Becoming an eCoach: training therapists in online cognitive-behavioral therapy for chronic pain

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Article details

Terpstra J.A., Van der Vaart R., Spillekom-Van Koulil S., Van Dam A., Rosmalen J.G.M., Knoop H., Van Middendorp H. & Evers A.W.M. (2018), Becoming an eCoach: training therapists in online cognitive-behavioral therapy for chronic pain, Patient Education and Counseling 101(9): 1702-1707.

Doi: 10.1016/j.pec.2018.03.029

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Short communication

Becoming an eCoach: Training therapists in online cognitive-behavioral therapy for chronic pain

Jessy A. Terpstra

^a,

*, Rosalie van der Vaart

^a,1

, Saskia Spillekom-van Koulil

^b

,

Arno van Dam

^c

, Judith G.M. Rosmalen

^d,1

, Hans Knoop

^e,1

, Henriët van Middendorp

^a

, Andrea W.M. Evers

^a,f,1

aInstituteofPsychology,Health,MedicalandNeuropsychologyUnit,LeidenUniversity,Wassenaarseweg52,POBox9555,2300RB,Leiden,TheNetherlands

bRadboudUniversityMedicalCenterNijmegen,DepartmentofMedicalPsychologyNijmegen,POBox9101,6500HB,TheNetherlands

cTilburgUniversity,TilburgSchoolofSocialandBehavioralSciences,POBox90153,5000LE,Tranzo,Tilburg,TheNetherlands

dUniversityofGroningen,UniversityMedicalCenterGroningen,DepartmentsofPsychiatryandInternalMedicine,POBox30001,9700RB,Groningen, TheNetherlands

eAcademicMedicalCenter,DepartmentofMedicalPsychology,POBox22660,1100DD,Amsterdam,TheNetherlands

fLeidenUniversityMedicalCenter,DepartmentofPsychiatry,POBox9600,2300RC,Leiden,TheNetherlands

ARTICLE INFO

Articlehistory:

Received31July2017

Receivedinrevisedform24February2018 Accepted29March2018

Keywords:

E-health Therapisttraining

Technologyacceptancemodel Implementation

Onlinecognitive-behavioraltherapy

ABSTRACT

Objective: Online cognitive-behavioral therapy (iCBT) is effective in supporting patients’ self- management.SinceiCBTdiffersfromface-to-faceCBTonseverallevels,propertrainingoftherapists is essential.Thispaperdescribesthedevelopmentand evaluationofatherapist trainingbasedon theoreticaldomainsthatareknowntoinﬂuenceimplementationbehavior,foraniCBTforchronicpain.

Methods:Thetrainingconsistsof1.5daysandcoverstheimplementationdomains“knowledge”,“skills”,

“motivation”,and“organization”,byfocusingonthetherapy’srationale,iCBTskills,andimplementation strategies.Usinganevaluationquestionnaire,implementationdeterminants(therapistcharacteristics, e-healthattitude,andimplementationdomains)andiCBTacceptancewereassessedamongparticipants aftertraining.

Results:Twenty-twotherapistsparticipated,whogenerallyshowedpositivee-healthattitudes,positive implementationexpectations,andhighiCBTacceptance.Organizationalaspects(e.g.,policyregarding iCBTimplementation)wereratedneutrally.

Conclusions:AniCBTtherapisttrainingwasdevelopedandinitialevaluationsamongparticipantsshowed favorableimplementationintentions.

Practiceimplications:Therapists’positivetrainingevaluationsarepromisingregardingthedissemination ofiCBTindailypractice.Organizationalsupportisvitalandneedstobeattendedtowhenselecting organizationsforiCBTimplementation.

1.Introduction

Internet-based cognitive-behavioral therapy (iCBT) is an importanttooltosupportpatients’self-management.Itempowers them by increasing their knowledge, skills, and conﬁdence to managetheircondition[1].PreviousresearchoniCBTforpatients withchronic somatic conditions hasshown positive results on psychologicalandphysicalfunctioning,aswellasontheimpactof the conditionson dailylife [2–4]. Thisinternet-based modeof deliveryprovidesﬂexibilityregardingtimeandlocationforboth patientsandtherapists,andthereforeincreasestheavailabilityof therapists[1]. Therapistcontact remainsimportant ininternet- basedtherapy,sinceithasbeenfoundthatguidediCBTappears moreeffectiveinsupportingbehaviorchangethaniCBTwithout Abbreviations:iCBT,internet-basedcognitive-behavioraltherapy;TDF,Theoret-

ical Domains Framework; DIBQ, Determinants of Implementation Behavior Questionnaire;HR-QoL,health-relatedqualityoflife; MREC,MedicalResearch EthicsCommittee;LUMC,LeidenUniversityMedicalCenter;IBMSPSSStatistics23, InternationalBusinessMachines CorporationStatisticalPackagefortheSocial Science23.

*Correspondingauthor.

E-mailaddresses:j.a.terpstra@fsw.leidenuniv.nl(J.A. Terpstra), r.van.der.vaart@fsw.leidenuniv.nl(R.vanderVaart),

Saskia.Spillekom-vanKoulil@radboudumc.nl(S.Spillekom-vanKoulil), a.vandam@uvt.nl(A.vanDam),j.g.m.rosmalen@umcg.nl(J.G.M. Rosmalen), hans.knoop@amc.uva.nl(H.Knoop),h.van.middendorp@fsw.leidenuniv.nl (H.vanMiddendorp),a.evers@fsw.leidenuniv.nl(A.W.M. Evers).

1MasterYourSymptomsConsortium.

https://doi.org/10.1016/j.pec.2018.03.029

ContentslistsavailableatScienceDirect

Patient Education and Counseling

j o u r n al h o m e p a g e : w w w . el s e v i e r . c o m / l o c a t e / p a t ed u c o u

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those attributes [5]. However, the implementation of iCBT is challenging[6].AsigniﬁcantfactorforsuccessfuliCBTimplemen- tationentailstheskillsoftherapists,whichincludedecidingwhen to use iCBT and motivating patients using written feedback.

Training therapists in applying these skills could therefore be valuabletoenhanceimplementation.

This paper describes the development and evaluation of a theory-basedtherapisttrainingregardinganiCBTforchronicpain.

Todevelopourtraining,aframeworkbyHuijgetal.[7],basedon the Theoretical Domains Framework (TDF [8]), was used. This frameworkconsistsofdomainsthatreﬂectpotentialdeterminants ofimplementationbehaviorforhealth-relatedinterventions,such as knowledge of the intervention, skills to deliver it, and motivationto deliver it. Huijg et al. subsequently developed a measurement instrument, theDeterminants of Implementation BehaviorQuestionnaire(DIBQ[7])andashorterversionofitasa checklist[9,p.175],toassessimplementationbehaviorinhealth- careprofessionals.Thechecklist[9,p.175]wasadoptedtoevaluate theeffectiveness of thetherapist training and to assessimple- mentation expectations of trained therapists. Additionally, the TechnologyAcceptanceModel(TAM[10,11])wasusedtoevaluate theacceptanceofiCBTamongstthetrainedtherapists,sinceavital factor associated with implementation of online therapy is acceptanceofitstechnologybytheforeseenuser.TAMisoneof themostinﬂuentialuseracceptancemodels,basedontheTheory ofReasonedAction(TRA[12]).Itpostulatesthatperceivedeaseof use and perceived usefulness of a new technologyare essential determinantsofusers’behavioralintentiontouseit.Subsequently, behavioral intentionpredicts actual useof the technology.The presentpaperprovidesanexplorativeoverviewoftheimplemen- tationexpectations and iCBTacceptance of therapistsafter our trainingandsummarizesimplicationsforclinicalpractice.

2.Methods

2.1.Participantsandprocedure

ThirteenmentalhealthcareinstitutionsacrosstheNetherlands expressed interest to implement the iCBT for chronic pain.

Participating therapists had a minimum of a clinical master’s degreeinpsychology,withtheexceptionofonemasterstudent who was about to complete the degree. The participating therapists received an information letter before the training, including the aims of the intervention and the content of the therapisttraining.

In this study, a descriptive design was applied, using an explorativeevaluationquestionnairetogatherdata.Thestudyhas beengrantedanexemptionfromrequiringethicsapprovalbythe MedicalResearchEthicsCommitteeofLeidenUniversityMedical Center.

2.2.iCBTforchronicpain

The iCBT for chronic pain “Master YourPain” (presented in Fig.1)wasdesignedtoprovidechronicpainpatientswithaneasily accessibleonlineprogram,inwhichmaladaptivecopingstrategies areadjustedinordertoimprovehealth-relatedqualityoflife.

2.3.iCBTtherapisttraining

Thetherapisttraining(outlinedinFig.2)wasdevelopedtooffer acomprehensivetrainingintheiCBTforchronicpaintotherapists whoareexperiencedintreatingchronicpainpatients.

2.4.Instruments

In order to evaluate the therapist training and assess iCBT acceptance, participants were asked to ﬁll out the evaluation questionnaire(summarizedinTable1)rightaftercompletionof thesecondtrainingday.

2.5.Dataanalysis

The StatisticalPackage forthe Social Sciences 23 (IBMSPSS Statistics23)wasusedtoperformanalyses.Descriptivestatistics wereappliedtodescribethestudysample(demographics,their attitudestowardse-health,internetexperience,andworkexperi- ence), their implementation expectations, and their iCBT

Fig.1.FlowchartofiCBT“MasterYourPain”.

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acceptance.Missingdataweredeletedpairwise,therebypreserv- ing more data in a small data set than after listwise deletion.

Pairwise deletion was applied after checking that data were missing completely at random (MCAR), using Little’s MCAR procedure[14].

3.Results 3.1.Studysample

A total of 23 therapists were trained and ﬁlled out the evaluationquestionnaire.Oneparticipanthadahighnumberof missingdata(19%)and wasthereforeexcludedfrom thedata analysis,whichmakesatotalNof22.Overall,alow1%ofitems (12items)weremissingfromthedataset,of whichthegreater

part (11 out of 12 items) were rated “not applicable”. A non- signiﬁcant Little’s MCAR test [14],

x

² ^(272, ^N⁼²²⁾⁼^44.31,

p=1.000, showed that the data were missing completely at random. Thetherapist characteristicsare listedinTable 2. The therapists generally had positive e-health attitudes (M=3.72, SD=0.93, on a 5-point scale; data not shown in table). They indicated agreement with items such as “E- health promotes patients’ self-management” (M=4.27, SD=0.63) and indicated disagreement with items such as “E-health undermines therapists’creativity”(M=2.18,SD=0.80).

3.2.ImplementationexpectationsandiCBTacceptanceaftertraining

Therapists had mostly positive implementationexpectations after training (see Table 3), with respondents agreeing with Fig.2.OverviewoftheiCBTtherapisttrainingof“MasterYourPain”.

Table1

ContentEvaluationQuestionnaireiCBTTherapistTraining.

Part Measuredconstruct Description Exampleitems

I background informationaboutthe healthcare

professional

Tenquestionsonage,sex,healthcarespecialism,numberof workingyears,experiencewithpsychological(chronicpain) treatments.

“Howmanyprotocolizedtreatmentshaveyoucompleted?”;“How manychronicpainpatientshaveyoutreated?”.

II. internetexperience Fourquestionsonthefrequencyofinternetuse,perceivedinternet skillslevel,andrangeofactivitiesexecutedviatheinternet.

“Howoftendoyouusetheinternet?”;“Whatactivitiesdoyou executeviatheinternet?”

III participants’attitudes towardse-health

ShortversionoftheE-healthquestionnaire[13]:eighteen questionsscoredona5-pointLikertscale,rangingfrom1 (completelydisagree)to5(completelyagree),withanacceptable overallinternalconsistency(a⁼^.76).

“E-healthpromotespatients’self-management”;“E-health underminestherapists’creativity”;“Theﬂexibilitythate-health offerstothepatientispositivefortreatment”.

IV Evaluationof implementation expectationsafter training

Fifteenquestions,basedonanimplementationdomainschecklist ([9]p.175).Thequestionscomprisedimplementationdomains (e.g.,KnowledgeandSkills)asdiscussedbyHuijg[9].Alldomains weremeasuredwith1itemthatwasscoredona5-pointLikert scale,rangingfrom1(completelydisagree)to5(completelyagree).

“IhavesufﬁcientskillstodelivertheiCBTfollowingthe guidelines”;“IhavesufﬁcientknowledgetodelivertheiCBT followingtheguidelines”.

V iCBTacceptance FourquestionsbasedontheTAM[10],evaluatingtheperceived usefulnessandtheperceivedeaseofuseoftheonlinetreatment, andtheintentiontousetheiCBTprogram.Onequestionwasadded tomeasuretheperceivedusefulnessofthetherapisttraining.All questionswerescoredona5-pointLikertscale,rangingfrom1 (completelydisagree)to5(completelyagree).

“IﬁndtheiCBTuseful”;“IintendtousetheiCBTwheneveritsuitsa patient’scomplaints”.

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statements indicating sufﬁcient acquirement of skills (M=3.91, SD=0.75), knowledge (M=4.00, SD=0.54), and motivation (M=4.64, SD=0.49) to deliver the iCBT following protocol.

Organizationalaspects,suchasthepresenceofformal arrange- mentswithintheorganizationregardingdeliveringtheiCBTand

anexpectedsufﬁcientinﬂuxofpatientsfortheiCBT,wererated neutrally(M=3.28,SD=1.07andM=3.18,SD=0.85,respectively).

Overall, respondents experienced the therapist training as useful(M=4.43,SD=0.51;seeTable4).RegardingiCBTacceptance, respondents mostly perceived the iCBT as useful (M=4.43, Table2

Backgroundinformationaboutthe22participatinghealthcareprofessionalsandtheirworkexperience

Characteristics(nincaseofmissings) Healthcareprofessionals

N(percentages) Sex

Female 18(81.8)

Age(M,SD)Professionalbackground^a 42.9(9.1)

Healthcarepsychologist 10(45.5)

Clinicalpsychologist 5(22.7)

Other([Basic]psychologist,MScHealthPsychologystudent,psychologistNIP^b) 5(22.7)

Psychotherapist 2(9.1)

Psychiatricnursepractitioner 1(4.5)

Psychiatrist 1(4.5)

Numberofworkingyearsasatherapist(n=21)

9 5(23.8)

10–19 9(42.9)

20 7(33.3)

Estimatedtotalnumberofcompletedprotocolizedtreatments(n=17)

50 4(23.5)

51–100 5(29.4)

>100 8(47.1)

Estimatedtotalnumberoftreatedchronicpainpatients

50 13(59.1)

51–100 4(18.2)

>100 5(22.7)

aMultipletypesofspecialismscanberegisteredsimultaneously.

b Psychologistswithamaster’sdegreeandworkexperiencecanbecomeamemberoftheNetherlandsInstituteofPsychologists(NIP),aprofessionalassociationof psychologistsinTheNetherlands.

Table3

ImplementationdomainsintheiCBTevaluationafterthetherapisttrainingwithM,SD,andRange(theoreticalrange:1–5).

Implementationdomain^a Item(nincaseofmissings) M SD Range

Knowledge IhavesufﬁcientknowledgetodelivertheiCBTfollowingtheguidelines 4.00 0.54 3–5

Skills IhavesufﬁcientskillstodelivertheiCBTfollowingtheguidelines 3.91 0.75 2–5

Innovation ItispossibletotailortheiCBTtoparticipants’individualcharacteristicsandneeds(i.e.,itisnotastraightjacket) (n=21)

3.90 0.63 3–5

Motivationandgoals IammotivatedtodelivertheiCBTfollowingtheguidelines 4.64 0.49 4–5

Beliefsaboutconsequences A(suspected)consequenceofdeliveringtheiCBTfollowingtheguidelinesisthatapatientwillbehinderedlessby his/herpain

4.25 0.55 3–5 Beliefsaboutcapabilities IamconﬁdentthatIcandelivertheiCBTfollowingtheguidelines,evenwhenIencounterbarriers(e.g.,limitedtime,

unmotivatedpatient)

3.82 0.59 3–5 Emotionsandoptimism IfeelgoodwhenIdelivertheiCBTfollowingtheguidelines(e.g.,comfortable,calm,relaxed,cheerful,elated)(n=19) 3.89 0.57 3–5 Behavioralregulation IhaveclearplansofhowIwilldelivertheiCBTfollowingtheguidelines 3.23 0.81 2–5 Memory IcaneasilyrememberwhatIneedtodotodelivertheiCBTfollowingtheguidelines 3.45 0.67 2–4 Socio-politicalcontext DeliveringtheiCBTisafreechoiceforme(i.e.,itisnotimposedbyothers) 4.36 0.85 2–5 Social/professionalroleand

identity

Ibelievethatasanonlinetherapist,itismyjobtokeepthepatientmotivatedforthetreatmentthroughmymessages 4.50 0.51 4–5 Organization Inmyorganization,formalarrangementsaremadewithregardtothedeliveryoftheiCBT(i.e.,policy,workplans,

etc.)(n=18)

3.28 1.07 1–5 Socialinﬂuences IcancountonsufﬁcientsupportwithregardtodeliveringtheiCBT(e.g.,fromcolleagues,management,others

involved)(n=21)

4.05 0.81 2–5 Participants Inmyorganization,thereis(Isuspect)asufﬁcientinﬂuxofpatientsfortheiCBT 3.18 0.85 2–5 Innovationstrategy IwouldliketohavemoretrainingtodelivertheiCBTfollowingtheguidelines 1.95 0.79 1–4

aAlldomainsweremeasuredwith5-pointLikertscaleitemswithscores1(completelydisagree),2(disagree),3(neutral),4(agree),and5(completelyagree).

Table4

PerceivedUsefulness,EaseofUse,andIntentiontouseiCBT.

Usefulness,easeofuse,andintentionitems^a(nincaseofmissings) M SD Range

IﬁndtheiCBTuseful(n=21) 4.43 0.51 4–5

TheiCBTprogramiseasytouse 3.95 0.65 2–5

IintendtousetheiCBTwheneveritsuitsapatient’scomplaints 4.77 0.43 4–5

IﬁndtheiCBTtherapisttraininguseful 4.55 0.51 4–5

aAllitemsweremeasuredona5-pointLikertscalewithscores1(completelydisagree),2(disagree),3(neutral),4(agree),and5(completelyagree).

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SD=0.51) and easy touse (M=3.95, SD=0.65). Moreover, they expressedtheintentiontousetheiCBTwheneveritwouldsuita patient’scomplaints(M=4.77,SD=0.43).

4.Discussionandconclusion 4.1.Discussion

Inthepresentstudy,atheory-basedtherapisttraininginiCBT was outlined and preliminary implications for implementation behaviorwereexamined.Overall,therapistshadpositiveattitudes and intentions regarding adoption of the iCBT after training.

Moreover, they indicated to have acquired sufﬁcient skills, knowledge, and motivation to implement the intervention in dailypractice.BeidasandKendall emphasizeintheirreviewon therapisttrainings [15] that trainings must useactive learning strategies, such as practice possibilities, to impact therapist behavior change. Our therapist training incorporated several active learning strategies, with practice opportunities in iCBT skillsduringthetrainingandbetweenthetwotrainingsessions.

Additionalsupervision in theformofe-learningmodules oran onlinecommunicationforumcouldbeusefultofurthersupport thetherapistswiththeimplementationoftheintervention[16].

Organizationalaspectsofimplementationwereratedneutrally by the trained therapists, which may point to insufficient knowledge or influence on these factors to rate them. The importanceoforganizationalaspectsintreatmentimplementation ishighlightedinseveralstudies[e.g.,15–17].Forinstance,Zazzalli etal.[17]havesuggestedthatforimplementationitisimportant thattheinterventionfittheorganization’smission,theorganiza- tion has sufficient means to implement the intervention, and patientreferralsarefacilitated. Thesemeasuresarelikely tobe outside of the scopeof integration in a therapist training, yet appearcriticalfactorstoattendtowhenselectingorganizationsfor therapisttrainingsandiCBTimplementation.

Toourknowledge,thisistheﬁrststudyinwhichatheory-based face-to-facetherapisttraininginiCBTwasdescribedandevaluat- ed.However,somelimitationshavetobeconsidered.Firstly,the sample size was small. Therefore, the ﬁndings cannot be generalizedbasedonthisstudyalone.Moreover,certainpsycho- metric properties of the evaluation questionnaire (e.g., factor structure)couldnotmeaningfullybecalculatedduetothesmall sample size. The evaluation questionnaire needsto be further validatedinlargersamples.Thirdly,onlyself-reportwasusedto assess implementation factors. Adding methods to measure implementationfactorsmoreobjectively,suchasaninvivoskill assessment, could yield more information on levels of iCBT competencyachievedthrough the training and inform training techniques.

4.2.Conclusion

Toconclude,therapists’positiveimplementationexpectations andhighiCBTacceptanceaftertrainingarepromisingwithregard tothedisseminationofiCBTinclinicalpractice.Futureresearch shouldfocuson relationsbetweeniCBTtherapist trainings and treatmentimplementationrates,usingfollow-upmeasurements toinvestigateactualimplementationandpotentialbarriers.

4.3.Practiceimplications

Organizationalsupportisvitalforimplementationandneedsto betargetedusingaholisticimplementationapproach.Aswellas trainingtherapists,creatinganopenatmosphereamongmanagers andcolleaguesisimportanttoensurethatthenewintervention becomespartoftheregulartreatmentoptions.

Authors'contributions

RV,SS,andAEmadesubstantialcontributionstotheconception anddesign ofthetrainingandthestudy,andtheacquisitionof data.RVandSSactedastrainersintheiCBTtherapisttraining.AD madetheE-healthattitudequestionnaireavailableforevaluation of the iCBT therapist training. JT subsequently analyzed and interpreteddataregardingtheevaluationscoresofthetherapist trainingandwasamajorcontributorinwritingthemanuscript.RV, SS,AD,JR, HK, HM,and AE revisedthe manuscriptcriticallyfor importantintellectualcontent.Allauthorsreadandapprovedthe ﬁnalmanuscript.

Consentforpublication Notapplicable.

Availabilityofdataandmaterials

Thedatasetsusedand analyzedduringthecurrentstudyare availablefromthecorrespondingauthoronreasonablerequest.

Competinginterests

Theauthorsdeclarethattheyhavenocompetinginterests.

Funding

ThisworkwassupportedbyInnovatiefondsZorgverzekeraars (Innovation Fund Health Insurances; grant number: 2619).

Innovatiefonds Zorgverzekeraars was not involvedin the study design,datacollection,dataanalysis,datainterpretation, norin publicationdecisions.

Ethicsapprovalandconsenttoparticipate

Thestudyhasbeengrantedanexemptionfromrequiringethics approval by the Medical Research Ethics Committee (MREC) of LeidenUniversityMedicalCenter (LUMC).Iconfirm allpersonal identifiershavebeenremovedsothepersons describedarenot identifiableandcannotbeidentifiedthroughthedetailsofthestory.

Acknowledgements

Master Your Pain is part of the “Master Your Symptoms” e-health system that provides tools to improve diagnosis, treatment,andmonitoringofpatientswithMedicallyUnexplained SomaticSymptoms(MUSS).WewouldliketothankInnovatiefonds Zorgverzekeraars(InnovationFundHealthInsurances)forrecog- nizing the value of the Master Your Symptoms project and providing funds. Moreover, we gratefully acknowledge the contributions of the researchers working in the Master Your SymptomsConsortium.Nexttoapartoftheauthorsofthispaper, thefollowingresearcherscontributetotheConsortium:Margreet Worm-Smeitink (ExpertCentrefor ChronicFatigue, VUMedical Centre,Amsterdam,TheNetherlands),AnnevanGils,DeniseJ.C.

Hanssen, and Lineke Tak (University of Groningen, University MedicalCenterGroningen,DepartmentsofPsychiatryandInternal Medicine,Groningen,TheNetherlands).

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