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Therapeutic alliance and different treatment formats when delivering internet-based CBT for depression
Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
2017 (English)Doctoral thesis, comprehensive summary (Other academic)Alternative title
Terapeutisk allians och olika sätt att förmedla internetbehandling med KBT vid depression (Swedish)
Abstract [sv]

Depression är en funktionsnedsättande problematik som påverkar en stor del av den vuxna populationen varje år. Trots ett omfattande behov av hjälp så råder det brist på tillgång till effektiv behandling. Kognitiv Beteendeterapi (KBT) är en evidensbaserad metod som har stöd vid behandling av depression och förmedlad via internet skulle metoden kunna tillgängliggöras för fler. Dock är det i dagsläget oklart vilka format och vilket innehåll som kan användas när behandlingen förmedlas via internet, samt vilken betydelse den terapeutiska alliansen har för en behandling som till största del sker på distans. Syftet med denna avhandling var att undersöka effekterna för olika format av internetbehandling (epostterapi, guidad självhjälp och blended treatment) vid depression, samt alliansens roll i dessa format.

Studiernas resultat visar på att epostterapi och internetförmedlade självhjälpsprogram med behandlarstöd var effektiva metoder för att behandla depression. Alliansskattningar var höga, vilket visar att en positiv terapeutisk allians kan uppnås i internetbehandling. Patientskattningar av allians kunde inte predicera utfallet i någon av behandlingarna, men behandlarskattad allians predicerade förbättring på depressionsskattningar i blended treatment. Den här avhandlingen innehåller den första randomiserade kontrollerade studien på KBT-baserad epostterapi vid depression, samt det första internet-förmedlade självhjälpsprogrammet baserat på beteendeaktivering och ACT.

Abstract [en]

Depression is a debilitating disorder that affects a large part of the adult population every year. Yet there is still a lack of access to effective care for people in need. Cognitive Behaviour therapy (CBT) is an evidence-based method for treating depression that together with the increased availability of Internet services provides an opportunity to increase access to effective treatment. Internet-based interventions can be effective in the treatment of depression, but there is a lack of knowledge concerning which formats of delivery that can be used and if therapeutic alliance is of equal importance when providing treatment over the Internet. The overall aim of this thesis was to examine the effects of different treatment formats (email therapy, guided self-help, and blended treatment) in internet-based CBT for depression and to further examine the role of alliance in these treatment modalities.

Findings from this thesis show that email therapy and internetbased treatment programs were effective methods for treating depression. Alliance ratings were high, showing that a positive therapeutic alliance can be achieved in internet-based treatments. Patient-rated alliance could not predict outcome in any of the different treatment formats. However, therapist-rated alliance predicted change in depression during blended treatment. This thesis includes the first randomized controlled study on CBTbased email therapy, and the first internet-based behavioral activation program with ACT-components, for adult depression.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2017. , 90 p.
Series
Linköping Studies in Arts and Science, ISSN 0282-9800 ; 725Linköping Studies in Behavioural Science, ISSN 1654-2029 ; 201
Keyword [en]
depression, internet-based treatment, cognitive behavioural therapy, therapeutic alliance, email therapy
Keyword [sv]
depression, internetbehandling, kognitiv beteendeterapi, terapeutisk allians, epostterapi
National Category
Applied Psychology
Identifiers
URN: urn:nbn:se:liu:diva-142389DOI: 10.3384/diss.diva-142389ISBN: 9789176854365 (print)OAI: oai:DiVA.org:liu-142389DiVA: diva2:1153429
Public defence
2017-11-23, VAL, Hus Vallfarten, Campus Valla, Linköping, 13:00 (English)
Supervisors
Available from: 2017-10-30 Created: 2017-10-30 Last updated: 2017-11-16Bibliographically approved
List of papers
1. Internet administered guided self-help versus individualized e-mail therapy: A randomized trial of two versions of CBT for major depression
Open this publication in new window or tab >>Internet administered guided self-help versus individualized e-mail therapy: A randomized trial of two versions of CBT for major depression
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2010 (English)In: BEHAVIOUR RESEARCH AND THERAPY, ISSN 0005-7967, Vol. 48, no 5, 368-376 p.Article in journal (Refereed) Published
Abstract [en]

Internet-delivered psychological treatment of major depression has been investigated in several trials, but the role of personalized treatment is less investigated. Studies suggest that guidance is important and that automated computerized programmes without therapist support are less effective. Individualized e-mail therapy for depression has not been studied in a controlled trial. Eighty-eight individuals with major depression were randomized to two different forms of Internet-delivered cognitive behaviour therapy (CBT), or to a waiting-list control group. One form of Internet treatment consisted of guided self-help, with weekly modules and homework assignments. Standard CBT components were presented and brief support was provided during the treatment. The other group received e-mail therapy, which was tailored and did not use the self-help texts i.e., all e-mails were written for the unique patient. Both treatments lasted for 8 weeks. In the guided self-help 93% completed (27/29) and in the e-mail therapy 96% (29/30) completed the posttreatment assessment. Results showed significant symptom reductions in both treatment groups with moderate to large effect sizes. At posttreatment 34.5% of the guided self-help group and 30% of the e-mail therapy group reached the criteria of high-end-state functioning (Beck Depression Inventory score below 9). At six-month follow-up the corresponding figures were 47.4% and 43.3%. Overall, the difference between guided self-help and e-mail therapy was small, but in favour of the latter. These findings indicate that both guided self-help and individualized e-mail therapy can be effective.

Place, publisher, year, edition, pages
Elsevier Science B.V., Amsterdam., 2010
Keyword
Internet treatment, Major depression, E-mail therapy, Guided self-help
National Category
Social Sciences
Identifiers
urn:nbn:se:liu:diva-57417 (URN)10.1016/j.brat.2010.01.005 (DOI)000278168000003 ()
Available from: 2010-06-18 Created: 2010-06-18 Last updated: 2017-10-30
2. Therapeutic alliance in guided internet-delivered cognitive behavioural treatment of depression, generalized anxiety disorder and social anxiety disorder
Open this publication in new window or tab >>Therapeutic alliance in guided internet-delivered cognitive behavioural treatment of depression, generalized anxiety disorder and social anxiety disorder
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2012 (English)In: Behaviour Research and Therapy, ISSN 0005-7967, E-ISSN 1873-622X, Vol. 50, no 9, 544-550 p.Article in journal (Refereed) Published
Abstract [en]

Guided internet-delivered cognitive behaviour therapy (ICBT) has been found to be effective in several controlled trials, but the mechanisms of change are largely unknown. Therapeutic alliance is a factor that has been studied in many psychotherapy trials, but the role of therapeutic alliance in ICBT is less well known. The present study investigated early alliance ratings in three separate samples. Participants from one sample of depressed individuals (N = 49), one sample of individuals with generalized anxiety disorder (N = 35), and one sample with social anxiety disorder (N = 90) completed the Working Alliance Inventory (WAI) modified for ICBT early in the treatment (weeks 3-4) when they took part in guided ICBT for their conditions. Results showed that alliance ratings were high in all three samples and that the WAI including the subscales of Task, Goal and Bond had high internal consistencies. Overall, correlations between the WAI and residualized change scores on the primary outcome measures were small and not statistically significant. We conclude that even if alliance ratings are in line with face-to-face studies, therapeutic alliance as measured by the WAI is probably less important in ICBT than in regular face-to-face psychotherapy.

Place, publisher, year, edition, pages
Elsevier, 2012
National Category
Social Sciences
Identifiers
urn:nbn:se:liu:diva-79399 (URN)10.1016/j.brat.2012.05.003 (DOI)000307909100003 ()22728647 (PubMedID)
Available from: 2012-07-16 Created: 2012-07-16 Last updated: 2017-10-30Bibliographically approved
3. Internet-based behavioral activation and acceptance-based treatment for depression: A randomized controlled trial
Open this publication in new window or tab >>Internet-based behavioral activation and acceptance-based treatment for depression: A randomized controlled trial
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2013 (English)In: Journal of Affective Disorders, ISSN 0165-0327, E-ISSN 1573-2517, Vol. 148, no 2-3, 331-337 p.Article in journal (Refereed) Published
Abstract [en]

Background: Internet-based cognitive behavior therapy for depression has been tested in several trials but there are no internet studies on behavioral activation (BA), and no studies on BA over the internet including components of acceptance and commitment therapy (ACT). The aim of this study was to develop and test the effects of internet-delivered BA combined with ACT against a waiting list control condition as a first test of the effects of treatment. less thanbrgreater than less thanbrgreater thanMethods: Selection took place with a computerized screening interview and a subsequent semi-structured telephone interview. A total of 80 individuals from the general public were randomized to one of two conditions. The treatment lasted for 8 weeks after which both groups were assessed. We also included a 3 month follow-up. The treatment included interactive elements online and a CD-ROM for mindfulness and acceptance exercises. In addition, written support and feedback was given by a therapist every week. less thanbrgreater than less thanbrgreater thanResults: Results at posttreatment showed a large between group effect size on the Beck Depression inventory II d = 0.98 (95%CI = 0.51-1.44). In the treated group 25% (10/40) reached remission defined as a BDI score andlt;= 10 vs. 5% (2/40) in the control group. Results on secondary measures were smaller. While few dropped out from the study (N = 2) at posttreatment, the average number of completed modules was M = 5.1 out of the seven modules. less thanbrgreater than less thanbrgreater thanLimitations: The study only included a waiting-list comparison and it is not possible to determine which treatment components were the most effective. less thanbrgreater than less thanbrgreater thanConclusions: We conclude that there is initial evidence that BA with components of ACT can be effective in reducing symptoms of depression.

Place, publisher, year, edition, pages
Elsevier, 2013
Keyword
Depression, Internet-based treatment, Acceptance and commitment therapy, Randomized controlled trial
National Category
Social Sciences
Identifiers
urn:nbn:se:liu:diva-94601 (URN)10.1016/j.jad.2012.12.020 (DOI)000318909700024 ()
Note

Funding Agencies|Swedish Science Foundation||Swedish Council for Social Research||Swedish Council for Work Life Research||

Available from: 2013-06-27 Created: 2013-06-27 Last updated: 2017-10-30

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