Monday 15 July 2019

Help from the comfort of your sitting room: Is this the next big thing in mental healthcare?

Phone and online resources, and even artificial intelligence, are transforming mental healthcare and could address a lot of shortcomings in our system, but there are some reservations, writes Katie Byrne

Let's talk: But is virtual replacement the way forward?
Let's talk: But is virtual replacement the way forward?

Talk to someone. So goes the oft-quoted refrain dispensed via mental health awareness campaigns. It's sound advice for those experiencing mental health difficulties - the trouble is that finding someone to talk to isn't always that easy.

Private one-to-one therapy can be prohibitively expensive; public waiting lists can be six months long and overprescription of antidepressants can become an unfortunate yet inevitable consequence of a mental healthcare system in crisis.

It's a serious problem and, according to Minister of State for Mental Health Jim Daly, it's a problem that requires a "radical" solution.

Last year Daly announced that the HSE are rolling out an eMental health strategy to address the mental health services staff shortage.

The support project will include an instant messaging active listening service and the piloting of online therapy initiatives - and it can all be accessed from the comfort of your sitting room.

Ireland isn't the first country to embrace eMental health. Digital interventions are popular in the US, where the health system is similarly overburdened, and the UK, where the NHS offers a library of apps that can help people overcome everything from panic attacks to unhelpful thinking.

By comparison, the Irish digital mental health strategy is still in its infancy. However, research has found that 94pc of an Irish adult sample expressed a willingness to use the technology.

eMental health is a vast ecosystem that encompasses everything from phone and video to mobile apps, computer-based programmes and even VR. It could be an online course in Cognitive Behavioural Therapy (CBT), a Skype session with a psychotherapist or a human-like, text-based conversation with a chatbot that checks in to ask how you're feeling.

At the entry level are apps like Headspace and Calm, which offer guided meditations that can help users manage stress and sleep better.

More sophisticated platforms include Talkspace, a subscription-based service that connects users with online therapists; depression app Moodpath, which was downloaded by more than 850,000 people last year, and 7 Cups, a free text chat service that connects users with trained active listeners and supports over 1.3 million people a month.

In the UK, over half of all 11-18 year olds have access to Kooth, a wellbeing platform for children and young adults that has been well received by schools and universities.

Paul Longmore, a social worker and psychotherapist and the clinical governance manager at Jigsaw, the National Centre for Youth Mental Health, says digital interventions can increase access to mental health services - especially for young people.

"I think there is a general acknowledgement across mental health, and indeed across health services in general, that the existing models that we use - and the existing ways that we are approaching health difficulties - just aren't enough any more," he says.

"At Jigsaw we work with young people aged 12-25, and an awful lot of their lives are lived using digital technology. So if we want to meet young people we have to go to where they are - and that's online."

Last week, Jigsaw launched a new website (jigsawonline.ie) that is dedicated to providing free information and support on a range of issues including bullying, exam stress and consent.

Additional features such as live group sessions, lesson plans and onscreen supports will be rolled out as the resource develops in the coming months.

It's the beginning of a journey, says Paul, who is hoping that they might one day be able to use digital technology to provide mental health services to young people, at scale, for free.

The question, of course, is what form that technology may take.

There are many emerging fields in the eMental health sector - and some of them are fast gaining ground.

Take Woebot - an artificially intelligent chatbot created by Dublin-born Stanford psychologist Dr Alison Darcy.

Woebot encourages users to discuss their emotions and guides them through practical techniques in a human-like, text-based conversation. The digital health company launched in June 2017 and they're already managing more than two million messages a week from people in 130 countries.

Virtual Reality Exposure Therapy (VRET) also holds promise. This technology can help patients face situations that they fear, and while it is mostly used as a supplementary tool in-clinic, it's only a matter of time before a credible at-home version is developed.

Other groups are exploring the intersection of predictive data analytics and clinical intervention. With the patient's consent, data from a smartphone could track everything from light exposure to daily steps, and issue alerts to the care team long before the patient realises that they might be at risk.

The opportunities of a technologically advanced mental health care service are obvious. It helps to fill the treatment gap, making early intervention services easier to access. Plus, it gives patients who value anonymity another therapy option.

"There is a role for some online supports that are anonymous because some young people would use the online space to dip their toe in the water," explains Paul. "It's their first effort at seeking help - they may not feel ready to speak to someone face-to-face so their initial experience of seeking information or acknowledging a difficult situation happens in a way that feels very safe - in a way that they can control."

The online disinhibition effect - the tendency for people to self-disclose more on the internet than they would in real life - can also be an advantage. Or a disadvantage if the e-therapist isn't aware of the dynamic...

This is one of the many points that the Irish Association for Counselling and Psychotherapy (IACP) raises in an extensive set of guidelines for online therapists.

Computer-based therapy presents its own unique challenges, they point out, and alongside specialist training, they recommend that practitioners prepare themselves for "the absence of visual and auditory signals"; "the awareness of fantasy and idealisation of the practitioner by the client... which stems from the increased transference and projection accompanying online therapy" and "how to proceed when clients 'disappear' through change of email addresses or other contact details".

More and more therapists are embracing the screen-to-screen medium, but there are still those who believe that it's no substitute for face-to-face interaction.

Psychotherapist Gillian Isaacs Russell, the author of Screen Relations: The Limits Of Computer-Mediated Psychoanalysis And Psychotherapy, argues that "physical co-presence" is essential for the therapeutic process.

Other critics have voiced concerns around privacy and safety.

The IACP advises practitioners to give clients all the information necessary to avoid threats to their privacy.

Likewise, patients should exercise due diligence on the type of platform encryption that online therapists are using and the privacy policies of app providers - a recent study found that 33 of 36 mental health apps share users' personal data with third parties without their knowledge.

Patient engagement with online mental health courses is another challenge, says Dr Conal Twomey, a psychologist in clinical training in UCD.

Online CBT programmes are a proven resource for mild to moderate mental health issues, explains Conal, but studies show that there is a high drop-out rate attached to them.

"The other thing that emerged as the research developed is that there was much more efficacy when computerised CBT was provided with regular guidance alongside it," he says.

"Say you met with a psychologist in advance and they explained the course to you and then you went off and did it and they then checked in with you six weeks later, the chances of you doing the course and benefitting from it are much greater."

The solution, he says, is to personalise the experience so that the person "feels valued" and not pawned off with a website address.

The HSE are aware of this particular drawback - Conal was a speaker at last year's eMental Health in Psychological Practice conference - just as they are aware of the inherent limitations of online therapy.

Digital intervention is not, to use their words, "a simple 'plug-and-play' game-changer or panacea" and "face-to-face therapy and in-person support will continue to remain centrally important".

Paul sums it up: "Online can supplement some services but it's by no means a replacement."

Irish Independent

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