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Title: Patients experiences of telephone and web-based Cognitive Behavioural Therapy for Irritable Bowel Syndrome: A longitudinal qualitative study
Short title: Experiences of CBT for IBS: A qualitative study
Authors
Stephanie Hughes, Senior Research Assistant1,
Alice Sibelli, Senior Associate2,
Andrea vas Falcao, Student3
J Matthew Harvey, Student3
Hazel Everitt, Professor of Primary Care Research1,
Sabine Landau, Professor of Biostatistics2,
Gilly OReilly, Trial Manager1,
Sula Windgassen, Research Assistant4,
Rachel Holland, Trial Statistician2,
Paul Little, Professor of Primary Care1,
Paul McCrone, Professor of Health Economics5,
Kim Goldsmith, Reader in Medical Statistics2,
Nicholas Coleman, Consultant Gastroenterologist6,
Robert Logan, Consultant Gastroenterologist 4,
Trudie Chalder, Professor of Health Psychology7,
Rona Moss-Morris, Professor of Health Psychology2
Felicity L Bishop, Associate Professor in Health Psychology3,
Affiliations
1 University of Southampton, Primary Care Population Sciences and Medical Education, Aldermoor Close, Southampton, SO16 5ST, UK
2 Kings College London, Health Psychology Section, Institute of Psychiatry, Psychology and Neuroscience, SE1 9RT, UK
3 University of Southampton, School of Psychology, Southampton, SO17 1BJ, UK.
2 Kings College London, Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, De Crespigny Park, London, SE5 8AF, UK
4 Kings College Hospital, London, SE5 9RS, UK
5 Kings College London, Institute of Psychiatry, Psychology and Neuroscience, SE5 8AF, London, UK.
6 Southampton University Hospital, Department of Gastroenterology, Southampton, SO19 6YD, UK
7 Kings College London, Academic Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, London, SE5 9RJ, UK.
Author notes
Paul McCrone is no longer employed by KCL and is currently employed by University of Greenwich, School of Health Sciences, SE10 9LS
Correspondence to Stephanie Hughes sh3r11@soton.ac.uk
Acknowledgements
Funding: UK National Institute for Health Research
Ethical approval: National Research Ethics Service Committee South Central Berkshire, 11/06/13, ref 13/SC/0206.
Corresponding Author
Stephanie Hughes
University of Southampton
School of Primary Care, Population Sciences and Medical Education (PPM)
1st Floor Aldermoor Health Centre
Aldermoor Close
Southampton
SO16 5ST
Email: sh3r11@soton.ac.uk
Tel: 023 8059 1787
(no fax available)
Patients experiences of telephone and web-based Cognitive Behavioural Therapy for Irritable Bowel Syndrome: A longitudinal qualitative study
Abstract
Background
Cognitive behavioural therapy (CBT) is recommended in guidelines for people with refractory irritable bowel syndrome (IBS). However, availability is limited and poor adherence has been reported in face-to-face CBT.
Objectives
Nested within a randomised controlled trial of telephone and web-delivered CBT for refractory IBS, the objectives of this qualitative study were to: identify barriers and facilitators of engagement over time with the interventions; identify social and psychological processes of change; provide insight into trial results.
Methods
Longitudinal qualitative study nested in a randomised controlled trial. Repeated semi-structured interviews at three (n=34) and twelve-months (n=25) post baseline. Participants received telephone CBT (n=17 at 3m, n=13 at 12m) or web-based CBT (n=17 at 3m, n=12 at 12m). Inductive thematic analysis.
Results
Participants viewed CBT as credible for IBS, perceived their therapists as knowledgeable and supportive, and liked the flexibility of online and telephone delivery; these factors facilitated engagement. Potential barriers to engagement in both groups (mostly overcome by our participants) included initial scepticism and concerns about the biopsychosocial nature of CBT; initial concerns about telephone-delivered talking therapy; challenges of maintaining motivation and self-discipline given already busy lives; and finding nothing new in the web-based CBT (web-based CBT group only). Participants described helpful changes in their understanding of IBS, attitudes towards IBS, ability to recognise IBS patterns, and IBS-related behaviours. Consistent with the trial results, participants described lasting positive impacts on their symptoms, work, and social lives. Reasons and remedies for some attenuation of effects were identified.
Conclusions
Both telephone and web-based CBT for IBS were positively received and had lasting positive impacts on participants understanding of IBS, IBS-related behaviours, symptoms and quality of life. These forms of CBT may broaden access to CBT for IBS.
Keywords
Irritable bowel syndrome; cognitive behaviour therapy; internet; primary care, self management
Introduction
IBS affects 10-20% of the general population ADDIN EN.CITE National Institute for Health and Care Excellence200841[1]4141012National Institute for Health and Care Excellence,Irritable bowel syndrome in adults diagnosis and managementNICE Guideline CG61201703-08-20172008April 2017nice.org.uk/guidance/cg61[1]. Official UK guidelines for the management of IBS ADDIN EN.CITE National Institute for Health and Care Excellence200841[1]4141012National Institute for Health and Care Excellence,Irritable bowel syndrome in adults diagnosis and managementNICE Guideline CG61201703-08-20172008April 2017nice.org.uk/guidance/cg61[1] recommend provision of diet and lifestyle advice, a trial of medications and referral for psychological intervention, such as Cognitive Behavioural Therapy (CBT), if patients have ongoing troublesome symptoms after 12 months (refractory IBS). CBT can improve IBS symptom severity and quality of life ADDIN EN.CITE ADDIN EN.CITE.DATA [2-5]. However, availability of face-to-face CBT for IBS is very limited, is of uncertain cost effectiveness ADDIN EN.CITE Zijdenbos20099[6]9917Zijdenbos, I. L.de Wit, N. J.van der Heijden, G. J.Rubin, G.Quartero, A. O.Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Stratenum 6.131, P.O. Box 85500, Utrecht, Netherlands, 3508.Psychological treatments for the management of irritable bowel syndromeCochrane Database Syst RevCochrane Database Syst RevCD00644212009/01/23Cognitive Therapy/methodsHumansIrritable Bowel Syndrome/psychology/*therapyPsychotherapy/*methodsPsychotherapy, Group/methodsRandomized Controlled Trials as TopicRelaxation Therapy/psychology2009Jan 211469-493X (Electronic)
1361-6137 (Linking)19160286https://www.ncbi.nlm.nih.gov/pubmed/1916028610.1002/14651858.CD006442.pub2[6] and has issues with poor adherence ADDIN EN.CITE Kennedy200510[7]101017Kennedy, T.Jones, R.Darnley, S.Seed, P.Wessely, S.Chalder, T.Department of General Practice and Primary Care, Guy's, King's, and St Thomas' School of Medicine, King's College, London SE11 6SP.Cognitive behaviour therapy in addition to antispasmodic treatment for irritable bowel syndrome in primary care: randomised controlled trialBMJBMJ4353317514AdolescentAdultCognitive Therapy/*methodsCombined Modality TherapyHumansIrritable Bowel Syndrome/*therapyMiddle AgedParasympatholytics/*therapeutic usePhenethylamines/*therapeutic useTreatment Outcome2005Aug 201756-1833 (Electronic)
0959-535X (Linking)16093252https://www.ncbi.nlm.nih.gov/pubmed/16093252PMC118811110.1136/bmj.38545.505764.06[7]. The ACTIB trial ADDIN EN.CITE ADDIN EN.CITE.DATA [8] aimed to determine the clinical and cost-effectiveness of therapist-delivered CBT over the telephone (TCBT) and web-based CBT (WCBT) for IBS. Both TCBT and WCBT groups showed significant improvements in IBS symptoms compared to treatment as usual at 12 months ADDIN EN.CITE ADDIN EN.CITE.DATA [9,10]; Scores from the IBS-Symptom Severity Scale ADDIN EN.CITE Francis199728[11]282817Francis, C. Y.Morris, J.Whorwell, P. J.Department of Medicine, University Hospital of South Manchester, West Didsbury, UK.The irritable bowel severity scoring system: a simple method of monitoring irritable bowel syndrome and its progressAliment Pharmacol TherAlimentary pharmacology & therapeuticsAliment Pharmacol TherAlimentary pharmacology & therapeuticsAliment Pharmacol TherAlimentary pharmacology & therapeutics395-4021121997/04/01AdultAgedColonic Diseases, Functional/*diagnosisFemaleHumansMaleMiddle AgedReproducibility of Results*Severity of Illness IndexSurveys and Questionnaires1997Apr0269-2813 (Print)
0269-2813914678110.1046/j.1365-2036.1997.142318000.xNLMeng[11] were 61.6 (95% ci 33.8 to 89.5) points lower (p<0.001) in TCBT and 35.2 (95% ci 12.6 to 57.8) points lower (p=0.002) in WCBT at 12 months, compared to treatment as usual.
Therapist delivered CBT over the phone and Web-based CBT may overcome some of the barriers to traditional face-to-face CBT by offering better cost-effectiveness for healthcare commissioners ADDIN EN.CITE Anderson201016[12]161617Anderson, G.The promise and pitfalls of the internet for cognitive behavioral therapyBMC MedicalBMC Medical8822010PMC300480610.1186/1741-7015-8-82[12] and providing greater flexibility in timing and location for patients ADDIN EN.CITE ADDIN EN.CITE.DATA [9]. Although some people may prefer remote access therapies, it may not be appropriate for all patients. Having remote options available can increase access and free up more intensive face to face resources for those patients for whom remote intervention is not appropriate. Patients experiences of these modalities of CBT for IBS have rarely been studied and could provide novel insights into the processes underpinning treatment uptake, adherence, and effectiveness.
We previously explored patients experiences of using web-based CBT as part of a feasibility trial of the prototype of the web-based CBT programme used in ACTIB ADDIN EN.CITE ADDIN EN.CITE.DATA [13]. Participants in that study were positive about web-based CBT and described the website as well designed and easy to understand and use, though some felt that a user had to be self-motivated to work through the material. Participants engaged with the website to varying degrees, with some having limited or no engagement because they did not find the website relevant to them or the website was too impersonal. Follow up was at just 12 weeks, so experiences of longer-term effects could not be assessed. To the best of our knowledge, this is the only study on patients experiences of telephone and web-based and CBT for IBS. Studies in other populations suggest that web-based CBT is acceptable and helpful, and allows a level of anonymity when disclosing personal thoughts ADDIN EN.CITE Beattie200911[14]111117Beattie, A.Shaw, A.Kaur, S.Kessler, D.Department of Social Medicine, Academic Unit of Primary Health Care, Natinoal Institute for Health Research (NIHR), School for Primary Care Research, University of Bristol, Bristol, UK.Primary-care patients' expectations and experiences of online cognitive behavioural therapy for depression: a qualitative studyHealth ExpectHealth Expect45-59121AdultAgedCognitive Therapy/*methodsDepression/*therapyEnglandFemaleHumans*InternetInterviews as TopicMaleMiddle Aged*Patient Satisfaction*Primary Health CareYoung Adult2009Mar1369-7625 (Electronic)
1369-6513 (Linking)19250152https://www.ncbi.nlm.nih.gov/pubmed/19250152PMC506047710.1111/j.1369-7625.2008.00531.x[14]. Similarly, trials of telephone based CBT in other populations have shown encouraging results in terms of symptom improvement, with no detrimental impact on patient satisfaction ADDIN EN.CITE Burgess201212[15]121217Burgess, M.Andiappan, M.Chalder, T.Cognitive Behaviour Therapy for Chronic Fatigue Syndrome in Adults: Face to Face versus Telephone Treatment - A Randomized Controlled TrialBehavioural and Cognitive PsychotherapyBehavioural and Cognitive Psychotherapy175-1914022012PMC21929831https://doi.org/10.1017/S1352465811000543[15].
We conducted a large qualitative study nested within the ACTIB trial. Previously reported analyses using this dataset have focused on treatment seeking and appraisal processes ADDIN EN.CITE ADDIN EN.CITE.DATA [16], patients perspectives on GP interactions ADDIN EN.CITE ADDIN EN.CITE.DATA [17], and emotional processing in IBS ADDIN EN.CITE ADDIN EN.CITE.DATA [18]. The aim of this study was to explore patients experiences and views of telephone and web-based CBT for IBS immediately post treatment and at 12 month follow up. The objectives were to identify factors that facilitate or impede engagement with web-delivered and telephone-delivered CBT in this patient group both during and after the main intervention period; to identify social and psychological processes of change in the short and longer term; and to provide insight into the quantitative results of this complex trial.
Methods
The ACTIB Trial and Interventions
The ACTIB trial recruited 558 participants from primary care (GP) and secondary care (gastroenterology clinics) in Southampton and London between March 2014 and March 2016. The participants were randomised to one of 3 groups: Therapist-delivered telephone CBT (TCBT), web-based CBT (WCBT) and treatment as usual (TAU). The TCBT group received 6 one-hour telephone CBT sessions over 9 weeks, a detailed patient manual, and two booster 60-minute follow-up phone calls at 4 and 8 months. The WCBT group received access to the previously piloted IBS digital self-management programme Regul8 ADDIN EN.CITE ADDIN EN.CITE.DATA [19,20]. Regul8 consisted of 8 online sessions to be completed on a weekly basis, three 30-minute telephone support sessions over 9 weeks, and two booster 30-minute follow-up phone calls at 4 and 8 months. The CBT content delivered by telephone in the TCBT arm, and by website in the WCBT arm was the same, with only the mode of delivery differing. Both intervention groups also received ongoing treatment as usual, in primary and/or secondary care as appropriate. The two interventions contained similar content and the same therapists provided telephone support. The CBT content was based on an empirical cognitive behavioural model of IBS ADDIN EN.CITE Spence200794[21]949417Spence, M. J.Moss-Morris R,The cognitive behavioural model of irritable bowel syndrome: a prospective investigation of patients with gastroenteritis.GutGutGut1066-1071568200710.1136/gut.2006.108811 [21] and comprised education, behavioural and cognitive techniques, aimed at improving bowel habits, developing stable healthy eating patterns, addressing unhelpful thoughts, managing stress, reducing symptom focussing and preventing relapse ADDIN EN.CITE ADDIN EN.CITE.DATA [8]. The TAU group continued with their usual care (in primary and/or secondary care as appropriate) and were offered access to Regul8 on completion of the trial. For further details see the trial protocol ADDIN EN.CITE ADDIN EN.CITE.DATA [8]. The study was granted approval by the relevant National Research Ethics Service Committee on 11th June 2013 (13/SC/0206).
Nested Qualitative Study
Design
A longitudinal qualitative study was nested within the ACTIB trial, in an embedded mixed methods design with the qualitative component acting in a supportive capacity ADDIN EN.CITE Creswell20110Designing and Conducting Mixed Methods Research[22]mixed methodsmixed methods researchMethodsResearchDesigning and Conducting Mixed Methods ResearchCreswell, J. W.Plano Clark, V. L.IN FILE1505392991Thousand Oaks, California620111002Sage15053929912[22]. Repeated, also known as serial, semi-structured interviews were conducted with the same participants at 3 months and at 12 months. Serial interviews are rarely used in medical research but compared to one-off interviews are better suited to exploring patients experiences over time and changes therein ADDIN EN.CITE Murray20090Use of serial qualitative interviews to understand patients' evolving experiences and needs[23]Sep2009Attitude to HealthData CollectionEthics, MedicalHealth Services Needs and DemandHumansInterviews as TopicPatient Selectionhttps://www.ncbi.nlm.nih.gov/pubmed/197864851756-1833Use of serial qualitative interviews to understand patients' evolving experiences and needsBMJb3702Murray, S. A.Kendall, M.Carduff, E.Worth, A.Harris, F. M.Lloyd, A.Cavers, D.Grant, L.Sheikh, A.2009/09/28eng156570289117749615657028911978648510.1136/bmj.b3702339[23]. We therefore chose serial interviews because our objectives were oriented towards processes that occur in time (e.g. identifying processes of change in the trial) and because we were interested in how patients experiences and reflections might change from the initial therapy phase to the subsequent follow-up phase.
Data Collection
Purposeful sampling was used to select a range of ACTIB participants to invite for interview. In order to best address our objectives and to capture the experiences of a diverse range of individuals, we sought to interview participants from all 3 ACTIB groups and to include variation within each group in gender, age, ethnic background, geographical location (Southampton or London), symptom severity score and recruitment path (primary/secondary care). 100 of the 558 participants were approached for interview, 58 of whom agreed to take part. The data for this analysis comprise the interviews conducted with people from the TCBT and WCBT groups at 3 months post-baseline (n=34) and at 12 months post-baseline (n=24); the characteristics of these participants are summarised in Table 1, demonstrating the breadth of our sample.
Table 1: Baseline Demographic and Clinical Characteristics of Interviewees by Trial Group
Therapist CBTWeb-based CBTTotal Sample3 month 12 month 3 month12 month 3 month 12 month n171217123424Gender
Female, n (%)
13, (76%)
10, (83%)
14, (82%)
9, (75%)
27, (79%)
19, (79%)Ethnicity, n
White British
11
7
12
9
23
16White other444387Mixed white & Asian11--11African1---1-Other ethnicity--1-1-Age
Mean (SD)
39.94 (11.71)
38.4 (10.4)
42.41 (17.37)
45 (18.63)
41.18 (14.64)
41.7 (15.14)IBS-SSS Baseline score
Mean (SD)
283.47 (117.11)
278.58 (126.07)
259.65 (124.39)
219.58 (123.01)
271.56 (119.57)
249.08 (125.35)Recruitment site, n
Primary care
11
8
13
9
24
17 Secondary care6443107Duration of symptoms in years before study entry
Mean (SD)
14.71 (7.10)
12.83 (6.94)
15.59 (8.89)
16.33 (9.24)
15.15 (7.93)
14.58 (8.19)Length of IBS diagnosis when entering the trial
Mean (SD)
7.94 (7.66)
6.5 (6.53)
11.82 (9.22)
13 (8.72)
9.88 (8.59)
9.75 (8.23)
Interviews were conducted either face-to-face (n=9) or by telephone (n=49), lasted between 22-113 minutes and were audio-recorded and transcribed verbatim using unique participant identification numbers to preserve anonymity and permit linkage between repeated interviews. A semi-structured topic guide was used flexibly, allowing the interviewer to explore any relevant issues raised by the participants. The topic guide included open-ended questions on expectations about the ACTIB trial and reasons for taking part, previous experiences of IBS therapies and management, experiences of being in the trial and the allocated therapy, and any changes that occurred since starting the trial. Interviews at 3 months continued until data saturation, i.e., the point at which no new themes relevant to the research questions were identified. This was reached when 34 participants had been interviewed. The same 34 participants were contacted again at 12 months. Twenty four of the 34 participants agreed to be interviewed again. The remaining 10 either failed to respond or declined citing lack of time to take part. Data saturation for themes related to post-trial experiences and longer term retrospective reflections on trial experiences was reached within those 24 interviews, making additional recruitment unnecessary.
Data analysis
Interviews were read repeatedly before being coded in NVivo (version 11) and analysed by working iteratively with the phases mapped out by Braun and Clark for inductive thematic analysis ADDIN EN.CITE Braun200613[24]1313017Braun, VirginiaClarke, VictoriaUsing thematic analysis in psychologyQualitative Research in PsychologyQualitative Research in Psychology77-1013220061478-0887
1478-089510.1191/1478088706qp063oa[24] supplemented with techniques from grounded theory ADDIN EN.CITE Strauss199013[25,26]13136Strauss, A.Corbin, J.Basics of Qualitative Research: Grounded Theory Procedures and Techniques1990Thousand Oaks, CA, USSage PublicationsGlaser19671779177917796Glaser, B, G.Strauss, A.The Discovery of Grounded Theory: Strategies for Qualitative Research1967New Brunswick (U.S.A.) and London (U.K.)Aldine[25,26] (see Table 2).
During the final phase of analysis we also mapped the themes and coded data across trial groups, and time-points creating cross-tabulations similar to those produced in framework analysis ADDIN EN.CITE Ritchie199415[27]15156Ritchie, J.Spencer, L.Qualitative Data Analysis for Applied Policy Research. In: Bryman, A. and Burgess, B., Eds., Analyzing Qualitative Data1994LondonRoutledge[27]. An audit trail was maintained including code definitions and memos to document the analytic process. Finally, a narrative description of the findings was produced in which the identified themes and patterns were related back to the research objectives.
Table 2: Summary of the Analytic Process.
Thematic analysis phaseImplementationSupplementary techniques derived from grounded theoryFamiliarizationInitial notes made as transcripts read repeatedly.Listen to audio-recordingsGenerate initial codesUsing the first 22 transcripts initial codes and a coding manual were developed. This coding manual was used to analyse subsequent transcripts and amendments were made iteratively when necessary. Line-by-line open coding on a portion of the data; constant comparisonSearching for themesAs the analysis evolved, codes related to similar manifest or latent concepts were grouped together. These groupings were considered as candidate themes and sub-themes.Constant comparison; identify key concepts in the data; write memosReviewing themes Candidate themes and sub-themes were reviewed to ensure they worked in relation to the coded extracts and the individual interviews, and that they captured relevant material from across the dataset. Constant comparison; search for deviant cases; generate selected case summaries to capture participant stories and changes across 3 and 12 month interviewsDefining and naming themes and their inter-relationsThemes were refined and explicitly defined to clearly and succinctly capture patterns in the data relevant to the research objectives.
Cross-tabulations (using NVivos matrix query) to compare theme content and relevance between the TCBT and WCBT groups and between 3 and 12 months.Constant comparisonReportingSelected compelling examples to illustrate themes and subthemes. Final analysis and contextualisation in relation to the literature and research objectives.
An attempt was made to bracket the influence of the researchers prior knowledge and assumptions on the coding, while acknowledging that this is never fully achievable and that the emerging analysis is necessarily a product of the interactions between interviewer, interviewee, and analyst, situated within their particular sociocultural, intellectual, and historical contexts. This analysis was guided by the research objectives, supervised by an investigator experienced in qualitative methods (FB), and led by junior non-clinical researchers trained in qualitative research but not CBT (SH, JMH, AvF) one of whom (SH) was very familiar with the Regul8 intervention. They identified initial themes and sub-themes, some of which resonated with the theoretical processes underpinning CBT. The initial and final themes and sub-themes were reviewed and interpreted (SH, AvF, JMH, AS) with input from trained CBT therapists (RMM, TC) health psychologists (RMM, TC, FB), and an academic GP (HE). RMM and TC led the development of the initial model underpinning the CBT intervention, and HE, SH, AS, and FB were involved in the development of Regul8. The credibility of this qualitative analysis was enhanced by the involvement of multiple researchers and the use of NVivo to facilitate (a) the iterative process of analysis moving between raw data, codes, and themes within a large data corpus and (b) systematic comparisons between and within individual participants.
Results
Four main clusters of themes, related to each objective, were identified and were evident to some extent within both TCBT and WCBT groups: Experiencing symptomatic and quality of life improvements; Developing a different mind-set: cognitive and behavioural changes; Barriers to engagement with CBT; Facilitators to engagement with CBT. Each cluster comprised multiple themes, which are summarised in Figure 1. Below, we discuss these in detail, highlighting individual themes in bold typeface.
Figure 1: Summary of Themes Capturing Participants Experiences of Telephone and Web-Based CBT for IBS, Clustered by Research Objective
Identifying Factors that Facilitate Engagement with Web-delivered and Telephone-delivered CBT for IBS
This objective was addressed by the themes collated under Facilitators to engagement with CBT. High levels of satisfaction with CBT were suggested by participants positive comments about their experiences at both 3 months and 12 months and may have facilitated and/or reflected high levels of engagement. Participants views of web and phone-based CBT as credible for IBS were shaped by perceptions that the ACTIB CBT: took a systematic well-ordered approach; presented material in a professional, engaging, and accessible manner; and provided clear explanations of IBS and a convincing rationale for CBT. Early improvements in symptoms also contributed to a view of CBT as credible for IBS. This was true for both CBT groups with no clear differences between the groups. A participant in the TCBT group explained:
Literally after the second week of doing it, sort of reading through the books and then - talking to [name of therapist] for the hour and going through everything, it was brilliant and the fact that it did really help, you know, week by week we were talking about different behaviours and and I think, literally, I sort of saw improvement quite quickly really. P24547 (3m, TCBT)
Similarly, a participant in the WCBT group reported:
overall I was very, very pleased, it was nicely laid out, and I think that its really contributed into helping me overcome some of the issues that Ive dealt with Ive been dealing with up until that point. P10074 (3m, WCBT)
Participants in both groups valued being able to talk to therapists who were perceived as knowledgeable and supportive. They valued just having someone to talk to (P39446, TCBT, 3m), and found it particularly helpful to talk to someone who had IBS specific knowledge: its just nice to have someone listen who is kind of understands all the ins and outs. P45322, WCBT, 3m). It would seem that the therapists were able to develop positive therapeutic relationships despite being constrained by the telephone to verbal communication only. Affective bonds were also evident, as participants described their therapists as really friendly (P25044, TCBT, 3m), very nice to speak to (P20850, TCBT, 3m), and friendly and approachable (P16084, WCBT, 3m).
One potential drawback of web-based interventions, at least for some patients, is the lack of human interaction and support ADDIN EN.CITE ADDIN EN.CITE.DATA [12,13]. The telephone sessions provided to support the WCBT mitigated this risk and participants described how this therapist contact helped to reinforce the messages from Regul8, provided the opportunity to discuss their particular case, and enabled them to ask questions and have them answered. In these ways, the 30-minute telephone sessions helped to support engagement with the WCBT, in particular:
I think with the actual online sessions, theyve been really helpful, but then, being able to talk to my therapist, has really helped me kind of put them into practice. I think, for me, the online sessions themselves werent enough to deal with my case and my symptoms. I think being able to talk them over with the therapist has kind of re-cemented things, reaffirmed things and just being able to talk about them has really helped. P28570 (WCBT, 3m).
talking to (therapist name) was really, really good. That was nice to have that kind of backup support and, you know, I had like I think it was half an hour and it was a really good amount of time P45322 (WCBT, 3m).
The flexibility afforded by both online delivery and telephone delivery was commented on positively by participants. Both modes of delivery were experienced as convenient for participants, who were able to organise their own schedules for completing the online modules and did not have to physically travel to attend appointments. For example, I liked the way it was presented and its certainly helped me because I was able to do it my own time P16033 (WCBT, 12m); and I liked that it was over the phone sometimes as well, that I didnt always have to go somewhere and park and that was good P25044 (TCBT, 12m).
Identifying Factors that Impede Engagement with Web-delivered and Telephone-delivered CBT for IBS
Barriers to engagement with CBT encompassed four main themes describing factors that impede engagement with WCBT and/or TCBT. Participants in both groups who discussed initial scepticism and initial concerns about the biopsychosocial nature of the intervention also reported mostly overcoming these potential barriers to engagement. Some described feeling sceptical about how remote CBT could be either relevant or effective for IBS; and this scepticism was typically couched in a perceived Cartesian disjunction between CBT as focused on mental processes and IBS as a physical condition. Scepticism in both groups was overcome through beginning the intervention and learning about the cognitive behavioural model of IBS used in ACTIB and developed in an earlier trial ADDIN EN.CITE Moss-Morris201024[28]2424017Moss-Morris, R.McAlpine, L.Didsbury, L. P.Spence, M. J.School of Psychology, University of Southampton, UK. remm@soton.ac.ukA randomized controlled trial of a cognitive behavioural therapy-based self-management intervention for irritable bowel syndrome in primary carePsychol MedPsychol Med85-944012009/06/18AdultCognitive Behavioral Therapy/*methodsFemaleFollow-Up StudiesHumansIrritable Bowel Syndrome/*psychology/*therapyMaleMiddle AgedPatient Education as TopicPrimary Health CareSelf Care/*psychologySocial AdjustmentYoung Adult2010Jan1469-8978 (Electronic)
0033-2917 (Linking)19531276https://www.ncbi.nlm.nih.gov/pubmed/1953127610.1017/S0033291709990195[28]. The cognitive behavioural model was presented by starting with the physiological and biological changes that underpin the IBS symptoms and then exploring how these changes can be influenced by thoughts, feeling and behaviours and the autonomic nervous system responses linked to stress.
To be honest, when I started I was very sceptical, I couldnt see how thought processes and things would actually affect your tummy, but when its explained through the literature and when you speak to a therapist, you can really see the connection between how you think and how your tummy reacts and I think it just takes somebody to tell you P25119 (TCBT, 3m)
Some participants across both groups expressed initial concerns about whether the telephone was an appropriate mode of delivery for CBT as a form of talking therapy. For a few (2 TCBT interviewees, and 4 WCBT interviewees) these concerns persisted and appeared to derive from discomfort with the lack of non-verbal cues in telephone interactions.
obviously over the phone its slightly trickier than face-to-face. So we dont know what the other persons thinking or anything P40192 (TCBT, 12m).
Others overcame their concerns once they had started telephone sessions and focused more on the content of the CBT being delivered:
I did think it is odd to do counselling over the phone, but now I think actually it doesnt matter, it doesnt really matter at all as long as the counselling is good. P40210 (TCBT, 3m)
Participants from both TCBT and WCBT groups referred to the need for self-discipline and motivation to complete the homework tasks contained within the CBT programme. Some found it difficult to motivate themselves to do this homework and may have been negatively impacted by the connotations of this terminology:
I found it hard um Im not very good at doing homework and never have been and I dont suppose I will be, um so where its given my homework to do, Ive not Ive not been, um lets say a Grade A student P21339 (WCBT, 3m)
Participants described wanting to do the homework in order to experience the anticipated health improvements but also finding it difficult to do this within the context of busy lives and competing priorities. There was a sense in both WCBT and TCBT groups that investing more time in the programme would result in getting more out of it.
I: What did you dislike about being in this group? P: I think probably the discipline of having to do the homework its kind of a bit of a paradox; I wanted to do the homework because Im keen to participate and kind of make the best of it, but its kind of remembering to do it and having something else to do during the week. P25044 (TCBT, 3m)
There could have been more I learned from it if Id maybe done spent more time on it or done it over a longer amount of time, then I might have got more out of it, but I did get a lot from it. P40567 (WCBT, 12m)
One final barrier that impeded engagement with WCBT (but was not identified in the narratives of TCBT participants) for some participants was the sense that this intervention did not offer anything new. This was mostly expressed by participants who felt that they had lived with their IBS for a long time and had already made themselves familiar with and tried to implement recommendations regarding lifestyle issues including diet, stress, and physical activity. Such participants felt that the WCBT did not therefore offer them any new insights or approaches to managing their IBS.
Ive followed all the little sections on the trial, looking at your diet, looking at your stress, looking at your activity and Ive kind of gone through all of those on my own in the last few, you know, over the years. So-from my point of view, I didnt get an awful lot out of it because it was already telling what I already knew. P20066 (WCBT, 3m) Although this theme was only present in the WCBT arm, it is important to note that the content of the CBT programme was the same in both TCBT and WCBT arms, with only the mode of delivery differing.
Identifying Social and Psychological Processes of Change
Social and psychological processes of change were captured in the cluster of themes Developing a different mind-set: cognitive and behavioural changes. Within this cluster, four themes described different changes experienced by participants across both WCBT and TCBT groups: changes in their understanding of IBS, changed attitudes towards IBS, a newfound ability to recognise IBS patterns, and subsequent changes in behaviour associated with an increased sense of control over their IBS. At 3 months, participants in both groups felt they had an improved understanding of IBS as a reassuringly common condition which they could manage to some extent, based on their personal experience of improvements in IBS since commencing the trial.
Im really pleased [with that] and it doesnt mean the symptoms are completely gone, but it means that I understand them and I can control some of them. So I think thats something Im going to keep for life; its not something Im going to forget about. P40015 (TCBT, 3m)
I feel relieved, relieved that because going through the programme I realised that there are people out there who suffer exactly the same symptoms as I do, that its actually fairly common P10074 (WCBT, 3m)
The CBT programme taught participants to recognise their personal cognitive and behavioural patterns related to their IBS and enabled participants to evaluate their responses to these patterns. When these ideas resonated with individuals they were able to reflect on them and think about things in a different way.
I think like with the thoughts, just being aware of the sort of things that can kind of perpetuate the cycle of stress. I think catastrophizing or black-and-white thinking and things like that, I think I can see them in myself and I think just being aware of that, you can kind of try and take a back step and see it in another way and re-evaluate the situation. P26417 (TCBT, 3m)
Possibly as a consequence of feeling that they understood their IBS better and could identify their personal patterns, participants also reported changing how they thought about IBS. For example, some described being able to feel more relaxed and less worried about their IBS. This change then appeared to be linked with positive changes in behaviour, for example enabling participants to liberate themselves from ingrained and socially limiting behaviours such as avoiding public or shared toilets.
I started thinking to myself, you know, I dont need to stress and worry about it, there is a toilet here, its there if I can use it, which has helped, because I used to go home early from parties and things like that with a tummy ache. But now I can just think, you know, Im working myself up about it and then, more often than not, the feeling goes away and then Im absolutely fine. P25119 (TCBT, 3m)
Participants valued the tools and strategies that they developed through the CBT programme when they were found to effectively help manage their (response to) IBS. In this way, both WCBT and TCBT appeared to promote an increased sense of control over IBS and greater self-efficacy for coping.
I would say Im more in control than um previously because I have a whole series of tools to help me. P20822 (TCBT, 3m)
I feel so much more in control of my IBS and if something flares up I dont feel like its the end of the world and I know that Ive got strategies in place to be able to deal with them P28570 (WCBT, 3m)
The cognitive and behavioural changes promoted by the CBT programme were nicely summed up by a participant in the TCBT group who experienced total relief from IBS which was maintained at 12 months:
I now have a different mind-set, if you like, and a few little aids along the way, which help me to remember the interviews and I dont have any problems and havent had any problems since the ACTIB course finished. P20822 (TCBT, 12m).
Insights into the Quantitative Results of the ACTIB Trial
Cross-tabulating the themes by trial group and interview time-point helped to relate the qualitative data to the following key findings from the quantitative trial: the overall effectiveness of WCBT and TCBT, the maintenance of effects at 12 months, and adherence to the interventions.
In the trial, all primary and secondary outcomes showed significant improvement in both CBT groups compared to TAU at 12 months ADDIN EN.CITE ADDIN EN.CITE.DATA [9] (the primary endpoint) and the overall pattern was for beneficial effects (in IBS symptom severity, mood, and impact on life roles) to be sustained, on average, from 3 to 6 to 12 months. There was also evidence of some sustained improvements and some attenuation of effects from 12 to 24 months ADDIN EN.CITE Everitt20195[10]5517Everitt, H.,Landau, S.O'Reilly, G.Sibelli, A.Hughes, S.Windgassen, S.Holland, R.Little, P.McCrone, P.Bishop, F.Goldsmith, K.Coleman, N.Logan, R.Chalder, T.Moss-Morris, R.Cognitive behavioural therapy for irritable bowel syndrome: 24-month follow-up of participants in the ACTIB randomised trialThe Lancet Gastroenterology & HepatologyThe Lancet Gastroenterology & Hepatology201924681253PMC702669410.1016/s2468-1253(19)30243-2[10]. The theme Experiencing symptomatic and quality of life improvements captures the range of patient perceived benefits of the CBT programme. The majority of participants in both therapy arms reported IBS symptom improvements over the period of the study; some participants also described how the symptomatic, cognitive and behavioural changes associated with CBT contributed to improvements in their work and social lives. These improvements were particularly emphasized when participants were interviewed at 3 months but were still very evident in the 12-month interviews, demonstrating the lasting positive impact on the lives of these IBS patients.
I think it is much improved really; Ive not had as much sort of constipation as what I used to have, so so yes for me, it has been really, really good. P24547 (TCBT, 3m).
if I do have a problem I know I can, you know, let my boss know and shes fine. Ill just say Im going to be in a bit late, whereas, you know, like I said before, I just I would have just been like Im sick Pt 45322 (WCBT, 3m)
I used to be very concerned about going round to people's houses or going out to dinner or going for food somewhere, because I'd get very concerned that I might have a reaction and I'd need to run to the toilet straightaway and I think that stress and worry beforehand would always then trigger a bout of IBS, but now it's kind of I started thinking to myself, you know, I don't need to stress and worry about it, there is a toilet here, it's there if I can use it, which has helped. Pt 25119 (TCBT, 3m)
However, while some participants maintained improvements and felt they would carry these on into the future, others felt they had not managed to maintain earlier improvements.
Unfortunately Im unable to control it as I did when I did the study and even though I still do a number of techniques and use the tools that I have learned last year, Ive come to think that my mind has become immune to them and knows that these are just things Im telling myself, but its not registering; so the mind controls my body, still. P10074 (WCBT, 12m)
To explore possible reasons why some participants felt they did not sustain beneficial changes after completion of active treatment we classified participants as responders (n=22) and non-responders (n=12) at 12 months and compared the themes and subthemes across these groups. A responder was defined as a participant with a 50-point improvement on the IBS-SSS from baseline to 12 months ADDIN EN.CITE ADDIN EN.CITE.DATA [8]. This analysis suggested that people classified as responders had more positive experiences of active treatment than those classified as non-responders: at three months the responders talked more about developing a different mind-set and making cognitive and behavioural changes in response to CBT. Non-responders placed more emphasis on barriers to engagement. This suggests that patients engagement with structured active therapy and their ability to embed cognitive and behavioural changes in their lives are, unsurprisingly, important for longer-term effects. Two case summaries presented in Box 1 help to illustrate this within the broader context of patients experiences. Participants reflections also suggest that any attenuation of beneficial effects could be partially mitigated by providing limited ongoing access to a therapist to help discourage relapse into unhelpful patterns.
I would have found it very useful, as Im sure most participants would, to perhaps long-term, for this kind of treatment, have maybe somebody that you could contact, a point of contact from time to time, when you were having a particularly difficult time or needed to be reminded of something or to re-motivate you, because like with all things, if we dont have somebody behind us, I think we tend to have good intentions and then just go back to our old habits P20850 (TCBT, 12m).
Box 1: Case summaries of a responder and non-responder to TCBT
Two participants were selected for in-depth presentation to illustrate how one responder and one non-responder experienced CBT for IBS. These are not presented as representative cases but rather to showcase the interplay between themes as participants answered open-ended interview questions about their experiences over the course of a CBT trial. Both started the trial with severe IBS symptom severity scores, both were randomised to the TCBT arm, and both completed all of their telephone sessions including their booster calls. Participant P24547 maintained improvements at 12 months and was classified as a responder while P40210 did not.
Participant P24547
P24547 had experienced IBS symptoms for 15 years and did not really expect to benefit personally from the trial, having previously tried many treatments and sort of thought it was something I just had to learn to live with, I didn't think that I'd get a huge amount out of [the trial]. She had not previously tried CBT and did not express any reservations about it. When describing the nature of CBT and its impact on her IBS P24547 emphasized the cognitive aspects of the treatment. For example, when asked about any changes experienced since starting the trial she described how I used to get quite stressed and worked up about people at work. So (therapist name) was always saying that a lot of people with IBS have got sort of a level of perfection in themselves and I've definitely changed in the fact that I I'm trying to do as much as I can, the best but I don't always the best I can but I don't always strive for perfection which which I think is that sort of side me has really helped, working through those exercises. Related to this perceived need to make active changes to ones thinking patterns, a strong sense of empowerment to make such changes and thus manage any symptoms emerged from P24547s account of CBT. I think through this therapy it really sort of highlighted some of the things, even simple things like doing more exercises and making myself go out and and not stay in and just sort of think and worry about my pain and get annoyed because of why this is happening to me, sort of thing. It was sort of understanding that there are things that I can do to work with the idea. So for me it was sort of being able to recognise the symptoms and then know how to deal with them. During the trial, P24547 found the interactions with the therapist helped to motivate her to practice implementing her new cognitive and behavioural styles and was concerned that she might struggle to sustain these changes after completing the trial, but at 12 months explained how actually I have continued to reflect on things and if I get cross about something, instead of getting myself wound up, which then tends to make my IBS even worse, I do even literally last week I got really cross about how something went and I then thought, no; I went to the toilet, I breathed, and I thought, right, how can I see this from their point of view, which is what the manual often went through. So even now Im still finding it really useful.
Participant P40210
P40210 had experienced IBS symptoms for 24 years and was struggling with her IBS symptoms, feeling desperate for help at the start of the trial and prepared to just try anything, I would have been happy to stand on my head if it had made it better. She had done CBT before for depression and was a little apprehensive about delving into her emotions to start with but appreciated the new insights that she gained from CBT for IBS now I know they [thoughts and feelings] are totally linked to my problems. So that's been a positive thing that's come out of it. When asked about the effects of CBT she evidenced her new insight into her IBS triggers, but emphasized the improvements in her IBS symptoms and did not describe having adopted any cognitive or behavioural changes. I have what symptoms I'm having now ... are a huge amount less, I mean a massive amount less. So it's mainly now wind, a bit of rumbling tummy and a little bit of a little bit of acid reflux, a very small amount, but I can actually control that if I don't eat certain things. And also I have had one incident a sort of very small amount of soiling incident, which is very unusual, I haven't had that for about three or four years. That was a day when I was particularly very stressed. And small amounts of pain, you know, sort of spasm-type pain, sort of low down in my tummy, but really a huge amount less than I had before. P40210s account of CBT did not suggest that she thought it was necessary to actively work on making cognitive changes to help her IBS. Instead, she seemed to engage with CBT on a more limited basis, accepting a new understanding of IBS but not acting on that understanding, instead focusing on dietary measures. Without cementing the underpinning cognitive changes, P40210 did not manage to sustain her dietary changes at 12 months But now a year later, I think Ive probably fallen back into probably old habits really and I think a lot of that is to do with the fact that and I was discussing this with my daughters earlier the fact that my IBS problems have been going for a considerable length of time. So its as if the problems have outweighed the solutions, you know, the problems are more dominant than the solutions.
Quantitative data suggested good levels of adherence to TCBT and WCBT. In TCBT 84% (156/186) of participants completed at least 4 telephone sessions and in WCBT 88% (163/185) completed at least one telephone session while 69% (128/185) completed at least 4 website sessions. Previous trials have varied in the way they have defined adherence, and reaching an appropriate definition is not straight forward ADDIN EN.CITE Donkin201127[29]272717Donkin, LiesjeChristensen, HelenNaismith, Sharon L.Neal, BruceHickie, Ian B.Glozier, NickA Systematic Review of the Impact of Adherence on the Effectiveness of e-TherapiesJ Med Internet ResJ Med Internet Rese52133Adherencepersistenceonline therapye-therapysystematic review20112011/08/051438-8871http://www.jmir.org/2011/3/e52/https://doi.org/10.2196/jmir.1772http://www.ncbi.nlm.nih.gov/pubmed/2182150310.2196/jmir.1772[29]. We pre-defined adherence in our protocol and based it on the notion that participants would need to have received at least half of the programme to be considered to have received CBT. Only 3 interviewees were classified as non-adherent in our trial, all of whom had received WCBT, and we were unable to identify any themes that differentiated adherent and non-adherent participants.
Discussion
Main findings
Participants provided positive feedback about both web-based and telephone CBT for IBS. They described improvements in IBS symptoms, positive changes in their understanding of and attitude towards IBS, a newfound ability to recognise IBS patterns, and change behaviours. This resulted in an increased feeling of control over their IBS and improved work and social life despite some initial scepticism regarding remote CBT for IBS. They highlighted the need for self-discipline to undertake CBT and maintain behavioural changes in the longerterm, but felt the flexibility of telephone or web-based CBT and high quality therapy input aided engagement. Telephone support in the WCBT group was important and valuable to the participants.
Strengths and limitations
This study was a rigorously conducted qualitative study that benefitted from interviewing participants just after the CBT interventions to gather immediate perceptions at end of treatment (3 months) along with longer-term perceptions at 12 months. Participants were not interviewed again at 24 months, which reduced our ability to relate our qualitative findings to the 24-month quantitative follow-up ADDIN EN.CITE Everitt20195[10]5517Everitt, H.,Landau, S.O'Reilly, G.Sibelli, A.Hughes, S.Windgassen, S.Holland, R.Little, P.McCrone, P.Bishop, F.Goldsmith, K.Coleman, N.Logan, R.Chalder, T.Moss-Morris, R.Cognitive behavioural therapy for irritable bowel syndrome: 24-month follow-up of participants in the ACTIB randomised trialThe Lancet Gastroenterology & HepatologyThe Lancet Gastroenterology & Hepatology201924681253PMC702669410.1016/s2468-1253(19)30243-2[10]. The qualitative interviews enabled an exploration of individual differences in responding that are masked by the necessary focus in the trial data on group-level differences and changes over time. Participants were recruited from both primary and secondary care, which encompassed participants at different stages of their IBS journey, improving transferability to different settings. Participants interviewed had volunteered to take part, and all bar 3 were classified as adherent to the programme. Results may have differed from a non-self-selecting, non-adherent sample. Participants were mostly white, British and female, which is representative of the main ACTIB trial sample, but does not allow us to draw inferences about how people from other demographic groups might experience CBT for IBS.
While various measures were taken to minimise any inappropriate or uncritical influence of investigators pre-existing frameworks, it is important to acknowledge the interpretation of the data may have differed if conducted by a different research team. The measures taken to enhance analytic rigour included: coding of data conducted by three different individuals, obtaining input throughout the analysis process from the multidisciplinary team, and consciously exploring possible alternate explanations and discussing these within the team. Furthermore, the individuals coding the data were not CBT therapists, and did not consult the CBT therapists or model underpinning the intervention until the interpretation phase, after the subthemes had emerged.
Comparison to existing literature
To the authors knowledge this is the largest qualitative study to date exploring the experiences of participants undertaking web-based and telephone CBT for IBS. This study expands on work by Tonkin-Crine et al. ADDIN EN.CITE ADDIN EN.CITE.DATA [13] by:
Including participants at two time points; 12 weeks and 12 months post baseline, rather than just 12 weeks
Using a larger sample
Including participants who had received telephone-CBT, rather than just web-based CBT
The results from the present study showed similarities to the findings from the Tonkin-Crine et al (2013) study, for example, the feelings of positivity about the web-based CBT, and the need for self-motivation to carry them through the programme. However, not all findings were replicated, notably the current findings did not describe the website as impersonal or not personally relevant enough. This difference in findings may be accounted for by the different levels of telephone support in each study; Web-based CBT participants in the current study received three 30-minute telephone sessions and two 30-minute booster sessions, all with a trained CBT therapist. Web-based CBT participants in the Tonkin-Crine et al (2013) study received much less telephone contact (one session of 30-45 minutes) which was conducted by a practice nurse. Participants in the present study valued the telephone support, and the expert knowledge of the therapists, and it may be that this extra contact time with expertly trained therapists addressed these previously reported barriers. Indeed, having individuals providing support who are perceived as trustworthy, benevolent experts may be vital for such support to effectively engage patients in digital interventions ADDIN EN.CITE Mohr201126[30]262617Mohr, David C.Cuijpers, PimLehman, KennethSupportive accountability: a model for providing human support to enhance adherence to eHealth interventionsJournal of medical Internet researchJ Med Internet ResJ Med Internet Rese30-e30131Behavior TherapyDelivery of Health Care/*methodsElectronic MailHealth Services Research/methodsHumans*Internet*Models, PsychologicalMotivation*Patient CompliancePopulation SurveillancePsychological Techniques*Social Responsibility*Social SupportTelemedicine/*methods2011Gunther Eysenbach1438-887121393123https://www.ncbi.nlm.nih.gov/pubmed/21393123https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3221353/PMC322135310.2196/jmir.1602PubMedeng[30].
Conclusions and implications for future practice/research
While acknowledging the difference in adherence rates between the TCBT and WCBT groups, more research is needed to investigate ways of increasing engagement in the web intervention. This may include a therapist portal where therapist can see what patients have completed online and provide support and encouragement online as well as by telephone. The data showed the telephone support in the WCBT group to be valued and important and keeping this element in any future versions would be beneficial.
Future versions of this CBT programme may benefit from addressing the identified barrier around long-suffering IBS patients feeling the web-programme does not offer anything new. It may be helpful for therapists to use Socratic questioning or guided discovery when discussing the patients personal cognitive behavioural model in the initial telephone call to unpick familiar/unfamiliar areas, and if appropriate, provide reassurance that more novel content will be covered later in the programme.
Future CBT programmes for IBS might benefit from addressing potential scepticism about the effectiveness of such treatment at the start of the programme, to help IBS sufferers understand how it might help. It is important to note that while this study focussed on remote CBT for IBS, the scepticism may be applicable more generally to CBT for IBS, rather than the delivery mode.
It is unclear why the theme around the website failing to offer anything new was only present in the WCBT arm, however, perhaps the therapists in the TCBT arm were able to better personalise the content and focus on the parts most novel or applicable to the participants. Participants in the web-CBT group indicated that the small amount of telephone support they received was helpful to keep them on track, provided an outlet to ask questions and talk about their progress. Future research may investigate the minimal amount of therapist contact time needed in the delivery of an effective web-based programme for IBS: which may fall somewhere between the 30-45 minutes of nurse contact offered in the previous trial (Tonkin-Crine et al) and the 150 minutes of therapist contact offered in the ACTIB trial. In addition to this, the longevity of this support/contact time needs to be explored as some participants expressed the desire for longer-term support they could return to when they started to slip back into old habits. The potential source of this longer-term support also needs to be explored, for example, it is unclear whether this would need to be provided by a therapist, a website or a patients GP.
Both telephone and web-based CBT for IBS were positively received by people with refractory IBS. The flexibility and perceived high quality of the interventions aided engagement. These forms of CBT have the potential to provide a lower-cost acceptable alternative to face-to-face CBT.
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