Motivation and Treatment Credibility Predicts Dropout, Treatment Adherence, and Clinical Outcomes in an Internet-Based Cognitive Behavioral Relaxation Program: A Randomized Controlled Trial
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BACKGROUND: In previous research, variables such as age, education, treatment credibility, and therapeutic alliance have shown to affect patients' treatment adherence and outcome in Internet-based psychotherapy. A more detailed understanding of how such variables are associated with different measures of adherence and clinical outcomes may help in designing more effective online therapy. OBJECTIVE: The aims of this study were to investigate demographical, psychological, and treatment-specific variables that could predict dropout, treatment adherence, and treatment outcomes in a study of online relaxation for mild to moderate stress symptoms. METHODS: Participant dropout and attrition as well as data from self-report instruments completed before, during, and after the online relaxation program were analyzed. Multiple linear and logistical regression analyses were conducted to predict early dropout, overall attrition, online treatment progress, number of registered relaxation exercises, posttreatment symptom levels, and reliable improvement. RESULTS: Dropout was significantly predicted by treatment credibility, whereas overall attrition was associated with reporting a focus on immediate consequences and experiencing a low level of intrinsic motivation for the treatment. Treatment progress was predicted by education level and treatment credibility, whereas number of registered relaxation exercises was associated with experiencing intrinsic motivation for the treatment. Posttreatment stress symptoms were positively predicted by feeling external pressure to participate in the treatment and negatively predicted by treatment credibility. Reporting reliable symptom improvement after treatment was predicted by treatment credibility and therapeutic bond. CONCLUSIONS: This study confirmed that treatment credibility and a good working alliance are factors associated with successful Internet-based psychotherapy. Further, the study showed that measuring adherence in different ways provides somewhat different results, which underscore the importance of carefully defining treatment adherence in psychotherapy research. Lastly, the results suggest that finding the treatment interesting and engaging may help patients carry through with the intervention and complete prescribed assignments, a result that may help guide the design of future interventions. TRIAL REGISTRATION: Clinicaltrials.gov NCT02535598; http://clinicaltrials.gov/ct2/show/NCT02535598 (Archived by WebCite at http://www.webcitation.org/6fl38ms7y).
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In a Swedish RCT, the level of treatment credibility predicted dropouts whereas attrition was associated with higher levels of impulsivity and low levels of intrinsic treatment motivation.
“In a Swedish RCT, 162 adults were investigated regarding their participation in iACT to explore variables predicting dropout, adherence, and outcomes. The authors concluded that the level of treatment credibility predicted dropouts whereas attrition was associated with higher levels of impulsivity and low levels of intrinsic treatment motivation [53].”
From The Impact of Parental Support on Adherence to Therapist-Assisted Internet-Delivered Acceptance and Commitment Therapy in Primary Care for Adolescents With Anxiety: Naturalistic 12-Month Follow-Up Study (2025) · cites this paper as [53]
The Results (Dropout and Attrition; page unavailable) support the reported associations: lower treatment credibility predicted early dropout, while greater focus on immediate consequences and lower intrinsic motivation predicted attrition. However, the Methods (Design, Procedure, and Participants; page unavailable) describe a four-week Internet-based applied relaxation program, not iACT. Although 162 participants entered the trial, the predictor analyses used 157. (LLM, conf=0.88)
Experimental — accuracy not yet measuredThe TCS has demonstrated good internal consistency in a Swedish sample of stress and anxiety patients (Cronbach's α = 0.83).
“The TCS has demonstrated good internal consistency in a Swedish sample consisting of stress and anxiety patients (Cronbach’s α = 0.83) (Alfonsson et al., 2016)”
From Acceptance and commitment therapy for autistic adults: A randomized controlled pilot study in a psychiatric outpatient setting. (2023) · cites this paper as Alfonsson et al., 2016
Methods > Predictor Variables reports that the TCS had an internal reliability of α=.83 in this study. Methods > Design, Procedure, and Participants describes people recruited from the general population with mild to moderate stress and anxiety symptoms, rather than a sample of stress and anxiety patients; Swedish-language proficiency was required, but the passage does not establish that all participants were Swedish. (LLM, conf=0.87)
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- Authors
- Alfonsson, S., Olsson, E., & Hursti, T.
- Affiliations
- Uppsala University (SE)
- Corresponding author
- Alfonsson, Sven
- Venue
- Journal of Medical Internet Research
- Publisher
- JMIR Publications Inc.
- Published
- 2016-03-08
- Volume
- 18
- Issue
- 3
- Pages
- e52
- ISSN
- 1438-8871 (ISSN-L)
- PMC
- PMC4804106
- OpenAlex
- W2293307891
- Cited by
- 118
- References
- 64
- Citations by year
- 2026: 5 · 2025: 8 · 2024: 16 · 2023: 8 · 2022: 13 · 2021: 21 · 2020: 11 · 2019: 11 · 2018: 11 · 2017: 12 · 2016: 2
- FWCI
- 18.49
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- cc-by
- Locations
- Journal of Medical Internet Research (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Uppsala University Publications (Uppsala University) (submittedVersion, other-oa)
- Funders
- Uppsala Universitet
- Topics
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Telemedicine and Telehealth Implementation
- Keywords
- treatment credibility, intrinsic motivation, medication adherence, dropout, internet-based psychotherapy, stress symptoms, therapeutic relationship, treatment progress, treatment outcome prediction
- MeSH terms
- Adult, Female, Humans, Male, Motivation, Patient Compliance, Patient Dropouts, Psychotherapy, Logistic Models, Treatment Outcome, Internet
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