A couple of months ago, a client of mine (who I’ll call May*) went overseas for three months. May has family all over the world and visiting her son at his home in New York represented a return to activities she had engaged in prior to her traumatic brain injury (TBI). Travel and visiting family are important to May and her family, but taking this extended trip presented significant challenges in continuity of care for her therapy at a critical time in her rehabilitation programme.
While I have a fair few colleagues who provide some therapy via video conferencing, this set-up was new for me and I was somewhat naïve to the basic practicalities of providing therapy in this way. But if there is a client who could make you step outside your comfort zone, May is it.
May is one of those clients who is just a gem – a woman in her mid-60’s, highly committed to her rehabilitation and a delight to work with. May has severe communication impairment which includes severe language and motor speech impairments. She needs assistance to communicate with family and support staff for everything beyond basic needs.
Due to her various challenges, May’s communication skills need a lot of support. Regular and frequent therapy is important for maintaining her rehabilitation. Travelling to New York for an extended stay threatened to derail therapeutic gains. Knowing that risk was enough to help me step outside my comfort zone.
Fortunately, May and her family gave fair warning the overseas trip was happening, which gave us all time to plan. We decided to give teletherapy a try in the lead-up to the trip – to see if and how it would work. We also decided to continue home visits for the remaining few weeks that May was in Sydney, adding one online session per week to May’s face-to-face programme. This allowed for a gradual transition to online therapy whilst abroad, with the added bonus of a short period of increased frequency of therapy prior to departure.
The video conferencing platform that suited both May and I was FaceTime. The Sydney-based online therapy sessions were a success and allowed us to iron out some of the smaller challenges ahead of the big trip.
Initially, we struggled a little with our connection, but we worked this out with a bit of help from the May’s daughter who acted as her support person. We learnt that making sure there was minimal internet use by others using the same connection was important. This meant no-one using Netflix and turning off automatic backups during our allocated session times.
Clear images and sound quality
We learned the best spots in our respective environments to get the best possible Wi-Fi signal – and hence, improved sound and image quality.
A quiet environment
Having minimal noise in the background was really important, especially as we were trying to conduct motor speech therapy. Removing background noise, such as kitchen noise, TV and chatter, was essential.
There is a 15 hour time difference between New York and Sydney. May also experiences significant fatigue typical of individuals with TBI. Managing vastly different time zones took some careful scheduling.
Preparation and set-up for therapy
Before May went away, I set up a folder of physical resources for her to refer to during the online therapy sessions. Our Sydney trial-run helped to identify what level of physical resources we needed access to on both sides to facilitate success. We had plans to update materials via email if we needed to add anything. As it turns out, this wasn’t required.
May and all her family speak Indonesian as their first language. Prior to going overseas, most of our therapy sessions were conducted with an interpreter. Whilst May was overseas, her daughter acted as interpreter. Whilst this isn’t ideal, it worked well in the circumstances.
Facilitators to success:
An engaged and invested support person
One thing absolutely paramount to our success was the quality of the relationship with May’s support person. This needed to be spot on. In this case, it was May’s daughter. May’s daughter accompanied her overseas to assist her with all her needs during the family visit. Given May’s physical, cognitive and language challenges, she (and I) needed a facilitator on the ‘other side’. May’s daughter was firmly aware of the intricacies of our therapy program and objectives. She was also able to manage the technology, including problem-solving connection issues which helped to ensure online therapy success.
As I mentioned above, May was a fabulous candidate for teletherapy, as she had always shown herself to be really motivated with her rehabilitation.
A good client/therapist relationship
May and I had already been working together for some time. May’s daughter had also been present for the vast majority of the face-to-face therapy sessions we had. I think this made conducting the therapy sessions online much easier, as we had already established a personal connection and a strong working relationship.
The need to communicate was REAL
The distance ended up being really beneficial to therapy. Being half a world apart meant we had so much conversation material! We were in completely different parts of the world, experiencing vastly different seasons. These true differences provided instant conversation content we could repeat and practice in a meaningful way each session. Also, the little quirks that go along with virtual travel ensured there was never a shortage of conversation topics. There was context and the need to communicate was REAL, but it was also a supportive place. The combination was extremely handy inlingt of the language work we were targeting.
How did it go?
What amazed me at first was just how natural it all felt. I’m not sure what I expected – something less real or less natural I guess. While I remained completely mindful of having an on-screen experience, it all felt completely okay and the positive nature of our therapy dynamic remained exactly the same.
There were some challenges specific to motor speech therapy. We were targeting fricatives — specifically ‘S’ and ‘F’— and these sounds don’t sound so great or sharp through a laptop. Like mobile phones, tablet and computer microphones don’t transmit high-frequency sounds, so it can be tricky to give accurate feedback. Fortunately, for this particular experience, we targeted these sounds at a single word and phrase level. As a result, the therapy tasks were highly controlled. Also, and much more poignantly, this was where May’s daughter worked her magic. She had received training and had witnessed a bunch of therapy sessions. She was adept at providing subtle yet specific, tactful feedback when the sound targets needed extra attention. She was able to give all the necessary information to May — and to me — to allow our therapy to flow.
Online therapy in this context and situation worked a treat. It allowed us to continue our therapy seamlessly and continuously, despite being on completely different continents and in different time zones. When I asked May and her daughter/carer how they felt, they both agreed that the sessions worked, albeit with some small hiccups with sound.
Naturally, there are major advantages to conducting therapy face-to-face, however, this experience proved to me that teletherapy certainly deserves a place in rehabilitation. Real-life gets in the way of therapy and this is a possible solution – if you can make it work. Of course, there are time, budgetary and geographical constraints (among other things).
We, as therapists, need to be both flexible and adaptable. May returned to Australia mid-September and I can truly say that our therapy was not negatively affected. Technology allowed for continuity and for a natural progression of our rehabilitation programme. And, I thoroughly enjoyed a weekly view of Brooklyn through the window in the background.
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