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15 May 2020updated 31 Mar 2021 3:32pm

The rise of the virtual therapy session

Social distancing has meant mental health support has gone remote. But can video conferencing really replace face-to-face sessions?

By Samir Jeraj

Before lockdown started, Hannah saw her therapist every week for anxiety, depression and post-traumatic stress disorder. But since the mandating of social distancing to stop the spread of Covid-19, the face-to-face sessions have become phone calls. Finding a private space for therapy in her north London flat means sending her partner out for a walk. It also means disrupting Hannah’s ritual of taking time on the bus to think about what she wants to discuss, and using the journey back to process the session. 

“I’m really missing being able to see their face and their reactions,” Hannah says of her therapist. “It’s hard to read their sympathy in their voice.”

Mental health services, particularly talking therapies, have been provided over the phone and online for decades. But the pandemic has forced even the most traditional of services to take the plunge to offer virtual support.  

“All my clients wanted to continue working and were prepared to move to online platforms,” says Fiona Ballantine- Dykes, a therapist and the deputy chief executive of the British Association for Counselling and Psychotherapy (BACP). While she has done online work before, Ballantine-Dykes says that now it is “different” because people have not chosen to have their therapy this way, and are often used to face-to-face meetings. The vast majority of BACP members (88 per cent) are also moving their practice to online, or sometimes telephone, therapy. 

In the NHS, the picture of demand across mental health services throughout the pandemic has been varied. At the end of January, a total of 1,394,378 people were using an NHS mental health service, including 352,081 new referrals. In the past year 163,182 people were referred to talking therapies on the NHS. Of these, 51,225 were getting treatment for depression and anxiety through cognitive behaviour therapy, Interpersonal Psychotherapy, and counselling. 

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Since lockdown Improving Access to Psychological Therapies (IAPT)services have had to cancel face-to-face appointments, including services covering most of London, as well as others in Manchester, Leeds, Sheffield and Merseyside. Referrals to mental health services have also fallen by 30 to 40 per cent during the pandemic, Claire Murdoch, NHS England’s national director for mental health, said when answering questions from MPs on 1 May. Child and Adolescent Mental Health Services have similarly reported a big drop in referrals – as high as 50 per cent in Birmingham. Some professionals fear this means problems are being stored up for once the pandemic ends. 

But there has been a dramatic rise in demand for some voluntary sector initiatives. For example, the number of calls to eating disorder services has risen, with charity Beat reporting a 30 per cent increase in people seeking support through their helpline. Eighty-three per cent of children with mental health needs said the pandemic had made their mental health worse, according to a survey by the charity Young Minds. A quarter of those children who had regularly received help were going without it during the lockdown. At the end of March, Murdoch, said in a letter to IAPT services to prepare for a rise in people needing help with the mental health effects of isolation, bereavement, and trauma as a result of the coronavirus crisis. 

An NHS spokesperson said there has been a “significant increase in phone and video consultations and online support” in response and anticipated that these services “will continue to be the right choice for many in the coming months and years”. However, they said that “face-to-face appointments have been and will continue to be available for anyone who needs them.”

The spokesperson also said the NHS is “pulling out all the stops” to respond to the coronavirus while “ensuring people can still safely access the mental health services they need”. They added that anyone experiencing poor mental health should “please help us help you, and come forward for the care you need.”

 “A lot of our assessment is about how we relate to other people”, says Dr Billy Boland, chair of the faculty of general adult psychiatry at the Royal College of Psychiatry. Communication and building a rapport is particularly important because many of the tools psychiatrists use to assess someone’s health are about how they interact and even how they move physically. 

“You are really starting from the moment you first see them,” he says, “how they look, how they behave, how they might stand up from their chair, how they walk towards me, how we greet each other.” Doing this online can be difficult, but remote consultations mean people who might struggle to access appointments in person because of work, care commitments or physical access can get help. 

The BACP has launched an Open University module to help train practising counsellors in delivering therapy online while maintaining ethical and professional standards. “It’s about… helping people make the transition, as well as saying ‘hang on a minute’, there’s also additional learning knowledge and skills that you need to develop to permanently move your practice online”, says Ballantine-Dykes. One of the challenges for clients is finding a safe place to have a therapy session, she says, especially in cases where somebody is in lockdown with lots of people, or with the people they need to talk to their therapist about. 

Services provided by the voluntary sector have had to adapt quickly, too. Kathy Roberts from the Association of Mental Health Providers, says that a lot of organisations, particularly those with a specific focus such as anxiety, obsessive-compulsive disorder, or phobias, have expanded their helpline support over the weekend and for longer hours to cope with an increase in calls and website hits. 

Others are shifting activities such as peer support and group sessions online as much as possible, but not everyone has the technology and equipment to make that happen. There is a great strain on resources, despite an extra £5m of funding released by the government to help charities support mental health. The reality is that parts of the sector, particularly specialist black and minority ethnic mental health providers, were chronically underfunded and financially fragile before the pandemic. In some cases, such groups are drawing on their cash reserves, and in others staff have been seconded into the NHS, or are suffering directly from the virus or symptoms meaning further pressure on staffing and volunteers. 

Those with a pre-existing anxiety disorder have particularly struggled, says Roberts, as isolation may have disrupted activities they have developed to manage their condition. The lack of available care coordinators and community psychiatric nurses means the people who headed into the crisis with existing mental health problems are at risk. This prompted the launch of NHS crisis urgent helplines to be brought forwards by a year to 10 April 2020 in order to cover some of the gaps that had emerged. In mid-March, half of mental health trusts did not have a public-facing 24/7 mental health support crisis telephone line according to a “rapid audit” undertaken by NHS England, which Murdoch mentioned in her letter. The audit found that some of these services were still hard to find on Trust websites, and others directed people to 111, 999 and A&E services.  

Additional support for front-line NHS staff has also been in greater demand. In the north-east, two mental health trusts are sending staff to help divert NHS 111 calls for people needing mental health support, leaving 111 operators to focus on people in crisis, and keeping people out of emergency departments. One of the trusts, Cumbria, Northumberland, Tyne and Wear NHS, is using digital to support the mental health of their staff and have set up virtual “wobble rooms” for staff to regularly talk and share their experiences as the work to counter the pandemic.

“It’s going to change things for the good as well,” Ballantine-Dykes says. In the long-term, she is expecting a greater need for counselling and therapy as we move beyond the current crisis and start to address the trauma we have all experienced. Already around a quarter of people referred to counselling or therapy from BACP members say it is because of coronavirus, and the related impacts of social isolation, financial concerns, and bereavement.

This article originally appeared in the New Statesman’s Spotlight report on mental health of May 2020. Click here for the full report.