The conceptual invariance, trajectory, and outcome associations of working alliance in unguided and guided internet-based psychological interventions: A randomized controlled trial (Preprint)

BACKGROUND The role of working alliance is largely unknown for internet-based interventions (IBI), an effective alternative for traditional psychotherapy. OBJECTIVE This study examined the conceptual invariance, trajectory, and outcome associations of working alliance in internet-based interventions incorporating or excluding clinician support via text or video. METHODS One hundred and forty-three adults with subclinical anxiety, stress, and/or depression symptoms were randomized to one of three treatment conditions for 7 weeks. All participants received access to MyCompass, an internet-delivered Cognitive Behavioral Therapy program. Participants in Condition 1 did not receive clinician support. Participants in Condition 2 and 3 received supplemental asynchronous clinician support via text or video respectively. Working alliance was measured weekly. Symptom outcomes were assessed at baseline, post-treatment, and 1-month follow-up. RESULTS We found scalar invariance of working alliance, indicating that working alliance was conceptually invariant across three conditions. Working alliance decreased significantly over time only in the text support group. Stronger baseline level and Faster increases in alliance predicted better outcomes at both post-treatment and follow-up only in the video support group. CONCLUSIONS Working alliance is methodologically comparable with or without clinician support and is generally established at initial sessions of IBI. Better alliance contributed to better outcomes only when clinician support is available via videos. CLINICALTRIAL clinicaltrials.gov ID: NCT05122429

Supported online cognitive behavioural therapy for bulimia nervosa: a study protocol of a randomised controlled trial

Background Despite the availability of effective treatments for bulimia nervosa (BN), a number of barriers to accessibility exist. Examples include access to trained clinicians, the expense of treatment, geographical limitations, and personal limitations such as stigma regarding help seeking. Self-help interventions, delivered via a digital platform, have the potential to overcome treatment gaps by providing patients with standardised, evidence-based treatments that are easily accessible, cost-effective, and require minimal clinician support. Equally, it is important to examine the shortcomings of digital interventions when compared to traditional to face-to-face delivery (e.g., high dropout rates) in order to maximise the therapeutic effectiveness of online, self-help interventions. Methods A three-arm, multisite randomised controlled trial will be conducted in Australia examining the effectiveness and cost-effectiveness of a newly developed online self-help intervention, Binge Eating eTherapy (BEeT), in a sample of patients with full or sub-threshold BN. The BEeT program consists of 10, multimedia sessions delivering the core components of cognitive behaviour therapy. Eligible participants will be randomised to one of three groups: independent completion of BEeT as a purely self-help program, completion of BEeT alongside clinician support (in the form of weekly telemedicine sessions), or waitlist control. Assessments will take place at baseline, weekly, post-intervention, and three-month follow up. The primary outcome is frequency of objective binge episodes. Secondary outcomes include frequency of other core eating disorder behavioural symptoms and beliefs, psychological distress, and quality of life. Statistical analyses will examine treatment effectiveness, feasibility, acceptability and cost effectiveness. Discussion There is limited capacity within the mental health workforce in Australia to meet the demand of people seeking treatment for eating disorders. This imbalance has only worsened following outbreak of the COVID-19 pandemic. Further research is required into innovative digital modes of treatment delivery with the capacity to service mental health needs in an accessible and affordable manner. Self-help programs may also appeal to individuals who are more reluctant to engage in traditional face-to-face treatment formats. This study will provide rigorous evidence on how to diversify treatment options for individuals with BN, ensuring more people with the illness can access evidence-based treatment. The study has been registered with the Australia New Zealand Clinical Trials Registry (ANZCTR Registration Number: ACTRN12619000123145p). Registered 22 January 2019, https://www.australianclinicaltrials.gov.au/anzctr/trial/ACTRN12619000123145.

Evaluating the feasibility and efficacy of the Amsterdam memory and attention training for children (Amat-c) following acquired brain injury (ABI): protocol for a pilot study with online clinician support

Background: Attention and memory deficits are common following paediatric acquired brain injury (ABI). However, there are few evidence-based interventions to improve these domains and benefit the everyday life of children post-injury. The Amsterdam Memory and Attention Training for children (Amat-c) has been translated from Dutch to English and shown to improve attention and memory skills in children following ABI. This protocol describes a study to expand accessibility of the program by using online, clinician-supported delivery with children post-ABI. Method/design: The study is a randomized controlled trial. Participants will be 40 children aged 8–16 a minimum of one-year post-ABI. Participants in the treatment group will complete 18 weekly sessions of the Amat-c program with weekly online clinician support. Participants in the active-control group will be administered ABI psychoeducation via a booklet for parents, with weekly online clinician contact. Attention and memory will be assessed at three time points up to six months post-intervention. Results: Analysis will be repeated measures multivariate planned comparisons; using the Statistical Package for the Social Sciences (IBM SPSS Statistics) General Linear Model procedure will compare pre- and post-intervention and six-month follow-up outcomes. Discussion: If shown efficacious in improving attention and memory, our team will then take a key role in implementing Amat-c into clinical care.

Integrating clinician support with intervention design as part of a programme testing stratified care for musculoskeletal pain in general practice

Background Stratified care involves subgrouping patients based on key characteristics, e.g. prognostic risk, and matching these subgroups to early treatment options. The STarT-MSK programme developed and tested a new stratified primary care intervention for patients with common musculoskeletal (MSK) conditions in general practice. Stratified care involves changing General Practitioners’ (GPs) behaviour, away from the current ‘stepped’ care approach to identifying early treatment options matched to patients’ risk of persistent pain. Changing healthcare practice is challenging, and to aid the successful delivery of stratified care, education and support for GPs was required. This paper details the iterative development of a clinician support package throughout the lifespan of the programme, to support GPs in delivering the stratified care intervention. We argue that clinician support is a crucial aspect of the intervention itself, which is often overlooked. Methods Qualitative research with patients and GPs identified barriers and facilitators to the adoption of stratified care, which were mapped onto the Theoretical Domains Framework (TDF). Identified domains were ‘translated’ into an educational paradigm, and an initial version of the support package developed. This was further refined following a feasibility and pilot RCT, and a finalised support package was developed for the main RCT. Results The clinician support package comprised face-to-face sessions combining adult-learning principles with behaviour change theory in a multimethod approach, which included group discussion, simulated consultations, patient vignettes and model consultation videos. Structured support for GPs was crucial to facilitate fidelity and, ultimately, a successful trial. Clinician support is a two-way process– the study team can learn from and adapt to specific local factors and issues not previously identified. The support from senior clinicians was required to ensure ‘buy in’. Monitoring of GP performance, provision of regular feedback and remedial support are important aspects of effective clinician support. Conclusion Designing effective clinician support from the onset of trial intervention design, in an evidence-based, theory-informed manner, is crucial to encourage active engagement and intervention fidelity within the trial, enabling the delivery of a robust and reliable proof-of-principle trial. We offer practical recommendations for future general practice interventions.

Testing Stratified Care for Musculoskeletal Pain in General Practice: Integrating Clinician Support and Intervention Design

Background Stratified care involves subgrouping patients based on key characteristics, e.g. prognostic risk, and matching these subgroups to early treatment options. The STarT-MSK programme developed and tested a new stratified primary care intervention for patients with common musculoskeletal (MSK) conditions in general practice. Stratified care involves changing General Practitioners’ (GPs) behaviour, away from the current ‘stepped’ care approach to identifying early treatment options matched to patients’ risk of persistent pain. Changing healthcare practice is challenging, and to aid the successful delivery of stratified care, education and support for GPs was required from the initial stages of the programme. This paper details the steps in integrating the development of a clinician support package throughout the 6-year programme, to support GP engagement in delivering the STarT MSK intervention. Practical recommendations are made for future general practice interventions. Methods Clinician support was developed through an iterative, mixed methods approach. Qualitative research with patients and GPs identified barriers and facilitators to the adoption of stratified care, which were mapped onto the Theoretical Domains Framework (TDF) and Behaviour Change Technique (BCT) taxonomy. Identified domains/BCTs were ‘translated’ into an educational paradigm, and an initial version of the support package developed. This was further refined following a feasibility and pilot RCT, and a finalised support package was developed for the main RCT. Results The clinician support package comprised face-to-face sessions combining adult-learning principles with behaviour change theory in a multimethod approach, which included group discussion, simulated consultations, patient vignettes and model consultation videos. Structured support for GPs was crucial in enabling fidelity and, ultimately, a successful trial. Results highlighted that clinician support is a two-way process– the study team can learn from and adapt to specific local factors and issues not previously identified. The support from senior clinicians was also required to ensure ‘buy in’, and results indicated the importance of monitoring GP performance and providing regular feedback. Conclusion Designing effective clinician support from the onset of trial intervention design, in an evidence-based, theory-informed manner, is crucial to encourage active engagement and intervention fidelity within the trial, enabling the delivery of a robust and reliable proof of principle trial.

Knowing in Nurses’ Belief and Attitude about Patient Activation: A Validation of the Korean Clinician Support for Patient Activation Measure Using Rasch Analysis

Background: Patient engagement is considered a critical factor in improving healthcare delivery. This study aimed to test the Korean version of the Clinician Support for Patient Activation Measure (CS-PAM) using Rasch analysis, and to explore nurses’ beliefs about patient self-management. Methods: A cross-sectional, exploratory study design was employed. The staff nurses who were recruited from six hospitals were requested to complete the Korean CS-PAM. Their responses were subsequently subjected to Rasch analysis to validate the Korean CS-PAM. The CS-PAM was paraphrased into Korean using the standardized forward–backward translation method. Results: The internal consistency of the scale had good Cronbach’s alpha value. For all items, the infit and outfit statistics fell well within the acceptable range of 0.5–1.5. This measure formed a unidimensional Guttman-like scale that explained 54.7% of the variance. Conclusions: The Korean version of the CS-PAM showed good psychometric properties and appeared to be consistent with the meaning of the original CS-PAM. However, the items have a somewhat different ranking order when compared to the English and Dutch versions. The instrument might be useful for identifying the supportive beliefs and attitudes of nurses or healthcare providers in order to improve patient activation in healthcare.

Factors affecting the use of neurally adjusted ventilatory assist in the adult critical care unit: a clinician survey

BackgroundNeurally adjusted ventilatory assist (NAVA) involves an intricate interaction between patient, clinician and technology. To improve our understanding of this complex intervention and to inform future trials, this survey aimed to examine clinician attitudes, beliefs and barriers to NAVA use in critically ill adults within an institution with significant NAVA experience.MethodsA survey of nurses, doctors and physiotherapists in four Intensive Care Units (ICUs) of one UK university-affiliated hospital (75 NAVA equipped beds). The survey consisted of 39 mixed open and structured questions. The hospital had 8 years of NAVA experience prior to the survey.ResultsOf 466 distributed questionnaires, 301 (64.6%) were returned from 236 nurses (78.4%), 53 doctors (17.6%) and 12 physiotherapists (4.0%). Overall, 207/294 (70.4%) reported clinical experience. Most agreed that NAVA was safe (136/177, 76.8%) and clinically effective (99/176, 56.3%) and most perceived ‘improved synchrony’, ‘improved comfort’ and ‘monitoring the diaphragm’ to be key advantages of NAVA. ‘Technical issues’ (129/189, 68.3%) and ‘NAVA signal problems’ (94/180, 52.2%) were the most cited clinical disadvantage and cause of mode cross-over to Pressure Support Ventilation (PSV), respectively. Most perceived NAVA to be more difficult to use than PSV (105/174, 60.3%), although results were mixed when compared across different tasks. More participants preferred PSV to NAVA for initiating ventilator weaning (93/171 (54.4%) vs 29/171 (17.0%)). A key barrier to use and a consistent theme throughout was ‘low confidence’ in relation to NAVA use.ConclusionsIn addition to broad clinician support for NAVA, this survey describes technical concerns, low confidence and a perception of difficulty above that associated with PSV. In this context, high-quality training and usage algorithms are critically important to the design and of future trials, to clinician acceptance and to the clinical implementation and future success of NAVA.

The Impact of COVID-19 on Systemic Anti-Cancer Treatment Delivery in Scotland

Understanding the impact of the COVID19 pandemic on systemic anti-cancer therapy delivery (SACT) is crucial for a full appreciation of the short and long-term consequences for cancer patients and for planning future cancer care. In this article we report real-time national SACT delivery data from NHS Scotland. We demonstrate an initial rapid reduction in patient attendance for SACT of 28.7% with a subsequent rapid and full recovery following service re-design. Regional variation in the magnitude of impact on SACT delivery was observed, but nadirs occurred at the same time and the rate of recovery was similar across all regions. This recovery reflected a co-ordinated national approach and associated patient and clinician support structures which facilitated the creation of COVID-19 protected areas for SACT delivery in Scottish cancer centres and enabled rapid sharing of successful and innovative strategies. The data shows that these actions have limited the disadvantage to cancer patients.

A place for therapy: Clients reflect on their experiences in psychotherapists’ offices

Previous research suggests that the physical environment of the psychotherapy office is important for treatment engagement, client feelings and behavior, and clinician support. However, there is limited research that includes the voices of psychotherapy clients. The purpose of this study was to explore the meanings clients ascribe to the offices in which they seek treatment in order to develop a fuller picture of the importance of the place of treatment. Eight psychotherapy clients in a large urban city were interviewed about their experiences of their psychotherapy offices using semi-structured protocols. Analysis of interviews identified three main themes in regard to client perception of the offices’ uses: (a) comfort, (b) connection, and (c) insight into the therapist. Results highlight the potential importance of the physical environment in psychotherapy treatment and implications for practice are provided.