A qualitative study of patients' perceptions of a 'minimal' psychological therapy

Types and mechanisms of idiographic change during guided self-help for anxiety

OBJECTIVES

To compare idiographic change during two formats of guided self-help (GSH); cognitive-behavioural therapy guided self-help (CBT-GSH) and cognitive analytic therapy guided self-help (CAT-GSH).

DESIGN

Qualitative inductive thematic analysis.

METHODS

Semi-structured interviews with N = 17 participants with a reliable change outcome on the GAD-7 after completing GSH for anxiety. Changes were categorised and themes extracted.

RESULTS

No differences between CAT-GSH and CBT-GSH were found regarding types of change reported. The five overarching themes found were personal qualities of success, enlightenment through understanding, specific tools and techniques, changes to relationships and tailoring support. Four themes maximally differentiated between the two different types of GSH; CAT-GSH enabled relational insight and change whilst CBT-GSH enabled better understanding of anxiety, new coping techniques and supportive relationships.

CONCLUSIONS

Both common and model-specific factors contribute to patient change during GSH. Whilst all forms of GSH are grounded in the psychoeducational approach, separate theoretical foundations and associated methods facilitate different types of ideographic change.

Internet-Administered Cognitive Behavioral Therapy for Common Mental Health Difficulties in Parents of Children Treated for Cancer: Intervention Development and Description Study

BACKGROUND

Following the end of a child's treatment for cancer, parents may report psychological distress. However, there is a lack of evidence-based interventions that are tailored to the population, and psychological support needs are commonly unmet. An internet-administered low-intensity cognitive behavioral therapy (LICBT)-based intervention (EJDeR [internetbaserad självhjälp för föräldrar till barn som avslutat en behandling mot cancer]) may provide a solution.

OBJECTIVE

The first objective is to provide an overview of a multimethod approach that was used to inform the development of the EJDeR intervention. The second objective is to provide a detailed description of the EJDeR intervention in accordance with the Template for Intervention Description and Replication (TIDieR) checklist.

METHODS

EJDeR was developed through a multimethod approach, which included the use of existing evidence, the conceptualization of distress, participatory action research, a cross-sectional survey, and professional and public involvement. Depending on the main presenting difficulty identified during assessment, LICBT behavioral activation or worry management treatment protocols are adopted for the treatment of depression or generalized anxiety disorder when experienced individually or when comorbid. EJDeR is delivered via the Uppsala University Psychosocial Care Programme (U-CARE) portal, a web-based platform that is designed to deliver internet-administered LICBT interventions and includes secure videoconferencing. To guide parents in the use of EJDeR, weekly written messages via the portal are provided by e-therapists comprising final year psychology program students with training in cognitive behavioral therapy.

RESULTS

An overview of the development process and a description of EJDeR, which was informed by the TIDieR checklist, are presented. Adaptations that were made in response to public involvement are highlighted.

CONCLUSIONS

EJDeR represents a novel, guided, internet-administered LICBT intervention for supporting parents of children treated for cancer. Adopting the TIDieR checklist offers the potential to enhance fidelity to the intervention protocol and facilitate later implementation. The intervention is currently being tested in a feasibility study (the ENGAGE study).

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1136/bmjopen-2018-023708.

[Implementation of a Web-Based Self-Help Intervention for Mood Enhancement during Waiting Times for Outpatient Psychotherapy - A Qualitative Study Exploring Participants' Perspectives]

OBJECTIVE

In Germany, waiting times for outpatient psychotherapy are on average 5 months long. Guided web-based interventions can be implemented to reduce depressive symptoms during waiting times. The study aims to explore how patients experience the usage of a web-based intervention for mood enhancement.

METHODS

Patients on the waiting lists of cooperating outpatient clinics were invited to participate in the study and apply a web-based intervention for mood enhancement. Eleven participating patients were interviewed about their experiences with the intervention. The data was analyzed based on the Grounded-Theory methodology.

RESULTS

Three categories could be derived from the data: prior expectations, experiences with the intervention and factors influencing adherence. The web-based intervention was experienced very differently and was associated with both positive and negative experiences. The participants could be grouped into 3 user types.

DISCUSSION

Not all patients report positive experiences with the intervention and some fail to adhere. In order to prepare patients adequately, they should be informed about the application and goals of the intervention in advance. Interventions should be implemented in accordance with the individual's need of support in order to enhance adherence and allow positive experiences.

Internet-based cognitive behavioral therapy for anxiety in an outpatient specialized care setting: A qualitative study of the patients' experience of the therapy

Knowledge about user experiences of internet-based cognitive behavioral therapy (iCBT) has mostly been drawn from non-clinical groups or with iCBT offered via self-referral. The present study therefore focused on patients who had undergone iCBT with minimal support while actively awaiting outpatient psychological treatment in the form of face-to-face CBT. To seek out barriers to adherence the study also included patients who had withdrawn from the iCBT treatment before completion. The study was performed in an outpatient clinic for anxiety disorders where twelve participants with a primary diagnosis of either social anxiety disorder or panic disorder were recruited from an ongoing randomized control trial for semi-structured interviews. Statements from the interviews showed that the iCBT treatment was unfavorably compared to the usual face-to-face treatment at the clinic. Despite this, a majority of the interview participants still expressed to have experienced various benefits from the treatment. Some participants did however, experience difficulties putting the materials to practical use. Furthermore, a large majority of the participants expressed a need for additional support, with a strong tendency for non-completers specifically expressing a need for face-to-face contact with a clinician. Implications for future research and implementation of iCBT in clinical practice are discussed.

Clients' experiences of one-to-one low-intensity interventions for common mental health problems: An interpretative phenomenological analysis

OBJECTIVES

Common mental health disorders such as depression and anxiety are highly prevalent and carry significant health care and economic burdens. The UK's improving access to psychological therapies (IAPT) initiative was developed as a cost-effective way of reducing the pernicious effects of these disorders. IAPT interventions, such as guided self-help, have been subjected to considerable quantitative evaluation. However, there has been minimal investigation into clients' experiences of the one-to-one low-intensity interventions (LIIs), which form a key component of IAPT service provision. Qualitative exploration could provide rich data regarding experiences of psychological change and factors affecting therapeutic experiences. This will enable informative, client led insights into how low-intensity therapy can be improved.

METHODS

Interpretative phenomenological analysis of eight semi-structured interviews was used to develop an idiosyncratic understanding of clients' experiences of one-to-one LIIs following entry into a randomized control trial (RCT).

RESULTS

Four superordinate themes were identified from clients' accounts: goals and expectations of therapy, beneficial aspects of therapy, non-beneficial aspects of therapy, and the experience of psychological change. A heuristic model of interrelationships between factors is proposed.

CONCLUSIONS

Both therapeutic techniques and relationships contribute to beneficial therapeutic experiences. The results reported here can be used to inform practice by harnessing the most beneficial aspects of therapy, such as developing adaptive therapeutic approaches to clients' clinical needs and facilitating idiosyncratic processes of psychological change. Due to limited qualitative research in this area, further research should be conducted in different service settings to assess differences and similarities in clients' experiences.

PRACTITIONER POINTS

Therapists who adapted to clients' individual needs were perceived as more effective than those who did not. Effective therapeutic experiences were exemplified by a personal therapeutic approach, enough time to discuss issues and normalizing client's experiences. Clients develop idiosyncratic models of change which should be encouraged by therapists over and above clinical models.

Experiences of internet-delivered and work-focused cognitive behavioral therapy for stress: A qualitative study

INTRODUCTION

Stress is one of the major challenges of modern society, causing significant costs and personal problems. In the recent decade a growing body of research has provided support for the efficacy of internet interventions for stress. However, few studies have focused on how participants experience internet interventions for stress.

METHOD

The current study was a qualitative follow-up study of an internet-delivered and work-focused cognitive behavioral treatment for stress. The aim was to capture participants' experiences of the treatment and their views on effects on health and well-being. Participants were selected from a controlled study (n = 27), using a criterion-based sampling approach selecting those participants who had completed all treatment modules. Nine semi-structured interviews were held, and the material was analyzed using Thematic Analysis.

RESULTS

The results indicated that most of the participants experienced positive effects on their mental health and well-being in both life and at work. All participants emphasized the importance of having access to therapist support. In line with previous research, participants found the intervention to be extensive and demanding and expressed the need for extended treatment time and therapist support.

CONCLUSIONS

Considering the limitations of the present study, future research could examine the feasibility of reducing the length of each session, extending deadlines and increasing therapist support. This could improve treatment efficacy and further enhance utilization in the target population.

"Unrigging the support wheels" - A qualitative study on patients' experiences with and perspectives on low-intensity CBT

Background

Low-intensity treatments imply reduced therapist contact due to an emphasis on self-help and the use of technologies to deliver treatment. The role of the remoteness, the reduced therapist contact, and the interplay of these components has not been differentiated from a patients’ perspective so far. This study’s purpose is to capture patients’ experiences with telephone-based self-help cognitive behavioural therapy (tel-CBT).

Methods

A subsample of mildly to moderately depressed patients (N = 13) who finished tel-CBT as part of a larger randomised controlled trial (RCT) in routine care were interviewed using a semi-structured questionnaire. Interviews were audiotaped, transcribed verbatim, and independently coded by two coders blind to treatment outcome. Using qualitative content analysis with deductive and inductive procedures, a two-level category system was established.

Results

The category system contains four category clusters regarding expectations, self-help related aspects, telephone-related aspects, and implications for patients’ treatment pathway, and subsumes a total of 15 categories. Self-help related aspects circulate around the interplay between written materials and professional input, trust and support in the therapeutic relationship and its relation to the initial personal contact, as well as CBT principles. Telephone-related aspects entail perceived advantages and disadvantages of the telephone on an organisational and content level as well as a discourse around distance and closeness in the interaction. Although patients raised doubts regarding the long-term effect of the intervention on symptomatology, patients expressed satisfaction with the treatment and reported an immediate as well as a longer lasting personal impact of the treatment. These results indicate user acceptance with tel-CBT.

Conclusions

This qualitative analysis captures patients’ experiences with tel-CBT and the perceived helpfulness of the diverse treatment components. This can facilitate refining aspects of low-intensity treatments and might improve dissemination.

Trial registration

ClinicalTrials.gov NCT02667366. Registered on 3 December 2015.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4495-1) contains supplementary material, which is available to authorized users.

Experiences of a transdiagnostic group, the Take Control Course, for clients with common mental health problems: A qualitative study

OBJECTIVES

Despite the promising effectiveness findings for transdiagnostic groups, studies have not explored clients' experiences. There is a risk that clients could perceive that the content of transdiagnostic groups is not sufficiently tailored to their specific problems. Our aims were to examine whether a brief transdiagnostic group, the Take Control Course (TCC), was acceptable to participants and to explore participants' perceptions of psychological change.

METHODS

Qualitative data were collected via 12 semistructured, in-depth interviews. Data collection and thematic analysis were concurrent and iterative.

RESULTS

Three superordinate themes were identified: "Style and format," "Control and flexibility," and "Change." The flexible group format was appreciated, as participants felt able to engage at their own pace and adapt relevant aspects. Greater clarity regarding what was within participants' control reduced distress and enabled effective pursuit of valued goals. Participants described significant (predominantly gradual) changes, including substantial improvements within relationships.

CONCLUSIONS

The transdiagnostic format did not prevent participants experiencing the TCC as individually relevant. The flexibility and consistent theoretical framework seemed to contribute to this. The results indicated that greater consideration of control and mindfulness allowed greater cognitive flexibility, an ability to reprioritize and let go of unhelpful habits, which better enabled participants to meet their goals. Implications for group therapy include (a) clearly explaining the format of such groups to clients and (b) providing flexibility in the way the group is delivered where possible. Additional qualitative studies of transdiagnostic groups are required to establish if themes generalize to other transdiagnostic groups.

Patients' experiences in a guided Internet- and App-based stress intervention for college students: A qualitative study

INTRODUCTION

Academic education is often associated with increased stress and adverse effects on mental health. Internet-based interventions have shown to be effective in reducing stress-related symptoms. However, college students as target group so far have not been reached appropriately with psychological interventions and little is known about college students' perception of Internet-based stress management interventions. The objective of this study was to explore the experiences of students participating in an Internet- and App-based stress management intervention originally developed for stressed employees and subsequently adapted and tailored to college students.

METHOD

Semi-structured interviews were conducted with ten participants selected from a randomized controlled trial that evaluated the effectiveness of an Internet- and App-based stress training. The selection of participants aimed to include students with different levels of treatment success. In order to enable an in-depth examination of intervention elements causing dissatisfaction, the interviews were systematically adapted regarding participants' statements in a precedent questionnaire. The interview material was analyzed based on the grounded theory method and thematic analysis.

RESULTS

Results suggest students perceive a necessity to adapt Internet-based interventions to their particular needs. Students' statements indicate that a scientific perspective on the intervention and instable life circumstances could be student-specific factors affecting treatment experience. General themes emerging from the data were attitudes towards individualization and authenticity as well as demands towards different functions of feedback.

DISCUSSION

Participants' experiences hint at certain intellectual and lifestyle-related characteristics of this population. Future studies should explore whether adaptions to these characteristics lead to a higher acceptance, adherence and effectiveness in the target population.

'One man's medicine is another man's poison': a qualitative study of user perspectives on low intensity interventions for Obsessive-Compulsive Disorder (OCD)

BACKGROUND

Low intensity interventions based on cognitive-behavioral therapy (CBT) such as computerized therapy or guided self-help can offer effective and accessible care for mild to moderate mental health problems. However, critics argue that by reducing therapist input and the level of experience of the professionals delivering therapy, low intensity interventions deprive users of critical 'active ingredients'. Thus, while demand management arguments support the use of low intensity interventions for OCD, their integration into existing mental health services remains incomplete. Studies of user views of low intensity interventions can offer valuable insights to define their role and optimize their implementation in practice.

METHODS

Qualitative interviews (n = 36) in adults with OCD explored user perspectives on the initiation, continuation and acceptability of two low intensity CBT interventions: guided self-help (6 h of professional support) and computerized CBT (1 h of professional support), delivered within the context of a large pragmatic effectiveness trial (ISRCTN73535163).

RESULTS

While uptake was relatively high, continued engagement with the low intensity interventions was complex, with the perceived limitations of self-help materials impacting on users' willingness to continue therapy. The addition of professional support provided an acceptable compromise between the relative benefits of self-help and the need for professional input. However, individual differences were evident in the extent to which this compromise was considered necessary and acceptable. The need for some professional contact to manage expectations and personalize therapy materials was amplified in users with OCD, given the unique features of the disorder. However, individual differences were again evident regarding the perceived value of face-to-face support.

CONCLUSIONS

Overall the findings demonstrate the need for flexibility in the provision of low intensity interventions for OCD, responsive to user preferences, as these preferences impact directly on engagement with therapy and perceptions of effectiveness.

Combining behavioural activation with physical activity promotion for adults with depression: findings of a parallel-group pilot randomised controlled trial (BAcPAc)

BACKGROUND

Depression is associated with physical inactivity, which may mediate the relationship between depression and a range of chronic physical health conditions. However, few interventions have combined a psychological intervention for depression with behaviour change techniques, such as behavioural activation (BA), to promote increased physical activity.

METHODS

To determine procedural and clinical uncertainties to inform a definitive randomised controlled trial (RCT), a pilot parallel-group RCT was undertaken within two Improving Access to Psychological Therapies (IAPT) services in South West England. We aimed to recruit 80 adults with depression and randomise them to a supported, written self-help programme based on either BA or BA plus physical activity promotion (BAcPAc). Data were collected at baseline and 4 months post-randomisation to evaluate trial retention, intervention uptake and variance in outcomes to inform a sample size calculation. Qualitative data were collected from participants and psychological wellbeing practitioners (PWPs) to assess the acceptability and feasibility of the trial methods and the intervention. Routine data were collected to evaluate resource use and cost.

RESULTS

Sixty people with depression were recruited, and a 73 % follow-up rate was achieved. Accelerometer physical activity data were collected for 64 % of those followed. Twenty participants (33 %) attended at least one treatment appointment. Interview data were analysed for 15 participants and 9 study PWPs. The study highlighted the challenges of conducting an RCT within existing IAPT services with high staff turnover and absences, participant scheduling issues, PWP and participant preferences for cognitive focussed treatment, and deviations from BA delivery protocols. The BAcPAc intervention was generally acceptable to patients and PWPs.

CONCLUSIONS

Although recruitment procedures and data collection were challenging, participants generally engaged with the BAcPAc self-help booklets and reported willingness to increase their physical activity. A number of feasibility issues were identified, in particular the under-use of BA as a treatment for depression, the difficulty that PWPs had in adapting their existing procedures for study purposes and the instability of the IAPT PWP workforce. These problems would need to be better understood and resolved before proceeding to a full-scale RCT.

TRIAL REGISTRATION

ISRCTN74390532 . Registered on 26 March 2013.

Attitudes and Preferences towards Self-help Treatments for Depression in Comparison to Psychotherapy and Antidepressant Medication

Background: Self-help is an effective treatment for depression. Less is known, however, about how acceptable people find different self-help treatments for depression. Aims: To investigate preferences and attitudes toward different self-help treatments for depression in comparison to psychotherapy and antidepressants. Method:N = 536 people who were not actively seeking treatment for depression were randomly assigned to read about one of five treatment options (bibliotherapy, Internet-based self-help, guided self-help, antidepressants, or psychotherapy) before rating how acceptable they found the treatment. Participants also ranked the treatments in order of preference. Results: Psychotherapy and guided self-help were found to be the most acceptable and preferred treatment options. Antidepressants and bibliotherapy were found to be the least acceptable treatments, with antidepressants rated as the most likely to have side effects. Preference data reflected the above findings – psychotherapy and guided self-help were the most preferred treatment options. Conclusions: The findings highlight differences in attitudes and preferences between guided and unguided self-help interventions; and between self-help interventions and psychotherapy. Future research should focus on understanding why unguided self-help interventions are deemed to be less acceptable than guided self-help interventions for treating depression.

Psicoterapia pela Internet: viável ou inviável?

A psicoterapia pela internet é uma prática que, no Brasil, só é permitida aos psicólogos na forma de pesquisa. O objetivo do presente artigo foi realizar uma revisão dos estudos em psicoterapia pela internet, discorrendo sobre os recursos e os limites desse atendimento psicológico e suas implicações para a relação terapêutica e para a efetividade do tratamento. São apresentadas questões legais e éticas concernentes à prática. Os resultados apontaram similaridades entre a relação terapêutica online e a presencial, mostrando-se a psicoterapia pela internet efetiva nas mais distintas modalidades, embora a maioria dos estudos seja sobre intervenções cognitivo-comportamentais. As questões legais e éticas podem ser parcialmente solucionadas com diretrizes claras das organizações profissionais e com o treino de terapeutas na modalidade online. Concluímos que a psicoterapia pela internet, embora requeira maiores estudos, anuncia-se como uma prática viável e promissora.

No pain, no gain: depressed clients' experiences of cognitive behavioural therapy

OBJECTIVES

Cognitive behavioural therapy (CBT) is an effective treatment for depression, but many clients do not complete therapy. What clients find difficult about CBT is poorly understood. This study explored clients' views and experiences of face-to-face CBT.

DESIGN

A mixed methods design was used to collect data as part of the CoBalT trial.

METHOD

Participants randomized to CBT indicated their reasons for never starting or stopping therapy on the follow-up questionnaires. In-depth qualitative interviews took place with a purposive sample (n = 26) of those randomized to CBT. Framework analysis was used to analyse across the data.

RESULTS

Seventy-four participants withdrew from therapy or were discharged for non-adherence. A total of 54 (73%) gave reasons for not starting or stopping CBT; mostly the time/location was inconvenient or they had other commitments. Interviews identified that clients could struggle in, and between, CBT sessions. This was true for those who did and did not complete therapy. CBT homework was the biggest challenge and was often associated with negative school homework experiences. Although clients may have disliked aspects of CBT, those who attended more than one session felt that they had gained insight into managing their depression.

CONCLUSION

Highlighting the possible barriers to adherence in CBT can help clinicians to better prepare clients in making an informed choice about therapy. Exploring these issues during therapy may also help with engagement. Despite the challenges, clients can still benefit from CBT by learning strategies that enable them to effectively deal with their depression.

Patients' experiences of helpfulness in guided internet-based treatment for depression: qualitative study of integrated therapeutic dimensions

BACKGROUND

Quantitative research on Internet-based cognitive behavioral therapy (ICBT) has collected substantial evidence for the effectiveness of this treatment approach on health outcomes. Less is known about how patients find ICBT to be generally meaningful and helpful for treating depression.

OBJECTIVE

To explore patients' experiences of being in ICBT treatment with a focus on the treatment dimensions that they considered helpful.

METHODS

Choosing a phenomenological-hermeneutical approach, 14 patients were interviewed with semistructured qualitative interviews to elicit their understanding of using ICBT. The patients took part in a clinical trial using ICBT with MoodGYM, which also featured brief consultations with a clinical psychologist. The interviews were transcribed and analyzed according to the chosen methodology and organized into significant themes.

RESULTS

The phenomenological-hermeneutical analysis identified 5 themes relating overall to the meaning of this mode of treatment in terms of helpfulness. Two related to treatment in general: (1) taking action to address one's problems and (2) the value of talking to a professional. The next two themes specifically addressed guided self-help using the MoodGYM program: (3) acquiring relevant knowledge, and (4) restructuring the new knowledge acquired through ICBT. A fifth theme concerned (5) actual changes in patients' perceptions and interactions, related to either the self-help material or the face-to-face consultations with the therapist.

CONCLUSIONS

Three important dimensions were made explicit: the active engagement of the patient, the guidance of the therapist, and the content of the treatment program. The findings pointed to (1) the role of MoodGYM as a source of new knowledge providing patients with a structured approach to work with their depression, (2) the patient's role as the primary agent of change through adapting relevant knowledge from MoodGYM to their situation, and (3) the dialogue with the therapist as a trusting relationship in which to share thoughts and feelings, receive feedback and advice, and to assist the patient in making use of the MoodGYM content.

Patients' perceptions of depression and coronary heart disease: a qualitative UPBEAT-UK study

BACKGROUND

The prevalence of depression in people with coronary heart disease (CHD) is high but little is known about patients' own perceptions and experiences of this. This study aimed to explore (i) primary care (PC) patients' perceptions of links between their physical condition and mental health, (ii) their experiences of living with depression and CHD and (iii) their own self-help strategies and attitudes to current PC interventions for depression.

METHOD

Qualitative study using consecutive sampling, in-depth interviews and thematic analysis using a process of constant comparison. 30 participants from the UPBEAT-UK cohort study, with CHD and symptoms of depression. All participants were registered on the General Practitioner (GP) primary care, coronary register.

RESULTS

A personal and social story of loss underpinned participants' accounts of their lives, both before and after their experience of having CHD. This theme included two interrelated domains: interpersonal loss and loss centred upon health/control issues. Strong links were made between CHD and depression by men who felt emasculated by CHD. Weaker links were made by participants who had experienced distressing life events such as divorce and bereavement or were living with additional chronic health conditions (i.e. multimorbidity). Participants also felt 'depressed' by the 'medicalisation' of their lives, loneliness and the experience of ageing and ill health. Just under half the sample had consulted their GP about their low mood and participants were somewhat ambivalent about accessing primary care interventions for depression believing the GP would not be able to help them with complex health and social issues. Talking therapies and interventions providing the opportunity for social interaction, support and exercise, such as Cardiac Rehabilitation, were thought to be helpful whereas anti-depressants were not favoured.

CONCLUSIONS

The experiences and needs of patients with CHD and depression are diverse and include psycho-social issues involving interpersonal and health/control losses. In view of the varying social and health needs of patients with CHD and depression the adoption of a holistic, case management approach to care is recommended together with personalised support providing the opportunity for patients to develop and achieve life and health goals, where appropriate.

Cognitive behaviour therapy (CBT) for depression by computer vs. therapist: patient experiences and therapeutic processes

Abstract This case series compares patient experiences and therapeutic processes between two modalities of cognitive behaviour therapy (CBT) for depression: computerized CBT (cCBT) and therapist-delivered CBT (tCBT). In a mixed-methods repeated-measures case series, six participants were offered cCBT and tCBT in sequence, with the order of delivery randomized across participants. Questionnaires about patient experiences were administered after each session and a semi-structured interview was completed with each participant at the end of each therapy modality. Therapy expectations, patient experiences and session impact ratings in this study generally favoured tCBT. Participants typically experienced cCBT sessions as less meaningful, less positive and less helpful compared to tCBT sessions in terms of developing understanding, facilitating problem-solving and building a therapeutic relationship.

Experiences of guided Internet-based cognitive-behavioural treatment for depression: a qualitative study

BACKGROUND

Internet-based self-help treatment with minimal therapist contact has been shown to have an effect in treating various conditions. The objective of this study was to explore participants' views of Internet administrated guided self-help treatment for depression.

METHODS

In-depth interviews were conducted with 12 strategically selected participants and qualitative methods with components of both thematic analysis and grounded theory were used in the analyses.

RESULTS

Three distinct change processes relating to how participants worked with the treatment material emerged which were categorized as (a) Readers, (b) Strivers, and (c) Doers. These processes dealt with attitudes towards treatment, views on motivational aspects of the treatment, and perceptions of consequences of the treatment.

CONCLUSIONS

We conclude that the findings correspond with existing theoretical models of face-to-face psychotherapy within qualitative process research. Persons who take responsibility for the treatment and also attribute success to themselves appear to benefit more. Motivation is a crucial aspect of guided self-help in the treatment of depression.

The acceptability of computerised cognitive behavioural therapy for the treatment of depression in people with chronic physical disease: a qualitative study of people with multiple sclerosis

BACKGROUND

People with chronic physical conditions are at elevated risk of depression. Due to a shortage of Cognitive Behavioural Therapy (CBT) practitioners, computerised CBT (CCBT) is recommended for people with mild to moderate depression. We assessed the applicability of CCBT for the treatment of depression in people with multiple sclerosis (MS).

METHODS

Depth interviews with 17 people with MS and mild to moderate depression who used one of the two CCBT packages for either eight (Beating the Blues; n = 8) or five (MoodGym; n = 9) weekly sessions were analysed using 'Framework'.

RESULTS

Participants found CCBT-use burdensome due to their physical symptoms. In addition to perpetuating social isolation, the lack of human input meant some participants were unable to define problems, set goals or distinguish between events, thoughts and beliefs as required. CCBT did not legitimise their grief over losses concomitant with their MS. They characterised depression symptom inventories as contaminated by somatic symptoms of their MS. One CCBT package (MoodGym) was perceived as using inappropriate case material for people with the symptoms of MS.

CONCLUSIONS

It is likely that generic CCBT packages for the treatment of depression will need to be adapted for people with chronic physical conditions to maximise their potential for health benefit.

A randomized, controlled clinical trial of standard, group and brief cognitive-behavioral therapy for panic disorder with agoraphobia: a two-year follow-up

A randomized controlled clinical trial with a wait-list control group was conducted to examine the effectiveness of three modalities (brief, group, and standard) of cognitive-behavioral treatment (CBT) for panic disorder with agoraphobia. A total of 100 participants meeting DSM-IV criteria were randomly assigned to each treatment condition: a 14-session standard CBT (n=33), a 14-session group CBT (n=35) and a 7-session brief CBT (n=32). Participants received a self-study manual and were assigned weekly readings and exercises. The results indicate that regardless of the treatment condition, CBT for moderate to severe PDA is beneficial in medium and long term. To this effect, all three-treatment conditions significantly reduced the intensity of symptoms, increased participants' quality of life, offered high effect sizes, superior maintenance of gains over time, and lower rates of relapse, compared to the wait-list control.

Primary-care patients' expectations and experiences of online cognitive behavioural therapy for depression: a qualitative study

OBJECTIVE

To explore expectations and experiences of online cognitive behavioural therapy (CBT) among primary-care patients with depression, focusing on how this mode of delivery impacts upon the therapeutic experience.

DESIGN

Qualitative study, using repeat semi-structured interviews with patients before and after therapy. The study was conducted in parallel with a randomized controlled trial examining the effectiveness and cost-effectiveness of online CBT for patients with depression.

PARTICIPANTS

Twenty-four patients with depression recruited from five general practices in southwest England, who were offered up to 10 sessions of CBT, delivered via the internet by a psychologist.

RESULTS

Most participants accessed the therapy from their home computer and found this to be a major advantage, in terms of convenience and fitting therapy into their daily routine, with any technical problems quickly resolved. Two key themes regarding expectations and experiences of online CBT were: developing a virtual relationship with a therapist, and the process of communicating thoughts and emotions via an online medium. Online CBT seems to be acceptable to, and experienced as helpful by, certain subgroups of patients with depression, particularly those who are familiar with computers, feel comfortable with writing their feelings down, enjoy the opportunities to review and reflect that written (or typed) communication offers are attracted to the 'anonymity' of an online therapeutic relationship and are open to the proactive requirements of CBT itself. However, on-line CBT may feed into the vulnerability of depressed people to negative thoughts, given the absence of visual cues and the immediate response of face-to-face interaction.

CONCLUSIONS

Online CBT has the potential to enhance care for patients with depression who are open to engaging in 'talking' (or typing) therapies as part of their treatment. If online CBT is to be provided via the NHS, it is important to establish patient preferences regarding this mode of delivery and ensure that referral practices are appropriately targeted. The results of our main trial will provide evidence regarding the effectiveness and cost-effectiveness of receiving therapy via this modality.

The centrality of personal relationships in the creation and amelioration of mental health problems: the current interdisciplinary case

An interdisciplinary case is made for the centrality of personal relationships in the creation and amelioration of mental health problems. Taking the work of John Bowlby as a starting point, the article summarizes accumulating evidence from the past 50 years about the link between childhood adversity and adult mental health problems. Evidence is also reviewed about contemporary interpersonal impacts on adult mental health from natural social settings and in professional therapy. These empirical summaries are then discussed in the context of dominant trends in professional knowledge about bio-determinism within psychiatry and the emphasis upon models and techniques in professional and political advocates of the psychological therapies. It is concluded that the latter trends are diverting us from policies, which properly concede the importance of relationships for improving the mental health of the population.

Help-seeking preferences for psychological distress in primary care: effect of current mental state

BACKGROUND

There is much debate over when it is appropriate to intervene medically for psychological distress, and limited evidence on patients' perspectives about a broad range of possible treatment options. It is currently unclear whether preferences may differ for those patients with milder symptoms compared to those experiencing more severe distress.

AIM

To determine patient preferences for professional, informal, and alternative help for psychological distress in primary care, and the impact of their current mental state on these.

DESIGN OF STUDY

Cross-sectional survey in seven general practices across suburban/urban London.

METHOD

Participants were 1357 consecutive general practice attenders aged 18 years and over. The main outcome measure was the General Health Questionnaire 12-item version and a questionnaire on help-seeking preferences.

RESULTS

Overall, only 47% of participants reported wanting 'some help' if feeling stressed, worried, or low and it was affecting their daily life. Those currently experiencing mild-to-moderate distress preferred informal sources of help such as friends/family support, relaxation/yoga, exercise/sport, or massage along with general advice from their GP and talking therapies. Self-help (books/leaflets or computer/internet) was not popular at any level of distress, and less favoured by those with mild-to-moderate distress (odds ratio [OR] = 0.50; 95% confidence interval [CI] = 0.35 to 0.70). Those experiencing severe distress were much more likely to want talking therapies (OR = 3.43, 95% CI = 2.85 to 4.14), tablets (OR = 3.07, 95% CI = 2.00 to 4.71), and support groups (OR = 3.07, 95% CI = 1.72 to 5.47).

CONCLUSION

People with mild-to-moderate distress appear to prefer informal sources of help and those involving human contact, compared to medication or self-help. This has implications for the implementation of potential interventions for psychological distress in primary care.

Promoting patient engagement with self-management support information: a qualitative meta-synthesis of processes influencing uptake

Background

Patient information has been viewed as a key component of self-management. However, little attention has been given to methods of dissemination or implementation of effective information strategies. Previous problems identified with the use and implementation of patient information point to the need to explore the way in which patients engage with and use information to support self-management for chronic conditions.

Methods

Four published qualitative studies from a programme of research about self-management were analysed as a group; these included studies of the management of inflammatory bowel disease (IBD); self-help in anxiety and depression (SHADE); menorrhagia, treatment, information, and preference (MENTIP) study; and self-help for irritable bowel syndrome (IBS). For the analysis, we used an adapted meta-ethnographic approach to the synthesis of qualitative data in order to develop an evidence base.

Results

The ontological status and experience of the condition in everyday life was the most dominant theme to emerge from this synthesis. This, coupled with access to and experience of traditional health services responses, shaped the engagement with and use of information to support self-management. Five key elements were found which were likely to influence this: the perception and awareness of alternative self-management possibilities; the prior extent and nature of engagement with information; the extent of and ability to self-manage; opportunities for use of the information and the stage of the illness career; and congruence and synergy with the professional role.

Conclusion

People with chronic conditions need support from providers in both supply and engagement with information, in a way which gives legitimacy to the person's own self-management strategies and possible alternatives. Thus, a link could usefully be made between information offered, as well as patients' past experiences of self-management and engagement with services for their condition. The timeliness of the information should be considered, both in terms of the illness career and the type of condition (i.e., before depression gets too bad or time to reflect on existing knowledge about a condition and how it is to be managed) and in terms of the pre-existing relationship with services (i.e., options explored and tried).

More considered use of information (how it is provided, by whom, and at what point it should be introduced) is key to facilitating patients' engagement with and therefore use of information to support self-management.