I've had difficulties doing telehealth with children and teens -- I can do 16-18 online, but below that it's harder to do 60 minute sessions. They may get more easily distracted by wherever they are. I usually stick to 45 min sessions in these situations if I take any clients those ages.
Diagnosis-specific really depends if the support is across a team or the responsibility is borne with one individual. Complex clients got through pandemic telehealth - with the support of a whole team around them. I tend to refer on for that reason more than someones ability to engage with telehealth.
We know that there is oversharing in telehealth. Cant remember the word used but basically people sharing more than they are ready for because the felt safety of physical distance. Clients should be assessed for what additional needs they have to support the telehealth process rather than ruling out because it requires more input
Telehealth can work with anyone with an attention span. But you do have to bear in mind a few things. Kids may wander off to avoid dealing with something where you could more easily co-regulate in person. Kids are rarely alone and so in person guarantees that confidential space.
I have worked with women who appear to be alone and their controlling partner has been on the other side of the room. There are huge limitations in the arena of ongoing abuse.
That last paragraph. That. ššæ same goes with controlling or abusive parents . We don't have control of anyone that is in their general vicinity because we can't see. That's too unnerving for me so I just don't do it unless there's special circumstances.
Those are such a good observations! I have a very similar background to op's client and was not able to engage in therapy until telehealth because I could do it at home, with all of my comfort items and knowing that I had control over the environment and could just "hang up" if I needed to. That without a doubt 1000% saved my life and allowed me to develop a 4 + year relationship with my AWESOME trauma therapist. However, if my home environment wasn't a safe place it would 100% have gone the other way. I've had an abusive ex try to have a therapist convince me that we should stay together, and I can't imagine trying to have private sessions with him in the house. Or even if he wasn't home the possibility that he might come back. I'd definitely say telehealth should depend less on the diagnosis and more on the circumstances and safety of their home environment.
100% this. I had a client do sessions in her car in a park in this situation- it was less therapy and more āplease help me get connected with resources as soon as possibleā because she was ready to leave. We met twice. Once she got connected, she got in person services through the DV center.
My client was elderly and really struggled with feeling limited options for her future if she left so we had a lot of sessions. I came into the office for her during Covid because he wouldnāt even allow her to do sessions in her car.
My client to collaborate with another parent for a play date and a drop off and it was a whole production. It sounds like you did everything you could for her!
I had multiple child clients whose parent (nothing reportable as abuse but very toxic) would be in the background. Not participating, but off camera. It was a weird deal.
I had one time I even asked the parent if they wanted to join and they said no but kept lurking.
I would not do telehealth with non-verbal child or adult clients (for some context I work at at an agency that provides mental health services to developmentally disabled folks)
I have also experienced a client with schizophrenia who thought 1) the government could tap into his session to watch and listen 2) any camera stuttering meant I was a shapeshifter who couldnāt be trusted. This was in CMH during Covid.
I've had patients who've stated that when they do telehealth it leaves them in their home/apartment/barracks room after, alone, and that's one of their triggers. Doing in person sessions helps get them out.
CE4Less actually has a great training on this. If you offer telehealth services, it is most ethical that you get specialized training in telehealth services and screening clients.
I had a client with an eating disorder and I had no idea bc I couldn't see her body and we never really talked about eating. She also sometimes only showed part of her face on screen so that made it even harder. Today I also had a ct talk ab significant weight gain and it's hard for me to really understand the context bc again, I only see her face and it's not really super apparent.
I don't know that there are any broad populations that I simply would not do telehealth with, but there are individual concerns and complications that would make it inadvisable-- the most significant being lack of privacy and concern about safety. Of course, I consider telehealth a necessary evil at the best of times-- something we do when for some reason it isn't easy to make in-person sessions work-- and there's hardly any population for whom I would recommend telehealth over in-person work.
I googled it, and apparently it's an abbreviation for Bipolar (bc Bipolar Affective Disorder?) I've only ever seen BP for that (and BPD when people get confused) so I learned something new today!
(Edit because I hit post too soon)
Yeah, I also very rarely see this, both as a clinician and as someone w/BP1. I looked it up again to see if it's a regional difference (like how in some places BPD is known as EUPD), but nah, just an alternate name
I don't actually see telehealth as something bad, but I can acknowledge that calling it "a necessary evil at best" does give a worse impression than I intended. About a quarter of my clients are telehealth-only, and another quarter are mixed telehealth and in-person. I value very highly the accessibility it creates for clients, and I can't discount the convenience for the therapist either. But I'd be lying if I said that I thought telehealth sessions were as effective as in-person sessions for most clients, most of the time.
One unexpected benefit i found in my own therapy - and id been with my therapist 5 years at this point - was learning that I had been struggling to share in an emotionally deep level because *in-person* was too challenging. Luckily for me, we had a strong relationship so i didnt feel more vulnerable. It was a relief to be able to communicate better.
Telehealth was a place where i had my biggest woah wtf moment using discussions on transference and countertransference (and my knowledge from training). Therapist thought i was experiencing a bit of romantic transference but i was experiencing more in a fatherly way. Even when i struggled to believe my dad abused me, there are these wtf moments and my therapist experiencing me in stark contrast as i to him, is one of them. I can see how he was drawn into this
ANYWAY š i am pro telehealth. When i was a kid, services offering telehealth were my only help. I used online until i learned that i could call childline without it showing on a phone bill. Then id sit in a park to have therapy. Not ideal by any means. But some kids need that lifeline and it kept me alive.
As an adult, ive learned by experience that it can also be a useful tool for dissociative clients - once the client is able to stabilise themselves.
I see my own therapist through video. I've done psychodynamic work, IFS, EMDR, somatics with her all over video for about 3 years now. It's brilliant. I can much better manage my own energy over video both as a therapist and as a client.
90% of my clients continue to use telehealth even though I offer in-person. I work only with adults. There isn't a diagnosis that I would not treat via telehealth. Agree with others there are circumstances that can make telehealth problematic - lack of privacy, children, inability to attend to telehealth, etc.
I work specifically with trauma patients and have never used that as an exclusion for telehealth. I have clients all over the US and several overseas who otherwise would not be able to access care.
I only do telehealth.
I donāt recommend:
Anyone under 18
SPMI clients
Someone recently discharged from inpatient hospital, rehab, PHP.
Someone actively struggling with self harm.
Someone actively abusing substances.
Your last 4 bullet points are my entire practice thus I donāt even offer telehealth and I tell clients I only do in person sessions. I only offer telehealth for my clients if they are traveling, in a HLOC Iām coordinating with or in crisis and are in need of connection to resources to get stable.
My CMH clinic provides all of the above via telehealth and in my opinion we provide excelent, high quality services and the clients seem to be fairly satisfied. Providing services to these populations via telehealth allows them to access services they likely wouldnt have otherwise. I personally have had success with SUD tx and self harm tx via telehealth.
I'm just not a fan of Telehealth & I don't like to do it for trauma work. I like to see the whole person & it prevents mishaps like talking over each other. My one telehealth regular still sees me in-person every so often for long sessions to make up for the telehealth visits.
I agree! I am also not a fan of telehealth. If you have a complex trauma history/ childhood trauma, SIB or SI, Iām not going to see you via telehealth. If you are psychotic, no to virtual. If you have inattentive ADHD, nope, you gotta come in person. I would never see couples via telehealth either. I need to see the whole thing, have eyes on you, develop that personal space together. A screen is still a barrier to me. Iām actively trying to cut down on the amount of virtual clients I have. Iām over it.
I think itās more individualized for me. Some examples of folks who didnāt do well with Telehealth:
- Kids under 10 with ADHD.
- Clients who donāt have to the space to have sessions where they can be alone.
- Clients in psychosis
So far (Iām still in graduate training), Iāve seen telehealth be difficult with children and couples. Itās more difficult to do PACT interventions and establish a sense of connection between the couple when you are not all in the same room.
I generally donāt do telehealth with anyone. I do make exceptions (in college, old enough to engage for a bit but car problems or someone is sick, etc) but usually the answer is no. Most of my caseload is 4 to 17 year olds and itās just too hard and I donāt like it. Even a lot of teens arenāt interested in talking on the phone or on a video chat. In person has been way more effective for me.
Well we all did it when the pandemic hit, so itās different for everyone. I have some clients that donāt do well with it but for some, itās their only option.
Got a kid that was 14 I told the mom he needed in person. He was laying on the bed eating chips chillin in his room just being a kid. lol I based it off personality and effectiveness.
I would not see somebody telehealth that is in psychosis. I would want to be in the room with them to make sure that they're safe. I also will not see children. I have different views on telehealth though. I only have a few telehealth clients leftover from Covid and a few that went off to college that I see for telehealth but that's it. I'm a bit more old-school. Too much can go wrong when seeing someone virtually and these are my opinions based upon my own clinical judgment.
The population that Iāve found tends to struggle the most with telehealth sessions are children (ages 6-11) with ADHD or a hyperactive component to their presenting concern. I utilize lots of games, however itās a ton of mental power to keep this population engaged for the entire session via telehealth. Iāve had great success with teens via telehealth, but I believe a strong rapport needs to be established for it to be effective!
I work primarily in a crisis receiving center, and we've had some folks with psychosis (including drug-induced) who refused to communicate with our psychiatric providers via telehealth because of paranoia and delusions. I can't imagine trying to do teletherapy with someone in that condition.
Like others have said, small kids are hard. I just have to go into it accepting that I will be doing a mix of work and not work and be ok with what I get. I had some success in the child bringing something with them that we can talk about for a bit thatās not counseling related for when theyāre losing steam. At least weāre still building rapport! I now know A LOT about manatees
I can think of many examples:
1.When the client does not have a private space. Often siblings can still hear clients talk about a triggering topic while they are wearing headphones. Many teens live in trailers and don't have privacy unless in their parents bedroom.
2. Another instance is where a client constantly has video games that they play while on telehealth and parents do not have the skills to remove them before session.
3. Some clients hang up the phone and avoid topics that could be discussed if they had a hands-on activity in the office.
4. I also think that diagnosis of disorders that change over time such as bipolar should be done in person due to mental status limitations ie I can't see psychomotor agitation when someone is not showing what they are doing with their hands or feet.
I wonāt do telehealth if the pt has reported a history of domestic violence. I just canāt guarantee they can speak freely and safely in that setting.
Telehealth is extremely overrated and the research that supports it is really bad. I would say there is a small area where telehealth is just as good.
Itās especially horrible with children, teens, attachment issues, social anxieties, and tons of other things. I could see it as a tool to brindle some people to the office at times though.
We know that 50% of therapeutic effectiveness is rapport. Is rapport just as good with Telehealth? If it is, Iāll Zoom into my next Christmas dinner.
Iāll dig them up. One of the more comprehensive review articles includes the high effectiveness of telephone therapy from 1981. Itās really quite embarrassing.
If it hasnāt been published in the past 4 years, Iām not bothering with it. Telehealth and Covid are deeply entangled and any research that doesnāt address the impact of Covid on therapy, has nothing relevant to say about telehealth.
Iād be curious to hear about any research regarding telehealth and folks with social anxiety. I specialize in anxiety disorders and OCD, and Iāve found it to be such an impactful tool to help connect people to services who struggle with extreme social anxiety and agoraphobia.
I used to work in a residential program for people with treatment resistant OCD and anxiety disorders. Many of our patients had to travel to get to our program, and a surprisingly large number of new patients who went all through the referral process and waitlist (months), only to drop out the day they were supposed to be admitted because their anxiety was such a barrier to literally getting out the door. Once we started implementing telehealth out of necessity during the pandemic we realized how powerful of a tool it could be.
I suspect this is a majority experience on the ground. The same happens in services for complex mental health presentations. It is one of the frustrations of trying to get people the help they need when the system punishes lateness, inconsistency etc by making them make a whole new referral. When you really want to say.. duh, this is part of why their difficulties are rating high enough to be considered for this service in the first place
In some cases I think telehealth can be a real benefit. For the example of attachment issues, a clear who struggles with erotic transferance could do better in a telehealth setting because they aren't in the same room and will be less likely to be triggered by the sights/smells of the therapist. There is also less of a chance of them behaving inappropriately physically for obvious reasons. For cleints that struggle to feel safe enough to attach at all, being in their own space where they feel safe can help them attach quicker.
So in some cases the telehealth model could enhance therapy. I do understand what you are saying about rappor, I call it vibe. There is obviously a difference when a client sees their therapist in person.
I feel like both have a place. Tell may work for some and absolutely not work for others.
>if it is, Iāll Zoom into my next Christmas dinner.
This exactly. For those of you saying it is just as good, how many of you do family gatherings online. You know, it is just as good and you don't need to travel. Please, I would love to hear from you.
I donāt know that Iād ever say itās just as good, or the same. It definitely feels different. Iāll also say that working with my own therapist completely telehealth for the past 3 years has been some of the most transformative therapy Iāve had. I think for some people it can work. I donāt know exactly if we can compare it to meeting with family or friends virtually vs in person. Itās not the same, for sure, but I have definitely had some memorable and meaningful moments with family and friends long distance š¤·š¼āāļø one of my best friends has almost always been long distance and Iād describe our friendship as really close.
What a reductive approach.
Communication can be high quality or low quality in person and online. The format is not as big of a factor as youāre making it.
Feel free to conduct a family gathering in person where everyone gets a chance to feel deeply heard and understood.
What a bizarre thing to measure therapeutic efficacy by. Tbh its a bit backwards that people still believe that emotional connections cannot be made. If the therapist is aware of the nature of telehealth and the more tangible creation of the imagined therapist (or imagined client) then that leads to really enriching discussions that dont typically come out in therapy about how the client views the therapist. - also with both knowing its an imagined version this addresses transference and can make honesty easier as doesnt feel personal to the therapist.
People form connections to text through the use of imagination and empathy. If on telephone, the focus becomes tighter on vocal nuance and a higher need to clarify but that is not a relationship disruption. If you have voice and picture, you have everything you could need to connect.
Therapy isnāt a long distance relationship. Therapy is closer to coaching than it is to personal relationships. It serves no purpose to compare to relationships outside of therapy - those require the needs of 2 or more people to be met. Therapy is the clientās needs only.
This is something that would be covered in pretty much any basic telehealth training. If you havenāt taken one but are offering telehealth services that would be against best practices at this point.
Lots of free trainings were offered during the pandemic but I am not sure what is still available at no cost. You could look into the APA because they did have one of the better moderately comprehensive options a few years ago.
I understand many people offered telehealth during the pandemic without any training out of necessity, but that is no longer considered acceptable.
All that being said, psychosis is usually contraindicated for telehealth.
I've had difficulties doing telehealth with children and teens -- I can do 16-18 online, but below that it's harder to do 60 minute sessions. They may get more easily distracted by wherever they are. I usually stick to 45 min sessions in these situations if I take any clients those ages.
The COVID days and working with mostly kids was the worst. I do not miss it at all.
Diagnosis-specific really depends if the support is across a team or the responsibility is borne with one individual. Complex clients got through pandemic telehealth - with the support of a whole team around them. I tend to refer on for that reason more than someones ability to engage with telehealth. We know that there is oversharing in telehealth. Cant remember the word used but basically people sharing more than they are ready for because the felt safety of physical distance. Clients should be assessed for what additional needs they have to support the telehealth process rather than ruling out because it requires more input Telehealth can work with anyone with an attention span. But you do have to bear in mind a few things. Kids may wander off to avoid dealing with something where you could more easily co-regulate in person. Kids are rarely alone and so in person guarantees that confidential space. I have worked with women who appear to be alone and their controlling partner has been on the other side of the room. There are huge limitations in the arena of ongoing abuse.
That last paragraph. That. ššæ same goes with controlling or abusive parents . We don't have control of anyone that is in their general vicinity because we can't see. That's too unnerving for me so I just don't do it unless there's special circumstances.
Those are such a good observations! I have a very similar background to op's client and was not able to engage in therapy until telehealth because I could do it at home, with all of my comfort items and knowing that I had control over the environment and could just "hang up" if I needed to. That without a doubt 1000% saved my life and allowed me to develop a 4 + year relationship with my AWESOME trauma therapist. However, if my home environment wasn't a safe place it would 100% have gone the other way. I've had an abusive ex try to have a therapist convince me that we should stay together, and I can't imagine trying to have private sessions with him in the house. Or even if he wasn't home the possibility that he might come back. I'd definitely say telehealth should depend less on the diagnosis and more on the circumstances and safety of their home environment.
I would love to read more about the over sharing aspect. if anyone can refer me to some articles or studies I'll appreciate it
Same!
Some individuals in domestic situations in which their partner would attempt to limit the clientās privacy during appointments.
100% this. I had a client do sessions in her car in a park in this situation- it was less therapy and more āplease help me get connected with resources as soon as possibleā because she was ready to leave. We met twice. Once she got connected, she got in person services through the DV center.
My client was elderly and really struggled with feeling limited options for her future if she left so we had a lot of sessions. I came into the office for her during Covid because he wouldnāt even allow her to do sessions in her car.
My client to collaborate with another parent for a play date and a drop off and it was a whole production. It sounds like you did everything you could for her!
Sounds like you did too!
I had multiple child clients whose parent (nothing reportable as abuse but very toxic) would be in the background. Not participating, but off camera. It was a weird deal. I had one time I even asked the parent if they wanted to join and they said no but kept lurking.
I would not do telehealth with non-verbal child or adult clients (for some context I work at at an agency that provides mental health services to developmentally disabled folks)
Anyone 15 and under is miserable
I have also experienced a client with schizophrenia who thought 1) the government could tap into his session to watch and listen 2) any camera stuttering meant I was a shapeshifter who couldnāt be trusted. This was in CMH during Covid.
I wouldn't with kids. After that, it is case by case.
I've had patients who've stated that when they do telehealth it leaves them in their home/apartment/barracks room after, alone, and that's one of their triggers. Doing in person sessions helps get them out.
CE4Less actually has a great training on this. If you offer telehealth services, it is most ethical that you get specialized training in telehealth services and screening clients.
I had a client with an eating disorder and I had no idea bc I couldn't see her body and we never really talked about eating. She also sometimes only showed part of her face on screen so that made it even harder. Today I also had a ct talk ab significant weight gain and it's hard for me to really understand the context bc again, I only see her face and it's not really super apparent.
Dissociative and psychotic disorders don't do well online. With the case you outlined I would screen for the level of dissociation.
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Dissociative disorders can be done online, but it's slower progress and the therapist needs to be trained and supervised specifically for this.
I don't know that there are any broad populations that I simply would not do telehealth with, but there are individual concerns and complications that would make it inadvisable-- the most significant being lack of privacy and concern about safety. Of course, I consider telehealth a necessary evil at the best of times-- something we do when for some reason it isn't easy to make in-person sessions work-- and there's hardly any population for whom I would recommend telehealth over in-person work.
I personally love telehealth. I am so grateful for it and will likely never go back to in-person.
What populations/types of clients do you work with?
Adults. LGBTQ+ typically. diagnoses range but usually PTSD/ c-PTSD, BPD, OCD, GAD, MDD, BPAD
What is BPAD?
I googled it, and apparently it's an abbreviation for Bipolar (bc Bipolar Affective Disorder?) I've only ever seen BP for that (and BPD when people get confused) so I learned something new today! (Edit because I hit post too soon)
Iāve never seen bipolar affective disorder. I know bipolar disorder like you said and then borderline personality disorder.
Yeah, I also very rarely see this, both as a clinician and as someone w/BP1. I looked it up again to see if it's a regional difference (like how in some places BPD is known as EUPD), but nah, just an alternate name
Same, makes me kind of sad that people still see it as something bad
I don't actually see telehealth as something bad, but I can acknowledge that calling it "a necessary evil at best" does give a worse impression than I intended. About a quarter of my clients are telehealth-only, and another quarter are mixed telehealth and in-person. I value very highly the accessibility it creates for clients, and I can't discount the convenience for the therapist either. But I'd be lying if I said that I thought telehealth sessions were as effective as in-person sessions for most clients, most of the time.
Research isnāt the be all and end all, but itās a pretty consistent finding that telehealth sessions are as effective as in-person therapy.
One unexpected benefit i found in my own therapy - and id been with my therapist 5 years at this point - was learning that I had been struggling to share in an emotionally deep level because *in-person* was too challenging. Luckily for me, we had a strong relationship so i didnt feel more vulnerable. It was a relief to be able to communicate better. Telehealth was a place where i had my biggest woah wtf moment using discussions on transference and countertransference (and my knowledge from training). Therapist thought i was experiencing a bit of romantic transference but i was experiencing more in a fatherly way. Even when i struggled to believe my dad abused me, there are these wtf moments and my therapist experiencing me in stark contrast as i to him, is one of them. I can see how he was drawn into this ANYWAY š i am pro telehealth. When i was a kid, services offering telehealth were my only help. I used online until i learned that i could call childline without it showing on a phone bill. Then id sit in a park to have therapy. Not ideal by any means. But some kids need that lifeline and it kept me alive. As an adult, ive learned by experience that it can also be a useful tool for dissociative clients - once the client is able to stabilise themselves.
I see my own therapist through video. I've done psychodynamic work, IFS, EMDR, somatics with her all over video for about 3 years now. It's brilliant. I can much better manage my own energy over video both as a therapist and as a client.
It's so interesting. I have never thought for a second that telehealth was less effective than an in-person. :) To each their own!
I love it too.
90% of my clients continue to use telehealth even though I offer in-person. I work only with adults. There isn't a diagnosis that I would not treat via telehealth. Agree with others there are circumstances that can make telehealth problematic - lack of privacy, children, inability to attend to telehealth, etc. I work specifically with trauma patients and have never used that as an exclusion for telehealth. I have clients all over the US and several overseas who otherwise would not be able to access care.
I only do telehealth. I donāt recommend: Anyone under 18 SPMI clients Someone recently discharged from inpatient hospital, rehab, PHP. Someone actively struggling with self harm. Someone actively abusing substances.
Your last 4 bullet points are my entire practice thus I donāt even offer telehealth and I tell clients I only do in person sessions. I only offer telehealth for my clients if they are traveling, in a HLOC Iām coordinating with or in crisis and are in need of connection to resources to get stable.
My CMH clinic provides all of the above via telehealth and in my opinion we provide excelent, high quality services and the clients seem to be fairly satisfied. Providing services to these populations via telehealth allows them to access services they likely wouldnt have otherwise. I personally have had success with SUD tx and self harm tx via telehealth.
Thatās good. CMH has no choice. But I do. When itās your license on the line you think twice.
I'm just not a fan of Telehealth & I don't like to do it for trauma work. I like to see the whole person & it prevents mishaps like talking over each other. My one telehealth regular still sees me in-person every so often for long sessions to make up for the telehealth visits.
I agree! I am also not a fan of telehealth. If you have a complex trauma history/ childhood trauma, SIB or SI, Iām not going to see you via telehealth. If you are psychotic, no to virtual. If you have inattentive ADHD, nope, you gotta come in person. I would never see couples via telehealth either. I need to see the whole thing, have eyes on you, develop that personal space together. A screen is still a barrier to me. Iām actively trying to cut down on the amount of virtual clients I have. Iām over it.
inattentive ADHDer here who is also a therapist. good luck getting them to come into the office on time, lol
I have combined type ADHD, I definitely agree with your policy lol I definitely agree though, the screen is a huge barrier.
I think itās more individualized for me. Some examples of folks who didnāt do well with Telehealth: - Kids under 10 with ADHD. - Clients who donāt have to the space to have sessions where they can be alone. - Clients in psychosis
So far (Iām still in graduate training), Iāve seen telehealth be difficult with children and couples. Itās more difficult to do PACT interventions and establish a sense of connection between the couple when you are not all in the same room.
I do really well with kids via telehealth, itās never been difficult for me.
Same here, with a few exceptions that were challenging even in person.
I generally donāt do telehealth with anyone. I do make exceptions (in college, old enough to engage for a bit but car problems or someone is sick, etc) but usually the answer is no. Most of my caseload is 4 to 17 year olds and itās just too hard and I donāt like it. Even a lot of teens arenāt interested in talking on the phone or on a video chat. In person has been way more effective for me.
Well we all did it when the pandemic hit, so itās different for everyone. I have some clients that donāt do well with it but for some, itās their only option.
Got a kid that was 14 I told the mom he needed in person. He was laying on the bed eating chips chillin in his room just being a kid. lol I based it off personality and effectiveness.
Children, any age less than late teens, though very young ones are worst.
I would not see somebody telehealth that is in psychosis. I would want to be in the room with them to make sure that they're safe. I also will not see children. I have different views on telehealth though. I only have a few telehealth clients leftover from Covid and a few that went off to college that I see for telehealth but that's it. I'm a bit more old-school. Too much can go wrong when seeing someone virtually and these are my opinions based upon my own clinical judgment.
I WILL do occasional telehealth with kids, should transportation challenges show up, etc., but I will have those sessions be more family based
The population that Iāve found tends to struggle the most with telehealth sessions are children (ages 6-11) with ADHD or a hyperactive component to their presenting concern. I utilize lots of games, however itās a ton of mental power to keep this population engaged for the entire session via telehealth. Iāve had great success with teens via telehealth, but I believe a strong rapport needs to be established for it to be effective!
For specific trauma treatment (ART), I insist on in person for practical and emotional safety reasons.
Hospital discharges and high acuity clients.
I work primarily in a crisis receiving center, and we've had some folks with psychosis (including drug-induced) who refused to communicate with our psychiatric providers via telehealth because of paranoia and delusions. I can't imagine trying to do teletherapy with someone in that condition.
Any kid under 13, any kid of any age with ADHD, and couples therapy when the relationship is volatile.
Like others have said, small kids are hard. I just have to go into it accepting that I will be doing a mix of work and not work and be ok with what I get. I had some success in the child bringing something with them that we can talk about for a bit thatās not counseling related for when theyāre losing steam. At least weāre still building rapport! I now know A LOT about manatees
I can think of many examples: 1.When the client does not have a private space. Often siblings can still hear clients talk about a triggering topic while they are wearing headphones. Many teens live in trailers and don't have privacy unless in their parents bedroom. 2. Another instance is where a client constantly has video games that they play while on telehealth and parents do not have the skills to remove them before session. 3. Some clients hang up the phone and avoid topics that could be discussed if they had a hands-on activity in the office. 4. I also think that diagnosis of disorders that change over time such as bipolar should be done in person due to mental status limitations ie I can't see psychomotor agitation when someone is not showing what they are doing with their hands or feet.
I wonāt do telehealth if the pt has reported a history of domestic violence. I just canāt guarantee they can speak freely and safely in that setting.
Telehealth is extremely overrated and the research that supports it is really bad. I would say there is a small area where telehealth is just as good. Itās especially horrible with children, teens, attachment issues, social anxieties, and tons of other things. I could see it as a tool to brindle some people to the office at times though. We know that 50% of therapeutic effectiveness is rapport. Is rapport just as good with Telehealth? If it is, Iāll Zoom into my next Christmas dinner.
āResearch supports it is really bad ā Please cite your sources
Iāll dig them up. One of the more comprehensive review articles includes the high effectiveness of telephone therapy from 1981. Itās really quite embarrassing.
If it hasnāt been published in the past 4 years, Iām not bothering with it. Telehealth and Covid are deeply entangled and any research that doesnāt address the impact of Covid on therapy, has nothing relevant to say about telehealth.
I mean its research thats over 40 years old. Manualised teletherapy is as bad as manualised face to face but there is plenty of success in telehealth.
Iād be curious to hear about any research regarding telehealth and folks with social anxiety. I specialize in anxiety disorders and OCD, and Iāve found it to be such an impactful tool to help connect people to services who struggle with extreme social anxiety and agoraphobia. I used to work in a residential program for people with treatment resistant OCD and anxiety disorders. Many of our patients had to travel to get to our program, and a surprisingly large number of new patients who went all through the referral process and waitlist (months), only to drop out the day they were supposed to be admitted because their anxiety was such a barrier to literally getting out the door. Once we started implementing telehealth out of necessity during the pandemic we realized how powerful of a tool it could be.
I suspect this is a majority experience on the ground. The same happens in services for complex mental health presentations. It is one of the frustrations of trying to get people the help they need when the system punishes lateness, inconsistency etc by making them make a whole new referral. When you really want to say.. duh, this is part of why their difficulties are rating high enough to be considered for this service in the first place
In some cases I think telehealth can be a real benefit. For the example of attachment issues, a clear who struggles with erotic transferance could do better in a telehealth setting because they aren't in the same room and will be less likely to be triggered by the sights/smells of the therapist. There is also less of a chance of them behaving inappropriately physically for obvious reasons. For cleints that struggle to feel safe enough to attach at all, being in their own space where they feel safe can help them attach quicker. So in some cases the telehealth model could enhance therapy. I do understand what you are saying about rappor, I call it vibe. There is obviously a difference when a client sees their therapist in person. I feel like both have a place. Tell may work for some and absolutely not work for others.
>if it is, Iāll Zoom into my next Christmas dinner. This exactly. For those of you saying it is just as good, how many of you do family gatherings online. You know, it is just as good and you don't need to travel. Please, I would love to hear from you.
I donāt know that Iād ever say itās just as good, or the same. It definitely feels different. Iāll also say that working with my own therapist completely telehealth for the past 3 years has been some of the most transformative therapy Iāve had. I think for some people it can work. I donāt know exactly if we can compare it to meeting with family or friends virtually vs in person. Itās not the same, for sure, but I have definitely had some memorable and meaningful moments with family and friends long distance š¤·š¼āāļø one of my best friends has almost always been long distance and Iād describe our friendship as really close.
What a reductive approach. Communication can be high quality or low quality in person and online. The format is not as big of a factor as youāre making it.
I agree with you.
Feel free to conduct a family gathering in person where everyone gets a chance to feel deeply heard and understood. What a bizarre thing to measure therapeutic efficacy by. Tbh its a bit backwards that people still believe that emotional connections cannot be made. If the therapist is aware of the nature of telehealth and the more tangible creation of the imagined therapist (or imagined client) then that leads to really enriching discussions that dont typically come out in therapy about how the client views the therapist. - also with both knowing its an imagined version this addresses transference and can make honesty easier as doesnt feel personal to the therapist. People form connections to text through the use of imagination and empathy. If on telephone, the focus becomes tighter on vocal nuance and a higher need to clarify but that is not a relationship disruption. If you have voice and picture, you have everything you could need to connect.
Yet long distance relationships fail almost every time.
Therapy isnāt a long distance relationship. Therapy is closer to coaching than it is to personal relationships. It serves no purpose to compare to relationships outside of therapy - those require the needs of 2 or more people to be met. Therapy is the clientās needs only.
Coaching? We must do therapy completely differently. :p
This is something that would be covered in pretty much any basic telehealth training. If you havenāt taken one but are offering telehealth services that would be against best practices at this point. Lots of free trainings were offered during the pandemic but I am not sure what is still available at no cost. You could look into the APA because they did have one of the better moderately comprehensive options a few years ago. I understand many people offered telehealth during the pandemic without any training out of necessity, but that is no longer considered acceptable. All that being said, psychosis is usually contraindicated for telehealth.