Practitioners’ experience of the working alliance in a blended cognitive behavioural therapy intervention for depression: A qualitative study of barriers and facilitators

Background Digital technologies have been acknowledged as a potentially useful resource for increasing mental healthcare access. The working alliance (WA) is a key influence on outcomes in conventional psychotherapy, but little is known about therapists’ experiences of forming an effective WA in blended interventions that involve in-person psychotherapy and a digital programme. Aims To investigate Psychological Wellbeing Practitioners’ (PWPs’) experiences of WA in a trial of blended cognitive behavioural therapy (b-CBT) for depression. Method Semi-structured qualitative interviews were conducted with 13 PWPs who delivered b-CBT in a two-arm, non-inferiority randomised controlled trial investigating the effectiveness of b-CBT compared to face-to-face CBT. Thematic analysis was used to analyse the data. Results Participants reported four facilitating factors when building and maintaining WA in b-CBT: having more time to deliver treatment, access to a wider toolkit, capacity to tailor components of b-CBT, and receiving appropriate training and support. Participants also identified four barriers to building and maintaining WA: time and resource constraints, usability challenges, limited flexibility to tailor the digital programme to client needs, and lack of confidence in delivering b-CBT. Conclusions Our study is the first to specifically investigate practitioners’ perceived facilitators and barriers to forming WA in b-CBT for depression. Findings suggest that PWPs’ experiences of WA can be improved by accounting for the time required to deliver b-CBT in service workflows to reduce time-pressure; increasing opportunities to tailor the digital programme through offering transdiagnostic tools and adaptable features; and providing appropriate b-CBT training and technical support.