This Way Up offers three self-help courses for people seeking assistance with shyness, stress management, and worry and sadness. Users begin by taking a ten-item symptom test, and then proceed onward to select a course if it is deemed to be useful. Each of the courses consists of three lessons which can be taken weekly. Users read a comic book-style story about how people were challenged by and managed the issues in question, and then are presented with printable homework assignments to complete over the course of the intervening week. The comics each describe how a person was challenged by a mental health issue, received Cognitive Behavioral Therapy-based advice from a psychologist about how to best manage it, and then put that advice into practice in daily life.
This Way Up incorporates materials intended to be used both online and offline. Printable homework assignments provide additional detail about the techniques discussed, and prompt participants to use them on their own. This Way Up has paid courses as part of its “This Way Up Clinic” which are intended to be used under the supervision of a clinician, and are not available without a prescription. Content in the “This Way Up Clinic” is outside the scope of this review.
Ease of Use and User Experience
This Way Up consists of a series of largely static content hosted on a secure website. Users must register an account before enrolling in a course. Once enrolled, users are presented with sequential lessons. Each lesson consists of roughly 60 comic book page. Users interact with the site by moving to the next page. As a result, the site is intuitive to use. However, as all the text on the comic book pages is a graphic (rasterized), it can at times be difficult to read. At times, the graphics surrounding the text in the comic books were recycled from page to page, making things seem visually repetitious.
At the beginning or end of each lesson, users are presented with a series of questions to perform a self-assessment, although the results of the self-assessments are never calculated. Once users complete lessons, they are provided with homework assignments to do during the following week. Homework assignments are PDFs which are intended to be printed. In order to encourage users to complete the homework assignments before moving on to the next lesson, users are required to wait a week before advancing. Users are asked to pick a date on a calendar by which they plan to complete the next lesson in order to increase their commitment to doing so. Emails are sent to users who have not kept their commitments to advancing to subsequent lessons.
This Way Up has a completely web-based interface. The content is primarily delivered through webpages containing graphics and text. Homework assignments are downloadable PDFs, and self-assessments are done using HTML radio buttons. As there are no animations or audio recordings, users must be able to read.
While the site may be viewed on either a computer or mobile device, its user interface is more suitable for tablets than for smartphones due to its heavy reliance on text embedded within graphics. The site’s layout does not adjust in response to use on a smartphone. The content on the site is not searchable, and is indexed only by lesson. Thus, users seeking to re-read a particular page must flip through all of the comic book pages of a lesson in sequential order.
Appropriateness of Content
While the content itself is not personalized, the availability of three separate courses for three anxiety-related disorders enables users to have a more personalized experience by self-selecting into the appropriate course. To varying extents, everyone experiences stress issues, worry, sadness, and shyness. Although some may benefit from the content more than others, the content is general enough to be applicable to nearly everyone. As the text is written at a middle school level and most of the vignettes involve young adults, the content is suitable for both teenagers and adults.
Many of the homework assignments provide frameworks for rationally facing various interpersonal challenges. Exercises are demonstrated in the context of helping the people described in the vignettes address their interpersonal issues. Afterwards, users are invited to apply frameworks to their own challenges.
Since This Way Up was created in Australia, there are a number of references to Australian social services throughout the site. While these are not useful for American users, they account for only a small portion of the content.
Appropriateness of Feedback
Feedback is not provided. The course is closer to being an online book than an interactive tool. The self-help course is designed to be used without the supervision of a clinician, and thus does not contain activities involving clinician interaction. This is done as the This Way Up Clinic, a separate set of courses, is designed for use in tandem with a clinician.
The cognitive challenge posed by the site is determined by the introspection of the user, and is relatively uniform across the content. Lessons consist of illustrated text, and progressively build upon prior lessons each week. As lessons are delivered in the form of a narrative involving characters, they are suitable for all ages, as well as for people who might not be accustomed to reading self-help materials or medical literature. No prior knowledge of mental health terminology is assumed.
Ease of Account Management
The site is intended to be anonymous. As a result, account management revolves around supplying a username, email address, and password. The email address is used to send users reminders to complete lessons and to congratulate them for doing so. While no other personal information is captured, the site is secured using https, and the site account is only used to track progress through the program and to determine when content is made available.
The scientific literature is not cited in the self-help lessons or homework assignments. However, the site mentions that the courses in the Clinic (paid service for use in conjunction with a clinician) are tested before they are released, and have been used to treat over 1,400 patients in a testing environment. The researchers found that 3 out of 4 people completed all their lessons, 3 out of 4 who completed their lessons are no longer troubled by their emotional disorder, and that 90% of users report they are satisfied. After testing, the courses have been used by 6,000 patients working in conjunction with over 2,400 clinicians.
The site’s section on research, which has not been updated since February 2013, states that research papers on This Way Up will be uploaded in the future, and that in the meanwhile, readers should refer to papers produced by the Clinical Research Unit for Anxiety and Depression (CRUfAD) to understand its scientific basis. CRUfAD is a joint venture of two Australian institutions, St Vincent’s Hospital and the University of New South Wales. The CRUfAD website contains an extensive bibliography ranging from 1963 to the present. While some of the articles may be about This Way Up, they are not identified, and many of the articles listed are clearly not related. That being said, CRUfAD has produced studies on the benefits of Internet-based interventions for shyness[i],[ii],[iii],[iv],[v], stress management[vi], and worry[vii],[viii],[ix] and sadness[x]. Many of the interventions studied were clinician-assisted, although several were designed to be used by people independently. Although works are not explicitly cited, the course content is clearly based on techniques used in clinical practice. In the homework assignments, the source materials behind various exercises and techniques are referenced.
Qualitative Review of Program Efficacy
The courses are likely to be of similar efficacy to books and other traditional media. The one factor differentiating the courses from book-based courses is that they are gated to encourage users to engage with the material over a series of weeks. Users can access condition-specific content on the site which is both free and empathetic in its presentation. The efficacy of the courses is likely to be largely determined by the engagement and motivation of the users. As the homework assignments are not interactive, users must take the initiative to complete them to receive the full benefits of their course. The site does not capture homework progress or allow for interaction around the homework assignments, making them entirely self-directed.
Estimate of Efficacy Relative to Similar Products
There are numerous tools for Cognitive Behavioral Therapy (CBT) available. CBT can be used to treat many different indications, and different tools have been optimized for different use cases. Given that there is no cost to the self-help programs, This Way Up may be a good starting place for people experiencing shyness, stress, worry, or sadness. It has been built on a stronger evidence base than many alternatives, making it a potentially more efficacious option. People who find it difficult to engage with the self-help program may consider enlisting a clinician to work with them through a clinician-guided program on the site or may consider a different online resource. As there are few digital options for people dealing with shyness, and shyness may impede visits to a live clinician, This Way Up’s self-help course may be a particularly useful option for this population.
The self-help courses are free.
[i] Aydos LR, Titov N, Andrews G: Shyness 5: The clinical effectiveness of internet-based clinician-assisted treatment of social phobia. Australasian Psychiatry. 2009, 17 (6):488-492.
[ii] Titov N, Andrews G, Schwencke G, Drobny J, Einstein D: Shyness 1: Distance treatment for social over the Internet. A randomized controlled trial. Australian and New Zealand Journal of Psychiatry. 2008,42(7):585-594.
[iii] Titov N, Andrews G, Schwencke G: Shyness 2: Treating social phobia online: replication and extension. Australian and New Zealand Journal of Psychiatry. 2008, 42(7):595-605
[iv] Titov N, Andrews G, Choi I, Schwencke G, Mahoney A: Shyness 3: An RCT of guided vs unguided internet based CBT for social phobia. Australian and New Zealand Journal of Psychiatry. 2008, 42(12):1030-1040.
[v] Titov N, Andrews G, Choi I, Schwencke G, Johnston L: Internet-based cognitive behavior therapy for social phobia without clinical input is effective: a pragmatic RCT of two types of reminders. Australian and New Zealand Journal of Psychiatry. 2009, 43:913-919.
[vi] Vliet H, van, Andrews G: An internet based course for the management of stress for junior high schools. Australian and New Zealand Journal of Psychiatry. 2009, 43(4):305-309.
[vii] Titov N, Andrews G, Robinson E, Schwencke E, Johnston L, Solley K, Choi I: Clinician-assisted Internet-based treatment is effective for generalized anxiety disorder: A randomized controlled trial. Australian and New Zealand Journal of Psychiatry. 2009, 43(10):905-912.
[viii] Wims E, Titov N, Andrews G, Choi I: Clinician-assisted internet-based treatment is effective for panic: a randomized controlled trial. Australian and New Zealand Journal of Psychiatry. 2010, 44(7):599-607.
[ix] Vliet H, van, Andrews G: An internet based course for the management of stress for junior high schools. Australian and New Zealand Journal of Psychiatry. 2009, 43(4):305-309.
[x] Perini SJ, Titov N, Andrews G: The Climate Sadness program: an open trial of Internet-based treatment for depression. Electronic Journal of Applied Psychology. 2008, 4(2):18-24.