Table 1 the Thematic Analysis of How Informational Support Is Used

Table 1 The Thematic Analysis of How Informational Support is Used

Sub-theme Code % (n/30) Example Units Method of Written 53.3% “A written board of daily services available to patients” (P6 M 33 EU 8) Delivery 16/30 “I often… print out exercise sheets.” (P86F 25 EU 1) “I spread papers with information about my 'therapy'” (P27F 26 AF 3) “Informational support given to service users as part of health promotion events” (P57F 00 EU 5) “Leaflets and other sources of information” (P106F 48 EU 25) “provide information leaflets” (P107F 54 EU 23) “pamphlets” (P114F 41 EU 1) “Pamphlet about this information also given to them” (P115F 31 AS 1) “It comes in … written format” (P119F 34 EU 7.5) “Always written and given as hand out if possible” (P42F 31 EU 4) “Posters” (P46F 50 EU 20) “We also provide written info on the afore mentioned topics.” (P99F 49 EU 19)

Verbal 13.3% “Advice” (P58F 27 EU 4) 4/30 “It comes in … verbal format” (P119F 34 EU 7.5) “Oral information” (P3F 36 EU 8) “Information verbally” (P5F 55 EU 20)

Content of Biopsychosocial 60.0% “leaflets on the benefits of being physically active in terms of fitness, weight loss, support Benefits of Exercise 18/30 mental health, social contact, fun, engagement with family/children” (P46F 50 EU 20) “Informational support given to service users as part of health promotion events” (P57F 00 EU 5) “Include health promotion messages within sessions e.g. when going for a walk.” (P90F 42 EU 0) “Posters … on the benefits of being physically active in terms of fitness, weight loss, mental health, social contact, fun, engagement with family/children” (P46F 50 EU 20) “will provide general physical activity information including CSP exercise” (P119F 34 EU 7.5) “I always discuss the issue of life habits in general and physical activity in particular” (P2M 35 EU 11) “I…give information about the negative influences on their health”( P16F 36 EU 13) “Often when I am working with patients I discuss informally the importance of being active” (P22F 45 EU 17) “Physical Activity and the benefits of it.” (P26F 52 EU 25) “I explain to my patients why it is important to be active” (P27F 26 AF 3) “I give sessions about 'energy', food, movement” (P27F 26 AF 3) “talk to them about the benefits of exercise…generally” (P35M 33 EU 8) “Educate the client about the benefits of taking part.”( P50F 54 EU 25) “Advice about healthy lifestyle, exercise etc.”( P52M 46 EU 4) “Inform patients that there is good evidence that physical activity has benefits for both physical and mental health” (P90F 42 EU 0) “Speak to patients about the benefits of exercise”(P98F 39 EU 16) “Explain to patient and the carer the importance of exercise for mental health and to relief stress” (P115F 31 AS 1) “Suggest an exercise program for weight control” (P8F 28 AS 1) “information of links between physical activity and weight , weight and illness” (P10M 24 AS 0) “Produce leaflets give information in simple text encouraging physical activity” (P43F 61 EU 20)

Exercise 30% “I often offer…exercise advice.” (P86F 25 EU 1) prescription 9/30 “Oral information connected to…physical activity on prescription” (P3F 36 EU 8) “The activity plan is evaluated at the regular follow-up meetings for at least a year” (P3F 36 EU 8) “Written information connected to …physical activity on prescription” (P3F 36 EU 8) “Information on the IOPTMH guidelines” (P11M 33 EU 8) “I explain the training methods (60% of your max. capacity is best to burn fats)” (P16F 36 EU 13) “Education about the types of exercise that is suitable for them”( P49F 51 EU 4) “I give patients information on pragmatics on how often they should be active” (P14F 45 AS 10) “This is direct information regards exercise and creating and teaching exercise” (P21F 34 EU 7.5) “discuss what activities they take part at this time and how they might increase these levels” (P32F 29 AS 5) “We have a looking after your health booklet which includes dietary and physical activity advice and support.” (P40F 57 EU 13) “Physical activity on Prescription (PaP) groups” (P3F 36 EU 8)

One-to-one support 26.7% “buddying to support the first steps to using gym/walks/ swimming activities.” (P5F approach 8/30 55 EU 20) “buddying with health instructors” (P40F 57 EU 13) “1:1 Physio sessions that build up basic skills to make them more confident to access group physical activity sessions would be esteem support” (P90F 42 EU 0) “group exercise sessions or on a one to one basis” (P58F 27 EU 4) “This entails a warm welcome when they arrive as well as attention” (P2M 35 EU 11) “if have to, it will do the exercise together with them and asked the carer to involve. after patient able and willing to do the exercise, then I will do the proper exercise.” (P115F 31 AS 1) “we provide regular positive feedback to the individual during one - one and group sessions.”( P118F 24 NA 0.5) “Work with patients to achieve specific goal. help someone who is housebound (due to anxiety) walk outside again - i.e. walk with them. work 1:1 with someone who has weakness to increase strength. Practice stairs with someone to gain confidence” (P52M 46 EU 4) Identification of the 26.7% “information [using] written material with times/dates / descriptions of local location and times 8/30 activities” (P5F 55 EU 20) of physical activity “directing to community support groups” (P5F 55 EU 20) classes. “Directing to local group which organises international sports events and national walking trips” (P5F 55 EU 20) “The availability of classes on various types of exercise, leaflets etc.”( P30F 65 EU 20) “Inform access to specific facilities within their area” (P106F 48 EU 25) “discuss what activities they take part [in]” (P32F 29 AS 5) “Remind people when a group is on” (P54M 55 EU 14) “Advice about our services - e.g. hospital gym open sessions, walking group (rehab), and community exercise at local leisure centre with our physio technicians. Advice about other service - e.g. OT - 1:1 swimming, dog walking, cycling etc.”( P52M 46 EU 4) “Info on accessing local exercise sessions” (P60M 56 EU 5) “Physical activity on Prescription (PaP) groups” (P3F 36 EU 8) Managing the 20.0% “Being mindful of how body concept / relationship changes in a different social positive symptoms 6/30 environment” (P42F 31 EU 4) and social anxiety “explain that exercise can be an aversive experience to begin with but if they persevere and get a bit fitter it becomes less of a struggle and might even start to be enjoyable” (P90F 42 EU 0) “Patients really need close feedback and knowledge of their physical limitations, some may want to quit prior to their actual ability to do a task and it requires great skill to negotiate and encourage the patient to overcome uncertainty and anxiety they may have in doing exercise” (P14F 45 AS 10) “Time try to extract what is their problem so that it can do exercise that didn't make them worse.” (P115F 31 AS 1) “Have problems of paranoia/anxiety/negative thoughts that keep them from moving. So you have to know what's going on in their heads to motivate them the right way. To take away their fears.” (P16F 36 EU 13) “information related to the side effects of antipsychotic medication (among others: fatigue, extrapyramidal symptoms, weight gain)” (P11M 33 EU 8) Using different 20.0% “home base task related exercise that is thought to both the patient and the carer” Environment 6/30 (P115F 31 AS 1) “Home exercise programmes”( P52M 46 EU 4) “[name of city] Leisure operate and exercise referral scheme” (P53M 33 EU 2) “Health promotion groups and one to one interventions, gym and groups in hospital” (P107F 54 EU 23)

Managing the 13.3% “information of…the importance of activity in managing illness” (P10M 24 AS 0) negative symptoms 4/30 “Studies proving decrease in depression, anxiety, etc.” (P26F 52 EU 25) “talk to them about the benefits of exercise when suffering with a mental health problems” (P35M 33 EU 8) “Explain the connection between body & mind & how we can feel better as a result of moving” (P54M 55 EU 14)

Consideration to 10% “Written information connected to the patient’s condition” (P3F 36 EU 8) the patient 3/30 “side effects…Weight gain” (P11M 33 EU 8) condition, health “the increased risk for cardiovascular diseases” (P11M 33 EU 8) and well-being “I give them information about the metabolic syndrome” (P16F 36 EU 13) “Oral information connected to the patient’s condition” (P3F 36 EU 8) Role of PT 6.7% “An information leaflet to emphasis on physiotherapy and its role in mental health” 2/30 (P3F 36 EU 8) “Explain why and what the physiotherapist’s role is. Inform the patient as to what his/her role is.” (P15F 47 AF 15.5) Techniques Understanding 36.7% “it is all integrated on an individual basis” (P42F 31 EU 4) which patient needs and 11/30 “It means joining patients in a group or individually in the activity rather than support providing choice imposing or suggesting activity” (P54M 55 EU 14) delivery “Teaching exercise of the patient’s choice (gleaned from assessment using change cycle and barriers to exercise).” (P21F 34 EU 7.5) “relates to personal meaning, and personal goals/function”(P42F 31 EU 4) “Considering specific/personal needs and how best to meet them”( P49F 51 EU 4) “find out which type of exercise they might enjoy most”(P98F 39 EU 16) “Depending where the individual is on the change cycle we will provide…or tailored information based on the patients’ needs and wants” (P119F 34 EU 7.5) “patient lead objective setting and realistic achievement goals to build on success” (P40F 57 EU 13) “Collaborative working with service users to achieve their health goals” (P40F 57 EU 13) “Support to get information on things of interest and support to engage, often over a fairly lengthy period of time.” (P46F 50 EU 20) “The patient plays an active part in shaping the physical activity on prescription” (P3F 36 EU 8) “We provide space to discuss options for activity, barriers to engaging and the benefits of exercise” (P99F 49 EU 19) “Helping patients identify their own ability and personal resource strengthens and builds self-esteem.”( P29F 34 EU 7) “[Informational support] relates to personal meaning, and personal goals/function” (P42F 31 EU 4) Style of delivery 30.0% “The information is mostly verbal and often in response to questions or 9/30 reservations they may have” (P41F 43 EU 9) “Sometimes I will provide written information for them to read in their own time to discuss later if they would like to.”( P41F 43 EU 9) “It can include written, picture or instruction information” (P21F 34 EU 7.5) “drawing or diagram” (P114F 41 EU 1) “Often when I am working with patients I discuss informally” (P22F 45 EU 17) “I try to promote capability and strengthen what is already, at least to some extent, functioning” (P4F 34 EU 10) “to promote their 'abilities' rather than their 'disabilities'.” (P30F 65 EU 20) “encouragement to consider other options” (P32F 29 AS 5) “I ask for permission to tell them more about the subject. If they are interested I ask them what they already know about physical activity and psychological well-being. Afterwards I offer additional information from the professional's point of view” (P2M 35 EU 11) “I always try to…acknowledge them as human beings” (P2M 35 EU 11)

Using the MDT 20.0% “It’s important to engage with the MDT (nurses). For example, we encourage 6/30 patients to be more active in their own time but if we don't include nurses in our reasoning it often won’t happen” (P1M 32 EU 6) “Encouraging them to take opportunities to leave with nurses to go off the ward and not sit still for longer than 20 minutes without getting up” (P28F 24 EU 1.5) “Also Health and Wellbeing incorporated into several MDT groups - e.g. rehabilitation and recovery group (led by OT)” (P57F 00 EU 5) “- always aware of the input of MDT colleagues” (P98F 39 EU 16) “referral to e.g. community support health care workers” (P106F 48 EU 25) “Seek out support for individuals from community mental health teams” (P21F 34 EU 7.5) Table 2 The Thematic Analysis of How Tangible Support is used

Sub-theme Code % (n/33) Example Units Preparing and Start Up Period 54.5% “Accompanying people to facilities in the community” (P5F 55 EU 20) Implementing Physical of Supervised 18/33 “tangible support would be in escorting individual to the session” (P90F 42 EU activity and support 0) Conditions “When patients are unlikely to succeed in beginning physical activity on their own I offer a start-up period at out hospital gym where they can come train under supervised conditions twice a week” (P2M 35 EU 11) “Accompanying people to facilities in the community” (P5F 55 EU 20) “Outpatients are assisted to enrol in local leisure centres and staff attend the induction and the first few sessions to enable the patient break barriers to exercise.” (P6 M 33 EU 8) “Being supported into exercise maintains the adherence” (P29F 34 EU 7) “ensure the person does not go on their own on the first visit”( P42F 31 EU 4) “Begin with 1:1 support before group work.” (P42F 31 EU 4) “Accompany them to sessions if necessary” (P49F 51 EU 4) “escort them or arrange for support if necessary” (P54M 55 EU 14) “Escort patients to sessions they might otherwise not be able to access.” (P90F 42 EU 0) “We will take patients to leisure activities, gradually encouraging people to make their own way there and meet them” (P98F 39 EU 16) “leading health walks” (P3F 36 EU 8) “Assist in the first few sessions at a leisure facility” (P6 M 33 EU 8) “Supported exercise groups ran by our staff on discharge from hospital” (P107F 54 EU 23) “We also run a number of health promotion initiatives that run each month and patients are involved” (P22F 45 EU 17) “Physical health and physical activity often come up and we have talks and quizzes about the benefits of PA on a ward level” (P22F 45 EU 17) “physical activity opportunities are provided on site (mental hospital setting)” (P90F 42 EU 0) “Informational support given to service users as part of health promotion events organised on inpatient wards” (P57F 00 EU 5) “We run multiple physical activity groups both in the hospital environment and in the community” (P99F 49 EU 19) “Built up using facilities within a controlled hospital setting and used during every session the patient attends for. This can include 1-3 times a week for 6 months.”( P21F 34 EU 7.5)

Understanding 12.1% “Outpatients are assisted to enrol in local leisure centres and staff attend the the Transitional 4/33 induction and the first few sessions to enable the patient break barriers to Periods to exercise.” (P6 M 33 EU 8) Community “Check out others participating in group...gender etc.” (P42F 31 EU 4) and a need for “We need excellent listening skills and empathy; this really helps in the continuity therapeutic relationship which keeps patients coming to physiotherapy. I have seen this continuity lost as patients get discharged to outpatient services and start using non specialist mental health physiotherapy input, e.g. exercise trainers.” (P22F 45 EU 17) “In the long run I always aim at prescribing physical activity on paper as a form of graduating from the supervised environment” (P2M 35 EU 11) Supporting an 9.1% “I often offer walking aids” (P86F 25 EU 1) individual’s 3/33 “issue of walking aids or wheel chairs”( P53M 33 EU 2) function “Giving of pieces of equipment to work with and aid in recovery.” (P86F 25 EU 1) Utilising Incentives Providing 45.5% “Some patients are on a rewards system on the ward, they receive tokens for Support with 15/33 good positive social behaviour. Once they get a certain number they are Costs allowed a community trip as a reward and some use this to visit leisure centres locally” (P22F 45 EU 17) “Give treats to the patient.” (P114F 41 EU 1) “Reduced rates of entry” (P106F 48 EU 25) “Free-tickets to the local sports arena.” (P3F 36 EU 8) “free access to fitness facilities”( P11M 33 EU 8) “for very severely ill patients we sometimes do apply the token system (although exceptional), tokens are chosen together with the patient”( P11M 33 EU 8) “Free sessions in hospital gym for up to 6 months.”( P21F 34 EU 7.5) “Reduced prices negotiated with local council gyms. First session free.”( P21F 34 EU 7.5) “Activity vouchers” (P32F 29 AS 5) “Provide clients with travel expenses for attendance.” (P50F 54 EU 25) “fund participation”( P54M 55 EU 14) “We have partner schemes with local councils to provide free or discounted access to leisure facilities and we have a number of joint ventures with the local voluntary organisations.” (P99F 49 EU 19) “Support to access specific facilities” (P106F 48 EU 25) “health Instructors are able to take service users there using trust transport / public transport subsidised by the ward in order to increase access to physical activity” (P57F 00 EU 5) “Encourage patients to engage in groups on the ward and support them to attend in the community with our staff or support staff”( P107F 54 EU 23) “I will give some token after patient can perform the exercise that I teach them. This will encourage them to do exercise more.”( P115F 31 AS 1) “Provide them with a period of up to 6 months access to our physiotherapy gym to introduce them to equipment and increase confidence on working in a programme…We will also support them into community facilities through initial free sessions and helping them get access to the cheapest options possible - e.g. we have arranged that individuals can use classes or gyms on a pay as you go basis, countdown card of ten prepaid sessions at reduced rate or direct debit membership.”( P118F 24 NA 0.5) “Support gaining access to leisure information for discounted access to sports facilities.”( P21F 34 EU 7.5) “Reduced prices negotiated with local council gyms. First session free.”( P21F 34 EU 7.5) Assisting 21.2% “Support to access facilities” (P106F 48 EU 25) Transport and 7/33 “Sort out transport.” (P42F 31 EU 4) Access to “Role play beforehand if needed. “ (P42F 31 EU 4) Physical “Transport provided to attend outpatient gym sessions” (P43F 61 EU 20) Activity “Arrange transport if necessary” (P49F 51 EU 4) “health Instructors are able to take service users there using trust transport / public transport subsidised by the ward in order to increase access to physical activity” (P57F 00 EU 5) “We run multiple physical activity groups both in the hospital environment and in the community” (P99F 49 EU 19)

Utilising 6.1% “Often physiotherapy and exercise is a means for the patient to get off the different 2/33 ward” (P1M 32 EU 6) environments “sometimes stay on their floor or garden instead of going to the sporting hall, for it is more accessible and they can join the activity whenever they feel attracted or ready” (P27F 26 AF 3)

Using local networks Using local 21.2% “Physical activity on prescription at local sports centres” (P3F 36 EU 8) and co-ordinating an community 7/33 “Links with local sports centres so gym instructors can continue to support an effective approach to centres individual” (P20F 34 EU 7.5) care “Connections with local sports providers so instructors can monitor and continue to support clients in the community when they are using the gym.” (P21F 34 EU 7.5) “positive links with community resources” (P107F 54 EU 23) “We have partner schemes with local councils to provide free or discounted access to leisure facilities and we have a number of joint ventures with the local voluntary organisations.” (P99F 49 EU 19) “We will also support them into community facilities through initial free sessions and helping them get access to the cheapest options possible - e.g. we have arranged that individuals can use classes or gyms on a pay as you go basis, countdown card of ten prepaid sessions at reduced rate or direct debit membership.”( P118F 24 NA 0.5) Don’t value Unsure of 6.1% “n/a I hold reservations about their being a "reward" for taking part in this type of support benefits 2/33 physical activity/looking after one's physical health as it needs to be something they want to do and will continue for the rest of their lives. I think it may make patients become too reliant on healthcare professionals.” (P41F 43 EU 9) “Very few patients are interested in this in my experience (nor are clinical staff)!” (P1M 32 EU 6) Doesn’t take 3.0% “that happens not very much…mostly they don't stay long at my section, if place much 1/33 they stay longer than they go to another section where they use tangible support more” (P97F 39 EU 6) Table 3 The Thematic Analysis of How Esteem Support is Used

Sub-theme Code % Example Units (n/38) Strategies for Providing 44.7% “social reinforcement constructive feedback by therapist” (P12M EU 35) Esteem Support reinforceme 17/38 “I keep records of their weight and show them their evolutions”(P16F 36 EU 13) nt “something like a programme to bike/walk, so they can see what they do and also the improvement they make” (P97F 39 EU 6) “with daily chart or diary that is kept by the patient or carer” (P114F 41 EU 1) “behavioural monitoring charts for good participation, feedback that moving up the risk levels will help them with goals of being more independent and moving on.” (P90F 42 EU 0) “All behaviour that is appropriate is to be reinforced when I am with the patient.” (P2M 35 EU 11) “As outpatients asking how past week went, congratulating on any activity and supporting problem solving if difficulty with maintaining activity” (P5F 55 EU 20) “Utilise outcome measures to reinforce improvement and enable an increase in self- esteem” (P6 M 33 EU 8) “Positive re-enforcement”( P8F 28 AS 1) “positive feedback in individual exercise” (P9 F 28 AS 1) “give compliment in their physical activity” (P10M 24 AS 0) “Every activity is an achievement. So it must be named/recognized and applause. It may not be seen as a normal any day thing.” (P16F 36 EU 13) “Giving a lot of positive feedback. - Using humour”( P27F 26 AF 3) “Positive feedback about any activity they take part in” (P32F 29 AS 5) “give lots of positive encouragement assist client to reflect on their improvement and achievement” (P43F 61 EU 20) “re-enforcing positive self statements, deliberately not feeding into poor opinion of self, when this is expressed trying to steer conversation so that individuals can recognise the positives about themselves. Recognising my positive qualities worksheet” (P52M 46 EU 4) “positive reinforcement” (P107F 54 EU 23) Providing 44.7% “Encouraging them to take opportunities to leave with nurses to go off the ward and encouragem 17/38 not sit still for longer than 20 minutes without getting up” (P28F 24 EU 1.5) ent and “encourage them to participate in exercises” (P58F 27 EU 4) praise “ Praise and stars” (P90F 42 EU 0) “the other members of the MDT look to us to engage/ encourage/ support patients to exercise… getting alongside them and giving the encouragement” (P1M 32 EU 6) “I always try to encourage patients engaging in physical activity” (P2M 35 EU 11) “To give encouragement” (P9 F 28 AS 1) “to encourage them” (P10M 24 AS 0) “It really can at times be a challenge to get patients to attend, therefore, this type of support is invaluable from the outset to encourage interest and compliance” (P22F 45 EU 17) “Encouragement and motivation” (P26F 52 EU 25) “Throughout all sessions we are encouraging them” (P28F 24 EU 1.5) “Support to undertake exercise and physical presence with verbal encouragement” (P30F 65 EU 20) “Always emphasise positives, never criticise, and bring in fun....until good rapport and trust built.”( P42F 31 EU 4) “Reassurance and praise are offered routinely in groups (mentioned above in informational support section). Also reassurance and praise are routinely offered when commencing a physiotherapy plan with service users - who are encouraged to set their own treatment goals - these are regularly reviewed and encouragement offered to achieve these” (P57F 00 EU 5) “Encourage and reassure patients that we are there to help them in new situations; reiterating the information about positive effects of activity etc.”( P98F 39 EU 16) “Try to persuade my patient and explain to them that the exercise that they going to is fun. it also try to change the exercise to more fun event.”( P115F 31 AS 1) “I encourage them.”( P13F 52 EU 25) “Positive encouragement about their achievement and the recovery journey they are on. Empowerment through taking small steps and gaining confidence.” (P40F 57 EU 13) “As inpatient encouraging first to join ward based physical activity groups”( P5F 55 EU 20) Using 36.8% “I use Motivational Interviewing to promote physical activity” (P2M 35 EU 11) specific 14/38 “basic body awareness therapy and give massage when needed” (P13F 52 EU 25) theories or “I use Motivational Interview” (P3F 36 EU 8) techniques “Using motivational interviewing techniques to establish the driving force behind the proposed change” (P50F 54 EU 25) “motivational interviewing approach at assessment and instigation of programmes.” (P40F 57 EU 13) “We have the expertise and motivational skills o really encourage them on a difficult journey to reverse sedentary behaviour. This is essential to overcome apathy; disinterest and can make or break a person with SMI interest/ success in exercise.” (P1M 32 EU 6) “I use Self-efficacy according to Bandura.” (P3F 36 EU 8) “we do apply the motivational interviewing techniques” (P11M 33 EU 8) “we offer activities that result in success experiences (see also Bandura's theory)” (P11M 33 EU 8) “if I have observed attitude change e.g. "You used to always say 'I can't do that' but now you will give it a try" Use adapted rules for games to accommodate lower ability” (P90F 42 EU 0) “Motivational interviewing” (P107F 54 EU 23) “Don't push too hard to let them do something, just invite them to the place (sport room) so they can do the exercises at their level”( P97F 39 EU 6) “I use Motivational Interview and Model of change according to Prochasca and Di Clemente, Self-efficacy and active strategies like follow them to the sports arena.”( P3F 36 EU 8) “reflective listening (motivational interviewing), empathy, autonomy support (related to the self-determination theory of Deci and Ryan)”( P11M 33 EU 8) “Exercise consultation which identifies where on the cycle of behaviour change a person is, what they would like to do, where and when, and also identifies potential problems and solutions (generated by the client).” (P46F 50 EU 20) Need to 36.8% “goes without saying - simple achievable success to begin with…....then appropriate praise small 14/38 levels of difficulty to facilitate mastery without full blown failure.” (P42F 31 EU 4) achievement “keep it all light hearted and fun....not too serious” (P42F 31 EU 4) and build up “Clients are supported to engage in a range of exercise environments and time is taken gradually for to reflect on initial difficulties and issues and identify small positive changes that can confidence lead together change over the long term.” (P46F 50 EU 20) increases “Work at developing their self-belief by grading sessions so they feel some mastery. Plan activities and goals that provide the appropriate level of challenge.” (P49F 51 EU 4) “I just take these patients to the sports room and tell them they can watch, so just being there is ok for me. So they can see that I don't expect too much of them (in terms of activity).”( P97F 39 EU 6) “Esteem support is the most important type. Many patients we work with a low on self- confidence/ self-esteem/ self-efficacy around engaging in physical exercise and they really need that to get off the ground” (P1M 32 EU 6) “many patients lack confidence in exercise and Physio can help overcome this” (P14F 45 AS 10) “Used it in some cases when a person lacked confidence and help the person to join in the exercise regimen”( P58F 27 EU 4) “it’s essential to ensure they continue with exercise due to low confidence and motivation” (P28F 24 EU 1.5) “Many patients lack confidence and are importantly reluctant to even begin to exercise. Therefore, this type of support [esteem] is essential to encourage them to initiate exercise, to maintain their interest and keep them coming back” (P22F 45 EU 17) Providing 31.6% “Positive verbal feedback and written progress.” (P50F 54 EU 25) Feedback 12/38 “Throughout all sessions we are giving patients positive feedback” (P28F 24 EU 1.5) “mentioning of positive aspects of patients treatment” (P26F 52 EU 25) “Patients really need close feedback”( P14F 45 AS 10) “special emphasis on constructive and positive feedback” (P11M 33 EU 8) “Praise given for attending and then for any activity , including staying for whole group”( P5F 55 EU 20) “This entails …positive feedback when they are at the gym” (P2M 35 EU 11) “appropriate feedback” (P52M 46 EU 4) “Give verbal & possibly tactile feedback & smiles when they participate” (P54M 55 EU 14) “feedback to MDT given when they have been achieved.” (P57F 00 EU 5) “give positive feedback or compliment or treats to the patient.” (P114F 41 EU 1) “we provide regular positive feedback to the individual during one - one and group sessions.”( P118F 24 NA 0.5) Table 4 The Thematic Analysis of How Emotional Support is Used

Sub-theme Code % (n/38) Example Units Strategies that Needing to 60.5% “I listen carefully if they express some doubts absolute them doping a specific accommodate the spend time and 23/38 exercise, or if it is about lack of self - efficacy in general” (P13F 52 EU 25) patient listen “A part of being there for the patient is listening to the stories they have to tell. I always make time for a distressed patient but depending on circumstances I may have to set boundaries. I try to make an agreement with patients that they can stop, take a break and step aside for a while if they are feeling anxious/uncomfortable but that I prefer they stay within the premises and not run out. I suggest that its better they stick around when things are tough than run away and this way I can be there for them.” (P2M 35 EU 11) “with every single patient - give valued receptive space for listening and keen observation to relate the person's emotional experience with any subtle triggers / environment / voice / body position etc. always allowing the person to lead and discover for themselves” (P42F 31 EU 4) “listening to their histories and daily trials” (P30F 65 EU 20) “give patients enough time when carrying out an assessment so that if they want to talk about anything then they feel that they can and are not being rushed”( P35M 33 EU 8) “Give the patient some time to express his/her feelings”( P9 F 28 AS 1) “I am aware of how the patient feels emotionally and physically every day by asking them, and listening to what makes them feel that way (if they wish to share.)”( P26F 52 EU 25) “I listen to them fully i.e., unconditional positive regard”( P54M 55 EU 14) “If service users appear to be in distress, time is offered for service users to discuss / talk as they feel necessary.” (P57F 00 EU 5) “In this item, what I need to do is just be a good listener.”( P115F 31 AS 1) “listen to clients” (P43F 61 EU 20) “listen” (P107F 54 EU 23) “listen to their concern and show understanding”( P10M 24 AS 0) “listen to what the patient have to say about the exercise given and talk to the patient regarding the exercise that is least irritating to the patient emotionally” (P114F 41 EU 1) “Listen, listen, listen”( P86F 25 EU 1) “Listening is probably one of the biggest parts of my role. Often I find that patients want to tell me about their past experiences and worries so I allow them to do that.”( P41F 43 EU 9) “Listening to their stories, problems, anxieties, Taking my time, do not rush: have a walk, have a drink, talk, listen, ... Not only be the 'movement therapist', but show them you can offer more, emotional” (P27F 26 AF 3) “We need excellent listening skills, this really helps in the therapeutic relationship which keeps patients coming to physiotherapy.”( P22F 45 EU 17) “opportunities to talk about their experiences and to express how they feel about themselves and their condition” (P40F 57 EU 13) “take time to listen and talk with patients about past experiences - always aware of the input of MDT colleagues” (P98F 39 EU 16) “The individual is encouraged to talk through any problems on a regular basis during interview and through treatment. Group exercise instructors will also listen to the patient when needed.”( P21F 34 EU 7.5) “The persons individual therapist provides opportunities to discuss and listen to individuals but therapists running the groups can also be available to chat.” (P118F 24 NA 0.5) “This is part of all interactions with all patients not purely around physical activity.”( P99F 49 EU 19) Specific 42.1% “Act as an interactive 'sounding board' promoting change and motivation techniques 16/38 while listening to their histories and daily trials.” (P30F 65 EU 20) (active “active listening, so that patients can feel a sense of authentic listening, compassion/care. information about other services i.e. bereavement counselling) counselling, Psychology” (P52M 46 EU 4) “facilitating not giving the therapist viewpoint. explaining, giving understanding to stress experience and using (rehearsed) ways of managing. Being able to talk about this experience afterwards i.e., self-reflection, facilitated by therapist. Therapist not being fearful of listening to trauma or being with distress....always acknowledging validity of the person's experience.”( P42F 31 EU 4) “again no formal system or approach but based on person centred approaches”( P53M 33 EU 2) “Anxiety management. Mindfulness practiced in various settings to allow them to engage with the reality of their lived experience” (P46F 50 EU 20) “Applying active listening techniques and utilising empathy.”( P50F 54 EU 25) “Empathy with patients about good and bad experiences they may have had.”( P32F 29 AS 5) “Be empathetic towards clients”( P43F 61 EU 20) “empathise with patients and support them to achieve their goals”( P107F 54 EU 23) “listen to their concern and show understanding”( P10M 24 AS 0) “Lot's of patients want to move/exercise but have problems of paranoia/anxiety/negative thoughts that keep them from moving. So you have to know what's going on in their heads to motivate them the right way. To take away their fears.” (P16F 36 EU 13) “We need empathy, this really helps in the therapeutic relationship which keeps patients coming to physiotherapy” P22F 45 EU 17 “Support in dealing with difficult situations, anxiety symptoms. Providing a listening ear when appropriate” (P49F 51 EU 4) “Mood is recorded before and after exercise and if this changes further one to one sessions can be arranged.”( P21F 34 EU 7.5) “Use the CORE tool to discuss vital aspects of the patients mental health” (P6 M 33 EU 8) “Very important. Due to my nature of work and clients I see, .providing reassurance, relaxation and physical activity may help to break ice and make people felt valued.”( P58F 27 EU 4) Providing 10.5% “being interested in the patient's bodily experiences, functions and conditions 4/38 expressions…and the partner-ship in that we are DOING something together… which allowing It is not just "instructions" or verbal guidance/support; it is a sharing of the expression and experience in the sense that we explore together, actively, the patient's being part of it possibilities and limitations. ” (P4F 34 EU 10) with the “I try to create a safe atmosphere, adjust each training session to the patient's patient possibilities that very day, and to promote acceptance that feeling frail is human - and ok to acknowledge - but that we all have the ability to grow.”( P4F 34 EU 10) “When patients get discouraged if they can't do something I explain it takes time to learn any new skill and some people will take longer than others because we are all individual. I disclose my own difficulties with balance coordination and lack of sporting ability (which they can also observe directly as I join in with games). I explain to patients that exercise can be an aversive experience for me and I would rather tell other people to do exercises than do them myself, however I do exercise because I know it's good for my health. Try to make physical activity fun and not "boring"” (P90F 42 EU 0) “make it part of there timetable.”( P54M 55 EU 14) “having fun,” (P27F 26 AF 3) “making your therapy attractive and fun, especially with chronic schizophrenias (not use the term 'therapy', but make it comparable with sporting clubs outside the hospital)” (P27F 26 AF 3) Being able to 5.3% “they prefer a more one on one encourage support and approach” (P1M 32 talk to the 2/38 EU 6) physiotherapist “Many patients really value coming away from the close knit ward based team away from the and talking about their difficulties during physiotherapy”( P1M 32 EU 6) ward Table 2 value of the group and peer support

Sub-theme Code % (n/40) Example Units Group Dynamics Need for 35.0% “an improved sense of belonging and social significance through belonging, 14/40 relationships with peers” (P12M EU 35) relatedness “belonging to a group of active people/friends” (P27F 26 AF 3) and unity “Being part of a group and accepted within a peer group while exercising helps to build confidence.” (P29F 34 EU 7) “[I]use dance for exercise, communication, body & self-awareness, relaxation ,fun & laughter & a sense of belonging” (P54M 55 EU 14) “Group work…Being part of a group.” (P29F 34 EU 7) “group exercise sessions or on a one to one basis” (P58F 27 EU 4) “small group sessions” (P90F 42 EU 0) “patients greatly value the social interaction/ support from other service users who have had comparable” (P99F 49 EU 19) “An improved sense of belonging and social significance through relationships with peers” (P12M EU 35) “As mentioned it is essential for maintaining exercise motivation to belong to a group.” (P29F 34 EU 7) “Those within a group are important to encourage the individual when they need it but our sessions are also created to allow individuals to work without forcing interaction with others.” (P21F 34 EU 7.5) “Many clients with mental health conditions are socially isolated and lack confidence by introducing them to a supportive group they realise that there are others who are like them and experiencing similar difficulties.” (P50F 54 EU 25) “I consider it important because you can create group interactions that are similar in daily living. They can learn from each other, from different situations, make friends.” (P27F 26 AF 3) “it’s also about the social aspects of meeting others” (P107F 54 EU 23) Challenges of 12.5% “Yes they are important, but if you get them wrong they can be damaging. groups 5/40 For instance, if you mix more active males with SMI in a group it is threatening for the sedentary patient to join” (P1M 32 EU 6) “Groups potentially can be very distressing and impossible for some patients to cope with....actually increasing symptoms. Introduction to group work needs to be done slowly with support. During groups, past experiences may be triggered, which needs a safe space to discuss and understand.” (P42F 31 EU 4) “Peer and network support is important and although we are keen to progress this it is difficult to encourage this if individuals do not want to support others.”( P118F 24 NA 0.5) “However, those with less abilities can feel ostracised in a group if they are significantly less able/ less confident and its more difficult to encourage them in a group setting without highlighting their difficulty” (P14F 45 AS 10) “But what we worry is the quality of network in their peer groups (bad friends? Which make the case more complicated in handling)” (P8F 28 AS 1) Role and Value of Peer General 60.0% “Peer support may also help” (P58F 27 EU 4) Support support for 24/40 “Our Health instructors provide group sessions to service users, and peer groups support is vital and a key element of how the groups are run.” (P40F 57 EU 13) “Peer supervision, seminars and networks are very important.” (P4F 34 EU 10) “it is important to get support from natural environment.” (P13F 52 EU 25) “Peer and network support is important” (P118F 24 NA 0.5) “Peer/network support is very important” (P30F 65 EU 20) “[peer support is] Very important” (P58F 27 EU 4) “Yes [peer support is positive]” (P60M 56 EU 5) “Yes it helps people” (P109F 30 EU 1) “Yes [peer support is positive]” (P10M 24 AS 0) “Yes, patients support each other” (P107F 54 EU 23) “Yes, extremely important”( P11M 33 EU 8) “Yes, groups are essential for peer support”( P14F 45 AS 10) “yes, it is important for peer/network” (P53M 33 EU 2) “Yes, It is important” (P26F 52 EU 25) “Yes, it’s important” (P117M 35 EU 5) “Yes, peer support is important” (P22F 45 EU 17) “Yes”( P43F 61 EU 20) “Yes” (P32F 29 AS 5) “Yes” (P115F 31 AS 1) “Patients peers are all important” (P5F 55 EU 20) “peer group support which is very positive” (P90F 42 EU 0) “I feel peer support can be very beneficial in some cases.” (P49F 51 EU 4) “I believe that for a large number of clients simply being in a group can lead to positive outcomes.” (P50F 54 EU 25) “Groups are very important” (P31M 55 EU 14) Benefits of 30.0% “Sharing experiences of other patients related to barriers, i.e. side effects of sharing with 12/40 medication, negative symptoms, social anxiety” (P11M 33 EU 8) others, “I work mainly with adolescents for whom the peer group is hugely relatedness important and praise and encouragement (or constructive criticism) from and the ability their peers is often better accepted than from adults.” (P90F 42 EU 0) to understand “Often the patient group can identify with each other in a way that clinicians and provide can't, this is mostly beneficial” (P52M 46 EU 4) support “patients need support of different persons” (P97F 39 EU 6) “Peer support takes away the power differential perceived by patients” (P46F 50 EU 20) “Peer/network support is very important, and it is ultimately important, due to the fact that unless you have been where the individual has been you can only hazard a 'best guess' at their feelings: motivations: desires: and hoped for futures. Peers and per support networks have been there before.” (P30F 65 EU 20) “it helps people see how they are in relation to others and helps them realise how much they have/can improve” (P109F 30 EU 1) “Sharing experiences is one of the core elements of our motivational groups; see also Irvin Yalom. We try to involve family members. Patients can exercise together in our fitness facilities.” (P11M 33 EU 8) “Peer groups are essential for peer support and help make patients realise they are in their journey together”( P14F 45 AS 10) “yes, it is important for peer/network due to the fact that unless a professional has had schizophrenia they are unlikely to fully understand a person’s trials and tribulations” (P53M 33 EU 2) “To have different perspectives and treatment focus.” (P117M 35 EU 5) “Groups reduce loneliness make activity more fun allow for partner work, build team skills,& allow for being with other people without emphasis on words” (P54M 55 EU 14)

Positive and 30.0% “The group offers many learning experiences from the things that happen to transferable 12/40 others as well as from things that happen to one’s self.” (P2M 35 EU 11) learning “They can learn from each other’s reflections, actions, etc.” (P27F 26 AF 3) experience in a “Groups give a chance for both cooperative and competitive play and to safe learn to cope with frustration or failure in a safe situation… Basic social skills environment need to be learned or re-learned.” (P90F 42 EU 0) “The idea being that relationships sustain the confidence to continue in main stream activities into the future” (P40F 57 EU 13) “Man is social animal and people share and learn a lot from each other” (P58F 27 EU 4) “Yes, patients support each other, learn from each other and relax and feel more comfortable” (P107F 54 EU 23) “Yes, it is important to know what peers are doing in their groups to ensure consistency of information and also sharing of experience and approach.” (P57F 00 EU 5) “We should establish a social support for returning to the community and getting independent from the professional support.”( P8F 28 AS 1) “If one or two report enjoyment or good exercise experience then more patients will want to attend” (P5F 55 EU 20) “peer support to access more community inclusive gyms”( P40F 57 EU 13) “Peer support…helps promote longer term engagement in main stream activities” (P46F 50 EU 20) “These groups always suggest patients to find a training buddy within or outside the group as a method of committing to the lifestyle change.” (P2M 35 EU 11) Motivation and 12.5% “Group sessions are important to build up…motivation” (P21F 34 EU 7.5) adherence 5/40 “it improves …-motivation of the patients involved in the group” (P26F 52 EU 25) “Groups are very important, peer support is very helpful to encourage the patient to engage and also stay motivated” (P31M 55 EU 14) “We have a concept of physical activity groups at our unit that try to motivate patients to increase physical activity and reduce sedentary time” (P2M 35 EU 11) “Can help maintain an interest” (P48F 50 EU 1)

Increased 10.0% “We endeavour to facilitate individuals into group activity groups as early as network of 4/40 possible to provide both professional and peer support for esteem.” (P99F support and 49 EU 19) unity of “working with their team and family to re assure that ; activity will not be support harmful that emotional distress will be listened to and support to work through situation will be provided” (P5F 55 EU 20) “peer support…takes the focus of the individual if they are struggling and this can bring a cohesive community trying to achieves physical fitness”( P22F 45 EU 17) “Peer support… gives the opportunity to develop a wider social network.” (P46F 50 EU 20) Build 7.5% “social interactions also help build self-confidence and are important”( P43F confidence 3/40 61 EU 20) (mastery) “Individuals contribution can start small & increase with confidence or willingness” (P54M 55 EU 14) “Group sessions are important to build up confidence” (P21F 34 EU 7.5)

Self-esteem 5.0% “Group sessions are important to build up…self-esteem” (P21F 34 EU 7.5) 2/40 “it improves self-esteem… of the patients involved in the group” (P26F 52 EU 25) Source of hope 5.0% “[Those] further down the road to recovery as a source of hope for the for recovery 2/40 future but equally value the opportunity to play that role for those who may be at an earlier stage of the journey.” (P99F 49 EU 19) “It's important to create hope. They can see that someone is already better, further on the line” (P16F 36 EU 13) mood 2.5% “it improves…mood…of the patients involved in the group” (P26F 52 EU 25) 1/40 Patience 2.5% “I encourage them and have patients with them… along the process to 1/40 increase their exercise.”( P13F 52 EU 25)