Intrinsic motivation
Gaining control of one’s life
Many of our participants had struggled with symptoms of depression for many years. They were aware of their problems, but had been unable to do anything about them. When they actively took initiative or accepted treatment it was experienced as motivating. Indeed, some participants felt they had gained more control of their life by taking action:
3: But I think primarily, just getting started with something had a tremendous effect. I was actually doing something instead of sitting, waiting and feeling distressed.
5: I knew that I had a programme that I could utilise, so I did when I had time, and when I had…was in my doing mode… I felt that I wanted to take some control of the process, now I’m… […] I feel inspired to take more control.
The ability to organise their everyday life to complete the ICBT modules was also related to this feeling of gaining control. The participants’ desires to manage their own lives, expressed both directly and indirectly, indicated that this was an intrinsic motivating aspect to persist with ICBT. A transition from passive to active behaviour was a basic driving force, constituting a change from being prepared to taking action. For some it was less important what they did as long as they did something, while others emphasised that they believed in and hoped that blended care would help them.
Hope for recovery
Some participants had heard about cognitive behavioural treatment and had expectations that a treatment based on these principles could help them. Others had faith in blended care because their GP had recommended it. Many participants expressed their personal hope for recovery and a desire to learn more about themselves and their condition. Their hope that recovery was possible was described as motivating.
8: I wanted to get better; therefore I wanted to learn some techniques in order to function better.
13: Feeling curious [towards the programme]! Or I had hoped it would help and it has.
Participants generally described the first two ICBT modules as informative and often felt that they started a learning process, which gave them hope that it was possible to learn more. Symptoms of depression were a problem in their lives, and they wanted to continue ICBT with the hope of recovery.
Supporting conditions and persistence constraints
Competence and autonomy
Learning while working on a laptop demanded very few practical adjustments from our participants, and computer skills were not an issue. The participants did not express any technical challenges of logging on or problems with manoeuvring within the ICBT programme.
12: Yes, it went quite well. I generally spend a fair amount of time using computers anyway.
13: For me it was not a problem working on the computer. You could do it in your own pace, relax and sit comfortably. In that way I found it to be good. The only thing was a few questions or words I didn’t understand, so you sit there alone and think… but luckily, I have Google to help me (laughter).
It is obvious that overall our participants were used to working with computers, and to using the Internet as a source of information. The mastery of technical challenges and the ability to understand the content of the ICBT programme revealed positive attitudes towards coping with it. This was conveyed together with a sense of competence.
Participants reported different experiences when the issue of time was raised, both due to long modules and competing priorities. Indeed, some modules were identified as especially time-consuming. Almost all patients expressed problems in finding time to complete the ICBT modules.
8: It was quite an effort, particularly in the beginning, when I spent a lot of time on each module.
7: It was difficult to find time for this. I’m struggling to find time to do everything. There is so much that has to be done, that most things get done half-heartedly.
Patients who were clearly taking action developed conscious strategies to overcome these constraints, such as choosing a set day to complete their modules, or using the date of the face-to-face consultation with the therapist as a deadline.
4: It was good to have a deadline [the consultation], which required me to be organised.
7: […] she [the therapist] said that this was nothing I needed to concern myself with. If it was unsuitable, I just skipped that part [module section]. It would just waste time, unnecessary time.
The flexibility to skip parts of the ICBT programme that were judged unsuitable by the participant was described as important to overcome time constraints. This flexibility was encouraged by the therapist and embraced by the participants who were strongly searching for solutions. Others were more caught up in the obstacles and were overwhelmed by time demands and long modules, but many appreciated the freedom to work at flexible hours and to select the parts of the ICBT programme they found suitable for them, which also correspond to their sense of autonomy.
Belonging
As mentioned above, finding time to persist with ICBT was a challenge. Participants emphasised the importance of supportive relationships, such as those with partners, friends and family who became directly involved in blended care and in the general process towards recovery. Their support and involvement became manifest and was appreciated in many ways, e.g. as encouragement to enrol in a treatment programme, to work on ICBT modules and to participate in face-to-face consultations. In this way partners, friends and family could help the participants to find the time and space to pursue their treatment.
9: No, I had my partner. I would probably have [dropped out] many times hadn’t it been for my partner [dry laughter] …she was good at pushing me… She had noticed that I felt better afterwards [consultation]. She told me that I should go [to the consultations] because I felt better after talking some… and done these tasks…
When participants allowed important others to play an active role in their treatment process, and when being open to their involvement was a positive experience, it promoted a sense of belonging, i.e. of not being alone in the process. Participants mentioned this as a motivator for moving forward in treatment.
When describing the period of treatment, the role of important others was also reported as supportive when feeling depressed in daily life. Being met with patience and that partners, friends and family were willing to make adjustments to their routines because of a participant’s limitations, was appreciated.
9: And my partner, who is quite kind [wry laughter] to me, lets me off the worst tasks. That relaxes my state of mind and in general.
14: When I haven’t been present socially and not had any social activity, questions regarding where I am and what’s wrong with me have been directed towards him [brother]. He’s been quite a helper.
These typical descriptions of caring actions revealed that the participants felt that their families or friends understood and acknowledged their problems. This pointed to the alleviating aspect of being part of social relationships during a difficult period.
Participants described that the feeling of belonging, feeling part of social relationships, directly strengthened their intrinsic hope of recovering and the motivation to engage and persist in treatment. Symptoms of depression sometimes represented a challenge to take part in social settings in a way the participant wanted. However, wanting to participate and the feeling of being welcomed by others were mutually motivating aspects. When describing what motivated participants for treatment, reasons that included their families were often expressed.
9: […] and it [engaging in treatment] was not just for my own sake, it was also for my partner’s sake.
3: Just when this happened, I became a father, and I wanted to function. I wanted to work and function. I did not want my illness to ruin the experience. Impact on the child in a negative way. The mother also needs help and support, especially just after giving birth.
Participants strove to contribute to, participate in and enjoy family life, and to interact with colleagues and friends. When this capacity was reduced it was experienced as a loss in their social life. Participants described their loss as experiencing less enjoyment and less interaction with the people they valued, which sometimes lead to isolation. Participants described this not only as a loss for them, but also for the people they were close to, revealing a confidence in feeling valued. To regain a social life was a driving force and an important motivating aspect for treatment.
Overall, the feeling of being part of a social environment, and not being alone was experienced as positive. A sense of belonging through attachment, being valued and understood, satisfied a need for relatedness and was positive for motivation. To want and be wanted socially was a driving force to engage and persist in treatment.
Recognition and self-identification
A positive feeling of not being alone was also experienced when participants were able to identify with and to relate to the content of the ICBT programme.
14: I found some recognisable bits there… that made it possible in a way, to connect with him or her in the various examples used. And I thought: Goodness, this is about me, right? That’s what I do!
10: Because you never know when you suddenly get an eye-opener. Wow! They [MoodGYM] hit the nail on the head again!
Patients sometimes strongly identified themselves with the fictional characters presented in the ICBT programme. This identification showed them that the problems they had, when symptoms of depression were present, were not specific to them; they were experienced by others, as well. This was perceived as essential to treatment progression and motivation.
On the other hand, participants were split on how they viewed the presentation of the ICBT content. The programme seemed superficial to some, with simplified problems, principles and strategies. It was perceived to target young people, and many expressed that the ICBT content did not correspond to their situation.
7: […] maybe it was directed towards a younger audience. Because it was a lot about exams and reading and coping with school situations. But I do understand that not everything can be right for everybody.
9: The reason I didn’t complete [all the modules completely] was because it didn’t seem right for me at the time.
The perception that the ICBT content was created to target a younger audience sometimes led to a sense of alienation. Two of the non-completers expressed difficulties with identification as the main reason for not completing the program (participant 1 and 7).
Yet, when participants gained self-identification through an ability to relate and to mirror themselves in the content, it motivated them to persist with ICBT. Discussing the ICBT programme with the therapist and important others was described as helpful in overcoming problems with the content. This strengthened the sense of identification with the content, but also the connectedness with the person in whom the participant was confiding, together satisfying the need for relatedness.
Connectedness and expert feedback
Participants described the face-to-face consultations as helpful and motivating. Some even expressed that they were absolutely necessary to participate in ICBT. It was through this dialogue they could reflect and develop.
3: If the consultations hadn’t been there, things would have faded somewhat.
4: […] it is in meetings with others that my thoughts fall into place. So for me it has been motivating and a very positive experience.
3: And I voiced my thoughts, and then we [patient and therapist] discussed the module. Then it was very straight forward to clear out the thoughts […]. To try to adjust the setting in the module to things that fitted me better.
Participants emphasised that the dialogue during consultations was an opportunity to put thoughts into words, rather than seeing it as a control or monitoring. It was an arena to connect, to open up, but, as mentioned earlier, was also useful to facilitate participants’ ability to identify with the ICBT content.
Connectedness was established through dialogue and strengthened when met with understanding, flexibility, acknowledgement and openness on the part of the therapist. For some, the therapist was just a person to interact with, but to others the therapist had a special expert status.
12: What was really important to me were the follow-up sessions. […] it was a person who I knew was knowledgeable and an expert on this…
Many participants wanted feedback and needed to trust the feedback given. Trust could be established when the patient was confident that the therapist was well-qualified, knew about depression and could provide therapy. This combination meant that some participants felt they were getting expert feedback. When asked, many expressed that their GP could not function as a therapist in the same manner, giving reasons such as lack of time and lack of competence in cognitive behavioural therapy.
Time constraints made the consultation stressful to some participants, both completers and non-completers alike. All three non-completers wanted to discuss their problems in more depth and wanted a more individualised approach in the face-to-face consultations as in traditional therapy. One of the non-completers was offered this and chose it instead of continuing with blended ICBT (participant 14).
1: The consultations could have been longer and more in-depth… about other things and how I functioned otherwise in life.
For some patients, short consultations were a barrier to open up and satisfy their need for connectedness. However, to summarise, all patients emphasised the importance of the dialogue with the therapist. Working with ICBT alone was not preferable.