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When we talk about ‘severe’ mental health difficulties or ‘complex presentations’, we usually mean mental health difficulties that significantly affect people in their day-to-day lives, often over a number of years or in conjunction with other health conditions. Some might consider particular diagnoses as evidence of a ‘complex presentation,’ such as psychosis or bipolar disorder. However, there is usually a spectrum of severity and experience within any ‘diagnosis,’ and a degree of overlap in signs and symptoms across conditions. For instance, the experience of hearing voices others can’t (be it internal or external) could result from: large doses of certain pain relief or immunosuppressant medication following a major surgery; intrusive thoughts associated with obsessive compulsive disorder (OCD) or eating disorders; psychosis; or dissociation. It is also widely recognised that stress, trauma and low self-compassion underpin many frightening and critical auditory hallucinatory experiences, for example. These are broadly psychosocial factors and not symptoms of illness. Therefore, for the purposes of this chapter, we will focus on supporting people with a range of ‘complex presentations’, rather than focusing on specific diagnoses or clusters of specific symptoms. The National Health Service within the UK recognise that complex mental health does not just refer to an individual’s diagnosis, but to a number of different factors (NHS England 2019). This includes: • The nature, duration and severity of mental health problems • Any co-occurring drug or alcohol dependency • The nature, duration and severity of co-existing physical health problems • Problems associated with ageing, such as frailty • The availability and quality of personal and social support and networks • Any associated functional impairment, or impact on activities of daily living • The effectiveness of current or past support or interventions

This guide shares best practice for delivering mental health support and treatment digitally. Part One considers aspects relevant to all digital mental health interventions, such as therapeutic alliance, risk, safeguarding, working with complexity, and what people are looking for from digital support. Part Two focuses on specific therapies and models, including CBT, ACT, DBT, CFT, CAT and EMDR, and how they can be adapted for digital delivery. Whatever technology is available to you, this book will support you in taking your practice onto whichever digital platforms both you, and your clients feel comfortable with. With top tips from a wide range of practitioners, this book opens a conversation about the benefits, challenges and best practice for delivering mental health therapies using digital platforms.