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COVID 19 TIPS: BUILDING RAPPORT WITH ADULTS
VIA TELEHEALTH
Compiled by Juliet Kroll, Ruben Martinez, and Ilana Seager van Dyk
UCLA Pediatric Psychology Consultation Liaison Service
SETTING THE SCENE
• Minimize any potential distractions in view of the camera in your workspace. If possible, initially use picture-in-
picture feature (e.g. where you can see both yourself and the patient) to see how you are viewed by the patient,
or if there is something distracting in the background.
• Similarly, encourage patients to minimize distractions in their space. Acknowledge that “off-screen” distraction is
common (e.g., dogs, traffic, partners or family) and remind patients to silence phones, close other browsers, etc.
• Use clinical judgment to ensure appropriate privacy is maintained (e.g., patient feels comfortable they are not
being overheard in their space or from others present “off-screen” in your space). Headphones can help if an
entirely private space is not available.
• Ensure your video is sufficiently “zoomed in” for the patient to see your facial expressions and you to see theirs.
• When appropriate, you may wish to ask patients to remove hats or large scarfs in session, as they might limit your
ability to read nonverbal cues from the patient given the video conferencing format.
• Try to maintain a constant gaze into the camera, rather than frequently looking away at your computer or notes.
• You may suggest that patients turn off the picture-in-picture function on their side after they have appropriately
framed the session. It could be distracting or prove more challenging for patients to share intense emotions. This
may be especially important when working with patients with body-image concerns, those who are new to
therapy, or individuals who are emotionally guarded. If you notice the patient’s gaze drifting to a corner of the
screen repeatedly, they may be looking at themselves. Encourage them to turn it off. This may be less important
in group sessions, as patients will have many other people to focus on.
• Check in with your patient to ensure that they are not experiencing your voice to be too loud. This can cause
echoing in the call, reduces the patient’s privacy, and can be simply unpleasant for the patient.
• Make sure you and the patient know how to mute your call, in case of an unexpected knock on the door.
• If poor video connectivity results in a pixelated image, have a low threshold for switching to the telephone.
• Ensure you have a crisis plan in place (discussed and understood with administration and team members
including contact information for emergency services at patient’s location.) Confirm the patient’s emergency
contact information and identify if someone is present in the patients home to use only in emergency setting.
• Establish a contingency plan if telehealth system stops working (e.g. clinician to start another session, transition
to phone).
INTRODUCING TELEHEALTH TO PATIENTS (ADA PTED FROM LOZANO ET AL., 2015 )
When working with patients unfamiliar with telehealth, a phone call to walk patients through the technology before
your first session is consistently recommended.
• 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 make references to common lay technology, such as Facetime, Skype, or Zoom and explain
key differences.
• Briefly acknowledge why telehealth sessions are being conducted. 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.” Inform the patient if therapy will resume in person when appropriate or remain through telehealth.
• Discuss security, if needed. While encrypted technology is the HIPAA (Health Information Portability and
Accountability Act) standard, HIPAA guidelines may not be entirely enforced during the COVID-19 outbreak.
Check with your local administration regarding suitable platforms.
• Let patient know that the same legal protections and limitations to confidentiality apply to telehealth, including
crisis responses to suicidal or homicidal ideation.
• Some institutions require verbal consent for telehealth to be gathered and documented at every session. Explicit
consent from the patient must be obtained to record a session.
• Prioritize written instructions (with illustrations on how to access telehealth session) and practice using
technology. For older adults, minimize the number of steps to access session. For instance, if using Zoom,
consider sending only the URL or a single phone number to join the meeting, rather than the whole invitation.
• Discuss technical difficulties immediately as they arise and throughout treatment (e.g., volume, echoing). For
instance, in the face of audio delays, it may be helpful to speak slower.
• Give patients ample opportunity to ask questions before starting the session and normalize that it might take time
to acclimate or “learn the technology together.” Invite discussion of the patient’s previous experience with
telehealth, current beliefs/attitudes about telehealth, and questions he/she might have regarding the modality
• Clearly communicate that treatment via telehealth is not a second-rate treatment option, but instead represents a
state-of-the-art approach to treatment delivery. Many research studies demonstrate equal efficacy in treatment
delivered over telehealth with in-person sessions.
BUILDING RAPPORT
• Offer a warm greeting and introduction, as you normally would; that is, the immediate focus is on you and patient,
not the technology.
• Try to avoid appearing that you are in a rush, even when you have had technological difficulties, and keep your
attention on the patient.
• 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 experiencing technical difficulties (e.g., an echo in the call, patient’s voice is low volume), try to address
these as soon as possible in session. Similarly, check in with the patient to make sure that they can hear you.
• Subtilties of communication may be lost during telehealth. Use exaggerated expressions and gestures if needed,
and consider sitting far enough away from the camera that the patient can see your hand gestures. If you are
working on a treatment target that requires you to be able to observe the patient more clearly (e.g., observing
patient’s tics), ask the patient to sit further away from the camera and demonstrate by sitting further back as well.
• 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.).
• Mirror the language patterns of patients and handle any threats to rapport with genuineness. Just like you may do
in office-based sessions, you can use your body language to indicate engagement (e.g., leaning closer to the
camera or leaning back, depending on what you would like to reinforce).
• Recognize that telehealth may help equalize the “power imbalance” between clinician and patient.
• Note that clinicians often report poorer rapport than is identified by clients. Simply having a conversation with the
patient is a reliable rapport builder, even over telehealth.
• Above all: try to weather the inevitable technical and clinical challenges associated with telehealth with patience
and humor.
KE EPING PATIENTS ENGAGED
• If relevant to your treatment, help the patient to identify a location for the session spacious enough for any in-
session activities (e.g. interoceptive exposures).
• Work with the patient to figure out a way to provide them with access to in-session assessment and intervention
materials (e.g., questionnaires, session handouts), either through the videoconferencing system screenshare or
via email, fax, or mail (if necessary). Use of handouts and repetition of psychoeducation may be particularly
important in telehealth as patients may become easily distracted.
• Consider sharing handouts and working through them in session via screen share. In Zoom, you can use the
whiteboard, under the share function, to illustrate concepts with your patient. Zoom also allows both you and your
patient to annotate documents via screen share.
• Research shows that satisfaction with telehealth and group rapport typically increases with repeated use; patients
initially anxious about telehealth reported decreased distress after one session. Indeed, some patients who are
more anxious in clinic settings may feel more comfortable conducting sessions from their homes.
• Some patients report that relaxation and imagery exercises feel “distant” via telehealth. You may encourage
patients to check or even increase their volume settings as part of “settling in” to any guided exercise.
• When possible and appropriate, use engaging videos and visual content through the screen-share function.
• Harness the benefits of the patient being in their home setting in your therapeutic interventions. For example,
when creating a coping kit, you could have the patient gather the items during the session. You could also use
pets or their own music as part of a mindfulness or soothing activity.
• 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!
TIPS FOR GROUPS
• Try to limit groups to 5-7 members, so the clinician can easily view all group members on the screen at one time.
• Some platforms (e.g., Zoom) allows the host of the meeting to mute any participant and assign “break out rooms”
for patients to do partner or small group-based activities. This can help to build rapport among group members,
when individual side bar conversations may not be as easily available.
• Monitor any “chat” function to minimize cross talk or other unhelpful discussions between members during
session. Encourage patients to not chat among themselves privately.
• It may be helpful to ask all group members to mute themselves until they wish to share, as this may decrease the
amount of ambient noise and distraction. That said, if patients are able to participate unmuted without any
ambient noise, this will allow for more fluid and natural reactions and responding to questions.
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