What explains trust in online mental health therapy provision platforms? An online descriptive survey

Abstract

Background

Currently, there is an increased interest in providing mental health care through digital devices and services, and the demand for these services is growing.

Objective

In this study, we considered the phenomenon of trust in online consultations, and the factors affecting this trust, within a Russian context.

Methods

An online survey was conducted using Google Forms in May 2023 and the data were analyzed using SPSS. All the participants were students from Moscow universities aged from 18 to 35 years. The final sample consisted of 203 students, of which 154 (75.9%) were women, 44 (21.7%) were men, and five (2.5%) preferred not to specify their gender.

Results

We found that students had a high level of trust, which depended on personal factors, such as experience, socio-economic status, and age, and contextual factors, such as geographical and temporal independence, price of the session, availability of recommendations, popularity of the platform, and the level of technical equipment.

Introduction

Psychotherapy is communication between a mental health specialist and a person in need of psychological help. ¹ A psychotherapy session takes place in the form of a dialogue: the client expresses their thoughts, and the therapist listens to the client, directs their thoughts, and gives them feedback to boost their self-reflection. ² In online therapy, the communication between the specialist and the client takes place using computer communication technologies. Online therapy could be a solely digital intervention in the field of mental health; it often involves computer therapy, smartphone applications, and wearable technologies. ³ They are claimed to have enormous potential to improve mental health coverage and accessibility, clinical effectiveness, and the personalization of mental health interventions. ³

Online therapy occupies a leading position among the methods for solving mental problems, and involves the use of psychology-related content, including audio podcasts, video materials, and art therapy, to maintain the work–rest balance and include relatives and specialists in providing help and support.^4–7 A special need for psychological assistance was observed during the COVID-19 pandemic. This demand was associated with increased levels of stress caused by the restriction of freedom aimed at minimizing the spread of infection. Due to its geographical independence, convenient communication format, and the availability of constant support, online therapy has become widespread. ⁸

However, in online therapy, the psychotherapist and client may have difficulty establishing interpersonal intimacy; therefore, multiple techniques and additional interaction channels may be used to enhance the sense of presence and reality and control the pace and content of the sessions. ⁹ For example, the use of shorter sentences facilitates a good flow of conversation and helps to prevent long gaps and waiting for the other's response, which can be distracting during text-based synchronous online therapy. Instead, the client is reading and absorbing while the therapist is typing. ⁹

Although the supply of digital psychological assistance services (DPAS) in many developed countries is rising and young people constitute the biggest share of users of such services, there is a lack of articles explaining why some young people actively engage in DPAS usage while others do not turn to them at all. ¹⁰ Furthermore, existing papers on the mentioned topic contradict each other, finding, for instance, different gender-based patterns of DPAS usage. ¹¹ Specifically, it was found that the confidence in DPAS is ambiguously impacted by gender self-identification. Given that women are more likely than men to seek psychological assistance, self-identification as female may, on the one hand, be linked to increased trust in DPAS.^12,13 Additionally, women utilize DPAS at a higher rate than males do. ¹⁴ It is possible that gendered views and expectations regarding manly emotional displays and health-related concerns contribute to men’s less frequent use of psychiatric services in society. ¹⁵ It’s still frowned upon for males to express their feelings in public in certain cultural contexts; men who ask for assistance often face ridicule and negative treatment. Furthermore, men who struggle with psychological health frequently experience self-stigmatization. ¹⁶ At the same time, women’s emotional regulation is encouraged, and self-care is regarded as more natural than it is for men. Women are more satisfied with internet therapy than men since sessions can be conducted anonymously. ¹⁷ This could be owing to women’s fears of stigma and criticism of therapy from loved ones. Meanwhile, males who seek psychiatric care tend to stay in therapy longer than women. ¹⁸ Their lengthier stay in therapy can increase their belief in the efficacy of the therapeutic intervention and, as a result, their faith in cognitive behavioral therapy (CBT). Therefore, this research aimed to identify the determinants of trust in digital psychological assistance services among Russian young adults aged 18–35, defining trust as the willingness to use the services. ¹⁹

Research in this specific direction is crucial because, in addition to pointing out the deficiencies in DPAS for different sociodemographic groups, it assists in identifying the routes for service providers to customize and promote these kinds of services. ²⁰ Moreover, it should be argued that there is an exceptional need to study DPAS in non-European countries^21,22 because in these countries, DPAS adoption is novel and new technologies from abroad have the potential to either flourish and improve individual wellbeing or to be ineffective and out of demand. Overall, identifying the reasons for increased or decreased use of the DPAS may aid in their adaptation to national healthcare system customs and population demands. ²² Furthermore, it is important to mention that our study is a pioneer for Russia as the phenomenon of DPAS emerged in the country only 3–5 years ago. Initially, there were only 1–2 services, but more than 10 large services are now present on the market, which continues to grow. ²³ DPAS in Russia is an online resource where a client can choose a psychological health specialist from among those registered on the resource, arrange a time for the consultation, and attend the session. Specialists working on DPAS do not provide medical services—they do not have the right to prescribe medications—but they can recommend drug therapy and provide the contact details of persons who are competent in its implementation. Meetings of specialists and clients are held online with the DPAS acting as the host, and the sessions can be one-off, or repeated and regular if the client and specialist agree. As a rule, clients are allowed to change specialists without explanation, and vice versa. Payment for the specialist services is made to the DPAS; some services allow the client to pay for a single session, while others allow clients to purchase a discounted tariff that allows them to visit a practicing specialist for a month, six months, or a year or more. There are also discounts for DPAS customers based on, for example, whether they decided to use the service on the recommendation of a celebrity or through an affiliate service—for example, a purchase from a DPAS-friendly store. The session prices are not always universal; some DPAS set uniform prices, while others vary prices depending on the qualifications of the specialist and other client and specialist parameters. The duration of one session is usually 40–50 min.

Methods

Study design

Using an online survey (N = 203) we examined the factors of trust in DPAS among Russian-language university students who resided in Moscow, Russia in May 2023. The data were collected using online survey in Google Forms. The specific factors considered were the socio-demographic characteristics of the students, their experience of psychotherapy, and the characteristics of the platforms through which psychological assistance was provided. This social group was examined since Russia is a country with high regional health heterogeneity. ²⁴ Furthermore, it is argued that its central regions, to which Moscow belongs, are more comparable to Europe than peripheral regions of Russia in terms of health indicators. ²⁴ Before this main period of data gathering, which was in May 2023, in January 2023 we piloted the questionnaire ²⁵ ; during the theoretical stage we consulted with experts, and during the empirical stage, we conducted five personal interviews, and eight questionnaires were filled out by respondents. As a result of the piloting, some of the item wording was amended, more answer options were added, and the section divisions were adjusted.

The final questionnaire consisted of 26 main questions and 49 individual items (see Appendix 1). The questionnaire included questions on the following: (a) the socio-demographic characteristics of respondents, (b) their personal experience of receiving psychological help, (c) their views on the effectiveness of online therapy assessment, and (d) their degree of confidence in the effectiveness of psychotherapy, (e) the safety of therapy methods, the safety of communication through the platform, and (f) the experience and sufficient qualifications of a psychotherapist. We also added a personal semantic differential to the questionnaire, in which the client's assessment of the therapist's personal subjective qualities was analyzed to identify whether there was a difference between perceptions of online and offline therapists.

The questionnaire was based on marketing and medical research and literature on DPAS users and the sociology of medicine. The survey also contained elements from the PART patient confidence assessment tools (assessment of patients’ perceptions of the factors that make up trust in telemedicine services), ²⁶ the UTAUT model (determinants of the adoption and use of technologies for mental well-being), ²⁷ a list of working alliances for adolescents and therapists (WAI-SR; “youth and therapist”), ²⁸ and a questionnaire measuring attitudes to psychological online interventions (APOI). ²⁹ All of the mentioned scales were validated in the previous non-Russia-held studies,^26–29 in our study we checked their reliability using Cronbach Alpha, which provided good results (0.8 and higher). Also, as it was mentioned we conducted piloting, to ensure the quality of the questionnaires used.

Measures

Level of trust was divided into three categories—trust in psychotherapy as a whole, trust in the specialist, and trust in digital services—based on Stompka's distinction between trust levels. ³⁰ This resulted in four scales (see Questions 6, 7, 15, and 18), with 27 individual items. The items were rated on a 5-point Likert-type scale (where 1 = “Absolutely disagree,” and 5 = “Absolutely agree”). The level of trust was computed using the sum of the individual answers on all the items (Cronbach's alpha = 0.816). The total possible score ranged from 18 to 90 points in total for the four scales.

The factors of trust were divided into personal and contextual factors. Experience, socio-economic status, and age were taken as personal factors (Questions 22–26); geographical and time independence, session price, recommendations, platform reputation, and technical equipment were taken as contextual (factors) (Questions 19 and 20; 12 individual items). All the items were presented as opinions (judgments) and rated on a 6-point Likert-type scale based on the degree of importance. The total level of trust in digital services of psychological help” was measured on an interval scale from 18 to 90 points. “Level of trust in online psychotherapy” was recoded into an interval scale, and “Level of trust in digital services of psychological help” was recoded into an ordinal scale, with division into low, medium, and high expression of the factor of trust in digital psychological help services.

Participants

Respondents were recruited via psychological assistance platforms and communities dedicated to mental disorders (specializing in Moscow and the Moscow region), student chat rooms, and the Russian social networking site Vkontakte. Participants were asked to volunteer and were not paid for their participation in the study. The volunteer sampling was employed. The final sample included 203 people (144 women, 44 men, and 5 who preferred not to answer the question about their gender; see Appendix 2, Table 1). Sixteen respondents were not included in the final sample because they were not from Moscow or the Moscow region, were under the age of 18 or over 35, or were not students. Most of the respondents were aged 18 (17.7%), 19 (34.5%), 20 (14.3%), or 21 (13.8%) years old (Appendix 2, Table 2).

Ethical considerations

All study participants provided written informed consent using an online Yandex survey tool. The study had been approved by HSE University’s ethical committee. To safeguard participants’ anonymity and confidentiality, we did not collect data on respondents’ IP addresses and did not ask for personal identifying information such as name and surname in the survey.

Data analysis

The data analysis was carried out using SPSS. All the statistical tables are presented in the Appendices. We focused on two main tasks: (a) analysis of the phenomenon of trust in online psychotherapy services, and (b) examination of the personal and contextual factors that may be associated with the degree of trust in online psychotherapy services.

1. We used exploratory factor analysis to identify the main factors that impacted trust in online psychotherapy services.

During the analysis, the questions with a subjective assessment, which used a 6-point Likert scale, were converted into a 5-point scale; the option “I find it difficult to answer” was coded with the third option “neutral” or “equally agree or disagree.”

1. In order to compare the level of trust in online psychotherapy services among Moscow students with experience of online and in-person psychotherapy, the parametric T-test for independent samples was used, this was because the dependent variable “level of trust in digital psychological assistance services” was measured on a pseudo-interval scale and the online therapy and face-to-face therapy groups had more than 30 respondents each.

To determine whether there was a relationship between the level of trust in DPAS and socio-economic status, we used Spearman's rank correlation, which allowed us to identify a monotonous relationship between variables. As both the scales were ordinal, to determine the pair coupling coefficient, the Spearman coefficient was used.

We recoded the interval variable “age” into a nominal scale, allocating the ages 18–20 years to one group and 21–35 years to another, based on the size of the groups. To compare the level of trust in online psychotherapy among the two groups, the non-parametric Mann–Whitney U analysis of variance was used, since the data on level of trust in online psychotherapy were not normally distributed.

We assessed the relationships between the contextual factors and trust using Pearson's Chi-square and conjugacy tables.

Results

Concept of trust

Exploratory factor analysis of trust in DPAS showed that the concept of trust in digital services for providing psychological assistance had more dimensions than were initially hypothesized. Initially, 22 judgments (items) were evaluated on a 5-point Likert scale, where 1 = “Absolutely disagree” and 5 = “Absolutely agree.” During the analysis, items with commonality scores of less than 0.5 were excluded in turn to improve the quality of the model.

First, the item “I believe that sessions on online platforms do not make it possible to establish the same strong emotional connection with a psychotherapist as face-to-face sessions” was excluded (0.333) (Appendix 3, Table 15), and then the items “I am not sure that psychotherapy is helpful for dealing with psychological disorders” (0.342) (Appendix 3, Table 16) and “I do not believe that psychotherapy can help me” (0.438) were excluded (Appendix 3, Table 17). This procedure helped to improve the quality of the model; the commonalities of the variables ranged from 0.512 to 0.884 (Appendix 3, Table 18), which indicated uniformity. The KMO (Kaiser-Meyer-Olkin) measure of sampling adequacy and Bartlett's test of sphericity improved, which indicated that the final scale provided the best fit (Appendix, Tables 14 and 19).

The percentage of cumulative variance was 69.388%, which is satisfactory (Appendix 3, Table 20). After applying an orthogonal varimax rotation (Appendix 3, Table 21) and considering the rotated matrix of the component (Appendix 3, Table 22), 19 items were identified; these made five factors that determined the structure of trust in online psychological assistance services: (a) trust in a specialist, (b) trust in psychotherapy in general, (c) trust in the platform, (d) trust in the education of a psychotherapist, and (e) trust when paying on the platform.

Personal factors

The t-tests, Spearman correlation, and Mann–Whitney U analysis of the relationship between personal factors and trust in DPAS showed that experience of online therapy affected the level of trust (p = .07) (Appendix 4, Table 23). It was also revealed that confidence in online therapy was rated on average 4.66 points higher than that for face-to-face therapy. No connection was found between socioeconomic status (p > .1) (Appendix 4, Table 24), age (p > .1) (Appendix 4, Tables 26 and 27), and level of trust.

Contextual factors

Respondents assessed the importance of the session venue, a convenient communication format, and freedom to choose the time on a 5-point scale.

Pearson's Chi-square analysis of the relationship between contextual factors and trust in DPAS revealed a relationship between convenient communication format and level of trust (p = .09) (Appendix 4, Table 29). Other relevant factors were significant temporary independence (p = .018) (Appendix 4, Table 31), availability of recommendations (p = .001) (Appendix 4, Table 32), and technical equipment (p = .046) (Appendix 4, Tables 38 and 40). Geographical independence, popularity of the platform, and price of the session were insignificant (p > .1) (Appendix 4, Tables 28, 33, and 35).

Discussion

Online therapy is becoming increasingly popular. New programs and services are emerging to provide psychological assistance and coordinate the relationship between the client and the therapist. Online therapy helps introverted and socially disadvantaged clients get psychological help and reduces physical and psychosocial barriers. For the formation of trust in the therapy process, the homogeneity of the relationship between client and therapist, their belonging to the same social environment, mutual sympathy, and similarity of worldview are important. DPAS platforms act as an intermediary in the relationship between the psychotherapist and client in the cyber environment, because they create resources for communication, mediate the session fee, resolve disputes, and are guarantors of the quality of online therapy, which increases confidence in it.

Structure of trust in digital psychological assistance services

We found that trust in online psychotherapy services depends on trust in the specialist, psychotherapy in general, the platform, the psychotherapist's education, and the payment process on the platform. The hypothesis that trust would be subdivided separately into psychotherapy, specialist, and platform factors was partially confirmed. The analysis showed two additional aspects of the trust structure: the psychotherapist's education and the payment process on the platform. Research suggests that it is important for clients to be aware of the professional competence of a psychotherapist and that this increases trust in the specialist. Specifically, the psychotherapist's education should be justified on the platform providing online therapy because of its influence on the level of trust between the client and the specialist. ³¹ The payment process on DPAS platforms also exits as a separate factor from trust in the platform. During the era of digitalization and active development of online services, fraud is spreading in parallel, and bank card data or simply paying for services via the Internet seems dangerous. A previously cited study reports that DPAS platforms act as organizers of online consultations, which reduces the likelihood of fraud; therefore, payment for services is an important determinant of trust in DPAS. ³²

Personal factors affecting the level of trust in digital psychological assistance services among Moscow students

Experience with online psychotherapy is a personal factor that affects the level of trust in online psychotherapy services among Moscow students. Age and socio-economic status were not found to be significant determinants of trust in online psychotherapy services. Initially, our respondents were divided into those who had and had not visited a therapist, which helped us to consider whether trust depended on the experience of therapy. As the results showed, experience is indeed an important personal factor that affects trust. Moreover, people who have experienced psychotherapy have a more complete understanding of it, so they are more inclined to trust communication with a psychotherapist online. ³³

Contextual factors affecting the level of trust in digital psychological assistance services among Moscow students

We identified contextual factors influencing the level of trust in DPAS among Moscow students. These included freedom in the choice of time, the ability to terminate the session whenever they liked, recommendations from acquaintances and media persons, and technical equipment. Attitudes toward psychotherapy and mental health are shaped by an individual's immediate environment. Therefore, people are more inclined to trust personal recommendations, so when making decisions about psychotherapy, it is easier to rely on the opinions of people who have already had similar experiences.^34,35 Geographical independence and the cost of the sessions were not related to the trust. We believe that the aforementioned price finding is related to the little price diversity on the DPAS market in Moscow, as well as the sample’s comparable levels of socioeconomic well-being.

Limitations and future perspectives

The main limitation of our study was the small sample size; we did not recruit enough respondents to generalize the results to the general population. Especially, the research underrepresents males, since they are less willing to take part in surveys ³⁶ and are generally more skeptical about mental health. ¹¹ Furthermore, in our final sample, there was a shortage of respondents who had experienced online therapy; most had attended offline sessions with a psychotherapist, which did not allow us to consider the differences between respondents’ perceptions of online and offline therapy. In addition, initially, our research focused only on young adult students from Moscow, but this excluded many other users of DPAS. Studying trust in DPAS using a wider audience would allow us to identify different preferences and needs. In conclusion, we utilized questionnaires that had only been validated outside of Russia and employed a single reliability test (Alpha Cronbach) to verify the instruments` quality. Consequently, further studies are required to explore the employed instruments` other types of validity such as criterion validity. ³⁷

One future direction of our research may be to study the factors that explain the trust of DPAS customers, including users from vulnerable social groups who cannot afford to pay for therapy and buy online equipment. Moreover, the online psychotherapy market is actively developing and, in the future, new forms of providing psychological assistance in an online environment may appear. Future research might consider the usefulness and ethics of using these new technologies to provide psychological support and analyze the attitudes of users and psychotherapists to the digitalization of mental health.

Conclusion

The concept of trust in DPAS is multidimensional. It is based on trust in psychotherapy in general, and trust of the specialist and the platform. Together, these dimensions of trust determine a person's desire to turn to online therapy. In this study, groups of highly trusting, skeptical, and average trust level participants for each dimension were identified among the sample. Young adults aged 18–35 years in Moscow first turn to people close to them for psychological help, and they then turn to psychotherapists. Thus, DPAS are becoming increasingly common tools for supporting mental health among Moscow students. This group's level of trust in DPAS is influenced by contextual (time, recommendations, technical equipment) and personal (online therapy experience) determinants. In general, psychotherapy is not stigmatized among this group and with continued experience of using DPAS, the level of trust in them will also increase. Healthcare providers in Moscow may be advised to create promotional materials for young adults on DPAS that stress the worth of the services based on the discovered trust factors.