Community, connection… challenges?

Psychologists and psychiatrists came together on 15 December to share evidence with the House of Lords Covid-19 Select Committee on the long-term impacts of our use of technology during the pandemic on our mental wellbeing. The peers also touched on the use of technology in delivering mental health services and the groups that may be missed by the increasing adoption of digital services. 

The witnesses for the first evidence session were Kate Cavanagh, Professor of Clinical Psychology, (University of Sussex), Dr Tom Foley, child and adolescent psychiatrist and honorary senior clinical lecturer (Newcastle University), Dr Richard Graham, Consultant Psychiatrist, (Good Thinking) and Akiko Hart, CEO of the National Survivor User Network. 

Lord Alderdice, who was previously a psychiatrist himself, asked the witnesses about the acceleration in the use of digital mental health services as well as their impact on users', and therapists', mental health. Foley said that he had seen a much larger increase in telephone consultations rather than online consultations during the pandemic, and suggested mature technologies had been most helpful during Covid-19 – but added that there was a mixed picture across services. 

Foley said that some patients, where digital consultations were used, benefitted from using technology, while others found it much more difficult to engage – particularly those with complex needs or those working with more than one therapist. Hart emphasised that digital mental health support was not for everyone. She said the switch to digital services excluded people we may not initially think about, including those living in multi-occupancy households, young LGBT people who may not have disclosed their sexual identity, and people experiencing domestic abuse – all of whom may not have the safety or privacy to speak openly while at home. 

Baroness Young pointed to the disproportionate negative outcomes that Black people and those of South Asian descent experienced. Hart replied that she hoped there was a more general awareness of structural and institutional racism in the wake of the murder of George Floyd and the work of Black Lives Matter. Young asked Cavanagh about the impact of the digitalisation of mental health services over the next five years – including what new technologies might emerge and potential barriers to using it. 

Cavanagh highlighted Foley's point that mature technology, such as the telephone, had been used during that pandemic and said over the next few years we may be likely to see services make use of technology that is already widely available and that has a good evidence base. 'This will include need for services to deliver more confidently a more blended approach to working so that we can draw on technology that many people already have access to. And to blend care, to add what's special and supportive from digital technology to well-established evidence-based practice in face to face working.'

Some of the barriers to using digital services, Cavanagh said, included infrastructure, hardware, connectivity problems, as well as training for staff about how to work in the digital world. She said that while NHS colleagues had been remarkable during the pandemic, when considering a longer timeframe more deliberate training and support was needed. She also pointed to the work of John Torous (Harvard University) who has suggested the necessity of introducing a new role in healthcare – digital navigators to support staff in digital literacy. 

Opportunities and challenges

The witnesses were also asked about the efficacy of online, or remote, appointments for mental health support. Foley said in his work he had met the whole range of patients, from those who loved appointments using digital technology to those who found it very unpleasant. 'I think there are opportunities as well as major challenges to this… sometimes you simply can't replace the face-to-face experience.'

Cavanagh pointed to the 'promising' evidence base for telehealth in delivering interventions but said that more evidence was needed. Chair of the committee, Baroness Lane-Fox, asked in which areas she would most like to see more research. Cavanagh said the key missing piece in the evidence base was in implementation of digital services at scale.

Lord Hain then touched on empathy and personal connection when using digital services. He asked if the witnesses looked five years ahead and were designing an optimal structure to pursue professional objectives, what would those be? Hart said one mistake during the switch to digital during the pandemic had been trying to recreate face-to-face experiences online. 

'I think it's really important to think about online support as a different set of skills, or perhaps a greater skill, than face-to-face support…  I think it is possible to create community, and connection online, but it is harder. For me there is something about acknowledging that within the service delivery and thinking a little bit more deeply about training and support for people who are delivering services online.'

A lifeline

Lane-Fox asked whether the inequality in access of mental health services could be worsened in the digital world. Hart said that while some people did struggle with access to digital mental health services, they had been a huge positive for some. She pointed to people living isolated lives for whom online networks of support had been a lifeline, but also said there needed to be an increased focus on supporting those who experience greater distress.  

Later two more witnesses joined the panel – Dr Bernadka Dubicka, Chair of the Faculty of Child and Adolescent Psychiatry, Royal College of Psychiatrists and Dr Linda Kaye, Chair of the British Psychological Society's Cyberpsychology section [who has blogged about 'Supporting BPS Policy to create real change']. Baroness Jay asked whether the rise in anxiety among people during the pandemic would decline, and whether the increasing use of digital technology would have an impact on mental health in the coming years. 

From the perspective of child and adolescent psychiatry, Dubicka pointed to a government-commissioned survey from 2017 which found a rise in emotional problems, and a more recent survey which found prevalence of mental health problems had increased from one in nine children and adolescents to one in six. 'The trajectory of mental health problems is not good in this country.' In terms of the use of digital technology and its role in mental health problems Dubicka said the picture was complex; for every study arguing it was potentially damaging she could find another which found the internet was a great source of support. 'What we need to do is learn how to harness the internet for the positives as well as trying to minimise potential harms.' 

Kaye emphasised that there was little good evidence for the longer-term impacts of using digital technology and social media, with many studies using cross-sectional designs revealing little about cause and effect. 'There are many different complexities… not just what we're actually engaging with, whether it's young people or adults, but why we're actually using technology and the internet. I think that's something that tends to get missed when people are thinking about the impacts – we don't just use it as an individual behaviour. 

When we're… trying to tease out where this stress and… these effects of spending time using technology come from we have to look beyond just the individual and their own experience of it and try… to understand organisations and structures around this and what we deem at societal level as being healthy and functional use.'

Online harms

Lord Pickles asked if Dubicka and Kaye looked five years into the future, given the fact the digital world was not an entirely benign environment, what safeguards and enhancements they would like to see to make it a healthier place. Dubicka pointed to the release of the government's Online Harms Bill – announced the same day of the meeting – and said this was a step in the right direction. 

'There needs to be a lot more work done on users being able to have much more control about what happens online… there should be much more control allowed on their own digital footprints… and social media companies, technology companies need to be taking a social responsibility approach… They need to let users have warnings, for example of the content that's coming up, and being much more proactive… not just pushing pernicious algorithms that pop up immediately there needs to be warnings to people and children can actually make a choice about whether they view and become involved with source material.'

Finally, when asked about their specific policy recommendations, Kaye highlighted a need for technology companies to be open in sharing data to allow researchers to examine the true impact of digital technology and social media and for organisations to consider employees' health and safety when using technology. Dubicka pointed to the prevalence survey of mental health issues which the government commissioned and suggested this type of survey should be run annually, with questions about technology. She also suggested a need for more research on the impact of technology use on the developing brains of younger children, and on the benefits of technology use more generally. 

- On Twitter we recently asked about online psychological services, and the potential for inequality of access.

'Hearing contrasting views on Psychology services in Covid times. "Brilliant, like before but more efficient because we've discovered Zoom!" vs "Hmm, is it really brilliant or is this increasing inequality in access, with covid as a smokescreen for lack of funding?" Comments?'

Here's a selection of those comments. Please visit the thread to add your own, or get in touch with the editor on [email protected]

Erin Stevens: Re access inequality - it will go both ways because of lack of privacy/Internet creates access issues, but people who are disabled/unable to travel now more likely to be able to attend. Zoom isn't the same, and I personally have lost so much as a client. Others prefer it.

Nick Scribbler: I fear this will spark a split in therapy, with face-to-face therapy coming to be seen as an expensive luxury, so publicly-funded therapy becoming online by default because it delivers significant savings - and some influential people are saying it's the same. It's not.

Windy Dryden: For me the issue is: what does the client want

Paul Tomlin: I hope you don't mind the opportunistic/shameless plug, but we are currently undertaking a research project on exactly this topic! Please do let your views be heard. 

Roseanna Brady: Concerned about the rush to embrace still poor quality technology given the sensitive nature of the work we do. Tech is an opportunity if we take great care around inequalities, safeguarding, building therapeutic relationship, self-care etc etc