How the pandemic spurred innovations in mental health services

Just as the COVID-19 pandemic created a greater demand for mental health support, lockdowns and other restrictions meant that organizations around the world had to get creative with how they could deliver these services, particularly to low-resource communities. Zoom calls weren’t always the answer, but technology did play a key role in connecting clients and partners, sharing information, and providing remote training. Since the start of the pandemic, StrongMinds, a social enterprise that treats women with depression in Uganda and Zambia, has been using remote therapy and WhatsApp chatbots to support its existing clients and reach new communities. Dena Batrice, the organization’s director of technical learning and innovation, believes the future will involve a hybrid model of remote services and some face-to-face interaction. “[These approaches are] not going away ... they have been so successful and the clients love them,” she said. “We have opened the door for [marginalized] people and we can't and won't close it — it's super exciting to find a way to reach them.” Devex finds out what innovations have emerged from the pandemic that are helping deliver mental health services. Remote group therapy In the spring of 2020, StrongMinds adapted its in-person group talk therapy to phone-based teletherapy. Groups were limited to five people to allow the trained mental health facilitator on the call to provide more personalized attention and come to grips with the phone conference technology. These facilitators also received guidance in new techniques for building trust remotely and encouraging clients to share information since physical cues could no longer be observed. Working with a local telecom company, StrongMinds set up a monthly subscription service that allowed participants to use registered SIM cards for cellphones and contact each other at no cost. According to Batrice, this has been a great solution for low-income settings where relying on Zoom calls or mobile data wasn’t an option. And participants no longer need to take so much time off work or cover travel or child care costs to attend the groups, which has allowed the organization to reach more people. “We’ve seen higher retention rates of people in the group, we’ve seen an expansion of the place[s] that we were working … it’s been absolutely amazing,” Batrice said. StrongMinds is now serving 42 districts in Uganda — six times as many as it did in 2019 — and services have expanded from one to 27 districts in Zambia. HIAS, an organization that supports refugees, has also been using WhatsApp to facilitate remote therapy groups for Venezuelan refugees based in Lima, Peru. The groups, designed to benefit children and other young people, are semistructured and use WhatsApp to coordinate art-based activities and the distribution of tools and materials to participants, said Christian Guzman, a mental health and psychosocial support coordinator who worked with the organization on the project. Participants are also provided with internet packages to add data to their phone credit since connectivity has been one of the key challenges of remote health services. Automated and asynchronous support As with many organizations, HIAS also launched a hotline where staff members offered remote screenings using adapted psychological first-aid protocols. This service now allows clients to connect by phone or WhatsApp voice or video calls. “That was immediately the most useful tool ever, we never thought that WhatsApp could be that useful,” Guzman said. However, with the huge demand facing Guzman’s small team, it soon became clear that this would not be enough. “We immediately saw that the need was there … that we couldn't reach them all through video calls … [and] that we needed to [provide support] in an asynchronous way.” The team identified the most common needs — which included depressive symptoms, anxiety-related symptoms, and parenting-related needs — and created a “package” for each of these containing prerecorded voice messages and guidance on respiratory or behavioral activation techniques. Clients can now access these packages through an automated service, depending on their response at different stages. There are also referral options for those with more complex needs. While initially reluctant to use the technology and preferring “old school methods,” Guzman now believes this approach is a “game changer.” E-mental health existed before the pandemic, he said, but this has been a huge learning opportunity in what tools and services work and how to build relationships using them. In Uganda and Zambia, StrongMinds started providing automated psychoeducation through a WhatsApp chatbot, as well as through prerecorded messages via Viamo, an interactive voice response platform where users can engage with an automated system. The idea of the bot is to provide “a secret place to ask somebody about your mental health, completely anonymous,” Batrice said. Where previously staff members were going into communities to ask people how they were feeling and provide information or referrals, the chatbot does this in an automated way and directs users down a pathway based on their answers, she said. Users can then access screenings for depression as well as information and coping strategies, or request a callback for further assessment with the potential to join one of the teletherapy groups. “It’s just a super simple way to provide psychoeducation,” Batrice said. The interactive voice response platform offers similar services for adolescents who can register to receive a series of eight voice messages with information on depression and mental health. Partnerships for greater reach To help promote its teletherapy groups and chatbot services, StrongMinds launched a public education campaign using various media platforms and partnerships. The campaign consisted of an animated video series — which had over 100,000 views by the end of 2020 — radio announcements aired in nine languages, and Facebook and Youtube adverts, which reached 1.6 million people. Building on previous partnerships, the organization also worked with civil society organizations and the Ministries of Health in both Zambia and Uganda to extend the campaign's reach. StrongMinds is also working with a range of partners to “layer” mental health services into their existing livelihood, food security, healthcare, and education programs, Batrice said, based on “the underlying belief that when people are mentally healthy, everything else works better.” Meanwhile in Peru, HIAS looked to new, and sometimes unusual, partners to help deliver support on the ground. Guzman’s team provided remote training in basic psychosocial skills to a small group of police officers working in the districts of Lima where the greatest needs were arising. While the police are often at odds with the refugee population, and the approach could be controversial, Guzman described the relationship building as “win-win.” There are now plans to expand the program and deliver this training remotely to police officers nationwide.