Blues Begone is a unique and powerful computerized cognitive behaviour therapy (cCBT) program. Blues Begone has helped thousands of NHS and private users over the years it has been in service. in first clinical trials Blues Begone seemed so effective that we were interested and motivated to learn how the user interacted with Blues Begone and through that interaction how they came to make Blues Begone useful for themselves. Therefore one of my (then) doctoral students, now Dr Janet Dutton conducted a series of interviews with people who had used Blues Begone to help them with problems of clinical depression. The document below is a summary of the research, and for those interested in qualitative research, in includes the questions asked of the participants and an analysis of their responses with the psychological interpretation of that data.
These data from Blues Begone: The user experience was later published in Counselling and Psychotherapy Research: Linking theory with Practice (2013) under the title: An exploration of the therapeutic process while using computerised cognitive behaviour therapy.
Blues Begone: The user experience
An Interpretative Phenomenological Analysis
Dr Janet Dutton & Dr David Purves
Therapy Software Solutions Ltd
Reading RG1 4HP
1 EXECUTIVE SUMMARY. 3
2 INTRODUCTION.. 5
2.1 Current situation. 5
2.2 The present study. 11
3 METHOD.. 12
3.1 Participants. 12
3.2 Procedure. 13
4 RESULTS. 14
4.1 PSYCHOLOGICAL POSITION.. 14
4.2 Client theory of change. 14
Novelty and hope. 16
“Down but not out” 16
Personal characteristics. 17
4.3 THE MEANINGFUL RELATIONSHIP. 18
The virtual therapist 18
The nature of the relationship. 19
4.4 SHAPE FROM CONFUSION.. 22
Bringing order 22
Framework for exploration and analysis. 24
4.5 STIMULATION.. 25
Awakening of cognitive activity. 26
Anticipation and motivation. 27
4.6 EMPOWERMENT. 29
A change in perspective. 29
The activity of self-help. 31
The “tool box” 33
5 DISCUSSION.. 33
6 CONCLUSIONS AND RECOMMENDATIONS. 37
7 REFERENCES. 39
8 APPENDIX 1. 42
9 APPENDIX 2. 43
1. EXECUTIVE SUMMARY
Aim: To explore the experience of clients as they carry out the self-help programme, Blues Begone and further our understanding of how individuals make use of self-help therapy to alleviate psychological distress.
Background: The study is set within the context of a rising interest in self-help treatments as mental health services become increasingly pressurised due to a high level of demand and a limited availability of appropriately trained therapists. As distinct from previous research which has tended to focus on the outcome of self-help interventions, the current study is an in-depth exploration of the subjective experience of clients as they engage in self-help activity.
Method: Seven individuals presenting with symptoms of mild to moderate depression completed the Blues Begone programme and reports of their individual experience were obtained using semi- structured interviews. Verbatim interview transcripts were analysed using the qualitative research method of Interpretative Phenomenological Analysis and underlying key themes identified.
Results: Analysis indicated that participants had found the Blues Begone programme easy to use and appeared to have become engaged with their self-help activity, with most reporting some improvement to their physical and/or emotional well-being. Themes to emerge included individuals’ development and use of a meaningful relationship with the self-help material, the importance of structure and stimulation provided by the programme, and the opportunities for empowerment afforded by a client led therapy.
Discussion and Conclusions: The importance of the Blues Begone programme as a facilitative tool in helping individuals maximise their own resources to address the symptoms of depression is highlighted, with recommendations made that self-help activity in general should be considered, implemented and researched as a sophisticated intervention in its own right within the wider field of mental health.
2. Introduction to Blues Begone research
2.1. Current situation
Within the field of mental health, the potential therapeutic benefits of self-help programmes are currently the focus of increased attention from the research community. A review of the literature suggests that such interest is being driven by some very practical concerns. Whilst the National Health Service seeks to provide a range of psychotherapies to address psychological problems, access to services is often restricted owing to a high level of demand and a limited availability of appropriately trained therapists (National Institute of Clinical Excellence, 2006).
This is particularly true of services offering Cognitive Behavioural Therapy (CBT).
CBT has been shown to have the greatest evidence base for effectively treating depression, panic and generalised anxiety disorders and as such is recommended as the treatment of choice for these conditions (NICE Guidelines, 2004a, 2004b). Understandably, demand for CBT is high, yet there are large disparities in the availability of CBT therapists across the United Kingdom and consequent restrictions in the choice of treatment available (The Centre for Economic Performance’s Mental Health Group, 2006).
By developing self-help programmes within a CBT framework, it is hoped that access to effective psychological support will be improved. Indeed, “the possibility of making available beneficial treatments for those who might otherwise go unserved is one of the great potentialities of self-administered therapy” (Scogin, 2003). But to what extent are self-help treatments useful and acceptable for those seeking psychological help? A broad review of the research literature past and present reveals some promising findings.
2.2. Existing research
As early as 1993, Gould and Clum analysed the findings of forty self-help studies where participants had used media-based treatments (book, manual, audiotape or videotape, or some combination) to address their problems largely independently of a helping professional. Results of this analysis indicated that the self-help approaches investigated were effective in addressing the kinds of problem that they targeted, with treatments for anxiety and depression being found to be more effective than those for habit behaviours such as smoking and drinking. No significant differences were found between end-of-treatment and follow-up data, suggesting that participants using self-help interventions generally maintained their treatment gains; and interestingly, an examination of twelve studies that compared self-help and therapist conditions revealed there to be no statistical difference in outcome between the two.
In a more recent review of self-help therapies, Mains and Scogin (2003) described similar outcomes, reporting a decade later that self-help treatments have been shown to be effective in alleviating depression, anxiety disorders and mild alcohol abuse; but less successful for smoking cessation and moderate to severe alcohol abuse.
With specific reference to computerised self-help treatments, Christensen and Jacobson (1994) cited a number of studies where computer-administered therapy was shown to achieve results comparable to traditional “face to face” therapy in the treatment of depression and anxiety; and in a more recent review of self-administered treatments for depression, McKendree-Smith, Floyd and Scogin (2003) reported similar findings, though went on to highlight that evidence from inpatient studies indicated that this mode of therapy may not be suited to the more severely depressed.
As highlighted previously, research into the application of computerised self-help programmes has gained particular prominence within the National Health Service, where the results of fourteen studies involving the use of five computer-assisted self-help packages have recently been evaluated. After taking into account both the clinical and cost effectiveness, and patient acceptability of the different programmes, the National Institute for Clinical Excellence has now recommended that the computerised CBT package, “Beating the Blues” should be offered as an option for delivering CBT in the management of mild and moderate depression, and the computerised CBT package “Fearfighter” be offered as an option in the management of panic and phobia (NICE, 2006).
At this stage, the committee did not recommend the use of computerised CBT in the treatment of Obsessive Compulsive Disorder, acknowledging amongst other factors patient preference for therapist administered treatment in this particular instance (NICE, 2006). Notwithstanding this particular concern, the recommendations from the National Institute for Clinical Excellence are significant and would appear to add weight to previous research evidence supporting the use of self-help activity to address mild to moderate depression and anxiety disorders.
However, it should be noted that some authors have questioned the level of scientific rigour with which previous studies of self-help have been conducted, thus casting some doubt on the reliability of results (see Kaltenthaler, Parry and Beverley, 2004). Whilst there is a body of research indicating that self-help interventions can be effective in alleviating psychological distress, this is not always the case, and the potential factors that influence positive or negative outcome remain unclear.
In seeking to develop our understanding of the factors that may influence a positive outcome in self-help treatments, Richardson and Richards (2006) acknowledge the widely held view that the relationship between the therapist and client is an important factor in determining a successful therapeutic outcome (see Hovarth & Bedi, 2002). Thus they argue that the ability of self-help materials to “recreate” the positive aspects of the patient’s relationship with a therapist could be a factor in influencing the effectiveness of self-help programmes. They contend that positive characteristics associated with the therapist such as warmth and credibility can and should be adapted to the self-help media through a considered use of wording, user friendly presentational techniques etc. Indeed it is proposed that the more explicitly such factors are incorporated into self-help materials, the more likely it is that clients will become engaged in the self-help process, thereby increasing the likelihood of a positive outcome.
Other authors have suggested that patient expectation of self-help treatment may be significant in determining its effectiveness. In a rare exploration of the individual’s experience of self-help activity, Rogers, Oliver, Bower, Lovell and Richards (2004) noted that some patients attending a Primary Care self-help clinic, experienced “a sense of dissonance” between prior expectations and their actual use of the self-help clinic, and were unprepared for the degree to which they were required to be a change agent within the self-help process. This mismatch between expectation and reality had a negative effect on patient engagement in self-help activity and the consequent therapeutic outcome.
Despite the work of Rogers et al., the majority of research in the field of self-help is still heavily outcome focused; with investigators asking to what degree are self-help programmes effective in treating specific conditions or comparable in outcome to more traditional forms of therapy. The process of self-help has received less attention from researchers and the issue of how clients are able to make use of self-help treatments to alleviate distress appears to be less clearly understood. Authors within the wider field of psychotherapy have offered some perspectives on the concept of self-help that may inform our understanding of the client’s process in self-help activity.
In their comparative study of psychotherapy, Frank and Frank (1991) highlight human powers of symbolisation, and argue that in the case of self-help treatments, the process of change is still supported by a therapeutic relationship but one that functions in symbolic form, the patient engaging in a “relationship” with a self-help material that carries the therapist’s authority. They also suggest that in the absence of a “live” therapist, the novelty of the self-help media might stimulate new hope in people for whom previous types of help might have failed, hope being an important factor in therapeutic outcome (Ilardi & Craighead, 1994).
Bohart and Tallman (1999) offer a humanistic perspective on the process of self-help, suggesting that ultimately it is the client rather than the therapist who is the primary agent of change; thus all therapeutic endeavours can be interpreted as examples of “self-help”. When an individual’s own abilities to deal with problems are insufficient or overwhelmed, the therapist is but one possible resource facilitating change within the client; self-help activity is another.
2.3. The present study
The potential benefits of individuals being able to “help themselves” to address mental health problems are far-reaching. Whilst computerised CBT programmes can be used to support the overburdened NHS, they also offer increased choice for those who are seeking help but do not wish to interact with a therapist or the mental health services; they provide opportunity for those who because of geographical distance or physical disability may not be able to engage with traditional services; and offer 24-hour availability for the individual to access support at his or her convenience, in the privacy of his or her own home or other location of their choice.
Within the field of mental health, self-help has been researched and written about from different practical, theoretical and philosophical positions. Yet despite increased interest in self-help activity, there is a paucity of research exploring the experience of individuals as they engage in the self-help process. Thus the study that follows seeks to explore this experience, hoping to further our understanding of the ways in which individuals find self-help therapy useful in alleviating psychological distress.
3. Method of Blues Begone Research
In advance of any research activity, the proposal for the current study was submitted to and cleared by the Ethics Committee of the Psychology Department at LondonMetropolitanUniversity.
Seven volunteers were recruited by means of an advert, placed in a local newspaper and circulated to contacts of the researcher. Primarily, volunteers were included in the study based on the very practical criteria that they were mildly depressed, and had access to computer facilities (see Appendix 1).
Participants used the interactive, computerised self-help programme, “Blues Begone” (Purves & Purves, 2005) as the focus of their self-help activity. Blues Begone is designed to help combat the symptoms of depression and anxiety. The programme contains thirty short episodes, providing assessment and an individually tailored programme of therapy within a CBT framework. It is sent to clients in the form of a CD-rom to be installed on to a personal computer and is designed to be used about five times per week, with no more than one episode per day. The whole programme usually takes about six weeks to complete.
Blues Begone is a standalone product, the individual requiring no assistance from a therapist or the researcher to complete the programme. Thus the opportunity was maximised for participants to truly engage in self-help.
Participants completed a preliminary questionnaire to assess their suitability for the study. Questions were designed to elicit participants’ current experience of common symptoms of depression and/or anxiety, and any previous clinical diagnosis or treatment. Written consent to participate in the study was obtained on the basis that all data relating to the participants would be maintained in confidence and that individual names would be changed in any written report.
Participants were then sent the Blues Begone programme to carry out at home. Contact with the researcher was limited to minimise any influence on participants’ self-help process, though in the interests of individual safety and well being, participants were encouraged to contact the researcher at any time by email to discuss any concerns, or to arrange face to face contact for further support.
After completing the programme, semi-structured interviews were conducted, using an interview schedule constructed and piloted in advance (see Appendix 2). The verbatim transcripts of the interviews were then analysed using a qualitative research method, Interpretative Phenomenological Analysis (see Smith & Osborn, 2003) and master themes within the data were identified.
In order to safeguard the rigour of the analysis, methods of inter-rater reliability and deviant case analysis were used as measures of reliability and validity.
4. Results of Blues Begone Research
Interviews indicated that participants had found the Blues Begone programme easy to use and appeared to have become engaged with their self-help activity. Six individuals reported improvements to their physical and/or emotional well-being including improved sleeping patterns, decision-making and general mood.
Five master themes emerged from the analysis of transcripts and can be summarised as follows:
4.1. PSYCHOLOGICAL POSITION
The psychological state, individual characteristics and expectations of the participant at the outset of their self-help activity
4.2. Client theory of change
Within the theme of Psychological Position, the importance of participants’ own “theory of change” emerged, with participants clear as to why a self-help activity might suit their needs at this particular time, and why the Blues Begone programme in particular could be of help. For Teresa, having reflected on her personality and coping style, the programme’s CBT framework was an attraction:
“The difference you know with this particular self-help
programme was that it did…make you…focus very specifically
on problems and analyse them which I am…I’m a bit lazy about
doing” (Teresa, 2. 38-41)
Similarly, Caroline commented:
“I have had a little CBT before, erm and I always spend an hour a day on the computer, so the whole thing seemed to be something that would…have advantages for me… it ticked the boxes” (Caroline, 1. 14-17and 35)
Caroline’s comment above highlights the importance of the format as well as the content of self-help activity. In choosing to do the Blues Begone programme, most participants viewed being able work at home as having advantages: firstly, using a computer at home offered a degree of privacy to the “client”. Jane in particular felt that this would suit her, being aware of her particular symptoms of depression:
“I withdraw when I’m depressed, I don’t like talking…I think that it (BBG) is private; if you’re…yes, there isn’t anybody there, it just is…you’re on your own and it’s private” (Jane, 2. 3-4, 17-18)
Secondly, using a computerised format at home offered flexibility with the opportunity for users to choose when they did the programme, fitting it in with other life commitments. As Tessa explained:
“(Using the computer) felt private, more intimate and being able to do it when I wanted; I used to do it early in the morning when no one else was up. And you know that felt you know, very comfortable for me” (Teresa, 4. 43-46)
Novelty and hope
It is interesting to note that five of the seven participants interviewed had had previous experience of face to face therapy. Whilst such experiences were described as being largely positive, all were now choosing to try a different approach. Analysis of the text seemed to suggest that a different type of therapy might offer participants new possibilities and hope. As Jane commented:
“I suppose there was another aspect to it of actually thinking you know people say they just want the magic wand, so (laughs) you know, maybe that somehow something might happen that was a different tack from face to face therapy” (Jane, 2. 27-31).
“Down but not out”
Whilst participants appeared “down”, their reported day to day activities indicated that they were not yet “out”; that is whilst psychological functioning appeared to be impaired to varying degrees, all participants demonstrated sufficient levels of personal agency to indicate that they were not completely overwhelmed by their psychological problems.
Analysis revealed a group of individuals who were actively seeking help of some form or other in order to address their issues, and indeed it seemed that some participants had chosen a self-help programme to be active in their treatment. For Caroline, the passivity of waiting for treatment at a GP’s surgery seemed depressing in itself:
“I don’t like going to GP’s surgeries! (Laughs). I mean I really hate it. I just have memories of sitting there for hours and waiting and waiting with all these miserable looking people” (Caroline, 2. 17-20)
Further to the largely active stance of participants, it was noticeable that participants demonstrated personal characteristics such as openness to new experience, curiosity, resourcefulness and a positive attitude to self-help. They reported a readiness to take on board new information and ideas but also a tendency to “see through” things that they had started.
Overall participants showed a desire for further understanding of themselves and their current psychological state. They seemed to place an emphasis on wanting to know, understand and learn techniques to alleviate their distress. The following comment made by Monica encapsulates well this particular sub-theme:
“I thought I must learn something from it and it’s going to open
me up to maybe some new ideas and some other things that
maybe I wouldn’t have otherwise considered. So let’s just give
this a try and see what it teaches me…” (Monica, 2. 22-25)
4.3. THE MEANINGFUL RELATIONSHIP
The nature, pattern and degree of the participant’s relationship with the self-help material and its impact on the participant’s psychological process.
The virtual therapist
For five of the seven participants who used this programme, the figures and voices of the programme’s cartoon characters or “talking heads” assumed a reality that was described with warmth, enthusiasm, and humour. Participants referred to these figures at length, seemingly so engaged within this “relationship” that they were able to feel genuinely encouraged, praised and thus motivated by the programme. Caroline reflected the views of Jane, Grace, Teresa and Frank when she said:
“It sounds silly but you felt as if someone was on your side.
The talking heads cheered you on and erm it did feel as
Though there was support, despite the fact that they were
invented” (Caroline, 6. 1-3)
For some of the participants, the “virtual relationship” even offered advantages over a real one. Frank identified the “standard approach” of the virtual therapist as a potential benefit; whilst Caroline seemed to find a virtual relationship less demanding as she did not have to concern herself with the reactions of a human being sitting opposite her:
“If you compared it to a human being being in front of you…I mean in a way it took out some of the problems of communication with a human being. Erm ….but I did find it, it felt…I had er the sound turned up loud and I didn’t have to worry about what they were thinking” (Caroline, 7. 19-23)
The nature of the relationship
As is often the case with face to face therapy, participants needed to build up trust in the Blues Begone programme. Grace, Teresa, Frank and Jane all described initial concerns as to the confidentiality of personal information being entered into the computer. However, narratives showed that as participants became more involved in the programme, such concerns largely disappeared. Caroline seemed to summarise the majority of participants’ views when she commented:
“The fact that the talking heads looked so real erm…and sounded real and always talked good sense, you know I wasn’t able to sort of…erm sort of trip them up if you know what I mean. I felt that everything they were saying made sense … I came to trust it, the programme” (Caroline, 4. 15-18 and 22)
Caroline’s words not only reflected a growing trust in the programme but also introduced the importance of the programme’s credibility for participants’ successful engagement and sustained activity. Grace described other aspects of the material that afforded the programme credibility in her eyes:
“…those guys are so confident about everything they say. Because there’s research behind it all, they’re not a pair of whacko new age people are they, they’re scientists and being a scientist myself, if there’s proper research behind it then that’s good” (Grace, 5. 38-42)
Participants’ continued engagement with the Blues Begone programme seemed reinforced further by the personalised nature of the computerised response. For Jane having the computer use her name signified familiarity and care:
“It’s already become something that seems to know you and also in some electronic way, some computerised way to care about you” (Jane, 11. 33-35)
The format of the Blues Begone programme provided a “tailored” approach to therapy or “Road Map” in order to try and address users’ individual issues. This was viewed by all participants as a distinct advantage over other media such as self-help books. For Frank the tailored approach provided ease of access and flexibility; for Grace, it gave her the power to pick out sections that were relevant to her particular problem; and for Teresa, having her own unique Roadmap seemed to produce an emotional connection with the programme:
“…the Roadmap to Recovery is individual, it’s personal to me and that felt good actually” (Teresa 5. 4-6)
Whilst users were positive in the main about the flexibility of the Blues Begone programme, the inability (as yet) of the computer to replicate the complexity, immediacy and specificity of human responsiveness understandably prevented the exchange between participant and virtual therapist moving to a deeper level. Thus in some respects, the ways in which participants were able to make use of the virtual relationship were inevitably limited. Nevertheless, whilst on occasions this was frustrating for some users who had become engaged and “wanted more”, in the main participants seemed to understand and accept the limitations of the medium they were using.
In accurately reflecting participants’ experience and the realities of computerised self-help, it should also be noted that four participants experienced some problems of a technical nature in installing and accessing certain aspects of the programme. From their accounts, all reported strong feelings of frustration, further evidenced by their emotive narratives on this subject. For Shelley, frustration arose out of an inability to understand what had happened and her apparent lack of power to rectify the situation:
“I found it frustrating because I didn’t, I couldn’t understand…it wasn’t the fact that I had a relationship or a commitment issue with the programme, it was why is it not working? And why has it done this and what can I do to fix it?” (Shelley, 9. 15-18)
For Caroline, as with a face to face therapeutic relationship, this “rupture” in the process seemed to dent her trust in the material and the credibility of the programme. Speaking about the technical failure, she said:
“I didn’t like it… (Voiced very sternly). And I can remember when it came back, erm…not quite wondering whether it was worth starting again. I knew I was going to do it, carry on, but wondering whether it was as good as I thought it was” (Caroline, 7. 33 and 8. 1-4)
Nevertheless, despite these issues, participants’ seemed to have become sufficiently engaged with the programme and motivated by the self-help process to persevere. Having liaised with the researcher for advice, they made determined efforts to rectify the problem and continue.
And finally, as with face to face therapy, the “ending of the relationship” was also commented upon by some participants. Jane, Monica, Grace, and Caroline voiced some regret that the programme had finished, making reference to having worked through the episodes quickly and wishing they had made it last longer. However reports indicated that due to the format of the self-help material, participants were indeed able to prolong their experience by revisiting areas of interest at their convenience. Unlike face to face therapy, it appeared that participants’ relationship with the self-help material did not actually end but was able to continue as a means of ongoing support.
4.4. SHAPE FROM CONFUSION
The participant’s uses of structure to bring order, focus, clarity, and shape to their psychological state.
The theme entitled “Shape from Confusion” was so called as participants seemed to use the Blues Begone programme not only to bring some order to their internal world but also to bring new shape and form to their thinking.
At the outset of the study, most participants were experiencing some degree of uncertainty, confusion, or lack of clarity as to how they might address their issues and improve their psychological well-being. Thus the majority of individuals seemed to find the structured format of the self-help programme useful in as much as it enabled them to break down their problems and deal with them in a more manageable way, restoring a sense of order and personal control in the process.
Frank described using the Blues Begone programme to help him find a methodical, realistic approach to addressing his issues. He described in detail how he was able to “untangle” his accumulated problems, making them feel more manageable.
“…because of the structured approach and the fact that you can start separating the problem into little problems…you can actually address each issue at its own time…you know it’s looking at the same issue from different angles until ok that’s it, you’ve addressed that issue, it’s not an issue anymore and you go onto the next one. So I think in untangling it’s quite powerful, the fact that you go through each step” (Frank, 5. 30-39)
Similarly, having described herself as having a “muddled mind”, Teresa was able to work through her issues in a more ordered fashion, appearing to feel contained by the well-defined process that such a structured format offered:
“I really liked the structure of it, I really liked there being a
beginning and an end and you know being able to you know you
have a Roadmap to Recovery and that was really helpful to sort
of see the different components of that and where you could go,
where you were going as it were, (Teresa, 3. 5-10
For Jane, Caroline, Frank and Teresa, being able to place some order and structure on their self-help efforts also seemed to afford them the mental space to be able to concentrate and focus on their issues. As Caroline commented:
“It’s letting go and clearing out and you’re left with a space which you can use more positively” (Caroline, 9. 5-6)
Framework for exploration and analysis
Having used Blues Begone to bring some order and focus to their problems and process, participants also seemed to use the self-help material to establish a framework within which they could then begin the work of exploring their problems in some detail, and identifying potential solutions.
In line with the CBT methodology that underpinned the Blues Begone programme, users were offered, and made use of, a number of opportunities to examine their thoughts, feelings and behaviours. Teresa used the framework of a daily life monitor facility as a discipline so that she might concentrate on and increase her awareness of herself in a life filled with responsibilities to others:
“(It) was making me think about what was happening because I’m very much the sort of person who gets on a treadmill and is not really paying attention about how …am I actually feeling today because there’s always something else to do, that’s going to get in the way” (Teresa, 3. 21-27)
For some participants different exercises in the self-help material seemed to provide a “check” for personal psychological assessments and responses: Shelley made use of the questionnaires to assess the nature and severity of her depression:
“(I was) intrigued to find out whether the programme would say whether I was or wasn’t depressed” (Shelley 1. 14-17and 24-26)
Frank described working through some of the scenarios and case examples described in the programme, using them as a checklist to help pinpoint and clarify his own issues and priorities for attention:
“You almost tick boxes, that’s not really an issue or actually that really hurts, yes this is something that I need to …you know…understand or have a look at now, probably a revisit as well” (Frank, 4. 11-16)
Whilst for Caroline, already aware of some of the personal characteristics that often caused her distress, the situational analysis seemed to provide a valuable framework within which she could objectively assess and check out her own feelings and behavioural responses:
“The situational analysis I found very helpful. I think with some problems, difficulties erm I know I’m being over-sensitive. So If I’ve got something that actually helps me analyse it and work out whether this really is a problem and perhaps it isn’t, that’s a big help” (Caroline, 4. 35 and 5. 21-24)
And finally for Monica, already aware of the difficulty of trying to change longstanding habits and behaviours on her own, the use of reminders built in to the self-help material to support the individual’s change process, seemed to be of great value:
“I kind of because it’s something new, you just forget, but then when you have the reminder, have you done it? When you’ve got certain habits, it’s very hard to break them. But if some if something keeps reminding you to break it, then you do” (Monica, 8. 10-15)
The stimulation of the participant’s senses and cognitive activity by the content and presentational format of the self-help material.
Participants’ descriptions of their engagement with the Blues Begone programme indicated that they were stimulated in some way as part of the self-help process. This experience seemed to occur in relation to both the presentation and content of the self-help material.
Awakening of cognitive activity
The presentational techniques of the Blues Begone programme were varied and participants were offered an array of colours, images, written information, sounds and music. Jane’s description of being “woken up” seemed to reflect well the interaction stimulated between user and material:
“Your brain’s being woken up by being stimulated in different ways, you know you’ve got the bit of music that comes up, you’ve got the different visuals and the screen is changing, you’re reading stuff and you’re thinking and I think that it’s that sort of interaction really” (Jane, 8. 17-21)
Participants commented on the use of humour and whilst many were amused some were not, with Shelley finding the jokes “just beyond not funny” (Shelley, 17. 12-13). Nevertheless, the level of engagement was such that users did not seem to be put off by this and continued with their self-help activity.
Cognitive activity appeared to be stimulated in a variety of ways, both reminding users of previously helpful information, ideas, and coping strategies once known but now forgotten, and presenting new ideas and perspectives. Grace described the huge impact of a new idea presented within the self-help material, information that subsequently changed her psychological perspective on depression:
“There were some astounding facts in there that I didn’t know (smiles)…like you are only as depressed as your last thought. That blew my mind! And yet it is so, so sensible! You can’t be happy and depressed at the same time. And I thought, is that right? And it’s right I mean you can’t really, can you?” (Grace, 3. 33-41)
Participants’ reports also underlined the importance of stimulation within the self-help process as a mechanism to maintain new learning. Teresa acknowledged the difficulty of adhering to new ways of thinking and behaving. She found the self-help material to be of use in that…
“…it kept reminding me. I think that’s what happens. You know about these things, you know about the alternative thoughts and that but sometimes you just get…pulled down by feeling so crap, that you forget about them and you’ve got to be reminded that there is another way of looking” (Teresa, 7. 6-10)
For Teresa and Caroline in particular, it appeared that a major function of the self-help material was to act as a stimulus, keeping the results of their learning at the forefront of their minds. Interestingly, at the end of the study, four out of the seven participants requested a personal copy of the programme for this very reason, wanting to have the facility of a “top up” should the benefits begin to fade.
Anticipation and motivation
Analysis of interview transcripts clearly showed that the level of stimulation experienced by participants as described above was such that all reported some sense of anticipation as they engaged with the programme. This sub-theme was evidenced in different ways. Having begun the programme, Jane, Caroline, Grace, Teresa, Shelley and Monica all reported wanting to proceed more quickly and do more of the programme than the daily guidelines advised. In retrospect, Caroline commented:
“I wish I’d done it slower at the beginning, I rushed through it, you know, I’ve got to do this now!” (Caroline, 3. 19-20)
Participant’s accounts almost seemed to reflect an element of greed as though individuals were hungry for whatever the self-help programme might provide. In some cases, participants’ interest was stimulated to such degree that their self-help endeavour began to take priority over other demands in life. Caroline again reported:
“I would start to do it before I looked to see if I had any emails
for instance because it was something I really wanted to do.
I stopped some of the time wasting stuff, you know like surfing the web to fit it in” (Caroline, 4. 1-3 and 27-28)
As alluded to earlier in discussing the theme of “Psychological Position”, the anticipation of the possibilities that the Blues Begone programme might bring, seemed to be an important stimulant for participants, both triggering hope and maintaining their motivation for the self-help process.
Increased sense of personal agency through engagement with the content and process of self-help activity.
The master theme of empowerment is not only worthy of discussion in its own right emerging as an important element in the self-help process, but also as a theme that seemed to link all others.
A change in perspective
Six out of seven participants reported that the self-help material offered them information that changed their perspective on a particular issue such that they
experienced some degree of increased empowerment. This experience was perhaps most clearly expressed by Grace. This excerpt from her transcript is long but worth quoting in full to observe the detail of her process:
“…(BBG) goes onto explain…you’re only as depressed as your last thought. That’s really powerful because that means if you think well what was I last thinking, then go through some of the things they teach you about that, it means you can erm, if you change your last thought then you’ll feel happier or change your next thought, then you’ll feel happier…it’s a relief to think well actually I’m not a depressed person and also to think well it’s not because of the menopause, there’s something I can do about it. If it is just that it’s my last thought, then I’m in total control of that. I can do something about it… (Voice shaky) I don’t need to feel like that anymore…” (Grace, 4. 17-33)
The information offered to Grace for consideration was presented from a CBT perspective in line with the theoretical framework of the programme, and as such is foregrounds the individual’s capacity to initiate change. Nevertheless, in the absence of a therapist, Grace’s report indicated that she was able to take this information, assess its personal relevance and implications, and see how it could be used to her benefit. As her words showed, the key element of this experience seemed to be a sudden realisation from the information provided and an accompanying sense of relief that she could do something about her low mood, that she had the power to control her experience.
Caroline also described experiencing a change of perspective as part of her self-help experience. Again as a result of information offered by the programme, she began to regard her own emotional needs in a different light:
“There was one lovely bit I think maybe on self care, that they tell you that, you know that it’s ok. You’re allowed to have needs; you don’t only need a roof over your head. And that had a big impact… (Voice slightly shaky)…It was a validation; that how I was feeling was ok and that was important for me” (Caroline, 5. 32-40)
Whilst Grace’s empowerment seemed to occur in a literal sense with her recognising her ability to regain control in her life, Caroline’s seemed to arise from an increased sense of self-worth and new found confidence to express her own needs. As she reported later, her change of perspective allowed her to recognise, and importantly to voice out loud, that she was “valid”:
“I think I can now say I’m good enough… You know… (Quietly)…I’m valid. And I don’t think I would have gone so far as to say that before (smiles)” (Caroline, 10. 34-37)
The activity of self-help
Whilst it would appear that the content of the Blues Begone programme helped several participants to feel empowered, reports also indicated that the activity of self-help itself could have an empowering effect.
The programme was structured around a series of daily episodes, a format that was commented positively on by four participants. Participants recounted how they each developed a routine and a regular time that suited them to carry out their self-help activity. Caroline seemed to find the physical process of sitting down at the computer and engaging in the self-help programme to be of benefit: She explained further:
“You did feel that with the computer, that it wasn’t passive, that in some way it was quite an active process; that you were being active yourself, partly by just sitting down and turning it on and then by trying to do the things that you were, that they suggest” (Caroline, 6. 9-13)
It would seem that the very action of operating the computer, created a more active frame of mind in the participant. Given that five out of seven participants initially reported a lack of motivation, and fatigue and lack of energy in their preliminary questionnaires, to be encouraged in this way into purposeful activity would indeed seem a positive step.
Similarly, participants described the positive effects of recognising their progress and achievement, and having their efforts reinforced. Teresa twice commented on the scale of her efforts with some sense of pride:
“At the end I felt, I did feel a sense of achievement because I had worked, you know hard at it and when it said I’d spent fifty-one hours on it, that felt a lot of hours, erm and it felt I’d learnt a lot from it as well” (Teresa, 10. 23-26)
Such comments appeared to emphasise not only the level of initiative required by participants in self-help activity but also the potential opportunity for reinforcement of their personal agency. Monica noticed a change in her own level of agency as the programme progressed:
“After a while, I started going into all the menus and exploring everything whereas first of all I was just letting it guide me” (Monica, 5. 12-16)
Nevertheless, whilst in some instances the very nature of self-help activity seemed be empowering in its own right, many of the participants discussed their belief that a client who felt very low, overwhelmed by their problems and lacking a sense of control would find self-help activity difficult. Shelley observed:
“And so I think it depends on how far down somebody actually was cos I don’t think if they were really, really in the doldrums, just don’t think they would even take it on board at all” (Shelley, 6. 12-15)
The “tool box”
And finally, reports indicated that the practical strategies and techniques offered by the programme provided a ”tool box”, enabling participants to put their new learning and perspectives into practice and empowering them to achieve and maintain lasting change. All made reference to printing out materials and making notes, regarding this as a resource that could be revisited, would act as a reminder and a continued source of support. Participants appeared to find some security in having such a resource, with Jane even deciding to create her own “handbook”. Indeed as highlighted earlier four participants requested personal copies of the Blues Begone programme to keep as a lasting resource. Whilst taking responsibility for carrying out the work, participants seemed to regard their “tool kit” as an important factor in making this ongoing work possible.
The aim of the current study was to explore the individual experience of participants as they engaged with the computerised CBT programme, Blues Begone, and further our understanding of how individuals find might find self-help therapy useful.
Analysis showed that by using the Blues Begone programme, most participants gained information to help clarify both their present situation and a way forward, and were offered techniques, strategies and “tools” to help them address their difficulties on a practical, ongoing basis. Through access to the skills development, coping strategies and behavioural techniques offered by the programme, participants were able to put their new learning and theoretical perspectives into practice. Thus empowered, the benefits of the programme were dramatic for some (Caroline, Frank and Grace in particular), with individuals experiencing an emotional shift, and regaining confidence in their own abilities as a result of recognising and challenging limiting self-beliefs about their capabilities and self-worth.
However, becoming empowered as part of the self-help process seemed to involve considerably more than being given information and education by the Blues Begone programme. In line with Frank and Frank’s (1991) hypothesis highlighted earlier, several participants seemed able to use their imagination and powers of symbolisation create a “relationship” with the self-help material, a relationship of sufficient depth as to be able to use it as a source of motivation, support, and encouragement, engendering hope that their situation could be improved.
The Blues Begone programme appeared to be able to engage users, incorporating several factors known to be important to successful face to face therapy: participants were reassured as to any concerns over confidentiality; the facility of being able to carry out self-help activity within the privacy of their own home seemed to provide participants with a secure base from which they could explore their issues; participants appeared to respond positively and felt “welcomed” by the friendly, supportive and often humorous nature of the material, and in the main, found both the content and process of the programme to be credible.
It would appear that the characteristics of face to face therapy, long since recognised as being conducive to creating the appropriate environment for therapeutic change, were translated into the self-help media, with the user becoming engaged into the self-help process and motivated to come back for more. Thus for several of the participants’ the virtual relationship seemed to offer many of the effective attributes of the face to face therapy.
This interaction between participant and self-help material seemed to support the views of Richardson and Richards (2006); that is if the factors that influence success in face to face therapy can be somehow adapted and explicitly incorporated into self-help materials, then self-help activity is likely to be more effective.
Importantly, the nature of participants’ interaction with the self-help material was felt to be active rather than passive, with the structure of the programme offering a physical framework for individuals’ efforts. Providing a similar function to the behavioural strategy of activity scheduling employed by CBT therapists (see Beck, 1995), this approach seemed to raise the lowered activity levels of some participants’, with individuals reporting an increased sense of mastery and control over their efforts.
Supported by an overall structure and a variety of frameworks with which to gain clarity and order, several participants were able to find the mental space to focus on their issues, their cognitive abilities being awakened by the stimulation of new information and perspectives. Whilst not necessarily being able to make use of the intensity and depth of a human relationship to address psychological problems, perhaps users were supported by the Blues Begone programme in a different way, their minds being stimulated instead by a breadth of information and ideas, such that they were able to create new experiences for themselves and through these develop new perspectives and solutions.
Participants’ growing sense of empowerment appeared to be reinforced by their achievements as progress in their self-help activity was recognised by the virtual therapist at key points in the programme and more importantly, by signs of their own clinical improvement. Research suggests that achievements individuals attribute to their own efforts enhance feelings of mastery and self-esteem more strongly than do those attributed to external factors (see Bandura, 1997 for discussion); perhaps self-help activities relying heavily as they do on the individual’s personal agency have the potential to be particularly effective in this respect.
However it would appear that the foregrounding of the individual in this way may be somewhat of a double edged sword. Whilst self-help material has the potential to stimulate and facilitate individual psychological process, the responsibility of the “work” of therapy lies with the client. Thus the client’s initial psychological position, their openness to new experience, their willingness to become engaged in and committed to the process becomes essential to the self-help material being used to maximum effect.
6. CONCLUSIONS AND RECOMMENDATIONS
In many respects, participants’ experience of the Blues Begone programme revealed that the process of self-help therapy shares several similarities with that of other psychotherapies. For example: whilst symbolic, findings showed that several participants developed a therapeutic “relationship” with the self-help material; individuals found a healing setting for their work in the privacy and intimacy of their own home rather than in a GP’s surgery or a therapist’s consulting room; the Blues Begone programme offered a framework through which participants could begin to understand their issues; and by means of an interactive format, the programme presented strategies with which participants could begin to restore their mental health.
However, participants’ reports also showed that whilst self-help therapy might be considered to have an underlying framework in common with other psychotherapies, the use of that framework varies considerably with the balance of “power” shifting from the therapist to the client. The responsiveness and degree of the face to face therapeutic relationship cannot be replicated through the self-help media; but it is presumptuous to then assume that the value of this intervention is thus irrevocably diminished. Findings indicated that most participants (though not all) were able to make use of other sources of support to “mobilise, focus and use their own resources for self-change” (Bohart &Tallman, 1999) and feel hope in the possibility of change.
In the absence of the “live” therapist, the client was fore-grounded in the healing process, becoming indeed the primary agent of change. Thus the role of the self-help material as Bohart and Tallman proposed is to act as facilitator to the client’s process, in the present instance providing participants with structure and stimulus for them to be able to access their own resources and help themselves. “Interventions” within this type of therapy are offered as aids to clients’ self-growth; not applied to clients as mechanistic techniques designed to change them.
Identifying the appropriate methods by which to do this, and exploring further the nature of the interaction between user and material would appear to be the future challenge of developing this type of therapy; a therapy that deserves to be considered as “a sophisticated intervention in its own right” (Richardson & Richards, 2006)
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8. APPENDIX 1
|“Name”||Age||Marital status||Occupation||Presentingissue||Previous experience of therapy|
|Caroline||56 yrs||Married||Volunteer /CharityWorker||Depression||Counselling and self-help books|
|Jane||57 yrs||Divorced||Therapist||Depression||Long-term therapy and self-help books|
|Grace||47yrs||Married||ProductionEngineer||Depression/ Anxiety||Self-help books and magazines.No formal therapy|
|Frank||34yrs||Married||ITManager||Stress/ Depression||Psychological therapy|
|Monica||30 yrs||Single||ProjectWorker||Low mood/Relationship problems||Brief counselling, self-help books and courses|
|Shelley||38yrs||Single||Disc Jockey||Low mood following physical illness||Brief counselling|
|Teresa||49yrs||Married||ProbationOfficer||Pressure of work/ family problems||Counselling, and self-help books|
9 APPENDIX 2
Central Research Question
How is it that individuals find self-help therapy useful?
Theory Question (1)
Under what conditions do individuals seek the external agency of self-help activity to support personal problem solving?
Interview Question (1)
What was happening in your life that made you consider doing a self-help activity?
Interview Question (2)
Can you tell me a little more about how you were feeling at the time?
How were you feeling about yourself in particular?
Interview Question (3)
What sort of things had you already tried to improve how you felt?
In what ways had they helped you?
In what ways hadn’t they worked for you?
Interview Question (4)
In what ways did you hope that a self-help approach might meet your needs?
Theory Question (2)
What factors do individuals take into account in determining the nature of self-help activity that they need?
Interview Question (1)
What attracted you to this particular self-help programme?
Of the reasons you’ve just shared with me, which was the most important one for you?
Interview Question (2)
What were your expectations of the programme?
Interview Question (3)
Can you tell me about any concerns you had about doing this particular self-help programme?
Interview Question (4)
What other types of help did you consider at this point?
For what reasons?
What made you choose the route you did?
Theory Question (3)
What psychological processes are activated when individuals engage in self-help therapy?
Interview Question (1)
Can you talk me through your experience of the programme?
Interview Question (2)
What parts of the programme stick in your mind as being helpful?
In what ways was…….helpful for you?
Interview Question (3)
Can you tell me about any parts of the programme that you did not find helpful?
What was it about……that was not helpful for you?
Theory Question (4)
In what ways is the client “in relation” to the therapy programme?
Interview Question (1)
How did you feel when you started the programme?
What sort of things made getting going easier for you?
What made getting going harder?
Interview Question (2)
Can you describe to me any particular points when you felt like giving up?
How did you feel then?
What do you think caused your negative feelings?
What kept you going?
Interview Question (3)
Can you describe any positive emotions you experienced during the programme?
Can you describe any negative emotions you experienced during the programme?
Can you remember what triggered these?
Interview Question (4)
Did you feel any differently about doing episodes towards the end of the programme as compared to nearer the beginning?
If so, can you tell me more about this?
Theory Question (5)
In what ways do clients take their experience of self-help therapy and actively use it in their lives?
Interview Question (1)
Can you give me an example of how something you learnt during the programme has resulted in a change in you?
Can tell me about any other changes in your life you have made as a result of doing the programme?
Interview Question (2)
At what point were you aware that a personal change was taking place?
How did you recognise this?
Interview Question (3)
In what ways did you feel differently about yourself at the end of the programme?
Interview Question (4)
Having completed the programme, have you been able to sustain any of the changes we have discussed?
How easy/ difficult has this been to do?
If a friend asked you to describe what it is like to do a self-help programme, what would you say?
Is there anything else you’d like to tell me about your experience of self-help therapy that we haven’t covered?
(Debriefing and Thanks).