Experiences of guided Internet-based cognitive-behavioral treatment for depression: A qualitative study

Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden.
BMC Psychiatry (Impact Factor: 2.21). 06/2011; 11(107):107. DOI: 10.1186/1471-244X-11-107
Source: PubMed
Internet-based self-help treatment with minimal therapist contact has been shown to have an effect in treating various conditions. The objective of this study was to explore participants' views of Internet administrated guided self-help treatment for depression.
In-depth interviews were conducted with 12 strategically selected participants and qualitative methods with components of both thematic analysis and grounded theory were used in the analyses.
Three distinct change processes relating to how participants worked with the treatment material emerged which were categorized as (a) Readers, (b) Strivers, and (c) Doers. These processes dealt with attitudes towards treatment, views on motivational aspects of the treatment, and perceptions of consequences of the treatment.
We conclude that the findings correspond with existing theoretical models of face-to-face psychotherapy within qualitative process research. Persons who take responsibility for the treatment and also attribute success to themselves appear to benefit more. Motivation is a crucial aspect of guided self-help in the treatment of depression.


Available from: Gerhard Andersson
Experiences of guided Internet-based
cognitive-behavioural treatment for depression:
A qualitative study
Nina Bendelin
, Hugo Hesser
, Johan Dahl
, Per Carlbring
, Karin Zetterqvist Nelson
and Gerhard Andersson
Background: Internet-based self-help treatme nt with minimal therapist contact has been shown to have an effect
in treating various conditions. The objective of this study was to explore participants views of Internet
administrated guided self-help treatment for depression.
Methods: In-depth interviews were conducted with 12 strategically selected participants and qualitative methods
with components of both thematic analysis and grounded theory were used in the analyses.
Results: Three distinct change proce sses relating to how participants worked with the treatment material emerged
which were categorized as (a) Readers, (b) Strivers, and (c) Doers. These processes dealt with attitudes towards
treatment, views on motivational aspects of the treatment, and perceptions of conseque nces of the treatment.
Conclusions: We conclude that the findings correspond with existing theoretical models of face-to-face
psychotherapy within qualitative process research. Persons who take responsibility for the treatment and also
attribute success to themselves appear to benefit more. Motivation is a crucial aspect of guided self-help in the
treatment of depression.
Keywords: Internet treatment, depression, cognitive behaviour therapy, self-help
The Internet offers a new way of providing psychologi-
cal treatment for common mental health problems [1].
Internet treatment has been described as a treatment
that is operationalized and transformed for delivery via
the Internet [2]. They are u sually highly structured, and
self-guided or partly self-guided with an identified thera-
pist [3]. Internet interventions may however also resem-
ble traditional psychotherapy with scheduled sessions
[4], but overall a characteristic feature is that that
patients are reached from a distance and that therapist
time is reduced compared with face-to-face treatment
[5]. Several independent research groups have developed
Internet-based cognitive-behavioral interventions [6,7],
and randomized controlled trials suggest that Internet-
based treatment with minimal therapist contact via e-
mail can be effective in t reating various conditions [8],
including depression [9] with moderate to large effect
sizes. Although several studies have shown that guided
Internet treatment of depression [10] can lead to
reduced symptoms, less is known about how partici-
pants experience these treatments. Reviews have how-
ever been conducted on t he reasons why people fail to
adhere to computerized interventions [11,12]. A few
qualitative studies have investigated experiences of
guided self-help [13], including computerized treatments
[14], showing that b oth advantages and disadvantages
are reported by patients who have received guided self-
help for depression. One study investigated experiences
of an Internet depression treatment that was delivered
in real time with schedule d online session appointments
[15]. Results revealed two themes: developing a virtual
relationship with a therapis and the process of commu-
nicating thoughts and emotions via an online medium.
There is also a recent study on unguided Internet-deliv-
ered depression treatment [16] which concluded that
* Correspondence:
Department of Behavioural Sciences and Learning, Swedish Institute for
Disability Research, Linköping University, Linköping, Sweden
Full list of author information is available at the end of the article
Bendelin et al. BMC Psychiatry 2011, 11:107
© 2011 Bendelin et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
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Page 1
the program tested did not work and that p rovision of
support could improve outcomes.
Studies using qualitative methods can be helpful
when investi gatin g the potential benefits and disadvan-
tages of treatment and explorative methodology of par-
ticipants experience can help us understand the
mechanism of change. Since relatively little is known
regarding predictors and mediators of change in Inter-
net treatments [17], qualitative research may be justi-
fied help identify the unique aspects of Internet
treatment. To our knowledge, no study has to date
investigat ed how participants experience guided Inter-
net-based self-help treatment for depression. This
study therefore used qualitative methods to explore
participants experience of an Internet administrated
guided self-help treatment for depression. We con-
ducted the study alongside a randomized controlled
trial [18], in which we investigated two forms of Inter-
net treatment for major depression: e-mail therapy and
guided self-help [19]. The overall aim of the study was
to obtain a detailed understanding of participants
experience of the treatment that could contribute to
improve the effectiveness and reduce dropouts in Inter-
net-based depression treatments.
Participants were recruited from the randomized con-
trolled trial that compared two forms of Internet-based
cognitive-behavioural the rapy for depression [19]. In
that study 88 patients with mild to moderate depression
were recruited via advertisement and later randomized
to Internet-based self-help with minimal therapist con-
tact (self-help group), individualised Internet-based
email-therapy (email group), or to a delayed treatment
waiting-list condition (control group). The first group
received an Internet-administrated self-help treatment
that consisted of 114 pages of t ext divided into seven
modules over a period of 8 weeks. The second group
received purely e-mail based treatment with no prepared
text, but in principle based on the same procedures and
cognitive-behavioural therapy (CBT). The control group
later received the Internet-based guided self-help, but
with less therapist contact (i.e., a few mi nutes per week,
responding to questions sent by the participant) and
participants from this group were also included i n this
study. More detailed information about the study is pre-
sented in the treatment trial [19].
Six months after treatment participants were con-
tacted by phone and invited to participate in a longer
interview concerning their experiences of the treatment
they had r eceived. This was done in association with
a follow-up and only persons participat ing in the
follow-up were asked for participation in this study. Of
the 74 that were contacted, 48 (64%) expressed an inter-
est in taking part in the study. Twelve of the 48 inter-
ested were selected and consented to participate in the
interview. The 36% who declined taking part of the
study did not differ systematically from the larger group
(in terms of de pression scores on the Beck Depression
Inventory [20]), and the main reason was lack of time.
A purposive sample selection according to the maxi-
mum variation strategy was used [21], based on both
treatment rece ived and overall improvement. The pur-
pose of this selection process was to explore the varia-
tion within participants, to ensure diversity in opinion,
as well as the shared experiences of the participants
who had received Internet-based treatment for depres-
sion. Overall improvement was measured with a revised
version of Clinical Global Impressions-Improvement
Scale (CGI-I) [22] at 6-month follow-up compared to
pre-treatment functioning. The CGI-I measures overall
improvement on a 4 grade sca le: very much improved,
much improved, minimally improved or no change.
The latter category also covers deterioration. Interviewer
was blind to treatment status (e .g., guided self-help vs.
e-mail treatment).
The primary aim of the strateg ic sample selection was
to include the same number of participants in relation
to their treatment group and their overall improvement.
Only one participant whose improvement was graded as
no change wanted to participate in the study. This was
however representative for the treatment trial where
only 5.9% showed no change on the CGI-I. In order to
obtain a bett er understanding of experiences of those
who had not made large improvements, two more parti-
cipants whose i mprovements were graded as minimally
improved were interviewed. Table 1 presents the 12
selected participants demo graphics, treatment group and
improvement as measured with CGI-I.
Four participants from each treatment group were
interviewed. Of the 12 participants whose interviews
were ana lysed, 6 were female. Age ranged from 20 to 62
years with a mean age of 36.3 years (SD = 16.5 years).
All were native Swedes and had an educational level of
collage/university or higher. Seven partic ipants were sin-
gle. Eight had employment, 2 were on sick-leave and 2
were students. Three participants had previously
received psychological treatment. Only 1 participant was
diagnosed with another diagnosis (simple phobia) in
addition to major depression disorder.
Before the interview information about the overall
purpose of the study was given and participants gave
informed consent. The medical ethics committee in Lin-
köping, Sweden, approved the protocol as part of th e
larger treatment study [19].
Bendelin et al. BMC Psychiatry 2011, 11:107
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Page 2
Material and Procedure
The t welve selected participants were interviewed. All
interviews were face-to-face and held within eight to ten
months after the treatment had ended. Two undergrad-
uate M.Sc. clinical psychology students conducted the
interview at the university clinic. The interviewers had
vious contact with the participants. The interviews ran-
ged from 42 to 111 minutes in length, with a mean of
68 minutes. All interviews were audio taped and tran-
scribed. In order to secure the confidentiality of the
participants, we made minor alterations to prevent iden-
tification of cases (e.g., names and places that could
identify the participant).
The interview was based on the Client Change Inter-
view [23], a nd the primary aim was to assess aspects of
clients experiences of the treatment. The interview con-
sisted of open-ended questions, which were used as a
guide to explore the clients experiences of change and
their understa nding of what f actors m ight have helped
during treatment. Questions in the interview guide were
classified in the following subject headings: (a) Clients
general impression of the treatmen t, (b) how the clients
perceived the way treatment was conducted, and (c)
changes perceived by clients over the course of the
treatment and their understanding of what might have
brought these changes about.
A method comprising components from both thematic
analysis [24] and g rounded theory [ 25] was used in the
analysis of the material. While these two approaches are
related thematic analysis seek to summarise/encapsulate
the data, but not necessarily with the aim of developing
a theory to explain it in the same sense [26]. We wanted
to expand a bit from a pure thematic analysis but did
not expect to reach saturation and reach a new theory
which are goals in grounded theory [27]. A flow chart
of the analysis used in the current study is shown in
Figure 1. In order to optimize the analytic process the
researchers first coded each others transcripts separately
without referring to other interviews. During the first
stage of the analysis the two interviewers worked inde-
pendently. They coded each other s transcripts into
mean ingful units. The units represented statem ents that
the participant made that conveyed a meaningful con-
cept. After coding independently, the researchers then
compared the meaning units in an iterative process and
discussed emerging themes from individual transcripts
among all the transcripts. The meaning units were ana-
lysed in order to obtain individual themes, which
remained close to the data and represented the
Table 1 Characteristics of selected participants
Participant Gender Age Martial status Employment
Treatment group
1 Female 62 Single Employed Email Very much
2 Male 40 Married Employed Email Much
3 Male 61 Married Registered sick Email Minimally
4 Male 30 Partner Employed Email No change
5 Female 29 Partner Employed Self-help Very much
6 Female 28 Partner Employed Self-help Much
7 Male 22 Partner Student Self-help Minimally
8 Male 33 Single Employed Self-help Minimally
9 Male 20 Single Student Control Very much
10 Female 60 Single Registered sick Control Much
11 Female 47 Single Employed Control Minimally
12 Female 24 Single Employed Control Minimally
Employed; full time or part time
The control group completed the self-help program after the active treatment groups had finished their treatment
Improvement measured with CGI-I, Clinical Global Impressions-Improvement, at 6-month follow-up
Figure 1 Flow chart of the stages in the analysis used in the
Bendelin et al. BMC Psychiatry 2011, 11:107
Page 3 of 10
Page 3
particular participants experience. For each participant
the individual theme was summar ized in a temporal fra-
mework of change as a way of clarifying change pro-
cesses [23]. During the next stage of the analysis process
commonalities among the individual themes were ana-
lysed and new themes emerged. The new themes were
then categorized. Themes that shared similarities were
grouped into a category. Seven categories were obtained.
In order to remain close to the data, the transcripts and
the individual themes were then re-examined based on
the seven new categories that had emerged. During the
reanalysis of the material t he seven categories were
reduced to four and communalit ies of experiences based
on the four categories formed three distinct groups
among participants. Three different change processes
among participants experiences in terms of the four
categories, characterized the three groups. Keywords
that were significant for the three change processes
were formed from themes among participants in the
groups. The four categories and the three change pro-
cesses are presented in the result section.
To ensu re t he interpretation of the data the research-
ers conducted a number of credibility checks. The
researchers constantly checked individual interpretation
and ensured that they reached consensus. They also rea-
nalysed material specific ally looking for discrepancy
between the material and the result. Throughout the
analysis the two researchers consulted with experienced
researchers in the field of Internet-based self-help treat-
ment and qualitative research to discuss the result of
the anal ysis. T wo of the more experienced researchers
had been part of the intial study and had extensive
experience from conducting trials on Internet treatment.
One researcher with expertise in qualitative research
had not previously worked with Internet treatment
research and supervised the M.Sc. s tudents indepen-
dently. Examples of data are provided to enable the
reader to judge the fit between the data and the inter-
pretation of them.
Overall results
Four categories (core themes) emerged from the analysis
of participants a ccounts of the treatment. Two of the
four categories comprised themes in relation to how the
participants worked with the treatment material and
experiences of how the treatment accomplished motivat-
ing participants: Working Process and Motivation. The
two other categories covered themes of participants opi-
nions of the treatment and what skills and knowledge
they had obtained from the treatment: Attitudes towards
treatment and Consequences of treatment. The four
categories were evident within all participants accounts.
Within the four categories, three groups of experiences
regarding different change processes emerged: (a) Read-
ers,(b)Strivers,and(c)Doers. Keywords that corre-
sponded with the change processes were formed from
participants themes within each category (see Table 2).
The three change processes are illustrated within the
four categories in the following text and quotations i n
Table 3.
Working Process
Three participants identifiedgainedawarenessthrough
reading the material as a main theme in their accounts
of how they worked with the treatment material. How-
ever, they were not able to o r did not want to put their
newfound insights into practice, nor did they report that
they applied treatment strategies in everyday life.
Instead, they expressed that t hey had required a general
theoretical understanding of treatment principals and/or
themselves by reading the material (Q1). Working spor-
adically with the material presented to them throughout
the course of the treatment, either going through it too
fast or skipping parts o f i t, also seemed to be a signifi-
cant theme within Readers narratives (Q 2). Determin-
ing workload and work pace on their own appeared to
be an obstacle and was often the reason why partici-
pants did not complete modules or dropp ed out o f
treatment altogether. Deciding not to continue working
with the material seemed to function as a way of hand-
ling difficulties (Q 3).
In contrast to the descriptions made by Readers,four
participants appea red to express that they not only read
but also worked with the material in a practical way. They
reported that they completed treatment assignments and
were therefore able to give specific details of their working
process to substantiate their perception of the treatment
(Q 4). Although th eir approach to work in terms of com-
pleting home-work assignments to some extent had made
it possible for them to integrate treatment in everyday life,
they also expressed ambivalence, and sometimes scepti-
cism, regarding practicing insights and working on their
own. One female participant described her way of working
in treatment, which to a large extent signified the working
process of Strivers (Q 5). This ambivalence towards
practice-oriented work appeared to play an important role
in their experience regarding not being able to profit from
the treatment to a full extent.
Testing the material, applying it and putting insights
into practice appeared to be themes for Doers within
their accounts of how they worked with the material.
When the participants talked about their working pro-
cess, they gave specific examples of key moments in
Bendelin et al. BMC Psychiatry 2011, 11:107
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Page 4
material in a practical way, applying it to experiences
and real-life events (Q 6) A structured and a methodical
way of working appeared to be a significant theme
within parti cipants narrative s in this group. If and when
barriers occurred their practice-oriented approach
seemed to have helped them overcome obstacles (Q 7).
Several participants also expressed that facing difficulties
and confronting challenges in treatment were of great
significance, and often describe d as the most valuabl e
lesson they had received (Q 8).
Lack of support, missing someone to talk to in real life,
and nee d for a push to c ontinue when it became diffi-
cult, were emphasized among some participants and
explicitly outlined by the Readers (Q 9). Some even
expressed that the treatment p rogram w as added as an
additional burden (Q 10). Lack of time was frequently
described as a reason for declining moti vation to con-
tinue treatment (Q 11).
Table 2 Participants themes presented as keywords, change processes and categories
Category Keywords Change process Themes Participant nr
Reading Readers Read 4, 8, 11
Giving up Eye-opener 4, 8
Sporadic work 4, 8
Giving up/avoid 8, 11, 12
Working Process Trying to practice Strivers Interpreting 2, 3, 7, 12
Ambivalent regarding practice 2, 7, 12
Uncertain 2, 3, 7, 12
Trying to redefine 2, 3, 12
Practice Doers Methodical work 1, 5, 6, 9, 10
Apply insights Emotional insights 1, 5, 6, 9, 10
Apply/practice 1, 5, 6, 9, 10
Redefine barriers 1, 5, 6, 9, 10
Lack of support Readers Lack of support 4, 8, 11
Not seen 8, 11
No response 8
Motivation Insufficient support Strivers Missing conversation 2, 3, 12
High demands 2, 7, 12
Need of more support 2, 3, 12
Proximal support Doers Self-reinforcement 1, 5, 6, 9,10
Optimal support 5, 6, 9, 10
Autonomy 5, 6, 9, 10
Security 1, 5, 6, 9, 10
Disappointed Readers Not suited for me 4, 8, 12, 11
Ambivalence 4, 12
Attitudes towards treatment Uncertain Strivers Avoidance 7, 12
Skepticism/fear 2, 3, 7
Helpful Doers Works 1, 5, 6, 9, 10
Faith in program 1, 5, 6, 9, 10
Awareness Readers Disappointed/shameful 4, 8, 11
Lonely 4, 8, 11
Lack of reinforcement 8, 11
Awareness of needs 4, 8
Consequences of treatment Integrated insights Strivers Ambivalence 2, 7
Dependence 12
Needed more help 3, 7, 12
Gained insights 2, 3, 7
Self-sufficiency Doers Emotional insights 1, 5, 6, 9, 10
Generalization 5, 6, 9, 10
Model of treatment 1, 6, 9, 10
Acceptance 1, 5, 6, 9,10
Bendelin et al. BMC Psychiatry 2011, 11:107
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Inadequate support in relation to needs and a wish for
more contact with the therapists was stressed by four
participants as a main reason for not feeling motivated.
Although they felt that th ey had support, they stated a
wish for more contact in form of conversation in order
to get a more profound understanding of their prob lem
and/or to help them overcome barriers in treatment (Q
12). Some reported feeling stressed by too high expecta-
tions and demands from the therapist behind the
Table 3 Quotes from participants got some information about a few things, statements, that you recognized and was relevant to you...I guess it (the treatment program)
gave me something...The material you read, it made you, it started something. Something new (Participant 8).
Q2.. I think Ive realized that Im kind of, I realized that Im kind of lazy, by nature, one likes to take shortcuts, and perhaps not do the things you
really ought to do. It might feel difficult or you can easily put these must-remember thoughts aside. I have realized that its really easy to do that. If
you got an assignment that made it clear that one should do so and so, then it might feel difficult, it was interesting though...but still, it felt difficult
(Participant 8).
Q3Yes, I got rid of that thing (laughter). Well not really, I stopped doing all those was kind of a relief when it was over (Participant 4). tried to register what you did at every moment. What you thought and how you felt. And I tried to do it regularly during the day, both
at work and home.... When you write it down, it forces you to put your thoughts into words. And theres something positive about that, when you
write it down, its almost like doing it, and then you can go back and look at it (Participant 2).
Q5I sometimes thought it was hard, that it was tough...I suppose, if it was a good day I got it (treatment assignments) done (laughter) (Participant 12).
Q6When you had read something, for example the night before, then you tried to practice it the following day, and you put effort into it. For
example every little action that you did, you try to think why am I doing this...And it was a lot of work, until you could practice it on a more
unconscious level (Participant 9).
Q7I sometimes feel it would be good for me to do the week (with behavioural activation) again (Participant 10).
Q8Yes, I guess it was that week (with behavioural activation), after all, I think, because it was tough, and it was noticeable, made me so aware...
(Participant 10).
Q9Yes, its important for me that Im able to show someone what Ive accomplished, and get some kind of response, someone who expresses his
or her opinion. I guess, you get some kind of assurance or something like that. Thats not what happened here (Participant 8).
Q10I felt guilty because I didnt do all the assignments (laughter). Yes, it became an extra burden, so I felt like, this is not what I really need (Participant 4).
Q11Put simple, I couldnt find time for it (the treatment program) (Participant 4).
Q12...someone to talk to, I think that would have motivated me (Participant 12).
Q13I felt like I couldnt control it, it became something of a burden that was added to me, you could say that it created anxiety, one more thing
that I couldnt do or complete, that I promised to do
(Participant 2).
4Of course, much of what I did, I did because I promised to do it (the treatment program) and then I felt like I had to do it (Participant 2).
Q15I think it was important for my self-esteem. To feel that I did it on my own, like I was able to do things (Participant 6).
Q16... if you needed to consult someone about something there was someone there. If I needed, I could choose to take contact (Participant 5).
Q17You felt like, I feel fine now, why should I continue (with the treatment) (Participant 9).
Q18The expectations were probably higher than the outcome (Participant 8).
Q19Although it wasnt what I expected, or whished for, but that had a lot to do with me....I still believe its a concept that works (Participant 4).
Q20Some part of me was all the time scared like, to work with it, I dont know...I dont think it was the material that frightened me...What if it goes
out of control? (Participant 7).
Q21I dont believe in going to a shrink, like the Americans do, right, I dont believe in that. But...if you feel bad, and if Id find myself in some
kind of crisis or something, right. Then I believe, or I know, that this is a good model to help you through a crisis. When a depression appears I
know that this is a good model (Participant 1).
Q22I sometimes find it difficult to sit down and talk to someone, whod try to understand me, and this way I got to work with a
completely different way (Participant 5).
Q23...perhaps, it has affected me, without my knowledge. But, I cant think on any specific part, that Im thinking about, that Imusing (Participant 4).
Q24I gave up after a while and I guess I thought: Theres no purpose of me sitting here doing this, its not going to make a difference anyway
(Participant 11).
Q25..And in that way Ive become more aware of how strange I sometimes think and how that affects my mood and Ive become better on
thinking other thoughts (Participant 12).
Actually, the treatment program could have made a larger impact than it did, but I guess thats
because I was too scared to work with it, I
didnt use the material enough... (Participant 7).
Q27Perhaps I should look at it (the treatment material) some more... At least its not uninteresting, its educational....I kind of see it as a course, a
course that you should look at some more, because when you think of it, it wasn t that bad (Participant 7).
Q28It feels like Ive regained the ability to take control of my life (Participant 10).
It (the treatment program) has meant a great, great deal to me in several different ways. Personally I feel a lot better, and then also, at work too, I
work in, as a nurse ... So I used it both in my work and on my self (Participant 1).
Q29I dont feel that its overwhelming, its much and its though, but you always know that youre going to get through it (Participant 9).
Q30Thats why I now look at depression and feeling down as a natural thing, which happens to people... (Participant 9).
Bendelin et al. BMC Psychiatry 2011, 11:107
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program and reported that as a factor contributing to
loss of motivation (Q 13). Rather than being motivated
by the treatment, several appeared to be driven by a
sense of duty (Q 14).
As a facilitat ing f actor for mot ivation several par tici-
pants emphasized a proximal degree of support from
the treatment program. They stressed the importance of
working on their own and appreciated the responsibility
that came with the program (Q 15). At the same time, if
faced with a difficult situation they were not able to
handle, they found that they had a security backup sys-
tem in the treatment program (Q 16).
However, some reported improvement as cause for
lowering motivation to continue with the treatment
(Q 17).
Attitudes towards treatment
Disappointment in relation to high expectations was a
significant theme for Readers within their accounts of
attitudes towards the treatment (Q 18).
However, even when they reported that the program
for different reasons was not suited for them, they
expressed t hat the treatment might benefit others (Q
Failing to improve fro m treatment made participants
express a wish of going back and working more with
the material hopping to profit from it.
Themes regarding doubt and uncertainty emerged
within Strivers accounts of attitudes towards the treat-
ment. They e xpresse d s cepticism about cognitive-beha-
vioural therapy or Internet self-help treatment. Some
found it scary to initiate contact with an unknown per-
son over the Internet. Other expressed a fear because
treatment made it possible for t hem t o explore and
work with their depression (Q 20).
Themes regarding the usefulness and helpfulness of
Internet self-help treatment emerged in the Doe rs
accounts of their attitudes tow ards the treatment. In
comparison to traditional remedies participants reported
treatment as a new, exciting and better way of receiving
care (Q 21). Several participants appreciated the inde-
pendence and that the program e nabled them to work
on their own. Some acknowledged that they did not
have to meet a therapist face-to-face (Q 22).
Consequences of treatment
No change of their situation, not having gained adequate
skills to deal with the depression, and a wish for more
help, were identified as main themes in three participants
accounts. Although they expressed that they had obtained
general insights i nto their problems and had become
more aware of their needs as a consequence of treatment,
they had not received skills to help them deal with their
depression (Q 23).
The lack of treatment effect had made them feel
lonely, shameful and disappointed (Q 24). As a result of
not b eing able to profit from the treatment they o ften
reported a wish for more help.
Four participants emphasised that the treatment had
encouraged them to revise their perceptions o f depres-
sion and of themse lves. They seemed to have gained a
greater understanding of themselves and their current
situation by working with the material and expressed
that they had acquired speci fic insights t o help them
cope with their depression (Q 25). However, ambiva-
lence regarding treatment effect also appeared to be a
main theme within their narratives. They often
expressed concern whether they could have improved
more if they had worked differently with the material or
had received another treatment (Q 26). This ambiva-
lence was also expressed as dependence towards treat-
ment and as a wish to receive more therapy in hope to
get better (Q 27).
Five participants underlined their autonomy and self-
sufficiency in their accounts of consequences of the
treatment. Participants in t he do ers group had not only
rece ived a greater understandin g of their particul ar pro-
blems but were also able to practice skills, insights and
approaches to problem solving in everyday life. They
appeared to have acquired a model of the treatment
that enabled them to develop skills and apply them in
various settings (Q 28). The fa ct that they had accom-
plished beating the depressi on on their own had made
them believe in their own ability to cope with eventual
relapses (Q 29). They also expressed accep tance of peri-
ods of feeling depressed and of themselves in their state-
ments regarding consequences of treatment (Q 30).
experience of Internet administrated treatment for
depression using qualitative methods. The analysis of
participants accounts of the treatment sixth months
after the treatment yielded three distinct patterns of
change. These related to participants motivational
experience of the treatment, how they worked with the
treatment material, their attitudes towards the treat-
ment, and their perception of what skills and knowledge
they had gained from the treatment.
Overall, the results correspond with existing theoreti-
cal models of change in traditional face-to face
Bendelin et al. BMC Psychiatry 2011, 11:107
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Page 7
psychothera py for depression within the qualitative pro-
cess research [28,29]. The three change processes are
partly in line with the three patterns of change
described in study of clients experience of a face-to-face
short-term counselling [30]. The current study also indi-
cates that therapeutic work in an Internet-based treat-
ment is as a dynamic process, and that the treatment is
perceived differently depending on expectations and
outcome. This is in line with a previous qualitative
study on guided self-help [13], and another qualitative
study o n h ow a mental health self-help clinic was per-
ceived [31]
Although more research is needed to draw definitive
conclusions, this study offers some clinical implications
of value to those developing Internet-based self-help
treatments. The results indicate that participants who
reported that they only worked sporadically with the
treatment, alternatively that they did not want to or
could not work practically with the treatment material,
were less inclined to view th e treatment positively and
also reported a less f avourable outcome of the treat-
ment. In comparison, participants who had a practical
hands-on approach to work (testing and applying
treatment strategies), expressed that they preferred the
treatment format and had integrated the treatment prin-
ciples in their everyday life. Redefining obstacles in
treatment, confronting challenges, believing in their own
ability, and acceptance of depression and of themselves
also seemed to be significant themes within the narra-
tives of participants who expressed improvement and a
favourable outcome. Those themes seemed to be consis-
tent with the fin dings in previous research on successful
therapeutic work [28,29].
Participants also gave different accounts in relation to
the three change processes of how they perceived the
support and the motivational aspects of the treatment.
Some appreciated that they had to work on their own
and felt that they had a back up support system,
while others missed real-life conversation or felt pres-
sured by the treatment program. This is partly in line
with previous research which showed that an intense
relationship with the therapist resulted in interrupted
change patterns in time-limited counselling [30]. Our
results i ndicate that both too much contact with the
therapists (in particular if it is perceived as inadequate)
and a lack of contact can both be hindering factors for
treatment success. While participants may need some
form of support in Internet administrated treatments
[32], the current study also points to the importance of
autonomy and feelings of self-efficacy in successful
therapeutic work. In line with previous research [33],
the findings highlight that an Internet program should
take into ac count the non-specific factors of therapeu-
tic work by developing a sufficient amount of support
[9]. But in doing so, one should not jump to t he co n-
clusion that much m ore support will necessarily lead to
better outcome. It might be that too much contact
from the treatment program r ender loss in self-efficacy
and make the partici pant beli eve that he or she is not
the agent in the t reatment or alternatively that the loss
of face-to-face contact becomes more apparent when
the contact is via electronic media [15]. Indeed, some
expressed that they missed conversation and needed
additional support, which might indicate that contact
(e.g. via e -mail or face-to-face) is important to a vary-
ing degree depending on the participant. Individuals
who have the ability and motivation to work on their
own and have a structured and practical approach to
work, a re perhaps more suited for this form of treat-
ment than others. More research is n eeded to deter-
mine if this is the case. On the other hand, a program
designed to fit participants motivation and ability (e.g.
giving participants more time to complete treatment or
more e-mail contact) might be suitable to increase
adherence [34]. Indeed, tailoring of treatment could be
feasible in particular in depression as comorbidity with
anxiety disorders and somatic disorders is common
This was an exploratory study and the interpretations
of the data should be con sidered within the context of
qualitative research [36]. The results can not be
regarded as representative for all people who receive
Internet administrated treatment for depression. The
sample was limited, small and selected, and from a qua-
litative research point of view a larger number of partici-
pants would have been preferred given the way we
analyzed our data as a fuller description might have
emereged. Most importantly, the study included only
one participant who had not improved at all from treat-
ment (as measured with the CGI-I). If more such parti-
cipants had been included the results might have been
different. However, on account of this misrepresentation
two more participants whose improvements were graded
as minimally change were interviewed. All of the partici-
pants had an e ducational level of collage or higher,
which may also limit how well our findings can be gen-
eralized. While qualitative research often involves rela-
tively few participants, our sample may have be en too
small. Moreove r, because the interviews took place six
months after treatment had ended, the results rely on
participants memories of treatment, which c ould o f
course be subject to bias and also dependent on how
well the treatment worked. This might make it difficult
to draw any firm conclusions about sequences of change
during treatment, participants experiences of treatment
content or attitudes towards treatment, because clients
tend to construct memories in accordance with their
present situation [37].
Bendelin et al. BMC Psychiatry 2011, 11:107
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Page 8
Another limitiation of the study relates to the poten-
tial bias since two of the involved researc hers had
worked with the treatment trial. We tried t o handle the
bias by involving a researcher with no previous experi-
ence of Internet research and also included a fifth co-
author to handle the possible bias. Moreover, we con-
stantly reflected on the research process and our own
role when coding and interpreting the interviews [38],
and were careful ton include not only participants who
were very pleased with the intervention but also persons
who had not improved.
The findings correspond with existing theoretical mod-
els of face-to-face psychotherapy within qualitati ve pro-
cess research. Persons who take responsibility for the
treatment and also attribute success to themselves
appear to benefit more from Internet-based treatment.
Further qualitative research is needed to investigate how
participants experience Internet-based treatment for
other problems than depression. This might not only
cast light upon how Internet based self-help t reatments
work but may also give additional information about the
active ingredients and the mechanism of change in face-
to-face psychotherapy, in particular in relation to com-
mon and specific factors.
This study was supported in part by a grant to the last author from the
Swedish Science foundation CHANGE TO Swedish Research Council. The
Swedish Research Council had no role in the study design, data collection,
data analysis, report writing, or the decision to submit the manuscript for
Author details
Department of Behavioural Sciences and Learning, Swedish Institute for
Disability Research, Linköping University, Linköping, Sweden.
Department of
Psychology, Umeå University, Umeå, Sweden.
Department of Clinical
Neuroscience, Psychiatry Section, Karolinska Institutet, Stockholm, Sweden.
Authors contributions
NB, JD and GA conceived of the study and its design. HH and GA worked
with the write-up and reanalyses, and KZN supervised the qualitative
analyses, PC added input on the treatment delivered and all authors read,
commented on and approved of the manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 15 February 2011 Accepted: 30 June 2011
Published: 30 June 2011
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Cite this article as: Bendelin et al.: Experiences of guided Internet-based
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Bendelin et al. BMC Psychiatry 2011, 11:107
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  • Source
    • "Some of the previous qualitative studies on ICBT look into motivators and motivations (Donkin and Glozier, 2012), expectations and experiences in primary care (Beattie et al., 2009) and therapist behaviors (Paxling et al., 2013; Holländare et al., 2016). A study on ICBT for depression (Bendelin et al., 2011) found that the process of change corresponded to theories of change in face-to-face therapy, and that patients who attribute success to themselves and take responsibility for their treatment benefit more. The report that is perhaps most relevant to our study is about patients' experience of helpfulness in ICBT for depression (Lillevoll et al., 2013), even though the therapist support in this study was face-to-face, making it more of a blended therapy. "
    [Show abstract] [Hide abstract] ABSTRACT: Insomnia and depression is a common and debilitating comorbidity, and treatment is usually given mainly for depression. Guided Internet-based cognitive behavioral therapy for insomnia (ICBT-i) was, in a recent study on which this report is based, found superior to a treatment for depression (ICBT-d) for this patient group, but many patients did not reach remission.
    Full-text · Article · Apr 2016 · Internet Interventions
  • Source
    • "In order to do this, it would be necessary to perform the specific task of disseminating the program, which would allow the patients most likely to benefit from this type of treatment to be identified and chosen, without losing sight of the factors that would enhance compliance. Those patients with symptoms of mild severity are seen as good candidates, as well as those who take responsibility for the treatment and who attribute success to themselves, focusing on action656667. According to our results, all participants would show moderate severity at most, with an attitude of general acceptance toward Web-based therapy and a certain inclination for the use of new technologies, as has been seen in other works [68], but most of all, they have to understand their possible usefulness in the specific field of psychotherapy. "
    Full-text · Dataset · Mar 2016
  • Source
    • "It is the case that participants were not incentivised to take part in this research, also interest in student research of this type can be sensitive and prohibitive for some. While Morse (2008) disputes that quality research is determined by the richness of the data obtained rather than the sample size, previous literature (i.e. Bendelin et al., 2011; Doherty et al., 2012; Gerhards et al., 2011) which have explored the effectiveness of online therapy all managed to acquire saturation for their target sample. In order to generalise these findings for the improvement and development of other internet-delivered interventions, it may be important to explore the barriers which hinder participation and to identify potential motivators or incentives which may improve engagement in qualitative research. "
    [Show abstract] [Hide abstract] ABSTRACT: Background: Outcome research has highlighted the efficacy of internet-based cognitive behavioural therapy (iCBT). Some process research has examined users experiences of iCBT. Understanding the user experience provides valuable feedback to developers of internet-delivered interventions.Aim: The present study aimed to evaluate user's experiences and engagement with the design features of an internet-delivered treatment programme for anxiety.Methods: Semi-structured interviews were conducted with 7 participant users of the Space from Anxiety programme. A thematic analysis framework was employed to analyse the data collected.Results: Identified themes related to participants engagement and adherence with the programme material, participant's experience of personal development through interaction with the programme content and participants experience of the social features employed in the programme. Another theme investigated the various attributes or conditions necessary for internet-delivered therapy to be helpful to an individual.Conclusion: Considering the experiences of users of online interventions provides insight into what works for whom both in terms of technological features and the various skills and strategies that may compose the treatment intervention. Knowing more about what design features and strategies/components of the intervention are attractive and keep users involved can only enhance the delivery of effective internet-delivered interventions for anxiety disorders.
    Full-text · Article · Feb 2016 · British Journal of Guidance and Counselling
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