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

Titzler, Ingrid; Saruhanjan, Karina; Berking, Matthias; Riper, Heleen; Ebert, David Daniel

doi:10.1016/j.invent.2018.01.002

Cited by 176Digital Mental Health InterventionsHealth Policy Implementation ScienceTelemedicine and Telehealth Implementation

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

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Titzler, Ingrid, Saruhanjan, Karina, Berking, Matthias, Riper, Heleen, Ebert, David Daniel·2018·Internet Interventions

DOI 10.1016/j.invent.2018.01.002PMC PMC6096333

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Abstract

Blended 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. Semi-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. The 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). Therapists 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.

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The European research suggests that blended care is scalable and could enhance mental health professionals' acceptance of DMHI use in routine care, as well as improve client engagement by increasing DMHI uptake and adherence.
“The European research suggests that blended care is scalable and could enhance mental health professionals’ acceptance of DMHI use in routine care, as well as improve client engagement by increasing DMHI uptake and adherence.”
From Needs and Expectations for the myNewWay Blended Digital and Face-to-Face Psychotherapy Model of Care for Depression and Anxiety (Part 2): Participatory Design Study including Mental Health Professionals (2025) · cites this paper as [30]
The Introduction identifies better adherence than with stand-alone online interventions as a possible advantage, and the Results > Facilitators report therapists’ acceptance of online modules, patient interest, and the possibility of treating more patients. These passages support the claim’s cautious framing, but the pilot study does not establish increased DMHI uptake or demonstrate scalability in routine care; the Discussion says treating more patients depends on actually reducing clinician time per patient. Page numbers were unavailable in our copy. (LLM, conf=0.84)
Experimental — accuracy not yet measured
Findings from Germany, the Netherlands, and Denmark indicate that blended care was acceptable to CBT-based therapists and psychologists before and during the COVID-19 pandemic.
“Findings from Germany, the Netherlands, and Denmark indicate that blended care was acceptable to CBT-based therapists and psychologists before and during the COVID-19 pandemic [28-31].”
From Needs and Expectations for the myNewWay Blended Digital and Face-to-Face Psychotherapy Model of Care for Depression and Anxiety (Part 2): Participatory Design Study including Mental Health Professionals (2025) · cites this paper as [30]
The Discussion reports that the interviewed therapists had a positive attitude toward blended therapy and were willing to use it again. The Methods identify them as five CBT therapists in training in Germany, employed in 2015–2016. This paper supports the pre-pandemic German portion of the multi-citation claim, but its own findings do not establish acceptability in the Netherlands or Denmark or during COVID-19. (LLM, conf=0.88)
Experimental — accuracy not yet measured
EA and MS created the interview guide with the help and synthesis of interview guidelines from a number of studies that qualitatively examined user experiences in applications developed in the field of digital health.
“EA and MS created the interview guide with the help and synthesis of interview guidelines from a number of studies that qualitatively examined user experiences in applications developed in the field of digital health [45-49].”
From Barriers to and Facilitators of a Blended Cognitive Behavioral Therapy Program for Depression and Anxiety Based on Experiences of University Students: Qualitative Interview Study (2023) · cites this paper as [48]
Recent surveys and qualitative studies amongst psychotherapists indicate that blended therapy approaches would be acceptable considering perceived advantages over conventional psychotherapy.
“Recent surveys and qualitative studies amongst psychotherapists indicate that blended therapy approaches would be acceptable considering perceived advantages over conventional psychotherapy, including e.g., bridging distances, flexibility, patient empowerment, and therapist support by standardized materials (17, 18, 23, 24).”
From Clinical and Cost-Effectiveness of PSYCHOnlineTHERAPY: Study Protocol of a Multicenter Blended Outpatient Psychotherapy Cluster Randomized Controlled Trial for Patients With Depressive and Anxiety Disorders (2021) · cites this paper as [24]
bCBT has been found to be better received by both providers and patients than iCBT.
“bCBT has been found to be better received by both providers and patients than iCBT, because the face-to-face contact in the blended format makes the treatment more personal, better addresses the needs of patients with complex symptomatology, and may help improve adherence rates [15, 19–21].”
From Acceptability, effectiveness and cost-effectiveness of blended cognitive-behavioural therapy (bCBT) versus face-to-face CBT (ftfCBT) for anxiety disorders in specialised mental health care: A 15-week randomised controlled trial with 1-year follow-up (2021) · cites this paper as [19]

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Buti, A. L., Eakins, D. R., Fussell, H. E., Kunkel, L. E., Kudura, A. G., & McCarty, D. W. (2012) · Journal of Substance Abuse Treatment · doi:10.1016/j.jsat.2012.08.220 · Cited by 18 · see citing works
Internet- und mobilebasierte Psychotherapie der Depression
Sander, L., Ebert, D., & Baumeister, H. (2017) · Fortschritte der Neurologie · Psychiatrie · doi:10.1055/s-0042-123540 · Cited by 18 · see citing works
Self-citation
Umsetzungsbarrieren bei der Akzeptanz, Implementation und Verbreitung von Telecare und Telehealth – Ergebnisse einer internationalen Literaturstudie
Merkel, S. (2017) · E-Health-Ökonomie · doi:10.1007/978-3-658-10788-8_7 · Cited by 3 · see citing works

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Mayring P. Einführung in Die Qualitative Sozialforschung: Eine Anleitung Zu Qualitativem Denken (5., Überarb. Und Neu Ausgestattete Aufl.). Studium Paedagogik Vol. 5 2002 Weinheim Beltz

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Psychotherapists’ attitudes toward online therapy during the COVID-19 pandemic.
Békés, V., & Aafjes-van Doorn, K. (2020) · Journal of Psychotherapy Integration · doi:10.1037/int0000214 · Cited by 393 · see citing works
Smartphone applications for depression: a systematic literature review and a survey of health care professionals’ attitudes towards their use in clinical practice
Kerst, A., Zielasek, J., & Gäebel, W. (2019) · European Archives of Psychiatry and Clinical Neuroscience · doi:10.1007/s00406-018-0974-3 · Cited by 158 · see citing works
Psychotherapists’ Challenges With Online Therapy During COVID-19: Concerns About Connectedness Predict Therapists’ Negative View of Online Therapy and Its Perceived Efficacy Over Time
Békés, V., Aafjes-van Doorn, K., Luo, X., Prout, T. A., & Hoffman, L. (2021) · Frontiers in Psychology · doi:10.3389/fpsyg.2021.705699 · Cited by 134 · see citing works
Toward an Objective Assessment of Implementation Processes for Innovations in Health Care: Psychometric Evaluation of the Normalization Measure Development (NoMAD) Questionnaire Among Mental Health Care Professionals
Vis, C., Ruwaard, J., Finch, T. L., Rapley, T., Beurs, D. P. D., van Stel, H. F., van Lettow, B., Mol, M., Kleiboer, A. M., Riper, H. M., et al. (2019) · Journal of Medical Internet Research · doi:10.2196/12376 · Cited by 84 · see citing works
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Internet and Face-to-face Cognitive Behavioral Therapy for Postnatal Depression Compared With Treatment as Usual: Randomized Controlled Trial of MumMoodBooster
Milgrom, J., Danaher, B., Seeley, J., Holt, C. J., Holt, C., Ericksen, J., Tyler, M. S., Gau, J. M., & Gemmill, A. W. (2020) · Journal of Medical Internet Research · doi:10.2196/17185 · Cited by 69 · see citing works
Advantages and disadvantages of online and blended therapy: replication and extension of findings on psychotherapists' appraisals
Schuster, R., Topooco, N., Keller, A., Radvogin, E., & Laireiter, A.-R. (2020) · Internet Interventions · doi:10.1016/j.invent.2020.100326 · Cited by 77 · see citing works
Why uptake of blended internet-based interventions for depression is challenging: a qualitative study on therapists’ perspectives
Mol, M., van Genugten, C., Dozeman, E., van Schaik, D. J. F., Draisma, S., Riper, H., & Smit, J. H. (2019) · Journal of Clinical Medicine · doi:10.3390/jcm9010091 · Cited by 61 · see citing works
Self-citation
Understanding Mental Health Professionals’ Perspectives and Practices Regarding the Implementation of Digital Mental Health: Qualitative Study (Preprint)
Mendes-Santos, C., Nunes, F., Weiderpass, E., Santana, R., & Andersson, G. (2021) · doi:10.2196/preprints.32558 · Cited by 52 · see citing works
Exploring medical students' views on digital mental health interventions: A qualitative study
Dederichs, M., Weber, J., Pischke, C. R., Angerer, P., & Apolinário-Hagen, J. (2021) · Internet Interventions · doi:10.1016/j.invent.2021.100398 · Cited by 50 · see citing works
Tailored implementation of internet-based cognitive behavioural therapy in the multinational context of the ImpleMentAll project: a study protocol for a stepped wedge cluster randomized trial
Bührmann, L., Schuurmans, J., Ruwaard, J., Fleuren, M. A. H., Etzelmueller, A., Piera-Jiménez, J., Finch, T. L., Rapley, T., Potthoff, S., Aouizerate, B., et al. (2020) · Trials · doi:10.1186/s13063-020-04686-4 · Cited by 51 · see citing works
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Online therapy: an added value for inpatient routine care? Perspectives from mental health care professionals
Sander, J., Bolinski, F., Diekmann, S., Gäebel, W., Günther, K., Hauth, I., Heinz, A., Kleiboer, A. M., Riper, H. M., Trost, N., et al. (2021) · European Archives of Psychiatry and Clinical Neuroscience · doi:10.1007/s00406-021-01251-1 · Cited by 52 · see citing works
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Acceptability, effectiveness and cost-effectiveness of blended cognitive-behavioural therapy (bCBT) versus face-to-face CBT (ftfCBT) for anxiety disorders in specialised mental health care: A 15-week randomised controlled trial with 1-year follow-up
Romijn, G., Batelaan, N., Koning, J., van Balkom, A., de Leeuw, A., Benning, F., Hakkaart van Roijen, L., & Riper, H. (2021) · PLOS ONE · doi:10.1371/journal.pone.0259493 · Cited by 46 · see citing works
“…thing, bCBT has been found to be better received by both providers and patients than iCBT, because the face-to-face contact in the blended format makes the treatment more personal, better addresses the needs of patients with complex symptomatology, and may help improve adherence rates [15, 19–21].”
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Effectiveness of Self-guided Tailored Implementation Strategies in Integrating and Embedding Internet-Based Cognitive Behavioral Therapy in Routine Mental Health Care: Results of a Multicenter Stepped-Wedge Cluster Randomized Trial
Vis, C., Schuurmans, J., Aouizerate, B., Craggs, M. A., Batterham, P. J., Bührmann, L., Calear, A. L., Pashoja, A. C., Christensen, H. M., Dozeman, E., et al. (2022) · Journal of Medical Internet Research · doi:10.2196/41532 · Cited by 42 · see citing works
Self-citation
Blended Psychological Therapy for the Treatment of Psychological Disorders in Adult Patients: Systematic Review and Meta-Analysis
(2024) · doi:10.2196/49660 · Cited by 45 · see citing works
Experiences from implementation of internet-delivered cognitive behaviour therapy for insomnia in psychiatric health care: a qualitative study applying the NASSS framework
Kadesjö Banck, J., & Bernhardsson, S. (2020) · BMC Health Services Research · doi:10.1186/s12913-020-05596-6 · Cited by 35 · see citing works
Improving the Course of Depressive Symptoms After Inpatient Psychotherapy Using Adjunct Web-Based Self-Help: Follow-Up Results of a Randomized Controlled Trial
Zwerenz, R., Baumgarten, C., Becker, J., Tibubos, A. N., Siepmann, M., Knickenberg, R. J., & Beutel, M. E. (2019) · Journal of Medical Internet Research · doi:10.2196/13655 · Cited by 42 · see citing works
Effectiveness of Mindfulness-Based Stress Management in The Mental Health of Iranian University Students: A Comparison of Blended Therapy, Face-to-Face Sessions, and mHealth App (Aramgar)
Borjalilu, S., Mazaheri, M. A., & Talebpour, A. (2019) · Iranian Journal of Psychiatry and Behavioral Sciences · doi:10.5812/ijpbs.84726 · Cited by 40 · see citing works
Patient and physician perspectives of a smartphone application for depression: a qualitative study
Patoz, M.-C., Hidalgo‐Mazzei, D., Blanc, O., Verdolini, N., Pacchiarotti, I., Murru, A., Zukerwar, L., Vieta, E., Llorca, P., & Samalin, L. (2021) · BMC Psychiatry · doi:10.1186/s12888-021-03064-x · Cited by 36 · see citing works
Unraveling the Black Box: Exploring Usage Patterns of a Blended Treatment for Depression in a Multicenter Study
Kemmeren, L. L., van Schaik, A., Smit, J. H., Ruwaard, J., Rocha, A., Henriques, M., Ebert, D. D., Titzler, I., Hazo, J.-B., Dorsey, M., et al. (2019) · JMIR Mental Health · doi:10.2196/12707 · Cited by 36 · see citing works
Self-citation
Organizational and Policy Barriers to the Use of Digital Mental Health by Mental Health Professionals
Ganapathy, A., Clough, B. A., & Casey, L. M. (2021) · Telemedicine Journal and e-Health · doi:10.1089/tmj.2020.0455 · Cited by 38 · see citing works
Patients’ Experiences of Web- and Mobile-Assisted Group Therapy for Depression and Implications of the Group Setting: Qualitative Follow-Up Study
Schuster, R., Sigl, S., Berger, T., & Laireiter, A.-R. (2018) · JMIR Mental Health · doi:10.2196/mental.9613 · Cited by 28 · see citing works
The Role of Compassionate Technology in Blended and Digital Mental Health Interventions: Systematic Scoping Review
van Lotringen, C. M., Lusi, B., Westerhof, G. J., Ludden, G., Kip, H., Kelders, S. M., & Noordzij, M. L. (2023) · JMIR Mental Health · doi:10.2196/42403 · Cited by 34 · see citing works
Implementation of e‐mental health for depression and anxiety: A critical scoping review
Ellis, L. A., Augustsson, H., Grødahl, A. I., Pomare, C., Churruca, K., Long, J. C., Ludlow, K., Zurynski, Y. A., & Braithwaite, J. (2020) · Journal of Community Psychology · doi:10.1002/jcop.22309 · Cited by 33 · see citing works
Effects of video viewing smartphone application intervention involving positive word stimulation in people with subthreshold depression: A pilot randomized controlled trial
Kageyama, K., Kato, Y., Mesaki, T., Uchida, H., Takahashi, K., Marume, R., Sejima, Y., & Hirao, K. (2020) · Journal of Affective Disorders · doi:10.1016/j.jad.2020.12.104 · Cited by 33 · see citing works
Counseling With Guided Use of a Mobile Well-Being App for Students Experiencing Anxiety or Depression: Clinical Outcomes of a Feasibility Trial Embedded in a Student Counseling Service
Broglia, E., Millings, A., & Barkham, M. (2019) · JMIR mhealth and uhealth · doi:10.2196/14318 · Cited by 34 · see citing works
Digitale Gesundheitsanwendungen (DiGA) in der ärztlichen und psychotherapeutischen Versorgung. Chancen und Herausforderungen aus Sicht der Leistungserbringer
Gerlinger, G., Mangiapane, N., & Sander, J. (2021) · Bundesgesundheitsblatt - Gesundheitsforschung - Gesundheitsschutz · doi:10.1007/s00103-021-03408-8 · Cited by 33 · see citing works
Clinical and Cost-Effectiveness of PSYCHOnlineTHERAPY: Study Protocol of a Multicenter Blended Outpatient Psychotherapy Cluster Randomized Controlled Trial for Patients With Depressive and Anxiety Disorders
Baumeister, H., Bauereiss, N., Zarski, A.-C., Braun, L., Buntrock, C., Hoherz, C., Idrees, A. R., Kraft, R., Meyer, P., Nguyen, T. B. D., et al. (2021) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2021.660534 · Cited by 30 · see citing works
Self-citation
Die Mischung macht’s eben? Blended-Psychotherapie als Ansatz der Digitalisierung in der Psychotherapie
Bielinski, L. L., Trimpop, L., & Berger, T. (2021) · Psychotherapeut · doi:10.1007/s00278-021-00524-3 · Cited by 31 · see citing works
Patients’ adherence to smartphone apps in the management of bipolar disorder: a systematic review
Patoz, M.-C., Hidalgo-Mazzei, D., Pereira, B., Blanc, O., de Chazeron, I., Murru, A., Verdolini, N., Pacchiarotti, I., Vieta, E., Llorca, P.-M., et al. (2021) · International Journal of Bipolar Disorders · doi:10.1186/s40345-021-00224-6 · Cited by 30 · see citing works
Effects, Adherence, and Therapists’ Perceptions of Web- and Mobile-Supported Group Therapy for Depression: Mixed-Methods Study
Schuster, R., Kalthoff, I., Walther, A., Köhldorfer, L., Partinger, E., Berger, T., & Laireiter, A.-R. (2019) · Journal of Medical Internet Research · doi:10.2196/11860 · Cited by 25 · see citing works
A blended rational emotive occupational health coaching for job-stress among teachers of children with special education needs
Okeke, F. C., Onyishi, C. N., Nwankwor, P. P., & Ekwueme, S. C. (2021) · Internet Interventions · doi:10.1016/j.invent.2021.100482 · Cited by 29 · see citing works
Acceptance of e-mental health services for different application purposes among psychotherapists in clinical training in Germany and Switzerland: secondary analysis of a cross-sectional survey
Braun, P., Drüge, M., Hennemann, S., Nitsch, F. J., Staeck, R., & Apolinário-Hagen, J. (2022) · Frontiers in Digital Health · doi:10.3389/fdgth.2022.840869 · Cited by 27 · see citing works
Exploring user-related drivers of the early acceptance of certified digital stress prevention programs in Germany
Apolinário-Hagen, J., Hennemann, S., Kück, C., Wodner, A., Geibel, D., Riebschläger, M., Zeißler, M., & Breil, B. (2020) · Health Services Insights · doi:10.1177/1178632920911061 · Cited by 26 · see citing works
Barriers and Facilitators for Referrals of Primary Care Patients to Blended Internet-Based Psychotherapy for Depression: Mixed Methods Study of General Practitioners’ Views
Titzler, I., Berking, M., Schlicker, S., Riper, H., & Ebert, D. D. (2020) · JMIR Mental Health · doi:10.2196/18642 · Cited by 25 · see citing works
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Design Considerations for the Integrated Delivery of Cognitive Behavioral Therapy for Depression: User-Centered Design Study
Stawarz, K., Preist, C., Tallon, D., Wiles, N., Kessler, D., Turner, K., Shafran, R., & Coyle, D. (2020) · JMIR Mental Health · doi:10.2196/15972 · Cited by 24 · see citing works
Die Mischung macht’s eben? Blended-Psychotherapie als Ansatz der Digitalisierung in der Psychotherapie
Bielinski, L. L., Trimpop, L. F., & Berger, T. (2021) · Open Access CRIS of the University of Bern · doi:10.48350/164137 · Cited by 24 · see citing works
Comparison of the Working Alliance in Blended Cognitive Behavioral Therapy and Treatment as Usual for Depression in Europe: Secondary Data Analysis of the E-COMPARED Randomized Controlled Trial
(2024) · doi:10.2196/47515 · Cited by 24 · see citing works
Self-citation
Immediate and long-term effectiveness of adding an Internet intervention for depression to routine outpatient psychotherapy: Subgroup analysis of the EVIDENT trial
Schuster, R., Laireiter, A., Berger, T., Moritz, S., Meyer, B., Hohagen, F., & Klein, J. P. (2020) · Journal of Affective Disorders · doi:10.1016/j.jad.2020.05.122 · Cited by 22 · see citing works
Feasibility, adherence, and effectiveness of blended psychotherapy for severe mental illnesses: scoping review
Ehrt-Schäfer, Y., Rusmir, M., Vetter, J., Seifritz, E., Müller, M., & Kleim, B. (2023) · JMIR Mental Health · doi:10.2196/43882 · Cited by 24 · see citing works
Patient and therapist expectations for a blended cognitive behavioral therapy program for depression: qualitative exploratory study
Atik, E., Schückes, M., & Apolinário-Hagen, J. (2022) · JMIR Mental Health · doi:10.2196/36806 · Cited by 22 · see citing works
Integrating the Digital and the Traditional to Deliver Therapy for Depression
Stawarz, K., Preist, C., Tallon, D., Thomas, L., Turner, K. M., Wiles, N., Kessler, D. S., Shafran, R., & Coyle, D. (2020) · CHI Conference on Human Factors in Computing Systems · doi:10.1145/3313831.3376510 · Cited by 24 · see citing works
E-mental health implementation in inpatient care: Exploring its potential and future challenges
Assche, E. V., Bonroy, B., Mertens, M., den Broeck, L. V., Desie, K., Bolinski, F., Amarti, K., Kleiboer, A. M., Riper, H. M., & Daele, T. V. (2022) · Frontiers in Digital Health · doi:10.3389/fdgth.2022.1027864 · Cited by 20 · see citing works
Self-citation
The therapist experience of internet delivered CBT for problem gambling: Service integration considerations
Rodda, S. N., Merkouris, S., Lavis, T., Smith, D., Lubman, D. I., Austin, D., Harvey, P. W., Battersby, M., & Dowling, N. A. (2019) · Internet Interventions · doi:10.1016/j.invent.2019.100264 · Cited by 19 · see citing works
Stress in teachers of children with neuro-developmental disorders: Effect of blended rational emotive behavioral therapy
Obiweluozo, P. E., Dike, I. C., Ogba, F. N., Elom, C. O., Orabueze, F. O., Okoye-Ugwu, S., Ani, C., Onu, A. O., Ukaogo, V. O., Obayi, L. N., et al. (2021) · Science Progress · doi:10.1177/00368504211050278 · Cited by 19 · see citing works
The ethics of artificial intelligence in psychotherapy
Manríquez Roa, T., Biller-Andorno, N., & Trachsel, M. (2021) · Oxford Handbook of Psychotherapy Ethics · doi:10.1093/oxfordhb/9780198817338.013.91 · Cited by 19 · see citing works
Australian psychologists experiences with digital mental health: a qualitative investigation
Scott, S., Knott, V., Finlay-Jones, A. L., & Mancini, V. O. (2022) · Journal of Technology in Behavioral Science · doi:10.1007/s41347-022-00271-5 · Cited by 18 · see citing works
“However, blended modalities have been less-frequently researched compared to purely digital mental health interventions (Titzler et al., 2018).”
Background
Measuring therapists' attitudes toward integration of technology in psychotherapy and predicting their use of technology
Bagarić, B., & Jokić‐Begić, N. (2020) · Journal of Clinical Psychology · doi:10.1002/jclp.22967 · Cited by 18 · see citing works
Implementing Digital Trainings within Medical Rehabilitations: Improvement of Mental Health and Synergetic Outcomes with Healthcare Service
Keller, F. M., Dahmen, A., Derksen, C., Kötting, L., & Lippke, S. (2021) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph18178936 · Cited by 19 · see citing works
Willingness to use internet-based versus bibliotherapy interventions in a representative US sample: cross-sectional survey study
De Jesús-Romero, R., Wasil, A., & Lorenzo-Luaces, L. (2022) · JMIR Formative Research · doi:10.2196/39508 · Cited by 18 · see citing works
Barriers to and Facilitators of a Blended Cognitive Behavioral Therapy Program for Depression and Anxiety Based on Experiences of University Students: Qualitative Interview Study
Braun, P., Atik, E., Guthardt, L., Apolinário-Hagen, J., & Schückes, M. (2023) · JMIR Formative Research · doi:10.2196/45970 · Cited by 17 · see citing works
A qualitative interview study of patients' attitudes towards and intention to use digital interventions for depressive disorders on prescription
Posselt, J., Baumann, E., & Dierks, M. (2024) · Frontiers in Digital Health · doi:10.3389/fdgth.2024.1275569 · Cited by 17 · see citing works
Shaping Blended Care: Adapting an Instrument to Support Therapists in Using eMental Health
Kip, H., Wentzel, J., & Kelders, S. M. (2020) · JMIR Mental Health · doi:10.2196/24245 · Cited by 16 · see citing works
Couple and family therapists’ experiences with Telehealth during the COVID-19 pandemic: a phenomenological analysis
Orlowski, E. W., Friedlander, M. L., Megale, A., Peterson, E. K., & Anderson, S. R. (2022) · Contemporary Family Therapy · doi:10.1007/s10591-022-09640-x · Cited by 16 · see citing works
Practitioners’ experience of the working alliance in a blended cognitive-behavioural therapy intervention for depression: qualitative study of barriers and facilitators
Doukani, A., Free, C., Araya, R., Michelson, D., Cerga-Pashoja, A., & Kakuma, R. (2022) · BJPsych Open · doi:10.1192/bjo.2022.546 · Cited by 15 · see citing works
From Theory to Implementation in Practice: A Qualitative Case Study of the Implementation of Virtual Reality in Mental Healthcare
Kip, H., Buitelaar-Huijsse, G. K. G., Kouijzer, M. M. T. E., & Kelders, S. M. (2023) · Global Implementation Research and Applications · doi:10.1007/s43477-023-00101-7 · Cited by 13 · see citing works
Two sides of the same coin? Patient and therapist experiences with a transdiagnostic blended intervention focusing on emotion regulation
Bielinski, L. L., Bur, O. T., Wälchli, G., Suter, J. M., Walsh, N., Kley, M. A., Krieger, T., & Berger, T. (2022) · Internet Interventions · doi:10.1016/j.invent.2022.100586 · Cited by 15 · see citing works
Blended cognitive behavior therapy : efficacy and acceptability for treating depression in the adult and adolescent population
Topooco, N. (2018) · doi:10.3384/diss.diva-148016 · Cited by 15 · see citing works
A Blended Cognitive–Behavioral Intervention for the Treatment of Postpartum Depression: Study Protocol for a Randomized Controlled Trial
Branquinho, M., Canavarro, M. C., & Fonseca, A. (2020) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph17228631 · Cited by 14 · see citing works
Usability, Feasibility, and Effect of a Biocueing Intervention in Addition to a Moderated Digital Social Therapy-Platform in Young People With Emerging Mental Health Problems: A Mixed-Method Approach
van Doorn, M., Nijhuis, L. A., Monsanto, A., van Amelsvoort, T., Popma, A., Jaspers, M., Noordzij, M. L., Öry, F. G., Álvarez‐Jiménez, M., & Nieman, D. H. (2022) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2022.871813 · Cited by 13 · see citing works
Increasing the effectiveness of psychotherapy in routine care through blended therapy with transdiagnostic online modules (PsyTOM): study protocol for a randomized controlled trial
Schaeuffele, C., Heinrich, M., Behr, S., Fenski, F., Hammelrath, L., Zagorscak, P., Jansen, A., Pohl, S., Boettcher, J., & Knaevelsrud, C. (2022) · Trials · doi:10.1186/s13063-022-06757-0 · Cited by 14 · see citing works
Qualitative analysis of university counselors’ online counseling experiences during the COVID-19 pandemic
Tuna, B., & Avcı, Ö. H. (2023) · Current Psychology · doi:10.1007/s12144-023-04358-x · Cited by 17 · see citing works
Designing personalized mental health interventions for anxiety: CBT therapists’ perspective
Balaskas, A., Schueller, S. M., Doherty, K., Cox, A. L., & Doherty, G. J. (2024) · International Journal of Human-Computer Studies · doi:10.1016/j.ijhcs.2024.103319 · Cited by 13 · see citing works
Making remote measurement technology work in multiple sclerosis, epilepsy and depression: survey of healthcare professionals
Andrews, J. A., Craven, M. P., Lang, A. R., Guo, B., Morriss, R. K., & Hollis, C. P. (2022) · BMC Medical Informatics and Decision Making · doi:10.1186/s12911-022-01856-z · Cited by 12 · see citing works
Psychological Analysis of Online Counselling Platforms Offering Mental Health Support
Java, S., Mohammed, H., & Bhardwaj, A. B. (2021) · International Conference on Computing, Communication and Networking Technologies (ICCCNT) · doi:10.1109/icccnt51525.2021.9579871 · Cited by 14 · see citing works
TONI - One for all? Participatory development of a transtheoretic and transdiagnostic online intervention for blended care
Behr, S., Fenski, F., Boettcher, J., Knaevelsrud, C., Hammelrath, L., Kovacs, G., Schirmer, W., Petrick, H., Becker, P., & Schaeuffele, C. (2024) · Internet Interventions · doi:10.1016/j.invent.2024.100723 · Cited by 11 · see citing works
A Blended Cognitive–Behavioral Intervention for the Treatment of Postpartum Depression: A Case Study
Branquinho, M., Canavarro, M. C., & Fonseca, A. (2022) · Clinical Case Studies · doi:10.1177/15346501221082616 · Cited by 11 · see citing works
“…also contributes to increasing women’s autonomy, by allowing them to advance in their own time and at their own pace, to access contents and exercises between sessions with a psychologist (Titzler et al., 2018), and reducing the shame and stigma associated with help-seeking (Ebert et al., 2018).”
BackgroundInfluential
Barriers to and facilitators of engaging with and adhering to guided internet-based interventions for depression prevention and reduction of pain-related disability in green professions: mixed methods study
Braun, L., Freund, J., Thielecke, J., Baumeister, H., Ebert, D. D., & Titzler, I. (2022) · JMIR Mental Health · doi:10.2196/39122 · Cited by 11 · see citing works
Self-citation
AI, automation and psychotherapy – A proposed model for losses and gains in the automated therapeutic encounter
Molden, H. (2024) · European Journal of Psychotherapy & Counselling · doi:10.1080/13642537.2024.2318628 · Cited by 11 · see citing works
Organizational Readiness for Implementing an Internet-Based Cognitive Behavioral Therapy Intervention for Depression Across Community Mental Health Services in Albania and Kosovo: Directed Qualitative Content Analysis
Doukani, A., Pashoja, A. C., Fanaj, N., Qirjako, G., Meksi, A., Mustafa, S., Vis, C., & Hug, J. (2021) · JMIR Formative Research · doi:10.2196/29280 · Cited by 11 · see citing works
Implementing internet-delivered cognitive behavioural therapy for patients with cardiovascular disease and psychological distress: a scoping review
Neher, M., Nygårdh, A., Nilsén, P., Broström, A., & Johansson, P. (2019) · European Journal of Cardiovascular Nursing · doi:10.1177/1474515119833251 · Cited by 11 · see citing works
A blended psychological intervention for postpartum depression: acceptability and preferences in women presenting depressive symptoms
Branquinho, M., Canavarro, M. C., & Fonseca, A. (2021) · Journal of Reproductive and Infant Psychology · doi:10.1080/02646838.2021.1969350 · Cited by 11 · see citing works
Determinants of psychotherapists’ attitudes to online psychotherapy
Rutkowska, E., Furmańska, J., Lane, H., Marques, C., Martins, M. J., Sahar, N. U., Meixner, J. M., Tullio, V., Argo, A., & Barros, D. M. B. (2023) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2023.1196907 · Cited by 10 · see citing works
Resources, support, and integration as potential barriers and facilitators to the implementation of blended therapy in the routine care of inpatients: a qualitative study
Gupta, N., Leuba, S., Seifritz, E., Berger, T., & Kawohl, W. (2024) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2024.1417784 · Cited by 10 · see citing works
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Authors: Titzler, I., Saruhanjan, K., Berking, M., Riper, H., & Ebert, D. D.
Affiliations: Friedrich-Alexander-Universität Erlangen-Nürnberg (DE)
Vrije Universiteit Amsterdam (NL)
Corresponding author: Titzler, Ingrid
ORCID: Titzler, Ingrid
Saruhanjan, Karina
Berking, Matthias
Riper, Heleen
Ebert, David Daniel
Venue: Internet Interventions
Publisher: Elsevier BV
Published: 2018-06
Volume: 12
Pages: 150-164
ISSN: 2214-7829 (ISSN-L)
DOI: 10.1016/j.invent.2018.01.002
PMC: PMC6096333
OpenAlex: W2782631640
Cited by: 176
References: 75
Citations by year: 2026: 15 · 2025: 21 · 2024: 21 · 2023: 17 · 2022: 34 · 2021: 33 · 2020: 17 · 2019: 15 · 2018: 3
FWCI: 21.44
Type: journal article
Language: en
Open access: gold
doi.org
Licence: cc-by
www.elsevier.com/tdm/userlicense/1.0/ (tdm)
creativecommons.org/licenses/by/4.0/ (vor)
Locations: Internet Interventions (publishedVersion, cc-by)
Europe PMC (PubMed Central) (publishedVersion, cc-by)
PubMed Central (publishedVersion, cc-by)
PubMed (publishedVersion)
Pure Amsterdam UMC (publishedVersion, other-oa)
Amsterdam UMC (VU Amsterdam) - Institutional Repository (publishedVersion, other-oa)
VU Research Portal (publishedVersion, other-oa)
DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
OPUS Repository (Kooperativer Bibliotheksverbund Berlin-Brandenburg) (submittedVersion, cc-by)
Data Archiving and Networked Services (DANS) (submittedVersion, other-oa)
Funders: European Commission (FP7)
Topics: Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Telemedicine and Telehealth Implementation
Keywords: blended therapy, depression, cognitive behavioral therapy, implementation barriers and facilitators, therapist perspectives, Theoretical Domains Framework, therapeutic relationship, treatment gap, implementation in routine care, patient motivation, face-to-face classes, general practitioners, digital mental health interventions

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

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