Occupational therapy telehealth groups in Covid-19 pandemic: perspectives from a Mental Health Day Hospital

Abstract

COVID-19 pandemic had a serious occupational impact on people with pre-existing mental disorders. To deliver care in this context, telehealth groups were a therapeutic option for occupational therapists for mental health care. This paper presents an occupational therapy experience with telehealth groups in Brazil, sustained by the Dynamic Occupational Therapy Method, seeking to discuss the use of technology during the COVID-19 outbreak, the limits and potential of occupational therapy in the face of the necessary change in work with groups. The paper is a critical analysis of practice sustained by a practice-based evidence perspective through a collaborative partnership between practitioners and academics from Brazil and the UK. Practitioners reflected on their professional skills in an online context, highlighting their initial concerns and their discoveries within this new practice scenario. The delivery of telehealth groupwork in occupational therapy in mental health practice requires multiple digital tools, and the occupational therapist needs to understand digital inequity issues (digital access or skills), be digitally upskilled to meet client needs, and also be guided by clear occupational therapy theoretical and methodological frameworks that underpin telehealth practices.

Keywords:
Occupational Therapy; Answering Service; Group Therapy; 2019 Novel Coronavirus Outbreak

Resumo

A pandemia de COVID-19 teve sério impacto ocupacional em pessoas com transtornos mentais pré-existentes. Para prestar o cuidado nesse contexto, os grupos de telessaúde foram uma opção terapêutica para terapeutas ocupacionais para o cuidado em saúde mental. Este artigo apresenta uma experiência de terapia ocupacional com grupos de telessaúde no Brasil, sustentada pelo Método Terapia Ocupacional Dinâmica, buscando discutir o uso da tecnologia durante a pandemia de Covid-19, além dos limites e das potencialidades do cuidado em terapia ocupacional diante da necessária mudança do trabalho com grupos. Trata-se de análise crítica da prática sustentada por uma perspectiva de produção de evidências baseadas na prática por meio de uma parceria colaborativa entre profissionais e acadêmicos do Brasil e do Reino Unido. Os profissionais refletiram sobre as habilidades necessárias no contexto online, destacando suas preocupações iniciais e suas descobertas neste novo cenário de prática. A prática de cuidado em grupo de terapia ocupacional em telessaúde na prática de saúde mental requer o uso de múltiplas ferramentas digitais. Além disso, a(o) terapeuta ocupacional precisa entender das questões de desigualdade digital (acesso digital e/ou habilidades digitais), aprimorar-se digitalmente para atender às necessidades das pessoas sob seu acompanhamento, além de possuir referenciais teórico-metodológicos claros que permitam sustentar práticas em telessaúde.

Palavras-chave:
Terapia Ocupacional; Serviços de Atendimento; Terapia de Grupo; Surto do Novo Coronavírus 2019

Introduction

The advent of the COVID-19 pandemic outbreak had demanded social distance to face it and placed us into a situation of several threats to occupations. Lockdown has been compromising the social rhythm, altering the usual daily routine, impacting increasing stress, fear, and anxiety as usual in occupational disruptions (Hammell, 2020). In people with pre-existing mental disorders, all of these problems can surface with greater severity, with possible losses in relational bonds, self-care activities, and adherence to medication (Chatterjee et al., 2020; Usher et al., 2020; World Federation of Occupational Therapists, 2020).

As Hammell (2020) argues, occupational therapists deal with life reconstruction processes after occupational disruptions. In this process, the importance of learning to take care of yourself and others, to make choices, and experience feelings of belonging and connection, pleasure, purpose, and meaning by engaging in occupations is highlighted. People with mental disorders benefit from care that helps them organize their routine and time management and live experiences of pleasure and satisfaction in doing, helping them build a positive sense of self-worth and hope (Hammell, 2020; Mello et al., 2021).

Faced with the challenges of providing care in the pandemic, occupational therapists quickly needed to incorporate emerging approaches and methodologies of care, maintaining person-centered and occupation-based values and delivering them virtually through telehealth (Scott, 2020). Telehealth is characterized by information and communication technologies in health care when clients and professionals are in different physical locations. Interactions through digital can occur in real-time, synchronously, as in a phone call, by videoconference, or applications (apps). Exchanges can also occur asynchronously when the information is stored and forwarded via email, videos, photos, audios (World Federation of Occupational Therapists, 2014).

In occupational therapy, telehealth resources can be used in the various stages of the therapeutic process, including groupwork, respecting the regulations for practice in each country (World Federation of Occupational Therapists, 2014). Groupwork is one of the care strategies that impels professionals to find solutions for their delivery, with videoconference being a possibility. There is consensus across the occupational therapy literature that group work is a central component within the profession’s skill set. Duncan (2011) describes groupwork within the core skill set of an occupational therapist. Traditional face-to-face groupwork can be done with a wide variety of possibilities.

However, due to the COVID-19 pandemic and social distancing, complexities to groupwork now include different layers involving the staff, customers, and family. Occupational therapists need to acknowledge and work on their digital skills to enable their clients to do activities and occupations (Hoel et al., 2021; Proffitt et al., 2021). Furthermore, as Pitliuk (2020) warns there is a need to have clear theoretical and methodological references to support our interventions, especially in this scenario. The complexity of the virtual setting and the experience and confidence in the use of technology need to be sustained by a framework that helps to conduct therapeutic processes.

Although the occupational therapist may have the digital skills, technology, and access to deliver groupwork online, clients may not have access to a computer, tablet, or mobile phone. Assuming clients have access to the technology needed and can afford to partake in groupwork is a fallacy. Digital divide, digital literacy, and ethical issues, therefore, need to be considered in clinical reasoning before its application (Butler et al., 2008; Almathami et al., 2020). Recommending a client access groupwork online is not enough, and that can even become a barrier (Butler et al., 2008; Almathami et al., 2020). The occupational therapist must consider part of their role if recommending to access materials online what that individual's circumstances are and their needs to access groupwork online (Hoel et al., 2021; Proffitt et al., 2021).

Butler et al. (2008) pointed to the group’s leadership responsibilities, which could be applied to the occupational therapist role. They stated online groups require maintenance and that it can be easier for a group member to leave an online group than a face-to-face group. The occupational therapist, therefore, needs to pay attention to their leadership responsibilities in this online domain with, as Butler et al. (2008) suggest, attention to both technological and social management.

Acknowledging the world changed overnight will not be with everyone's view. Clients, relatives, and staff may not be able to understand all of this. They may not be able to take in the concept that a previously face-to-face service has gone online permanently as they may not connect the current situation with a view of permeance. Benefits to online groups involve clients saving travel and car park costs, and they have the privacy of doing the group from their home (if their home environment is private), which may be a client’s preference. Acknowledging the pros and cons will allow the occupational therapist to actively listen to the client’s circumstances and explore if any adjustments can be made to accommodate them.

Although occupational therapists are facing these challenges, there is a call to advance knowledge about the evidence-based application of telehealth, with emphasis on the use of technology to assess and intervene in the context of everyday life and to deliver telehealth (Proffitt et al., 2021). To expand practice-based evidence (Gélinas, 2016), collaborative inquiry between practitioners and scholars can be fertile to pursue clues for occupational therapy care through telehealth. This paper, through a situated analysis of a practice developed in Brazil, seeks to contribute to the identification of positive clues for this enterprise.

In São Paulo, Brazil, occupational therapists had to quickly deal with this new context to provide responsible and appropriate treatment within these unique circumstances of social restrictions (Malfitano et al., 2020; World Federation of Occupational Therapists, 2020). Regulatory standards for telehealth occupational therapy in Brazil were quickly implemented, ensuring that occupational therapists’ work could be delivered to diverse population groups (Ricci et al., 2020). There was no lockdown policy in Brazil to face the pandemic (The Lancet, 2020). Still, many Brazilian health services have incorporated telehealth practices, in search of remote screening, care, and treatment resources, with health benefits indirectly related to COVID-19 (Gois-Santos et al., 2020; Caetano et al., 2020).

In a joint decision with the staff, clients, and their families to prevent the virus spread, a mental health day hospital, in São Paulo city, following WHO guidelines (World Health Organization, 2020), decided to move to telehealth treatment. The responsibility for the continuity of clients’ treatment led the day hospital to deliver telehealth groups (Associação Brasileira dos Terapeutas Ocupacionais et al., 2020; World Federation of Occupational Therapists, 2014). Telehealth groups were used as a therapeutic option in the pandemic (Hoel et al., 2021; Pavani et al., 2021; Silva et al., 2020), but existing groupwork theory was not developed using telehealth. To contribute to occupational therapy literature when discussing the complexities of a pandemic, technology, and the potential for occupational therapists to change the way they deliver groupwork, this paper presents a practice analysis of occupational therapy telehealth groups in Brazil.

Method

This paper is characterized as a critical reflection on practice. Searching for practice-based evidence (Gélinas, 2016), one Brazilian expert occupational therapist with 45 years of mental health practice experience and three scholars, one of them from Brazil and the two others from the United Kingdom, developed a collaborative partnership.

In May 2020, the scholars discussed how to face the challenges imposed by the pandemic to conduct fieldwork activities in Brazil and the UK. In the Brazilian university a remote fieldwork experience was taking place in a mental health practice scenario, supervised by the experienced occupational therapist, the paper’s first author. The first interaction between the scholars and the practitioner occurred in an educational exchange activity in October 2020, when the occupational therapist presented her experience in delivering telehealth groups in a mental health day hospital for UK students.

Given the excellent discussions instigated by sharing her practical experience, the authors decided to deeper analyze and evaluate the limits and the strengths of telehealth groupwork as a new, evolving, and flexible treatment approach. The methodological procedures for this practice analysis included (a) the description of the experience in the first person, (b) the identification of relevant issues to be deepened in a dialogue with the field literature, and (c) the selection of questions that this practical experience could raise for future research.

Ethical aspects

The article’s emphasis relies on occupational therapist practice and not details of the clients' particular experience. Ethical aspects for experience reports were followed. There is confidentiality about the identity of clients as well as changes in sensitive data that allow identification.

Context of practice

This practice analysis is about a mental health day hospital in Sao Paulo city, Brazil, a private health service covered by health insurance, offering multidisciplinary care for people with intense psychic suffering, not economically vulnerable. The day hospital is organized around therapeutic groups, such as psychotherapy, occupational therapy, culinary, assembly, radio, theater, outings, and income generation initiatives (Ferrari, 2015).

The experience related here is based on the Dynamic Occupational Therapy Method (DOTM), developed by Jo Benetton in Brazil since the 1970s (Marcolino et al., 2020). The main objective for the DOTM is the expansion of health spaces in the target person's everyday life, for social insertion and participation. The word “target person” is used in DOTM as similar to the term “client” - less common in Brazilian Occupational Therapy (Gomes et al., in press).

In DOTM, we do not work with initial assessment protocols, but with a continuous situational diagnostic, which involves knowing the target person in their way of being, doing and relating. The aim is to understand the target person’s needs situationally, through careful and investigative observation in the setting, in everyday life, and through information from the target person and from other relevant people, such as other professionals or family members (always obtained with the person's consent). Assessment protocols can be used later, based on the needs identified in the situational diagnostic (Marcolino et al., 2020).

The intervention process is centered on the dynamic movement of the triadic relationship (occupational therapist, target person, and activities), searching for the establishment of a positive relationship in which affections are mobilized so that the person can discover desires, abilities and limitations, favoring the emergence of “the desire to learn, to do, to move on” (Marcolino et al., 2020, p. 1325). It is a flexible framework, in which the activities are considered another term of the triadic relationship, as important as the occupational therapist and the target person, especially because they give greater dynamism to the relationship, and allow new occurrences to happen, which may later gain new meanings, in a reflective process of meaning-making (Mello et al., 2020).

In the group setting, the presence of other participants expands the possibilities of new occurrences, which adds a new layer of complexity and dynamism to the intervention. The activities are developed through the interests, desires, and needs of the participants, carried out in the group setting collectively (all participants doing the same activity) or individually (each one, in the same group environment, doing their own activity) (Ferrari, 2015).

The results will be presented by a descriptive text in the first person, followed by a literature discussion triggered by selected points from the practical experience.

Results and Discussion

Our time to prepare and to create alternatives for our interventions was short. We interrupted the face-to-face groups on 15th March 2020, keeping only a daily shift for emergencies. In parallel, each team organized their clients in a message group app and gave information about the online platform chosen for mobile and PC. The occupational therapy telehealth group, the focus of this practice analysis, started on 23rd March, delivered by two senior occupational therapists, who shared the group coordination, one newly qualified occupational therapist, one fieldwork student, and 12 clients. Each group session lasted 1.5 hours, twice a week.

Our clients' routine was built around the daily commuting to the day hospital. When the commute was interrupted because of the pandemic, significant disorganization of everyday life took place. Thus, our clinical reasoning needed to focus on opportunities for helping clients directly in their daily lives, keeping their routine, and creating alternatives. This context presents a unique opportunity to improve their situation, better understand who they are, how they live, and their needs in this situation.

In the beginning, there were only doubts: Was the online setting suitable and appropriated for any of our clients? How would the sessions happen without the concreteness of materials and tools? And, above all, without the physical presence, an essential need for most of our clients? How would this experience of caring take place while they are at home and us at ours? Consideration of the challenges and barriers needed to be addressed for provision equity (Almathami et al., 2020).

At first, some clients were more familiar with the platform. Others had many difficulties, which we thought would be unbridgeable, such as not having a mobile phone or access to the internet. Gradually, we found solutions, and clients overcame many difficulties with our help and their families and friends. We started with individual sessions with the ones who had more difficulties teaching them how to use the platform and had support from their families.

The groups, initially, were focused on the use of the platform. We had to teach them how to turn their sound on and off and use their headphones. We helped them locate the best internet access, and we guided them where to put their devices so that they could see us better. We also taught them how to change their backgrounds during a video call to ensure privacy and provide choice. Surprisingly the groups started to work very creatively! The idea of a group activity - in which everyone does the same activity - seems welcome for this new setting. At first, we suggested a game that did not work well. However, a client gave us the idea of doing origami, and everybody accepted. It was a success! The client helped everyone step by step to do a “Tsuru”. After that, we did an activity called The view from my window during quarantine, where participants described interesting facts involving their window view. This group already knew each other, which made this activity possible. Considering why individuals may not want to show what surrounds them needs to be considered, including social inequalities and the digital divide (Butler et al., 2008; Almathami et al., 2020).

After those first group activities, we did some stretches exercises, relaxation exercises, and visits to virtual museums. We also tour around the world using an app that simulates a car ride through any location in the world and allows you to tune in to a radio station in real-time, in that country’s language. The range of group activities started to increase: show and tell of the client’s favorite photographs that were shared on the screen; each client choosing their favorite bands’ video clips; their favorite artists and songs; recipe exchange; developing a magazine for the day hospital; a group collage using a graphic design app. For all these activities to become a reality, the occupational therapist had to gain expertise to manage all apps, offering flexibility for online groupwork, but mainly enabling clients to learn and develop their singular needs overcoming difficulties in using technologies (Almathami et al., 2020).

Usually, in groupwork, the occupational therapist needs to be attentive to the group's dynamic and the needs of each client (Finlay, 1997). In the online environment, there is another complex layer, the attention to both “technological” and “social” management (Butler et al., 2008). It is a greater demand for attention and observation to monitor each window’s movements: who left? Who reacted? There are very particular communication cues in this context, and the degree of closeness and perception of the other can be even more acute. One situation occurred where a client was sure that everyone was looking only at him, and he left the meeting. All the time, therapists need to observe, ask to understand the reasons for what was observed and intervene explaining how the virtual environment works.

Interventions focused on the needs of each client, which stemmed from groupwork: finding creative solutions for a client to take a private shower while she was at their mother’s home; assisting a client to go to the bank to get the government money; helping another client to organize herself for surgery, accompanying her virtually until the appointment, and on the day of the surgery accompanying her until the moment she entered the operating room. The message group app also became an extension of the group, enabling asynchronous interventions: talking about what they were experiencing, helping each other, and sharing ideas related to activities they can do together on their next meeting. The composition of using different technologies made it possible to expand the possibilities of interaction between the participants. This extended setting allowed the experience of situations in which we would not have the opportunity to live if not for the virtual environment, showing us possibilities of expanding relationships and activities that may remain hybrid in the future.

Just as with our face-to-face approach, we continued facilitating activities that were either individual or collective. Some clients had access to resources at home and could develop activities throughout the group sessions (e.g., paintings, handcrafts). Others had their activities related to their new routine. The group ultimately supported each other despite significant differences in mental health needs. To some, the despair of being at home was much worse than their fear of the virus. For others, the extreme comfort of not needing to face the outside world began to result in not wanting to leave home. Despite existing groupwork literature focusing on face-to-face groups, we analyze that telehealth groups also make it possible to strengthen relationships and promote mutual help, objectives of all groupwork (Finlay, 1997; Duncan, 2011).

One client, Ellen, always had many difficulties participating in face-to-face groups because she always felt threatened by others, participating from a distance and in her rhythm. In the beginning, and for many meetings, she would always join with her audio turned off. People from the group would warn her about this condition, but she would only laugh and demonstrate that she was fine through gestures. However, she was always highly connected to the group. During a conversation with her sister, she informed us that Ellen was well at home. She said that Ellen had gotten out of a depressive state with her participation in the telehealth groups and had gone back to reading, listening to music, and was more communicative with her family.

That surprised us! One day, she started to open her microphone and to answer our requests. She gradually participated in some activities. Other times, Ellen would pay close attention but decline the invitation to participate. At last, she participated during a session where she shared a video of the Bach Violin Symphony that she likes a lot. This was an important activity because she had learned how to play the violin at some point in her life. We had already invited her to bring her violin and play for us, but she always declined. However, sharing the symphony has been the closest we could get to this particularity of her.

Another client, George, caused lots of concern because he was intensely affected by the isolation/lockdown and could not organize himself at home to take his medicine, eat properly, or use the group meeting app. In response to this, we offered several individual sessions to help him with everyday tasks and teach him how to use the app. As a result of attending the online therapeutic group, this client returned to his occupations and initiated more self-care, resulting in a significant improvement of his mood and thinking processes. He started to enjoy the group space and learned from the other’s experiences, and he made his interests wider. Finally, he rekindled his relationship with his daughter, from whom he was very distant.

Final Considerations

More than a year into the pandemic, this new practice is still evolving, hence our need to share our reflections to analyze and evaluate the limits and strengths of telehealth groupwork as a new, evolving, and flexible treatment approach. Occupational therapy telehealth groupwork in mental health settings has many benefits, especially during the pandemic crisis; however, further investigation into the impact of this form of intervention is necessary.

The dynamic framework of DOTM favored this new challenge insofar allowing us to offer an intervention tailored to each one and, at the same time, open to new possibilities mediated by technologies. The process of running telehealth groups made it possible to experiment with new ways of doing and being in the world. It has also promoted a sense of belonging, which has helped our clients to go through this difficult time.

Telehealth groupwork on occupational therapy is possible but requires many considerations regarding individuals' needs (Almathami et al., 2020; Proffitt et al., 2021). Internet and technology access and the digital skills of clients, family members, and even professionals are the main factors for analyzing telehealth groups’ implementation (Hoel et al., 2021; Proffitt et al., 2021). There is a need to investigate aspects that characterize good practices for telehealth groupwork and characteristics that influence clinical reasoning.

Implications for practice include considerations that mental health telehealth groupwork needs multiple digital tools. The occupational therapist needs to understand digital inequity issues (digital access or skills) and be digitally upskilled to meet client needs, and also be guided by clear occupational therapy theoretical and methodological frameworks that underpin online practices. Occupational therapy students need to be taught this now to prepare them for future work. Furthermore, although telehealth work definitions include offering online groups, there is still a need for studies that better delineate its specificit ies.

• How to cite: Ferrari, S. M. L., Pywell, S. D., Costa, A. L. B., & Marcolino T. Q. (2022). Occupational therapy telehealth groups in Covid-19 pandemic: perspectives from a Mental Health Day Hospital. Cadernos Brasileiros de Terapia Ocupacional, 30, e3019. https://doi.org/10.1590/2526-8910.ctoRE22883019

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• World Health Organization – WHO (2020). 2019 Novel Coronavirus (2019-nCov): Strategic preparedness and response plan Geneva: WHO. Recuperado em 5 de janeiro de 2021, de https://www.who.int/publications/i/item/strategic-preparedness-and-response-plan-for-the-new-coronavirus
  » https://www.who.int/publications/i/item/strategic-preparedness-and-response-plan-for-the-new-coronavirus

Edited by

Section editor

Prof. Dr. Milton Carlos Mariotti

Publication Dates

• Publication in this collection
  07 Jan 2022
• Date of issue
  2022

History

• Received
  10 May 2021
• Reviewed
  01 Sept 2021
• Reviewed
  16 Sept 2021
• Accepted
  27 Sept 2021