Background
Method
Study design
Participants and recruitment
Full sample at pre-treatment (n = 59) | Completed quantitative assessment at 10-month follow-up (n = 17) | Interviewed for qualitative analysis (n = 10) | |
---|---|---|---|
Age (years): M (SD) Range: Min-Max | 37.5 (11.4) | 33.5 (9.3) | 33.4 (9.1) |
20–69 | 20–49 | 20–49 | |
Sex: n (% male) | 34 (58%) | 7 (41%) | 4 (40%) |
Highest Educational Level: n (%) | |||
Elementary school | 2 (7%) | 1 (6%) | 1 (10%) |
Upper secondary school | 23 (39%) | 7(41%) | 3 (30%) |
Vocational education | 2 (7%) | 1 (6%) | 0 |
University (ongoing) | 8 (14%) | 3 (18%) | 1 (10%) |
University (completed) | 19 (32%) | 4 (24%) | 4 (40%) |
Other | 5 (8%) | 1 (6%) | 1 (10%) |
Occupation: n (%) | |||
Student | 22 (37%) | 10(59%) | 5 (50%) |
Employed | 10 (17%) | 2(12%) | 2 (20%) |
Unemployed | 14 (24%) | 2 (12%) | 1 (10%) |
Sick leave (> 3 months) | 2 (3%) | 1 (6%) | 1 (10%) |
Parental leave | 1 (2%) | 2 (12%) | 1 (10%) |
Other | 10 (17%) | 0 | 0 |
Prior psychological treatment: n (% yes) | 9 (15%) | 6 (36%) | 4 (40%) |
Taking medication: n (%) | |||
Yes | 10 (17%) | 4 (24%) | 2 (20%) |
No, but previously | 6 (10%) | 2 (12%) | 1(10%) |
No | 43 (73%) | 11 (65%) | 7(70%) |
Born in Sweden: n (%) | |||
Yes | 0 | 0 | 0 |
No | 59 (100%) | 17 (100%) | 10 (100%) |
Immigration status: n (%) | |||
Immigrant | 4 (7%) | 2 (12%) | 1 (10%) |
Refugee | 46 (78%) | 13 (77%) | 8 (80%) |
Do not want to answer | 9 (15%) | 2 (12%) | 1(10%) |
Intervention
Quantitative measures
Data collection
Data analysis
Results
Quantitative outcomes
Measure and condition | Pre-treatment* | Post-treatment* | 10-month Follow-up** | ||||||
---|---|---|---|---|---|---|---|---|---|
M | SD | N | M | SD | N | M | SD | N | |
PHQ-9 | |||||||||
ICBT | 15.63 | 6.67 | 30 | 11.67 | 6.05 | 18 | 11.38 | 7.15 | 8 |
wait-list | 17.79 | 5.29 | 29 | 17.33 | 5.29 | 18 | 9.33 | 7.5 | 9 |
GAD-7 | |||||||||
ICBT | 13.07 | 4.73 | 30 | 9.11 | 5.46 | 18 | 8.9 | 6.85 | 8 |
wait-list | 13.93 | 5.0 | 29 | 13.56 | 5.28 | 18 | 8.9 | 6.43 | 9 |
PSS-14 | |||||||||
ICBT | 36.17 | 5.41 | 30 | 29.44 | 7.16 | 18 | 27.5 | 11.15 | 8 |
wait-list | 38.21 | 6.18 | 29 | 36.78 | 6.84 | 18 | 29.78 | 9.68 | 9 |
ISI | |||||||||
ICBT | 15.53 | 6.07 | 30 | 11.72 | 6.69 | 18 | 15.13 | 8.36 | 8 |
wait-list | 16.59 | 6.21 | 29 | 15.72 | 7.15 | 18 | 10.11 | 8.58 | 9 |
IES-R | |||||||||
ICBT | 52.23 | 17.58 | 30 | 45.61 | 19.23 | 18 | 51.0 | 25.17 | 8 |
wait-list | 54.34 | 16.02 | 29 | 48.61 | 16.98 | 18 | 32.5 | 20.78 | 8 |
BBQ | |||||||||
ICBT | 38.77 | 17.91 | 30 | 50.22 | 18.58 | 18 | 45.6 | 23.3 | 8 |
wait-list | 34.17 | 20.46 | 29 | 33.61 | 16.74 | 18 | 52.88 | 32.22 | 8 |
Thematic analysis
Overall results
1) The importance of being seen
In contrast, other participants expressed that they would have wanted more contact throughout the treatment, preferably via telephone or in a physical meeting, and felt limited by only having contact via email.“... I felt safe, that there was someone who understood … there was someone who cared. You feel that your condition is recognized.” (P5)
As shown in this quote, for some participants, an increased connection with the therapist and a sense of being seen and understood could have helped facilitate engagement in and adherence to the treatment. When this connection failed to establish, this led to less motivation to engage with the treatment material.“[ … ] I probably work best when I have direct contact. It was a little difficult during that period to concentrate. But if I had had [telephone] conversations with my therapist then I would probably have felt more seen and that there is some connection between us, that I am understood [ … ] which could perhaps make me follow the treatment a little better.” (P4)
2) New ways of knowing and doing
In addition, participation also seemed to result in increased self-awareness, where engagement with the treatment program enabled participants to self-reflect in new ways.“One thing that I thought was good in the study was that you kind of understand how it comes about that you get sick, [ … ] how come you get like this and that certain things that happen in life can affect you [ … ] so I just thought these texts that you got about, for example, a certain diagnosis or so, contained a lot of information, [ … ] you learned certain things you knew nothing about. "(P8)
Finally, participants also described new ways of doing things in their everyday life which seemed to impact them in a positive way. This included changing their routines, changes in their thinking patterns as well as focusing their attention in a different way, as exemplified by the following participant.“The questions were made in a way that allowed me to go inside and search within me for answers. Some of these questions I had never been able to ask myself before, I feel like I did not have access to them, so through the questions and taking part of all the advice in the texts that you got through the treatment, this encouraged me to search within me for answers.” (P2)
As mentioned by this participant, changes in thinking patterns and new ways of focusing attention resulted in a sense of having more energy and a more positive feeling state, which was also echoed by other participants. One participant also mentioned an increased sense of direction and purpose in life.“[ … ] maybe that you change routines and such, that was what was most helpful to me, when you change the direction from inside, self-focus, to starting to focus more outwards. When I did so, and became more aware of how I think, and directed the thoughts outwards and also when I stop thinking negative thoughts, and more positive ones, [I feel] more positive force, or energy.” (P5)
3) Treatment format not for everyone
Participants also expressed appreciation for the contact with their therapist and for the fact that the treatment was delivered in Arabic, which according to one participant was preferable to face-to-face therapy with an interpreter. However, several difficulties and limitations with the treatment format were also encountered including technical problems logging in to the treatment platform as well as difficulties understanding the questionnaire items and the treatment texts."... I felt that all the steps were simple, that it was laid it out in a good way, [ … ] it was no problem for me to follow along." (P3)
In addition, some participants also reported difficulties in applying the material that they learned in real life. Some participants reported that it was hard to understand how to perform some of the homework assignments while others reported that following the steps outlined did not produce the desired results.“[ … ] but sometimes there were difficult words and terms used in the text so that it required an effort to go through and understand.” (P5)
This quote also gives an indication that an experience of lack of desired result led to decreased motivation for this participant. Other participants reported difficulties engaging with the written treatment material due to symptoms related to their mental health problems, such as difficulties concentrating or high anxiety."So I tried to follow those steps, but sometimes I followed the steps but I didn't get much results, and sometimes I gave up." (P8)
Similarly, some participants also reported stressful circumstances in their life situation that were not fully considered in the treatment format, which led to difficulties in focusing on the treatment and which exacerbated their mental health problems.“[ … ] in my situation, I had difficulties focusing, sometimes I could not take in what I read.” (P9)
As exemplified by the above quotation, some participants demonstrated a tendency to either blame themselves or external circumstances for lack of effect of the treatment on their well-being, rather than the treatment itself not being sufficiently tailored to their individual needs.“... my big problem is not in the treatment itself, my big problem is my situation here at home, how I feel now, how I live and this whole process I have gone through, that is what makes me continue to not feel well” (P3)
4) Changing attitudes towards mental health and help-seeking
However, participants also differed regarding to what extent they self-identified with this view, and some also emphasized that mental health problems are normal and not something to feel ashamed about. Seeking help via the internet was considered more accessible due to the increased anonymity that it provides."This was my first time [seeking help], I know that it is very difficult as many in my community feel that this is something unknown or even have a fear of contacting a psychologist" (P1)
Participants also noted a need for professional help when suffering from mental health problems and the importance of addressing these problems. They also mentioned an increased awareness that it was possible to receive help which, according to them, was a result of their participation in the study. This also included a more favorable attitude towards the healthcare system and towards seeking help for mental health problems.“You feel safe online and it's personal, that's what was good about the study, no one sees and no one hears [ … ] No one looks at the person negatively. Personally, I do not mind mental illness or that sometimes you need to seek help” (P5)
As shown in this quote, this changed attitude towards help-seeking was not confined only to the participants themselves but also led to recommending other people to seek help for their mental health problems.“... this whole experience gave me a new perspective when it comes to seeking help for mental health problems, I mean, I’ve started telling others around me [that] help was available. You do not have to keep feeling bad” (P2)
5) The healthcare system as a complex puzzle
“It is not so easy when you are newly arrived, not so easy when you do not know much about how the system works here.” (P3)
In addition, some participants also report difficulties being understood once contact is established, as exemplified by the following quote.“[ … ] but at the same time it is difficult to get through, I had to seek help several times before I finally received it.” (P9)
In this example, even the use of an interpreter is not always sufficient to bridge the gap in understanding between participants and healthcare professionals, with resulting frustration and inability to receive the care that one needs. This difficulty also speaks to the complexity of conveying emotional experiences to healthcare professionals and the importance of the latter having an understanding of the patients’ cultural context in order to facilitate communication surrounding these complex issues.“I think I have good knowledge of Swedish but when I seek healthcare or other help, I still think it has been very difficult when you cannot make yourself understood, even when I have an interpreter I feel that what I want to say is not understood, the interpreter does not convey what I want to convey.” (P2)