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PhD Study: Enhancing engagement with between-session work in Low Intensity Cognitive Behavioural Therapy (CBT) based interventions

This research was led by Mia Bennion as part of her PhD Fellowship. For more information about Mia please check out our PhD Fellowships page. 
 
 
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 within primary care.
 
By seeking to further understand what, how and why factors affect patient engagement with between-session work, the findings of this study could be used 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 between 6 and 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 showed 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 had been inconsistent, contradictory, and inconclusive. It was concerning that the factors affecting engagement with between-session work were poorly understood, particularly given the possible influence this could have on the clinical and economic success of mental health services, particularly 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 (read the published article). 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), was associated with 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 (read the published article) and practitioners (read the published article) 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, findings could improve practice guidelines, ultimately leading to better treatment outcomes and quality of care across various settings.  
  • Patient and public involvement and engagement (PPIE) was integral to this project and involved working with a lived experience advisory panel throughout the research journey. This panel guided the study by shaping interview topics and patient-facing materials, offering insights on initial findings, and jointly developed a knowledge mobilisation strategy to optimise dissemination.

 


Findings
Findings identified barriers to engagement such as:

  • passive treatment expectations
  • comorbid health conditions
  • limited use of culturally sensitive BSW.

 

Patients voiced the importance of prioritising BSW; both during and between-sessions, with social support from networks helping to mitigate barriers such as time constraints.

 

Both patients and practitioners emphasised the need for clear task planning and personalised BSW, tailored to patients’ sociocultural contexts, to secure sustained engagement. 

 


 
Who did we work with?

 


 
Downloadable resources


 
More information


 

 

PhD Fellow
Lecturer in Mental Health & Research Associate
Mia Bennion
mia.bennion@manchester.ac.uk

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