Practitioners’ experience of the working alliance in a blended cognitive–behavioural therapy intervention for depression: qualitative study of barriers and facilitators

Abstract

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.

Implementing Technologies to Enhance Coordinated Specialty Care Framework: Implementation Outcomes From a Development and Usability Study

“…While considering what may have facilitated higher levels of adoption and feasibility, this project suggested that the versality and multicomponent design, rather than the complexity, of DMHIs is important as evidenced by the diversity of responses to how clinicians and patients imagined the DMHI could be used to align with treatment goals. This is reflective of similar findings, which found that approaching DMHI development from a versatile rather than a complex perspective may be preferable [ 21 ]. Results from the case examples and follow-up survey responses also suggest that DMHI autonomy is important to allow the DMHI to appropriately align and augment the unique clinical styles of clinicians and the needs of patients, which has also been evident in other recent findings [ 22 ].…”

Digital mental health: challenges and next steps

“…Policy makers need also to consider factors outside the clinic in order to integrate these technologies more fully into the mental healthcare system. These include providing proper reimbursement for their use and the costs of staffing and infrastructure, in order to ensure successful implementation and continued use 1 30…”

Barriers to and Facilitators of a Blended Cognitive Behavioral Therapy Program for Depression and Anxiety Based on Experiences of University Students: Qualitative Interview Study

“…The 6-week bCBT intervention comprised 6 face-to-face individual CBT sessions via videoconferencing combined with the depression or anxiety module of the app. 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.…”

“…Thus, to increase treatment uptake among students with depression or anxiety symptoms, there is a need for bCBT approaches that fit therapists’ as well as patients’ needs and preferences [ 39 ]. 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. A study by Etzelmueller et al [ 41 ] reported predominantly positive experiences with a bCBT program among patients with major depressive disorder.…”