By Jacinta Jardine, Innovation Associate at SilverCloud Health
This qualitative study exploring the experiences of 100 users over 8 weeks, found that guided online therapy provides a largely supportive and therapeutic experience for users.
Many participants had high expectations of treatment, and clear hopes for personal development. The study suggests a number of directions for the future development of online therapy systems.
This research is an analysis of secondary outcomes in a naturalistic RCT, conducted in a real-world healthcare setting (the UK’s NHS IAPT program). Users were asked about their expectations, their experience, and when and how they were using the guided online therapy programme (SilverCloud).
The results of this study highlight the fact that guided online therapy is not a one size fits all solution; creating one platform to suit many varied individuals is a design challenge that can be addressed via personalization.
The results also indicate a huge variance in usage patterns – the treatment was being used as a coping mechanism during periods of low mood, as part of a daily or weekly routine, more sporadically as therapy “on the go” and as a long-term, lifestyle support system.
Why study user experiences of guided online therapy?
Mental health is a huge global issue and a rapidly growing one. Guided online therapy allows us to overcome some of the common barriers people face when accessing traditional face-to-face therapy, such as long waiting lists, stigma, high costs and personal time constraints.
The experience of using guided online therapy is a personal and multifaceted one, layered with many qualities including engagement with therapy, technology usage, self-reflection and learning and adopting new skills.
In order to design effective interventions we need an in-depth understanding of how people are using these interventions and what their experiences are.
What do we mean by ‘experience’?
Experience is made up of many different parts, which change over time. In order to get a rounded, complete picture of the user’s experience of guided online therapy, we collected feedback before, during and after treatment. This was to cover the user’s expectations, their ‘in the moment’ experience and their memory of the experience - three core parts of a person’s experience.
Research methods and analysis
We used a 10 question open-ended questionnaire which was delivered to participants via the SilverCloud platform, along with the other measures in the trial. Of the 361 participants randomized in the trial, 256 completed at least one question on our questionnaire and 183 completed all ten questions.
We drew our sample from those who had completed all ten questions over the 3 timepoints because we wanted to examine this complete picture of experience across time. We stopped at 100 records because we reached saturation and no new themes were being created.
Expectations of guided online therapy
Users generally had high hopes and expectations for the experience and their own self-development through use of the intervention; only 23% expected anything negative or difficult of the experience. This strong sense of belief, both in the treatment and the user’s ability to make changes to their lives, is a key factor that has been shown to affect outcomes.
If we look a bit deeper at what is causing this sense of belief and hope, we will see that there are two external elements at play here – implementation and personal factors.
Implementation factors include the service where this research was conducted and the treatment pathways they have in place. Participants in this study were, for the most part, well prepared for treatment and knew what to expect from it.
Personal factors relate to the individual’s own readiness for change (how likely they are to take action and make changes to their lives) and motivation. Many participants in this study were ready to take action and make changes to their lives.
This research demonstrates that when we look at designing effective interventions, exploring the context of how they are accessed and implemented within services is crucial. It also highlights an interesting area for future work, that is assessing and potentially influencing the user’s state of mind and level of motivation before accessing treatment (e.g. with Motivational Interviewing techniques).
User experiences of guided online therapy
Online therapy as a field has traditionally drawn on concepts from psychotherapeutic practice, with the aim of bringing the therapeutic qualities of traditional therapy into the digital sphere.
It is not surprising then that some of the helpful aspects of guided online therapy (e.g. provision of information, learning CBT skills, therapist support) found in this study and their associated impacts for the user (e.g. insight/awareness, behavior change, empowerment, feeling understood), are similar to those found in traditional psychotherapy.
Many other helpful aspects of the experience of online therapy are unique to this form of treatment, such as being able to access the treatment in the user’s own time and at their own pace and the autonomous nature of the treatment. Responses suggest that these aspects can lead to improved self-efficacy and self-belief, as users become the agents of their own change:
“I have enjoyed the feeling of 'self-teaching' as it were as it is me that is reading the information rather than somebody telling me what to do. I feel in control.”
Not a one size fits all solution
This study also found that some of the core features of guided online therapy elicit diverse experiences and perspectives from different users.
For example, the flexible and self-directed nature of the treatment was empowering and motivational for 36% of participants, yet for 10% it made the treatment feel burdensome or like “a chore”. Similarly 46% of participants felt supported and reassured by the treatment, whereas 9% would have preferred more support or guidance.
But how can we provide the same treatment to so many unique individuals, who have such different experiences of the same thing?
The design challenge of creating one platform to suit many varied individuals can be assessed using the Design Tensions Framework (Tatar, 2007), which helps us to understand that there is no perfect solution, just opposing elements that need to be balanced. This challenge further motivates our efforts to explore more personalized or customizable treatment delivery, as we strive to design treatments that are relevant for each individual.
This study found variance in usage patterns both between people and within each person. The platform was being used as a coping mechanism - as a way to find answers and seek help in the moment. It was also used on a routine, habitual basis, and more erratically as therapy “on the go”.
“I tend to try and use it a bit every day so that I can progress gently but I do binge as well.”
This research also suggests that many users understand the experience of using the platform as a long-term journey. Users recognize that they are gaining skills to help them stay well into the future, rather than simply treating an illness. They see guided online therapy as lifestyle support system, empowering them to help themselves:
“SilverCloud makes me think of working towards a happier and rewarding end to feeling over whelmed and quite unsatisfied with life, something to look forward and not back. Help is always at hand”.
Going beyond the ‘treatment’ model
Guided online therapy is often designed around traditional therapy delivery formats and structures e.g. the user does one 40 – 60 minute session a week. These interventions currently exist within the paradigm of traditional therapies, yet this could be limiting their potential to fully provide for the user’s needs.
By going beyond the “treatment” model we can look at some alternatives, including:
- other theoretical models that support growth and flourishing (e.g. positive psychology),
- alternative treatment formats such as blended methods which combine face-to-face therapy with online programs,
- different types of interactions and functionality that make the most of the technology, and
- alternative target user groups, who may have previously been unsupported e.g. using guided online therapy as a preventative measure for those at risk.
Designing guided online therapy
Three of the main implications of this study for the design of interventions are:
- The systems and structures that surround the treatment and each individual user’s level of motivation, readiness for change and hopefulness can have as much of an impact on user experience as the intervention itself.
- Exploring design tensions can help us to make informed decisions about how we mediate polarized elements such as flexibility, motivation and engagement.
- Understanding how users integrate guided online therapy in their lives can help us to design future technologies that go beyond traditional models of therapy, focusing instead on how we can make the best use of technology to effectively address user needs.
Tatar, D. (2007). The Design Tensions Framework. Human-Computer Interaction, 22, 413–451.