Opinion / by Conor D'Andrade
Waiting times for initial mental health appointments in Wales are getting longer, and people are turning to online services to get the help they need. But is online therapy what the country needs to avert a so-called ‘mental health crisis’? Conor D'Andrade analyses the pros and cons of a telehealth-only approach.
Throughout the UK, the number of people seeking help to deal with the psychological impact of the pandemic has grown considerably, placing extra strain on mental health services that were already underfunded prior to Covid-19 ever becoming an issue.
This is particularly the case in Wales where new data show that the proportion of people waiting over 4 weeks for a first appointment with Special Child and Adolescent Mental Health Services (sCAMHS) has more than doubled since the same time last year. In July 2021, 60% of patients waited over 4 weeks for their first sCAMHS appointment, compared with 26% in July 2020. A similar picture can be seen among adults too with some NHS boards reporting a 47% increase in adult referrals compared with pre-pandemic levels.
To mitigate the issue, a spokesperson for Rhun ap Iorwerth, deputy leader of Welsh political party Plaid Cymru, recently stated that quick access to mental health services needs to be a priority for the government, without which the country may soon be faced with "a mental health crisis in the middle of a public health crisis.”
Despite the concern though, there does seem to be an alternative route to therapy that the Welsh public is already turning to: telehealth. According to data published by SilverCloud Wales, an online self-help service provided by the NHS, the number of people signing up to the app across Wales has substantially increased, with some areas reporting a 56% jump in new registrations since May 2021. Of these, many are due to "a rise in social anxiety symptoms relating to Covid measures being relaxed, loneliness and feeling isolated" to "low mood and sometimes consequently self-esteem and body image concerns," says Fionnuala Clayton, lead psychological assistant for SilverCloud Wales.
Considering the marked increase in mental health issues seen across the country, coupled with longer waiting times for therapy, it's easy to understand why the public would turn to online services for help. But, as has been asked of telehealth solutions since their first emergence in the 1950s, is going the digital therapy route the best possible option?
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Weighing up the pros and cons of telehealth
Telehealth has seen success in some areas, perhaps most notably with the introduction of suicide hotlines. Samaritans, one of the world's first suicide crisis lines, is contacted roughly every 6 seconds and has undoubtedly saved countless lives since its founding in 1953.
But elsewhere in the mental health sphere, telehealth solutions continue to struggle to become a mainstream option, especially when pitched as an alternative to face-to-face appointments with qualified professionals. So what does telehealth offer that traditional therapy doesn't? And where does it still need to improve?
A common issue with face-to-face appointments is service users often don’t attend appointments, with transportation difficulties being cited as the most common reason for patient absence. Some studies have even found no-show rates as high as 60% with traditional therapy.
According to available data, this is where telehealth really excels. It provides a service that users are significantly more likely to attend, largely due to the savings made by not having to travel, opening up access to mental health services for poorer and rural communities. This is particularly relevant to the pandemic, where people either can't or don't want to travel, and perhaps also to the SilverCloud online service where a common reason for registration was a general anxiety related to Covid infection.
But despite making access easier, telehealth doesn't necessarily make delivering therapy easier.
The main issue both clinicians and service users cite with online therapy relates to losing non-verbal cues when conversing. Psychologist Kristy Keefe revealed the extent of this issue in an interview with NBC News, saying that using video calls can cause lag and poor audio quality, making it hard to detect changes in tone of voice. Because of this she prefers to use audio only, which she says made her and her students “really sensitive to tone fluctuations” allowing them to more easily “pick up emotion”. However, she also notes that by losing video she misses out on non-verbal cues displayed through body language.
Kate Barnes, a teacher that struggles with anxiety and depression, also told NBC News that while she didn’t see teletherapy as less effective, she would like to see her therapist in person as “you can pick up on their body language better, it’s a lot harder over a video call to do that.” This suggests the importance of non-verbal cues for both clinicians and service users may make online therapy less desirable to some, specifically those that depend on them for communication.
Sourcing – and retaining – a workforce
Another issue presented by online therapy relates to the people needed to deliver it, particularly with regards to their capacity.
Many online therapy services advertise themselves as allowing you to connect to a therapist whenever you need to. While this is in theory great for service users - especially those in crisis - it has also meant that the clinicians they engage with are often in a state of hyper-vigilance as they know they could be contacted at any moment. The IAPT Survey revealed in 2019 that 70% of respondents (people employed in the online mental health service) had experienced burnout due to working in the service.
Compounding this issue further is the fact these platforms pay doctors lower fees than traditional practices. Considering 10% of mental health workers in the UK made no money from their profession throughout the pandemic, if this trend of poorer compensation for clinicians continues, more will likely leave the profession. The more recent and incomplete Covid-19 survey also revealed that as more clinicians offered online alternatives, their wages decreased. This means burn out due to more work and less pay would likely be an issue for clinicians carrying out online therapy.
Providing a personal touch
One of the biggest criticisms of online therapy has always been the removal of the interpersonal relationship between clinician and service user, which is often taught as an important part of the therapeutic process. Hannah Zeavin, author of The Distance Cure: A History of Teletherapy, has criticised services similar to SilverCloud Wales as expecting patients "to click, scroll and type their way to a better state of mind at the expense of deeper, open-ended work and systemic solutions." This is arguably the case for many apps that rely on chatbots to deliver a therapist's part of the conversation.
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The effect of this lack of personalisation has even been scientifically tested. One study, which aimed to measure whether a therapist’s levels of empathy, non-possessive warmth (friendliness, sensitivity and consideration), and genuineness were causally linked to the degree of patient improvement, found that the combination of these three traits resulted in the best patient outcomes. Across all patients, therapists showing high levels of all three traits had a 90% patient improvement, compared 50% patient improvement for therapists that did not have these traits.
These findings are important to consider, as if implementing online therapy results in poorer patient outcomes, it is likely patients will need to return for help again at a later date – where they will be added to a waiting list again.
Perhaps the biggest hurdle telehealth still needs to overcome though is proving its ability to provide quality outcomes on par with face-to-face appointments.
In 2016, a literature review of 452 studies was conducted to assess the effectiveness of 'telepsychiatry' – AKA telehealth – and concluded that it performed at least as well as traditional therapy. A 2021 study also found that online cognitive behavioural therapy (CBT), the most common psychological treatment for a range of conditions, was equally as effective as face-to-face CBT when carried out in people with mild-to-moderate depression.
But the data isn't quite so clear cut. In the same 2021 study, online CBT also made symptoms worse in people with severe depression.
And therein lies a big issue for telehealth: it's not a one-size-fits-all approach for treating mental health issues. What works for one person might not necessarily work for someone else.
The final obstacle
So, bearing all this in mind, can online therapy tackle the long waiting lists in Wales and prevent a looming 'mental health crisis'?
As we've seen, online therapy could be a viable alternative for some people in Wales, specifically those with milder forms of more common mental health issues. This in turn could help speed up waiting times for people with more severe mental illnesses. It also offers treatment access to typically neglected patients, again potentially removing them from the queue.
But of course, if telehealth is indeed the solution to Wales' problems, there remains one final element that needs to be considered: the ability to implement it.
Many sectors are suffering from staff shortages, and mental health services are no different. If there aren’t enough staff for face-to-face therapy, there won’t be enough to provide online therapy. This means Wales would most likely have to rely on more self-help services such as SilverCloud Wales, which we have seen are not beneficial for everyone.
To avoid a reliance on self-help services and provide services that link a patient directly to a clinician when needed, a huge effort would need to be put into training new staff. And because training in psychiatry or clinical psychology takes several years, it wouldn’t be a realistic aim to train the number that would be required to tackle the immediate issue being faced.
Instead, it may be more feasible to provide shorter, specialist training to individuals, that is specific to helping with acute distress through an online platform. Although there is no data on how successful this might be, a study piloting a new 'low intensity' CBT intervention designed to be implemented by frontline mental health staff (such as mental health nurses, rather than a psychologist that would typically carry out CBT), may hold some relevant findings.
Results found that service users reported learning news skills and achieving their goals, which are both important positive outcomes. Staff reported they were able to use a brief, structured intervention to achieve a positive outcome for the service user. However, they both felt a longer and more sophisticated intervention would be needed for more complex issues.
These results suggest it may be a viable solution to provide training to individuals with backgrounds similar to frontline mental health staff, that could provide low-intensity CBT to people with acute distress (such as anxiety around Covid) online – while freeing up psychologists to implement traditional therapies for service users with more complex conditions. However, a comprehensive system would need to be developed to triage service users – to determine who should be prioritised for a face-to-face intervention and who would suffice with online services.