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

Recent advances in technology have led the way to a myriad of face-to-face services being transplanted to the Internet. Rehabilitation professionals have begun to evaluate and harness the utility of email, instant messaging and video conferencing to serve their clients (Zack, 2008). Using the internet to conduct counseling, psychotherapy and even rehabilitation is a cutting-edge method of service delivery. Providing services without the hassle and cost of travel, traffic and parking is beneficial to both the client and professional alike. The convenience of being able to access rehabilitation services from the comfort of one’s own home broadens the catchment area to virtually eliminate the constraints of geography and busy lifestyle.

“Providing services without the hassle and cost of travel, traffic and parking is beneficial to both the client and professional alike.”

Can it be that simple – to forgo the traditional face-to-face therapy visit and make use of rehabilitation services online? The scope of the rehabilitation field is as broad as it is deep and requires the integration of a variety of schools, theories and disciplines. As rehabilitation tools become more sophisticated to meet the demands of the twenty-first century, so does the process of therapeutic delivery. The advantages are numerous as many of us are ‘plugged-in’ in so many ways. The regulatory bodies and professional associations to which rehab professionals traditionally turn to for guidance on such matters may not have ‘technology-specific’ guidelines, as their development requires keeping pace with current technology innovation, which has always been a struggle (Nicholson, 2011). As awesome as the utility and breadth these new technologies offer, rehabilitation professionals must heed the gravity of potential legal and ethical concerns.

Professionals conducting therapy and rehabilitation online are bound by the same professional ethics as apply to face-to-face treatment, including maintaining confidentiality, being available in case of emergency, intervening when a client is a danger to themselves or others, reporting the abuse of a minor, and following relevant regulations related to licensure (Finn & Banach, 2002; Zack, 2008).

Ethical issues related to providing online therapy and rehabilitation include:

• Uncertain privacy and confidentiality of online communications
• Provision of emergency assistance
• Ability to fulfill mandatory reporting requirements
• Reliance on a fragile technology
• Billing, fees and jurisdiction (Finn & Barak, 2010)

Both the Vocational Rehabilitation Association of Canada (VRA) and Canadian Psychological Association (CPA) have codes of ethics with nearly identical guiding principles:

Ontario’s Personal Health Information Protection Act (PHIPA) of 2004 stipulates that the health care professional “take steps that are reasonable in the circumstances to ensure that personal health information (PHI) … is protected against theft, loss and unauthorized use or disclosure” (PHIPA, 2012).

The CPA specifically addresses the issues concerning therapy conducted via electronic media with these guidelines:

• “Psychologists educate themselves regarding current practices and security devices for electronic communications, and use those systems and practices that are reasonably available, and that best protect their clients’ privacy.”
• “Psychologists keep up to date with the e-service literature, including research literature regarding the efficacy and effectiveness of services using electronic media, and take this literature into consideration when deciding what services to provide to which clients, with what methods, and under which circumstances.” (Canadian Psychological Association, 2012)

However, the CPA does not provide any guidelines that are specific to any particular type of technology. This makes sense, as it’s an exercise in futility to try to construct applicable guidelines to a moving target such as today’s technologies. With each new advance and innovation in technology ethical and legal issues do arise from their use. The four principles of both the VRA and CPA can and do serve as a framework to guide the rehabilitation professional towards protection of PHI and compliance with PHIPA.

To Skype or Not To Skype

Some technologies, such as Skype have made it easy, possibly too easy, to conduct therapy online. Let’s look at the Health Insurance Portability and Accountability Act (HIPAA), the US’ equivalent to PHIPA. HIPAA doesn’t certify software as being HIPAA compliant or not. Instead, various companies claim that their software is HIPAA compliant. Furthermore, HIPAA requires professionals (business associates) to sign an agreement with third parties such as software vendors (covered entities) if they are handling confidential information. How does this all apply to Skype? Skype does not state on its website that it is HIPAA compliant. Skype does not offer Business Associate contracts to therapists or clinics, which use it for online therapy purposes. Skype, by their own admission, fails to guarantee the privacy of its users by remaining mute on the matter. In fact Skype explicitly declines to meet with HIPAA’s standards. A representative from Skype shared the following, “Skype is not a business associate subject to HIPAA nor have we entered into any contractual arrangements with covered entities to create HIPAA compliant privacy and security obligations” (Zur, 2012). As Skype continues to abstain from transparent practices that promote the privacy and protection of those that use its products, how can we be sure that using Skype is safe and meets the requirements of PHIPA? Well, we can’t.

The terms “eCounselling” and “eHealth” have become commonplace, and describe vast categories of online treatment.  Likewise, Brainworks has followed suit and coined the term “eRehabilitation”, as a comprehensive treatment platform that uses interactive audio, video, or data communications to provide rehabilitation services at a distance. Our eRehabilitation services can be linked to online at www.eRehabilitation.ca

eRehabilitation includes:

• Rehabilitation counseling, consultation and therapy delivered via a secure web interface
• Video on demand, Video conferencing
• Interactive web based health metrics
• Email, text messaging
• Interactive web based learning modules

At Brainworks we ensured that privacy, and the protection of PHI and compliance with PHIPA was incorporated into the design of the eRehabiltiation platform.

Dr. Ann Cavoukian, Ontario’s Information and Privacy Commissioner, is the founder of Privacy by Design (PbD), a framework and approach of embedding privacy into the design specifications of various technologies. Dr. Cavoukian’s recent paper (Cavoukian & Alverez, 2012) recommends that the rehabilitation professional be proactive, not reactive; that privacy be the default setting and that privacy be embedded into design.

“The scope of the rehabilitation field is as broad as it is deep and requires the integration of a variety of schools, theories and disciplines.”

Privacy is not an option; rather it is incumbent for the rehabilitation professional conducting online therapy to integrate the principles of PbD into everyday practice. The onus is on the rehabilitation professional to implement good communication practices that include ensuring online interactions: meet clinical standards, are culturally sensitive, and are met with meticulous confidentiality procedures (Prabhakar, 2012). eRehabilitation and online therapy can be practiced in an environment where the client feels safe, facilitating full participation as “technology will continue to evolve, but the ethical principles remain constant” (Koocher & Keith-Spiegel, 2008).

References

References available upon request. Please contact us for more information and literature to support your referral!

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

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.

Wanting what you don’t have, and, NOT wanting what you already have. The difficulty with change can start with that dichotomous view of the human condition. We do not want the love handles, we want to get rid of the debt, and many of us detest the turbulence with the stresses at work and at home. Then we turn around and look towards what could be; the dream home, a better job and that lifestyle we have all been dreaming of. We all have struggles on some level and we all want to change. Some of our challenges are much harder to change; addictions, maladaptive behaviours and habits that have been formed after years of practice.

Prochaska and DiClemente (1986) and their colleagues identified the components and structure of staged behaviour change. Through their work, Prochaska and DiClemente developed a transtheoretical model of behavioural change, which describes behaviour change as a non-linear process that occurs in five distinct stages through which people move.

Such challenges can be addressed in counseling or therapy. The client needs to be ‘ready’ to change in order for there to be success in counseling or psychotherapy.

In such working alliances, Gerald Young, Ph.D., describes the importance of an assessment on the part of the therapist, to determine the readiness to change in each client. Some clients just may not be ready, may not understand the nature of their own maladaptive behaviours let alone the potential within them to make changes. The therapist needs to themselves be ‘ready’ and recognize when the client is open to change and should take on a role of a guide to instruct the client down the river of change. Form a therapeutic standpoint, the working alliance has the therapist as the facilitator and the client being the one seeking change and actually being the person doing the changing.

Di Clemente summarizes the readiness to change model as follows:
People change voluntarily only when,
• They become interested in or concerned about the need for change
• They become convinced that the change is in their best interests or will benefit them more than cost them
• They organize a plan of action that they are committed to implementing
• They take the actions that are necessary to make the change and sustain the change

Change can be a frightening endeavor. Some of us may not feel ready, and we may navigate back and forth through the stages of change. When we do make significant strides, when we recognize that we are ready – change can and often is empowering.

Prochaska, J.O. and Di Clemente, C.C. (1986). Towards a comprehensive model of change. In: W.R. Miller and N. Heather (Eds), Treating addictive behaviours: Processes of change. NewYork: Plenum Press.