Harper, Victoria, Andrews, Jacob, Dawson, David, Dermendzhiyska, Elitsa, Malins, Samuel and Moghaddam, Nima
(2025)
Is the Betwixt application effective and acceptable in improving emotion regulation for an adult clinical population?
DClinPsy thesis, University of Nottingham.
Abstract
Background: Mental health is central to overall wellbeing, and there is an increasing demand for mental health services, resulting in longer waiting times. A potential solution could be apps which support emotion regulation, as systematic reviews of such apps have found promising results. Emotion regulation can be defined as regulating positive and negative emotions, based upon personal goals. The smartphone application ‘Betwixt’ aims to improve emotion regulation, and it could offer interim support to those waiting, with an immediate and potentially effective intervention. Betwixt is a narrative gaming app, and it is purported to be based upon psychological theory, and the emotion regulation strategies of cognitive reappraisal, and self-compassion. Previous studies of Betwixt found positive results, though none had investigated individuals with mental health conditions. Numerous apps purport to improve mental health, though few are evaluated empirically, therefore this study evaluated an app with promise for clinical utility.
Aims: A) Evaluate the effectiveness of the Betwixt intervention in improving emotion regulation, cognitive reappraisal, and self-compassion in a clinical population. B) Investigate whether changes in processes targeted by Betwixt resulted in improvements in clinical outcomes. C) Explore the acceptability, and theoretical components of Betwixt within a clinical context.
Methods: A mixed-methods single-case experimental design was used to investigate the effectiveness and acceptability of Betwixt within an adult clinical population of individuals experiencing depression or anxiety disorders. Seven participants were recruited from the waiting list for an NHS Talking Therapies service within the UK. These are publicly funded mental health services, which support individuals experiencing depression or anxiety disorders (including generalised anxiety disorder and post-traumatic stress disorder) with talking therapies. The average age of participants was 44.6 years, and they were all female. They used Betwixt every other day for four weeks, and there were weekly check-in calls to troubleshoot technical issues and support app engagement. Participants also completed qualitative interviews or surveys, which focused on acceptability and perceived changes associated with Betwixt use.
Results: Findings were mixed regarding improvements in emotion regulation, cognitive reappraisal, and self-compassion as three participants had significant improvements in emotion regulation, one had significant deteriorations, and one had a combination of improvements and deteriorations. Two participants had a significant improvement in cognitive reappraisal and two in self-compassion. However, there were positive indications that Betwixt may improve clinical outcomes as three participants had significant improvements in low mood (and one had a significant deterioration), four in anxiety, four in wellbeing and three (of four eligible participants) in functioning. Participants’ views on acceptability ranged from positive to negative, with three of the participants having overall positive views of Betwixt, two having mixed views, and one having overall negative views. It is worth noting that the majority of individuals on waiting lists for talking therapies can experience a deterioration, hence, these significant improvements were deemed encouraging by comparison.
Discussion: This study indicates the feasibility, acceptability, and effectiveness of a narrative-based ER gaming app for individuals with depression or anxiety disorders. With further evaluation, Betwixt could be a promising intervention for individuals waiting for talking therapies. Future research should include randomised controlled trials, long-term studies, and assessments of feasibility in severe mental health conditions. Betwixt has promise for clinical applications; the design of this study could be replicated to assess other apps; check-in calls could be included in other interventions; and targeting ER in an intervention may indirectly improve low mood or anxiety. This research is an original contribution of knowledge as it was the first study to evaluate Betwixt within a clinical population; the design was innovative and could be replicated for other apps; and there was a novel finding that emotion regulation and psychological distress may be correlated across timepoints. The journal paper was appraised positively, with numerous strengths, though some limitations. A critical reflection on the study process and a conference poster have also been included.
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