Delivering Let’s Introduce Anxiety Management (LIAM) online during Covid-19 Lockdown 2021-2022
Background
NES TIPS-EIC applies Implementation Science principles to engage with a range of stakeholders to deliver early, evidence-based interventions to children and young people, in school settings, across Scotland. These interventions have been ideal to address Covid-19 related distress and are delivered by staff such as School Nurses and Pupil Support Officers with coaching provided by local NES-funded Psychology staff to translate new skills into practice and ensure clinical governance. Care pathways are managed consistent with the CAMHS Service Specification and the Community Services Framework.
Following the first COVID-19 lockdown in March 2020, NES adapted the Cognitive Behavioural Therapy (CBT)-informed intervention, LIAM, for online delivery of the training, coaching and intervention delivery.
We interviewed two practitioners about their experience of using this remote delivery model during 2021.
How has this change to online delivery gone in 2021?
Jennifer Grant, School Nurse and Specialist Community Public Health Nurse (SCPHN) Practice Assessor, NHS Fife said:
“We had some challenges implementing LIAM such as getting to know the Video Appointments (nearme.scot). But we were fortunate to receive support to do that very quickly. We also developed a ‘five easy steps’ fact sheet to help young people who would be attending online appointments to support joining a coaching session.
“The intervention aspect has been very good and young people are able to choose where they want to be. LIAM includes sessions that involve relaxation, mindfulness, calm imagery, and progressive muscle relaxation which they could opt to do in their own home - where they could choose a comfortable space - rather than in a school or clinic setting. Pupils shared this helped them feel more relaxed about participating, compared to sitting in a room feeling someone may be watching them. They could move away from the camera to be more comfortable or switch it off.
“LIAM online allowed me to offer appointments earlier on receipt of referrals than if I had to arrange a face-to-face meeting.”
Dr Paul Stone, Clinical Psychologist in NHS Fife, is one of the NES funded psychologists who provides coaching and training in LIAM to school staff, e.g., school nurses / pastoral care staff:
“As a coach, one thing that stood out was the good relationships within the coaching group when it came to introducing the adaptions. Because a lot of the team had already used LIAM, we could discuss how we make those changes work online. We were thinking about how to support the young people.
“Moving to an online programme also allowed colleagues who could not be in the office to connect in, be part of the team and undertake the learning. That has been a great benefit.”
Has online training and coaching made any difference to LIAM?
Jennifer Grant said:
“As a school nursing service, having training available for our trainee school nurses has been invaluable. When restrictions were in force and schools had to close, our trainees could still access training and coaching. They could then implement the programme and continue their learning and development. This has been very useful especially for new staff who joined us during COVID.
“Staff who had to work at home for example, due to health conditions have also benefitted. They have been able to continue with LIAM, to have a caseload and connect with young people. They have been able to provide and receive support in turn.”
Paul Stone added:
“We spoke a lot about how we use the digital resources and make them work depending on which presentation comes in from the young person. As a team we had a lot of case discussion to help resolve issues and make changes to LIAM to suit the needs of the young person.
“In terms of delivering the training, the biggest challenge for me was to keep it engaging. We did a lot of group work in the sessions with staff. It wasn't always about talking to a slide or talking to the content. It was about small groups where you could have conversations and work on the material together.”
What do children and young people think of online LIAM? Do they prefer face to face or online sessions?
Jennifer Grant said:
“Young people have appreciated the opportunity to have online appointments and the flexibility to choose when and where to connect with support. Sometimes my online appointments are better attended than face-to-face ones. It’s difficult to pinpoint why but this could be due to greater control over the time, the place, the format and the importance of having the opportunity for them to connect with someone when they have felt isolated.
“In the evaluations I conduct at the end of each LIAM intervention, questions such as, did you like coming here? how is this venue? always score highly.
“Some pupils have struggled with being on camera, which was initially a surprise. Young people may want to have a virtual appointment, but they do not necessarily want to see themselves. It can take a few sessions before they feel comfortable in doing so.
“I have had some pupils who kept their camera off the whole time we worked together. They could still see me and all things that were shared on the screen. They were participating and interacting - they just did not want to be seen.”
Paul Stone added:
“I think the LIAM intervention works well online if the young person is comfortable enough with this medium.”
Jennifer Grant agreed:
“The initial part of my meeting with any young person, is the contract, which is about setting that safe communicative space and checking they still consent to be part of this intervention. The confidentiality aspect is important too. I let them know nobody else can hear me and I ask about their environment. Is anyone able to hear them? What would happen or how would they feel if somebody could hear this conversation?
“It’s about checking in and setting the scene as well as boundaries and expectations. I would do the same face to face.”
Paul Stone added:
“The main challenge with anything online, is how the young person feels about the validity of that intervention. Young people value relationships. When we're doing any sort of therapeutic work, we are working hard on the relationship to help with the change. But that has probably been the single biggest challenge for a young person - how to forge a relationship with a clinician online? And some young people have been able to do that superbly.”
Paul Stone continued:
“Pre COVID, young people would always say, face to face intervention was the preference. But in 2021 they have appreciated that they have had the option to do online interventions and they have been able to have that relationship, even though it has been more difficult.”
Jennifer Grant continued:
“Young people who are non-school attenders due to anxiety and may not have attended for a very long time. They have become isolated from their attainment as well as their peers and that is a real concern for education staff and parents. For them a face-to-face appointment could be anxiety provoking.
“Initially when we first started using LIAM and COVID arrived, it was all related to COVID anxiety. I would say we’re seeing that much less. Now it's about transitions, perhaps to high school. Young people may have had a chaotic first couple of years because they've lacked the continuity of being at school and making relationships in the same way. So, peer relationships and separation anxiety are some examples. Others include concern about being full time in a new environment after a long absence and having to do self-directed study.
“But I agree with Paul, the important thing is for the young person to have the connection, whether face-to-face or online.”
Reflecting on the online delivery of training, coaching and intervention Dr Suzy O’Connor, Head of Programme for NES TIPS-EIC at NES, said:
“With the LIAM programme we have successfully created capacity to deliver a high-quality, evidence-based intervention to children and young people who would not otherwise have been able to access these.
“Analyses of training data show that our remote training is just as effective as face-to-face training at increasing the pre to post training ratings for knowledge and confidence of attendees. It is also accessible to colleagues in remote and rural areas. Since we developed our remote training/coaching/intervention delivery model we have had good engagement with NHS Shetland, NHS Orkney and NHS Dumfries and Galloway.”
Suzy O’Connor continued:
“School nurses, pupil support officers, pastoral care staff, third sector staff, social workers, and educational psychologists rate the quality of the clinical skills coaching delivered by NES-funded Clinical Psychology staff very highly. They say coaching translates the new skills into changed work practices, is containing, keeps the momentum of the implementation going and builds staff confidence. Coaching also prevents therapeutic drift, improves consistency, and ensures safe delivery of the intervention.”
Feedback from Children and Young People and their goals
‘It was great to speak to someone I could trust,’ ‘Calming exercises were good and helpful,’ ‘I felt listened to and that they wanted to help me,’ ‘I got to speak about my worries, and they don’t stop me anymore.’
‘Feeling more confident to speak out in class,’ ‘having less worries and fears and sleeping better,’ ‘worry less about exams,’ ‘be kinder to myself,’ ‘reduce anxiety about coming to school.’
Suzy O’Connor explained:
“Whenever possible we measure clinical outcomes for every child or young person who receives LIAM. These demonstrate highly significant reductions in distress and progress towards children and young people’s own goals for therapy. Online delivery of LIAM is just as effective as face-to-face in terms of our clinical outcome measures.
“Additionally the Neurodevelopmental Service Specification highlights the importance of meeting the mental health needs of neurodivergent children and young people. During 2021-22, we recorded highly significant reductions in anxiety and low mood and progress toward goals with a sample of children and young people who have neurodevelopmental complexity who completed LIAM.
“This suggests that LIAM is effective for these children and young people when an individual intervention for anxiety is required and appropriate, e.g., when all supports, and environmental accommodations have been made and the child wishes to learn more about managing their own anxiety.”
Useful links
Relaxation session Let’s practice self-care
Training in psychological skills – early intervention for children (TIPS-EIC)
January, 01 0001