Connecting the dots: Twenty-first century technologies to tackle twenty-first century challenges in early intervention

The emergence and challenges of early intervention for psychosis

The last two decades have seen a shift in emphasis in the treatment of psychotic disorders, from a palliative, generic, symptom-focused approach to a recovery-focused model. In keeping with this shift, the early intervention model has emerged with a focus on timely access to treatment and specialised support for young people in achieving both symptomatic remission and full functional recovery.

However, as evidence mounts that early psychosis services improve clinical and psychosocial outcomes (Petersen et al., 2005), new challenges confront the field. Firstly, the ongoing engagement of young consumers in preventive interventions remains a significant issue (Alvarez-Jimenez et al., 2009). Secondly, the long-term maintenance of treatment benefits from early intervention services poses a major challenge (Bertelsen et al., 2008). Indeed, the period of risk for relapse and need for psychosocial support extends well beyond the availability of specialized early intervention (Alvarez-Jimenez et al., 2012a). Finally, although symptomatic remission is frequently achieved following early interventions, severe social isolation, unemployment and self-stigma affect many young people with psychosis and their carers (Carr et al., 2012).

The role of the internet revolution in transforming early intervention services

The rapid development of information and communication technologies (ICTs) has transformed the way in which young people interact with one another and the wider community. Never before has information and communication been so accessible to so many. Surprisingly, modern early intervention services have not capitalized on the potential for such technologies to improve long-term clinical and psychosocial outcomes (Alvarez-Jimenez et al., 2012b).

We believe that novel ICTs can help to address major challenges in early intervention. These technologies should be used to enhance early psychosis services and tackle existing treatment challenges by increasing their accessibility, attractiveness, flexibility and capacity to provide ongoing support. Modern early intervention services should provide a dynamic and supportive environment that integrates online with face-to-face interventions in response to consumer needs, phase of illness, and preferences for care. Integrated online support could provide an important component of care which enhances engagement with and effectiveness of face-to-face interventions. Ultimately, ongoing online interventions could be offered beyond discharge from early intervention services in order to maintain treatment benefits over the longer term.

The MOST model: A twenty-first century internet-based intervention for young people suffering from psychosis

To date, internet-based interventions have typically facilitated the interaction of a single user with an automated education program. However, a substantial proportion of patients using these programs drop out before completion or stop using the web-based application (Eysenbach, 2005). Importantly, evidence is mounting that human support enhances effectiveness and adherence in internet-based interventions (Eysenbach, 2005). However, this evidence has rarely been used to inform the development of specific innovations for severe mental disorders.

Alongside structured internet programs, online discussion forums have proliferated, but these generally lack structure, evidence-based content, and professional moderation. It has been argued that these missing components may adversely affect participants’ sense of community – a pivotal element of peer support (Alvarez-Jimenez et al., 2012b). In addition, unmoderated and unstructured forums may result in increased levels of depression and lower quality of life (Alvarez-Jimenez et al., 2012b). Similarly, although it is generally assumed that being able to be of assistance to others can improve self-esteem and reduce self-stigma, the absence of formal supervision or guidance from trained mental health professionals or senior peer moderators may generate higher level of distress in some peer supporters (Alvarez-Jimenez et al., 2012b).

To address these limitations we have formulated a new model for online interventions entitled ‘Moderated Online Social Therapy’ (MOST) (Gleeson et al., 2012). The MOST model integrates: i) asynchronous peer-to-peer on-line social networking; ii) individually tailored interactive psychosocial interventions; and iii) involvement of expert mental health and peer moderators. MOST has been developed by a multidisciplinary team of experts in consultations with stakeholders.

In the MOST model social networking is designed to provide a therapeutic milieu which reinforces and validates online psychoeducation modules and which fosters engagement by creating a dynamic and supportive online community. For example, the social networking features prompt participants to carry out therapy modules. Similarly, within tailored interactive therapy modules participants are encouraged to discuss therapy themes and practice therapeutic techniques in the online social network. We believe that MOST provides an entirely new and safe therapeutic milieu in which participants can self disclose, learn about their disorder and its treatment, gain encouragement and validation, take positive interpersonal risks, gain perspective, learn how to solve problems, and broaden and rehearse coping skills. To this end, MOST has been designed to target identified groups of consumers (i.e. young people suffering from psychosis) providing a safe environment for young people to experiment with self-disclosure and peer-support.

In MOST, expert moderation follows a theory-driven model known as ‘supportive accountability’. This model poses that human support enhances engagement through accountability to a moderator who is perceived as trustworthy, benevolent and having expertise (Mohr et al., 2011). Uniquely, the MOST model provides expert clinicians with the potential to utilize the feedback, posts and data from a large social network to challenge consumers’ negative perceptions and beliefs and to support consumers’ strengths. In addition to expert moderation, the MOST model includes peer moderators or ‘super-users’. Super-users receive peer-support training and supervision. Their role is to provide guidance, information and emotional peer-to-peer support to counteract self-stigma and foster empowerment. A recent study has demonstrated that MOST is feasible, engaging and safe, and may augment social connectedness and empowerment in young people suffering from psychosis (Alvarez-Jimenez et al., submitted).

The MOST model and beyond

We believe that the MOST model provides a unique, integrated platform, which can be adapted to support diverse mental health conditions (i.e., social anxiety, depression, psychosis) and caregivers through tailoring the evidence-based content, peer-to-peer and multidisciplinary expert support. Importantly, MOST has been designed to enhance the accessibility, flexibility and effectiveness of current early intervention services and to significantly improve models of treatment maintenance across mental health disorders.

Looking forward, the internet has the potential to foster long-term recovery beyond what is possible in traditional interventions and mental health services. Theory-driven, evidence-based and user-guided online interventions can be empowering, enabling consumers to link up, and even shape the nature of the services and care they are receiving in line with the main principles of the recovery framework. The e-mental health revolution offers exciting possibilities for consumers, carers, and service providers.