How would you approach a follow-up consult with a patient who has not engaged with prescribed digital cognitive behavioural therapy (CBT) and reports frustration with lack of progress?

From the Guidelines

I would approach this follow-up consult by first validating the patient's frustration and exploring specific barriers to their engagement with digital CBT, as sustained engagement is a complex process crucial for intervention success 1. To address Ian's situation, I would begin by asking open-ended questions about his experience with the digital platform, technical difficulties he may have encountered, and whether the content felt relevant to his situation. This assessment is in line with the Connect, Attend, Participate, and Enact (CAPE) model, which identifies and defines four aspects of engagement at various stages of intervention 1. Understanding these barriers is essential to determine why Ian has not engaged with the digital CBT modules.

After understanding these barriers, I would discuss alternative treatment options, which might include traditional face-to-face CBT sessions, group therapy, or potentially medication options such as SSRIs (e.g., sertraline 50-200mg daily or escitalopram 10-20mg daily) if clinically appropriate for his condition, as guided by the management of major depressive disorder guidelines 1. I would also assess whether the initial diagnosis and treatment plan need reconsideration, considering the effectiveness of digital cognitive behavioral therapy is comparable to face-to-face therapy 1.

Throughout the conversation, I would emphasize that lack of engagement with digital CBT doesn't represent personal failure but rather indicates a need to find a better-suited approach. This personalized approach acknowledges that digital interventions aren't effective for everyone, and treatment adherence improves when therapy modalities match patient preferences and learning styles, as noted in the assessment of self-guided cognitive behavioral therapy apps for depression 1. Before concluding, I would collaborate with the patient to develop a revised treatment plan with concrete next steps and a clear follow-up timeline to monitor progress, ensuring that the chosen approach aligns with the most recent and highest quality evidence available.

From the Research

Approach to Follow-up Consult

When approaching the follow-up consult with Ian, who has not engaged with the prescribed digital cognitive behavioural therapy (CBT) and reports frustration with his lack of progress, several key points should be considered:

• Re-evaluation of Barriers: It is essential to re-evaluate the barriers that might be preventing Ian from engaging with the digital CBT, such as technical issues, lack of motivation, or misunderstanding of the therapy's benefits 2.
• Therapeutic Alliance: Establishing a strong therapeutic alliance is crucial. The therapist should be perceived as genuine, which can provide a sense of safety and enable Ian to open up in sessions 3.
• Structured Approach: A structured approach to therapy, combined with flexibility, can be helpful. Ensuring that tasks are perceived as manageable and goals as achievable is important for participation 3.
• Cognitive Restructuring: Cognitive restructuring can be a useful technique, although some individuals might tend to engage in distraction from thoughts as an alternative strategy 3.

Addressing Frustration and Lack of Progress

To address Ian's frustration and lack of progress:

• Problem-Solving: Techniques like problem-solving (SOLVE) can be applied to raise awareness for specific triggers and evaluate more effective options 2.
• Re-attribution: Re-attribution techniques can help replace negative self-statements with more appropriate ones, and decatastrophizing can aid in evaluating situations more realistically 2.
• Affect Regulation: Affect regulation techniques can teach Ian how to recognize stimuli that provoke negative emotions and mitigate the resulting emotional arousal 2.

Digital CBT Effectiveness

Evidence indicates that digital CBT can be as effective as face-to-face therapy for various conditions, including depression and anxiety 4, 5, 6. It is crucial to discuss these findings with Ian to reinforce the potential benefits of digital CBT.

Next Steps

The next steps should include:

• Re-engagement Strategies: Developing strategies to re-engage Ian with the digital CBT, possibly by setting smaller, achievable goals or providing additional support.
• Regular Follow-ups: Scheduling regular follow-ups to monitor progress, address any challenges, and adjust the treatment plan as necessary.
• Combination with Other Interventions: Considering the combination of digital CBT with other interventions, such as face-to-face sessions or community-based support, to enhance its effectiveness 4.