Journal Article

Capitalizing on natural language processing (NLP) to automate the evaluation of coach implementation fidelity in guided digital cognitive-behavioral therapy (GdCBT)

Fitzsimmons-Craft, Ellen E., Eisenberg, Daniel, Eckhardt, Regina, Rojas-Ashe, Elsa, Funk, Burkhardt, Newman, Michelle G., Barr Taylor, Craig, Zainal, Nur Hani, Rackoff, Gavin N., Wilfley, Denise E.

2025

Overview

As the use of guided digitally-delivered cognitive-behavioral therapy (GdCBT) grows, pragmatic analytic tools are needed to evaluate coaches' implementation fidelity. We evaluated how natural language processing (NLP) and machine learning (ML) methods might automate the monitoring of coaches' implementation fidelity to GdCBT delivered as part of a randomized controlled trial. Coaches served as guides to 6-month GdCBT with 3,381 assigned users with or at risk for anxiety, depression, or eating disorders. CBT-trained and supervised human coders used a rubric to rate the implementation fidelity of 13,529 coach-to-user messages. NLP methods abstracted data from text-based coach-to-user messages, and 11 ML models predicting coach implementation fidelity were evaluated. Inter-rater agreement by human coders was excellent (intra-class correlation coefficient = .980-.992). Coaches achieved behavioral targets at the start of the GdCBT and maintained strong fidelity throughout most subsequent messages. Coaches also avoided prohibited actions (e.g. reinforcing users' avoidance). Sentiment analyses generally indicated a higher frequency of coach-delivered positive than negative sentiment words and predicted coach implementation fidelity with acceptable performance metrics (e.g. area under the receiver operating characteristic curve [AUC] = 74.48%). The final best-performing ML algorithms that included a more comprehensive set of NLP features performed well (e.g. AUC = 76.06%). NLP and ML tools could help clinical supervisors automate monitoring of coaches' implementation fidelity to GdCBT. These tools could maximize allocation of scarce resources by reducing the personnel time needed to measure fidelity, potentially freeing up more time for high-quality clinical care.

• Publisher: Cambridge University Press
• Subject: Adult / Anxiety / Anxiety disorders / Anxiety Disorders - therapy / Automation / Avoidance behavior / Behavior modification / Clinical trials / Cognition / Cognitive behavioral therapy / Cognitive Behavioral Therapy - methods / Cognitive Behavioral Therapy - standards / Cognitive-behavioral factors / Disorders / Eating disorders / Feeding and Eating Disorders - therapy / Female / Fidelity / Health care management / Humans / Implementation / Internal validity / Intervention / Machine Learning / Male / Medical treatment / Mental disorders / Mental health / Mentoring / Natural Language Processing / Neural networks / Original / Original Article / Pragmatics / Psychotherapy / Quality of care / Resource allocation / Self help / Sentiment analysis / Supervision / Supervisors / Therapists / Therapy