Actualising therapy 2.0: enhancing engagement with computerised cognitive behavioural therapy for common mental health disorders

Computerised cognitive behavioural therapy (CCBT) is a clinically effective method of delivering CBT which may help address the under – treatment of common mental health disorders (CMHDs) in the population. However, concerns regarding acceptability, attrition rates and the therapeutic alliance are obstacles to widespread population dissemination. This thesis aimed to address these implementation issues by applying concepts from human – computer interaction (HCI) and attachment theory to the field of CCBT. Chapter 1 presents a meta – analysis investigating the effectiveness of CCBT for CMHDs and moderators of this effect. Chapter 2 presents a systematic review and analysis conducted to examine predictors of CCBT engagement. A process – based model of engagement with CCBT developed from the findings of this review is also presented. Adult attachment is known to influence engagement and alliance in face to face therapies, but research has not explored whether these relationships are mirrored in CCBT. Four empirical studies intended to address this question. Study 1 used a student population based survey to explore the acceptability of CCBT in a student population and the associations with adult attachment. Results demonstrated adult attachment was not associated with acceptability of CCBT. Study 2a utilised an open trial of a supported CCBT program to investigate whether adult attachment would predict engagement and alliance in vivo. Results showed attachment did not predict these outcomes. Study 2b utilised an open trial with a non – supported online CCBT program. Results indicated attachment security was positively associated with program engagement and alliance. It is proposed a combination of attachment system activation and perceiving computers as social actors account for these findings. Study 3 used a randomised, experimental paradigm to test the benefits of security priming in CCBT. Security priming produced higher levels of program engagement and better working alliance compared to neutral primes. Furthermore these effects were not moderated by dispositional attachment styles. These results demonstrate something so uniquely human, dispositional attachment orientations, founded on the intimate bonds we form in infancy and in adulthood , extend their influence into the experience of unguided CCBT, a solely human – computer interaction. Unguided – CCBT, a highly cost effective intervention with the potential for considerable public health impact, may benefit from incorporating security priming techniques in program designs to maximise engagement and alliance. Engagement and alliance is attainable in CCBT and paying attention to the attachment styles of program users may present a distinctive opportunity to overcome these implementation barriers.