Can Between-Session Homework Be Delivered Digitally? A Pilot Randomized Clinical Trial of CBT for Adjustment Disorders
Abstract
:1. Introduction
2. Method
2.1. Design
2.2. Participants
2.3. Measures
2.3.1. Diagnostic Instrument
2.3.2. Primary Outcomes
2.3.3. Secondary Outcomes
2.3.4. Treatment Satisfaction
2.4. Treatment
CBT AjD Protocol
- (1)
- In the Traditional condition, the homework component is composed of: (1) reading material in the form of brief manuals as reminders of the different therapeutic contents; (2) writing materials in the form of self-registers and exercises in order to practice the contents seen in the therapy sessions in real life; and (3) therapy session audio recordings in order to practice the elaboration/processing of the stressful event.
- (2)
- In the TEO condition, a digital support system was used. TEO is a completely open web-based technology that allows therapists to create and easily send personalized therapeutic material to patients via the Internet (http://www.teo.uji.es). The system has a database with media contents (audio, images, videos, and texts), and the therapists can access these materials and combine them to create homework sessions. TEO is a therapeutic tool developed to complement therapy. In the present study, it is used to administer the homework sessions in the period between the treatment sessions. Therefore, the system is designed to consolidate, support, and improve the therapeutic intervention by assigning homework that can be practiced at home via the Internet. Moreover, through this program, several clinical variables (e.g., mood state or positive and negative emotions) can be assessed before and after each homework session. The therapist can access the reports resulting from a patient’s activity: assessment, content, assigned sessions, completed sessions, dates, etc. The TEO system includes two platforms with different functions:
- Therapist platform: In this platform, the therapist can manage and administer the users and the results of each user’s treatment and create sessions and customize homework protocols using multimedia materials included in the TEO multimedia base (pictures, texts, narratives, music, and videos). These multimedia elements cover the clinical needs of each patient and work on all the therapeutic components included in the AjD protocol. The therapist can view the content created and assign homework sessions (see Figure 2a). Moreover, assessment protocols are assigned to the users and composed of brief questionnaires assessing key clinical variables. The therapist can download the results of these evaluations in order to monitor each patient.
- Patient platform: The main function of the patient platform is to allow the user to receive and view the session assigned and sent by the therapist (see Figure 2b). First, the patients can complete the pre-session assessment protocol (see Figure 2c) and choose a virtual environment (a beach or a forest environment) to go to throughout the homework session (see Figure 2d). This virtual environment also appears at the end of each session, so that the patients can move around to reflect on the session and their experience. Then, they can complete the post-assessment protocol and repeat the session as many times as necessary. In the present study, we used the TEO system to reinforce the treatment components described above. To do so, we designed a homework session component using audios, videos, and images that were available in the TEO system database. Specifically, the TEO system allows access to all the therapeutic material available in EMMA’s world (symbols, audios, and images), with the aim of continuing with the processing/elaboration treatment component from home. Figure 2e presents an example of therapeutic material included in a specific TEO homework session for the treatment of AjD.
2.5. Procedure
2.6. Data Analyses
3. Results
3.1. Participant Flow and Attrition
3.2. Baseline Data and Participants’ Characteristics
3.3. Treatment Efficacy
3.4. Treatment Satisfaction
4. Discussion
5. Conclusions
Author Contributions
Funding
Conflicts of Interest
References
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Traditional Group (N = 28) | TEO Group (N = 29) | |
---|---|---|
Age, mean (SD) | 31.71 (11.27) | 28.48 (9.55) |
Gender, n (%) | ||
Male | 6 (21.4%) | 8 (27.6%) |
Female | 22 (78.6%) | 21 (72.4%) |
Education, n (%) | ||
Elementary or secondary | 10 (35.7%) | 5 (17.2%) |
University | 18 (64.3%) | 24 (82.8%) |
Marital status, n (%) | ||
Single | 16 (57.1%) | 25 (86.2%) |
Married/partnered | 8 (28.6%) | 2 (6.9%) |
Widowed/divorced | 4 (14.3%) | 2 (6.9%) |
Medication, n (%) | ||
Yes | 7 (25.9%) | 3 (10.7%) |
No | 20 (74.1%) | 25 (89.3%) |
Months since symptom onset, mean (SD) | 29.00 (44.23) | 20.03 (31.41) |
Homework | |
---|---|
1 | Treatment explanation |
The impact of stressful events | |
Cognitive Model of AjD (part I) | |
Logic of using the Book of Life and EMMA’s world | |
2 | Explanation if the exposure and elaboration techniques |
Breathing exercises (optional) | |
Elaboration of stressful event practice | |
Self-exposure tasks to the first item in the exposure hierarchy | |
3 | Elaboration practice |
“Positive” meaning of problems (Part I) | |
Breathing exercises (optional) | |
Self-exposure tasks | |
4 | Elaboration practices |
“Positive” meaning of problems (Part II) | |
Self-exposure tasks | |
5 | Elaboration practices |
Cognitive Model of AjD (Part II) | |
“Letter to my future self” | |
6 | Practice of a new “metaphorical description” of the stressful event in EMMA’s world |
Choose of search for a heuristic/proverb to apply in everyday situations |
BL Mean (SD) | Post Mean (SD) | Baseline vs. Post-Treatment | ||||
---|---|---|---|---|---|---|
Within-Group d [95% CI] | Within-Group Comparison | Between-Group d [95% CI] | Between-Group Comparison | |||
BDI | ||||||
Traditional group | 24.18 (8.91) (n = 28) | 4.91 (3.93) (n = 24) | 2.09 [1.34; 2.85] | F1, 50.61 = 119.80, ρ = 0.000 ** | 0.36 [−0.92; 0.20] | F1, 91.39 = 0.52, ρ = 0.473 |
TEO group | 22.48 (10.86) (n = 29) | 7.19 (7.68) (n = 26) | 1.37 [0.81; 1.92] | F1, 49.75 = 86.82, ρ = 0.000 ** | ||
SLI | ||||||
Traditional group | 35.38 (11.97) (n = 28) | 15.87 (11.18) (n = 24) | 1.58 [0.95; 2.20] | F1, 49.75 = 75.07, ρ = 0.000 ** | 0.11 [−0.67; 0.44] | F1, 85.79 = 0.03, ρ = 0.862 |
TEO group | 37.22 (10.58) (n = 29) | 17.15 (11.43) (n = 26) | 1.84 [1.18; 2.50] | F1, 49.02 = 102.87, ρ = 0.000 ** | ||
PANAS + | ||||||
Traditional group | 22.64 (6.95) (n = 28) | 32.68 (7.34) (n = 25) | 1.40 [−1.97; −0.82] | F1, 49.84 = 41.04, ρ = 0.000 ** | 0.30 [-0.25; 0.86] | F1, 90.08 = 0.84, ρ = 0.362 |
TEO group | 21.91 (8.45) (n = 29) | 30.20 (8.63) (n = 25) | 0.95 [−1.44; −0.46] | F1, 50.49 = 31.50, ρ = 0.000 ** | ||
PANAS - | ||||||
Traditional group | 27.30 (7.69) (n = 28) | 16.84 (5.96) (n = 25) | 1.32 [0.76; 1.88] | F1, 47.44 = 43.76, ρ = 0.000 ** | 0.11 [−0.66; 0.45] | F1, 93.73 = 0.01, ρ = 0.909 |
TEO group | 25.86 (8.33) (n = 29) | 17.48 (5.75) (n = 25) | 0.97 [0.48; 1.47] | F1, 48.18 = 30.93, ρ = 0.000 ** |
9 | Post Mean (SD) | Fup Mean (SD) | Post-Treatment vs. Follow-Up | |||
---|---|---|---|---|---|---|
Within-Group d [95% CI] | Within-Group Comparison | Between-Group d [95% CI] | Between-Group Comparison | |||
BDI | ||||||
Traditional group | 4.91 (3.93) (n = 24) | 2.00 (2.17) (n = 15) | 0.70 [0.11; 1.29] | F1, 34.22 = 3.91, ρ = 0.056 | 0.44 [−1.13; 0.24] | F1, 78.26 = 1.38, ρ = 0.244 |
TEO group | 7.19 (7.68) (n = 26) | 4.05 (5.69) (n = 19) | 0.39 [−0.09; 0.87] | F1, 32.25 = 5.07, ρ = 0.031 * | ||
SLI | ||||||
Traditional group | 15.87 (11.18) (n = 24) | 5.33 (4.17) (n = 15) | 0.89 [0.26; 1.52] | F1, 31.14 = 19.28, ρ = 0.000 ** | 0.43 [−1.12; 0.25] | F1, 76.17 = 1.18, ρ = 0.282 |
TEO group | 17.15 (11.43) (n = 26) | 8.09 (7.49) (n = 19) | 0.76 [0.23; 1.29] | F1, 29.59 = 14.37, ρ = 0.001 ** | ||
PANAS + | ||||||
Traditional group | 32.68 (7.34) (n = 25) | 39.13 (8.40) (n = 15) | 0.83 [−1.45; −0.21] | F1, 41.46 = 7.67, ρ = 0.008 ** | 0.40 [−0.28; 1.09] | F1, 79.68 = 1.96, ρ = 0.165 |
TEO group | 30.20 (8.63) (n = 25) | 35.47 (9.25) (n = 19) | 0.58 [−1.09; −0.08] | F1, 37.36 = 5.40, ρ = 0.026 * | ||
PANAS - | ||||||
Traditional group | 16.84 (5.96) (n = 25) | 13.73 (2.89) (n = 15) | 0.49 [−0.06; 1.05] | F1, 36.48 = 4.23, ρ = 0.047 * | 0.45 [−1.14; 0.23] | F1, 79.34 = 1.21, ρ = 0.276 |
TEO group | 17.48 (5.75) (n = 25) | 15.63 (4.83) (n = 19) | 0.31 [−0.16; 0.78] | F1, 32.78 = 1.56, ρ = 0.220 |
Post M (SD) | Fup M (SD) | |||
---|---|---|---|---|
Traditional Group | TEO Group | Traditional Group | TEO Group | |
Treatment was logical | 8.80 (0.82) | 8.96 (1.00) | 9.00 (1.16) | 9.00 (0.91) |
Treatment was satisfactory | 9.24 (0.78) | 9.13 (1.15) | 9.46 (0.97) | 9.11 (1.18) |
Would recommend the treatment | 9.44 (0.71) | 9.33 (0.87) | 9.31 (0.86) | 9.39 (0.85) |
Treatment was useful for the problem | 9.28 (0.68) | 9.00 (1.14) | 9.54 (0.97) | 9.00 (1.33) |
Treatment was useful for other problems | 8.56 (1.12) | 8.71 (1.12) | 8.77 (1.01) | 8.89 (1.37) |
Treatment Satisfaction at Post-Treatment | Treatment Satisfaction at 12-Month Follow-Up | |||||||
---|---|---|---|---|---|---|---|---|
R2 | β | t | ρ | R2 | β | t | ρ | |
BDI | ||||||||
Traditional group | 0.19 | −0.47 | −2.50 | 0.021 * | 0.20 | −0.51 | −1.98 | 0.074 |
TEO group | 0.08 | −0.35 | −1.73 | 0.099 | 0.00 | −0.25 | −1.03 | 0.319 |
Total | 0.12 | −0.37 | −2.72 | 0.009 ** | 0.08 | −0.34 | −1.92 | 0.065 |
SLI | ||||||||
Traditional group | −0.05 | −0.03 | −0.14 | 0.892 | 0.39 | −0.67 | −2.97 | 0.013 * |
TEO group | 0.22 | −0.50 | −2.72 | 0.013 * | 0.08 | −0.37 | −1.57 | 0.136 |
Total | 0.10 | −0.34 | −2.45 | 0.018 * | 0.20 | −0.48 | −2.92 | 0.007 ** |
PANAS+ | ||||||||
Traditional group | 0.11 | 0.38 | 1.99 | 0.059 | 0.47 | 0.72 | 3.42 | 0.006 ** |
TEO group | 0.11 | 0.39 | 1.97 | 0.062 | −0.01 | 0.22 | 0.90 | 0.380 |
Total | 0.12 | 0.37 | 2.73 | 0.009 ** | 0.14 | 0.41 | 2.42 | 0.022 * |
PANAS- | ||||||||
Traditional group | −0.04 | −0.02 | −0.08 | 0.938 | 0.05 | −0.36 | −1.29 | 0.225 |
TEO group | 0.21 | −0.49 | −2.64 | 0.015 * | 0.03 | −0.30 | −1.25 | 0.230 |
Total | 0.05 | −0.26 | −1.82 | 0.075 | 0.07 | −0.32 | −1.81 | 0.080 |
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Quero, S.; Rachyla, I.; Molés, M.; Mor, S.; Tur, C.; Cuijpers, P.; López-Montoyo, A.; Botella, C. Can Between-Session Homework Be Delivered Digitally? A Pilot Randomized Clinical Trial of CBT for Adjustment Disorders. Int. J. Environ. Res. Public Health 2019, 16, 3842. https://doi.org/10.3390/ijerph16203842
Quero S, Rachyla I, Molés M, Mor S, Tur C, Cuijpers P, López-Montoyo A, Botella C. Can Between-Session Homework Be Delivered Digitally? A Pilot Randomized Clinical Trial of CBT for Adjustment Disorders. International Journal of Environmental Research and Public Health. 2019; 16(20):3842. https://doi.org/10.3390/ijerph16203842
Chicago/Turabian StyleQuero, Soledad, Iryna Rachyla, Mar Molés, Sonia Mor, Cintia Tur, Pim Cuijpers, Alba López-Montoyo, and Cristina Botella. 2019. "Can Between-Session Homework Be Delivered Digitally? A Pilot Randomized Clinical Trial of CBT for Adjustment Disorders" International Journal of Environmental Research and Public Health 16, no. 20: 3842. https://doi.org/10.3390/ijerph16203842