Quality of engagement with in-the-moment digital CBT during periods of distress: A study of patients with suicidal thoughts and behaviors.

Practicing CBT skills outside of therapy sessions is a core component of effective treatment, yet meaningful engagement can be difficult during periods of elevated psychological distress. Smartphone-based ecological momentary interventions (EMIs) offer a promising approach to support real-time skill use, but most research has focused on frequency rather than quality of engagement. This study examined the quality of CBT skills practice in a 28-day smartphone-based EMI following inpatient discharge and explored its associations with internal context and intervention effectiveness. Twenty-three adults hospitalized for suicidal thoughts and behaviors participated, selecting and practicing one of three guided CBT skills exercises (Mindful Emotional Awareness, Countering Emotional Behavior, or Cognitive Flexibility) up to three times daily. A structured coding system was used to rate the completeness and relevance of 945 total exercises (0-2 scale). Quality varied primarily within individuals and was lower during moments of high suicidal intent and urge. When combining across all skills, quality was not associated with proximal change. However, higher-quality Countering Emotional Behavior practice predicted greater reductions in suicidal intent, and higher-quality Countering Emotional Behavior and Cognitive Flexibility practice predicted greater reductions in anger. These findings suggest that momentary distress can impact engagement quality, and that the short-term impact of skills practice may depend on both the specific CBT strategy and type of distress targeted. Understanding and enhancing engagement quality is a key step toward optimizing mobile interventions for individuals in the midst of psychological distress.