title: Motivation and Treatment Credibility Predicts Dropout, Treatment Adherence, and Clinical Outcomes in an Internet-Based Cognitive Behavioral Relaxation Program: A Randomized Controlled Trial.
abstract: BACKGROUND
  In previous research, variables such as age, education, treatment credibility, and therapeutic alliance have shown to affect patients' treatment adherence and outcome in Internet-based psychotherapy. A more detailed understanding of how such variables are associated with different measures of adherence and clinical outcomes may help in designing more effective online therapy.
  
  
  OBJECTIVE
  The aims of this study were to investigate demographical, psychological, and treatment-specific variables that could predict dropout, treatment adherence, and treatment outcomes in a study of online relaxation for mild to moderate stress symptoms.
  
  
  METHODS
  Participant dropout and attrition as well as data from self-report instruments completed before, during, and after the online relaxation program were analyzed. Multiple linear and logistical regression analyses were conducted to predict early dropout, overall attrition, online treatment progress, number of registered relaxation exercises, posttreatment symptom levels, and reliable improvement.
  
  
  RESULTS
  Dropout was significantly predicted by treatment credibility, whereas overall attrition was associated with reporting a focus on immediate consequences and experiencing a low level of intrinsic motivation for the treatment. Treatment progress was predicted by education level and treatment credibility, whereas number of registered relaxation exercises was associated with experiencing intrinsic motivation for the treatment. Posttreatment stress symptoms were positively predicted by feeling external pressure to participate in the treatment and negatively predicted by treatment credibility. Reporting reliable symptom improvement after treatment was predicted by treatment credibility and therapeutic bond.
  
  
  CONCLUSIONS
  This study confirmed that treatment credibility and a good working alliance are factors associated with successful Internet-based psychotherapy. Further, the study showed that measuring adherence in different ways provides somewhat different results, which underscore the importance of carefully defining treatment adherence in psychotherapy research. Lastly, the results suggest that finding the treatment interesting and engaging may help patients carry through with the intervention and complete prescribed assignments, a result that may help guide the design of future interventions.
  
  
  BACKGROUND
  Clinicaltrials.gov NCT02535598; http://clinicaltrials.gov/ct2/show/NCT02535598 (Archived by WebCite at http://www.webcitation.org/6fl38ms7y).
authors.affiliation: Clinical Psychology in Healthcare, Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden. sven.alfonsson@pubcare.uu.se.
authors.forename: Sven
authors.identifier: http://orcid.org/0000-0003-4570-5891
authors.initials: S
authors.lastname: Alfonsson
authors.forename: Erik
authors.identifier: http://orcid.org/0000-0002-1591-7407
authors.initials: E
authors.lastname: Olsson
authors.forename: Timo
authors.identifier: http://orcid.org/0000-0003-1990-5785
authors.initials: T
authors.lastname: Hursti
mesh_terms: D000328:Adult; D005260:Female; D006801:Humans; D020407:Internet; D016015:Logistic Models; D008297:Male; D009042:Motivation; D010349:Patient Compliance; D010352:Patient Dropouts; D011613:Psychotherapy / Q000379:methods; D016896:Treatment Outcome
keywords: Internet; adherence; motivation; patient compliance; psychotherapy