Internet Interventions 25 (2021) 100405
Available online 26 May 2021
2214-7829/© 2021 Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Online consultations in mental healthcare during the COVID-19 outbreak:
An international survey study on professionals' motivations and
Nele A.J. De Witte
, Per Carlbring
, Anne Etzelmueller
, Tine Nordgreen
, Maria Karekla
, Svein Øverland
, Rudy Abi-Habib
, Sylvie Bernaerts
, Angelo Compare
, Aranzazu Duque
, David Daniel Ebert
, Angelos P. Kassianos
, Andreas Schwerdtfeger
, Eva Van Assche
, Tom Van Daele
Expertise Unit Psychology, Technology & Society, Thomas More University of Applied Sciences, Antwerp, Belgium
Department of Psychology, Stockholm University, Stockholm, Sweden
GET.ON Institute/HelloBetter, Hamburg, Germany
Department of Clinical Psychology, Department of Clinical, Neuro-, & Developmental Psychology, Faculty of Behavioural and Movement Sciences, VU Amsterdam,
Psychotherapy, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
Haukeland University Hospital, University of Bergen, Bergen, Norway
Department of Psychology, University of Cyprus, Nicosia, Cyprus
Department of Psychology, Rouen University, Rouen, France
Union Professionnelle des Psychologues Cliniciens Francophones et Germanophones, Belgium
Regional Research Center for Forensic Psychiatry, St. Olavs Hospital, Trondheim, Norway
Department of Social Sciences, School of Arts and Sciences, Lebanese American University, Beirut, Lebanon
Department of Human and Social Sciences, University of Bergamo, Bergamo, Italy
Universidad Internacional de Valencia, Valencia, Spain
Cibersalud, Mallorca, Spain
Institute of Psychology, Vilnius University, Vilnius, Lithuania
Department of Applied Health Research, UCL, London, United Kingdom
University Institute of Maia - ISMAI, Maia, Portugal
Center of Psychology at University of Porto - CPUP, Porto, Portugal
Institute of Psychology, University of Graz, Graz, Austria
Introduction: While the general uptake of e-mental health interventions remained low over the past years,
physical distancing and lockdown measures relating to the COVID-19 pandemic created a need and demand for
online consultations in only a matter of weeks.
Objective: This study investigates the uptake of online consultations provided by mental health professionals
during lockdown measures in the rst wave of the COVID-19 pandemic in the participating countries, with a
specic focus on professionals' motivations and perceived barriers regarding online consultations.
Methods: An online survey on the use of online consultations was set up in March 2020. The Unied Theory of
Acceptance and Use of Technology (UTAUT) guided the deductive qualitative analysis of the results.
Results: In total, 2082 mental health professionals from Austria, Belgium, Cyprus, France, Germany, Italy,
Lebanon, Lithuania, the Netherlands, Norway, Portugal, Spain, and Sweden were included. The results showed a
high uptake of online consultations during the COVID-19 pandemic but limited previous training on this topic
undergone by mental health professionals. Most professionals reported positive experiences with online con-
sultations, but concerns about the performance of online consultations in a mental health context (e.g., in terms
* Corresponding author at: Department of Psychology, Stockholm University, SE-106 91 Stockholm, Sweden.
E-mail address: firstname.lastname@example.org (P. Carlbring).
Contents lists available at ScienceDirect
journal homepage: www.elsevier.com/locate/invent
Received 17 March 2021; Received in revised form 11 May 2021; Accepted 19 May 2021
Internet Interventions 25 (2021) 100405
of relational aspects) and practical considerations (e.g., relating to privacy and security of software) appear to be
major barriers that hinder implementation.
Conclusions: This study provides an overview of the mental health professionals' actual needs and concerns
regarding the use of online consultations in order to highlight areas of possible intervention and allow the
implementation of necessary governmental, educational, and instrumental support so that online consultations
can become a feasible and stable option in mental healthcare.
Mental health interventions delivered through information and
communication technologies (ICT) have consistently been accumulating
an evidence base over the past decades (Carlbring et al., 2018; Phillips
et al., 2019). Such interventions can be labeled as e-mental health ser-
vices, although numerous other terms have been proposed and the eld
is hampered by a lack of shared terminology (Smoktunowicz et al.,
2020). Despite public interest and research support, the general uptake
of e-mental health in clinical practice remains low (Irvine et al., 2020;
Van Daele et al., 2020). While many mental health professionals
remained skeptical or did not perceive the need for e-mental health over
the past years, physical distancing and lockdown measures relating to
the COVID-19 pandemic have created the demand for these services in a
matter of weeks (Wind et al., 2020).
The advantages of e-mental health and blended approaches
combining e-mental health and face-to-face interventions include easy
access to mental healthcare, cost effectiveness, exibility, lower stigma,
and services offered in the natural context of the individual (Ebert et al.,
2018; Musiat et al., 2014). Mental health professionals generally have a
positive attitude toward e-mental health, but some barriers to the
implementation of this technology have also been reported. The lack of
knowledge on e-mental health, concerns about relational aspects, con-
cerns about the technology itself (e.g., data security), as well as ethical,
practical, and contextual factors have been suggested as hindering
implementation (Mayer et al., 2019; Stallard et al., 2010). Embedding
online consultations in healthcare also requires strong commitment
from healthcare organizations and the support of policymakers (Shaw
et al., 2018). The extent to which e-mental health is implemented in the
policy and practice of mental health services varies greatly between
countries. A comprehensive legal and regulatory framework, along with
reimbursement schemes, is often lacking but awareness at the policy
level is increasing. Some countries, such as the Netherlands and the
United Kingdom, are already more advanced in the implementation of e-
mental health as compared to other European countries such as Belgium
and Germany (Gaebel et al., 2020). In association with the European
Federation of Psychologists' Associations (EFPA) Project Group on
eHealth, Van Daele et al. (2020) have recently formulated general
guidelines for mental health professionals, health services, regulatory
agencies, and developers to promote the development and imple-
mentation of high-quality e-mental health interventions.
Insights into mental health professionals' actual needs and concerns
regarding the use of online consultations will highlight areas of possible
intervention and allow for the implementation of necessary govern-
mental, educational, and instrumental support so that online consulta-
tion can become a feasible and stable option in mental healthcare.
Therefore, this study investigates the uptake of online consultations
provided by mental health professionals during the rst wave of the
COVID-19 pandemic and aims to perform qualitative analyses to provide
in-depth insights into motivations of past and current (non-)use and
barriers for current use of online consultations. In this paper, online
consultations are dened as an e-mental health intervention entailing
digital contacts between clients and mental health professionals in the
context of psychological counseling or psychotherapy, via text, audio,
video, or a combination of all these. No specic hypotheses were
formulated for the current study as researchers aimed to summarize the
data with minimal interpretation.
2. Material and methods
In March 2020, the EFPA Project Group on eHealth set up an online
survey on the use of online consultations in response to the perceived
acute shift to e-mental health in and beyond Europe due to the COVID-
19 pandemic. This project group was initiated in 2015 and unites experts
in the eld to develop a better understanding of the eHealth domain and
design a sensible strategy for EFPA and its member associations. The
online survey was designed to assess the extent to which mental health
professionals provided online consultations at that time, their experi-
ences with this (new) treatment modality, and their concerns. The term
online consultations was not further specied and includes any digital
contact between clients and mental health professionals, e.g., continu-
ation of therapeutic sessions, but also therapist support in guided e-
mental health interventions. A question on telephone consultations was
also included in the survey to provide a broader picture of the shift to e-
mental health in the COVID-19 pandemic, but the questions of interest
for the qualitative analysis focused on online consultations. The survey
consisted of 14 multiple-choice questions and 9 open-ended questions
(some of which were follow-up questions that not every participant
received), which could be accessed through a link on the Qualtrics
platform (Appendix A). The survey was translated into 17 languages by
local researchers and professionals in the eld of psychology. This study
focused on the qualitative analysis of mental health professionals'
training in online consultations, reasons for (not) providing online
consultations in the past and during the pandemic, and current barriers
for the implementation of online consultations. A separate paper will
utilize the quantitative survey results to model predictors of the use and
experience of online consultations.
International recruitment was carried out between March 18 and
May 5, 2020 through opportunity sampling via mailing lists and social
media announcements of the EFPA, as well as national psychologists'
associations and project collaborators from 18 countries. At this time,
the participating countries imposed lockdown measures, including
nationwide closure of schools and non-essential services as well as
mobility limitations and physical distancing measures (all of which
mandatory, except in Sweden where only the closing of upper secondary
school was mandatory). The in-depth qualitative analysis relied on a
subsample in which participants were included if (1) the sample from
their country comprised 25 or more participants, in line with sample size
recommendations for qualitative research (Guest et al., 2017; Morse,
2000), and (2) the research team's local collaborators were available to
conduct a culturally sensitive analysis in the native language. A small
minority of participants were excluded from the qualitative analysis
because they used a language other than English or their national lan-
guage(s) (e.g., Russian). In case more than 250 respondents from one
country participated in the survey, a random sample of 250 participants
that followed the distribution of the use of online tools of the full sample
from this country was selected (Table 1). This was the case for Belgium,
France, Italy, Norway, Portugal, and Sweden. This study was approved
by the ethical committee of the Department of Applied Psychology of
Thomas More University of Applied Sciences (Antwerp, Belgium) and
N.A.J. De Witte et al.
Internet Interventions 25 (2021) 100405
informed consent was obtained from all participants.
2.3. Theoretical framework for qualitative analysis
Uptake, usage, and acceptance of technology is a multifaceted pro-
cess for which several theoretical models have already been developed.
Therefore, a deductive approach to qualitative analysis with a codebook,
in accordance with directed content analysis (Hsieh and Shannon,
2005), was used to analyze the two main open-ended questions relating
to the reasons why online consultations were not used in the past and the
mental health professionals' concerns regarding online consultations at
that time (Q6 and Q14 in Appendix A). To identify perceived barriers,
the codebook for analysis was designed based on the Unied Theory of
Acceptance and Use of Technology (UTAUT; Venkatesh et al., 2003).
According to this model, technology usage behavior is determined by
the intention to use, as well as facilitating conditions, including the
perceived availability of technological and organizational facilities. In
turn, intention to use is predicted by performance expectancy, effort
expectancy, and social inuence. Performance expectancy refers to
whether the type of technology is expected to help in achieving goals.
Effort expectancy relates to ease of use, and social inuence captures
whether an individual believes that important others think that they
should use the technology. Other relevant factors in this framework are
attitudes toward using technology, self-efcacy, and anxiety in relation
to the use of technology. The UTAUT model can explain as much as 70%
of the variance in the intention to use ICT (Venkatesh et al., 2003). Since
participating professionals also discussed client factors in their re-
sponses, the model was extended with categories included in an adap-
tation of the model for end users (Ebert et al., 2015). Contextual factors
and practical concerns were also included in the codebook, since the
UTAUT model is mainly concerned with attitudes and beliefs. A nal
category of non-specic factors was incorporated, for example to ac-
count for the lack of a perceived need for online consultations alto-
gether. Each broad category was further specied in multiple
subcategories, based on the UTAUT questionnaires (Venkatesh et al.,
2003; Ebert et al., 2015) and rst inspection of the dataset, to provide
more in-depth insights and promote clarity in the coding process.
The question on the training on online consultations (Q4_T in Ap-
pendix A) was also analyzed through deductive qualitative analysis. A
coding scheme with ve categories comprising a total of 17 codes was
designed. These ve categories were education programs focused on
online consultations or e-mental health, education on online consulta-
tions as part of a different education program, informal education,
knowledge based on the professionals' own experimentation, and un-
clear education. Further differentiation was based on the duration of
training in the rst category (e.g., 4 h or less), the type of education
program in the second category (e.g., academic bachelor or master's in
psychology), or the source of information in the third category (e.g.,
peer learning – intervision).
The rst versions of the UTAUT-based and training codebooks were
presented to all co-authors to assess clarity and piloted using small
samples consisting of 10 individuals from Belgium, Lebanon, and
Lithuania. The nal codebook was subsequently developed through
feedback and discussion with co-authors. Fig. 1 provides an overview of
the categories that are represented in the nal UTAUT-based codebook.
The full codebook and coding instructions can be found in Table B.1 in
Provision of online consultations in recent days.
No intention to offer
Austria 64 38 (59.38) 10 (15.36) 16 (25.00)
Belgium 250 167 (66.80) 42 (16.80) 41 (16.40)
Cyprus 45 30 (66.67) 6 (13.33) 9 (20.00)
France 250 103 (41.20) 50 (20.00) 97 (38.80)
Germany 167 83 (49.70) 38 (22.75) 46 (27.54)
Italy 250 194 (77.60) 24 (9.60) 32 (12.80)
Lebanon 73 60 (82.19) 8 (10.96) 5 (6.85)
Lithuania 99 62 (62.63) 31 (31.31) 6 (6.06)
Netherlands 81 65 (80.25) 13 (16.05) 3 (3.70)
Norway 250 187 (74.80) 28 (11.20) 35 (14.00)
Portugal 250 147 (58.80) 47 (18.80) 56 (22.40)
Spain 31 20 (64.52) 6 (19.35) 5 (16.13)
Sweden 250 119 (47.60) 64 (25.60) 67 (26.80)
Total 2060 1275
367 (17.82) 418 (20.29)
Performance expectancy Usefulness of technology, productivity, & career prospects
Effort expectancy Difficulties in performing or learning online consultations
Attitude towards technology Job satisfaction & (dis)liking online consultations
Social influence Opinion of important others & organisational support
Facilitating conditions Resources, knowledge, compatibility with practices, & availability of assistance
Anxiety Comfort, apprehension, & fear of making mistakes
Client-oriented factors Client performance expectancy, effort expectancy, social influence, facilitating
conditions, anxiety, concerns regarding data security, knowledge, & attitudes
Contextual factors Policy, reimbursement, payment, legal aspects, technical difficulties,
privacy, costs, & ethics
Fig. 1. Graphical representation of the extended UTAUT-based framework of the codebook to analyze the two main open-ended questions relating to the reasons why
online consultations were not used in the past and the mental health professionals' concerns regarding online consultations at that time.
N.A.J. De Witte et al.
Internet Interventions 25 (2021) 100405
Qualitative analysis based on the aforementioned codebook was
performed at the national level by 14 researchers who were native-
language speakers and aware of the local context of each participating
country. All researchers were trained in psychology and held a PhD or
were doctoral candidates. Researchers were provided with excel or SPSS
sheets with anonymized data from their respective countries and addi-
tional empty variables for coding, along with coding instructions
(Table B.1 in Appendix B). Any ambiguities about coding were discussed
with the rst author, after which consensus was reached. However, the
codebook was prior developed in co-creation with the researchers,
carefully piloted, and questionnaire responses were generally concise
and precise. As a result, only a small minority of cases required discus-
sion. The researchers additionally translated two open-ended multiple-
choice options in which the participants could provide further input
about their reasons for (not) deciding to use online consultations (Q7
and Q8 - response “other, please specify” in Appendix A). Since no
coding scheme for these questions could be determined beforehand, the
rst author conducted inductive qualitative analysis (thematic analysis;
Nowell et al., 2017) of these translated responses. An aggregated dataset
was created, and frequency analyses were used to compare responses
within and among countries. Distributions of the answers were visual-
ized in frequency tables (see also B.2-B.3 in Appendix B) and country-
specic as well as general ndings are discussed in the results.
Descriptive statistics were also calculated through frequency statistics or
summary statistics for age, years of professional experience, and overall
experience with online consultations (Q10, Q16, Q17 in Appendix A).
The current paper focuses on the in-depth qualitative analysis in a
subsample of the survey participants, a separate paper will use statistical
modeling to analyze predictors of the use, the overall experience,
comfort and telepresence in online consultations (including Q5, Q9, Q10
in Appendix A) in a larger sample.
3.1. Descriptive statistics
The sample consisted of 2082 individuals, including participants
from Austria (N =65), Belgium (N =250), Cyprus (N =45), France (N
=250), Germany (N =168), Italy (N =250), Lebanon (N =73),
Lithuania (N =119), the Netherlands (N =81), Norway (N =250),
Portugal (N =250), Spain (N =31), and Sweden (N =250). The par-
ticipants had a mean age of 41.83 years (SD =10.86; range: 16–80) and
on average, 13.72 years of professional experience (SD =9.96; range:
0–55). The survey included women (N =1737), men (N =336), and
individuals who identied themselves as non-binary (N =4). The ma-
jority of the included mental health professionals comprised psycholo-
gists (N =1848), followed by psychiatrists (N =22), mental health
nurses (N =3), or other self-specied professions (N =206), such as
psychotherapist or social worker. Most participants were self-employed
(N =859), employed in mental health organizations (N =395),
healthcare organizations (N =355), group practices (N =56), or other
organizations (N =413), such as educational institutions. In the
Netherlands, Norway, Sweden, and to a lesser extent, Lithuania,
(mental) healthcare organizations appeared to be the main employers of
the participating mental health professionals.
Approximately 62% of the sample had provided online consultations
in recent days, and 18% of the remaining participants intended to do so
in the near future (Table 1). The survey also assessed telephone con-
sultations, which showed a similar distribution with 1392 users, 236
planned users, and 453 non-users in recent days. France had the highest
proportion (39%) of participants who were not interested in offering
online consultations, while the Netherlands had the lowest (5%). The
types of online consultations used in this sample were video calls (N =
1338), e-mail (N =291), and chat (without video; N =250). The large
majority of the participants who had provided online consultations had
a positive experience (n =1111/1413), and only 94 individuals had a
negative experience, resulting in a group mean score of 3.95 (SD =0.82)
on a 5-point Likert scale, with small differences among countries,
ranging from 3.65 in Lithuania to 4.41 in Spain.
The participants who provided online consultations were asked to
report the platforms they used to do so. The responses showed that many
professionals used multiple platforms, depending on their clients' needs.
Skype, including Skype for business, was used most often (N =622),
with the highest prevalence in Austria, Cyprus, France, Italy, Lithuania,
Portugal, Spain, and Sweden (Table 2). Other frequently used platforms
were ZOOM (N =294), Whatsapp (N =260), Whereby (N =109),
Confrere (N =88), Microsoft teams (N =53), FaceTime (N =53),
Facebook Messenger (N =52), and Google services (Hangouts, Duo,
Meet; N =45).
3.2. Training in online consultations
The participants were asked to indicate whether they had received
any form of training on online consultations or e-mental health and if so,
to describe such training. In general, about 11% of the sample (n =226/
2082) reported having received a form of training (Table 3). Nearly half
of these training programs were specic to e-mental health (n =112/
226). However, half of the e-mental health-specic training programs
(N =55) had a duration of less than 4 h. The remainder of the e-mental
health-specic forms of education consisted of training with a duration
of one day or less (N =16), less than one week (N =27), more than one
week (N =4), or a specic master's or postgraduate course (N =6). A
minority of participants had also received training in online consulta-
tions as part of a broader program, specically in the academic training
to become a psychologist in Sweden (N =3), a professional bachelor's
program in psychology in France (N =1), a postgraduate course (Swe-
den: N =1, the Netherlands: N =2), a training school in Belgium (N =
1), or a conference workshop (Belgium: N =1, France: N =4, Lithuania:
N =1, Norway, N =1). Informal education was offered through
guidelines from a professional psychological organization (N =18) or
peer learning through intervision (N =3) or supervision (N =17).
Finally, eight individuals reported having learned to use e-mental health
from their own experience or experimentation.
3.3. Reasons for not providing online consultations in the past
Of the sample, 38% (n =791/2078) had provided online consulta-
tions prior to the COVID-19 outbreak, with substantial differences
among the countries (Table 4). Over half of the sample had previously
provided online consultations in Lebanon, Spain, Cyprus, Lithuania, and
Sweden, but only about a quarter of Belgian, French, and German par-
ticipants had prior experience in providing online consultations.
Top three most used platforms for online consultations, self-reported per
Country 1 N 2 N 3 N
Skype 21 ZOOM 15
Belgium Whereby 81 ZOOM 58 Skype 56
Cyprus Skype 24 ZOOM 6 Viber 5
France Skype 65 Whatsapp 34 ZOOM 20
Germany RED medical 29 ZOOM 12 Skype 10
Italy Skype 163 Whatsapp 96 ZOOM 32
Lebanon Whatsapp 37 Skype 31 ZOOM 13
Lithuania Skype 60 Facebook 24 ZOOM 22
Netherlands Quli 25 ZOOM 18 Skype 12
Norway Confrere 86 Skype 41 Norsk Helsenett 16
Portugal Skype 97 ZOOM 67 Whatsapp 46
Skype 12 ZOOM 6
Sweden Skype 36 ZOOM 15 Visiba Care 13
Platforms used by fewer than 5 individuals are excluded from this table.
N.A.J. De Witte et al.
Internet Interventions 25 (2021) 100405
The remaining participants (N =1287) reported multiple reasons for
not offering online consultations in the past (Textbox 1; Table B.2 in
Appendix B). By far, the most common singular reason, reported by 33%
of the individuals who had not provided online consultations in the past,
was the lack of a perceived need for online consultations (n =421/
1287). The largest overall category, excluding non-specic factors, was
performance expectancy. Among the professionals, 19% (n =249/1287)
were uncertain about whether online consultations were useful for their
work, citing concerns about relational aspects (N =82), using it in
certain age groups, such as children (N =35), using it with certain in-
terventions (N =30), working with non-verbal behavior and emotions
(N =26), using it in certain target groups or disorders (N =20), or
effectiveness (N =20). Another commonly reported reason for not
previously offering online consultations was related to the professionals'
attitude, mostly disliking performing online consultations (N =142).
Problems regarding social inuence were hardly related to feeling social
pressure against offering online consultations (n =3/108) but repre-
sented the lack of perceived support for online consultations by the or-
ganization or the association to which each respondent belonged (n =
103/106). In the area of facilitating conditions, the lack of resources
(space and materials; n =41/81) and the lack of knowledge (n =33/81)
were the most common reasons for not using this technology. The most
common client-oriented factor that negatively inuenced the imple-
mentation of online consultations was the professionals' perceived lack
of client interest in using it (n =43/70).
The countries showed some differences in the most common reasons
for not offering online consultations in the past (Fig. 2). The lack of a
perceived need was cited by the largest subgroup of previous non-users
in all countries except Sweden, where facilitating conditions (mostly the
lack of resources) comprised the most commonly reported category. In
Training in online consultations.
Country Specic training Part of program Informal training Own experimentation Unclear or unspecied Total
Austria 9 0 1 0 5 15
Belgium 5 2 5 1 2 15
Cyprus 2 0 2 0 0 4
France 0 5 2 0 2 9
Germany 7 0 2 0 3 12
Italy 6 0 2 1 8 17
Lebanon 4 0 1 0 6 11
Lithuania 7 1 0 0 2 10
Netherlands 7 2 3 1 2 15
Norway 35 1 1 2 5 44
Portugal 6 0 13 0 5 24
Spain 3 0 0 0 2 5
Sweden 21 4 6 3 11 45
Total 112 15 38 8 53 226
Experience with online consultations prior to the COVID-19 outbreak.
Country Sample size
Austria 65 28 (43.08) 37 (56.92)
Belgium 249 59 (23.69) 190 (76.31)
Cyprus 45 25 (55.56) 20 (44.44)
France 250 62 (24.80) 188 (75.20)
Germany 166 48 (28.92) 118 (71.08)
Italy 250 93 (37.20) 157 (62.80)
Lebanon 73 52 (71.23) 21 (28.77)
Lithuania 119 62 (52.10) 57 (47.90)
Netherlands 81 38 (46.91) 43 (53.09)
Norway 250 84 (33.60) 166 (66.40)
Portugal 249 94 (37.75) 155 (62.25)
Spain 31 18 (58.06) 13 (41.94)
Sweden 250 128 (51.20) 122 (48.80)
Total 2078 791 (38.07) 1287 (61.93)
Most frequently reported reasons for not providing online consultations prior to the COVID-19 outbreak, both as singular coded responses and in
the form of categories of the UTAUT-based coding scheme. Non-specic factors are not included in most common broader categories.
Most reported singular reasons
1. I did not or do not have a need for online consultations (non-specic factors; N =421).
2. I do not like doing online consultations (compared with face-to-face sessions) (attitude toward using technology; N =142).
3. My organization or association has not provided sufcient support for online consultations (social inuence; N =103).
4. I have concerns about relational aspects (e.g., impersonal contact, fostering a therapeutic relationship) (performance expectancy; N =82).
5. Clients are not interested in using online consultations (client-oriented factors - attitudes; N =43).
Most common broader categories
1. Performance expectancy (N =249)
2. Attitude toward using technology (N =181)
3. Social inuence (N =106)
4. Facilitating conditions (N =81)
5. Client-oriented factors (N =70)
N.A.J. De Witte et al.
Internet Interventions 25 (2021) 100405
Spain, the perceived need for online consultations was very low, and
performance expectancy and social inuence were not reported; how-
ever, the interpretation of these ndings is hampered by the small
sample size (13 participants without previous use out of a total of 31
Spanish participants). Factors relating to social inuence, specically
the lack of perceived support from the participants' organizations or
associations, were more regularly reported in Sweden (N =23) and
Norway (N =28) compared with the other participating countries.
3.4. Reasons for (not) providing online consultations during the pandemic
When answering a multiple-choice question, the mental health pro-
fessionals indicated multiple reasons why they decided to start
providing online consultations at present or in the near future. Among
the participants, 75% (n =1237/1642) considered online consultations
a necessity from a public health perspective, 69% (n =1139/1642)
wanted to serve and support their clients who could not attend face-to-
face sessions, 35% (n =576/1642) reported that their clients wanted it,
31% (n =505/1642) wanted to stay in touch with new developments in
technology, and another 30% (n =491/1642) did not want to lose in-
come. Among the participants, 9% (n =148/1642) provided additional
self-specied reasons; the most common ones include the following: it
was necessary due to the pandemic and the related lockdown and
quarantine measures (N =44); online consultations were required by
their organization, association, or government (N =33); they wanted to
continue the therapeutic process and care (N =17); and they were
already conducting online consultations before the pandemic (N =16;
mostly to overcome distance barriers with clients who were living far
away, N =11).
The mental health professionals who had not provided online con-
sultations during the rst month of the outbreak (N =418) selected the
following UTAUT-based reasons for this in a multiple choice question:
online consultations do not seem as effective as face-to-face consulta-
tions (performance expectancy; N =129); I lack the required hardware
or software (facilitating conditions; N =129); my clients do not want
this (client attitude; N =83); I do not know how to use it in practice
(facilitating conditions; N =56); I generally dislike using technology in
practice (attitude; N =55); I currently do not see the value over
continuing face-to-face (performance expectancy; N =43); technology is
unreliable (contextual factors; N =36); I am afraid to make mistakes
(anxiety; N =23); it requires too much effort (effort expectancy; N =
18); my colleagues disapprove (social inuence; N =3); or another self-
specied reason (N =81). The most reported additional reasons were
the following: their work context did not allow online consultations (N
=22); they were not seeing patients (N =13); and they were concerned
about privacy issues (N =10).
3.5. Perceived barriers for current use of online consultations
Fig. 3 provides an overview of the concerns of professionals
regarding online consultations. A total of 1420 participants reported one
or more concerns regarding the current use of online consultations
(Table 5). A detailed report of regional responses can be found in
Table B.3 in Appendix B.
3.5.1. Performance expectancy
Performance expectancy was the largest category of concerns. The
participants in all countries clearly had several concerns about whether
online consultations would be useful for their work. Approximately 17%
of the entire sample (n =357/2082) were worried about relational as-
pects of online consultations, which could include fostering a thera-
peutic relationship, the lack of eye contact and physical presence, and
the lack of authentic contact. Other common themes, reported by over
10% of the entire sample, involved how to work with non-verbal
behavior and emotions (n =215/2082) and how to carry out certain
diagnostic assessments or interventions (n =231/2082; e.g., exercises or
specic therapeutic interventions, such as exposure therapy and eye
movement desensitization and reprocessing). Professionals further re-
ported concerns about using online consultations with specic pop-
ulations (N =126), such as individuals who experienced trauma, and
age groups (N =111), such as children. A limited number of participants
had concerns about effectiveness (N =74). A minority of participants (N
=11) reported lower productivity due to online consultations, and only
one noted a negative inuence of online consultations on his/her career.
Concerns about performance expectancy were common in all coun-
tries and especially prominent in the Netherlands and Lithuania. Dutch
participants were particularly concerned about executing certain in-
terventions (n =23/81) and working with non-verbal behavior and
emotions (n =21/81). Lithuanian participants were more concerned
about relational aspects (n =23/119) and using online consultations
with clients with certain disorders or target groups (n =22/119).
3.5.2. Effort expectancy
The mental health professionals reported a limited number of con-
cerns about the amount of effort required in online consultations. A
minority of participants reported difculties in performing online con-
sultations (N =31), found online consultations more exhausting (N =
27), or struggled with learning to use the technology (N =5). However,
it is relevant in this regards that most professionals used common online
communication software (e.g., Skype) as opposed to specialized plat-
forms for online therapy, which might require more effort and techno-
logical competencies. In Cyprus and Lebanon, no concerns were raised
regarding effort expectancy, in contrast to Belgium (N =23) and, to a
lesser extent, the Netherlands (N =10).
No perceived need Performance expectancy Attitude Social Influence Other
Fig. 2. The proportions of the four most common cate-
gories, i.e., lack of perceived need, performance expectancy,
attitude, and social inuence, are reported relative to each
country's number of participants who did not provide online
consultations prior to COVID-19 (Austria: N =37, Belgium:
N =190, Cyprus: N =20, France: N =188, Germany: N =
118, Italy: N =157, Lebanon: N =21, Lithuania: N =57,
Netherlands: N =43, Norway: N =166, Portugal: N =155,
Spain: N =13, and Sweden: N =122).
N.A.J. De Witte et al.
Internet Interventions 25 (2021) 100405
Disliking online consultations or preferring to work face-to-face was
not a main concern for the professionals (N =12). While a small number
of participants reported missing closeness, contact, and an authentic
meeting (N =64), only 3 indicated that online consultations made their
job less interesting.
3.5.4. Social inuence
A minority of cases reported the lack of support from their organi-
zations or associations as their current main concern (N =16), and only
one individual noted unnecessary prejudice from clients and colleagues.
3.5.5. Facilitating conditions
Concerns about lacking the necessary resources for online consulta-
tions were common and mainly involved lacking knowledge about or
wanting more education about online consultation (N =148). Further-
more, a small group of participants lacked materials or undisturbed
space to do online consultations (N =60). A minority of participants
voiced concerns about incompatibility of online consultation software
with other systems or practices (N =27) or about lacking support in
terms of assistance with system difculties (N =5). The reported need
for more education was greater in France (n =48/250) and Lithuania (n
=22/119) than in Norway (n =5/250), Italy (n =7/250), and Lebanon
Non-verbal behaviour & emotions
Performing specific activities
Fig. 3. Visual overview of the results of the qualitative analysis on the main concerns or questions professionals had regarding online consultations during the rst
wave of the COVID-19 pandemic. The size of the spheres is proportional to the number of concerns that were reported in each category. Further specications are
included for the two largest categories.
Overview of the number of concerns (per country) in the different categories.
Austria 43 1 9 0 5 6 11 55 4
Belgium 159 23 7 0 35 29 65 147 3
Cyprus 29 0 2 2 3 6 8 22 0
France 119 2 3 2 54 7 33 127 0
Germany 97 2 8 0 10 15 40 97 1
Italy 134 6 5 0 10 12 40 88 0
Lebanon 30 0 1 0 5 4 11 40 0
Lithuania 89 3 1 2 32 4 27 71 0
Netherlands 91 10 13 0 7 7 24 34 0
Norway 116 1 7 7 17 14 40 67 1
Portugal 164 6 15 0 23 13 45 109 0
Spain 4 2 2 1 3 0 3 9 0
Sweden 96 7 6 3 36 19 27 76 10
Total 1171 63 79 17 240 136 374 942 19
PE: performance expectancy.
EE: effort expectancy.
AT: attitude toward online consultations.
SI: social inuence.
FC: facilitating conditions.
COF: client-oriented factors.
CF: contextual factors.
NF: non-specic factors.
N.A.J. De Witte et al.
Internet Interventions 25 (2021) 100405
A limited number of participants reported concerns about feeling
apprehensive toward online consultations (N =80). However, this was
mostly due to some therapists' fear of loss of privacy (e.g., sharing a
Skype number, patients recording the session; N =48) and to a lesser
extent, to some professionals feeling uncomfortable with doing online
consultations (N =32). The participants who reported their fear of
making mistakes that could not be corrected (N =50) were mostly afraid
of experiencing technical difculties (N =33). Online consultations
were generally not considered as intimidating (N =6). Apprehensions
about online consultations were mainly noted in Belgium (n =20/250),
and the fear of making mistakes was most common in Sweden (n =15/
3.5.7. Client-oriented factors
Mental health professionals also raised concerns about potential
problems with the implementation of online consultations on the client
side. They were concerned about facilitating conditions for their clients
(N =230), including clients' lack of the necessary technical possibilities
or undisturbed quiet space (N =193) and to a lesser extent, lack of
technical knowledge (N =33) or support (N =4). A smaller number of
the respondents raised other client-related concerns, such as clients
feeling apprehensive about or uncomfortable with online consultations
(N =52) and the lack of client interest (N =47; with the highest rate in
Belgium (n =14/250)). A small number of concerns were raised
regarding their clients' own issues: performance expectancy (N =16),
concerns regarding data security (N =14), effort expectancy (N =7),
knowledge about online consultations (N =7), and social inuence (N
3.5.8. Contextual factors
The concern that was raised most often in the survey, by over 20% of
the entire sample, involved the privacy and security of online consul-
tation software (n =442/2082), especially in Austria (n =28/65),
Lithuania (n =36/119), and Germany (n =46/166), as opposed to
Norway (n =31/250), Sweden (n =36/250), and Lebanon (n =10/73).
The second concern was related to unreliable connectivity and technical
difculties (N =261). A number of professionals asked other practical
questions about charging and management of payments (N =88;
especially in France, n =23/250), the limits of responsibility and legal
aspects (N =50), ethical standards (N =38), policy and administration
(N =36), the price of high-quality platforms (N =16), and reimburse-
ment and insurance (N =11).
Mental health professionals quickly and exibly adopted online
consultations in the beginning of the rst wave of the COVID-19
pandemic. The majority of them had positive experiences with this
mode of delivery, and it seems that online consultations have the po-
tential to become more than just temporary replacements of face-to-face
consultations in times of crisis. This study provides an overview of the
factors that can hinder implementation with the goal of promoting the
provision of the necessary support for the deployment of online con-
sultations and other e-mental health interventions.
While the lack of the need for online consultations was the most
important reason for not implementing them in the past, this need has
become strong and acute due to the COVID-19 pandemic. Several other
barriers to using online consultations have nevertheless remained.
Mental health professionals still share concerns about whether online
consultations are useful for their work, for example, concerning rela-
tional aspects, working with non-verbal behavior and emotions, per-
forming certain assessments or interventions, or working with certain
populations. Such concerns are not new (e.g., Stallard et al., 2010), but
accumulating evidence shows the relevance of the therapeutic rela-
tionship in e-mental health (Kaiser et al., 2021) and suggests the
equivalence of relational aspects in different modes of delivery (Irvine
et al., 2020). Online consultations also appear feasible across different
diagnostic groups and capable of reaching similar clinical outcomes as
compared to conventional treatment (Chiauzzi et al., 2020). This in-
cludes individuals with serious mental illness, although extra care and
consideration is warranted for individuals with elevated suicide risk. As
noted in the survey, the professionals also had practical concerns about
the privacy and security of online consultation software and experi-
encing technical difculties, as well as about clients having the neces-
sary technical possibilities or undisturbed quiet space. This study
indicates that internal factors, such as the professionals' attitudes or
fears regarding online consultations, did not have a great inuence
during the rst wave of the COVID-19 pandemic. However, the mental
health professionals expressed a clear need for knowledge on psycho-
logical processes in online consultations, as well as technical imple-
These perceived barriers are in line with the mental health pro-
fessionals' lack of pertinent education in online consultations or e-
mental health, especially in France, Belgium, Italy, and Germany. The
training received by the participants consisted mostly of a session of a
few hours. The COVID-19 pandemic did result in several short-term local
and international initiatives, providing training in online consultations
for professionals through brief webinars. Many psychologists' associa-
tions and the EFPA (European Federation of Psychologists' Associations,
n.d.) also provided guidelines for the implementation of online consul-
tations. Nevertheless, even in the countries with the highest reported
rates of education, i.e., Austria, the Netherlands, and Sweden, still over
75 to 80% of mental health professionals did not receive any education.
Centralized international initiatives that outline institutional training
requirements in order to use virtual care services and promote common
standards in e-mental health education programs, good practice exam-
ples of online consultations, and information on how to deal with ethical
concerns and condentiality issues (of communication software) are
necessary. We need to consider devising future guidelines on these
topics for Europe, knowing that guidelines for telepsychology have
existed since 2013 in the USA (Joint Task Force for the Development of
Telepsychology Guidelines for Psychologists, 2013).
There were cross-national differences in uptake and perceived bar-
riers for the implementation of online consultations. Over a quarter of
mental health professionals in France and Germany did not intend to
implement online consultations. These countries, together with
Belgium, also show the lowest rates of previous use. On the other hand,
in Lithuania, the Netherlands and Lebanon (the only participating Arab
country), mental health professionals have a higher current uptake and
more existing experience in delivering online consultations. While
mental health problems carry a lot of stigma in Arab countries (Househ
et al., 2019), which could increase interest in more anonymous e-mental
health contacts, mental health legislation and infrastructure (including
telepsychiatry) is often still underdeveloped in these countries,
including Lebanon (El Hayek et al., 2020). A considerable number of
Lebanese mental health professionals have received at least a portion of
their training outside the Arab countries' borders, which could imply
that they are more culturally “close” to the western societies.
Gaebel et al. (2020) have shown that European countries are in
varying stages of implementing e-mental health in their mental health-
care systems. Some differences among the countries in this study can be
associated with different regulations and “maturity” in the eHealth
domain. For example, both Norway and Sweden have a reimbursement
scheme for digital interventions, as well as its national health author-
ities' guidelines on which platforms to use. The Netherlands also have a
regulatory framework for online consultations. In other countries, such
as Germany and Belgium, governments have provided a temporary
framework and guidelines within which mental health professionals
could operate for the duration of the COVID-19 pandemic. Results
N.A.J. De Witte et al.
Internet Interventions 25 (2021) 100405
indeed show that mental health professionals from Norway, the
Netherlands, and Germany use more specialized platforms for online
consultations. However, Sweden showed a lot of variation in the plat-
forms used, including several organization-specic tools. Germany has a
list of tools that professionals are allowed to use within the legal
framework (adjusted due to the COVID-19 pandemic), and the use of
other tools, such as Skype, is not in line with the country's regulations. In
Spain, the Guide for Telepsychological Intervention (De la Torre and
an, 2018) is a rst reference document of the psychothera-
peutic online approach and the Ofcial College of Psychologists of
Madrid provides free access to a platform for online psychotherapy to
afliated members. While regulating digital health applications holds
many challenges, innovative approaches engaging policy makers, de-
velopers, and patients and professionals have already been suggested
(Rodriguez-Villa and Torous, 2019).
This study has several limitations. Qualitative analyses were guided
by a theoretical framework and executed in a uniform way, but different
local researchers performed the coding for the different countries with
varying sample sizes. While local researchers were aware of the national
context in terms of culture and policy, having just one rater precluded
the calculation of interrater agreement and reliability. It also leaves
room for subjective interpretation in the inductive analysis, however,
given that the thematic analysis was only performed on brief and con-
crete survey responses (e.g., “due to COVID-19”), the potential for rater
bias was limited. While similar lockdown measures were implemented
in all countries during the 39-day recruitment period, concerns
regarding online consultations and other questionnaire responses could
potentially vary depending on the exact moment of questionnaire
completion. Considering the survey was disseminated and completed
online, a potentially biased sample toward individuals who were already
fairly comfortable with the use of online tools cannot be ruled out. In-
dividuals who were disinclined to use online tools were likely under-
represented in the results. The sample of mental healthcare professionals
mostly consisted of psychologists. We did not differentiate between
types of online consultations while experiences and perceived barriers
could vary depending on implementation characteristics. While online
consultations could be a part of a guided self-help intervention, the vast
majority of online consultations are expected to have taken place in the
context of traditional therapeutic contacts, given the acute shift online
due to the pandemic. Future research should differentiate between types
of online consultations and would benet from a common glossary
regarding digital psychological interventions (Smoktunowicz et al.,
2020). The clients' concerns, beliefs, and practical requirements should
also be assessed rst-hand.
To conclude, for some mental health professionals, the current crisis
will prove to be a turning point that will lead to an increased use of
digital tools in practice. However, other professionals have difculty in
nding their way, perceive that online consultations do not meet their or
their clients' needs, or work in a context that does not easily lend itself to
online consultations. Moving forward from the acute threats that the
COVID-19 pandemic poses to mental health practice, policymakers and
practitioners should aim for a selective implementation of high-quality
e-mental health interventions by professionals who have received suf-
cient training. However, as Shaw et al. (2018; p95) state, “main-
streaming virtual consulting across multiple departments in multiple
organizations will be neither smooth nor quick. The clinical and logis-
tical realities will play out differently for different clinical specialties
and different hospital departments (not to mention primary care).” This
study shows a clear need for training in online consultations that is
shared by different countries and provides further insights into the
barriers to high-quality implementation of online consultations and e-
mental health. These factors should be considered when healthcare or-
ganizations and local, national, and European governmental agencies set
up long-term strategic goals and implementation roadmaps for the
Supplementary data to this article can be found online at https://doi.
Declaration of competing interest
The authors declare the following nancial interests/personal re-
lationships which may be considered as potential competing interests:
Assoc. Prof. Ebert reports to have received consultancy fees or served
in the scientic advisory board from several companies such as Mind-
district, Sano, Lantern, Sch¨
on Kliniken, German health insurance
companies (BARMER and Techniker Krankenkasse), and chambers of
psychotherapists. Dr. Ebert is one of the stakeholders of the Institute for
health trainings online (GET.ON/HelloBetter), which aims to implement
scientic ndings related to digital health interventions into routine
care. Anne Etzelmueller is employed by the Institute for health trainings
online (GET.ON/HelloBetter) as research coordinator. All other authors
do not report any conict of interest.
The development of the survey was supported by the Project Group
on eHealth of the European Federation of Psychologists' Associations.
Members of the project group include: Andreas Schwerdtfeger (Austria),
elique Belmont (Belgium), Tom Van Daele (Belgium), Maria Karekla
(Cyprus), Angelos P. Kassianos (Cyprus), Iben Sejerøe-Szatkowski
(Denmark), Lise Haddouk (France), David Daniel Ebert (Germany),
Christine Knaevelsrud (Germany), Angelo Compare (Italy), Glauco
Trebbi (Luxembourg), Tine Nordgreen (Norway), Svein Øverland
ao Salgado (Portugal), Jan Zaskalan (Slovakia), David
Gosar (Slovenia), Per Carlbring (Sweden), Christopher Schütz
(Switzerland), Aslı Çarko˘
glu (Turkey), Kotryna Danieleviciute (EFPSA).
The authors furthermore want to acknowledge the following colleagues
and organizations: for her aid with the coding of the German data,
Annika Montag; for their aid in the translation and dissemination of the
survey, Juanjo Martí Noguera (CiberSalud), Vitalina Ustenko and Oleh
Burlachuk (National Psychological Association Ukraine), Anna Leybina
(Russian Psychological Society), David Gosar, Beti Kovaˇ
c, and Sara
sen (Slovenian Psychologists' Association), the Associazione Italiana
di Psicologia, the Bulgarian Psychological Society, the Ordine degli
Psicologi della Lombardia and the Consiglio Nazionale dell'Ordine degli
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