Following up internet‐delivered cognitive behaviour therapy (CBT): A longitudinal qualitative investigation of clients' usage of CBT skills

Abstract

Background: While the acquisition and application of Cognitive Behaviour Therapy (CBT) skills is a core component and likely mechanism of effect maintenance in all CBT-based treatments, the extent of post-therapeutic CBT skills usage among internet-delivered CBT (iCBT) clients remains under-researched.Method: Nested within a pragmatic randomized controlled trial, 241 participants received an 8-week supported iCBT intervention for anxiety and/or depression and answered open-ended questions about their use and experience of CBT skills at 3-, 6-, 9-, and 12-month follow-up. Recurrent, cross-sectional qualitative analysis following the descriptive and interpretive approach was used to create a taxonomy, through which all qualitative data was coded.Results: In total, 479 qualitative responses across 181 participants were analysed.Participants reported using a wide range of CBT skills and associated helpful and hindering experiences and impacts. The reasons for discontinued CBT skills usage were diverse, ranging from rare adverse effects to healthy adaptation. Conclusion:The study shows how clients receiving iCBT in routine care learn CBT skills during treatment and utilize them in productive ways post-treatment. Findings coincide with similar research in face-to-face CBT and may inform future research to drive innovation and iCBT intervention development.

The relationship between posttherapeutic Cognitive Behavior Therapy skills usage and follow‐up outcomes of internet‐delivered Cognitive Behavior Therapy

“…Extending upon the qualitative findings from the same cohort of participants previously reported on by Eilert et al ( 2021 ) and other qualitative studies on follow‐up outcomes of iCBT (Berg et al, 2020 ; Halmetoja et al, 2014 ), our findings align with the idiosyncratic benefits (e.g., reduced symptoms, insight, active engagement in skills usage) participants describe in relation to using CBT skills after completing iCBT in those studies. In relation to face‐to‐face CBT, our findings of positive associations between skills usage and clinical outcomes somewhat resonate with previous research (Michalak et al, 2008 ; Morgan et al, 2014 ; Powers et al, 2008 ; Strunk et al, 2013 ); nevertheless, questions around the direction of this relationship remain.…”

“…In particular, while the frequency of CBT skills usage predicted the functional impairment in a contemporaneous fashion as expected, frequency of CBT skills seemed more likely to be contemporaneously predicted by symptoms of anxiety and depression. Surprising as it is, this finding resonates with qualitative accounts obtained from some of the same participants (reported in Eilert et al, 2021), suggesting that at least some participants purposefully select and combine different CBT skills based on the symptoms they are currently experiencing. Thus, it is possible that the relationship between CBT skills usage and clinical outcomes is a circular one, in which current symptomatology gives rise to skills usage, EILERT ET AL.…”

“…The modules include psychoeducation and aim to develop skills like self‐monitoring and cognitive distancing, cognitive restructuring, problem solving, graded exposure, mindfulness, and behavioral activation. Unlockable modules include identification of core beliefs, anger management, relaxation, or worry management (Eilert et al, 2021 ; Richards et al, 2018 ). Platform interactive tools encourage participants to practice these skills through mood monitoring, worksheets, and audio meditation exercises.…”

“…However, most research on CBT skills has been conducted in the context of face‐to‐face CBT, while only a handful of studies have explored skills usage in iCBT to date. There is now some research to suggest that increases in CBT skills usage early in treatment lead to reductions in symptoms during later stages of iCBT (Forand et al, 2018 ) and that iCBT clients do in fact acquire and use CBT skills in productive ways posttreatment (Berg et al, 2020 ; Eilert et al, 2021 ; Halmetoja et al, 2014 ). Beyond the aforementioned qualitative studies, longitudinal quantitative explorations of posttherapeutic CBT skills usage after iCBT are scarce and the specific relationship between posttherapeutic CBT skills usage and follow‐up clinical outcomes, therefore, remains unclear.…”

“…Accordingly, the overall aim of the present study was to explore the relationship between posttherapeutic CBT skills usage and clinical outcomes (i.e., anxiety, depressive symptoms, and functional impairment) after the completion of iCBT treatment and across four follow-up time-points (3-, 6-, 9-, and 12-month follow-up). Given that previous research has proposed CBT skills usage to contribute to the maintenance of effects in CBT-based interventions (Hollon et al, 2006;Powers et al, 2008) and previously reported qualitative data suggest that clients perceived helpful impacts of continued CBT skills usage posttreatment (including reduced symptoms; Eilert et al, 2021), we hypothesized that: Hypothesis 1. Higher frequency of CBT skills usage is associated with lower level of anxiety, depressive symptoms and functional impairment after completed iCBT treatment.…”