Analysis

The qualitative interview data was anonymised and transcribed (in the case of telephone or face-to-face interviews) by LH. A thematic analysis approach was used to analyse the interview data, following the recommended steps of Braun and Clarke (2006) Appendix I contains a table which details these steps. Thematic analysis is not at odds with the critical realist position of the study, which states that an external reality exists, but our ability to know it accurately is limited by the human senses and the inherent interpretive nature of investigation (Maxwell, 2012; Pernecky, 2016). Although thematic analysis is epistemologically flexible (Braun & Clarke, 2006),

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thematic analysis was felt to suit critical realism since critical realism aims to identify “generative mechanisms” (Bhaskar, 1989) which are theoretical

explanations for observed events. As this study aims to identify what can promote engagement or a sense of alliance with a TBI, using thematic analysis to identify common themes across participants’ accounts was felt to be useful.

All transcripts were first read through several times to familiarise LH with the data. A list of initial codes was generated, which were systematically identified across the dataset. These codes were used to label any salient aspect of the

participants’ account, to address the research aims of exploring users’ TBI

experiences and to identify aspects of that experience (for example, technological features, or the situational context) that influenced their interactions with the program..

There were roles for both inductive and deductive logic in the analysis

strategy. With regard to deduction, some codes were informed by existing theoretical constructs (such as therapeutic alliance dimensions; e.g. “goal setting”), and thus resembles “testing” an existing theory as per a deductive approach (Bryman, 2008). This choice was made because previously-outlined theories can provide a useful structure with which to explore unknown areas (Silverman, 2015). There was also a role for the inductive logic typically associated with qualitative research, in which a researcher starts with data collection, and then seeks patterns in data with which to build theory (Bryman, 2008). In this paper, this was used to code interesting aspects of participants’ experiences which did not map onto therapeutic alliance elements. A thematic analysis rather than a framework analysis approach was used in this paper since the alliance in TBIs is such a new field, and an approach which allowed more for identifying codes outside an existing theoretical structure was felt to be valuable.

These codes were then sorted into overarching "themes", to begin a broader level of analysis. This was done by arranging the codes into conceptually similar groups, which were examined for the extent to which they addressed the research aims (i.e. identifying common threads across users’ experiences, identifying features of TBIs which promote interaction or engagement, and the relation of these code groupings to therapeutic alliance dimensions). These themes were continually reviewed and refined through discussion among the research team, in order to

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identify each theme’s essential meaning. The analysis repeatedly moved backwards and forwards between the data and subsequent themes and interpretations, to ensure that the explanations remain consistent with the original data. The research team examined what each theme could tell us about users' interaction and engagement with TBIs, continually referring back to the study’s original aims and research questions. Whilst much of the theme content can be related to therapeutic alliance theory, the themes were titled according to their core content, rather that being forcibly labelled in the terms of therapeutic alliance theory. This was done in the interest of remaining faithful to the data, but the themes are later interpreted in light of therapeutic alliance theory.

This team approach also ensured that any biases in interpretation of the data due to individual preconceptions could be identified and taken into account. Table 5 gives an example of this process, by illustrating the progression of analysis on an excerpt of text. NVivo 11 Pro (QSR International Ltd, 2017) was used to assist with analysis.

There were some attempts to reduce bias (e.g. keeping an analysis diary, checking preconceptions with wider team). This project was undertaken with a critical realist position, as outlined above, which acknowledges that meaning is co- constructed in context by researchers and participants (Blaikie, 2007; Silverman, 2015). Accordingly, the element of co-construction in participants’ account is acknowledged, but there were attempts made to limit the risk of LH unduly influencing participants’ accounts.

Table 5: Example of differing levels of analysis on a transcript

Transcript excerpt Code Subtheme Theme

So the computer doesn’t know me as a person, it’s not judgemental. So that – I think that’s quite a good thing. It’s not judgemental, and I know counsellors are not judgemental but they’re still a person and they’re still human, and they’ve probably still got views, which they’re entitled to. Computers don’t have that.

Non- judgemental Friendliness and compassion A supportive, safe interaction

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4.4 Results

Table 6 contains details of the sample’s demographics and the TBIs that each participant accessed.

Participants ranged in age from 22-60 years old, with 7 women and 6 men. The most common clinical issues reported were depression, anxiety and bipolar disorder. The majority of participants (n = 9) participants accessed a TBI via official health services referral, sometimes instead of or whilst waiting for face-to-face treatment. Two participants came to use their TBIs via recommendations from support groups, and the other two found them on their own initiative.

The dataset was overwhelmingly rich in its coverage of peoples’ experiences of using TBIs, and a huge range of experiences were expressed and discussed by participants. As a result, this paper focuses on four particularly salient themes, which illustrate the most novel and unexpected findings that add to knowledge regarding engagement with TBIs. The themes and subthemes covered in this paper are outlined in Table 7. The connections between themes and subthemes are outlined in Figure 2. Where participant quotes have used the name of the TBI they have used, this has been replaced simply with “TBI”.

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Table 6: Participant demographics and TBI details

Age Gender Clinical Issue

TBI Description Location

of access Level of support* P101 45 Female General distress Website promoting wellbeing via creativity. No set number of sessions – used as often as the person likes. Home Face-to-face to access service, none after that. P102 N/K Female Bipolar disorder & anxiety

Online CBT for anxiety and depression accessed via a website, 5 modules.

Home None

P103 28 Male Bipolar

disorder & depression

Online CBT for stress, anxiety and depression accessed via a website, 8 weekly sessions.

Clinic Face-to-face

P104 37 Female Bipolar disorder & depression

Self-help website for bipolar disorder, 8 modules. Home None P105 58 Female Reactive depression, bereavement & trauma

Online CBT for stress, anxiety and depression accessed via a website, 8 weekly sessions.

Clinic Face-to-face

P106 24 Male Bipolar

disorder & anxiety

Mobile apps for meditation. No set number of sessions - used as often as the person likes.

Home None

P107 44 Female Depression Online CBT for anxiety and depression accessed via website and app, 8-10 weekly sessions.

Home Telephone

P108 49 Female Depression Online CBT anxiety and depression accessed via website and app, 8-10 weekly sessions.

Home Telephone

P109 22 Female Anxiety Online CBT anxiety and

depression accessed via website, 8-10 weekly sessions. Home Telephone P110 52 Male Bipolar disorder & OCD

App for tracking and managing mood, used as often as the person likes.

Home None

P111 N/K Male Anxiety & depression

Online CBT for anxiety and depression accessed via website, 8-10 weekly sessions.

Home Telephone

P112 60 Male Bipolar

disorder

Website for tracking and managing mood, and a website aimed at reducing bipolar relapse.

Home N/K

P113 N/K Male Anxiety Online CBT for anxiety

and depression accessed via website and app, 8-10 weekly sessions.

Home Telephone

N/K: Not known, due to researcher error or information not provided by participant

*If there was human support as part of the TBI’s delivery, this was always minimal, or provided in short sessions, in line with our inclusion criteria.

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Table 7: Overview of themes and subthemes.

Theme Subthemes

Mutual understanding Does the TBI show understanding?

Does the user understand the TBI? A supportive, safe interaction Friendliness and compassion

Trust

Interactivity User control

Personalisation

Is it a relationship? Objection to a human-technology “relationship”

A “human face” Functionality

Role of interactivity in the therapeutic relationship

Figure 2: Diagram illustrating the connections between themes and subthemes.