Let's keep talking

Steve Flatt and Suzi Curtis (The Psychological Therapies Unit, Liverpool) on how Covid disrupted mental health service delivery, but in a positive way…

As a community we know that in addition to reducing the accessibility of face-to-face services, the Covid-19 pandemic has negative implications for mental wellbeing across the country. During the first lockdown, one survey found that 24 per cent of UK adults and 44 per cent of young people (aged 18-24) reported experiencing loneliness during the lockdown period (Niedzwiedz et al., 2020), while the most recent predictive model developed by the Centre for Mental Health (in collaboration with the NHS) has estimated that up to 10 million people (almost 20 per cent of the population) in England could require new or additional mental health support as a direct consequence of the crisis. The majority of these are expected to need support for anxiety, depression, or both, with a significant number also struggling with bereavement and/or trauma (O’Shea, 2020). 

So, what can be done? Continuing to deliver established mental health service models is one answer. But these were under strain pre-Covid. Disruption offers opportunities for innovation, so at the Psychological Therapies Unit (PTU), Liverpool, we seized the opportunity and embarked upon delivering a new talking therapies service, a telephone service, 'Let's Keep Talking'.

Our service is delivered by a combination of professional therapists and trained volunteers, solution-focused practice our preferred approach. We designed the service so that individuals are able to refer themselves into the service by calling a phone number or emailing an email address, both provided on flyers distributed to relevant organisations and shared via social media. We then get a trained volunteer to explore their hopes from the service and pass their details on to one of the callers to call at an agreed time. 

The service is entirely free and open to anyone in need. There are no long waiting lists and no assessment process to determine eligibility. Clients are also not limited on the number of calls they can receive, and call length is dependent on their individual needs and preferences, though these are generally limited to a maximum of around 30 minutes. Calls are centred around a structured conversation with clients about what is helping them to keep going and how they would like to be coping, also allowing space for clients to talk openly about their issues without being told what to do.

Does it work?

We asked our colleagues at the University of Liverpool, Professor Philippa Hunter-Jones, Chloe Spence and Dr Rachel Spence, to undertake a separate evaluation to find out for us. They interviewed clients and volunteers to better understand this, asking clients about entering into the service, their experiences and impact of the service, and volunteers why they volunteered along with their experiences and impact of the service. Clients and volunteers identified a number of benefits from which four overriding themes can be identified: accessibility and immediacy; collaboration and flexibility; the mitigation of isolation; and trust. The solution-focused approach underpinning the service was associated with various benefits, with clients describing how this: helped to alter their perspectives; enabled them to think more optimistically or proactively; to recognise their strengths or resilience; and focus on their desired futures. 

Thinking about the longer-term place for this service we got the team to explore what does it do that other established services are not already doing? The feedback identified a number of features which make it particularly inclusive and innovative: it has the flexibility to be responsive to client needs in an all-important timely fashion; it is entirely free; it does not operate an eligibility assessment process. It is open to all; there are no long waiting lists; there is no limit to the number of calls a client can receive; call length is dependent upon individual needs and preferences; calls are structured to enable client-centred conversations; clients receive calls from the same volunteer unless they choose otherwise. When we compare this to the other services being offered in this geographical area, none offer this agility. 

Is the service scalable to a national roll out?

One of our key advantages is that we enable both client and practitioner the facility of arranging calls by the use of an app that we devised ourselves to simplify the booking system. It is not carried out centrally, nor is there a bottle neck of triage and assessment. The system enables flexibility so fewer calls are lost and the client is able to engage actively with the service and with their own therapist. Calls are also at mutually convenient times for both client and practitioner, so again less call time is lost.

We employ people from all over the UK (and other parts of the world – who are learning about the service to use it elsewhere). We train people to use the solution focused conversation structure, and this can be done easily and relatively quickly. Clients have easy access to feedback to help monitor the effectiveness of practitioner interventions. We also ask practitioners to record sessions for quality checks and for preparation for accreditation. 

The big difference we consider we have achieved is that of fast response, immediate effective intervention that seeks progress rather than information through assessment. Information that is of questionable value to both therapist and client in any case (defining a problem does not produce a solution). We also do not use medicalised language (another big barrier to clients) but use the client’s own language to help develop the conversation. 

All these differences that create impact (McLean et al., 2020) offer the possibility that this service would be much easier to scale than a traditional medically based service which brings the client into an alien world with a new language and culture that they have to comply with. Rather, we go to the client in their world and work with what is real to them in their language at a time when they are already often confused and bewildered by the distress they are suffering as a result of their experiences.

Finally, our practitioners are universally feeding back that they enjoy the work, the learning and the conversations they have with their clients, simply because they see progress quickly and which appears to be sustained (a long-term research study will be necessary to confirm this).

So, is there a place for the service in our post-pandemic lives? We would argue that speed, agility and personalised support have to be central pillars of any approach to meeting need in the 'new normal'. Our approach offers a chance for some clients to resolve their issues themselves without deteriorating on long waiting lists. How many other services offer that at the moment?

References

McLean, R. Gargani, J. Lomofsky, D. (2020). Scaling what works doesn’t work: we need to scale impact instead

Niedzwiedz, C. L., Green, M., Benzeval, M., Campbell, D. D., Craig, P., Demou, E., ... & Katikireddi, S. V. (2020). Mental health and health behaviours before and during the COVID-19 lockdown: Longitudinal analyses of the UK Household Longitudinal Study. medRxiv.

O'Shea, N. (2020). Covid-19 and the nation's mental health: forecasting needs and risks in the UK.

Royal College of Psychiatrists. (2020, October 6). Two-fifths of patients waiting for mental health treatment forced to resort to emergency or crisis servicesRoyal College of Psychiatrists.. 

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