How Can School-Based Clinicians Deliver High-Quality Services in a Telemental Health Environment?

This blog is part of a series to share research and analysis prepared for the Rapid Response Network (RRN). The RRN is an initiative of the California Mental Health Services Oversight and Accountability Commission (MHSOAC) and Social Finance, providing actionable research to agencies responding to the Covid-19 crisis.

As school counselors in a California county transitioned to telehealth services during Covid-19, they noticed that engagement with clients had decreased, resulting in shorter sessions. Counselors requested help from county leadership who reached out to the RRN for best practices to help improve service delivery.

In the current environment, nearly all interaction between school-based mental health clinicians and their clients is being conducted virtually. Telemental health–through videoconferencing or mobile phones—previously a lesser-used tool in the clinician’s toolbox, is now the only option.

Fortunately, national authorities, including HHS, have relaxed HIPPA regulations around telehealth to accommodate new realities. This includes allowing clinicians to utilize platforms such as Zoom, Skype, or FaceTime, which were previously non-HIPPA compliant. While the structural barriers have been lowered, the interpersonal barriers—such as lower client engagement—have increased. This leaves clinicians to answer the question: how can you continue to deliver high-quality services in a telemental health environment?

To help answer this question, MHSOAC and Social Finance spoke with clinicians, medical professionals, and healthcare executives about their experiences with virtual delivery, and referenced national guidance documents. Here are six themes to help telemental health practitioners:

• Virtual delivery requires clinicians to change how they interact: maintaining eye contact is critical—and challenging—over video, and often requires keeping greater-than-anticipated distance from the clinician and the monitor/camera. Additionally, clinicians may need to heighten their animation level, including more voice modulation and hand movement.
• Clinicians should be comfortable with the chosen platform: comfort starts with the technology medium being used. One individual we interviewed stated that clinicians must ask, “What is it that the care provider feels comfortable with, and what is it that the person you are working with feels comfortable with?” Talking about tech at the beginning of a session can be a good icebreaker.
• Therapeutic activities should be incorporated into telemental health: activities, like worksheets for families and clients to track escalations in behavior, handouts to reinforce treatment components, and interactive games, are an important tool for clinicians—and these should not go by the wayside during telemental health sessions. However, it is important to think through challenges related to access—if a client does not have access to the Internet (and sessions are conducted over the phone), consider mailing materials ahead of time.
• Telemental health is an opportunity to provide structure: in a moment when many adolescents and children are struggling with disrupted routines, scheduled appointments can provide a constant. Focusing on ways to ease a child’s distress concerning the new situation could result in improved engagement in sessions.
• It’s about quality over quantity: Session length isn’t indicative of session quality. One interviewee advised, “If you achieve the desired outcome during the session—even if it is shorter—the session is successful.” When it comes to virtual delivery, more frequent, shorter sessions may improve engagement.
• Parents need resources, too: One interviewee highlighted the changed daily dynamics for both parents and clients as a major component of successful service delivery. “Kids are not used to being at home with their parents all the time, and parents are used to having others to help deal with their child’s issues. This is scary for parents—and they need resources, too.” Resources include the clinician’s phone number, crisis hotlines, wellness apps, and tips for healthy parenting.

Professional organizations and training organizations such as American Psychiatric Association, the National Association of School Psychologists, and Relias have released trainings and webinars to assist with the transition to telemental health during COVID-19. See here for a list of seven tools and training videos and four issue briefs.

While “normal” service delivery has changed quickly for school-based clinicians, session engagement and counseling outcomes do not have to suffer. By utilizing some new resources and incorporating old tricks, clinicians can provide high-quality services and needed structure for their clients during a stressful time.

We are grateful for the support of the Robert Wood Johnson Foundation, the invaluable in-kind support from GLG, which supports the RRN through access to their expert network, and the partnership of Jim Mayer and Anna Naify from MHSOAC.