Barriers and facilitators for the implementation of blended psychotherapy for depression: A qualitative pilot study of therapists' perspective

Abstract

IntroductionBlended therapies (BT) combine face-to-face (f2f) sessions with internet- and mobile-based interventions (IMIs). However, the use of blended interventions in routine care is still rare and depends on the acceptance of key health care professionals such as the therapists. Little is yet known about the therapists' perspective on and experiences with blended approaches. The aim of this pilot study was to identify barriers and facilitators, as perceived by psychotherapists, for implementing a blended therapy for depression.MethodsSemi-structured expert interviews were conducted with five therapists, who were part of the German study arm of the FP7-project E-Compared (www.e-compared.eu). All patients (N = 173) were treated in the context of a registered RCT (DRKS00006866) in which the clinical and cost-effectiveness of BT for depression, consisting of ten internet- and mobile-based cognitive behavioral therapy modules and six f2f sessions, was compared to the treatment usually provided by general practitioners. To identify barriers and facilitators an interview guide based on the theoretical domains framework (TDF) was developed. The interviews were audio-recorded, transcribed verbatim and analyzed using a qualitative content analysis by two independent coders.ResultsThe results revealed 29 barriers and 33 facilitators, which are hindering or enabling factors on the levels of ‘implementation in the health care system’, ‘therapy’, ‘therapists’ and ‘patients’. Key barriers stated by all therapists were ‘Limited customizability and autonomy of decisions concerning blending the therapy’ (number of statements, k = 44); ‘Disease-related contraindications for BT’ (k = 25); ‘Negative affect was caused by burden through technical problems’ (k = 18); ‘Limited number of f2f sessions hindered the therapy process’; and ‘Establishment of therapeutic alliance was burdened by technical issues’ (each k = 15). Key facilitators stated by all therapists were: ‘Patients’ interest, willingness and motivation to participate’ (k = 22); ‘Patients' access to online content between f2f sessions and after therapy end’ (k = 20); ‘Preset structure of IMI-part guided the treatment course of BT’ (k = 18); and ‘Effective help with BT in a short time frame’ (k = 15), as well as ‘Reduction of the treatment gap’ (k = 13).DiscussionTherapists supported the implementation of BT for depression. Results indicated the consideration of a wide range of determinants: among others, the possibility of individualizing the treatment; the autonomy of decision making in respect to the ratio and number of online and f2f sessions; the necessity of providing training; the need to develop a concept of embedding BT in the health care system and funding the additional effort; and the use of sophisticated technical solutions.

Why Uptake of Blended Internet-Based Interventions for Depression Is Challenging: A Qualitative Study on Therapists’ Perspectives

“…In a qualitative study in Germany, several barriers and facilitators were identified based on the perspectives of therapists (n = 5) providing bCBT alongside a randomized controlled study [19]. Key issues varied from problematic platform technology to an unclear concept of embedding bCBT in the mental health care system.…”

Therapist-related feasibility of blended group therapy (bGT): Mixed methods study of a brief online- and mobile-supported group intervention for major depression (Preprint)

“…Fourthly, depending on design aspects and technical issues, blended therapy has been related previously to risks for the establishment of therapeutic alliance [31,32]. While technical problems are inherently connected to the application of technology, bGT enables new alliance-building functionalities for group therapists, as it provides multiple interfaces for personal patienttherapist exchange.…”

“…In this regard, first studies in routine care found additive effects of traditional face-to-face therapy augmented with online therapy elements [29,30]. ****************** Figure 1 about here *********************** According to therapists, patients can profit from blended interventions in form of increased treatment accessibility and flexibility, as well as from the improvement of patients' selfmanagement and the optimal use of face-to-face sessions [31,32]. Additionally, mental health care providers, policy makers and other such organisations seem to have a more positive conception of blended therapy compared to pure online therapy [17], and therapists seem to prefer the blended format because it is associated with less risks [16].…”

“…Additionally, mental health care providers, policy makers and other such organisations seem to have a more positive conception of blended therapy compared to pure online therapy [17], and therapists seem to prefer the blended format because it is associated with less risks [16]. Amongst the potential disadvantages of the integrated format, therapists frequently remark that blended therapy is not feasible for all patients, and that the format at times could hamper the therapeutic process -in particular the establishment of the therapeutic alliance [31,32]. Consequently, those issues should be investigated in patient-and therapist-related studies.…”

Blended cognitive behavior therapy : efficacy and acceptability for treating depression in the adult and adolescent population

“…It has become increasingly evident that the cautious attitudes seen towards ICBT are often related to perceived risks. Depression is a serious disorder and therapist-patient contact is thought to be necessary for reasons of safety monitoring, to allow treatment to be tailored to individual patient needs (Titzler, Saruhanjan, Berking, Riper & Ebert, 2018;van der Vaart et al, 2014) as well as to achieve therapist-patient collaboration and therapeutic alliance (e.g., Horvath & Bedi, 2011). Moreover, therapist-patient contact seems essential for clinicians to perceive their work as meaningful (Folker et al, 2018).…”