Linguistic Analysis of Communication in a Therapist- Assisted Internet-Based Cognitive Behaviour Therapy Program for Individuals with Generalized Anxiety Disorder

Abstract

Background: Therapist-assisted Internet-based Cognitive Behaviour Therapy (TAICBT) is an empirically supported method of treating generalized anxiety disorder (GAD). In addition to the cognitive and behavioural elements found within face-to-face Cognitive Behaviour Therapy (CBT), TAICBT includes elements of expressive writing, through email communication with a therapist. Expressive writing has been associated with positive outcomes; furthermore, certain linguistic dimensions in expressive writing have been associated with psychological and physical health benefits, such as less frequent use of negative emotion words, and greater use of positive emotion words. No research to date has analyzed linguistic dimensions in client communication over the course of a TAICBT program. Objective: The purpose of the present study was to understand how clients with symptoms of GAD are communicating with their online therapists, and explore whether their communication style was related to successful participation. Research Questions: Six research questions were posed for analyses: Is there a relationship between client online communication (i.e., word count and percentage of specific word categories) and symptom measures (e.g., general anxiety, work and social adjustment)? Does communication change over the course of 12 modules? Do participants who have completed all 12 modules, compared to those that completed fewer than 12 modules, differ in baseline communications submitted to their therapists? Do program completers who are classified as symptomatic versus asymptomatic on the GAD-7 after program completion differ in overall communication submitted to their therapists? For program completers, do change scores on symptom measures from preto post-treatment correlate with overall communication? For program completers, do scores on therapeutic alliance, treatment satisfaction, and comfort with emotional expressivity correlate with overall communication? Method: Data was obtained from a previously-conducted study. Specifically, written communication submitted to therapists by 107 adult clients with symptoms of GAD during the course of a 12 module TAICBT program was analyzed along with generalized anxiety, worry, and work and social adjustment scores completed pre-, mid- and post-treatment. Analyses: Clients’ written communication was screened for typographical errors and analyzed by the Linguistic Inquiry and Word Count Software (Pennebaker, Chung, Ireland, Gonzales, & Booth, 2007). Results: Significant relationships emerged between negative emotion words, anxiety words, insight words, and past tense words, with symptom measures of anxiety and worry; these categories also changed over time. A higher number of negative emotion and anxiety words differentiated clients that dropped out of the program earlier versus those that dropped later, and demonstrated a negative relationship with therapeutic alliance and treatment satisfaction. Discussion: Results suggest there is utility in paying attention to linguistic categories as they can be used as indicators of client progress and well-being. Findings improve our understanding of the client experience of participating in TAICBT, with some linguistic trends being consistent with what clinicians would expect to see from a client's successful participation in therapy. Other findings offer new insight into communication that may be particularly relevant to clients with symptoms of GAD. Findings confirm that clients are engaging with the program and opening up to their therapists. In addition to generating new knowledge about the process of TAICBT, the potential mechanisms of change, and potential predictors of success within TAICBT, the current findings could also facilitate improvement in the way TAICBT is delivered in the future.