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"I Kind of Bounce off It":Translating Mental Health Principles into Real Life Through Story-Based Text Messages

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Adopting new psychological strategies to improve mental wellness can be challenging since people are often unable to anticipate how new habits are applicable to their circumstances. Narrative-based interventions have the potential to alleviate this burden by illustrating psychological principles in an applied context. In this work, we explore how stories can be delivered via the ubiquitous and scalable medium of text messaging. Through formative work consisting of interviews and focus group discussions with 15 participants, we identified desirable elements of stories about mental health, including authenticity and relatability. We then deployed story-based text messages to 42 participants to explore challenges regarding both the stories' content (e.g., specific versus generalized) and format (e.g., story length). We observed that our stories helped participants reflect on and identify flaws in their thinking patterns. Our findings highlight design implications and opportunities for mental wellness interventions that utilize stories in text messaging services.
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398
I Kind of Bounce o It”: Translating Mental Health
Principles into Real Life Through Story-Based Text Messages
ANANYA BHATTACHARJEE, Computer Science, University of Toronto, Canada
JOSEPH JAY WILLIAMS, Computer Science, University of Toronto, Canada
KARRIE CHOU, Rotman Commerce, University of Toronto, Canada
JUSTICE TOMLINSON, Cognitive Science, University of Toronto, Canada
JONAH MEYERHOFF, Preventive Medicine, Northwestern University, USA
ALEX MARIAKAKIS, Computer Science, University of Toronto, Canada
RACHEL KORNFIELD, Preventive Medicine, Northwestern University, USA
Adopting new psychological strategies to improve mental wellness can be challenging since people are often
unable to anticipate how new habits are applicable to their circumstances. Narrative-based interventions have
the potential to alleviate this burden by illustrating psychological principles in an applied context. In this work,
we explore how stories can be delivered via the ubiquitous and scalable medium of text messaging. Through
formative work consisting of interviews and focus group discussions with 15 participants, we identied
desirable elements of stories about mental health, including authenticity and relatability. We then deployed
story-based text messages to 42 participants to explore challenges regarding both the stories’ content (e.g.,
specic versus generalized) and format (e.g., story length). We observed that our stories helped participants
reect on and identify aws in their thinking patterns. Our ndings highlight design implications and
opportunities for mental wellness interventions that utilize stories in text messaging services.
CCS Concepts: Human-centered computing Empirical studies in HCI.
Additional Key Words and Phrases: stories, text messages, cognitive distortions, narrative intervention, mental
health
ACM Reference Format:
Ananya Bhattacharjee, Joseph Jay Williams, Karrie Chou, Justice Tomlinson, Jonah Meyerho, Alex Mariakakis,
and Rachel Korneld. 2022. I Kind of Bounce o It”: Translating Mental Health Principles into Real Life Through
Story-Based Text Messages . Proc. ACM Hum.-Comput. Interact. 6, CSCW2, Article 398 (November 2022),
31 pages. https://doi.org/10.1145/3555123
1 INTRODUCTION
Improving mental wellness often requires adopting new practices or thinking processes, which
demands substantial motivation and eort [
32
]. This endeavor can be especially challenging when
Authors’ addresses: Ananya Bhattacharjee, ananya@cs.toronto.edu, Computer Science, University of Toronto, Canada;
Joseph Jay Williams, williams@cs.toronto.edu, Computer Science, University of Toronto, Canada; Karrie Chou, karrie.chou@
mail.utoronto.ca, Rotman Commerce, University of Toronto, Canada; Justice Tomlinson, justice.tomlinson@mail.utoronto.ca,
Cognitive Science, University of Toronto, Canada; Jonah Meyerho, jonah.meyerho@northwestern.edu, Preventive
Medicine, Northwestern University, USA; Alex Mariakakis, mariakakis@cs.toronto.edu, Computer Science, University of
Toronto, Canada; Rachel Korneld, rachel.korneld@northwestern.edu, Preventive Medicine, Northwestern University,
USA.
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https://doi.org/10.1145/3555123
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398:2 Ananya Bhaacharjee et al.
individuals are unable to recognize the benets of engaging in the dicult process of change or
visualize how those strategies apply to their own lives [
17
]. Therefore, when it comes to promoting
mental wellness, it is important that researchers devise engaging and innovative ways of capturing
people’s interest and demonstrating the value of change.
We posit that stories from real people about their personal struggles can serve as an engaging
method of promoting mental wellness by illustrating theories and principles of psychology in an
applied context. Stories have historically been a well-established medium for sharing knowledge
and experience, particularly in the form of fables, parables, and allegories [
4
,
103
]. A growing
literature also speaks to the potential ecacy of stories in supporting mental health [
6
,
67
,
68
,
84
].
Stories can normalize mental health challenges and validate the diculty involved in making
changes [
128
]. Past work in CSCW has found that individuals experiencing mental health concerns
draw on interactions with others to motivate and guide their own behavior change process, but
these interactions need not require face-to-face or direct communication [
19
,
85
]. We hypothesize
that stories could likewise provide a low-burden experience through which readers can connect
with others. By giving concrete examples of how others have overcome similar challenges, stories
can potentially create a blueprint for how readers can take action on their own struggles. For
example, a story about someone who learns how to overcome rejection while trying to nd a
new job could help other individuals who are actively experiencing rejection of their own. Stories
also invite comparison between the circumstances of the story character and the reader. Such
comparisons provide an implicit point of self-reection [
33
], helping people notice patterns in their
behaviors or thoughts and yielding insights that can support change [62].
Stories can be written, formatted, and shared in many dierent ways. We explore text messaging
as a medium for story delivery since it is by far one of the most accessible services to a wide range
of people. A large proportion of the population routinely carries their mobile phones with them
and engages with text messaging throughout the day [
34
]. Text messaging also has accessibility
advantages relative to app-based tools, which require downloading an app, opening the app
to refresh its content, and maintaining access to data services. Past works have leveraged text
messaging services to help people manage negative emotions, build awareness of mental health
resources, engage in strategies to manage symptoms, and enhance their psychological wellbeing [
26
,
75
,
76
,
89
,
111
]. However, researchers have not extensively used text messaging services to deliver
stories, leaving many open questions about how stories can be best designed and integrated into
text messaging services to support mental wellness. This motivated us to investigate the following
research questions:
RQ1:
What features of story-based text messages related to the content and format can
motivate people to apply mental health lessons (e.g., management of cognitive distortions)
into their lives?
RQ2:
How can story-based text messaging interventions elicit the benets of self-reection
with regards to mental health?
RQ3:
What design tensions might arise when story-based text messages for promoting
mental health are deployed in real life?
In this work, we present insights generated from interviews, focus group discussions, and a
real-world deployment of a story-based SMS service. We focus our investigation on young adults
between 18–25 years old an adult age group with a high prevalence of mental health concerns,
but limited use of traditional options for mental health treatment (e.g., face-to-face therapy) [
1
].
Mobile phone usage is also particularly high in this age range, irrespective of demographics or
socioeconomic status [
14
,
44
,
118
]. We rst conducted a formative study consisting of six one-
on-one interviews and four focus group discussions with 2–5 participants each. We asked our
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I Kind of Bounce o It”: Translating Mental Health Principles into Real Life Through Story-Based Text Messages 398:3
participants about how they envisioned a text messaging service with stories could support their
mental wellness. We found that participants emphasized the importance of concreteness and
authenticity in story-based text messages, as well as an appropriate balance between presenting
positive and negative aspects of people’s experiences.
Based on what we learned from our literature review and formative work, we designed a series of
true stories to be delivered via text messages. These stories centered on cognitive distortions [
11
,
92
],
which are frequently recognized and addressed as a component of cognitive behavioral therapy
(CBT) [
101
]. Cognitive distortions involve exaggerated or unhelpful thought patterns and are
often linked to aective disorders like depression and anxiety [
101
]. We examined stories that
demonstrate how characters were able to recognize these distortions and subsequently expand
their ways of thinking, reduce negative biases, and improve their psychological wellbeing. We
then deployed these stories through text messages to 42 participants, experimenting with features
like the amount of details the stories contained and the inclusion of reection prompts. We then
interviewed a subset of our participants to investigate the implications of our design decisions and
to surface other possible renements. Our participants appreciated that our stories were drawn
from real-life experiences, which helped them connect with the characters. Explicit explanations of
cognitive distortions at the end of the stories also helped them come away with a concrete lesson,
adding to the stories’ value. At the same time, we observed trade-os between story depth and
message length; although people appreciated learning more about the story characters, longer
stories required more eort to read and were thus inconvenient at times.
In summary, this paper aims to shed light on desirable properties of story-based text messaging
when applied to mental wellness, highlighting design challenges encountered while deploying such
interventions in the real world. To achieve this, we rst present data from a formative study of
people’s perspectives on story-based text messages, consisting of (i) six interviews and (ii) four
focus group discussions. We use these insights to design and deploy story-based text messages
with 42 participants, and conduct further interviews to better understand how people perceive and
gain benet from these text messages in their everyday lives.
2 RELATED WORK
For the following overview of related work, we rst describe how stories have been used to
communicate principles related to mental health. We then summarize recent eorts that have
leveraged text messaging to promote behavior change and mental wellness. We conclude by
describing psychological strategies that can be applied to address cognitive distortions unhelpful
patterns of thought that can exacerbate depression and anxiety symptoms.
2.1 Theories and Applications of Stories
Storytelling is a historically common practice for communicating morals and lessons [
39
,
103
].
Stories with lessons can take many forms: fables, allegories, parables, poems, etc. One of the most
famous examples of stories explicitly designed to communicate morals are Aesop’s Fables [
4
], which
end with brief takeaway messages like “slow but steady wins the race” or “look before you leap”.
There is growing literature that speaks to the ecacy of stories in helping people manage their
mental wellness [
6
,
67
,
68
,
84
]. Stories can help normalize dicult experiences and illustrate a road
to recovery from these challenges [
106
], inspiring audiences to apply the same approaches in their
own lives [
66
,
84
,
124
]. Moreover, stories promote self-reection by giving people the opportunity
to draw parallels between the stories’ characters and themselves [
30
,
47
,
88
]. For these reasons and
many others, stories are a signicant component of certain therapies wherein individuals share
stories with one another to learn about others’ processes for overcoming struggles [66,88].
Proc. ACM Hum.-Comput. Interact., Vol. 6, No. CSCW2, Article 398. Publication date: November 2022.
398:4 Ananya Bhaacharjee et al.
Evidence has emerged supporting the ecacy around narrative-oriented approaches to mental
wellbeing. For example, entertainment-education interventions insert educational content into an
entertainment framework [
109
], and narrative persuasion transports the audience into the story to
inuence their attitudes and behaviors [
80
]. Stories have been successful in reducing symptoms of
depression among adults with severe depressive disorder [
121
], primary school children [
105
], and
cancer patients [
98
]. Stories have also been used in interventions to encourage healthy eating [
42
]
and physical activity [
102
], promote citizen journalism [
72
], and counter stigma towards sexual
harassment victims [25].
Digital tools are becoming increasingly popular for exchanging peer narratives [
71
,
78
,
82
,
90
].
Many individuals with symptoms of depression use dedicated online support groups (e.g., 7 Cups [
9
],
National Alliance on Mental Illness programs [
2
]) and general social media platforms [
82
,
96
] (e.g.,
Facebook and Twitter) to share their lived experiences with others, read about others’ experiences,
or solicit advice from people who are going through similar problems. By interacting with peers’
stories online, individuals can form social connections that induce a feeling of belonging to a group
and can gain knowledge about mental health management [
82
]. Zachariah et al
. [129]
and Thiha
et al
. [117]
demonstrated the potential of this approach by using peer narratives as part of an online
education program among high school students to prevent youth suicide. Several digital campaigns
have also crafted stories from individuals’ personal experiences and shared them with targeted
communities to mitigate stigmas surrounding mental illness [
20
,
31
,
49
,
107
]. Online groups can
provide a safe space for people to discuss sensitive issues and explore their identity [15,30], such
as the online fandom communities that have given people a platform for combating prejudices
about the LGBTQ+ community [30].
Although the promise of narrative-based interventions has been explored to some degree, limited
prior work has explored the dierent design dimensions and challenges associated with delivering
stories through particular computer-mediated communication platforms. This paper explores how
one of the most commonly used communication mediums text messaging can present both
challenges and opportunities for story delivery. To understand how the features of texting can be
leveraged to deliver stories that will engage users in improving mental wellness, we explore ques-
tions like “What are the desirable properties of peer stories that are sent through text messaging?”,
"What forms of interactivity would support users in reecting on and learning from stories?", and
“How can a message with only a few sentences still be engaging?”.
2.2 Text Messaging as a Medium for Promoting Behavior Change and Mental Wellness
Text messaging services have shown promise in producing behavior change for various physical and
mental health challenges. For example, Haug et al
. [45]
developed a combination of personalized
motivational messages and behavioral-change support texts to promote smoking abstinence among
adolescent smokers. Their approach resulted in lower cigarette consumption rates, particularly
among occasional smokers. A similar approach [
46
] was also eective in reducing binge drinking
among vocational school students. Suoletto et al
. [116]
delivered text messages that prompted
users to set a goal for their weekly drinking limit; the messages helped users stick to their drinking
limit goal and eventually reduce alcohol consumption. Informational texts on behavioral change
have been found to be eective as well, particularly in the context of weight management [
55
].
Even simple reminder texts can be useful, as several studies have used regular reminders to help
people attend their appointments with doctors [16] or improve medication adherence [36,57].
Text messaging services for promoting mental wellness are also varied in form and purpose [7,
21
,
28
,
51
,
63
,
70
,
77
,
114
,
125
]. For example, Levin et al
. [65]
sent a combination of psychoedu-
cational messages, reminders, and mood rating probes to help users manage their hypertension
and bipolar disorder. Participants reported that the messages were helpful because they found
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I Kind of Bounce o It”: Translating Mental Health Principles into Real Life Through Story-Based Text Messages 398:5
the messages informative and applicable within their own lives. Memo, a text messaging service
by Whittaker et al
. [123]
, was also able to mitigate depression among adolescent participants by
sending psychoeducational texts grounded in cognitive behavioral therapy (CBT) that addressed
common challenges for young people (e.g., cybersecurity, healthy eating). More generally, reminder
messages have been used as cues for people to integrate specic healthy activities into their daily
lives [56,62,81].
An important motivation behind our work is to nd ways of promoting self-reection through
stories. Self-reection is considered an important mechanism for converting an individual’s inten-
tion into immediate action [
10
]. Some digital tools have leveraged interactive agents like chatbots
to encourage people to participate in self-reection. Tielman et al
. [119]
suggest that chatbots can
encourage people to maintain digital diaries, improving awareness about their mental state. Inkster
et al
. [51]
created a chatbot called Wysa that prompts users to reect on their mental wellness by
asking questions like “How was your day?” and “Last time we talked, you were feeling anxious. How
are you feeling now?”. They found that highly engaged users experienced signicant improvements
in their self-reported symptoms of depression. Another chatbot called Reection Companion [
62
]
sent adaptive mini-interventions on a daily basis to encourage physical activity (e.g., graphs of
physical activity, prompts for daily comparisons). Participants who used the chatbot appreciated
the messages since they served as timely reminders and helped participants keep track of their
daily progress.
Only a few recent text messaging interventions have leveraged the benets of stories to support
behavior change and mental wellness. Story-based text messages were found to be an eective
intervention strategy for addressing obesity [
27
,
52
]. Moreover, Irvine et al
. [52]
reported that 80%
of their participants appreciated reading story-based text messages to the point that they would
recommend the text messaging program to others. Stories have also been used in text messaging
services to educate students about sexual and reproductive health [
35
]. Lastly, Willoughby et al
.
[126]
explored the potential of using story-based text messages for discouraging binge drinking
and unprotected sex among young college women. All of these examples show the potential power
of narratives in text messaging interventions; however, none of them have explored how decisions
around the content and format of the stories aect their reception.
2.3 Cognitive Distortions
Psychological interventions can target a number of transdiagnostic and disorder-specic mecha-
nisms in order to motivate change and symptom reduction. For example, common targets when
treating aective disorders like depression and anxiety can include cognitive (e.g., thought patterns
or styles), behavioral (e.g., engagement in pleasurable or mastery activities), and relational mecha-
nisms (e.g., addressing interpersonal role changes). In this work, we craft our stories to help people
identify and address cognitive distortions systematic errors in an individual’s thinking that can
negatively skew that individual’s experience of reality [
11
,
92
]. These distortions represent pro-
posed cognitive mechanisms that drive aective systems, particularly depressive ones. Challenging
cognitive distortions is a key element of CBT [
101
] a form of psycho-social intervention rooted in
the understanding that there are fundamental connections between how we think, feel, and behave.
CBT is one of the most well-researched approaches for addressing mental health diculties and has
been shown to be eective for problems ranging from depression to eating disorders [69,93,99].
Our story topics cover three of the many cognitive distortions that exist: overgeneralization [
59
],
all-or-nothing thinking [
87
], and fortune-telling [
113
]. We provide a brief overview of these three
distortions below:
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398:6 Ananya Bhaacharjee et al.
Overgeneralization
refers to the act of drawing overly broad conclusions from a few selected
negative experiences [
59
]. An example of this distortion would be the following: “My plant
died despite watering it every day. I could not take care of the plant, so I won’t be able to
take care of my kids. People who overgeneralize are prone to viewing negative occurrences
in their lives as revealing an inevitable pattern of mistakes [50].
All-or-nothing thinking
is a negative thought process where someone splits their views
into black-and-white extremes with little gray area in between [
87
]. An example of this
distortion would be the following: “If I can’t give this 100% of my time and attention, then
it’s not going to work. People with this pattern of perception may view their experiences in
rigid, polarized ways [120].
Fortune telling
involves anticipating that a negative outcome will occur regardless of the
context of the situation [
113
]. Key distinctions of fortune telling from other cognitive distor-
tions are that it is focused on future situations, generally involves a negative or catastrophic
outcome, and comprises a disregard for the true or realistic likelihood of a negative outcome.
An example of this distortion would be the following: “Even though I have an interview and
am prepared, I will mess it up and will lose the job. People who frequently experience this
cognitive distortion weigh the negative outcome of an upcoming scenario more heavily than
a neutral or positive outcome [113].
Past work has leveraged computer-mediated communication to help people re-evaluate thought
patterns associated with cognitive distortions. O’Leary et al
. [86]
designed a messaging platform that
guided asynchronous conversations between people using a sequence of reective prompts. Earlier
prompts motivated people to open up and share their worries, while latter prompts encouraged
them to seek possible solutions. Other work in this space has leveraged behavioral chaining [
97
]
the process of reminding individuals about past situations by asking them specic questions on
how certain emotions were triggered. Behavioral chaining can help people recognize their own
faulty thinking patterns and help them prepare for similar events in the future [
22
]. We expand
upon this literature by exploring how stories can prompt people to reect on cognitive distortions.
3 FORMATIVE STUDY
To create story-based text messages for promoting mental wellness, we rst conducted a formative
study to better understand the features people would appreciate in them. The formative study
consisted of six semi-structured interviews and four focus group discussions, which we describe
below.
3.1 Participants
For the semi-structured interviews, we recruited six undergraduate and graduate students between
18–25 years old from a North American university via snowball sampling [
40
]. At the time of the
interviews, the students were either studying computer science or psychology.
Recruitment for the focus group discussions was facilitated by Mental Health America, a
community-based nonprot organization that promotes mental wellness in the United States.
Individuals who showed at least moderate levels of depression or anxiety symptoms according to
the Patient Health Questionnaire-9 (PHQ-9) [
64
] and the General Anxiety Disorder-7 (GAD-7) [
112
]
(i.e., scores of 10 or higher) were invited to learn more about study activities by following a link
presented alongside their results. Potential participants completed an additional screening survey
and were eligible if they were located in the United States, were between 18–25 years old (or
19–25 years in Nebraska, reecting the state’s age of majority), and owned a mobile phone. Nine
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I Kind of Bounce o It”: Translating Mental Health Principles into Real Life Through Story-Based Text Messages 398:7
individuals in total were involved as focus group participants, and they attended as many of the
focus group meetings as they wished.
Our diverse participant pool allowed us to assess the perspectives of people with and without
symptoms of depression or anxiety, reecting that many mental health interventions appeal to and
benet those in the both general and clinical populations; however, drawing explicit comparisons
between these groups is beyond the scope of this work. We refer to our one-on-one interviewees
as FP1–FP6 and focus group participants as FP7–FP15. Overall, the mean age of our participants in
the formative study was 22.3
±
0
.
4years old. The participants identied with multiple genders (12
female, 3 male) and several racial groups (7 Asian, 4 white, 1 African American, 2 with more than
one racial identity, 1 undisclosed).
3.2 Procedure
We anticipated that some people would feel comfortable discussing their experiences and pref-
erences one-to-one because of the sensitivity of our research topic, while others would prefer to
open up in a group and collaboratively generate ideas. As such, we gathered feedback through
both individual interviews and focus group discussions. Our questions centered on understanding
participants’ mental health needs and how these needs could be met by a text messaging service that
provides story-based interactions. We rst asked people to share their experiences with existing
mental health applications. We then asked questions to understand how story-based messages
could help them manage their mental health concerns. Our questions included, but were not limited
to: “What types of messages do you think you’d like to receive about other people’s experiences?”,
“How can a story about someone else be made more engaging?”, “Would you want to pick the
topic of the story? Why or why not?”, “How much background information do you want about the
person whose experience is being shared? What do you need to know about them to get something
out of the story?”. We also asked participants if they could foresee any challenges to delivering
peer stories through the medium of text messaging. Since the interviews were semi-structured, we
deviated from the interview script as needed to follow up on participants’ insights and observations
that were relevant to the research questions.
Both the individual interviews and focus group discussions were conducted via the Zoom
videoconferencing platform. Interviews were conducted by a single member of the research team.
The size of the focus groups ranged from 2–5 participants each and were facilitated by two
members of the research team. The interviews and focus group discussions centered on participants’
experiences with digital tools for mental health and their ideas for how such programs could support
them in changing their behaviors and thought patterns. In addition, we sought to better understand
the features participants would like to see in a text messaging-based program and participants’ ideas
for how narratives could be incorporated into text messaging. Each interview lasted 20–30 minutes,
while focus group discussions lasted 60–75 minutes. All of the participants were compensated at a
rate of $20 USD per hour. Research activities took place in two universities and were approved by
both universities’ Research Ethics Boards.
3.3 Data Analysis
After transcribing the interviews and focus group discussions, we followed a thematic analysis
approach [
23
] to analyze the qualitative data. Two team members, referred to as coders”, rst
reviewed all transcripts to become familiar with the data. The coders then assigned segments of the
data to distinct codes through an open-coding process [
60
]. Each coder developed a preliminary
codebook on their own before convening to decide on a shared one. These deliberations occurred
across several meetings, during which they identied overlapping codes, rened code denitions,
and excluded codes that were not central to our research questions. The coders then each applied
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398:8 Ananya Bhaacharjee et al.
the shared codebook to a subset of the data (four interview transcripts), before meeting to rene
the codebook to better t the data. After repeating this iterative process, the coders reached a
consensus and applied the nal codebook to separate halves of the data.
3.4 Ethical Considerations
Our team members included graduate students and faculty members in computer science, human-
computer interaction, cognitive science, and clinical psychology. Since research promoting mental
wellness can raise several ethical considerations, we have addressed these issues throughout the
research process. During the interviews and focus group discussions, participants were informed
of the fact that they could leave the conversation or skip any questions if they felt uncomfortable.
Interviewers were also trained to conduct the Columbia-Suicide Risk Assessment protocol [
91
] and
address any emergent suicidal thoughts or behaviors in a collaborative manner that aligned with
best practices (e.g., delivery of safety planning, referral to crisis services). No such risks emerged
during the study.
4 FINDINGS FROM FORMATIVE STUDY
Several themes emerged from our formative work regarding the desirable features participants
envision in story-based text messages. Below, we discuss each of these themes and their implications
for our deployment.
4.1 Conveying Authenticity
Findings:
Participants expressed a strong desire for messages that convey “authenticity” by
which they meant the feeling that a message is from a real person. Participants like FP7 and
FP37 mentioned that knowing a story is written by a real person would increase the sense of
authenticity, allowing them to connect to story characters and nd greater motivation for change.
They anticipated that such stories would also give them a sense of comfort in knowing that someone
else was able to overcome their dicult situation, which would boost their condence in dealing
with their own struggle. FP9 said,
I like hearing other people’s stories and what they did, and it kind of helps me feel a little
better. And I kind of bounce o it and do what they did and try these new things that
they’re doing.
Some participants also shared negative experiences reading what they believed to be manufactured
stories that were fabricated to make them feel better. These individuals preferred stories that
came from real people since they felt that manufactured stories were disingenuous and had little
credibility. When we asked our participants how they distinguish manufactured stories from real
ones, they stated that they often relied on “gut feelings”. However, FP7 speculated that stories with
less specicity were more likely to be manufactured: “If the story sounds like this could happen to
anybody, my mind makes me think, ‘Oh, then it didn’t happen to anybody.”’
Implications for Our Deployment:
We engendered authenticity in our stories using three dif-
ferent approaches. First, we created stories as a research team by drawing from our own real-world
experiences rather than fabricating scenarios. The stories were written by members of our research
team (see Section 5.1 for details about story generation). To make the origin of the stories clear,
each one started with a sentence that explicitly indicated that they were true stories from real
people. Second, we wrote stories in the rst-person perspective with the intention to give the story
character a voice, which would in turn help form a connection with the reader [
24
]. Third, we
included enough details about the characters and situations to paint a concrete image in the readers’
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I Kind of Bounce o It”: Translating Mental Health Principles into Real Life Through Story-Based Text Messages 398:9
minds. For example, rather than just referring to college students in general, we included details
like their academic majors or their relationship to other characters in the story (e.g., an economics
student sharing their problems with a close friend). These details are not always necessary for
understanding a story, yet messages with more details are often perceived as more credible since
they are more likely to trigger people’s memory of related experiences [
100
]. These nuances align
with practices that generate authenticity while creating personas (i.e., concrete representations of
target users) in user-centered design [3].
4.2 Having Concrete Takeaways
Findings:
Participants perceived that existing online resources and digital intervention services
for mental health only provide supercial and generic suggestions like “do not overthink” and “try
out a fun activity”. Despite sometimes nding these suggestions useful, participants felt that they
have little impact because people often do not have the time or energy to think through how to
apply them in their own lives. Hence, participants advocated for messages that give more precise
guidance and suggestions. Participants recommended that messages should be able to explain
why a certain practice would be benecial to their wellbeing. FP12 explained that even a brief
justication would be benecial to them:
I think one sentence would be nice. So, for me, I didn’t ever take breathing exercises
seriously until someone said to me, ‘Oh, but the reason why it helps is because it brings
you back to the present and helps you concentrate or prevent anxiety. So, that makes me
take it more seriously.
Implications for Our Deployment:
Inspired by the structure of Aesop’s Fables [
39
,
103
], we
explicitly provided a concrete takeaway message for the reader at the end of each story. This
practice aligns with Barthes’ three-layer narrative structure [
8
], which consists of layers for actions,
characters, and morals. The action and character layers describe the physical setting of the world
and the characters involved, while the moral layer pinpoints the goal of the story [
29
]. For the
action and character layers, our stories involved real people in real situations. For the moral
layer, we introduced a psychological concept (e.g., “This person experienced a thinking trap of
‘overgeneralization’.”) and expanded on how the concept is tied to the story. Thus, we prompted
readers to reect on the purpose of the story and what it illustrates rather than on particular details
or characters. In our case, a team member trained in clinical psychology designed the concrete
takeaway messages to highlight how the stories illustrate common cognitive distortions.
4.3 Encouraging Active Participation
Findings:
A frequent suggestion from our interviews was that the users of a story-based text
messaging service should be involved as active participants rather than as passive readers. Our
participants suspected that if all of the communication is one-way (i.e., from the system to the
user), users might not spend as much time reecting on the stories. FP1 and FP3 posited that we
could increase engagement by following the stories with prompts for people to share their own
experiences. When this suggestion was mentioned to other participants, many agreed that there is
value to composing their own messages, but concerns were also raised. Some participants expected
that people would be hesitant about sharing their personal details through a messaging platform,
while others speculated that people will not always have the time or energy to write more than a
couple of sentences.
Implications for Our Deployment:
We encouraged active and reciprocal participation in our
deployment by asking users a reective question at the end of each story, typically along the lines
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398:10 Ananya Bhaacharjee et al.
of “Have you had a situation where you had to deal with a similar challenge?”. To mitigate some
of the concerns raised about people’s willingness to share personal information, participants in
our deployment were made aware that their responses would not be shared beyond the research
team. We anticipated that by answering such questions, users would be able to reect on their own
experiences and how the stories’ messages could be applied to their situation. This approach is
similar to dialogic inquiry between parents and children during storytelling, in which the parent
periodically pauses to ask the child to relate the story to their own experience [110].
4.4 Balancing Positivity with Realistic Struggles
Findings:
Participants in our studies suspected that reading too much about people’s struggles
could sometimes induce sadness or decrease motivation. They instead suggested that we should
focus on positive stories that inspire hope. That being said, participants also mentioned that
presenting too rosy a picture of living with mental health symptoms would appear disingenuous or
set unrealistic expectations for people. Therefore, participants suggested nding a balance between
positivity and a realistic depiction of people’s struggles. FP8 explained that stories should show
how a person overcame their struggles without trivializing the time and eort involved in making
change:
I like the idea of a successful story. But I would also like to be like, ‘Oh, people were going
through something really bad, and now they’re getting help. Even though they’re not 100%,
they are seeing how that’s helping and how it’s making everything better’. So not really
just skipping directly to the end, just being able to say, ‘Hey, I’m still struggling, but I’m
getting better. It’s just kind of a reminder, like, ‘Hey, it’s not going to x itself overnight.
Implications for Our Deployment:
Although we avoided content around experiences that have
potential to trigger secondary trauma (e.g., sexual assault, family deaths) [
79
], we sought to relay
the serious issues young adults face. These topics included, but were not limited to, struggles
precipitated by academic stress, relationships with parents, or failures in school and careers.
We ended each of our stories on a positive note wherein an individual achieves some level of
improvement in their situation or a new outlook on their problems, allowing the reader to see the
value of making change. We sought to make these conclusions as realistic as possible; instead of
claiming that characters had made tremendous progress or completely resolved their problems, our
stories showed that small steps can be made to improve one’s situation.
4.5 Message Format and Length
Findings:
Participants provided a range of opinions regarding the appropriate length of stories. Four
interview participants preferred longer stories that provided more context, detailed explanations,
and clear examples. FP6 said,
When you receive just a short like one sentence, it’s very easy just to like read it and be
like, ‘Okay, I’m done. But if you force someone to read ve sentences, then they’re much
more likely to like take those like extra 10 seconds to process what they’re reading.
Participants in the focus groups also felt that people would be able to more easily connect with
messages that had more detail, expecting that shorter messages would be “vague” and “unclear”. In
contrast to these views, FP2 and FP5 worried that longer stories would be broken across a long
series of consecutive text messages, reecting that most text messaging services limit the number
of characters per message. Breaking stories across too many messages was predicted to lead to
annoyance, particularly since many people set their phones to vibrate or ring whenever they receive
a notication. FP5 speculated that seeing and hearing many notications in quick succession would
be overwhelming, especially for people who are preoccupied with other tasks. Another point that
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I Kind of Bounce o It”: Translating Mental Health Principles into Real Life Through Story-Based Text Messages 398:11
was raised by participants was that it would be nice to have a mechanism for customizing the kinds
of stories that users would see. FP7 expressed that the feeling of control would create a sense of
ownership over the system, which would keep them engaged.
Implications for Our Deployment:
To investigate the importance of message length, we created
short and long versions of each story with either 3 or 5 messages, respectively. Most of the
consolidation for the short versions came at the beginning of the stories; while the long stories
used a couple of messages to set up the context and describe the characters and their problems,
the short stories only used one message for that purpose. The short versions were also condensed
when the character reaches a resolution to their problem, but both the short and long versions
had similar amounts of text at the end dedicated to explaining how the story illustrates a common
cognitive distortion.
Participants also wanted the ability to control the content of the stories that they read. We also
experimented with a couple of dierent mechanisms for allowing participants to control the content
of the stories that they read:
Up-Front Choice format
: With this approach, participants were given a single sentence or
question to gauge their interest in a particular story (e.g., “Do you ever feel like everything is
going wrong at once?”). If the participant expressed interest in that topic by responding “yes”,
they were sent the rest of the story; if not, they were sent another prompt and the process
repeated until a suitable match was identied.
Start and Switch-Out format
: With this approach, users received the rst 3–4 messages
of the story and then an additional message asking them if they wanted to continue hearing
the rest of the story. Users who requested more of the same story would see the rest of the
story that they had already started, while users who requested a dierent story were given a
new story on a dierent psychological principle.
Our rationale behind both of these formats was that seeing a short teaser or segment of a story
would be less overwhelming and would also give users enough information to decide if they want
to engage with it. Although the Up-Front Choice format arguably allows the greatest control in
selecting a relevant story, it also demands more action from the user at the outset. Therefore,
we were interested in how users would respond to both strategies. Figure 1illustrates the key
interactions in these two approaches. Note that the Start and Switch-Out format was only applied
with longer stories since there is no need to extend shorter ones.
5 DEPLOYMENT STUDY PROCEDURE
In this phase, our goal was to test and extend the ndings from our formative work. We developed a
small collection of stories using the ndings and design questions that emerged from our formative
study. We integrated these stories into a text messaging probe that was deployed to participants.
We describe the logistics of this deployment below.
5.1 Story Generation
We followed an iterative design process within our own research team to generate stories suitable
for our investigation. Team members were asked to share their real life experiences that could be
linked with one of the three cognitive distortions listed in Section 2.3 (overgeneralization [
59
],
all-or-nothing thinking [
87
], and fortune-telling [
113
]). They were aware that their stories could
potentially be shared with people outside the research group, so they did not disclose private
information during this brainstorming period. The connection with cognitive distortions enabled
us to craft a clear takeaway message for the readers. The takeaway messages was designed by a
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398:12 Ananya Bhaacharjee et al.
Fig. 1. Illustrations of how participants would receive stories under (a) Up-Front Choice format and (b) Start
and Switch-Out format. For the Start and Switch-Out format, participants would receive the first few messages
of the story before being asked if they wanted to see the rest of it.
clinical psychologist from our team. After collecting around ten stories, we held multiple meetings
to rene their content according to our ndings in the formative work and subsequently selected
one story per cognitive distortion.
The stories themselves are briey summarized in Table 1. The stories all share a similar ow:
the characters and their unique challenges are introduced, the characters experience negative
thoughts that center on one of the identied cognitive distortions, and the characters eventually
reach some sort of resolution. The rst four design elements we elicited from our formative study
conveying authenticity, having concrete takeaways, encouraging active participation, and balancing
positivity with realistic struggles had yielded clear implications which we followed when crafting
stories. The appropriate message formats were less clear, so our probes considered a range of
possible solutions by introducing stories of shorter and longer lengths and by testing multiple
options for topic selection. Figure 2shows the long and short versions of the same story involving
overgeneralization.
5.2 Participants
We used two distinct recruitment methods to enroll participants between the ages of 18–25 for
our deployment study. The rst group of participants (P1–P14 and P39–P42) was recruited via
snowball sampling [
40
] with no inclusion criteria beyond having interest in a text message-based
intervention to promote mental wellness. The second group of participants (P15–P38) was recruited
via targeted ads posted on the Mental Health America website, the same community-based nonprot
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Table 1. Summary of the three stories that were sent to participants in our deployment study.
Topic Summary
Overgeneralization
This story is about an individual who had a series of unfortunate events
happen to them over the course of a week, which left them “thinking
about how big [of] a failure [they were]”. They sought support from
a roommate, who reassured them that everyone goes through periods
where “everything is going wrong all at once”. The roommate also
suggests that experiencing one or two “unpleasant” events should not
be an indicator of a “never-ending pattern of defeat. The narrator comes
to accept that, by focusing only on the negative, they are overlooking
that there are many positive events in their life as well.
All-or-nothing
thinking
This story is about an individual who felt overwhelmed by all of the
work they had to do on a given day. As a result, they “spent over two
hours in bed on Instagram just scrolling”, which made them feel even
worse. They were able to break this cycle once they realized that they
could still make some worthwhile progress even if they had not started
their day in an optimally productive way. Thus, they challenged the
assumption that everything must go exactly as planned in order for
them to feel successful during a given day.
Fortune-telling
This story is about an individual whose career interests diverged from
their parents’ expectations. The narrator explains that they had been
avoiding a conversation with their parents about switching their major
due to worries it would lead to a ght. After getting advice from a friend,
they decide to test their assumptions by having the much-dreaded
conversation with their parents. Contrary to their expectations, the
narrator nds that their parents are relatively supportive of the new
career path and express that they just want their child to be happy.
Therefore, the narrator learns that “fortune-telling” about other people’s
responses is not always a reliable way to navigate the world.
organization that facilitated the focus group discussions. Five of those people came from our focus
group discussions (P34–P38). These participants self-reported symptoms of moderate depression
or anxiety according to their scores on the PHQ-9 and GAD-7 [
112
]. Deploying our probe to
both populations allowed us to assess the suitability of our approach for people with and without
symptoms of depression or anxiety; as with our formative study, however, we do not attempt to
draw comparisons between these two groups. We rst deployed our probe to the student sample
to gauge any unforeseen issues with the messaging and study approach before moving to the
population with clinical symptoms who are potentially more vulnerable.
Overall, our deployment study involved 42 participants who were living in North America at the
time of the study. The mean age of our participants was 22.0
±
0.4 years. Our cohort spanned multiple
genders (29 females, 13 males) and ethnicities (40.5% Asian, 35.7% White, 9.5% African American,
4.8% American Indian or Alaska Native, 4.8% multiple racial identities, and 4.8% undisclosed).
5.3 Procedure
Our investigation of story-based messages was part of a broader project that aimed to understand
how dierent types of messages (e.g., didactic messages, action prompts and reminders, and stories)
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398:14 Ananya Bhaacharjee et al.
Fig. 2. The (a) long and (b) short versions of the story involving the cognitive distortion of overgeneralization.
can be delivered via texting to support mental wellness. Participants were recruited in several
waves. For the purposes of this study, our deployment lasted between September 2020–February
2021.
The composition of the overall program was adjusted between waves. Specically, the project
was initially structured so that participants would be enrolled for a week of messages, of which one
day was dedicated to story-based messages. In order to test additional content types and formats,
the protocol was later extended to two weeks, allowing us to distribute story-based messages to
participants for two days. All participants (in the one-week and two-week deployments) received
one long or short story in the Up-Front Choice format. Participants who had an additional day for
stories (two-week deployment only) also received a long story in the Start and Switch-Out format (the
Start and Switch-Out format was not conducive to short stories). Table 2shows which participants
received which formats of story-based messages. Because we had three stories, participants were
able to change their story up to two times. Those who received stories on multiple days never
saw the same story twice. On the days that participants were assigned stories, their rst message
was sent around 9:30 AM in their local timezone and subsequent messages were sent in 30-second
intervals unless they required a user response.
At the end of each story, participants were sent an additional text message asking whether they
could relate to the story scenario with an instruction to reply with “yes” or “no”. We refer to this
question as the relatability prompt. If a participant responded “no”, they were thanked for their
participation and received no further messages that day. If a participant responded “yes” or did
not respond within a two-hour window, they were also asked to further contemplate the cognitive
distortion depicted in the story via an open-ended reection prompt. The prompt asked them to
write about a similar situation from their life. Participants who provided a written response were
thanked for sharing.
Participants were sent messages using Twilio, an automated message delivery platform. Research
team members sent the messages manually using a Wizard-of-Oz approach [
83
]. This enabled our
research team to handle unexpected participant responses using human judgment (e.g., open-ended
responses to closed-ended questions). The team members followed a detailed script that specied the
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I Kind of Bounce o It”: Translating Mental Health Principles into Real Life Through Story-Based Text Messages 398:15
Table 2. Distribution of story-based messages among dierent participants
Participants Up-Front Choice format
received?
Start and Switch-Out format
received?
P1–P33 Yes No
P34–P42 Yes Yes
timing of each message and how the messages should be selected based on experimental condition
assignments and participant replies. Participants were informed during the consent process and at
the start of the study that a research team member would be reviewing their responses.
After participants completed the study, they were invited to take part in a semi-structured
interview to provide feedback on the stories and other messages they had received; 20 people
accepted this invitation. In the interviews, we asked people to comment on the design themes from
our formative work (e.g., authenticity, concrete takeaways). We also asked them about the factors
that impacted their level of engagement with the intervention (e.g., busyness, mood). Finally, we
asked participants what thoughts and feelings, if any, they experienced during and after engaging
with the messages. The interviews took 10–30 minutes. Participants were not compensated for
engaging with the text messages to ensure that payment would not inuence the extent to which
people would interact with them. However, all participants were compensated for their time
participating in the interviews.
5.4 Data Analysis
We analyzed participants’ responses to the stories using mixed methods. We report the response
distribution for the relatability and reection prompts, as well as the average word count to the
open ended reection prompt. The interview transcripts were analyzed using the same thematic
analysis procedures used for our formative work [23], albeit with a separate codebook.
5.5 Ethical Considerations
Participants were informed at the beginning of our study that our messaging program was not
intended to be a crisis service. We provided participants with the contact information of several
crisis services (e.g., crisis text lines and suicide hotlines) in the possible event that such information
would be useful. Although we did not solicit suicide-related information at any point in the
study, we recognized that given the open-ended nature of text messaging, there was an unlikely
possibility that participants may disclose (unprompted) suicidal thoughts or behaviors. Therefore,
we developed procedures to ensure safety of participants. We reviewed all received text messages
on a daily basis. If any message indicated a risk of self-harm or suicide, team members were trained
to reach out to the participant and conduct the Columbia-Suicide Risk Assessment protocol [
91
].
Similar considerations were applied to the interviews, as previously described in Section 3.4. No
risks emerged during the study, and therefore no follow-up assessments were needed.
6 FINDINGS FROM DEPLOYMENT STUDY
In this section, we discuss the insights generated from the text message responses and the post-
study interview sessions. We rst talk about how participants engaged with the stories and the
accompanying prompts, as well as the factors that impacted their responsiveness. We then describe
the feedback we received on the four design features we identied from our formative study. Finally,
we conclude our ndings by discussing the diverse opinions people had regarding message format
and length.
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398:16 Ananya Bhaacharjee et al.
Table 3. The response rates to the various message configurations during our deployment study.
Prompt Up-Front Choice
format long story
Up-Front Choice
format short story
Start and Switch-Out
format long story
relatability
prompt
13/17
(77%)
18/18
(100%)
5/9
(56%)
reection
prompt
6/17
(35%)
11/18
(61%)
5/9
(56%)
6.1 Overall Engagement with the Story-Based Text Messages
Engagement with a text messaging service like ours is challenging to measure since people can
read and reect on messages without writing and submitting a response. With that in mind, we
turned to both quantitative and qualitative data to understand the extent to which people engaged
with our stories. In our deployment study, 7 people did not respond to the question on selecting a
story topic in the Up-Front Choice format, so 35 out of 42 participants received a complete story
after in response to one of our selection methods. Table 3shows that participants were moderately
responsive to the relatability prompt and the reection prompt across the various formats.
During our interviews, we spoke with two participants (P2 and P22) who did not not respond to
any of the story-based messages but engaged with other messages in our broader program. P22
stated that they never responded to the Up-Front Choice format prompts because they anticipated
the stories would be from the perspective of famous celebrities and would not resonate with their
situation. Meanwhile, P2 stated that they saw the prompts for choosing a story topic but simply
forgot to reply. When we asked our other interviewees about situations that might cause them to
not respond to messages, the most common explanations related to forgetfulness, being preoccupied
with other tasks, or a lack of energy. Some participants said that they generally disable audio or
vibration notications on their phone, and so they did not see our messages until later in the day
and felt that it was too late to respond. To address the potential for missed messages and forgotten
responses, participants like P35 advocated for reminders:
I forget to do stu for myself sometimes, so I might forget to reply as well. So you can
send me prompts that come a little bit after the initial message. Those messages will work
as reminders.
6.2 Feedback on Previously Identified Design Elements
Based on insights from our formative work, we explicitly considered four design features when
crafting our story-based text messages. We revisit these features below to assess the degree to
which we satised our goals.
6.2.1 Authenticity. Participants believed that the stories were authentic and actually came from
a real person. When we asked them why they believed this to be true, some noted the level of
concrete details within the stories. A few reported that they found the stories authentic because
the scenarios they described mimicked what was happening in their own lives. For example, P27
coincidentally took an economics class just like the central character in the overgeneralization
story and was thus able to imagine themselves in that character’s situation:
As the person was describing how they were trying to look for ways to snap themselves
out of it, I saw those as coping mechanisms that anybody could use with the things that
they were trying to do.
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I Kind of Bounce o It”: Translating Mental Health Principles into Real Life Through Story-Based Text Messages 398:17
Others expressed that although they had not gone through similar experiences to the ones presented
in the stories, they could still connect to the feelings being portrayed. After reading the story
on all-or-nothing thinking, P3 and P35 resonated with the feeling of being unproductive due
to procrastination, despite being involved in dierent occupations and elds. Nevertheless, P11
acknowledged that it is impossible to come up with a small set of stories that resonate with people
across all demographics, occupations, cultures, and circumstances; even so, they argued that stories
with specicity could still seem relatable since most people have felt helpless or anxious at some
point of their lives.
Contrary to these perspectives, our stories did not resonate with P37, who advocated for greater
personalization:
If you guys already had basic information about me, like I am out of school or working
or whatever, and then gave me stories that were already tailored to what my life might be,
then I think that would be really helpful and it would just resonate with me easier.
On the whole, we observed that participants were more likely to regard stories as authentic if they
described experiences that they had gone through themselves, either in terms of characters’ specic
circumstances in life or their feelings and mental health struggles. In other words, participants
often correlated relatability with authenticity. One suggestion we received for making stories more
relatable was to leverage literary tropes since they are generally familiar to many audiences. An
example of a broadly recognizable literary trope would be an underdog story in which a character
is able to overcome signicant adversity relative to their peers to achieve a successful outcome.
6.2.2 Concrete Takeaways. Most of our participants appreciated the fact that each story was explic-
itly connected to a concept from psychological literature. For many, the connection transformed
reading the text messages from being a casual leisure activity into being a productive learning
opportunity with a concrete benet: the lesson that was learned at the end of the story. P30 men-
tioned that “putting a name [psychological term] to the story” was helpful because it gave them
the knowledge and terminology they needed to conduct further online research. Other participants
felt that without the concrete takeaway message at the end, they may not have known how to
interpret the stories or make use of them. P28 stated,
I like that stories were tied to a principle because if this was used with a younger crowd,
like teenagers, and if the teenagers I know read this, they’ll be like ‘Why did you make us
read this?’. So you have to connect it back to something so that people understand why it’s
being told.
On the other hand, P3 felt that the explicit connections to psychological concepts detracted from
the emotional experience of reading the stories and made them sound too prescriptive. They went
on to say that stories should have room for interpretation so that people can decide for themselves
how to best apply the lessons to their own lives. P13 felt similarly and said that stories should leave
room for interpretation since psychology does not have a denitive solution for everyone’s problems.
These ndings suggest that more work is needed to understand how explicit messaging should be
when connecting stories to the principles they are meant to illustrate.
6.2.3 Active Participation. We added the reection prompt to encourage participation from users
and help them to reect on their life experiences similar to the stories. In the interviews, participants
like P11 noted that the writing activity was a “fun break” from their other work and school
obligations. Other participants expressed that the action of writing responses to the reection
prompt made the stories feel more interactive and helped them better understand a persistent
source of troubles in their lives. Some participants went as far as suggesting that the reective
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398:18 Ananya Bhaacharjee et al.
prompt should explicitly request users to share stories that they think would help other people,
creating a sense of community with the broader userbase.
People who did not respond to the reection prompt noted that they did not always have the time
or energy to write about their life, although some of them claried that they did not necessarily
dislike the prompts. In some cases, people told themselves that they would nd a better time to
respond to the prompt, only to forget later in the day. Another common complaint was that some
people had diculty writing long messages on their mobile phones. P7 said,
It’s kind of hard to text or message a lot on the phone. The reason why I had done the
writing is that I could do it on my computer since my phone and computer are linked, so
it was easier to do it that way. I wouldn’t have done it if it was just on my phone, because
there’s just too much typing and if you make edits, it’s just too much.
6.2.4 Balance between Positivity and Realistic Struggles. Participants generally desired stories that
had the reasonable balance between portraying the struggle of the character and inspiring hope
in the end. P20 commented that although having a positive ending results in a psychologically
healthier mindset, reaching an improbable resolution to complicated issues (i.e., a fairytale ending)
could be dissatisfying. In this regard, P39 appreciated acknowledgements of people’s struggles,
saying:
I found the stories helpful because they weren’t trying to spread toxic positivity, like
‘ignore bad thoughts’ or ‘concentrate on all the good’. It’s about acknowledging the bad as
well.
Some participants felt that our stories should have also covered more sensitive topics like child
abuse or sexual harassment. For example, P27 posited that our text messaging service would have
signicant benet for them if our stories acknowledged traumatic experiences like child abuse
and illustrated how people have overcome such experiences. Nevertheless, participants suggested
that stories with sensitive topics should be designed with caution so that they validate the readers’
struggles without inducing secondary trauma.
6.3 Perceived Benefits of the Stories
We now describe how the participants applied the stories into their life and the corresponding
benets they experienced.
6.3.1 Scaolding Feelings of Connection. Participants often reported that they felt connected with
the story characters, with the degree of perceived authenticity playing an important role. The
authenticity of our stories led our participants to recognize that there are other people in the world
who are going through similar experiences. Moreover, the feeling of connectedness gave them the
condence to overcome their struggle. In the words of P34,
Remembering that other people experienced the same thing is encouraging. It reminded
me, ‘This is life, I can deal with it.
Finding connection with others also gave participants a new perspective on their own problems.
P36 reported that due to the COVID-19 pandemic they could not reach out to friends to talk about
how they were struggling academically, but they perceived that reading the stories and answering
the reection prompt served as a sort of replacement for supportive discussions. On a dierent note,
P20 felt that the story characters were experiencing even more severe problems than them, which
gave them condence to tackle their relatively less dicult life issues.
6.3.2 Adapting Stories to Personal Contexts. The reection prompt that we added after the story
encouraged people to identify and elaborate on similarities between the characters’ situation and
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I Kind of Bounce o It”: Translating Mental Health Principles into Real Life Through Story-Based Text Messages 398:19
their own. Many participants voluntarily shared their own life experiences after this prompt, writing
in detail about their struggles and their negative thought processes. For example, P1 connected the
cognitive distortion of fortune-telling to their relationship with their roommates, nding that they
had made assumptions about what their roommates were thinking and feeling without ever testing
these assumptions:
I can easily tell when my roommates use some of my things that are not theirs (e.g., olive
oil, body wash, etc.) and I often think that me confronting them about it will make them
dislike me and use my stu even more out of spite because in my head, I think they’ll
say I’m being uptight since they only use a little bit at a time.
Participants informed us that the stories gave them a template into which they could insert their
own experiences to better visualize how certain behaviors aected themselves and others. In P12’s
words,
I want to simulate people in my brain. I prefer to know their initial state. I want to know
what their input and output was, given such a problem exists. I want the information to
be complete so I can do a simulation more properly. It helps me gure out how I can apply
those situation in my own life.
In some cases, placing one’s situation into the story format helped people identify faults in their
behavior for the rst time. For example, P14 was not familiar with the concept of fortune-telling
before reading the story on that topic, nor did they realize that they had the habit of expecting bad
things from any situation; the story made them aware of their own pattern of thinking despite the
example being in a dierent context.
6.3.3 Exploring Alternative Solutions. In addition to reecting on their experiences, participants
also used the reection prompt as a chance to devise alternative ways of approaching their problems.
For example, P16 read the story about all-or-nothing thinking and subsequently reected on their
approach to online courses:
When needing to complete school work, there are times where I’m just not in the mood to
do so even though I know something is due soon and needs to get done. I usually end up
spending hours with distracting myself and forget all about what needed to be done in
the rst place. The thing that I forget is I should always leave myself with plenty of time
between assignments and I know this, it’s just that I tend to forget that fact when I get
into one of these moods.
The stories also had continuing impact after participants wrote out their thoughts. For example,
P27 informed us that the overgeneralization story stayed in their mind a few days after they had
seen it. The story made them realize that they should not have manage their situation alone, and
prompted them to reached out to their social circle for support. P27 also noted in the interview
that they planned to deal with future situations dierently.
6.4 Feedback on Message Format and Length
Lastly, we talk about the diverse responses we received regarding message formats and length.
6.4.1 Message Format. Table 3suggests moderate to high levels of engagement for dierent formats,
but we refrain from making claims about a preferred format due to the small sample size and
potential confounds (e.g., for those in the two-week deployment, the Start and Switch-Out format
was received after the Up-Front Choice format, which may cause order eects). Instead, we rely
on the qualitative data from our interviews to understand the potential benets and challenges
related to dierent formats. In our interviews, participants appreciated that the Up-Front Choice
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398:20 Ananya Bhaacharjee et al.
format allowed them to choose a story topic instead of directly starting a story. Participants like P4
and P33 expressed that choosing the topic of the story gives a sense of control and helps them to
nd relatable contents. However, P3 felt that asking multiple questions before the actual story may
make users “overwhelmed”.
Participants provided diverse opinions about the Start and Switch-Out format. P34 felt that this
approach gave them the opportunity to see the actual story, with the choice to continue or to switch
out a story allowing them to dismiss content they found boring or unrelatable. The people who did
not appreciate the Start and Switch-Out format usually felt that the story was cut o in an awkward
position when they were asked about continuing, potentially leaving the stories unresolved. Since
the rst few sentences of each story introduced the characters and their struggles, participants
who never responded to the prompt for Start and Switch-Out format prompt only saw the negative
setup for the story without any positive resolution. P19 said,
Don’t just tease something horrible. And then, you know, if you never see more of the
story, all you’re left with is something horrible.
To address this, P12 suggested that the text messaging services could continue the story anyway
after a certain time of non-response so that stories do not go unresolved.
6.4.2 Message Length. Participants also had dierent reactions to the length of the stories we
sent them. The qualitative data suggests that not all users were satised with the length of the
stories they received. Some participants preferred shorter stories and felt overwhelmed when they
received many consecutive messages. P39 recounted how receiving a long story made them feel
like an emergency had arisen:
I am often in classes or meetings. If I get six or seven notications in the middle of a class,
I would probably think, ‘Oh my God! What has happened?’ I would probably panic, and if
I see these text messages then, I would be very annoyed.
Another reason that some participants preferred shorter stories was because they felt that longer
stories required them to “waste their brainpower” (P8) that could otherwise be applied to their
work and responsibilities.
In contrast, people who enjoyed the longer stories appreciated the level of detail they included.
Rather than having a single sentence to introduce the characters and set up the narrative, these
stories used 2–3 sentences to convey rich information and draw the user in to read further. These
participants felt that short stories were lacking context and ended too abruptly. P13 commented,
I want to know the person’s initial mindset or his initial conditions. And how exactly the
scenario leads to whatever decision he made. At least for me, I think that’s how I simulate
people in my brain. I prefer to understand their initial state and then their input and
output, given such a problem exists. I want the information to be complete so I can do a
simulation more properly.
Because of the perceived eort it took to read stories, particularly longer ones, some participants
delayed engaging with text messages until later in the day. There were also situations when people
were either not around their phone or were preoccupied with other tasks. Regardless of the reason,
participants encountered two problems while engaging with stories after-the-fact: (1) the story
messages were buried in a collection of other unread messages, making them dicult to nd; and
(2) people struggled to nd the start and end of each individual story. Hence, participants requested
some way for them to dierentiate stories from other messages. P8 came up with one solution,
suggesting that each story could be wrapped in a unique symbol (e.g., =, +) as a delimiter.
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I Kind of Bounce o It”: Translating Mental Health Principles into Real Life Through Story-Based Text Messages 398:21
7 DISCUSSION
In the following discussion, we rst summarize the key ndings of our work and their relevance to
CSCW. We then describe opportunities for future work and the limitations of our work.
7.1 Key Findings
7.1.1 RQ1: Applying Mental Health Principles into Real Life. We used stories as a way of engag-
ing people’s attention and providing concrete examples of seemingly abstract concepts, thereby
reducing the cognitive burden associated with other mental wellness interventions. Our investiga-
tions enabled us to identify desirable properties of narrative interventions that would motivate
people to apply mental health lessons in their lives. The authenticity engendered by the realistic
portrayal of events enabled participants to connect with the story characters and gave them the
required condence to overcome their own struggle. The concrete takeaways at the end played
an important role in helping people translate the stories’ lessons into their own lives. The explicit
prompts for reection went a step further by encouraging people to visualize the potential ben-
ets of making changes in their own pattern of thinking. Together, the concrete takeaways and
prompts for reection not only reduced the cognitive eort needed to interpret the stories but also
mitigated the potential for misinterpretation. That being said, some participants preferred a less
prescriptive presentation of stories and wanted to interpret the stories on their own when they had
the cognitive resources to do so. A potential way to resolve this tension could be to present the
concrete takeaway message after rst giving people the chance to contemplate the story on their
own through a reective prompt.
7.1.2 RQ2: Eliciting Benefits of Self-Reflection through Story-Based Text Messages. Since automated
text messaging interventions do not have a live conversational partner to motivate users, we took
additional steps to build interactivity into our messaging program and to elicit active participation
with our intervention most notably adding a reection prompt to encourage people to write
about their own experiences. Some people used the prompt as an opportunity to draw connections
between their own struggles and those of the story characters, ultimately giving them increased
condence in solving their own problems. Other people used the prompt to assess their thought
patterns and discover previously unknown cognitive distortions that had been aecting their
decisions. Although we did not explicitly ask participants to seek a solution to their problem,
some reported that they were often motivated to make changes after such reections, including
exploring new ways to frame their experiences and alternative actions they could take. Even when
participants did not write anything, interview data suggested that the prompt still served as a
valuable forcing function for users to read and reect on the story. We therefore argue that a simple
question at the end of a set of story messages can encourage self-reection that may help users
immediately after reading a story, and also beyond.
7.1.3 RQ3: Balancing Message Length and Story Depth. Our investigations also allowed us to
identify several design tensions between message length and story depth that should be considered
for future deployments of story-based text messages. On the one hand, participants noted a greater
degree of realism when they read stories with more specic details, such as the background of
the characters and the actions that led up to their challenges; this nding echoes the observation
from prior work that people seek some degree of honesty when they interact with computer
systems [
104
]. On the other hand, participants expressed that text messaging interventions should
also be respectful of people’s time and energy since they may be received during a variety of
activities. Longer stories take more eort to read and digest, and mobile phones can only t
so many characters on the screen at the same time. The combination of these factors led some
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398:22 Ananya Bhaacharjee et al.
participants to feel distracted or overwhelmed by our messages. Some participants appreciated our
Start and Switch-Out format because it allowed them to see the beginning of a story and make an
informed decision about whether they should continue or not. However, since the previews often
centered on the characters’ struggles, they could also be o-putting at times. Future work could
explore how to generate previews that recognize characters’ struggles while also foreshadowing
the success they will have in addressing them.
7.2 Contributions to CSCW
Our work extends a body of literature in CSCW on collaborative mental health self-management. A
number of mental wellness interventions have sought to facilitate collaborative self-management
by connecting peers to communicate with one another and exchange support. However, recent
work also suggests that even when individuals are not directly interacting with one another, just
learning about someone’s experience can create a sense of “diuse sociality” [
19
] the feeling
of connectedness with others without direct interactions. Facilitating “diuse sociality” may be
key in mental wellness interventions, because many individuals with mental health concerns may
prefer to use interventions independently [
94
]. Our study shows that important benets of sociality
may be maintained through low-stakes and accessible interactions with an automated system.
Furthermore, our work informs the literature on collaborative self-management by suggesting
that people can connect to story characters even when knowing relatively little about them. Some
related work on digital peer-support platforms has recommended matching people based on their
similar life experiences, beliefs, or needs [
85
], but our ndings suggest that just knowing other
people are going through similar challenges can validate one’s struggle and help them manage
their mental health [
5
,
66
,
128
]. Finding connections to story characters enabled participants to
draw parallels between stories and their own lives, helping them identify aws in their behavior
patterns and take necessary actions.
We believe our approach could also be improved through further integration of peer support
and use of crowdsourcing platforms, drawing on past work from CSCW. For example, after being
provided with a short introduction to a psychological principle, crowdworkers could be asked if they
have a relevant story that they would be willing to share with others. The quality of these stories
could be improved by using a structured sequence of reection questions (i.e., trigger
feelings
solutions [
86
]). We foresee that crowdworkers, if appropriately trained, could also help iterate on
early story drafts and evaluate them to ensure that they meet a standard of authenticity, relevance,
and clarity. Numerous studies suggest that individuals can actually benet from the process of
composing and sharing messages [
61
,
84
], so this mechanism for story generation could also
potentially serve as a mental health intervention in itself. Moreover, when a large number of user-
written stories are stored in a structured format, peer support platforms can leverage information
retrieval techniques to select relevant stories from people experiencing similar problems [
77
], which
may further improve the experience of receiving stories.
7.3 Opportunities for Future Work
7.3.1 Rethinking Text Messaging Applications for Longer Exchanges. There were some ways in which
standard text messaging applications were not ideal for our envisioned interactions. Participants
who received longer stories were overwhelmed by the amount of screen space and scrolling it
took to read the messages [
37
], while those who wrote longer responses were forced to switch
back-and-forth between the story and the text they were writing [
115
]. A dedicated smartphone app
can address all of these inconveniences to better accommodate lengthier interactions. In fact, an app
could even extend the benets of narrative-based interventions by including multimedia content
that makes the stories more engaging with rich multisensory experiences [
127
]. However, text-only
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I Kind of Bounce o It”: Translating Mental Health Principles into Real Life Through Story-Based Text Messages 398:23
interventions invite readers to use their own imagination to visualize the stories, simultaneously
encouraging greater participation and providing greater exibility as to how readers personalize the
scenarios for themselves [
41
]. The decision of whether to use the default text messaging application
or a separate dedicated app warrants further investigation and may require consideration of
the target population. For example, text messaging might be one of the very few ways to reach
non-smartphone users or people with limited access to smartphones [115].
7.3.2 Personalizing User Experience. Past work suggests that personalization and variety can
increase engagement with stories [
114
]. There are several promising avenues for engendering these
features into our envisioned intervention. Although most participants in our deployment study
were satised with the relatability of our stories, they also appreciated opportunities to customize
stories, and participants made moderate use of two techniques for story topic selection in our
deployment study (i.e., selecting a topic at the beginning of the interaction, and switching out
a story for a more relevant one partway through). Future interventions could further build the
extent of customizability of stories. For example, stories may allow users to “choose their own
adventure” by making decisions in multiple junctures about the way the story should unfold (e.g.,
picking not only the topic, but also the actions taken by characters), which may allow a more
game-like and engaging experience while allowing users to narrow in on the content that interests
them the most. Personalization can also be applied to the structure of the stories. Some of our
participants appreciated how the concrete takeaway message at the end of the stories helped them
interpret the content, summarizing and reiterating points that could otherwise be lost in a thread
of messages or matching the straightforwardness of most text messaging interactions. On the other
hand, other participants found the takeaway message to be too prescriptive and wanted to come
to their own conclusions. Although past literature has noted the benets of indirect pathways to
persuasion [
80
] and collaborative approaches to sense-making like collaborative empiricism [
12
],
our ndings highlight that directness has considerable value for some people. Future work might
therefore examine how text messaging systems can adjust the directness of the messaging to
people’s preferences. Lastly, personalization can be extended to the timing of the stories, as users
are more likely to engage with their phones at certain times (e.g., weekend, non-working hours)
than others [114].
7.3.3 Enabling Research on the Web. The concrete takeaway messages at the end of our stories
not only helped our participants interpret the content of the stories, but also provided them with
vocabulary for situations or feelings that were previously dicult for some people to put into
words. In doing so, participants felt that they were better equipped to search online for other
helpful resources and examples. This opens up the possibility for stories to serve as a gateway to
more expansive online resources, broadening the potential benets of text messaging services for
mental health support. However, due to the abundance of information about mental health online,
people might still stumble upon unvalidated or counterproductive advice. Therefore, future work
could investigate whether stories could be improved by integrating hyperlinks that lead readers to
carefully chosen or crafted online resources.
7.3.4 Considerations for Large-Scale Deployments. To sustain engagement for more than a few
weeks and thereby support a broader set of cognitive interventions, there should be a mechanism for
regularly generating new stories. Limiting story creation to a small group of individuals is not only
inecient but would also limit the diversity of the story content. One approach to facilitate large-
scale story generation that reects rsthand understanding of mental health problems would be to
leverage users’ own content [
61
]. Many users in our deployment study willingly shared detailed
life experiences in response to the reection prompt, which suggests potential for intervention
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398:24 Ananya Bhaacharjee et al.
users to crowdsource content during their use of the system. Taking motivation from literature on
guided identication of cognitive distortions [
86
], rich stories could potentially be elicited through
structured multi-step prompts that ask users to dene their problems, elaborate their experience
with the problem, and identify aspects of their behavior or lifestyle they changed to address the
problem [
54
]. Since multi-step prompts require more eort from users, it will be important to
understand how users feel about providing such detailed information and sharing it with others.
To reduce burden, story generation could be suggested on an infrequent basis (e.g., once every 1–2
weeks) or only to participants who are highly engaged.
As mentioned earlier, another source of stories could be dedicated crowdsourcing platforms
like Amazon Mechanical Turk (MTurk). Crowdworkers could be asked not only to create stories,
but also rate them according to design goals like authenticity and proper balance of positivity
and negativity [
48
,
61
]. The provided ratings could be used to both identify stories that require
iteration and examples that can be shared with other story creators. Promisingly, some prior studies
have found that non-experts can produce content of comparable quality to experts, while also
being much more ecient [
13
,
78
]. However, it is important to note that crowdworkers may lack
understanding of psychological strategies compared to mental health treatment experts, and it
may be important for clinicians to continue to play a role in curating and editing stories to ensure
they accurately represent psychological concepts and strategies. Highly engaged crowdworkers
could also potentially be trained to recognize high quality stories, and could play a role in creating,
rating, and revising others’ stories over time [
78
]. Regardless of how users are prompted to provide
stories, special considerations should go into maintaining users’ privacy and acquiring their explicit
consent before disseminating their stories to others.
7.4 Limitations
We designed our text messaging probe specically for young people between the ages of 18–25 since
mobile phone usage [
118
] and susceptibility to mental health concerns [
1
,
18
,
58
,
74
,
95
,
108
,
122
] are
both high in that demographic. Although our participants spanned multiple races and ethnicities,
all of them lived in North America at the time of our studies. Hence, our ndings regarding people’s
perceptions of the stories’ contents and qualities may be situated within those demographics
and cultures. Future work could extend our investigation by recruiting participants from other
backgrounds. We also recruited a diverse sample as far as representing both those with mental health
symptoms and young adults from the general population, but we were limited in the conclusions
that we could draw about dierences between these groups due to our small sample sizes. We also
believe having more participants would have allowed us to better identify salient themes about the
message format.
We also limited our investigations to a subset of cognitive distortions, yet there are many more
distortions (e.g., emotional reasoning [
43
], perfectionism [
53
]) and psychological principles (e.g.,
self-compassion [
38
], behavioral activation [
73
]) that may be well suited to our design space. Finally,
we did not conduct an extended longitudinal deployment since we were primarily concerned with
the prerequisite problem of understanding how stories should be designed in the rst place. We
anticipate that new challenges and opportunities would arise as people engage with a text messaging
service over the span of several weeks or months. For instance, our participants generally stated a
preference for seeing new stories every time, but seeing the same story weeks later may serve as a
helpful reminder.
8 CONCLUSION
Adopting a new way of thinking for improving mental wellness requires a great deal of motivation
and eort from people. In this work, we argued that narrative-based interventions have the potential
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I Kind of Bounce o It”: Translating Mental Health Principles into Real Life Through Story-Based Text Messages 398:25
to reduce that burden by concretely illustrating how certain theories and principles from psychology
can be applied in one’s own situation. We investigated how stories can be sent via text messaging
a ubiquitous communication platform with limited aordances using a combination of interviews,
focus group discussions, and a deployment. We found that the features that participants appreciated
included authenticity, relatability, and a balance between realistic struggles and positivity. We
also uncovered challenges regarding the content and format of narrative-based interventions. For
example, we found that although longer stories with more details were more relatable to some
people, others found them to be overwhelming. We look forward to our ndings serving as a catalyst
for future investigations regarding narrative-based interventions on text messaging platforms.
ACKNOWLEDGEMENTS
We are grateful to the young adults who participated in this work, and to Theresa Nguyen and
Kevin Rushton at Mental Health America. We also thank Bei Pang, Jehan Vakharia, and Alvina
Lai for their help collecting these data. This work was supported by grants from the National
Institute of Mental Health (K01MH125172, R34MH124960), the Oce of Naval Research (N00014-18-
1-2755, N00014-21-1-2576), and the Natural Sciences and Engineering Research Council of Canada
(RGPIN-2019-06968). In addition, we acknowledge a gift from the Microsoft AI for Accessibility
program to the Center for Behavioral Intervention Technologies that, in part, supported this work
(http://aka.ms/ai4a).
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