Exploring User Perspectives on Brief Reflective Questioning Activities for Stress Management: Mixed Methods Study

Computer-mediated communication platforms provide accessible resources for managing stress and negative emotions, but many existing online interventions require substantial time commitments that can lead to dropout. The authors investigate whether a brief digital reflective questioning activity (RQA) can provide rapid, convenient support for the general public during moments of stress. Guided by cognitive behavioral therapy (CBT) principles, the RQA aims for minimal time commitment (target ~15 minutes), broad applicability across populations and contexts, and scalability without a live conversational partner or heavy scaffolding. The paper explores whether a concise series of structured questions adds value beyond unstructured reflection, tests whether benefits justify added time, and examines feasibility and engagement when delivered repeatedly via email and SMS. The main contribution includes the creation of a 9-question RQA probe, qualitative insights from first-time users, a controlled comparison against a single-question baseline, and observations from a 2-week deployment to inform design considerations for brief interventions.

The work draws on literature in clinical psychology and HCI showing that brief, low-burden interventions can support behavior change and well-being, complementing or seeding more extensive treatments. It leverages CBT techniques, notably thought records and behavioral chaining, which guide users to connect triggers, thoughts, feelings, and behaviors to identify cognitive distortions and alternative appraisals. Prior studies demonstrate benefits of concise interventions (eg, pamphlets reducing risky behaviors) and digital tools that promote self-reflection through mood/activity summaries or conversational agents. However, conversational agents remain limited in nuanced empathy, and research suggests that even simple why/how prompts can elicit reflection without full dialogue. Potential drawbacks of brief RQAs include lack of tangible feedback, need for repeated exposure, possible surfacing of negative emotions, and user preference for social sharing. These tensions motivate testing whether structured, brief questioning provides incremental benefits over unstructured reflection while maintaining low burden.

Design of the RQA: A 9-question web-based activity was created by researchers with psychology and HCI expertise, inspired by CBT thought records and behavioral chaining. The questions guide users through trigger → thought → feeling → behavior, include a structured summary, challenge whether the trigger justifies the thought pattern, and prompt alternative ways of thinking. Four clinical psychologists reviewed the RQA, confirming alignment with psychotherapy practices while noting risks of length and difficulty without psychoeducation.

Study 1 (First-time user perspectives): Participants—48 total (42 Amazon Mechanical Turk [AMT] crowdworkers after quality screening; 6 university students). Procedure—All completed the RQA on Qualtrics. AMT participants provided survey feedback; students completed semistructured interviews (45–60 min). Analysis—Thematic analysis with open coding; codebook iteratively developed and applied by two researchers to survey and interview data.

Study 2 (Between-participants comparison to baseline): Participants—255 recruited; 215 retained after screening (111 baseline; 104 RQA); mean age 33.8 years; 61.9% men, 35.8% women, 2.3% undisclosed. Conditions—RQA (9 questions) vs Baseline (single open-ended prompt describing a stressful situation). Measures—Perceived utility (7-point, -3 to +3), perceived stress before/after (11-point, -5 to +5; difference reported as perceived stress change), completion time (minutes), response length (word count), perceived time commitment (7-point, -3 to +3). Analysis—Independent 1-tailed Welch t tests across conditions for each measure; paired 1-tailed t test within RQA for pre-post stress.

Study 3 (Two-week field deployment with repeated prompts): Participants—11 university participants (8 men, 3 women; mean age 20.6). Procedure—Two-week participation; participants specified preferred hours for email and SMS prompts. Randomized crossover: one week email, one week SMS; up to 3 prompts per week (1/day on selected days). Same web link used each time. Engagement counted if participants completed the RQA at any time following a prompt. Exit survey and semistructured interviews (15–30 min; 7 participants). Measures—Response rate, completion time, response length, pre-post perceived stress change; qualitative analysis with a new codebook.

Ethics: Risks were disclosed; helpline information provided; interviewers trained in empathy and Columbia-Suicide Severity Rating Scale protocols; participants could skip questions/withdraw. Approved by University of Toronto Research Ethics Board (36582).

Study 1 (qualitative): Participants valued the RQA’s structured reflection for organizing thoughts, recognizing maladaptive patterns, and facilitating problem-solving; writing enabled venting and externalization. Some reported confusion or frustration when unable to find solutions or reconcile alternative thoughts.

Study 2 (quantitative comparison): RQA vs Baseline

• Perceived utility: higher for RQA (mean 1.2, SE 0.2) vs baseline (0.5, SE 0.2); t(213)=2.82; P=.003; Cohen d=0.38.
• Perceived stress change: greater reduction with RQA (mean +0.7, SE 0.2) vs baseline (−0.4, SE 0.1 increase); t(213)=4.46; P<.001; d=0.61. Within RQA, pre-post stress decreased: t(103)=3.59; P<.001; d=0.36.
• Effort: RQA longer completion time (8.9 vs 1.6 min); t(213)=9.09; P<.001; d=1.27. Greater response length (87 vs 29 words); t(213)=4.52; P<.001; d=0.63. Perceived time commitment did not differ (RQA −0.2 vs baseline −0.3); t(213)=0.33; P=.37; d=0.05. Interpretation: Structured questioning added perceived utility and reduced stress beyond unstructured reflection, without increasing subjective burden despite longer objective time.

Study 3 (field deployment): Overall engagement: 54 prompts (27 email, 27 SMS); 50% response rate (27 completed prompts; 30 completions due to 3 double responses). Average per-completion metrics: 18.5 min (SE 1.2), 212 words (SE 24.2), stress reduction 1.2 points (SE 0.3). Response rate declined over repeated prompts (e.g., 64% first prompt to 38% by the sixth), with reported monotony and difficulty finding new situations. Email was preferred for completing the activity (typing and focus advantages), while SMS was valued for timely notifications; participants sometimes switched devices/channels. Repeated use supported habit formation and applying the reflection process mentally outside the tool.

Findings indicate that a brief, self-guided, structured RQA can immediately reduce perceived stress and be seen as more useful than unstructured reflection, addressing the research question about the value of concise, scalable interventions without conversational partners. The structured CBT-inspired sequence helps users externalize emotions, identify triggers and distorted thoughts, and generate alternative appraisals, which likely underpins observed benefits. Despite longer objective completion times, subjective time burden did not increase, suggesting favorable effort–benefit tradeoffs.

In real-world, repeated deployment, engagement is feasible but declines with frequent repetition, highlighting challenges of monotony, mobile typing constraints, and misalignment between prompt timing and availability of new stressors. Technology choices matter: desktops/emails facilitate thoughtful writing and reduced distraction, while SMS is effective for reminders. The results suggest design opportunities: personalized timing (user-controlled or just-in-time adaptive prompts), varied microinterventions to mitigate repetition, supportive examples to reduce confusion, and channel/device integration to combine notification efficacy with better input affordances. These insights are relevant for designing low-burden, scalable mental health supports that can serve as gateways to deeper interventions.

Using CBT principles, the authors designed a brief, 9-question RQA that people can complete on web or mobile to articulate and reframe thoughts and emotions about a troubling situation. Across three studies, the RQA was perceived as useful, yielded greater immediate stress reduction than unstructured reflection, and was acceptable in time commitment. Repeated use is possible but requires attention to frequency, variety, and delivery channels to sustain engagement. Future research should explore personalization (timing and content), integration with other microinterventions, just-in-time adaptive delivery, and applicability to clinical populations to maximize utility while minimizing burden and monotony.

The RQA was designed for the general population rather than clinical groups; effects and risks for individuals with mental health disorders require dedicated study. Participant samples (AMT crowdworkers and university students) limit generalizability. Brief self-reflection can sometimes exacerbate negative thoughts for some users. The 2-week deployment highlights challenges of repeated use (monotony, device constraints, lack of new stressors), suggesting that frequency and variety need careful tuning. Longer-term outcomes and sustained benefits were not assessed.