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.

Clinical practitioners will recognize those words – as they often find their way into reports. The very nature of therapy can be encapsulated by such terms. Some clients may need extensive provisions of care while others will benefit from just a gentle nudge.

Brainworks provides a number of services. Each of the various forms of therapy we offer can be thought of as helping our clients learn new ways of doings. Change is hard: it is hard enough to go through trauma, sustaining a brain injury let alone trying to adopt new behaviours and routines. When it comes to the development of new routines and habits some interesting research was conducted to see how long it takes for behaviours to become automatic. Researchers asked students to adopt a new health-related behaviour, to be repeated once a day for the next 84 days. The new behaviour had to be linked to a daily cue. Example behaviours included: going for a 15 minute run before dinner; eating a piece of fruit with lunch; and doing 50 sit-ups after morning coffee. The average time to reach maximum automaticity was 66 days (the range varied from 18 to 254 days). This is much longer than most previous estimates of the time taken to acquire a new routine. The more complex the behaviour the longer it took to reach automaticity. Participants who’d chosen an exercise behaviour took about one and a half times as long to reach their automaticity plateau compared with the participants who adopted new eating or drinking behaviours.

Never Give Up Hope

What’s the take home message: be prepared to be patient. Developing new routines takes time, sometimes quite a long time. The encouragement we provide our clients is crucial towards facilitating success. Sometimes that encouragement, that guidance – it may need to be provided dozens of times before we can step back and see independence with a particular behaviour or goal.

Reference

Lally, P., van Jaarsveld, C., Potts, H., and Wardle, J. (2010). How are habits formed: Modelling habit formation in the real world. European Journal of Social Psychology DOI: 10.1002/ejsp.674

We’re all aware of the evolution as we expanded from the medical to the bio-psycho-social models of conceptualizing pain. When the current generation started in healthcare, the medical model was still very much in vogue. As our knowledge base expanded, our model of thinking about pain expanded.

That was then, this is now. With research, with advocacy, with numerous campaigns we have moved forward, we are progressing into a biopsychosocial-spiritual framework. Whether we are aware of it or not, it is happening all around us. This new paradigm: includes & encompasses all applicable domains that we have: physical, biological, psychological, social and spiritual.

Plato once said, “The greatest mistake in the treatment of diseases is that there are physicians for the body and physicians for the soul … although the two cannot be separated”. Throughout history, and in our collective clinical experience, we’ve seen countless “suffering” individuals turning to their higher power. For many of us turning to a higher power is the FIRST thing and the LAST thing we do when we are in pain. What’s interesting is that this connection between spirituality and pain is often overlooked by medical & psychological practitioners, who consider spirituality to be out of their scope of practice.

In this piece we are going to explore pain management at this intersection, we are going to look at why it is important to make sure that while we treat the mind and body … That we incorporate spirituality into assessment and treatment of chronic pain.

There a number of reasons to include spirituality in health care. For starters it is being legislated and the World Health Organization now includes all the domains of the Biopsychosocial-spiritual model in its World Health Organization Quality of Life (WHOQOL) Domains. Patients, when asked, are voicing a need that has yet to be met. Adults consistently state that they welcome a discussion with their physicians about spirituality. 83% of patients surveyed reported that they want physicians to ask about spiritual beliefs, especially during serious illness (Oyama & Koenig, 1998).

The body of studies in the literature is growing and is showing the vast number of benefits spirituality has in general health care and specifically within pain management. Let’s look at just a few of the studies and the results:

Frequent attendance at church was related to:

• Lower sensory and affective experiences of pain,
• Lower self reports of pain intensity
• Fewer symptoms of somatization, depression, and anxiety – (Harrison et al., 2005)

Spiritual coping strategies exert a predictive role in psychological and physical health outcomes

– (Hill, & Pargament, 2003)

Spirituality increased acceptance of pain

– (Glover-Graf et al., 2007)

Three different survey studies, prayer was either the primary or second most frequently used coping strategy used to deal with physical pain

– (Koenig, 2001) & (Rippentrop, 2005)

“Pain is inevitable, suffering is optional.“

We all know a number of strategies that have fundamentally changed the meaning of “suffering” for individuals with chronic pain. As this inspirational quote suggests, we have the ability to influence, and even transcend, our experience of pain. Inclusion of spirituality into assessment and treatment can be and is a pathway to nurture the soul and alleviate chronic pain.

References

Glover-Graf, N. M., Marini, I., Baker, J., & Buck, T. (2007). Religious and spiritual beliefs and practices of persons with chronic pain. Rehabilitation Counseling Bulletin, 51 (1), 21-33.

Harrison, M. O., Edwards, C. L., Koenig, H. G., Bosworth, H. B., DeCastro, L., & Wood, M. (2005). Religiosity, spirituality, and pain, in patients with sickle cell disease. Journal of Nervous and Mental Disorders, 193, 250–257.

Hill, P. C., & Pargament, K. I. (2003). Advances in the conceptualization and measurement of religion and spirituality: Implications for physical and mental health research. American Psychologist, 58, 64–74.

Koenig, H. G. (2001). Religion and medicine IV: Religion, physical health, and clinical implications. International Journal of
Psychiatry in Medicine, 31, 321–336.

Oyama, O., & Koenig, H. G. (1998). Religious beliefs and practices in family medicine. Archives of Family Medicine, 7, 431–435.

Rippentrop, E. (2005). A review of the role of religion and spirituality in chronic pain populations. Rehabilitation Psychology, 50, 278–284.

Wachholtz, A., Pearce, M., & Koenig, H. (2007). Exploring the relationship between spirituality, coping, and pain. Journal of Behavioral Medicine, 30, 311–18.