We published an article in the Spring 2012 issue of Rehab Matters.

We posted it below:

By Arden McGregor, MA, CPsychAssoc, CBIST, and Dennis Radman, Hons. BSc, RRP, CBIST

Advances in internet technology, creative interfaces and evidence-based therapies are combining to propel healthcare to levels only dreamed of. “The motive behind the use of this technology is to maintain the essential qualities of the health-care interaction, while improving access by overcoming barriers such as economics, culture, climate, and geography,” (Rees, 2004). The dominant theme of therapy is so often to examine and collaboratively develop solutions rather than allowing any one barrier to prohibit progress.

On September 23, 2011 The New York Times featured an article entitled, ‘When Your Therapist is Only a Click Away’.  Based on the buzz this article caused, it was placed on the homepage of the New York Times website, on September 25, 2011.   The piece beautifully illustrates how online therapy is used by real people in the real world. The landscape of mental health is shifting dramatically. Online therapy is becoming mainstream and the evidence-base for such therapy services is growing in Canada and around the globe. Technology is exciting and it allows us to provide services to people that would not otherwise get help.

Many vocational rehab professionals use their cell phone to talk to or text their clients.  Some professionals use regular Skype sessions to communicate with clients, employers or other professionals.  But it’s not just as simple as jumping online with a client. Professionals must be aware of and heed their legal and ethical obligations before practicing online.

Telehealth has been touted as the most significant contribution to health-care delivery systems of the future (Bashshur, 1997). eRehabilitation, a component of telehealth, is a cutting-edge and flourishing means of delivering rehabilitation services. At Brainworks, we have further developed and defined eRehabilitation as a comprehensive treatment platform that uses interactive audio, video, or data communications to provide rehabilitation services at a distance.

eRehabilitation embraces both mainstream and emergent technologies to deliver evidenced-based therapies.  Some examples of how eRehabilitation can be used include:

•    rehabilitation counseling via a secure web interface
•    videos demonstrating job skills available on demand
•    executive skills coaching (planning, scheduling, prioritizing, troubleshooting) assisted by video conferencing & the use of apps
•    email and text messaging  to  access job support
•    interactive web based learning modules for skill development

There are several advantages to providing therapy services online. By taking advantage of the power of the internet, services can be provided in context, with no commute for client or therapist, resulting in an overall cost savings.  Moreover, shorter, more frequent sessions make good sense from a learning theory perspective, but until now have not been practical.  Therapists can now provide more frequent mini sessions to spread out their involvement and contain costs while boosting efficacy.  Clinical experience, confirmed by the literature, indicates that e-based sessions result in fewer cancellations.

Granted, online therapies are often the most convenient for the tech savvy professional, but do they actually work? The research is supportive and growing: There are similar efficacy rates to face-to-face therapy; strong efficacy rates for depression, anxiety and agoraphobia. (Andersson, 2009). These online modalities are not as effective with serious psychotic episodes requiring inpatient treatment. Clearly, the practitioner must always critically analyze how, where and with whom they are used to ensure best practices.

One might wonder if the efficacy of online counseling improves if there is a prior face-to-face relationship. According to the literature, there is very little difference (Spek, Nyklıcek, et al., 2007).  Online therapies such as eRehabilitation therapies work best with clients who are functional and want to do better.  Client satisfaction rates are similar when comparing face-to-face and online therapy, with those who live in rural areas typically reporting higher satisfaction rates.

We’ve been asked about whether a practitioner can really establish a therapeutic alliance with a client they work with online.  Our answer is a resounding, “Absolutely!!!”  With certain provisos, the establishment of rapport works in the same way as it does in person. Countless individuals have met, courted, and become engaged—all over the internet. With people getting married that meet online; it is not surprising that we can develop adequate therapeutic alliances to provide rehabilitation services online.

As promising as the advantages are, there are pitfalls to avoid. Much of our communication, particularly during therapy, relies on “non-verbals”. Natural eye-contact patterns can unexpectedly change as the client and therapist are looking at a screen rather directly at one another. Clients can feel self-conscious about being on camera, and become distracted by the technology.  A practice session may be necessary to reach a stage of “comfort” before sessions can focus on therapy.

Legal and ethical issues, such as privacy, and liability must be carefully addressed in advance. It’s not just a matter of jumping onto the online-therapy bandwagon. There are a number of public network systems that escape federal oversight by remaining completely silent on compliance to privacy legislation. Without any statements about privacy and security, in a way that ties them to healthcare requirements, such networks potentially put health care providers at risk if they were to use these platforms. By using the most advanced encryption protocols, software and secure web-interfaces these issues can be appropriately handled.

There is no gold standard in terms of specific professional guidelines for the provision of online rehabilitation services.  This is an emergent field and our laws and standards have always struggled to keep up with practice. We all need to practice ethically, according to our professional guidelines, and within our professional scope.

These are exciting times. Cutting –edge technology, clinical research and practice are converging in ways we never thought possible even ten years ago. The landscape of rehab service delivery is being transformed. Clinical excellence is being redefined as the bar for health-care delivery continues to rise while barriers are overcome.

References

Andersson, G. (2009). Using the Internet to provide cognitive behaviour therapy. Behaviour Research and Therapy, 47, 175–180.

Bashshur, R., L. (2002). Telemedicine and Health Care, Telemedicine Journal and e-Health, 8, 5-12.

Rees, C., S. (2004). Telepsychology and videoconferencing: Issues, opportunities and guidelines for psychologists, Australian Psychologist, 39:3, 212-219.

Spek, V., Nyklıcek, I., Smits, N., Cuijpers, P., Riper, H., Keyzer, J., et al. (2007). Internet based cognitive behavioural therapy for subthreshold depression in people over 50 years old: A randomized controlled clinical trial. Psychological Medicine, 37, 1797–1806.

This article was originally published in Rehab Matters, the Vocational Rehabilitation Association of Canada’s national magazine.

A new study hot off the presses highlights the effectiveness of using the advances in technology to promote clinical excellence in vocational rehabilitation.

Catherine Ipsen and her colleagues conducted an exploratory survey of 1,187 counselors; here’s the abstract:

Telecommunication offers a cost-saving alternative to face-to-face vocational rehabilitation (VR) service delivery, yet little is known about the current use. This article describes findings from an exploratory survey of 1,187 counselors, representing 13 VR agencies across the United States. The online survey explored agency, counselor, and client facilitators and barriers to telecommunication use during the VR process. Staff with training in telecommunication strategies reported significantly higher rates of email telecommunication (p < .01). Counselors with a higher rural caseload mix engaged in significantly less email telecommunication during the VR process, and rural clients as compared with urban clients were characterized as having less personal access to a computer with Internet. Although counselors use and rely on simple telecommunication methods such as phone and email to serve their clients, strategies to address barriers are needed to expand telecommunication use during the VR process.

The goal of the study was to identify potential facilitators of and barriers to effective telecommunication use during the rehabilitation process and can be summarized as follows:

• Agency and counselor factors: Unfortunately, very few VR counselors (18%) were actually trained in distance counseling method
• Access to technology: Many counselors also indicated that rural clients received fewer opportunities to communicate with their counselor using both face-to-face and telecommunication methods.
• Communication skills: The loss of nonverbal communication cues and misinterpreted meanings are described in the literature. In all, 53% of counselors in this study felt that written communication was less effective than verbal communication with clients, due to a lack of nonverbal cues, client literacy issues that make written communication problematic, and difficulties checking on client understanding. In addition, many counselors felt these barriers were particularly problematic for clients with cognitive and mental health impairments.
• Assistive technology: Counselors also noted that certain telecommunication methods were inappropriate for some types of disabilities because clients lacked the necessary assistive technology
  Confidentiality: A major concern of telecommunication use is that client privacy may be jeopardized
• Technical difficulties: Technical difficulties are described as a major barrier to telecommunication use

The study sheds light on both the powerful utility of using these emerging tools and to heed the need for education and training for both the delivery and receipt of service.

At Brainworks, we are now able to provide online services to complement our traditional face-to-face services by using cutting-edge technology, through several multimedia channels (e.g., text, graphical, audio, and video). Brainworks’ eRehabilitation services were created to increase affordability and accessibility while at the same time maintaining the high standards and the guidelines we abide by.

References

Ispen, C., Rigles, B., Arnold, N. & Seekins, T. (2012). The Use of Telecommunication to Deliver Services to Rural and Urban Vocational Rehabilitation Clients. Rehabilitation Counseling Bulletin, 55, 144-155.

Every morning we wake up and regain consciousness — that is a marvelous fact — but what exactly is it that we regain? Neuroscientist Antonio Damasio uses this simple question to give us a glimpse into how our brains create our sense of self.