141 providers responded to the survey, 65 of whom completed the optional open response question. The open response responders were primarily female and non-Hispanic White. Participants’ average age was about 41-years. Most participants who completed the survey had a Ph.D. and prescribed to an orientation related to cognitive-behavioral therapy (CBT; e.g., cognitive, third-wave behavioral). Over half of survey completers were employed in a private practice setting with an average of 12.6 years of clinical experience (SD = 11.9) Full demographic and clinical variables from the total survey sample (N = 141) are reported in Peipert et al. (2022). See Table 1 for full demographic information of those who responded to the open response question.
Thematic coding yielded 11 themes across the 65 open responses: patient appropriateness, feasibility, research evidence and efficacy, patient barriers, liability, patient personal contact, additional resources, positive attitudes, trust in programs, systemic problems, and downplaying distress. The themes and example quotes are presented in Table 2.
A frequent theme mentioned in the open responses was concerns about whether a patient may be appropriate for using LITs while on a waiting list. This theme appeared to reflect two main concerns: (1) lacking information available on the patient to recommend an intervention at the time of being placed on a waiting list, and (2) a perceived mismatch between the client population served with those for whom LITs would be helpful. Responders noted a perceived lack of appropriateness for LIT use given they have not had time to do a proper assessment of the patient prior to them being placed on the waiting list. Therefore, the clinician would not know what LIT to recommend which would be appropriate for that patient. Other factors associated with patient appropriateness included level of severity, of perceived risk, a perceived lack of available LITs for their target population (e.g., couples, eating disorders, multiple comorbidities), and individual patient’s level of motivation.
Providers identified barriers associated with the feasibility of recommending LITs for patients on a waiting list. These included a general lack of knowledge of available LITs, feeling overwhelmed by the number of LITs available, and the effort and time required to acquire the required level of knowledge to integrate LITs into waiting list practices. Participants also discussed confusion around billing and compensation for LITs, and a lack of insurance coverage. At an administration level, participants mentioned a lack of system support (“…the clinic has not been open to it for reasons that are unclear to me”), a lack of personnel dedicated to LIT delivery, and lack of training around integrating LITs into clinical practice. Finally, one participant noted the requirement to generate revenue in order to continue providing services may hinder them from recommending LITs for patients waiting for treatment: “… I am running a business. Businesses have to generate revenue to survive. I don’t feel a responsibility to advertise other businesses, such as online guided programs and bibliotherapy coaches, to people who call my business!”
Research evidence and efficacy
Participants noted barriers related to a lack of strong research evidence for LITs, or beliefs around LITs not being effective for their patients. One noted, “From a risk management perspective, I see no evidence thus far to demonstrate the efficacy of such programs. These programs may give the clinician a false sense of doing good for their patient on a waitlist when in fact they may be doing harm.” Another wrote, “[Apps] tend to be underresearched and overhyped.” Some of these comments were specific to the guidance or coaches used in guided LITs (“I would not refer to a coach as they are untested and inconsistent”), while others pointed out that efficacy may vary depending on the individual and their needs (e.g., diagnosis, comorbidities, level of severity). Conversely, a few individuals noted there was sufficient evidence to support the use of LITs in clinical practice (“I have suggested to our clinic having a “wait-list” intervention program (1–3 sessions with suggestions of apps, books, and other resources) since there is evidence to support this type of program”). One individual noted an interest in knowing more about research on LIT efficacy and uptake.
Providers noted a variety of barriers that patients face which prevent them from recommending LITs. The most commonly noted barriers were access to resources such as internet and computer for online programs, and money to pay for an app or book. Furthermore, some providers believed patients may be limited in their abilities, such as those with intellectual disabilities, visual/hearing impairments, low literacy levels, and a lack of knowledge or familiarization with technology that may prevent them from comfortably navigating a phone- or computer-based program. Many providers noted patients experience a lack of privacy outside of the therapy office which may inhibit patients’ ability to participate with a LIT. Another provider noted that some patients are limited to only services which will be reimbursed by insurance, which prevents them from recommending LITs. A few providers noted lack of motivation or willingness to complete LITs as a barrier for their patients. Language was also mentioned as a patient barrier, such that most online interventions and guided interventions are not available or accessible in a non-English language for their patients.
Providers questioned the legal and ethical liability of offering a LIT for patients on a waiting list. In the case of providing guidance for those using a LIT, it was unclear to some providers the extent to which the recipient would be officially a “patient” rather than someone on the waiting list who is not yet a patient in their clinic. One participant wrote, “I am reluctant to provide any clinical care to someone who is not officially my patient. I think that is ethically a little sticky.” Providers were also concerned about using LITs with high-risk patients, “liability concerns – if we provide any “between” support, are we then liable for the patient if something happens before they begin [our] treatment?”
Patient personal contact
Providers expressed that personal contact was an important factor for patients when considering use of LITs. Some expressed that patients need personal contact to be accountable and engaged in a LIT. Others mentioned that patients have varying needs when it comes to personal contact, where some require personal contact and others may simply prefer it. One provider noted that patients would not use LITs because of their interest in developing a therapeutic relationship, which would be more effective for their treatment overall. Finally, one provider mentioned LITs may be a useful adjunct to the therapy relationship, though not a standalone intervention.
Providers highlighted resources they recommend to patients when waiting for treatment. Many included the assumption that patients will seek out a different provider when on the waiting list “and not stay on wait-list.” Other resources that providers mentioned include websites, books, podcasts, blogs, and relaxation exercises. Though some of these may overlap with LITs, most were not considered to be treatment-related, but rather psychoeducational. One provider also mentioned accessing books available through public libraries for individuals who face financial barriers.
Providers expressed positive attitudes towards LITs in their open responses. These included statements related to using or recommending LITs already, or an interest in changing behavior to recommend LITs for patients waiting for treatment, “I would be willing to use most of the options listed above.” Others expressed the belief that these options are effective, helpful, and accessible to patients, and that LITs would be useful specifically for those waiting for treatment. One provider theorized that starting a LIT prior to face-to-face treatment may lead to faster improvement overall, “…perhaps I should be willing to consider giving my couples resources who are waiting to get in to see me to see if that would help them progress faster when they start.” Providers expressed a common goal towards increasing access to care and decreasing wait times, and the possibility that research could lead to insurance coverage for LITs.
Trust in programs
Some provider’s comments suggested a hesitancy to use LITs given that they have not personally vetted these resources. A couple comments highlighted uncertainty around the security and financial motives of LITs, “I am hesitant to recommend online services [because] I am uncertain about security and setting up vulnerable people to businesses that have nonclinical motives.” Another comment highlighted distrust towards the coaches involved in guided intervention. Finally, one comment included beliefs that most LITs do not include all aspects of a treatment or address all presenting problems, but instead use a “superficial approach.”
A few responses commented on systemic problems that prevent people from seeking or accessing quality mental health care. One provider noted how clinical practice procedures can erect barriers that cause clients to wait for treatment or drop out prior to accessing care, such as requiring a phone screen. Another provider discussed the systemic issues associated with community-based care, including high caseloads, low pay, and high turnover rates, which ultimately impact the quality of patient care. Furthermore, this provider added that mental health care systems would use LITs as replacements for therapy to reduce overall expenses. “We serve some of the most vulnerable. They deserve every bit the same high quality care offered to commercially insured or private pay clients.” Overall, this responder highlighted how LIT use may further increase mental health disparities rather than increase equity because the root causes of systemic barriers remain unaddressed while LITs may become more common for those who have higher-level needs in low-resource settings. “So, when I think about ways to manage wait lists, replacing even temporarily therapy with AI, apps, or even a peer support group just doesn’t cut it. Is it better than nothing? Maybe. Is it how we should be designing our systems or where we should be dedicating resources? Absolutely not. It just doesn’t meet the need.”
One provider noted concerns around patients feeling dismissed by being offered a service that was less intense than face-to-face psychotherapy.