Table 2 TDF themes including barriers and enablers to improve delivery and aid implementation of guided-self-help delivered over the telephone (GSH-T)

DEFICITS IN PRACTITIONERS’ KNOWLEDGE

• Service centred drivers for the use of GSH-T

• Patient preference-driven approach to GSH-T (access, flexibility)

• Lack of use of different modalities to deliver GSH

• Balance on the use of different modalities of delivery

• Positive experience on telephone assessment facilitates telephone treatment

SUB-OPTIMAL PRACTITIONER TELEPHONE SKILLS

• Lack of telephone specific skills

• Developing verbal communication skills to deliver GSH-T through telephone specific training

• Lack of quality assessment and monitoring on telephone delivery before and after becoming qualified

• Developing a warm and safe therapeutic environment

• Moving to a positive attitude through practice, changes in negative beliefs and growth in self-confidence

PRACTITIONERS’ LACK OF BELIEFS IN TELEPHONE CAPABILITIES & SELF-CONFIDENCE

• Feeling less capable to develop a therapeutic relationship over the telephone compared to face-to-face

• Lack of self-confidence to work over the telephone related to the lack of visual and non-verbal cues

• Lack of visual increases sense of control over patient’s perceptions

PRACTITIONERS’ NEGATIVE BELIEFS ABOUT CONSEQUENCES

• Lack of effectiveness of telephone delivery regardless of the evidence

• Effectiveness of telephone delivery grounded on the evidence, practice and experience

• Drop-out rates perceived to be higher for GSH-T (related to lack of patient engagement)

• Lack of visual helps to focus on patient’s verbal responses and increases efficiency

NEGATIVE EMOTIONS

• Feeling anxious and out of the comfort zone working over the telephone

• Feeling like a ‘robot’ working over the telephone (lack of flexibility to deliver patient-centred care)

• Feeling overwhelmed, disconnected and burn out

• Feeling lonely and isolated

PROFESSIONAL ROLE EXPECTATIONS

• Professional role varies pending on mode of delivery: coach vs therapist

• Delivering GSH-T perceived as a lower version of treatment

• Feelings of PWP role being undervalued

• Majority of telephone work done at Step 2 care only

NEGATIVE SOCIAL INFLUENCES

• Negative preconceptions about telephone treatment

• Managing patient expectations

• Patient expectations to receive f2f treatment

• Patient association of ‘therapy’ with ‘counselling’

• Practitioner’s patient perceptions of telephone being ‘not proper’ therapy

• Lack of awareness of psychological treatments and its different modes of delivery

CHALLENGES IN THE ENVIRONMENTAL CONTEXT & RESOURCES

• Working in a noisy ‘call centre’ with limited resources

• Informal peer support and supervision

• Planning and preparation for telephone sessions is time consuming (before and after the session)

• Sessions over the telephone take less time (structure, focus, boundaries)

• Lack of telephone-focused guidelines and service procedures for GSH-T

• Flexible working and/or improvements in working environmental conditions

• Lack of formal supervision addressing challenges related to telephone delivery and telephone procedures