Received: 18 December 2020 | Revised: 21 March 2021 | Accepted: 4 June 2021

DOI: 10.1002/capr.12465

ORIGINAL ARTICLE

A qualitative study of university students' experience of

Internet-­based CBT for depression

Franco Gericke1 | David D. Ebert2 | Elsie Breet1 | Randy P. Auerbach3 |

Jason Bantjes1

1
Institute for Life Course Health Research,
Department of Global Health, Faculty of Abstract
Medicine and Health Sciences, Stellenbosch Internet-­based treatments for depression have the potential to promote the men-
University, Stellenbosch, South Africa
2 tal health of university students. Yet, little is known about students' experiences of
Psychology & Digital Mental Health Care,
Department of Sport and Health Sciences, Internet-­based mental health interventions (also known as e-­interventions) and the
Technical University Munich, Munich,
acceptability of this mode of treatment in low-­resource settings. Our aims were to in-
Germany
3
Department of Psychiatry, Columbia
vestigate South African university students' experiences of using a brief semi-­guided
University, New York, NY, USA Internet-­based cognitive behavioural therapy (iCBT) for depression and document the

Correspondence
acceptability of this mode of psychotherapy. Data were collected via in-­depth semi-­
Jason Bantjes, Department of Global Health, structured interviews with students (n = 9) who had moderate to moderately severe
Faculty of Medicine and Health Sciences,
Institute for Life Course Health Research,
symptoms of depression (as assessed by the PHQ-­9) and had used a 7 session guided
Stellenbosch University, Stellenbosch, South skills-­based iCBT intervention. Data were analysed inductively using thematic analy-
Africa.
Email: [email protected]
sis, with the aid of Atlas-­ti software. Participants found the anonymity, privacy and
accessibility of iCBT appealing, believing this facilitated use of the intervention and
Funding information
The iCare intervention was developed with
overcame stigma associated with accessing traditional campus counselling services.
funding from the European Union's Horizon The intervention was helpful and facilitated self-­disclosure, emotional expression,
2020 research and innovation programme
awarded to David Daniel Ebert under grant
self-­awareness and skill acquisition. However, students also reported disappointment
agreement #634757. This work was also with the lack of human contact and immediate responsiveness, articulating an ex-
supported with funding from the South
African Medical Research Council (SAMRC)
pectation that the e-­intervention would mimic face-­to-­face psychotherapy. Moves
under its mid-­c areer scientist development to incorporate iCBT into student counselling should take account of and manage stu-
programme (awarded to Jason Bantjes). The
views expressed in this manuscript do not
dents' expectations about the ability of e-­interventions to mimic traditional therapy
represent those of the SAMRC. Additional and/or incorporate more opportunities for human interaction.
funding was provided by the Ithemba
Foundation in the form of a study bursary to
KEYWORDS
Franco Gericke
acceptability, depression, digital health, e-­interventions, experiences, iCBT, South Africa,
university students

1 | I NTRO D U C TI O N interventions (Hill et al., 2017). There is an ever-­growing range of

digital mental health interventions available including mobile ap-
Growing interest in the potential use of digital technologies, includ- plications, such as Headspace and MoodyMe (Flett et al., 2020);
ing Internet-­based treatments and smart phone applications, to de- self-­guided and guided Internet-­based interventions, such as ICare
liver treatments for common mental disorders has resulted in rapid (Taylor et al., 2020); online video conferencing group interventions
expansions in the availability and utilisation of digital mental health (Bantjes et al., 2021); and automated conversational agents (i.e.

© 2021 British Association for Counselling and Psychotherapy

792 | 
wileyonlinelibrary.com/journal/capr Couns Psychother Res. 2021;21:792–804.
GERICKE et al. | 793

chatbots), such as WoeBot (Fitzpatrick et al., 2017). Digital interven-

tions (also known as e-­interventions) may be particularly appropriate
Implications for Practice
to expand access to evidence-­based treatments on university cam-
• Internet-­based CBT (iCBT) for depression is an accept-
puses and meet the high demand for student counselling services
able mode of intervention for some university students
(Auerbach et al., 2018; Bruffaerts et al., 2018, 2019a). Indeed, a
and may help to overcome barriers typically associated
number of studies have shown the effectiveness of e-­interventions
with accessing campus-­based mental health services.
for treating a range of emotional and behavioural problems, including
• Uptake of iCBT on university campuses may be im-
depression, anxiety, smoking and substance use (Spek et al., 2007;
proved by stressing accessibility, autonomy, anonymity
Watkins et al., 2012). Using digital interventions to promote the
and privacy.
mental health of university students may be particularly appropri-
• iCBT has the potential to improve access to, and utilisa-
ate in low-­ and middle-­income countries, like South Africa, where
tion of, student counselling services, could be an integral
the marked shortage of mental health professionals is a significant
component of a stepped-­care treatment and could be
barrier to the provision of accessible and effective treatments. Yet
offered to students on waiting lists.
comparatively little is known about students' experiences of using
e-­mental health interventions and the acceptability of these, espe-
Implication for Policy
cially in low-­and middle-­income countries. Understanding students'
experiences of e-­interventions and whether they find digital treat- To expand students' treatment choices and improve access
ments acceptable and user-­friendly have important implications for to care, Internet-­based CBT for depression should be inte-
both the design and implementation of digital mental health on uni- grated into campus counselling services, either as a stand-­
versity campuses. Furthermore, understanding and responding to alone treatment, as an adjunct to individual psychotherapy
students' expressed treatment preferences are closely aligned with or offered to students on waiting lists.
the principles of evidence-­based practice and person-­centred care
(APA Presidential Task Force on Evidence-­Based Practice, 2006) and
with adopting a human-­factor approach to designing e-­interventions & Blase, 2011). Furthermore, in resource-­constrained environments
(Russ et al., 2013). It is within this context that we investigated a like South Africa, where there are marked shortages of trained men-
group of South African university students' experiences of using a tal health professionals and high rates of mental illness, it seems un-
semi-­guided Internet-­based cognitive behavioural therapy (iCBT) in- likely that labour-­intensive traditional modes of psychotherapy will
tervention to treat symptoms of depression. The aims of the study be a feasible or affordable way to meet students' mental health care
were to document students' experience of using the intervention needs (Bantjes et al., 2020).
and their perceptions of the acceptability of iCBT. We present the Internet-­based treatments and the use of mental health mo-
findings and discuss the implications for the design and use of digital bile device applications (apps) may be a viable and cost-­effective
mental health interventions on university campuses. alternative to traditional psychotherapy (Berger, 2017; Kazdin &
It is estimated that 31.4% of students report a common mental Blase, 2011; Riper et al., 2010) and may be as effective as tradi-
disorder in the preceding 12 months (Auerbach et al., 2018). Major tional treatments for most common mental disorders (Andrews
depressive disorder is particularly prevalent among students and is et al., 2010; Baumeister et al., 2014; Lin et al., 2013; Richards &
associated with a range of adverse outcomes including academic Richardson, 2012). Digital interventions have the potential to pro-
failure, suicidal thoughts and behaviours, and severe role impairment vide greater anonymity, availability and accessibility than tradi-
(Alonso et al., 2018; Bruffaerts et al., 2018; Mortier et al., 2018). Yet tional psychotherapy (Chan et al., 2016; Fleischmann et al., 2018).
treatment rates are very low among students, with estimates sug- iCBT interventions are as efficacious as face-­to-­f ace CBT in
gesting that fewer than 20% of students receive minimally adequate treating mild-­to-­moderate major depressive disorder, with effect
treatment even when mental healthcare services are freely available sizes ranging from d = 0.18 to d = 1.60 (Andersson et al., 2015;
and accessible (Bruffaerts et al., 2019b). Providing mental health- Andersson, 2009; Andersson & Cuijpers, 2009; Andersson &
care services to students is challenging, with common barriers to Hedman, 2013; Carlbring et al., 2018; Schröder et al., 2018). Digital
care including stigma, concerns about privacy and perceptions about interventions are, however, not without their problems and con-
the ineffectiveness of traditional interventions (Corrigan, 2004; cerns have been expressed about the lack of evidence to support
Corrigan et al., 2014; Kazdin & Blase, 2011; Mowbray et al., 2006). the design and use of many mental health mobile applications,
Face-­to-­face individual counselling is an effective approach to pro- privacy and data security problems, and patient safety (Huckvale
moting student mental health (Amanvermez et al., 2020), but it has et al., 2020). Among the barriers to implementing digital treat-
been argued that this mode of providing treatment may itself be a ments are the attitudes of key stakeholders towards this mode of
barrier to care for some students, highlighting the need to develop therapy and the acceptability of this alternative to traditional psy-
alternative models of intervention which do not rely on direct con- chotherapy (Baumeister, Nowoczin, et al., 2014; Gun et al., 2011;
tact between therapist and patient (Ebert, Nobis, et al., 2017; Kazdin Musiat et al., 2014; Topooco et al., 2017). The attitudes of service
794 | GERICKE et al.

users directly influence both the utilisation and implementation symptoms of depression (as measured by scores of between 10–­14
of e-­interventions (Bennett & Glasgow, 2009). Furthermore, the and 15–­19 on the PHQ-­9; Kroenke et al., 2003), irrespective of their
acceptability and subsequent use of e-­interventions are strongly GAD-­7 scores, were randomly assigned at a ratio of 2:1 to either the
influenced by the quality and quantity of available information intervention group or control group (treatment as usual). Those in
about their effectiveness, as well as perceptions about their the intervention group were offered the use of an iCBT interven-
availability and usability (Gun et al., 2011; Musiat et al., 2014). tion. In this way, 91 students were invited to join the intervention,
Indeed, providing potential users with information about the ef- of which 29 (39.1%) accepted the invitation and 22 initiated use of
fectiveness and usability of e-­interventions, known as Acceptance the intervention. Only six (i.e. 27.3% of those who started treatment)
Facilitating Interventions (AFIs), significantly increases the accept- completed all components of the intervention. At the end of the in-
ability and, subsequently, the likelihood of utilising digital mental tervention period, all students (n = 22) who had engaged with the
health solutions (Ebert et al., 2015; Mitchell & Gordon, 2007). For e-­intervention for at least one session were invited to share their
example, one AFI, based on the Unified Theory of Acceptance and experience by participating in a semi-­structured interview. A total of
Use of Technology (Venkatesh et al., 2003), employed a video clip nine students volunteered to be interviewed (yielding a participation
to present information about the efficacy of a iCBT intervention rate of 40.9%); five of these participants had completed all online
and share patients' testimonials about positive experiences, which components of the intervention, and four had started the interven-
significantly increased the acceptability of the intervention among tion but discontinued use.
adult primary care patients (Ebert et al., 2015). The role of attitudes
and perceptions in shaping the use of e-­interventions highlights the
importance of qualitative research to explore individuals' prefer- 2.2 | Description of the iCBT intervention
ences for, attitudes towards, and experiences of e-­interventions
(Kaltenthaler et al., 2004). All participants in this study made use of a transdiagnostic semi-­
It is within this context that we wanted to explore South African guided iCBT intervention (known as ICare) (Weisel et al., 2018;
university students' experiences of using iCare, a iCBT semi-­guided Weisel et al., 2019). This Internet-­based intervention was devel-
brief intervention for symptoms of depression. Rates of mental disor- oped to address the symptoms of, and risk factors associated with,
ders among South African university students are marked, with anxi- major depressive disorder and generalised anxiety disorder. The
ety and depressive disorders being the most common mental health content of the intervention was based on CBT materials previously
problems (Bantjes, Breet, et al., 2019; Bantjes, Lochner, et al., 2019). shown to be effective in the prevention and treatment of depres-
Furthermore, treatment rates on South African university campuses sive disorders and the targeting of sleeping problems (Buntrock
are low, with less than a third of students with mental disorders re- et al., 2016; Buntrock et al., 2015; Ebert, Nobis, et al., 2017; Ebert,
ceiving treatment (Bantjes et al., 2020). Digital interventions could Cuijpers, et al., 2017; Nobis et al., 2015). The iCBT intervention
have the potential to close this treatment gap and improve access to consists of seven weekly online sessions and an additional booster
care if students find them acceptable and useful. session, covering topics such as behavioural activation; reducing
incongruence; overcoming difficulties and scheduling pleasant
activities; psychoeducation; cognitive restructuring; problem-­
2 | M E TH O DS solving, exposure; and planning for the future. The online sessions
make use of student testimonials, audio-­video material, practical
The aims of this qualitative study were (1) to document students' ex- exercises and homework assignments. Participants could tailor
periences of using an iCBT intervention, and (2) to investigate their some of the content by selecting optional modules covering top-
perceptions of the acceptability of digital interventions to promote ics like sleep hygiene and procrastination. Students were respon-
student mental health. sible for working through the online material on their own and
at their own pace, but anonymous eCoaches provided guidance
and support using individualised structured feedback at the end
2.1 | Recruitment of each session via email. Students also received reminders from
the eCoach to complete the weekly sessions. The eCoaches were
Participants for this study were recruited from the intervention arm postgraduate psychology students who received supervision from
of a pilot study to assess the feasibility of an iCBT intervention at a registered psychologist.
a university in South Africa. All first-­year students at Stellenbosch
University were invited to complete a web-­
based mental health
screening survey, which consisted of a sociodemographic question- 2.3 | Sample characteristics
naire, Patient Health Questionnaire (PHQ-­9; Kroenke et al., 2003)
and the Generalized Anxiety Disorder Questionnaire (GAD-­7; Spitzer The sample was racially mixed (seven identified as White and two
et al., 2006). Students who reported moderate to moderately severe identified as Black) and consisted of three self-­identified men and six
GERICKE et al. | 795

self-­identified women. The mean age of the sample was 18.9 years interviews with completers and non-­completers, apart from reasons
(SD = 1.2, range = 17–­20), and the means on the PHQ-­9 and GAD-­7 given for discontinuing the intervention. We have indicated clearly
scores at the start of the intervention were 12.78 (SD = 1.99, in the findings below where completers and non-­completers had dif-
range = 10–­15) and 10.46, (SD = 4.06, range = 0–­21). ferent experiences of the e-­intervention. The seven superordinate
themes identified are presented below with verbatim quotes to illus-
trate each theme and enhance the credibility of the findings. Quotes
2.4 | Data collection from all nine interviews have been included in an effort to guard
against bias and the selective use of interview data.
Data were collected via in-­
depth semi-­
structured interviews, in
which participants were asked about their experience of using the e-­
intervention, their motives for utilising it, their perception of its us- 2.6 | Ethics
ability and effectiveness, their suggestions for improving or adapting
the intervention to make it more appealing to university students, Ethical approval for this study was obtained from the Human
and their reasons for either completing or discontinuing use of the Research Ethics Committee at Stellenbosch University (Reference
intervention. Interviews were conducted by the first author (FG) in M17/10/036; project reference #1788), and the necessary institu-
either English or Afrikaans, in a private space on campus at a time tional permissions were obtained from the university. Participation
convenient to participants. Throughout the interviews, participants was entirely voluntary, and participants provided written informed
were asked to clarify what they were saying and to expand on things consent prior to data collection. Participants were informed about
which were not clear. The interviewer also employed the technique the aims of the study and were told that they could withdraw at any
of ‘member checking’ (asking clarifying questions to check that the time without prejudice. Participants were given pseudonyms to en-
interviewer was correctly understanding and interpreting what par- sure anonymity, and all de-­identified data were securely stored on a
ticipants were communicating) in an effort to improve the trustwor- password-­protected digital storage device. Information about coun-
thiness of the data (Mays, 2000). Interviews were audio-­recorded selling and crises services was provided to participants at the end
and typically lasted between 45 and 60 min, and participants were of the interview. Students who reported suicidality were individu-
compensated for their time with a gift voucher valued at ZAR 50 ally followed up via email to encourage them to seek professional
(equivalent to approx. $3.39 at the time of data collection). assistance and to provide them with the details of campus-­based
Depressive symptoms were assessed before and after the in- crises and counselling services. Although no incentives were given
tervention using the PHQ-­9 and GAD-­7. The PHQ-­9 is a 9-­item for completing the iCare intervention, students who agreed to be
self-­
report questionnaire which is widely used to assess symp- interviewed received a modest gift voucher as compensation for
toms of depression and which has been shown to be a reliable and their time.
valid measure of symptoms of major depressive disorder (Kroenke
et al., 2003). The GAD-­7 consists of seven items assessing frequency
of symptoms of anxiety disorders over the past two weeks, scored 3 | Findings
using a response scale from 0 (not at all) to 3 (nearly every day) and
yielding a total score ranging from 0 to 21, with a cut-­off of 10 used Participants described their experience of using the e-­intervention
to identify clinically significant symptoms (Spitzer et al., 2006). All as mostly positive, saying it was accessible, helpful and facilitated
data are available from the authors on reasonable request. symptom relief. Significantly, 80% of the participants who com-
pleted the e-­intervention showed clinically significant improvements
in the severity of their depressive symptoms at one-­month post-­
2.5 | Data analysis intervention follow-­up. A paired-­samples t-­test, using an intention to
treat analysis, showed significant reductions from baseline to one-­
Interviews were transcribed and analysed by the first author (FG) month post-­intervention follow-­up for PHQ-­9 scores (t(253) = 4.12;
using the six-­step process of thematic analysis outlined by Braun & p = .0001) but not GAD-­7 scores (t(207) = 0.39; p = .696). It is not sur-
Clarke (2006). An inductive data-­driven approach was used to code prising that the reduction in GAD-­7 scores was not significant given
the data, with the assistance of Atlas-­ti software. In the first phase that students were included in the intervention irrespective of their
of data analysis, the interviews for the subgroup of participants who baseline GAD-­7 score, which resulted in some students with very low
completed the intervention (i.e. the completers) were analysed sepa- baseline anxiety symptom scores participating in the intervention.
rately from the subgroup who did not complete the intervention (i.e. Although the students had positive experiences of the intervention,
the non-­completers). The themes identified were independently ver- they also identified aspects of the e-­intervention which they experi-
ified by the last author (JB) to triangulate the findings and increase enced as frustrating and made suggestions for how the intervention
trustworthiness. Once agreement on the themes was achieved, might be implemented to make it more effective and acceptable to
they were organised into superordinate themes by FG and JB. There university students. Seven superordinate themes were identified as
was a high level of congruence between the themes identified in follows: (1) awareness and acceptance of symptoms as prerequisites
796 | GERICKE et al.

to access the e-­intervention; (2) valuing anonymity, convenience and Participants affirmed how much they valued privacy by referring
accessibility; (3) facilitating self-­
disclosure, emotional expression to the security features of the e-­intervention. They said they were
and self-­awareness; (4) building competence through skills acquisi- aware of the dangers of private information being accessed through
tion; (5) expectation that the intervention would mimic traditional cybercrime and said they felt reassured by the privacy features on the
psychotherapy; (6) frustration with the amount of mental effort and e-­intervention. Mari, for example, said:
time required to complete the intervention; and (7) suggestions for
implementing iCBT on university campuses. Each of these superor- ‘…like the anonymity helps to put you at ease because
dinate themes and the associated subthemes is discussed below. it is online, because, I mean, things can easily leak out…
1. Awareness and acceptance of symptoms as a prerequisite to if it does, it is anonymous, so yes, password protected
access the e-­intervention and all those things…’
Most participants said that they were inclined to use the iCBT
because they had been aware of their symptoms and they had ac- Participants expressed a perception that the iCBT was more ac-
cepted that they needed help. They found the feedback received cessible and convenient than traditional psychotherapy. They shared a
from the initial online screening survey to be congruent with their perception that it was time-­consuming, difficult and complicated to ac-
own perception that they were not coping, saying that the feedback cess conventional services and that the iCBT provided a user-­friendly
validated their experience of distress and motivated them to seek alternative. Chris described this, saying:
treatment. Ayanda described this, saying:
‘…it’s not this, go through ten forms and then you have
‘… If I stayed in that whole denial stage, I wasn’t gonna to go to this and this building and then meet this and
do the program… So first you need to accept that this person and then you get on to this list somewhere’.
there is something that needs to be sorted out…then
it will be easier to do the program’. Some participants said that they were precluded from using
campus-­based services because the student counselling centre only
Many participants said they had been contemplating treatment operated during normal office hours, when they had academic com-
but had not yet taken any concrete action to access care until this was mitments and lectures. This was particularly apparent among stu-
offered to them in the form of an e-­intervention. In this way, the invita- dents enrolled in courses such as engineering and health sciences,
tion to make use of the e-­intervention seemed to function as a bridge which have very full academic programmes. James described this,
facilitating access to treatment which would otherwise not have been saying:
sought.
2. Valuing anonymity, convenience and autonomy ‘…people don't have time. So, you can't make a therapist
Most participants reported that they found the anonymity of the appointment at eight at night… they're just unavailable’.
iCBT appealing, saying this facilitated their initial engagement with
the programme. They said that being able to use the e-­intervention iCBT was perceived as a more accessible alternative to traditional
privately enabled them to overcome the stigma associated with ac- services because it could be used at the convenience of the user. Chris
cessing traditional face-­to-­face campus services. Participants de- expressed this, saying:
scribed the student counselling centre as ‘very public’, expressing a
fear that it would be visible to peers if they accessed campus-­based ‘You can go home, it's there. You don't have to drive
services. By comparison, iCBT offered participants a more private anywhere. You don't have to book an appointment. It's
and confidential way to access psychological help. Stephanie said just available anytime…’
she was drawn to the e-­intervention because: ‘…no one would've ever
known that I’d done it unless I told them’. Similarly, Mia described her Participants said that iCBT gave them greater autonomy and con-
reluctance to visit the student counselling centre and her preference trol over their treatment. They said they appreciated being able to use
to access services more discretely, saying: the e-­intervention flexibly, at their own convenience and for as long
as they wanted. Being able to select optional modules engendered a
‘…everyone walks past there (the counselling centre)… sense of control over their treatment, which was experienced as em-
You shouldn’t feel embarrassed to go, but if you walk powering. Mari said:
in there, it does feel as if everyone is looking at you…
You are less because everyone else can handle life, ‘…it (the e-­intervention) was easy for me because I sat
but you can’t. … It was easier to get me to do this (use at my laptop, in my room when I had time. … And the
the e-­intervention) than to go to someone… It is just additional modules that you could do, that was nice be-
easier to do an e-­intervention, it does not have that cause, like, that week I could decide…I am going to do
same (negative) connotation to it’. this module!’
GERICKE et al. | 797

Similarly, Stephanie described her positive experience of autonomy and effective. They said that they had learnt ‘tools’ which were
and flexibility, saying: relevant to their context and enabled them to cope with the con-
crete everyday problems that they faced. Christopher, for exam-
‘… as opposed to just a therapist that you have an hour ple, said:
session with…I could spend as long as I want to on that,
and still go access it afterward…’ ‘And I feel like this intervention thing was very useful
in that it gives you a lot of tools, a lot of guidelines
3. Facilitating self-­
disclosure, emotional expression and and examples…that you can try and apply to your own
self-­awareness life…’
Participants reported that iCBT facilitated self-­disclosure and
emotional expression, saying that they found it easier to acknowl- Likewise, Ayanda described how iCBT facilitated skills acquisition,
edge their feelings and thoughts online. Anisha said: saying:

‘ …over the computer, I figured that is the easiest. To ‘… you learn how to deal with your emotions, you also
open up easier…I have been to a psychologist, but I’ve learn to accept things… so, it also helped with that’.
never opened up…’
Participants reported feeling empowered by acquiring new
Similarly, Ayanda said: skills, and said this aspect of iCBT helped them to feel less like ‘a
patient in need of treatment’ and more like ‘a person in need of
‘I find it extremely difficult to talk to anyone I know coaching’. Participants said it was affirming to see that the skills they
about feelings or emotions. So, the fact that it was over had learnt were effective, and this made them feel more competent.
the internet … it was better for me, because I was able Chris explained: ‘I don't need sympathy or that. I just need to know the
to express myself…it helped me express the other emo- tools that I need to cope’. And Kevin spoke about feeling empowered
tions that I’d been suppressing for so long…’ by the skills he had acquired and expressed his satisfaction with
iCBT, saying:
Chris echoed this, saying:
‘That is why I give this (iCBT) a big thumbs up’.
‘Some people would find it (the e-­intervention) very
nice because they can be open’. 5. Expecting the e-­intervention to mimic traditional psychotherapy
Most participants said that they valued the feedback received
Participants also said the e-­intervention facilitated self-­reflection from the eCoach at the end of each session and believed this was
and enabled them to become more aware of their thoughts, feelings, an important component of the programme. They said that the in-
needs and behaviours. This greater self-­awareness helped participants dividualised interaction helped to make iCBT more personable and
identify areas where changes were needed and facilitated seeking in- helped them to consolidate the learning in each session. Mari ex-
dividual psychotherapy. Stephanie said: pressed this perception, saying:

‘I went after this to a therapist, because I realised that I ‘The feedback that you got, it was not the interac-
needed that…This (e-­intervention) was like a thing that tion as such, but it was still as if you were talking to
helped me diagnose my problems, and figure out, where someone…’
I stood. … It (the e-­intervention) was the starting point.
Because it was the push in the right direction. And, my And Christopher said:
life, as a whole, has become a lot better since then’.
‘All the responses were very much individualised
Similarly, Kevin explained how the e-­intervention paved the way to which I very much liked… I feel like that helped me get
accessing individual psychotherapy, saying: the most out of the course’.

‘So, seeing a psychologist was no longer like a shameful Nonetheless, most participants reported frustration with the
thing for me’. lack of direct human contact and disappointment with the lack of
immediate responsiveness, articulating an expectation that the iCBT
4. Building competence through skills acquisition would mimic the responsiveness and immediacy of face-­
to-­
face
Most participants said that the iCBT intervention was helpful therapy. For example, Stephanie described her experience of the
because it enabled them to learn new skills which were practical eCoach, saying:
798 | GERICKE et al.

‘The feedback that I got from the therapist (eCoach) text online and expressed a wish for a more interactive and less text-­
was pretty average… that was a bit disappointing ac- intensive format:
tually. … (it would help) if the feedback happened a
lot quicker … and a bit more analysis of what I’d said… ‘…because there is a lot of reading work… I know
and it felt like I could have had more. …I needed more some of my friends won’t like this; it is just a bit too
(human interaction)’. static. Like, it is read, read, read, answer, answer, an-
swer…The videos were cool, and I know that a lot of
Some participants said that the limited online interaction with the my friends will really like a more interactive thing…
eCoach and the format of the feedback created opportunities for mis- instead of reading the tips or the layout of the session,
understandings which could not be easily clarified in a more direct dis- you could have everything in a video’.
cussion. Peter explained:
7. Suggestions for implementing e-­interventions
‘Basing the online platform on text, therefore, cre- In addition to noting the need for the e-­intervention to be less
ates opportunities for misunderstandings or misin- text-­
intensive and more interactive, participants also suggested
terpretations… It (the feedback) can seem extremely truncating the intervention. Peter, for example, expressed his desire
judgemental, and this is where the lack of face-­to-­face for the sessions to be shorter and more focused, suggesting that the
contact comes in the most….’ intervention could be improved by ‘… maybe cramming it more…’.
In noting how iCBT motivated and prepared them for seeking indi-
Most participants said that they had wished for more interaction vidual therapy, some participants suggested the e-­intervention might
with the eCoach. Mari stated: be effectively used as a first-­line treatment or as a prelude to face-­to-­
face therapy. Participants also suggested that iCBT might be a helpful
‘I realised that (not being able to interact with the adjunct to traditional psychotherapy. Peter explained how blending
eCoach) was an issue -­I had no one to discuss it with the e-­intervention with face-­to-­face therapy could enable students
further, because the program only goes so far…Like, it to learn skills online while establishing a relationship with a therapist:
suggested solutions, but I did not necessarily always
want a solution’. ‘…the same format as an online program to improving
yourself with step-­by-­step instructions, coupled with
And Rachel said: face to face contact sessions…’

‘An internet intervention isn’t enough. It is still you Participants explicitly expressed a desire for iCBT to include more
and a screen…whereas when you make that connec- human interaction and more opportunities for relating to others. Some
tion with someone, and you trust someone …it is a suggested that one way to achieve this might be to combine the e-­
very different feeling and you don’t feel so alone…’ intervention with other interactive digital forums (like chatrooms or
blogs) where students could interact with one another in real time.
6. Frustration with the time and mental effort required for the Rachel, for example, said:
intervention
Participants said that the intervention was time-­consuming and ‘…thinking of it like a chat room, or like a… a blog even’.
sustained mental effort was required to engage with the online con-
tent, making it difficult to persist with treatment and to stay moti- Participants were emphatic that they could not imagine iCBT as an
vated to complete the intervention. Most participants who did not alternative to, or substitute for, face-­to-­face individual therapy. Mari
complete the e-­intervention cited these as reasons for discontinu- articulated this perception, saying:
ing. For example, Ayanda explained that she stopped using the e-­
intervention because of time constraints: ‘… I think it is good in getting you to that level where
you are aware of what is going on…I don’t think that
‘It was during the intervention thing. And I was just, you will ever get it on that level where it will take over
dealing with a lot of doctors’ appointments and, deal- the role of a person’.
ing with my social worker, and dealing with school
and, and, and…’
4 | D I S CU S S I O N
Many participants spoke about how hard it was to sustain con-
centration, engage with the text on screen and sustain engagement. This study is the first of its kind from South Africa to document uni-
Mari explained how iCBT required participants to read a great deal of versity students’ experiences of using iCBT and adds to the growing
GERICKE et al. | 799

body of literature describing the acceptability of e-­interventions to both of which highlight how the propensity to adopt novel technol-
promote mental health. The initial uptake of the e-­intervention was ogies is shaped by factors such as ease of use, the capacity for self-­
relatively low, with only 39.1% of students who were offered the determination and the need for autonomy (Lu et al., 2019; Venkatesh
intervention initiating treatment, and with only 27.3% completing all et al., 2003; Venkatesh & Bala, 2008).
modules of the intervention. This suggests that there may be a large Third, participants identified how iCBT engendered feelings
group of students with symptoms of depression who do not perceive of competence by promoting acquisition of relevant and effective
a need for treatment, are unmotivated to seek treatment and/or who skills. They experienced this skills-­based approach as de-­stigmatising
are not drawn to e-­interventions. This finding is, however, consistent and helpful, which suggests that it may be appropriate to promote
with previous findings of low rates of treatment seeking among stu- e-­interventions by positioning them as tools which build resilience
dents with major depressive disorder (Bantjes et al., 2020), and high and impart psychological skills. Presenting iCBT in this way may also
rates of attrition and low rates of engagement with mental health e-­ help to debunk participants’ expectation that the e-­
intervention
interventions (Lattie et al., 2019). Research is needed to understand will mimic conventional psychotherapy. This conclusion is congru-
the low uptake and completion rates we observed. Nonetheless, ent with the Emotional-­Technology Acceptance Model which, among
students who engaged with iCBT reported positive experiences. other things, highlights the significance between the diffusion of
As discussed below, these findings have eight implications for the new technologies and the extent to which the technologies foster a
development and implementation of e-­interventions for university sense of competence (Lu et al., 2019).
students. Fourth, students’ disappointment with the lack of interaction
First, it is interesting that all participants reported that aware- and engagement with the eCoach suggest that it might be import-
ness of their symptoms and acceptance of the need for assistance ant to manage users’ expectations and educate them more carefully
motivated them to utilise iCBT. This is consistent with research indi- about how online semi-­guided interventions are different from other
cating that individuals are unlikely to seek treatment in the absence ‘talking therapies’ which are more relational and personal. Managing
of a perceived need (Andrade et al., 2014; Mojtabai et al., 2011), students’ expectations of e-­interventions is particularly important
and implies that the Trans-­theoretical Model For Stages of Change given the evidence that treatment outcome expectancies predict
(Prochaska, 1994; Prochaska & Norcross, 2001; Prochaska & therapeutic change in CBT (Kazdin, 2015). Students’ expressed
Velicer, 1997) might be an appropriate framework to understand stu- desire for more human interaction is also interesting in the light of
dents’ decisions to utilise e-­interventions. This finding also suggests literature showing the importance of therapist factors and human
that it may be helpful to use motivational interviewing (Norcross interaction in iCBT interventions (Richards & Richardson, 2012).
et al., 2011; Rollnick & Miller, 1995) as an integral component of Indeed, the level of human interaction seems to be an important
promoting students’ uptake of e-­interventions. Indeed, motivational predictor of therapeutic outcome, as is evident in the observation
interviewing is effective in promoting utilisation, completion and by Richards and Richardson (2012) that there is a hierarchy of ef-
retention in mental health e-­interventions (Saulsberry et al., 2013; fectiveness within iCBT; therapist-­supported interventions are the
Titov et al., 2010; Van Voorhees et al., 2009). most efficacious (g = 0.78), followed by interventions supported by
Second, participants recognised how iCBT enabled them to non-­clinical staff (g = 0.58), with unguided interventions being the
overcome typical barriers to accessing campus-­based mental health least effective (g = 0.36) (Richards & Richardson, 2012).
services, including stigma, inconvenience and inaccessibility, all of Fifth, students reported that iCBT facilitated self-­awareness and
which are congruent with the barriers to care reported by students paved the way for them to seek individual psychotherapy which they
(Mowbray et al., 2006). Participants valued the anonymity, privacy, were not previously inclined to do. Other studies have also found that
availability and accessibility provided by iCBT, a finding which is students who use guided e-­interventions for depression reported
also congruent with other qualitative research (Chan et al., 2016; greater self-­awareness and consider this to be a crucial component
Fleischmann et al., 2018). It is significant that students found self-­ of the effectiveness of the intervention (Ly et al., 2015). Our data
disclosure and emotional expression were facilitated by the e-­ suggest that iCBT may be a useful bridge into traditional psychother-
intervention. This phenomenon, which has been termed the ‘online apy, not only by enabling students to overcome perceived barriers
disinhibition effect’, is consistent with other studies reporting that to accessing psychological care but also by facilitating awareness of
individuals typically feel more comfortable disclosing sensitive in- areas in need of change and thus increasing their motivation to seek
formation when using technology (Lapidot-­Lefler & Barak, 2015; care. iCBT may thus be an important component of a larger strategy
Suler, 2004). Taken together, these findings suggest iCBT might be to increase utilisation of traditional campus-­based psychotherapeu-
useful in engaging students who would not otherwise access men- tic services by, for example, offering e-­interventions as the first line
tal health services, particularly if the interventions are presented as of help in a stepped-­care approach to student counselling services
an anonymous, user-­friendly, convenient and private way to access (Bower, 2003) or by offering iCBT to students who are on waiting
psychological help. This conclusion is consistent with The Unified lists at student counselling centres.
Theory of Acceptance and Use of Technology (Venkatesh et al., 2003) Sixth, our findings highlight students’ need for autonomy
and the Emotional-­Technology Acceptance Model (Lu et al., 2019), and how much they valued being able to use iCBT at their own
800 | GERICKE et al.

convenience and control the content by selecting optional modules. recruited from one university. Similar studies with larger, more rep-
Studies have documented the benefits of tailored content which is resentative samples drawn from diverse settings and including sen-
flexible to users’ needs within guided e-­interventions (Fleischmann ior students (who may be more familiar with issues of cyber-­security)
et al., 2018; Palacios et al., 2018). The need for autonomy may be are needed to understand the factors that shape university students’
particularly marked among students, given the developmental tasks engagement with iCBT. We relied on a self-­selected sample of stu-
of young adults (i.e. the attainment of autonomy and independence) dents which may have resulted in a sample biased towards those
(Robards et al., 2018; Wilson et al., 2011). who had mostly positive experiences of the intervention.
Seventh, students showed an awareness of cyber-­security and
the need to safeguard their information, a finding which is not
surprising given recent incidents like the Facebook/Cambridge 5 | CO N C LU S I O N
Analytica scandal and the cyber-­hack on the Ashley Madison dating
website (in which the private information and identity of users were Taken together, these findings suggest that some South African
made public; Hinds et al., 2020). Students’ concerns about data secu- first-­year university students may find iCBT acceptable and effec-
rity highlight the importance of emphasising privacy and confidenti- tive as a mode of delivering psychological treatment for symptoms
ality as key features of iCBT and ensuring that security features are of depression. Participants explicitly appreciated the autonomy and
robust and explicit. Musiat et al. (2014) have, however, noted that convenience of being able to access treatment via the Internet and
stressing the privacy and security features of e-­interventions may reported that this mode of therapy overcame common barriers to
not be sufficient to promote use, as the utilisation of mental health accessing traditional campus-­based services while also promoting
services is also strongly influenced by the perceived effectiveness feelings of competence. Crucially, the findings of this study highlight
and credibility (Musiat et al., 2014). students’ disappointment with the lack of immediate personalised
Eighth, it is interesting that students indicated a need for human interaction. This implies that any move to incorporate iCBT
more responsiveness and reflectiveness, expressing a desire for into student mental health services will need to take account of and
human interaction. Similarly, Fleischmann et al. (2018) and Palacios manage students’ expectations about the ability of e-­interventions
et al. (2018) found that students who used semi-­guided iCBT ex- to mimic traditional therapy and/or incorporate more opportunities
pressed dissatisfaction with feedback being too generic and artic- for human interaction as part of the e-­intervention.
ulated a need for more personal and immediate tailored feedback
(Fleischmann et al., 2018; Palacios et al., 2018). It is unclear to what C O N FL I C T O F I N T E R E S T
extent this expressed need for individual feedback is a function of None.
students’ desire for personal connection and a therapeutic relation-
ship, rather than a function of their expectations about what ther- AU T H O R C O N T R I B U T I O N S
apy entails. Nonetheless, this finding may point to the potential for FG was involved in conceptualisation of the project; data collection
iCBT to be used as an adjunct to face-­to-­face therapy or, at the least, and data analysis; and preparation of the first draft of manuscript.
to be blended with real-­time interaction with a human therapist, as DE was involved in conceptualisation of the project; funding acquisi-
has been suggested by others (Wilhelmsen et al., 2013). Crucially, tion; development of the iCare intervention; and reviewing the final
this finding highlights two distinct paradigms for conceptualising e-­ manuscript. EB was involved in project management, data collection
interventions. On the one hand, technology can be seen as a con- and data management. RA was involved in conceptualisation of the
duit for delivering content (i.e. content-­based interventions), thus project; data analysis; and reviewing and editing the final manu-
dispensing with the need for human therapists. On the other hand, script. JB was involved in conceptualisation of the project; funding
technology can be a tool for establishing a therapeutic relationship acquisition; supervision of data collection and data analysis; and
(relationship-­centred interventions). While the students in our study preparation of the final manuscript.
seemed to value the content-­centredness of iCBT, they also ex-
pressed a desire for a relationship-­centred approach. Understanding ORCID
how content-­
centred and relationship-­
centred approaches can Franco Gericke https://orcid.org/0000-0002-6925-9366
be blended in the design and delivery of digital mental health may David D. Ebert https://orcid.org/0000-0001-6820-0146
be important for achieving high utilisation rates among university Elsie Breet https://orcid.org/0000-0002-6974-8215
students. Randy P. Auerbach https://orcid.org/0000-0003-2319-4744
Jason Bantjes https://orcid.org/0000-0002-3626-9883

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804 | GERICKE et al.

AU T H O R B I O G R A P H I E S
How to cite this article: Gericke, F., Ebert, D. D., Breet, E.,

Franco Gericke is registered as a psychometrist with the Health Auerbach, R. P., & Bantjes, J. (2021). ‘I give this a big thumbs up!’:

Professions Council of South Africa. He is currently registered A qualitative study of university students' experience of

for a joint-­PhD (Stellenbosch University and KU Leuven) focus- Internet-­based CBT for depression. Couns Psychother Res., 21,

ing on suicide prevention. His previous research focused on the 792–­804. https://doi.org/10.1002/capr.12465

relationships between university students’ mental health and ac-

ademic achievement.

David Daniel Ebert is Professor for Psychology & Digital Mental

Health Care, Department of Sport and Health Sciences, Technical
University Munich. He is also the Director of the Protect Lab and
co-­founder, co-­managing director and chief scientific officer of
HelloBetter. Dr Ebert serves as the president of the International
Society for Research on Internet Interventions. His research
focuses on the development and evaluation of evidence-­based
Internet and mobile-­based health interventions for the promo-
tion of mental health in different settings and environments with
a special focus on the prevention and early intervention of men-
tal illness.

Elsie Breet is a researcher at the Institute for Life Course

Health Research in the Department of Global Health, Faculty of
Medicine and Health Silences, Stellenbosch University. Her re-
search focuses on suicide prevention, the relationships between
substance use and suicidal behaviour and the epidemiology of
mental disorders among college students.

Randy P. Auerbach is Associate Professor in the Department

of Psychiatry at Columbia University, College of Physicians
and Surgeons, and the Division of Clinical Developmental
Neuroscience, Sackler Institute. Additionally, he is Director of
the Translational Research on Affective Disorders and Suicide
Laboratory and serves as Co-­Director for the WHO World Mental
Health International College Student Initiative. Dr. Auerbach’s re-
search is committed to improving our understanding of depres-
sion and suicide in adolescents.

Jason Bantjes is a practising psychologist and associate pro-

fessor in the Institute for Life Course Health Research in the
Department of Global Health, Faculty of Medicine and Health
Silences, Stellenbosch University. His research has focused on
suicide prevention and the promotion of mental health.
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