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.

Friday was International Procrastination Day and this post was put off until today. All joking aside, procrastination is something we are all familiar with and its deleterious effects can be serious. Delaying this blog posting will likely not make any top ten list of “important” tasks. People delay writing up reports, and we often assert that that we will start something tomorrow, perhaps an exercise regime. Further, many postpone activities and projects of various kinds to the weekend or next week.

Dr. Pamela Wiegartz gives us some insight into the reasons behind procrastination. In this piece she wrote, she first asks the reader some questions, as follows:

1. When faced with a task, do you think of all the ways it could go wrong?
2. Do you picture how important people in your life might react if you failed?
3. Do you believe it’s better to not try at all than to try your best and fail?
4. Are you overwhelmed by the possibility of new responsibilities if you are successful?
5. Do you subscribe to the idea “If I do well, then others will expect more of me”?
6. Do you feel your success will lead to other people finding out the “real you”?
7. Do you believe that if you’re going to do something, you should try to do it perfectly?
8. Do you find it difficult to persist when things aren’t going just right?
9. Would you rather avoid doing something than do it imperfectly?

Based on which questions resonate with you here is a breakdown of what lies beneath procrastination:

Fear of failure: Questions 1-3
Fear of success: Questions 4-6
Perfectionism: Questions 7-9

Dr. Wiegartz concludes by stating that procrastination doesn’t work because avoidance, of failure, of success or other reason does not erase the underlying thoughts and feelings – it just delays it.

There are many strategies to combat the paralyzing effects of procrastination. For example cognitive-behaviour therapy has proven beneficial to re-frame the underlying thoughts and beliefs that contribute to procrastination. We will not go into the research or specifics of CBT here. However, we will share one interesting research study that looked at how deadlines can help us overcome our procrastinating behaviours.

The researchers posited three questions:
(a) Are people willing to self-impose meaningful deadlines to overcome procrastination?
(b) Are self-imposed deadlines effective in improving task performance?
(c) When self-imposing deadlines, do people set them optimally, for maximum performance enhancement?

The research took place within the context of a semester long course at the Massachusetts Institute of Technology. Participants were students in a class, and as part of their tasks for the course they had to write either three short papers or one short paper. The instructor explained that each student was free to choose the dates by which they wanted to hand in the papers, but that the deadlines had to be announced in advance and were binding.

Check out the video below as the principal researcher, Dr. Dan Ariely, describes this fascinating study.

Their results showed that the answer is “yes” to the first two questions, and “no’’ to the third. We all experience difficulty with self-control and we often can actually recognize these challenges. We sometimes try to control them by self-imposing deadlines. These deadlines help us to control procrastination, but they are not as effective as some externally imposed deadlines in improving task performance.

What do you all think? From your own experiences which method will enable you to ward off procrastination: an internally imposed deadline or one imparted externally?

References

Ariely, D. & Wertenbroch, K. (2002). Procrastination, Deadlines, and Performance: Self-Control by Precommitment. Psychological Science, 13 (3), 219-224.