By James J. Crist, Ph.D., author of What’s the Big Deal About Addictions?
Since the COVID-19 pandemic emerged in the United States in mid-March, most therapists have stopped seeing patients in their offices. Insurance companies allowed therapists to switch to telehealth sessions to protect patients and therapists and prevent the spread of the virus. While video calls are the most common form of telehealth, phone sessions have also been allowed since not everyone has access to video chats. While some practices have started resuming in-person visits, not all have. If you are thinking of seeking mental health care via telehealth for your child, here are some things you need to know.
While there is not much research on the effectiveness of telehealth, some studies have shown that it has been comparable to in-office care. For some people, such as those with autism or social anxiety, they may actually be more comfortable speaking with a therapist from home than sitting face-to-face in the therapist’s office.
Teenagers have made the transition to telehealth sessions more easily than younger children have. They are quite comfortable with FaceTime and other methods of video chatting with their friends. It can be challenging to engage kids in telehealth visits, especially with younger kids. Most kids cannot stay engaged for 45-minute sessions. Including parents in video sessions, as well as other family members, can make it easier. This also allows parents to be a part of their child’s therapy. Parental involvement in children’s therapy enhances its effectiveness.
Insurance and Legal Issues
Many insurance companies were already authorizing telehealth sessions prior to the pandemic. Some required therapists to get special training to be certified to treat patients with telehealth. As a result of the pandemic, insurance companies have been more flexible, allowing all therapists to use telehealth to see patients. They have even authorized sessions by phone in cases where video sessions are not an option. Most likely, insurance companies will continue to allow telehealth sessions, but they are less likely to authorize phone sessions once the pandemic has eased. It is much harder for therapists to assess patients accurately over a phone call, especially if they have never met the person and particularly if safety issues such as addiction, self-injury, or suicidal thoughts are present.
In most cases, your therapist needs to be in the same state as you when conducting telehealth sessions. This makes it more difficult if you move or happen to live in a different state from where your therapist’s office is located, which is somewhat more common in urban areas such as Washington, D.C., where suburbs are in Virginia and Maryland and many people commute between locations. During the pandemic, some states are allowing therapists to practice across state lines temporarily. If this applies in your situation, be sure to ask your therapist about it.
Efforts are underway to allow practitioners to practice across state lines without having to be licensed in each jurisdiction. PsyPact is the organization that is assisting psychologists in achieving this goal. Social Work Practice Mobility is an organization for licensed clinical social workers. Similar organizations exist for physicians and licensed professional counselors. Many patients would benefit from being able to keep seeing their therapist via telehealth sessions after moving to a different state instead of starting with someone new.
Maintaining confidentiality and privacy can also pose challenges. HIPAA is the federal law that, among other things, protects patient privacy and requires therapists to take certain actions to do so. Normally, use of telehealth services require that communication be encrypted for security purposes. HIPAA-compliant platforms include Zoom for Healthcare, Doxy.Me, Thera-LINK, TheraNest, and GoToMeeting. This requirement has been relaxed during the pandemic. As a result, use of FaceTime, Skype, and Zoom to provide remote telehealth communications is allowed. Be sure to ask your child’s therapist if you have questions or concerns about confidentiality, insurance, or other issues related to telehealth.
Benefits of Telehealth
Telehealth platforms have some advantages over in-person sessions. Some families, parents and kids alike, find that it is less stressful to not have to worry about driving to the therapist’s office and being stuck in traffic. If you forget an appointment, being contacted by your therapist via video allows for the session to still occur and helps families avoid missed appointment fees. Many online platforms allow screen sharing and file sharing. This allows therapists to share resources, which can include handouts and videos that provide useful coping strategies.
Some platforms give therapists the option of texting patients prior to the start of a session. This serves as a reminder and can reduce the chances of missing a session. This can also allow teens more control over the session, which can be useful if they alternate between locations, such as when parents are divorced.
Video chats allow therapists to get to know a child’s environment more intimately than would otherwise be possible. Children can show therapists things at home that are important to them, such as pets, artwork, or Lego creations. Using a phone or laptop while laying on one’s bed can reduce defensiveness and make it easier for kids to talk freely.
Drawbacks of Telehealth
As noted above, privacy can be an issue during telehealth sessions. Even when parents set up video sessions for children, other family members may be listening in without the parent’s or child’s knowledge, or that of the therapist. Kids, and especially teens, may be much less comfortable sharing sensitive issues if they know a parent might be nearby listening in. The same may be true for parents—they may not know if children are listening in and may want to share information with the therapist that they don’t want children to hear. So be prepared to give your child some privacy when they are talking with the therapist. And be sure you are in a private space while talking. Some people have sessions while in public places, such as at the store. Therapists may be reluctant to hold sessions with you if you are not in a private place, since confidentiality can be compromised.
Some aspects of therapy cannot be matched online. It is harder for younger kids to stay engaged. Many are already burned out by participating in online schooling. A therapist may have a harder time picking up on more subtle signs that a child is uncomfortable or that show how anxious or depressed a child may be. Addressing suicidal thoughts is also more difficult. Since sessions can be held anywhere there is internet or phone service, it may be harder to utilize 911 services in the event of an emergency, such as intervening if a child is suicidal, if the therapist is unsure of where the child is. Finally, there is a closeness and connection that comes from being in the same room that is hard to match during video sessions.
Be Prepared Ahead of Time
Whatever platform your therapist is using for telehealth, be sure to test it well before the session. It is frustrating to spend the first five or ten minutes trying to connect. Also, consider the strength of your internet connection. If you are using a cell phone or tablet, the strength of your connection may differ if you are using wifi or your data connection. If you don’t have unlimited data on your cell phone plan, you may have to pay extra if you exceed your monthly limit.
Try to reduce background distractions. Check the lighting to make sure the therapist can see you. Too much light behind you makes it harder to be seen. Depending on the speed of your internet connections, it may help to close any other browsers on your computer if you are using a computer. You might also have trouble if too many people in your household are online at the same time.
Consider having paper and pencil handy before starting a session. Making a list of topics you’d like to address can make the session go easier. Parents can make some suggestions for children to talk about, though it’s important to give kids some decision-making ability in what they discuss, just as they would have in in-person sessions. Encourage your child to make a list of topics to discuss as well.
If you are meeting with the therapist with your child, ask your child where they may want to sit. Many seating arrangements can work for children. Children can sit next to you, on their bed, on your lap, or in their own chair. Larger rooms tend to work best with younger patients, so they can move around.
Making the Most of Telehealth Sessions
Most platforms have a chat function as part of a video call. Some kids enjoy using the chat function when communicating. Some therapists encourage drawing together. The therapist can draw in their office while children draw at home. This allows both to share their drawings and talk about them, much as would happen in the office. Providing your child with art supplies such as crayons, markers, or colored pencils can facilitate this sort of interaction. Remember that kids often feel more comfortable talking about difficult subjects when they can play while they talk.
Using screen sharing, therapists can share information, videos, or PowerPoint presentations during sessions. You can also encourage kids to share their own sites or videos. PBS Kids is a fun website that allows patients to play fun games. ABCya allows kids to develop their own games, such as a word search based on words the child picks. Toy Theater is another such resource. You might suggest these to your child’s therapist if they are unaware of these options. Be careful with this, however, since using such sites as part of a therapy session may be too distracting for some kids.
Encourage your child to introduce other family members or pets to the therapist. This can be an easy way for your child to feel more comfortable with video sessions and can give your child’s therapist insights into life in your household.
If you have board games at home, suggest that your child select a game to play with the therapist. Whoever is hosting the game (it can be the therapist or the child) can move the other person’s pieces based on the directions you give them. Candyland, Chutes and Ladders, and Connect 4 are some examples of easy games to play that don’t take a lot of time. Checkers and chess may be a little harder. Playing games while talking can make therapy easier for many kids.
Don’t expect that your child will stay engaged for the entire time. Kids may ask to use the restroom, get a snack, or show something to the therapist. Be patient; you may need to gently redirect them. Allowing kids to use fidgets during sessions can help.
Telehealth sessions have definite advantages and are likely here to stay for a while. While it may take some time to get used to this format, it allows children and teens to get help that they might not otherwise be able to obtain. Parents can also benefit by having more contact with their child’s therapist; this allows therapists to provide guidance on how to best help their children at home.
Here are some resources if you are interested in learning more about how telehealth works for mental health. Feel free to share them with your child’s therapist if you find something that interests you.
Telehealth.hhs.gov. This US Department of Health and Human Services website is devoted to educating consumers about telehealth services.
“Connecting with Children and Adolescents Via Telehealth During COVID-19.” This article on the American Psychological Association website is directed at therapists but contains information that may be useful for parents as well.
Dr. James J. Crist is a psychologist specializing in children with ADHD, depression, and anxiety disorders. He is the clinical director and a staff psychologist at the Child and Family Counseling Center in Woodbridge, Virginia, where he provides psychological testing and individual, couples, and family psychotherapy for children, adolescents, and adults. Visit his website at jamesjcrist.com.
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