What helps and what hinders in cognitive behavioural therapy interactions? The development and validation of the consultation interactions coding scheme
Publication Date
July 22, 2019
Creator
Abstract
Background
Motivation is an important factor affecting outcomes of Cognitive Behavioural Therapy (CBT) for anxiety disorders. Recent research has defined motivation in terms of “patient activation”: the degree to which a person feels confident and able to actively manage their health. Patient activation has had widespread influence on healthcare, because it predicts a range of health outcomes. However, assessment of patient activation suffers from similar problems evident in other questionnaire-based measures of motivation: Patients’ often describe themselves as highly motivated even if they are not, for fear of negative consequences. Therefore, this thesis reports the development and validation of the Consultation Interactions Coding Scheme (CICS), which assesses patient activation from observations of turns-of-speech in CBT sessions.
Method. The CICS was developed in a total sample of 61 CBT recipients who experienced severe health anxiety alongside high rates of multimorbidity and high service use. Firstly, a systematic literature review addressed the question: Does observer-rated motivation predict clinical outcome in CBT for anxiety disorders? Next a mixed methods design was used to develop the CICS from a thematic analysis of CBT session interactions. Then the predictive validity of first and second session CICS scores was assessed with long- and short-term outcomes using multilevel modelling. Lastly, the relationship between short and long-term outcomes was explored with similar methods.
Results
The systematic review identified that observed motivation showed promise as a predictor of outcomes in CBT for anxiety disorders, but high risk of bias restricted generalisability. The CICS was developed to address the shortcomings identified. Good-to-excellent inter-rater reliability was achieved in all studies. Two naïve CICS raters were trained to use the measure reliably. The CICS achieved moderate-to-strong convergent validity with observer-rated therapeutic alliance and therapist competence. Specific interaction themes demonstrated predictive validity across outcomes, measurement methods and assessment time points. One consistent finding was that more time spent describing problems in early sessions predicted poorer outcomes both during treatment and up to 12-months later. Problem description interactions also significantly decreased directly prior to sudden outcome gains. Conversely, when patients were more engaged in discussion of positive changes they had noticed early in CBT, better outcomes ensued in physical and mental health both during therapy and several months afterwards.
Conclusion
A reliable measure has been developed, which has the potential for long- and short-term outcome prediction. The predictive validity is heavily weighted towards specific interaction types, which can be instructive for CBT therapists working with patients who have health anxiety and other comorbidities.
Item Type
ethesis
Thesis Type
PhD
Supervisors
Subjects (LC)
Associated Schools / Departments
School of Medicine
eprints ID
59231
UoN Repository URI
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