Therapy by Video: What Works in Telehealth?

The COVID-19 pandemic has changed the way we live, including how mental health providers serve their clients. Providers have overwhelmingly shifted to providing services by video, an option that allows clients to receive services while following social distancing recommendations. According to a recent survey by the Minnesota Department of Health, the percentage of psychologists who provide some form of telehealth services increased from 17% in 2019 to 80% in the summer of 2020.

In addition to ensuring access to care during the pandemic, telehealth can reduce distance and transportation barriers and increase access to specialty care providers or culturally responsive services in areas where providers are limited. Extensive research has also demonstrated telehealth’s effectiveness to treat a wide range of concerns for a variety of different cultural and demographic groups.

However, telehealth poses unique challenges, and providers generally don’t receive training specific to telehealth. Fortunately, research suggests there are several strategies providers can use to ensure they meet the needs of the clients they serve.

Consider the needs of every client.

Mental health providers regularly individualize their approach depending on client needs, and this should extend to the unique context of telehealth. When determining whether a client is a good fit for telehealth and how to best meet their needs, providers should consider:

• Internet and device access - does the client have consistent access to a reliable device and an adequate internet connection?
• Technological literacy - does the client have the ability to operate telehealth software independently? Alternatively, does the client have access to adaptive equipment and/or a support person who can provide consistent assistance if needed?
• Age, developmental stage, and cognitive ability - is the client’s developmental stage and cognitive ability appropriate for telehealth?
• Privacy - does the client have access to a completely private space in which to receive services?
• Preference - does the client have a strong aversion to telehealth, and will it impact their engagement in services?

Additional considerations could include communication skills and client safety. For some clients, telehealth may be impractical, or even inadvisable. In these instances, providers may need to adapt their approach, such as offering telephone services to clients without internet access, or find a way for the client to receive services in-person.

Adjust strategies to develop the therapeutic relationship.

The therapeutic relationship is crucial to positive treatment outcomes. Although research indicates the therapeutic relationship is not negatively affected by the use of telehealth, other challenges include a reduced sense of connection or engagement and difficulty reading non-verbal cues. To address these challenges, providers can:

• Convey connection and attentiveness. Signal delays and other technological issues may complicate communication and the interpretation of cues. Providers should maximize eye contact, minimize distractions, and confirm their observations of client affect and behavior more frequently.
• Personalize the format to ensure each client feels comfortable. For some clients, providers may want to reduce session lengths; allow clients to turn off their camera or the picture-in-picture function; and allow clients to draw, color, or play with a minimally distracting toy during the session.
• Adapt to cultural differences. Communication styles, the use of technology, and concerns regarding mental health services vary across cultural communities, and providers should tailor services accordingly.

Anticipate technological challenges.

Technological issues are inevitable, and providers can use several strategies to address them:

• Develop a plan for addressing disruptions. Providers should determine and communicate the process for responding to technological problems before they occur. For example, the plan may involve finishing the session by phone if an internet connection is disrupted.
• Acknowledge technological issues. Providers should acknowledge technological disruptions as they occur and use these instances to demonstrate patience and humor, strategies that can help develop the therapeutic relationship and prevent miscommunications.

What’s next for therapy by video?

Although much of telehealth's recent popularity is due to the pandemic, evidence suggests it may be here to stay: according to a recent survey of Minnesota mental health providers, about three-quarters reported they would continue providing at least some care via telehealth after the pandemic ends.

Unfortunately, there are still barriers to the adoption and expansion of telehealth. Many telehealth coverage policies implemented in response to the pandemic are temporary, and some health insurers are already reverting to previous levels of coverage. Moreover, there are significant disparities in digital literacy and internet and device access that prevent many clients from using telehealth.

Providers should hone their telehealth skills, but policy and equity issues also need to be addressed before telehealth can achieve its potential of ensuring access to mental health care for all.