Delivery of an online psychosocial recovery program during COVID-19: A survey of young people attending a youth mental health service.

AIMS: The COVID-19 pandemic forced the rapid move of mental health services to being delivered online. This included the delivery of a psychosocial recovery program (PRP) delivered in youth mental health services in Melbourne, Australia which consists of groups that address functional recovery. At the time, there was limited evidence about how this switch in service provision would be received by service users or what impact the pandemic was having on their mental health.
METHODS: Young people engaged with the PRP between March and May 2020 were sent a link to complete an online survey that was co-developed by young people and clinicians. Attendance data at groups were extracted as a proximal measure of feasibility and acceptability.
RESULTS: A total of 44 young people undertook the survey with the domains of wellbeing most impacted by lockdown being work/study, motivation and social connection. Groups provided online were generally well attended during lockdown, particularly those that had a focus on therapeutic content. Young people indicated little preference for continuing to attend groups run purely online when restrictions eased, with many expressing a preference for these to be offered face-to-face or in a combined format.
CONCLUSIONS: These findings suggest that implementation of online psychosocial groups during periods of lockdown is both feasible and acceptable. Whilst young people found accessing groups online to be of benefit at the time, they felt that continued substitution of face-to-face groups would not necessarily be preferable and clinical services should consider these preferences in their long-term service delivery.

INTRODUCTION

The COVID‐19 pandemic has undoubtably had a substantive impact on population health across the globe since its emergence in late 2019. People's lives were significantly impacted in 2020, in part as a result of various public health interventions implemented to reduce the spread of. While these restrictions may be the most effective way of preventing the spread of the virus (Center for Disease Control et al., 2003), a major adverse consequence of these restrictions can be increased social isolation and loneliness (Holmes et al., 2020). Some of the other anticipated consequences include increased unemployment, homelessness, relationship breakdown, financial stress, lack of meaning and entrapment, all potential key risk factors for the onset and exacerbation of mental health issues (Holmes et al., 2020). Initial findings from recently published studies suggest that young people are amongst those who are experiencing the greatest increase in mental distress during the pandemic. For example, a US based study conducted amongst adults showed that psychological distress rates were higher in April 2020 compared to 2018 and that young people were one of the most affected groups (McGinty et al., 2020). A UK based study found that young people were one of the groups experiencing the greatest increase in mental distress during COVID (Pierce et al., 2020).

Physical distancing restrictions due to COVID‐19 has led to major changes in the way health care is being delivered. In many cases, mental health services have been required to reduce care to the provision of pharmacotherapy and crisis intervention (Medalia et al., 2020). Importantly, the availability of digital technology during the pandemic has allowed rapid transition to the delivery of other valuable services online through telehealth and videoconferencing platforms such as zoom. This option has allowed for continuity of care and opens up avenues for the ongoing delivery of vital therapeutic and psychosocial support during this challenging time.

The provision of psychosocial services is a cornerstone of Australian youth mental health services. This is because mental health difficulties can have a significant impact on a young person's ability to take part in everyday activities (Productivity Commission, 2020) and research has shown that a focus on psychosocial recovery during the earlier stages of intervention is necessary in order to counteract the restrictive impact of mental illness on young people's functioning (Killackey & Alvarez‐Jimenez, 2019). Psychosocial supports can include interventions that assist young people to manage daily tasks, get involved in activities, undertake work or study, find housing, participate in their community, and make connections with family and friends. Psychosocial interventions delivered in a group format can increase the social and vicarious learning amongst members who are often at different stages of illness (Burlingame et al., 2020). Group interventions can therefore create a support system which can reduce loneliness and promote belongingness—both factors that protect against suicide, self‐harm and emotional problems (Holmes et al., 2020).

In order to address the increase in potential risks for young people's mental health and wellbeing during the pandemic and to provide continuity of care when needed most, Orygen's Psychosocial Recovery Program initiated a prompt response through the use of digital technology. This move was supported by evidence from a systematic review that has indicated that video teleconference groups are feasible and produce outcomes similar to in‐person treatment, with high participant satisfaction (Gentry et al., 2019). Preliminary evidence from Wood et al. (2021) concluded that implementing online group therapy for individuals with first‐episode psychosis (FEP) during the COVID‐19 pandemic had the potential to become a standard treatment modality for clients receiving specialty care for FEP. While online, telehealth delivered group interventions had not been previously used at Orygen, this existing research and the context of the COVID‐19 pandemic enabled the rapid move to this mode of delivery and to proactively evaluate the provision of these services. Evaluating the acceptability of an online group‐based psychosocial program is essential for clinical youth mental health services to better understand how they should focus the provision of these services in the future.

The current study aimed to address the following questions relating to young people's psychosocial functioning and the provision of psychosocial supports online:

The impact of the COVID‐19 pandemic on the psychosocial functioning of young people attending a youth mental health service;

Young peoples' experiences of receiving psychosocial services online, including barriers and benefits;

What may be the preferred future delivery method of the psychosocial recovery program;

Did attendance rates demonstrate that it was feasible and acceptable to provide psychosocial groups online.

METHODS

Study design

This mixed methods study involved the analysis of routinely collected data via the Orygen Specialist Programs (OSP) Psychosocial Recovery Program (PRP).

Study setting and participants

Participants were recruited from Orygen Specialist Programs (OSP), a youth mental health service for young people aged between 15 and 24 years based in the North‐Western area of Melbourne, Australia. OSP provides services to young people with severe and complex mental illness including First Episode Psychosis, Mood Disorders, and Borderline and other Personality Disorders. All OSP clients have access to the PRP with case managers discussing the program with their clients. If they are interested, case manager and client meet with a member of the psychosocial team and a collaborative decision is made by this team (case manager, young person and psychosocial team member) around which aspects of the program are best suited to the young person and their treatment goals. The PRP provides individual and group interventions aimed at supporting young people to build on their own strengths and interests, develop stronger relationships, build skills in vocational and educational domains, better manage their physical health, and connect with their community. In Victoria, Australia the COVID‐19 state of emergency was declared on the 16th of March 2020 during which the whole country went into lockdown, with severe restrictions on social contact, ability to attend work, exercise, other recreational services, and reduced and changed access to clinical services. Therefore, all young people that were engaged in the PRP between 16 March 2020 and 24 May 2020 were invited to complete a bespoke survey on their views of psychosocial supports being provided online.

Psychosocial recovery program interventions

The PRP ran at Orygen offers a variety of groups that are delivered by clinicians and peer workers with sessions typically run once a week with sessions lasting between 1 and 2 h in length. The aim of these groups is to provide support, relevant discussions and a range of meaningful activities in a supportive peer group environment. Type of groups include support around school, study and work (vocational support); improving physical health including diet; socializing, feeling comfortable with, and connecting with others; creative activities; and learning how to manages specific problems such as mood or psychotic illness.

Prior to the pandemic, all PRP interventions were provided in‐person. In response to the “stay at home” orders issued, the PRP team developed a number of digital resources so that psychosocial supports were still able to be provided. This was done following consultation with Orygen's lived experience workforce, and young people who were already engaged in the program. All therapeutic and educational groups (e.g., about psychosis and depression) were all shifted to being delivered online using the “zoom” online platform. A “Drop‐In” social interaction group was developed and delivered on zoom in order to help young people stay connected to others and workshops on topics such as vocation and staying physically healthy were also delivered.

Measures

Demographics

Demographic data were collected on gender, age, relationship status, country of birth, Aboriginal and Torres‐strait islander status, living situation and employment/educational status using a file audit tool.

Impact of COVID‐19 on psychosocial functioning and supports questionnaire

A novel questionnaire on the impact of the COVID‐19 pandemic on young people's functioning and their views of psychosocial supports being provided online was developed. Clinicians, researchers and young people engaged in the PRP in early March 2020 were consulted about the development of this questionnaire, designed to be easy to complete by PRP attendees and disseminated using the existing text messaging service used by clinicians. The questionnaire included 31 questions relating to how much young people feel that various areas of their life have been disrupted by COVID‐19, the positives and negatives of running psychosocial activities online, their preferences for how they would like to access these activities after COVID‐19, and barriers to accessing psychosocial activities online. Participants were invited to complete the survey online using the RedCap web application.

Attendance data

Attendance data were routinely collected as part of the PRP with access to these via an online database. Data were accessed on the average number of participants that attended each session for each group or activity per month between October 2019 and December 2020. These dates therefore cover pre, during and post lockdown.

Analysis

Statistical analyses were conducted using SPSS v24 with the results presented as descriptive statistics and using horizontal 100% stacked bar charts. Qualitative data on young people's views of online groups were collated and reduced into manageable summary statements (Weber, 1990) by two authors (J. S. and E. B.). The frequency that each summary statement was reported was then presented quantitatively.

Ethics

Approval for the collection and reporting of these data as part of a quality assurance project was issued by Melbourne Health ethics committee (QA2021026).

RESULTS

Demographic characteristics

Of the 160 young people who were invited to take part in the study, 44 young people undertook the survey (27.5%), of which 56.8% (n = 25) were female. As set out in Table 1, the mean age of the cohort was 19.8 years (SD ± 3.08) with 48.8% (n = 20) having a primary diagnosis of psychosis, 36.6% (n = 15) of mood disorder and 9.8% (n = 4) a personality disorder. The majority of the cohort were born in Australia or New Zealand (75%, n = 33) and living with their family of origin (76.2%, n = 32). Regarding vocational status, 44.2% (n = 19) were full time students and 34.9% (n = 15) were not in education, employment or training. A total of 39.4% (n = 13) of the sample currently used a substance.

TABLE 1

Demographics of study sample

	Total cohort (n = 44) n (%)
Age (mean ± SD) (n = 36)	19.8 ± 3.08
Gender identity (n = 41)
Male	16 (36.4)
Female	25 (56.8)
Country of birth (n = 41)
Australia/New Zealand	33 (75.0)
Other	8 (18.2)
Aboriginal or Torres Strait Islander (n = 41)	0 (0.0)
Current co‐morbid substance use (n = 33)
Yes	13 (39.4)
No	18 (54.5)
Do not know	2 (6.1)
Education/employment status (n = 43)
Full time student	19 (44.2)
Part time student	5 (11.6)
Full‐time worker in paid employment	1 (2.3)
Part‐time worker in paid employment	3 (7.0)
Not in Education or Employment (NEET)	15 (34.9)
Living status (n = 42)
Living with parents, caregivers, or siblings	32 (76.2)
Living with friends	2 (4.8)
Living with romantic partner	1 (2.4)
Living in shared accommodation	5 (11.9)
Living alone	2 (4.8)
Primary diagnosis (n = 41)
Psychoses	20 (48.8)
Personality	4 (9.8)
Mood	15 (36.6)
Other	2 (4.9)

The impact of COVID‐19 on functioning

A total of 28.6% (n = 12) of the sample reported that their life was disrupted “a lot” by COVID, a further 23.8% (n = 10) reported life was disrupted “quite a bit”, 28.6% (n = 12) “somewhat” and 19.0% (n = 8) “a little bit”. The domains of wellbeing most impacted by lockdown were work/study, motivation and social connection, as shown in Figure 1. Those least impacted were living situation, finances and family relationships. Raw data are available in Table S1.

FIGURE 1

Impact of the COVID‐19 pandemic on domains of psychosocial functioning

Views on online groups

Young people were asked how likely they would be to attend specific groups online, with results displayed visually in Figure 2, and raw data available in Table S2. The groups that young people reported being least likely to attend were exercise and cooking groups. Young people were more open to engaging in social groups online.

FIGURE 2

Likelihood of attending online groups after lockdown

When considering preference for how groups should be delivered in the future, post‐lockdown(s), this cohort of young people indicated little preference for continuing to attend groups that are run purely online (Table 2). The most frequently reported preference was for PRP groups to be conducted face‐to‐face or as a combination of online and face‐to‐face. The activities with the strongest preference for face‐to‐face were social (47.5%, n = 19), exercise (50.0%, n = 20) and cooking (35.0%, n = 14) activities. The activities with the strongest preference for a combined approach were vocational (32.5%, n = 13) and gaming (37.5%, n = 15) activities.

TABLE 2

Participant's views of ongoing group provision method

Preference for group provision after lockdown	Social n(%)	Psychosis n(%)	Exercise n(%)	Cooking n(%)	Vocational n(%)	Gaming n(%)
Online	1 (2.5)	2 (5.0)	0 (0)	0 (0)	3 (7.5)	5 (12.5)
Face‐to‐face	19 (47.5)	13 (32.5)	20 (50)	14 (35.0)	11 (27.5)	9 (22.5)
Combined	11 (27.5)	13 (32.5)	5 (12.5)	10 (25.0)	13 (32.5)	15 (37.5)
Not interested	9 (22.5)	12 (30.0)	15 (37.5)	16 (40.0)	13 (32.5)	11 (27.5)

Barriers and benefits

The results of analysis of qualitative statements made by young people are presented in Table 3. The biggest barrier to participants attending group activities online was feeling too anxious or shy to join (67.4%, n = 29), this was followed by participants not feeling comfortable on camera (46.5%, n = 20). Participants reported that the benefits of accessing group activities online included being able to stay socially connected during lockdown (42.9%, n = 12) and convenience (35.7%, n = 10). Finding interacting online more difficult (36.0%, n = 9), missing face‐to‐face connection (24.0%, n = 6), and internet connection problems (24.0%, n = 6) were the main disadvantages of accessing group activities online.

TABLE 3

Qualitative data on young peoples' views of online groups

Qualitative data on young peoples' views of online groups
Advantages of online groups	n (%)
Opportunity for social connection whilst in lockdown	12 (42.9)
Convenience	10 (35.7)
Less anxiety	6 (21.4)
Disadvantages of online groups
Internet connection problems	6 (24.0)
Harder to interact online	9 (36.0)
Missing face to face connection	6 (24.0)
Privacy harder to maintain	2 (8.0)
Being at home and not having the opportunity to go out	2 (8.0)
Barriers to attending online groups
Feel too shy or anxious to join	29 (67.4)
Not comfortable on camera	20 (46.5)
Not interested in types/topics of groups	14 (32.6)
Poor internet/data connection	11 (25.6)
Worried about privacy/confidentiality	8 (18.6)
Not having appropriate environment/space to participate	7 (16.3)
Day/time of group does not suit	6 (14.0)
Do not have appropriate devices/technology	4 (9.3)

Group attendance

Data on group attendance were extracted from service records and summarized as attendance per group offered that month. Table 4 shows that during the months that Melbourne was subject to “hard” lockdown (March 2020–October 2020) groups that were offered were well attended, particularly those that had a focus on therapeutic content. In comparison to attendance at the therapeutic group for low mood and social isolation ran face‐to‐face before March 2020, running the same group online appeared feasibility and acceptable given that attendance numbers were similar.

TABLE 4

Attendance at psychosocial groups per group by month

	October‐19	November‐19	December‐19	January‐20	February‐20	March‐20	April‐20	May‐20	June‐20	July‐20	August‐20	September‐20	October‐20	November‐20	December‐20
Boxing		5.25		4.50	6.00	6.50
Cooking group		5.00	3.00			3.00	2.50
Walking group	3.00	3.67			1.67
Vocational workshop	2.00	2.00						9.00	4.00			8.00
Gym group	1.75	1.00	1.67
Social Drop‐in Group							5.00	4.75	5.00	5.40	5.50	7.50	5.00	5.67	4.80
Art group			2.00			3.00		2.25	3.50		5.67	3.75	3.00
Therapeutic group for psychosis									13.00	10.60	8.50	11.00	9.00	5.67
Therapeutic group for low mood and social isolation	6.00	4.33	4.00		8.00	7.00	6.50		9.00	6.67	10.33	8.50	7.20
Physical health workshop												14.00		3.00
Totals	12.75	21.25	10.67	4.50	15.67	19.5	14.00	16.00	34.50	22.67	30.00	52.75	24.20	14.34	4.80

DISCUSSION

This study reports on the findings from a survey of young people engaged in the PRP at a specialist youth mental health service with regard to the impact of the COVID‐19 pandemic on their functioning and their views on accessing online psychosocial groups. Overall, young people reported that running groups online allowed them to have some social connection at a time when physical distancing restrictions were in place. Doing so appeared feasible and acceptable given attendance rates at online groups but preference remained for psychosocial groups to be delivered face‐to‐face as well as potentially online when restrictions allowed. We found that over two thirds of the sample reported that social connection was disrupted by the pandemic. This unsurprising finding is inline with previous studies showing that restrictions around physical distancing due to the pandemic have contributed to feelings of loneliness and a lack of social support in young people (Jones et al., 2021; Munasinghe et al., 2020). Concerningly, these factors are strongly associated with anxiety, depression, self‐harm and suicide (Holmes et al., 2020), indicating that the provision of services which support young people to stay socially connected during periods of lockdown are an important aspect of mental health intervention that should be built into youth mental health services globally.

The results of this study highlight that the biggest benefits of conducting group programs online were that young people were provided with an opportunity to stay socially connected during the pandemic and that attending groups online was convenient. Similar to findings from Childs et al. (2020) and Medalia et al. (2020) the findings indicate that there is utility to conducting groups online during periods where physical distancing restrictions are in place, and possibly even where face‐to‐face groups are not accessible for other reasons such as geographical distance or transport difficulties.

In the present study, participants indicated little preference for continuing with online activities outside of lockdown periods. Instead, participants conveyed a desire for activities to be delivered face‐face or as a combination of online and face‐face, dependent on the type of activity. Studies regarding preferences for online versus face‐face group intervention are limited, and those that exist vary in their conclusions, with some reporting that online delivery has the potential to become a standard treatment modality (Wood et al., 2021) and others reporting that it is worth considering ways that online groups can be incorporated into current service models (Lal et al., 2020). Findings from the current study suggests that further consideration around the integration of online groups and face‐face groups will be useful.

Clinical implications

As the COVID‐19 pandemic restrictions continue in Australia and across other parts of the world, findings from the current study provide an opportunity for clinical youth mental health services to better understand where and how to focus the provision of psychosocial services during lockdown periods. The current study also provides some insight into the future use of online modalities to deliver group‐based programs suggesting blended models may be helpful where appropriate.

Recognition of the need to provide opportunities for social connection during lockdown periods is essential for those delivering youth mental health services. The current study suggests that it is acceptable to provide online social groups to promote connection between young people when physical distancing restrictions are in place. It is important to note that two thirds of participants reported that feeling too shy/anxious was a barrier to attending a group online. Further investigation into the reasons that young people feel shy or anxious may allow the development of specific interventions to reduce these barriers and increase the likelihood of engagement in online groups. For example, if young people are anxious about using online platforms, basic technological support and trial one‐to‐one sessions prior to joining a group may ease these concerns. Alternatively, if young people are anxious about being on camera, as was indicated by nearly half of participants in the current study, alternative options to camera use could be discussed.

The results of this study suggest that while young people found accessing psychosocial groups online during lockdowns to be of benefit at the time, they felt that continued substitution of face‐to‐face groups would not necessarily be preferable. The main disadvantages of online groups reported in the current study included: finding online interaction more difficult, missing face‐face connection, and internet connection problems. These findings are consistent with previous studies highlighting that incorporating interpersonal dynamics between group members online (Gentry et al., 2019) and the loss of human contact (Lal et al., 2020) may pose unique challenges to delivery of online group interventions.

The current study suggests that future service delivery should continue to offer group activities in‐person, however in circumstances where this is not possible or not accessible, online group activities provide a suitable alternative. One option, where possible, may be moving groups to be undertaken outdoors, particularly in the case of physical health interventions. In order to address some of the disadvantages associated with online group activities, clinical services may benefit from providing clinicians with access to training specifically focusing on facilitating interaction and managing interpersonal dynamics online. Furthermore, ensuring that clients accessing online groups have the appropriate level of internet access or facilitating such resources will be important.

Limitations

The results of this study need to be considered in light of the following limitations. First, this was a descriptive study of a convenience sample and contained no comparison group or randomization. It also consisted of a sample of young people who volunteered to complete the survey, that is 27.5% of those who were invited to undertake the survey responded to the request. Therefore, the findings may not be comparable to the wider clinical population that uses the youth mental health services. We also do not have data on how the sample who completed the survey compared to those who chose not to engage in the PRP or not complete the survey. Recruitment from one service may also mean these data are not representative of young people with mental health difficulties from a different location, both in Australia and globally. Finally, data relating to the effectiveness of online groups in improving social and occupational functioning were not collected, and it is therefore not possible to establish what impact online groups had on participants' psychosocial functioning.

CONCLUSIONS

The results of this study indicate that the COVID‐19 pandemic and associated physical distancing restrictions have led to disruptions in young people's psychosocial functioning, particularly in the areas of social connection and work/study. The findings suggest that implementation of online group activities to promote social connection during periods of lockdown is both feasible and acceptable. Whilst young people found accessing groups online during lockdowns to be of benefit at the time, they felt that continued substitution of face‐to‐face groups would not necessarily be preferable. Research in the area of online group interventions is limited, and studies comparing the effectiveness of online and face‐face groups in improving young people's functioning would be beneficial.

Appendix S1: Supplementary information.

Click here for additional data file.