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Abstract

Tipsheet for clinicians working with youth during the COVID-19 pandemic: Ways to build rapport during telehealth sessions
COVID-19 TIPS: BUILDING RAPPORT WITH YOUTH VIA TELEHEALTH
Compiled by Ilana Seager van Dyk, Juliet Kroll, Ruben Martinez, Natacha Emerson & Brenda Bursch
UCLA Pediatric Psychology Consultation Liaison Service
SETTING THE SCENE
Minimize any potential distractions in view of the camera in your workspace. Similarly, encourage caregivers to
minimize distractions in the room where the patient will be completing the session.
Young patients say they prefer a “less formal” room set-up, so you may wish to avoid having a table between the
patient and the video-recording device (or you and the video-recording device).
Many seating arrangements can work for children. Children can sit next to the caregiver, between the caregivers,
on a caregiver’s lap, or in front of the caregiver in either their own chair or on the floor.
Larger rooms tend to work best with younger patients, so they can move around. In addition, if a child's motor
skills, play, exploration, and movements are being assessed, the room should be large enough for this activity to
fit within the camera frame.
Teens may prefer to be seen without a caregiver present. Use clinical judgment to ensure appropriate privacy is
maintained (e.g., patient feels comfortable they are not being overheard). If a patient expresses any discomfort
with full video, text/chat functions are available in some telehealth systems and may be useful for older patients
(likely over 11 years old).
Ensure your video is sufficiently “zoomed in” for the patient to see your facial expressions.
Try to maintain a constant gaze into the camera, rather than frequently looking away at your computer or notes.
If you can, use picture in picture feature (e.g., where you can see both yourself and the patient) to see how you
are being viewed by the patient, or if there is something distracting in the background (e.g., your cat!).
Patients may enjoy using telehealth background features. This can support the patient’s sense of control, by
allowing the patient to choose the “location” for next session (e.g., in outer space or even upload a background
picture of a favorite location).
WAYS TO INTRODUCE TELEHEALTH TO PATIENTS: (ADAPTED FROM GLUECK, 2013)
The following recommendations must be adapted to the developmental age of the patient:
Ask whether the patient has ever seen a doctor on a phone or computer. If the patient has not used telehealth, it
may be helpful to refer to common lay technology (i.e. Facetime, Skype, or Zoom) and explain key differences.
Let patients know why telehealth is being used. For example, mental health clinicians are using technology to
meet with patients during the COVID-19 outbreak so that everyone can stay as healthy as possible,” or “I am
using this so I don’t have to use a face mask to see you today.”
Communicate to patients that the session is happening in “real time,” if needed. You may demonstrate this by
commenting on the patient’s gestures, or what they are wearing, saying that “everything you can see about me, I
can see about you. For instance, you are wearing...” and “you just...” Children in particular seem to enjoy this
exercise and proof that they are being seen.
Discuss security, if needed. For example, teens might understand the concept of encrypted technology, which is
the HIPAA (Health Information Portability and Accountability Act) standard. If younger children express any
concerns about who else can hear or see them, it can be described as having an “electronic tunnel from the
camera where the clinician is sitting to the one where the patient is sitting.” Additional information regarding
technological specifications should be available if requested. Some patients appreciate being reassured that the
session is not “on the internet” in the sense that it can neither be openly viewed nor will it be placed online.
It is important to inform patients if a session is being recorded. If you want to record a session, then you must
obtain explicit consent from the patient. Teen patients who are recorded may appreciate information about what
recorded information may be shared with their parent (e.g. substance use, sexual activity, etc.). As appropriate,
provide information about mandatory disclosures. If sessions are being recorded solely for supervision purposes,
this may also be shared with the family so as to diffuse any worry about loss of privacy.
Establish a visual context of where you are sitting. Ask patients if they would like to see your office. Using the
camera’s zoom and pan features or manually moving your device, you can give patients a virtual tour of your
workspace to assure them that no one else is present and to provide context to the clinical setting. After the tour,
let the patient know that the camera will be zoomed in so that the patient can see your facial expressions.
Discuss any technical difficulties noticed immediately as they arise during the introduction. For instance, if there is
a slight lag in audio that makes it seem as if you and patient are talking over each other, you can suggest adding
a small pause after each statement. Socialize youth to the videoconferencing system, and highlight that it might
take time to acclimate to the technology and ‘‘not talk over each other.’’
Give patients an opportunity to ask questions before starting the session. This may be especially helpful to
younger and older patients who are not as comfortable with electronic media.
BUILDING RAPPORT
Provide opportunities for your patient to speak and/or assert control over the conversation given their inability to
"interrupt or speak over someone" with some telehealth formats.
If you are using or creating worksheets or other visual activities, consider allowing the patient to choose the
colors/fonts/pictures in order to provide them with some control.
Use exaggerated expressions and gestures if needed to engage the youth (virtual high 5s, thumbs up, etc.).
Use summary statements, reflections, and observations frequently to remind your patient that you are listening.
Seek more verbal confirmations of mutual understanding of what is being done in treatment (e.g., rationale for
relaxation, exposures, etc.).
Children may enjoy drawing pictures that they can then share through the camera while telling a story. These
drawings may help you assess children’s attention, fine motor skills and creativity. Children may also use play
figures (e.g., dolls, action figures) to demonstrate their ability for symbolic play and reveal their thought content.
For younger kids, ask them to share their favorite things about home toys, books, blankets, etc. insofar as
these can be related to clinical activities and are not disruptive. Encourage children to hold their drawings up to
the camera so they can explain them.
For older kids, ask if they have any art, journaling, music, or anything else to share with you. Consider engaging
adolescents by exploring an online site, such as YouTube or Facebook.
Children and teens may appreciate getting to know clinicians as well. Consider using a brief question and answer
game to share some facts about you and gathering information about your patient. For example, your patient and
you can take turns answering: What is your favorite TV show?”, “What is your favorite color?”, “What is your
favorite food?”, “How many siblings do you have?
Tentative language when interpreting patients’ statements, open-ended questions, and figurative language may
be helpful when conducting an initial session online.
Mirror the language patterns of the youth and handle any threats to rapport with genuineness (including using
informal language).
Simply have a conversation with the patient! This is shown to be a reliable rapport builder, even over telehealth.
Weather the inevitable technical and clinical challenges associated with telehealth with patience and humor.
KEEPING KIDS ENGAGED
Arts-based therapeutic methods may help engage younger patients. You can have the patient show you their
work on the camera or use screen share options to create art together (based on your platform’s capabilities).
Consider sharing handouts and working through them in session if your platform has the functionality (e.g., Zoom
screen share with editable documents or PowerPoints).
Try utilizing different functions to increase engagement (e.g., Zoom has a “whiteboard” feature where a patient
and clinician can draw together or play tic-tac-toe). Check with technology services at your site for specific
trainings and tips on functionality for your platform.
In sessions with younger children, make sure there are toys in the room where the patient is streaming from
but ask caregivers to avoid loud, noisy toys that will interfere with the audio quality. If needed, recruit caregivers to
help with engagement.
A hyperactive or autistic child may have difficulty remaining in the frame. Consider keeping the caregivers in
frame and call the child back to the camera when they need to answer a question.
If anxious or defiant youth refuse to sit within the camera frame, try to use typical behavior management
strategies first. Then, prior to the next session, ask the caregiver to turn off the self-monitor image and seat the
youth farther away from the camera so as to remain in the frame. Another strategy is to allow the youth to have
more privacy for part of all of the session.
Especially with younger patients, recognize that staying engaged via telehealth is challenging! Adjust your
expectations of how long sessions may last if you are having a hard time keeping your patient engaged.
Research shows that youth’s satisfaction with telehealth will likely increase with repeated use; youth who were
initially anxious about telehealth showed decreased distress in about 10-15 minutes.
It is important to continue conversations related to technical difficulties, unique challenges, or positives that come
from using telehealth throughout the treatment course. Keep asking!
REFERENCES
Boydell, K. M., Volpe, T., & Pignatiello, A. (2010). A qualitative study of young people’s perspectives on receiving
psychiatric services via televideo. Journal of the Canadian Academy of Child and Adolescent Psychiatry = Journal
De l’Academie Canadienne De Psychiatrie De L’enfant Et De L’adolescent, 19(1), 511.
Gloff, N. E., LeNoue, S. R., Novins, D. K., & Myers, K. (2015). Telemental health for children and adolescents.
International Review of Psychiatry, 27(6), 513524. https://doi.org/10.3109/09540261.2015.1086322
Glueck, D., Myers, K., & Turvey, C. (2013). Establishing therapeutic rapport in telemental health. In Telemental health:
Clinical, technical and administrative foundations for evidence-based practice (pp. 2946).
Goldstein, F., & Glueck, D. (2016). Developing Rapport and Therapeutic Alliance During Telemental Health Sessions with
Children and Adolescents. Journal of Child and Adolescent Psychopharmacology, 26(3), 204211.
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Myers, K. M., Valentine, J. M., & Melzer, S. M. (2008). Child and Adolescent Telepsychiatry: Utilization and Satisfaction.
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Myers, K., Nelson, E.-L., Rabinowitz, T., Hilty, D., Baker, D., Barnwell, S. S., Boyce, G., Bufka, L. F., Cain, S., Chui, L.,
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Rockhill, C., & Goldstein, F. (n.d.). Child & Adolescent Telepsychiatry: Developing a Virtual Therapeutic Space. American
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therapeutic-space
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ResearchGate has not been able to resolve any citations for this publication.
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Concepts of rapport and therapeutic alliance have been found to be robust predictors of treatment response and can be impacted by technology found in telemental health. This chapter reviews the relevant research on rapport and the concepts of therapeutic alliance as they impact telemental health and discusses practical considerations impacting technology choices, such as technology that allows sufficient bandwidth for fluid transmissions and detailed observations of patients. Careful consideration of rapport within the context of individual interactions, relationships with local clinicians, and communities at large are also discussed. The focus is on a practical understanding of rapport with concrete recommendations to develop relationships within the telemental health setting.
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Child & Adolescent Telepsychiatry: Developing a Virtual Therapeutic Space
  • C Rockhill
  • F Goldstein
Rockhill, C., & Goldstein, F. (n.d.). Child & Adolescent Telepsychiatry: Developing a Virtual Therapeutic Space. American Psychiatric Association. Retrieved March 17, 2020, from https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit/child-adolescent/developing-a-virtualtherapeutic-space
Child & Adolescent Telepsychiatry: Participant Arrangement
  • D Roth
Roth, D. (n.d.). Child & Adolescent Telepsychiatry: Participant Arrangement. American Psychiatric Association. Retrieved March 17, 2020, from https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit/childadolescent/participant-arrangement