If necessity is the mother of invention, the pandemic has dramatically challenged Canadian health care providers to alter their practices by both adapting and adding to the existing telehealth infrastructure and procedures.  The astonishing technological developments and the growth in widespread availability of telecommunications devices and platforms during the past twenty years allowed health care providers to begin to explore and develop novel methods of assessing, diagnosing, treating, and monitoring patients.  While there was widespread acknowledgment of some of the advantages that telehealth offered—especially in extending healthcare to under-serviced rural areas and remote communities—there existed multiple sources of resistance and reluctance amongst health care providers to pursue what many regarded as a radical, untested, and unproven departures from established practices and procedures.  The pandemic rendered all such objections and hesitancy to embracing telehealth and virtual practices moot.

Responding to the pandemic protocols, practitioners of various disciplines—including physicians, nurses, psychotherapists, and physiotherapists—have been compelled to rely on technology as the means of meeting with their patients.  Despite the realistic apprehension with which so many professionals have undertaken this course of action, there has been widespread acknowledgement that providing care remotely—via telephones, smartphones, tablets, and computers—offers innumerable advantages to both patients and providers.  The convenience of being able to schedule appointments without having to leave the workplace or to arrange for child care, doing away with the transportation distance and time involved, and having access to services that might otherwise be denied to them are just some of the advantages that patients derive from the provision of remote healthcare.  For providers, their concerns about the limitations of assessing and treating patients without having direct contact with them have been largely alleviated.  Though there are significant cases and conditions in which the lack of person-to-person contact is problematic, health care providers have been pleasantly surprised to discover that, by and large, technological access allows them to implement satisfactory alternatives to direct provision of health care services.

Psychotherapists of all stripes—psychologists, psychiatrists, and counsellors—find themselves confronted by the pandemic’s alarming impact on mental health.  Reports of concerning rises in the rates of anxiety, depression, substance abuse, and marital discord highlight the urgent and widespread need for access to counselling and psychotherapy services.  While the provision of psychotherapy by telephone has been an established practice for decades, many professionals have resisted or been reluctant to provide that option to clients because of a variety of concerns.  Most prominently, psychotherapists have questioned the unknown impact of remote contact on the cultivation of the “therapeutic alliance”: the therapist-client relationship that is well-documented as being critical to effective treatment.   Nevertheless, the results of a modest body of research on psychotherapy delivered by telephone have been encouraging with respect to the development and strength of the therapeutic alliance.  However, the differences reported, in one study, between the effectiveness of Cognitive Behavioural Therapy as compared to Emotion-Focused Therapy when delivered by telephone, serve as an important caution.  Researchers have speculated that the apparent superiority of CBT versus EFT might be attributable to the fact that delivery of the latter by telephone may preclude the establishment of the necessary therapist-client intimacy upon which EFT success depends.  The implications of that difference, in weighing treatment approaches for assorted conditions, certainly give psychotherapists pause when considering how to conduct remote psychotherapy.

Despite the many unanswered questions associated with the provision of psychotherapy through virtual platforms, such as Zoom and Skype, that approach is intriguing in its potential for the extension and refinement of services.  The opportunity to visually observe clients during sessions addresses therapists’ concerns about being able to monitor and gauge clients’ nonverbal behaviour—albeit not as fully as in-person.  Given the lack of evidence regarding the effectiveness of alternative treatment approaches in addressing various presenting problems, therapists are, effectively, in the very disconcerting and uncomfortable position of flying blind.  For example, most therapists would agree that severely depressed clients, who are suicide risks, require in-person monitoring and support.  On the other hand, questions—as to how to most effectively provide virtual assessment and treatment of moderate or situationally-dependent depression—remain moot.  It may well be that remote services will provide access to many clients who would have otherwise been denied psychotherapy, and that such contact will prove effective in addressing clients’ conditions.

Although physiotherapy would appear, at first blush, to be an inherently hands-on profession, that misconception has been dispelled by the impressive successes that practitioners have achieved in providing remote services.  Though the circumstances in which physiotherapists provide treatment have altered and limited their functions, there have been some unexpected benefits from remote interactions with patients.  For example, the chance to observe patients in their own homes provides therapists with important data and context in assessing and determining the course of treatment.  Many patients have come to regard remote treatment sessions as active learning opportunities that therapists can supplement by providing them with video demonstrations of exercise routines to be reviewed following sessions.  The existence of a wide range of digital behaviour change tools allows for exciting innovations that will increasingly tailor treatments to patients’ needs, while also increasing compliance rates with prescribed exercise regimens.  In response to remote treatment, some physiotherapists believe there has been an important shift in their patients’ perspectives—such that they now regard themselves as being more responsible for and in control of their rehabilitation.  Such unanticipated positive consequences indicate potential undiscovered promise arising from innovative physiotherapists’ continuing provision of remote services.

The extent to which telehealth has been extended and refined in response to the pandemic has accelerated its development, inspired innovation, and resulted in creative advances within various treatment disciplines.  Though there continues to be a need to develop reliable and affordable internet accessibility throughout Canada, as well as making devices available to all Canadians, the future of telehealth appears to promise a fundamental reappraisal and reformulation of the delivery of Canadian health care services.

Peter A. Lawriw-Bahan B.A. (Hons.), M.A. & Editorial Committee

Director of Medical-Legal Services