During the COVID-19 pandemic, mental health services are providing support remotely. In this blog, Dr Warren Mansell, Reader in Clinical Psychology, discusses the positive ways that services have adapted and how they can be sustained in the future.

• The COVID-19 crisis has put into stark relief a chronic, pre-existing problem with the provision of talking therapies for mental health problems.
• Mental health services are having to be more flexible, providing more informal booking arrangements that don’t rely on prior screening and diagnosis.
• Research over the last ten years shows that new ways of working can be just as effective because universal talking therapies can help people with different potential diagnoses.

Prior to the crisis, and despite over a decade of government initiatives, demand has outstripped supply. Now during the crisis, particularly during lockdown, there has been a recognition of the increased mental health needs for issues such as domestic violence and abuse, traumatic grief, and addiction.

On top of the increased demand, the crisis has revealed that mental health services rely on procedures that make normal services impossible to deliver at the necessary scale and urgency during lockdown. These include:

1. screening patients to check that their problems are severe enough to warrant any support;
2. diagnosing patients to triage them for one of dozens of therapies known to have an evidence base for their specific condition – such as post-traumatic stress disorder, obsessive compulsive disorder, and social anxiety;
3. appointments being set for people by services, often weeks ahead, and limiting the appointment to a specific number (eg six sessions in primary care);
4. written materials such as questionnaires, thought diaries and activity schedules that patients are expected to complete before, during and after therapy, and storing clinical notes of what patients reveal during therapy and keeping these confidential.

Adapting to a new normal

However, the crisis has also provided the kernel of a solution. Many mental health services are adapting to remote working. There is a new normal emerging for many therapists during the crisis. This could be the model going forward.

Firstly, therapists (eg clinical psychologists, cognitive behavioural therapists, counselling psychologists) in mental health services should provide an array of slots for their clients to book to video call or telephone with them – potentially at home. The informality of this arrangement is potentially a benefit rather than an issue.

Services should provide a talking therapy (counselling, psychotherapy or cognitive behavioural therapy) that is directed by the client’s own immediate priorities, and the therapy should draw upon therapeutic principles for dealing with distress that are universal to everyone – to include people without a diagnosable mental health disorder.

A talking therapy of this kind – focusing just on enhancing the process of recovery within the client – would not require the huge degree of screening, diagnosis, extensive note-taking and confidentiality requirements that are commonplace at present – and that have proved so burdensome to manage during the COVID-19 crisis.

The effect would be to greatly increase the capacity for psychological therapy so that the existing unmet need can be met. Also, because people would book sessions when they needed them, this would ensure that the service is used efficiently, with greater support for those in greater need. By removing the requirement for much of the paperwork, the whole system would be more efficient. Such a vision may seem idealistic. Yet our research group has been accumulating evidence for such an approach for the last decade.

Universal approaches

The changes in mood, thinking and behaviour used to assess the severity of a psychiatric disorder are extremes of experiences in the wider population. For example, the majority of university students report some of the symptoms of bipolar disorder; and many people in religious movements value hearing voices (known as auditory hallucinations). Conversely, the sources of distress in people with severe mental health problems are often nothing to do with their psychiatric symptoms. All of this evidence suggests that people don’t need to have a ‘disorder’ to deserve and benefit from talking therapies. Without the stigma and often extensive referral procedure, therapies are much more accessible. It also opens the door for professions – health professionals, emergency staff, armed forces, teachers, prison officers – to get help to deal with their challenging work and be supported before their problems get more serious.

The changes in mood, thinking and behaviour that are targeted in talking therapies are largely the same, whatever the diagnostic label that a person is given; they are ‘transdiagnostic’. A series of studies we carried out consistently found the same ‘core process’ across a wide range of different mental health diagnoses. We are testing whether this core process is the restricted awareness of chronic goal conflict. Evidence of this kind indicates that there is little scientific case for requiring a lengthy diagnosis to establish different therapies for different disorders.

Control and self-direction

When people can choose their own appointments, they are more likely to attend, they choose a modest number of sessions (averaging three to four) to suit their own needs, and together this greatly increases the efficiency of the therapy. Moreover, in mental health services, and even in counselling in high schools, we have found that people prefer to book their own appointments and choose the topic for the session themselves. People thrive when given control.

In our in-depth interviews with people who have achieved long-term recovery from long-term mental health problems, they consistently tell us that they are ‘the directors of their own recovery’. We have evidence that the active ingredient of change during talking therapy may be a process that improves when a person can express their problems openly and freely. The therapist can enhance this through their questioning rather than requiring homework, psychoeducation or sharing of information. This process may even be carried out by trained novices, or enabled by an automated system that encourages the exploration of a problem. It may even work through instructions to write about one’s difficulties – expressive writing or journaling.

There is an opportunity now, to keep the new normal, and to make headway in supporting all those in need of psychological help, by providing user-led, remote, informal and universal talking therapies.

Take a look at our other blogs exploring issues relating to the coronavirus outbreak.

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