The landscape of mental health services provision is changing rapidly. Today technology enables access to on-demand, flexible, state-of-the-art care, where choices of providers and formats are vast. An average consumer is better informed, more engaged in the process, and has higher expectations.

Technology-supported care is more than simply using web-based and mobile technology for convenience and cost-saving. Many clinicians are adding virtual care components to their services to enhance the outcome for their clients.

From well-executed and individualized therapy treatment plans that offer autonomy through self-paced on-line modules to providing regular feedback between in-person sessions and monitoring progress via mobile apps, research findings on blended care programs are increasingly showing greater levels of client engagement and better patient outcomes.

What is Blended Care?

While there is no standardized definition for blended care, practitioners and experts in the niche of mental health generally describe it as a combination of face-to-face interventions and online/digital therapy sessions.[1]

For example, a patient is still required to come into the therapist’s office and have an offline conversation, but another part of their therapy will take place online, through the use of modern technology like smartphone apps or video conferencing software.

There are lots of different digitally-based modalities that could formulate a blended care solution, including, but not limited to:

  • Digitized treatment plans
  • Self-paced online learning modules[2]
  • Internet-based cognitive-behavioral therapy (iCBT)[3]
  • Scheduled video consultations with a therapist, either to provide feedback on progress or to replace a traditional in-person session
  • Progress monitoring apps, including data monitoring and health information from wearable sensors and experience sampling methodology data from in-app journals.[4][5]

Blended Care vs. Virtual Care

The history of blended care has gone hand in hand with the development of eHealth, which has shown a lot of promise in the field of mental health.[6] Online therapy services can provide many opportunities for continuous care and, in some instances, even self-management.

Telehealth, eHealth, virtual care are only some of the names used to describe the technological trends that allow patients to access health care services remotely. Some swear by them, others are concerned that these methodologies cannot offer the same level of safety and quality of care as traditional face-to-face means of care.

Online therapy services can provide many opportunities for continuous care and, in some instances, even self-management.

But there are obvious limitations to eHealth services. For one thing, they are not appropriate for immediate help, such as a medical emergency that requires immediate care or when an individual is battling suicidal thoughts in the case of a mental health emergency. Many virtual care platforms add this disclaimer, urging users to use the 911 emergency number rather than log on to their platform in these situations.

The limitations of eHealth don’t stop there. There is a rather big concern regarding their safety. A lot of questions have been raised about the accuracy of the diagnosis or treatment on these services, who generally work on a first meeting model. Users sign up, describe their symptoms, then the algorithm will pair them with an expert that is believed is most competent to help them. An analysis of the level of accuracy in the diagnosis process of virtual care services has found a lot of variations in quality.[7]

The emerging sector of blended care offers a promising middle ground by helping to overcome the limitations of both virtual-only and traditional (offline) care. 

The Benefits of Blended Care

Though there can be disparities in terms of how blended care is implemented, there are still some obvious benefits that can be noticed. Some are shared with those from eHealth, while others seem to pick up where eHealth left off.

Here are some of the benefits that blended care may bring to the table:

  1. Increased Self-Care

Blended care could potentially increase the level of accountability and responsibility that patients have over their own mental health – critical components in activation and patient health engagement.[8] The process of therapy is no longer confined to the occasional face-to-face meetings with the mental health professional – in a way, patients can be at least partially in control of their own therapeutic process.

For instance, mental health apps that have to be used daily as part of the treatment, as a way to monitor their own emotions or behaviors, could potentially lead to a better understanding of how certain triggers (life events, for instance), affect people on a psychological level.

This recognition is essential to therapy and sometimes can be hard to establish just through traditional therapeutic methods.

  1. A Comprehensive Treatment Plan

Based on the previous principle, it’s safe to assume that blended care can overall improve the quality of treatment. When the process of healing is conducted even outside of the therapist’s office, it can have faster, and better positive results with regard to efficacy.[9]

Of course, it depends on what kind of online method is employed, and how it will be used in the course of treatment. This is a decision that should be taken based on the target goals of the patient, and the mental health issue they are facing.

  1. Lower Therapy Costs

Blended care also has the potential to lower the overall cost of therapy.[10] Online therapy can reduce the need for more frequent (and more expensive) face-to-face meetings with a therapist, without necessarily lowering the quality of the treatment.

Payment for therapy sessions is generally done on a per session model, but when the traditional sessions move to an online medium, the costs will be modified as well. For instance, the cost of a therapy session using a mobile app cannot be the same as the real deal because the resources implicated in each are different, while the reasons for them remain the same. We’ve outlined some examples elsewhere on this site of different teletherapy apps that are worth checking out.

This may also encourage those without large financial resources to get help for mental health issues. A big downside of many eHealth platforms is that a lot of health insurance does not cover these costs, but when online methods are integrated with traditional offline methods, insurance coverage may no longer be an issue.[11]

  1. Less Pressure on the Therapists

Blended care can also have noticeable benefits for the therapist. In fact, psychologists generally have a positive attitude towards blended care and are often open to using this model in their own practice.[12]

A lighter caseload is often cited as one of the main benefits of blended care. Online therapy, or e-therapy tools often streamline communications, meaning the overall length of a session can be reduced (if the format remains similar to a traditional session) or patients can make less-frequent office visits.

This opens up the possibility of therapists even adding more patients to their practice.

Blended care could potentially increase the level of accountability and responsibility that patients have over their own mental health.

A Proposed Set of Guidelines for Blended Care

To ensure that blended care doesn’t make the same mistakes as many virtual care solutions, it’s imperative to effectively decide which traditional components of therapy can be done remotely through online means, and which should be left to tradition. But doing it can be difficult, mostly because up until now only a fraction of possible blended care applications have been explored.

Research shows that is a lack of consensus as to what constitutes blended care, who are those who would most benefit from it, and how these types of treatment should be organized and implemented.[13]

Without these definitions, it’s difficult to know whether blended care advances the landscape of mental health services and whether the improvement pays off by adding genuine value to a patient’s mental health.

What Do Experts Suggest?

There have been some steps forward, however. Based on the existing research on blended care and eHealth, Wentzel et al.[14] propose the following postulates:

  • Blended care should mean that online and offline components of therapy are interconnected in some way, and not separate methods put together. When blended care is perceived as the ideal model to treat the patient, the course of treatment (meaning what is online, and what is not), should work together to achieve the same goals[15];
  • Both online and offline therapies should contribute to the treatment process. This will avoid the mistake of using technology as an alternative to offline therapy methods based solely on criteria like comfort or convenience;
  • The online component of blended care must be carefully chosen and adjusted to the scope of the treatment and its process. A common belief in this sense is that online and offline therapies in blended care should operate on a 50/50 ratio, but the researches point out that for some patients this may not be appropriate;
  • The offline and online dynamic of blended care should be rooted in the protocol of the treatment, the capabilities of the chosen technology, and the abilities of the patient to use them. Blended care should be perceived as flexible, not fixed, meaning therapists should alter it in order to achieve the best results for the patient;
  • Therapists should propose a blended care model only after they discuss it with the patient. During these discussions, the therapist must both see what the best online/offline model is most appropriate, and explain the abilities and limitations of the chosen technology to their patient.[16]

Though not all-encompassing, these guidelines serve as a good starting point to make sure blended care models are designed based on the patient’s needs above all else.

Limitations of Blended Care

On paper, blended care seems to take the very best from traditional therapy and digital therapy, and combine them into a more efficient process.

However, due to the sector’s relative infancy, one of the biggest flaws of blended care is the lack of consistency in how it is defined and applied, leading to mixed success rates.

The studies that have been conducted into the benefits of blended care illustrate just how different this model looks from practice to practice:

  • Using computer-assisted therapy such as video therapy to replace (partially) traditional sessions[17];
  • Using self-help, unguided modules combined with scripted offline sessions[18];
  • Using online modules in addition to face-to-face therapy sessions.

Until there is general consensus into how blended care should be conducted, the effectiveness of blended care will vary and can be influenced by various factors:

  • Patient’s comfort level with using digital technology[19];
  • The therapist’s own understanding of what blended care is;
  • The methods employed in these types of mental health services.

Another issue that is less of a disadvantage of blended care and more of a factor that holds the sector back from evolving is the therapist’s attitude towards blended care, or using technology in therapy in general.

Whenever a new technology emerges, some degree of mistrust or criticism is inevitable: oftentimes, the industry may fear the technology aims to replace its human predecessor; or, certain applications raise a lot of important questions about ethics or safety.

Though many therapists are open to the idea of using more digital tools in their sessions, there are some things that are holding them back, specifically the many risks these new technologies can pose.[20] Inexperienced therapists, in particular, seem to lack knowledge as to how web-based tools can complement traditional therapy.

Without addressing these limitations, the widespread adoption of blended care cannot occur. Therapists have a great influence when it comes to promoting new technologies, but if they don’t understand or have confidence that a particular tool will be beneficial for their patients, then they will continue to rely on traditional therapy methods.

Final Thoughts

In an age of digital transformation, blended care is a natural evolution in the mental health services landscape that better complements consumers’ lifestyles and has been shown to improve accessibility, client engagement, and overall outcomes.

Blended care is certainly an interesting solution that helps overcome the limitations of solely relying on either eTherapy or traditional (offline) therapy alone.

However, more research is needed to validate its impact on client outcomes, as well as more definitive guidelines on how to construct blended models and consistently apply them in practice.

Have you started moving towards a blended care approach? We’d love to hear what’s working for you – drop a comment below!

References

  1. ^ Massoudi, B., Blanker, M. H., van Valen, E., Wouters, H., Bockting, C., & Burger, H. (2017). Blended care vs. usual care in the treatment of depressive symptoms and disorders in general practice study protocol of a non-inferiority randomized trial. BMC Psychiatry, 17(1), 218.
  2. ^ Clough, B. A., & Casey, L. M. (2015). The smart therapist: A look to the future of smartphones and mHealth technologies in psychotherapy. Professional Psychology: Research and Practice, 46(3), 147
  3. ^ Williams, A.D., O’Moore, K., Mason, E., Andrews, G. (2014). The effectiveness of internet cognitive behaviour therapy (iCBT) for social anxiety disorder across two routine practice pathways. Internet Interventions, 1(4), 225.
  4. ^ Morris, M. E., Kathawala, Q., Leen, T. K., Gorenstein, E. E., Guilak, F., DeLeeuw, W., & Labhard, M. (2010). Mobile therapy: case study evaluations of a cell phone application for emotional self-awareness. Journal of Medical Internet Research, 12(2), e10.
  5. ^ van Os, J., Verhagen, S., Marsman, A., Peeters, F., Bak, M., Marcelis, M., & Simons, C. (2017). The experience sampling method as an mHealth tool to support self‐monitoring, self‐insight, and personalized health care in clinical practice. Depression and Anxiety, 34(6), 481.
  6. ^ Richards, D., & Richardson, T. (2012). Computer-based psychological treatments for depression: a systematic review and meta-analysis. Clinical Psychology Review, 32(4), 329.
  7. ^ Schoenfeld, A. J., Davies, J. M., Marafino, B. J., Dean, M., DeJong, C., Bardach, N. S., & Mei, Y. J. (2016). Variation in quality of urgent health care provided during commercial virtual visits. JAMA Internal Medicine, 176(5), 635.
  8. ^ Graffigna, G., Barello, S., Bonanomi, A., & Riva, G. (2017). Factors affecting patients’ online health information-seeking behaviours: The role of the Patient Health Engagement (PHE) Model. Patient Education and Counseling, 100(10), 1918.
  9. ^ Titov, N., Andrews, G., Davies, M., McIntyre, K., Robinson, E., & Solley, K. (2010). Internet treatment for depression: a randomized controlled trial comparing clinician vs. technician assistance. PloS one, 5(6), e10939.
  10. ^ Olthuis, J. V., Margo C. W., Bailey, K, Hayden, J. A., & Stewart, S.H. (2016). Therapist‐supported Internet cognitive behavioural therapy for anxiety disorders in adults. Cochrane Database of Systematic Reviews, 3.
  11. ^ DeAngelis, T. (2012). Practicing distance therapy, legally and ethically. Monitor on Psychology, 43(3), 52.
  12. ^ Dijksman, I., Dinant, G. J., & Spigt, M. (2017). The Perception and Needs of Psychologists Toward Blended Care. Telemedicine and e-Health, 23(12), 983.
  13. ^ van der Vaart, R., Witting, M., & Riper, H. (2014). Blending online therapy into regular face-to-face therapy for depression: content, ratio and preconditions according to patients and therapists using a Delphi study. BMC Psychiatry, 14(1), 355.
  14. ^ Wentzel, J., van der Vaart, R., Bohlmeijer, E. T., & van Gemert-Pijnen, J. E. (2016). Mixing Online and Face-to-Face Therapy: How to Benefit From Blended Care in Mental Health Care. JMIR Mental Health, 3(1), e9.
  15. ^ Andersson, G., Cuijpers, P., Carlbring, P., Riper, H., & Hedman, E. (2014). Guided Internet‐based vs. face‐to‐face cognitive behavior therapy for psychiatric and somatic disorders: a systematic review and meta‐analysis. World Psychiatry, 13(3), 288.
  16. ^ Messner, E. M., Probst, T., O’Rourke, T., Stoyanov, S., & Baumeister, H. (2019). mHealth applications: potentials, limitations, current quality and future directions. In Baumeister, H. & Montag, C. (Eds.) Digital Phenotyping and Mobile Sensing (pp. 235-248). Cham: Springer
  17. ^ Wright, J. H., Wright, A. S., Paul Salmon, Aaron T. Beck, Jeffrey Kuykendall, L. Jane Goldsmith, Mary Beth Zickel (2002). Development and initial testing of a multimedia program for computer-assisted cognitive therapy. American Journal of Psychotherapy, 56(1), 76.
  18. ^ Wilhelmsen, M., Lillevoll, K., Risør, M.B. et al. Motivation to persist with internet-based cognitive behavioural treatment using blended care: a qualitative study. BMC Psychiatry, 13, 296.
  19. ^ Oravec, J. A. (2000). Online counselling and the Internet: Perspectives for mental health care supervision and education. Journal of Mental Health, 9(2), 121.
  20. ^ Schuster, R., Pokorny, R., Berger, T., Topooco, N., & Laireiter, A. R. (2018). The Advantages and Disadvantages of Online and Blended Therapy: Survey Study Amongst Licensed Psychotherapists in Austria. Journal of Medical Internet Research, 20(12), e11007.

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