Article summary of Therapist behaviours in Internet-delivered cognitive behaviour therapy by Paxling et. al. - Chapter

What is this article about?

There are many studies that show that therapist factors are important for the outcome of the therapies. One study found that therapist factors and therapeutic relationships accounted for a third of the outcomes in psychotherapy. One review found that this is twice as much as can be explained by specific therapeutic techniques. Not all scientists agree on what is seen as the therapeutic factor. Some think that it is a broad spectrum of characteristics and/or behaviours, like the therapist’s demographics and characteristics. These include their religion, age, gender and personality. Other characteristics and behaviours are the therapeutic bonds and the goals of psychotherapy. Also, treatment methods and therapist factors interact with each other and because of this, it is difficult to distinguish specific factors from therapist factors. This may especially true for cognitive behaviour therapy, because here it is common to discuss the role of adherence and competence, but it is not that common to discuss non-specific factors. One study estimates that only five percent of the outcome variability in clinical trials of psychotherapy can be attributed to the therapist factor. There are also some scientists who do not place a big importance on therapist factors, but overall, there is support for the importance of therapist factors.

Nowadays, we use the computer and the internet a lot. Therefore, it is isn’t weird to us that there is also internet-delivered cognitive behaviour therapy (iCBT). This has been found to be an effective treatment for some health problems, such as panic disorders, major depressions, insomnia and social phobias. Internet-delivered interventions vary greatly. Some are therapist-assisted, while others are not. In some, the patients only contact therapists when needed, while in others there are more extensive contacts over the telephone, chat or e-mail. Meta-analyses have shown that it is important to keep in contact with the therapist during internet-delivered treatment, but there has also been a study on iCBT that showed that patients with social phobia, who did not have contact with a therapist during the treatment phase, did as well as two other groups that did have contact with a therapist. But, it must be said that this contact was with study coordinators and that there are high dropout rates in iCBT studies in which no contact is included. Studies have also looked at the frequency of contact with the therapist. Many studies have shown that a higher frequency of contact has a positive effect on treatment outcome.

Researchers are also concerned with treatment completion. In one study, treatment completion and adherence increased by adding weekly telephone calls with individuals with a panic disorder. But in another study on iCBT for headache, telephone calls didn’t make a difference. Also, researchers still do not know whether the therapist in iCBT needs to be a trained therapist or not. In one study, a group of patients with generalized anxiety disorder (GAD) received technician-assisted iCBT and their outcomes were similar to a group that received additional support from a clinician.

Another study with depressed patients had the same results. Some studies found that in a therapist-patient alliance form in online settings, it doesn’t seem to matter which therapist provides the treatment. However, even though it doesn’t matter who guides iCBT, what the therapist does may still be important. There is much interest in therapist factors in iCBT, but there is little known about specific therapist behaviours and whether these factors have an impact on the treatment outcome. Most studies have looked at the time the therapist has spent on the client, but they have not looked at the actual content of that therapy. In this article, the authors studied the actual content of the therapist contact in iCBT for generalized anxiety disorder (I will use GAD in the rest of the article). The authors wanted to identify therapist behaviours and wanted to determine whether therapist behaviours are related to therapy outcomes.

What is the method in this study?

In this study, three male therapists delivered iCBT to 44 participants with GAD in a randomized controlled trial. There were eight online text modules in the treatment and these communicated CBT strategies to the participants in order to help them to reduce the problems they experienced, such as excessive worrying. The modules had to be completed on a weekly basis by the participants. Some of the modules included problem solving, applied relaxation techniques, cognitive restructuring and exposure.

There were also homework assignments for each module and at the end of each week, patients sent an e-mail to the therapist, in which they answered questions about their progress in the programme and also sent their own questions to the therapist. Therapists had to send back an e-mail with feedback on the homework and answers on the questions that the patient asked. Communication could also take place more often than once a week. This was based on the patient’s own initiative. A psychotherapist with experience in the treatment of patients with GAD provided the therapist weekly, with clinical supervision. The therapists did not use a specific manual and had to answer questions about the programme, they also had to try to keep the patients in the programme and they had to give recommendations on how the patients might use the techniques to their advantage.

Coding

The e-mails from the therapists to the patience were analysed and examiners looked at different independent factors. The researchers did not want to include patient behaviour and did not want to analyse the interaction between therapist and patient. The coding procedure resulted in eight coding categories. This study looked at the topography of the therapist’s e-mail correspondence. This way, the researchers tried to see whether there were any stable patterns of therapist behaviours linked to other therapist behaviour patterns. After all the e-mails had been coded for the eight behaviour types, a frequency matrix was constructed. A behaviour was either present or not present. The interrater reliability was also tested and it was very high, almost perfect. This means that all the coders ascribed a particular behaviour in a similar type. The only exception was for the variable psychoeducation, for which the researchers did not find a significant correlation between the raters.

What are the results?

As previously mentioned, there were eight behaviour types. These were:

What is this article about?

There are many studies that show that therapist factors are important for the outcome of the therapies. One study found that therapist factors and therapeutic relationships accounted for a third of the outcomes in psychotherapy. One review found that this is twice as much as can be explained by specific therapeutic techniques. Not all scientists agree on what is seen as the therapeutic factor. Some think that it is a broad spectrum of characteristics and/or behaviours, like the therapist’s demographics and characteristics. These include their religion, age, gender and personality. Other characteristics and behaviours are the therapeutic bonds and the goals of psychotherapy. Also, treatment methods and therapist factors interact with each other and because of this, it is difficult to distinguish specific factors from therapist factors. This may especially true for cognitive behaviour therapy, because here it is common to discuss the role of adherence and competence, but it is not that common to discuss non-specific factors. One study estimates that only five percent of the outcome variability in clinical trials of psychotherapy can be attributed to the therapist factor. There are also some scientists who do not place a big importance on therapist factors, but overall, there is support for the importance of therapist factors.

Nowadays, we use the computer and the internet a lot. Therefore, it is isn’t weird to us that there is also internet-delivered cognitive behaviour therapy (iCBT). This has been found to be an effective treatment for some health problems, such as panic disorders, major depressions, insomnia and social phobias. Internet-delivered interventions vary greatly. Some are therapist-assisted, while others are not. In some, the patients only contact therapists when needed, while in others there are more extensive contacts over the telephone, chat or e-mail. Meta-analyses have shown that it is important to keep in contact with the therapist during internet-delivered treatment, but there has also been a study on iCBT that showed that patients with social phobia, who did not have contact with a therapist during the treatment phase, did as well as two other groups that did have contact with a therapist. But, it must be said that this contact was with study coordinators and that there are high dropout rates in iCBT studies in which no contact is included. Studies have also looked at the frequency of contact with the therapist. Many studies have shown that a higher frequency of contact has a positive effect on treatment outcome.

Researchers are also concerned with treatment completion. In one study, treatment completion and adherence increased by adding weekly telephone calls with individuals with a panic disorder. But in another study on iCBT for headache, telephone calls didn’t make a difference. Also, researchers still do not know whether the therapist in iCBT needs to be a trained therapist or not. In one study, a group of patients with generalized anxiety disorder (GAD) received technician-assisted iCBT and their outcomes were similar to a group that received additional support from a clinician.

Another study with depressed patients had the same results. Some studies found that in a therapist-patient alliance form in online settings, it doesn’t seem to matter which therapist provides the treatment. However, even though it doesn’t matter who guides iCBT, what the therapist does may still be important. There is much interest in therapist factors in iCBT, but there is little known about specific therapist behaviours and whether these factors have an impact on the treatment outcome. Most studies have looked at the time the therapist has spent on the client, but they have not looked at the actual content of that therapy. In this article, the authors studied the actual content of the therapist contact in iCBT for generalized anxiety disorder (I will use GAD in the rest of the article). The authors wanted to identify therapist behaviours and wanted to determine whether therapist behaviours are related to therapy outcomes.

What is the method in this study?

In this study, three male therapists delivered iCBT to 44 participants with GAD in a randomized controlled trial. There were eight online text modules in the treatment and these communicated CBT strategies to the participants in order to help them to reduce the problems they experienced, such as excessive worrying. The modules had to be completed on a weekly basis by the participants. Some of the modules included problem solving, applied relaxation techniques, cognitive restructuring and exposure.

There were also homework assignments for each module and at the end of each week, patients sent an e-mail to the therapist, in which they answered questions about their progress in the programme and also sent their own questions to the therapist. Therapists had to send back an e-mail with feedback on the homework and answers on the questions that the patient asked. Communication could also take place more often than once a week. This was based on the patient’s own initiative. A psychotherapist with experience in the treatment of patients with GAD provided the therapist weekly, with clinical supervision. The therapists did not use a specific manual and had to answer questions about the programme, they also had to try to keep the patients in the programme and they had to give recommendations on how the patients might use the techniques to their advantage.

Coding

The e-mails from the therapists to the patience were analysed and examiners looked at different independent factors. The researchers did not want to include patient behaviour and did not want to analyse the interaction between therapist and patient. The coding procedure resulted in eight coding categories. This study looked at the topography of the therapist’s e-mail correspondence. This way, the researchers tried to see whether there were any stable patterns of therapist behaviours linked to other therapist behaviour patterns. After all the e-mails had been coded for the eight behaviour types, a frequency matrix was constructed. A behaviour was either present or not present. The interrater reliability was also tested and it was very high, almost perfect. This means that all the coders ascribed a particular behaviour in a similar type. The only exception was for the variable psychoeducation, for which the researchers did not find a significant correlation between the raters.

What are the results?

As previously mentioned, there were eight behaviour types. These were:

1. Deadline flexibility: lenience from the therapist concerning deadlines for homework submissions and extra time working with a module.
2. Task reinforcement: therapists show behaviour aimed at reinforcing assignments completed by the participant.
3. Alliance bolstering: this is a type of writing that is not treatment specific and it shows interest in the participant’s life situation.
4. Psycheducation: this is information about psychological processes and explanation about the purpose and meaning of the treatment
5. Self-efficacy shaping: these are behaviours that reinforce the participant to engage in health promoting behaviours they have learnt through the treatment.
6. Task prompting: these are behaviours that prompt the participant to work on a homework assignment and interests in future results of the progress of the participants.
7. Empathetic utterance: writings that show empathy for the participant’s suffering or life situation.
8. Self-disclosure: writing that describes circumstances in the therapist’s own life situation that are relevant to the patient’s situation.

What are the results?

The most common behaviour was task reinforcement, followed by self-efficacy shaping, task prompting, alliance bolstering, psychoeducation, empathetic utterance, deadline flexibility and self-disclosure. Significant correlations were found between module completion and task reinforcement, self-efficacy shaping, task prompting and empathetic utterance. Deadline flexibility and task reinforcement were significantly associated with treatment outcome. The results show that different types of therapist behaviours can be identified in iCBT. Many of these behaviours are significantly correlated to each other. The types of therapist behaviours also had an impact on module completion. For instance, deadline flexibility was negatively associated with treatment outcome. It seems that deadline flexibility is a marker of slow progress. Task reinforcement correlated with a positive outcome. The behaviours are no inseparable units and therapeutic alliance significantly correlated with every other therapist behaviour except deadline flexibility. Every behaviour except for deadline flexibility correlated with a positive outcome, but task reinforcement was the only type that significantly correlated with a positive outcome. It is complicated to compare these results with traditional face-to-face CBT.

This study had a couple of limitations. The first limitation is that the behaviour of the participants wasn’t analysed. This means that the e-mails of the therapists were analysed out of context. This in turn means that the therapists’ behaviours could be merely responses to the content of the patient e-mails. However, the writers still think that these behaviours were not merely responses. The second complication is that all the patients suffered from GAD and it is therefore possible that the therapist behaviours identified are specific for the treatment of anxiety and worry and the therapist might have behaved differently in the treatment of another condition. Another limitation is that there were only three therapists in this study and that it is not known whether the results can be generalized. Future research should include a larger sample size and should have more therapists in the study. Also, future research should have different types of coaches/therapists and different kinds of psychological disorders.  

1. Deadline flexibility: lenience from the therapist concerning deadlines for homework submissions and extra time working with a module.
2. Task reinforcement: therapists show behaviour aimed at reinforcing assignments completed by the participant.
3. Alliance bolstering: this is a type of writing that is not treatment specific and it shows interest in the participant’s life situation.
4. Psycheducation: this is information about psychological processes and explanation about the purpose and meaning of the treatment
5. Self-efficacy shaping: these are behaviours that reinforce the participant to engage in health promoting behaviours they have learnt through the treatment.
6. Task prompting: these are behaviours that prompt the participant to work on a homework assignment and interests in future results of the progress of the participants.
7. Empathetic utterance: writings that show empathy for the participant’s suffering or life situation.
8. Self-disclosure: writing that describes circumstances in the therapist’s own life situation that are relevant to the patient’s situation.

What are the results?

The most common behaviour was task reinforcement, followed by self-efficacy shaping, task prompting, alliance bolstering, psychoeducation, empathetic utterance, deadline flexibility and self-disclosure. Significant correlations were found between module completion and task reinforcement, self-efficacy shaping, task prompting and empathetic utterance. Deadline flexibility and task reinforcement were significantly associated with treatment outcome. The results show that different types of therapist behaviours can be identified in iCBT. Many of these behaviours are significantly correlated to each other. The types of therapist behaviours also had an impact on module completion. For instance, deadline flexibility was negatively associated with treatment outcome. It seems that deadline flexibility is a marker of slow progress. Task reinforcement correlated with a positive outcome. The behaviours are no inseparable units and therapeutic alliance significantly correlated with every other therapist behaviour except deadline flexibility. Every behaviour except for deadline flexibility correlated with a positive outcome, but task reinforcement was the only type that significantly correlated with a positive outcome. It is complicated to compare these results with traditional face-to-face CBT.

This study had a couple of limitations. The first limitation is that the behaviour of the participants wasn’t analysed. This means that the e-mails of the therapists were analysed out of context. This in turn means that the therapists’ behaviours could be merely responses to the content of the patient e-mails. However, the writers still think that these behaviours were not merely responses. The second complication is that all the patients suffered from GAD and it is therefore possible that the therapist behaviours identified are specific for the treatment of anxiety and worry and the therapist might have behaved differently in the treatment of another condition. Another limitation is that there were only three therapists in this study and that it is not known whether the results can be generalized. Future research should include a larger sample size and should have more therapists in the study. Also, future research should have different types of coaches/therapists and different kinds of psychological disorders.