Cognitive behaviour therapy (CBT) is one of the psychological treatments for tinnitus with the best empirical evidence of efficacy (Cima, Andersson, Schmidt, & Henry, 2014) and cost effectiveness (Maes et al., 2014). Although CBT has been demonstrated to be effective, there are specific barriers in tinnitus patients seeking psychotherapy in the face-to-face setting, such as the fear of being stigmatized for going to a therapist for example (Cuijpers, van Straten, & Andersson, 2008). Internet-based interventions (iCBT) can abolish these barriers and have been demonstrated to be as effective as face-to-face CBT in the treatment of tinnitus (Nyenhuis, Golm, & Kröner-Herwig, 2013). Although efficacy of iCBT for chronic tinnitus patients has been shown, studies demonstrated that 29 to 44% of tinnitus patients in iCBT do not benefit from the intervention (Andersson, Strömgren, Strom, & Lyttkens, 2002; Hesser et al., 2012; Kaldo et al., 2008). In 2% of the patients tinnitus handicap even deteriorates after an iCBT. These findings emphasize how important it is to have a stronger focus on patients who do not reach clinical significant changes in Internet-based treatments. Only a few studies investigated baseline patient characteristics as predictors of the outcome in iCBT for chronic tinnitus patients (Kaldo-Sandström, Larsen, & Andersson, 2004; Lindner et al., 2016; Theodoroff, Schuette, Griest, & Henry, 2014). However variables such as the quality of the therapeutic alliance and the early patient progress have not been considered as predictors of response/non-response in iCBT for tinnitus yet.
In the current study, baseline and process variables were compared between non-responders and responders of an iCBT for chronic tinnitus patients. Data from patients participating in two randomized controlled trials on iCBT for chronic tinnitus were re-analyzed. A pre-post difference on the Tinnitus Handicap Inventory (THI) of less than 7 points improvement indicated non-response. The role of baseline variables (age, gender, and questionnaire scores), patient progress (THI), the process of the therapeutic alliance (Working Alliance Inventory-Short Revised), and other process variables (number of logins, sent messages, received messages) was investigated. The results showed that non-responders had a less favorable change on the THI than responders already at mid-treatment. The alliance during iCBT was not associated with response/non-response. Non-responders showed more severe sleep disturbances, logged in less in the iCBT platform, and received fewer messages from the therapists than responders, but these differences were mostly not significant anymore when correcting for multiple testing.
In summary, no symptom change in the first half of iCBT for chronic tinnitus patients is a risk factor of having no benefit from iCBT. It should be considered to administer weekly process and outcome measures in the context of Internet-based interventions to investigate processes of change more exactly. Such a progress monitoring could be combined with feedback on patient progress and clinical support tools (e. g., Lambert, 2017) which can be easily implemented into iCBT.
Read the full paper: Probst, T., Weise, C., Andersson, G., & Kleinstäuber, M. (in press). Differences in baseline and process variables between non-responders and responders in Internet-based cognitive behavior therapy for chronic tinnitus. Cognitive Behaviour Therapy. doi:10.1080/16506073.2018.1476582
Photo by: Matthias Ripp