Telehealth Online Behaviour Support and Counselling Psychotherapy
Having taught for many years at a few of Australia’s premier universities offering distance education, and having worked in therapy for even longer via distance technologies and across countries, our practice naturally embraces this form of consultation. Even more so, working in the New England North West that spans over 400 km in each direction, online services are essential for everyday life and for therapy.
In private cases, people often choose to work via distance technologies. As simple as phone or Skype, Facetime, Whatsapp, or texts, people today have fully embraced IPad, tablet, computer, or hand-held devices and their utility. No longer is this a generational issue with reluctant uptake by the older gen – many people in their 80s and 90s are using a range of technologies. We have senior clients who sometime use, and others who prefer to use distance methods to stay in touch with family, friends, and yes their therapist!
In NDIS cases, participants of the scheme are just as varied in their techno-choices as the mainstream population. But sadly, the NDIS has tended not to fund purchase of devices per se, so the hard reality is that many of our NDIS participants cannot afford to purchase or update equipment. As you well know, a new smart phone these days can easily top $1000.00 in Australia.
Having said all of this, online social networking, family communication, shopping, and therapy is here to stay. In a sense it is no wonder. In many ways over the past thirty years distance education and online university education has had extensive research. Likewise, telehealth and distance medical consultations have generated a very robust literature for efficacy. In the realms of health and wellness and in counselling, distance methods have extensive research.
Overall these bodies of knowledge suggest that online or distance technologies have a great deal of utility. They are not the be all and end all. But face to face therapy is also not the be all and end all option in many situations. In reality, different methods for each situation seems to be a utilitarian question. Effectively, telehealth methods do the job when necessary or when preferred by the people who use the technology. Research into the use of online telehealth and distance therapy methods with people who have disabilities also shows a fair share of the research.
We did a search in Google Scholar on ‘telehealth and cognitive disability’ and the results show 14,000 results. We notice a higher percentage of telehealth use by Psychiatry, no surprise given that practitioners are few and far between and they tend to be based in large urban centres with vast territories of outreach. Telehealth appears to be embraced by Occupational Therapists, Counsellors, Psychologists, Mental Health Workers, and a wide range of professions.
When working with people who have disabilities, the use of technology can often provide an additional resource. In many cases in rural and remote areas, telehealth methods are essential to provide a professional and high quality clinical assessment. Travel costs are prohibitive and funding for travel is ever on a diminishing scale.
Since the NDIS launch our service maintained a fortnightly clinic in the west of regional New England out of Inverell NSW. However, NDIS funding cuts to participants during 2019 led to the fateful decision to cease the regular clinic. Travel happens these days in more rare situations and we always work to book two or three participants so that the costs of therapist travel is shared and reduced among participants.
The long and short for many NDIS participants is that choice and control of therapy options is extremely limited. Few providers offer distance behaviour support and counselling psychotherapy is a rare area of specialisation for people with complex disabilities. For people seeking counselling or psychotherapy the NDIS tends to push people toward using first the Medicare rebate scheme, fair enough. However, raising a change of circumstances once the rebate is expended virtually never happens. The long and short of this strategy is that the Scheme saves a great deal of funding but NDIS participants are likely not receiving the specialist care they need.
Additionally, the rebate is more or less restricted to Psychologists when the vast majority of the NDIS therapist workforce who have experience and specialization in disabilities fall outside of the restrictions. Also, Australia has a large workforce of registered Counselling Psychotherapists who cannot access Medicare rebates – a workforce that could help reduce the waiting lists and who are specifically trained to address the needs that the Medicare rebate is designed to meet. The fractured nature of NDIS verses health care and the outdated uses of allied health and mental health related funding continues to diminish the effectiveness of all these systems in Australia.
For all of these reasons, we find that an increasing number of our cases happen via telehealth distance and online methods. We also find ourselves consulting in cases where people cannot visit our service because distances are too great. We note studies that have explored the use of telehealth with children who have Autism. In such cases, therapists conducted functional behaviour assessments, and worked with parents via online systems, and with children where possible. The outcomes suggested that functional assessments could be effectively and efficiently conducted online. Similar outcomes arise in studies on the efficacy of online functional communication training with people with cognitive disabilities and Autism and their families or carers. Of note, other research findings appear to suggest that telehealth has been useful in cases of self-injurious behaviour and a range of other behaviours of concern.
Across all of these research findings one thing is clear. Research in this area so far relies heavily on case studies and tends to rely on small sample sizes. This is largely due to the fact that disability research is wholly underfunded; and the concurrent reality that complex disabilities and dual diagnosis is a smaller population among the NDIS disability population
Perhaps a scheme like NDIS may encourage wider studies in future to examine the effectiveness of various methods of service delivery. For now, the best advice the literature seems to suggest is a that NDIS participants can seek a highly professional case by case assessment that clarifies the use and utility of online service delivery in each situation. In many ways, a behaviour specialist may be best placed to provide this kind of assessment and to recommended services.
What is also clear is that one size will not fit all people. NDIS choice and control principles rely on diversity of service options. Telehealth distance and online methods provide another choice for NDIS participants who either cannot access due to distance and travel issues, or who want to choose a telehealth form of behaviour support or counselling psychotherapy. In either situation, the therapist can likely develop a service plan to match the context.
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