Leveraging telepsychology and behavioral economics to increase fidelity to CBT - PROJECT SUMMARY
Telepsychology (“telepsych”) provides a unique opportunity to use behavioral economics (BE) strategies to
structure the therapy encounter in ways that nudge clinicians to deliver high-quality services. BE strategies are
best suited for changing discrete provider behaviors that are observable and measurable. This R34 aims to
develop and evaluate “Tele-BE,” a novel telehealth infrastructure that nudges and incentivizes clinicians to use
core structural components of cognitive behavioral therapy (CBT), a leading psychosocial treatment with
demonstrated efficacy and effectiveness for a range of mental health concerns. Across protocols, CBT contains
many discrete components; however, nearly all CBT protocols include the following elements: (1) patient
symptom tracking, (2) collaborative agenda setting at the session start, (3) out-of-session practice (“homework”)
review, (4) skill instruction, (5) skill practice, and (6) homework planning. These CBT structural components
are likely to be responsive to BE strategies. Structural components also represent a core and distinct CBT
competency and serve as the foundation upon which specific intervention techniques are delivered; as such,
they are common to other evidence-based psychosocial practices beyond CBT as well. However, our prior work
illustrates that community clinicians have consistently low fidelity to these components. Aim 1 will use
participatory design to refine our Tele-BE prototype in collaboration with clinicians and supervisors (our target
end-users). In Aim 2, we will work closely with our web development team to field test and iteratively refine Tele-
BE using rapid cycle prototyping to optimize the user experience and refine our specific BE strategies. Aim 3
will test the preliminary effectiveness of the refined Tele-BE to engage our target mechanisms and enhance
clinician CBT structural component fidelity in a 12-week open trial with 30 community mental health clinicians
randomized to Tele-BE or telehealth as usual (Tele-AU). The trial will include 2 patients per clinician (60 patients
in total). All sessions will be recorded and coded for CBT fidelity. Clinicians and patients will complete
questionnaires at Weeks 1, 5, 9, and 12 and qualitative interviews at post. Aim 3 primary outcomes will be CBT
structural component fidelity, measured through coding of recorded sessions. Secondary outcomes include
target implementation mechanisms (intentions and their determinants: attitudes, norms and self-efficacy),
measured via mixed methods, and overall CBT fidelity. Using data from the open trial, Aim 4 will examine
acceptability and feasibility of Tele-BE from patient and clinician perspectives, as well as potential ethical issues
with Tele-BE. This R34 aligns with NIMH Strategic Plan Strategy 4.2.C to develop decision-support tools and
technologies that increase the implementation of mental health EBPs. Results will lead to a hybrid effectiveness-
implementation R01 to test strategies for optimizing Tele-BE's effect on clinician fidelity to improve patient
outcomes.
