Student Research

DO EXPECTATIONS AND CREDIBILITY SHAPE ALCOHOL OUTCOMES IN INTERNET-DELIVERED COGNITIVE BEHAVIOURAL THERAPY? Background: Despite alcohol misuse representing a significant public health concern, treatment seeking behavior remains disproportionately low (<15%). Traditional face-to-face interventions are often associated with barriers that include cost, time, distance, stigma, low expectations of improvement, and treatment credibility. Internet-Delivered Cognitive Behavioural Therapy (ICBT) offers a flexible, cost effective, and accessible alternative to care that works to overcome these barriers. Several studies investigating the effectiveness of face-to-face therapy compared to ICBT found equivalent ratings in successful outcomes for a variety of mental health conditions. Methods: In this mixed-methods study, expectations and perceptions of treatment credibility were examined in 81 participants enrolled in the Alcohol Change Course Enhanced (ACCE), an 8-week, evidenced based ICBT aimed at reducing alcohol consumption. All measurements were administered at pre-, mid-, and post-treatment. Changes in credibility, expectancy, and alcohol consumption levels were captured using a Linear-fixed effects model, while correlational measures examined associations between participant characteristics, baseline measures, and alcohol outcomes. In addition, 10 Qualitative interviews were conducted to identify themes and patterns that influence credibility and expectancy in ICBT. Results: The results obtained from the study showed that credibility and expectancy reduced across treatment, with relationship status emerging as the strongest predictor that drives these perceptions. Individuals who scored higher on the Credibility and Expectancy Questionnaire at pre-treatment were associated with greater levels of post-treatment satisfaction. Exploratory and qualitative findings revealed that participants reported significant reductions in alcohol consumption and mental health symptoms. Although clinical improvements were not associated with changes in credibility and expectancy across time, these variables were influenced by baseline symptom severity, expectations of behavior change, internal shifts such as increased motivation, and external shifts such as perceived relevance and relatability of treatment content and material. Conclusion: The findings from this study, along with the existing literature on ICBT for alcohol misuse highlights how digital mental health services are an innovative approach that support clinical outcomes. Moreover, patient perspectives and testimonials shared during the interview process provided clinicians with valuable feedback that can be utilized to improve future ICBT interventions for alcohol misuse.

Examining motivational interviewing and booster sessions in Internet-delivered cognitive behaviour therapy for post-secondary students: An implementation trial PhD Thesis Results, Vanessa Peynenburg 2022 Background: Nearly one-third of post-secondary students meet criteria for a mental disorder within any given year, with many students not receiving treatment. Internet-delivered cognitive behaviour therapy (ICBT) is an alternative to face-to-face services that is effective in general adult populations, but has been associated with high attrition rates and smaller effect sizes in student populations. Motivational interviewing (MI) is used by therapists in face-to-face settings and can help improve treatment completion and outcomes. Booster sessions are often used in face-to-face therapy to maintain long-term changes. To date, the use of online MI and booster sessions in ICBT for students has not been examined. In this implementation trial, the role of MI and booster sessions on treatment completion and outcomes was examined in Saskatchewan. Methods: In this factorial trial (factor 1: presence of pre-treatment online MI); factor 2: presence of a booster lesson), a total of 308 clients were randomized to one of four groups: standard care, MI, booster, and MI + booster. All clients received a 5-week transdiagnostic ICBT course (the UniWellbeing Course) for symptoms of depression and anxiety. Primary outcomes included symptoms of depression, anxiety, and perceived academic functioning. All primary measures were administered at pre-treatment, post-treatment, and 1- and 3-month follow-up, Implementation outcomes (i.e., acceptability, adoption, and fidelity) were also examined. Results:  Across all four groups, clients experienced large reductions in symptoms of depression and anxiety, as well as small improvements in perceived academic functioning. Changes were maintained at 1-month and 3-month follow-up. No benefit was found for the inclusion of MI on treatment completion, although clients who were assigned to MI had slightly larger improvements in symptoms of depression and anxiety at post-treatment. 30.9% of client assigned to one of the booster groups accessed the booster. When examining the booster groups as a whole, no benefits were found for improvements in depression, anxiety, or perceived academic functioning at 3-month follow-up. However, a sub-analysis of clients who accessed the booster found a small advantage in favour of the booster for depression. Overall, clients were satisfied with ICBT, although treatment completion remained low. Uptake of the ICBT course was highest at the two largest post-secondary institutions in Saskatchewan. Conclusions: There is some evidence to suggest that including MI at pre-treatment results in greater symptom reduction, although these benefits do not persist to 1-month and 3-month follow-up. The inclusion of a self-guided booster lesson may also help with continued symptom management up to 3-month follow-up, but low uptake is a barrier to clients experiencing these benefits. Findings from this trial contribute to the literature on improving ICBT outcomes for post-secondary students. Perceptions of and preferences for Internet-delivered cognitive behaviour therapy for anxiety and depression in post-secondary students Masters Thesis Results, Vanessa Peynenburg 2019 Background: Anxiety and depression are prevalent mental health concerns experienced by post-secondary students. Rates of help-seeking are often low in this population, and students face several barriers to accessing psychological treatment. Internet-delivered cognitive behaviour therapy (ICBT) is an effective alternative to face-to-face therapy that addresses these barriers in adult populations with some evidence showing ICBT can also be effective with students. Additional research is necessary to identify students perceptions of and preferences for ICBT to assist with future implementation efforts in student populations.  Methods: 314 Canadian post-secondary students completed an online survey and completed questionnaires about their symptoms of depression, anxiety, alcohol and drug use, and medical service utilization over the last 12 months. Students rated the acceptability and credibility of three treatment options (ICBT, face-to-face therapy, and medication) for the treatment of anxiety and depression. They also rated the utility of different kinds of content to be included in an ICBT course.  Results: The three treatment options were rated as moderately acceptable and credible. Students expressed a preference for face-to-face services (44.6%), followed by medication (31.9%), and finally ICBT (23.5%). ICBT became more preferable once students would have to wait to receive face-to-face therapy. Students who were female and had less severe symptoms of depression had more positive perceptions of the use of ICBT in the treatment of anxiety and depression. Conclusions: While many students expressed a preference for face-to-face therapy or medication over ICBT, a substantial number preferred ICBT. Students often have to wait to receive face-to-face therapy, so ICBT may also be more desirable in these circumstances. Implementation trials in student populations are necessary to identify barriers to implementation efforts.

Treating comorbid insomnia in patient enrolled in therapist-assisted transdiagnostic internet-delivered cognitive behaviour therapy for anxiety and depression: A randomized controlled trial Doctoral Dissertation Results, Michael Edmonds 2023 Background: Transdiagnostic Internet-delivered cognitive behaviour therapy (ICBT) for patients experiencing anxiety and depression can produce large improvements in symptoms. Comorbid insomnia is common among individuals seeking treatment for anxiety and depression, yet transdiagnostic ICBT rarely targets insomnia and many ICBT patients report that symptoms of insomnia remain after treatment. This trial explored the impact of including a brief intervention for insomnia alongside an existing transdiagnostic ICBT course that included brief weekly therapist assistance.Method: The current study used a two-group randomized controlled trial design. Patients were randomly assigned to receive one of two 8-week interventions: a Standard transdiagnostic course or a Sleep-Enhanced course, which included information on sleep restriction and stimulus control. Primary outcomes were assessed at pre-treatment, weekly during treatment, post-treatment, and three-month follow-up. Primary outcomes included symptoms of insomnia, depression, and anxiety.Results: Patients reported significant, large reductions in all primary outcomes from pre-treatment to post-treatment, with changes maintained at 3-months. Patients assigned to the Sleep-Enhanced course reported larger reductions in insomnia than patients in the Standard transdiagnostic course at post-treatment but no significant group differences in any of the primary outcomes were found at follow-up. Patient-reported adherence to sleep restriction guidelines was associated with greater reductions in insomnia symptoms during the course.Conclusions: Overall, patients who received the Sleep-Enhanced course were satisfied with the materials and most patients reported making sleep behaviour changes. The trial results demonstrate that including a brief intervention targeting insomnia can be beneficial for many patients who enroll in ICBT primarily for symptoms related to anxiety and depression. Can patient characteristics at intake predict patient response to therapist-assisted transdiagnostic internet-delivered cognitive behavioural therapy? Masters Thesis Results, Michael Edmonds 2018 Background: The Wellbeing Course is a transdiagnostic  online program designed to treat anxiety and depression. The five lesson  course teaches patients skills for managing anxiety and depression  based on principals of cognitive behavioural therapy and includes weekly  therapist contact via telephone or secure message. The program has been  shown to reduce symptoms in patients overall and, on average, patients  report a high degree of satisfaction. Although the program is effective  overall, only 75% of patients complete the program and only 50% of  patients complete the program and report a reliable reduction in either  anxiety or depression. The aim of this research was therefore to examine  patient outcomes further and look for relationships with patient  characteristics that might allow us to predict which patients are most  likely to benefit from online therapy.Method: Patient case records from 1201 patients who enrolled in the Wellbeing Course were compiled and analyzed to look for relationships between patient  characteristics at intake and patient outcomes. Autoregressive latent  trajectory modeling was used to look for relationships between patient  characteristics and patient symptom change over time. Classification  trees were created to predict treatment dropout and overall treatment  success.Results: Younger people were found to be at greater risk of  dropping out from online therapy. Higher initial severity of anxiety or  depression was related to greater improvement over the course of  therapy. Age and relationship status were related to anxiety symptom  trajectories, while education and initial psychological distress and  disability scores were related to depressive symptom trajectories.Conclusions: Although some groups were identified as being at  higher risk of dropout or not improving, none of these effects were  strong enough to suggest that exclusion criteria for the program should  be changed. Instead, future research should look at how the program can  be modified to improve outcomes for at-risk groups.

A Randomized Controlled Trial of an Online Psychoeducation Course for Improving Knowledge and Access to Mental Health Accommodations Doctoral Dissertation, Nichole Faller, 2021 Background: Available research on mental health accommodations within the workplace  suggests that employees with mental health concerns require  accommodations to improve work functioning. Unfortunately, only a  fraction of employees requiring mental health accommodations will  receive the accommodations they have requested. Reported barriers to  receiving mental health accommodations include lack of knowledge about  appropriate accommodations, concerns regarding stigma, and financial  constraints of the employer. There is a paucity of research available on  interventions aimed at improving accommodation knowledge and usage for  mental health concerns. Method: The primary goal of the current study was to assess the efficacy of a  four-lesson, online, psychoeducational course developed to provide  information on anxiety/depression symptoms in the workplace, appropriate  accommodations to help manage symptoms, considerations for disclosure  of a mental health concern and accommodation requests, and general tips  for symptom management. A total of 89 participants with  anxiety/depression symptoms that were negatively impacting work  functioning were randomly assigned to a treatment group that received  access to the Workplace Coping Strategies (WCS) course or an eight-week  waiting list group. All participants received questionnaires at four-  and eight-weeks post randomization. Primary outcomes of interest  included the impact of the WCS course on requesting/receiving  accommodations, employee knowledge of accommodations, self-stigmatizing  attitudes, and workplace relationships. Organizational inclusivity and  supervisory leadership were also examined to determine how these  variables impacted accommodation usage and disclosure rates. Secondary  outcomes assessed the efficacy of the WCS course on comfort levels  disclosing and rates of disclosure. Exploratory analyses examined the  impact of the WCS course on absenteeism/presenteeism scores,  self-efficacy, and symptomology. Finally, quantitative content analyses  were used to examine qualitative data on accommodations identified,  barriers/facilitators to requesting/receiving accommodations, and  participant feedback on the course. Results: Results suggest that those who participated in the WCS course relative  to the waiting list group had large improvements in accommodations  knowledge, increased self-efficacy, and improved presenteeism scores.  Both groups reported reduced internalized mental health stereotypes and  increased disclosures of mental health concerns over time. Regression  analyses further demonstrated that partial disclosures were associated  with organizational inclusiveness and supervisory leadership. The  results suggest that the intervention did not have an impact on  accommodation usage, symptomology, workplace relationships, or comfort  level disclosing a mental health concern. Qualitative analyses showed  that participants most frequently identified accommodations related to  scheduling flexibility and job description modification with limited  mention of communication facilitations and/or modifications to physical  space. The most frequently cited barrier was poor relationships with  management, while supportive relationships were considered a facilitator  for requesting/receiving an accommodation. Participants reported liking  the clarity and conciseness of the course content the most and disliked  aspects of the  course structure, such as a lack of video options. Areas  for improvements included changes to questionnaires (e.g., less  frequent), addition of employer-centered material (e.g., tips for  discussing mental health), and the use of persuasive design to increase  engagement. 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.

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.

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.

GAD Online for older adults: A randomized controlled trial Doctoral Dissertation Results, Shannon Jones 2013 ‘GAD Online for Older Adults’ was made available to adults in Saskatchewan aged 60 years and older from March 2012-November 2013. The therapist-assisted Internet delivered Cognitive Behaviour Therapy (ICBT) program was modified for older adults who experience generalized anxiety (e.g., worry about many topics, difficulty controlling worry). The ICBT program involved 7 interactive modules that included text, graphics, animations, audio, and video. Topics included: (a) education about general anxiety, (b) monitoring anxiety and worry, (c) relaxation techniques and enjoyable activities, (d) examining and challenging unhelpful thoughts, (e) worry reduction strategies, overcoming avoidance and worry behaviours, and (f) problem-solving and sleep hygiene. Forty-six older adults with generalized anxiety disorder or subclinical anxiety were randomized to receive ICBT or waited for treatment. The findings were very encouraging. General anxiety and depressive symptoms decreased more quickly for adults who received ICBT when compared to those who waited for treatment. Significant differences were also found between the two groups on measures of geriatric anxiety and depression, and on most quality of life scales. ICBT participants continued to improve during the four-week follow-up period – in fact, participants tended to improve the most on symptoms of worry and depression during the follow-up period. It was also found that ICBT participants who rated the credibility of treatment higher before starting ICBT, improved at a faster rate on a measure of anxiety. Completing more treatment modules, sending more e-mail to the therapist, and writing more to the therapist in the weekly Check-In page was predictive of lower anxiety scores at follow-up, whereas writing more to the therapist in e-mails and taking longer to complete ICBT was predictive of higher anxiety scores at follow-up. The final component of the study asked older adults about their experiences with ‘GAD Online for Older Adults’. Numerous positive experiences and challenges were identified. Older adults valued being able to access therapy online, liked the convenience, felt that ICBT promoted insight, found the information educational and helpful, and they liked the easy-to-follow format of the program. Older adults appreciated having therapist support while using ICBT. Some participants noted that the content of the program did not always fully match their experiences or difficulties, and felt that there was too much content to cover in the time recommended. Narrative feedback from older adults who took part in this study will help to inform revisions of existing or future ICBT programs in this age group.

Maternal Depression Online: A preliminary study Doctoral Dissertation Results, Nicole Pugh 2014 Maternal Depression Online (MDO) was made available to Saskatchewan women from May 2012-Feburary 2014. The therapist-assisted Internet delivered Cognitive Behaviour Therapy program was designed specifically for the treatment of postpartum depression. MDO consisted of 7 interactive modules including text, graphics, animation, audio and video, and covered:(a) psychoeducation on maternal depression, (b) activity planning, (c) relaxation, (d) thinking styles, (e) cognitive restructuring, (f) problem solving, and (g) relapse prevention. Using a randomized control design, 50 women with mild to moderate postpartum depression either received MDO or waited for treatment. Results were very promising. Symptoms of postpartum depression decreased more quickly for women participating in MDO when compared to those who waited for treatment. These results were maintained at four-week follow-up, providing preliminary support of the durability of the program. Participants who received MDO also demonstrated a reduction in symptoms of postnatal anxiety, general stress, and parental distress and an increase in quality of life when compared to participants who waited for the treatment. Participants reported high satisfaction with MDO and indicated that they enjoyed working with their Internet therapist. Discussion for future implementation of this program is underway.

Transdiagnostic Internet-delivered cognitive-behaviour therapy for recent cancer survivors: A feasibility trial and examination of clinician perspectives Doctoral Dissertation Results, Nicole Alberts 2014 This dissertation involved two studies. In Study 1, Wellbeing After Cancer was made available to cancer survivors in Saskatchewan from February 2013 to May 2014. The therapist-guided Internet delivered cognitive behaviour therapy (ICBT) program was based on the Wellbeing Course, which is a transdiagnotic ICBT program developed and tested by the eCentre Clinic in Australia. The Wellbeing Course was modified for recent cancer survivors who experience anxiety and/or depression. Eighteen individuals who completed primary cancer treatment within the past 18 months received CBT-based online lessons, homework assignments, once weekly contact from a therapist via e-mail or phone, and automated emails. Results of Study 1 showed that symptoms of anxiety and depression improved significantly from pre to post treatment. Participants also rated the program as highly acceptable and identified several program strengths. Study 2 examined the acceptability of Wellbeing After Cancer and ICBT more generally among clinicians currently working within cancer care in Saskatchewan. Ten clinicians viewed a brief online video and completed a telephone interview regarding their perceptions of the program. ICBT and the program were viewed as acceptable by clinicians, with most envisioning themselves referring clients to the program. Several program strengths as well as areas for improvement were identified. Approval from directors as well as clinician availability and time were seen as factors likely to influence training, delivery, and implementation. Together, the results of both studies indicate to researchers, clinicians, and healthcare providers that ICBT is a viable avenue for offering mental health services to cancer survivors.

A randomized controlled trial of Internet-delivered cognitive behaviour therapy for individuals with fibromyalgia Doctoral Dissertation Results, Lindsay Friesen 2015 The focus of this study was to assess the efficacy of Internet-delivered cognitive behaviour therapy (ICBT) for individuals with fibromyalgia (FM) who experience difficulties with pain, depression and or anxiety.  The Pain Course for Fibromyalgia was offered to Canadians from January 2014 to January 2015.  In this study, we were interested in the impact of the Pain Course for Fibromyalgia on FM symptoms, pain, depression and/or anxiety, and improving overall quality of life after the course. The Pain Course for Fibromyalgia included topics of symptom identification, examining and challenging unhelpful thoughts, controlled breathing, pleasant activity scheduling, pacing, graded exposure, and relapse prevention. The course was administered to a randomized group of 30 individuals with FM and compared to a group of 30 individuals with FM who received standard care alone. The findings were very encouraging.  The results of this study showed that symptoms of FM, anxiety, and depression improved significantly from pre to post treatment.  Participants also rated the course as highly acceptable and identified several course strengths. Results from this study indicate to health professionals that ICBT is a viable avenue to improve the clinical management and the health status of individuals with FM.

Examination of therapist behaviours in therapist-assisted Internet-delivered cognitive behavioural therapy for generalized anxiety disorder Doctoral Dissertation Results,Christina Drost 2016 Background: Therapist-Assisted Internet-Delivered Cognitive Behavioural Therapy (TAICBT) for the treatment of generalized anxiety disorder (GAD) is found to be efficacious. The nature of therapist-assistance, however, is not well understood. This research aimed to enhance understanding of the nature of therapist-assistance by examining: 1) therapist behaviours in emails sent to clients treated with TAICBT for GAD and the extent to which these qualitatively overlap with behaviours described in face-to-face therapy; and 2) if therapist behaviours in the current study (using a larger and more diverse therapist sample) compared to therapist behaviours reported in a past study of TAICBT for GAD (Paxling et al., 2013). The relationship between therapist behaviours and treatment outcome, treatment satisfaction, and therapeutic alliance was also examined. Method: Data was collected as part of an open trial investigating a 12 module TAICBT program delivered to 107 clients presenting with symptoms of GAD. TAICBT was provided by 21 registered therapists or 31 graduate students; therapist-assistance was delivered through secure e-mails. Anxiety was assessed before and after treatment.  Results: Nineteen therapist behaviours were identified in the secure messages sent from therapist to patients. These behaviours qualitatively overlapped with therapist behaviours that are commonly observed in face-to-face therapy. Alliance Bolstering was the most frequently coded therapist behaviour. Eight therapist behaviours were found that largely overlapped with behaviours reported in a past study of therapist behaviour in TAICBT (Paxling et al. 2013); however, the frequency of these behaviours varied substantially between studies. Correlational analyses suggested that therapists provided more frequent feedback on weekly mood ratings and self-report questionnaires when clients demonstrated less improvement on anxiety measures. Analyses also suggested that therapists were more likely to provide Psychoeducation and Task Prompting when clients demonstrated less improvement on anxiety. Of note, Repair of Potential Alliance Ruptures was significantly and positively associated with higher client ratings of therapeutic alliance. Therapist e-mails received during the first two modules by treatment completers contained significantly more instances of statements coded as Course Procedure and Goal Setting than e-mails received during the first two modules by treatment non-completers.  Conclusions: Overall, preliminary evidence was found to suggest that: 1) there is both overlap and variability in terms of therapist-assistance provided in face-to-face therapy and across different TAICBT programs, and 2) the relationship between therapist behaviours, treatment outcome, therapeutic alliance, and treatment satisfaction is complex and needs to be examined further. The findings shed substantial light on the nature of therapist-assistance in TAICBT.

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.