Cynthia Beck

A Usability Study of Internet-Delivered Cognitive Behaviour Therapy and Resource Tailored to Agriculture Producers

Masters Thesis Results, Cynthia Beck 2022

Background: Agriculture producers experience high rates of mental health challenges and are less likely to seek or to receive help for mental health concerns than the general population. Internet-delivered cognitive behaviour therapy (ICBT) is demonstrated to be effective for reducing symptoms of anxiety and depression and overcomes many barriers to receiving mental health care. This study assessed the usability of ICBT for Saskatchewan agricultural residents and its impact on symptoms of anxiety/depression, perceived stress, and resiliency.

Method: Saskatchewan residents involved in agriculture (n = 34) participated in the Agricultural Wellbeing Course (AWC), which is an online, five-lesson course providing strategies for dealing with symptoms of anxiety/depression with therapist-assistance. A mixed methods approach was used with measures completed at pre- and post-treatment and a follow-up interview. This study included developing an agriculturally tailored resource and exploring participant perceptions of ICBT post-treatment.

Results: 100% of participants reported that doing the course was worth their time and recommended it to other producers. Overall, their symptoms of anxiety, depression, and perceived stress largely improved, as did their reported resiliency. The agricultural participants had higher rates of engagement and completion than the general population in the Wellbeing Course. Participants spoke to strengths of the course, which included high therapist credibility, cultural appropriateness, and course content. All participants commented on how ICBT overcame barriers for them to access mental health care, including the ease of accessibility, convenience, flexibility, and reduced stigma. Areas for improvement included providing alternative delivery formats and therapist contact options. Challenges to participating included internal barriers (i.e., lack of motivation) and external barriers (i.e., time constraints, priorities). Course impact included improved skills, positive client impact on others and information sharing, improved view of mental health support, and words of advice to others.

Conclusion: Results suggest that ICBT is a usable and effective mental health treatment for the agriculture population and overcomes the many barriers that producers face in accessing mental health care.

Mixed-method Evaluation of an Online Motivational Interviewing Intervention as a Potential Adjunct to Internet-delivered Cognitive Behaviour Therapy

Honours Thesis Results, Cynthia Beck 2019

Background: While Internet-delivered cognitive behaviour therapy (ICBT) can effectively reduce anxiety and depression, not all clients benefit equally from treatment. Motivational Interviewing (MI) can result in behaviour change and, coupled with face-to-face therapy, can lead to enhanced outcomes; however, little research has examined MI as an adjunct to ICBT.

Purpose: The aim of the current study was to evaluate user feedback on a newly developed online MI intervention and to explore the immediate impact of the MI lesson on motivation for change.

Method: Two samples of participants, one with ICBT experience (n = 21) and one without ICBT experience (n = 20), worked through the exercises and watched the videos in the online MI intervention. Pre and post lesson participants reviewed and evaluated the online MI intervention.

Results: Following MI, both samples of participants reported a statistically significant increase in ability to reduce symptoms (p < .0001) and an increase that approached statistical significance in perceived importance of reducing symptoms (p < .052). Furthermore, after completing the MI intervention, participants reported increased confidence in recommending the lesson to a friend (p < .002) and increased belief that the lesson would be successful in helping someone to prepare for ICBT (p < .0001). Examination of ratings of the MI intervention and open-ended comments were positive, with participants recommending to expand the exercises and content to assist with self-reflection.

Conclusion: The current research provides evidence for the face validity of the MI intervention and sets the foundation for research on MI as a potential adjunct to ICBT for improving motivation prior to active treatment.

Sasheen Horse

Transdiagnostic Internet-delivered Cognitive Behaviour Therapy: Utility of a Motivational Interviewing Resource

Honours Thesis Results, Sasheen Horse 2022

Background: There is strong evidence for the effectiveness of internet-delivered cognitive behaviour therapy (ICBT) but clients can struggle with motivation during treatment. Online motivational interviewing (MI) has not yet been investigated during ICBT as a method of facilitating engagement and outcomes.

Purpose: This feasibility study investigated the potential use of an MI resource offered during ICBT by examining: (1) use of the resource; (2) patient and treatment variables associated with using the resource; (3) whether use of the resource was associated with improved engagement and outcomes; and (4) how those who used the resource evaluated it.

Method: This study used data collected from 763 clients enrolled in an ICBT course. Clients completed an MI resource evaluation measure at post-treatment. Symptoms were assessed at pre- and post-treatment. The website tracked treatment engagement.

Results: Approximately 15% of clients used the resource. Clients who were older, had higher education, higher depression, and lower anxiety at pre-treatment were more likely to use the resource. Those who reported using the resource had higher engagement (i.e., more lessons and more messages) in ICBT, but lower improvement in disability, which may have been a trigger for using the resource. Positive feedback on the MI resource outweighed the negative feedback, with 94% of clients identifying a positive aspect of the resource and 68% of clients reporting changes made in response to the resource.

Conclusion: Overall, the MI resource appears to have utility for a small portion of clients who complete ICBT and this study provides insight to who will use the resource. The resource will be available longer term for patient use in the Online Therapy Unit.

Taylor Patterson

Transdiagnostic Internet-delivered therapy among post-secondary students: Are booster lessons beneficial?

Honours Thesis Results, Taylor Patterson, 2021

Background: Internet-delivered cognitive behaviour therapy (iCBT) has been found to be effective among post-secondary students. Booster lessons have been proposed as a strategy for maintaining and improving outcomes but have yet to be investigated among students.

Method: To inform future use of booster lessons with students completing iCBT, this study used a mixed-methods approach to identify student (n = 101) use of a booster lesson, predictors of completion, and student preferences regarding delivery of a booster lesson one month following a 5-week transdiagnostic iCBT course.

Results: Approximately one-third of clients utilized the booster lesson; among this group the booster lesson was perceived as worthwhile, client satisfaction was high, and every client who completed the booster indicated that the length was appropriate. Clients provided varied responses regarding the ideal timing of a booster lesson (1-2 weeks to 3-6 months) and whether therapist support is preferred while completing the lesson (50% of completers and 40% of non-completers expressed preference for therapist support). The only significant predictors of use of the booster lesson were the number of iCBT lessons completed and whether the client was currently receiving treatment for mental health concerns. School-related time constraints (27.0%) were identified as a large concern for non-completers.

Conclusions: Understanding client use and gaining feedback about their preferences provides direction for future research to maximize the likelihood a booster lesson would be beneficial. Future research incorporating a booster lesson in iCBT should consider student preferences and exhibit flexibility to elevate client engagement.

Victoria Suchan

Examining the acceptability and effectiveness of transdiagnostic, Internet-delivered cognitive behaviour therapy for symptoms of postpartum anxiety and depression: A randomized controlled trial

Doctoral Dissertation, Victoria Suchan, 2021

Background: Following childbirth, women experience significant biological, physical, social, and emotional changes, wherein 20% of new mothers experience clinically impairing symptoms of anxiety or depression. Although effective treatment options exist, such as cognitive behaviour therapy (CBT), new mothers report barriers to accessing such services. Importantly, many of these barriers can be overcome using Internet-delivered CBT (ICBT), which has been found to be effective in the treatment of various mental health concerns, including depression and anxiety. As postpartum anxiety and depression often co-occur, transdiagnostic ICBT that addresses both

Method: The current study explored the acceptability and effectiveness of a transdiagnostic ICBT program, the Wellbeing Course for New Moms, with a sample of Saskatchewan women who had an infant less than one year of age. Participants (= 60) endorsing symptoms of depression or anxiety were randomly assigned to the Wellbeing Course for New Moms or a waitlist control (WLC) group. Participants completed measures pre-treatment, post-treatment, and 1-month follow-up. Treatment satisfaction, therapeutic alliance, and open-ended questions assessing participant experiences with treatment were also explored.

Results: The analyses revealed that both treatment and WLC participants experienced significant reductions in anxiety, depression, and distress over time, as well as improvements in mother-infant bonding.  The treatment group reported significantly superior improvements in symptoms of anxiety and distress as compared to the WLC. For the treatment group large changes were seen on measures of anxiety and depression and symptom improvement was maintained at follow-up. On some measures of depression, however, differences between the WLC and the treatment group not statistically significant, although trends were observed.

Conclusions: Participants were satisfied with this treatment modality and were able to establish a strong working alliance with their online therapist. Results from the current study provide emerging evidence for transdiagnostic ICBT in the treatment of postpartum anxiety and depression.

Increasing favourable expectations of therapist-assisted Internet-delivered cognitive behaviour therapy: Importance of testimonial-based versus statistically-based information

Masters Thesis Results, Victoria Owens 2017

The current study explored whether transdiagnostic, Internet-delivered cognitive behaviour therapy (ICBT) is effective in the treatment of health anxiety, characterized by excessive worry about one’s health and fear that one will acquire an illness. Further, the level of therapist support, namely weekly therapist support or optional therapist support, was examined. Ninety-six clients participating in the Wellbeing Course, an 8-week transdiagnostic ICBT program, with elevated health anxiety symptomatology (≥15 on the Short Health Anxiety Inventory [SHAI]) were included in the current study. Results suggest that health anxiety symptoms significantly reduce following transdiagnostic ICBT. Additionally, clients receiving both weekly and optional therapist contact experienced symptom reduction to a similar extent; however, clients that received weekly therapist contact displayed more favourable treatment engagement (i.e., more lessons completed, more messages sent). Future research is warranted to disentangle the role of therapist contact on symptom reduction and treatment engagement. The results from the current study lend support for the use of transdiagnostic ICBT in the treatment of health anxiety.

Increasing favourable expectations of therapist-assisted Internet-delivered cognitive behaviour therapy: Importance of testimonial-based versus statistically-based information

Honours Thesis Results, Victoria Owens 2015

Background: Internet-delivered Cognitive Behaviour Therapy (ICBT) is an effective method of treating anxiety and depression. Nevertheless, many individuals have low expectations about this treatment given that it is novel. This presents a problem, as higher expectations of treatment have been linked to more favourable treatment outcomes.

Objective: The aim of the present study was to determine if an educational video about ICBT is an effective way to increase individuals’ views of this treatment.

Methods: Participants were assigned to view an educational video about ICBT containing testimonial-based (n = 44) or statistically-based information (n = 53). Questionnaires administered pre- and post-video were analyzed to assess for changes in attitudes towards ICBT, and to determine whether one video was more effective. Correlates between participant characteristics and views of ICBT were examined.

Results: Perceptions of ICBT significantly improved post-video; however, the difference between the two video conditions was not significant. While participant characteristics (e.g., age, sex) were not correlated with views of ICBT, how participants rated the video were.

Conclusion: Educational videos effectively increase expectations of ICBT, and the quality of information presented in the video is more important than the particular information presented.

Practice Implications: In order to facilitate the greatest therapeutic benefit from an ICBT treatment program, it may be beneficial for clients to watch an educational video prior to the onset of treatment.

Carly Chadwick

Pre-treatment change in Internet-delivered alcohol use disorder treatment

Honours Thesis Results, Carly Chadwick 2020

Background: Alcohol misuse is a common mental disorder that can have devastating effects on an individual’s physical and mental health. Although alcohol misuse is both prevalent and disabling, only 21% of individuals receive treatment. Internet-delivered cognitive behaviour therapy (ICBT) may serve as a promising solution for the treatment gap, as it minimizes concerns about the stigma surrounding seeking treatment. Previous studies in alcohol treatment literature address a phenomenon named Assessment Reactivity (AR) which suggests that assessment interviews are predictive of significant changes in pre-treatment drinking. This may be of clinical importance as early abstinence from alcohol has been significantly associated with longer periods of continuous abstinence.

Purpose: The primary objective of the current study was to explore pre-treatment change by experimentally manipulating assessment in an ICBT program for alcohol misuse.

Method: The present study used data from 87 clients who were randomly assigned to receive an assessment interview or no assessment interview prior to beginning treatment.

Results: Results indicated that there were no significant differences in drinking behaviours between groups at pre-treatment. However, significant reductions in alcohol consumption were observed amongst both groups, suggesting that factors other than an assessment interview may contribute to client’s willingness to improve their drinking behaviours. No significant differences in motivation to change or depressive symptoms were observed between groups, although, both groups experienced a significant increase in motivation and decrease in depressive symptoms over time. 

Giuliano La Posta

Internet-delivered Cognitive Behaviour Therapy for Chronic Health Conditions With and Without Guidance: Exploring Changes in Benefit Finding

Honours Thesis Results, Giuliano La Posta 2019

Background: Internet-delivered cognitive-behaviour therapy (ICBT) is effective in reducing symptoms of anxiety and depression when targeted to specific groups with chronic health conditions (e.g., pain, cancer, cardiac, spinal cord injury). Nevertheless, there are some gaps in the literature regarding:

  •  the efficacy of ICBT programs that are transdiagnostic and address multiple chronic health conditions;
  • whether outcomes are improved when offered with support of team of providers compared to when ICBT is self-directed; and
  • whether ICBT is associated with improvements in benefit finding.

Purpose: To examine the efficacy of self-directed versus team-directed transdiagnostic ICBT Chronic Health Conditions course in improving benefit finding, as well as anxiety and depression among individuals with diverse chronic health conditions.

Method: Participants were divided into self-directed (n=15) and team-directed (n=16) groups and were measured for changes in benefit finding scores, as well as in anxiety and depression symptoms, at both pre-treatment and post treatment.

Results: There were no between group differences or interactions. For both self-directed and team-directed groups, significant time effects were present for anxiety (Cohen’s d=0.83), depression (Cohen’s d=0.69), distress (Cohen’s d=0.65) and disability (Cohen’s d=0.18). Benefit finding did not change significantly over time, although a small effect was seen when examining Cohen’s d=.30.

Conclusion: The transdiagnostic ICBT Chronic Conditions course when either self-directed or team-directed shows promise in reducing symptoms of anxiety and depression, distress, and disability over time.

Danielle Earis

Patient perspectives of internet-delivered cognitive behavioural therapy for psychosocial issues post-spinal cord injury

Honours Thesis Results, Danielle Earis 2018

Background: Individuals with a spinal cord injury (SCI) confront numerous physical and psychological adjustments. Many report clinically significant depression and anxiety disorders post-SCI; thus, attention to psychological distress is crucial. Cognitive behaviour therapy (CBT) has been shown to be effective in reducing anxiety and depression. Despite the availability of treatment, there are barriers such as accessibility, cost, and transport to appointments. Internet-delivered CBT (ICBT) can increase access to psychological services.

Purpose: The purpose of this study is (a) to evaluate patient perspectives on the acceptability of an eight-week guided ICBT course (Chronic Conditions Course for Persons with SCI) and (b) to gain understanding of SCI experiences that may impact ICBT.

Method: Semi-structured interviews were conducted with patients (n = 8). The interviews were audio-recorded, transcribed verbatim, and examined by means of thematic analysis. Emerging themes were summarised and explored.

Results: Patient comments were organized into three broad categories: SCI experience, ICBT experience, and ICBT outcomes. Interviews provided insight into SCI outcomes and support ICBT acceptability with identified strengths (e.g., accessibility, flexibility, guided support). Suggested changes included improved breadth of case stories, course timeframe, and more support from the guide.

Implications: This research provides a better understanding of ICBT as an acceptable treatment for psychosocial issues post-SCI. Patient feedback provided valuable information for improving and tailoring the ICBT course to the SCI population and in understanding SCI experiences.

Catherine Couture

Client correspondence in Internet-delivered cognitive behaviour therapy: An examination into client communication with therapists and symptom improvement

Honours Thesis Results, Catherine Couture 2017

Background: Internet-delivered cognitive behavioral therapy (ICBT) is an efficacious treatment for anxiety and depression. Most ICBT programs include therapist assistance in the form of secure online messaging; however, a high degree of variability has been found in the content of client and therapist correspondence. Recent research conducted by Svartvatten et al. (2015) found that client statements suggesting alliance bolstering and text expressing a positive change in mood after the implementation of a suggested skill or exercise appear to correlate with greater symptom improvement.

Purpose: The current study sought to examine: (1) if previously identified themes in client communication with their Internet therapist (Svartvatten et al., 2015) would replicate in a transdiagnostic ICBT program for depression and anxiety; and (2) if these themes correlated with symptom improvement and treatment completion. 

Method: The present study used data from 80 randomly selected patients from a previously published trial of ICBT for depression and or anxiety. Client emails (on average 5.69 per client) were examined for the presence of 10 themes reported by Svartvatten et al. (2015).

Results: Statistically significant differences were found in the frequency of all themes between the two studies. Further, in the current study, greater frequency of statements classified as maladaptive repetitive thinking and problems with treatment content correlated with smaller improvements in symptoms of anxiety from pre- to post-treatment.

Implications: This research provides a better understanding of the parameters of client communication and information for future therapists regarding the content of clients’ correspondence in ICBT.

Kristen Klassen

Analyzing therapist emails in Internet-delivered cognitive behavioural therapy

Honours Thesis Results, Kristen Klassen 2017

Background: Internet-delivered cognitive behaviour therapy (ICBT) arose as a response to barriers associated with face-to-face therapy and has shown to be efficacious especially when offered with therapist assistance.

Objective: Despite the importance of therapist-assistance to ICBT, there has been minimal research on this topic. No scales have been developed to specifically assess presence of therapist behaviours during ICBT. As such, the purpose of this study was to: 1) develop an ICBT rating scale that captures the main elements of the therapist/client interactions in secure email messages, and 2) evaluate a random selection of ICBT therapists using this scale to assess average ratings on therapist/client interactions during the course of ICBT.

Method: The initial scale was developed based on past content analysis of therapist behaviours during ICBT. Five therapists trialed this initial measure and provided feedback on their experiences during a focus group. The measure was then revised and inter-rater reliability was established between three student raters. The scale was used to examine emails that were sent to 50 patients who completed an 8-week transdiagnostic ICBT course for depression and anxiety (Wellbeing Course).

Results: Review of ratings suggested that most therapists were providing high quality emails. Multiple significant correlations were found which indicated that clients who sent more emails to their therapist were receiving better quality emails, that therapists who were solely focused on delivering ICBT, and therapists with a psychology background obtained higher ratings on the scale.

Practical Implications: Numerous directions for future research exist, such as exploring the applicability of the scale to other ICBT units.

Chantalle Fuchs

Development and initial evaluation of a psychoeducational resource to facilitate social support for cancer survivors

Honours Thesis Results, Chantalle Fuchs 2014

Most cancer survivors appear to adjust well to having a cancer diagnosis over time, but research has shown that some cancer survivors experience clinical levels of anxiety and depression. In addition, it has been shown that social support often decreases after cancer treatment.

Wellbeing After Cancer (WAC) is an online cognitive behavioural therapy program designed to treat anxiety and depression among cancer survivors. Feedback from program participants suggested that information and strategies regarding social support would be beneficial.

To date, no known online educational resource has been developed to address social support among cancer survivors and family members. The objectives of the study were to:

  1. Develop a supplementary psychoeducational resource focused on social support to accompany the WAC online program. Information discussed on the resource included fatigue, concentration and memory changes, pain, swelling, nervous system changes, low moods, anxious feelings, worries about cancer returning, feeling alone, benefits of social support, communication strategies, styles of communication, and sources of support.
  2. Conduct a preliminary evaluation of this resource. Assessing the face-validity of this resource is an important first step in adding educational materials to online programs like WAC.

Survivors and family members reviewed the resource, rated different sections within the document, and responded to open-ended questions pertaining to the acceptability and helpfulness of the resource. Participants indicated that the resource was informative, applied to their personal relationships, enhance their understanding of what can occur after completing cancer treatment, and that the suggestions listed within the resource were feasible. All individual sections within the resource were deemed informative as well as accurate.

The open-ended responses revealed areas for improvement such as integrating more specific examples and information on additional challenges faced by survivors. Additional challenges described by cancer survivors included feelings of anger and frustration, difficulties with eating, as well as sexual and intimate concerns.