1 Advantages and disadvantages of web-based and ...

Advantages and disadvantages of web-based and blended therapy: Attitudes towards both interventions amongst licensed psychotherapists in Austria Raphael Schuster*1, Raffaela Pokorny2, Thomas Berger3, Naira Topooco4, Anton-Rupert Laireiter1,2 1. Outpatient Center for Clinical Psychology, Psychotherapy and Health Psychology, Department of Psychology, University of Salzburg, Salzburg, Austria 2. Faculty of Psychology, University of Vienna, Vienna, Austria 3. Department of Clinical Psychology and Psychotherapy, University of Berne, Berne, Switzerland 4. Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden

*Corresponding author: Raphael Schuster, MSc. Department of Psychology, University of Salzburg Hellbrunnerstraße 34, 5020 Salzburg, Austria [email protected]

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Abstract Background: Web-based and blended (face-to-face plus web-based) interventions for mental health disorders are gaining in significance. However, many licensed psychotherapists still have guarded attitudes towards computer-assisted therapy, hindering dissemination efforts. Objective: This study provides a therapist-centered evaluation of web-based and blended therapy, and aims at identifying commonalities and differences in attitudes towards both formats. Furthermore, it tests the impact of an information clip on expressed attitudes. Methods: In total, 95 Austrian psychotherapists were contacted and surveyed via their listed occupational e-mail address. An eight-minute information video was shown to half of the therapists, before 19 advantages and 13 disadvantages had to be rated on a six-point Likert-scale. Results: The sample resembled all assessed properties of Austrian psychotherapists (age, theoretical orientation, and region). Therapists did not hold a uniform overall preference. Instead, perceived advantages of both interventions were rated as neutral (t(94)= 1.89, p= .063; d= 0.11), whereas webbased interventions were associated with more disadvantages and risks (t(94)= 9.86, p 0.6) [33], we conducted a maximum likelihood FA (rotation based on Varimax-method) to roughly explore the basic factor structure of our questionnaire. The analysis revealed a single factor with high factor loadings (average λ = 0.680). Here, perceived advantages were related positively and disadvantages negatively to the identified factor. Detailed results of the FA are listed in Appendix B. Production of the video clip An eight-minute video clip presented the definitions, and the usual content of web-based and blended interventions, as well as their evidence-base. There was no particular sequence on advantages and disadvantages of both interventions. The video clip consisted of a sequence of presentation slides depicting graphs, tables and text-based information on unguided and guided web-based interventions, as well as on blended therapy. A professional rehearsal voice recorded the audio stream. The video did not feature any visible speaker or interview partner (e.g. psychologist, professor, or patient). Procedure Therapists were contacted via the national register for licensed psychotherapists administered by the Federal Ministry of Health and Women in Austria, renamed and reorganized into Federal Ministry of Labour, Social Affairs, Health and Consumer Protection (Bundesministerium für Arbeit, Soziales, Gesundheit und Konsumentenschutz, www.bmgf.gv.at) after state elections of 2017. The register contains a comprehensive list of all licensed psychotherapists in Austria (N = 8643), and is frequently used for research purposes. The entire register was downloaded, and 1050 addresses were selected at random (12.1%). Therapists were invited to participate in the survey via e-mail, and the survey was provided via an online survey platform (LimeSurvey). The cover letter was entitled Survey on webbased and blended interventions in psychotherapy and entailed information on the study background, purpose and privacy issues, as well as detailed contact information. Following best practice guidelines (e.g. Tailored Design Method [34]) efforts were made to keep the perceived costs of responding low (e.g. easy to complete), to address the relevance (e.g. currency of the topic) and the benefits of 5

participating (e.g. 3 x 20 Euro tombola), as well as to establish trust by ensuring data security and a professional presentation. Additionally, we attempted to provide therapists with basic knowledge about both interventions by screening an eight-minute video clip at the beginning of the survey. Due to the conflicting priorities of providing some information on the topic but not interacting with personal attitudes, we decided to randomly present this video clip to 50 % of the surveyed psychotherapists. Answering the survey took 23 minutes on average. Analyses Statistical analyses were conducted using SPSS Statistics 23 (IBM SPSS Statistics). Responses were based on mandatory field completion, thus no missing data arose. Results were not normally distributed and non-parametrical statistics therefore would be indicated. For reasons of interpretability we preferred to present the investigated differences in Cohen’s d [35]. Therefore, obtained data were analyzed parametrically (t-tests) and non-parametrically (Wilcoxon tests). As the results corresponded almost perfectly, we decided to present the results based on t-tests together with effect sizes in Cohen’s d. Differences in demographic variables between surveyed therapists and the population of Austrian therapists were analyzed by chi-squared tests. Influences of demographic variables (e.g. occupational computer usage or therapeutic orientation), as well as the impact of the presented video clip were analyzed by point-biserial correlations. Dependent sample item-level t-tests were applied to contrast both interventions against each other (19 positive items, 13 negative items). We decided to adjust for type l error inflation by applying Bonferroni correction to each scale separately, resulting in a critical t-value of t = 2.78 for advantages and t = 2.65 for disadvantages. Results below the critical threshold are labelled in the corresponding tables. For Table 3 and 4 the average deviation from the scale mean was calculated. Here, the average value of a given item (e.g. treatment flexibility) was tested against the total value of the corresponding subscale (e.g. advantages of web-based interventions). According to power analyses (G*Power 3 [36]), the calculated power to detect a given effect size of d = 0.3 was β =.83, and β = .99 for a given effect size of d = 0.5.

Results Surveyed therapists In response to our nationwide invitation, 95 out of 1050 contacted therapists completed the survey between May and June 2016, resulting in a response rate of 9.31 %. The information clip was presented to 46 out of 95 therapists (48.4%). For estimating representativeness and potential selection biases, information on therapists’ theoretical orientation (e.g., cognitive behavioral therapy) and other features are provided in Table 1. The majority of the surveyed psychotherapists were female (65 %), which corresponds to the population of psychotherapists in Austria (71.8 %). The proportion of behavioral psychotherapists in Austria (11.9 %) is traditionally lower than in other German-speaking countries, such as Germany (35 %) [37]. This was reflected in our sample (15 %). Apart from humanistic therapists, our sample seems to reassemble the population of Austrian therapists largely. Another important feature of our sample is the full range of possible professions a licensed psychotherapist in Austria may originate from. Only 42 % of the surveyed therapists were psychologists. The remaining 58 % stemmed from diverse professional areas, such as medicine, social work etc. Survey results can benefit from this heterogeneity, as many different perspectives entered the appraisal of web-based and blended therapy.

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Table 1. Demographic and professional characteristics of the sample Sample n(%) Number of therapists Gender Female Male Age (SD) Theoretical orientation Psychodynamic/analytic Humanistic Behavioral Systemic Basic profession Psychology Counselling Medicine Social work Education Pedagogics University professor Theology / philosophy Nursing Economy / management Other No specification Years in profession M (SD) Region (urban/rural) %

Population in %

Statistics

62 (65.3) 33 (34.7) 48.7 (12.2)

71.8 28.2

X²= 2.139, p= .144 X²= 2.139, p= .144

28 (29) 26 (27) 14 (15) 27 (28)

25.8 37.4 11.9 24.9

X²= 0.596, p= .440 X²= 4.083, p= .043 X²= 0.729, p= .393 X²= 0.593, p= .441

42 (44) 7 (7) 5 (5) 6 (6) 6 (6) 6 (6) 2 (2) 3 (3) 2 (2) 4 (4) 4 (4) 8 (8) 12.4 (11.3) 76.8/23.2

70/30

X²= 2.118, p= .146

95

Therapists’ computer and internet behavior The vast majority of our sample used computers regularly for e-mail correspondence and for online search (c.f. Table 2). Regular e-mail contact with clients was substantially lower and only 12 – 13 % already used computers for video conferencing or to supply modern media, videos or book chapters to patients. Table 2. Therapists’ occupational computer usage data (N=95) Yes (%)

No (%)

General computer use (daily)

93 (97.9)

2 (2.1)

General e-mail use (daily)

91 (95.8)

4 (4.2)

Conduct online search

83 (87.4)

12 (12.6)

General administration tasks

77 (81.1)

18 (18.9)

41 (43.2)

54 (56.8)

Daily patient contact (e-mail) a

45 (47.4)

50 (52.6)

Application of modern media during therapy a Use of video conferencing a

13 (13.7)

82 (86.3)

12 (12.6)

83 (87.3)

Patient related documentation tasks

a activities

a

which are relevant to web-based and blended therapy

Overall differences in perceived advantages and disadvantages 7

The primary aim of this survey was to depict advantages and disadvantages of each intervention strategy on item-level. Still, the overall perception of each methods’ (dis-)advantages helps to reveal general attitudes. With scores of M = 3.45 and M = 3.61 the rating of perceived advantages can best be described as neutral (3= “I somewhat disagree”; 4= “I somewhat agree”). Whilst average perceived advantages of blended and web-based interventions only differed tentatively with a small effect (t(94) = 1.89, p = .063; d = 0.11), the appraisal of possible disadvantages differed strongly with a high effect to the detriment of web-based interventions (t(94) = 9.86, p =.001; d = 0.81). Rankings of advantages and disadvantages Table 3 and Table 4 present rankings of the most important advantages and disadvantages separated for each intervention. Perceived advantages of web-based interventions (Table 3) on average scored M = 3.45 (SD = 0.72). With an average of M = 3.61 (SD = 0.58) blended interventions scored slightly above this value (4 = “I somewhat agree”). Perceived disadvantages of web-based interventions (Table 4) on average scored M = 4.24 (SD = 0.59). With an average of M = 3.66 (SD = 0.45) blended interventions scored significantly below this value. Table 3. Ranking of advantages of web-based and blended interventions, deviation from average (N = 95) Web-based interventions

Blended interventions

#

Advantage

Score

#

Advantage

Score

1

Bridging distances

4.80 ***

1

Bridging distances

4.47***

2

Discrete

4.36 ***

2

Discrete

4.45 ***

3

Timewise flexible

4.35 ***

3

Psychoeducation

4.21 **

4

Psychoeducation

3.97 **

4

Contemporary

4.03 **

5

Repetition of work material

3.97 **

5

Bridging waiting time

4.03 **

6

Suitable for young patients

3.92 **

6

Helping minorities / underserved

3.97 **

7

Helping minorities / underserved

3.77 *

7

Repetition of work material

3.95 **

8

Contemporary

3.76 *

8

Suitable for young patients

3.91 *

9

Bridging waiting time

3.71 *

9

Low threshold to care

3.87 *

10

Low threshold to care

3.58

10

Timewise flexible

3.75

11

Online disinhibition effect

3.41

11

Suitable for generation 50+

3.63

12

Suitable for generation 50+

3.28

12

Treatment intensification

3.43

13

Improve self-management

3.13*

13

Improvement of treatment quality

3.38 *

14

Delivering evidence based treatment Easy to share with family

2.99**

14

Delivery of evidence based treatment

3.24 *

2.93**

15

Improve self-management

3.22 **

2.47 ***

16

Online disinhibition effect

3.04 **

17

Improvement of treatment quality Can support therapist

2.45 ***

17

Easy to share with family

2.85 ***

18

Independency from therapist

2.40 ***

18

Can support therapist

2.72 ***

19

Treatment intensification

2.33 ***

19

Independency from therapist

2.38 ***

Average

3.45

Average

3.61

15 16

# = rank number, * p < 0.05, ** p < 0.01, *** p < 0.001 of deviation from average.

Table 4. Ranking of disadvantages of web-based and blended interventions, deviation from average (N = 95) 8

Web-based Interventions

Blended Interventions

#

Disadvantage

Score

#

Disadvantage

Score

1

Lack of non-verbal signals

5.11 ***

1

Data security issues

4.4 ***

2

Missing important disease aspects

4.87 ***

2

Lack of non-verbal signals

4.08 **

3

Missing problems in therap. Process

4.83 ***

3

Not applicable for the majority

4.02 *

4

Not applicable for the majority

4.66 **

4

Missing problems in therap. Process

3.87 *

5

Data security issues

4.57 *

5

Missing important disease aspects

3.85 *

6

Avoidance of difficult situation

4.49 *

6

More effortful than classical therapy

3.78

7

Risk of therapy discontinuation

4.22

7

Avoidance of difficult situation

3.77

8

Dealing with crisis

4.18

8

Might result in side effects

3.77

9

Too much technology

4.03 *

9

Risk of therapy discontinuation

3.57

10

Might result in side effects

3.89 *

10

Transfer into daily life

3.43 *

11

Transfer into daily life

3.66 **

11

Too much technology

3.32 *

12

Technology devaluates therapist’s work

3.53 ***

12

Technology devaluates therapist’s work

3.02 ***

13

More complicated than classical therapy Average

3.08 ***

13

Dealing with crisis

2.74 ***

Average

3.66

4.24

# = rank number, * p < 0.05, ** p < 0.01, *** p < 0.001 deviation from average.

Comparison of both interventions This section analyses most salient differences between both interventions. Table 5 presents differences in perceived advantages between web-based and blended interventions. Besides absolute deviations of both scores, effect sizes of the deviations are also provided as a standardized indicator. Table 6 presents differences in perceived disadvantages between both interventions. Table 5. Comparison of advantages between web-based and blended interventions (independent ttests) (N = 95) Blended interventions

Web-based interventions

M deviation

SD deviation

M Cohen’s d

Treatment intensification

3.43

2.33

1.11***

1.14

0.97

Improvement of treatment quality

3.38

2.47

0.91 ***

1.17

0.77

Suitable for generation 50+

3.63

3.28

0.35***

0.78

0.45

Bridging waiting time

4.03

3.71

0.32 **

1.17

0.27

Low threshold care

3.87

3.58

0.29 *

1.18

0.25

Contemporary

4.03

3.76

0.27 **

0.86

0.31

Can support therapist

2.72

2.45

0.27 **

0.93

0.29

Delivering evidence based treatments

3.24

2.99

0.25 **

1.01

0.25

Psychoeducation

4.21

3.97

0.24 *

0.97

0.25

Helping minorities / underserved

3.97

3.77

0.20

1.06

0.19

Improve self-management

3.22

3.13

0.09

0.77

0.12

Discrete

4.45

4.36

0.09

1.27

0.07

Suitable for young patients

3.91

3.92

-0.01

1.05

- 0.01

Independency from therapist

2.38

2.40

-0.02

1.19

- 0.02

9

Repetition of work material

3.95

3.97

- 0.02

0.85

- 0.02

Easy to share with family

2.85

2.93

- 0.08

1.02

- 0.08

Bridging distances

4.47

4.80

- 0.33 **

1.05

- 0.31

Online disinhibition

3.04

3.41

- 0.37 **

1.30

- 0.28

Timewise flexible

3.75

4.35

- 0.60 ***

1.51

- 0.40

* p < 0.05, ** p < 0.01, *** p < 0.001, M = Mean, SD = standard deviation.

Table 6. Comparison of disadvantages between web-based and blended interventions (independent ttests) (N = 95) Web-based interventions

Blended interventions

M deviation

SD deviation

M Cohen’s d

Dealing with crisis

4.18

2.74

1.44 ***

1.17

1.22

Lack of non-verbal signals

5.11

4.08

1.03 ***

1.16

0.89

Missing important disease aspects

4.87

3.85

1.02 ***

1.14

0.89

Missing problems in therap. Process

4.83

3.87

0.96 ***

1.02

0.94

Avoidance of difficult situation

4.49

3.77

0.72 ***

1.25

0.58

Too technologically

4.03

3.32

0.71 ***

1.38

0.51

Risk of therapy discontinuation

4.22

3.57

0.65 ***

1.16

0.56

Not applicable for majority

4.66

4.02

0.64 ***

1.31

0.49

Technology devaluates therapist’s work

3.53

3.02

0.51 ***

1.39

0.37

Transfer into daily life

3.66

3.43

0.23 *

1.06

0.22

Data issues

4.57

4.40

0.17

1.13

0.15

Might result in side effects

3.89

3.77

0.12

1.11

0.11

More effortful than classical therapy

3.08

3.78

- 0.70 ***

1.24

- 0.56

* p < 0.05, ** p < 0.01, *** p < 0.001, M = Mean, SD = standard deviation.

Additional findings Additionally, we investigated the relation between demographic variables, as well as two variants of therapists’ occupational computer usage (wide and narrow perspective) with therapist attitudes. Age (r(95) = -.019 , p = 0.853), years in profession (r(95) = -.062 , p = 0.549), gender (r(95) = .039, p = 0.708), rural work-place (r(95) = -.-060 , p = 0.565) or presentation of the short video clip (r(95) = -.109 , p = 0.295) did not relate to given appraisals, but computer usage did. In the wide perspective of therapists’ occupational computer usage (all four marked variables from Table 2), a trend towards more favorable attitudes was found (r(95)= .177,p = 0.087). In the narrow perspective (application of modern media and/or video conferencing; the last two items presented in Table 2), this relation became more evident (r(95) = .241,p = 0.018). Finally, we correlated the therapeutic orientation with attitudes, and found a trend towards more positive attitudes amongst behavioral therapists (r(95) = .188 ,p = 0.068). As a last aspect, we were interested in the perceived applicability of blended therapy elements, as well as in therapists’ interest of potentially applying those elements. Corresponding results are listed in Table 7. Table 7. Applicability of, and interest in blended therapy elements (N=95) Applicability of elements

%

Interest in elements

%

10

Psychoeducation

95.7

Record about mood and activities

84.8

Online diary

83.7

Exercises at home (homework)

83.7

Videos and multimedia (like YouTube) Mediation and relaxation exercises Diary on smartphone Reflection of therapy elements Introduction into treatment Debriefing of the session

78.3 73.9 63.0 58.7 52.2 31.5

Videos and multimedia (psychoeducation, short videos) Communication (text message, e-mail, feedback about exercises) E-learning (short texts, case example, online exercises) Smartphone/app (diary, behavioral observation, real-time-monitoring) None of the components

53.7 45.3 41.1 33.7 26.3

Discussion The present study contributes to the understanding of licensed psychotherapists’ attitudes towards web-based and blended therapy. By focussing on different levels of detail (general appraisal, internal and comparative profiles, as well as item-level analyses), the perceived advantages and disadvantages of both interventions are depicted. Major findings concern the neutral perception of both interventions’ advantages, as well as the increased perception of disadvantages of web-based interventions. Additionally, a mismatch between therapists’ concepts about both interventions and the corresponding empiric evidence can be identified at the item-level of analysis. Finally, the effect of an eight-minute information video was found to be negligible. Therapists’ overall perception of advantages in web-based and blended therapy can be described as neutral, as average ratings ranged around the survey’s scale midpoint. Although this finding does not suggest negative attitudes towards both interventions, it seems to be more in line with studies suggesting that psychotherapists are reserved and cautious in their views [20,28,29]. Even though therapists might be expected to have more positive attitudes towards technology-aided face-to-face therapy (blended format), there was no overall preference, nor was there a significant difference between both intervention formats’ advantages. Blended therapy pursues the frequently stated goal of unifying the advantages of traditional face-to-face and computer-supported treatments [10], and our results suggest, that this relates primarily to risk-related aspects. According to the Diffusion Of Innovations theory (DOI [38]) and the Unified Theory of Acceptance and Use of Technology (UTAUT [39]) perceived advantages, as well as compatibility with personal beliefs and preferences, play a pivotal role in the successful dissemination of new technologies. Accordingly, a lack of perceived advantages or benefits can result in reduced interest, and, consequently, in the possible obstruction of dissemination efforts. In this context, several studies [17,24,40] have stressed the relevance of eHealth knowledge and experience as facilitators of more positive attitudes. We found a tendency towards more positive attitudes amongst therapists who had already used some computer- or mediasupport in their practice. However, when comparing perceived disadvantages, results are a bit different. While the attributed disadvantages of blended therapy again can be described as neutral, the surveyed professionals showed particularly more negative attitudes towards the presented risks associated with web-based interventions. This finding is in accordance with results from previous studies [20,41,42]. Some authors have ascribed the low acceptance of web-based interventions to professionals’ concerns, that their work may be replaced by such technologies [12,43]. Although surveyed therapists did not per se 11

agree with the statement that technology would devaluate therapist’s work (a minor disadvantage in Table 4), more negative attitudes towards web-based interventions emerged when the approach was compared to blended treatment (Table 6). Still, the most salient disadvantages of web-based therapy concerned therapeutic process aspects, such as the lack of non-verbal signals, missing important disease aspects or dealing with crisis. Since the relevance of these aspects differs between guided and unguided forms of web-based therapy, a further differentiation between both forms would have been advisable. In this regard, both guided and unguided forms of web-based therapy are represented equally in this study. In the synopsis, both formats failed to elicit positive responses among psychotherapists. Additionally, risks and disadvantages seem to be particulary relevant to web-based interventions, resulting in a more negative perception of this format. This result is in line with previous studies, reporting on stakeholders’ and therapists’ overall preferences of blended therapy over webbased interventions that are completely delivered via Internet [18,44], and suggests that perceived risks could play a pivotal role in this regard. At the item-level, a mismatch between empirical evidence and therapists’ personal beliefs was found. Recognizing such differences can help to improve training and consumer information, and, thus, improve the dissemination of Internet-based interventions. For example, the empirical base of webbased interventions in delivering evidence-based treatments was not acknowledged by surveyed professionals (Table 3, Rank 14). The same applies to the improvement in patients’ self-management abilities in blended therapy approaches - a benefit suggested in previous literature [6,19]. Finally, the increased salience of potential risks of web-based interventions is currently not supported by evidence [45, 46, 48]. In this context, previous studies have successfully promoted positive attitudes towards eHealth in general and patient populations by providing text or video-based information [49,50]. At the same time, comparable studies yielded less successful results [51,52]. In this context, the mode of presentation (text vs. video-based), and the use of persuasive methods (e.g. expert evaluations or testimonials) [53] could influence the impact of the presented material. Whether such a strategy could change therapists’ attitudes towards web-based or blended treatments for now remains an open question. In the present study, the randomized presentation of a short information clip did not effect therapists’ attitudes. Ultimately, more profound implementation strategies appear most promising [47]. Amongst others, such strategies should focus on teaching, therapist trainings, incentives and reimbursement policies. In the light of the above-mentioned innovation theories (DOI and UTAUT [38,39]), a further strategy to improve uptake emphasizes on therapist-oriented co-design. On one hand, practitioners agreed that blended interventions constitute a contemporary and flexible approach. Simultaneously, a strikingly high number of therapists doubted, that blended therapy would support them in their daily work (Table 3, rank 18 of 19). Thus, the criterion of performance expectancy – which was an identified key factor for (patient-based) acceptance and use in previous web-based therapy studies [21,40] – remains unsatisfied from the therapist-perspective in blended therapy. Furthermore, therapist-based effort expectancy for blended therapy is very high (Table 6, last item), as therapists do expect more workload from using blended formats. Although therapists frequently participate in the development of new interventions [54], developers should particularly emphasize on how therapist-based performance and effort expectancies can be addressed in blended therapy. Therapist attitudes were related to their personal experience in using modern technologies, but not to work experience (years in profession) or other demographic variables. The relevance of personal experience has frequently been stressed in previous qualitative and quantitative studies [17,22-24,44]. Concerning the role of therapeutic orientation, our results revealed only a statistical tendency towards more positive attitudes amongst cognitive behavioral therapists. Thus, the present results contradict findings from several studies, showing more negative attitudes amongst psychodynamic and 12

humanistic therapists [20,23], while they support studies identifying more liberal attitudes amongst behavioral therapists [22]. When interpreting these results, the small sample size, which further spreads over several different therapeutic orientations, needs to be taken into account. Regarding the study’s validity, certain factors support representativeness, while others restrict generalizability. Essential features of the sample resemble available population characteristics (therapeutic orientation, gender or regionality), suggesting that the attitudes of the respective sample represent those of Austrian therapists. However, recent literature indicates critical regional differences in the knowledge about and acceptability of Internet-assisted and blended interventions. Stakeholders in countries with more advanced eHealth services tend to have more positive attitudes [18], and, as priorly mentioned, personal experience with technology- and media-supported therapy elements relates to more positive evaluations of both treatment formats [24]. Consequently, the present study seems to primarily represent therapist attitudes in surroundings with less advanced eHealth services, while therapists in advanced eHealth environments might hold more positive attitudes.

Limitations The present study has several limitations. First, as the study was carried out online and therapists were only contacted via e-mail, a selection bias may have been introduced. In order to counteract this tendency, it would have been advisable to use an additional paper-pencil version of the questionnaire [33]. Second, the low response rate increases the risk of introducing response bias. To estimate this risk, available population data on essential sample characteristics are provided and corresponding deviations from the population range from around 3.1 to 10.4 percentage points. While the sample can be considered representative for psychodynamic, behavioral and systemic therapists (deviation = 3.1 % - 3.2 %), therapists with a humanistic orientation are underrepresented (deviation = 10.4 %). Third, the sample size in the present study was rather small. Consequently, the study lacks sufficient power to detect small effects or subgroup effects reliably. Therefore, findings on the influence of therapeutic orientation or the relevance of personal experience in therapists’ appraisals should be interpreted with caution. Fourth, many previous studies have employed standardized questionnaires [31,32]. Due to the specific aim of the present study and the lack of a corresponding pre-tested questionnaire, we have not been able to implement any validated survey. As a result, the translation of the survey is prone to language errors, and assumptions about its factor structure are unconfirmed. However, the reported exploratory factor analysis does indicate a single factor structure, in which factor loadings of advantages and disadvantages load according to expectations. Additionally, the full translation of each survey question is provided in Appendix A. As a last aspect, we assessed therapists’ daily personal computer usage, but we did not assess computer literacy by means of a standardized questionnaire. Applying computer literacy questionnaires might have led to additional findings.

Conclusion This study is the first to investigate therapist attitudes towards blended therapy, and to directly compare therapist appraisals of web-based and blended intervention formats. Therapists’ general attitudes can be described as neutral to cautious, and therapists’ preferences of blended therapy over web-based interventions seem to be risk-driven. According to two mentioned innovation theories, positive beliefs and preferences play a pivotal role in the successful dissemination of new technologies. As one crucial aspect, therapists seem to lack knowledge on how to benefit from technology-aided treatments. This aspect should be regarded in the development of new 13

interventions. However, contrarily to personal experience with technology- and media-supported therapy, an unspecific information video did not influence therapists’ appraisals. In this context, the study provides a starting point for improved therapist education (e.g., fostering knowledge on potential benefits, or addressing frequent mismatches between empirical evidence and therapists’ concepts). While this study is likely to represent therapist opinions in countries with less advanced eHealth services, the small sample size restricts its sensitivity to detect small or subgroup effects.

Competing interests The authors declare that they have no competing interests.

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