Hi I'm Jacinta Jardine a design researcher at SilverCloud Health. I'm going to talk about
the experience of guided online therapy, a longitudinal qualitative analysis of client
feedback in a naturalistic RCT. Mental health is a huge global issue and a rapidly growing
one. Online interventions allow us to overcome some of the common barriers to people accessing
traditional face-to-face therapy, such as long waiting lists, stigma and high costs,
essentially allowing more people to get the help they need when they need it. But in order to
design effective interventions, and improve existing ones, we need an in-depth understanding
of how clients are using these interventions and what their experiences are. That's what
this study is exploring. So I'm going to do a bit of a demo of SilverCloud now and talk
a little bit about our research and the wider RCT that this study was part of, and then
I'll go into the analysis, results and discussion. So this is the homepage of SilverCloud, it's
customisable so the client can tailor it to create their own personal space. SilverCloud
is designed around these three core elements - the programme, tools and the supporter.
The programme is where the main therapeutic content is housed and the programmes used
in this study were our depression and anxiety programmes, and they're a bit like an educational
course, so there's normally about 7 or 8 modules in each programme. They're laid out in a logical
order, but they don't have to be completed in order, so the client can skip ahead if
there's something they're interested in, or they can go back to content they've already
viewed. It was designed to be a light, calm and safe space for the user, so not overwhelming
them with too much content in one go. The second element is the tools, there are normally
2 or 3 of these in each module and they are interactive activities that facilitate personal
reflection and create a sense of self-efficacy for the user. The third thing is our supporter,
clients get weekly written reviews from a clinician, giving feedback on the work they
have completed and encouragement and support to keep going, and this really helps with
attrition and keeping people engaged. SilverCloud was designed around traditional therapy format,
so it was thought that the client would do one module, spending about 40 minutes, per
week, as they would with a therapy session. But we'll see from our current study that
sometimes how you design something to be used isn't always how it's used in real life.
This platform has a background in HCI research. It was first presented at CHI in 2012, this
is the paper exploring the original design of the platform. Since then there have been
several randomised controlled trials, but the current study forms part of what is definitely
our largest trial to date. The main study was a parallel-groups randomised controlled
trial examining the effectiveness and cost-effectiveness of iCBT for depression and anxiety, against
a waitlist control group. This was conducted in one particular service in the UK's National
Health Service, the NHS, which was the Berkshire Healthcare Trust. This service has been using
SilverCloud for years, they've delivered it to thousands of clients. So the treatment
pathway that clients went through during this research is just business as usual for this
service, and this is what we mean when we say a naturalistic RCT. The clients in our
study would have been using the intervention regardless of the research, which is a really
valuable part of the study because we can test how the intervention is being used in
natural implementation settings. Berkshire is an IAPT service, and IAPT stands for Improving
Access to Psychological Therapies. This is a stepped-care model that the NHS uses where
clients arrive at the service and they are triaged, so those with mild or moderate symptoms
are offered low intensity treatments like group therapy or online therapy (SilverCloud)
and then those with more severe symptoms might go straight to face-to-face therapy. This
is just a bit of context around where this study took place. What we wanted to explore
with this research was what does it feel like to use online interventions, what are people's
experiences of it and how and when are they using it. Experience isn't just a singular
thing, its made up of a lot of different aspects. Our expectations about something have an effect
on our experience of it, our 'in the moment' experience is clearly a big part of our experience,
but also our memory of an experience, our reflective self-narrative, is also a key component
of our experience. All these 3 things contribute to what constitutes a person's experience.
To that effect we collected our data at baseline, 4 weeks and at 8 weeks (that's usually the
endpoint of treatment). We used an open-ended therapeutic experience questionnaire, which
we designed ourselves, which had 10 questions in total. This explored the client's expectations
of treatment, their experience during treatment and their experience on reflection. This questionnaire
was collected via the SilverCloud platform, along with the other measures in the trial.
So on to the participants, we decided to only draw from those participants who had completed
all 10 questions over the 3 timepoints because we wanted to examine this full picture of
experience across time. We do recognise this as a limitation in the study - the fact that
we were only examining the experiences of those who completed all the questions. We
stopped at 100 records because saturation was reached and no new themes were being created.
So onto the results, we'll look at expectations first. You can see that clients had very high
expectations for their own self-development, so actually only 23 clients expected anything
negative or difficult of the treatment. There is a really strong sense of hope there.
So what does this mean? A lot of these clients had a very strong belief in themselves and
in their ability to make changes, and also a strong belief in the treatment itself. These
are key factors that have shown to effect outcomes. So if we look a bit deeper at what
is maybe causing this sense of belief and hope, we can see that there are 2 elements
at play here - implementation factors, this is the service where this study was conducted
and the pathways that are in place. The clients in this study were well prepared for treatment,
they knew what to expect and they had good health literacy. These are all to do with
the implementation of this treatment. But also the personal factors at play here, so
the client's readiness for change, how likely they are to take action and make changes,
their motivation, locus of control, things like that all have an effect. Both of these
things are outside of the design of the intervention itself, so when we're looking at designing
interventions, implementation is really crucial - so this is around service design and the
context of how online interventions are accessed. Also, there's a really interesting design
tension in terms of the personal factors here. Typically with online interventions, only
suitable clients are referred, so these are clients who are motivated or maybe more ready
to change, but its worth thinking about - is there something we can do to help clients
become more ready to change? This could involve things like pre-therapy interventions, or
maybe incorporating motivational interviewing techniques into the onboarding or the intervention itself.
Our second area we looked at was context of use. We asked clients when and how they
were using the intervention. You can see almost half of them said they were using it at a
specific or routine time, but there are lots of other patterns here as well, of people
using it in their free time (whenever they could), when they were reminded, when they
were feeling low - this was interesting around mood dependent usage, also in terms of the
situation - when they were alone maybe, and then using it for specific tools in the programme.
So what we are seeing here, these common usage patterns of clients using the platform in
times of low mood, as a coping mechanism or more erratically in these 'on the go' formats
this is not how online interventions are typically designed to be used. These types
of interventions are usually designed to be used in a more intensive way. So for example
with this platform it was intended for clients to use it for 40 minutes, or maybe do one
module, a week as with a therapy session. This is maybe one way that its being used,
but there are also lots of other ways that its being used. One interesting reason for
this could be that low mood acts as a reminder for clients to log in, so they are maybe forgetting
about it if they are feeling well. To make these interventions more useful and relevant
for the user, we need to think about design to support these real life usage patterns,
rather than sticking to those traditional therapy delivery formats and structures.
This could involve things like introducing shorter interactions, ecological momentary interventions
and mood regulation strategies - all to address these desired usage patterns.
So onto experience, we can see here that this mirrors the expectations, the clients were both expecting
and experiencing personal development, and that's interesting in terms of how much of our experience is
shaped by our expectations. The experiences were quite positive overall, but something
interesting to note is this difference in opinion - certain things like the flexibility
of the platform were either good for engagement or they hindered engagement, depending on
who was saying it. Similarly with support, clients were either feeling connected, supported
and reassured or feeling like the platform needs more support and guidance. Some of these
core features of iCBT can be perceived as either positive or negative, or sufficient
or insufficient by different people. This brings us on to our first discussion point
which is polarised preference. How can we provide the same treatment to so many unique
individuals who have such different experiences of the same thing? Design tensions come up
again here in the interplay between these 4 core aspects of online interventions, which
are autonomy, flexibility, motivation and engagement. We can see that the responsibility
inherent in the autonomy of online treatment is on the one hand, for some clients, motivational
they are feeling in control of what they are doing, but on the other hand it can be
quite burdensome and stressful - some clients were feeling like its just another thing they
have to do, its another thing on their list. Similarly with the flexibility of online treatment,
there's a hugely positive and enabling aspect for a lot of people, yet it also appears to
be a big barrier to engagement for some people, so people are feeling like if there is not
a set appointment they forget about it, or its easier to put off. Design tensions are
a really useful construct here because there is no perfect answer or solution to this,
so its just about balancing these opposing elements. Being aware of that can actually
be quite helpful. But there are some tools we can use to address these polarised preferences
tailoring, personalisation and customisation are really key to making these treatments
relevant to each individual. Finally our last area we are going to look at is skills for
life. A lot of clients in this study really understood that they were gaining the skills
to help them stay well into the future, that this isn't just treating an illness, its more
of a long term process. We saw this previously in the context section as well, that these
treatments currently exist within this paradigm of traditional therapies, yet this could be
limiting their potential to fully provide for the clients needs. By going beyond this
treatment model we can look at some alternatives, things like incorporating alternative theoretical
models that support growth and flourishing, such as positive psychology, exploring different
approaches, so looking at blended methods which combine face-to-face with online interventions,
or incorporating online support groups, or different types of interactions and functionality
that make the most of the technology we have. Also we could maybe reach and benefit previously
unsupported groups, online interventions could be used as a preventative measure for those at risk.
In conclusion then, some of the key take away points from this study are - that
the systems and structures that surround the treatment and each individual client's level
of motivation, readiness for change and hopefulness, can have as much of an impact of the client's
experience as the actual intervention itself. Exploring design tensions can help us to make
informed decisions about how we mediate these polarised elements such as flexibility and
engagement. Understanding how clients use and integrate these interventions in their
lives can help us to design future technologies that maybe go beyond traditional models of
therapy and we can focus instead on how we can make the best use of technology to effectively
address client needs. Thank you for your time, if you have any queries about this presentation
or the paper itself you can send me an email, I'd be delighted to answer any questions you might have.