Advantages and disadvantages of online and blended therapy: replication and extension of findings on psychotherapists' appraisals
Open accessAbstract
Therapists hold a key role for the uptake of digital mental health interventions (DMHI) within regular care services but have demonstrated cautious attitudes towards such interventions. It is relevant to explore in detail what factors may positively influence therapists' perception when considering DMHI implementation within routine care. We recently assessed therapist views towards Internet-based and blended treatment in Austria (low implementation level). The present study aims at testing the reliability of previous findings, and moreover, it compares therapists' appraisals to a country with advanced DMHI implementation (Sweden). An online survey was conducted February through June of 2019. Respondents were recruited via email and social media. The survey assessed first-hand experience with Internet-based treatment (IT) and blended treatment (BT). To start, the survey presented a short informational video to half of the respondents, then assessed therapists' views on 17 advantages and 13 disadvantages of IT and BT on 6-point Likert scales. In total N = 300 therapists responded to the invitation, of which N = 165 provided full survey data (Germany 114/220, 52%; Sweden 51/80, 64%). German therapists rated the advantages of IT and BT as neutral (IT, M = 3.6; BT, M = 3.8) and to some extent agreed with disadvantages of IT (IT, M = 4.5; BT, M = 3.5). In comparison, Swedish therapists rated significantly greater advantages (IT, M = 4.6; BT, M = 4.5) and less disadvantages (IT, M = 3.2; BT, M = 2.8). Effect sizes ranged from d = 0.89 to d = 1.83; all P's < .001. Those with first-hand experience with DMHI reported more positive appraisals in both countries. No significant effect was found for exposure to the short informational video. The German sample represented essential characteristics of current German therapists; in comparison Swedish respondents skewed towards younger less experienced therapists (P's < .001). Those confounders accounted for a small non-significant proportion of variance (0.1–4.7%). We found that therapists considered blended treatment to have less disadvantages than Internet treatment, and that first-hand experience with DMHI, but not exposure to an acceptance facilitating video clip, predicted greater acceptability on individual level. The responses among German therapists closely resembled findings from our preceding study in Austria, indicating that reliable results can be achieved in small survey studies if sample and population parameters correspond. Swedish therapists held significantly more favorable attitudes towards both interventions. The comparison between countries, however, is limited by a number of potential confounding variables.
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Overall, psychotherapists considered blended care to have fewer disadvantages than stand-alone Internet-based interventions.
“Overall, psychotherapists considered BC to have fewer disadvantages than stand-alone IBIs.”
From TONI - One for all? Participatory development of a transtheoretic and transdiagnostic online intervention for blended care (2024) · cites this paper as Schuster et al., 2020
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“Both therapists and patients view the rigidity and nonexclusiveness of existing digital tools as the reasons for their current limited use [52].”
BackgroundSimon, N. A., Ploszajski, M., Lewis, C., Smallman, K., Roberts, N. P., Kitchiner, N., Brookes‐Howell, L., & Bisson, J. I. (2021) · Psychology and Psychotherapy Theory Research and Practice · doi:10.1111/papt.12341 · Cited by 19 · see citing works
Rognsvåg, T., Lindberg, M. F., Lerdal, A., Stubberud, J., Furnes, O., Holm, I., Indrekvam, K., Lau, B., Rudsengen, D., Skou, S. T., et al. (2021) · BMC Health Services Research · doi:10.1186/s12913-021-07177-7 · Cited by 18 · see citing works
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Békés, V., Bőthe, B., & Doorn, K. A. (2025) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.70085 · Cited by 16 · see citing works
Blended Treatment for Depressive Disorders in Youth: a Narrative Review
Rasing, S. P. A. (2020) · International Journal of Cognitive Therapy · doi:10.1007/s41811-020-00088-1 · Cited by 15 · see citing works
“Most important disadvantages that were mentioned by therapists were risks in the therapeutic process, such as limited nonverbal signals, missing an increase in symptoms, or dealing with crisis (Schuster et al. 2018, 2020).”
BackgroundInfluentialPérez, J. C., Fernández, O., Cáceres, C., Carrasco, A. S., Moessner, M., Bauer, S., Espinosa-Duque, D., Gloger, S., & Krause, M. (2021) · JMIR Mental Health · doi:10.2196/26814 · Cited by 20 · see citing works
Schuster, R., Fischer, E., Jansen, C., Napravnik, N., Rockinger, S., Steger, N., & Laireiter, A.-R. (2022) · Internet Interventions · doi:10.1016/j.invent.2022.100551 · Cited by 15 · see citing works
Self-citationBielinski, L. L., & Berger, T. (2020) · Counseling Psychology and Psychotherapy · doi:10.17759/cpp.2020280305 · Cited by 14 · see citing works
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
Kalde, J., Atik, E., Stricker, J. H., Schückes, M., Neudeck, P., Pittig, A., & Pietrowsky, R. (2023) · Psychotherapy Research · doi:10.1080/10503307.2023.2277866 · Cited by 12 · see citing works
“…interventions through mobile phone or web applications (Erbe et al., 2017). bCBT is thought to address shortcomings of traditional face-to-face CBT by supporting treatment adherence between sessions, thereby extending CBT treatment to patients ’ everyday lives (Schuster et al., 2018; 2020a).”
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
“Whilst there are studies about barriers and facilitators for psychother-apists in the implementation of BC, to our knowledge, this is the first study to analyze the requirements of PWLE as well as psychotherapists of cognitive-behavioral, systemic, and psychodynamic approaches alike.”
BackgroundInfluentialVideoconferencing psychotherapy from a psychodynamic point of view. A qualitative analysis
Laczkovics, C., Blüml, V., Kapusta, N. D., Hoffmann‐Lamplmair, D., Casini, E., Bazan, M., Torres, M. Á. G., Lendvay, J., Normandin, L., Nowacki, H., et al. (2023) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2023.1235478 · Cited by 11 · see citing works
Bisson, J. I., Ariti, C. A., Cullen, K., Kitchiner, N., Lewis, C., Roberts, N. P., Simon, N. A., Smallman, K., Addison, K., Bell, V., et al. (2023) · Health Technology Assessment · doi:10.3310/ytqw8336 · Cited by 8 · see citing works
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“110 114 In the studies included in this review evaluating these aspects, no noticeable issues arise.”
Digital interventions in mental health: challenges and perspectives
Ivanets, N. N., Kinkulkina, M. A., & Tikhonova, Y. G. (2023) · National Health Care (Russia) · doi:10.47093/2713-069x.2023.4.2.5-14 · Cited by 7 · see citing works
Blended Care: Stand der Forschung und Implementierungsmöglichkeiten
Fenski, F., Behr, S., Schaeuffele, C., Boettcher, J., & Knaevelsrud, C. (2023) · Der Nervenarzt · doi:10.1007/s00115-023-01579-0 · Cited by 7 · see citing works
Connected Mental Health Solutions: Global Attitudes, Preferences, and Concerns
Drissi, N., Ouhbi, S., Serhani, M. A., Marques, G., & Díez, I. D. L. T. (2022) · Telemedicine Journal and e-Health · doi:10.1089/tmj.2022.0036 · Cited by 7 · see citing works
Case report for an internet- and mobile-based intervention for internet use disorder
Bernstein, K., Zarski, A., Pekarek, E., Schaub, M. P., Berking, M., Baumeister, H., & Ebert, D. D. (2023) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2023.700520 · Cited by 6 · see citing works
["Achieving closeness in video treatment despite distance"].
Gumz, A., Kanal, S., Ünser, A., Kästner, D., & Beck-Hiestermann, F. M. L. (2021) · PubMed Central · doi:10.1007/s00278-021-00529-y · Cited by 6 · see citing works
Child therapists’ views and experiences of video conference psychotherapy with children
Usluoğlu, F., & Balık, E. A. (2023) · Current Psychology · doi:10.1007/s12144-023-04820-w · Cited by 5 · see citing works
“…mentioned difficulties and limitations of VCP implementations similar to the distant psychotherapy implementations reported in the literature (Békés et al., 2021; Cataldo et al., 2021; Haberstroh et al., 2007, 2008; Rochlen et al., 2004; Schuster et al., 2020; Stoll et al., 2020; Tanrikulu, 2009).”
Dech, M., Klawohn, J., & Romanczuk-Seiferth, N. (2022) · Verhaltenstherapie · doi:10.1159/000524332 · Cited by 6 · see citing works
“Wahrgenommene Barrieren und mögliche Maßnahmen Es konnten drei quantitative Studien [Schuster et al., 2018a; Baumeister et al., 2020; Schuster et al., 2020] sowie drei qualitative Studien [Titzler et al., 2018; Paul et al., 2019; Mol et al., 2020] identifiziert werden, in denen von…”
BackgroundInfluentialSextl-Plötz, T., Titzler, I., Schmidt-Hantke, J., Denninger, M., Steubl, L., Baumeister, H., Ebert, D. D., & Zarski, A. (2025) · Digital Health · doi:10.1177/20552076251377943 · Cited by 4 · see citing works
Stalujanis, E., Engesser, D., Kemmerer, P., Dotzauer, L., der Salm, S. M. A. V., Scheibe, S., Mergenthal, K., Voigt, K., & Singer, S. (2025) · Journal of Medical Internet Research · doi:10.2196/78597 · Cited by 4 · see citing works
“This finding has been consistently reported in previous studies beyond several mHealth applications and settings [26,28-30 , 45 ].”
Nordby, E., Schønning, V., Barnes, A., Denyer, H., Kuntsi, J., Lundervold, A., & Guribye, F. (2025) · BMC Psychiatry · doi:10.1186/s12888-025-06476-1 · Cited by 4 · see citing works
Mohamadpour, F. (2023) · Frontiers in Psychology · doi:10.3389/fpsyg.2023.1128308 · Cited by 4 · see citing works
Wüllner, S., Hecker, T., Flottmann, P., & Hermenau, K. (2025) · PLOS mental health. · doi:10.1371/journal.pmen.0000270 · Cited by 3 · see citing works
Mobile Applications to Promote Mental Health among Breast Cancer Patients: A Rapid Review
BorjAlilu, S., Karbakhsh, M., Lotfi, M., Haghshenas, E., & Kaviani, A. (2023) · Archives of Breast Cancer · doi:10.32768/abc.2023102103-113 · Cited by 3 · see citing works
Ganapathy, A., Casey, L. M., Rowland, D. P., Grady, A. B., Sotheren, K. V., & Clough, B. A. (2023) · Advances in Mental Health · doi:10.1080/18387357.2023.2254864 · Cited by 4 · see citing works
Jamshidi, F., de Jongh, A., Rajabi, S., Dehghani, Y., & Pakizeh, A. (2025) · Cognitive Therapy and Research · doi:10.1007/s10608-025-10641-x · Cited by 2 · see citing works
García-Huércano, C., Cerón, S. C., Martínez-Vispo, C., Bellón, J. Á., Morejón, A. R., Tamayo‐Morales, O., & Moreno-Peral, P. (2025) · Psychological Medicine · doi:10.1017/s0033291725102262 · Cited by 2 · see citing works
“…them at any time and from virtually any location, lower costs compared to face-to-face interventions, the ability to bridge geographic distances, and the option to revisit therapy material as needed (Khanna, Aschenbrand, & Kendall, 2007; Schuster, Topooco, Keller, Radvogin, & Laireiter, 2020).”
Fenski, F., Böttcher, J., & Hörz‐Sagstetter, S. (2023) · PPmP - Psychotherapie · Psychosomatik · Medizinische Psychologie · doi:10.1055/a-2050-3413 · Cited by 2 · see citing works
Digital Interventions for Attention Deficit/Hyperactivity Disorder
Marten, L., Kaiser, A., & Häge, A. (2024) · Integrated science · doi:10.1007/978-3-031-76414-1_11 · Cited by 2 · see citing works
Atik, E., Kalde, J., Stricker, J. H., Schückes, M., Neudeck, P., Pietrowsky, R., & Pittig, A. (2025) · Cognitive Behaviour Therapy · doi:10.1080/16506073.2025.2503834 · Cited by 2 · see citing works
Panitz, K., Wagenaar, C., Sahan, F., Kairies‐Schwarz, N., Guthardt, L., Bau, J., Loerbroks, A., Vomhof, M., Zinn, M., Pischke, C. R., et al. (2026) · Frontiers in Digital Health · doi:10.3389/fdgth.2026.1656614 · Cited by 2 · see citing works
Behr, S., Fenski, F., Böttcher, J., Knaevelsrud, C., Hammelrath, L., Kovacs, G., Schirmer, W., Becker, P., & Schaeuffele, C. (2023) · doi:10.31234/osf.io/8xu5z · Cited by 2 · see citing works
Near and far: Representation of online psychotherapy in a group of clients
Cordella, B., Miano, A., & Pennella, A. (2023) · Rivista di Psicologia Clinica · doi:10.3280/rpc1-2023oa15698 · Cited by 1 · see citing works
Social workers’ perspectives on adapting methods during the COVID-19 pandemic
Khatib, A., Kapulnik, E., & Abo‐Rass, F. (2024) · Journal of Social Work · doi:10.1177/14680173241258918 · Cited by 1 · see citing works
“…it has been found that barriers to seeking and receiving treatment for mental health problems can be overcome by increasing the accessibility and the fl exibility of treatment through online interventions (Casey et al., 2013; Lo Iacono et al., 2016; Schuster et al., 2018; Schuster et al., 2020).”
The Use of Mobile Apps in Adolescent Psychotherapy: Assessment of Psychotherapists’ Perspectives
Wüllner, S., Hermenau, K., Hecker, T., & Siniatchkin, M. (2025) · JMIR Formative Research · doi:10.2196/65788 · Cited by 1 · see citing works
“Psychotherapists play an important role in integrating MHAs into adolescent psychotherapies [38,61].”
Tiburcio, M., Martínez-Vélez, N. A., Pérez, R. P. B., Huss, J. H., & Eichenberg, C. (2025) · Frontiers in Digital Health · doi:10.3389/fdgth.2025.1584171 · Cited by 1 · see citing works
Silva, S., Magalhães, N., Salgado, J., & Cunha, C. A. C. (2025) · Journal of Contemporary Psychotherapy · doi:10.1007/s10879-025-09695-5 · Cited by 1 · see citing works
“Prior experience with digital interven - tions is linked to more positive appraisals, while therapists highlight flexibility, greater access to psychoeducational content, and stronger carryover effects between sessions (Bielinski et al., 2022 ; Schuster et al., 2020 ).”
Kneubühler, A. M., von Känel, E., Grgić, K., Munkovic, E., Berger, T., & Bielinski, L. L. (2026) · JMIR Mental Health · doi:10.2196/78079 · Cited by 1 · see citing works
“BT has been perceived more favorably than stand-alone digitally delivered interventions by clinicians [13,18,19].”
Luyten, P., Speybrouck, D., Martin, P., Claes, S. J., Midgley, N., Eeren, H. V., Busschbach, J. J. V., & Tang, E. (2026) · JMIR Research Protocols · doi:10.2196/80511 · Cited by 4 · see citing works
“…[15,27,30], and studies have suggested that although therapists and patients both report advantages associated with blended psychotherapy, they also experience disadvantages and barriers in relation to blended psychotherapy for depression in terms of acceptability and suitability [28,42-44].”
Mondragón-Gómez, R., Martínez-Vélez, N., Fernández-Torres, M., & Sainz, M. A. T. (2022) · International Journal of Mental Health and Addiction · doi:10.1007/s11469-021-00747-0 · Cited by 1 · see citing works
Blended Care für Jugendliche mit depressiven Erkrankungen aus der Sicht von Behandelnden
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Digital Technology Interventions for Preventing and Treating Youth Depression
Lira, D., & Martínez, V. (2022) · Depression and personality · doi:10.1007/978-3-031-13029-8_4 · Cited by 1 · see citing works
Raya-Ayala, L. E., & González-Celis, A. L. (2022) · Escritos de Psicología · doi:10.24310/espsiescpsi.v15i2.14665 · Cited by 1 · see citing works
Atik, E., Schückes, M., & Apolinário-Hagen, J. (2022) · doi:10.2196/preprints.36806 · Cited by 1 · see citing works
Schaeuffele, C., Heinrich, M., Behr, S., Fenski, F., Hammelrath, L., Zagorscak, P., Jansen, A., Pohl, S., Boettcher, J., & Knaevelsrud, C. (2022) · doi:10.31234/osf.io/ugwsx · Cited by 1 · see citing works
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Natural environment and its psychological effects: Exploring individuals' narratives
Abate, R., & Rogier, G. (2023) · Rivista di Psicologia Clinica · doi:10.3280/rpc1-2023oa15851
Ruzek, J. I. (2024) · CBT: science into practice · doi:10.1007/978-3-031-72720-7_3
van Lotringen, C. M., Zirnheld, A., Kelders, S. M., Westerhof, G. J., & Noordzij, M. L. (2025) · medRxiv · doi:10.1101/2025.02.26.25322921
Hamilton, J., Brennan, K., Brown, D., & Barnhofer, T. (2025) · Mindfulness · doi:10.1007/s12671-025-02598-5
“Meta-analytic research provides encouraging evidence for the use of these interventions (Nunes-Zlotkowski et al., 2024) and therapists’ appraisals of the general approach are positive (Schuster et al., 2020).”
Pereira, A. I., Cordeiro, D., Gomes-Pereira, B., Saraiva, M., Vicente, V. N., Paulino, B., Pereira, A. M., Perdigão, M., Oliveira, M. F., & Moreira, H. (2025) · Child & Family Behavior Therapy · doi:10.1080/07317107.2025.2515290
“Nevertheless, few studies exploring clients’ perspectives on blended treatment suggest that when responses are based on experience, the perception of blended treatment is more favorable (Schuster et al., 2020).”
Jordan, S., Becker, P., Behr, S., Fenski, F., Knaevelsrud, C., Boettcher, J., & Schaeuffele, C. (2025) · Internet Interventions · doi:10.1016/j.invent.2025.100847
Charvát, M., Jochmannová, L., Sluková, P. Z., & Viktorová, L. (2025) · Psychology and Psychotherapy Theory Research and Practice · doi:10.1111/papt.70010
“…al., 2020) and are often associated with therapists' previous experience with the online modality (Austen & McGrath, 2006; Connolly et al., 2020; Doran & Lawson, 2021; Interian et al., 2018; Tohme et al., 2021) or professional experience (Cwikel & Enav, 2020; McLeod, 2007; Schuster et al., 2020).”
Bala, N. S., Bandi, S., Stephen, R., Dandu, R., & Balakrishnan, C. (2025) · Lecture notes in networks and systems · doi:10.1007/978-981-96-7807-5_14
Rayner, C. L., Bradshaw, C., & Davies, J. (2025) · Drug Science Policy and Law · doi:10.1177/20503245251391113
“Online delivery of psychoeducation before festivals may overcome these barriers by offering broader access, cost ef fi ciency, and convenience (Schuster et al., 2020).”
Exploring Patients’ Experiences in a Blended Transdiagnostic Group Treatment: Qualitative Study
Jiménez-Orenga, N., Fadrique‐Jiménez, A., García‐Palacios, A., Osma, J., Díaz‐García, A., & Bretón-López, J. M. (2026) · JMIR Human Factors · doi:10.2196/86016
“There are some qualitative studies on blended interventions from the patients’ [26,27] and the therapists’ points of view [28,29].”
- Authors
- Schuster, R., Topooco, N., Keller, A., Radvogin, E., & Laireiter, A.-R.
- Affiliations
- University of Salzburg (AT)
- Linköping University (SE)
- University of Vienna (AT)
- Corresponding author
- Schuster, Raphael
- Venue
- Internet Interventions
- Publisher
- Elsevier BV
- Published
- 2020-09
- Volume
- 21
- Pages
- 100326
- ISSN
- 2214-7829 (ISSN-L)
- PMC
- PMC7251770
- OpenAlex
- W3021166376
- Cited by
- 77
- References
- 61
- Citations by year
- 2026: 4 · 2025: 19 · 2024: 5 · 2023: 17 · 2022: 16 · 2021: 11 · 2020: 5
- FWCI
- 11.07
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- Internet Interventions (publishedVersion, cc-by-nc-nd)
- PubMed Central (publishedVersion, cc-by-nc-nd)
- PubMed (publishedVersion)
- DiVA (Linkoping University) (submittedVersion, other-oa)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Topics
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Telemedicine and Telehealth Implementation
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Keywords
- digital mental health interventions, online therapy, blended treatment, therapist attitudes, acceptability, implementation in routine care, therapist experience, cross-national comparison, Germany, Sweden, replication, informational videos, therapist characteristics, therapist gender, therapist workload, therapist motivation, therapist self-efficacy
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