Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2024 Apr 18:36:100743.
doi: 10.1016/j.invent.2024.100743. eCollection 2024 Jun.

The use of coaching in smartphone app-based cognitive behavioral therapy for body dysmorphic disorder

Emily E Bernstein  1   2 , Jennifer L Greenberg  1   2 , Hilary Weingarden  1   2 , Ivar Snorrason  1   2 , Berta Summers  1 , Jasmine Williams  1 , Rachel Quist  1 , Joshua Curtiss  1   3 , Oliver Harrison  4 , Sabine Wilhelm  1   2
Affiliations

The use of coaching in smartphone app-based cognitive behavioral therapy for body dysmorphic disorder

Emily E Bernstein et al. Internet Interv. .

Abstract

Background: Body dysmorphic disorder (BDD) is severe and undertreated. Digital mental health could be key to expanding access to evidence-based treatments, such as cognitive behavioral therapy for BDD (CBT-BDD). Coach guidance is posited to be essential for effective uptake of digital interventions. However, little is known about how different patients may use coaching, what patterns correspond to meaningful outcomes, and how to match coaching to patient needs.

Methods: Participants were 77 adults who received a 12-week guided smartphone CBT-BDD. Bachelor's-level coaches were available via asynchronous messaging. We analyzed the 400 messages sent by users to coaches during treatment. Message content was coded using the efficiency model of support (i.e., usability, engagement, fit, knowledge, and implementation). We aimed to clarify when and for what purposes patients with BDD used coaching, and if we can meaningfully classify patients by these patterns. We then assessed potential baseline predictors of coach usage, and whether distinct patterns relate to clinical outcomes.

Results: Users on average sent 5.88 messages (SD = 4.51, range 1-20) and received 9.84 (SD = 5.74, range 2-30). Regarding frequency of sending messages, latent profile analysis revealed three profiles, characterized by: (1) peak mid-treatment (16.88 %), (2) bimodal/more communication early and late in treatment (10.39 %), and (3) consistent low/no communication (72.73 %). Regarding content, four profiles emerged, characterized by mostly (1) engagement (51.95 %), (2) fit (15.58 %), (3) knowledge (15.58 %), and (4) miscellaneous/no messages (16.88 %). There was a significant relationship between frequency profile and age, such that the early/late peak group was older than the low communication group, and frequency profile and adherence, driven by the mid-treatment peak group completing more modules than the low contact group. Regarding content, the engagement and knowledge groups began treatment with more severe baseline symptoms than the fit group. Content profile was associated with dropout, suggesting higher dropout rates in the miscellaneous/no contact group and reduced rates in the engagement group. There was no relationship between profile membership and other outcomes.

Discussion: The majority of participants initiated little contact with their coach and the most common function of communications was to increase engagement. Results suggest that older individuals may prefer or require more support than younger counterparts early in treatment. Additionally, whereas individuals using coaching primarily for engagement may be at lower risk of dropping out, those who do not engage at all may be at elevated risk. Findings can support more personalized, data-driven coaching protocols and more efficient allocation of coaching resources.

Keywords: Body dysmorphic disorder; Clinical trial; Coach; Cognitive behavioral therapy; Digital health; Smartphone.

PubMed Disclaimer

Conflict of interest statement

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Dr. Bernstein has received research support from Koa Health Digital Solutions LLC. Dr. Bernstein is a presenter for the Massachusetts General Hospital Psychiatry Academy in educational programs supported through independent medical education grants from pharmaceutical companies. Dr. Bernstein has a consulting agreement with Otsuka Pharmaceutical Development & Commercialization, Inc. and is on the Scientific Advisory Board for AugMend Health Inc. Dr. Greenberg has received research support from Koa Health Digital Solutions LLC and is a presenter for the Massachusetts General Hospital Psychiatry Academy in educational programs supported through independent medical education grants from pharmaceutical companies. She has received speaking honoraria from L'Oreal (for a presentation at a SkinCeuticals cosmetic surgery and dermatology conference) and RBC Consultants for the CeraVe Psychodermatology Advisory Board. Dr. Weingarden has received research support from Koa Health Digital Solutions LLC and the National Institute of Mental Health (NIMH) (K23MH119372) and is a presenter for the Massachusetts General Hospital Psychiatry Academy in educational programs supported through independent medical education grants from pharmaceutical companies. Dr. Weingarden has a consulting agreement with Hello Therapeutics, Inc. Dr. Snorrason has received research support from Koa Health. Dr. Summers has no potential conflicts to report. Ms. Williams has no potential conflicts to report. Ms. Quist has no potential conflicts to report. Dr. Curtiss has received research support from Koa Health. Dr. Harrison is Founder/CEO of Koa Health, a digital mental health company that collaborated with Dr. Wilhelm and her team at MGH to build Perspectives. Dr. Harrison also serves on the WHO Roster of Experts for Digital Health, sits on the Board of EMPOWER (a non-profit organization promoting the training of community health workers to provide mental healthcare), and is a member of the Expert Panel for implementing the Wellcome Trust's mental health strategy. Dr. Harrison is a Royal Society Entrepreneur in Residence in healthcare AI at Oxford University. Dr. Wilhelm is a presenter for the Massachusetts General Hospital Psychiatry Academy in educational programs supported through independent medical education grants from pharmaceutical companies. She has received royalties from Guilford Publications, New Harbinger Publications, Springer, and Oxford University Press. Dr. Wilhelm has also received speaking honoraria from various academic institutions and foundations, including the International Obsessive Compulsive Disorder Foundation, the Tourette Association of America, and the Centers for Disease Control and Prevention. In addition, she received honoraria for her role on the Scientific Advisory Board for One-Mind (PsyberGuide), Koa Health Digital Solutions LLC, and Noom, Inc. Dr. Wilhelm has received research support from Koa Health Digital Solutions LLC.

Figures

Fig. 1
Fig. 1
Average number of messages sent per participant.
Fig. 2
Fig. 2
Frequency and content of user-sent messages. Note. (A) Frequency: Profile 1 = communication peaks mid-treatment; Profile 2 = communication peaks beginning and end of treatment; Profile 3 = consistent low communication. (B) Content: Profile 1 = engagement, Profile 2 = fit; Profile 3 = knowledge; Profile 4 = miscellaneous/no contact.
Fig. 3
Fig. 3
Individual plots grouped by profile. Note. (A) Frequency: (Red) Profile 1 = communication peaks mid-treatment; (Green) Profile 2 = communication peaks beginning and end of treatment; (Blue) Profile 3 = consistent low communication. (B) Content: (Red) Profile 1 = engagement, (Green) Profile 2 = fit; (Blue) Profile 3 = knowledge; (Purple) Profile 4 = miscellaneous/no contact.
Fig. 4
Fig. 4
Message categories.
See this image and copyright information in PMC

References

    1. Association AP . 5th ed. 2013. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. - DOI
    1. Attkisson C., Zwick R. The client satisfaction questionnaire. Psychometric properties and correlations with service utilization and psychotherapy outcome. Eval. Program Plann. 1982;5(3):233–237. - PubMed
    1. Baumeister H., Reichler L., Munzinger M., Lin J. The impact of guidance on internet-based mental health interventions — a systematic review. Internet Interv. 2014;1:205–215.
    1. Bernstein E, Weingarden H, Wolfe E, Hall M, Snorrasson I, Wilhelm S. Human support in app-based cognitive behavioral therapies for emotional disorders: a scoping review. J. Med. Internet Res. - PMC - PubMed
    1. Bernstein E.E., Weingarden H., Wolfe E.C., Hall M.D., Snorrason I., Wilhelm S. Human support in app-based cognitive behavioral therapies for emotional disorders: scoping review. J. Med. Internet Res. 2022;24(4) - PMC - PubMed

LinkOut - more resources