
- Health and Counselling Services, Simon Fraser University, Burnaby, Canada
| | - Jennifer D. Shapka
- Department of Educational and Counselling Psychology, and Special Education, University of British Columbia, Vancouver, Canada
| | - Jose F. Domene
- Werlund School of Education, University of Calgary, Calgary, Canada
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The working alliance in blended versus face-to-face cognitive therapy for depression: A secondary analysis of a randomized controlled trial. Internet Interv 2021; 25:100404. [PMID: 34401364 PMCID: PMC8350587 DOI: 10.1016/j.invent.2021.100404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 05/06/2021] [Accepted: 05/18/2021] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION We explored the working alliance as measured by both clients and therapists. The working alliance has been known to predict the outcome of psychotherapy and is often considered an important common factor. This study raised the question of how to conceptualize the working alliance in the blended format. METHODS This was an exploratory study derived from a randomized controlled trial comparing bCBT and face-to-face cognitive behavioural therapy (ftf CBT) on depression. The change in depressive symptoms was measured with the Patient Health Questionnaire (PHQ-9) and the working alliance was measured using the Working Alliance Inventory. ANALYSES Correlation coefficients were calculated for the working alliance as reported by clients and therapists, working alliance was then examined at item and dimension level (task, bond, goal). Linear regression models were applied to investigate the predictive value of the working alliance on treatment outcome. Interaction between the level of working alliance and treatment condition was also considered. RESULTS Client and therapist working alliance ratings correlated at r = 0.44 and clients rated the working alliance higher than therapists (x̄ clients = 48.6, x̄ therapists = 44.6). ftf CBT and bCBT had comparable joint working alliance ratings (x̄ ftf = 46.4, x̄ bCBT = 46.8). Items had little deviation apart from item 4 with high positive values. The level of working alliance from the total sample did not significantly predict outcome based on the client's perspective. Contrarily, seen from the therapist's perspective, it did (b = 0.00, p = .044). Using the mean from these predictors as a composite variable, was also significant (b = 0.00, p = .039, R2 adj = 0.07). There was no significant interaction with treatment condition. DISCUSSION Clients and therapists may lay emphasis on different aspects of the working alliance. The finding that therapist-rated working alliance was better than client working alliance at predicting outcome went against common findings; this pattern may be specific to bCBT. CONCLUSION Clients rated the working alliance slightly higher than therapists on average. Clients and therapists as well as treatment conditions had different profiles on dimension deviations. Therapist ratings of the working alliance appeared to better predict treatment outcome than client ratings. Joint working alliance predicted outcome using client and therapist composite means. The working alliance was equally strong in ftf CBT and bCBT. The absence of interaction with treatment condition indicated that the working alliance was equally predictive of outcome in ftf CBT as in bCBT.
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Darcy A, Daniels J, Salinger D, Wicks P, Robinson A. Evidence of Human-Level Bonds Established With a Digital Conversational Agent: Cross-sectional, Retrospective Observational Study. JMIR Form Res 2021; 5:e27868. [PMID: 33973854 PMCID: PMC8150389 DOI: 10.2196/27868] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 03/23/2021] [Accepted: 04/04/2021] [Indexed: 01/20/2023] Open
Abstract
Background There are far more patients in mental distress than there is time available for mental health professionals to support them. Although digital tools may help mitigate this issue, critics have suggested that technological solutions that lack human empathy will prevent a bond or therapeutic alliance from being formed, thereby narrowing these solutions’ efficacy. Objective We aimed to investigate whether users of a cognitive behavioral therapy (CBT)–based conversational agent would report therapeutic bond levels that are similar to those in literature about other CBT modalities, including face-to-face therapy, group CBT, and other digital interventions that do not use a conversational agent. Methods A cross-sectional, retrospective study design was used to analyze aggregate, deidentified data from adult users who self-referred to a CBT-based, fully automated conversational agent (Woebot) between November 2019 and August 2020. Working alliance was measured with the Working Alliance Inventory-Short Revised (WAI-SR), and depression symptom status was assessed by using the 2-item Patient Health Questionnaire (PHQ-2). All measures were administered by the conversational agent in the mobile app. WAI-SR scores were compared to those in scientific literature abstracted from recent reviews. Results Data from 36,070 Woebot users were included in the analysis. Participants ranged in age from 18 to 78 years, and 57.48% (20,734/36,070) of participants reported that they were female. The mean PHQ-2 score was 3.03 (SD 1.79), and 54.67% (19,719/36,070) of users scored over the cutoff score of 3 for depression screening. Within 5 days of initial app use, the mean WAI-SR score was 3.36 (SD 0.8) and the mean bond subscale score was 3.8 (SD 1.0), which was comparable to those in recent studies from the literature on traditional, outpatient, individual CBT and group CBT (mean bond subscale scores of 4 and 3.8, respectively). PHQ-2 scores at baseline weakly correlated with bond scores (r=−0.04; P<.001); however, users with depression and those without depression had high bond scores of 3.45. Conclusions Although bonds are often presumed to be the exclusive domain of human therapeutic relationships, our findings challenge the notion that digital therapeutics are incapable of establishing a therapeutic bond with users. Future research might investigate the role of bonds as mediators of clinical outcomes, since boosting the engagement and efficacy of digital therapeutics could have major public health benefits.
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Affiliation(s)
| | | | | | - Paul Wicks
- Woebot Health, San Francisco, CA, United States
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Rasing SP, Stikkelbroek YA, den Hollander W, Riper H, Deković M, Nauta MH, Creemers DH, Immink MC, Spuij M, Bodden DH. Pragmatic Quasi-Experimental Controlled Trial Evaluating the Outcomes of Blended CBT Compared to Face-to-Face CBT and Treatment as Usual for Adolescents with Depressive Disorders. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18063102. [PMID: 33802913 PMCID: PMC8002752 DOI: 10.3390/ijerph18063102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 03/11/2021] [Accepted: 03/15/2021] [Indexed: 12/14/2022]
Abstract
Depression is a major problem in youth mental health. Current treatment is on average effective, but adolescents are hesitant to seek help. Blended treatment could lower the barriers to seeking treatment. Evidence on effectiveness is, however, scarce. The present pragmatic quasi-experimental controlled trial aimed to compare the outcomes of blended cognitive behavioral therapy (CBT) to face-to-face CBT and treatment as usual. A total of 129 adolescents with clinical depression (82.2% female), aged 13–22 (M = 16.60, SD = 2.03) received blended CBT, face-to-face CBT or treatment as usual. Clinical diagnosis, depressive symptoms, and secondary outcomes were assessed at baseline, post-intervention, and six-months follow-up. Participants receiving blended CBT were, compared to participants receiving face-to-face CBT and treatment as usual, evenly likely to be in remission from their depressive disorder at post-intervention and at six-month follow-up. Depressive symptoms decreased significantly over time in all three conditions, and changes were not significantly different between conditions. Other secondary outcomes (suicide risk, internalizing and externalizing symptoms, severity of depression, and global functioning) did not differ between treatment conditions at post-intervention and six-month follow-up. Since there was no evidence for favorable outcomes for face-to-face therapies above blended CBT, blended CBT may also be an effective treatment format in clinical practice.
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Affiliation(s)
- Sanne P.A. Rasing
- Clinical Child and Family Studies, Utrecht University, 3508 TC Utrecht, The Netherlands; (Y.A.J.S.); (M.D.); (M.S.); (D.H.M.B.)
- Child and Adolescent Psychiatry, GGZ Oost Brabant, 5427 EM Boekel, The Netherlands;
- Correspondence: ; Tel.: +31-30-253-4744
| | - Yvonne A.J. Stikkelbroek
- Clinical Child and Family Studies, Utrecht University, 3508 TC Utrecht, The Netherlands; (Y.A.J.S.); (M.D.); (M.S.); (D.H.M.B.)
- Child and Adolescent Psychiatry, GGZ Oost Brabant, 5427 EM Boekel, The Netherlands;
| | | | - Heleen Riper
- Department of Clinical, Neuro- and Developmental Psychology, VU University, 1081 HV Amsterdam, The Netherlands;
- Department of Psychiatry, VU University Medical Centre, 1081 HV Amsterdam, The Netherlands
- APH Institute for Health and Care Research, VU University Medical Centre, 1081 HV Amsterdam, The Netherlands
| | - Maja Deković
- Clinical Child and Family Studies, Utrecht University, 3508 TC Utrecht, The Netherlands; (Y.A.J.S.); (M.D.); (M.S.); (D.H.M.B.)
| | - Maaike H. Nauta
- Department of Clinical Psychology and Experimental Psychopathology, University of Groningen, 9712 CP Groningen, The Netherlands;
- Accare Child and Adolescent Psychiatry, Groningen University Centre, 9712 CP Groningen, The Netherlands
| | - Daan H.M. Creemers
- Child and Adolescent Psychiatry, GGZ Oost Brabant, 5427 EM Boekel, The Netherlands;
- Behavioural Science Institute, Radboud University, 6525 XZ Nijmegen, The Netherlands
| | | | - Mariken Spuij
- Clinical Child and Family Studies, Utrecht University, 3508 TC Utrecht, The Netherlands; (Y.A.J.S.); (M.D.); (M.S.); (D.H.M.B.)
- TOPP-Zorg, Driebergen-Rijsenburg, 3972 WG Driebergen-Rijsenburg, The Netherlands
| | - Denise H.M. Bodden
- Clinical Child and Family Studies, Utrecht University, 3508 TC Utrecht, The Netherlands; (Y.A.J.S.); (M.D.); (M.S.); (D.H.M.B.)
- Child and Youth Psychiatry, Altrecht, 3524 SH Utrecht, The Netherlands
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Hall CL, Sanderson C, Brown BJ, Andrén P, Bennett S, Chamberlain LR, Davies EB, Khan K, Kouzoupi N, Mataix-Cols D, McKenzie C, Murphy T, Townsend M, Hollis C, Murray E. Opportunities and challenges of delivering digital clinical trials: lessons learned from a randomised controlled trial of an online behavioural intervention for children and young people. Trials 2020; 21:1011. [PMID: 33298127 PMCID: PMC7724811 DOI: 10.1186/s13063-020-04902-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 11/15/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Despite being the gold standard of research to determine effectiveness, randomised controlled trials (RCTs) often struggle with participant recruitment, engagement and retention. These issues may be exacerbated when recruiting vulnerable populations, such as participants with mental health issues. We aimed to update understanding of the scope of these problems in trials of health technology and identify possible solutions through reflecting on experiences from an exemplar trial (Online Remote Behavioural Intervention for Tics; ORBIT). METHOD We extracted anonymised data on recruitment, retention and requests for more funding and time from trials funded by the largest funder of health technology trials in the UK (the National Institute of Health Research Health Technology Assessment) between 2010 and 2020, and compared these with data from a recent, successful trial (ORBIT). ORBIT aimed to assess the clinical- and cost-effectiveness of blended online and human behavioural therapy for tics in young people. Many of the trial procedures, including recruitment, the intervention and data collection, were undertaken online. RESULTS Data were extracted on 51 trials conducted between 2010 and 2020. Sixty per cent of trials failed to reach their original recruitment target and only 44% achieved their follow-up in the specified time frame. In contrast, ORBIT recruited to target and achieved 90% follow-up. We posit that these achievements are related to (a) judicious use of digital technology for trial procedures and (b) adequate numbers of highly trained and motivated trial staff. We provide details of both these to help other research teams plan and cost for successful trials. CONCLUSION An approach combining human and online methods may be advantageous in facilitating trial delivery, particularly in paediatric mental health services. Given the importance of successful clinical trials in advancing healthcare delivery and the waste of human and economic resources associated with unsuccessfully delivered trials, it is imperative that trials are appropriately costed and future research focusses on improving trial design and delivery. TRIAL REGISTRATION The ORBIT trial is registered with ISRTCN ( ISRCTN70758207 ) Registered on March 20, 2018. and ClinicalTrials.gov ( NCT03483493 ). Registered on March 30, 2018.
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Affiliation(s)
- Charlotte L. Hall
- NIHR MindTech Medtech Co-operative, School of Medicine, Division of Psychiatry and Applied Psychology, Institute of Mental Health, University of Nottingham Innovation Park, Triumph Road, Nottingham, UK
| | - Charlotte Sanderson
- University College London, Great Ormond Street Institute of Child Health, London, UK
| | - Beverly J. Brown
- NIHR MindTech Medtech Co-operative, School of Medicine, Division of Psychiatry and Applied Psychology, Institute of Mental Health, University of Nottingham Innovation Park, Triumph Road, Nottingham, UK
| | - Per Andrén
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Sophie Bennett
- University College London, Great Ormond Street Institute of Child Health, London, UK
| | - Liam R. Chamberlain
- NIHR MindTech Medtech Co-operative, School of Medicine, Division of Psychiatry and Applied Psychology, Institute of Mental Health, University of Nottingham Innovation Park, Triumph Road, Nottingham, UK
| | - E. Bethan Davies
- NIHR MindTech Medtech Co-operative, School of Medicine, Division of Psychiatry and Applied Psychology, Institute of Mental Health, University of Nottingham Innovation Park, Triumph Road, Nottingham, UK
| | - Kareem Khan
- NIHR MindTech Medtech Co-operative, School of Medicine, Division of Psychiatry and Applied Psychology, Institute of Mental Health, University of Nottingham Innovation Park, Triumph Road, Nottingham, UK
| | - Natalie Kouzoupi
- University College London, Great Ormond Street Institute of Child Health, London, UK
| | - David Mataix-Cols
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Caitlin McKenzie
- NIHR MindTech Medtech Co-operative, School of Medicine, Division of Psychiatry and Applied Psychology, Institute of Mental Health, University of Nottingham Innovation Park, Triumph Road, Nottingham, UK
| | - Tara Murphy
- University College London, Great Ormond Street Institute of Child Health, London, UK
| | - Mark Townsend
- National Institute for Health Research, University of Southampton, Alpha House, Enterprise Road, Southampton, UK
| | - Chris Hollis
- NIHR MindTech Medtech Co-operative, School of Medicine, Division of Psychiatry and Applied Psychology, Institute of Mental Health, University of Nottingham Innovation Park, Triumph Road, Nottingham, UK
| | - Elizabeth Murray
- Research Department of Primary Care and Population Health, University College London, London, UK
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Doukani A, Free C, Michelson D, Araya R, Montero-Marin J, Smith S, Cerga-Pashoja A, Kakuma R. Towards a conceptual framework of the working alliance in a blended low-intensity cognitive behavioural therapy intervention for depression in primary mental health care: a qualitative study. BMJ Open 2020; 10:e036299. [PMID: 32967872 PMCID: PMC7513595 DOI: 10.1136/bmjopen-2019-036299] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES To examine and adapt a conceptual framework of the working alliance (WA) in the context of a low-intensity blended (psychological well-being practitioner (PWP) plus computerised program) cognitive behavioural therapy intervention (b-CBT) for depression. DESIGN Patient involvement was enlisted to collaboratively shape the design of the project from the onset, before data collection. In-depth semi-structured interviews were carried out with participants who experienced b-CBT as part of the E-compared trial. A thematic analysis was conducted using a constant comparative method informed by grounded theory. SETTING Recruitment was carried out in four psychological primary care services across the UK. PARTICIPANTS Nineteen trial participants with major depressive disorder who completed at least one computerised program and face-to-face session with a PWP in the b-CBT arm were recruited to the study. RESULTS Qualitative interviews that were guided by WA theory and patient involvement, revealed four themes: (1) a healthcare provider (PWP and computerised program) with good interpersonal competencies for building a working relationship with the client ('bond'); (2) collaborative efforts between the client and the provider to appropriately identify what the client hopes to achieve through therapy ('goals'); (3) the selection of acceptable therapeutic activities that address client goals and the availability of responsive support ('task') and (4) the promotion of active engagement and autonomous problem solving ('usability heuristics'). Participants described how the PWP and computerised program uniquely and collectively contributed to different WA needs. CONCLUSIONS This study is the first to offer a preliminary conceptual framework of WA in b-CBT for depression, and how such demands can be addressed through blended PWP-computerised program delivery. These findings can be used to promote WA in technological design and clinical practice, thereby promoting engagement to b-CBT interventions and effective deployment of practitioner and program resources. TRIAL REGISTRATION NUMBER ISRCTN12388725.
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Affiliation(s)
- Asmae Doukani
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Caroline Free
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Ricardo Araya
- Health Service and Population Research Department, King's College London, London, UK
| | | | - Sarah Smith
- Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Arlinda Cerga-Pashoja
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Ritsuko Kakuma
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
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Immediate and long-term effectiveness of adding an Internet intervention for depression to routine outpatient psychotherapy: Subgroup analysis of the EVIDENT trial. J Affect Disord 2020; 274:643-651. [PMID: 32663998 DOI: 10.1016/j.jad.2020.05.122] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 04/27/2020] [Accepted: 05/17/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To examine immediate and long-term effectiveness of an adjunctive Internet intervention for depression in a large sample of patients undergoing routine psychotherapy. METHOD The current study evaluated a subgroup of patients from the Evident trial, a randomized investigation of a 12-week minimally guided Internet intervention (Deprexis) for the treatment of mild to moderate depression. 340 adults (mean age = 43.3 years; 71.7 % female) of the original sample received routine outpatient psychotherapy during the trial period, resulting in a standard psychotherapy group (n = 174) and an augmented therapy group (n = 166). Outcomes were assessed at baseline, post-treatment and 6-month follow-up. RESULTS Intention-to-treat analyses indicated that combined treatment led to a greater reduction in symptoms of depression (effect size d = 0.32; p = .002), improved therapeutic progress (d = 0.36; p = .003), and higher mental health-related quality of life (d = 0.34; p = .004). There was no intervention effect on physical health-related quality of life. The same pattern was found at 6-month follow-up, and adjunctive treatment also resulted in increased rates of clinical improvement. Treatment success was independent from therapeutic orientation of combined face-to-face therapy. CONCLUSION Results indicate that the adjunctive use of the investigated intervention can produce additional and lasting effects in routine outpatient psychotherapy for mild to moderate levels of depression. The study adds to the ongoing evidence on augmented effects of blended treatment. Future studies should investigate different types of blends in diverse populations by means of change-sensitive assessment strategies.
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Working Alliance Inventory for Online Interventions-Short Form (WAI-TECH-SF): The Role of the Therapeutic Alliance between Patient and Online Program in Therapeutic Outcomes. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17176169. [PMID: 32854381 PMCID: PMC7503297 DOI: 10.3390/ijerph17176169] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/17/2020] [Accepted: 08/19/2020] [Indexed: 11/18/2022]
Abstract
Background: Therapeutic alliance (TA) between the patient and therapist has been related to positive therapeutic outcomes. Because Internet-based interventions are increasingly being implemented, a tool is needed to measure the TA with Internet-based self-guided programs. The Working Alliance Inventory for online interventions (WAI-TECH-SF) was adapted based on the WAI Short Form (Hatcher & Gillaspy, 2006). The objectives of this study were: (1) to analyse the psychometric properties of the WAI-TECH-SF; (2) to explore the differences in the WAI-TECH-SF scores according to different categories of the sample; and (3) to analyse whether the WAI-TECH-SF can predict therapeutic outcomes and satisfaction with the treatment. Methods: 193 patients diagnosed with depression were included and received blended Cognitive-Behavioural Therapy. Measures of preferences, satisfaction, and credibility about the treatment, TA with the online program, depressive symptoms, and satisfaction with the treatment were administered. Results: An exploratory factor analysis revealed a one-dimensional structure with adequate internal consistency. Linear regression analyses showed that the WAI-TECH-SF predicted changes in depressive symptoms and satisfaction with the treatment. Conclusions: WAI-TECH-SF is a reliable questionnaire to assess the TA between the patient and the online program, which is associated with positive therapeutic outcomes and satisfaction with the treatment.
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Smoktunowicz E, Barak A, Andersson G, Banos RM, Berger T, Botella C, Dear BF, Donker T, Ebert DD, Hadjistavropoulos H, Hodgins DC, Kaldo V, Mohr DC, Nordgreen T, Powers MB, Riper H, Ritterband LM, Rozental A, Schueller SM, Titov N, Weise C, Carlbring P. Consensus statement on the problem of terminology in psychological interventions using the internet or digital components. Internet Interv 2020; 21:100331. [PMID: 32577404 PMCID: PMC7305336 DOI: 10.1016/j.invent.2020.100331] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 05/18/2020] [Accepted: 05/31/2020] [Indexed: 12/21/2022] Open
Abstract
Since the emergence of psychological interventions delivered via the Internet they have differed in numerous ways. The wealth of formats, methods, and technological solutions has led to increased availability and cost-effectiveness of clinical care, however, it has simultaneously generated a multitude of terms. With this paper, we first aim to establish whether a terminology issue exists in the field of Internet-delivered psychological interventions. If so, we aim to determine its implications for research, education, and practice. Furthermore, we intend to discuss solutions to mitigate the problem; in particular, we propose the concept of a common glossary. We invited 23 experts in the field of Internet-delivered interventions to respond to four questions, and employed the Delphi method to facilitate a discussion. We found that experts overwhelmingly agreed that there were terminological challenges, and that it had significant consequences for conducting research, treating patients, educating students, and informing the general public about Internet-delivered interventions. A cautious agreement has been reached that formulating a common glossary would be beneficial for the field to address the terminology issue. We end with recommendations for the possible formats of the glossary and means to disseminate it in a way that maximizes the probability of broad acceptance for a variety of stakeholders.
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Affiliation(s)
- Ewelina Smoktunowicz
- Department of Psychology, SWPS University of Social Sciences and Humanities, Chodakowska 19, 31 03-815 Warsaw, Poland,Department of Psychology, Stockholm University, Frescati Hagvag 8, 114 19 Stockholm, Sweden
| | - Azy Barak
- Department of Counseling and Human Development, University of Haifa, Israel
| | - Gerhard Andersson
- Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Rosa M. Banos
- Universidad de Valencia, Valencia, Spain,CIBER Fisiopatologia Obesidad y Nutrición (CIBEROBN), Instituto Salud Carlos III, Madrid, Spain
| | - Thomas Berger
- Department of Clinical Psychology and Psychotherapy, University of Bern, Switzerland
| | - Cristina Botella
- CIBER Fisiopatologia Obesidad y Nutrición (CIBEROBN), Instituto Salud Carlos III, Madrid, Spain,Uiversitat Jaume I, Valencia, Spain
| | - Blake F. Dear
- Department of Psychology, Macquarie University, Sydney, Australia
| | - Tara Donker
- Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit, Amsterdam, the Netherlands
| | - David D. Ebert
- Faculty of Behavioural and Movement Sciences, Clinical, Neuro- & Developmental Psychology, Vrije Universiteit, Amsterdam, the Netherlands
| | | | | | - Viktor Kaldo
- Department of Psychology, Faculty of Health and Life Sciences, Linnaeus University, Växjö, Sweden,Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Region Stockholm, Sweden
| | - David C. Mohr
- Center for Behavioral Intervention Technologies, Department of Preventive Medicine, Northwestern University, Chicago, IL, USA
| | - Tine Nordgreen
- Division of Psychiatry, Haukeland University Hospital, Bergen, Norway
| | | | - Heleen Riper
- Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit, Amsterdam, the Netherlands
| | - Lee M. Ritterband
- Center for Behavioral Health & Technology, Department of Psychiatry and Neurobehavioral Sciences, University of Virginia, Charlottesville, VA, USA
| | - Alexander Rozental
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden,Institute of Child Health, UCL, London, UK
| | - Stephen M. Schueller
- Department of Psychological Science, University of California, Irvine, Irvine, CA, USA
| | - Nickolai Titov
- Department of Psychology, Macquarie University, Sydney, Australia
| | - Cornelia Weise
- Department of Psychology, Division of Clinical Psychology and Psychotherapy, Philipps–University of Marburg, Marburg, Germany
| | - Per Carlbring
- Department of Psychology, Stockholm University, Frescati Hagvag 8, 114 19 Stockholm, Sweden,Corresponding author at: Department of Psychology, SE-106 91 Stockholm, Sweden.
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Miloff A, Carlbring P, Hamilton W, Andersson G, Reuterskiöld L, Lindner P. Measuring Alliance Toward Embodied Virtual Therapists in the Era of Automated Treatments With the Virtual Therapist Alliance Scale (VTAS): Development and Psychometric Evaluation. J Med Internet Res 2020; 22:e16660. [PMID: 32207690 PMCID: PMC7139418 DOI: 10.2196/16660] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 12/09/2019] [Accepted: 12/15/2019] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Automated virtual reality exposure therapies (VRETs) are self-help treatments conducted by oneself and supported by a virtual therapist embodied visually and/or with audio feedback. This simulates many of the nonspecific relational elements and common factors present in face-to-face therapy and may be a means of improving adherence to and efficacy of self-guided treatments. However, little is known about alliance toward the virtual therapist, despite alliance being an important predictor of treatment outcome. OBJECTIVE In this study, we aimed to evaluate the first alliance instrument developed for use with embodied virtual therapists in an automated treatment format-the Virtual Therapist Alliance Scale (VTAS)-by (1) assessing its psychometric properties, (2) verifying the dimensionality of the scale, and (3) determining the predictive ability of the scale with treatment outcome. METHODS A psychometric evaluation and exploratory factor analysis of the VTAS was conducted using data from two samples of spider-fearful patients treated with VRET and the help of an embodied, voice-based virtual therapist (n=70). Multiple regression models and bivariate correlations were used to assess the VTAS relationship with treatment outcome, according to self-reported fear and convergence with presence and user-friendliness process measures. RESULTS The VTAS showed a sound two-factor solution composed of a primary factor covering task, goal, and copresence; adequate internal consistency; and good convergent validity, including moderate correlation (r=.310, P=.01) with outcomes over follow-up. CONCLUSIONS These preliminary results suggest that alliance toward a virtual therapist is a significant predictor of treatment outcome, favors the importance of a task-goal over bond-factor, and should be explored in studies with larger sample sizes and in additional forms of embodiment.
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Affiliation(s)
- Alexander Miloff
- Department of Psychology, Stockholm University, Stockholm, Sweden
| | - Per Carlbring
- Department of Psychology, Stockholm University, Stockholm, Sweden
| | | | - Gerhard Andersson
- Department of Behavioral Sciences and Learning, Linköping University, Linköping, Sweden
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Lena Reuterskiöld
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Philip Lindner
- Department of Psychology, Stockholm University, Stockholm, Sweden
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
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Del Giacco L, Anguera MT, Salcuni S. The Action of Verbal and Non-verbal Communication in the Therapeutic Alliance Construction: A Mixed Methods Approach to Assess the Initial Interactions With Depressed Patients. Front Psychol 2020; 11:234. [PMID: 32153459 PMCID: PMC7047748 DOI: 10.3389/fpsyg.2020.00234] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 01/31/2020] [Indexed: 01/17/2023] Open
Abstract
In psychodynamic psychotherapy, verbal (structures and intents) and non-verbal (voice and interruptions) dimensions of communication intertwine conveying information and determining the mutual regulation between therapist and patient through conversational sequences. The communication components interplay is the foundation for building the therapeutic alliance, a relational dimension that predicts a psychotherapy outcome and change, influenced by patient-therapist exchanges from the initial stages of their encounter. Depressed patients present specific verbal and non-verbal communication and show difficulties in developing and maintaining the therapeutic alliance. Based on the reviewed literature, the main aim of this study was to analyze how the action of specific communicative modes, implemented by the therapist and depressed patients, affect the reciprocal construction of the early therapeutic alliance by each participant during the mutual regulation processes. We employed a mixed methods approach based on a systematic observation of communication and alliance ruptures and repairs within the audio recordings and verbatim transcripts of 20 psychotherapy sessions (6,232 speaking turns) with seven depressed patients. The observational design was nomothetic, follow-up, and multidimensional. The choice of methodology is justified because we developed a comprehensive procedure that integrates an ad hoc indirect observation system (the Communicative Modes Analysis System in Psychotherapy), analyzing verbal and non-verbal communication, and an observational tool with deductive categories (the Collaborative Interactions Scale-Revised), assessing the therapeutic alliance construction. Once we confirmed the intra-and inter-observer reliability for the ad hoc system and the inter-rater reliability for the tool with deductive (or theoretical) categories, we performed descriptive statistics (to describe quantitatively communicative modes and alliance ruptures and repairs), lag sequential analysis (to detect stable patterns in communication-alliance interactions), and polar coordinate analysis (to identify significant relationships between communicative modes and alliance ruptures and repairs). Results confirm that the therapist's verbal (asking and exploring) and non-verbal (elaborating and cooperatively interrupting) modes and the depressed patients' verbal (asserting and exploring) and non-verbal (expressing emotions and cooperatively interrupting) modes determine stable patterns and significant associations with collaborative behaviors connected to the reciprocal construction of alliance by each participant. All this may provide professionals with useful information to increase the psychotherapy effectiveness with depressed patients.
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Affiliation(s)
- Luca Del Giacco
- Department of Social Psychology and Quantitative Psychology, University of Barcelona, Barcelona, Spain
- Department of Developmental Psychology and Socialization, University of Padua, Padua, Italy
| | - M. Teresa Anguera
- Faculty of Psychology, Institute of Neurosciences, University of Barcelona, Barcelona, Spain
| | - Silvia Salcuni
- Department of Developmental Psychology and Socialization, University of Padua, Padua, Italy
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Kooistra L, Ruwaard J, Wiersma J, van Oppen P, Riper H. Working Alliance in Blended Versus Face-to-Face Cognitive Behavioral Treatment for Patients with Depression in Specialized Mental Health Care. J Clin Med 2020; 9:jcm9020347. [PMID: 32012722 PMCID: PMC7073833 DOI: 10.3390/jcm9020347] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 01/14/2020] [Accepted: 01/18/2020] [Indexed: 12/24/2022] Open
Abstract
This study investigates working alliance in blended cognitive behavioral therapy (bCBT) for depressed adults in specialized mental health care. Patients were randomly allocated to bCBT (n = 47) or face-to-face CBT (n = 45). After 10 weeks of treatment, both patients and therapists in the two groups rated the therapeutic alliance on the Working Alliance Inventory Short-Form Revised (WAI-SR; Task, Bond, Goal, and composite scores). No between-group differences were found in relation to either patient or therapist alliance ratings, which were high in both groups. In the full sample, a moderate positive association was found between patient and therapist ratings on Task (ρ = 0.41, 95% CI 0.20; 0.59), but no significant associations emerged on other components or composite scores. At 30 weeks, within-and between-group associations between alliance and changes in depression severity (QIDS, Quick Inventory of Depressive Symptomatology) were analyzed with linear mixed models. The analyses revealed an association between depression over time, patient-rated alliance, and group (p < 0.001). In face-to-face CBT, but not in bCBT, lower depression scores were associated with higher alliance ratings. The online component in bCBT may have led patients to evaluate the working alliance differently from patients receiving face-to-face CBT only.
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Affiliation(s)
- Lisa Kooistra
- Department of Clinical, Neuro-and Developmental Psychology and the Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
- Department of Research and Innovation, GGZ inGeest Specialized Mental Health Care, Oldenaller 1, 1081 HJ Amsterdam, The Netherlands; (J.W.); (P.v.O.)
- Correspondence:
| | - Jeroen Ruwaard
- Department of Research and Innovation, GGZ inGeest Specialized Mental Health Care, Oldenaller 1, 1081 HJ Amsterdam, The Netherlands; (J.W.); (P.v.O.)
- Department of Psychiatry and the Amsterdam Public Health Research Institute, GGZ inGeest/Amsterdam UMC, Vrije Universiteit, de Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Jenneke Wiersma
- Department of Research and Innovation, GGZ inGeest Specialized Mental Health Care, Oldenaller 1, 1081 HJ Amsterdam, The Netherlands; (J.W.); (P.v.O.)
| | - Patricia van Oppen
- Department of Research and Innovation, GGZ inGeest Specialized Mental Health Care, Oldenaller 1, 1081 HJ Amsterdam, The Netherlands; (J.W.); (P.v.O.)
- Department of Psychiatry and the Amsterdam Public Health Research Institute, GGZ inGeest/Amsterdam UMC, Vrije Universiteit, de Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Heleen Riper
- Department of Clinical, Neuro-and Developmental Psychology and the Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
- Department of Research and Innovation, GGZ inGeest Specialized Mental Health Care, Oldenaller 1, 1081 HJ Amsterdam, The Netherlands; (J.W.); (P.v.O.)
- Department of Psychiatry and the Amsterdam Public Health Research Institute, GGZ inGeest/Amsterdam UMC, Vrije Universiteit, de Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
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Blended cognitive behavioural therapy for adolescents with panic disorder co-morbid with autism spectrum disorder: a case study. COGNITIVE BEHAVIOUR THERAPIST 2020. [DOI: 10.1017/s1754470x20000392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Abstract
Cognitive behavioural therapy (CBT) is an effective treatment for improving anxiety symptoms in patients with autism spectrum disorder (ASD). However, some patients with ASD take extra time for learning, and they can find it hard to change their thinking styles and behaviour due to cognitive deficits. The therapist must be creative when implementing CBT in this context. Here, it may be helpful for the patient with ASD to understand CBT’s concepts by using visual aid material. Blended CBT during which the patient is shown visual aid material with his or her therapist has been suggested as effective for adults without ASD to reduce anxiety. Blended CBT combines face-to-face treatment with internet guided support and resource. Blended CBT may facilitate an understanding of essential knowledge and help people with ASD and anxiety acquire skills based on cognitive behavioural science. However, as far as we know, no previous studies have reported on the use of blended CBT for patients with panic disorder co-morbid with ASD. This study, therefore, consecutively performed 16 blended CBT sessions on a biweekly basis to treat panic disorder (PD) in an adolescent Japanese female co-morbid with ASD. The patient exhibited improvements in PD symptoms and agoraphobia after treatment: the Panic Disorder Severity Scale score decreased from 18 to 2. These results indicate that visual aid-assisted treatment may help patients with impaired imagination and social cognition related to ASD. Furthermore, this study’s therapist notes the need for paced treatments and repeated psychoeducation for patients with impairments in central coherence and cognitive flexibility.
Key learning aims
(1)
Blended CBT may patients with panic disorder (PD) co-morbid with autism spectrum disorder (ASD) to understand concepts based on cognitive behavioural science and symptoms.
(2)
Blended CBT sessions can each be conducted in approximately 20 min (about one-third of the time needed for typical 45- to 90-min CBT sessions); in other words, it is less burdensome for the patient and therapist.
(3)
How to adjust blended CBT for those who have low average intelligence quotients (IQ) and/or ASD.
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Torous J, Cerrato P, Halamka J. Targeting depressive symptoms with technology. Mhealth 2019; 5:19. [PMID: 31463305 PMCID: PMC6691087 DOI: 10.21037/mhealth.2019.06.04] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 06/24/2019] [Indexed: 12/17/2022] Open
Abstract
Interest in digital mental health, driven largely by the need to increase access to mental health services, presents new opportunities as well as challenges. This article provides a selective overview of several new approaches, including chatbots and apps, with a focus on exploring their unique characteristics. To understand the broader issues around digital mental health apps, we discuss recent reviews in this space in the context of how they can inform care today, and how these apps fail to address several important gaps. Framing apps as either tools to augment versus deliver care, we explore ongoing struggles in this space that will determine how apps are used, regulated, and reimbursed for. Realizing that many mental health apps today exist in this still undefined space and often possess no evidence, we conclude with an overview of the American Psychiatric Association (APA)'s app evaluation framework with the goal of offering a more informed approach to these digital tools.
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Affiliation(s)
- John Torous
- Department of Psychiatry and Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - John Halamka
- Department of Emergency Medicine, Harvard Medical School, Boston, MA, USA
- Chairman of the New England Healthcare Exchange Network, Boston, MA, USA
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Andersson G, Titov N, Dear BF, Rozental A, Carlbring P. Internet-delivered psychological treatments: from innovation to implementation. World Psychiatry 2019; 18:20-28. [PMID: 30600624 PMCID: PMC6313242 DOI: 10.1002/wps.20610] [Citation(s) in RCA: 301] [Impact Index Per Article: 60.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Internet interventions, and in particular Internet-delivered cognitive behaviour therapy (ICBT), have existed for at least 20 years. Here we review the treatment approach and the evidence base, arguing that ICBT can be viewed as a vehicle for innovation. ICBT has been developed and tested for several psychiatric and somatic conditions, and direct comparative studies suggest that therapist-guided ICBT is more effective than a waiting list for anxiety disorders and depression, and tends to be as effective as face-to-face CBT. Studies on the possible harmful effects of ICBT are also reviewed: a significant minority of people do experience negative effects, although rates of deterioration appear similar to those reported for face-to-face treatments and lower than for control conditions. We further review studies on change mechanisms and conclude that few, if any, consistent moderators and mediators of change have been identified. A recent trend to focus on knowledge acquisition is considered, and a discussion on the possibilities and hurdles of implementing ICBT is presented. The latter includes findings suggesting that attitudes toward ICBT may not be as positive as when using modern information technology as an adjunct to face-to-face therapy (i.e., blended treatment). Finally, we discuss future directions, including the role played by technology and machine learning, blended treatment, adaptation of treatment for minorities and non-Western settings, other therapeutic approaches than ICBT (including Internet-delivered psychodynamic and interpersonal psychotherapy as well as acceptance and commitment therapy), emerging regulations, and the importance of reporting failed trials.
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Affiliation(s)
- Gerhard Andersson
- Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden
- Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Stockholm, Sweden
| | - Nickolai Titov
- MindSpot Clinic, Macquarie University, Sydney, Australia
- eCentreClinic, Department of Psychology, Macquarie University, Sydney, Australia
| | - Blake F Dear
- MindSpot Clinic, Macquarie University, Sydney, Australia
- eCentreClinic, Department of Psychology, Macquarie University, Sydney, Australia
| | - Alexander Rozental
- Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Stockholm, Sweden
- Institute of Child Health, University College London, London, UK
| | - Per Carlbring
- Department of Psychology, Stockholm University, Stockholm, Sweden
- Department of Psychology, University of Southern Denmark, Odense, Denmark
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