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: jbantjes@sun.ac.za
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

Growing interest in the potential use of digital technologies, includ-
ing Internet-­based treatments and smart phone applications, to de-
liver treatments for common mental disorders has resulted in rapid
expansions in the availability and utilisation of digital mental health
digital mental health interventions available including mobile ap-
plications, such as Headspace and MoodyMe (Flett et al., 2020);
self-­guided and guided Internet-­based interventions, such as ICare
(Taylor et al., 2020); online video conferencing group interventions
(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.
chatbots), such as WoeBot (Fitzpatrick et al., 2017). Digital interven-
tions (also known as e-­interventions) may be particularly appropriate
to expand access to evidence-­based treatments on university cam-
puses and meet the high demand for student counselling services
(Auerbach et al., 2018; Bruffaerts et al., 2018, 2019a). Indeed, a
number of studies have shown the effectiveness of e-­interventions
for treating a range of emotional and behavioural problems, including
depression, anxiety, smoking and substance use (Spek et al., 2007;
Watkins et al., 2012). Using digital interventions to promote the
mental health of university students may be particularly appropri-
ate in low-­ and middle-­income countries, like South Africa, where
the marked shortage of mental health professionals is a significant
barrier to the provision of accessible and effective treatments. Yet
comparatively little is known about students' experiences of using
e-­mental health interventions and the acceptability of these, espe-
cially in low-­and middle-­income countries. Understanding students'
experiences of e-­interventions and whether they find digital treat-
ments acceptable and user-­friendly have important implications for
both the design and implementation of digital mental health on uni-
versity campuses. Furthermore, understanding and responding to
students' expressed treatment preferences are closely aligned with
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
(Russ et al., 2013). It is within this context that we investigated a
group of South African university students' experiences of using a
semi-­guided Internet-­based cognitive behavioural therapy (iCBT) in-
tervention to treat symptoms of depression. The aims of the study
were to document students' experience of using the intervention
and their perceptions of the acceptability of iCBT. We present the
findings and discuss the implications for the design and use of digital
mental health interventions on university campuses.
It is estimated that 31.4% of students report a common mental
disorder in the preceding 12 months (Auerbach et al., 2018). Major
depressive disorder is particularly prevalent among students and is
associated with a range of adverse outcomes including academic
failure, suicidal thoughts and behaviours, and severe role impairment
(Alonso et al., 2018; Bruffaerts et al., 2018; Mortier et al., 2018). Yet
treatment rates are very low among students, with estimates sug-
gesting that fewer than 20% of students receive minimally adequate
treatment even when mental healthcare services are freely available
and accessible (Bruffaerts et al., 2019b). Providing mental health-
care services to students is challenging, with common barriers to
care including stigma, concerns about privacy and perceptions about
the ineffectiveness of traditional interventions (Corrigan, 2004;
Corrigan et al., 2014; Kazdin & Blase, 2011; Mowbray et al., 2006).
Face-­to-­face individual counselling is an effective approach to pro-
moting student mental health (Amanvermez et al., 2020), but it has
been argued that this mode of providing treatment may itself be a
barrier to care for some students, highlighting the need to develop
alternative models of intervention which do not rely on direct con-
tact between therapist and patient (Ebert, Nobis, et al., 2017; Kazdin
| 793
Implications for Practice
• Internet-­based CBT (iCBT) for depression is an accept-
able mode of intervention for some university students
and may help to overcome barriers typically associated
with accessing campus-­based mental health services.
• Uptake of iCBT on university campuses may be im-
proved by stressing accessibility, autonomy, anonymity
and privacy.
• iCBT has the potential to improve access to, and utilisa-
tion of, student counselling services, could be an integral
component of a stepped-­care treatment and could be
offered to students on waiting lists.
Implication for Policy
To expand students' treatment choices and improve access
to care, Internet-­based CBT for depression should be inte-
grated into campus counselling services, either as a stand-­
alone treatment, as an adjunct to individual psychotherapy
or offered to students on waiting lists.
& Blase, 2011). Furthermore, in resource-­constrained environments
like South Africa, where there are marked shortages of trained men-
tal health professionals and high rates of mental illness, it seems un-
likely that labour-­intensive traditional modes of psychotherapy will
be a feasible or affordable way to meet students' mental health care
needs (Bantjes et al., 2020).
Internet-­based treatments and the use of mental health mo-
bile device applications (apps) may be a viable and cost-­effective
alternative to traditional psychotherapy (Berger, 2017; Kazdin &
Blase, 2011; Riper et al., 2010) and may be as effective as tradi-
tional treatments for most common mental disorders (Andrews
et al., 2010; Baumeister et al., 2014; Lin et al., 2013; Richards &
Richardson, 2012). Digital interventions have the potential to pro-
vide greater anonymity, availability and accessibility than tradi-
tional psychotherapy (Chan et al., 2016; Fleischmann et al., 2018).
iCBT interventions are as efficacious as face-­to-­f ace CBT in
treating mild-­to-­moderate major depressive disorder, with effect
sizes ranging from d = 0.18 to d = 1.60 (Andersson et al., 2015;
Andersson, 2009; Andersson & Cuijpers, 2009; Andersson &
Hedman, 2013; Carlbring et al., 2018; Schröder et al., 2018). Digital
interventions are, however, not without their problems and con-
cerns have been expressed about the lack of evidence to support
the design and use of many mental health mobile applications,
privacy and data security problems, and patient safety (Huckvale
et al., 2020). Among the barriers to implementing digital treat-
ments are the attitudes of key stakeholders towards this mode of
therapy and the acceptability of this alternative to traditional psy-
chotherapy (Baumeister, Nowoczin, et al., 2014; Gun et al., 2011;
Musiat et al., 2014; Topooco et al., 2017). The attitudes of service
794 | GERICKE et al.
users directly influence both the utilisation and implementation
of e-­interventions (Bennett & Glasgow, 2009). Furthermore, the
acceptability and subsequent use of e-­interventions are strongly
influenced by the quality and quantity of available information
about their effectiveness, as well as perceptions about their
availability and usability (Gun et al., 2011; Musiat et al., 2014).
Indeed, providing potential users with information about the ef-
fectiveness and usability of e-­interventions, known as Acceptance
Facilitating Interventions (AFIs), significantly increases the accept-
ability and, subsequently, the likelihood of utilising digital mental
health solutions (Ebert et al., 2015; Mitchell & Gordon, 2007). For
example, one AFI, based on the Unified Theory of Acceptance and
Use of Technology (Venkatesh et al., 2003), employed a video clip
to present information about the efficacy of a iCBT intervention
and share patients' testimonials about positive experiences, which
significantly increased the acceptability of the intervention among
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-
ences for, attitudes towards, and experiences of e-­interventions
(Kaltenthaler et al., 2004).
It is within this context that we wanted to explore South African
university students' experiences of using iCare, a iCBT semi-­guided
brief intervention for symptoms of depression. Rates of mental disor-
ders among South African university students are marked, with anxi-
ety and depressive disorders being the most common mental health
problems (Bantjes, Breet, et al., 2019; Bantjes, Lochner, et al., 2019).
Furthermore, treatment rates on South African university campuses
are low, with less than a third of students with mental disorders re-
ceiving treatment (Bantjes et al., 2020). Digital interventions could
have the potential to close this treatment gap and improve access to
care if students find them acceptable and useful.
2 | M E TH O DS
The aims of this qualitative study were (1) to document students' ex-
periences of using an iCBT intervention, and (2) to investigate their
perceptions of the acceptability of digital interventions to promote
student mental health.
2.1 | Recruitment
Participants for this study were recruited from the intervention arm
of a pilot study to assess the feasibility of an iCBT intervention at
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-
naire, Patient Health Questionnaire (PHQ-­9; Kroenke et al., 2003)
and the Generalized Anxiety Disorder Questionnaire (GAD-­7; Spitzer
et al., 2006). Students who reported moderate to moderately severe
symptoms of depression (as measured by scores of between 10–­14
and 15–­19 on the PHQ-­9; Kroenke et al., 2003), irrespective of their
GAD-­7 scores, were randomly assigned at a ratio of 2:1 to either the
intervention group or control group (treatment as usual). Those in
the intervention group were offered the use of an iCBT interven-
tion. In this way, 91 students were invited to join the intervention,
of which 29 (39.1%) accepted the invitation and 22 initiated use of
the intervention. Only six (i.e. 27.3% of those who started treatment)
completed all components of the intervention. At the end of the in-
tervention period, all students (n = 22) who had engaged with the
e-­intervention for at least one session were invited to share their
experience by participating in a semi-­structured interview. A total of
nine students volunteered to be interviewed (yielding a participation
rate of 40.9%); five of these participants had completed all online
components of the intervention, and four had started the interven-
tion but discontinued use.
2.2 | Description of the iCBT intervention
All participants in this study made use of a transdiagnostic semi-­
guided iCBT intervention (known as ICare) (Weisel et al., 2018;
Weisel et al., 2019). This Internet-­based intervention was devel-
oped to address the symptoms of, and risk factors associated with,
major depressive disorder and generalised anxiety disorder. The
content of the intervention was based on CBT materials previously
shown to be effective in the prevention and treatment of depres-
sive disorders and the targeting of sleeping problems (Buntrock
et al., 2016; Buntrock et al., 2015; Ebert, Nobis, et al., 2017; Ebert,
Cuijpers, et al., 2017; Nobis et al., 2015). The iCBT intervention
consists of seven weekly online sessions and an additional booster
session, covering topics such as behavioural activation; reducing
incongruence; overcoming difficulties and scheduling pleasant
activities; psychoeducation; cognitive restructuring; problem-­
solving, exposure; and planning for the future. The online sessions
make use of student testimonials, audio-­video material, practical
exercises and homework assignments. Participants could tailor
some of the content by selecting optional modules covering top-
ics like sleep hygiene and procrastination. Students were respon-
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
of each session via email. Students also received reminders from
the eCoach to complete the weekly sessions. The eCoaches were
postgraduate psychology students who received supervision from
a registered psychologist.
2.3 | Sample characteristics
The sample was racially mixed (seven identified as White and two
identified as Black) and consisted of three self-­identified men and six
GERICKE et al.
self-­identified women. The mean age of the sample was 18.9 years
(SD = 1.2, range = 17–­20), and the means on the PHQ-­9 and GAD-­7
scores at the start of the intervention were 12.78 (SD = 1.99,
range = 10–­15) and 10.46, (SD = 4.06, range = 0–­21).
2.4 | Data collection
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-
ability and effectiveness, their suggestions for improving or adapting
the intervention to make it more appealing to university students,
and their reasons for either completing or discontinuing use of the
intervention. Interviews were conducted by the first author (FG) in
either English or Afrikaans, in a private space on campus at a time
convenient to participants. Throughout the interviews, participants
were asked to clarify what they were saying and to expand on things
which were not clear. The interviewer also employed the technique
of ‘member checking’ (asking clarifying questions to check that the
interviewer was correctly understanding and interpreting what par-
ticipants were communicating) in an effort to improve the trustwor-
thiness of the data (Mays, 2000). Interviews were audio-­recorded
and typically lasted between 45 and 60 min, and participants were
compensated for their time with a gift voucher valued at ZAR 50
(equivalent to approx. $3.39 at the time of data collection).
Depressive symptoms were assessed before and after the in-
tervention using the PHQ-­9 and GAD-­7. The PHQ-­9 is a 9-­item
self-­
report questionnaire which is widely used to assess symp-
toms of depression and which has been shown to be a reliable and
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
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
to identify clinically significant symptoms (Spitzer et al., 2006). All
data are available from the authors on reasonable request.
2.5 | Data analysis
Interviews were transcribed and analysed by the first author (FG)
using the six-­step process of thematic analysis outlined by Braun &
Clarke (2006). An inductive data-­driven approach was used to code
the data, with the assistance of Atlas-­ti software. In the first phase
of data analysis, the interviews for the subgroup of participants who
completed the intervention (i.e. the completers) were analysed sepa-
rately from the subgroup who did not complete the intervention (i.e.
the non-­completers). The themes identified were independently ver-
ified by the last author (JB) to triangulate the findings and increase
trustworthiness. Once agreement on the themes was achieved,
they were organised into superordinate themes by FG and JB. There
was a high level of congruence between the themes identified in
| 795
interviews with completers and non-­completers, apart from reasons
given for discontinuing the intervention. We have indicated clearly
in the findings below where completers and non-­completers had dif-
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
from all nine interviews have been included in an effort to guard
against bias and the selective use of interview data.
2.6 | Ethics
Ethical approval for this study was obtained from the Human
Research Ethics Committee at Stellenbosch University (Reference
M17/10/036; project reference #1788), and the necessary institu-
tional permissions were obtained from the university. Participation
was entirely voluntary, and participants provided written informed
consent prior to data collection. Participants were informed about
the aims of the study and were told that they could withdraw at any
time without prejudice. Participants were given pseudonyms to en-
sure anonymity, and all de-­identified data were securely stored on a
password-­protected digital storage device. Information about coun-
selling and crises services was provided to participants at the end
of the interview. Students who reported suicidality were individu-
ally followed up via email to encourage them to seek professional
assistance and to provide them with the details of campus-­based
crises and counselling services. Although no incentives were given
for completing the iCare intervention, students who agreed to be
interviewed received a modest gift voucher as compensation for
their time.
3 | Findings
Participants described their experience of using the e-­intervention
as mostly positive, saying it was accessible, helpful and facilitated
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-­
intervention follow-­up. A paired-­samples t-­test, using an intention to
treat analysis, showed significant reductions from baseline to one-­
month post-­intervention follow-­up for PHQ-­9 scores (t(253) = 4.12;
p = .0001) but not GAD-­7 scores (t(207) = 0.39; p = .696). It is not sur-
prising that the reduction in GAD-­7 scores was not significant given
that students were included in the intervention irrespective of their
baseline GAD-­7 score, which resulted in some students with very low
baseline anxiety symptom scores participating in the intervention.
Although the students had positive experiences of the intervention,
they also identified aspects of the e-­intervention which they experi-
enced as frustrating and made suggestions for how the intervention
might be implemented to make it more effective and acceptable to
university students. Seven superordinate themes were identified as
follows: (1) awareness and acceptance of symptoms as prerequisites
796 | GERICKE et al.
to access the e-­intervention; (2) valuing anonymity, convenience and
accessibility; (3) facilitating self-­
disclosure, emotional expression
and self-­awareness; (4) building competence through skills acquisi-
tion; (5) expectation that the intervention would mimic traditional
psychotherapy; (6) frustration with the amount of mental effort and
time required to complete the intervention; and (7) suggestions for
implementing iCBT on university campuses. Each of these superor-
dinate themes and the associated subthemes is discussed below.
1. Awareness and acceptance of symptoms as a prerequisite to
access the e-­intervention
Most participants said that they were inclined to use the iCBT
because they had been aware of their symptoms and they had ac-
cepted that they needed help. They found the feedback received
from the initial online screening survey to be congruent with their
own perception that they were not coping, saying that the feedback
validated their experience of distress and motivated them to seek
treatment. Ayanda described this, saying:
‘… If I stayed in that whole denial stage, I wasn’t gonna
do the program… So first you need to accept that
there is something that needs to be sorted out…then
it will be easier to do the program’.
Many participants said they had been contemplating treatment
but had not yet taken any concrete action to access care until this was
offered to them in the form of an e-­intervention. In this way, the invita-
tion to make use of the e-­intervention seemed to function as a bridge
facilitating access to treatment which would otherwise not have been
sought.
2. Valuing anonymity, convenience and autonomy
Most participants reported that they found the anonymity of the
iCBT appealing, saying this facilitated their initial engagement with
the programme. They said that being able to use the e-­intervention
privately enabled them to overcome the stigma associated with ac-
cessing traditional face-­to-­face campus services. Participants de-
scribed the student counselling centre as ‘very public’, expressing a
fear that it would be visible to peers if they accessed campus-­based
services. By comparison, iCBT offered participants a more private
and confidential way to access psychological help. Stephanie said
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
reluctance to visit the student counselling centre and her preference
to access services more discretely, saying:
‘…everyone walks past there (the counselling centre)…
You shouldn’t feel embarrassed to go, but if you walk
in there, it does feel as if everyone is looking at you…
You are less because everyone else can handle life,
but you can’t. … It was easier to get me to do this (use
the e-­intervention) than to go to someone… It is just
easier to do an e-­intervention, it does not have that
same (negative) connotation to it’.
Participants affirmed how much they valued privacy by referring
to the security features of the e-­intervention. They said they were
aware of the dangers of private information being accessed through
cybercrime and said they felt reassured by the privacy features on the
e-­intervention. Mari, for example, said:
‘…like the anonymity helps to put you at ease because
it is online, because, I mean, things can easily leak out…
if it does, it is anonymous, so yes, password protected
and all those things…’
Participants expressed a perception that the iCBT was more ac-
cessible and convenient than traditional psychotherapy. They shared a
perception that it was time-­consuming, difficult and complicated to ac-
cess conventional services and that the iCBT provided a user-­friendly
alternative. Chris described this, saying:
‘…it’s not this, go through ten forms and then you have
to go to this and this building and then meet this and
this person and then you get on to this list somewhere’.
Some participants said that they were precluded from using
campus-­based services because the student counselling centre only
operated during normal office hours, when they had academic com-
mitments and lectures. This was particularly apparent among stu-
dents enrolled in courses such as engineering and health sciences,
which have very full academic programmes. James described this,
saying:
‘…people don't have time. So, you can't make a therapist
appointment at eight at night… they're just unavailable’.
iCBT was perceived as a more accessible alternative to traditional
services because it could be used at the convenience of the user. Chris
expressed this, saying:
‘You can go home, it's there. You don't have to drive
anywhere. You don't have to book an appointment. It's
just available anytime…’
Participants said that iCBT gave them greater autonomy and con-
trol over their treatment. They said they appreciated being able to use
the e-­intervention flexibly, at their own convenience and for as long
as they wanted. Being able to select optional modules engendered a
sense of control over their treatment, which was experienced as em-
powering. Mari said:
‘…it (the e-­intervention) was easy for me because I sat
at my laptop, in my room when I had time. … And the
additional modules that you could do, that was nice be-
cause, like, that week I could decide…I am going to do
this module!’
GERICKE et al.
Similarly, Stephanie described her positive experience of autonomy
and flexibility, saying:
‘… as opposed to just a therapist that you have an hour
session with…I could spend as long as I want to on that,
and still go access it afterward…’
3. Facilitating self-­
disclosure, emotional expression and
self-­awareness
Participants reported that iCBT facilitated self-­disclosure and
emotional expression, saying that they found it easier to acknowl-
edge their feelings and thoughts online. Anisha said:
‘ …over the computer, I figured that is the easiest. To
open up easier…I have been to a psychologist, but I’ve
never opened up…’
Similarly, Ayanda said:
‘I find it extremely difficult to talk to anyone I know
about feelings or emotions. So, the fact that it was over
the internet … it was better for me, because I was able
to express myself…it helped me express the other emo-
tions that I’d been suppressing for so long…’
Chris echoed this, saying:
‘Some people would find it (the e-­intervention) very
nice because they can be open’.
Participants also said the e-­intervention facilitated self-­reflection
and enabled them to become more aware of their thoughts, feelings,
needs and behaviours. This greater self-­awareness helped participants
identify areas where changes were needed and facilitated seeking in-
dividual psychotherapy. Stephanie said:
‘I went after this to a therapist, because I realised that I
needed that…This (e-­intervention) was like a thing that
helped me diagnose my problems, and figure out, where
I stood. … It (the e-­intervention) was the starting point.
Because it was the push in the right direction. And, my
life, as a whole, has become a lot better since then’.
Similarly, Kevin explained how the e-­intervention paved the way to
accessing individual psychotherapy, saying:
‘So, seeing a psychologist was no longer like a shameful
thing for me’.
4. Building competence through skills acquisition
Most participants said that the iCBT intervention was helpful
because it enabled them to learn new skills which were practical
| 797
and effective. They said that they had learnt ‘tools’ which were
relevant to their context and enabled them to cope with the con-
crete everyday problems that they faced. Christopher, for exam-
ple, said:
‘And I feel like this intervention thing was very useful
in that it gives you a lot of tools, a lot of guidelines
and examples…that you can try and apply to your own
life…’
Likewise, Ayanda described how iCBT facilitated skills acquisition,
saying:
‘… you learn how to deal with your emotions, you also
learn to accept things… so, it also helped with that’.
Participants reported feeling empowered by acquiring new
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
coaching’. Participants said it was affirming to see that the skills they
had learnt were effective, and this made them feel more competent.
Chris explained: ‘I don't need sympathy or that. I just need to know the
tools that I need to cope’. And Kevin spoke about feeling empowered
by the skills he had acquired and expressed his satisfaction with
iCBT, saying:
‘That is why I give this (iCBT) a big thumbs up’.
5. Expecting the e-­intervention to mimic traditional psychotherapy
Most participants said that they valued the feedback received
from the eCoach at the end of each session and believed this was
an important component of the programme. They said that the in-
dividualised interaction helped to make iCBT more personable and
helped them to consolidate the learning in each session. Mari ex-
pressed this perception, saying:
‘The feedback that you got, it was not the interac-
tion as such, but it was still as if you were talking to
someone…’
And Christopher said:
‘All the responses were very much individualised
which I very much liked… I feel like that helped me get
the most out of the course’.
Nonetheless, most participants reported frustration with the
lack of direct human contact and disappointment with the lack of
immediate responsiveness, articulating an expectation that the iCBT
would mimic the responsiveness and immediacy of face-­
to-­
face
therapy. For example, Stephanie described her experience of the
eCoach, saying:
798 | GERICKE et al.
‘The feedback that I got from the therapist (eCoach)
was pretty average… that was a bit disappointing ac-
tually. … (it would help) if the feedback happened a
lot quicker … and a bit more analysis of what I’d said…
and it felt like I could have had more. …I needed more
(human interaction)’.
Some participants said that the limited online interaction with the
eCoach and the format of the feedback created opportunities for mis-
understandings which could not be easily clarified in a more direct dis-
cussion. Peter explained:
‘Basing the online platform on text, therefore, cre-
ates opportunities for misunderstandings or misin-
terpretations… It (the feedback) can seem extremely
judgemental, and this is where the lack of face-­to-­face
contact comes in the most….’
Most participants said that they had wished for more interaction
with the eCoach. Mari stated:
‘I realised that (not being able to interact with the
eCoach) was an issue -­I had no one to discuss it with
further, because the program only goes so far…Like, it
suggested solutions, but I did not necessarily always
want a solution’.
And Rachel said:
‘An internet intervention isn’t enough. It is still you
and a screen…whereas when you make that connec-
tion with someone, and you trust someone …it is a
very different feeling and you don’t feel so alone…’
6. Frustration with the time and mental effort required for the
intervention
Participants said that the intervention was time-­consuming and
sustained mental effort was required to engage with the online con-
tent, making it difficult to persist with treatment and to stay moti-
vated to complete the intervention. Most participants who did not
complete the e-­intervention cited these as reasons for discontinu-
ing. For example, Ayanda explained that she stopped using the e-­
intervention because of time constraints:
‘It was during the intervention thing. And I was just,
dealing with a lot of doctors’ appointments and, deal-
ing with my social worker, and dealing with school
and, and, and…’
Many participants spoke about how hard it was to sustain con-
centration, engage with the text on screen and sustain engagement.
Mari explained how iCBT required participants to read a great deal of
text online and expressed a wish for a more interactive and less text-­
intensive format:
‘…because there is a lot of reading work… I know
some of my friends won’t like this; it is just a bit too
static. Like, it is read, read, read, answer, answer, an-
swer…The videos were cool, and I know that a lot of
my friends will really like a more interactive thing…
instead of reading the tips or the layout of the session,
you could have everything in a video’.
7. Suggestions for implementing e-­interventions
In addition to noting the need for the e-­intervention to be less
text-­
intensive and more interactive, participants also suggested
truncating the intervention. Peter, for example, expressed his desire
for the sessions to be shorter and more focused, suggesting that the
intervention could be improved by ‘… maybe cramming it more…’.
In noting how iCBT motivated and prepared them for seeking indi-
vidual therapy, some participants suggested the e-­intervention might
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
adjunct to traditional psychotherapy. Peter explained how blending
the e-­intervention with face-­to-­face therapy could enable students
to learn skills online while establishing a relationship with a therapist:
‘…the same format as an online program to improving
yourself with step-­by-­step instructions, coupled with
face to face contact sessions…’
Participants explicitly expressed a desire for iCBT to include more
human interaction and more opportunities for relating to others. Some
suggested that one way to achieve this might be to combine the e-­
intervention with other interactive digital forums (like chatrooms or
blogs) where students could interact with one another in real time.
Rachel, for example, said:
‘…thinking of it like a chat room, or like a… a blog even’.
Participants were emphatic that they could not imagine iCBT as an
alternative to, or substitute for, face-­to-­face individual therapy. Mari
articulated this perception, saying:
‘… 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
you will ever get it on that level where it will take over
the role of a person’.
4 | D I S CU S S I O N
This study is the first of its kind from South Africa to document uni-
versity students’ experiences of using iCBT and adds to the growing
GERICKE et al.
body of literature describing the acceptability of e-­interventions to
promote mental health. The initial uptake of the e-­intervention was
relatively low, with only 39.1% of students who were offered the
intervention initiating treatment, and with only 27.3% completing all
modules of the intervention. This suggests that there may be a large
group of students with symptoms of depression who do not perceive
a need for treatment, are unmotivated to seek treatment and/or who
are not drawn to e-­interventions. This finding is, however, consistent
with previous findings of low rates of treatment seeking among stu-
dents with major depressive disorder (Bantjes et al., 2020), and high
rates of attrition and low rates of engagement with mental health e-­
interventions (Lattie et al., 2019). Research is needed to understand
the low uptake and completion rates we observed. Nonetheless,
students who engaged with iCBT reported positive experiences.
As discussed below, these findings have eight implications for the
development and implementation of e-­interventions for university
students.
First, it is interesting that all participants reported that aware-
ness of their symptoms and acceptance of the need for assistance
motivated them to utilise iCBT. This is consistent with research indi-
cating that individuals are unlikely to seek treatment in the absence
of a perceived need (Andrade et al., 2014; Mojtabai et al., 2011),
and implies that the Trans-­theoretical Model For Stages of Change
(Prochaska, 1994; Prochaska & Norcross, 2001; Prochaska &
Velicer, 1997) might be an appropriate framework to understand stu-
dents’ decisions to utilise e-­interventions. This finding also suggests
that it may be helpful to use motivational interviewing (Norcross
et al., 2011; Rollnick & Miller, 1995) as an integral component of
promoting students’ uptake of e-­interventions. Indeed, motivational
interviewing is effective in promoting utilisation, completion and
retention in mental health e-­interventions (Saulsberry et al., 2013;
Titov et al., 2010; Van Voorhees et al., 2009).
Second, participants recognised how iCBT enabled them to
overcome typical barriers to accessing campus-­based mental health
services, including stigma, inconvenience and inaccessibility, all of
which are congruent with the barriers to care reported by students
(Mowbray et al., 2006). Participants valued the anonymity, privacy,
availability and accessibility provided by iCBT, a finding which is
also congruent with other qualitative research (Chan et al., 2016;
Fleischmann et al., 2018). It is significant that students found self-­
disclosure and emotional expression were facilitated by the e-­
intervention. This phenomenon, which has been termed the ‘online
disinhibition effect’, is consistent with other studies reporting that
individuals typically feel more comfortable disclosing sensitive in-
formation when using technology (Lapidot-­Lefler & Barak, 2015;
Suler, 2004). Taken together, these findings suggest iCBT might be
useful in engaging students who would not otherwise access men-
tal health services, particularly if the interventions are presented as
an anonymous, user-­friendly, convenient and private way to access
psychological help. This conclusion is consistent with The Unified
Theory of Acceptance and Use of Technology (Venkatesh et al., 2003)
and the Emotional-­Technology Acceptance Model (Lu et al., 2019),
| 799
both of which highlight how the propensity to adopt novel technol-
ogies is shaped by factors such as ease of use, the capacity for self-­
determination and the need for autonomy (Lu et al., 2019; Venkatesh
et al., 2003; Venkatesh & Bala, 2008).
Third, participants identified how iCBT engendered feelings
of competence by promoting acquisition of relevant and effective
skills. They experienced this skills-­based approach as de-­stigmatising
and helpful, which suggests that it may be appropriate to promote
e-­interventions by positioning them as tools which build resilience
and impart psychological skills. Presenting iCBT in this way may also
help to debunk participants’ expectation that the e-­
intervention
will mimic conventional psychotherapy. This conclusion is congru-
ent with the Emotional-­Technology Acceptance Model which, among
other things, highlights the significance between the diffusion of
new technologies and the extent to which the technologies foster a
sense of competence (Lu et al., 2019).
Fourth, students’ disappointment with the lack of interaction
and engagement with the eCoach suggest that it might be import-
ant to manage users’ expectations and educate them more carefully
about how online semi-­guided interventions are different from other
‘talking therapies’ which are more relational and personal. Managing
students’ expectations of e-­interventions is particularly important
given the evidence that treatment outcome expectancies predict
therapeutic change in CBT (Kazdin, 2015). Students’ expressed
desire for more human interaction is also interesting in the light of
literature showing the importance of therapist factors and human
interaction in iCBT interventions (Richards & Richardson, 2012).
Indeed, the level of human interaction seems to be an important
predictor of therapeutic outcome, as is evident in the observation
by Richards and Richardson (2012) that there is a hierarchy of ef-
fectiveness within iCBT; therapist-­supported interventions are the
most efficacious (g = 0.78), followed by interventions supported by
non-­clinical staff (g = 0.58), with unguided interventions being the
least effective (g = 0.36) (Richards & Richardson, 2012).
Fifth, students reported that iCBT facilitated self-­awareness and
paved the way for them to seek individual psychotherapy which they
were not previously inclined to do. Other studies have also found that
students who use guided e-­interventions for depression reported
greater self-­awareness and consider this to be a crucial component
of the effectiveness of the intervention (Ly et al., 2015). Our data
suggest that iCBT may be a useful bridge into traditional psychother-
apy, not only by enabling students to overcome perceived barriers
to accessing psychological care but also by facilitating awareness of
areas in need of change and thus increasing their motivation to seek
care. iCBT may thus be an important component of a larger strategy
to increase utilisation of traditional campus-­based psychotherapeu-
tic services by, for example, offering e-­interventions as the first line
of help in a stepped-­care approach to student counselling services
(Bower, 2003) or by offering iCBT to students who are on waiting
lists at student counselling centres.
Sixth, our findings highlight students’ need for autonomy
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.
Studies have documented the benefits of tailored content which is
flexible to users’ needs within guided e-­interventions (Fleischmann
et al., 2018; Palacios et al., 2018). The need for autonomy may be
particularly marked among students, given the developmental tasks
of young adults (i.e. the attainment of autonomy and independence)
(Robards et al., 2018; Wilson et al., 2011).
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
Analytica scandal and the cyber-­hack on the Ashley Madison dating
website (in which the private information and identity of users were
made public; Hinds et al., 2020). Students’ concerns about data secu-
rity highlight the importance of emphasising privacy and confidenti-
ality as key features of iCBT and ensuring that security features are
robust and explicit. Musiat et al. (2014) have, however, noted that
stressing the privacy and security features of e-­interventions may
not be sufficient to promote use, as the utilisation of mental health
services is also strongly influenced by the perceived effectiveness
and credibility (Musiat et al., 2014).
Eighth, it is interesting that students indicated a need for
more responsiveness and reflectiveness, expressing a desire for
human interaction. Similarly, Fleischmann et al. (2018) and Palacios
et al. (2018) found that students who used semi-­guided iCBT ex-
pressed dissatisfaction with feedback being too generic and artic-
ulated a need for more personal and immediate tailored feedback
(Fleischmann et al., 2018; Palacios et al., 2018). It is unclear to what
extent this expressed need for individual feedback is a function of
students’ desire for personal connection and a therapeutic relation-
ship, rather than a function of their expectations about what ther-
apy entails. Nonetheless, this finding may point to the potential for
iCBT to be used as an adjunct to face-­to-­face therapy or, at the least,
to be blended with real-­time interaction with a human therapist, as
has been suggested by others (Wilhelmsen et al., 2013). Crucially,
this finding highlights two distinct paradigms for conceptualising e-­
interventions. On the one hand, technology can be seen as a con-
duit for delivering content (i.e. content-­based interventions), thus
dispensing with the need for human therapists. On the other hand,
technology can be a tool for establishing a therapeutic relationship
(relationship-­centred interventions). While the students in our study
seemed to value the content-­centredness of iCBT, they also ex-
pressed a desire for a relationship-­centred approach. Understanding
how content-­
centred and relationship-­
centred approaches can
be blended in the design and delivery of digital mental health may
be important for achieving high utilisation rates among university
students.
4.1 | Limitations
The generalisability of our findings is limited by the small sample
size and the fact that our participants were all first-­year students
recruited from one university. Similar studies with larger, more rep-
resentative samples drawn from diverse settings and including sen-
ior students (who may be more familiar with issues of cyber-­security)
are needed to understand the factors that shape university students’
engagement with iCBT. We relied on a self-­selected sample of stu-
dents which may have resulted in a sample biased towards those
who had mostly positive experiences of the intervention.
5 | CO N C LU S I O N
Taken together, these findings suggest that some South African
first-­year university students may find iCBT acceptable and effec-
tive as a mode of delivering psychological treatment for symptoms
of depression. Participants explicitly appreciated the autonomy and
convenience of being able to access treatment via the Internet and
reported that this mode of therapy overcame common barriers to
accessing traditional campus-­based services while also promoting
feelings of competence. Crucially, the findings of this study highlight
students’ disappointment with the lack of immediate personalised
human interaction. This implies that any move to incorporate iCBT
into student mental health services will need to take account of and
manage students’ expectations about the ability of e-­interventions
to mimic traditional therapy and/or incorporate more opportunities
for human interaction as part of the e-­intervention.
C O N FL I C T O F I N T E R E S T
None.
AU T H O R C O N T R I B U T I O N S
FG was involved in conceptualisation of the project; data collection
and data analysis; and preparation of the first draft of manuscript.
DE was involved in conceptualisation of the project; funding acquisi-
tion; development of the iCare intervention; and reviewing the final
manuscript. EB was involved in project management, data collection
and data management. RA was involved in conceptualisation of the
project; data analysis; and reviewing and editing the final manu-
script. JB was involved in conceptualisation of the project; funding
acquisition; supervision of data collection and data analysis; and
preparation of the final manuscript.
ORCID
Franco Gericke https://orcid.org/0000-0002-6925-9366
David D. Ebert https://orcid.org/0000-0001-6820-0146
Elsie Breet https://orcid.org/0000-0002-6974-8215
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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