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Providing Art Therapy in Palliative Care using Telehealth Technology

17 April 2017

Art Therapist and BAAT member, Gudrun Jones tells us about her art therapy practice using Telehealth technology in a rural setting...

Introduction

I work within a rural palliative care team. I first used video conferencing technology twelve years ago, to provide supervision to an Art Therapist working 85 miles away; technology made the 170 mile round trip unnecessary. We were able to see the art work on screen and discuss it. Since then, the team has used this technology for our meetings and training. Our NHS Arts Therapies pan-Wales meetings are also held using this mode of electronic communication.

In 2014 our team was approached by a doctorate student from the Psychology Department at a local University. He was undertaking a research study into the use of telehealth technology in palliative care.  The aim of the longitudinal case study explored how rural living patients made sense of the psychological support facilitated through the implementation of telehealth (Keenan, J. et al, 2014). 

Eight laptops were made available for patients or carers to use at home, so that they could connect remotely with health professionals at our palliative care resource centre. As part of the research, I worked with three patients using this technology. Both the patient and I dialed into a secure number for the virtual meeting at an allocated time. This is like a ‘Skype’ link up, but is secure to protect confidentiality. 

Distance and transport were a barrier for all three patients, preventing them from accessing our palliative care service. Without this technology I would not have been able to provide therapy sessions face-to-face, because of the time and distance required for me to travel to their homes.

Collie, et al (2006) describe the findings from various focus groups to discuss flexible ways of providing art therapy support to cancer patients at a distance The study concludes that in order to overcome  the barriers for women with cancer, living in a rural area, the use of computers, e-mail and telehealth technology, offered a flexible and inclusive service.

Figure 1: Test session with a colleague

First thoughts and concerns

I was familiar with using technology for meeting and training sessions, but not with providing art therapy and emotional support to patients by this means. My initial concerns were as follows:

What would be the impact of missing non-verbal cues?
What would happen if there was of a technological break down of connectivity in the middle of the session?
Would the intervention feel distant and unsupportive?
How would the flow of conversation be affected by a delay in technology? I was reminded of interviews on the television; presenters talking to someone over a satellite connection with an unnatural delay in reply.
Would the quality of the image viewed on screen be good enough?
Would not seeing the mage being made have an impact on the therapy process? 
How would the impact of the abrupt ending of the session - the hang up - affect the therapeutic relationship? (After the hang up the therapist is left with an image of yourself on the screen, as the other person will have left the virtual meeting room). 

What happened during the interface with the screen (and the patient)?

1. Non-verbal cues
I was certainly able to see when the patient was struggling to speak with emotion or was crying. Whilst I did miss out on observing how someone was holding themselves or moving as they walked into the therapy space, it did feel that there was enough visual information available there for discussion about how that person was feeling at that point in time. I had worked with these three patients on a face-to-face basis in assessment before the research opportunity was offered. I feel that the initial face-to-face session enhanced the knowledge I had about them. Perhaps this is why some loss of non-verbal cues did not feel as if it was detrimental to the therapy process. 

2. Technological break down
In terms of the technological problems, the researcher could have gone out to their home if they needed help with the connection. I agree with Wood (2015) in her reflections that technical support is important. I would add that having technical support and equipment that is well looked after is also crucial. We have a supportive tele-medicine manager, who I could depend upon, either on site or at the end of a phone. On one occasion when a technical difficulty arose, phone contact replaced the telehealth session. I learned to always carry a mobile phone to the room, so that immediate contact could be made between the patient and myself. During the research only one session was conducted over the phone for technical reasons. As with face-to-face sessions, should a patient need to make contact between sessions, this could be made by phone or now increasingly patients choose e-mail.

3. Distant or unsupported
I was anxious for the first few session, about the physical distance, and found myself sitting forward and pushing against the table top in a strange attempt to reduce the distance. This concern lessened as time went on and both myself and the patients relaxed into a more comfortable sitting position. 

4. Time delay
The pacing in the conversation became more familiar with time. There were moments when we spoke over each other, but these were infrequent and no more problematic than when meeting in person. However, it is a new pace to get used to, which comes with time, confidence and relaxing into the session. 

5. Quality of image on screen
In order to view the art work clearly it has to be held still in front of to the camera in the laptop. Like a face-to-face session, discussion takes place about the images and their significance. Sometimes additional questions need to be asked in order to make sure you have understood the different elements in the art work that may not have been clear in the showing on screen. 

Figure 2: Test session with a colleague

Seeing oneself on screen is something to get used to! For one patient, it was important not to have to look at themselves on the large screen, but to have a small image of themselves in a square in the corner of the laptop screen.  

In terms of how I position myself in the room, I was careful to arrange the camera before each session centering myself in the screen, not too distant and not too close. This would be similar to the mid-distance you would see when watching a newsreader on television. I cleared away any clutter, such as my diary, files or bits of papers in order to gives an impression that there is space for the work in the session; it and the client have my full attention. 

6. Movement delay
I found that moving in the chair, or waving arms and hands around highlighted the time delay and could be distracting. I have learned to sit quite still. Although having a patient on screen, who moves around a lot, is something you will get used to as time goes on. Like the sound delay there is a movement delay, the picture can become stuck for a short space of time.

7. Not observing the image being made
Depending on the camera position, it can be a private making process for the patient if they wish it to be. It was also possible to change the position of the camera and be able to view the work being made. In terms of being present and observing the production I have missed this experience, perhaps this is where the distance is felt most from my perspective. It was often left to the verbal discussion to offer information about the making experience.

8. Ending the session
I experienced the ‘hang-up’ as abrupt and I was uncomfortable if I hung up before the patient. It gave me the experience of cutting off that person, despite having verbally brought the session to an end, arranged the date of the next session and said goodbye. Discussing this with the tele-medicine manager, she suggested that I put the system on mute and wait until the patient has hung up, this surprisingly simple piece of advice, helped me to feel that the ending was more contained. As this element of the experience was not mentioned in the research findings, I assume it was more about my own anxieties. 

Other factors to be aware of

External noise in the background can drown out the sound of someone speaking, and disturbs the sense of privacy and confidentiality. In this study, this was not a problem, but in the future I would discuss this with the patient at assessment to ensure that they make a quiet, private space for themselves within their home for the session duration.

The art therapy process

The following is a quote from the research; the participant was asked what the Art Therapy session entails:

“Well really what we do, we just work on images that reflect how I am
feeling and help then to kind of reflect back to you, you know, when we 
discuss it, about things maybe I haven’t realised that was going on with 
myself, that sort of thing.” 

The activity in the session is the same as in a face-to-face art therapy session. There is time to reflect on the previous week; then moving into using art materials and image making to illustrate thoughts, issues and feelings; with the latter half of the session, for discussion on the significance of the image.

Unlike a face-to-face session, the image has disappeared once the patient has moved it away from the camera, out of view. I was more aware that I needed to hold the image in mind and revisit it during the session. The patient quoted above had a small A4 drawing pad, which was easy and manageable to hold up to the screen. I missed not having the image available should I need to reflect on a previous session, in preparation for the next session. However, having the image in our minds, added an extra dimension to the communication. The use of imagery, metaphor and visualisation throughout the Art Therapy process, enhanced the communication possible via telehealth. Perhaps this advantage can offer some compensation for the loss of direct face-to-face contact.

Research findings and feedback from participants

As part of the research project conducted by Keenan, et al. (2014) participants were interviewed once a month. The results of the findings identified two main themes (with some sub-themes) which are explored below:

1. ‘Facilitation of a relatedness supportive environment’

This was explained as telehealth helping to enhance the sense of connection between the medical professional and the patient. The therapist was perceived as providing a sense of companionship and diminishing the sense of burden experienced. Patients indicated that telehealth provided them with an immediate access to psychological support services. Making appointments was easier than organising face-to-face contacts which involved more time, travel and physical effort.

2. Empowerment – Control,  Liberation of Choice, Emotional Self Awareness

2.1 Control
It was identified that telehealth offered a more equal dynamic, between the therapist and patient through the patient being in their own home. The researchers stated that there was a perceived sense of control for patients through not having to visit the health professional in the health setting – this removed a power divide. 

“… you’re in their space aren’t you. Whereas at home you’re on 
your own grounds, so you’re kind of more confident anyway”. 

I had been very concerned about the physical distance causing a psychological distance. I wasn’t prepared for the experience to be reported by the patient as offering a more equal dynamic, with one participant saying: “there isn’t that sense of divide”. 

It was also perceived that being able to see the therapist, ensured patients had their full attention during the session; as opposed to a phone contact where therapist could be engaged in other activity, such working on the computer.

2.2 Liberation of choice
The patients involved in the study were either living in a remote area, unable to drive, too ill to travel or had an existing physical disability. Patients often make numerous visits to the hospital, which costs them time and money. Telehealth saved their resources, as one participant said: 

“ …if I’d gone to (town), it’s pretty much the whole day really……, but 
because I get tired when I do that sort of thing, then that would be me
finished for the rest of the day. Whereas sitting here in your own lounge 
on a computer is not as tiring by any stretch of the imagination, so it 
kind of leaves you more time to do other things”

Figure 3: One patient’s representation of telehealth made for a conference poster 2014

2.3 Emotional self-awareness
The study recognised the process of growing self-awareness taking place during the art therapy process. This happened through the patients talking about their images and their symbolic importance in their experience of their cancer journey. They identified that therapy via telehealth, without the time and effort spent getting to a health setting, enabled them to have more time to reflect on the work before and after the session, and thus, enhancing the process of self-development. The study findings suggest that telehealth in its remote monitoring, can play a role in establishing patient empowerment and also, in managing their own psychological well-being and emotional needs.

Conclusion

These were three patient who had never experienced telehealth before and only one of whom was familiar with computers. Very quickly all three became relaxed with this method of communication. When used alongside clear boundaries and structure in the art therapy session, it did not appear that the therapeutic process or therapeutic relationship was adversely affected by the perceived limitations of the technology.

I valued the opportunity to work with the University researchers last year. It enhanced my learning regarding setting up a research study and I can see that in the future, working like this will make it possible for oncology and palliative care patients and families to have a choice in terms of the psychological support that they can access. There is much to learn about working in this way. I am both excited to be working again with researchers and nervous about this next pilot project. 

In the future, I am certain that further research from the perspective of patients and therapists will develop a body of knowledge about offering art therapy using this technology. Other art therapist and psychological therapists working in this way, will contribute to understanding the experience of offering and receiving psychological support in this way.

Written by Gudrun Jones


References

Keenan, J. ( 2014) ‘Professionals attitude to telehealth, patients and carers experience of rural palliative care and exploring patients experiences of accessing psychological support through telehealth’, unpublished doctorate study 

Keenan, J. et al. (2014) ’Exploring palliative care patients’ experience of accessing psychological support through telehealth’, unpublished

Wood J. (2015) ‘A summer researching digital art therapy’ in Newbriefing British Association of Art Therapists (BAAT), December

Weitz, P. (Ed.) (2014) ‘Psychotherapy 2.0: Where Psychotherapy and Technology meet’, Karnac Books

Collie, K., Bottorf, J.L., Long, C.B., Conati, C. (2006) ‘Distance art group for women with breast cancer: guidelines and recommendations’. Online Resource. Available at: https://www.researchgate.net/publication/7281566_Distance_art_groups_for_women_with_breast_cancer_Guidelines_and_recommendations