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Mental Health OT's: This is Our Moment

Updated: Apr 23, 2020

Like me, you must have seen the messages posted all over the internet. Therapists everywhere are struggling to adapt to the rapid changes in our world wrought by the virus. Among those changes, is the use of teletherapy as a modality. Until a few short months ago, telehealth in occupational therapy was primarily a fringe modality used sparingly in some pediatric school settings where there was a desperate shortage of therapists. This past February, I predicted that telehealth would be extended--slowly--to other areas of practice, maybe 5-10 years from now.


I saw first hand how quickly this "wave of the future" was happening now when I went to my local emergency department for a personal health crisis. I'd been through this procedure before for myself and with family members. You receive an ID bracelet at the front desk, then a triage nurse takes your vitals, then--unless you are in respiratory arrest--you most likely take a seat in the waiting area again until you are called back.


My experience was similar to this scenario, but with one added difference. As the triage nurse took my vitals, a voice boomed from beside her asking me questions in a rapid-fire staccato voice. I jumped out of my skin I was so startled. What was this? I saw no one else in the room. "Oh," said the nurse, seeing my confusion. "This is Dr.________, live from Boston." I cocked my head 90 degrees and sure enough, here was a large video screen on wheels, with a camera on top facing me, and live streaming video of a tired-looking gentleman with bags under his eyes. His manner cued me that he'd probably already done this a hundred times.


"Can you lift the affected leg and bend forward, towards me?" he said in a deadpan, Southie accent, sounding a bit like a professional version of Cliff Clavin from Cheers. "Okay, numbness or tingling? No? Okay, that's great."


I stopped him. There was a live-streamed image of the Golden Gate Bridge in the background. I could see cars crossing it. "You're in Boston?" I said.


The doctor gave me a half-smile. "Oh, that? Yeah, I'm in front of a green screen in Boston. They let us pick our backgrounds. I went to med school in the Bay Area. The bridge brings back memories. Nurse--sorry, what was your name? He's oriented x 4 and stable. You can prep him."


What's next, I thought? Will I walk into an exam room and see a video of a doc standing in front of Machu Pichu, but he'll actually be in Sidney, Australia and have a Minnesota accent? Or maybe my doctor will be at Mount Everest basecamp, squeezing in a few patient visits before her guided summit attempt, but she'll be standing in front of a background depicting a remote Caribbean island.


This interaction occurred about a month before the Corona virus hit, when a person was lucky enough to be able to go to the ER for a serious but non-life threatening medical problem, and not worry that doing so will risk your life--or your doctor's.


In terms of the way we communicate, socialize and practice medicine, we have just leapt forward 10 years in the span of a month. Note to self: anytime you write "wave of the future," you will sound about three decades older than you actually are.


The pace of globalism has advanced since the dawn of the internet age, and regional barriers to in-person contact between different parts of our world, both nationwide and internationally, are disappearing. While I'm writing about the use of telehealth care so far, we all know that the use of telehealth is rapidly expanding (side note: one of our members and a distinguished OT just published a very forward-thinking book explaining telemedicine to children in a picture book. Find a review of it and a link to it here: https://redheadedbooklover.com/why-is-there-a-person-in-my-computer-a-childs-guide-to-teletherapy-brittany-ferri/). But what I am most interested in, is how telemedicine and the health crisis that accelerated its use can help us broaden our scope of services in order to help more people.


The use of telehealth in mental health seems like a no-brainer. It allows us to sit face to face with our clients in real time. By utilizing telehealth as a modality for providing mental health services, we can also expand our practice areas far beyond the constricted range we have been relegated to. Apart from a few privately funded or grant-supported programs, mental health occupational therapy in America is primarily found in acute or long-term inpatient hospital settings with patients who have already experienced a crisis or suffer from severe psychiatric symptoms. This is usually a prerequisite to qualify for or access our services.


I loved my job as an inpatient forensic mental health OT, in a variety of settings. Nothing was more satisfying than helping people in severe distress. However, from a purely public health point of view, I sometimes wonder if I could make a greater difference by providing mental health services to people in community settings before their symptoms escalate to the point of crisis. I simply ask, why should we only be deployed for group therapy at inpatient hospitals and at evaluation and treatment centers that primarily exist to react to crisis when we have far more professional skills to offer?


Mental health occupational therapy is grossly underutilized, and its practitioners are caught in a self-perpetuating cycle whereby we are mostly viewed as providers of inpatient group therapy, which in turn leads to fewer and fewer career opportunities to perform many roles outside of inpatient group therapy. There are not many silver linings to a deadly pandemic, but there is one: it forces us, as a society, to reevaluate our entrenched perspectives, our understanding of what is and isn't possible, and to consider moving on from outmoded models of care.


Telehealth opens the door to providing services and promoting wellness and meaningful occupation for people who cannot or will not leave their homes because they have a physical or mental health condition, they live in a a rural area and lack reliable transportation, experience poverty and a lack of access to services--or a combination of these factors. Not only that, but I am hearing from social media contacts that they are also able to transition their current mental health work from in-person, inpatient hospital settings to the virtual context--even when conducting therapeutic groups. Although there are complex laws and bureaucratic hurdles to consider, it may soon be possible to reach across oceans to serve clients in other nations who can benefit from our work, and vice versa. In ideal conditions, the only barriers to service provision should be timezone and language incompatibility, but emerging technologies may help us surmount even these challenges in the near future, especially considering the fast pace at which artificial intelligence powered language translation technologies have already advanced.


Of course, we must approach the advent of shifting service provision practices and the shift toward telehealth with caution, and with the understanding that some of its limitations and risks will only be revealed through time and experience. As with other virtual contexts like social media, telehealth has the power to bring people together, or to alienate them and make them feel even more isolated. The current medical model under which we all toil is the byproduct of unchecked free market capitalism. This model equates efficiency and productivity with high quality care, and treats business objectives and health care concerns as mutually inclusive and synonymous. If we aren't thoughtful architects and staunch advocates of a humane vision of health care, compassion will not be the driving force of change, but revenue generation will.


Telehealth offers a tantalizing opportunity for corporations to vastly increase their profitability. It drastically reduces their overhead costs and cuts down on the time required for service delivery, thereby fueling the demand that providers of all stripes increase the size of their already bloated and barely manageable caseloads and number of patient visits. It has the potential to redefine productivity and continue to ramp up the pace that many providers say detracts from the quality of their services, their ability to establish therapeutic rapport, and increases their feelings of burnout and compassion fatigue. Hospitals and clinics will continue to exist, but in the near future they may become much smaller, quieter places (or conversely, only reserved for the most severe and complex cases) staffed more by techs than providers. Telehealth is not the only technology making these changes possible. There is an ongoing podcast on Medscape called Medicine and the Machine

(https://www.medscape.com/features/public/machine) which provides a fascinating ongoing dialogue between two doctors about how the use of artificial intelligence technologies are changing the face of medicine, and in some ways are making it more impersonal.


Now is the moment for us, as providers and as mental health occupational therapists to seize the moment by crafting and articulating our own standards of best practice with the use of telehealth, telephonic, and other virtual health care technologies. We need to create a set of protocols so that these technologies are are not used to subvert our patients' agendas, so that they do not become mere tools to enforce efficiency and productivity, so that they can be used intelligently and compassionately to promote the health and wellness of the people we serve. Except where limited by geography, AI should not be viewed as a replacement for in-person services, but as an important adjunct to it. Telehealth and other technologies may well become the hands of health care, but they cannot replace its heart and soul: us.


We must use this historic moment to assert our full scope of practice, by expanding our range and domain of practice. Breaking into telehealth is is not the ultimate goal here, but a means to an end. Providing group therapy in inpatient mental health hospital settings will always be an important (and for some of us, very fulfilling) service we provide. Rather than talking about "breaking into telehealth," I suggest instead that we use telehealth to practice in those additional areas where we know--but others don't--we can have a beneficial impact, especially serving people in their own homes, in the community, and in what soon we will be saying "used to be called" outpatient settings.


Creating new opportunities for mental health OT practice entails getting in on the ground floor with telehealth by outlining and publicizing how mental health OT can effectively utilize it in community settings. It also means advocating for far more community housing and program opportunities for people with metal illness than what currently exists. In most places jails, prisons, and inpatient hospital settings are serving as "home" for severely disenfranchised people, because no other options exist. Even law enforcement representatives are beginning to note the fact that jails and hospitals have become the dumping ground for people who would be far better served elsewhere.


"A pinch of prevention is worth a pound of cure," my Grandmother used to say. COVID-19 has highlighted and underscored the already dire need for mental health services in the community. Not only that, it's adding to those needs by expanding the degree to which previously well people are now feeling the deleterious effects of isolation, alienation and their attendant mood states. Occupational therapists and other providers can help meet those needs, and help prevent people from spiraling into further crisis. More than simply dousing the flames of emotional disintegration, we can contribute to community wellness by serving both relatively stable individuals with less severe problems, as well as act as consultants for community organizations and programs that promote health.


Right. That's great, you're thinking. Where does the talk stop and the action start? Where does the rubber meet the road? Here is where we must begin: We all can contribute our collective ability to do what we do best: solve problems, so that we can translate idealism into practical realities. Aside from outlining and publicizing how telehealth can expand mental health occupational therapy roles to the community context, we can also start our own private practices--even if it's just part-time and small. No one is going to recognize or offer additional roles for mental health occupational therapy practice until and unless we claim it and own it first.


Maybe that tiny, part-time practice can only accept private-pay clients since we cannot currently obtain insurance reimbursement--but that also means we are not beholden to their red tape and other arbitrary, time-consuming demands. Maybe we only end up serving a few of our neighbors, and do so at a rate we know we could never make a living on, because they're paying out of pocket. Maybe. But while we all need to make a living, that need not be the goal, at first. Planting seeds of change of a worthwhile endeavor can be the impetus not just for expanding our own professional repertoire, but changing the way our entire society envisions health care, so that once companies and other organizations see that it can be done, it will be done. And society will be better served as a result.


Understandably, not everyone can start a private practice. But my challenge to you is this: think about and share your own constructive, pragmatic ideas about how we can both realize our full scope of practice as mental health OT's and expand our roles into other settings. I look forward to hearing from you.


Happy National Occupational Therapy month!


--Justin Teerlinck, MOTR/L









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