A qualitative study of sexual minority young people’s experiences of computerised therapy for depression

Sample and data collection

Participants in the trial of Rainbow SPARX were recruited from four high schools and a youth-led organization for sexual minority youth. The study was also advertised by the sexual minority media. All were sexual minority youth from Auckland, New Zealand.

Ethics

Approval for this study was granted by the Multi Region Ethics Committee (Ref: MEC/09/01/002). Written parental and participant consent was obtained from those aged 13 to 15 years and young people were able to consent for themselves if they were 16 or older.

Interviews

Interviews were carried out immediately after the post-intervention assessment point by MFGL. The interviews were conducted in a private room in one of three locations selected by the participant (i.e. at the University of Auckland, at the youth-led organization, or at the participant’s school). The interviews lasted from eight to 36 minutes (mean=18 min, SD=7 min). A semi-structured interview format (available from the corresponding author) was used. The initial question for each section was broad and open, but was then followed by more specific questions. For example:

A series of more precise questions was asked next:

The interviewer, MFGL, was a doctoral candidate at the time, experienced in clinical youth mental health work. All the participants had previously met MFGL during the face-to-face pre- and post-intervention assessments. The participants were aware that MFGL was a gay male and a co-developer of Rainbow SPARX. All the interviews were audio-recorded and professionally transcribed. No field notes were taken.

Data analysis

We used the general inductive approach (GIA) for data analysis. ¹² Like grounded theory and phenomenological approaches, GIA is a method of qualitative content analysis which seeks to build understandings from observations as opposed to testing pre-existing hypotheses. However, unlike some qualitative methods, GIA focuses on obtaining views and perspectives of participants based on pre-existing evaluation questions (or topics), rather on than building an in-depth description of personal experience or on generating new theory. ¹³ Our aim was to investigate common themes and points of agreement/disagreement. The transcripts were read with the research objectives in mind, but no a priori models were imposed. MFGL read and re-read the transcripts several times, and identified lower order units of meaning which were then clustered with similar units. Within each area, contradictory views and subtopics were searched for and then clusters were reviewed for redundancy and identification of the essence of each category. TMF reviewed a random sample of the data (10% ofeach interview) and independently coded these excerpts. Excerpts coded by TMF were then compared withthose coded by MFGL. This accuracy check identified only minor discrepancies in interpretation and these were resolved through discussion. Data were codedusing the themes identified and quotes capturing the themes are provided in Table 1. NVivo8 software was used to manage the data and support analyses. A preliminary summary of results was sent to participants for their feedback. Only one participant responded, but they recommended no changes be made.

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Table 1.

Feedback about Rainbow SPARX

Major theme	Associated subthemes	Descriptions and examples from data
Appealing aspects	Liked – ‘look and feel’	Most of the participants commented positively about the ‘look and feel’ of Rainbow SPARX, for example, ‘I liked, like, how it looked really shiny on my computer, and it looked like a completely different world’ – Bob (male, 13 years old, bisexual).
	Liked – certain characters	Six of the characters from Rainbow SPARX were perceived to be positive and likeable, specifically Hope, the Guide, the Mentor, Cass, Te Hokioi and the Yeti, with Hope being the most frequently mentioned: ‘I liked Hope actually, I really liked Hope. I thought it was a cool idea…I liked the fact that it [the program] realised that hope was something tangible. Even though in real life it might not be, it was cool to give it as a tangible thing and to talk about it as something that was real’ – Andy (male, 19 years old, gay)
	Liked – format	Numerous participants stated that they liked having a self-helpprogram in a game-like format, they liked the accompanying notebook, and they liked the overall flow/format: ‘I like the concept that a computer game could work towards solving those problems [depression] so it was a good way of getting you interested’ – John (male, 17 years old, gay)
	Liked – content	Most of the participants thought that Rainbow SPARX consisted of useful messages or content and they talked about this more generally (e.g. ‘I liked the tips given’ – Natasha (female, 19 years old, bisexual)), or they provided detailed examples of the content they liked or valued.
	Liked – ‘rainbow’ content	Nine participants liked the ‘rainbow’ content in the program and they perceived it to be valuable: ‘…I liked how it talked about problems that were relevant to people going with different sexualities and stuff’ – Maree (female, 15 years old, bisexual).
Applying it to real life	Completing challenges and applying skills	The vast majority of young people reported having completed at least some of the challenges (cognitive behavioural therapy homework tasks) set at the end of each level of Rainbow SPARX, for example, ‘…I think the “spot it” one most appealed to me because if you can spot what it is [recognise negative cognitions], it is a lot easier, kind of, to be happy because you know what is bothering you’ – Jack (male, 14 years old, bisexual). However, seven participants thought that the challenges were not relevant to them.
	Did it help participant feel better?	Seventeen participants stated that Rainbow SPARX helped them feel better (or less depressed). Four participants thought that it did not help them feel better, but they attributed this to the fact that they were not depressed to begin with. Two participants thought the program was ‘kind of’ helpful, with a further two stating it was not helpful, for example, ‘I wouldn’t say it made me feel better, worse on some occasions’ – Stefan (male, 17 years old, gay).
Things to improve	General improvements	Eighteen participants described various technical issues that needed to be addressed in Rainbow SPARX (e.g. numerous older participants thought that the mini-games or puzzles should be more challenging). Participants also said there should have been less talking or dialogue and more game play.
	Improve ‘rainbow’ content	Nine participants thought that there was insufficient ‘rainbow’ content: ‘…it could be a little bit more focused on gay, or all types of queer youth…Not turn it into a queer game, I don’t know but maybe just a little bit more’ – Andy (male, 19 years old, gay). A few participants recommended that the terminology pertaining to sexuality be improved.
Aspects that did not appeal	–	Three of the older participants (16 years or older) thought the program was patronising or that it ‘babied’ them. However, two participants acknowledged that there could be some value in keeping the programthat way, for example, ‘I thought some things were a little easy…Like overall it wasn’t difficult to figure out what you needed to do. Those little puzzles were quite easy to do. I guess it would be hard to make them more difficult though because you would have to be careful that everyone could actually get it’ – Andy (male, 19 years old, gay).
Other themes	Usefulness for sexual minority youth	Ten participants said that they thought Rainbow SPARX could help other sexual minority young people feel better or less depressed: ‘It could give them techniques and stuff on how to be more open. Because like lesbians are pressured in different ways and stuff like that…because the gay community apparently is pressured more’ – Lara (female, 17 years old, lesbian). Three participants thought Rainbow SPARX would be useful for all young people.
	Usefulness for whom?	Eighteen participants expressed an opinion on the ideal age range for use of Rainbow SPARX, with the majority suggesting that the program was best suited to those aged between 13 and 17 years. Some older participants cautioned against pre-teens using the program: ‘…if it is specifically aimed at people who are questioning their sexuality or whatever, then it is only going to apply to people who are. So if someone is 10 and stuff and they have no concept of sexuality…it is not going to apply for them’ – Goldie (female, 16 years old, ‘Other’).
	Suggestions for rollout	Three participants made suggestions about the rollout of the program, with school guidance counsellors being identified as being important in a rollout: ‘You could do it [Rainbow SPARX] through a guidance counsellor at school possibly which I think would be easier because you get a lot of confidentiality with that. So if you are doing it at school I think through a counsellor would be a very good idea’ – Sapphire (female, 16 years old, bisexual).

Strengths and limitations

This study is unique and adds to what is known about making computerised (and face-to-face) interventions acceptable and relevant to sexual minority individuals. Previous research in this field has been limited to brief quantitative surveys ⁹ and our study adds a more detailed account from all those who had used Rainbow SPARX and completed a post-intervention assessment. An additional strength of this study is that an established method of qualitative data analysis was utilised.

Participants knew that MFGL was a developer of Rainbow SPARX, and as such they may have felt inhibited to express any criticisms of the program. To attempt to remedy this, every participant was specifically asked to comment on what they did not like about Rainbow SPARX. Some of the interviews were very brief, partly because some participants had less to say, or because there was a pressure to finish (as three participants needed to get back to school at a certain time). All the participants in this study were sufficiently confident about their sexuality to take part in this project and this may limit generalizability (i.e. participants questioning their sexuality were likely under-represented). The analyses were conducted by developers of Rainbow SPARX and as such this is a limitation of the study.

Comparisons with other research

Our findings resonate with earlier research evaluating adolescent satisfaction with cCBT. ⁹ Rainbow SPARX was perceived favourably with most participants liking the look and feel of it. As with two previous studies in the field,^15,16 a sizeable proportion of participants identified technical glitches or things requiring improvement, albeit fairly minor (e.g. to reduce the amount of ‘clicking’ required in the program). Previously, the makers of ‘Master Your Mood Online’ in the Netherlands reported having difficulty ‘pitching’ their program to the right developmental level, with some users finding theprogram too difficult. ¹⁶ Conversely, in our study some of the older participants thought that our intervention ‘babied’ them; however, overall the program wasdeemed suitable for the target age group. Rainbow SPARX is the first cCBT program for a mood disorder to address challenges specific to lesbian, gay, bisexual or sexual minority individuals. ¹⁷ As previously highlighted by our team, ⁶ and in a recent analysis of the applicability of e-therapies for lesbians and gay men, ¹⁷ participants in the current study endorsed the need for sexuality-specific or ‘rainbow’ content in computerised interventions. We concur with Rozbroj and colleagues that e-therapies need to address the specific needs of lesbian, gay, bisexual or sexual minority people, so that these unique sub-populations can benefit from the rise of e-therapies. ¹⁷ We hope this rise will become a positive step towards reducing the disparities in mental health between heterosexual and non-heterosexual populations. ¹⁷ In the future we hope to modify Rainbow SPARX, incorporating the changes suggested by our study participants, and subsequently conduct a randomised controlled trial of the program.