CopingTutor is an interactive web-based application designed to help people with schizophrenia learn cognitive-behavioral therapy (CBT) so that they may better cope with hearing voices (auditory hallucinations). In doing so, it strives to improve mental health and resiliency while reducing stress. CopingTutor offers a structured, subscription-based program in which users learn coping skills through formal lessons and quizzes, log their recent experiences hearing voices, and read experiences logged by other users.
The site is intended to be used as an independent self-help program over the course of twelve to sixteen weeks. As CopingTutor slowly and carefully describes CBT, it could be used by a person with no prior background. CopingTutor attempts to accommodate users with limited reading and writing ability by delivering information through narrated animations and pictures. That being said, there are a number of places within the program where an illiterate person would need assistance.
CopingTutor has a number of educational goals which are intended to help users learn CBT techniques, and ultimately, to meet new people, feel less worried, and live more enjoyable lives. The framework behind CBT is that events and situations lead to thoughts, beliefs, and interpretations, which in turn lead to feelings, which ultimately lead to actions and behaviors. CopingTutor seeks to enable users to better coach themselves to have more accurate thoughts.
Ease of Use and User Experience
CopingTutor is hosted on a secure website with an invalid security certificate. As a result, browsers block the site when users attempt to visit it, and then require users to acknowledge the security issue before displaying the contents of the site. Despite this substantial issue, the actual site is very easy to use. The landing page of the site describes the program and has links advising users to start a free trial. The trial may be initiated without providing any personal information beyond an email address; enabling the site to offer a high level of confidentiality and to overcome the potential paranoia of users.
The user experience is designed around a series of ten training sessions. In each, content is delivered through lectures and then reinforced through quizzes and activities. Lectures are given by an animated avatar with a female voice. The user experience is rather linear, which limits the ambiguity in the steps that should be completed next. That being said, the linearity limits the value of revisiting the site, except for the purpose of logging voices which have been heard or for completing subsequent lessons.
CopingTutor is a user-friendly web application made to be viewed from a browser. Web-based delivery is appropriate, as a 2014 study found that only 32% of patients with schizophrenia in community based treatment owned smartphones.[i] Activities primarily require the use of a mouse. Typing may be used as desired when logging voices. The content of the site appears to be relatively static, although it is possible to read a stream of voices which other users claim to have heard. The website is professionally designed, and is somewhat reminiscent of CD-ROM-based “edutainment” produced during the 1990s due to its modest degree of interactivity. The animated lessons featured on the site are analogous to videos, and must be watched in order. Limited captions are provided, so it is possible to fast-forward through the animations to obtain the content more quickly. However, the captions do not cover the entire script read by the avatar, and thus cannot serve as an alternative to viewing the animations.
Appropriateness of Content
While the content is quite detailed and instructive, it is not personalized to the needs of the user. As the registration process is very streamlined, with no information captured beyond an email address, the site does not have any knowledge of the needs of specific users. Some of the lessons might be useful to people who do not hear voices, but struggle with unhealthy thinking styles (e.g. mind reading, emotional reasoning, catastrophizing). However, the site does not have any options for users who are not hearing voices. Thus, the site is only appropriate for users with schizophrenia.
Appropriateness of Feedback
When users answer activity questions, the site often explains both the correct and incorrect answers, even when questions are answered correctly. Personalized feedback is not provided by the site. As a result, it takes users who are adept at the content a long time to progress through the questions, and may cause some to experience boredom. While users may log the voices they hear, no feedback is provided on the log entries. The logs of other users are visible through a social feed, and are presented in unmoderated form.
The site offers a relatively uniform level of cognitive challenge which does not adapt based upon the user. Nonetheless, the lessons are delivered in a manner which encourages introspection and fosters the development of emotional intelligence. Each week, users gain access to another lesson. The lessons are progressive and build upon content previously delivered. Topics covered include an introduction to CBT, a review of unhealthy thinking styles, and coping behaviors.
Ease of Account Management
CopingTutor keeps a very minimal profile on its users. No personal information is requested beyond an email address at registration. Gender, date of birth, country of residence, and level of education completed may optionally be added to a user’s profile. However, none of these details are publicly visible, so it is not clear why they would be provided. There is no mechanism on the site for sharing information with a therapist.
Although not mentioned on the website, the creators of CopingTutor conducted a clinical trial of the site or another website similar to it. During a 21 subject trial in which patients with schizophrenia spectrum disorders and auditory hallucinations used an online CBT program to help them cope with voices, 17 (81%) completed more than half the content in the program. Among these active participants, there were statistically significant improvements in several measures of auditory hallucinations.[ii]
The creators of CopingTutor have the training necessary to credibly translate prior findings into practice. CopingTutor’s VP of Content is a psychologist with 18 years of experience helping patients use CBT. CopingTutor has a five scientific advisors, comprised of four psychologists and one psychiatrist. One of the advisors is a psychologist who has been diagnosed with schizophrenia, and thus is able to see the site from both the perspective of a clinician and a patient.
Finally, there is an extensive body of scientific research behind Internet-based CBT[iii], and some prior research has validated the efficacy of Internet-based CBT for patients with schizophrenia[iv] and agoraphobia[v]. In-person CBT for use in the management of schizophrenia is recommended by both the Substance Abuse and Mental Health Services Administration (SAMHSA) in the United States and the National Institute for Health and Care Excellence (NICE) in the United Kingdom.[vi],[vii] While government agencies have been supportive of the use of CBT for patients with schizophrenia, several reviews of the literature provide more mixed support.[viii],[ix] ,[x]
Qualitative Review of Program Efficacy
The site presents its lessons in a straightforward and easy to digest fashion. If the site can sufficiently engage users to the extent that they complete the ten lessons of content, then there is likely to be substantial therapeutic value. However, the degree of participation on the social feed on the site (descriptions of voices heard by other users) suggest that long-term participation is limited. In May, three different users posted logs, each doing so only once. Over the course of the first six months of 2015, none of the users appear to have engaged with the site beyond the length of the free trial. This may be a result of the cost of access or the level of engagement of the users. Thus, while the site could potentially be effective, in practice, it does not appear that people are engaging with it. Furthermore, the site doles out content slowly over a ten week period, and does not allow users to engage in “binge” learning. As a result, users who might benefit from rapidly learning about CBT, but might lose interest after a few days, do not have the ability to quickly absorb all the content.
Estimate of Efficacy Relative to Similar Products
There are numerous tools for both online CBT training and logging experiences. Given the lack of adoption of the site and the relatively low level of engagement between users, other free services offering CBT training or logging could easily be substituted. However, there appears to be a limited range of options for people specifically needing CBT training to manage auditory hallucinations related to schizophrenia.
Users are automatically enrolled in a 14 day free trial without providing a credit card. Subsequent access to the service may be purchased on a subscription basis or through prepayment. As the site is currently in beta, a 50% discount is being offered. The monthly fee has been reduced from $79 to $39. Users who prepay for three or more months can receive an additional 10% discount.
[i] Ben-Zeev D, Brenner CJ, Begale M, Duffecy J, Mohr DC, Mueser KT. Feasibility, Acceptability, and Preliminary Efficacy of a Smartphone Intervention for Schizophrenia. Schizophr Bull. 2014 Mar 19.
[ii] Gottlieb JD, Romeo KH, Penn DL, Mueser KT, Chiko BP. Web-based cognitive-behavioral therapy for auditory hallucinations in persons with psychosis: a pilot study. Schizophr Res. 2013;145(1-3):82-7.
[iii] Cuijpers, P., van Straten, A., & Andersson, G. (2008). Internet-administered cognitive behavior therapy for health problems: a systematic review. Journal of behavioral medicine, 31(2), 169-177.
[iv] Lewis, S., Tarrier, N., Haddock, G., Bentall, R., Kinderman, P., Kingdon, D., … & Dunn, G. (2002). Randomised controlled trial of cognitive—behavioural therapy in early schizophrenia: acute-phase outcomes. The British journal of psychiatry, 181(43), s91-s97.
[v] Kiropoulos, L. A., Klein, B., Austin, D. W., Gilson, K., Pier, C., Mitchell, J., & Ciechomski, L. (2008). Is internet-based CBT for panic disorder and agoraphobia as effective as face-to-face CBT?. Journal of anxiety disorders, 22(8), 1273-1284.
[vi] Available at: http://www.nrepp.samhsa.gov/ViewIntervention.aspx?id=256. Accessed July 8, 2015.
[vii] Available at: http://www.nice.org.uk/guidance/cg178/chapter/recommendations#how-to-deliver-psychological-interventions. Accessed June 30, 2015.
[viii] Jauhar S, Mckenna PJ, Radua J, Fung E, Salvador R, Laws KR. Cognitive-behavioural therapy for the symptoms of schizophrenia: systematic review and meta-analysis with examination of potential bias. Br J Psychiatry. 2014;204(1):20-9.
[ix] Jones C, Hacker D, Cormac I, Meaden A, Irving CB. Cognitive behaviour therapy versus other psychosocial treatments for schizophrenia. Cochrane Database Syst Rev. 2012;4:CD008712.
[x] Wykes T, Steel C, Everitt B, Tarrier N. Cognitive behavior therapy for schizophrenia: effect sizes, clinical models, and methodological rigor. Schizophr Bull. 2008;34(3):523-37.
Review date: July 2015