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Psychological therapy is an effective treatment method for mental illness; however, many people with mental illness do not seek treatment or drop out of treatment early. Increasing client uptake and engagement in therapy is key to addressing the escalating global problem of mental illness. Attitudinal barriers, such as a lack of motivation, are a leading cause of low engagement in therapy. Digital interventions to increase motivation and readiness for change hold promise as accessible and scalable solutions; however, little is known about the range of interventions being used and their feasibility as a means to increase engagement with therapy.
This review aimed to define the emerging field of digital interventions to enhance readiness for psychological therapy and detect gaps in the literature.
A literature search was conducted in PubMed, PsycINFO, PsycARTICLES, Scopus, Embase, ACM Guide to Computing Literature, and IEEE Xplore Digital Library from January 1, 2006, to November 30, 2021. The PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) methodology was applied. Publications were included when they concerned a digitally delivered intervention, a specific target of which was enhancing engagement with further psychological treatment, and when this intervention occurred before the target psychological treatment.
A total of 45 publications met the inclusion criteria. The conditions included depression, unspecified general mental health, comorbid anxiety and depression, smoking, eating disorders, suicide, social anxiety, substance use, gambling, and psychosis. Almost half of the interventions (22/48, 46%) were web-based programs; the other formats included screening tools, videos, apps, and websites. The components of the interventions included psychoeducation, symptom assessment and feedback, information on treatment options and referrals, client testimonials, expectation management, and pro-con lists. Regarding feasibility, of the 16 controlled studies, 7 (44%) measuring actual behavior or action showed evidence of intervention effectiveness compared with controls, 7 (44%) found no differences, and 2 (12%) indicated worse behavioral outcomes. In general, the outcomes were mixed and inconclusive owing to variations in trial designs, control types, and outcome measures.
Digital interventions to enhance readiness for psychological therapy are broad and varied. Although these easily accessible digital approaches show potential as a means of preparing people for therapy, they are not without risks. The complex nature of stigma, motivation, and individual emotional responses toward engaging in treatment for mental health difficulties suggests that a careful approach is needed when developing and evaluating digital readiness interventions. Further qualitative, naturalistic, and longitudinal research is needed to deepen our knowledge in this area.
Mental illness is a pervasive global problem, estimated to be the second most prominent cause of the global burden of disease, surpassed only by cardiovascular disease [
One significant problem that perpetuates this treatment gap is
Many of the practical barriers that have historically impeded access to and engagement with FTF psychological therapy (eg, cost, accessibility, and time constraints) [
Arguably, the most significant barriers to engagement across all types of therapy delivery stem from the client’s attitude toward seeking help and engaging in therapy [
Motivation is a term used to describe the analytical and habitual processes that energize and direct behavior [
The most prominent theory explaining motivation for therapy and readiness for change is the
The mechanism by which a client’s stage of change affects their overall therapy outcomes could manifest in their initial experiences of treatment [
There are several FTF pretherapy interventions aimed at moving clients through the stages of change and preparing them for subsequent therapy. Examples of such pretherapy interventions include motivational interviewing (MI), role induction, and vicarious therapy pretraining [
Digital methods of intervention delivery hold promise as a way of creating accessible and timely solutions that can be easily scaled to cover entire populations, including those who have not yet reached out for help [
Outside MI, other digital approaches have begun to emerge, such as engagement-facilitation interventions, which aim to increase both the uptake of and adherence to web-based mental health programs [
Collaboration with clinical professionals and human-centered design processes are key to developing effective mental health interventions, given their sensitive and complex nature [
The aim of this study was to define the emerging field of digital interventions to enhance readiness for psychological therapy. By exploring the current state of research in this area, we hope to identify the conceptual boundaries of the topic and identify gaps in the literature. Our research questions were as follows:
What types of digital interventions have been used to prepare clients for psychological therapy?
What components have been used in these interventions and which of these show evidence of effectiveness?
What design processes have been used to develop these interventions?
Is the digital delivery of preparatory interventions to enhance readiness for psychological treatment feasible?
The protocol for this review was registered with the Open Science Framework on March 26, 2021 [
We chose a scoping review approach because the research studies in question are heterogeneous in nature and spread across multiple disciplines; they use different study designs to measure different outcomes, with different populations, in different contexts. As this is an emerging field, there are few boundaries on the extent, range, and nature of evidence [
Publications were included for assessment if they met the following criteria: (1) the article concerns an intervention, a specific target of which is enhancing engagement with
The rationale for examining only recent evidence (past 15 years) is that digital technology is advancing rapidly; older studies may be out of date in terms of client attitudes and acceptance of technology [
The following electronic databases were searched: PubMed, PsycINFO, PsycARTICLES, Scopus, Embase, ACM Guide to Computing Literature, and IEEE Xplore Digital Library. Search terms reflected the 3 main eligibility criteria (
Search terms.
Criteria | MeSHa terms | Free-text terms |
Target treatment (further psychological treatment or therapy) | “Mental Health” OR “Psychotherapy” OR “Stress, Psychological” OR “Anxiety Disorders” OR “Mood Disorders” | “CBT” OR “psychological” OR “mental ill-health” OR “anxiety” OR “depressi*” OR “stress” OR “wellbeing” OR “well-being” OR “resilience” OR “mood” OR “disorder*” OR “phobia*” |
Digital delivery | “Therapy, Computer-Assisted” OR “Internet” OR “Digital Technology” | “digital” OR “technolog*” OR “comput*” OR “e-health” OR “ehealth” OR “m-health” OR “mhealth” OR “mobile” OR “online” OR “web” OR “web-based” OR “smartphone*” |
Intervention type (readiness intervention; takes place before the target treatment) | “Transtheoretical Model” OR “Motivational Interviewing” | “readiness” OR “pre-therapy” OR “pre-treatment” OR prepar* OR “prelude” OR “prequel” OR “prior” OR “stage of change” OR “stages of change” OR “motivation to change” OR “motivational enhancement” OR “motivation interview” OR “motivational intervention” |
aMeSH: Medical Subject Headings.
An initial exploratory search of PubMed and ACM databases was conducted, and words contained in the titles and abstracts of retrieved papers were analyzed. The search terms were adjusted based on the identified papers, and the final search strategy was decided. Once the protocol was registered with the Open Science Framework, a full search was undertaken across all included databases in March 2021; the search was updated in November 2021. Additional records were retrieved by checking the reference lists of included articles.
The first and second authors (JJ and RB) began by independently reviewing a subset (1300/9412, 15%) of the titles and abstracts against the eligibility criteria and comparing their findings. Discrepancies were found; hence, the eligibility criteria were clarified through discussion between the 2 authors by using relevant examples from the first sample reviewed. A further subset (1300/9412, 15%) was reviewed, the findings were compared, and consensus in decision-making about inclusion and exclusion was reached. The remaining articles were then split between the 2 reviewers (JJ and RB), who independently assessed the titles and abstracts. The final list of selected articles was reviewed by both reviewers. The first author (JJ) then retrieved the full text of the selected articles, and both reviewers independently evaluated them against the eligibility criteria. Reasons for exclusion were recorded, and where there were discrepancies, a discussion was held between the 2 reviewers, and a consensus was reached on the final selection of articles.
Data charting was performed in Excel (Microsoft Corporation) by the first author (JJ), with checks and calibration by the second author (RB). The data charting form contained general study details as well as variables related to research questions, including target treatment, intervention type (eg, technology used, duration, and interaction level), intervention pathway (eg, how and when the intervention was delivered to clients and the relationship between the intervention and target treatment), intervention components, the model or framework used, measures and outcomes, user experience or acceptability, design process, critical appraisal (eg, limitations in the study, biases, strength of methodology, and generalizability of results), and key learnings.
The charted data were further summarized based on the key characteristics of the data. For example, within a charted column such as
The search resulted in 13,571 hits. A further 1379 studies were identified via other sources. After removing duplicates and screening titles, abstracts, and full texts, 45 (0.30%) papers met the eligibility criteria (
Flow diagram of the study selection process.
The studies included in this review (
Characteristics of the included papers.
Author, study, and year | Study design | Country | Condition |
Christensen et al [ |
RCTa | Australia | Depression |
Reis and Brown [ |
RCT | The United States | General mental health |
Haas et al [ |
Observational | The United States | Suicide |
Costin et al [ |
RCT | Australia | Depression |
Olson et al [ |
Historically controlled | The United States | General mental health |
Titov et al [ |
RCT | Australia | Social anxiety |
Brunette et al [ |
NRCTb | The United States | Smoking |
Johansen et al [ |
RCT | The United States | General mental health |
Strassle et al [ |
RCT | The United States | General mental health |
Ferron et al [ |
Observational | The United States | Smoking |
Reins et al [ |
Protocol | Germany | Depression |
Hötzel et al [ |
RCT | Germany | Eating disorder |
Taylor-Rodgers and Batterham [ |
RCT | Australia | Anxiety and depression |
Ahmedani et al [ |
Pre-post | The United States | Depression |
Ebert et al [ |
RCT | Germany | Depression |
King et al [ |
RCT | The United States | Suicide |
Batterham et al [ |
RCT | Australia | Anxiety and depression |
BinDhim et al [ |
Observational | Australia, the United Kingdom, Canada, New Zealand, and the United States | Depression |
Moessner et al [ |
Observational | Germany | Eating disorder |
Birnbaum et al [ |
Observational | The United States | Psychosis |
Bommelé et al [ |
NRCT | The Netherlands | Smoking |
Brown et al [ |
Development process | The United States | Smoking |
Griffiths et al [ |
RCT | Australia | Social anxiety |
Krampe et al [ |
RCT | Germany | General mental health |
Metz et al [ |
Protocol | The Netherlands | General mental health |
Muir et al [ |
Development process | The United Kingdom | Eating disorder |
Liu et al [ |
Development process | New Zealand | General mental health |
Suka et al [ |
Observational | Japan | Depression |
Batterham et al [ |
Protocol | Australia | Anxiety and depression |
Dannenberg et al [ |
Development process | The United States | Depression |
Denison-Day et al [ |
RCT | The United Kingdom | Eating disorder |
Dreier et al [ |
Protocol | Germany | Suicide |
Ebert et al [ |
RCT | Germany | General mental health |
Johansen et al [ |
Qualitative | Norway | Gambling |
McLean et al [ |
Observational | Australia | Eating disorder |
Shand et al [ |
Protocol | Australia | Depression |
Beck et al [ |
Pre-post | Canada | Anxiety and depression |
Brunette et al [ |
RCT | The United States | Smoking |
Duffy et al [ |
Pre-post | The United Kingdom | Anxiety and depression |
Peter et al [ |
RCT | The United States | Gambling |
Keller et al [ |
RCT and pre-post | The United States | General mental health |
Olthof et al [ |
Protocol | The Netherlands | Substance use |
Soucy et al [ |
RCT | Canada | Anxiety and depression |
Tobias et al [ |
RCT | The United States | Social anxiety |
Yoon et al [ |
Historically controlled | The United States | Substance use |
aRCT: randomized controlled trial.
bNRCT: nonrandomized controlled trial.
To assess the interventions analyzed in the included papers, we first distinguished the interventions themselves from the papers. A total of 6 studies in the sample [
We explored the interventions under several categories: intervention format, target treatment or therapy for which the intervention was designed to prepare clients for, the level of support provided, whether the intervention was designed for repeated or once-off use, the duration of the intervention, the theoretical model used, and how the intervention was delivered to the client (
Types of interventions in the selected studies (N=48).
Category | Studies, n (%) | |||
|
|
|||
|
Web-based program | 22 (46) | ||
|
Screening tool | 7 (15) | ||
|
Video | 6 (13) | ||
|
App | 4 (8) | ||
|
Website | 3 (6) | ||
|
Automated emails and website | 2 (4) | ||
|
Screening tool and messaging | 2 (4) | ||
|
Advertisement | 1 (2) | ||
|
Advertisement and website | 1 (2) | ||
|
|
|||
|
General professional help | 27 (56) | ||
|
|
21 (44) | ||
|
|
Specific face-to-face therapy | 14 (29) | |
|
|
Specific web-based therapy | 6 (13) | |
|
|
Specific phone therapy | 1 (2) | |
|
|
|||
|
No support | 35 (73) | ||
|
|
13 (27) | ||
|
|
Asynchronous (clinician) | 5 (10) | |
|
|
Synchronous (digital) | 4 (8) | |
|
|
Synchronous (clinician) | 2 (4) | |
|
|
Asynchronous and synchronous (peer) | 1 (2) | |
|
|
Asynchronous and synchronous (clinician) | 1 (2) | |
|
|
|||
|
Once-off | 28 (58) | ||
|
Repeated | 20 (42) | ||
|
|
|||
|
|
25 (52) | ||
|
|
≤30 minutes | 14 (29) | |
|
|
31-90 minutes | 9 (19) | |
|
|
91 minutes-4.5 hours | 2 (4) | |
|
|
16 (33) | ||
|
|
1-4 | 9 (19) | |
|
|
≥4 | 7 (15) | |
|
Duration not specified | 12 (25) | ||
|
|
|||
|
No model mentioned | 16 (33) | ||
|
Motivational interviewing | 16 (33) | ||
|
Cognitive behavioral therapy | 6 (13) | ||
|
Transtheoretical model | 4 (8) | ||
|
Theory of planned behavior | 4 (8) | ||
|
|
|||
|
|
32 (67) | ||
|
|
Social media | 9 (19) | |
|
|
Clinician or health service referral | 8 (17) | |
|
|
Print marketing (flyers or brochures) | 6 (13) | |
|
|
Trial panel (eg, Amazon Mechanical Turk) | 6 (13) | |
|
|
Email (student email, newsletters, or from the electronic medical record portal) | 5 (10) | |
|
|
Digital marketing (web-based advertisements or media) | 5 (10) | |
|
|
Postal screening questionnaire | 4 (8) | |
|
|
General practitioner waiting room | 2 (4) | |
|
|
Events (community events or school workshops) | 2 (4) | |
|
|
12 (25) | ||
|
|
Before first use or session | 6 (13) | |
|
|
On waiting list for treatment or assessment | 3 (6) | |
|
|
During intake | 2 (4) | |
|
|
Before intake | 1 (2) | |
|
|
3 (6) | ||
|
|
Downloaded screening app | 1 (2) | |
|
|
Via e-mental health portal | 1 (2) | |
|
|
Via referral website for clinic | 1 (2) | |
|
Unclear | 1 (2) |
aOther models used in only 1 or 2 studies: health belief model, acceptance and commitment therapy, self-determination theory, unified theory of acceptance and use of technology, screening brief intervention and referral to treatment, motivational enhancement therapy, theory of reasoned action, and extended parallel process model.
The 48 interventions examined in the included studies all comprised several different topics and tools, which we refer to as components. The most prevalent component was general psychoeducation (40/48, 83%), followed by symptom assessment (23/48, 48%) and information on various treatment options (21/48, 44%). Refer
Identifying components that showed evidence of effectiveness was difficult owing to the variety of interventions and components covered in this review, as well as the diversity in the outcomes of the experimental studies (see the
Components used in the included interventions.
Component | Description | Frequency, n (%) |
Psychoeducation | Information about condition, symptoms, risks, prevalence, treatment benefits, recovery chances, and myth busting | 40 (83) |
Assessments | Self-administered assessments of symptoms or behavior | 23 (48) |
Treatment options | Information about potential treatment options | 21 (44) |
Assessment feedback | Tailored or generic feedback on assessments; for example, severity relevant to the general population | 18 (38) |
Referral information | Direct contact information or guidance for further treatment | 17 (35) |
Testimonials | Videos or written stories from people with similar issues or from those who have been through treatment | 16 (33) |
Expectation management | Guiding expectations on treatment or help seeking and expectation setting | 16 (33) |
Pro-con list | Cost-benefit analysis of change, treatment, or help seeking | 15 (31) |
Coping skills | Cognitive behavioral therapy skills (eg, cognitive restructuring or behavioral activation), relaxation, mindfulness, and emotion regulation | 10 (21) |
Planning | Planning for change or treatment or planning for overcoming obstacles to change or treatment (implementation intentions) | 8 (17) |
Goal setting | Personal goals, life goals, and treatment goals | 8 (17) |
Values | Using values to develop discrepancy between ideal and actual self | 5 (10) |
Self-efficacy | Building belief in ability to change, self-esteem, and positive self-affirmations | 4 (8) |
Problem-solving | Identifying problems, brainstorming solutions, and solution planning | 4 (8) |
Only 18 of the 45 (40%) included papers discussed how the intervention was designed or developed. Of these 18 studies, only 4 (22%) mentioned the design approach: a study used a user-centered design [
To better understand the effectiveness of the included interventions, we took the controlled studies (24/45, 53%) and charted their outcomes (
Of the 16 studies that measured actual behavior or action (eg, engagement with target treatment or help-seeking behavior), 7 (44%) showed evidence of intervention effectiveness compared with controls [
A further 7 studies found no differences between controls and interventions in terms of behavior [
A total of 2 studies indicated worse behavioral outcomes for the IG compared with the CG [
Considering the other variables measured in these studies, the findings are mixed. Some indicated that the interventions increased help-seeking intentions [
No obvious patterns were observed among intervention format, support level, duration, components (see the
Outcomes of the controlled studies in the sample (standardized measures are abbreviated).
Study | Study design | Control | Sample size, N | Intervention | Measures | Significant outcomes |
Olson et al [ |
Historically controlled | TAUa | 163 | Screening tool | Acceptance and quality of physician appointment survey; qualitative physician feedback | IGb more likely to discuss alcohol and tobacco use with physician but not mood disorders. IG increased acceptance of subsequent physician appointment |
Yoon et al [ |
Historically controlled | TAU | 301 | Screening tool | Screen for unhealthy drinking behaviors and alcohol use disorders; motivation to change and referral interest survey; acceptance survey | CGc used to compare response rate only (responses were comparable). Only 16% of the IG had unhealthy drinking habits. Of these, 14% were interested in further help, and 40% would cut back on their own |
Bommelé et al [ |
NRCTd | NTCCe | 757 | WPf | POg: receptivity to information, motivation to change, self-efficacy and referral interest survey; SOh: cigarettes per day and quit attempts | IG more receptive to information than CG after the intervention but not at the 2-week or 2-month follow-up. IG had reduced smoking at all time points. No differences in quit attempts or referral |
Brunette et al [ |
NRCT | Wait-list | 41 | WP | PO: treatment seeking and motivation to change survey (verified by medical records); SO: FTNDi; 1 item from SCSj; ATSk | IG more likely to have taken action toward change than CG (eg, attempting to quit, meeting with a clinician to discuss, or start treatment) |
Strassle et al [ |
RCT | No intervention | 68 | Video | PO: return for second session of TTl; SO: SCL-90m; IIP-32n; CASF-Po; therapist measures: GAFp; CASF-Tq | No differences between IG and CG in adherence to TT, therapeutic alliance, or TT outcomes (all clients had high adherence to TT) |
Ebert et al [ |
RCT | No intervention | 128 | Video | PO: acceptance survey; SO: expectations, social opinions, internet concerns, help-seeking attitudes, and web-based therapy literacy survey | IG had higher acceptance, expectations, and literacy and lesser internet concerns than CG. No differences in social opinions or help-seeking attitudes |
Ebert et al [ |
RCT | No intervention | 1374 | Screening tool | PO: intention to seek help survey; moderators: CIDISr; AUDITs; CSSRt; SITBIu; subjective health, lifetime and current treatment use, intention to use mental health services, barriers to treatment use, and readiness to change survey | IG had higher intentions to seek help than CG. Intervention was more effective for those with panic disorder and worse physical health and those who were nonheterosexual. No effect of intervention for those in the action stage of change |
Soucy et al [ |
RCT | No intervention | 231 | WP | PO: CQv; TT lessons accessed; GAD-7w; PHQ-9x; SO: motivation to engage in TT survey; acceptance survey; K10y; SDSz | IG spent longer in TT than did CG. IG had higher anxiety and perceived disability at post-TT period than did CG. No differences in motivation or acceptance |
Christensen et al [ |
RCT | NTCC | 414 | 2 IGs: Waa and WP | CES-Dab; help- and treatment-seeking survey | Both W and WP reduced depression symptoms compared with CG. W less likely to seek informal help than CG. WP more likely to use certain evidence-based treatments |
Reis and Brown [ |
RCT | NTCC | 125 | Video | Therapist measure: TSQac | IG had lower dropout from TT than did CG |
Costin et al [ |
RCT | NTCC | 348 | 2 IGs: both automated emails and W | PO: AHSQad; informal help-seeking survey; SO: GHSQae; beliefs about help-seeking survey; depression and help-seeking literacy survey; CES-D; acceptance survey | No differences among IGs or between IGs and CG in help-seeking behavior, intentions, literacy, or depression symptoms. IGs had more positive beliefs about formal help than did CG |
Johansen et al [ |
RCT | NTCC | 105 | 2 IGs: WAaf video and EAag video | Acceptance survey; PANASah; WAI-Sai (client and therapist); return for second session of TT | WA had higher negative affect and lower therapist-rated alliance than CG. No difference in client-rated alliance among IGs. No differences in adherence to TT between IGs and CG |
Taylor-Rodgers and Batterham [ |
RCT | NTCC | 67 | WP | PO: A-Litaj; D-Litak; LSSal; DSSam; GASSan; SOSSao; ATSPPH-SFap; GHSQ; SO: PHQ-9; GAD-7; acceptance and adherence survey | IG had increased anxiety literacy, help-seeking attitudes and intentions, and reduced depression stigma compared with CG. No differences in symptoms, acceptance, or adherence |
Griffiths et al [ |
RCT | NTCC | 83 | WP | PO: GHSQ; SO: ATSPPH-SF; SA-Litaq; SASS-Iar; perceived need for treatment and interest in TT; acceptance survey | IG had higher literacy, perceived need, and positive attitudes toward treatment than did CG. No differences in help-seeking intentions or stigma |
King et al [ |
RCT | STCC | 76 | Screening tool and messaging | Perceived need for help and treatment use survey; 2 items from DDSas; readiness to access help survey | IG had higher readiness to access help and use treatment and lower stigma than did CG at the 2-month follow-up |
Batterham et al [ |
RCT | STCC | 2773 | Screening tool | PO: AHSQ; SO: PHQ-9; SOPHSat 2 items from GHSQ; AQoL-4Dau; self-reported days out of role | IG had higher study attrition than did CG. For social anxiety, IG had lower treatment use and intentions to seek help than did CG, no differences found for depression |
Peter et al [ |
RCT | STCC | 805 | 2 IGs: screening tools—IMav and NMaw | PO: choice between BBGSax and 3 items from GBQay; moderators: gambling history, psychological distress, and treatment interest survey | IM more likely to complete gambling screener than NM or CG |
Titov et al [ |
RCT | Intervention control | 108 | 2 IGs: WPs—Education and Education+Motivation | PO: SIASaz; SPSba; SO: PHQ-9; K-10, SDS, and CEQbb; literacy and motivation to change survey; time spent, log-ins, and homework downloads of TT | Education+Motivation had higher use of TT than Education. No differences in TT outcomes or acceptability. No differences in motivation to change |
Tobias et al [ |
RCT | Intervention control | 267 | 2 IGs: WPs—Education and Education+Motivation | Motivation for individual treatment steps, attitudes toward and intentions to seek treatment, perceived ability to engage in treatment seeking, and treatment use survey; CSQ-8bc | Education+Motivation had improved treatment-seeking attitudes and behaviors, compared with Education. Both groups improved on all outcomes |
Brunette et al [ |
RCT | Intervention control | 162 | 2 IGs: WPs—IWPbd and DEPbe | PO: treatment use (verified by medical records); SO: expired carbon monoxide; TFBbf (quit attempts); PUEUSbg | No differences between IWP and DEP in TT use, quit attempts, or abstinence (both groups had high use of TT) |
Denison-Day et al [ |
RCT | TAU | 313 | WP | PO: attendance at initial assessment appointment; SO: use of TT, acceptance, and motivation (interview) | No differences between IG and CG in attendance at initial appointment. Only 34% of the IG used the intervention, and of these, 98% attended the appointment |
Krampe et al [ |
RCT | TAU | 220 | Screening tool | PO: treatment use; SO: URICAbh; BSI-GSIbi | IG had lower treatment use and worse symptoms than CG. IG and CG were comparable for those with high readiness to change scores |
Keller et al [ |
RCT | Wait-list | 320 | 3 IGs: videos—7 minutes, 13 minutes, and 17 minutes | SSOSHbj; stigma survey | Only the 17-minute IG reduced stigma compared with CG |
Hötzel et al [ |
RCT | Wait-list | 212 | WP | PO: SOCQ-EDbk; SO: P-CEDbl; SESbm; RSESbn; EDE-Qbo | IG had higher motivation to change, self-esteem, and symptom improvement than CG. No differences in motivation to begin treatment |
aTAU: treatment as usual.
bIG: intervention group.
cCG: control group.
dNRCT: nonrandomized controlled trial.
eNTCC: nonspecific treatment component controls.
fWP: web-based program.
gPO: primary outcomes.
hSO: secondary outcomes.
iFTND: Fagerström test for nicotine dependence.
jSCS: Stage of Change Scale.
kATS: Attitudes Toward Smoking Scale
lTT: target treatment.
mSCL-90: Symptom Checklist-90-Revised.
nIIP-32: Inventory of Interpersonal problems-32.
oCASF-P: Combined Alliance Short Form-Patient version.
pGAF: Global Assessment of Functioning Scale.
qCASF-T: Combined Alliance Short Form-Therapist version.
rCIDIS: Composite International Diagnostic Interview Screening Scales.
sAUDIT: Alcohol Use Disorders Identification Test.
tCSSR: Columbia Suicidal Severity Rating Scale.
uSITBI: Self Injurious Thoughts and Behaviors Interview.
vCQ: Change Questionnaire.
wGAD-7: Generalized Anxiety Disorder 7-item.
xPHQ-9: Patient Health Questionnaire 9-item.
yK-10: Kessler 10-item.
zSDS: Sheehan Disability Scales.
aaW: website.
abCES-D: Centre for Epidemiological Studies Depression Scale.
acTSQ: Termination Status Questionnaire.
adAHSQ: Actual Help Seeking Questionnaire.
aeGHSQ: General Help Seeking Questionnaire.
afWA: working alliance.
agEA: experimental acceptance.
ahPANAS: Positive and Negative Affect Schedule.
aiWAI-S: Working Alliance Inventory.
ajA-Lit: Anxiety Literacy Scale.
akD-Lit: Depression Literacy Scale.
alLSS: Literacy of Suicide Scale.
amDSS: Depression Stigma Scale.
anGASS: Generalised Anxiety Stigma Scale.
aoSOSS: Stigma of Suicide Scale short form.
apATSPPH-SF: Attitudes Toward Seeking Professional Help Short Form Scale.
aqSA-Lit: Social Anxiety Literacy Questionnaire.
arSASS-I: Social Anxiety Stigma Scale.
asDDS: Discrimination-Devaluation Scale.
atSOPHS: Social Phobia Screener.
auAQoL-4D: Assessment of Quality of Life.
avIM: interactive message.
awNM: noninteractive message.
axBBGS: Brief Biosocial Gambling Screen.
ayGBQ: Gamblers’ Beliefs Questionnaire.
azSIAS: Social Interaction Anxiety Scale.
baSPS: Social Phobia Scale.
bbCEQ: Credibility/Expectancy Questionnaire.
bcCSQ-8: Client Satisfaction Questionnaire.
bdIWP: interactive web-based program.
beDEP: digital education pamphlet.
bfTFB: Timeline Follow-Back method.
bgPUEUS: Perceived Usefulness and Ease of Use Scale.
bhURICA: University of Rhode Island Change Assessment.
biBSI-GSI: Global Severity Index of the Brief Symptom Inventory.
bjSSOSH: Self-Stigma of Seeking Help Scale.
bkSOCQ-ED: Stages of Change Questionnaire for Eating Disorders.
blP-CED: Pros and Cons of Eating Disorders Scale.
bmSES: Self-Efficacy Scale.
bnRSES: Rosenberg Self-Esteem Scale.
boEDE-Q: eating disorder symptomatology.
This scoping review explores digital interventions to enhance readiness for psychological therapy. These interventions are delivered most often as unsupported web-based programs designed for once-off use that takes <90 minutes. They are used to prepare clients for specific therapies or, more generally, to enhance readiness for professional treatment; they are provided to clients either via outreach methods for those who have not sought help, or they are inserted into the care pathway before the main treatment for those who have already reached out. Thus, these interventions appear to cater to clients across multiple stages of change, from those in precontemplation, who are not yet aware that they need help, to those in the preparation stage, who are taking initial steps toward change.
What is the most apparent from this review is the substantial variation not only in the types of digital readiness interventions that have been used but also in their development, delivery, and evaluation. When it comes to the feasibility of digitally delivering interventions, the included studies indicate that there is potential in this area. The current state of the literature, however, does not yet support the possibility of determining which components or types of interventions are effective or not effective; this is a complex undertaking with multiple factors to consider. For example, in some contexts, interactivity appears to be an important aspect of these interventions, which makes sense when considering the conversational nature of traditional FTF MI. However, many simple, noninteractive interventions such as videos and advertisements were also effective at improving variables related to further treatment seeking or engagement. Despite the variability among the studies included in this review, several common topics emerged:
The existing literature indicates the effectiveness of tailoring psychosocial interventions to clients’ stages of change [
The effective identification of a client’s stage of change is a significant aspect of tailoring. This can be done by asking simple binary questions, such as those in the aforementioned studies (eg, Are you interested in treatment?) or more formally with readiness measures such as the General Help Seeking Questionnaire [
In all, 2 studies in this review illustrate the importance of effective stage identification and tailoring, with findings indicating negative or no effects of their inventions on those who already had high motivation or intentions to seek help [
The implementation of digital readiness interventions involves both onboarding (ie, the uptake of the intervention itself) and off-boarding (ie, the link between the intervention and further treatment). In terms of onboarding, the first point of contact and framing of digital readiness interventions are crucial, as uptake issues can drastically impact their effectiveness in the real world. Denison-Day et al [
Several studies included in this review were conducted in health care settings, where client trust has already been established [
An important aspect that surfaced while reviewing these studies was the potential risk of readiness interventions impairing treatment engagement, reducing help seeking, worsening symptoms, and increasing self-stigma. Batterham et al [
Stigma adds another layer of complexity to the help-seeking and treatment readiness process; Keller et al [
The final discussion concerns the evaluation of readiness interventions and issues when conducting research in such a sensitive area. Several studies in this review found that clients in the control arms improved as much as those in the intervention arms [
In addition, the trial design has a significant influence on the “effectiveness” of a given intervention. Constrained processes that force engagement with an intervention may provide rigor in intervention effects but have little ecological validity. There is also potentially greater baseline motivation among people who are prepared to participate in clinical trials than among the general population [
Another aspect of evaluation involves the chosen research methodology, which not only has a fundamental impact on the outcomes of the study but also on how we come to understand complex social constructs such as stigma, motivation, and the stages of change. Using quantitative measures to isolate and examine phenomena such as attitudes and emotions is limited because these experiences are highly subjective and contextual [
There are several limitations to this study. First, we did not include help seeking as a search term (we decided to focus our search on the more general areas of readiness, preparation, and motivation); therefore, our coverage of help-seeking interventions was not comprehensive. Furthermore, our digital-only inclusion criteria excluded some interesting interventions that could easily be reproduced digitally (eg, a postal survey on implementation intentions [
Given the inconclusive nature of findings presented here, further research is needed to enhance our knowledge and shape the field of digital readiness interventions for psychological therapy. In-depth qualitative research is crucial to understanding individual differences in emotional responses to readiness interventions and how constructs such as self-stigma affect motivation. Longitudinal research could also provide insights into individual trajectories through the stages of change because the process of becoming ready for treatment can be a long-term one, involving many layers and influences [
Digital interventions to enhance readiness for psychological therapy are broad and varied. The interventions in question range from brief, simple videos and advertisements to supported web-based programs. They are used to help clients across multiple stages of change, from those in precontemplation who have not yet sought help to those already preparing to take action. Although these easily accessible digital approaches show potential as a means of preparing people for therapy and thus reducing the mental health treatment gap, they are not without risks. The complex nature of stigma, motivation, and individual emotional responses toward engaging in treatment for mental health difficulties suggests that a careful approach is needed when developing and measuring readiness interventions. The results of this review indicate that the implementation and uptake of these interventions are important elements to consider in design, delivery, and measurement and that further qualitative and longitudinal research is needed to deepen our knowledge of the process of change in relation to readiness for therapy. Overall, this review highlights the fact that the field of digital readiness interventions is an emerging one, and more research is needed in this area.
PRISMA-Scr checklist. PRISMA-Scr: Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews.
cognitive behavioral therapy
control group
face-to-face
intervention group
motivational interviewing
Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews
transtheoretical model
The work of JJ was supported by SilverCloud Health and the Irish Research Council (grant EBPPG/2020/53). The work of RB is supported by Microsoft Research through its PhD Scholarship Programme and the Science Foundation Ireland Centre for Research Training in Digitally Enhanced Reality (d-real; grant 18/CRT/6224). The work of GD was supported by Science Foundation Ireland (ADAPT, grant 13/RC/2106_P2 and LERO, grant 13/RC/2094_P2).
JJ is partly funded by SilverCloud Health, a company that develops digital mental health interventions.