COVID-19
Adaptations for Pain Psychology Treatment During COVID-19
By Yasmin Cole-Lewis, PhD, MPH; Catherine E. Stewart, PhD; Deirdre E. Logan, PhD
Pediatric Pain Psychology
Pain Treatment Service
Boston Children's Hospital
Boston, Massachusetts
COVID-19 has impacted nearly every aspect of healthcare, and pain psychological services are no exception. Our psychology group in the Pain Medicine Division at Boston Children’s Hospital includes nine faculty psychologists and two full-time postdoctoral psychology fellows.
Pain psychologists regularly offer services across several areas of the division, including the outpatient chronic pain clinic, outpatient headache clinic, and intensive interdisciplinary pain treatment program. In each setting, pain psychologists are engaged in clinical evaluation, treatment, and program development, as well as clinical research. They work alongside colleagues in anesthesia, neurology, pediatrics, nursing, physical and occupational therapies and other disciplines to deliver comprehensive care to youth with chronic pain.
Our outpatient clinics provide an average of 15 multidisciplinary new patient evaluations and 20-25 psychology follow-up visits weekly. In addition, our Division houses our Pediatric Pain Rehabilitation Center (PPRC), an intensive interdisciplinary pain treatment day hospital program with a typical census of eight patients receiving daily integrated medical, nursing, psychological, physical and occupational therapies along with social work, recreational therapy and creative arts therapies.
Finally, our psychology services include The Comfort Ability Program (CAP), a cognitive-behaviorally oriented pain education program offering workshops and other support for youth and families facing chronic pain. Work from home directives from hospital leadership related to COVID-19 began in March 2020, dramatically impacting psychology services across these settings. Herein, we describe our efforts to serve our patients under these challenging conditions.
Outpatient Care
Adapting outpatient follow-up visits using telehealth was one of the first directives. Prior to the pandemic, medical and psychological appointments for established patients could be conducted via the hospital’s approved virtual visit technology if certain criteria were met. With the onset of COVID-19 restrictions, the information services department worked to expand telehealth services through the hospital’s virtual visit platform, converting all psychology outpatient follow-up visits from in-person to virtual. Administrators provided additional support for virtual scheduling. Government-issued state of emergency declarations helped to convince insurance companies to reimburse for behavioral telehealth visits.
The hallmark of the outpatient programs are the multidisciplinary new patient evaluations, which run five days a week in both outpatient programs. Transitioning this experience to telehealth was challenging, with many moving parts. Still, providers quickly developed a system where patients underwent back-to-back telehealth evaluations with a physician and a psychologist. Following the evaluations, the providers conferred as a team and then signed back on to deliver feedback to the families. We followed up by sending written educational materials and a summary of our discussion. This virtual model has been working quite well and both providers and patients report satisfaction with it. Moreover, we were able to adapt this model quite quickly and have maintained our patient volume at the same level as it was prior to the pandemic when all services were in person. In fact, we have experienced a lower rate of cancelled visits as some of our patients and families experience fewer barriers to telehealth sessions.
While telehealth offers increased access to care with decreased potential virus exposure, it has not been without its challenges for mental healthcare. Psychologists providing telehealth have had to grapple with new safety and confidentiality concerns. The location of the patients and their parents is important in the case emergency services are needed during the evaluation, so this must be confirmed at the outset of the session. Confidentiality also needed to be taken into account. When in person, providers can ensure that the physical space is private; however, when patients are at home the environment is less controlled and family members may be listening in. Additionally, it is important that telehealth platforms themselves meet confidentiality standards. There are also challenges to developing effective rapport and assuring that patients are appropriately engaged in the encounter.
Intensive Interdisciplinary Pain Treatment (IIPT) Day Program
At the PPRC, patients enrolled in the program at the time of the shutdown were transitioned to virtual care. Psychologists worked together with their colleagues to develop detailed daily schedules for each patient. They provided resources and materials typically utilized in individual and group treatment and provided guidance as to how patients could navigate this unexpected change. As much as possible, psychologists worked to maintain the collaborative nature of the program by providing coordinated care with other PPRC providers. Different from the typical in-person meetings and constant collaboration afforded providers within the same space at the PPRC, collaboration mostly occurred on a consultative basis, due to restrictions on virtual physical and occupational therapy treatment. With the phased re-opening plan currently underway in our state, the PPRC now offers a hybrid model of care where patients receive some in-person therapies and some virtual therapies to reduce the length of time on site, with the cohort of patients split into a group who come into the program in the morning and another group who present in the afternoon.
Outreach and Brief Intervention
The Comfort Ability Program (CAP) offers introductory cognitive behavioral therapy skills and strategies for adolescents with chronic pain and their parents. This program, typically offered in a comprehensive day long group-based workshop, was developed at Boston Children’s Hospital and has been disseminated and implemented in many hospitals internationally. In the context of the COVID-19 pandemic, this group workshop was redesigned for a virtual platform. Currently, the virtual intervention is running at three children's hospitals and will soon be disseminated further to ensure that partner sites can continue to provide ongoing support to their patients. Structured evaluation of this virtual intervention is underway. In addition to the virtual workshop, CAP currently provides freely accessible support to families through regular online health chats about coping with chronic pain for teens and parents, online resources such as educational videos and guided relaxation exercises, and webinars for parents.
One of the major challenges we have faced in caring for our patients at this difficult time is the issues of professional licensure when dealing with patients who reside in other states. Our program has a national referral base, so patients seek care from all over the US. and abroad. Fortunately, many states enacted emergency legislation that allowed for either a waiver of licensure or the issuance of a temporary license to practice in that state. With our large faculty group, we were able to “divide and conquer,” so different psychologists applied for emergency licensure in different states so that we were able to serve as many families as possible. Now that states are lifting emergency restrictions, we are finding this to be more difficult, as the process of obtaining full psychology licensure in another state is time consuming and expensive. Advocacy efforts are underway to try to shift the model of care so that we can ethically and legally serve patients seeking our services from other parts of the country.
Offering Resources and Connection
During the pandemic and the reduction of services such as elective surgeries at our hospital, our Pain Division nurses, often our frontline responders to families, noted increased distress expressed by many of our patients and families. Our psychology postdoctoral fellows created and compiled resource guides to provide support and structure for patients with increased stressors and challenges. Resource guides provided comprehensive suggestions for patients to maintain routines, stay physically engaged and active, practice psychological strategies, and continue academic engagement. These guides were provided to patients to give support while coping with the many stresses and uncertainties of the quarantine and shutdown.
Though the transition has largely been successful, there have been challenges that highlight the value of in-person treatment when possible. Patients’ lack of access to physical therapy providers in the outpatient clinic and limited real-time collaboration of physical and occupational therapy providers in the IIPT setting, continue to pose challenges for treatment. Another factor to consider specifically for the IIPT setting is the change in treatment expectations, acknowledging that patients who require intensive treatment would likely benefit most from the consistency and structure of being engaged with providers in a therapeutic treatment space rather than via video conference.
It is yet unknown the degree to which these adaptations will change treatment outcome or patient experience. While some patients and session content transition well to telehealth, others are more challenging. Younger patients who are more easily engaged in person with physical interaction, require additional care and adaptations. Those with externalizing behaviors (e.g. aggression, hyperactivity) may pose challenges to the telehealth model. Aspects of rapport building can be more challenging with some patients and parts of the interpersonal relationship may develop differently online.
Despite these challenges, virtual platforms have provided the ability to offer much needed treatment for patients across the spectrum of needs. With the foundation laid for effective virtual pain treatment, it will be interesting to see how the field moves forward, and whether these newfound structures meet the needs of patients and treating clinicians alike.
