Gibson et al NAHO November 2009

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Reference: Gibson, K., Kakepetum-Schultz, T., Coulson, H., O’Donnell, S. (2009) Telemental Health with Remote and Rural First Nations: Advantages, Disadvantages, and Ways Forward. National Aboriginal Health Organisation (NAHO) Conference. Ottawa, November 24-27.
Telemental Health with Remote and Rural First Nations: Advantages, Disadvantages, and Ways Forward
Kerri Gibson National Research Council
Tina Kakepetum-Schultz Keewaytinook Okimakanak Telemedicine
Heather Coulson Keewaytinook Okimakanak Telemedicine
Susan O’Donnell National Research Council
Remote and rural First Nation communities have limited mental health services compared to urban communities yet their needs are similar and sometimes greater. Community members living in remote, isolated communities requiring mental health services are usually faced with two choices: having no service or leaving their community to access services in larger centres. Certain First Nation communities offer a third choice: using telemental health delivered via videoconferencing to provide clinical mental health services for community members. Like all technology uses, telemental health services have advantages and disadvantages, both for the individual and the community.
Understanding mental health workers’ experiences of telemental health and its benefits and drawbacks for remote and rural First Nations people was the focus of our study. Qualitative data were collected through interviews with mental health professionals (clinicians and nonclinicians) working with First Nations communities. Quantitative and qualitative data were collected from a national online survey of mental health workers working with clients in rural and remote First Nations. This paper presents a thematic analysis of the data collected. Advantages include allowing community members to remain within their community for treatment and connecting First Nations trauma survivors to each other; disadvantages include increased difficulty building and maintaining clinical relationships via videoconference and ethical concerns of using the technology. These and other pros and cons of using telemental health are discussed. Certain ways forward that seem promising are proposed, including incorporating traditional practices and the seven teachings into telemental health initiatives. Finally, policy recommendations are offered.

1. Introduction
Telemental health service delivery to remote and rural First Nations communities is growing in adoption across Canada. It plays a key role in helping remote and rural First Nation communities access needed mental health services. However, aside from program evaluations, little research exists on telemental health for First Nations within the Canadian context.
According to the 2004 Telemental Health in Canada Status Report, telemental health activities usually involve videoconferencing (Polycom or Tandberg systems, connecting two or more sites in real-time audio and video) and encompass the following activities: consultation between health professionals, managing care of clients between professionals, and service and care provision to clients. In addition, educational activities related to mental health often take place via videoconferencing. These activities span home, community, and institutional settings (Health Canada, 2004).
Despite the lack of published research, significant benefits (including increased access to services and user satisfaction) and challenges (such as lack of funding and infrastructure) to using telemental health for First Nation communities have been identified (KO 2002; KO 2006; Shore et al. 2008). It would seem obvious that the use of telemental health for remote and rural First Nations will also depend on the attitudes of the users – in this case the service providers and the clients. However there has been very little research on this topic internationally and none in Canada.
Our study is exploring the perspectives of mental health professionals – both clinicians and non-clinicians. This paper, an initial report from a larger study, explores some patterns of telemental health for First Nation communities as well as some advantages, disadvantages and challenges, and ways forward. Based on the findings, policy recommendations are proposed.
The current study – and this paper - focuses on the attitudes of mental health workers. We are planning more community-level research to gain an understanding of how communities and potential clients perceive these technologies for mental health. We believe research on this topic has exciting potential: increasing knowledge of the current use and benefits of this technology and how to address its challenges can stimulate the use of telemental health to provide increased services that could increase community wellness.
2. Literature Review and Research Questions
Telemental health, originally known as closed-circuit two-way television, has been existence for close to five decades (Wittson & Benschoter, 1972). However, in Canada its use only began to grow in the mid-1990s (Health Canada, 2004). Since then, all the provinces and territories have used telemental health to some degree (Health Canada, 2004). Telemental health provides an opportunity to reach rural and remote populations who may have difficulty accessing services. Remote communities are usually only accessible by plane, and so are particularly isolated and in need of services. A 2002 report by the Keewaytinook Okimakanak Tribal Council noted that certain Northern Ontario First Nation communities only had access to

approximately 57 days of direct psychiatric care a year (KO, 2002). The cost of in-person visits to the community for psychological and psychiatric care can be very costly, and so telemental health represents a potentially cost-effective alternative (Brasfield & Clement, 2007; KO, 2002). First Nation communities that have been able to access telemental health services have experienced many benefits (KO, 2002; KO, 2006).
One of the conclusions reached by Health Canada’s telemental health status report was that the key informants viewed telehealth as a “strategic tool, capable of improving the access to and quality of mental health services at the local or community level. They foresee a great potential for rural and remote communities in particular, where serious shortages of health professionals are felt. Almost all forecast an expansion of telemental health services in the near future” (p. iii, Health Canada, 2004).
The report outlined a number of key challenges to reaching this potential. These include: a lack of service providers, under developed information and communication technology (ICT) infrastructures, insufficient funding, a lack of capacity to implement projects, and “cultural issues.” In addition, like within the general telehealth climate – difficulties also exist related to reimbursing service providers and licensing; some mental health associations have developed guidelines for telemental health use by practitioners, and others have yet to do so.
Furthermore, mental health care policies were designed for face to face interactions (Health Canada, 2004). Finally, clinicians attitudes toward using the technology can be a challenge in the use – if clinicians do not perceive there to be benefits, perceive it to be a useful service, and perceive that they are able to use the technology, it is unlikely that they will be engaging with the ICT. We know from several landmark studies over the last two decades as well as our own recent work that there is great importance in perceived usefulness and perceived ease of use of the technology in terms of prediction of actual use of the ICT and satisfaction with using it (Davis, 1989; Gibson & O’Donnell, 2009; Townsend, Demarie, & Hendrickson, 2001). In one pilot study of telepsychiatry in First Nation communities, there was a fairly high level of user satisfaction for both the client and the service provider (KO, 2002).
Shore and colleagues (2008) have explored telemental health for rural American Indian communities. They concluded that “safety nets” and emergency protocol (support resources and a plan to respond in the case of crisis or necessity), in addition to guidelines, are necessary to facilitate telemental health for these rural communities. Furthermore, collaboration with local service providers can be beneficial, as their knowledge of and connection to the community can help inform the process.
Shore has also pointed out an interesting dynamic that can exist within telemental health for rural American Indian communities (and often in telemental health in general) – the greater interpersonal space that exists within telemental health encounters can have different impacts. The distance can sometimes facilitate disclosure in some clients who might feel more comfortable being more physically distant from the clinician. The same effect has been documented in telepsychiatric services involving Canadian First Nation communities in Northern Ontario (K0, 2002). Nevertheless, in some circumstances the distance can potentially detract from the therapeutic relationship if a sense of connection is lacking. Finally, Shore has suggested that obtaining an understanding of the community’s culture and their experiences

with different organizations (at different political levels), as well as their tribal history, can be important for successful telemental health experiences.
The holistic model of mental health and well-being that characterizes many First Nation communities is markedly different from the typical western model of mental health. The latter has traditionally focused on problems within the individual, and medical or individual therapeutic treatment is usually the intervention of choice. Within traditional First Nations models, an individual’s well-being is seen within a much broader context. Hunter and colleagues (2006) elaborate on what holistic healing means for many First Nation communities, explaining that is a process of “following a cultural path, regaining balance (physically, spirituality, emotionally, and mentally), and sharing in the circle of life (respectful interactions with others).” This is a healing that is not time-specific and does not end with an intervention, but instead becomes a way of life. Some First Nations communities have been using telehealth and other ICT in working toward community wellness and healing, and in attempts to address social determinants of health (Molyneaux & O’Donnell, 2009). For instance, First Nation communities in Northern Ontario have successfully been using videoconferencing to unite Chiefs, community members, and service providers for planning of the H1N1 Pandemic response.
3. Case Study: KOTM’s Telemental Health Program and Their Work with First Nation Communities
In spite of the many challenges discussed earlier in this paper, certain First Nation communities have found ways to develop successful telemental health initiatives. Keewaytinook Okimakanak Telemedicine (KOTM), operated under the Northern Chiefs Tribal Council in northwestern Ontario has been one of these success stories.
KOTM has used video conference for telepsychiatry since 2002. This was the first mental health service offered through the KOTM program. Since then there has been many service providers in the field that use video for, follow-up, reassessments, regular counseling sessions, education for clients, education for professionals, human resources, case management, and all of this is related to mental health services.
Keewaytinook Okimakanak has a Mental Health (KOMH) and Crisis program that supports the wellbeing of all 6 communities under that Tribal Council. They have worked towards a partnership with other mental health and social programs to augment KOMH and all the 26 communities in general. Their unique practice of mental health service delivery has inspired and encouraged other users (clients) to use the services and other the service providers to utilize the excising protocols, procedures and secure sites available in the communities. KOTM listens to what the communities want and need for services. One way in which to help the communities decide is to offer a wide range of mental health education sessions to keep them informed. Presentations are made to the Elders at the monthly Elders meetings; while the focus is not mental health per say, it is health related anything from prescription drug abuse to chair exercises. KOTM education coordinator looks for and supports professionals and coordinates community CTCs (Community Telemedicine Coordinators) to get the much needed factual, informative, relative information to all communities so that they can make requests that address their community needs.

4. Research Questions and Method
The following research questions guided the analysis of the data for this paper: What are the advantages to using telemental health for First Nations communities and individuals? What are the disadvantages or challenges to using telemental health for First Nations communities and individuals? How can telemental health be improved to better meet the needs of the communities?
Our analysis is based on preliminary data from the ongoing larger study – Telemental Health with First Nations project. This project is the result of collaboration between the National Research Council, the University of New Brunswick, and three First Nation organizations – located in Northern Ontario, Quebec, and Atlantic Canada in association with the VideoCom project ( Partner representatives have provided expertise, feedback and support throughout various stages, such as the design of the project and measures, recruitment, contributions to papers and co-authoring.
The data presented in this paper are from in-depth interviews and an online survey. Individual interviews were conducted with mental health professionals (clinicians and non-clinicians) who had telemental health experience with First Nations individuals and communities. The national online survey is open to all mental health workers in Canada, and measures attitudes toward the use of ICT for mental health work.
Online survey participants. Fifty respondents to the online survey on ICT for mental health services reported having experience working with clients in remote and rural First Nations. Only the survey responses of those participants with this specialized experience were included in this analysis. Participants ranged in age from 18-64, with the majority falling in the 45-54 age group. Males represented 24.1% of the sample, and females 75.9%. Participants represented various provinces and territories, including Newfoundland and Labrador, Nova Scotia, New Brunswick, Quebec, Ontario, Manitoba, Saskatchewan, Alberta, British Columbia, and the Yukon. A wide variety of professional positions were represented among participants: social workers, psychologists, community workers, nurses, students, among others.
Interview participants. Five in-depth interviews were conducted with individuals who had experience working with telemental health in the First Nations context. These participants came from Nova Scotia, Ontario, and British Columbia. They held a variety of positions, including psychiatrist, psychologist, community engagement worker, administrator, and program developer.
The online survey had 38 items including demographic information, personal use of technology, experience working with different populations, attitudes toward using videoconferencing, video, and patient portals, and other ICT for mental health work, and more. The online survey was created and administered through

The interview guide focused on experience with telehealth and other ICT. Specifically, questions asked about: successes and challenges with ICT use (with a focus on videoconferencing), how to use ICT in the clinical context, how traditional First Nations practices can be included, and what is needed for better support of telemental health use. Limited demographic information (position, experience with population) is also collected using the interview guide.
Online survey. A variety of recruitment methods were employed. These included poster advertisements distributed widely. Our First Nation partner organizations forwarded the information on to potential participants. Emails with a text advertisement for the survey were also circulated to potential participants. Certain provincial colleges of psychologists and social workers advertised the study to their members.
Interviews. Poster advertisements were also used to help with recruitment of interview participants. Four of the five interviews were conducted over videoconference, with the remaining conducted in person. Interviews were conducted one-on-one and lasted between 45 and 60 minutes.
The research protocols for this study were reviewed by the National Research Council’s Research Ethics Board. All participants were treated in compliance with the ethical guidelines put forth by the American Psychological Association (APA, 1996).
5. Research Findings
The data analysis for this preliminary investigation is restricted to reporting descriptive data and percentages for the quantitative data, with relevant quotes from the interviews related to each theme. Again, all the data reported here are from mental health professionals who work with clients in remote and rural First Nation communities.
5.1: How frequently is telemental health used?
As a starting point, we investigated participants’ frequency of use of telemental health services. Chart 1 outlines their responses. It is interesting to note that 52% of respondents indicate no experience with telemental health. In addition, no participants reported everyday use of videoconferencing.

Chart 1: Frequency of videoconferencing use for telemental health
5.2: How useful is videoconferencing? Participants were asked to rate how useful they found videoconferencing for communicating with clients. The response range was from 1 (not useful at all) to 5 (very useful). The mean response for this scale was 3.29, and the most common rating was a “4”, indicating a fairly moderate to high perception of usefulness among the responding mental health workers (Chart 2). Chart 2: Perceived usefulness of videoconferencing

When an interview participant who was a clinical practitioner was asked about his evaluation of the usefulness of telemental health, he had this to say:
“I think it's absolutely invaluable. I can't imagine how we would do without it.” - Interview participant 5.3: How easy is it to use videoconferencing? Participants were asked about the ease of use of videoconferencing. Survey participants rated the ease of use on a scale from 1 (very difficult) to 5 (very easy). Both the mean score and the common response were a 3 (Chart 3). Chart 3: Perceived ease of use of videoconferencing
5.4: Does telemental health increase access to services? Most participants (from both the survey and interviews) viewed telehealth as a way to increase access to services. Telemental health allows community members to remain in their communities while receiving services. The following quotes elaborate on the importance of this:
“We need professional mental health therapy, and also people, patients, clients would come out of the communities, and it would disrupt their whole lives, their lifestyle. And they would come into town with these problems, personal problems. How can they do it when they’re away from home, and living in a hotel, and all the temptation that comes with it, drinking and drugs, and away from their family, away from their spouses? They

need all that, all that support from home. And here they’re expected to travel away from it – how can you heal under those circumstances?” - Interview participant.
“Weather conditions make it often impossible to send clients via plane, this way they can stay in community and either use phone or video to access services.” - Survey participant.
5.5: Can distance be an advantage?
In a later discussion, we explain that the interpersonal distance created by the geographical distance and lack of in-person interactions can be a challenge for telemental health. However, some participants identified this same challenge as a benefit. They explained that certain clients may have a tendency to feel shy and somewhat uncomfortable around people, and the greater interpersonal distance can be an advantage to telemental health. This is exemplified in the following quote:
“Clients feel freer to disclose to people they won't see every day. Some clients are more comfortable with being one step removed, not in the room with a clinician, it is somewhat empowering.” - Survey participant
5.6: What are some professional and ethical concerns?
Some participants commented on how not being able to directly intervene during a crisis with a client makes them uncomfortable. The importance of having protocols and a “safety-net” ready for emergencies or crises during telemental health activities was highlighted.
“You have to train the mental health coordinators to be on hand when that should happen, and they have to have ability to find someone else in the community to make sure that the client is not left in a lurch… I’m always stressing that you need to have a back-up in case something happens…. Because we’re so busy, we tend to forget about doing little things like that, that they can become a really big thing…” - Interview participant
Some participants raised the concern of the appropriateness of ICT use for clients experiencing certain symptoms – paranoia, dementia, and visual or hearing challenges for example. Other participants felt that the first meeting with a client should be face-to-face, and then the remainder of meetings can be via telehealth. Others noted that some types of assessment and therapy would be difficult to deliver via telemental health.
“Initial consultations and suicide risk assessments would be difficult to deliver in this mode.” - Survey participant
Nevertheless, there were participants who expressed that face to face meetings were not always a necessary first step, and are not always possible.

5.7: What are some of the challenges?
Lack of adequate infrastructure was reported by several participants - the broadband network infrastructure within some of the isolated communities simply cannot support this type of technology. Indeed, within our own past research the obstacles of broadband communication within remote and rural First Nations communities have been highlighted (O’Donnell, Perley, Simms and Hancock, 2009). In several communities, the infrastructure has not been developed and therefore members simply cannot engage in video communications; this is clearly an obstacle to the increase use of telemental health.
“Here in Northern Canada (YT) there is little technological infrastructure outside of capital city Whitehorse.” - Survey participant.
Sustainable funding is a precious and scarce resource in telemental health service delivery. In addition to the general lack of funding for mental health care of First Nations individuals, telemental health programs in particular could benefit from receiving more financial support. Furthermore, funds allocated for research could be very beneficial but are rarely available. Many of the First Nations telemental health initiatives that are ongoing collect data as part of their program evaluations. Unfortunately, due to a lack of funding for research, much of their valuable data and findings go unpublished and important knowledge contributions are lost.
“I think one (challenge) is funding and sustainability, definitely. There is a monthly charge for communities to keep Telehealth in their community health centre. They do have to pay for that…so my challenge is try and come up with funding to keep that going.” -Interview participant
“The big issue, of course…is funding….we should have some separate funding for research.” - Interview participant
Limits to access were raised. Telemental health can increase access to mental health services; however the equipment needed for its use is often located in places in the community where it is not always accessible when it is needed. At the current time, the majority, if not all, telemental health initiatives within communities use videoconferencing systems like Polycom or Tandberg that are not easily transported, and cannot easily be used within a person’s home. Often, communities only have one videoconferencing system, limiting the number of clients who can access services at a time. Further, because these communities are often very small, and clients frequently need to go into a band council or health centre to use the technology, their confidentiality and privacy can be compromised. This challenge is described in the following quotes:
“Because this is a program through (provincial health authority), we can't take the machine off the site. There's no way to connect it anywhere else in the community because of (health authority) security issues. And that's fair enough. It's their equipment. It's their policies….We're just waiting for the time when we can just do this on someone's

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Gibson et al NAHO November 2009