Telephone-Supported Internet-Based Cognitive Behavioral Therapy for People With Depression: Users’ Perspective

Abstract

Background

Little is known from the perspective of service users on the quality and benefits of receiving telephone counseling in a guided Internet-based Cognitive Behavioral Therapy (iCBT).

Purpose

This study aimed to investigate, from the user’s perspective, the feasibility, quality, and benefits of a telephone-supported iCBT which provided eight self-learned online modules and weekly telephone counseling from a social worker for people with depression.

Research design

This study adopted interpretive qualitative research, involving semi-structural in-depth individual interviews with participants.

Study sample

Purposive sampling method was adopted, involving ten adults receiving a diagnosis of depression and completing the telephone-supported iCBT.

Data collection and/or analysis

Qualitative content analysis was adopted, involving coding data and identifying themes.

Results

The telephone-supported iCBT was appreciated by service users by offering convenience, efficiency, anonymity, privacy, synchronous and asynchronous support. Additionally, the counselor demonstrated competence in counseling via telephone, and provided various support, including: delivering CBT, handling personal issues outside the scope of iCBT, encouragement, guiding & monitoring learning progress, and solving technical difficulties. Perceived outcomes included improved abilities in cognitive restructuring, emotion regulation, and self-awareness.

Conclusions

The guided iCBT with telephone-supported is a feasible, effective, and preferable intervention for people with depression in Chinese societies.

Keywords

online cognitive behavioral therapy depression telephone counseling qualitative study Chinese societies

According to the World Health Organization (2017), depression is the most common mental disorder worldwide and has been ranked as the single most significant contributor to global disability. While previous surveys indicated a 4.7% prevalence rate of depression globally with regional differences before the COVID-19 pandemic (Ferrari, Somerville, Baxter, & Norman, 2013; World Health Organization, 2017), the COVID-19 pandemic has significantly increased the prevalence rate of depression by 27.6% globally with regional differences (COVID-19 Mental Disorders Collaborators, 2021). During the early stage of the COVID-19 outbreak in China, the prevalence of depression in Chinese societies increased to 26.9% (Bareeqa et al., 2021). Depression has adverse effects on individuals, including reduced quality of life, reduced functioning, increased risk of suicide, increased mortality rates, and increased personal and societal costs (Andersen, Toner, Bland, & McMillan, 2016; Qi et al., 2019). Various treatments, including pharmacological and psychosocial treatments, have been developed to treat depression effectively (Cuijpers, Karyotaki, De Wit, & Ebert, 2020; Kappelmann et al., 2020). However, more than 70% of people with depression in Western societies (Olfson, Blanco, & Marcus, 2016) and more than 80% of people in Chinese society have not received any treatment from mental health professionals (Qi et al., 2019; She et al., 2021), which is detrimental to their mental health. Barriers to traditional face-to-face treatment include social stigma, inaccessibility, long waiting times, and lack of trained counselors (Beevers et al., 2017; She et al., 2021). It is vital to overcome these treatment barriers so that people with depression can receive early assessment and treatment to facilitate their mental health recovery as soon as possible.

Guided Internet-based Cognitive Behavioral Therapy

Guided Internet-based cognitive behavioral therapy (iCBT) has been developed in Western societies so that cognitive behavioral therapy (CBT) can be delivered through the Internet (Andersson, Carlbring, Titov, & Lindefors, 2019). The iCBT is found to overcome the barriers of traditional face-to-face psychological treatments and has the following advantages: accessible at anytime anywhere, anonymous, self-directed, flexible, and low service fee (Andersson, 2015; Ebert et al., 2015; Webb, Rosso, & Rauch, 2017).

From the perspective of CBT, negative beliefs and automatic thoughts experienced by people with depression are related to their depressive mood (Beck, 2011). Thus, iCBT aims to help people with depression challenge these negative beliefs and automatic thoughts and to replace them with more rational and positive beliefs by using various skills developed by CBT, including guided discovery, thoughts records, cognitive restructuring, relaxation, stress management, and behavior re-scheduling (Beck, 2011). In general, guided iCBT is short-term, structured, and provides online modules for participants to read and learn via the Internet and/or mobile phone app to learn a variety of CBT skills to manage their depressive mood. Additionally, guided iCBT offers counselor support and guidance through asynchronous emails, synchronous online chats, or telephone calls to support counselor as they help people go through the modules and apply the skills that they learn in the modules (Andersson, 2015; Freire et al., 2015; Gratzer & Khalid-Khan, 2016).

Reviews of research evidence have consistently shown that guided iCBT is effective in treating depression with a moderate effect size (Karyotaki et al., 2021). Those with mild to moderate depression, but not those with severe depression and/or suicidal risk, benefit most from guided iCBT (Andersson, 2015; Gratzer & Khalid-Khan, 2016; Johansson & Andersson, 2012). Also, some research studies have suggested that guided iCBT is as effective as traditional face-to-face CBT for treating depression (Carlbring, Andersson, Cuijpers, Riper, & Hedman-Lagerlöf, 2018), but at a lower cost (Andersson, 2015; Gratzer & Khalid-Khan, 2016).

Moreover, guided iCBT is found to be more effective than unguided iCBT, which offers self-helped online modules only, without any staff support (Andersson, Carlbring, Ljótsson, & Hedman, 2013; Gratzer & Khalid-Khan, 2016; Johansson & Andersson, 2012; Newman, Szkodny, Llera, & Przeworski, 2011; Webb et al., 2017). Thus, the counselor support in guided iCBT plays an important role and contributes to better treatment outcomes (Almlöv et al., 2011; Andersson, Cuijpers, Carlbring, Riper, & Hedman, 2014; Johansson & Andersson, 2012). Moreover, differences in the qualifications and experience of counselors in guided iCBT have been found to have minimal effects on treatment outcomes (Păsărelu, Andersson, Nordgren, & Dobrean, 2017; Johansson & Andersson, 2012). This research evidence indicates that a social worker who is experienced in mental health counseling and has completed CBT training is capable of providing appropriate guidance and support to clients through the Internet with positive treatment outcomes in guided iCBT.

The quality of counselor support is important in guided iCBT (Svartvatten, Segerlund, Dennhag, Andersson, & Carlbring, 2015). A therapeutic relationship between counselor and client is related to positive treatment outcomes in guided iCBT (Bergman Nordgren, Carlbring, Linna, & Andersson, 2013). A therapeutic relationship can be established via communication and interaction between counselors and clients through the Internet (Jasper et al., 2014). The therapeutic relationship in guided iCBT could be as good as the therapeutic relationship in traditional face-to-face CBT (Preschl, Maerckere, & Wanger, 2011).

Additionally, research studies have shown that certain specific counselor behaviors produced positive treatment outcomes in guided iCBT. Paxling et al. (2013) identified eight common distinguishable counselor behaviors in guided iCBT based on the content analysis of 490 emails sent from three counselors to 44 clients. Results showed that task reinforcement was positively related to treatment outcome, while task reinforcement, task prompting, self-efficacy, and empathy were associated with module completion. Similarly, Holländare et al. (2016) identified eight common counselor behaviors in guided iCBT based on the content analysis of 664 emails sent from five counselors to 42 clients. Results revealed that encouraging, affirming, and self-disclosure were positively related to treatment outcomes, while guiding, urging, informing module content, emphasizing users’ responsibilities, and confrontation were associated with module completion.

In addition, Svartvatten et al. (2015) performed content analysis on 3756 units of messages emailed to 29 clients from therapists of guided iCBT and reported that rather than focusing on reducing psychiatric symptoms, observing positive consequences and alliances between counselors and clients were related to positive treatment outcomes of guided iCBT. Similarly, Soucy et al. (2019) performed content analysis of 2785 units of messages emailed to 80 clients from therapists of guided iCBT and reported that observing positive consequences and reduced maladaptive repetitive thinking were related to better treatment outcomes. Additionally, trying out alternative behaviors and identifying patterns and problem behaviors were related to better treatment adherence.

However, counselor support provided via asynchronous emails is very different from counselor support provided via telephone counseling. Therefore, the research findings of the above four studies on the content analysis of emails between clients and counselors cannot be generalized to those guided iCBT with telephone counseling. To our knowledge, little is known from the perspective of service users on the quality, professional competence, and benefits of receiving counselor support via telephone counseling in guided iCBT.

In view of this research gap, the present study adopted a qualitative study method to investigate, from the perspective of service users, the feasibility, quality, and benefits of receiving counselor support via telephone in guided iCBT for people with depression in a Chinese society.

Guided iCBT in Chinese society—A Telephone-Supported iCBT

A new indigenized form of guided iCBT for people with depression has been developed in Hong Kong since January 2019 (please see https://icbthk.com). This indigenized guided iCBT, named telephone-supported iCBT, targets adults with mild to moderate depression in Hong Kong, providing eight self-learned online modules and weekly telephone support from a social worker. The self-learned online modules allow participants to read and learn via the Internet and/or a mobile phone app a variety of CBT skills to handle their depressive symptoms. Each online module and related assignments were completed weekly over an 8-week treatment period. The self-learned online modules covered the following themes: psychoeducation about depression, normalizing the experiences of emotional distress, and breathing exercises (session 1); introducing the ABC model, identifying cognitive distortions, and teaching relaxation skills, including abdominal breathing, imagery relaxation, and listening to relaxing music (session 2–3); learning cognitive restructuring techniques (session 4–6); promoting a healthy lifestyle by re-scheduling daily activity (session 7); and preventing relapse, based on the vulnerability-stress model (session 8). Additionally, this telephone-supported iCBT offers guidance and support from a social worker with more than 5 years of working experience in mental health counseling and completed training on CBT. The course includes a telephone contact at the pre-treatment period for initial assessment, regular support via asynchronous voice/text WhatsApp messages, and telephone counseling of about 30–45 min per week over an 8-week treatment period.

It has been suggested that culturally adapted psychological interventions produce better treatment effects than non-adapted psychological interventions for people with depression (Chowdhary et al., 2014; Hall, Ibaraki, Huang, Marti, & Stice, 2016), and culturally adapted CBT produces a better treatment effect than non-adapted CBT for people with depression (Ng & Wong, 2018). Therefore, this telephone-supported iCBT was adapted to make it more acceptable to Chinese people with depression. First, concerning the language of the intervention, the technical terms of CBT in English were expressed in more culturally appropriate words in Chinese to improve its cultural relevance and acceptability. For example, “cognitive distortion” was replaced by “mistakes in analyzing methods.” Second, with regard to treatment methods, especially cognitive restructuring, “face concern” (Mianzi in Chinese) is an important issue among local Chinese people (Mak, Chen, Lam, & Yiu, 2009), and “loss of face” leads to psychological distress when their ideas or experiences are being challenged or ignored by others (Mak et al., 2009). Therefore, rather than challenging participants’ thoughts directly, the social worker emphasized a non-directive approach and used guided discovery to facilitate participants to progressively transform their negative thoughts. Third, it is very common for Chinese people with depression to be afraid of being as labeled “mentally ill” (Chien, Yeung, & Chan, 2014; Chung, Tse, Lee, Wong, & Chan, 2019). Hence, guided iCBT allowed participants to use the online modules anonymously and receive non-face-to-face telephone counseling to protect their privacy and help them avoid social stigma (Young & Ng, 2016). Fourth, the well-structured learning modules and homework assignments are preferred by many Chinese people, as Chinese cultural values emphasize controlling emotional expression, focusing on practical solutions, and placing a high value on education and learning (Guo & Hanley, 2015).

Method

Research Design

A large-scale program evaluation study, which is based on a randomized controlled trial design, is still in progress on the effectiveness of the telephone-supported iCBT for people with depression in Hong Kong. Research subjects have been openly recruited in collaboration with local community mental health centers. Each community mental health center serves more than 1,000 Chinese people with mental illnesses in a particular region in Hong Kong. The present study was part of a program evaluation study that aimed to investigate the feasibility, quality, and benefits of the telephone-supported iCBT from the perspective of service users by using interpretive qualitative research (Fossey, Harvey, McDermott, & Davidson, 2002). The following research questions (RQs) framed the present study:

• RQ1: Was the telephone-supported iCBT acceptable to service users? And why?

• RQ2: What kind of professional competencies were demonstrated by social workers through telephone counseling?

• RQ3: What kind of supportive behaviors were provided in the telephone-supported iCBT by social workers?

• RQ4: What were the treatment outcomes of the telephone-supported iCBT?

Subject Inclusion Criteria

A purposive sampling method was adopted for this study (Baxter & Jack, 2008). The first cohort of participants of the large-scale evaluation study of the telephone-supported iCBT were the target subjects of the current study. The inclusion criteria were as follows: (1) age above 18 years old; (2) had received a diagnosis of depression from their medical officers according to the Diagnostic and Statistical Manual of Mental Disorder (fifth edition) (American Psychiatric Association, 2013); (3) manifested mild to moderate clinical depression before joining the telephone-supported iCBT as assessed by a research assistant using a standardized assessment tool, that is, the Chinese Beck Depression Inventory (BDI) (i.e., a BDI score ranging between 14 and 30) (Byrne, Stewart, & Lee, 2004); (4) Completed the telephone-supported iCBT course, including the eight self-learned online modules and weekly telephone support; (5) willing and able to share their feedback about the telephone-supported iCBT course through face-to-face interviews; (5) receiving service(s) from a collaborating community mental health center; and (6) giving consent to participate in this research.

Data Collection

An in-depth, semi-structured, one-on-one interview was used to collect data from the participants. In-depth interviews are a common data collection method in qualitative research. They are intensive interviews conducted to obtain in-depth understanding, explore ideas, and/or clarify meanings with participants, generally through open-ended questions (Berg & Lune, 2017). In this study, interviews were conducted with each participant just after completion of the telephone-supported iCBT between December 2019 and March 2020. At the beginning of the interview session, the researcher explained the purpose of the study collected signed informed consent forms from the participants. Interviews were audiotaped using a mobile phone application for transcription and data analysis. The duration of each interview ranged from 45 to 90 min, with an average of 60 min.

Participants were asked a series of interview questions that followed an interview protocol. The interview protocol was newly designed for this study and reviewed through the interview protocol refinement framework (Castillo-Montoya, 2016) prior to the interviews. It comprised a four-phase process of alignment between interview questions and research questions, construction of inquiry-based conversation, feedback on interview protocol and piloting the interview. A pilot interview was conducted with one participant to test the length of the interview and the sequence of the interview questions. Some interview questions were revised to improve their coherence and fluency. In general, the major interview questions were conducted using the following strategies. For instance, The participants were asked to share their experiences of interactions with the counselor “What do you think the counselor helps you to do in this program?” followed by another question, “What do you think would happen if you did not have a counselor to support you in this program?” which assesses the value of involving counselor support in the program. Furthermore, other questions were raised to guide respondents to discuss having support via telephone or without telephone, perceived changes before and after finishing the telephone-supported iCBT, and the advantages and disadvantages of telephone-supported iCBT. All interviews, including the pilot interviews, were audiotaped and transcribed to text. Each participant received a shopping voucher of HK$100 as a token of appreciation after completing the interview.

Data Analysis

Qualitative content analysis refers to the subjective interpretation of the content of text data by systematically coding and identifying themes or patterns (Hsieh & Shannon, 2005). The constant comparative approach was adopted for the coding process (Lindlof & Taylor, 2011). This method refers to the newly identified code being constantly compared with the previously identified codes to decide whether to retain the new code or revise the existing codes (Corbin & Strauss, 2007). Data analysis in this study referred to the following steps: First, the researcher conducted open coding based on the text contents from the collected cases. All ideas related to the research questions were coded through sorting, tagging, and creating categories for the data. Second, the researcher conducted axial coding to refine the codes by grouping and relating the codes to each other. Finally, all categories were integrated and refined to develop themes (Corbin & Strauss, 2007)

Fidelity

A registered social worker in Hong Kong, who had over 3 years working experience in mental health services and had completed training on CBT, was employed to provide telephone counseling in the telephone-supported iCBT. A research assistant with a master’s degree in counseling was responsible for conducting in-depth individual interviews with each participant and performing verbatim transcription. Another research assistant, who is currently a PhD student in social work, was responsible for the data analysis. A principal investigator reviewed the coding tables and identified themes. The verbatim quotes from participants were translated from Chinese into English and reviewed by a professional translator with a PhD degree in English literature. Participants’ privacy was protected, and personal data were removed before data analysis. Neither research assistant knew the participants before they were involved in the study.

Ethical Considerations

The ethical aspects of this study were evaluated and approved by the Research Ethics Committee of Hong Kong Baptist University. Written informed consent was obtained from each participant before conducting the interviews.

Results

Characteristics of Research Subjects

Ten subjects participated in this study. They had all received a diagnosis of depression from their case medical officers and were receiving service(s) from a local community mental health center. The majority of participants were female (90%, n = 9), with only one male participant (10%, n = 1). Participants’ ages ranged from 18 to 67 years, an average age of 38.8 years old. Participants’ educational backgrounds were diverse. One participant had primary school education, five participants had a middle school education, two participants had an undergraduate degree, and two participants had a postgraduate degree. Regarding marital status, five participants were married, three participants were single, one participant widowed, and one participant was unreported. In terms of occupational status, three participants were full-time employees, two participants were part-time employees, three participants were housewives, one was retired, and one participant was unreported.

Results of Qualitative Analysis

The responses from the participants in the interviews, marked as cases 01–10, are shown throughout this section as exemplars to elaborate the participants’ views. SW represents the counselor. Because the original expressions from the participants were in Cantonese and some of the statements from people with depression were not coherent enough, the verbatim was translated and restructured by the authors in line with the original meanings.

Acceptability of telephone-supported iCBT

To address the first research question, the participants were asked to provide feedback on telephone-supported iCBT. All participants accepted the counselor’s support via telephone. Some typical advantages of telephone-supported iCBT were identified, including convenience, efficiency, anonymity, privacy, and synchronous and asynchronous support.

Convenience and efficiency

In the telephone-supported iCBT, participants could attend the online learning modules anytime and anywhere by using portable devices such as mobile phones, laptops, and tablets as long as the Internet was available. The counselor support via telephone enabled the participants to connect with the counselor more easily by using a mobile phone. Since no face-to-face counseling sessions were involved, the cost of travel and meeting premises was reduced. It was time-saving and cost-effective. Interestingly, participants preferred to use the mobile phone to directly talk to the counselor because they believed this communication method was the fastest and most convenient.

I prefer to use the mobile phone to talk with a counselor because it is not necessary to be baked by the sun or walk a long distance for a meeting. Moreover, using a mobile phone is quite convenient because you can do it as soon as you unlock the phone. (Case 06)

In fact, I can do homework at any time, except when I am on duty. Sometimes, I do it at home when my family members go to sleep. But more often, I do it at the office when I am off duty. (Case 07)

If people cannot make an appointment over the phone, it is even more difficult for them to make the appointment face-to-face. In fact, telephone (counseling) is not very different from face-to-face counseling. If you are busy and want to be more efficient, I believe using a telephone (counseling) is much better. (Case 10)

Anonymity and privacy

Most participants appreciated the approach to telephone counseling. Participants reported that remote and non–face-to-face settings gave them a sense of comfort. Some participants preferred telephone counseling to traditional face-to-face counseling because they felt more comfortable sharing their feelings/views anonymously, without seeing the counselor in person. They felt relaxed, safe, avoided embarrassment, and found it easy to talk because they did not need to meet the counselor in person and worry about their facial expressions or appearance if they were talking or crying.

I think using the phone would be a better option for me because I do not need to directly meet a SW I am not familiar with so that I feel more comfortable. (Case 02)

It is pretty good. I do not feel any stress because I can talk with SW. Since we do not see each other, I feel relaxed…I think it’s a relaxed approach. Sometimes, I feel so embarrassed when I talk and cry in front of a person. If we can talk with each other over the phone, the counselor will not see me yelling or even crying. (Case 03)

I prefer to use a mobile phone and talk over the phone. It is casual and I can avoid the embarrassment that I might have during the face-to-face talk. (Case 09)

Synchronous support

Without meeting in person, the counselor and participants could have conversations through telephone calls so that the counselor could provide instant support for participants’ inquiries. More importantly, weekly counseling sessions were also conducted over the phone. Based on the direct phone calls, CBT was a kind of conversational therapy that could be implemented. CBT techniques and skills could be discussed and practiced as well, in particular, guided discovery, imagery relation, and role-playing.

Therefore, it is necessary to discuss the content of cognitive restructuring. In particular, if you want to deepen the application of cognitive restructuring in daily life, you have to talk and practice it as much as possible. (Case 10)

Asynchronous support

In addition to regular follow-up sessions by telephone, participants can contact the counselor during the day by using a direct phone call or text and/or voice messages on social media. Although no strict service agreement of the response time was in place, the counselor provided almost instant feedback, which was highly appreciated by the participants.

The SW was so nice and replied to my inquiries more promptly than I expected. For example, I sometimes sent her messages through WhatsApp, and she was able to reply to me immediately, even at midnight. (Case 01)

Professional competencies in telephone counseling

To address the second research question, participants were asked to share their impressions of the counselor during telephone counseling. All participants shared their satisfaction with the services they received and mentioned professional competencies demonstrated by the counselor, including having a nice tone of voice, patience, empathetic understanding, skills, and sincerity.

Nice tone of voice

Since the support was provided over the phone, the tone of voice played an important role in the impressions between both sides of the communication. More importantly, it was also a key factor in building the client-counselor relationship.

The SW’s voice was so gentle and made me feel comfortable. I really liked the words ‘Come on,’ she used in the course. (Case 03)

Her voice tone was nice and tender. I learned about the talking style from her. (Case 05)

Patience

Since the counselor provided individual support, there were many similar or same questions raised by the participants. However, the counselor could maintain a good service attitude to help participants address their questions and show a good understanding of their situation.

The SW was so patient. When I told her that I did not understand, she guided me step by step. She also comforted me and always said, “It does not matter.” She even sought help from other parties to make the content easier for me. (Case 02)

Sincerity

Participants emphasized the importance of sincerity in their minds, even during telephone counseling.

The SW was like my teacher, as well as a friend of mine. From my perspective, everyone should be sincere to get along with each other when they join this program. (Case 01)

Empathetic understanding

Empathetic understanding is an important factor in building a good client-counselor relationship in counseling. The participants appreciated that their feelings were understood by the counselor.

Sometimes, I can talk to the SW when I have difficulties coping with my emotions. She could listen to me, encourage me, and support me. I knew that she understood my feelings. (Case 03)

Skills

Participants recognized the counselor’s skills shown in the telephone counseling.

The SW was so nice and skillful. She was good at motivating the people. (Case 01)

Sometimes, our topic at the beginning could be not about CBT, but eventually, it was connected to CBT. I enjoyed this freestyle conversation, similar to a chit-chat. (Case 10)

Helpful behaviors shown by the counselor

To address the third research question, a total of six aspects of counselor support were identified: 1) delivering CBT; 2) handling personal issues outside the scope of iCBT; 3) offering encouragement; 4) guiding the learning process; 5) monitoring completion progress; and 6) solving technical issues.

Delivering CBT

During the weekly telephone follow-up sessions, the counselor helped participants learn and apply the skills of CBT to regulate emotions, practice cognitive restructuring, and review homework assignments according to the CBT approach.

The SW taught me cognitive behavioral therapy, as well as emotion regulation skills, and helped me link CBT with my daily life. (Case 10)

Handing personal issues outside the scope of iCBT

In addition to the services originally designed in the program, the counselor also supported participants in dealing with other mental health issues that were not directly related to the current depressive symptoms. For instance, conflicts with family members, unfinished businesses from early life, and self-exploration participants raised their expectations of this support even though they knew that these matters might be out of the program’s scope.

Sometimes, I have some difficulties. I told the SW that I could handle some of the difficulties, such as the changes in my own mood, but I could not deal with my relationship with my mother. She told me that it was a transitional period, and she encouraged me to keep it that way… Apart from those issues/mental illnesses covered in the course, The SW has also helped me discover other contradictions that existed in my mind, but that I was not fully aware of. This helped me understand myself better. (Case 03)

I appreciated the SW’s support. She was an experienced social worker. My main concerns were not only about the things covered in the course but also included inner problems, such as my emotions, depression, and knowing myself. I have even consulted her about my unfinished business and also had an in-depth discussion with her… I really appreciated the humanized arrangement which provided you with the opportunities to talk to a social worker about any problem you encountered. If any serious problem was found, we could address it in advance before discussing the topics covered in the course. (Case 04)

I wanted to make some changes to myself so that I could know more about my own feelings and better understand other people’s feelings. The SW taught me methods beyond the scope of online CBT and guided me to practice them. (Case 10)

Offering encouragement

The counselor provided encouragement, compliments, and praise to motivate participants, and improve the frequency of positive behaviors by the participants, such as learning a new online module of the iCBT, moving forward in the self-learned online modules, and maintaining a positive mood.

I always worried about whether my answer was correct or not, or whether I did anything wrong. I once told the SW that I could not understand the questions, and I wanted to quit. She said that I had done nothing wrong and encouraged me to continue learning. Finally, I felt more comfortable and laid aside all my concerns. (Case 02)

Actually, the SW supported me all the way. I heard her positive and encouraging words quite often, such as ‘come on’ and ‘I support you’. I felt warm and strongly motivated by these words. (Case 03)

This could be a great motivation when someone accompanied you for eight weeks. By contrast, if you only do it alone, you may feel tired and delay progress. Finally, you may give up because people are generally lazy. (Case 06)

Guiding the learning process

The role of the counselor in the telephone-supported iCBT was predesigned as a facilitator rather than a leader. Therefore, the counselor did not dominate the learning process, but guided the participants to take ownership of the process. The participants appreciated this kind of guidance. They felt respected and did not form a dependency.

The SW guided me in the discussion. In the beginning, she picked up 1-2 examples from my assignments. Later, she asked me to choose the case for discussion by myself. (Case 05)

Monitoring progress to completion

One of the significant responsibilities of the counselor is to monitor the participants’ progress toward completing the program and ensuring that all participants complete the online self-learning modules on time. This activity helped participants overcome the difficulties they faced during the program and motivated them during the learning journey.

The SW pushed me regularly and encouraged me to keep moving so that I could finish the online modules one by one. Eventually, I completed the entire online modules on time. (Case 03)

Yes, the SW urged me regularly. This made me pay more attention to my own progress. (Case 08)

Without the SW’s calls, I could not have completed the course quickly. I would have been much slower. (Case 09)

Solving technical difficulties

One frequently asked question in the telephone-supported iCBT was about technical issues regarding system functionality, such as user login/logout, record submission and amendments, unlocking new courses, and other related matters. When participants faced these issues, they also sought help from the counselor. The counselor helped solve these technical matters based on her best knowledge and/or referred the matter to the technical support engineer in a timely manner.

There were technical problems. For example, whenever I couldn’t log in or out of the system, I contacted the SW. Then, she could identify that there was something wrong with my processing steps. So, I reported to her immediately when I encountered any problem, and she could help me take a look at the problem and solve it. (Case 01)

Yes, I could follow the course progress because the SW patiently taught me how to click the buttons in the system. For example, there are different mobile phone platforms, called Android and IOS. I could ask my son to teach me or ask the SW to help me as well. (Case 07)

Outcomes of the Telephone-Supported iCBT

To address the fourth research question, participants were asked to share their perceived outcomes or changes after completing the telephone-supported iCBT. There were three commonly reported therapeutic outcomes for users: cognitive restructuring, emotion regulation, and the improvement of self-awareness.

Cognitive restructuring

Cognitive restructuring is the core content of the telephone-supported iCBT. All participants mentioned that they had experienced cognitive restructuring, even though the degree of understanding and level of cognitive restructuring were diverse among different individuals.

My cognition has improved significantly. I think the negative feeling was actually a punishment for me. I was treating myself terribly, but people should learn how to treat themselves better. If you maintain a negative attitude, you will end up hurting yourself. (Case 01)

My main emotional problem was with my Mum. Previously, I thought bearing the burden of her was my responsibility because I am her daughter. After joining this program, I changed my mindset and learned that everyone should be responsible for their own lives. Now, I feel much more relaxed. (Case 03)

When I know what negative thoughts I have, I will try to restructure my thoughts. After that, I will naturally become easier and relaxed. I will not feel as upset as in the past. (Case 05)

After taking part in this program, I learned about cognitive restructuring. It is unnecessary to always think of the worst or negative things. (Case 06)

Some people (e.g., critics of politics or Youtubers) often mention that we must do this or we must do that. They have many extreme ideas. Now, I have learned how to prevent myself from thinking about these extreme ideas and not to easily believe in what people say in general. (Case 08)

The most important thing was to teach me how to restructure my cognition. In fact, it was not a good practice to judge everything without clear and sufficient evidence. This was the way to a dead end. (Case 07)

Emotion regulation

Many participants shared that their emotions became more stable and calmer than before. Although a few emotional disturbances occurred, they could adjust their emotions better independently.

The most helpful learning accomplishment was the relaxation through breathing. Now, when I feel that I am going to lose control of my emotions, I can conduct a breathing exercise in the washroom. Therefore, I think my stress has been greatly reduced. (Case 03)

The biggest learning accomplishment was learning the breathing exercises. Usually, I listened to the audio file twice a day (in the morning and evening), and did the breathing exercise following the voice recording. I felt calm and no longer anxious. (Case 06)

Yes, my emotional pressure has been released. If there are any problems in the future, I can seek help from other people. (Case 07)

I feel better now. For example, when I encountered an emotional problem, I had to spend quite a long time getting through the matter, but the time I spent recently was much shorter than the time I spent previously. (Case 02)

Improvement in self-awareness

Another typical perceived outcome mentioned by the participants was improved self-awareness. The participants appreciated that the iCBT provided systematic guidance to understand mental illnesses and themselves. The ultimate goal was to improve people’s self-awareness, which helped them deal with mental illnesses.

I gained a more systematic and clear understanding of my disease. I also understood some of my shortcomings and weaknesses. The whole process, which included self-understanding, cognitive restructuring, setting a target, and imaging the future after recovery, was similar to a guideline to help people keep improving. (Case 04)

Discussion and Implications for Practice

This qualitative study adds to the findings of empirical research on guided iCBT by investigating, from the user’s perspective, the feasibility, quality, and benefits of receiving counseling’ support via telephone in guided iCBT. The results support that telephone-supported iCBT is a feasible, effective, and preferable treatment approach for Chinese people with depression in Hong Kong. Specifically, convenience, efficiency, anonymity, privacy, and synchronous and asynchronous support are advantages of telephone-supported iCBT identified by service users. Additionally, the counselors demonstrated professional competencies via telephone counseling. From the user’s perspective, six aspects of counselor behavior were supportive, including delivering CBT, handling personal issues, offering encouragement, guiding the learning process, monitoring completion progress, and solving technical issues. Moreover, telephone-supported iCBT produced positive outcomes, including cognitive restructuring, emotion regulation, and improvement of self-awareness.

The above research findings are especially relevant to the mental health services in Chinese society, including Hong Kong, because, to our knowledge, this is the first study to investigate, from the user’s perspective, the feasibility, quality, and benefits of the telephone-supported iCBT for people with depression in Chinese society. Therefore, these findings deserve further discussion.

First, the advantages of the telephone-supported iCBT distinguished the telephone-supported iCBT from other CBT programs, such as traditional face-to-face CBT (Beck, 2011), unguided iCBT (Beevers et al., 2017; Cuijpers et al., 2011), and iCBT with therapist-delivered asynchronous email (Richard, Timulak, & Hevey, 2012). Telephone-supported iCBT has the following advantages over traditional face-to-face CBT: convenience, efficiency, privacy protection, and avoidance of embarrassment and social stigma. The online self-learning modules of the telephone-supported iCBT offered flexible learning opportunities for the participants on the techniques and skills of CBT. The program was available on an online platform accessible at anytime, anywhere, and anonymously, which are the typical advantages of iCBT over traditional face-to-face CBT (Ebert et al., 2015; Webb et al., 2017). Additionally, the telephone sessions allowed the counselor to carry out the counseling over the phone, which is more convenient and cost-effective than conducting face-to-face counseling in traditional counseling centers (Andersson, 2015; Andrews et al., 2018; Freire et al., 2015; Gratzer & Khalid-Khan, 2016; Kraepelien et al., 2018). Telephone-supported iCBT sessions solved problems of time and place and saved transportation and waiting time. This made them more convenient and efficient than face-to-face counseling sessions conducted in the traditional counseling centers, which suits the needs of busy urban life in Hong Kong and other Chinese communities. Moreover, because mental illness is stigmatized in traditional Chinese culture, people with depression are afraid of being labeled “mentally ill,” and experience “shame,” “being a family burden,” and “devaluation” (Young & Ng, 2016). Thus, “face concern” (mianzi) is an important issue among local Chinese people seeking counseling, and “loss of face” leads to additional psychological distress for them (Mak et al., 2009). This telephone-supported iCBT allowed participants to complete online modules and receive telephone counseling anonymously and privately, without meeting with the counselor in person. Accordingly, participants found it easier to express their emotions and feelings and avoid any embarrassment from face-to-face counseling. Furthermore, since telephone counseling has been developed for decades (Irvine et al., 2020), people are confident that it will protect their privacy and confidentiality. This aligns with Chinese societies and cultural values, which emphasize avoiding social stigmatization for seeking mental health services (Lam et al., 2015).

Compared with unguided iCBT (Beevers et al., 2017; Freire et al., 2015) and iCBT with asynchronous email support (Richard et al., 2012), this telephone-supported iCBT offered synchronous telephone counseling so that participants had more direct and interactive communication with the counselor. This kind of synchronous support and interactions with the counselor were appreciated by participants, which in turn facilitated the establishment of a therapeutic alliance between participants and the counselor (Jasper et al., 2014; Irvine et al., 2020; Preschl et al., 2011). Moreover, it allowed the counselor to provide asynchronous support to the participants through WhatsApp text/voice messages on mobile phones. Reminders, information, and encouragement delivered through mobile phones met the service needs of participants between telephone counseling sessions. Thus, this telephone-supported iCBT offered better support than the unguided iCBT (Beevers et al., 2017; Freire et al., 2015) and iCBT with asynchronous email support (Richard et al., 2012) by providing both synchronous and asynchronous support.

Second, the quality and professional competency of counselors delivering guided iCBT has been a primary concern (Paxling et al., 2013), and researchers wondered whether counseling competency could be demonstrated well, and would benefit participants over telephone counseling (Irvine et al., 2020). There were some essential skills needed for telephone counseling, including active listening, skilled questioning, appropriate empathetic reflections, summarizing, and ending (Rosenfield, 2013). In the present study, professional competencies in counseling included a nice tone of voice, patience, sincerity, empathetic understanding, and skills recognized and appreciated by users. The empathy was in line with previous studies. Other identified professional competencies that were inconsistent might have been caused by perspective of the participants. From the participants’ viewpoint, without visual clues and cues, their direct impression was created by the counselor’s tone of voice. By hearing the words spoken, the participants might have formed certain judgments in their first impressions of the counselor. Besides the dialog content, the essential aspects conveyed by the tone of voice are attitudes, such as patience and sincerity. In general, the counselor in the telephone-supported iCBT demonstrated professional competencies in counseling over the phone that participants recognized and appreciated. This finding is supported by previous studies, which indicated that CBT conducted by telephone produced effects comparable to face-to-face CBT (Andersson et al., 2014; Andrews et al., 2018; Carlbring et al., 2018; Freire et al., 2015; Hammond et al., 2012). Additionally, a recent systematic review revealed that counseling conducted over the phone and face-to-face were comparable in terms of therapeutic alliance, disclosure, empathy, attentiveness, and participation (Irvine et al., 2020).

Third, six aspects of counselors’ supportive behavior were identified by participants. Among them, offering encouragement, guiding the learning process, and monitoring completion progress were in line with the findings of previous studies (Holländare et al., 2016; Paxling et al., 2013). In particular, encouraging, guiding, conveying module content, and urging were identified by Holländare et al. (2016), while task reinforcement and task prompting were identified by Paxling et al. (2013) as counselors’ supportive behavior. Interestingly, two unique counselor behaviors, namely, handling personal issues outside the scope of iCBT and solving technical difficulties were identified as counselors’ supportive behavior in the present study. While handling personal issues outside the scope of iCBT and solving technical difficulties were reported in a previous study to be the main concerns among users of guided iCBT (Soucy et al., 2019), and technical difficulties in using iCBT were reported to be related to negative effects and drop out of iCBT (Gullickson, Hadjistavropoulos, Dear, & Titov, 2019Gullickson et al., 2019). This study adds that handling personal issues outside the scope of iCBT and solving technical difficulties are counted as counselors’ supportive behaviors. As depression is triggered by multiple factors, people with depression suffer from different kinds of stress and problems, and all these stresses and problems, from the users’ perspective and experience, could not be properly handled by CBT only. Technical difficulties in using iCBT are common among participants because of the diverse functionalities of online platforms and mobile phones as well as unfamiliarity with navigating the online platform (Soucy et al., 2019). As shown in this study, the counselors’ timely support and guidance in these two areas were appreciated by the participants.

Fourth, concerning perceived treatment outcomes, the most reported outcomes from the participants were improved abilities in cognitive restructuring, emotion regulation, and self-awareness. In this study, most participants reported the techniques and skills of CBT that they learned, instead of the reduction of depressive symptoms. In particular, improved abilities in cognitive restructuring is very similar to the reduced maladaptive repetitive thinking reported by Soucy et al. (2019), while the improved abilities in emotion regulation is similar to the observing positive consequences reported by Soucy et al. (2019) and Svartvatten et al. (2015) as the positive treatment outcomes of guided iCBT. This study adds that improved abilities in self-awareness is an important favorable treatment outcome of guided iCBT. Furthermore, the three positive treatment outcomes identified in this study are in line with the therapeutic goals of the telephone-supported iCBT, which aims to help participants learn the skills of CBT to manage their depressive symptoms (Andersson, 2015; Beck et al., 2011; Carlbring et al., 2018; Webb et al., 2017).

In sum, the findings of this qualitative study add to the literature on guided iCBT. In particular, the research findings of this study support the feasibility of telephone-supported iCBT for people with depression in Chinese communities by offering the advantages of convenience, efficiency, anonymity, privacy, synchronous and asynchronous support, and facilitating users to improve cognitive restructuring, emotion regulation, and self-awareness. Additionally, this study provides insights for mental health professionals on telephone-supported iCBT for people with depression. In particular, a social worker who is experienced in mental health counseling and has completed training on CBT can demonstrate professional competencies in counseling through telephone calls and provide various supportive behaviors including delivering CBT, handling personal issues outside the scope of iCBT, encouragement, guiding the learning process, monitoring progress, and solving technical matters in telephone-supported iCBT.

This study has methodological limitations. Specifically, the sample size was small and dominated by female participants. Therefore, in future studies, it would be better to conduct a large-scale survey adopting both qualitative and quantitative research methods to investigate the feasibility, quality, and treatment outcomes of telephone-supported iCBT for people with depression coming from a more diversified demographic and cultural background. Moreover, participants from different parties, such as the participants’ caregivers and counselors, should also be included so that the triangulation of qualitative study can be fulfilled to obtain more comprehensive information.

Footnotes

Acknowledgments

Special thanks are given to the non-government organizations for their kind support to this research project. The authors would like to sincerely thank the participants and staffs for their considerate cooperation

Author Contributions

YOUNG Daniel Kim-wan Author’s role: Study concept and design, negotiating with other social service organizations involved in this project, acquisition of subjects and data, analysis and interpretation of data, and preparation of manuscript.

Per CARLBRING: Study concept and interpretation of data.

NG Petrus Yat-nam: Study concept and interpretation of data.

CHEN Qi-rong: Data analysis and preparation of manuscript.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Hong Kong Baptist University [Ref. No: FRG2/17-18/022].

Ethical Approval

The ethical considerations of this study will be evaluated and approved by the Research Committee of Hong Kong Baptist University. Written informed consent will be obtained from all participants on the day of the pre-treatment assessment.

ORCID iDs

Daniel KW YOUNG

Per CARLBRING

Joseph Chen Qi-rong

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