Teletherapy for Kids: How to Work with Young Children during Virtual Behavioral Health Sessions

April 28, 2020 Mark Wilhelm

Working with children in a behavioral health setting can be challenging. Care providers may have difficulty keeping young children focused, communicative and engaged in the session even when they are in the same room together. Telehealth sessions with children make this task even harder, reducing the provider’s control over the situation as well as the immediacy of their presence.

We’ve previously shared some tips and best practices for engaging behavioral health consumers via telecommunication, and many of these suggestions can also apply to children. To recap, consumers should be coached through any aversions they may have to virtual care, encouraged to participate with motivational interviewing and rapport-building, and engaged with visuals and activities whenever possible. However, high-quality engagement throughout the session is especially critical with children, as they could easily lose interest when the provider is just a face on a screen or a voice on the phone.

Fortunately, it’s possible to conduct successful virtual sessions even with young children, and a growing body of research shows that telehealth therapies and behavioral interventions for children can be just as effective as in-person treatment. Care providers need only alter their engagement strategy slightly to keep young children interested and interacting in the session.

Dr. Ashleigh Woods, one of our psychologists here at Cummins Behavioral Health, recently held a training seminar to educate our staff on the best ways to work with children over phone or video chat. Her advice can be broken down into two categories: interventions for overcoming technical issues and limitations, and strategies for keeping children engaged during virtual sessions.

Making the Best of Technical Limitations

Depending on the age and disposition of the child, behavioral health sessions with children can be much more “lively” than those with teens or adults. Young children often like to move around, explore their environment and play with objects in the room, especially if elements of play therapy are being utilized in the session. Although these behaviors aren’t usually problematic during in-person sessions, they can cause some disruption when the provider can only see the child through the camera on their device.

Providers can take the following steps to compensate for these technical limitations:

1. Find the best camera position

If you are communicating via video chat (which is recommended over voice-only calls), you should work with the child at the start of the session to determine the best location for your camera. Ideally, you should be able to see as much of the area where the child may be interacting or playing as possible.

“I’ve found in my own work with kids that having the device on the floor tends to work out well for me, because that way I can see more of the space and what’s happening in it,” Dr. Woods says. However, you should also be prepared for this position to change as the child moves to different parts of the room or moves the device, which leads to our next point.

2. Anticipate and be patient about technical difficulties

Providers can save themselves some angst by accepting that no virtual session with a child will go completely smoothly. “As the clinician, we might feel that every minute of the video chat needs to be productive and goal-oriented, but I think that we need to have patience and know that the child is going to wander out of the frame. That’s just a normal part of working in this kind of virtual space with kids,” Dr. Woods says.

Instead of becoming flustered when this happens, respond with patience. If the child leaves the frame, simply let them know that you can’t see them and ask them to come back. Continue speaking to let the child know you’re still present, and calmly encourage them to move your camera or return to view. If you are direct yet reasonable about what must be done, most children will accommodate your needs so that the session can continue.

3. Ask the child to show and explain what they’re doing

Even when you’ve taken the above precautions, there will likely be times during the session when you cannot fully see what the child is doing. Instead of nitpicking the placement of the camera, it is sometimes easier to have the child bring items to you or verbally explain what they are doing off-frame.

“Any opportunity you have to ask the child to ‘tell me about,’ ‘show me,’ any of those kinds of things, you may have to take,” Dr. Woods explains. “You might need the child to be a little bit more aware of the position of the camera and that they might have to hold something up to show you, and they also might have to be more verbally engaged in describing what they’re doing or describing the item they’re holding.”

Improving Engagement in Virtual Sessions

In addition to overcoming technological limitations, providers must also do their best to keep children engaged throughout virtual sessions. Because the provider and child are no longer in the same room, it may be more difficult to build rapport and hold the child’s attention. Providers will need to change some of the ways they interact with children over video or phone in order to keep them interested and participating during the session.

Providers can use the following strategies to improve telehealth engagement when working with children:

1. For first sessions, try a “scavenger hunt” activity to build rapport

It’s important to establish a sense of trust and rapport in your first session with a consumer (especially with children), but this can be slightly harder to do when meeting virtually. If your first meeting with a child is conducted virtually, consider starting with a “scavenger hunt” activity in which you ask the child to find their favorite toys and tell you something about them.

“This intervention can apply for therapy, and it can also be modified for skills training,” Dr. Woods explains. “It’s a nice rapport-building, ‘getting-to-know-you’ activity. Most kids are going to be pretty excited to show off their space and the things they have at home.”

2. Use more verbal communication and instruction than normal

During in-person sessions with children, a significant amount of interaction may be nonverbal. For example, the provider might engage in an activity with the child or read their body language to assess what they’re thinking and feeling. Since this is often not possible during virtual sessions, you may need to rely on verbal communication more often than you normally would. Ask the child how they’re feeling when you can’t determine their mood, and instruct them to show you how they perform certain activities when you can’t do the activities with them.

“In the virtual space, we don’t have the luxury of being in the room with the child to see how the play is going to unfold, so there has to be a little bit more verbal conversation about it,” Dr. Woods says. “This can really encourage the child to get into the play and show the therapist how to play with the item. And as they show the therapist how they play with the item, the therapist can do all of the things they would normally do in play therapy, such as providing empathic reflections, wondering about thoughts and feelings, and seeing what conceptual themes emerge.”

3. Exaggerate your nonverbal communication and cues

Of course, nonverbal communication still has its place during virtual sessions. Facial expressions can be excellent tools for encouraging children or conveying your emotions to them, and inflection can be utilized to draw their attention to certain words. However, you should exaggerate your nonverbal cues when communicating virtually so they are easier for children to pick up on.

“It’s harder to convey emotions via video, so I encourage anyone to practice with that. Use exaggerated facial expressions like bigger smiles, and exaggerate the affect behind emotion words. I think that’s really helpful for getting kids engaged,” Dr. Woods says.

Although telemental health sessions with young children can be uniquely challenging for care providers, a little preparation can smooth over difficulties and make these sessions just as productive and rewarding as any other. We encourage all behavioral health professionals to use these tips to improve the quality of their virtual care sessions with children!

Looking for more information about mental health issues faced by children and teens? Here are a few more blog posts you might enjoy!

Teletherapy Tips: Best Practices for Engaging Behavioral Health Consumers over Phone and Video

April 21, 2020 Mark Wilhelm

The COVID-19 crisis has led to a paradigm shift in the way behavioral health care is provided. With in-office visits now inadvisable, care providers have begun to adopt telehealth technologies on a scale that’s never before been seen. While this rapid change has allowed mental health professionals to continue serving the needs of their clients, it has also created many questions about the most effective way to provide care from a distance.

Perhaps the biggest challenge of telemental health care is how it alters the dynamic of the consumer-provider relationship. In a virtual session, nonverbal communication is more difficult to utilize and detect, which places a greater emphasis on the words spoken in the session. The environment is also less controlled than in an office setting, which makes it harder for participants to focus and allows more opportunities for distraction. Finally, the balance of power is different in a virtual session, as consumers have more agency to ignore provider recommendations, end the session prematurely or skip it altogether.

These issues can be compounded if care providers are simultaneously struggling to adapt to remote work. Working remotely comes with unique advantages and challenges, and many behavioral health professionals may be unprepared for the realities of working outside the office. In addition to effectively engaging consumers over phone or video chat, providers must also take care to manage their environment and behaviors in order to be successful under these new circumstances.

The good news is that telemental health sessions can be just as effective and achieve the same outcomes and as in-person care when conducted correctly. Kristen Yost, a therapist for Cummins’ Marion County school-based program, has developed her own methods for working around many common telehealth difficulties. We spoke with Kristen to learn what obstacles you should expect during a telehealth session, how to engage consumers under the altered dynamics of virtual care, and what remote work practices will help you excel under the new telehealth paradigm.

Best Practices for Engaging Consumers via Telehealth

As mentioned above, bringing the consumer-provider relationship into the virtual realm changes the nature of this relationship. Consumer engagement is a continual concern even in face-to-face treatment, but a lapse in engagement during virtual treatment can be more damaging and more difficult to recover from. Therefore, providers must take special measures to keep consumers engaged with treatment when sessions are being conducted virtually.

There are several points in the virtual treatment process where consumer engagement can dwindle. First, consumers may be reluctant to engage with virtual services at all, which could be due to anxiety about the telehealth process or the belief that virtual services are not necessary. “If they were engaged in services before, it would first be helpful to identify the underlying reason for this change,” Kristen says. “It may be anxiety about transitioning to teletherapy, a dislike for talking on the phone, or concern that others may overhear conversations. If these are the barriers, then identifying and working through them would be therapeutic. Otherwise, it may be helpful to work with the consumer to revise or identify new goals, as changes in the environment and daily living may have resulted in a change in needs.”

Second, some consumers might engage with treatment during their sessions but become difficult to contact between sessions. If a consumer doesn’t join the session or answer their phone at the scheduled appointment time, simple forgetfulness could be to blame. “I will work with my consumers to set a reminder alarm on their cell phones for our session. It’s helpful to have them set a reminder to go off before the actual time of the session so they are ready at the scheduled time,” Kristen suggests. “I also ask my consumers to answer the phone even if they aren’t able to meet at that time; that way we don’t have a lapse in communication.”

Finally, other consumers may be difficult to engage during their session or express a desire to end the session early. Kristen explains what she does to work with these kinds of consumers during virtual sessions:

“For my consumers who tend to process information internally (as opposed to those who process by talking out loud), there can be a discomfort when too much emphasis is placed on dialogue. For these consumers, I love doing timelines and/or visuals to guide discussion and understand past history. The option for consumers to share photographs or special objects offers additional ways to engage. For my consumers who communicate via resistance, I use motivational interviewing and rapport-building techniques while also setting firm boundaries. Humor and sarcasm, if appropriate, can be helpful to change the mood and tone of the session. If there is insistence on ending the session, I provide the option of taking a five-minute break. Regardless of how much time they give to the session, I make note of the small successes, and I strive to end on a positive note. And for my consumers who struggle to focus, I make these sessions as active and engaging as I can over the phone. For those with video access and their own deck of cards, I may supplement dialogue or skill-building with a card game. It can also be helpful to add some type of physical activity, such as every time the consumer engages in an undesired behavior, they will then implement a physical activity of their choice. This serves the purpose of bringing attention to the thoughts, feelings or behaviors we are trying to change while also enhancing focus and engagement.”

Best Practices for Adapting to Remote Work

Of course, keeping consumers engaged with treatment is harder if you as the provider are also struggling to stay engaged. Remote work is a new arrangement for many behavioral health professionals, and some might be surprised to find that working from home requires a different type of discipline than working in an office environment. Fortunately, providers can take a few simple precautions to improve their focus and productivity when treating consumers virtually.

It can be tempting when working from home to relax your regular morning routine. Waking up late and working in pajamas sounds nice, but departures from your normal work preparations can instead prime you to be unproductive. “Every day feels like the weekend if I don’t create my own structured work routine at home. I’m trying to make it feel as much like a typical workday as I can so that I keep that mindset,” Kristen says. “This helps me maintain consistency with my own behaviors, which also creates a feeling of familiarity for my consumers.“

If possible, it’s also best to work in a different area of the home than where you spend your leisure time. Just as maintaining your normal work routine can help you stay in a working mindset, having separate environments for work and leisure can improve your focus and productivity during working hours. “Setting up an area of my home that I use specifically for work helps me create a conscious separation between work and home. This helps with productivity during the workday and also makes it easier to transition out of ‘work mode’ when my workday is done,” Kristen says.

One more thing to consider is the privacy of your workspace. Anyone else who lives in your home should know when you are working and when it is and isn’t acceptable to disturb you. Setting and adhering to these boundaries is important for the confidentiality of your sessions as well as your productivity, as Kristen explains:

“My family understands the nature of my work, and they are respectful of my need for a confidential space. I make my consumers aware that although I am working from home, their privacy and confidentiality is important to me. I let them know about the measures I have taken in order to provide a secure and safe place to open up, and I ask my consumers to follow suit by finding a space in their homes away from distractions and other people. My hope is for our teletherapy sessions to have the same safe and comfortable atmosphere as when we meet in the office.”

Although teletherapy requires some adjustment on the part of care providers, it is an extremely valuable asset when seeing consumers in person isn’t possible. We encourage behavioral health providers to utilize these tips in their day-to-day work to overcome some of the most common obstacles of telemental health care!

Looking for more tips to help improve your professional skills and behaviors? Take a look at our posts on multitasking and the Imposter Syndrome below!

Observing Alcohol Awareness Month with Cummins’ Erin Flick and Virtual IOT

April 14, 2020 Mark Wilhelm

Have you ever wondered how long it takes to form a new habit? While the process varies from person to person, one influential study found that it takes 66 days on average. However, some participants in the experiment were able to learn a new habit in just 18 days. This research suggests that under the right circumstances, people are capable of making long-lasting changes to their behavior in a relatively short amount of time—for better or worse.

Since 1987, the National Council on Alcoholism and Drug Dependence has designated April as Alcohol Awareness Month. This public health program aims to educate Americans about the dangers of alcohol use and alcohol dependence, and it comes at a crucial time this year. With many people stuck at home on account of the COVID-19 crisis, some are turning to alcohol use to pass the time. A quick search of Google Trends shows that online searches for “drinking games” have been on the rise since March, with “quarantine drinking games” and “virtual drinking games” exploding in popularity.

Although moderate alcohol consumption may be safe for some people, periods of increased use can lead to the development of dependence and other issues. And since people are capable of ingraining new behaviors over the span of just a few weeks, the ongoing lockdown provides ample time for someone’s drinking habits to change. For these reasons, it’s important that we keep track of our alcohol consumption, recognize the signs of problem use, and know where to get help if we need it.

For more information about identifying and treating alcohol use disorder, we spoke with Erin Flick, a Substance Use Disorder Specialist and Team Lead based out of our Greencastle office. In this post, Erin shares some of the most common symptoms of alcohol dependence, and she also explains how Cummins Behavioral Health has begun providing virtual outpatient services to help people with substance use disorder during the current pandemic.

Erin Flick on Identifying Problematic Substance Use

Substance use disorder (or SUD) can cause immeasurable harm to a person’s life, but one big challenge of prevention is that SUD can sometimes be difficult to detect. Although there are many signs that someone may be chemically dependent on a substance, they can be subtle and tough to spot in ourselves or others, especially early in the progression of the disorder. Knowing the signs of problematic use can help us identify and seek help for substance use disorder sooner rather than later.

“Problematic substance use may look different for everybody, but if you’re questioning whether someone is developing a problem, one thing to reflect on is what their ‘normal’ has been and if there have been changes to their normal,” Erin says. She also encourages you to ask yourself the following questions; if the answer to one or more is “yes,” then it’s possible that the person is suffering from substance use disorder:

“Does the person have a change in friends, or if they’re normally very social, are you not seeing or hearing from them as much? Has their sleep hygiene changed? For example, are they staying up all night, or do they have their days and nights mixed up? How is their energy level? Have they usually been laid-back, easy-going and task-oriented, and now they appear more energetic and focused on things that they weren’t focused on before? If the person would come home and have one beer at dinner, for instance, are they drinking a little bit more? Are they continuing throughout the evening? If they have responsibilities such as work or school, have they been neglecting those responsibilities?”

In addition to these signs, the Mayo Clinic lists the following behaviors as possible symptoms of substance use disorder:

Having intense cravings for the substance that block out other thoughts
Needing more of the substance to get the same effect as before
Experiencing withdrawal symptoms when you stop using the substance
Spending money on the substance even when you can’t afford it
Continuing to use the substance even though you know it’s causing negative consequences in your life
Doing things to obtain the substance that you normally wouldn’t do, such as stealing

Introducing Virtual IOT for Treatment of Substance Use Disorder

If you or someone you know develops a problem with alcohol or other substances, the ongoing State lockdown isn’t a good reason to put off seeking treatment. Early intervention has been proven effective at addressing risky substance use behaviors before a disorder can develop, so it’s crucial to get help as soon as you notice a problem. Fortunately, the option of virtual treatment makes this possible even during the COVID-19 pandemic.

We’ve spoken previously about how Cummins BHS has adopted telehealth technologies to care for our consumers, and this extends to our services for substance use disorder. Intensive Outpatient Treatment, or IOT, is one of our most popular services for treatment of substance use disorder, and it’s now being provided virtually in Montgomery and Putnam counties. “We utilize a platform called RingCentral Meetings,” Erin says. “Group members can log in through their phone or their computer, and we engage the group with the same rituals and format as we would if we were sitting in a circle together.”

Just like with any telehealth service, it can take some time for providers and group members to adjust to the dynamics of virtual IOT meetings. However, virtual sessions allow participants to continue receiving care from the safety and comfort of their own homes, and they can even provide some unanticipated benefits to the therapeutic process. Erin explains,

“There’s been a lot of positive feedback in regards to consumer engagement. Those clients that previously had barriers to get to the facility for Group seem to be the ones that are ready to go every morning virtual Group is facilitated, so it’s been encouraging to see that commitment level. And for the providers, it’s nice to get to see some of their consumers’ home environments. We hear about them and can only imagine when we’re sitting in Group, but with video chat, we have an inside look into whatever their environment is. For example, their family members or children might pop in as they’re walking through the house, so it’s a nice way to get a visual of those things.”

As Indiana’s coronavirus lockdown continues, we encourage our consumers to make use of all our virtual care services for their behavioral health needs. You can read more about how our telehealth sessions work in this blog post.

If you believe you may need treatment for a substance use problem during this time, virtual services may be an option for you. Speak with your provider if you’re already a Cummins consumer, or call (888) 714-1927 Ext. 1501 to schedule a new consumer appointment.

Explaining Telehealth: How It Works and What to Expect During a Virtual Behavioral Health Session

April 6, 2020 Mark Wilhelm

Telehealth, the practice of conducting health care via telephone, video or other means of communication technology, has been slowly growing in popularity and practicality over the past several decades. However, the ongoing COVID-19 pandemic has led to a rapid adoption of telehealth services across the mental health industry. Organizations like Cummins Behavioral Health have a responsibility to continue providing life-saving mental health care for our consumers, and this is where telehealth can help.

Although telehealth for behavioral health care is a relatively new frontier, research has shown that virtual sessions with a behavioral health professional can be just as effective as face-to-face meetings. For example, one 2013 research review found that telemental health care is effective for diagnosis and treatment across many populations and appears to be comparable to in-person care. Some care recipients might even prefer telehealth sessions to in-office visits, as a 2012 survey found that 42% of teens and 33% of adults feel more comfortable sharing personal information online than in person.

Nevertheless, most people have very little experience using telehealth services, so the process might seem somewhat confusing or intimidating. Those who aren’t well versed in the latest communication technologies might feel especially uncertain about navigating a phone or video conference with their care provider. Fortunately, most of these technologies are very easy to operate using some basic instructions.

To make the transition to telehealth services as seamless as possible for our consumers, we spoke with IT Director Kevin Dykes about the technologies Cummins is using to provide virtual care during the current health crisis. In this blog post, we explain exactly how to use each of our videoconferencing tools and what you should do to prepare for a virtual session with your care provider.

How to Connect to a Virtual Session with Cummins BHS

Until the Centers for Disease Control (CDC) and Indiana state government relax their guidelines on social distancing, the vast majority of appointments at Cummins BHS will be conducted virtually, which includes individual therapy and counseling, group therapy and counseling, skills training, employment skills training, peer recovery sessions and medical appointments. This means that most consumers will be asked to call into a phone or video appointment instead of meeting at their local Cummins office.

Before you attend your first virtual session, your care provider will contact you to determine which electronic devices you have access to. “You’ll have the option to use your smartphone, a tablet or a computer, and your care provider will have a discussion with you about the audio/video requirements,” Kevin explains. “In the event that you don’t have video capabilities, then your provider can resort to a basic phone call.”

Your provider will choose the best option for conducting the virtual session based on the resources available to you. Video calls require that you have a device with a camera and microphone, access to the Internet, and a personal email address. However, you might still be able to join a video call if you lack one or more of these items. “There are several meeting options available and more than one way to connect to your meeting. For instance, if you don’t know your email address or you don’t have access to the email address, there are ways to work around that,” Kevin says.

In most cases, your provider will ask to connect with you using one of three possible videoconferencing technologies. Once you know which technology you’ll be using, simply follow the steps below to connect to your virtual session.

If you are meeting via RingCentral:

Your provider will send you an email containing a link to the video meeting. On the appropriate date and time, you can join the meeting by clicking the link on any device that is connected to the Internet. Alternatively, your provider could send the link via text message, which you can follow to the meeting in the same way. If you do not have Internet access, you can instead call into the meeting via phone by dialing the phone number included in the email or text message.
If you would like, you can also download the RingCentral Meetings app on your smartphone, tablet or computer. If you do this, clicking the link your provider sent will open the meeting in the RingCentral Meetings app.
If you don’t have an email address or don’t have access to your account, your provider will call you and give you a ten-digit meeting ID. On the appropriate date and time, you can join the meeting by visiting ringcentral.com, clicking on “Join a meeting” at the top right of the screen, and entering the meeting ID when prompted.
You may be asked to enter your name before you can join the meeting. Once you’ve done so, you’ll be connected to the meeting session.
If you see a pop-up window on your device asking for permission to access your camera and/or microphone, select “yes.”

If you are meeting via Zoom:

Your provider will send you an email containing a link to the video meeting. On the appropriate date and time, you can join the meeting by clicking the link on any device that is connected to the Internet. Alternatively, your provider could send the link via text message, which you can follow to the meeting in the same way.
If you don’t have an email address or don’t have access to your account, your provider will call you and give you a nine-digit meeting ID. On the appropriate date and time, you can join the meeting by visiting zoom.us, clicking on “Join a meeting” at the top right of the screen, and entering the meeting ID when prompted.
You may be asked to enter your name before you can join the meeting. Once you’ve done so, you’ll be connected to the meeting session.
If you see a pop-up window on your device asking for permission to access your camera and/or microphone, select “yes.”

If you are meeting via Doxy.me:

Your provider will send you an email containing a link to the video meeting. On the appropriate date and time, you can join the meeting by clicking the link on any device that is connected to the Internet. Alternatively, your provider could send the link via text message, which you can follow to the meeting in the same way.
The link will take you to your provider’s “virtual waiting room,” where you will be asked to enter your name. Once you’ve done so, you’ll need to wait until your provider initiates the meeting.
If you see a pop-up window on your device asking for permission to access your camera and/or microphone, select “yes.”

Preparing for a Successful Telehealth Session

Knowing how to join a telehealth session isn’t the only thing that determines the success of virtual care, however. Since you won’t be meeting in the controlled environment of your care provider’s office, there are more opportunities for distractions and problems that could reduce the quality of your session. To prevent this from happening, you should take the following steps to prepare for your meeting:

Find a private space. It’s important that you have privacy to speak openly with your care provider. If other people are in the home during your meeting, inform them that you are attending a telehealth session and ask not to be interrupted during it.
Keep extraneous noise to a minimum. Noise from other people and activities in the home can be very distracting during your session. Ask others to stay as quiet as possible while you are meeting, or consider wearing headphones to help drown out other sounds.
Try to ensure a stable connection if possible. Poor connection to the telehealth session could make it difficult for you and your provider to see or hear each other, or it could result in the call dropping. Use the fastest and most reliable Internet connection available to you, whether that’s a wired connection, WiFi or your mobile phone data network.
Minimize distractions. Do everything possible to eliminate any potential distractions prior to your session. For example, you should refrain from multitasking during the session, which includes eating or drinking any food items. Keep pets contained in another room if possible, and provide children with an activity to do during the session if they will not be involved in the session. Take care of personal needs such as eating and using the restroom prior to the start of the session. Finally, silence all electronic devices and alerts for the duration of the meeting.
Gather supplies before the session if possible. Again, your meeting will go most smoothly if all interruptions can be avoided. Check with your provider to see if you’ll need any supplies for activities during your session, and gather them together before your session begins.
Use a computer or tablet with video capabilities if possible. In order for you and your provider to see each other’s facial expressions, share files, and share screens (to review handouts/resources, complete activities, etc.), we recommend that you use a webcam and a computer or tablet so that you have the largest possible screen. It’s also best to place the device on a hard surface rather than hold it, as this reduces movement and noise during the session.
Maintain a professional relationship and boundaries. Even though you won’t be meeting at your care provider’s office, you should still adhere to all the normal guidelines of the provider-consumer relationship. Dress and behave just as you would if you were coming into the office for your session.

Although telehealth services might take some time to get used to, they allow organizations like Cummins Behavioral Health to continue providing crucial behavioral health care while keeping our employees and consumers safe during this health crisis. We encourage you to refer back to this post if you forget what happens next in the virtual care process, or consult your care provider if you need further clarification regarding specific details.

For more information about safeguarding your physical and mental health during the COVID-19 crisis, we recommend reading the articles below!