Reflections on intervention delivery

We experienced telehealth, in this context, as patient-focused, safe and efficient. This is in line with best available evidence supporting the feasible implementation and acceptability of telehealth for mental health service users (Santesteban-Echarri et al. Reference Santesteban-Echarri, Piskulic, Nyman and Addington2020), research identifying clinicians’ largely positive attitudes towards telehealth (Connolly et al. Reference Connolly, Miller, Lindsay and Bauer2020) and case examples describing telehealth’s benefits in psychosis management (Donahue et al. Reference Donahue, Rodriguez and Shore2021). A multidisciplinary team was necessary for delivery of condensed, concise, dynamic, educational presentations and the provision of vital support to families. In intervention delivery, we needed to be flexible and agile to engage in real-time team working and problem solving.

We believe certain features of PERCEPTION augmented accessibility, improved families’ engagement in care, and contributed to our positive experience of providing it. We hypothesise that the blended approach adopted fostered trust, and consequently engagement, by enabling us to get to know families initially through in-person interaction (Farrelly et al. Reference Farrelly, Lester, Rose, Birchwood, Marshall, Waheed, Henderson, Szmukler and Thornicroft2015). Families appeared happy to engage with this type of intervention as it could offer a safe and secure environment, enable participation from any location with an internet connection, and reduce carer burden (through enhancing ease of access to services – from home). While the experience of clinicians feeling ‘uncomfortable’ in situations involving high expressed emotion, complex countertransference reactions, and high-risk disclosure online have been previously reported with telehealth (Richardson et al. Reference Richardson, Reid and Dziurawiec2015), we perceived the online environment not to be conducive to such occurrences. We posit that this may be linked to how communication between clinicians and families occurred predominantly through group interaction via video or instant messaging. The emotional content of families’ communication may have been curtailed as a consequence.

In line with conclusions of a recent literature review, we perceived telehealth to be a favourable environment in which to implement the principles of trauma informed care (Gerber et al. Reference Gerber, Elisseou, Sager and Keith2020). For example, using headsets promoted confidentiality and clinicians ensuring participants could see their body language promoted trustworthiness. Though PERCEPTION required additional technology and human resources (e.g. laptops for team members, a large monitor to enable an assessment of participant wellbeing throughout and extra clinicians to provide technical support to families).

It was our experience that the online environment was conducive to the type of peer support offered by the intervention. The vast majority of families freely shared aspects of their lived experience without being prompted by the team. However perhaps communication, prior to intervention commencement, of the relevance of all family experiences to learning about recovery in psychosis might have improved engagement. This could offset the risk of participants questioning the value of learning through peer support when circumstances differ between families. However, we believe that telehealth afforded families ample opportunity to interact, perhaps even more so than in-person interventions, where more extroverted families might dominate.

We encountered multiple barriers to intervention implementation, including the challenges of appraising distress online (due to the absence of in-person cues) and supporting participants to fully comprehend education material in a virtual environment. In order to promote a motivating group dynamic and to maintain momentum, we encouraged frequent use of the Zoom ‘chat feature’ during Microsoft PowerPoint presentations, role-played communication styles and posed questions to families to actively stimulate conversation, while sticking to strict timelines.

Recommendations and future directions

As PERCEPTION was developed and delivered out of necessity, rather than as a planned study, a scientific evaluation is now imperative. To our knowledge, evaluations of four telehealth psychoeducational interventions (augmented with peer support) for family members in psychosis have been published. The data available indicate such interventions are acceptable, feasible, and efficacious in enhancing knowledge about prognosis, reducing stress, and increasing perceived social support (Chan et al. Reference Chan, Tse, Sit, Hui, Lee, Chang and Chen2016; Rotondi et al. Reference Rotondi, Haas, Anderson, Newhill, Spring, Ganguli, Gardner and Rosenstock2005, Reference Rotondi, Anderson, Haas, Eack, Spring, Ganguli, Newhill and Rosenstock2010; Sin et al. Reference Sin, Henderson and Norman2014), but require adequate digital confidence, competence, and governance (Lobban et al. Reference Lobban, Appelbe, Appleton, Billsborough, Fisher and Foster2020). While our clinical experience corresponds with these data, there is currently an urgent need not just to replicate these studies but also to broaden evaluation foci. These include more rigorous quantitative appraisals of efficacy, that afford enhanced control of bias, as well as in-depth qualitative examinations, exploring: intervention acceptability; why certain aspects of the intervention were, or were not, helpful to families; the perceived value, benefits, harms and unintended consequences of the intervention; and families’ recommendations for intervention improvement. For post-pandemic service planning, identifying the preferences for clinicians providing, and family members receiving, online versus in-person family interventions in FEP would be helpful. There is also a need for evidence on the extent of family member exclusion from telehealth due to sensory or cognitive impairment, poverty and the lack of digital literacy and how such obstacles can be surmounted.

Until such data are published, we recommend that post-pandemic – in line with the accessibility, choice and autonomy objectives of recovery oriented services (Davidson et al. Reference Davidson, Rowe, Tondora, O’Connell and Lawless2008) – the option of receiving in-person or online interventions is offered to families. As a policy recommendation, we suggest that EIP services currently, and considering, utilising telehealth to provide services should consult guidelines for its use, identify the privacy, security, and administrative measures that should be taken, and assess the impact of their implementation (Watzlaf et al. Reference Watzlaf, Zhou, DeAlmeida and Hartman2017). Also, to optimise platform functionality and improve the support provided to families, training for clinicians in both telehealth and the use of newly developed online platforms is required.