There were 320 responses to the young person survey. Of the 48 participants (15%) who reported receiving online mental health care in place of usual face-to-face services during COVID-19, 38 (79% of those receiving online care) provided free-text responses (Table 2). These participants were mostly female (71%) and had a median age of 19 years (range 14 – 24 years). Characteristics of the total survey sample are reported elsewhere [28].
Eleven young people expressed interest in participating in a focus group. All were eligible and took part, resulting in three groups composed of six, three and two participants. Seventeen practitioners responded to adverts but two were not eligible (trainee, unqualified). The remaining 15 were invited and took part, seven attending focus groups (n = 3 group 1, n = 4 group 2) and eight attending a one-to-one interview. The young people were females and one non-binary participant, aged between 16 and 24 years and reporting a range of mental health difficulties. Mental health practitioners were from varying settings and had been practicing for between 5 and 43 years (median, 18) (Table 3). Five parents expressed interest in participating; four took part. All were mothers. Together, they had supported five young people (3 male, 2 female), receiving remote appointments at the ages of 10, 16, 19, 20 and 23 years due to presenting issues of anxiety, emotional dysregulation, self-harm behaviour, eating disorder, depression and bipolar disorder.
Thematic analysis
We conceptualised five key themes. Participants focused primarily on issues relating to i) appointments being situated within the private space of the home, this being the typical site of remote appointments (‘home as clinic’) and ii) on the impact of remoteness on therapeutic relationships and interpersonal communication between practitioner and patient (‘disrupted therapeutic relationships’). This prompted discussion about the quality and safety of a remote exchange centring around the further three themes of iii) ‘difficulties with engagement’, iv) ‘uncontained risk’, and v) the ‘scope of care provision’ where this is provided remotely.
Home as clinic
Young people and parents commonly contrasted the familiarity of their home environment to appointments held in ‘unknown’ formal settings. Home could afford feelings of comfort, relaxation and safety, which could facilitate participation. This included having ‘a hot drink’, drawing on comforting objects and having supporters nearby.
I deffo like [online support group] better – can play with playdoh/ kinetic sand at the same time. (YPs).
[Daughter] asked if it would be okay to do [appointment] in her own room… I feel that is working because she’s in her safe space and she’s able to engage one-to-one without feeling threatened because she’s in her comfort zone, she’s got her cushions around her and she’s very often got the cat because he is like her comfort cat (P3)
One parent described ‘moving’ therapy to capitalise on this opportunistically:
We’ve got like a little snug room downstairs and [son] sort of sees that as his space… he tends to be in it most of the time. And so he’d been watching something on TV and so I went and sat next to him with the laptop there (P1)
Online appointments also presented a welcome alternative for young people whose symptoms made it difficult for them to leave the house or meet others.
I have severe anxiety and depression so going out is such a big deal for me… for me it’s [remote appointments] a lot of pressure taken off. (YPfg1)
Some practitioners noted that connecting with a young person at home could create a more naturalistic exchange, affording insights into the living environment, unexpected inroads into private narratives or opportunities for rapport building.
I’ve met so many pets and stuff led to stories and actually told us information… it’s opened up a whole number of possibilities. (MHPfg2)
However, for some young people, bringing appointments into the home encroached upon a space and identity they preferred not to associate with their mental health difficulties, and two described how ‘meeting’ at home denied them the helpful “ritual of going to appointments” (YPs):
I’m not in the headspace, I’m just at home, which I don’t like. Part of that is just getting the nervous energy out by walking there… for the whole morning I was just not doing anything, fretting about [appointment]. But if I like had to get a shower and go there that would be better for me. (YPfg2)
All participants agreed that having a confidential space to join appointments at home could be problematic, especially if presenting problems involved family members or young people. Fear of being overheard or witnessed as a patient was a barrier to disclosure:
It was much less private due to being in the same building as parents, so I couldn’t talk about some things. It didn’t help at all (YPs)
Parents were required to manage space to enable appointments:
Her room’s next door to her sister’s. So, I explained to her sister that on a Wednesday between 10 and 12 you can’t go in your bedroom… Luckily the weather was quite nice so we could sit out on the balcony (P2)
Practitioners noted how holding appointments in a chaotic or non-private environment could result in a suboptimal exchange.
Many of the people I work with have big families. There are loads of kids running round… then you’re going to be careful about which kinds of things you ask… often people can’t talk as well. They’ll be like, ‘[vocalises muffled noises]’, and I can hear there’s loads going on for them (MHPi4).
Disrupted therapeutic relationships
The impact of remoteness on communication between patient and practitioner was a common concern. Parents and young people described struggling to ‘open up’ to ‘a stranger talking over a screen’ (P1), commenting ‘I feel like we don’t really know each other as well as if it was in person’ (YPfg3). Similarly, practitioners questioned whether it was possible to establish or maintain comparable relationships to those built offline:
Students that have been referred since lockdown, we’ve said as a team, we’re all struggling to remember them…there’s definitely a feeling that we’re not as close, as connected… It’s quite sad not seeing students that I was seeing face-to-face and going to ringing and video calling them and that does change the relationship that was already there (MHPi8)
You can build the relationship with people over a computer screen but whether it’s the same, I’ve got no idea. (MHPi6)
Some participants explicitly linked in-person contact with trust:
With a lot of therapists, it’s about that really deep trust relationship and maybe not being able to see a person face-to-face despite it being on Zoom, for stuff like that I find it very difficult (YPfg2).
I’m so concerned of the importance for me as well as for the young person of that relationship on a face-to-face level for engagement, for privacy, for connection and for trust. (MHPfg2).
Young people also discussed how remoteness may hinder practitioners from imparting other important components of a therapeutic relationship such as empathy, attention and reassurance.
It’s hard [online] because you don’t really understand if someone’s like showing you empathy, like you don’t have that. They can tell you what you want to hear but you don’t know if they really care because you’ve not got the eye contact, like face to face. I think that’s vital (YPfg1)
I prefer face to face just because I think it’s easier to read body language and so it’s more, like, reassuring (YPfg1)
However, a contrasting observation by one practitioner was that distance between practitioner and patient can also be advantageous:
Nonetheless I mean, yeah, like I said people are disclosing much sooner I feel than they would otherwise, so there’s something around the sense of anonymity (MHPi4).
Of fundamental concern was the potential for remoteness to disrupt non-verbal communication and a practitioner’s observation of their patient. Some practitioners expressed this as being denied part of their clinical toolkit, which removed the opportunity to attain a more nuanced understanding:
I’ve been a child psychiatrist for twenty years and I’ve spent all that time honing my skills in working with people face to face … in the room, working with the non-verbal communication, you know, the unsaid and all of that, that feeling that you get about don’t go there, all of that is in the room. Doing it online is completely new (MHPi6)
I get more out of a discussion being in a room with someone, thinking about what’s that emotion that I can feel, what’s being transferred from this young person, how can I use that. Silences don’t feel so awkward because you’ve got all that body language and the non-verbal communication, it just gets lost on a screen (MHPfg2).
Parents and young people similarly acknowledged these limitations in both new and established relationships:
You have eye contact over a screen, but it’s not the same as sitting in a room and I suppose [practitioner] would observe things about [son] like, ‘Oh J, you’re sitting on the edge of the sofa now, what’s wrong? (P1)
Soon as we were able to go face to face that worked better … being able to read body language and like signs and as your clinician gets to know you. I know with my therapist, she knows from certain things I’ll be doing with my hands for example, she can tell if I’m like anxious or whatever. So, if I’m sitting [on Zoom call] and she can’t see anything necessarily, it’s really difficult (YPfg2).
Other examples implied a good therapeutic relationship can be built remotely. Some suggested the personal characteristics of the practitioner may be of heightened importance while others alluded to a learning curve:
At the beginning, I definitely found it easier working online with the people that I knew already. But that’s just because I wasn’t very practiced at working online. But actually, some of the newer people I’ve only ever worked with them online and it’s been absolutely fine and they’re doing really well (MHPfg2)
Difficulties with engagement
Challenges with engagement were commonly reported, both in relationships that had commenced remotely and those that were pre-existing. A direct difficulty was where a young person refused to join an appointment or dropped out.
[Son] was sort of sticking his feet up in front of the camera and wriggling around the bed and trying to kind of hide behind me…Within about a minute of the counsellor asking him how he was, had he thought of a goal, he said, ‘I don’t want to bloody do this’, slammed the laptop shut and ran off (P1)
Parental engagement could also be difficult:
A lot of young people have found it really easy to not engage, either not answer their phone, or video calls, or text a few minutes before, say they’re too busy… Parents as well! … they can say, ‘no, not today. We’re busy,’ and not quite appreciate the importance of the support. (MHPfg1)
All participant groups noted that the nature of remote appointments permits avoidance – though some young people also recognised this was undesirable:
If you’re sitting in a room with someone, it’s very hard to walk away isn’t it. ‘Bye bye’. That’s the downside to [remote appointments]. (P2)
If I go face-to-face I’m less likely to back out than online because it’s easy to just disappear (YPfg2).
I did not like it as I could easily miss sessions without having to explain myself (YPs).
Poor engagement was explained in various ways—a virtual appointment: cannot hold the attention of a child who is ‘easily bored’ (P2); may cause anxiety; exacerbates pre-existing difficulties in relating to a practitioner; or is confronting because the young person has to ‘witness’ themselves as a patient, seeing their own expressions reflected on the screen. Some participants also described it resulting from the content of what was offered remotely, for example, usual therapy being replaced with an inappropriate online alternative, or the young person finding virtual therapy distressing but being unsupported due to the remote context. For one participant, this compromised future care:
Now she doesn’t do group because she can’t cope with it online. It’s quite easy on zoom if you’re not coping to shut that laptop down. Or she’d mute it and turn the camera off and just say I’m listening, but she’s not… and now she’s not allowed any therapy because she couldn’t cope with zoom. So now that’s it, finito. She won’t get a one-to-one. If it had been different, if she’d been going to a group there would have been more support. Virtual support didn’t cut it I suppose… the only contact she had was from the guy that runs it and he said if you don’t come next week, it counts as a fail… they kick you off (P2)
However, one practitioner offered the contrasting interpretation that their patient’s disengagement was a positive sign that the young person was acting to preserve the therapeutic relationship by disengaging where they found therapy unhelpful:
One client often hangs up on me when they feel that, ‘actually you know what? I’ve had enough of this conversation now and I’m taking control’. But every week we speak again. And I don’t know whether that would happen if they knew they had to sit through 50 minutes of me kind of asking them questions [laughter] (MHPi4)
Where engagement was problematic, parents could inadvertently become a conduit, engaging for the child or adopting a quasi-professional role in an attempt to assist therapy or plug gaps in services. This created tension and fears about inadequacy.
[Daughter] was dead nervous because obviously she’d never done video calling… So I said, ‘well I’ll sit with you’… she was really anxious the following week when she was going to do it by herself to the point where she wanted to throw up… It got to the point where I put an I-phone on loudspeaker and [she] would stand beside me but again she wouldn’t engage. She’d be like “yeah” “no” and she’d be looking to me all the time to answer for her…. Her caseworker actually said to me [daughter] is very fortunate because she has got you and we know she’s being fully supported and I thought well that puts a lot of pressure on me… you’re just thrown back to the lions basically. It was a very scary time. (P3)
Other problems with engagement were more subtle, exhibited by patient behaviours such as not creating sufficient time or space for appointments, having divided attention, behaving informally, opting for telephone rather than video calls, or attending sessions with cameras switched off.
They’ll go, ‘I’m at a supermarket’ and you know, they’re walking round Sainsbury’s pouring their heart out to you. You go, ‘are you sure?’ ‘Yeah, yeah, fine, carry on’ … one of my colleagues had a video call and the [young person] was in bed, in her pyjamas which weren’t particularly covering and then it turned out that somebody else was in the room as well and he was a bit like, ‘look’ I’ll ring you back in 10 minutes, you know, you need to get dressed, to get up and maybe we can have a chat when it’s just you in your bedroom’ (MHPi8)
Some young people, who I hadn’t met before, refused to put their camera on during a risk assessment which was extremely difficult. I think that is hugely problematic at the moment. (MHPfg1)
Such digressions from usual doctor-patient encounters could be difficult for practitioners to manage or interpret, particularly where there was no prior relationship, and could raise safeguarding concerns, discussed in theme iv, below):
There’s very few [young people] that will sit, say like [other focus group participant] is sitting where you can feel you’re having a conversation…. Say we’re on a video call and they’re on their phone or they’ve got their game station playing, I found that really tricky. Where the relationship is already there, it’s easy to say, ‘Pick it up and talk to me,’ but with some, it’s very, very hard because you don’t know if they actually need that distraction before they can engage. (MHPfg1)
Often times people are eating or that kind of thing that because it’s, you know, you’re not face-to-face, it’s not so formal and you can kind of lounge around and snack. And it’s quite hard to manage those sorts of frames and boundaries and for it to feel professional.
Uncontained risk
Participants discussed how the practitioner’s physical absence afforded them less control. A primary concern was around the safety of provoking emotion yet being unable to intervene sufficiently to manage this.
Speaker 1: Our therapy is often going to raise their emotions [other participants expressing agreement]. Yeah, and then we press the off button.
Speaker 2: Normally if at the end of the session someone was stressed, someone in the nursing team would be able to help them through that. Some of them [receiving remote therapy], their parents are at work, would be on their own. (MHPfg2).
These concerns were felt acutely by parents who felt left to sweep up strong emotions.
[Daughter] said “Mum [online group] was really hard. Everyone was talking about things they really shouldn’t be”…It got to about midnight and she was still not coping … On the second week she came downstairs and said “I’ve logged out, I can’t do it” … I said explain that they’re talking about things that are quite triggering ..,But they were very much like ‘well it’s group, you’ve got to do it’. (P2)
Two parents noted that remote practitioners are also less able to monitor changes of mood during an appointment, especially if cameras are turned off.
I’d literally be holding the phone and [daughter]’d be stood there in tears while [caseworker] had been talking …because [caseworker] couldn’t see her, she didn’t know those words she was saying were impacting so badly. If she’d been face-to-face, she’d have seen that the minute she said that, that’d triggered that emotion (P3)
While some young people also expressed these concerns, their comments were juxtaposed with alternative perspectives about the safety and comfort of home as a setting for therapy (above). The helpfulness of being surrounded by coping strategies was identified as a positive aspect of remote appointments.
I found online therapy a lot more helpful because I found [therapy] like quite a risky situation for me. Because I live with loads of things in my head it would be really hard to go home. So, I found it a lot easier and not only that I’ve got my room and I’ve got my blanket if I want to just go to bed and just lie in bed after. I can speak to my family, yeah so being in like my safe space is actually a lot more helpful. (YPfg2)
Practitioners extended discussion to the challenges of managing high-level risk and disclosures during remote sessions.
You have less control of what you’re doing, so for example if someone has said they’re about to kill themselves… people can handover their means of suicide, which I have done in the past. You can’t do that remotely (MHPi1).
Practitioners were at differing stages in anticipating and responding to the challenges raised:
I had a session a couple of weeks ago where a young person went to get a knife in session so again it was like that wouldn’t happen [in service setting]… without wanting to sound too dramatic, the worst case scenario was someone harming themselves on screen whilst being completely unable to stop it. So that’s one thing that’s stuck in my mind and we’re [the team] still thinking about it… (MHPfg2)
I have to be quite clever about using messages as well as visuals and stuff if I think there’s something else going on [in home environment]… If it’s an acute risk, I kind of come up with something quite crazy, something like, ‘what I’m going to do is show a video to you and I’ll type in the thing that will keep the video on while I’m going to get the police. So, yeah, you have to think fast. (MHPi1)
Risk also related to safeguarding concerns. Remoteness rendered practitioners unable to ensure a confidential space, uncertain about the privacy of the space they were operating in and sometimes struggling to navigate obvious transgressions to confidentiality.
I’ve got one boy… I think [there are] some very dysfunctional adults who are piling into those conversations with us… I’m not entirely clear, because he doesn’t put his camera on, whether he’s got a conversation going alongside as well (MHPfg1).
[Patient’s] always been in her bedroom and at the end of the [third] video call, she shifted her laptop and there was a mirror on the wall behind her and there was somebody sat on the bed I could see reflected in the mirror… I don’t know how to address that… should I have said, ‘actually, this needs to be confidential and you need to be in a space we’re not overheard’, or do I trust [patient’s] instincts and as long as they are happy in the environment (MHPi8)
Scope of care provision
Participants (particularly practitioners) discussed how delivering mental health services remotely may impact upon the scope of what can be offered, though it was evident that experiences varied according to the type of service provision that was being transferred for remote delivery and a range of types were represented within the sample from student counselling sessions, through family therapy and group sessions, to inpatient care.
Remoteness could increase accessibility because it offered a convenient and anonymous solution for those who are anxious or hard to reach. This extended to the inclusion of ‘dads in family therapy’ and working or separated parents who could ‘hop out for a video call’ (MHPfg2). Some found remoteness allowed them to extend their services. Improved continuity and an extended duration of care could be offered to students outside term-time as geographical constraints became unimportant; and meal support for eating disorders could be carried out at home and with parental involvement, instead of being limited to a clinical service setting. It was argued that remote appointments may be a tool for building independence and treating some young people at home when they might otherwise have been hospitalised.
There were one or two young people who were on the edge of needing specialist EDU [Eating Disorders Unit] so being really separated from their family at the time when they needed them most, but the Skype has enabled them to stay at home. I think that’s a huge benefit…for us to see what it was like in the family home, what the young person was experiencing, what the parents were having to cope with. (MHPfg2).
However, other practitioners argued that remoteness limited what they could deliver. They deemed some types of therapy highly problematic and were uncertain whether remote assessment could be carried out satisfactorily.
Certain things we can’t do, for example if you’re doing PTSD work, grounding is very difficult to do when someone’s not in the room. Exercises like mindfulness are very, very hard. Physically giving them objects to look at, focus on. (MHPi1).
Further, one practitioner implied that concerns about being able to contain risk (above) could limit the line of enquiry.
If I’m in a room with someone I can really gauge much better… ‘Do we need to kind of help them come back into a normal, you know, ‘this is the world we’re living in and what are you going to do today?’ If they’re already in this really chaotic situation, which many people are, I’m not going to push a question or something related to an issue that could be really distressing for them because I know that there’s nothing to contain it (MHPi4)
This led to a feeling of holding – ‘literally just supporting’ (MHPfg2)—rather than progressing treatment for patients, which was also evident in the accounts of some young people and parents. Yet, for others, there was a sense that over time they had adapted to new, successful ways of working:
Actually what we’ve found is that we are treating people and we are bringing them forward in their recovery. Whilst we’re working differently, people are improving and they’re having positive experiences from their input. (MHPfg2)