Attitudes of the general population and mental health practitioners towards blended therapy in Austria

Mental health problems are steadily increasing worldwide. For example, the prevalence of both depression and anxiety showed rising trends during the last years [1, 2]. Young adults are especially vulnerable after the coronavirus disease 2019 (COVID-19) had an additional detrimental effect on mental health in adults [3]. Mental illness has become a primary factor contributing to the burden of disease among young individuals in high-income countries [4]. In Austria, the supply of mental health services, institutions and specialists is low compared to the need for such services in the population [5, 6].

Technological approaches have the potential to overcome problems with service provision [7], for example by reaching patients in more rural areas. One option for using technology is mhealth apps—mobile apps that “are software programs on mobile devices that process health-related data on or for their users” [8].

In general, mhealth apps seem to be beneficial in a mental health context, especially concerning depression and anxiety [9, 10]. For example, Rathbone et al. [11] found in their systematic review that apps based on cognitive behavioral therapy (CBT) had a positive impact on several mental health issues such as symptom severity and Firth et al. [12] found in their review with 18 randomized controlled trials (RCT) that mhealth apps significantly reduced depression symptoms compared to control groups. There is also some evidence that digital interventions and mhealth apps can be effective in suicide prevention [13].

Most of these apps which apply to a therapeutic context are more likely to be used as an alternative to traditional face-to-face therapy rather than an addition to in-person therapy. In a review about downloadable Android and iOS apps for psychosocial well-being, less than 2% (19/1009) of the apps were designed as a supplement to in-person psychotherapy [14].

Using supplementary apps in an ongoing therapeutic process is called blended therapy, blended care or blended counselling. Blended therapy means combining elements of both face-to-face and internet interventions [15].

A decisive factor for therapeutic success is the therapeutic relationship [16]. A fear around mhealth is the lack of therapeutic relationship due to the online character of the therapy, including the loss of therapeutic alliance. Contrary to that belief, ehealth therapy was found to be equally as good as traditional therapy [17]. Pihlaja et al. [18] found in their systematic review about etherapy for depression and anxiety that the therapeutic alliance is not only as good as in face-to-face therapy but might even exceed it.

Research found that most mhealth apps are usually found via social media, personal searches and private recommendations and not due to recommendation by professionals [19]. Furthermore, acceptance of mhealth apps among healthcare providers is still moderate to low [20]. This is due to various barriers experienced by health professionals, such as technical, social and organizational problems. Most prominently, fears around workload and training are factors impacting adoption [21]. Yet, staff play a central role for the uptake of mhealth apps [22] and engagement from both sides is crucial for continued use [23]. Other research around potential barriers found that technical problems are often considered a limitation [22, 24, 25]. Yet, attitudes towards mhealth apps might depend on the country and even the region people live in.

In 2016, Schuster et al. [26] explored differences of advantages and disadvantages of online and blended therapy with Austrian psychotherapists. They found that most therapists preferred blended therapy over online therapy. The current study expanded their study in several ways: First, it included an open question format to gather more qualitative data on practitioners’ attitudes. Second, it included a broader spectrum of occupations, including psychiatrists and clinical psychologists. Third, it re-evaluated the topic after the COVID-19 pandemic, where on the one hand mental illnesses have become more prevalent and on the other hand digital technologies have gained rapid adoption due to their necessity during lockdowns. While Schuster et al. [26] found an increased perception of disadvantages of web-based interventions, this might have changed in the population of practitioners during the last years. Lastly, to our knowledge, no one has mapped attitudes towards mhealth apps in a general population of adults in Austria.

Blended therapy is not widely common in Austria. Yet, due to its rural characteristics, mhealth apps especially in a blended approach could potentially be an advantageous addition to mental health services to be able to reach people. This exploratory study aimed to map the attitudes of Austrian adults with and without mental illnesses and practitioners of the mental health sector towards blended therapy and the use of an mhealth app.

In this exploratory study, we investigated attitudes of both the general population and practitioners in Austria towards the use of a blended therapy app in the mental health sector. Only 16.2% of practitioners had any previous experience with blended therapy, showing that this concept is not widely used in Austria. Even though there was very little internet anxiety in our samples, both the general population and practitioners seem to be cautious, but slightly positive about blended therapy. An earlier review about studies using the UTAUT found an average acceptance of low to moderate (M = 2.82, SD = 1.12, scale range 1–5). This review was conducted in 2021, analyzing studies between 2014 and 2020. Our results show that both practitioners and general population had a higher acceptance rate (3.36 and 3.75, respectively), suggesting that blended therapy has become more accepted nowadays than 5–10 years ago. This might be due to several reasons, such as the need of technology during the COVID-19 pandemic or the ever-increasing use of technology. Yet, it needs to be mentioned that comparisons might be limited due to diverse settings and outcomes of the studies. Practitioners are most worried about the therapeutic process and their work-life balance, while the general population worries that they would be too overwhelmed by the concept, mainly due to the time investment. Tracking, recording and reminding functions (e.g., for mood, homework) are seen as especially valuable features and accessibility was deemed the biggest advantage by both samples. Interestingly, in our open format, our sample of general population and practitioners often suggested the same additional things: a diary function, encouraging messages, relaxation techniques, reminder and tracking functions (e.g., medication, exercising) as well as literature recommendations were suggested for interesting features, while insufficient technical equipment and fear of mandatory use was mentioned as concerns. An example regarding exercise tracking/reminding can be found in a RCT that found that in-person counselling and the use of a mobile app significantly increased physical activity for the experimental group compared to a control group [29]. Yet, the study showed only short-term effects, with no significant difference after 3 months, highlighting the importance of testing long-term effects.

Even though it is not yet clear that blended therapy is superior to face-to-face therapy, it might have advantages for practitioners [15] and might help patients to internalize therapeutic content between sessions with a practitioner. As one focus group participant in a qualitative study by Richards et al. [25] said about the impact of technology in a therapeutic context: “the voice of therapy is going to stay with the client and […] they will become their own therapist”.

The literature supports the notion that practitioners do not use apps for several reasons, such as too little information or no knowledge about existing apps [24], yet evaluations about apps already being used show that they are largely accepted and liked [e.g. 30]. Our results suggest that blended therapy is not common in Austria and that this might be connected to practitioners’ cautiousness towards this form of therapy. Yet, research shows that positive attitudes about ehealth and blended therapy from practitioners are positively linked to patients’ attitudes [31]. Patients are more likely to use web-based therapy recommended by practitioners [32], which influences whether and how much patients use an mhealth app [22]. All in all, practitioners play a major role in the uptake and adherence to such programs.

Practically, several directions might help with changing the attitude of users of blended therapy. Firstly, the literature on blended therapy is largely supportive [17, 18]. For example, blended approaches can lead to superior treatment outcomes according to Lindhiem et al. [33], who conducted a review of 26 empirical studies. A more positive awareness could be sought especially in practitioners through advocating these findings, as more awareness for these positive aspects might help with diminishing the concerns of Austrian practitioners. Our results show that practitioners with experience with blended therapy had a higher acceptance, supporting the notion that experience and knowledge could lead to higher acceptance. Secondly, given the concerns about payments – the general public is concerned about additional cost and practitioners are concerned about problems with the billability of blended services – it is important that blended therapy apps are embedded in health insurance policies. One example close at hand are digital health applications (Digitale Gesundheitsanwendungen, DiGA), which already exist in Germany but not in Austria. With DIGAs, a blended therapy app could be prescribed by a doctor via the health insurance, eliminating costs for patients as well as practitioners. This official process might also eliminate some fears about data security and time management, which were some of the biggest concerns for both the general population and practitioners.

This study showed that blended therapy in Austria is not used widely and, while cautiously positive, both practitioners and the general population have some concerns and fears about such a form of therapy. Yet, our sample had various ideas what a blended therapy app could include that would help with traditional face-to-face therapy, which could steer blended therapy development in Austria.