Online therapy? It works.

Mental health care is not accessible to everyone. It’s a fact that less than fifty percent of people who need treatment actually get it. But access to an internet connection is available to most people. So it makes sense to offer more health services online.

Although the opinions are divided about Dr Google, health experts now agree on one thing: internet therapy for many mental health problems works.

5 benefits

E-mental health is a broad term used for mental health services delivered via internet programs, telehealth, mobile phone applications and websites. There are five benefits:

  1. It can be accessed anytime and anywhere
  2. There are no or low costs to patients
  3. It fills service gaps
  4. It reduces wait lists
  5. It’s cost-effective to the health system.

Some patient groups will benefit less from online therapy, such as people with complex or severe mental illness, personality disorders, substance dependence, or people who have a higher risk of self-harm or suicide and need urgent clinical management.

Who is it for?

E-mental health probably works best for people at risk of illness or people with mild to moderate symptoms. It is used in many ways including first-line treatment and relapse prevention. Evidence shows that it can be as effective as face-to-face therapy. Using the services in combination with regular visits to a doctor is ideal.

If you want to know what e-mental health services are available and how reliable they are, click here (free registration). The site uses a smiley system to show how much evidence there is that a service works.

More information and free e-mental health training for health professionals can be found here. The RACGP has published a handy e-mental guide for GPs.

Have a look at the video as well. Before you use any of the online services it is recommended to check the terms and conditions so you know what happens with the personal information you provide.

Sources:

A painful topic: what doctors need to know (according to patients)

Ok, so I was wrong. I really liked the RACGP good GP television commercial. It had some flaws but I thought they were small in the grand scheme of things (see my last post). But many patient advocates did not agree and were unhappy about the lack of communication portrayed in the video.

Blogger Michelle Roger commented: “My current GP asks me what I want to do, what I think is most important and together we sort through the problem at hand and potential solutions. I feel valued and heard and trust her more knowing that she listens and knows me and my family.”

“That for me was missing in the video. It was one-sided and the patients appeared little more than props to be talked at. In fact the patients had no voice at all. A problem that still permeates a lot of medicine.”

Crockey health blog posted an article titled ‘The Good GP never stops learning: the RACGP video that made doctors cry – and patient advocates wince’. In a response to this article Irish blogger Marie Ennis-O’connor wrote on her blog: “We can’t just talk about a commitment to patient centred care – we have to live it. It is only by bridging the divide which places patient and doctor expertise on opposite sides that we can achieve more personalized and meaningful care of the patient.”

Patient blogs

I wondered why the patient opinion was so different to mine. On Twitter it was suggested to me that more doctors should read patient blogs to understand their view better. I thought that was a good idea so I asked for some recommendations and started reading.

I can tell you, it didn’t cheer me up but it was enlightening. It felt a bit like a refresher course “do’s and dont’s for doctors”. What I read was that, in the eyes of patients:

  • Doctors often don’t know how to deal with disabilities
  • Doctors sometimes blame patients for treatment failures
  • Some doctors find it hard to accept patients as experts
  • Doctors don’t always communicate well.

Now that I’ve read the blog posts I feel that I can better appreciate the patient response to the RACGP video – and I learnt a lot more along the way.

I have been given permission to share parts of these blogs and I recommend anyone who works in healthcare to read on. It may help to bridge the divide. Doctors beware: don’t expect flattery.

Empathy towards disability

Carly Findly
Carly Findlay: “Doctors need to move past the textbook and immerse themselves in the disability community to truly learn and empathise with our experiences.” Source: Carly Findly

In one of her posts writer and speaker Carly Findlay tells the story of how doctors gave up on her and told her parents to prepare for her death, and how she later met one of these doctors.

(…) “Over the Christmas holidays, I introduced myself as an adult to the dermatologist who gave me a pretty dismal prognosis as a baby. He pretended not to remember me until he told me I always had blocked ears. I think he was surprised to see me. I told him some of my achievements including how I am now educating dermatologists about my condition (something he needed when he treated me).”

(…) “Other people with Ichthyosis tell me that doctors didn’t give them a chance either. My friends have said that their parents were told they wouldn’t make it into mainstream school, that they wouldn’t have relationships or children, and that they would be social outcasts.”

(…) “The political models of disability can determine a person’s compassion and empathy towards disability. And so a doctor’s low expectations for a baby born with a disability can set the scene for their attitude through the lifespan of that patient.” (…) Doctors need to move past the textbook and immerse themselves in the disability community to truly learn and empathise with our experiences.”

Read the complete post here. Follow Carly on Twitter

Blaming patients

Caf
Caf: “I’m not sure that I truly trust any doctors, despite having a lovely GP.” Source: Rellacafa

Blogger Caf explains how doctors told her to see a psychiatrist when their attempts to treat her chronic pain failed.

“I had arrived at the appointment of the reveal, hobbling with a pair of forearm crutches. I could hardly bear any weight on the offending ankle. It didn’t take long for him to deliver his message, laced with condescension and arrogance. ‘There’s nothing wrong with your ankle. Why are you on crutches?’”

(…) “Chronic pain has been misunderstood and stigmatised for so long that many people probably don’t know what to believe. Even patients themselves often wonder if they’ve just gone crazy because their symptoms are so utterly illogical.”

Caf says that her experiences have affected her trust: “I’m not sure that I truly trust any doctors, despite having a lovely GP.”

Read the complete post here. Follow Caf on Twitter

Michelle also writes about pain in this post: “And there is a pervasive idea of the drug-seeker, seen in every patient who has chronic pain. That those who simply don’t get over pain and require ongoing pharmaceutical management are weak.”

“Friends who have used pain clinics tell stories of dismissal and blame. That they are not trying hard enough when they don’t recover, when I know the lengths they have gone to to try and alleviate their pain. And compassionate pain doctors who become the exception not the rule.”

The patient as expert

In another post she writes: “As a patient with an unusual, complex, and poorly understood disorder, 9 times out of 10 when I see a new doctor I am the expert in the room.”

(…) “I spend my spare time researching my disorders on Medline. I flip through Cochrane Reviews, and review consensus statements regularly. I read up on the drugs I’m taking and keep abreast of current research trials. On forums, I can ask questions of other patients.

“The constant fight to be heard is exhausting

Arm rash Michelle Rogers
Michelle Rogers: “I awoke to welts and rashes across my body. My pre-op information met with eye rolls, a sense that I was over-anxious, and thus completely ignored.” Source: Living with Bob (dysautonomia)

(…) “Some doctors are quite happy to acknowledge that I may know more about my disorder than they do. For example, my GP is happy for me to take the lead on my treatment needs. Even my cardiologist is happy to discuss my disorder in more of a collegiate manner, than the traditional doctor-patient relationship.”

(…) “Yet there are many others who are nothing short of dismissive. Should I dare to suggest a potential treatment or line of investigation the appointment can become adversarial. At times what I say is outright ignored.”

“Case in point my recent hospital admission. Despite having a red allergy band on my arm, sharing the information from my Allergist, and speaking to both my neurosurgeon, anaesthetist and senior nurse about my allergy to adhesives, I awoke to welts and rashes across my body. My pre-op information met with eye rolls, a sense that I was over-anxious, and thus completely ignored.”

(…) “The constant fight to be heard is exhausting. We are told that we must be our own advocates. That the future is patient-centred medicine. That rapport and making a patient feel part of the decision-making model leads to more compliance and more successful outcomes.”

New technology

Michelle: “Patients no longer live in a bubble where they are reliant upon their doctors as the only source of information. With the advent of social media and the ease of access to medical journals, patients can be as up to date, and at times, in front of their doctors, with regard to advances within their various disorders. We come empowered and informed to our appointments and have an expectation that our doctors will be equally informed or at the least, willing to listen and work with us.”

“We have an expectation that our doctors will be equally informed or at the least, willing to listen and work with us

“The medical community needs to be aware of the new ways information is being shared, especially the speed at which information can now travel. Instead of criticising patients for researching their ailments, they should instead be working with them, especially to direct them to more appropriate medically sound sources of information.”

“Patients are already distrustful of big pharma and the way research is funded. If their physicians also refuse to help them navigate these areas or are dismissive of their efforts, such distrust will also pass to them, to the detriment of both practitioner and patient.”

Read the complete post here. Follow Michelle on Twitter

Doctors who listen

Carly: “I went to hospital earlier this year. I was so sore, and a bit miserable. I saw a junior doctor, one I had not seen before. I spent an hour in the consult room, talking to her about Ichthyosis, but also my job, blogging, wedding plans, travel and the Australian Ichthyosis meet.”

“Their compassion means I am a human being first

“She said I was the first patient she’d met with Ichthyosis and she wanted to learn more than what she’d seen in the textbook. Her supervisor came in to provide further input into my treatment. Again, we talked about life, not just Ichthyosis.”

“And she told this junior doctor how lucky they are to have me as their educator. What a compliment. I am so lucky to feel empowered as a patient at my hospital. These doctors listen to me. They treat me as a person not a diagnosis. They see my potential and are proud of my achievements. Their compassion means I am a human being first.”

An unusual ANZAC story: How my grandfather evacuated Australian troops from Timor

“ANZAC day is a time when Australians reflect on the many different meanings of war” ~ Australian War Memorial

As an immigrant I have often thought about the meaning of ANZAC day: My family and I make an effort to attend ANZAC ceremonies and pay respect to Australian men and women who fought for freedom, but somehow I always feel like an outsider. I thought this was because I don’t share a common history. I was wrong.

I recently re-discovered my grandfather’s remarkable Timor mission in 1942. It is also part of the history of Australian soldiers sent to Timor to help the Dutch defend the island against the Japanese invasion. When Timor yielded to the Japanese, about 400 Australian troops were cut off in the mountainous jungle. They refused to surrender and embarked upon a guerrilla war against thousands of Japanese soldiers.

Many of the Australian soldiers sent to Timor never came home. But those who did, I’m proud to say, were rescued by my grandfather during a hazardous navy operation.

A difficult mission

“In the night of 4 December 1942 the Dutch destroyer Tjerk Hiddes lay moored alongside the pier in Fremantle.” That’s how the report in the US Naval Institute Proceedings begins. The story, written by US Navy Admiral Gordon, reads like a novel.

My grandfather, Lieutenant Commander William Kruys, was the skipper of the vessel. That night in Fremantle he received orders to proceed, via Darwin, to the island of Timor and bring the remainder of the Australian Forces, Dutch troops and civilians back to Darwin.

My grandfather’s ship, the Dutch destroyer Tjerk Hiddes.
Image: My grandfather was Commander of the Dutch destroyer HNLMS Tjerk Hiddes.

My grandfather knew this was a dangerous mission. Torpedo planes had sunk the Australian corvette Armidale while it was attempting to evacuate troops from the island. The Australian destroyer Voyager had run aground on the Timorese coast and was damaged beyond recovery after Japanese dive bombers spotted the ship on the beach.

The Tjerk Hiddes had been under attack before by a Japanese squadron of high altitude bombers from bases on Timor. On that occasion my grandfather managed to successfully manoeuvre his ship to avoid the bombs. And now he was heading back to the Timor Sea.

Admiral Gordon’s report continues: “In Darwin he had obtained a patrol schedule, just recovered from a downed aircraft, which showed every detail of Japanese air reconnaissance in the area. The RAAF was sure that they would change the schedule at once.”

“Kruys, an old Far East hand, said, ‘When they get a good plan, they stick to it. I’ll work on this one because the Japs won’t alter it too quickly.’ His second asset was nothing more than a name on a chart. In his own words: ‘I could rely on the charts because I knew the Dutch hydrographer who made the surveys in about 1932.'”

The men of Timor

What my grandfather didn’t know was the incredible story of the Australian soldiers defending Timor against the invading Japanese troops. After many months in the jungle the soldiers of 2/2nd Independent Company, plus remnants of Sparrow Force, managed to build a radio transmitter from a broadcast receiver and a car generator, and got a signal through to Darwin which eventually led to the rescue mission.

The Tjerk Hiddes arrived at Betano in the middle of the night. My grandfather’s navigation officer, Lieutenant Keesom, used the artillery radar and ASDIC sonar to navigate the reefs and cliffs along the Timorese coast – advanced technologies at the time.

But my grandfather was just as familiar with the old sailor’s tricks: “I went ahead dead slow and ran my anchor two or three shackles out. It was actually a sounding lead hanging down and if it hit the bottom I would know that we were in shallow water.”

“Suddenly we saw ahead, on the beach, the three fires agreed as the landing beacon. We dropped the collapsible boats, while still going ahead and towed them in with our two power boats. These power boats stayed just to seaward of the surf to tow the collapsible boats back out.”

“My first man ashore looked around with Tommy Gun ready, thinking ‘what shall I meet, Japs or whatsoever?’ It seemed a long time to him before a lone figure in the darkness made the correct recognition signal with a feeble light, and asked. ‘Did you come to pick us up?'”

“‘Yes. I came for that,’ my man replied. Then the stranger whistled and suddenly the beach was crowded with men. First they loaded the sick and wounded and about twenty women and children and sent them out to the ship.”

“At a certain moment, two of the men on the beach, one from the ship and one from shore realised that even though they were talking English, they were both Dutchmen. It was hard for these people to believe that they were being rescued by a Dutch man-of-war. When they did accept the reality, they said that Tjerk Hiddes must have been sent by God!”

The Tjerk Hiddes made three high-speed return trips, successfully evacuating over 1000 people. The ship was never sighted by a Japanese plane. Admiral Gordon reported: “Kruys had been right in his gamble that the Japanese wouldn’t change their patrol schedule. He learned years later that the patrol was finally changed in March 1943, right on schedule.”

My grandfather was awarded the Legion of Merit by President Roosevelt: ‘By his fearless determination, excellent judgment, and outstanding professional ability throughout this period, he brought to a successful conclusion an extremely difficult and perilous mission.’

After World War II my grandfather became vice-admiral in the Royal Netherlands Navy. He lived in the Netherlands until his death on 20 April 1985.

Sacrifice and freedom

As fate would have it, I had the privilege of looking after one of the Australian Timor veterans rescued by my grandfather. He was in his nineties but he spoke about how they built the radio transmitter as if it happened yesterday.

Re-discovering this story in the family archives has changed the way I think about ANZAC day. I realised that, although it’s a primarily Australian-New Zealand-British tradition, its values of sacrifice and freedom are non-exclusive, and its tragedies universal. 

With some imagination most of us can relate to the ANZAC spirit – even if we were born outside Australia or don’t have ancestors who took part in an Australian military conflict. 

In loving memory of my grandfather Willem Jan Kruys (1906-1985). Lest we forget.

Lieutenant Commander W. J. Kruys received Legion of Merit
Image: My grandfather receives the Legion of Merit in Fremantle, 1943. Article from the West Australian, 18 September 1943.

What really matters

Dying is an intense sad process, but there is another side to it as well: people often take the opportunity to reflect.

As a doctor I have the privilege to talk to people who are nearing the end of their lives. A while back I asked one of my wonderful 85-year old patients what had been most important in her life.

She didn’t need much time to think, and said: “That has to be my family, doctor, and the move from England to Australia with my husband.” Her loved ones, and the journey that changed her life – she couldn’t have been more concise.

I asked myself: what matters most? I found three inspiring life lessons.

#1: Achieving childhood dreams

Randy Pausch was a professor in computer science who died of pancreatic cancer. He became well-known after he gave a lecture titled The last lecture: Really achieving your childhood dreams. It went viral on YouTube.

In the video below Pausch gives another, shorter, inspiring speech to university students about how to live your life well by nourishing relationships with others and expressing passion. Pausch died 68 days after giving the speech.

#2: Don’t be afraid to fail, be afraid not to try

“If today were the last day of my life, would I want to do what I am about to do today?” Apparently Steve Jobs asked this question everyday, and it has become a guiding principle for many. Like Randy Pausch, Jobs was looking for passion: “There is no reason not to follow your heart,” he says in one of his famous speeches. Jobs reminds us that all negatives, like fear of embarrassment or failure, just fall away in the face of death.

#3: Begin with the end in mind

One way of following your heart is to begin with the end in mind. This principle is very similar to Steve Jobs’ philosophy, and it’s habit two of Covey’s famous 7 habits of highly effective people:

(It) is based on imagination – the ability to envision in your mind what you cannot at present see with your eyes. It is based on the principle that all things are created twice. There is a mental (first) creation, and a physical (second) creation. The physical creation follows the mental, just as a building follows a blueprint. If you don’t make a conscious effort to visualize who you are and what you want in life, then you empower other people and circumstances to shape you and your life by default.

A patient once told me that he and his wife took their four-wheel drive and caravan five times on a trip around Australia. I said I’d love to do the same one day but that five times was a hard act to follow. He looked at me and replied: “Aim for it.”

When I listen to my terminally ill and elderly patients, they remind me – like Pausch, Jobs and Covey – to keep on trying, have fun and be there for others.

Try win-win instead of hardball

Teamwork is essential in healthcare. Yet, too often, we act as individuals looking after our own interests. Solving problems together, even if the objectives seem opposed, is beneficial for all parties for many reasons.

Stephen Covey introduced the principle of win-win in his book the Seven habits of highly effective people. It’s still a great principle for conflict resolution, incl in teams, groups, organisations etc. Covey:

Win-win sees life as a cooperative arena, not a competitive one. Win-win is a frame of mind and heart that constantly seeks mutual benefit in all human interactions. Win-win means agreements or solutions are mutually beneficial and satisfying. We both get to eat the pie, and it tastes pretty darn good!

A win-loose outcome is bad for all parties. Even though the winner may feel triumphant, the loser may not want to deal with the winner ever again.

So what’s required for a win-win result? First of all it requires an open mind. Black & white or good & bad thinking is not helpful and often not realistic either. Secondly, understanding the other party is crucial:  Where do they stand? What is important for them? Where is the common ground?  And finally: flexibility, as there are always more solutions to a problem.

Win-win is not about being nice, as Covey said. It’s about being courageous and considerate at the same time.

Predicting what makes us happy

Is the grass always greener on the other side of the fence? Most people will answer ‘no’ to this question. Yet we often want what we don’t have. Against better judgement, we sometimes hope that happiness lives on the other side of the fence too.

The commercial world thrives on selling happiness: it’s not the new phone, car or dress, but the dream of a better life that’s on offer. And we all fall for it, thinking that somehow we will be happier after the purchase.

The reason for this is that we’re not good at predicting what makes us happy. Unfortunately, happiness as a result of a treat, purchase, or even winning the lottery, is short-lived – probably less than three months. Spending money on others makes us happier than spending it on ourselves, according to a study published in Science magazine.

Interestingly, happy people enjoy themselves without expensive treats. One happiness study showed that it’s the simple, cost-free things in life that matter, like listening to music, reading a book, going swimming, or enjoying a hobby.

What makes you happy? There’s a good chance that it’s an inexpensive, relaxing activity, or an act of kindness.

Don’t wait until tomorrow

Over the years I’ve known several people who became ill shortly after their retirement. I remember one hardworking business man who suddenly died after he signed off. He left his wife behind with the tickets for their world trip.

Our emigration to Australia is part of the our dream. My wife and I feel privileged that we have been able to find a beautiful spot where we are truly happy. I try to teach my kids to do what they love and to enjoy the journey.

It’s a recurring theme in discussions with patients: how to give passion a place in your life, now, not later. It is easy to do and can be as simple as blocking off a few designated hours every week.

But sometimes I forget. It’s easy to lose myself in daily routines, busy schedules and tight deadlines. Everyday business sometimes seems more important than my dreams. There are always plenty of reasons why not to do something I’m passionate about.

So I remind myself, like some businesses do by writing their mission and vision on the wall. It can be a message on my home screen or a piece of paper on the mirror.

What change in your life makes you happier? Whatever it is, start today. Don’t wait.