Cited by 189Digital Mental Health InterventionsTelemedicine and Telehealth ImplementationHealth Literacy and Information Accessibility

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Negative Effects of Internet Interventions: A Qualitative Content Analysis of Patients' Experiences with Treatments Delivered Online

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Rozental, Alexander, Boettcher, Johanna, Andersson, Gerhard, Schmidt, Brad, Carlbring, Per·2015·Cognitive Behaviour Therapy

DOI 10.1080/16506073.2015.1008033

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Abstract

Internet interventions are defined as the delivery of health care-related treatments via an online or a smartphone interface, and have been shown to be a viable alternative to face-to-face treatments. However, not all patients benefit from such treatments, and it is possible that some may experience negative effects. Investigations of face-to-face treatments indicate that deterioration occurs in 5-10% of all patients. The nature and scope of other negative effects of Internet interventions is, however, largely unknown. Hence, the current study explored patients' reported negative experiences while undergoing treatments delivered via the Internet. Data from four large clinical trials (total N = 558) revealed that 9.3% of patients reported some type of negative effects. Qualitative content analysis was used to explore the patients' responses to open-ended questions regarding their negative experiences. Results yielded two broad categories and four subcategories of negative effects: patient-related negative effects (insight and symptom) and treatment-related negative effects (implementation and format). Results emphasize the importance of always considering negative effects in Internet-based interventions, and point to several ways of preventing such experiences, including regular assessment of negative events, increasing the flexibility of treatment schedules and therapist contact, as well as prolonging the treatment duration.

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10.1002/1098-240X(200008)23:43.0.CO;2-G · DOI

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Batterham, P. J., Christensen, H. M., Calear, A. L., Werner‐Seidler, A., & Kazan, D. (2020) · Archives of Suicide Research · doi:10.1080/13811118.2020.1848671 · Cited by 11
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“…least one NE attributed to an IMI range from 8.6 % to 51.9 % (Boettcher et al., 2014; Braun et al., 2021, 2022; Fenski et al., 2021; Oehler et al., 2021; Rozental et al., 2015), the rates of NEs unrelated to an IMI seem to be higher (Braun et al., 2021; Schlicker et al., 2020; Zarski et al., 2021).”
BackgroundInfluential
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Background
Metacognitive Training Online
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Background
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“At the 3-month follow-up assessment (t2), any adverse effects will be identified using Rozental’s Negative Effects of Internet Interventions [46].”
Method
Digitale Hoffnungsträger?
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Leroux, J., Johnston, N., Brown, A.-A., Mihic, A., DuBois, D., & Trudell, A. (2022) · INQUIRY: The Journal of Health Care Organization, Provision, and Financing · doi:10.1177/00469580221097427 · Cited by 4
“In addition to investigating severe adverse events resulting from internet interventions, researchers are pointing to other types of negative effects, including deterioration, less serious adverse events, novel symptoms, dropout, nonresponse, unwanted events.(50) Future research would benefit from using an open system…”
Background
Efficacy of Smartphone Apps in Patients With Depressive Disorders: A Systematic Review
Hernández-Gómez, A., Valdés-Florido, M. J., Lahera, G., & Andrade‐González, N. (2022) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2022.871966 · Cited by 4
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“A study conducted by Rozental et al. (2015) showed that some adverse effects of online treatment exist for adults they described as having psychiatric disorders.”
Background
Comparing a mindfulness- and CBT-based guided self-help Internet- and mobile-based intervention against a waiting list control condition as treatment for adults with frequent cannabis use: a randomized controlled trial of CANreduce 3.0
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“Rozental A, Boettcher J, Andersson G, Schmidt B, Carlbring P. Negative effects of internet interventions: a qualitative content analysis of patients’ experiences with treatments delivered online.”
Method
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Stephenson, K. R., Latimer, S. R. E., Zippan, N., & Brotto, L. A. (2023) · Archives of Sexual Behavior · doi:10.1007/s10508-023-02685-5 · Cited by 4
“…like eSense have many upsides in terms of cost and scalability (e.g., Batterham et al., 2022; Dear et al., 2020), it is important to identify populations for which such an approach may be less effective, or even contraindicated (e.g., Marks & Cavanagh, 2009; Rozental et al., 2015, 2017).”
Background
Internet- und mobilbasierte Interventionen zur Prävention und Behandlung psychischer Störungen
Ebert, D. D., Zarski, A., Berking, M., & Baumeister, H. (2016) · Springer eBooks · doi:10.1007/978-3-662-49504-9_20 · Cited by 4
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Self-citation
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Method
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“Negative effects are known to occur following most psychological treatments (Boettcher et al., 2014; Rozental et al., 2015), but this remains a relatively recent topic in ICBT research (Rozental et al., 2018).”
InfluentialSelf-citation
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Hegerl, U., Dogan-Sander, E., Oehler, C., Sander, C., & Stöber, F. (2018) · Springer eBooks · doi:10.1007/978-3-662-57611-3_4 · Cited by 2
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“Qualitative methods have previously been used to investigate various aspects of digital mental health interventions, such as acceptability and usability [16], therapists’ experiences of providing treatment [17], and participants’ experiences of negative effects [18].”
BackgroundMethodSelf-citation
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“Fifth, reporting UE can be susceptible by social desirability effects, such as patients not wanting to report UE if they are satisfied with their treatment in general, or primacy and recency effects (Rozental et al., 2015).”
Self-citation
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Self-citation
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“Monitoring adverse effects effectively prevents them and helps reduce dropout rates in web-based interventions [38, 39].”
Patients prefer easy adverse event reporting: Observational study within clinical trial
Lukka, L., Vesterinen, M., Juvonen, J. J., Palva, S., & Palva, J. M. (2025) · Digital Health · doi:10.1177/20552076251345894 · Cited by 1
“18 Another study found that 22.7% of participants with self-reported depressive symptoms using a self-help smartphone application reported AEs when measured using a standardized inventory for assessing negative effects.”
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“Nevertheless, this rate exceeded both our previous trial (9.0%; Bjureberg et al., 2023), and typical rates reported in iCBT (9.3%; Rozental et al., 2015).”
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“In particular, qualitative studies have been useful for analyzing clients’ perceptions of a wide range of domains, including facilitators and barriers [19], acceptability [20], nonadherence [21], dropout [22], or negative effects [23] of IBTs.”
User Experiences and Perceptions of Internet Interventions for Depression
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“Despite the well-established advantages of internet-based interventions (Andersson et al., 2019; Andersson and Cuijpers, 2008; Andersson and Titov, 2014), unwanted effects can also occur (Boettcher et al., 2014; Karyotaki et al., 2018; Rozental et al., 2015).”
Additional file 1 of Knowledge gain and usage of knowledge learned during internet-based CBT treatment for adolescent depression - a qualitative study
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Additional file 1 of Experiences of internet-based cognitive behavioural therapy for depression and anxiety among Arabic-speaking individuals in Sweden: a qualitative study
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Additional file 4 of Barriers and facilitators to the implementation of social robots for older adults and people with dementia: a scoping review
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Additional file 3 of Barriers and facilitators to the implementation of social robots for older adults and people with dementia: a scoping review
Koh, W. Q., Felding, S. A., Budak, K. B., Toomey, E., & Casey, D. (2021) · Figshare · doi:10.6084/m9.figshare.14759576
Additional file 1 of Self-esteem in new light: a qualitative study of experiences of internet-based cognitive behaviour therapy for low self-esteem in adolescents
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Additional file 1 of The experience of participating in an internet-based cognitive behavioral therapy program among patients with cardiovascular disease and depression: a qualitative interview study
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Additional file 1 of Barriers and facilitators to the implementation of social robots for older adults and people with dementia: a scoping review
Koh, W. Q., Felding, S. A., Budak, K. B., Toomey, E., & Casey, D. (2021) · Figshare · doi:10.6084/m9.figshare.14759570
Additional file 2 of Barriers and facilitators to the implementation of social robots for older adults and people with dementia: a scoping review
Koh, W. Q., Felding, S. A., Budak, K. B., Toomey, E., & Casey, D. (2021) · Figshare · doi:10.6084/m9.figshare.14759573
Client perspectives of internet-based treatment for depression in Arabic-speaking countries
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“The proportion of participants reporting at least one negative change in the study was comparable to the findings of Rozental et al. [46], in which an average of 9.3% of IBI participants reported at least one adverse event.”
Influential
Übersichtsarbeiten / Review Articles. Digitale Psychotherapie bei Depressionen im Kindes- und Jugendalter: Evidenzbasierte Wirksamkeit, Rahmenbedingungen und Empfehlungen für die klinische Praxis / Digital Psychotherapy for Depression in Children and Adolescents: Evidence-Based Efficacy, Conditions and Recommendations for Clinical Practice
Lüttke, S. (2026) · Praxis der Kinderpsychologie und Kinderpsychiatrie · doi:10.13109/prkk.2026.75.4.337
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Sarrión-Castelló, P., Desdentado, L., Rodríguez, A. D., Westerhof, G. J., Bohlmeijer, E. T., Cebolla, A., & Baños, R. (2026) · Contemporary Clinical Trials Communications · doi:10.1016/j.conctc.2026.101663
“Additionally, research has shown that internet-based interventions may have negative effects in some cases [74], including the worsening of existing symptoms or the emergence of new symptoms not directly addressed by the intervention.”
Thérapie cognitive et comportementale sur Internet pour le personnel de la sécurité publique : analyse qualitative de la rétroaction des usagères et des usagers du Québec
Fournier, A., Rivest, M.-C., Price, J. A. B., & Hadjistavropoulos, H. D. (2026) · Revue québécoise de psychologie · doi:10.7202/1126758ar
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“In some cases, these extend beyond subjective experiences to include symptom deterioration or the emergence of new symptoms in a subset of patients (Rozental et al., 2015; Ebert et al., 2016; Fenski et al., 2025).”
Internet-Delivered Affect Phobia Therapy for Neuroticism: Results from an Uncontrolled Pilot Study with 6-Month Follow-Up
Lindegaard, T., Berg, M., Käll, A., Lockman, J., Schönberg, E., Björklund, M., Frederick, R. J., & Andersson, G. (2026) · Psychodynamic Psychiatry · doi:10.1521/pdps.2026.54.3.511
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Designing a Mobile App for Post Traumatic Stress Disorder: Insights From Lived Experience and Clinical Practice
Laugharne, R. A., Loizou, M., Varga, M. N., Lin, S., Lennard, S., Srdanovic, B. D., Farrell, R. P., & Shankar, R. (2026) · Healthcare Technology Letters · doi:10.1049/htl2.70098
“Importantly, PLE strongly rejected patronising language and unsolicited notifications, echoing concerns raised in prior qualitative studies that poorly designed digital feedback can exacerbate shame, self-criticism and disengagement in trauma survivors [ 20 ].”
Internetbasierte Selbsthilfe bei Einsamkeit aus Sicht der Nutzenden
Seewer, N., & Krieger, T. (2026) · Die Psychotherapie · doi:10.1007/s00278-026-00881-x

Authors: Rozental, A., Boettcher, J., Andersson, G., Schmidt, B., & Carlbring, P.
Affiliations: Stockholm University (SE)
Freie Universität Berlin (DE)
Linköping University (SE)
Florida State University (US)
Corresponding author: Rozental, Alexander
ORCID: Rozental, Alexander
Boettcher, Johanna
Andersson, Gerhard
Carlbring, Per
Venue: Cognitive Behaviour Therapy
Publisher: Informa UK Limited
Published: 2015-02-23
Volume: 44
Issue: 3
Pages: 223-236
ISSN: 1650-6073 (ISSN-L)
1651-2316
DOI: 10.1080/16506073.2015.1008033
OpenAlex: W2061701598
Cited by: 189
References: 64
Citations by year: 2026: 10 · 2025: 19 · 2024: 15 · 2023: 19 · 2022: 13 · 2021: 23 · 2020: 23 · 2019: 16 · 2018: 20 · 2017: 11 · 2016: 12 · 2015: 8
FWCI: 27.55
Type: journal article
Language: en
Open access: green
urn.kb.se
Licence: other-oa
Locations: Cognitive Behaviour Therapy (publishedVersion)
PubMed (publishedVersion)
DiVA (Stockholm University) (submittedVersion, other-oa)
UCL Discovery (University College London) (submittedVersion)
Topics: Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Telemedicine and Telehealth Implementation
Health Sciences › Health Professions › General Health Professions › Health Literacy and Information Accessibility
Keywords: online intervention, online therapy, adverse outcomes, patient experience, treatment deterioration, treatment implementation, treatment format, therapist contact, treatment duration, treatment scheduling
MeSH terms: Mental Disorders, Clinical Trials as Topic, Humans, Therapy, Computer-Assisted, Patient Satisfaction, Internet, Qualitative Research

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Negative Effects of Internet Interventions: A Qualitative Content Analysis of Patients' Experiences with Treatments Delivered Online

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