The self-directed patient in guided internet-delivered CBT: a qualitative study of patient role expectations

Therapist-guided internet-delivered cognitive behavioral therapy (guided iCBT) is an effective and scalable treatment for anxiety and depression. Central to this format is the expectation that patients work independently with therapeutic content. However, limited attention has been paid to how healthcare professionals and patients within guided iCBT understand the patient role.

This study explores how healthcare professionals and patients understand the patient role in guided iCBT, using self-determination theory to examine how autonomy, competence, and relatedness shape experiences of the patient role.

A qualitative study was conducted in Norwegian specialist mental health services, where guided iCBT is delivered as part of routine care, combining interviews and observations with healthcare professionals (n = 31) and free-text responses from patients (n = 296). Healthcare professional data were analyzed using reflexive thematic analysis and patient responses using inductive qualitative content analysis.

Healthcare professionals constructed an ideal of the "motivated and self-driven" patient, reflecting an implicit norm of self-direction as a core expectation of the patient role. Patients varied in their ability to enact this role: some described themselves in ways that aligned with this expectation, emphasizing independence and skill use, while others experienced tensions between demands for autonomy, their perceived competence, and their need for structure and relational support. Although many patients reported gaining skills, the treatment was also described as demanding and, at times, overwhelming, with difficulties in participation frequently framed as personal failure, accompanied by self-criticism and guilt.

Guided iCBT relies on an implicit expectation that patients will be self-directed, but patients' experiences vary depending on how well they can assume this role. From a self-determination theory perspective, autonomy may function not only as a supportive resource but also as a demand when support for competence and relatedness is insufficient. These findings highlight the importance of carefully structuring and supporting expectations of self-direction within guided iCBT.