Practitioners’ experience of the working alliance in a blended cognitive-behavioural therapy intervention for depression: qualitative study of barriers and facilitators
Open accessAbstract
BACKGROUND: Digital technologies have been widely acknowledged as a potentially useful resource for increasing mental healthcare access. The working alliance is a key influence on outcomes in conventional psychotherapy, but little is known about therapists' experiences of forming an effective working alliance in blended interventions that involve in-person psychotherapy and a digital programme. AIMS: To investigate psychological well-being practitioners' (PWPs') experiences of the working alliance in a trial of blended cognitive-behavioural therapy (b-CBT) for depression. Trial registration ISRCTN12388725. METHOD: Semi-structured qualitative interviews were conducted with 13 PWPs who delivered b-CBT in a two-arm, non-inferiority randomised controlled trial investigating the effectiveness of b-CBT compared with face-to-face CBT. Thematic analysis was used to analyse the data. RESULTS: Participants reported four facilitating factors when building and maintaining a working alliance in b-CBT: having more time to deliver treatment, access to a wider toolkit, capacity to tailor components of b-CBT and receiving appropriate training and support. Participants also identified four barriers to building and maintaining a working alliance: time and resource constraints, usability challenges, limited flexibility to tailor the digital programme to patients' needs and lack of confidence in delivering b-CBT. CONCLUSIONS: Our study is the first specifically to investigate practitioners' perceived facilitators and barriers to forming a working alliance in b-CBT for depression. Findings suggest that PWPs' experiences of the working alliance can be improved by: accounting for the time required to deliver b-CBT in service workflows to reduce time pressures; increasing opportunities to tailor the digital programme through offering transdiagnostic tools and adaptable features; and providing appropriate b-CBT training and technical support.
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Adequate training and minimizing the time burden of DMHI use with clients is important to European mental health professionals.
“Adequate training and minimizing the time burden of DMHI use with clients is also important to European mental health professionals [283138-40undefinedundefined].”
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 [40]
The Results sections on training and time in b-CBT report that training helped practitioners feel prepared and that the intervention added time to their workload. The Method (Participants) identifies them as psychological well-being practitioners recruited from UK services, so the study does not establish that these priorities apply to European mental health professionals generally or to DMHI use broadly. (LLM, conf=0.86)
Experimental — accuracy not yet measuredEuropean research shows that local mental health professionals value blended DMHIs that are flexible to use, can be customized to suit client needs, and help clients with symptom tracking and homework completion between therapy sessions.
“European research also shows that local mental health professionals value blended DMHIs that are flexible to use [3839], can be customized to suit client needs [283140], and help clients with symptom tracking and homework completion between therapy sessions [2838].”
A few studies have focused on therapists' perspectives regarding their expectations for and experiences with bCBT, but to date, there is little qualitative research on patients in general and with students in particular.
“A few studies have focused on therapists’ perspectives regarding their expectations for and experiences with bCBT [38,40], but to date, there is little qualitative research on patients in general and with students in particular.”
This study is the first to investigate factors related to the use (and nonuse) of an app within a bCBT program among students.
“Although there are some qualitative studies covering health care providers’ [40] and patients’ experiences with bCBT [41] as well as with stand-alone iCBT [54], this study is, to our knowledge, the first to investigate factors related to the use (and nonuse) of an app within a bCBT program among students.”
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- Authors
- Doukani, A., Free, C., Araya, R., Michelson, D., Cerga-Pashoja, A., & Kakuma, R.
- Affiliations
- London School of Hygiene & Tropical Medicine (GB)
- King's College London (GB)
- University of Sussex (GB)
- Corresponding author
- Doukani, Asmae
- Venue
- BJPsych Open
- Publisher
- Royal College of Psychiatrists
- Published
- 2022-07
- Volume
- 8
- Issue
- 4
- Pages
- e142-e142
- ISSN
- 2056-4724 (ISSN-L)
- PMC
- PMC9344874
- OpenAlex
- W4287220633
- Cited by
- 15
- References
- 34
- Citations by year
- 2026: 1 · 2025: 1 · 2024: 6 · 2023: 6 · 2022: 1
- FWCI
- 3.09
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Locations
- BJPsych Open (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- LSHTM Research Online (London School of Hygiene and Tropical Medicine) (acceptedVersion)
- Sussex Research Online (University of Sussex) (submittedVersion, cc-by)
- Figshare (submittedVersion, cc-by)
- Research Portal (King's College London) (submittedVersion, cc-by)
- Funders
- European Commission (603098)
- Topics
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Telemedicine and Telehealth Implementation
- Keywords
- therapeutic relationship, depression, digital mental health interventions, therapist experience, barriers and facilitators, service workflows
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