This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.
Blended group therapy (bGT) has been investigated a several times for anxiety and depression, but information on patients’ adherence to and therapists’ perception of the novel format is nonexistent. Furthermore, many studies investigated mainly female and highly educated populations, limiting the validity of previous findings.
This study aimed to reduce the gaps and limitations of the previous findings by evaluating an integrated internet- and mobile-supported bGT format.
A total of 27 patients diagnosed with major depression (14/27, 52% female and 7/27, 25.9% compulsory education) participated in a 7-week treatment at a university outpatient clinic. Furthermore, 8 novice therapists participated in semistructured interviews and a subsequent cross-validation survey.
Primary symptom reduction was high (
Results suggest high feasibility of bGT in a gender-balanced, moderately educated sample. bGT provides group therapists with tools for individual care, resulting in an optimization of the therapy process, and high completion rates of the implemented bGT elements. The limited work experience of the involved therapists restricts the study findings, and potential drawbacks need to be regarded in the development of future bGT interventions.
Depression is one of the most prevalent mental disorders and a leading cause of disability. It imposes suffering and high costs on individuals, societies, and health systems [
Among their most frequent formats, mobile and Web-based interventions offer flexible and anonymous access to mental health services, resulting in low social barriers and low risk of stigmatization [
However, Web-based and mobile interventions also exhibit limitations as they do not meet all patients’ needs and preferences, and therapist contact usually is restricted to a wide degree. Furthermore, therapeutic guidance frequently is associated with better treatment outcomes and reduced dropout rates [
The techniques developed in the field of Web-based therapy [
According to therapists, patients can profit from blended interventions in the form of increased treatment accessibility and flexibility, as well as from the improvement of patients’ self-management and the optimal use of face-to-face sessions [
While most blended research focuses on individual therapy [
Blends of Web-based and face-to-face therapy.
This study wants to carry this work forward by investigating an integrated bGT intervention based on Acceptance and Commitment Therapy (ACT) principles [
The trial was preregistered at the German trial register (DRKS Number: DRKS00010888), and the regional ethics committee of the University of Salzburg approved the study procedure. Participants were recruited via a multimodal recruitment strategy by handing out flyers in public health centers and densely populated public areas and by advertisements on depression-related Web pages. After registering on the study platform participants obtained detailed information about the procedure and goals of the study and were asked to give informed consent.
The selection of participants followed 2 steps. Participants were asked to fill out a short screening questionnaire. This included the short version of the Center of Epidemiologic Studies Depression (CES-D) scale [
Personal clinical interviews were conducted by 3 independent and experienced psychologists, applying the German Mini-Diagnostic Interview for Psychological Disorders (DIPS) [
After preassessment, participants were provided with access to the internet platform (Minddistrict) and scheduled to one of 2 weekly groups, depending on personal preferences. To provide personal support in case of technical problems, the app-based diary was installed at the end of the first group session. Group meetings lasted 7 weeks, and each session was preceded by a preparatory Web-based module. The therapist gave supportive feedback after completion of a given Web-based session and occasionally gave reminders to participants by sending out prompts via the platform. The app-based diary complemented the blended treatment with a focus on the transfer of previously learned techniques into daily life. Participants were free to logon to the platform after treatment had ended but did no longer receive therapist guidance. As recommended by several guidelines [
Study flow chart. ITT: intention to treat.
The 7 weeks intense group treatment was based on the ACT and BA principles. ACT [
With regard to the use of computer- and mobile-based elements, the patients’ weekly routine consisted of 3 steps. First, a preparatory Web-based module, featuring video clips, text-based tasks, and an asynchronous therapist chat, had to be completed. Afterward, patients received individualized feedback from the assigned therapist (if applicable within 2 days). Second, patients participated in the weekly reunions, which again were partially complemented by modern media (ie, short clips or PowerPoint presentations). As a last step, patients were guided by weekly mobile phone diary tasks, which were scheduled for 7 days following the weekly group session. All reminders and prompts were modifiable according to personal preferences, and wherever possible, therapists were instructed to balance media and personal treatment elements according to patient needs and their professional judgement. If patients did not adhere to the Web-based tasks, therapists were instructed to send out a prompt in the middle of the treatment week and, again, once on the day before the forthcoming group session. If patients complained about the number of reminders, the prompts were reduced or stopped.
Group sessions and computer and multimedia elements of the intervention.
Week | Web-based module | Group session | App | Workbook |
1 | Introduction into mindfulness | Introduction into ACTa, mindfulness | Feature 1: Mindfulness in daily life | List of mindful activities |
2 | Natural suffering and suffering through avoidance | Avoidance and acceptance | Feature 2: Acceptance | Acceptance of a difficult situation, topic, character trait, or conflict; Reflection on mindfulness |
3 | Defusion | Fusion and defusion | Feature 3: Defusion | Typical examples of defusion |
4 | Values, goals, and self-management | Values, mastery, and self-management | Feature 4: Mastery activities | Bull’s-eye exercise; Example and sheet for SMARTb principle; Activity planning |
5 | Commitment | Commitment and positive reinforcement | Feature 5a: “Do activities” Feature 5b: “Do not activities” | Determination, ranking, and planning of do- and do not activities; Self-management; Activity planning |
6 | Expansion of behavioral activation | Expansion of behavioral activation | Continuation of previous features of the app | Contracts |
7 | Review and transfer | Transfer and conclusion | Continuation of previous features of the app | Plan for relapse |
aACT: Acceptance and Commitment Therapy.
bSMART: frequent self-management principle.
User interfaces of the web-based platform and the smartphone app.
A total of 8 novice therapists (2 male and 6 female) conducted the groups in a double trainer setting. Of the 8 therapists, 2 finished their master’s degree (MSc) or Doctor of Science in psychology and underwent tertiary training in psychotherapy (CBT), clinical psychology (CBT), or medicine at the time of the intervention. The remaining 5 therapists were in their final year of clinical psychology (MSc) and had clinical experience with conducting classical forms of individual or group therapy, as well as with drafting psychological expert reports. None of the therapists had previous experience with conducting bGT or any other form of Web-based therapy. All participating therapists underwent previous training (minimum 40 hours), including a 6-digital versatile disc ACT-series (ACT in Action) and 2 textbooks [
The principal outcome of the study was reduction of depressed mood. It was measured by the short version of the German translation of the CES-D scale [
As a more general self-report questionnaire that measures psychological distress, nonspecific current mental health, and the risk of developing psychological disorders, the General Health Questionnaire-12 (GHQ-12 [
Psychological flexibility (ie, acceptance of unpleasant feelings, worry, and control agendas) is the central psychological construct of the ACT and was measured by the Fragebogen zu Akzeptanz und Handeln II [
Anxiety was measured with the Anxious Thoughts Inventory (AnTi) [
Finally, worry was measured with the PSWQ-3 [
System usability of applied app and Web elements was measured by the System Usability Scale (SUS) [
The ZUF-8 (Fragebogen zur Patientenzufriedenheit) [
SPSS 24 (SPSS Inc) was used to carry out the analyses. Significant differences between pre, post, and follow-up were analyzed by linear mixed models, with compound symmetry as covariance type and restricted maximum likelihood estimation. Missing outcome values were analyzed according to the intention-to-treat (ITT) principle. Individual pre to post changes served as a base for the reliable change indexes (RCIs) [
On the basis of a structured interview guide (
A comprehensive overview of participant characteristics at baseline is provided in
Demographic, behavioral, and clinical characteristics of the sample at pretreatment (N=27).
Characteristic | Statistics | |
Age (years), mean (SD) | 37.70 (13.66) | |
Gender, female n (%) | 14 (51.9) | |
≥9 years (compulsory school) | 7 (25.9) | |
≥12 years (A level) | 12 (44.4) | |
≥any tertiary education (eg, university) | 8 (29.6) | |
Full time | 11 (40.7) | |
Part time | 6 (22.2) | |
None/marginally | 5 (18.5) | |
Currently in education | 5 (18.5) | |
Current psychopharmacological treatment, n (%) | 3 (12) | |
Previous psychotherapeutic treatment, n (%) | 14 (54) | |
Daily use | 25 (92.6) | |
Weekly use | 2 (7.4) | |
F32.0 (mild depressive episode), n (%) | 3 (11.1) | |
F32.1 (moderate depressive episode), n (%) | 8 (29.6) | |
F33.0 (recurrent depressive episode, current episode mild), n (%) | 10 (37.0) | |
F33.1 (recurrent depressive episode, current episode moderate), n (%) | 4 (14.8) | |
F33.4 (recurrent depressive disorder, in remission—elevated levels of depression), n (%) | 2 (7.4) | |
F10.1/2 (harmful use of alcohol/addiction) | 1 (3.7) | |
F40.0 (agoraphobia without panic disorder) | 1 (3.7) | |
F40.1 (social phobia) | 2 (7.4) | |
F40.2 (specific phobia) | 1 (3.7) | |
F41.1 (generalized anxiety disorder) | 3 (11.1) | |
F43.2 (adjustment disorder) | 1 (3.7) | |
F50.2 (bulimia nervosa) | 1 (3.7) |
Linear mixed models unveiled significant changes in all outcome measures, and pre- to posteffect sizes for primary outcomes were large to very large (
For applied secondary outcomes, the treatment resulted in less pronounced effects (
Means, SDs, effect sizes (Cohen
Questionnaire | Estimated mean (SD) | Effect sizes (estimated mean [95% CI]), pre to post effect size | Reliable change | |||
Pre | Post | Follow-up | Pre to post RCIa | Pre to follow-up RCI | ||
CES-Db | 22.44 (5.18) | 13.56 (6.48) | 12.19 (7.94) | 1.51 (0.89 to 2.09) | 74 | 78 |
GHQ-12c | 16.07 (5.41) | 9.63 (4.39) | 11.94 (7.12) | 1.31 (0.70 to 1.87) | 63 | 52 |
AAQ-IId | 26.15 (8.87) | 20.71 (8.85) | 18.63 (9.71) | 0.59 (0.02 to 1.14) | —e | — |
AnTif | 44.33 (10.22) | 36.46 (10.45) | 36.25 (11.59) | 0.72 (0.14 to 1.27) | — | — |
PSWQ-3g | 7.63 (2.50) | 6.67 (2.76) | 6.50 (2.97) | 0.37 (−0.19 to 0.91) | — | — |
aRCI: reliable change index.
bCES-D: Center for Epidemiological Studies-Depression scale.
cGHQ-12: general health questionnaire (12-item version).
dAAQ-II: Acceptance and Actions Questionnaire.
eNot applicable.
fAnTi: Anxious Thoughts Inventory.
gPSWQ-3: Penn State Worry Questionnaire (ultra-short version).
After a follow-up period of 3 months, the reduction of self-reported depression (CES-D) remained stable (
System usability of applied app and Web elements, measured by the SUS [
Besides group attendance=82.4% (5.9/7 sessions), usage of digital elements was high (
(1) Patients’ completion rates of all intervention elements. (2) Therapists’ average guidance time per patient during entire treatment; a total of 24 min was spent on personal topics, whereas 48 min was spent on feedback on specific exercises. (3) Therapists’ weekly Web-based guidance by single group.
The therapists’ experiences with and attitudes toward bGT can be described as cautiously positive to positive. Important themes concerned the functionality and applicability of bGT and patients’ interaction with the format, as well as the general appraisal of bGT.
In the wider perspective, therapists agreed that bGT can have a positive impact on current forms of group therapy and that they had more positive attitudes toward bGT after applying this format. Perceived merits of bGT were augmented monitoring, in addition to patients’ responsiveness to given online reminders in terms of increased treatment adherence. Most therapists agreed that patients would profit from the technology-aided treatment transfer and from the repeated presentation of therapy materials (platform, app, and group sessions). Furthermore, they agreed that Web-based modules would prepare patients for subsequent group reunions. A total of 6 out of 8 therapists reported that particular patients disclosed more openly via private Web-based communication (online disinhibition effect) compared with the group meetings. Individual differences emerged in the preference of particular treatment elements. Although some therapists emphasized the added value of between-session elements, others underpinned the merits of applied in-session tools.
With regard to the potential risks of bGT, a consensus emerged that in-session media should be applied cautiously (eg, overloaded sessions) and that the intervention at times may have hampered some of the desired group dynamics (eg, too little time for discussions). In this context, the preservation of technology-free group sessions was suggested. Furthermore, 2 therapists also advocated a cautious use of Web-based reminders and prompts to prevent less interested patients from feeling overwhelmed or discouraged. During the interview, 1 therapist expressed serious concerns about data safety.
Main themes, subthemes, and frequent codes of therapist interviews.
Main theme and subtheme | Frequent codes | |
Patients | Content repeatable; greater learning effect; increased engagement with therapy tasks | |
Therapists | Additional information through monitoring; helpful for younger therapists; guiding thread | |
Interaction | Patients more open (online disinhibition); building relationship through intimate Web-based communication | |
General | Additional effort; data security; limited management of acute crisis; predefined treatment course | |
Specific | Effects on group climate and cohesion; sessions overloaded | |
Positive | Contemporary; suitable for in-patient settings; improved handling with increased routine | |
Negative | Preference toward classic therapy; more training than therapy; technical issues; initial skepticism | |
Online reminders | Require organized working style; increase compliance; unwanted effects | |
Online feedback | Important feature; needs to be short in duration | |
Optional classic treatment path | Adaptation to patient preferences; possible side effects | |
Differences in patients | Not for severe depression; amount of required guidance time; differences in media affinity; requires openness and compliance |
Benefits and drawbacks of blended group therapy (bGT) according to interview follow-up survey (n=8).
Statementa | Percentages | Mean (SD) | |
Agree (rather agree) | Disagree (rather disagree) | ||
I am more open after experience with bGTa | 25 (75) | 0 (0) | 3.25 (0.46) |
I am more critical after experience with bGTa | 0 (0) | 13 (88) | 1.86 (0.36) |
I have serious concerns about data safetya | 0 (25) | 25 (50) | 2.00 (0.76) |
bGT may also be feasible for in-patient treatmenta | 13 (75) | 0 (13) | 3 (0.53) |
Advantages of more flexible working hours because of Web-based guidancea | 50 (38) | 13 (0) | 3.25 (1.03) |
Computer elementsb should be used for in-session supporta | 50 (25) | 0 (25) | 3.25 (0.89) |
Overuse of in-session media can hamper group dynamicsa | 50 (38) | 0 (13) | 3.38 (0.75) |
Overuse of in-session media did hamper dynamics in my groupsa | 0 (25) | 50 (25) | 1.75 (0.87) |
Computer elementsc should be used for between-session supporta | 63 (38) | 0 (0) | 3.63 (0.52) |
Platform prepares patients optimally for group reunionsa | 38 (63) | 0 (0) | 3.38 (0.52) |
Repeated application of therapy content fosters abilities (CE, app, and session)a | 38 (63) | 0 (0) | 3.38 (0.52) |
Reminders increased compliance with Web-based tasksa | 13 (75) | 0 (13) | 3.00 (0.53) |
bGT cannot increase treatment transfera | 0 (13) | 38 (50) | 1.75 (0.71) |
Reminders did exert a lot of pressure on some patientsa | 13 (50) | 0 (38) | 2.75 (0.71) |
Additional between-session therapist time needs to be reimburseda | 88 (13) | 0 (0) | 3.88 (0.35) |
Patients shared additional private concerns over platform (online disinhibition)a,d | 50 (34) | 0 (17) | 3.33 (0.82) |
Between-session contact made me feel more connected with clientsa,d | 17 (83) | 0 (0) | 3.17 (0.41) |
Between-session contact does not promote relationship with clienta,d | 0 (0) | 33 (67) | 1.67 (0.52) |
aExact wording is provided in
bSlides and videos.
cPlatform, app, and monitoring.
dOptional questions only applied to 6 therapists.
This study investigated the feasibility of a mobile- and Web-supported bGT for depression, with a focus on therapists’ perception of and patients’ adherence to the novel format. High effects on self-reported depressiveness and general health, as well as beneficial effects on ACT-related secondary outcomes, were observed. Effects remained stable over a short follow-up period. Therapist interviews revealed high treatment applicability and perceived benefits concerned treatment availability and monitoring and transfer, as well as the establishment of the therapeutic relation. On an average, therapists spent 10 min per patient per week with online guidance, with decreasing guidance over the course of time and variation between individual groups. Regarding patients’ system usage, participants almost equally engaged in weekly group reunions and Web-based tasks. Usage patterns of the mobile-based diary varied to some extent.
Applied primary outcome measures indicated substantial effects on self-reported depressiveness and general health after the outpatient treatment had ended. Observed effects correspond to earlier bGT depression studies [
This study adds a first therapist-related perspective to the growing evidence on bGT. Retrospectively, novice therapists described the format as contemporary, featuring patient- and therapist-related, as well as interactional, advantages. They reported patients to engage intensely with the bGT tasks, leading patients to be well prepared for the next group session. Furthermore, they appreciated the format for providing flexible working hours, as well as information about the individual treatment progress. Even though not all therapists were initially fond of the novel format, personal experience increased the self-reported willingness to work with the novel approach [
With regard to the reported improvement of therapeutic alliance, the therapist back-end system allowed personalized feedback on completed tasks (two-third of the time), as well as intimate lateral communication between therapists and clients (one-third of the time). Interviewed therapists appreciated both functionalities, and according to the therapists, patients responded to online prompts, resulting in an increased completion of outstanding therapy tasks. As a last consideration, all therapists that used software with implemented confidential communication (6 out of 8 therapists) reported that some of their patients disclosed more openly via intimate lateral communication. This phenomenon can be classified as a form of the online disinhibition effect [
As another important feasibility criterion, the amount of additional workload because of Web-based guidance is from particular relevance [
Treatment flexibility is of particular interest in outpatient groups, as the scheduling of group sessions is usually restricted to evening hours on a specific weekday. On one hand, technology-induced treatment flexibility is appreciated by patients [
bGT takes a special position in the field of internet interventions. First, bGT can be a cost-efficient treatment option situated between guided Web-based interventions and blended individual therapy (
With regard to potential disadvantages of bGT, therapists mentioned that certain participants may feel overwhelmed by the close monitoring of between-session activities or by the number of set reminders. For this reason, the intensity of monitoring and Web-based activities should be adaptable to patient needs. As a second aspect, 2 therapists expressed concerns about data safety. These concerns should be treated with high priority to prevent therapists from being deterred. Third, extensive in-session media use was described as a risk factor, potentially dampening desired group dynamics. Although observable incidences were reported less frequently (
This study has several noteworthy strengths and limitations. First, this study adds a first therapist-related perspective to previous findings on bGT [
Among its most important limitations, this study was designed and powered to investigate the feasibility of bGT for depression. The study design, therefore, does not allow any conclusions about technology-induced increases in efficiency or effectiveness. Together with blended individual therapy trials [
This study adds a first therapist perspective to previous research on bGT. Feasibility was supported within a university outpatient setting, treating a demographically balanced sample with a short but intense ACT-based group intervention. Even though the intervention entailed a variety of Web- and app-based elements, the amount of online guidance was manageable, and guidance resulted in more flexible working hours. The Web-based platform was appreciated for the implementation of between-session monitoring and the establishment of therapeutic alliance. According to therapists, compliance with CBT tasks can be fostered by prompts via the Web-based platform, resulting in high adherence rates. Potential negative effects of blending should be regarded in the design and implementation of bGT interventions.
Interview guide.
Subsequent questionnaire based on previous therapist-interviews.
acceptance and action questionnaire-II
Acceptance and Commitment Therapy
Anxious Thoughts Inventory
Behavioral Activation
Blended Group Therapy
Cognitive Behavioral Therapy
Center of Epidemiologic Studies Depression
Diagnostic Interview for Psychological Disorders
Generalized Anxiety Disorder
General Health Questionnaire
intention-to-treat
Penn State Worry Questionnaire
Reliable Change Index
System Usability Scale
Fragebogen zur Patientenzufriedenheit
This research did not receive any specific grant from funding agencies in the public, commercial, or non-profit sectors.
None declared.