Following up internet-delivered cognitive behaviour therapy (CBT): A longitudinal qualitative investigation of clients' usage of CBT skills

“The following cut offs for Fleiss' kappa and its confidence interval were implemented: 0.0–0.4 poor to fair agreement, 0.41–0.60 moderate agreement, 0.61–0.8 substantial agreement and 0.81–1 almost perfect agreement (Landis & Koch, 1977).”

“Generalized Anxiety Disorder-7 Item (GAD-7) The GAD-7 is a self-administered questionnaire assessing the frequency of anxiety symptoms over the past 2 weeks (Spitzer et al., 2006).”

“…evidence-based techniques and strategies implemented in CBT now stretch from behavioural techniques like activity scheduling and exposure (Foa & Kozak, 1986; Lewinsohn & Graf, 1973) and cognitive techniques like cognitive restructuring and distancing (Beck & Clark, 1997; Zettle & Hayes,…”

“The M.I.N.I.7.0.2 is composed of lettered modules corresponding to diagnostic categories (Sheehan et al., 1997).”

“…activity scheduling and exposure (Foa & Kozak, 1986; Lewinsohn & Graf, 1973) and cognitive techniques like cognitive restructuring and distancing (Beck & Clark, 1997; Zettle & Hayes, 1988) to also include problem solving, distress tolerance and other practical coping skills (D'Zurilla & Nezu,…”

“CBTs of differing complexity and length have been developed, and research confirms their effectiveness for various psychological issues across a broad range of symptomology (e.g., Forman et al., 2007; D. A. Richards et al., 2016; Wiles et al., 2013).”

“…techniques and strategies implemented in CBT now stretch from behavioural techniques like activity scheduling and exposure (Foa & Kozak, 1986; Lewinsohn & Graf, 1973) and cognitive techniques like cognitive restructuring and distancing (Beck & Clark, 1997; Zettle & Hayes, 1988) to also…”

“…(Beck & Clark, 1997; Zettle & Hayes, 1988) to also include problem solving, distress tolerance and other practical coping skills (D'Zurilla & Nezu, 2007; Linehan, 2013) as well as relaxation, mindfulness and acceptance-focused techniques (Manzoni et al., 2008; Masedo & Rosa Esteve, 2007).”

“…argued that in fact the acquisition, use and practice of evidence-based CBT techniques and strategies (referred to as CBT skills from here on) plays a mediating role in how initial change occurs as well as in how this change is maintained into follow-up (Hollon et al., 2006; Strunk et al., 2013).”

“Percentage agreement, Fleiss' kappa and its bootstrapped confidence interval were calculated in line with and utilizing R code provided by Zapf et al. (2016).”

“Here, some have suggested that the change that occurs during treatment (e.g., reductions in cognitive reactivity and internalizations of therapists; Knox, 2003; Segal et al., 1999) permanently affects clinical outcomes, while others highlight the role of compensatory skills (e.”

“CBTs of differing complexity and length have been developed, and research confirms their effectiveness for various psychological issues across a broad range of symptomology (e.g., Forman et al., 2007; D. A. Richards et al., 2016; Wiles et al., 2013).”

“Richards & Timulak, 2012) but also bear resemblance with those reported during psychotherapy in general (e.g., improved symptoms and relief, selfknowledge, understanding and belief, problem solution and using techniques learnt in therapy to manage their everyday thoughts and feelings; McPherson et al., 2020; Timulak,…”

“Different theories exist that link various skill deficits (e.g., problem solving, social and emotion regulation skills) to the occurrence and maintenance of specific disorders as well as psychopathology generally (Hopko et al., 2001; Lukas et al., 2018; Nezu, 1987).”

“…adaptation, which is achieved through the implementation of specific evidence-based techniques and strategies (sometimes referred to as CBT skills) designed to drive universal change principles like context engagement and attention and cognitive changes (Hayes & Hofmann, 2018; Mennin et al., 2013).”

“, 2004) to include minimally supported iCBT—further establishing iCBT's ability to produce change at a meaningful and sustainable level (Mogoaşe et al., 2017; Strunk et al., 2007).”

“…larger reductions in depression and anxiety symptoms from baseline to 8 weeks than those in the waitlist control group (d = 0.55–0.63), with significant further improvements in symptoms observed in the iCBT group from 8 weeks to 12-month follow-up (for details, see D. Richards et al., 2020).”

“…however, irrespective of the specific techniques introduced by the treatment, the independent application of these techniques by clients during treatment as well as after treatment has ended represents a core component of all CBT-based interventions (Hayes & Hofmann, 2018; Hundt et al., 2013).”

“during treatment and practice them after their mostly short-term, minimally supported active treatments have ended (Folker et al., 2018; Titov et al., 2018).”

“…acquisition and performance during active treatment, as well as ongoing CBT skills practice after it has ended, have been shown to relate to lower relapse rates and better depression outcomes during follow-up (Michalak et al., 2008; Morgan et al., 2014; Powers et al., 2008; Strunk et al., 2013).”

“Available research has predominately investigated the relationship between CBT skills usage and symptom alleviation during treatment, finding various forms of CBT skills usage to be related to depression and anxiety symptom outcomes of varying levels of severity, in adults and adolescents, receiving individual CBT, gr…”

“Different theories exist that link various skill deficits (e.g., problem solving, social and emotion regulation skills) to the occurrence and maintenance of specific disorders as well as psychopathology generally (Hopko et al., 2001; Lukas et al., 2018; Nezu, 1987).”

“Previous quantitative research has highlighted iCBT's potential for long-term clinical effects (Buntrock et al., 2016; Fogliati et al., 2016; Ruwaard et al., 2010); however, regarding posttherapeutic CBT skills usage as a possible mechanism of effect maintenance, both of the aforementioned studies…”

“Previous quantitative research has highlighted iCBT's potential for long-term clinical effects (Buntrock et al., 2016; Fogliati et al., 2016; Ruwaard et al., 2010); however, regarding posttherapeutic CBT skills usage as a possible mechanism of effect maintenance, both of the aforementioned studies…”

“…and exposure (Foa & Kozak, 1986; Lewinsohn & Graf, 1973) and cognitive techniques like cognitive restructuring and distancing (Beck & Clark, 1997; Zettle & Hayes, 1988) to also include problem solving, distress tolerance and other practical coping skills (D'Zurilla & Nezu, 2007; Linehan, 2013)…”

“clinical outcomes to date (Forand et al., 2018; Terides et al., 2018), only a limited number of qualitative studies have touched on posttherapeutic CBT skills usage after iCBT (Berg et al.”

“…finding various forms of CBT skills usage to be related to depression and anxiety symptom outcomes of varying levels of severity, in adults and adolescents, receiving individual CBT, group-based CBT or internet-delivered CBT (Hawley et al., 2017; Terides et al., 2018; Webb et al., 2016, 2019).”

“…acquisition and performance during active treatment, as well as ongoing CBT skills practice after it has ended, have been shown to relate to lower relapse rates and better depression outcomes during follow-up (Michalak et al., 2008; Morgan et al., 2014; Powers et al., 2008; Strunk et al., 2013).”

“Available research has predominately investigated the relationship between CBT skills usage and symptom alleviation during treatment, finding various forms of CBT skills usage to be related to depression and anxiety symptom outcomes of varying levels of severity, in adults and adolescents, receiving individual CBT, gr…”

“…acquisition and performance during active treatment, as well as ongoing CBT skills practice after it has ended, have been shown to relate to lower relapse rates and better depression outcomes during follow-up (Michalak et al., 2008; Morgan et al., 2014; Powers et al., 2008; Strunk et al., 2013).”

“Halmetoja et al. (2014) qualitatively followed-up a cohort of participants who had received iCBT for Social Anxiety Disorder 4 years after treatment had ended and discovered that at least some had continued working with the material covered during their iCBT programme.”

“…previous research on clients' continuous use of CBT skills after face-to-face CBT (French et al., 2017; Glasman et al., 2004) to include minimally supported iCBT—further establishing iCBT's ability to produce change at a meaningful and sustainable level (Mogoaşe et al., 2017; Strunk et al., 2007).”

“Different theories exist that link various skill deficits (e.g., problem solving, social and emotion regulation skills) to the occurrence and maintenance of specific disorders as well as psychopathology generally (Hopko et al., 2001; Lukas et al., 2018; Nezu, 1987).”

“…those reported by participants during iCBT (e.g., insight, self-efficacy, learning coping skills and relief; D. Richards, Dowling, et al., 2018; D. Richards & Timulak, 2012) but also bear resemblance with those reported during psychotherapy in general (e.g., improved symptoms and relief,…”

“Post-therapeutic skills usage represents an under-researched and dynamic concept, likely occurring along a continuum between formal and informal, explicit and implicit (French et al., 2017; Glasman et al., 2004), and as such would have only been partially addressed by quantitative measures.”

“In addition, while Berg et al. (2020) followed-up participants soon after iCBT had ended, in Halmetoja et al.'s (2014) case, there were many years between treatment and follow-up, with neither study capturing how CBT skills usage evolves over time.”

“…(Quick et al., 2018; Timulak, 2007), it could also be construed as client agency, which in the psychotherapy context is defined as ‘expectations related to the active, purposeful use of psychotherapy to meet needs, solve problems, and make life changes’ (Coleman & Neimeyer, 2015, p. 3).”

“…coding of all available qualitative data in line with that taxonomy, was informed by Elliott and Timulak's (2005) descriptive–interpretative approach, which has previously successfully been used with qualitative data of a similar nature (Jardine et al., 2020; D. Richards, Dowling, et al., 2018).”

“…acquisition and performance during active treatment, as well as ongoing CBT skills practice after it has ended, have been shown to relate to lower relapse rates and better depression outcomes during follow-up (Michalak et al., 2008; Morgan et al., 2014; Powers et al., 2008; Strunk et al., 2013).”

“As such, the findings extend upon previous research on clients' continuous use of CBT skills after face-to-face CBT (French et al., 2017; Glasman et al., 2004) to include minimally supported iCBT—further establishing iCBT's ability to produce change at a meaningful and sustainable level (Mogoaşe…”

“Similarly, there is some preliminary research suggesting the same might be true for anxiety outcomes (Kim et al., 2008).”

“While this category may be understood as ‘client involvement’ in the context of previous research on helpful impacts in psychotherapy (Quick et al., 2018; Timulak, 2007), it could also be construed as client agency, which in the psychotherapy context is defined as ‘expectations related to the…”

“…adaptation, which is achieved through the implementation of specific evidence-based techniques and strategies (sometimes referred to as CBT skills) designed to drive universal change principles like context engagement and attention and cognitive changes (Hayes & Hofmann, 2018; Mennin et al., 2013).”

“Here, some have suggested that the change that occurs during treatment (e.g., reductions in cognitive reactivity and internalizations of therapists; Knox, 2003; Segal et al., 1999) permanently affects clinical outcomes, while others highlight the role of compensatory skills (e.”

“These are a common component of many CBTs nowadays, were part of the current iCBT interventions, and participants reported benefits from their usage (Eilert et al., 2021), resulting in a potential underreporting of skills usage via the FATS.”

“This is similar to a previous study by Eilert et al. [48], which found that in a pragmatic randomised controlled trial of internet-based CBT for anxiety and/or depression, the selection of skills was partly driven by perceived symptoms and strategy effectiveness.”

“Research indicates that long-term retention of therapeutic benefits is often linked to the internalization of skills learned during intervention sessions, such as cognitive restructuring and emotional regulation [71, 72].”

“The content varies on the programme, but it generally includes a mixture of psychoeducation and guided exercises to help develop core CBT skills such as self-monitoring, awareness of thoughts and emotions, and ways to change cognitive content and processes (Eilert et al ., 2022).”