Differences in the Use and Perception of Telehealth Across Four Mental Health Professions: Insights From a Secondary Analysis of Qualitative Data

Abstract

There is growing evidence that the uptake and use of telehealth is influenced by the distinct specialty area or type of healthcare service provided, with mental health services presenting particular challenges. However, little is known about how telehealth use differs between different mental health professions, and no qualitative research has explored variations in telehealth use and perspectives at the profession level within Australian mental health services. To address this gap, we analyzed transcripts from 19 semi-structured interviews conducted with mental healthcare professionals in a local health district within New South Wales, Australia. A secondary analysis of the data revealed the distinct ways in which different mental health professions perceive and engage with telehealth depending on their specific role and approach to practice. Application of a systems theory lens highlighted the challenges each profession faces at different levels of telehealth engagement, and the macro-systemic power dynamics and hierarchies that shape profession-specific differences in telehealth use.

Introduction

During the COVID-19 pandemic, mental health services worldwide had to adapt quickly to implement or increase the use of telehealth (defined as the use of telecommunications technologies to deliver health-related services and information; Doarn et al., 2014; Zangani et al., 2022). This rapid transformation has provided an unprecedented opportunity to examine more closely the use of telehealth in mental health services. While mental health providers appear to be largely positive toward telehealth (Connolly et al., 2020), they also highlight multiple drawbacks. Clinicians have expressed concerns that telehealth may not offer a secure and safe space for service users to discuss their experiences and needs and that it poses challenges to risk assessment and rapport building (Franzosa et al., 2021; Heinsch et al., 2022). Since mental health providers are often referred to as the “gatekeepers of telehealth” (Cowan et al., 2019, p. 1), exploring their engagement with telehealth is vital to its continuing use and development.

Emerging research suggests that uptake of telehealth may be influenced by the distinct specialty area or type of healthcare service provided. For example, Connolly et al.’s (2022) survey of 866 mental health, primary care, and specialty care clinicians identified specialty-specific differences in clinicians’ perceptions and use of telehealth. Sugarman et al.’s (2021) survey of 107 outpatient mental health clinicians also found that telehealth challenges differed according to type of mental health service and service user characteristics. These findings suggest that experiences and use of telehealth may vary across mental health professions and that an examination of distinct differences at the professional level might yield valuable insights to inform future telehealth implementation efforts in mental health services.

To date, little is known about how the perception and use of telehealth differs between mental health professions. While studies have examined the use of telehealth by distinct mental health professions, such as social workers (Cristofalo, 2021; Tickner, 2023); psychologists (Lin et al., 2022; Sammons et al., 2021); psychiatrists (Cowan et al., 2019; Kalin et al., 2020); and nurses (James et al., 2021; Koivunen & Saranto, 2018), they tend to consider the perspectives of each profession independently. This approach limits the potential for meaningful between-group comparisons. Furthermore, prevailing research on profession-specific differences in telehealth use tends to employ quantitative methodologies, with the majority of studies originating from the United States.

To address this gap, we analyzed a subset of findings from a qualitative study that investigated multidisciplinary mental health service providers’ perceptions and use of telehealth in Australia (see Heinsch et al., 2022). Although this study did not explicitly set out to examine profession-specific differences in telehealth use, secondary analysis revealed that references to professional roles and approaches were interwoven throughout participants’ accounts of telehealth use in practice. A decision was therefore made to focus on, and tease apart, the use of telehealth by different mental health professions. To our knowledge, no qualitative research has explored variations in telehealth use at the profession level within Australian mental health services. We sought to address the research question: How do mental health professionals from diverse disciplines perceive and engage with telehealth in their practice? In our discussion, we apply a systems theory lens to enhance understanding of the multilevel and dynamic ways in which different professions engage with telehealth.

Systems Theory

Systems theory proposes a multidimensional perspective that can enable better understanding of complex roles, practices, groups, and organizations in health systems and how they interact (Smith et al., 2019). A system is defined as “an organised whole made up of components that interact in a way distinct from their interaction with other entities and which endures over some period of time” (Anderson et al., 1999, p. 4). Systems theory terminology commonly identifies key interconnected components of social systems as micro-, meso-, or macrosystems based on their size and complexity (Friedman & Allen, 2014). Microsystems refer to small social systems, including individuals and the people immediately surrounding them. Mesosystems refer to intermediate systems, including groups, support networks, extended families, and local communities. Macrosystems commonly refer to larger systems, such as cultures, organizations, policies, and societal norms (Friedman & Allen, 2014). Adopting a multilevel perspective like systems theory is essential to understand how phenomena unfold within complex and dynamic environments (Hitt et al., 2007). Systems thinking facilitates understanding of interrelationships between as well as within systems and interlevel dynamics (i.e., the interactions between phenomena at different levels). Through the application of a systems perspective, we aim to extend the existing literature on telehealth use, which has tended to direct less attention to the broader macrosystems level (Heinsch, Wyllie, et al., 2021) and the dynamic interplay between different levels (Greenhalgh et al., 2017).

Methods

This paper presents the findings from a secondary data analysis of two qualitative studies with shared methodological and contextual features. This approach is consistent with comparable research (Jackson et al., 2013; Johannessen et al., 2014; Percival et al., 2017). This paper draws on the concept of Morse’s (2010) QUAL + qual design, where one core qualitative method is combined with a supplementary qualitative method, of which the latter provides crucial insight to the former but might not be sufficient to be published alone. As such, this paper draws upon data from a core qualitative study that involved in-depth semi-structured interviews as the primary method (see Heinsch et al., 2022). It further includes previously unpublished data from a supplementary qualitative study that included in-depth semi-structured interviews within the broader dataset of a mixed-methods study. The core study aimed to explore the perspectives of mental health professionals on the implementation and uptake of eHealth (a contested term, but broadly defined as “health services and information delivered or enhanced through the internet and related technologies,” including telehealth; Eysenbach, 2001) technologies, whereas the supplementary study sought to explore the barriers, facilitators, and capabilities for mental health clinician uptake and use of telehealth (earlier defined by Doarn et al., 2014). While participants of the core study were asked to consider forms of eHealth more broadly in their practice, most tended to focus on telehealth, primarily in the context of communicating with service users via telecommunication software such as Zoom or Skype. Given these shared features, the interviews from each study were pooled and treated as one dataset (Morse, 2010). Ethics approval for the core study was granted in September 2020 (2020/ETH01176) and for the supplementary study in July 2022 (2022/ETH01007).

Sampling and Recruitment

Participants across both studies were eligible to participate if they were (i) aged 18 years or over and (ii) employed as a mental health clinician or practice manager in a hospital, community-based health service, mental health service, or a drug and alcohol service. Participants were recruited from a local health district within New South Wales. Participants involved in the supplementary mixed-methods study were recruited from one of the three pre-identified mental health and/or drug and alcohol services where additional participant observation was conducted as part of the broader study. Consistent with previous reporting of the core qualitative study (Heinsch et al., 2022), a decision was made not to identify the specific health district to avoid compromising the anonymity of the participants.

For the core study, participants were recruited in two ways, First, email invitations were sent to service managers and clinicians across the health district, along with a request to share the invitation with other clinicians. Second, the study was advertised on the social media accounts (Facebook and Twitter) of the research team members. For the supplementary study, service managers of the three participating services were provided with an email invitation template and study documentation to disseminate to the clinicians within their service.

A total of 32 interviews were conducted across the two studies referred to in this article, including 29 interviews from the core study and 3 interviews from the supplementary study. While the core study sought a sample that was consistent with comparable research using semi-structured interviews (Baker & Edwards, 2012; Sim et al., 2018), the inclusion of the three additional interview transcripts from the supplementary study serves to enrich the dataset. The supplementary interviews, though not representative of a standalone study, contribute valuable insights to understanding multidisciplinary perspectives of telehealth use. As the purpose of the study was to conduct a secondary analysis on a subset of findings that focused on profession-specific differences in telehealth use, only the interviews that made explicit reference to these differences were included. As such, this paper reports the findings from 19 interviews from the core (n = 16) and supplementary (n = 3) studies. The professions represented were social work (n = 9), psychology (n = 2), nursing (n = 4), medicine (n = 2), and dietetics (n = 2). Interviews with dietitians exclusively addressed the mental health practices of other professions and were thus not included in a distinct section. Finally, we included a separate section on the multidisciplinary team. While participants did not always specify the professions represented in their multidisciplinary team, these teams generally included the professional groups previously discussed. However, depending on the service setting, additional team members such as occupational therapists, speech pathologists, and physiotherapists were also mentioned. This section reported instances where participants referred to the use of telehealth by their entire team or described the ways in which team dynamics, hierarchies, or roles influenced the use of telehealth by different professions.

Data Collection

Participants took part in semi-structured audio-recorded qualitative interviews, conducted either via telephone, via videoconferencing, or in person. The interviews lasted between 40 and 60 minutes and were mostly conducted remotely due to COVID-19 pandemic restrictions prohibiting face-to-face research. Interviews were conducted by three of the authors (two social workers and one sociologist), all of whom have expertise in qualitative research. Recorded verbal consent was obtained by the interviewer prior to each interview.

Each interview was guided by a semi-structured interview schedule. Across both the core and supplementary studies, each interview began with a broad question regarding the participant’s current role and practice. Participants in the core study were asked about their perspectives on eHealth technologies, current use of eHealth, organizational support for eHealth implementation, and their training and resource needs to support the implementation and uptake of eHealth. Participants in the supplementary study were asked about perspectives on telehealth, current use and experience with telehealth, training and resource needs to support uptake and use of telehealth, and their opinions around applicability of telehealth to practice context. Although the core study focused on the concept of eHealth more broadly, as previously reported (Heinsch et al., 2022), participants tended to focus on telehealth as the primary form of eHealth used in practice.

Data Analysis

Primary analysis of the data followed Braun and Clarke’s (2006, 2019, 2022) reflexive thematic analysis approach. A full account of these methods can be found reported in Heinsch et al. (2022). In the secondary analysis for this paper, we employed an analytic expansion approach (Thorne, 2013) to interrogate explicit accounts of profession-specific differences in telehealth use. This approach makes use of a dataset to ask new or emerging questions that were not originally envisioned within the study’s primary aims (Thorne, 2013). For this secondary analysis, we applied qualitative content analysis to focus on the interview transcripts where participants made explicit reference to profession-specific differences in telehealth use. Qualitative content analysis is useful when researchers wish to focus on “selected aspects of meaning, namely those aspects that relate to the overall research questions” (Schreier, 2014, p. 170). For the purpose of this paper, the results are organized by profession to illuminate and better understand profession-specific differences.

Results

Social Work: “In Terms of Just the General Spirit of Social Work, I Think It’s a Good Fit”

Nine social work interviews were included in the analysis. Four of these also referred to other professional groups. Additionally, one dietitian referred to the social work role.

Several social workers noted that telehealth is useful for the “practical stuff” related to their professional role, such as referrals to services, websites and interventions, online applications, and resource sharing with clients and colleagues. One participant noted that this can require adaptation to new roles and relationships “even when it feels awkward.” For example, he noted that “sometimes when a client is using telehealth, I’ve almost had a kind of coaching or oversight role.” This participant also described how telehealth changes the interpersonal dynamics of the social work referral process:

The idea of a warm [assisted] referral doesn’t happen so much if you are referring to an online program. It’s not like there are three of us sitting together, working this out. You’re using something virtual as an adjunct to whatever you’re doing.

Some social workers spoke about the synergies between telehealth and the social work role, with one participant noting that “in terms of just the general spirit of social work, working across contexts and facilitating social capital and connectedness, I think it’s a good fit.” Given social work’s focus on connecting people, this participant felt “drawn to digital tools where there is an online community, or someone calls once a fortnight or at the end of an intervention.” Similarly, a dietitian described the creation of a “Facebook family group page” by the social worker on her team, to facilitate social support and information sharing.

Social workers also described the challenges telehealth poses to their professional role and perspectives. For example, one participant suggested that telehealth may not align well with social work’s critical stance toward capitalism, noting that “there’s a sense of commodifying parts of social work practice and turning them into products.” This perspective influenced his decision to use, or not use, telehealth tools:

Even if clients don’t have to pay for interventions, if they involve adds, or if I am just unaware of who is benefiting and who is profiting from them, I am less comfortable moving someone into this space that could be reinforcing structural inequalities.

Some social workers reported that they assume responsibility for challenging their colleagues’ “assumptions around class or age or ability” concerning clients’ use of telehealth, with one participant noting that “the assumption that people with mental health and substance use issues will steal iPads from the health service bothers me.” He highlighted the importance of encouraging “confidence that people with mental illness can be trusted.”

Participants expressed differing opinions on the effectiveness of telehealth for certain aspects of social work practice. One participant noted that doing initial assessments over the phone is “very not social work … because you can’t read body language.” Another participant observed that using telehealth “assessment around violence in the home is really challenging for social work … because of the risk of adverse outcomes,” particularly concerning uncertainties about who might be present in the home with the service user and the potential consequences of attempting such an assessment. One participant differentiated between different “types” of telehealth, noting that the use of video can be challenging when attempting to both maintain eye contact with the camera and simultaneously look at the service user on screen, noting that telehealth “is not as strong for the family member if I’m not looking directly at them.” In contrast, he observed, “sometimes the phone can be even a bit more powerful for the social worker … I can feel more connected because I’m not distracted.”

Psychology: “As a Psychologist, It’s Harder to Read Facial Expressions”

Two psychology interviews were included in the analysis. Additionally, three nurses and one psychiatrist also referred to the psychology role.

Both psychologists reported using telehealth in certain aspects of their professional practice, such as client follow-up, establishing connections with family members, carers, and other service providers, and sharing information about useful websites or interventions. One nurse also noted that the psychologists on her team “have a 10-week program that uses DBT [dialectical behavior therapy] skills and they’re doing that over Skype, and I hear that’s going okay.”

Both psychologists highlighted specific aspects of their professional practice where the use of telehealth was less appropriate or presented more challenges. One noted that “as a psychologist, it’s harder to read facial expressions, and in a group, it is much harder to follow which person is saying what.” This participant also highlighted the challenges of working with younger children over telehealth, noting that “it is much harder to engage them, you can’t play with them, you can’t provide toys and those sorts of things.” The other noted that telehealth is less useful “if the psychologist is conducting a pure therapy session, just talking therapy” than when “helping [people] to look at a website or look up some information.”

Comments by several participants from other professional backgrounds highlighted a perceived mismatch between telehealth use and the specific interventions and professional roles of psychologists. For example, one nurse reported that “I’ve worked with some psychologists who have a fairly fixed view that delivering a CBT [cognitive behavior therapy] intervention [using telehealth] isn’t suitable for everyone.” A psychiatrist also noted that “there seems to be a consensus among the psychologists I’ve spoken to in the psychotherapy realm that it’s really important, at least initially, to develop that relationship, and then maybe it could be transferred [online].” Additionally, one nurse highlighted the “complexity of doing a psychiatric assessment or therapy,” noting that “the feedback I am getting from the psychologists who’ve tried to do therapy over various platforms is that it hasn’t been particularly helpful.”

Nursing: “Nurses Are Increasingly Connecting With Families via Text Message”

Four interviews with nurses were included in the analysis. Additionally, two social workers referred to the nursing role.

Both nurses highlighted the “face-to-face” nature of their professional role when working with patients, particularly those who were acutely unwell. One participant noted that, even at the height of COVID, “we would always be face-to-face, we didn’t stop, we just increased the use of PPE.” The other reported that “we would sometimes branch out to phone contact with carers and family.” A social worker also observed that “nurses are increasingly connecting with families via text message,” noting that “families are busy and might not have a time to sit and chat, but with a text you can just send a line.”

Two social work participants also highlighted the use of telehealth by nursing staff to manage “the practical day-to-day stuff with families around medications, or pain, or equipment.” For example, one social worker noted that “the family might say, ‘we’re having trouble getting an appointment here’ so the nurse might try and set up a telehealth appointment for that.”

Medicine: “Doctors Can Be Reluctant to Use Telehealth Because I Guess There’s a Risk in Relying on a Video Image”

Two interviews with psychiatrists were included in the analysis. Additionally, a nurse, a dietitian, and three social workers referred to the medical role.

Both psychiatrists reported that they rarely use telehealth in their practice, with one participant noting that “the other psych registrars and the consultants, the other doctors that work here in the community, I imagine that it’s probably a similar rate to what I would use, which is rare.” However, the other highlighted a potential shift in receptiveness to telehealth among the upcoming generation of medical professionals, observing that “they are quite interested in online stuff because they are familiar with doing stuff online.”

One psychiatrist reported that she uses telehealth for specific aspects of her professional practice, noting that “I have done one off assessments via telehealth. It’s not been an enduring relationship type of thing, it’s been more around, okay, a diagnosis and a plan when things aren’t too complicated.” However, she emphasized the inadequacy of telehealth for psychotherapy interventions because “speaking specifically to psychotherapy, face to face is highly important in the building of the relationship.” She also expressed concern that telehealth may exacerbate the stress people experience when seeing a psychiatrist:

People already feel, you’re coming to see a psychiatrist or any doctor, and it can be an overwhelming experience. There’s a lot of technical jargon or concepts that may be very unfamiliar to you and then you add in something like navigating a screen or the computer, this software, and it may even make you feel overwhelmed by that process potentially.

One nurse also noted that “psychiatry’s always been a stigmatised and vulnerable area to be in,” noting that “it may be more difficult to talk about yourself in that way over the phone.”

Several participants from other professional backgrounds described the difficulties doctors on their team had experienced when using telehealth. For example, one dietitian noted that “some of the doctors were talking to somebody and then the next person would kind of login or ring in.” Another noted that “our doctors did some online assessments but had issues because the tools we were using weren’t great.” One social worker noted that, while “most people were on board and willing to learn” how to work with telehealth, “there was a bit of a push from some of the doctors because they didn’t want to do the setting up stuff. They wanted someone else to do it for them.”

Two social workers observed that “doctors can be reluctant to use telehealth because I guess there’s a risk in relying on a video image rather than seeing someone in person, being able to touch them or take their temperature or something like that.” One social worker noted that, during the pandemic, doctors who were working with “the most unwell people in our community” “refused to do initial assessments [using telehealth] because of the concerns about missing something.”

Multidisciplinary Team: “Throughout the Team Everyone Has Their Different Opinions and Thoughts and Experiences”

Seven participants referred to the use of telehealth by their multidisciplinary healthcare team, describing the different forms of telehealth use by the team, including “video and phone, email and mobile phones, texts and things like that.” One social work participant noted that members of the multidisciplinary team have differing perspectives on telehealth use:

There’s been a lot of critique throughout the team because nurses, social workers, psychologists, OTs everyone has their different opinions and thoughts and experiences.

Some participants, including social workers and nurses, reported that they “sit in with one of the other team members” via telehealth when they are meeting with a client or a family to reduce the need to repeat information to different team members and mitigate the siloing of care. One social worker explained that multidisciplinary telehealth meetings increased during COVID because such work could now be funded through Medicare, Australia’s universal health insurance scheme. She explained that “before Covid, telehealth was the exception because [the hospital] could only get money from Medicare if the person came to the premises and came into the appointment.”

The most commonly cited reason for multidisciplinary telehealth appointments was to conduct a joint assessment, although one social worker noted that “part of the reason for having a social worker and/or nurse joining a doctor for those clinics is physically about just getting clients to the appointments [troubleshooting the technology].” Another social worker, employed in a rural mental health service, reported that she sits “in the room” with patients while “they’re with the psychiatrist” “because the psychiatrist couldn’t assess [the patient] properly via Skype.” Their role in this context, the social worker described, was to support the assessment by observing and reporting physical symptoms that would otherwise be missed by the psychiatrist through telehealth.

When using telehealth resources, one social worker pointed out the priority given to certain members of the multidisciplinary health team depending on their professional backgrounds:

I guess my priority as a social worker, I was right down the list, in terms of the neuropsychs, and the physios, and speech paths to a lesser one. Yeah, those guys pulled rank in terms of the booking systems.

Discussion

This secondary analysis sought to explore how mental health professionals from different professions perceive and engage with telehealth in their practice. By examining distinct differences at the professional level, we aimed to provide valuable insights to inform future telehealth implementation efforts in mental health services. Findings from this analysis extend on our previous research, which primarily focused on individual professional perspectives on telehealth use, with minimal exploration of between-group comparisons. Application of a systems theory lens to the findings enabled us to highlight the influence of broader macrosystems factors and the dynamic interplay between different systems on telehealth use, aspects that have received limited attention in the existing eHealth literature (Greenhalgh et al., 2017; Heinsch, Wyllie, et al., 2021).

Participants in this study clearly engaged with telehealth differently depending on their professional role and approach to practice. For example, social workers described a strong fit between telehealth and the role of social work in working across contexts and facilitating social capital and connectedness. This focus led them to use digital tools that actively promoted community connection and provided avenues for social support. In contrast, psychiatrists and psychologists highlighted the challenges of delivering psychotherapy interventions using telehealth. They emphasized the heavy reliance of these therapeutic approaches on the therapeutic relationship and described the difficulty of developing an intimate connection through online or phone interactions. This perspective led them to use telehealth primarily for “one off assessments” “that aren’t too complicated.” These findings suggest that mental health professionals may currently view telehealth as better suited to fostering meso-level social networking and community connections rather than to developing micro-level intimate therapeutic relationships, where technology-mediated interactions tended to be viewed as less favorable or riskier. While online interactions have been identified as an important source of social support (Dewa et al., 2021; Fuss et al., 2019; Newman et al., 2019), there remains a lack of clarity about whether the articulated challenges or reservations in conducting micro-level therapeutic work through telehealth are attributable to inherent characteristics of the communication technology or are a consequence of limited experience or training among clinicians in the realm of telehealth-mediated psychotherapy.

Some participants suggested that engaging with clients using telehealth requires adaptation to new roles and relationships. For example, one social worker described assuming a “coaching or oversight role” when working with clients using telehealth. He also noted the shift in interpersonal dynamics when referring a client to an online program rather than to a person, emphasizing that “it’s not like there are three of us sitting together, working this out.” This finding supports previous research conducted by our team, which showed that technology can function as a mediator of human relationships, transforming the micro- and meso-social space inhabited by service providers and clients (Heinsch, Geddes, et al., 2021). Of interest was that professions demonstrated varying levels of flexibility in redefining their roles and relationships to accommodate telehealth. For example, social workers described modifying their roles and approaches even in situations where this felt “awkward,” whereas some doctors refused to use telehealth for certain aspects of their practice citing concerns about potential oversights. This suggests that greater capacity to tolerate discomfort and uncertainty may increase willingness by mental health professionals to navigate the challenges of telehealth use. The recent identification of uncertainty tolerance among doctors as a knowledge gap (Han et al., 2021) underscores this as an important area for further research.

Only two professional groups identified macro-systemic factors impacting telehealth engagement. One nurse described psychiatry as a stigmatized field, suggesting that the stigma surrounding mental illness could heighten clients’ sense of vulnerability during telephone communication. Social workers raised a number of macro-systemic issues: (1) expressing concern that telehealth may lead to the “commodification of social work practice” and, in doing so, “could reinforce structural inequalities”; (2) highlighting the impact of broader policy incentives such as changes to Medicare on their team’s adoption of telehealth; and (3) assuming responsibility for challenging colleagues’ assumptions about the impact of clients’ class, age, mental health condition, or ability on their capability or trustworthiness in using telehealth. It is noteworthy that social workers were the only professional group to identify and address macro-level factors at the micro-level of interpersonal interaction, suggesting they could play an important role in bridging boundaries between macro- and micro-level practices. This finding is not wholly surprising since recognition that macro-level social change begins with micro-level interactions has been emphasized as a hallmark of the social work profession (Mosley, 2017). Given the growing imperative to address equity and justice in the implementation of digital health technologies (Heinsch et al., 2022), there is a justified need to explore social work’s role in this context.

Comments by several participants highlighted the impact of professional power dynamics and hierarchies in shaping telehealth engagement by certain professions. Specifically, participants described the role of social workers and nurses in creating or facilitating telehealth appointments to assist the doctor or psychiatrist, often requiring significant time and resource investment. One social worker explicitly mentioned the resistance from doctors who preferred to delegate the responsibility of setting up telehealth to someone else. Another social worker highlighted the priority given to certain members of the multidisciplinary team when allocating telehealth resources, noting that “as a social worker, I was right down the list.” The finding that asymmetrical power relations impact telehealth use by certain professions supports recent research by Tan et al. (2023), which showed that the unspoken power imbalance and hierarchy between nurses and physicians influenced interprofessional telehealth engagement. These findings underscore the need for further research on interprofessional collaboration using telehealth, including how professional power dynamics and hierarchies influence the use of telehealth use among diverse professional groups.

Limitations

This paper presented a secondary analysis of a dataset composed of two qualitative studies with shared features in order to ask new research questions that were not originally envisioned. As such, it is worth acknowledging that the primary limitation of this approach is that neither study specifically asked participants about their distinct professional approach to telehealth use, and therefore it was not possible to ask the participants themselves to further reflect on the profession-specific differences identified within the data. This represents an opportunity for future research to focus on these differences and how further telehealth implementation may address perceived and material challenges to developing effective practice. Moreover, social workers were more greatly represented in the participant sample used for the purpose of this paper. Future research should seek to increase representation from other professions.

Conclusion

Findings from our study suggest distinct ways in which different mental health professions perceive and engage with telehealth depending on their specific role and approach to practice. Application of a systems theory lens highlighted the distinct challenges professions faces at multiple levels of telehealth engagement, including the macro-systemic power dynamics and hierarchies that can shape profession-specific differences and interpersonal dynamics in telehealth use. Implementing and expanding the use of telehealth in mental health services will require adapting to new roles and ways of working. This includes greater capacity to tolerate the potential discomfort and uncertainty that can arise when working with complex mental health presentations at a distance, particularly in the context of psychotherapeutic work.