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Treatment dropout continues to be reported from internet-delivered cognitive behavioral therapy (iCBT) interventions, and lower completion rates are generally associated with lower treatment effect sizes. However, evidence is emerging to suggest that completion of a predefined number of modules is not always necessary for clinical benefit or consideration of the needs of each individual patient.
The aim of this study is to perform a qualitative analysis of patients’ experiences with an iCBT intervention in a routine care setting to achieve a deeper insight into the phenomenon of dropout.
A total of 15 purposively sampled participants (female: 8/15, 53%) from a larger parent randomized controlled trial were interviewed via telephone using a semistructured interview schedule that was developed based on the existing literature and research on dropout in iCBT. Data were analyzed using a descriptive-interpretive approach.
The experience of treatment leading to dropout can be understood in terms of 10 domains: relationship to technology, motivation to start, background knowledge and attitudes toward iCBT, perceived change in motivation, usage of the program, changes due to the intervention, engagement with content, experience interacting with the supporter, experience of web-based communication, and termination of the supported period.
Patients who drop out of treatment can be distinguished in terms of their change in motivation: those who felt ready to leave treatment early and those who had negative reasons for dropping out. These 2 groups of participants have different treatment experiences, revealing the potential attributes and nonattributes of dropout. The reported between-group differences should be examined further to consider those attributes that are strongly descriptive of the experience and regarded less important than those that have become loosely affiliated.
The evidence base supporting internet-delivered cognitive behavioral therapy (iCBT) in the treatment of depression and anxiety is well established [
To date, there has been a large body of quantitative research on dropout from web-based psychological therapies that has explored the associated variables to predict which individuals may be more at risk [
More recent research has focused exclusively on qualitatively analyzing individuals’ experiences of web-based treatment dropout [
Efforts to further understand web-based dropout must also take into consideration the conceptualization of the dropout and the implications of this [
The gaps in the web-based treatment dropout literature and the questioning of the current conceptualization suggests that dropout may be more nuanced, with individuals who meet dropout criteria in terms of a predefined number of sessions or modules having widely varied treatment experiences and motives for leaving treatment
This study aims to conduct an in-depth exploration of the subjective experience of web-based treatment dropout by incorporating current literature on treatment dropout and adherence in both face-to-face and web-based contexts to create a robust semistructured interview. By interviewing and qualitatively analyzing individuals’ experiences of dropout from an iCBT program in a routine care setting, it is hoped that a deeper insight into the experience of treatment dropout will be achieved.
The study was a nested, semistructured qualitative interview study exploring clients’ experiences of dropping out from an iCBT program for depression and anxiety [
The larger RCT included 361 individuals; of these 361 individuals, 66.8% (241/361) were randomized to the immediate treatment group and 33.2% (120/361) to the waiting-list control group. The design followed a 2:1 randomization procedure to reduce the likelihood of having many participants waiting for treatment after presenting to the IAPT service. All adult users of the Berkshire NHS Trust IAPT Talking Therapies step-2 services were eligible to participate. Clients were deemed suitable for an internet intervention by their psychological well-being practitioner (PWP) based on their willingness to engage with an iCBT intervention, the presence of mild to moderate levels of anxiety or depression, no suicidal or self-harm risk, and having internet access. In line with the study protocol for the main RCT, a participant was considered to have dropped out of treatment if they received less than 6 web-based reviews from their supporter, as defined by the IAPT.
To identify eligible participants, the lead researcher (KL) manually went through each RCT participant’s iCBT account history from the treatment group to verify the number of modules viewed, reviews received, and how responsive each of these participants was to their research contacts. Their level of responsiveness was determined by their history of answering calls from the RCT research team to complete the research measures. Eligibility criteria included (1) providing written informed consent, (2) completing fewer than 6 reviews with a supporter, and (3) completing a minimum of 1 module. The criterion of completing at least 1 module was necessary so that participants reporting on treatment dropout had some experience with each of the domains of investigation (see
Characteristics of study participantsa.
Participant identifier | Gender | Age (years) | Mini-International Neuropsychiatric Interview diagnosis at baseline | iCBTb program | Modules completed, n (%) | Reviews received | Reported reason for change in motivation |
P1 | Female | 24-26 | Depression current or past | Space from Depression—8 modules (1 unlockable) | 1 (13) | 4 | Negative reason (not in a receptive frame of mind, contextual obstacles, and iCBT not considered to be personally fitting) |
P2 | Female | 50-53 | Depression current or past, panic disorder, and GADc | Space from Depression—8 modules (1 unlockable) | 4 (50) | 5 | Negative reason (not in a receptive frame of mind, contextual obstacles, and iCBT not considered to be personally fitting) |
P3 | Female | 34-36 | No diagnosis | Space from Depression and Anxiety—10 modules (2 unlockable) | 3 (30) | 5 | Felt ready to leave treatment early |
P4 | Female | 24-26 | Depression current or past | Space from Depression—8 modules (1 unlockable) | 7 (88) | 3 | Felt ready to leave treatment early |
P5 | Male | 30-33 | GAD | Space from Depression and Anxiety—10 modules (2 unlockable) | 5 (50) | 3 | Negative reason (iCBT not considered to be personally fitting) |
P6 | Male | 37-39 | Depression current or past | Space from Depression and Anxiety—10 modules (2 unlockable) | 5 (50) | 4 | Negative reason (iCBT not considered to be personally fitting) |
P7 | Male | 27-29 | Depression current or past and GAD | Space from Depression and Anxiety—10 modules (2 unlockable) | 1 (10) | 3 | Negative reason (not in a receptive frame of mind) |
P8 | Male | 40-43 | Depression current | Space from Depression and Anxiety—10 modules (2 unlockable) | 7 (70) | 2 | Did not report |
P9 | Female | 44-46 | Panic disorder and GAD | Space from GAD–8 modules (1 unlockable) | 4 (50) | 2 | Negative reason (not in a receptive frame of mind and iCBT not considered to be personally fitting) |
P10 | Male | 44-46 | Depression current or past, GAD, and SADd | Space from Depression and Anxiety—10 modules (2 unlockable) | 3 (30) | 1 | Negative reason (iCBT not considered to be personally fitting) |
P11 | Male | 20-23 | Depression past | Space from Depression and Anxiety—10 modules (2 unlockable) | 4 (40) | 4 | Felt ready to leave treatment early |
P12 | Male | 20-23 | GAD | Space from Depression—8 modules | 3 (38) | 5 | Negative reason (contextual obstacles, and iCBT not considered to be personally fitting) |
P13 | Female | 37-39 | No diagnosis | Space from Depression and Anxiety—10 modules (2 unlockable) | 1 (10) | 4 | Did not report |
P14 | Female | 34-36 | GAD | Space from GAD—8 modules (1 unlockable) | 3 (38) | 5 | Felt ready to leave treatment early |
P15 | Female | 20-23 | Depression current, panic disorder, GAD, and SAD | Space from GAD—8 modules (1 unlockable) | 2 (25) | 1 | Felt ready to leave treatment early |
aParticipants have been allocated participant identifiers P1-P15 to protect their anonymity.
biCBT: internet-delivered cognitive behavioral therapy.
cGAD: generalized anxiety disorder.
dSAD: social anxiety disorder.
The programs also use supporters that monitor patients’ progress and provide asynchronous postsession feedback; this is referred to as a
The Mini-International Neuropsychiatric Interview 7.0 is a short diagnostic structured interview based on both the Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Diseases criteria. The interview and its administration by telephone have been well validated [
KL and CE reviewed and analyzed the existing literature on treatment dropout to identify the recurring domains of investigation [
Stages of formation of interview schedule. Author initials are provided parenthetically.
The interview (
This research project was led by a researcher with a background in e-Mental Health, who conducted the interviews and analysis (KL). The team of auditors was made up of a researcher undertaking counseling training (CE), a postdoctoral clinical researcher (AE), and a senior researcher (DR) who were all members of the e-Mental Health Research group at the Trinity College Dublin. In addition, a psychologist with a humanistic orientation (LT) who emphasized clients’ agency and interest in psychotherapy research was also a member of the auditor team.
The interviews were conducted by 2 researchers via telephone and lasted between 27 minutes and 67 minutes, depending on the extent to which each participant explored their own experience of treatment dropout. The interviews were recorded and transcribed verbatim by a third-party transcription service. The web-based program was free to access, and participants received a £20 (US $27.32) gift voucher for their participation in the interviews.
Data were analyzed using descriptive and interpretive qualitative research methods [
First, the data were divided into discrete meaning units that captured the essence of what participants were trying to convey [
Second, meaning units were assigned to the domains of investigation headings (Experiences of Technology, Motivations to Engage in Treatment, Experiences of Intervention’s Content, and Experiences of Support) to organize the data. The preliminary literature review that informed the creation of the semistructured interview schedule that was used for this study suggested domains of investigation; however, these were not finalized until after the data analysis.
Third, meaning units within the domains were grouped into categories based on their similar meanings. Some meaning units were included in more than 1 category, as they contained more than 1 relevant meaning (therefore, the categories are not mutually exclusive). For example, the meaning unit P2.29 stated the following:
[the supporter] kind of made suggestions...but I didn’t feel [they] was imposing anything on me...[they] emailed something to me that wasn’t on the platform[...] so I really felt they were taking their time to think of what I was going through.
The meaning unit was included in both categories—the category titled
Fourth, strategies were used to maintain rigor and credibility. The first author (KL) divided the data into discrete meaning units, and audits were performed at various intervals by the other authors to review this process. The process of organizing meaning units into domains and categories was conducted in several phases. The meaning units were first grouped into domains, and these choices were then discussed with fellow researchers who were experts in the literature, methodology, and iCBT, revising as necessary until agreement was reached. The same method was followed for categorization: the meaning units within each domain were grouped into categories and then presented to fellow researchers for comments and feedback. This process would be repeated until consensus was reached. Records were maintained for each step of the analysis. The feedback provided sometimes outlined a need for clarification of particular meaning units or their reallocation. Using this feedback sometimes resulted in the creation of new domains and categories or the removal of existing domains and categories.
Finally, during data analysis, 2 distinct participant groups emerged, characterized by reasons for the change in motivation to engage with the iCBT treatment: (1) those who felt ready to leave treatment early (5/15, 33%) and (2) those who had negative reasons for their change in motivation (8/15, 53%). Of the 15 participants, 2 (13%) did not report on the reason for their change in motivation to engage with treatment, and so they were excluded from the between-group comparison; however, they contributed to the formation of the overall domains and categories (Table S1 in
A total of 10 domains capturing the areas of investigation of the subjective experiences of dropout from an iCBT intervention were formulated: relationship to technology, motivation to start, background knowledge and attitudes toward iCBT, change in motivation, use of the program, perceived changes because of the intervention, engagement with content, experience interacting with the supporter, experience of web-based communication, and termination of the supported period (Table S1 in
Participants who felt ready to leave treatment early (5/15, 33%) reported that they felt they had already obtained what they needed from the treatment without finishing the prescribed number of sessions:
I think it’s just that point I sort of felt like I was getting better. I sort of got what I needed out of [the program]...I was feeling a bit better in my jowls and I didn’t think I really needed it too much.
I got out of it what I needed and...the [supporter] I was speaking to gave me the option just to carry on logging on (my own)...I’m quite comfortable with logging on.
Participants who had negative reasons for their change in motivation (8/15, 53%) responded across 3 categories: not being in a receptive frame of mind, contextual obstacles, and considering iCBT not to be personally fitting:
But also and perhaps because I was just, my brain was just full up of loads of things going on I just wasn't in a receptive frame of mind.
I wasn’t receptive enough to it at the time, but I do think in that frame of mind of feeling so low that you’re kind of not...for months my brain didn’t feel it was working very well.
Relationship to technology corresponds to technology literacy, familiarity, and usability, both in general and specific to the iCBT program. Participants’ reported relationships with their use of technology in general and with the technology itself were clustered into 10 categories that had both positive and negative connotations (
Participants’ relationships to technology based on their reported reasons for their change in motivation.
Domain and categories | Felt ready to leave treatment early (n=5)a,b | Negative reason for their change in motivation (n=8)a,b,c | |
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Being familiar with technology | General | General |
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Sense of privacy and anonymity on the web | General | General |
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Good memorability | General | Typical |
|
Trusted the platform | Typical | Typical |
|
Easy-to-use web-based platform | Typical | Typical |
|
Spends too much time on the web | None | Variant |
|
User dashboard not clear enough | None | Variant |
|
Layout too structured | None | Variant |
|
Difficulty figuring out how to use it | Variant | Variant |
|
Poor computer literacy | Variant | None |
aOnly 13 participants (5/13, 38% felt ready to leave treatment early, and 8/13, 62% had negative reasons for their change in motivation) reported on the reasons for their change in motivation.
bGeneral results apply to all cases (ie, 5/5 and 8/8),
cReported negative reasons for change in motivation to continue engaging with treatment are not being in a receptive frame of mind, contextual obstacles, and internet-delivered cognitive behavioral therapy not considered to be personally fitting.
This category referred to the reasons why participants sought mental health treatment in the first place. All participants reported on their motivations to seek treatment, and their responses were clustered into 2 categories (
It was the most severe bout of depression that I’ve experienced. And it scared me, like I felt like I was having thoughts and reacting to things in a way that I couldn’t control.
So my husband had just left and I was panicking about like financially I didn’t know what was gonna happen.
Participants’ motivation to start treatment based on their reported reasons for their change in motivationa.
Domain and categories | Felt ready to leave treatment early (n=5)a,b | Negative reason for their change in motivation (n=8)a,b,c | |
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Symptoms of psychological distress | General | General |
|
Stressful life events | Variant | Typical |
aGeneral results apply to all cases (ie, 5/5 and 8/8 cases),
bOnly 13 participants (5/13, 38% participants felt ready to leave treatment early, and 8/13, 62% participants had negative reasons for their change in motivation) reported on the reasons for their change in motivation.
cReported negative reasons for change in motivation to continue engaging with treatment are not being in a receptive frame of mind, contextual obstacles, and internet-delivered cognitive behavioral therapy not considered personally fitting.
Stressful life events as a motivation to start treatment was a typical category for participants who had negative reasons for their change in motivation but a variant category for participants who felt ready to leave treatment early, indicating that there were some differences between groups with regard to the motivation to start treatment.
This category was characterized by what participants knew and believed about the iCBT program. Overall, the belief that iCBT could help was typical to both groups:
So when I started the sessions...I thought it would work really well for me because it would be [able to] take my own reflective time and think through my problems.
I think I thought that [CBT] could change the way I think.
There were between-group differences across the 3 categories (
I didn’t really know what CBT was [...] to a certain extent I didn’t recognize that it would be so much about my thought processes and how it works.
Participants’ background knowledge and attitudes toward iCBTa based on their reported reasons for their change in motivationb.
Domain and categories | Felt ready to leave treatment early (n=5)b,c | Negative reason for their change in motivation (n=8)b,c,d | |||
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Belief that iCBT could help | Typical | Typical | ||
|
Willingness to try it | Typical | Variant | ||
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Had an understanding of CBTe | Variant | Variant | ||
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Trusted provider of web-based treatment | Variant | Variant | ||
|
No prior knowledge or awareness of CBT | Typical | Variant | ||
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Skeptical of treatment approach | Typical | Variant |
aiCBT: internet-delivered cognitive behavioral therapy.
bGeneral results apply to all cases (ie, 5/5 and 8/8 cases),
cOnly 13 participants (5/13, 38% participants felt ready to leave treatment early, and 8/13, 62% participants had negative reasons for their change in motivation) reported on the reasons for their change in motivation.
dReported negative reasons for change in motivation to continue engaging with treatment are not being in a receptive frame of mind, contextual obstacles, and internet-delivered cognitive behavioral therapy not considered personally fitting
eCBT: cognitive behavioral therapy.
This category was characterized by reports on how, why, and when participants used the program (
I set [a reminder] up for like every day at seven o’clock or something...When I’m sitting doing nothing it just gave me a little suggestion to go and do it, I guess.
Participants’ use of the program based on their reported reasons for their change in motivationa.
Domain and categories | Felt ready to leave treatment early (n=5)a,b | Negative reason for their change in motivation (n=8)a,b,c | |||
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Could use it wherever and whenever needed | General | General | ||
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Productive and regular use | General | Variant | ||
|
Using the program for own benefit | Typical | Variant | ||
|
Could not prioritize time to use it | Typical | Typical | ||
|
Using it out of a sense of obligation rather than for a positive outcome | Variant | Typical | ||
|
Using it when feeling low | Variant | Typical | ||
|
Kept forgetting about the program and appointments | Variant | Variant |
aGeneral results apply to all cases (ie, 5/5 and 8/8 cases),
bOnly 13 participants (5/13, 38% participants felt ready to leave treatment early, and 8/13, 62% participants had negative reasons for their change in motivation) reported on the reasons for their change in motivation.
cReported negative reasons for change in motivation to continue engaging with treatment are not being in a receptive frame of mind, contextual obstacles, and internet-delivered cognitive behavioral therapy not considered personally fitting.
It was typical for those who had negative reasons for their change in motivation to use it out of obligation or when feeling low:
It felt like obligation. It felt like a tick box exercise.
Participants’ perceived changes because of the intervention, that is, new skills they acquired and changes to themselves and their everyday lives, were all positive (
When my dad did pass away because I was aware of all this stuff that I’ve learned [from the intervention]...And I purposefully the following week, on the exact same day, just to make sure that it [my OCD] wasn’t there, I wore the exact same outfit. To push myself...to prove a point that it’s got nothing to do with what I’m wearing, like it doesn’t matter, it won’t change it.
Participants’ perceived changes because of the intervention based on their reported reasons for their change in motivationa.
Domain and categories | Felt ready to leave treatment early (n=5)a,b | Negative reason for their change in motivation (n=8)a,b,c | |
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Symptom improvement | General | Typical |
|
Applying learned CBTd techniques in everyday life | Typical | Typical |
|
Developed a knowledge of CBT treatment | Typical | Variant |
|
Increased awareness or insight | Variant | Variant |
|
Encouraged to get the help needed | None | Variant |
aGeneral results apply to all cases (ie, 5/5 and 8/8 cases),
bOnly 13 participants (5/13, 38% participants felt ready to leave treatment early, and 8/13, 62% participants had negative reasons for their change in motivation) reported on the reasons for their change in motivation.
cReported negative reasons for change in motivation to continue engaging with treatment are not being in a receptive frame of mind, contextual obstacles, and internet-delivered cognitive behavioral therapy not considered personally fitting.
dCBT: cognitive behavioral therapy.
Conversely, being encouraged to get the help they needed was deemed a variant category for those who had negative reasons for their change in motivation, whereas it was not reported by any participants who felt ready to leave treatment early:
I think it was definitely a benefit to kind of like dip my toes in and just get a feel for...cognitive behaviour therapy...it was definitely a good starting point for me.
This category was characterized by reports of what participants liked and disliked about aspects of content within the program (
[I reflected] sometimes, ‘cos if I was having a really bad day and it wasn’t as bad before, it made me feel a little bit better.
Participants’ engagement with content based on their reported reasons for their change in motivationa.
Domain and categories | Felt ready to leave treatment early (n=5)a,b | Negative reason for their change in motivation (n=8)a,b,c | |
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Useful tools and exercises | Typical | General |
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Reflecting back on completed work was beneficial | Typical | Variant |
|
Content relevant and relatable to concerns | Typical | Variant |
|
Manageable workload | Variant | Variant |
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Reading and writing provided clarity | Variant | Variant |
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Writing about thoughts and feelings felt therapeutic | Typical | Variant |
|
Felt supported by the program content | Typical | Variant |
|
Information laid out clearly and concisely | Variant | Variant |
|
Felt like too much work | Variant | Variant |
|
Disliked reading and writing | Variant | Variant |
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Content was too generic at times | Variant | Variant |
|
Did not like the personal stories | Variant | Variant |
|
Content was boring | None | Variant |
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Content exacerbated symptoms | None | Variant |
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Reflecting of no benefit | None | Variant |
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Difficult to understand | None | Variant |
|
Questionnaires felt pointless | None | Variant |
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Did not like the mood monitor | Variant | None |
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Content felt disconnected from one section to the next | None | Variant |
aGeneral results apply to all cases (ie, 5/5 and 8/8 cases),
bOnly 13 participants (5/13, 38% participants felt ready to leave treatment early, and 8/13, 62% participants had negative reasons for their change in motivation) reported on the reasons for their change in motivation.
cReported negative reasons for change in motivation to continue engaging with treatment are not being in a receptive frame of mind, contextual obstacles, and internet-delivered cognitive behavioral therapy not considered personally fitting.
However, these categories were deemed variant among those who had negative reasons for their change in motivation
[the content] was a bit long winded to be honest with you. There was probably too much reading. So I probably skipped bits.
This category relates to participants’ comments on their relationship with their supporters and how they felt that interaction contributed to their overall treatment experience. Participants described these experiences across positive and negative dimensions (
I recognise that I’m not looking someone in the face but it turns out to be the same to me because I still felt supported in everything that I did [...] there was just someone there and that to me, was really good.
Participants’ experience interacting with supporters based on their reported reasons for their change in motivationa.
Domain and categories | Felt ready to leave treatment early (n=5)a,b | Negative reason for their change in motivation (n=8)a,b,c | |
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Felt supported by and connected to supporter | General | Variant |
|
Supporter tailored treatment to needs | Typical | Typical |
|
Supporter provided a good introduction and explanation of treatment | Variant | Typical |
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Felt able to speak freely | Typical | Variant |
|
Supporter encouraged engagement | Typical | Variant |
|
Benefitted from having a supporter | Typical | Variant |
|
Supporter demonstrated a good level of expertise | Typical | Variant |
|
Supporter discussed treatment goals | Variant | Variant |
|
Supporter offered understanding | Variant | Variant |
|
Support felt scripted and impersonal | None | Variant |
|
Had no sense of connection with supporter | None | Variant |
|
No feedback from supporter on work completed or messages sent | Variant | Variant |
|
Supporter never discussed treatment goals and expectations | None | Variant |
|
Lack of empathy and understanding from supporter | None | Variant |
|
Lack of guidance from supporter | None | Variant |
|
Felt like supporter did not care | None | Variant |
|
Supporter never made contact | None | Variant |
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Did not feel comfortable talking with supporter | None | Variant |
aGeneral results apply to all cases (ie, 5/5 and 8/8 cases),
bOnly 13 participants (5/13, 38% participants felt ready to leave treatment early, and 8/13, 62% participants had negative reasons for their change in motivation) reported on the reasons for their change in motivation.
cReported negative reasons for change in motivation to continue engaging with treatment are not being in a receptive frame of mind, contextual obstacles, and internet-delivered cognitive behavioral therapy not considered personally fitting.
Furthermore, feeling able to speak freely with their supporter and the supporter demonstrating a good level of expertise was typical to those who felt ready to leave treatment early, whereas these categories were variant to those who had negative reasons for their change in motivation:
They do help you sort of really, really open up and you’ve got to remember, you know, they do this every single day. So, it was quite easy to open up in the first session.
Having no connection with the supporter was a variant category for participants with negative reasons for their change in motivation but was not reported by those who felt ready to leave treatment early:
If I had felt a bit more that somebody was really listening and engaging [maybe we could have had a connection]. I just found it hard to build any sort of relationship.
Although there was low reporting across the other negative categories, the same pattern applied between groups as with the lack of connection with the supporter.
This category was characterized by participants’ likes and dislikes on using a web-based medium to communicate with a supporter. Participants’ reports relating to the medium of web-based communication were described across positive and negative categories, with large differences between groups (
I preferred [the online reviews] to be honest. And it was easy enough to do as well.
Participants’ experience of web-based communication based on their reported reasons for their change in motivationa.
Domain and categories | Felt ready to leave treatment early (n=5)a,b | Negative reason for their change in motivation (n=8)a,b,c | |||
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Frequency of web-based communication worked well | Typical | Typical | ||
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Liked communicating web-based with supporter | Typical | Variant | ||
|
Easier to open up on the web and feeling of disinhibition | Typical | Variant | ||
|
Preference for face-to-face communication | None | Typical | ||
|
Needed more contact with supporter | Variant | Variant | ||
|
Communicating on the web was too formal and structured | None | Typical | ||
|
Lack of instantaneous responding with supporter | None | Variant | ||
|
Could not open up to a computer | None | Variant | ||
|
Web-based communication felt too anonymous | None | Variant |
aGeneral results apply to all cases (ie, 5/5 and 8/8 cases),
bOnly 13 participants (5/13, 38% participants felt ready to leave treatment early, and 8/13, 62% participants had negative reasons for their change in motivation) reported on the reasons for their change in motivation.
cReported negative reasons for change in motivation to continue engaging with treatment are not being in a receptive frame of mind, contextual obstacles, and internet-delivered cognitive behavioral therapy not considered personally fitting.
Conversely, a preference for face-to-face interactions was a typical category for those who had negative reasons for their change in motivation but not reported at all by those who felt ready to leave treatment early:
I think looking back that maybe I should’ve had both, even though I was short on time, actually the (face-to-face) probably would’ve been better than maybe moving to [iCBT.].
This category was characterized by participants’ reports relating to how the supported period of the iCBT program was discontinued and how they felt about it (
If I explored a different route and it didn't work out then I was always welcome to rejoin SilverCloud, or rejoin Talking Therapies...So that is really positive.
Being happy with how the supported period ended was a general category for those who felt ready to leave treatment early but was not reported at all by those who had negative reasons for their change in motivation:
I think I got out of it what I needed...[my supporter] gave me the option just to carry on logging on (without support) and I’m quite comfortable with logging on.
More negative reports relating to the termination of the supported period were variant categories for those who had negative reasons for their change in motivation, whereas they were not reported by those who felt ready to leave treatment early: support stopping unexpectedly and feeling abandoned and feeling relieved that support stopped because of it being such a negative experience:
[Support] stopped. I heard nothing, done nothing...I was shocked and disappointed.
I haven't got time for this, you're not useful enough to me. Therefore, I'm not wanting to carry it on and give you my time because my time was too precious and as I say it just wasn't useful enough.
Participants’ experience of termination of the supported period based on their reported reasons for their change in motivationa.
Domain and categories | Felt ready to leave treatment early (n=5)a,b | Negative reason for their change in motivation (n=8)a,b,c | |||
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Feels able to go back to treatment if needed | Typical | Typical | ||
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Happy with how support was terminated | General | None | ||
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Had a conversation with supporter about finishing treatment | Variant | Variant | ||
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No longer a priority, just let it go | Variant | Variant | ||
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Support stopped unexpectedly, felt abandoned | None | Variant | ||
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Felt relieved that support stopped as it was a negative experience | None | Variant |
aGeneral results apply to all cases (ie, 5/5 and 8/8 cases),
bOnly 13 participants (5/13, 38% participants felt ready to leave treatment early, and 8/13, 62% participants had negative reasons for their change in motivation) reported on the reasons for their change in motivation.
cReported negative reasons for change in motivation to continue engaging with treatment are not being in a receptive frame of mind, contextual obstacles, and internet-delivered cognitive behavioral therapy not considered personally fitting.
This study qualitatively investigated dropout from iCBT interventions for depression and anxiety as part of routine mental health service delivery. It explored dropout across a continuum of 10 experiential domains. These domains are multiple and varied and demonstrate the conceptualization of treatment dropout as an experience not confined to one moment. Furthermore, this study establishes that when we conceptualize dropout in terms of the number of sessions completed, there are 2 distinct groups of participants: those with negative reasons for their change in motivation and those who feel ready to leave treatment early. However, the differences in treatment experiences observed between these groups point to a potential shift in how we think about treatment dropout.
This study has taken a deeper dive into dropout from iCBT treatment research. Previously, personal characteristics, individual capabilities, aspects of technology, intervention content, relationship with the supporter, motivation and treatment expectancies, and credibility have all been identified as reasons for treatment dropout [
Considering that participants described both their relationship with technology in general and to the iCBT program specifically as largely positive and that there were little to no differences in reporting between the 2 groups, it should be further considered whether technology is now a nonattribute of treatment dropout. To date, the literature has reported it to play an important role in dropout in terms of technology literacy, attitudes toward the technologization of health care, and technical difficulties [
Stressful life events before beginning iCBT treatment seem to be an attribute of dropout because proportionately more participants who had negative reasons for their change in motivation reported them than those who felt ready to leave treatment early. This is not surprising, as one of the main characteristics of this group is not continuing with treatment because of contextual obstacles such as work, relationships, and commitments. The literature has previously documented the influence of external factors on treatment dropout [
On the basis of the findings reported in relation to
Negative interactions with a supporter and a lack of a connection characterize the dropout experience of those who had negative reasons for their change in motivation and who, according to the consensual qualitative research method categorizations [
There were also differences in reporting between groups in relation to the experience of web-based communication. A dislike for web-based communication and a preference for face-to-face treatment characterizes the dropout experiences of those who had negative reasons for their change in motivation. This finding is reflective of the pattern in reporting experiences with the supporter, and it would be interesting to investigate whether they are correlated. The role played by preferences in treatment dropout has been identified previously, concluding that despite the comparable efficacy of web-based communication with a supporter, an overwhelming number of patients only prefer face-to-face interaction [
The multiplicity and variance of the domains presented in this study expand our understanding of dropout. This nuanced portrayal was achieved through a robust methodology consisting of the development of a semistructured interview based on the existing literature pertaining to dropout and adherence in both face-to-face and web-based therapies and rigorous analysis using the descriptive-interpretive method [
Although the ecological validity provided by the IAPT setting was a strength of this study, it may also have positively skewed participant reports, as their suitability for iCBT would have been assessed before beginning treatment. In addition, some individuals did not want to participate in the dropout interview. By not capturing the experiences of these individuals, the data presented may be positively biased to the intervention. The between-group differences that have been identified are based on qualitative data from a sample of 15 participants who dropped out in response to open-ended questions rather than closed-ended questions that would have investigated the presence or absence of an experience and so should be considered tentative. Future research into dropout should focus on identifying these 2 groups of participants on a larger scale and quantitatively investigate their outcomes. As with any qualitative interview study, the potential roles played by social desirability, historical reporting, and researcher subjectivity should be taken into account. However, the results for all 15 participants were analyzed first, and it was determined only afterward that a second analysis with the participants divided into 2 groups would be useful to avoid any potential bias from the researcher.
The data presented from the qualitative interviews provide insight into the subjective experiences of participants who dropped out from an iCBT treatment for depression and anxiety in a routine care setting. In doing so, it moved beyond the current understanding of treatment dropout as a seemingly negative outcome attributable to a singular event and presents it as a phenomenon that must be considered experientially. The findings bring to light a more nuanced picture of treatment dropout when looked at through the perspective of varied domains that shed light on the experience. This suggests that participants who drop out can be distinguished in terms of their change in motivation: those who felt ready to leave treatment early and those who had negative reasons for dropping out. In doing so, it facilitated a comparison of treatment experiences that revealed potential attributes (stressful life events before beginning treatment, using the iCBT program when feeling low or out of a sense of obligation, perceived changes because of the intervention, negative experiences with content, negative experiences with the supporter, a dislike for web-based communication, and a preference for face-to-face therapy) and nonattributes (relationship to technology, background knowledge and attitudes toward iCBT, and termination of the supported period) of dropout. To understand why individuals drop out, these between-group differences should be examined to consider those features that are strongly descriptive of the experience and regard those that have become loosely affiliated with less importance. The evidence presented in this study stipulates that there is a difference between what we label as a dropout and what should actually be considered a dropout. Further work, either quantitative or exploratory, is needed to comprehensively develop a typology of dropout participants and potentially reconceptualize the phenomenon in this rapidly changing digital health care setting.
Semistructured interview schedule exploring the experience of dropout from an internet-delivered cognitive behavioral therapy intervention.
Participants’ experiences of treatment based on their reported reasons for their change in motivation.
cognitive behavioral therapy
Consolidated Criteria for Reporting Qualitative Research
Improving Access to Psychological Therapies
internet-delivered cognitive behavioral therapy
National Health Service
psychological well-being practitioner
randomized controlled trial
thought feeling behavior
The authors wish to thank the psychological well-being practitioners at Berkshire National Health Service Foundation Trust for providing the supported service for the internet-delivered cognitive behavioral therapy program. The authors thank the employees of the clinical and innovation team at SilverCloud for assisting in the development of the interview schedule. The authors also thank the patients who volunteered their time and shared their experiences to participate in our study. The study was funded by SilverCloud Health and the Irish Research Council. Employees at SilverCloud Health and Trinity College Dublin managed the data collection, data analysis, and writing of the manuscript. All authors approved the decision to submit for publication. SilverCloud is a commercial organization that sells its digital programs to commissioners within the National Health Service, who provide the service free to patients through the Improving Access to Psychological Therapies program.
KL had full access to the data and was responsible for the integrity of the data and the accuracy of the data analysis. The study was conceptualized and designed by KL, CE, DR, and AE, and data acquisition, analysis, and interpretation was led by KL, CE, and LT. Theoretical discussion and conceptual interpretation of the findings were provided by DR, AE, and LT. KL drafted the manuscript. Critical revision of the paper was provided by LT, DR, AE, and CE. All authors reviewed and approved the final manuscript for submission. KL is the recipient of an Irish Research Council Scholarship under the Enterprise Partnership Postgraduate Scheme (EPSPG/2019/504).
KL is a past employee of SilverCloud Health, the developer of computerized psychological interventions for depression, anxiety, stress, and comorbid long-term conditions. CE, DR, and AE are current employees of SilverCloud Health. LT serves as a research consultant for SilverCloud Health.