Old Wine in New Bottles: Electronic Counselling from a Family Medicine Perspective

1. Old Wine in New Bottles: Electronic Counselling from a Family Medicine Perspective Yonah Yaphe Community Health School of Health Sciences University of Minho Braga, Portugal

2. Objectives • By the end of this session participants will: • Know the uses of electronic counselling in family medicine. • Know how to respond to a request from a patient for counselling via e-mail. • Value the use of e-mail in counselling patients in family medicine.

3. Growth of E-mail in medicine • Claim: E-mail is growing as a versatile, effective, accessible, rapid and safe form of communication between doctors and patients. • What is the evidence?

4. Use of e-mail in doctor-patient communication: 14 months’ experience. Granja M, RPCG 2009

5. Use of e-mail in doctor-patient communication: 14 months’ experience. Granja M, RPCG 2009

6. Use of e-mail in doctor-patient communication in family medcicinePinhão R, et al. RPCG 2009

7. 2. The growth of e-counselling • Ideas about counselling • Structure of an e-counselling service • Content: types of problems • Structure of letters • Feedback from patients

8. How would you respond to Robert? I'M FEELING VERY STRESSED AND ABSOLUTELY 'AT-RISK‘ IN TERMS OF MY CURRENT JOB POSITION. WHY? BECAUSE OF MY RECENT YEAR-END PERFORMANCE REVIEW WHERE I WAS GIVEN A FINAL OVERALL RATING OF 'DID NOT MEET EXPECTATIONS' EVEN THOUGH MY INDIVIDUAL OBJECTIVE RATINGS WERE ALL GOOD! ALL THIS WITHOUT ANY SPECIFIC JUSTIFICATION OR DETAILS...I FEEL I'M BEING SETUP TO TAKE THE FALL FOR MY DIRECT BOSS! THIS IS VERY CONCERNING, UNFAIR, UNSUBSTANTIATED & CERTAINLY STRESSFUL.

9. What would you say to Nicole? Hi there. I have just finished cancer treatments 3 weeks ago. I find recovery difficult. I'm anxious, stressed. My doctors tell me I responded well to treatments and I should be fine. I just thought I would be happier, relieved and ready to take on the world but I'm sad and down. Thanks. Nicole

10. Underlying concepts of counselling • All of us have potential for growth and change. • Therole of the counsellor is to enable the client to mobilize strengths in order to make appropriate decisions and act on them

11. Stages of change (PROCHASKA) • Pre-contemplative • Contemplative • Decision • Action • Follow-up

12. Stages of counselling • Problemdefinition • Assessment of previous solutions • Assessment of resources • Assessment of readiness to change • Setting objectives • Deciding on a course of action • Arranging follow-up

13. Structure of an E-Counselling program • Initial request for help • Initial response of counsellor • Screening to assess risk, triage • Initial approach • Exchange of messages • Termination • Feedback

14. Need for referral • Immediate risk to self or others • Children at risk • Psychosis

15. Initial approach • Get the patient to describe their sitaution • Assess suicide risk, risk of violence, addictions, history of abuse or trauma, current sources of care. • Screening questionnaire or questions embedded in the counsellor’s first reply.

16. The “CARE” model Connect and contain “Your challenge is human and manageable.” Assess and affirm “You’ve got what it takes to get through this.” Reorient and reaffirm “You are not defined by your life situation.” Encourage and empower “Keep going, one step at a time.”

17. Structure of an initial reply • Introduction, welcome, limits to counselling, statement of the task • Restatement of the presenting issue in positive terms • Exploration and validation of feelings, restatement of the task • Statement and exploration of client’s strengths • Exploration of resources • Clarification of medical issues and previous treatment • My impression of what is going on and ways to cope • Why now, suggestions for reframing events • Exploring Options, Specific Suggestions And Homework • Affirmation and hope

18. Termination • How many messages are necessary? • Referral to other forms of care • Information on available resources • Emergency referral

19. Safety • Risk assessment • Safety contract with the patient • Advice on emergency resources

20. Feedback • During counselling - “Is this useful to you?” • Formal, at the end of counselling: - Questionnaire on global satisfaction, time saved, suggestions for improvement

21. Quality control and supervision • Look at patient feedback • Direct look at the process of counselling • Possibilities for ongoing supervision

22. Research • Number of cases • Demographics (age, gender, occupation) • Types of problems • Types of interventiosn • Outcomes • Referrals • Satisfaction

23. Six years’ experience with e-counselling • Types of problems • Patient demographics • Results

24. Age distribution: e-counselling 2005

25. Problemas addressed (n=100)

26. Frequent problems • Anxiety • Depression • Alcohol and drug abuse • Marital and relationship problems • Coping with illness • Parenting • Adolesncents coping with their parents

27. Range of problems Most frequent • Depression • Anxiety • Marital conflict • Illness • Anger • Grief • Job performance • Work conflict • Bullying Less frequent • Post-Trauma, Post-abuse • Problems with children • Blended families • Problems with parents • Alcohol • Smoking • Drugs • Legal • Financial

28. Special cases suited to e-counselling • Agoraphobia • Shyness, shame • Stuttering • Aphasia, post-laryngectomy

29. Advantages of e-counselling • Access • Respect • Low cost • Privacy • Confidenciality • No time limits

30. Disadvantages of e-counselling • Lack of direct contact • Invisible body language • No use of other non-verbal cues like tone • Requires computer and written literacy • Inappropriate for psychotic and high risk patients • Possible time delays in replies

31. Feedback 1 – significant event “I found the counselling one of the most valuable experiences in my lifein regards to my mental health.”

32. Feedback 2 - access “As someone suffering from agoraphobia it was probably the only chance of me ever receiving counselling as I for sure would never go outside my home in order to attain help.”

33. Feedback 3 – positive regard “I felt respect and care throughout thecorrespondence and feel that I grew in the process.” 

34. Feedback 4 - retrievable “The format is excellent you can go back to what you have written and also the thoughts and suggestions of your counsellor.”

35. Feedback 5 - reflective ““The process of articulating my concerns, needs, goals and strategies for meeting them is therapuetic in its own right.”

36. Conclusions • Electronic communication provides an additional effective tool to the family physician for helping patients. • Understanding its advantages and limitations can enhance its use.