Using the Behaviour Change Wheel to identify barriers and enablers to the delivery of webchat counselling for young people

Webchat counselling is increasingly utilised to deliver mental health services to young people. Despite potential barriers to its delivery, a systematic investigation has not yet been conducted. This qualitative study examined barriers and enablers to the delivery of webchat counselling through text communication and identified possible strategies to tackle these, on behalf of counsellors volunteering for an online charity offering psychological support to young people aged below 25. The current investigation was conducted using the Behaviour Change Wheel, a validated and systematic framework employed to guide intervention development and optimisation. Qualitative interviews were carried out with eight volunteers. Thematic analysis identified 11 core themes. Barriers were lack of online communication skills, lack of training to work online with young people, technical difficulties, reduced technical supervision during out- of- office hours, duration of webchat counselling sessions, perceived level of effectiveness, perceived establishment of a therapeutic relationship and perceived confidence in delivering webchat counselling. Enablers were familiarity with technology, flexibility and the absence of physical characteristics.

to the delivery of webchat counselling through text communication and identified possible strategies to tackle these, on behalf of counsellors volunteering for an online charity offering psychological support to young people aged below 25. The current investigation was conducted using the Behaviour Change Wheel, a validated and systematic framework employed to guide intervention development and optimisation. Qualitative interviews were carried out with eight volunteers. Thematic analysis identified 11 core themes. Barriers were lack of online communication skills, lack of training to work online with young people, technical difficulties, reduced technical supervision during out-of-office hours, duration of webchat counselling sessions, perceived level of effectiveness, perceived establishment of a therapeutic relationship and perceived confidence in delivering webchat counselling. Enablers were familiarity with technology, flexibility and the absence of physical characteristics. These themes were perceived by counsellors as barriers or enablers depending on factors such as experience with technology and work shifts. Using the Behaviour Change Wheel (BCW), intervention functions and behaviour change techniques to address these barriers and optimise the service were identified, such as providing counsellors with training to work online with young people, learning new presence techniques to foster emotional connectedness between counsellors and clients, adding time to sessions to compensate for time taken to complete questionnaires and increasing technical support and supervision during out-of-office hours.
1. Online webchat counselling for young people can be optimised to better meet their service needs and provide more effective provision for this underserved age group.
2. Behaviour change theory and tools can be used to identify appropriate and effective intervention strategies to improve the practice of webchat counselling.

| INTRODUC TI ON
Mental health difficulties account for 16% of the global burden of disease and injury in young people across the world (Kessler et al., 2007). The World Health Organisation (2019) indicates that young people are particularly at risk of suffering from psychological distress and mental health difficulties, with approximately 20% of adolescents experiencing mental health difficulties in any given year. Extensive attention has been devoted to the development of practices that can help to prevent and treat these issues. One of the approaches that has become increasingly utilised to offer psychological support is webchat counselling. Delivery of webchat counselling through text communication is a behaviour that has been associated with several enablers and barriers. Due to its anonymous, confidential and remote nature, webchat counselling overcomes many of the barriers associated with traditional face-to-face counselling (Sweeney et al., 2019). At the same time, research has highlighted barriers to its delivery (Glasheen et al., 2013). As of yet, however, there has been no attempt to identify the barriers and enablers to the delivery of webchat counselling and pinpoint strategies for improvement using a systematic framework.
The current study addresses this research gap by employing the Behaviour Change Wheel (BCW), a systematic and validated framework to design, implement and evaluate behaviour change interventions (Michie et al., 2014). Counsellors from a free online counselling service were interviewed to identify the main barriers and enablers associated with the delivery of webchat counselling for young people. Corresponding behaviour change techniques (BCTs) are suggested to improve the service.

| RE S E ARCH BACKG ROUND
While access to mental health services should be readily available for young people, the provision of mental health services is often weakest for this age group (Patel et al., 2007). A recent report by The Children's Society (2019), for example, estimates that 110,000 young people with mental health issues aged 10-17 in the United Kingdom were turned away from the National Health Service (NHS) in 2017, because their difficulties were not considered serious enough. Consequently, a mounting concern has grown around mental health difficulties of children and adolescents, resulting in the commitment to provide a more targeted approach to the prevention and treatment of mental health problems (Membride, 2016).
Psychological treatments can be a crucial resource in addressing mental health issues and can be effective in ameliorating mental health symptoms (Das et al., 2016;Weisz et al., 2005). One of the therapeutic approaches that has received extensive attention for its effectiveness in addressing young people's mental health needs is counselling. With the advent of new and improved technologies, there is growing consensus that counselling can be delivered in many different forms, such as via telephone or online through email, realtime webchat or videoconferencing. These approaches have been grouped under the term online counselling. This study focuses on a text-based approach to counselling, namely real-time webchat communication between counsellors and clients, which has been the focus of early research in this area. However, it is important to note that more recently, and particularly with the advent of the COVID-19 pandemic, research in the area of distance-based counselling has incorporated other approaches such as videoconferencing.
Online counselling has been at the centre of numerous discussions and debates (Stoll et al., 2020). Much of the discourse around this topic has focused on establishing whether this service can offer a valid and effective alternative to traditional face-to-face counselling and whether it is safe and ethical.
Research on online counselling has also focused on issues associated with this service which might impair its optimal delivery. For example, Finn and Barak (2010) carried out a descriptive study of e-counsellors' attitudes, ethics and practices. One of the problem areas identified was training and supervision of counsellors: indeed, the majority of counsellors in this study reported that their professional programme did not provide any training in e-counselling and that this would have repercussions on a series of ethical and practical factors. Similarly, a study by Hanley (2006) and a systematic review in the area of text-based synchronous webchat counselling (Ersahin & Hanley, 2017) found that inadequate training of counsellors often leads to a lack of awareness regarding regulations surrounding online counselling, how to deal with risks that online counselling presents (e.g. when to break confidentiality) and even how to communicate online with young people.
Another barrier to the delivery of online counselling is the counsellor's perceptions of its effectiveness. Several studies have found that counsellors reported being uncertain about the effectiveness of online compared with face-to-face counselling (Finn & Barak, 2010;King et al., 2010). A systematic review of online counselling highlighted the need for stronger empirical evidence to establish its effectiveness and efficacy (Dowling & Rickwood, 2013).
A further barrier is the lack of non-verbal cues, considered to be crucial to establish a therapeutic relationship between counsellors 3. Training in the delivery of online counselling for young people can be provided as part of counselling education and professional qualifications.
4. Presence techniques can be helpful in addressing the shortcomings of webchat counselling as they are designed to compensate for the lack of non-verbal cues. and clients (Weisz, 1998). The therapeutic relationship is an interactive relationship between a therapist and a client that is caring, clear, boundaried, positive and professional (Ridling et al., 2011). Online counselling, particularly through text communication, could have a 'disinhibition effect' on clients (Suler, 2004). While greater disinhibition may give clients the courage to 'articulate emotions without fear of witnessing a judgmental response in the listener' (Dunn, 2014, p. 83), it can also prompt them to disclose information at an accelerated rate rather than gradually easing into their problem (Barak et al., 2008). Furthermore, the lack of non-verbal cues can lead to misinterpretation or misconstruction of certain phrases on the part of the client or counsellor, especially if they do not clearly articulate themselves when writing. As a consequence, the powerful effects of the therapeutic relationship might be mitigated in online counselling and, in some cases, eliminated (Baker & Ray, 2011), which can impede its effective delivery.
A study by Glasheen (2014) offers support to many of the abovementioned findings. Student counsellors were asked about the barriers they perceived that were preventing them from offering online counselling in schools. Both qualitative and quantitative data highlighted that counsellors were unsure about the effectiveness of online counselling. Moreover, counsellors also reported feeling unprepared to deliver online counselling and needing extensive training on legal, ethical and technical skills before being able to offer this service.
Overall, these studies highlight barriers associated with the delivery of online counselling. While some attention has focused on the identification of practices that could facilitate online counselling and help overcome these barriers, such as the training of counsellors, this has been limited (Finn & Barak, 2010;Glasheen et al., 2013). A systematic examination of the enablers and barriers to online counselling and the corresponding intervention strategies that target these could improve the effectiveness of its provision. This can be accomplished using the BCW approach (Michie et al., 2014), which has been shown to characterise and optimise interventions, such as those focused on the communication behaviour of professionals working with young people surrounding their mental health (Moran & Gutman, 2020).

| Behaviour Change Wheel
The Behaviour Change Wheel (BCW) is a systematic framework that arises from the synthesis of 19 behaviour change frameworks identified in the research literature (Michie et al., 2014). It is used to systematically design, implement and evaluate behaviour change interventions aimed at changing behavioural patterns. The BCW has, as its central hub, the COM-B model, which recognises that behaviour is part of an interacting system involving capability, opportunity and motivation (see Table 1). The COM-B model posits that changing behaviours involves changing one or more of these components relating to the behaviour itself or the behaviours that compete with or support it.
These components interact with each other. For example, increasing capability and opportunity can increase motivation.
Increasing motivation can lead people to do things that will increase capability or opportunity by changing their behaviour. Through COM-B, it is possible to 'diagnose' barriers and enablers that influence a person (or a group) to carry out a certain behaviour, thus identifying sources of the behaviour that could be targeted through The BCW and BCTT are useful tools to translate research into clinical practice (Moran & Gutman, 2020). This process facilitates a solid foundation to design, implement and optimise behaviour change interventions.

COM-B components Definition
Psychological capability Knowledge of psychological skills, strength or stamina to engage in the necessary mental processes to carry out the behaviour Physical capability Physical skills, strength or stamina to carry out a behaviour Physical opportunity Opportunity afforded by the environment, involving time, resources, locations or cues Social opportunity Opportunity afforded by interpersonal influences, social cues and cultural norms that influence the way that we think about things

| The current study
Using the COM-B, the current study aimed to identify the barriers and enablers to the delivery of webchat counselling for counsellors, which is one of the most relevant behaviours associated with the provision of this service. The current study further uses the BCW approach to identify intervention functions and BCTs to address these barriers and improve the delivery of webchat counselling.
These aims are represented by the following research questions:

| Ethical approval
The study was approved by the UCL Research Ethics Committee (07/07/2020).

| Participants
Webchat counsellors were recruited through the organisation.
In order to be accepted for the role of volunteer counsellor in the organisation, counsellors must have a level 4 qualification in counselling. Students in their final year of their level 4 qualification are also considered for the role. Volunteers were encouraged to contact researchers to express their interest in taking part in the study via email and, afterwards, to arrange a suitable date and time to carry out the interview. Consent was obtained through an e-document that participants were required to sign and send back to researchers before the interview. The aim was to conduct between six and 12 interviews, based on samples from similar qualitative studies conducted in this research area (Navarro et al., 2020). Nine counsellors expressed their interest in participation, but eight were interviewed as one did not follow up to arrange a meeting.
Interviews were conducted via videoconferencing with Microsoft Teams. As a token of appreciation for their participation, counsellors were offered a £10 voucher.
To participate, counsellors were required to be qualified or collecting working hours towards their level 4 qualification. The lower age limit for recruitment was 18+, and there was no upper age limit.
Furthermore, participation was directly dependent on counsellors' agreement to being audio-recorded during interviews, as this was necessary for transcription and data analysis. Finally, only counsellors who had been with the organisation for at least three months were eligible to participate, as this was deemed to be the minimum amount of time in which they could have appropriately familiarised themselves with the service and organisation.

| Counsellors' service induction and counselling process
Volunteer counsellors have an initial training upon joining the organisation and before receiving any clients, and an induction period for the first month. The training takes place over two days, and it covers how to use the systems that are employed by the team to facilitate the sessions, the safeguarding policies of the organisation, cancellation and confidentiality policies, the effectiveness of online counselling and supervision requirements. After the volunteer counsellors complete their training, they are in an induction period that lasts for four weeks (one month). During this period, the volunteer counsellors have up to two clients per week and are being monitored by the team weekly. Every week, feedback is provided to the volunteers, to support them with any issues they may encounter. After the completion of the induction period, the volunteers can see up to four clients per week and are monitored monthly.
The platform used to facilitate webchat sessions is AWS (Amazon Web Services). The charity creates accounts for the volunteers to use on this platform and is also responsible for activating and deactivating the counsellors from the platform before and after each counselling session. The volunteer counsellors log on to the system a few minutes before their session to prepare. The volunteer counsellors work from their own locations, most often in their homes.

| Procedure
Data were collected through explorative semi-structured interviews. First, the interview schedule was piloted to assess its duration, to ensure it would not exceed 60 min, and to identify any Interviews were carried out by MR and GM, each of whom conducted and transcribed four interviews. In order to mitigate and account for any technical difficulties, and to ensure that they were able to retain recordings for accurate transcription, both researchers were present during the interviews.

| Organisational support outside of normal working hours
This refers to the support offered to counsellors in situations where the delivery of webchat counselling is impaired (e.g. technical issues, ethical issues and relationship with the client). This theme was perceived as an enabler to the delivery of webchat counselling by counsellors working during normal working hours. Indeed, these participants reported being greatly satisfied with the support the organisation provides to its staff and argued that the support has been crucial in encouraging them to increase their commitment to their role as it made them feel valued as counsellors and as volunteers.
However, the same theme was perceived as a barrier by participants working outside of normal working hours (e.g. 10 p.m. or later in the evening). These participants argued that the organisation was not prompt in offering support in dealing with risks and technical issues and this negatively impacted their ability to deliver webchat counselling, as well as the quality of the counselling sessions.

| Absence of physical characteristics
Counsellors reported that face-to-face contact can impair coun-

and it's a lot easier to detach myself when I'm not as invested').
However, some counsellors argued that this impersonality was not necessarily detrimental as it allowed clients to quickly open up, more so than would be done in a face-to-face approach ('Because there's a lack of personal touch, so they feel a bit more okay just opening up to their computer screen rather than to my face').

| Perceived confidence in delivering webchat counselling
Some of the participants reported not feeling very confident in their ability to deliver webchat counselling, due to lack of tools, experience and training in delivering webchat counselling to young people

('I still feel there's a lot for me to learn […] I still feel like I lack a lot of tools').
Other counsellors were confident in their ability to perform the behaviour ('I've got every confidence in my ability as a counsellor').
Some argued that this confidence derived from training and experience, although it was something that most counsellors had acquired prior to their experience ('training I think is absolutely crucial in feeling confident in myself and crucial in providing tools and frameworks to young people').

| D ISCUSS I ON
Overall, 11 core themes were identified. Barriers were lack of online communication skills, lack of training to work online with young people, technical difficulties, reduced technical supervision during out-of-office hours, duration of webchat counselling sessions, perceived level of effectiveness, perceived establishment of a therapeutic relationship and perceived confidence in delivering webchat counselling. Enablers were familiarity with technology, flexibility and the absence of physical characteristics.
As aforementioned, whether these themes were perceived by counsellors as barriers or enablers to the delivery of webchat counselling depended on factors such as experience with technology and work shifts. Indeed, depending on these factors, the same theme could be perceived either as a barrier or enabler of the behaviour.
Through the Behaviour Change Wheel, intervention functions and behaviour change techniques to address these barriers and optimise the service are identified and discussed. Moreover, those counsellors who had not worked with young people under the age of 18 before believed that more training was necessary to allow them to feel more comfortable with this age group.
According to the BCW, psychological capability influences can be addressed through the intervention functions of education, training and/or enablement. In this case, training and education could be optimal functions to tackle these issues. Indeed, this is in line with themes identified in previous research in this area, where counsellors have argued that one of the main barriers to the adoption of webchat counselling is the perceived lack of skills needed to deal with young people online, which causes counsellors to thus require more extensive training before feeling ready to take on this particular challenge (Ersahin & Hanley, 2017;Finn & Barak, 2010;Hanley, 2006 webchat counselling, has also been attributed to the lack of online communication skills. Counsellors argue that they struggle to communicate online with young people, which influences their ability to establish a therapeutic alliance with them, mainly due to the lack of non-verbal cues. One way to address both of these influences would be to adopt techniques that can foster a sense of emotional connectedness between the two parties. Murphy and Mitchell (1998) ' Mitchell and Murphy, 2009, p. 216). These techniques have been shown to increase and improve the level and quality of the therapeutic relationship between counsellors and clients (Murphy & Mitchell, 1998) and could therefore be employed by organisations to improve the delivery of webchat counselling by volunteers.
Similar suggestions have been identified by Glasheen et al., (2013), who argued that lack of training in counselling with new technologies is one of the major difficulties identified by counsellors working online. Consequently, they argued that courses for the development of skills 'particular to a process that lacks visual and auditory communication cues, would need to be readily available to ensure effective therapeutic relationships are developed' (Glasheen et al., 2013, p. 9). Recommendations for the development of youth online counselling services in the United Kingdom also highlighted such training as an important requirement for online counselling (Hanley, 2006). According to the BCW, one way to address physical opportunity barriers is through environmental restructuring. In this particular instance, a straightforward suggestion would be to restructure the physical environment by increasing the duration of sessions.
However, literature in this area is unclear on whether this would be an effective strategy. In a study by Bambling et al. (2008), counsellors working online discussed barriers to the efficient delivery of the service and identified time constraints as one of the major difficulties.
Although some participants argued that they felt they could extend the session to 100 minutes (instead of 60 minutes) without losing concentration, the majority believed that they did not possess the emotional capacity to provide online counselling for more than one A final barrier to webchat counselling was the perceived level of effectiveness of the service. The majority of participants were positive about the efficacy of the medium, but several participants argued that they did not believe webchat counselling was able to achieve any significant changes and that it was less effective than traditional face-to-face counselling. Glasheen and Campbell (2009) also discussed the lack of evidence that online counselling is effective as a potential barrier for practitioners. Glasheen et al. (2014)

| Limitations
The current study presented several limitations. First, the sample size was relatively small due to constraints related to the arising situation of COVID-19. However, similar studies in this area have employed a similar number of participants (Navarro et al., 2020). Second, participants were obtained from a single organisation, and thus, the findings may have limited generalisability. As a result, the findings may be more relevant for charities aimed to support the mental health of young people, especially in the United Kingdom. It is also important to note that many of the barriers identified could have also been influenced by counsellors' characteristics and relative inexperience, such as the level of qualification obtained, although this was not examined in the analysis. Lastly, while intervention strategies are suggested, their implementation has not been evaluated. Future research in this area should aim to evaluate the effectiveness of the proposed intervention strategies on improving counsellors' experience with the delivery of webchat counselling, as well as service users' perceptions of counselling sessions and, consequently, their mental health.

| CON CLUS I ON AND FUTURE DIREC TIONS
The current study identified barriers and enablers to the delivery of webchat counselling on behalf of volunteer counsellors and, using the BCW, systematically provided solutions to optimise the delivery of the service and improve counsellors' experience. Counsellors' interviews revealed a series of difficulties related to the skills needed to deliver webchat counselling, the support offered at particular times during the day, the duration of the sessions, and counsellors' confidence and perceptions of the effectiveness of webchat counselling overall. Using the BCW, several implications for practice have been identified to address these issues, such as providing counsellors with training on how to work online with young people, learning new presence techniques to foster emotional connectedness between counsellors and clients, increasing the duration of sessions to compensate for administrative tasks such as questionnaires and providing technical support and supervision during out-of-office hours.
Given the barriers to service provision, the optimisation of webchat counselling for young people has the potential to better meet their service needs and provide more effective provision for this underserved age group.