Defining the Role of the Online Therapeutic Facilitator: Principles and Guidelines Developed for Couplelinks, an Online Support Program for Couples Affected by Breast Cancer

“The association between therapeutic alliance and outcomes in IP settings is well established [38,39].”

“Such lack of knowledge is problematic given that online programs demonstrate higher attrition rates relative to traditional in-person (IP) therapy, rendering the significant outcomes achieved applicable to only a subsample of participants [13,14].”

“There has been a steady increase in the number of Internet-delivered psychological interventions addressing a range of different issues that include chronic medical conditions (see [1,2]), eating disorders [3-5], substance use (see [6] for review), depression and anxiety [7-9], and cancer (eg, [10,11]).”

“There has been a steady increase in the number of Internet-delivered psychological interventions addressing a range of different issues that include chronic medical conditions (see [1,2]), eating disorders [3-5], substance use (see [6] for review), depression and anxiety [7-9], and cancer (eg, [10,11]).”

“There has been a steady increase in the number of Internet-delivered psychological interventions addressing a range of different issues that include chronic medical conditions (see [1,2]), eating disorders [3-5], substance use (see [6] for review), depression and anxiety [7-9], and cancer (eg, [10,11]).”

“There has been a steady increase in the number of Internet-delivered psychological interventions addressing a range of different issues that include chronic medical conditions (see [1,2]), eating disorders [3-5], substance use (see [6] for review), depression and anxiety [7-9], and cancer (eg, [10,11]).”

“Methods of online support that have been used and found to increase program adherence include online, telephone, or mailed reminders and brief written descriptions on how to use the program [25-27]; online feedback aimed to emphasize new learning and encourage ongoing engagement [28,29]; and/or telephone contact [7,30…”

“As well, younger couples tend to lead busier lives, as they juggle work and family commitments, and may have difficulty scheduling and obtaining professional support, particularly if they have young children [62,65-67].”

“Indeed, research has found that couples with higher levels of we-ness or dyadic coping in relation to breast cancer experience better adjustment (eg, [70-73]).”

“There has been a steady increase in the number of Internet-delivered psychological interventions addressing a range of different issues that include chronic medical conditions (see [1,2]), eating disorders [3-5], substance use (see [6] for review), depression and anxiety [7-9], and cancer (eg, [10,11]).”

“A well-established finding is that younger, mainly premenopausal breast cancer survivors (age 50 or younger) and their partners are significantly more likely than older couples to experience relationship distress and poorer quality of life [61,62], and are more likely to continue experiencing declines in relationship…”

“Berger and colleagues [34] found no difference between therapist-supported and unsupported versions of an online depression intervention.”

“Methods of online support that have been used and found to increase program adherence include online, telephone, or mailed reminders and brief written descriptions on how to use the program [25-27]; online feedback aimed to emphasize new learning and encourage ongoing engagement [28,29]; and/or telephone contact [7,30…”

“Breast cancer tends to be more aggressive, more likely to recur, and more fatal in younger women [74-76]; hence, the possibility of a change in health status and ongoing worry with respect to health are very real concerns for this population.”

“Methods of online support that have been used and found to increase program adherence include online, telephone, or mailed reminders and brief written descriptions on how to use the program [25-27]; online feedback aimed to emphasize new learning and encourage ongoing engagement [28,29]; and/or telephone contact [7,30…”

“For example, the clinician can review participant’s progress via the data entered online and provide feedback accordingly [48].”

“Palmqvist et al’s [17] quantitative synthesis of several Internet-based interventions found that the amount of online therapist support provided in an intervention was positively correlated with outcome, such that more support related to greater benefits derived from the program.”

“There has been a steady increase in the number of Internet-delivered psychological interventions addressing a range of different issues that include chronic medical conditions (see [1,2]), eating disorders [3-5], substance use (see [6] for review), depression and anxiety [7-9], and cancer (eg, [10,11]).”

“There has been a steady increase in the number of Internet-delivered psychological interventions addressing a range of different issues that include chronic medical conditions (see [1,2]), eating disorders [3-5], substance use (see [6] for review), depression and anxiety [7-9], and cancer (eg, [10,11]).”

“Breast cancer tends to be more aggressive, more likely to recur, and more fatal in younger women [74-76]; hence, the possibility of a change in health status and ongoing worry with respect to health are very real concerns for this population.”

“Specifically, self-help Web programs that are entirely self-guided (ie, have no contact with or guidance from an online expert or professional incorporated into the program) demonstrate much higher attrition rates with program completion ranging anywhere from 1% [15,12] to 53% [16].”

“Few studies have compared the same online intervention with and without therapist guidance and for the few that have been done, the results are equivocal with some finding superior outcomes for an online therapist-guided program over a non-therapist-guided version [31,32] and others finding no significant difference […”

“Similarly, Warmerdam and colleagues [29] suggest that the primary role of the online facilitator is to offer feedback with the aim of helping the client work through the program rather than to provide advice or foster a therapeutic relationship per se.”

“effective (eg, [12]), few studies have examined the components of an online intervention that contribute to program adherence and positive outcomes.”

“Cancer is destabilizing to the relationship system and invariably results in significant relationship reorganization and strain [51].”

“Few studies have compared the same online intervention with and without therapist guidance and for the few that have been done, the results are equivocal with some finding superior outcomes for an online therapist-guided program over a non-therapist-guided version [31,32] and others finding no significant difference […”

“There has been a steady increase in the number of Internet-delivered psychological interventions addressing a range of different issues that include chronic medical conditions (see [1,2]), eating disorders [3-5], substance use (see [6] for review), depression and anxiety [7-9], and cancer (eg, [10,11]).”

“Different from IP therapy, however, alliance ratings for online interventions have reportedly had a small to no significant effect on outcome despite the high level of therapeutic alliance achieved in them [41-43].”

“There has been a steady increase in the number of Internet-delivered psychological interventions addressing a range of different issues that include chronic medical conditions (see [1,2]), eating disorders [3-5], substance use (see [6] for review), depression and anxiety [7-9], and cancer (eg, [10,11]).”

“Different from IP therapy, however, alliance ratings for online interventions have reportedly had a small to no significant effect on outcome despite the high level of therapeutic alliance achieved in them [41-43].”

“There has been a steady increase in the number of Internet-delivered psychological interventions addressing a range of different issues that include chronic medical conditions (see [1,2]), eating disorders [3-5], substance use (see [6] for review), depression and anxiety [7-9], and cancer (eg, [10,11]).”

“Breast cancer tends to be more aggressive, more likely to recur, and more fatal in younger women [74-76]; hence, the possibility of a change in health status and ongoing worry with respect to health are very real concerns for this population.”

“are not privy to the nonverbal communication and paralinguistic cues of their clients [20].”

“Different from IP therapy, however, alliance ratings for online interventions have reportedly had a small to no significant effect on outcome despite the high level of therapeutic alliance achieved in them [41-43].”

“The rather modest collection of research examining online facilitation with cancer populations focuses predominantly on Internet-based support groups for patients (eg, [52-60]).”

“The rather modest collection of research examining online facilitation with cancer populations focuses predominantly on Internet-based support groups for patients (eg, [52-60]).”

“Methods of online support that have been used and found to increase program adherence include online, telephone, or mailed reminders and brief written descriptions on how to use the program [25-27]; online feedback aimed to emphasize new learning and encourage ongoing engagement [28,29]; and/or telephone contact [7,30…”

“The rather modest collection of research examining online facilitation with cancer populations focuses predominantly on Internet-based support groups for patients (eg, [52-60]).”

“In contrast, Lancee and colleagues’ [31] online intervention for”

“Indeed, research has found that couples with higher levels of we-ness or dyadic coping in relation to breast cancer experience better adjustment (eg, [70-73]).”

“A well-established finding is that younger, mainly premenopausal breast cancer survivors (age 50 or younger) and their partners are significantly more likely than older couples to experience relationship distress and poorer quality of life [61,62], and are more likely to continue experiencing declines in relationship…”

“Consequently, such partners engage in greater perspective-taking, empathy, and interpersonal support and therefore experience greater relationship satisfaction [68,69].”

“Such lack of knowledge is problematic given that online programs demonstrate higher attrition rates relative to traditional in-person (IP) therapy, rendering the significant outcomes achieved applicable to only a subsample of participants [13,14].”

“Cavanagh and Millings [44] suggest that the significance of other factors, such as support and accountability to the program, will be more salient for the online therapist relationship.”

“When comparing working alliance client ratings online versus IP therapies, no significant difference in ratings were found, suggesting that a strong therapeutic alliance can be established equally in IP and online mediums (see [40] for review).”

“In what ways does the online therapist provide this support and encourage such engagement? Despite recommendations that online interventions require the development of specific skills [46], little work has been done to date to articulate the type of specialized skills required to provide the most effective online faci…”

“As well, younger couples tend to lead busier lives, as they juggle work and family commitments, and may have difficulty scheduling and obtaining professional support, particularly if they have young children [62,65-67].”

“The rather modest collection of research examining online facilitation with cancer populations focuses predominantly on Internet-based support groups for patients (eg, [52-60]).”

“Serious illnesses such as cancer affect not just the person with the illness, but their family members and their intimate partner [50].”

“For instance, Module 4 is an exercise designed to assist the couple develop a sense that cancer is a common enemy by having the couple create a shared metaphor in relation to the illness using image, collage, or poetry (see [70]).”

“In other studies, the therapist provided more tailored “feedback” to clients; for instance, specific strategies or access to additional relevant resources [36] or a discussion regarding the interpretation of assessment outcomes and the client’s reaction to this information [37].”

“Not surprisingly, relative to IP clinicians, online clinicians express a lack of clarity around how to fulfill similar objectives as the IP therapist using text-based formats for interaction [21].”

“As well, younger couples tend to lead busier lives, as they juggle work and family commitments, and may have difficulty scheduling and obtaining professional support, particularly if they have young children [62,65-67].”

“The program, called Couplelinks, was previously developed and tested in a Phase I pilot trial [22] and is presently being evaluated in a multisite randomized controlled trial (RCT) [23].”

“As well, younger couples tend to lead busier lives, as they juggle work and family commitments, and may have difficulty scheduling and obtaining professional support, particularly if they have young children [62,65-67].”

“The rather modest collection of research examining online facilitation with cancer populations focuses predominantly on Internet-based support groups for patients (eg, [52-60]).”

“The rather modest collection of research examining online facilitation with cancer populations focuses predominantly on Internet-based support groups for patients (eg, [52-60]).”

“Similarly, Mathieu et al [18] found that although most participants of an Internet-based psychological program liked if not preferred Internet-based delivery of an intervention because it was flexible, easy to use, and not burdensome, they also reported feeling restricted, disconnected, and unmotivated to continue bec…”

“The observations of the facilitation process in the pilot trial led to greater elaboration and precision of the facilitation guidelines and were formally described in the Couplelinks Program Facilitation Manual [24] for the RCT.”

“Peck [45] addresses this paradox by reinterpreting the well-established finding that the therapy relationship contributes to outcomes by suggesting that it is not the relationship itself but the processes it activates within a client that impacts outcomes.”

“Furthermore, Stephen and colleagues [49] reported that facilitators found the physical distance of the online format helped them to better manage the emotional content of the group.”

“A recent qualitative study with individuals that participated in online interventions without an online therapist found that the most commonly cited reasons for program dissatisfaction and disengagement included the lack of personalized support, feedback, and guidance [18,19].”

“The rather modest collection of research examining online facilitation with cancer populations focuses predominantly on Internet-based support groups for patients (eg, [52-60]).”

“there are some indications that tailored email support is more effective than no support or automated email support [32,34].”

“Recent studies have revealed that personal guidance is essential for the effectiveness of, and adherence to, eHealth interventions [34-37].”

“The group environment and the experience that is co-created by the group members and facilitator(s) play important roles in influencing treat-ment outcome, ensuring the provision of evidence-based care, and safeguarding against negative experiences [9–12].”