Using Telehealth With Families

Telemental health care is more popular than ever. This mode of care brings with it unique challenges and opportunities, especially when used to provide treatment for families or other groups. We spoke with two experienced clinicians about tips and advice for utilizing telemental health with families.

Leslie Contos, PhD, NCC, CCMHC, LCPC, is a 2018 NBCC Minority Fellowship Program Doctoral Fellow with extensive experience in telemental health. As a student, she conducted research and presented on the topic. During the pandemic, she shifted her practice to telemental health and has continued on that course.

Michael Jones, PhD, NCC, BC-TMH, LPC-S, President-Elect for SACES, has been utilizing telemental health modalities for over 15 years. As the owner of Renewed Vision Counseling Services, he provides both client services and practitioner training. Renewed Vision Counseling Services is a Registered Credential Training Provider for the Board-Certified Telemental Health Provider (BC-TMH) credential from the Center for Credentialing & Education (CCE).

Major benefits of telehealth are accessibility and convenience. 

“I think one of the hardest parts for families right now when it comes to counseling in general is being able to find a time and space where everybody is available to do counseling together,” says Jones. “Telehealth makes that process a lot simpler because they can do it from their home.”

“When I worked with families in Chicago, I saw a lack of providers near low-income neighborhoods,” says Contos. “Now living in Idaho, I see a lack of providers in remote rural areas. Families who do not have access to providers where they live or who have difficulty getting to provider appointments have an opportunity for support through telehealth that may not otherwise be available.”

Orienting the family to telemental health is an important first step. However, getting buy-in from all participants can be a challenge. 

“I like to find out first what everyone’s comfort level is with video and also with telehealth and understanding how it works,” says Jones. “I help them understand the security that goes into the video software that I use. I remind them about confidentiality and the standards that I’m held to when it comes to privacy.”

“Encourage the creation of a pre-session routine at home to help everyone get ready,” advises Contos. “Begin a discussion about expectations and limit-setting during sessions. It’s important to practice technology setup, so that the phone, tablet, or computer in the family’s home is set up in a way that allows a large enough frame of view to see the whole family.”

As a provider, it’s important to be educated on the ethical and legal ramifications of telemental health.

“Consider the legal and ethical requirements,” says Contos. “Have telehealth guidelines in your informed consent. Know where your client is located and have resources and referrals for their location. Know your appropriate ACA Code of Ethics around telehealth and the NBCC Policy Regarding the Provision of Distance Professional Services. Keep up with telehealth legislation and insurance reimbursement practices in your state.”

One benefit of telemental health is the comfort level of a family in their home environment.

“When they come into my counseling office, sometimes people tend to put on a facade of this is what our family looks like,” says Jones. “But when you’re on camera, you sit there long enough, and the family dynamics come out a lot easier with telemental health.”

Contos agrees: “One of the more interesting benefits is the ability to observe families in the more natural setting of their home, where there is typically a higher comfort level and a more genuine display of family dynamics.”

Jones says that one of the key considerations when using telehealth with a family is to set clear ground rules to ensure smooth communication. 

“One of the big things when it comes to working with families in telehealth is making sure there are rules set up, communication-wise, so that people aren’t talking over each other,” he says.

Just as important when using video is a clear picture of the clients. 

“It’s important with video to make sure that things are set up so I’m actually able to see as much as of the family’s bodies as possible,” says Jones. “If I’m talking to the caregivers and the children at the same time, that means making sure that their camera is set up in such a way that I’m able to see everybody and see facial reactions and body language.”

While the camera must be far enough back to view the entire family, it’s important to have the microphone close enough to easily and clearly pick up everyone’s words. Lighting is another important aspect. Light sources should be in front of both clients and provider for the best visibility.

Video communication does have its limitations, according to Contos.

“There is some loss of ability to read subtle physical cues, especially direct eye contact,” says Contos. “Asking for family members’ observations is the best workaround.”

Ideally, all participating family members are in a single location communicating with the same device. Sometimes, though, it’s necessary for members to call in using different devices. When that happens, Jones makes sure to start the session at the same time for everyone. It’s important that all clients feel they receive equal time.

“When working with families, it is important to clarify who will be present during sessions, how they will be present, and their developmental needs,” says Contos. “Some families may always meet as a full group, while others may want time for subsets to meet such as a parent check-in, or a parent with a particular child.”

Technical issues are an unfortunate part of telemental health services. To help avoid problems, Jones suggests maximizing system resources and bandwidth by closing unnecessary programs for both the provider and client. A further benefit of doing so is a reduction in potential distractions, such as new email alerts or other notifications. Similarly, Jones encourages clients to quiet cell phones and avoid using them during session.

It’s also important to be aware of technical limitations that clients may have. 

“Be mindful of the type of internet service that your client has,” says Jones. “Maybe they are using data from their phones or whatever the case may be. So just being mindful. ‘OK, how much time am I spending in the sessions with the family. How are they connecting to the internet?’”

In some cases, the limitations may be too significant for telehealth to be a good fit.

“Families who do not have access to adequate hardware or internet speed to provide a strong stable connection are not suitable,” says Contos. “Technical difficulties in video or audio can disrupt interventions and interfere with the therapeutic alliance.”

Flexibility and patience are important assets in family telehealth.

“Remember foundation, forgiveness, and flexibility,” says Contos. “Create a strong foundation by having a consultation with parents before the first family session, where expectations are set and technology is tested. Practice forgiveness by letting go of the idea that it will look just like an office visit. Telehealth can be challenging at times, so be kind to yourself. Flexibility is key. Whether it’s a glitch in the technology or a disturbance in the client environment, adapt and figure out what else will work.”

“I think my best advice is to be patient with the process,” says Jones. “Anytime you go to having more than one person in the room together, the dynamic changes significantly. So we have to be mindful that there’s going to be different family roles that we need to understand.”

Jones encourages more counselors to utilize telemental health in order to reach clients who may have difficulty accessing traditional services. 

“There is such a huge need for services right now,” says Jones. “I know lots of clients are looking to get in, and telehealth provides that opportunity for people to be able to see the clinicians they really want to work with. I’ve noticed that my population has changed significantly. I work with about 90% African American clientele. That happened once I switched to telehealth.”

“Some of my clients range anywhere between 30 minutes to 4 hours away from me,” Jones continues. “But they chose me specifically because of the skills that I bring. As a clinician, that gives us a much better opportunity to reach populations who are underserved, who may be needing that help but don’t know where to turn to because they can’t travel that far.”