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Treatment Adherence in Internet-Based CBT: The Effects of Presentation, Support and Motivation
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Clinical Psychology in Healthcare.ORCID iD: 0000-0003-4570-5891
2016 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Homework assignments that patient work with between sessions is a key component in both face-to-face and Internet-based Cognitive Behavior Therapy (CBT). However, adherence to assignments is often low and it is largely unclear what factors predict or affect treatment adherence, and in the end, treatment outcomes. The overall aim of this thesis was to investigate if treatment presentation and therapist support can affect adherence and treatment outcome in internet-based CBT, whether adherence can be predicted by motivation variables and to compare differences in face-to-face and online conditions in this regard.

A randomized controlled trial with a brief online relaxation program for people with stress and anxiety symptoms was conducted (n = 162). Participants in the enhanced support conditions completed a larger proportion of the online treatment but adherence was not affected by enhanced treatment presentation (Study I). Participants reported reduced symptoms of stress and anxiety after the relaxation program but there were no significant additional effects of enhanced presentation or support (Study II). Participants who adhered to the prescribed assignments reported lower symptom levels at study end, regardless of treatment conditions. Adherence to the online treatment was predicted by subject factors such as treatment credibility prior to the treatment and intrinsic motivation during the treatment (Study III). To further elucidate how motivation may affect adherence, an experiment with a one-session psychotherapy model was subsequently conducted (n = 100). Participants who were randomized to the face-to-face condition reported higher motivation for the assignment and completed significantly more of the homework compared to participants in the online condition (Study IV). Self-reported intrinsic motivation could predict adherence in both conditions while new motivational variables were identified specifically for the online condition.

The results from these studies confirm that adherence to assignments in Internet-based CBT is difficult to affect with treatment features but can be predicted early in treatment by subject factors such as treatment credibility and motivation. How such motivational variables can be affected to improve treatments is still unclear.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2016. , 79 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1196
Keyword [en]
Cognitive Behavior Therapy, Internet, Treatment adherence, Compliance, Motivation
National Category
Applied Psychology
Research subject
Medical Science
Identifiers
URN: urn:nbn:se:uu:diva-280804ISBN: 978-91-554-9514-5 (print)OAI: oai:DiVA.org:uu-280804DiVA: diva2:912254
Public defence
2016-05-13, The auditorium, Museum Gustavianum, Akademigatan 3, Uppsala, 14:00 (Swedish)
Opponent
Supervisors
Available from: 2016-04-21 Created: 2016-03-15 Last updated: 2016-04-29
List of papers
1. Is online treatment adherence affected by presentation and therapist support?: A randomized controlled trial
Open this publication in new window or tab >>Is online treatment adherence affected by presentation and therapist support?: A randomized controlled trial
Show others...
2016 (English)In: Computers in human behavior, ISSN 0747-5632, E-ISSN 1873-7692, Vol. 60, 550-558 p.Article in journal (Refereed) Published
Abstract [en]

In both face to face and Internet based Cognitive Behavior Therapy, patients' adherence can be improved by different means such as by using motivational techniques or automatic reminders. The main aim of this study was to investigate whether enriched treatment material presentation and/or increased frequency and quality of support would increase participants' adherence to an online relaxation program. One hundred and sixty-two participants with mild to moderate symptoms of stress or worry were included in this study. Participants were randomized to either Normal or Enhanced intervention presentation and Normal or Enhanced support in a full factorial design. Main outcome variables were progress through the online intervention and adherence to prescribed exercises. Participants in the Enhanced support group progressed further through the program than participants in the Normal support group (Z = 2.11, p = .035, r = .17) but there were no significant differences found between the Normal and Enhanced presentation groups. Participants registered a mean of 60% of the prescribed exercises with no significant differences between groups. This study shows that adherence to online interventions can be increased by increased frequency and quality of therapeutic contact. Future studies may investigate how to increase adherence to prescribed homework assignments and whether parts of the therapeutic support may be substituted with automatic systems with retained effects.

Keyword
Internet; Psychotherapy; Stress; Adherence
National Category
Psychology Engineering and Technology
Identifiers
urn:nbn:se:uu:diva-279739 (URN)10.1016/j.chb.2016.01.035 (DOI)000375811900056 ()
Available from: 2016-03-03 Created: 2016-03-03 Last updated: 2017-11-30Bibliographically approved
2. The effects of therapist support and treatment presentation on the clinical outcomes of an Internet based applied relaxation program
Open this publication in new window or tab >>The effects of therapist support and treatment presentation on the clinical outcomes of an Internet based applied relaxation program
2015 (English)In: Internet Interventions, ISSN 2214-7829, Vol. 2, no 3, 289-296 p.Article in journal (Refereed) Published
Abstract [en]

Symptoms of stress are common in the general population and associated with health risks and economic costs. Applied relaxation training has shown to be effective for reducing stress and worry both as a self-help treatment and as an internet-based intervention with therapist support. However, what factors may affect the outcome of internet based relaxation training is unclear. The aims of the present study were to investigate the effect of a brief internet based relaxation program for people with symptoms of stress or worry and to assess whether enhancing the quality of intervention presentation or therapist support had an impact on outcomes.

Participants were randomized in a full factorial design to either Normal or Enhanced treatment Presentation and either Normal or Enhanced therapist Support in a four-week online program with applied relaxation. The main outcome measures were self-report instruments of stress and worry.

A total of 162 participants were included in the study and 94 and 84 participants completed the post and follow-up measurements respectively. Participants in all conditions improved significantly on the main outcome measures, and the different levels of Presentation or therapist Support did not significantly affect treatment outcome. Registered number of completed exercises was a predictor of better treatment outcome, but this effect was independent of treatment condition. Enhancing internet based interventions by improving presentations and the quality of support may thus not be the best way to further improve the effect of internet based interventions. More specific knowledge of the mechanisms that affect outcomes in online psychotherapy is needed.

National Category
Psychology
Identifiers
urn:nbn:se:uu:diva-260069 (URN)10.1016/j.invent.2015.07.005 (DOI)
Available from: 2015-08-14 Created: 2015-08-14 Last updated: 2017-12-04Bibliographically approved
3. Motivation and Treatment Credibility Predicts Dropout, Treatment Adherence, and Clinical Outcomes in an Internet-Based Cognitive Behavioral Relaxation Program: A Randomized Controlled Trial.
Open this publication in new window or tab >>Motivation and Treatment Credibility Predicts Dropout, Treatment Adherence, and Clinical Outcomes in an Internet-Based Cognitive Behavioral Relaxation Program: A Randomized Controlled Trial.
2016 (English)In: Journal of Medical Internet Research, ISSN 1438-8871, E-ISSN 1438-8871, Vol. 18, no 3, e52Article in journal (Refereed) Published
Abstract [en]

Background: In previous research, variables such as age, education, treatment credibility, and therapeutic alliance have shown to affect patients' treatment adherence and outcome in Internet-based psychotherapy. A more detailed understanding of how such variables are associated with different measures of adherence and clinical outcomes may help in designing more effective online therapy.

Objective: The aims of this study were to investigate demographical, psychological, and treatment-specific variables that could predict dropout, treatment adherence, and treatment outcomes in a study of online relaxation for mild to moderate stress symptoms.

Methods: Participant dropout and attrition as well as data from self-report instruments completed before, during, and after the online relaxation program were analyzed. Multiple linear and logistical regression analyses were conducted to predict early dropout, overall attrition, online treatment progress, number of registered relaxation exercises, posttreatment symptom levels, and reliable improvement.

Results: Dropout was significantly predicted by treatment credibility, whereas overall attrition was associated with reporting a focus on immediate consequences and experiencing a low level of intrinsic motivation for the treatment. Treatment progress was predicted by education level and treatment credibility, whereas number of registered relaxation exercises was associated with experiencing intrinsic motivation for the treatment. Posttreatment stress symptoms were positively predicted by feeling external pressure to participate in the treatment and negatively predicted by treatment credibility. Reporting reliable symptom improvement after treatment was predicted by treatment credibility and therapeutic bond.

Conclusions: This study confirmed that treatment credibility and a good working alliance are factors associated with successful Internet-based psychotherapy. Further, the study showed that measuring adherence in different ways provides somewhat different results, which underscore the importance of carefully defining treatment adherence in psychotherapy research. Lastly, the results suggest that finding the treatment interesting and engaging may help patients carry through with the intervention and complete prescribed assignments, a result that may help guide the design of future interventions.

National Category
Psychology (excluding Applied Psychology)
Identifiers
urn:nbn:se:uu:diva-279736 (URN)10.2196/jmir.5352 (DOI)000380777800004 ()26957354 (PubMedID)
External cooperation:
Available from: 2016-03-03 Created: 2016-03-03 Last updated: 2017-11-30Bibliographically approved
4. Differences in motivation and adherence to a prescribed assignment after face-to-face and online psychoeducation: A randomized experiment.
Open this publication in new window or tab >>Differences in motivation and adherence to a prescribed assignment after face-to-face and online psychoeducation: A randomized experiment.
(English)Article in journal (Refereed) Submitted
National Category
Applied Psychology
Identifiers
urn:nbn:se:uu:diva-280799 (URN)
Available from: 2016-03-15 Created: 2016-03-15 Last updated: 2016-04-29

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