How coached eCBT is returning the workplace to good mental health

Occupational health provider Health Management won ‘Best mental health initiative’ for its innovative coached electronic cognitive behavioural therapy (eCBT) service at the 2021 Occupational Health & Wellbeing Awards. Nic Paton hears how it has become valued part of the employer mental health toolkit during the pandemic.   

We all know that one of the ongoing consequences of the Covid-19 pandemic has been its impact on mental health.

The experience of living and working through the pandemic – the experience of lockdowns; the fears for our own health and that of loved ones; the financial, economic and job insecurity of the past two years – has fuelled anxiety and affected emotional wellbeing across the board. Indeed, the United Nations even went so far last year as to warn of a ‘parallel pandemic’ of mental ill health running alongside the Covid-19 pandemic.

To that end, how organisations respond to and manage mental ill health is an increasingly important workplace  conversation. Occupational health provider Health Management caught the eye of our judges in the Occupational Health & Wellbeing Awards 2021 with its innovative and creative approach to mental health support and counselling.

As a result, its coached eCBT (electronic cognitive behavioural therapy) service for anxiety and depression won it the ‘Best mental health initiative’ category, something that Dr Nick Zygouris, director of mental health at Health Management’s parent company Maximus UK, describes as “a tremendous validation”.

Health Management operates 300 occupational health clinics and 25 mobile health units and employs 250 occupational health doctors and nurses, making it one of the UK’s largest OH providers. In fact, it claims it employs more consultant occupational health physicians than any other organisation outside the NHS.

Evidence-based intervention

Working with a large UK employer, Health Management was tasked with putting in place a cost-effective solution to help employees with mild to severe symptoms of anxiety and depression. This personalised solution also needed to be flexible to accommodate employees’ varying work schedules and locations.

The result was a unique, confidential, evidence-based intervention, trialled through a pilot scheme initially comprising a cohort of 40 employees. The employees were either referred by managers or could self-refer to the service, with the eCBT platform available online 24/7 and remote health coaching at a convenient time within working hours.

Employees were led through eight online CBT sessions, each comprising of three to five modules. However, the innovation was the addition of motivational support from trained health coaches within a service that complied with Health Management’s robust clinical governance. This, it argued, has led to increase engagement and completion rates, improved mental health outcomes, improved symptom reduction, increased work-related functioning and increased relapse prevention.

Users reported their work-life balance had improved, they had become less insular and less likely to react negatively. Seven out of 10 had achieved “clinically significant” reduction in their symptoms of depression and/or anxiety.

Users positively associated having a health and wellbeing coach as part of the therapy, and specifically associated their progress with having this additional support. They also reported learned and employed mechanisms for recognising and avoiding stressful or depressive thought patterns.

As one participant to the programme put it: “My personal targets became clear after the first two sessions and by the end of session three, I felt much more in control of my feelings.”

“Reflecting on my own beliefs in session five helped me put my thoughts into perspective. I still use the techniques regularly to overcome my anxiety and manage my mood,” said another.

“Having a coach keeps me accountable and responsible for my own journey – with therapy you leave a session then don’t always follow up on the tasks you are set, I am gaining so much more because knowing you (the coach) are working with me. I wanted to complete the module, so we would have more to talk about, now, I want to complete the modules to find out more about me,” explained a third participant.

“I have managed to sleep through the whole night for the last two nights, which I have not done in months, maybe even years! My whole outlook has changed, I am really enjoying my work at the moment – challenging my thoughts with finding evidence for and against something I would tell myself has made such a difference to how I see the world,” agreed a further participant.

Our judges were impressed by the additional health coaching element, including the feedback that it had led to higher engagement and reduced drop-out rates. “The addition of health and wellbeing coaching the eCBT was a creative response to what can often be a complex challenge and, while the overall numbers going through the programme have been relatively small to date, the results have been positive,” they said.

“The coaching was, for us, the key element,” agrees Dr Zygouris. “The way we went about the delivering of the coaching was invaluable in that we utilised a trained health coaches with experience delivering interventions like motivational interviewing as well as an understanding of CBT.

“They [the coaches] were able to support the individual with motivation. They could support the individual with generalising the skills that they had learned using their eCBT platform. Another key part of the role of the coach was that, at the end, they completed a relapse prevention plan. So, the participant, after they were discharged, they had a plan in place should some of those symptoms come back, they knew what to do and what action they should take to limit further decline,” he continues.

Such has been the success of the programme that it has continued beyond its pilot phase and expanded. “The companies we are working with remain enthusiastic about it and have an interest in continuing with it. We’re now in the process where we are using some of the learnings we have had from the pilot and improving our systems and processes to make sure they can deliver the same quality at scale,” explains Zygouris.

“Some of the key learnings that we are working to implement into the existing intervention, include changes to further improve its effectiveness in reducing symptomatology – anxiety and depression – but also enhance the improvements in day-to-day functioning, with a particular focus on workplace functioning. That is also an area that we saw consistent improvements and potential in the pilot, but hasn’t been reported widely in the academic literature.

“The element we are now building into this intervention is a set of nudges – often text messages or emails – that are optimised using behavioural science, to support the individual through their journey by providing them with useful information, but also a sense of motivation and achievement. This aims to improve further the engagement and completion rates, and crucially, sustain their therapeutic gains.

“CBT is quite a challenging process because you really need to dig deep sometimes, and some of the things you get to realise are issues that can take an emotional toll. We have identified points within the intervention when this is likely to happen and have also added more customised, more tailored support.

“The additional nudges will be automated, to complement the tailored interventions of the coaches. Basically, the new improvements would allow the coaching session to be even more focused on enhancing the application of new skills without the need, perhaps, to clarify information or improve motivation,” says Zygouris.

How to sustain an effective mental health intervention

Given how challenging many employers find managing and supporting mental health, what is the secret to an effective mental health intervention?

“First of all, obviously, the intervention needs to be effective, and seen to be effective,” Zygouris tells OHW+.

“People need to be able to see its demonstrated value. That’s why running pilots is important. The pilot allowed us to demonstrate the clinical effectiveness of our specific implementation of coached eCBT. Listening to the feedback you’ve had from participants showing how it has benefited them is also invaluable.

“Whether that’s getting a better night’s sleep after however many months or being able to understand the nature of the problems they’re experiencing in a way that allows them to do something about, rather than staying trapped within those vicious cycles that are so easy to fall into.

“The second thing that is really important is making the intervention easy to access. For example, with our second pilot we had a self-refer pathway whereas the first one was professional referral. That self-refer pathway allowed participants to start the intervention on the day they expressed interest. It captured that window of opportunity of high motivation,” Zygouris advises, adding that it is important to be working to tackle any stigma or fear around mental ill health within your organisation to enable staff utilise such interventions.

“Another key element for many employers, is being able to demonstrate return on investment,” Zygouris continues. “Many companies want to offer wellbeing and mental health support but this also needs to be at a price-point that demonstrates a really good return on investment. And coached eCBT, for example, has quite a low cost compared to seeing a therapist face-to-face, while still offering demonstrable clinical improvement.”

Finally, the peer and external validation of winning in the Occupational Health & Wellbeing Awards has been important to the team of colleagues who created this intervention. “A lot of effort is rightly required to create a quality service, and significant effort has been made to ensure the participants found it easy to use and effective,” says Dr Zygouris.

“Having Health Management’s coached eCBT service recognised by OHW+, an organisation with a deep understanding of the wellbeing needs of current workforce, is a real stamp of approval,” he adds.