What lessons can be learned from a supportive accountability study on an online anxiety intervention?

Werntz, A., Silverman, A. L., Behan, H., Patel, S. K., Beltzer, M., Boukhechba, M. O., Barnes, L., & Teachman, B. A. (in press). Lessons learned: Providing supportive accountability in an online anxiety intervention. Behavior Therapy. 

https://doi.org/10.1016/j.beth.2021.12.002

Summarized by Ariel Ervin

Notes of Interest:

• Although technology-delivered interventions (TDI) can help bridge the gap in seeking mental health treatments, TDI dropout rates are high.
• Providing participants with coaching or minimal contact with a non-specialist might increase TDI engagement.
• This study assesses anxious people’s* reactions to a low-intensity coaching protocol.

*More specifically, the sample consisted of anxious people who were at risk of dropping 

out of an intervention.

• ~30% of the sample completed the intervention with their coaches.
• Approximately half of the sample didn’t respond to coaches who tried to set up an initial call.
• There was a lack of evidence that explained the unresponsiveness of the sample.
• A sample of lessons learned from this study to improve TDI engagement:
  • Apply a user-centered design approach to future online interventions since it allows participants to provide feedback early on in the program design.
  • Let users choose what kind of coaching they receive (e.g., calling or texting)
  • Further train coaches in explaining how TDI operates and why they are important.

Introduction (Reprinted from the Abstract)

Technology-delivered interventions have the potential to help address the treatment gap in mental health care but are plagued by high attrition. Adding coaching, or minimal contact with a nonspecialist provider, may encourage engagement and decrease dropout, while remaining scalable. Coaching has been studied in interventions for various mental health conditions but has not yet been tested with anxious samples. This study describes the development of and reactions to a low-intensity coaching protocol administered to N = 282 anxious adults identified as high risk to drop out of a web-based cognitive bias modification for interpretation intervention. Undergraduate research assistants were trained as coaches and communicated with participants via phone calls and synchronous text messaging. About half of the sample never responded to coaches’ attempts to schedule an initial phone call or did not answer the call, though about 30% completed the full intervention with their coach. Some anxious adults may choose technology-delivered interventions specifically for their lack of human contact and may fear talking to strangers on the phone; future recommendations include taking a more intensive user-centered design approach to creating and implementing a coaching protocol, allowing coaching support to be optional, and providing users with more information about how and why the intervention works.

Implications (Reprinted from the Discussion)

To reduce attrition in an online anxiety intervention, we paired participants who were at high risk of dropout with coaches. Coaches were intended to provide support for using a web-based CBM-I program, and interactions with coaches were not meant to serve as teletherapy. Fewer than 30% of participants assigned to the coaching condition completed the online anxiety intervention with their coach. In a follow-up survey for those who did not engage with coaches, over half reported not wanting to talk to a coach. However, for the majority of nonresponders, there are no data on reasons for not engaging. There were also a few comments suggesting that added human support reduced the likelihood that someone with anxiety would engage in the intervention. Although there is a growing body of evidence for the efficacy of coaching in the context of TDIs (and some recommendations to enhance coaching; Lattie et al., 2019), the field is lacking clear recommendations for implementing coaching with individuals with anxiety. Our goal is to offer lessons learned to improve future iterations of coaching for anxious individuals.

Offering coaching for highly anxious individuals

MindTrails is likely an appealing option for individuals struggling with anxiety because it is a free, convenient, and anonymous intervention. Except for coaching, participants do not have to engage with anyone to enroll or participate, which could make it most appealing to individuals with social anxiety who may not wish to interact with others. We speculate this could make MindTrails (along with other TDIs) more appealing than traditional one-on-one therapy for some people, and could even serve as a stepping-stone to higher-intensity services if needed in the future. In the coaching condition, we required participants to have an initial phone session because we hoped it would lead to increased engagement and alliance with coaches. This approach is similar to a successful TDI plus coaching intervention (Graham et al., 2020) for individuals with depression and/or anxiety. However, in the Graham et al. trial, participants were from a primary care clinic, and were often referred to the TDI by their clinician. Thus, this sample likely consisted of participants who expressed openness to that type of interaction. In our case, baseline anxiety symptoms did not predict whether the participant would respond to the coaching scheduling e-mail, suggesting that symptom severity was not necessarily influencing this result. Nonetheless, approximately half of our sample completed the initial call with the coach, leading us to recommend that coaching be optional, as there is not a one-size-fits-all model.

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