This research was led by Mia Bennion as part of her PhD Fellowship. For more information about Mia please check out our PhD Fellowships pages. 

 

What did we do?

The aim of the project was to enhance patient engagement with between-session work in Low Intensity (LI) CBT-based interventions.

 

By seeking to further understand what, how and why factors affect patient engagement with between-session work, the findings of this study can inform future patient information resources, workforce training guidelines and service planning.

 

Why was it important?

Encouraging patients to complete therapeutic work outside of treatment sessions is neither new nor uncommon in psychotherapy and is considered an integral aspect of Cognitive Behavioural Therapies. Sometimes described as ‘between-session work’, these activities allow patients to transfer adaptive skills learnt in therapy sessions into everyday life where presenting problems naturally occur.

 

Between-session work is particularly pertinent during LI interventions, given treatment duration and practitioner input are often minimal (usually involving around 6-8 30-minute treatment sessions). This means that a lot of the therapeutic activity encouraged to take place during LI interventions is completed by the patient independently in the form of between-session work.

 

Previous research has shown that when patients engage well with between-session work during therapy, treatment outcomes are enhanced, and symptoms are reduced. Yet between session engagement appears to vary and a lack of patient engagement with between-session work in CBT is commonly reported.

 

Findings from individual studies seeking to identify factors which affect patient engagement with between-session work have been inconsistent, contradictory, and inconclusive. It is concerning that the factors affecting engagement with between-session work are poorly understood, particularly given the possible influence this may have on the clinical and economic success of mental health services, particularly Improving Access to UK NHS Talking Therapies.

 

 

 How did we do it?

  

• Phase 1 - We conducted a mixed methods systematic review and “best fit” framework synthesis which analysed 59 studies to explore the predictors of engagement with between-session work (BSW) in CBT-based interventions. You can read the published article here. Existing evidence has unclear findings, yet several factors emerged as relatively consistent predictors of between-session engagement. The review emphasised the importance of positive patient beliefs regarding BSW and treatment such as perceived helpfulness, and practitioner competency when planning and reviewing tasks, relating to specificity and troubleshooting difficulties. Instances of patient in-session resistance, such as Counter-change talk (CCT - a client's language that expresses arguments, or objections), showed decreased engagement between sessions. Findings are less clear concerning the impact of patient symptomology, sociocultural environment, practitioner beliefs and the therapeutic relationship. Whilst the review was helpful to determine some pertinent factors affecting engagement with BSW, there was a significant absence of studies involving low intensity interventions and qualitative evidence.

 

• Phase 2 – A qualitative  study followed to interrogate and augment review findings within low intensity settings. 46 semi-structured interviews were conducted with NHS Talking Therapies patients and practitioners to explore the barriers and facilitators of engagement with BSW during low intensity CBT-based interventions delivered in primary care. By focusing on patient and practitioner insights, we aimed to improve practice guidelines, ultimately leading to better treatment outcomes and quality of care across various settings.  Patient and public involvement and engagement (PPIE) has been integral to this project and has involved working with a lived experience advisory panel throughout the research journey. This panel has guided the study by shaping interview topics and patient-facing materials, offering insights on initial findings, and have jointly developed a knowledge mobilisation strategy to optimise dissemination.

 

Findings

Findings from the paper Predictors of engagement with between-session work in Cognitive Behavioural Therapy (CBT)-based interventions: a mixed-methods systematic review and “best fit” framework synthesis were:

 

Overall, the following factors emerged as relatively consistent predictors of engagement with between-session work: 

• positive patient beliefs regarding BSW and treatment such as perceived helpfulness
• practitioner competency in planning and reviewing BSW, including providing a rationale and addressing difficulties. 

 

A factor that indicated poor engagement between sessions was patient in-session resistance, including counter-change talk (where a patient’s language expresses opposition to change). 

 

The impact of the following factors was unclear:

• the range of symptoms patients experience
• sociocultural environment
• practitioner beliefs
• the therapeutic relationship. 

 

No clear associations to engagement with BSW were identified for:

• gender
• marital status
• age
• education

 

These findings offer a testable framework for researchers and a guideline for practitioners.
 

 

Who did we work with?

• Lancashire & South Cumbria NHS Foundation Trust
• Greater Manchester Mental Health Trust 
• The Big Life Group

 

Downloadable resources

 

• Publication

  Bennion M, Lovell K, Blakemore A, Vicary E, Bee P. (2024) Predictors of engagement with between-session work in Cognitive Behavioural Therapy (CBT)-based interventions: a mixed-methods systematic review and “best fit” framework synthesis. Cognitive Behaviour Therapy, 1–37

 

More information

 

 

 

PhD Fellow, Lecturer in Mental Health & Research Associate.

 

Mia Bennion

mia.bennion@manchester.ac.uk