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14th - 15th October 2013 | Mercure Geelong, VIC5th Australian Rural & Remote
Mental Health Symposium
Proceedings
Conference Proceedings 5th Australian Rural and Remote Mental Health Symposium 2013
ISBN: 978-1-922232-09-0
Publisher Details Publisher Name: Australia and New Zealand Mental Health Association Contact Name: Cindy Axisa Address Line: PO Box 29 City: Nerang State: QLD Postcode: 4211 Telephone: +61 7 5502 2068 Fax: +61 7 5273298 Email: [email protected]
Table of Contents
Author Title Page
Baker, D Suicide Prevention Apps: A fresh approach & new options for suicide prevention in rural & remote area
4
De Torres Therapy without a body: crossing the boundaries of therapy through technology
12
Newby, D Management of chronic pain in regional Australia: can we farewell the acute pain treatment model? PEER REVIEWED
24
Raghavan, N An Audit into the documentation of Crisis Intervention and Recovery Plans in case managed patients
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Suicide Prevention Apps:
A fresh approach & new options for suicide prevention in rural & remote area
Deli Baker, Psychologist
Abstract
With new technology, comes new opportunities. The proliferation of smart phones, creates an opportunity for the development of mental health specific Apps - both as an adjunct to existing services - giving people another, potentially more independent and discrete option, but also, to reach traditionally hard-to-reach cohorts (youth, males, rural/remote, disability, single parents, GLBTIQ etc) when they are in the grips of a mental health crisis.
Melbourne based Psychologist, Deli Baker, has self-funded the development of a suite of three Apps designed particularly for suicide prevention. The first, called ‘R U Suicidal?’ is for someone who may be suicidal. The second, called ‘Is S/o Suicidal?’, is for anyone concerned someone is suicidal and wanting to help appropriately. The third, called ‘Did S/O Suicide’ is for someone bereaved through suicide. This App focuses on traumatic bereavement but also directly references the risks of suicide for those bereaved in this way.
The Apps are all video based – designed to be a warm, human connection – potentially at a time of great distress, fear and isolation. They are structured and interactive - guiding the person through steps designed to pave the way forward in a safer way such as by focussing and planning. They make regular references to self support to promote empowerment as well as other, personal and professional supports such as local services if those are available.
They are designed as a low-cost, private & discrete, widely accessible, self help intervention ‘in the palm of your hand’. The Apps, and especially ‘R U Suicidal?’, are key for GP’s, Mental Health Professionals, Crisis Services, Schools, Youth Services, Community agencies, Police and the like, to refer clients to, especially for ‘Out of hours’ or when no other services are available or if the person has engaged services but still feels suicidal and in need.
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Background /Context
World Health Organisation (WHO) estimates that around one million people die from suicide each
year worldwide - around one death every 40 seconds [1]. WHO also estimates that for every
suicide death there are 20 or more who attempt suicide – that’s approximately 20 million suicide
attempts per year worldwide [2]. Given the many issues around recording such as many countries
not having the level of organisation necessary to keep sound statistical records; that some suicide
deaths are not recorded as such (i.e., accidental drug overdose, single occupant vehicle accident
fatalities); and some suicide attempts not being known to reporting authorities, it is likely that these
numbers are low estimates – potentially just the ‘tip of the iceberg’.
Suicide is a complex problem underpinned by myriad social, health, economic and other factors and
many suicide deaths are preventable.
The specific challenge
Many people experience barriers to service when they are in the grips of a mental health crisis.
Youth, males, the elderly, people living in rural and remote locations, people living with disabilities,
single parents, severely economically disadvantaged & Gay, Lesbian, Bisexual, Transgender,
Intersex, Queer (GLBTIQ) are traditionally hard-to-reach cohorts. Other barriers include social
stigma and acute emotional distress and social isolation. Still further barriers lie in service
shortages, including insufficient numbers of mental health beds (public & private), waiting queues on
national crisis lines – potentially worse overnight and on weekends where rosters are harder to fill;
public crisis assessment teams (CAT) being overwhelmed by the volume of need – also potentially
worse overnight and on weekends. Ironically, these are common times for suicidal crises due to
loneliness, isolation and many services being closed. Some people in a crisis do manage to
transgress these and other barriers but still feel suicidal after accessing services.
A specific response
It would be nice to think that these challenges could be redressed by increased Government
spending either directly to service or into research and public awareness campaigns. In the first
case, is seems unlikely that any such figure as ‘adequate’ exists. Secondly, as already mentioned,
suicide is a complex and egregious social problem. Our response to complex problems should
always be, not ‘this or that’, rather ‘this and that’.
Many people survive acute suicidal crises due to an inbuilt survival instinct or ‘will to live’ - this is
common to all mammals. The proliferation of smart phones creates an opportunity for the
development of self help tools that tap into this most basic of instincts. The following ‘Apps’ for
smart phones are just so – tools that may be privately and discretely obtained, in an increasing
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number of locations worldwide, and available ‘in the palm of one’s hand’ at any such time – day or
night, as the need arises.
‘R U Suicidal?’ is an App for anyone who is, or thinks they may be, suicidal. It is predominantly a
video of a psychologist talking directly to the user. It is designed to be warm and engaging – a
human connection, potentially at a time of great distress, fear and isolation.
Figure 1.
Figure 1. Screen shot of the App, ‘R U Suicidal?’ – shows the video element
The App is based on neuroscience principles, for example it is structured, interactive and organised
in such a way as to promote a progressive shift in neural activation and cortical blood flows from
predominantly emotion centres of the brain (eg., predominantly right hemisphere; limbic structures)
toward cognitive and cerebral cortices (eg., predominantly left hemisphere; frontal cortex). This
hopefully helps the person to down-regulate emotional hyperarousal or ‘feel better’ plus up regulate
higher order function – be more able to think, cope and progress through and out of the crisis (for
example, be more able to get the other support and assistance they need).
‘R U Suicidal?’ has six interactive phases – in each case a section of video (see figure 1) followed
by an interactive slide (see figure 2).
Figure 2.
Figure 2. Screen shot of the App, ‘R U Suicidal?’ – shows the interactive slide element
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The first three slides are state related, or about the crisis itself. They aim to focus the person on
single aspects of their experience at a time instead of the overwhelming ‘everything all at once’ state
that many people who are suicidal report. The first state aspect is ‘Feelings’. This section contains
an introduction and aims to engage the person. It then promotes a focus on, and acknowledgment
of, the deep and painful feelings the person is experiencing - the symptoms or basis for the crisis.
The second is ‘Triggers’ – an opportunity to stop, acknowledge and think about what has
contributed to or brought about the crisis. The App refers to internal triggers such as deep feelings,
memories or intrusions, and external triggers, such as events or circumstances. The third state
aspect is ‘Thoughts’. This section provides for a proper examination of how deep and painful
feelings and potentially a confluence of unusual or accumulating factors (including fatigue /
exhaustion) combine to produce extreme thoughts such as ‘I must end my life’.
A person in the grips of a suicidal crisis may be ‘stripped back’ to basic instincts, for example,
dispossessed of their usual outlook, level of self-integration or rationality. The App is pitched to the
person in this raw and potentially un-trusting state. It is designed to be reassuring and encouraging
– explicitly saying, “You can get through this”. As the App progresses toward the support and
recovery phase, or second half, the user is referred firstly to themselves as a resource. For
example, the ‘Self Support’ section of film and interactive slide asks the person, ‘What have you
ever done to make yourself feel better?’. The slide provides some tips or suggestions and the user
can enter things they have done or could do with a view to regulating or soothing themselves.
Next the App moves on to ’Other Supports’ where the person is guided to tell someone what they
are thinking of doing, if they haven’t already, and asking that person to ‘come & keep them
company’. The person is urged to contact one or any (if these are available) crisis or professional
services in their local area; national crisis lines; a hospital based crisis service and other
professional help such as GPs especially for referral to a Psychologist, Psychiatrist or Counsellor.
Some people try and fail to engage a crisis service and so the user is encouraged to be patient and
keep trying. Some people will already have an existing relationship with a counsellor and so are
urged to make contact as soon as possible to make an appointment. Some people find it difficult to
trust and so err away from people, this is acknowledged also and the person in crisis is urged to
seek other comforts such as pets, items or doing things and/or going places they feel safe and calm.
The last section of film and interactive slide relate to a ‘Safety Plan’.
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Figure 3.
Figure 3. Screen shot of the App, ‘R U Suicidal?’ – shows the safety plan element
This initially focuses on the very short term, such as getting through the next hour, then midterm – a
day at a time, then longer term – a chance to explore what had given meaning to their life prior to
the crisis, is this still applicable and if not what new goals and structures and a sense of meaning
needs to be documented as a way forward. Once the video session ends – the data stored can be
re-entered from a ‘history’ or episodes tab and amended, for example, the safety plan can be
modified and remodified as recovery shifts. This is also a useful adjunct to therapy.
The second App of three, ‘Is S/o Suicidal?’ is a much needed guide for anyone concerned that
someone else is suicidal and wanting to help them appropriately. This App also is a step-by-step
guide through safety, then engagement, then helping the person resource themselves, as well as
recognizing the care and support needs of anyone supporting someone through a suicidal crisis and
beyond. This App is very important, as it is often others, rather than the person themselves, who
recognize the situation as a suicidal crisis. Many people want to help but do not know how.
The third App is called ‘Did S/O Suicide?’ and is for someone bereaved through suicide. This App
focuses on traumatic bereavement but also directly references the risks of suicide for those
bereaved in this way. It also, is a structured and interactive experience that tracks through some
common problems for those bereaved by suicide such as the deep despair and sometimes sense of
responsibility or blame that people carry and the importance of reality-testing these assumptions –
are they real and to be ameliorated and managed going forward or are they false? - more the body’s
response to the abject powerlessness felt when a loved one dies in suicide.
The problem of ‘Rural Suicide’
The problem of suicide in country locations is a specific one due to specific issues being faced by
people living in rural and remote settings. One key problem is the ease of access to means that can
lead to immediate death. Obviously, the Apps in question cannot specifically redress this. The
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other issues facing people living in rural and remote settings include: economic and financial
hardship; social isolation; stoicism - which can limit help seeking; and reduced availability of support
services, and especially mental health services.
In contrast, there is often a strong culture of ‘community support’, of people wanting to help each
other in the country. Additionally, country people are often proud and pragmatic, wanting solutions
to things rather than a problem focus. The Apps being introduced here redress some of these
issues and harness some of the strengths found within rural communities. The Apps are based on
a real person, ‘being real’ and this is especially important in a rural setting where pretence is
commonly disparaged. Being ‘a person’ rather than text or ‘widgets’, the Apps are a ‘someone’
when there may be ‘no one’. This can redress social isolation. This was a key facet in the design of
the tools. Also, the user is specifically, encouraged to suspend fear and dare to ‘reach out to
somebody’ and tell them what they are thinking of doing. This can be a loved one, such as friend or
relative or a professional help source such as local GP or national crisis line.
Being private and discrete, the Apps are a good face saving option, especially for Males or anyone
else facing barriers to help seeking and prefer to work though problems independently.
Independence is traditionally a very deep and common instinct in people living in the country.
The Apps, join the e-health movement - a part of an answer to health services shortages in the
bush. The App ‘Is S/O Suicidal?’ has an educational focus and harnesses that community spirit
where people want to help each other but don’t know how because suicide prevention is seldom
discussed overtly. ‘Did S/O Suicide?’ is a self help tool for anyone who has lost someone to suicide
in the country – of which there have been far too many.
General Weaknesses
These Apps are a self-funded project. This gave flexibility and autonomy to the project, however it
has meant that the Apps needed to be released for a cost – at this stage $1.99 each. Going forward
we seek user licence agreements or similar, to indemnify start up costs and the Apps can be put up
for free. This said, the current cost is ‘low’ - less than the cost of an average cup of coffee or mobile
phone call. It is certainly ‘low cost’ help compared to some, such as a fee paying therapy session.
Another problem is that one needs a credit card and a smart phone or other electronic device onto
which an App can be downloaded and viewed / used. Sadly, this will exclude some and probably
disadvantage certain cohorts in particular, such as youth and people who face the harshest
economic challenges. These are significant problems to be overcome and we are hoping that
parents, friends & organisations can be some remedy offering their devices and resources.
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One other important weakness is that smart phones and other electronic technology & devices are
not embraced by all. It is likely that certain groups, such as the elderly, could be disadvantaged
thus.
General Strengths
On the other hand, Apps such as these may be especially appealing to some, such as young people
– arguably a cohort most ravaged by suicide. Whether real or imagined, young people today seem
to be faced with possibly unprecedented social challenges via the advent of social media such as
Twitter & Facebook. These mediums make it easier to communicate and connect with friends but
are also an extraordinary platform for the proliferation of bullying and social abuse. Why shouldn’t
the technology they embrace, also be part of the solution as well as the problem.
Apps are a private and discrete option for males - some of whom find ‘help seeking’ difficult. People
living in rural and remote locations may not have mental health specific services for hundreds of
kilometres but may have the ability to download an App – a tool they can use on their smart phone
or other device anywhere at any time it is needed. Apps are also a suitable tool for single parents
because their use, unlike many traditional mental health services, is not reliant on child care. Apps
are also highly suitable for people living with disabilities and particularly mobility limitations.
GLBTIQ people face social barriers such as discrimination and can steer away from mainstream
service for fear of misunderstanding or judgment. In general, people in the grips of a suicidal crisis,
often withdraw all together and Apps may well be a first step or ‘bridge to service’. Apps are also a
good option for those who access services but still feel at risk or need more help, or deteriorate in
terms of state, after accessing services and feel too embarrassed to return.
The Apps represent an important tool for a wide range of helpers, including teachers, counsellors
(inc. school, youth, family, military/defence force, prison etc); workers (inc. social, health, community
development, youth, disability, age care etc.); Medical (i.e., GPs, practice nurses); as well as
specific mental health (ie., Psychologists; Psychiatrists) and Emergency & Crisis services (i.e.,
Police, ambulance, first responders, help lines etc). This is especially true at ‘the water’s edge’ in
terms of service, for example, a resource to be given to clients for use ‘Out of hours’.
The Apps are widely available, for example on Apple & Android devices – download from ‘App
Store’ and Google Play.
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REFERENCES
[1.]. World Health Organization(2012). Public health action for the prevention of suicide. Geneva:
World Health
Organization, 2012.
[2.]. WHO: http://www.who.int/mediacentre/news/statements/2007/s16/en/ (last visited 25th July
2013)
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Paper title: Therapy without a body: crossing the boundaries of therapy through technology
By: Alisa de Torres, Clinical Psychologist, Clinical Director of MyPsych.com
Firstly, I think it appropriate that I disclose that I am the founder and part
owner of a site called MyPsych.com. This is an Internet site, which is
essentially an “online practice” for psychologists. I am also one of the clinical
psychologists providing services via this site. I will use the experiences of
developing this service and building the website to illustrate the issues which
emerge in the field of online therapy. As Grohol (2001) has pointed out, online
therapy is a field in itself; a “new type of therapy – not simply psychotherapy
transplanted online” and the needs and applications of this online therapy
cross over with face-to-face therapy but also require a rethinking of the
approach to the interaction.
Although much of what follows may seem a little distant from the therapeutic
issues we are all used to dealing with on a day-to-day basis, it is important to
attend to what underpins our practices. And for referrers to online services, it
is useful to understand the benefits and appropriate clinical protocols of
telehealth services. Many clinicians have begun online practice or interacted
with patients via the Internet without considering the many issues that
surround this new technology. Few seem to be addressing the critical
limitations and possibilities that must be addressed if we are to practice in a
clinically appropriate and adequately safe framework within the emerging
technologies. In order to adapt to change, we must be well informed about the
issues. This paper seeks to address some of these issues.
These technologies cross borders, time zones and cultures giving rise to the
potential for therapeutic interactions which co-mingle vastly different
economics and politics. It is intriguing to contemplate where these
relationships will take us as humans but also as a therapeutic community,
which will have to rise to the challenges of newly emerged forms of
communication. In much the same way as the advent of the telephone, it is
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proposed that these technologies will further collapse the frames of time and
space, thus changing the form and demographic of relationships.
Issues such as management of the frame, clinical emergencies and
technological limitations must be addressed in a stringent and critical manner
in order to provide appropriately safe and effective care for our patients.
However, the assumption that treating individuals is necessarily safer or more
effective because they are in the same city or the same room is probably a
little over-stated. Most of us spend a maximum of an hour a day, on one to
five days a week with our patients. The rest of our patients’ lives are lived out
of our purview and accessing them or close others in an emergency can be
tricky. The new technologies, allied with well thought out clinical protocols,
diminish the risk to distant patients and the anxiety for clinicians.
A clinical example might be useful here. Recently, I was treating an individual
in a remote location who exhibited marked impulsivity and lack of capacity to
regulate affect or normal daily functions such as sleep or eating. At the time of
our scheduled session I received a text message from him informing me that
he was going to miss our session. I called him and he indicated was in a
petrol station in a disoriented state due to lack of sleep and emotional
exhaustion. He informed me that he had been driving very fast and did not
care what happened to him or others on the road. He said he was frightened
and did not know what to do. I asked him to call his partner to collect him, to
call work and say he would not be in today and to go to his local doctor for
assessment. I talked to the doctor to review his case before his appointment.
The doctor did a full assessment and gave him a medical certificate for some
days off work. We had our scheduled appointment two days later. The
situation was well managed. Whether he had been in Sydney or a remote
location, I believe I would have managed it in exactly the same manner. In
order to manage this situation, I had the following protocols in place. Firstly, I
have a VOIP telephone that provides very cheap or free telephone calls
around the world. This means that I have no hesitation, conscious or
unconscious, in contacting whoever it is necessary to contact with respect to
managing my patient’s care in the same way I would were they in the same
city as me. I also insist as a condition of taking a new patient on that they
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provide the full contact details of a close friend or family member who is able
to get to them in an emergency. I also require their full address and contact
details and a signed consent to speak to others if I should need to in case of
emergency. I believe that these protocols should always be in place but they
are particularly pertinent in the case of remote patient treatment. If these are
in place, an acceptably safe frame is established and it is possible then to
work to understand the more complex issues that arise due to the new frame
which technology provides.
These technologies now allow the provision of therapy via SKYPE and live
synchronous chat. Both these technologies have made it possible to
communicate in real time with others in very different times and contexts from
the therapist. Both modalities offer new challenges to the therapist and their
clients but also expand the meaning of the relational. Moreover, these
technologies expand access of many formerly excluded individuals to a wide
range of clinicians. Live synchronous chat opens up a new dialogue that
contains the therapeutic interaction in a realm of language without the usual
visual cues available to the therapist. The evidence suggests it frees some
individuals from the normal affective constraints that challenge them in face-
to-face interactions, which may prove beneficial or make the therapeutic task
more difficult. (Suler 2004) Of course, it is also beneficial to replace the
spoken word for some individuals of disability such as the hearing impaired, or
for individuals with English as a second language.
The latest research is indicative that therapy provided online is at least as
effective as face-to-face therapies. My personal experience with the provision
of online psychological therapy supports this, although I do note that each
type of clinician to patient interaction has different exigencies. Thus the
treatment of a patient in a hospital setting versus a private practice in a bricks
and mortar clinic versus an online practice, all have different benefits and
constraints. There are, of course, also commonalities.
Rochlen et al. (2004) pointed out some of the benefits of online interaction
such as the convenience and increased access, which may increase
openness of communication and overcome difficulties of access caused by
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distance or disability. However, as with much early research, a cautious
approach has been advocated for individuals with severe mental disorders
(Rochlen et al. 2004). I am not certain that this is proving to be warranted as it
appears that the perception that a clinician needs a patient to be in the same
room as them to engage in effective therapeutic work and keep them safe
might be less than accurate. In fact, it may be true that more disrupted
patients do better interacting from their own secure environment although
more research certainly needs to be done on this.
The latest research, it appears that telehealth interventions, particularly for
psychological therapies, increasingly supports their efficacy. In a very recent
study in 2013, Wagner et al. from Zurich University found that psychotherapy
via the internet was at least as efficient as conventional therapy. In fact, their
findings suggested that three months after the end of treatment, the online
treatment group showed fewer symptoms than the face-to-face group.
Also this year, in a meta-analysis conducted by Osenbach et al (2013),
published in Depression and Anxiety, a review of 14 studies which compared
synchronous telehealth to standard non-telehealth approaches, found there
was no evidence to suggest that synchronous telehealth solutions were any
less effective than non-telehealth solutions in treating depression. They
proposed that this was evidence to support the use of telehealth solutions to
overcome the problem the lack of access to immediate care.
The benefits of online access to mental health care are many and include
increased access for example for individuals with disabilities, those who live
regionally, or who need to access therapy in a different language (Rochlen et
al. 2004). Another study indicates that, for mental health care, it is also helpful
in reducing the patient’s experience of stigma or shame as it can be carried
out in the privacy of their own home and, some evidence suggests, it can
encourage reduced feelings of inhibition in the therapy allowing the client to
“cut to the chase” of the core issues (Suler, 2002b).
It is also notable that the online mental health information and therapeutic
environment has become increasingly rich and diverse over the past decade.
Therefore, mental health treatment can be approached in a multi-dimensional
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manner in the online environment where online talking therapies can be
combined with free or subsidized mental health services such as
Mindspot.org.au or moodgym.anu.edu.au, which provide information and
guided self-help treatments for anxiety and depression. Other services such
as the The Black Dog Institute and Beyond Blue are also rich sources of
information and support for individuals with mental health issues. Many apps
are also being developed although it is often difficult to identify which are
clinically validated and which are not. Some good apps are the PTSD Coach
app developed by the American military and The Black Dog institute app
called MyCompass. There are also numerous helpful tools such as meditation
and exercise tracking which offer a useful adjunct to clinical tools.
Patients who try these services appear to experience high satisfaction with
online treatment. In 2011, in a study by Gun and Titov, respondents rated
their online programmes as acceptable and their ratings increased if they had
previously used the services, which imply that satisfaction increases with
familiarity of use of online services.
It seems important that registered health care providers with appropriate
training are present in the online world as it is increasing in currency every
day. This is supported by the massive uptake in online access worldwide. To
give a quick snapshot of the prevalence of Internet use in the world and the
therefore expanded web of conversations, therapeutic and otherwise, which
are now possible, in 2001 56% of American adults reported having internet
access while in 2006, this number had increased to 73% and it has increased
since then. (Jones, 2002; Madden, 2006) Importantly, health care is one of
the most significant areas of interest for the general public. 80% of all Internet
users had searched for health care information in 2005. (Fox, 2005;
Andersson, 2006) These figures are already very out of date and increasing
dramatically each year. As of 2009, in the USA alone, there were 246.9 million
users of the Internet. (World Stats, 2009)
It is also important to note that a range of unprofessional services, and
unlicensed or untrained individuals will take up space in the online
environment and several studies recommend that health care professionals
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“therefore need to engage in modern forms of interaction with clients to
ensure that clients receive the best counselling services available” or at least
have the choice (Childress 2001, p 4; Barak 1999, p 14).
As these figures suggest, the number of individuals using the Internet is vast
and the implications for an increase in the amount of human interaction in this
realm is inestimable. It is thought that psychotherapy will be one of the fastest
increasing services areas of the Internet. (Norcross, Hedges and Prochaska,
2002) It is also notable that approximately 10% of individuals with a
diagnosable mental disorder ever seek treatment from a psychologist,
psychiatrist or psychotherapist. (Titov, 2008) That is, most individuals do not
seek out treatment. (Grohol, 2001) There are many reasons for this, including
social stigma, embarrassment, accessibility of suitable services, time,
expense and awareness of the utility of accessing mental health services. The
Internet offers a new kind of accessibility and anonymity to clients.
The effectiveness of online interventions has now been under review for about
15 years. Researchers have found that some forms of online therapy have
proven as effective as face-to-face treatment and that the research
increasingly supports it as an appropriate medium. (Proudfoot, et al, 2007;
Titov, et al, 2008; Titov, et al, 2007) Although there is much more research to
be done, it has been increasingly clear that what was formerly thought
impossible, that is, effective online therapy, is being proven not only possible
but highly effective and that the perceived risks and barriers are not as real as
formerly thought. (Fenichel, 2002)
Suicide prevention over the Internet has been a hotly debated subject since
the inception of online therapy. Many contend that, without the necessary
visual cues and nuances, an adequate assessment of an individual’s state is
not possible and intervention is difficult. However, telephone counselling
worldwide and a groundbreaking Internet chat based suicide prevention
service in Israel have disproven this assertion. (Fenichel, 2002) As for
identification and location of individuals for emergency intervention, sites such
as MyPsych.com are designed to obtain adequate contact details of both the
patient and another family member or friend who can be contacted in an
17
emergency situation. This is more than many clinicians do in their day to day
practice and, even if they do, is more accessible to most clinicians than their
own clinical data. Think, for example, of a client ringing on a clinician’s mobile
phone at midnight, informing them that they had swallowed a bottle of pills.
How many clinicians have all their client’s contact details to hand at home at
midnight or rather may be required to rush into work to access their patient file
and then contact emergency services?
In a review of randomized controlled trials of Internet interventions, Griffith
and Christensen (2006) found a consistent pattern of evidence of the
effectiveness of online treatments. The ISMHO study group has also found
this. (Fenichel, 2004)
This is the context in which I became involved in the provision of therapy over
the Internet. Initially, I approached it with some naïveté; ignorant of the
complex world I was entering. My online practice and the Internet site
MyPsych.com have developed in tandem.
In developing the online clinic, I enlisted the help of a clinical board including
Prof Ron Rapee of Macquarie University and Assoc Prof Judy Proudfoot of
the Black Dog Institute, Michael McDonald, Clinical Psychologist in private
practice, and Tessa Philips, Clinical Psychologist in practice. MyPsych.com is
designed to be a secure online “consulting room” for multiple psychologists,
each effectively running their own online practice as consultants. Given this is
a new area, it was thought to be particularly important that qualifications and
registration and PI insurance status were all verified as part of joining the
service. Given the reach of the internet, after much consideration it was
thought appropriate to retain consultants from Australia, New Zealand, South
Africa and the UK. Psychologists in these countries have very closely aligned
and equivalent professional training and ethics which means that a high
standard of clinical care can be reliably provided. It will also mean 24-hour
coverage and limit the number of jurisdictional issues we have to contend with
until some of them are resolved by legislation.
Jurisdiction is an important subject to take note of in telehealth. Jurisdiction is
a major issue for provision of services over the Internet. At the moment, the
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legislation lags well behind the practice of internet clinical services.
Organisations such ISMHO are providing a forum for discussion of the issues
that arise in this area and providing good ethical guidelines for practice. There
are numerous individuals, government agencies and organizations that are
entering the field in various formats but there is little or no legislation to cover
most issues; For instance, no binding decision or legislation is yet available to
indicate “where” the therapy takes place if the clinician and patient are in
different jurisdictions. A recent American Bar Association report on
Telemedicine suggests that it would be appropriate to locate the treatment in
the jurisdiction of the clinician so long as that jurisdiction had appropriate
standards of training and ethical regulation to promote good care (Report to
the House of Delegates, American Bar Association, Health Law Section,
August 2008). In particular, the report stipulated that the usefulness of the
Internet in providing broader access to health care would not be achieved
unless the legal restrictions surrounding it in the USA were removed.
(American Bar Association Report, 2008)
We have taken legal advice on the issue but it is still very unclear how these
issues will ultimately be resolved. Therefore, it is necessary to engage in a
manner that allows the flexibility to adapt to change in the online clinical
environment as necessary. This is pertinent to all clinicians who choose to
engage with clients via technology. It is also necessary to point out that, in the
absence of much longitudinal experience of what may arise in Internet clinical
interactions, that clinicians must strive at all times to maintain the highest
clinical and ethical standards to avoid harm. It is perhaps tempting to regard
the informality of connection, which these technologies allow, as acceptable
but it should be noted that the possibility of breach of the clinical frame is of
the same significance online or offline. The unexpected happens online
because we are all new to it. An example is an early session I had with one of
my online clients. He turned up in Starbucks in Abu Dhabi because his
Internet connection was down! We rescheduled the session.
A critically important issue that has been identified is that storage of personal
data on the Internet has risk attached. Every Internet site is ultimately at risk
of being hacked into. There is no absolutely failsafe protection for the Internet,
19
just as there is not in life. Encryption is an important idea to get your head
around. It provides some protection against intrusion into your online
communications. It is one reason why free use public communication tools,
such as chat or Skype, carry a higher risk than bespoke services, which can
build in more secure encryption and protection against intrusion.
One reputable source of useful guidelines and information regarding online
therapy is ISMHO.org, the site of the International Society for Mental Health
Online. I would recommend that anyone considering online practice should
have a look at this site.
One way to maintain consistent standards in online practice is to build in
appropriate triage measures in order to provide detailed information to the
clinician. This can be done more effectively via the internet since
questionnaires can be administered in a standardized fashion online without
the clinician present. On my online platform, after completing the necessary
consents, the client can book and pay for a session with their chosen
psychologist. They are required to login one half hour early for their first
session in order to complete a comprehensive psychological triage
questionnaire that is comprised of: SEE SLIDE
1. some demographic data such as gender and ethnicity, in order for our
psychologists to be able to respond to their client with cultural and
social sensitivity and be aware of their own limitations of understanding
in relation to certain peoples. In some cases, this may alert a clinician
to the need to refer a client on to someone with better understanding of
the social or cultural issues facing the client.
2. The Life Interference Scale derived from the work of Prof Ron Rapee at
Macquarie University. This scale gives a general indication of how
much the client’s problem interferes with their daily functioning.
3. The Depression Anxiety Stress Scales (Short version – DASS21)
which Peter Lovibond of University of NSW Psychology Department
has generously allowed us to use for the site. This is a reliable
instrument in the measurement of various facets of affective functioning
and mood.
20
4. The Alcohol Use Disorders Identification Test (AUDIT), which
measures alcohol use and alerts clinicians to potential drug and alcohol
issues which the client may face. This, of course, may impact directly
on the type of psychotherapy, if any, which is suitable for a client in
certain circumstances.
5. The Psychosis Screening Questionnaire (PSQ), which is an instrument
for identification of psychosis, again alerting the clinician to the need for
specific kinds of immediate response.
6. Suicide and Risk Assessment: this consists of a group of questions that
alert the clinician to suicidal or harmful ideation or action towards self
or others. It is an indication to the clinician that a more immediate and
thorough assessment or intervention is needed.
These areas are constantly under review and expansion as the site
progresses and feedback from clients and clinicians, as well as from further
research, leads the way in the development of this new modality.
The exploitation of the online environment for effective mental health care
seems essential if we are to provide a democratic availability of services to
the whole community. It is of course, particularly pertinent for patients outside
major urban areas or those facing other difficulties of access. Thus far, the
research is strongly suggestive that online therapies are at least as effective
as face-to-face interventions and it certainly solves many of the access issues
of remote and rural communities.
21
Bibliography
Andersson, G., Strömgren, T., Ström, L. & Lyttkens, L. (2002). Randomised
controlled trial of internet‐based cognitive behaviour therapy for distress
associated with tinnitus. Psychosomatic Medicine, 64, 810 –816.
Fenichel, M. A. (2004). Online behavior, communication, and experience. In
R. Kraus, J. Zack & G. Stricker (Eds.), Online counseling: A handbook for
mental health professionals (pp. 3-18). San Diego, CA: Elsevier Academic
Press.
Griffiths, K. M. & Christensen, H. (2006). Review of randomised
controlled trials of Internet interventions for mental disorders and related
conditions. Clinical Psychologist, 10, 16 –29. Grohol, J. (2009) From Netscape to Twitter: 15 Years of Mental Health Online,
McGill Talks 2001. http://bcooltv.mcgill.ca
Grohol, J. M. (2001). Best Practices of eTherapy: Clarifying the definition of
eTherapy. PsychCentral.com.
Norcross, J.C., Hedges, M., & Prochaska, J.O. (2002) The face of 2010: A
Delphi poll on the future of psychotherapy. Professional Psychology:
Research and Practice, 33(3). 316-322
Proudfoot, J., Parker, G., Hyett, M., Manicavasagar, V., Smith, M., Grdovic,
S., & Greenfield, L. (2007) The next generation of self‐ management
education: a web‐based bipolar disorder program. Australian & New Zealand
Journal of Psychiatry, 41:903‐909.
Suler, J. R. (2004). The Online Disinhibition Effect. CyberPsychology and
Behavior, 7, 321‐326.
Suler, J.R. (2000). Psychotherapy in cyberspace: A 5‐dimension model of
online and computer‐mediated psychotherapy. CyberPsychology and
Behavior, 3, 151‐160.
Titov, N, Andrews G, Schwencke G, Drobny, J, & Einstein D. (2008).
Shyness: Distance treatment for social phobia over the Internet. A
randomized controlled trial. Australian and New Zealand Journal of
Psychiatry, 42, 585 594.
22
Titov, N. (2007). The status of computerized cognitive behavioural therapy
(CCBT) for adults: A review. Australian and New Zealand Journal of
Psychiatry, 41, 95 ‐ 114.
23
Management of chronic pain in regional Australia: can we farewell the acute
pain treatment model?
Dr Daiva Newby Community Mental Health Team (CMHT), Armidale NSW, Australia
ABSTRACT
Objectives: To provide rural community with access to multidisciplinary chronic pain management group treatment. Design: Multidisciplinary team, formed temporarily and not employed by a specialist pain service, provided biopsychosocial intervention using current health infrastructure. Measures: Participant and attrition rates; severity and interference from chronic pain, anxiety, depression and stress, self efficacy beliefs and significant others’ responses. Results: Low referral and attrition rates. Reduction in emotional distress and especially pain severity and interference, improvement in self efficacy beliefs. Conclusions: The acute pain treatment model which focuses just on reducing sensation of chronic pain can be replaced by a multidisciplinary treatment model where temporarily formed teams provide treatment from a biopsychosocial perspective at a local level in rural Australia. Keywords: chronic pain, biopsychosocial, multidisciplinary team rural treatment model. Introduction
The International Association for the Study of Pain (IASP) defines pain as “an unpleasant
sensory and emotional experience associated with actual or potential tissue damage, or
described in terms of such damage” (IASP, 2013). Acute pain refers to short duration
pain often related to tissue damage with a clear medical cause (e.g., post surgery, a
broken bone). Pain which becomes recurrent daily for three or more months after the
initial physical cause is resolved (i.e., when the broken limb heals) is defined as chronic,
persistent pain when ongoing pain without any obvious useful purpose becomes a
disease in itself. In 2007, around 3.2 million Australians experienced chronic pain, with
an estimated economic cost of $34.3 billion, inclusive of productivity loss, disease
burden and health care costs and the number of Australians suffering chronic pain is
expected to rise to 5 million by 2050, as the Australian population ages (Access
Economics, 2007). Rural sufferers of chronic pain have limited or no access to a
multidisciplinary team intervention approach which views chronic pain not solely as a
medical problem or a biological event, but a biopsychosocial experience. The
biopsychosocial model views pain not just as a disease with biological, anatomical
pathology, as in a medical model, but also as an illness (subjective response) with
biological, psychological, financial and social influences. According to the
biopsychosocial model, chronic pain expression, such as severity, duration and impact,
24
is influenced by biological changes, psychological status and socio-cultural influences, in
the process shaping a person’s perceptions and responses to illness (Turk and Monarch,
2002). For example, the intensity or interference from chronic pain is not solely
influenced by the tissue damage, but is also influenced by such factors as the
attentional focus, meaning attributed to the pain sensation, mood, social supports or
available financial resources. Subsequently, in biopsychosocial model for chronic pain
multidisciplinary treatment teams consisting of various specialists, such as physicians
specialising in pain, anaesthetists, nurses, physiotherapists, clinical psychologists,
occupational therapists, psychiatrists or rehabilitation physicians, address various
interrelated aspects of chronic pain experience. In biopsychosocial model treatment
focus is shifted from just medical to understanding biological, cognitive (e.g., meaning
ascribed to pain, catastrophising, self efficacy beliefs), emotional (e.g., anxiety,
depression, anger) and behavioural (e.g., avoiding physical or social activities) aspects
of chronic pain aiming to increase active coping skills (e.g., pacing, active use of
relaxation), physical and social functioning reducing passive response (e.g., excessive
rest, overreliance on medication, activity, exercise avoidance) to pain and provide
evidence based and cost effective treatment for chronic pain (Goucke, 2003; Access
Economics, 2007).
Almost all major metropolitan areas have dedicated specialist chronic pain research,
assessment and treatment services to support sufferers with timely, evidence based and
cost effective treatment. Rural sufferers of chronic pain often rely on their general
practitioner (GP) for chronic pain management, and the treatment focus may often be
solely what is offered for acute pain using mostly medical (medication, surgery)
intervention rather than from a biopsychosocial perspective. Identification only of
biopsychosocial issues is not a treatment and most rural areas do not have
multidisciplinary treatment teams in the process often requiring rural residents to travel to
the metropolitan areas to access specialist services. Multidisciplinary treatments often
require weeks of attendance, placing significant demands on already vulnerable clients,
and only those with significant financial and social supports can pursue this pathway.
One Australian study looked at the provision of persistent pain services and found that it
took on average 150 days from the referral receipt to initial clinical assessment by public
outpatient pain services (Hogg et al, 2012). The authors suggest that poor geographical
access and waiting times may inhibit GP referrals to specialist pain services.
Chronic Pain Management Group (CPMG). Two coordinators and presenters of
the CPMG noted that regular referrals were made to a community mental health team
and a child, youth and family service for people who suffered chronic pain. Many were
reporting distress over a perceived lack of medical resolution to their predicament and
25
ongoing deterioration in emotional, physical, financial, vocational and social functioning.
Many could only access GP support with a treatment focus mostly aimed at reducing
physical sensation of chronic pain, usually through medication. Nationally, there has
been a 40-fold increase in oral morphine prescription between 1990-2006 and a four-fold
increase in oxycodone supply between 1990-2003 in Australia (The Royal Australasian
College of Physicians, 2009). However, only one in three chronic pain sufferers benefits
from opioids alone, and there is evidence suggesting physiological damage (e.g., on
testosterone levels, the immune system, heightened infection risk) from long term high
dosage opioid use (Duncan, 2012). The current program was designed to provide
access for rural chronic pain sufferers to a multidisciplinary treatment group
implementing biopsychosocial treatment approach.
Design. Both in 2012 and 2013, each participant could only be referred to the
program by their GP in the process ruling out acute medical (red flags) conditions. The
GPs, as central health care coordinators, were provided outcome information. Chronic
pain sufferers’ significant others were encouraged to attend to increase their insight and
support skills. Sessions were 1.3 hours long in 2012 and were extended to 3 hours in
2013 to increase active participation. The design included a presentation by a GP to
discuss medical aspects of chronic pain, pharmacist to review such issues as medicines
and their effectiveness, tolerance and dependence, physiotherapist to discuss the role of
physical activity and psychological interventions (Kerns, Sellinger and Goodin, 2011) as
per published treatment protocols (Nicholas, Molloy, Tonkin and Beeston, 2006). The
Hunter Integrated Pain Service (HIPS, Newcastle) senior clinical psychologist provided
consultation to the coordinators.
Table 1. CPMG treatment content structure in 2012 and 2013.
Week 2012 2013 One Introduction Introduction Two Biomedical background: GP and
physiotherapist presentation Chronic pain: past and future trends presented by a pain advocacy member Medicines use in chronic pain presented by a pharmacist
Three Pacing activities and managing flare-ups
Biomedical background presented by a GP
Four Relationships and cognitive aspects of chronic pain
Exercise in chronic pain presented by a physiotherapist
Five Sleep and relaxation Cognitive Behavioural Therapy (CBT) Six Review of learnt material and follow
up options Mindfulness, and Acceptance and Commitment Therapy (ACT)
Seven Relationships Eight Sleep and relaxation Nine Pacing activities and managing flare-ups Ten Summary and follow up options
26
Outcome measures Referral, participant, including significant others, attrition numbers and attendance rates
were tallied. Following four outcome measures were administered before and after the
program: Brief Pain Inventory (BPI) (Cleeland and Ryan, 1994) measures severity and
interference of pain, and higher scores out of 0-10 indicating higher difficulties.
Depression, Anxiety and Stress Scales (DASS 21) (Lovibond and Lovibond, 1995)
measures respective emotions with higher scores indicative of higher levels of respective
concerns. Pain Self Efficacy Questionnaire (PSEQ) (Nicholas, 1989) measures the
strength and generality of coping beliefs with higher scores out of 0-60 indicating
stronger coping beliefs. Significant others were asked to complete West Haven-Yale
Multidimensional Pain Inventory (WHY MPI) for significant others (Kerns and Rosenberg,
1995) measuring their punishing, solicitous or distracting responses to the chronic pain
sufferer.
Results
Number of 2012 referrals: 15; unable to attend: 5; rejected: 1; attrition: 0. Participants 9:
eight females and one male, average age 54 years; significant others: 4.
Table 2. Outcome measures for 2012 CPMG: participants’ scores pre- and post
CPMG when there was a change in the severity range.
Before the 2012 CPMG After the 2012 CPMG
DASS Depression Client D: mild Client D: normal Anxiety Client G: severe Client G: moderate Stress Client B: moderate
Client D: severe Combined mean: 26
Client B: severe Client D: mild Combined mean: 21
BPI Severity Client B: severe Client D: moderate Client E: moderate Client G: severe Combined mean: 7.28
Client B: moderate Client D: mild Client E: severe Client G: mild Combined mean: 5.32
Interference Client B: severe Client D: severe Client E: moderate Client F: severe Client G: severe Combined mean: 7.4
Client B: moderate Client D: mild Client E: severe Client F: moderate Client G: mild Combined mean: 5.67
PSEQ Client B: moderate Client B: high WHY-MPI Punishing Sig other Solicitous Distracting
Combined mean: 2.32 Combined mean: 3.86 Combined mean: 4.13
Combined mean: 2.19 Combined mean: 3.51 Combined mean: 3.25
Number of 2013 referrals: 11; unable to attend: 5; rejected: 0; attrition: 1; participants 5:
four females and one male, average age 59 years; significant others: 2.
27
Table 3. Outcome measures for 2013 CPMG: participants’ scores pre- and post
CPMG when there was a change in the severity range.
Before the 2013 CPMG After the 2013 CPMG DASS Depression Client 2: extremely severe
Client 3: mild Combined mean: 21
Client 2: moderate Client 3: normal Combined mean: 14
Anxiety Client 1: extremely severe Client 2: extremely severe Client 3: mild Combined mean: 19
Client 1: mild Client 2: severe Client 3: normal Combined mean: 11
Stress Client 2: severe Client 3: normal Client 5: extremely severe Combined mean: 24
Client 2: mild Client 3: mild Client 5: severe Combined mean: 20
BPI Interference Client 2: severe Client 3: moderate Client 4: moderate Client 5: moderate Combined mean: 6.5
Client 2: moderate Client 3: mild Client 4: mild Client 5: mild Combined mean: 4.9
PSEQ Client 1: low Client 2: low Client 3: moderate Client 4: moderate Combined mean: 22
Client 1: moderate Client 2: moderate Client 3: high Client 4: low Combined mean: 29
Discussion, conclusions and future directions
The current project provided rural clients access to multidisciplinary treatment for chronic
pain utilising already established health infrastructure and implemented by health care
professionals, including clinical psychologists, GP, physiotherapist and pharmacist not
employed by a specialist pain service. Two coordinators of the program were supported
by a senior clinical psychologist from HIPS. While referral levels remained low (<20) for
the population (>20 000), attrition rates also remained low (1). The program was free, at
a local level and significant others were encouraged to attend. Outcome measures
demonstrated reduction in some aspects of emotional distress of anxiety, depression,
stress in 2012 for 3/9 clients and 4/5 clients in 2013; reduction in chronic pain perception
of severity and interference for 5/9 clients in the 2012 group and interference for 4/5
clients in the 2013 group. Self efficacy beliefs improved for 1/9 participants in 2012 and
3/5 in 2013, with one participant’s scores indicating a drop. Combined sample mean for
BPI interference and severity means pre-program and post-program in 2012 (Table 2)
indicated that both means moved from pre-program severe to moderate range at post-
program, and 2013 data (Table 3) indicated interference mean remaining within
moderate range pre- and post-program. PSEQ pre-program and post-program means for
2013 (Table 3) indicated that pre-program participants were more confident in their ability
to manage their pain than 45% of the normative sample (with lower back pain) while after
the program they were more confident of their ability in managing their pain than the
65% of the normative sample (Nicholas et al, 2008). Caution is required in interpreting
28
results, as the sample numbers were very low in each cell. It appears though that in
2013 more participants achieved better outcomes in some aspects of their functioning
and it is not clear whether it relates to some fundamental characteristics between these
two groups or more and longer sessions in 2013, which would have provided more
educational material, encouraged more active participation and mutual group support.
Conclusions: Medical treatments, such as opioid medication, form a part of and not
the sole treatment for chronic pain (Goucke, 2003) and an acute pain treatment model,
focused just on reducing pain sensation, will not address issues related to cognitive,
emotional, social, financial and vocational circumstances. Multidisciplinary intervention
for chronic pain model in rural areas can involve the temporary formation of a
multidisciplinary team which utilises current health infrastructure and provides treatment
from a biopsychosocial perspective at a local level with free access.
Future directions: Chronic pain is a chronic disease and requires a shift in how
health care professionals view and treat it, including identification of early prevention
strategies. The application of an acute pain treatment model (passive, resting, ongoing
solely medical investigations and interventions) to chronic pain is inadequate as it
focuses only on one aspect of chronic pain experience (mono-therapy) and reduces the
self to being a passive receiver of treatment. Mitchell (2013) proposes three “fault” lines
for those whose pain is unresolved within three months: the first includes a prolonged
cycle of tests and medicinal treatment, secondly followed by a wait for the assessment
and/or treatment at multidisciplinary clinics and thirdly, maintenance of community
treatments once treatment plans have been established. Early identification of those at
risk (yellow flags) of developing chronic pain should call for referrals not only for medical
investigations, but also referrals to allied health professionals to obtain a biopsychosocial
assessment of sufferers’ circumstances. Specialist pain services cannot meet the
demand, and few from rural areas are fortunate enough to be able to access them. The
formation of temporary multidisciplinary teams within rural areas could meet this need in
a sustainable, local and economic way, as demonstrated by the current project. Pain
specialist services still have an important role in this treatment model by aiming to
provide meaningful support to the coordinators and presenters of these temporary
treatment teams while also being able to provide more individual support such as
Medicare funded video conferencing between GPs, specialists and chronic pain clients
(Mitchell, 2013; Goucke 2003).
29
References
Access Economics (2007). The high price of pain: the economic impact of persistent
pain in Australia. MBF Foundation in collaboration with University of Sydney Pain
Management Research Institute, November.
Cleeland, CS and Ryan, KM (1994). Pain assessment: global use of the Brief Pain
Inventory. Annals of the Academy of Medicine, 23, 129-38.
Duncan, B (2012). The problem of pain: Relief without opiates? Of Substance: The
National Magazine on Alcohol, Tobacco and Other Drugs, 10(3), 10-13.
Goucke, RC (2003). The management of persistent pain. The Medical Journal of
Australia, 178, 444-7.
Hogg, MN, Gibson, S, Helou, A, DeGabriele, J and Farrell MJ (2012). Waiting in pain: a
systematic investigation into the provision of persistent pain services in Australia. The
Medical Journal of Australia, 196(8), 386-390.
International Association for the Study of Pain (IASP). IASP Taxonomy, accessed
(Sept 2013) at:
http://www.iasppain.org/Content/NavigationMenu/GeneralResourceLinks/PainDefinitions/
default.htm
Kerns, RD and Rosenberg, R (1995). Pain-relevant responses from significant others:
development of a significant-other version of the WHYMPI scales. Pain, 61, 245-9.
Kerns, RD, Sellinger, J and Goodin, BR (2011). Psychological treatment of chronic pain.
Annual Review of Clinical Psychology, 7, 411-434.
Lovibond, PF and Lovibond, SH (1995). The structure of negative emotional states:
comparison of the depression anxiety stress scales (DASS) with the Beck Depression
and Anxiety Inventories. Behavioural Research Therapy, 33, 335-43.
Mitchell, GK (2013). Improving coordination of care between specialist and general
practice for people with chronic pain. The Medical Journal of Australia, 198(6), 301-302.
Nicholas, MK (1989). Self-efficacy and chronic pain. Paper presented at the annual
conference of the British Psychological Society, St Andrews.
Nicholas, MK, Molloy A, Tonkin, L and Beeston L (2006). Practical and positive ways of
adapting to chronic pain: Manage your pain. Sydney: ABC Books.
Nicholas, MK, Asghari, A and Blyth, FM (2008). What do the numbers mean? Normative
data in chronic pain measures. Pain, 134, 158-173.
The Royal Australasian College of Physicians, Prescription Opioid Policy: Improving
management of chronic non-malignant pain and prevention of problems associated with
prescription opioid use, Sydney 2009.
30
Turk, DC and Monarch, ES (2002). Biopsychosocial perspective on chronic pain. In DC
Turk and RJ Gatchel (Eds), Psychological Approaches to Pain management: A
practitioner’s handbook (2nd Ed), 3-29. NY: The Guilford Press.
31
An Audit into the documentation of Crisis Intervention and Recovery Plans in case managed patients Dr Neera Raghavan Gold Coast Hospital and Griffith University, Gold Coast, Queensland, Australia
Abstract This audit was performed to look at the documentation of crisis intervention plans and recovery plans in the notes of case managed patients. The notes of 926 patients aged 18-65 years were reviewed; data was collected on the following questions: From September 2012 – March 2013 did the patient 1)have a documented crisis intervention plan, 2)have a documented recovery plan 3)present to the emergency department in crisis. The results showed that overall documentation of both plans fell below the expected standard. A high number of case managed patients from all community teams had presented to the emergency department in crisis, and very few of these had completed plans. A recommendation would be to increase education of staff, and review local guidelines. Keywords Psychiatry, Crisis plan, Recovery plan Introduction
Mental illness is, more often than not, chronic in nature, with the vast majority of
management taking place in the community. The purpose of this audit was to review
the documentation of community management plans in the notes of case managed
patients in my local mental health service – specifically recovery plans and crisis
intervention plans. Data was also collected to ascertain the proportion of case
managed patients that attend the Emergency Department in a crisis. The focus was on
optimising crisis management in the community, improving patient- specific care plans
and reducing presentations to the Emergency Department.
The three questions asked by this audit were: 1) Does the patient have a documented
Crisis Intervention Plan within the last 6 months? 2) Does the patient have a
documented Recovery Plan within the last 6 months? 3) Did the patient present to ED
within the last 6 months?
National standards
National Standards for Mental Health Services. Endorsed by the Australian Health
Ministers' Advisory Council's National Mental Health Working Group, December 2010.
Criteria 10.4.6, Criteria 10.4.8.
32
National Institute for health and Clinical Excellence: NICE guidelines for service user
experience in adult mental health, 14th Dec 2011. Guideline 1.4.5.
Queensland Health Protocol
This guideline was taken from the Queensland Health Protocol for community mental
health services, section 3.4.3 and 3.4.4. It is partly based on the national standards
outlined above, and is available online and also in community clinics as a hard copy.
Aims and Objectives
To improve the documentation of Crisis Intervention Plans, as a means of optimising
the crisis management of mental health clients, and reducing presentations to the
Emergency Department. This would also help to improve achievement of National
Emergency Access Target (NEAT) targets, and improve continuity of care. Improving
the documentation of recovery plans may help to promote recovery in the community
and improve prognosis.
Methods
This audit was completed by reviewing the notes of every case managed patient in the
Gold coast Mental Health Service, from the ages of 18-65 yrs old. Clients who fell
outside this age range were excluded, as were new clients who were pending referral
to case management. Case managed patients who were currently inpatients were
included in data collection. The data was collected for each of the community teams:
Mobile Intensive Treatment team (MITT) north/ south, Community Care Team (CCT)
north/ south, Homeless Health Outreach team (HHOT), Early Psychosis Team (EPT).
The electronic database (CIMHA) was used to generate a ‘current consumer list’ of all
case managed patients. Each patient’s notes were reviewed retrospectively over a 6
month period, from September 2012 – March 2013. For each patient it was recorded
whether or not they had a documented recovery plan and crisis intervention plan (CIP).
The notes were also reviewed to see if they had presented to the Emergency
Department over this time, and if they had then whether or not they had these plans in
place.
33
Data was collected in an excel spreadsheet, documenting ‘Y/N’ to the above questions
against the URN of each patient. In total data was collected for 926 patients.
The target was that 100% of case managed patients should have documented up-to-
date recovery and crisis intervention plans in their notes.
Results
The results are summarised in the table below:
MITTn – 53 case managed patients. 13 patients (24.5%) had a documented CIP, 21
patients (39.6%) had a documented recovery plan. 34 patients (64.2%) had attended
ED in the last 6 months, of which 14.7% had the above documented plans.
MITTs - 33 case managed patients. 16 patients (48.5%) had a documented CIP. 16
patients (48.5%) had a documented recovery plan. 20 patients (60.6%) had attended
ED in the last 6 months, of which 25.0% had the above documented plans.
CCTn - 412 case managed patients. 30 patients (7.3%) had a documented CIP. 33
patients (8.0%) had a documented recovery plan. 175 patients (42.5%) had attended
ED in the last 6 months, of which 0.6% had the above documented plans.
CCTs - 277 case managed patients. 26 patients (9.4%) had a documented CIP. 64
patients (23.1%) had a documented recovery plan. 93 patients (33.6%) had attended
ED in the last 6 months, of which 8.6% had the above documented plans.
34
HHOT - 75 case managed patients. 6 patients (8.0%) had a documented CIP. 19
patients (25.3%) had a documented recovery plan. 31 patients (41.3%) had attended
ED in the last 6 months, of which 3.2% had the above documented plans.
EPT - 76 case managed patients. 5 patients (6.6%) had a documented CIP. 10 patients
(13.2%) had a documented recovery plan. 31 patients (40.8%) had attended ED in the
last 6 months, of which 3.2% had the above documented plans.
Discussion
The results show that there is room for improvement all round. Generally recovery
plans were documented better than crisis plans – this is likely to be because under
Queensland Health Protocol they are required to be updated every 3 months, whereas
the local protocol around crisis plans still remains vague, despite national
recommendations.
It can also be seen that across all teams there were a high percentage of case
managed patients presenting to the Emergency department in crisis. Of these patients
very few had a documented crisis plan. One could argue that perhaps focusing on the
completion of these plans may help to reduce ED presentations, which would not only
reduce the burden on ED and help reach NEAT targets, but would also improve
continuity of care for the patient, and be more beneficial for prognosis than repeated
admissions.
On further discussion of crisis plans it appeared that there was poor understanding of
how these should be completed or what they should include. As per NICE guidelines,
the crisis plan should include:
• possible early warning signs of a crisis and coping strategies
• support available to help prevent hospitalisation
• where the person would like to be admitted in the event of hospitalisation, the
practical needs of the service user if they are admitted to hospital (for example,
childcare or the care of other dependants, including pets)
• details of advance statements and advance decisions
• whether and the degree to which families or carers are involved
35
• information about 24-hour access to services
• named contacts.i
Recommendations
Main problems identified:
• poor completion of both CIP and recovery plans
• poor understanding of the use of CIP
• high percentage of case managed patients attending ED
• Very few patients attending ED have these care plans in place
Suggestions:
• Aim for each patient to have a documented Crisis Intervention Plan and
Recovery Plan, updated every 3 months and clearly identified in CIMHA as two
separate documents.
• It is already a requirement that each patient has an updated Care Review
Summary every 3 months, which is done by a presentation and discussion of
each patient in a multi-disciplinary team meeting. I suggest that at this time the
Crisis Intervention and Recovery Plans can also be updated, as this would not
create a large amount of extra work but would also benefit from an MDT
discussion.
• Present findings of audit at Medical Education Session to all consultants and
registrars of the service.
• Findings can be discussed with each community team leader and presented to
each community team.
• Make Queensland Health Protocol readily available to all community teams
• Re-audit and complete audit cycle.
i National Institute for health and Clinical Excellence: NICE guidelines for service user experience in adult mental health, 14th Dec 2011. Guideline 1.4.5
36
