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Keeping young people connected during COVID-19: the role of online groups
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  1. Halina Flannery,
  2. Sara Portnoy,
  3. Xeni Daniildi,
  4. Chandrika Kambakara Gedara,
  5. Gina Korchak,
  6. Danielle Lambert,
  7. James McParland,
  8. Lara Payne,
  9. Tania Salvo,
  10. Charlotte Valentino,
  11. Deborah Christie
  1. Child and Adolescent Psychology Service, University College London Hospitals NHS Foundation Trust, London, UK
  1. Correspondence to Dr Halina Flannery, Child and Adolescent Psychology Service, University College London Hospitals NHS Foundation Trust, London NW1 2PG, UK; halina.flannery{at}nhs.net

Abstract

The COVID-19 pandemic has had a profound impact on young people, disrupting education, routines, hobbies and peer interactions and there is concern for longer term effects on physical and mental health outcomes. Young people living with chronic health conditions face additional challenges including reduced or no face-to-face contact with medical teams, shielding and the increased stressors of being in ‘at-risk’ groups and social isolation. In a climate of social isolation and disconnectedness, online groups could provide a method of delivering healthcare and support that strengthens social connectedness and reduces isolation. Despite the technology being available, uptake and evidence for online groups is limited. This article shares learnings from a paediatric and adolescent psychology service delivering online groups for young people with chronic health conditions and their healthcare teams. Ideas for how to transfer group process to online platforms are considered, with examples and tips. With sufficient staffing, preparation, thought, creativity and innovation, it is possible for face-to-face groups to successfully be offered online. Caution should be exercised trying to run online groups without these provisions in place, as the safety, comfort and experience of young people could be jeopardised. Further research is needed to better understand group processes online and to consider what is lost and what is gained when comparing online to face-to-face groups.

  • adolescent health
  • psychology

Data availability statement

Data sharing not applicable as no data sets generated and/or analysed for this study.

This article is made freely available for use in accordance with BMJ’s website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.

https://bmj.com/coronavirus/usage

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What is already known on this topic?

  • COVID-19 has had a significant impact on adolescents, with disruption to their education, routine and opportunities for peer and social interactions.

  • The effectiveness of psychological group interventions iswell evidenced for young people with chronic health conditions, but little isknown about online group delivery.

  • The pandemic has provided an opportunity to advance virtualsupport but little guidance has been published on how best to adapt groups to onlineplatforms.

What this study adds?

  • This paper describes the experiences of a clinical psychology service and literature on the effectiveness of online groups for young people with chronic health conditions and practical and clinical considerations on how to adapt groups for online delivery.

  • The ideas presented in this paper are timely and applicable for all healthcare professionals working with adolescents.

Introduction

The COVID-19 pandemic has had a profound impact on young people, disrupting education, routines and peer interactions and there is concern for longer term physical and mental health outcomes.1 2 Young people living with chronic health conditions face additional challenges including reduced or no face-to-face contact with medical teams, shielding and social isolation.

Peer support improves resilience and well-being among participants. Nine key psychosocial mechanisms underlie this process including learning new coping techniques, influencing social environments, enlarging perspectives on what is normal, examining alternative perspectives, understanding the causes of personal stressors, confirmation of positive changes in attitudes, reducing a sense of isolation, enhancing social identity through group approval and extending help to others.3 Similar processes have been found in peer support groups for adolescents living with cancer, particularly increasing knowledge, decreasing isolation and improved adjustment.4 Online groups could strengthen social connectedness and reduce isolation; however, despite the technology being available, uptake and evidence for online groups is limited. When families live too far from hospitals to attend face-to-face groups, or effects of illness make groups harder to access, the benefits include not being restricted by geography or travel time and opportunities to access support when it is most needed. COVID-19 has provided a unique climate in which experience of online platforms is emerging at a fast rate as health services navigate how to work safely and innovatively to provide continuity of care.

Connecting young people living with chronic illness, their families and professionals supporting them is a core part of the University College London Hospital paediatric psychology service,5 with consistently reported positive outcomes in relation to identity, connectedness and the management of health conditions.6–9 While navigating the move to virtual consultations for individual and family therapy due to the pandemic,10 it was as important to find ways of making groups accessible for adolescents living with chronic health conditions to enable opportunities for connection in a time of widespread social isolation.

This article considers the process of adapting psychological group interventions for young people (aged 12–24 years) with a range of chronic health conditions for online delivery. It draws on the current literature for online psychological intervention groups and its application to adolescent healthcare. We will share our learnings from delivering online group interventions for young people with chronic health conditions and their healthcare teams, which are applicable to groups delivered by different healthcare professionals.

Effectiveness of online groups

Despite the well-documented advantages of group interventions within psychology literature,11 12 research on online group psychological interventions for children and adolescents is minimal.13 Preliminary research has shown that online therapy groups can be effective in different populations. A small pilot study found online groups for families of young people with low mood and anxiety disorders were as effective as face-to-face group support,14 while a randomised controlled trial (RCT) looking at the effectiveness of an online group course for depression in adolescents and young adults found the online group course was more effective in reducing depressive symptoms and anxiety and in increasing mastery in young people with the effects still evident at 6 months than the waitlist control.15

Evidence for the effectiveness of online group interventions for young people living with chronic health conditions is even more sparse. The ‘Recapture Life’ RCT compared online group cognitive–behavioural therapy (CBT), peer support and waitlist control for adolescent and young adults following cancer treatment.16 Participants rated strong therapeutic alliances with their therapists lasting throughout the CBT group. It was also possible for interpersonal processes, such as working alliance between participant and therapist and alliance to the group as a whole, to be built via online group delivery. Scores on these measures were similar or higher compared with face-to-face interventions with young people and adults.17 Therapists also reported increased confidence in delivery of videoconferencing groups at the end of intervention, suggesting that increased exposure to online interventions can help therapists feel more comfortable in delivering them.17

The emerging evidence for online group psychological interventions is limited, and even more so for adolescents living with chronic health conditions but suggests that outcomes can be similar to face-to-face groups. Group cohesion has been highlighted as an important factor related to positive psychological outcomes in face-to-face groups,18 and it is promising to see emerging evidence that alliance between participants and facilitators is possible using online platforms.17

Adapting groups for online delivery

We offer face-to-face group interventions for young people living with cancer, type 1 diabetes, chronic fatigue and chronic pain, drawing on principles of narrative therapy. Narrative approaches assume people have the skills, abilities and values which help reduce the influence of problems in their lives, such as living with a health condition.19 The groups offer space for people to tell their stories in their own words in a way that acknowledges the hardships people have experienced and their responses to them.19 Groups begin by creating a ‘safe place to stand’,20 before talking about challenges; group members talk about their interests, skills and important people to help connect them to their ‘preferred identity stories’ to counteract the dominant medical stories in their lives.6 7

The groups we have adapted to online delivery, since the onset of the pandemic, include the ‘Beads of Life’,6 and ‘Journeying after Cancer’ for young people who have had a diagnosis of cancer, ‘Tree of Life’ for young people living with type 1 diabetes7 20 and ‘Living with Chronic Pain’. Most of our groups are full (10:00–16:00) or half-day group interventions facilitated by clinical psychologists, with support from trainee and assistant clinical psychologists, and are attended by young people aged 12–24 years.

New online groups were also created in response to the perceived needs of young people during the pandemic, and to take advantage of the possibilities that online platforms can bring. A ‘Navigating Uncertainty’ group was offered to young people in school years 10–13 living with a health condition awaiting decisions around A-level and General Certificate of Secondary Education examinations. We have also run an online ‘Song Writing Workshop’ for young people who were able to connect over their shared love of music and their experiences of cancer. They wrote a collaborative song with words generated from sharing stories of their experiences and together they created the rhythm and the melody. They performed the song by recording their part on their smartphone and emailing it to one of the therapists who mixed the tracks using music-making software.

The psychology team also offers ways for young people with complex medical problems and their families to meet with their multidisciplinary team.21 22 Local team members are invited to these network meetings to enhance communication and create a ‘resource-full’ team that can think creatively about how to work together to create the best outcomes for the young person and their family. It creates an opportunity for the young person, family and professionals to feel listened to, understood and supported and for the development of a collaborative plan.22

Social distancing has created challenges for facilitating face-to-face network meetings and we were concerned about the risk of young people becoming disconnected from their support network, and for professionals within those networks becoming disconnected from each other. There have been some very noticeable advantages of hosting the meetings online. Grandparents, who would not have been able to travel all the way to the hospital, were able to join a meeting, and a head teacher at a young person’s school was able to attend because she/he did not have to travel. An 18-year-old young person whose inpatient rehabilitation admissions have been switched to virtual appointments commented that the online network meeting was the first time they had seen all the professionals supporting her on the same screen, which made her feel more supported and less alone. The increased accessibility of online meetings has significantly helped improve the coming together of young people living with chronic health conditions and their support networks.

In response to the rapid move to online platforms, guidelines for navigating this change have emerged.10 23–26 They highlight important considerations for patient safety, confidentiality, risk assessments and safeguarding. Based on our experience of running face-to-face groups and increasing experience of delivering groups using online platforms since the onset of the COVID-19 pandemic, we hope to further existing guidance by focusing on group processes and considerations for adjusting to an online group format and by offering our 'top tips' (see Box 1.)

Box 1

Top tips for adapting groups for online delivery

Know your platform

  • Ensure the online platform has the required functionality and can cater to the number of potential attendees.

Groundwork is key!

  • Contact attendees in advance of the group to ensure access to the necessary devices, and a private space at the scheduled time, and that they understand how, and are able, to download and use the online platform.

  • Encourage use of a laptop (if possible) so that they can see everyone on the same screen.

Facilitators matter

  • Have enough facilitators to manage the group and be able to hold all group members in mind. Plan what you will do if a facilitator struggles with internet connection (eg, making sure all facilitators have access to any slides and session plans).

  • Set up a separate channel of communication (eg, telephone, text or email) to communicate with other facilitators during the group.

  • Ensure facilitators meet before and after the group to plan and debrief. Facilitators should leave the meeting at the same time as attendees and use a different space to debrief.

Managing the group

  • Develop a protocol (to be communicated to group members) to manage people leaving the group or feeling unsafe.

  • Consider disabling the option for participants to record and ask participants not to record or take photographs on other devices.

  • Ask participants (and facilitators) to close other apps and email to reduce distraction and noise. Be conscious of visual or hearing difficulties that may make it more difficult for people to participate.

  • Use the chat function creatively. In addition to being used to flag technological issues, we have found it helpful in capturing and communicating points as they arise in group discussion.

  • Allow enough time for icebreakers and exercises, and do not include too much in one session: it is important to remain ‘spacious’ and allow flexibility. Plan frequent breaks from the screen to facilitate engagement and support memory and concentration, in addition to coffee breaks.

  • Ask group members to complete exercises or tasks individually at points. We have also experimented with inviting people to take collective stretching or yoga breaks, to move around the room and enjoy music.

Create opportunities for connection in smaller groups

  • If your platform allows (or consider alternatives such as additional meeting links or smaller group size).

  • Split into smaller groups to allow attendees opportunities to connect and tell their personal stories.

  • Consider asking sections of the group to turn off their cameras for parts of the group to create the impression of a smaller group at times. Setting ‘listening’ tasks for those with cameras off can help them stay engaged.

  • Include unstructured or ‘freeform’ time to encourage connection with other group members.

Share your computer screen

  • Look at presentations, pictures, videos or internet pages together.

  • Be mindful of what is on your screen before sharing, for example, emails and personal information.

  • Use a ‘whiteboard’ function or website to create group documents.

  • Make collective documents and share them with others.

  • Be mindful that young people may not feel confident in sharing their work/materials on screen. Consider doing this in smaller groups or 1:1 with a facilitator.

Seek regular feedback

  • Some platforms have options for live polls.

  • Websites and apps are available for polling and word clouds.

Well begun half done

We first develop a clear intention for the group to guide content planning and how the group is offered and evaluated, for example, to meet others with shared experience, to share and learn ways of coping and managing difficult symptoms or to build a positive view of the self. It is important to invest time building relationships with young people in advance to help them understand what to expect, the intentions of a group and to feel comfortable attending as there may be additional concerns about confidentiality, safety and online etiquette when attending online. We do this through telephone calls, emails, letters, posters, videos and sending resources in advance.

Introductions

We start by introducing the group and explaining the context and the plan for the group, including timings and breaks. We ‘warm the context’27 by thinking about how we would like the group to work, including discussing the importance of confidentiality and how to keep safe while participating (eg, use of mobile phones, how to take breaks if needed). We offer a short tutorial in using the software, including how and when to mute, turn the camera on/off and the chat function. We ensure young people understand how to select the option that allows them to view every group member in the same size window on their screen and ask attendees to change their display names to reflect what they would like to be called without including surnames or additional information. We consider issues of recording and taking photos during online groups; on many platforms it is possible to disable the record option and we ask all attendees to agree to not record or take photos on other devices.

Engagement

Group cohesion is one of the most important factors related to positive psychological outcomes.18 In online groups, there is a noticeable loss of spontaneous moments for connection that usually contribute to a sense of group cohesion; these social ‘micro-interactions’ may include brief conversations that happen in breaks, talking with the person sat next to you and even catching another person’s eye. It is therefore essential for facilitators to create opportunities for connection within the structure of the group. We begin with a gentle ‘icebreaker’ that helps attendees get to know each other and start to create a sense of group connectedness. We have experimented with longer time for introductions and icebreakers and using ‘breakout’ rooms where young people can talk in pairs or small groups and adapt icebreakers for the age of attendees, for example, active ‘scavenger hunts’ for younger groups. Group members share a personal item or belonging, for example, an item they have used differently during lockdown or an object that helps us get to know them, helps join with people more naturally in their homes. We pay attention to participants who may be nervous or reserved and offer more scaffolding. For some groups, we are fortunate to have ‘peer trainers’ who have attended previous groups and help cofacilitate.28 They have an important role in helping group members feel comfortable and supporting everyone to contribute.

Clinicians may have concerns about building relationships and ensuring young people feel heard in the absence of the full range of non-verbal and verbal communication available in face-to-face interactions. There are challenges around maintaining safety and boundaries in an online format. Facilitators of online groups must increase attention to must be conscious of ‘zoom fatigue’,29 for facilitators and attendees. This means we often offer shorter groups, or split groups over different days.

Creativity is a crucial element in maintaining presence in an online format. It is helpful to keep a sense of variability in the structure and tasks within a group, as well as inviting young people to move around the room using music to allow a break from talking and from the screen.

Group principles

Much of the power and benefit of the groups we have run comes from participants ‘witnessing’ each other’s stories.6 7 This principle is embodied in offering opportunities for each person to talk and for others to respond and reflect on what might be different for them on account of hearing these stories. In adapting groups for online delivery, we use breakout rooms to allow attendees the space to tell their personal stories in smaller groups. Facilitators may join the breakout groups or we may create smaller groups within the main group by asking some group members to place themselves in a listening role for parts of the session by turning their cameras off and muting their microphones. This process has worked well with older adolescents once a sense of the group has been developed. As with face-to-face groups, we have found it important to adapt and scaffold to support more nervous or reserved participants, for example, using smaller groups and providing more support with a facilitator.

Creating collective documents

In our face-to-face groups, we often try to capture collective themes and stories by creating a shared document, such as a written document or poem, a picture, song or a video.30 These documents describe the knowledge and abilities held by individuals, groups and communities that sustain them through hardship. These documents are shared (eg, with parents, medical teams, other young people) in ways that attendees experience as making a contribution to others.31 We have incorporated these approaches into online groups. Depending on the platform being used, a facilitator may lead the creation of the document and some platforms and apps allow participants to create a document together simultaneously. It is important that the intention of a document is clear and that facilitators can edit content, while also privileging young people’s words. This process supports connectedness within the groups and creates a record that can be shared with potential future group members.

Outcomes and experience

We measure quantitative and qualitative outcomes and experience using questionnaires delivered by email, survey links and telephone, although questionnaires sent after the group sessions have relatively low response rates. Feedback is easier and more reliably captured ‘live’ during and/or at the end of the group using group polls and chat functions.

Outcomes for online groups have been in line with that from face-to-face groups, with participants highlighting the value of connecting with others who have had similar experiences and learning new ideas to manage challenges, feeling more comfortable talking about their condition and learning positive things about themselves and average ratings across quantitative measures being very similar. Statistical analysis will be possible as more data are collected. Time spent on achieving group cohesion, allowing time for multiple icebreakers and ‘getting to know you’ activities, is appreciated. Connecting young people through activities and discussions around COVID-19 and experiences of lockdown received positive feedback, ‘lockdown bingo was fun’, ‘hearing from lots of different people about how they’re coping at the moment, this was good as I sometimes feel bored with COVID-19’.

Creating space for smaller groups in breakout rooms was well received; ‘splitting off into little groups helped to have more open conversations’, ‘liked going into smaller groups’, ‘breakout rooms were useful, they gave more time to talk about your point of view’. We have enough staff facilitators to have one for each small group. Attendees said, ‘it was nice that there was a lot of staff as well, to help facilitate the conversations.’

The move to online platforms invites its own challenges; one young person noted the difficulty of ‘knowing when to speak’ in a large online group, while another explained that long group running times were ‘fine, you just need longer breaks’. This feedback was in line with our personal experiences of switching to long hours working online and efforts to encourage movement and screen breaks were appreciated, with one young person praising the ‘lunch break away from the laptop’.

The online groups were largely received positively by young people and group cohesion and group content was transferable to an online format. A small number felt the group ‘would have ideally been better in person’ but others preferred attending online sessions, ‘It worked really well and this was my first time using it’, suggesting the transition to an online platform can be simple and achievable, even for those who had previously been unfamiliar with it.

Conclusion

During the pandemic, we have found ourselves thrown into a new digital world.32 As well as adapting individual psychology sessions to telephone and video, it was necessary to reformat the groups we offered to provide opportunities for young people to connect with each other. Despite the advantages of group interventions,11 12 research on the effectiveness of online group psychological interventions has been minimal. We have highlighted the value of online groups for young people with chronic health conditions, and as a way of keeping young people connected to their professional support systems. At the time of writing, almost 12 months after the onset of the COVID-19 pandemic in the UK, online groups remain well attended and well evaluated within our service. We were aware prior to the pandemic that distance often precluded some young people from attending our groups and we, and the young people we support, have appreciated the extended reach of our service.

Online group delivery is reliant on services supporting access to technology that meets the requirements of the group. Within our service we have used Zoom and how found this to be an effective platform, but we are aware that policies and recommended platforms vary for different services. Groups for young people living with chronic health conditions can provide a sense of social connectedness, peer support, shared experience and opportunities for learning and growth that cannot be mirrored in individual appointments. With sufficient staffing, (considerable) preparation, thought, creativity and innovation, it is possible for face-to-face groups to successfully be offered online. Caution should be exercised in trying to run online groups without these provisions in place, as the safety, comfort and experience of young people could be jeopardised.

There has been growing interest in group clinics within adolescent health services, and while distinct from psychological intervention groups, ‘creating affinity’ and attending to needs of both individuals and the group have been highlighted as key principles in the implementation of group clinics.33 The learnings we have shared are applicable to those considering online group clinics, particularly how to translate group process and create a sense of affinity between patients when using online platforms.

While offering groups online may improve access for many who would find it difficult to travel, it may limit access for those who do not have the necessary technology, internet connection or privacy at home. At the time of writing, no young people invited to the groups reported this as a barrier to attending. The groups we have adapted so far have been aimed for young people aged 12 years and over. Additional adaptations are likely to be needed for younger children, which we hope to explore in the future.

Further research is needed to better understand group processes online, for example, by considering the nine key processes of peer support groups outlined by Olsson et al,3 and to consider what is lost and what is gained when comparing online to face-to-face groups. While this article has been written from the perspective of a single paediatric psychology service, we would argue the ideas and considerations are applicable to all healthcare professionals who may plan to facilitate groups.

Data availability statement

Data sharing not applicable as no data sets generated and/or analysed for this study.

Ethics statements

References

Footnotes

  • Twitter @halinaflannery

  • Contributors HF and DC edited the manuscript. GK and DL conducted a literature review and contributed to the effectiveness section of the manuscript. JMP, LP, SP and TS contributed to the ‘adapting groups for online delivery section’. XD, CKG and CV collated the ‘outcomes’ section of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; externally peer reviewed.

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