Theme: A supportive, safe interaction

Participants frequently stated the importance of the technology coming across as friendly, compassionate and with a positive tone. Tasks that were positive in nature could boost users’ mood, and help them to feel more optimistic, hopeful and uplifted:

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“The whole site is designed to make you feel good, so the things it gets you thinking about, they’re always positive or nice (…). So every single activity is designed to

make you feel better and stronger” – P101

Although participants were often using TBIs for serious issues, it was often suggested that a sense of fun could facilitate engagement. Undertaking fun activities as part of the TBI could help to foster transferable coping skills to be used in other areas of the participant’s life. Unsurprisingly, when tasks were perceived as tedious, participants were less likely to complete them, and often suggested ways that the TBI could become less dull.

“I’d like some entertainment, you know what I mean? I’d like something to come back and say something fun, (…) maybe something to keep me interested” – P111

Crucially, it may be beneficial for TBIs to be framed positively, rather than focusing excessively on negative mental health experiences. When TBIs

demonstrated empathy and understanding towards their users, participants felt more comfortable during treatment and were more likely to engage in therapeutic tasks.

“He [clinician providing TBI’s voiceover] gave the impression that you were both working on it together (…) I felt quite positive because he’s broken everything down,

and he’s explained certain things (…), and then he’s given you a couple of minutes to just get your thoughts in order” – P103

A sense of TBIs as being potentially less judgemental than humans indicates that technology’s perceived lack of personal views and attitudes could influence user engagement. When participants felt they weren’t being judged, they were able to be more open and honest, and could tackle their issues more directly. This is

particularly interesting given the above findings which indicate the positive aspects of the technology behaving in a human-like fashion (i.e. by being friendly), as there were also benefits of the inherently impersonal behaviour of technology. By

interacting with technology rather than another person, there was a sense of added privacy.

“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

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4.4.2.2 Subtheme: Trust

It was also paramount that users could build trust with the TBI, by feeling secure whilst using TBIs and perceiving the TBI as credible. Particularly important was a feeling of privacy, for example:

“You were looking at your screen, you were going at your pace, and you had headphones on which isolated you. (…) I wouldn’t have liked it if it had been, for

instance, a group therapy thing, because I would have felt more embarrassed. I would have felt exposed.” – P105

Shame, embarrassment and stigma was often reduced, as others might be entirely unaware of the participants’ TBI use. A lack of privacy in public spaces sometimes made it difficult to engage with the TBI. However, participants often deployed creative strategies to overcome these barriers, which could be situational or by using features of the technology:

“I just put my headphones in, put sunglasses on so I could close my eyes behind those and no one would know, and listen to my TBI app” – P106

“I liked that the app has an added security feature of fingerprint recognition on use” – P113

It’s important to note the potential limitations of some of these strategies. They may be much easier to undertake if the TBI is accessed via a mobile

application owing to their small size and portability, when compared to accessing a TBI on a laptop or desktop computer. The perception of privacy risks could

contribute to a sense of technology as being less trustworthy than another person; being able to mitigate against these increased risks was a suggestion for developing trust:

“I think a website lacks the personal touch which makes you be able to build up trust. One way maybe would use password-protected documents to make you feel

your information was secure.” – P107

Developing trust with the TBI also involved users’ perception of the TBI’s credibility as a viable treatment option. There were multiple ways that credibility

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was perceived; this could be achieved by the TBI itself (for example, by consistency in the materials), or owing to a credible referral source:

“I heard about it through [mental health charity] which is like the number one support group (…) it made me feel more confident that I can trust it.” – P104

Perceptions of a low credibility presented a major barrier to engagement with the TBI. If it appeared that the input of appropriate experts had not been considered during development, perceptions of the quality and usefulness of the TBI suffered.

“I don’t know whether it’s educationists that have actually built the program, but it should be. (…) and also people who are good at technology. (…) You’d have a better

quality product, you’d be looking more at innovative ways of education, getting people to see things, other than the very flat way of interacting.” – P102