PCAR Technical Assistance Bulletin Telecounseling with Children and Teens Telecounseling uses interactive technologies, such as videoconferencing, to provide mental health services to clients remotely as an alternative to in-person counseling sessions. Telecounseling can increase access to services for people who may not be able to attend in-person counseling due to barriers such as illness, inclement weather, natural disasters, or transportation challenges. While there are many benefits to telecounseling, these services should only be offered in cases where clients will be able to engage meaningfully with their counselor (Jones, et al., 2014; Stewart, et al., 2017). In cases where a client cannot attend in-person counseling sessions and does not have access to the technology needed for videoconferencing, phone counseling may still be a viable option, depending on the needs and ability of the child or teen. Benefits of telecounseling for children and teens Research has shown telecounseling to be an effective mode of service delivery for children and teens across racial and ethnic identities who are experiencing a variety of mental health issues. Shown to be as effective as in-person counseling services, clients have expressed high rates of satisfaction with telecounseling. In general, young people are used to using technology to communicate, and telecounseling allows them to remain in familiar, comfortable surroundings while connecting with their counselor. Additionally, connecting remotely is less disruptive to their schedules and routines, likely contributing to research findings that meeting virtually increases the likelihood that clients will attend their sessions. It is also important to note that telecounseling can be more cost-effective. For families, virtual counseling appointments reduce transportation costs and caregivers’ time off from work (Boydell, et al., 2014; Jones, et al., 2014; Stewart, et al., 2017; Stewart & Orengo-Aguayo, 2020). Telecounseling is shown to reduce barriers to help-seeking for many clients. The ability to meet virtually can reduce the stigma that is often associated with mental health services. For example, a child or teen may not want to be seen at school meeting with a counselor-advocate, but would be open to logging on from a guidance counselor’s office or from home. Many children, teens, and families struggle to access services. In rural communities, brick-and-mortar services may be far away, and the additional travel time or transportation costs can be prohibitive for many families. For children and teens with disabilities, accessibility to offices can be a challenge. Telecounseling offers an alternative option if offices are not accessible to people who use assistive devices, such as walkers or wheelchairs. Additionally, for children and teens who have limited English proficiency and/or are from marginalized communities, virtual services provide an opportunity to receive services from bi-lingual or culturally-specific service providers that may not be available within their own geographical communities (Boydell, et al., 2014; Jones, et al., 2014; Stewart, et al., 2017; Stewart & Orengo-Aguayo, 2020). Challenges While telecounseling is a viable, effective option for many survivors, it is important to recognize that virtual services can present some challenges. Most notably, not all children and teens will have access to the technology they need to participate in telecounseling. internet connection, or the skills to navigate virtual platforms. Additionally, when people participate in counseling remotely, privacy and confidentiality may be compromised. It is important to note that for many clients and counselors, the elimination of in-person contact can reduce feelings of connection, and can bring about safety concerns. Counselors must put in the effort to adapt their methods in ways that boost connection and reduce logistical barriers for simple tasks, such as obtaining signed consent forms or administering assessments (Boydell, et al., 2014; Stewart, et al., 2017). Considerations for telecounseling If you or your organization is considering the use of telecounseling with children and teens, planning ahead for success is essential. It is important to remember that telecounseling may not be the best choice for every client, even with careful planning. Each child or teen needs to be assessed to ensure that virtual services are appropriate for them and that everyone has the tools and information they need for the remote relationship to be beneficial. If you are unable to provide the same standard of care for child and teen clients as you would with in-person services (such as adherence to policies and protocols, working within your competence, access to effective supervision, privacy and confidentiality), telecounseling may not be appropriate (Boydell, et al., 2014; Stewart & Orengo-Aguayo, 2020; Stewart & Wallace, 2020). Access to technology and service-provision platforms What do clients need? -Smart phone, tablet, laptop, or computer -Ability to charge the device -Microphone and speakers (or headset), and camera -Internet access What do counselor-advocates need? -Smart phone, tablet, laptop, or computer -Ability to charge the device -Microphone and speakers (or headset), and camera -Secure platform (such as doxy.me) -Familiarity/comfort with the technology and platform Informed consent As always, clients and families must understand the services they are receiving and provide consent to receive those services. For children and teens under the age of 14, a parent or guardian must provide consent; for mental health services, teens aged 14 or older may provide consent for themselves. The nature of telecounseling should be explained, along with any limitations the modality may present. Additionally, in cases where the counselor is being asked to share confidential information, informed written consent must always be granted by the child’s (under age 14) parent or guardian. As noted, telecounseling is most commonly used in situations where in-person counseling is not an option or where meeting face-to-face creates a burden to the client or their family. In these cases, your organization should draft policies that provide options when it is necessary to obtain written consent. Options to consider may include the use of mail to send forms between the counselor and parent/guardian, or in cases when the need is emergent, electronic signatures, email verification, or pictures of the signed consent may fulfill the requirement. Privacy and confidentiality Confidentiality (https://pcar.org/sites/default/files/resource-pdfs/parameters_of_privilege_and_confidentiality_booklet_508.pdf) is at the foundation of counseling services provided by Pennsylvania’s rape crisis counselor-advocates. Confidentiality standards must be upheld when providing services virtually. As with all clients, counselors must explain the limits to confidentiality (including mandated reporting and threats of harm to self or others), as well as the unique considerations for providing confidential services remotely. Not only must the counselor take steps to protect the client’s private information, the client can also take steps to help maintain confidentiality. For clients: -Recommend that they participate in counseling from a quiet, private location. -Explain how confidentiality and privacy are compromised if other people are in the room or can overhear. For counselors: -Use a private location with a door. -Set up a noise machine outside your door, if needed. -Always confirm the location and identity of your client. Setting parameters For many counselors and clients, telecounseling may be a new experience. As with any relationship, it is important to set reasonable boundaries and expectations for the sessions and the use of technology. The most important topic to discuss with clients is a plan for ensuring their safety while engaging in telecounseling (Stewart & Orengo-Aguayo, 2020; Stewart & Wallace, 2020). Safety planning -Develop safety protocols for providing telecounseling to children and teens. -Always assess the client’s level of risk. For example, are they experiencing suicidal ideation? Are they engaging in self-harm? Do not practice beyond your competence, or use telecounseling if the child’s needs are beyond what can be addressed effectively in a virtual format. Make appropriate referrals when necessary. -Make sure to confirm the telephone number and physical address of the child’s or teen’s location while they are participating in a telecounseling session in case of emergency. -For children under age 14, always ensure that there is an adult caregiver in the same location as the child for the entirety of the session, and make sure to have a way to contact that adult in case of a crisis or emergency during the session. -The counselor should contact the caregiver to come into the room with the child in the event of an emergency. -The counselor should call 911 when necessary. -Be sure to include information about the limits of confidentiality in cases of emergency in your consent for services forms. It is essential that survivors and their parents/guardians understand the limits of confidentiality and can provide informed consent. Technology back-up plan -Formulate a plan for technology failures. Planning in advance reduces stress and anxiety if the technology fails. -Obtain permission to contact the client in other ways if the connection is lost. Be sure you have their phone number or email address so you can follow up and touch base if you lose connection. Basic boundaries -Explain guidelines and expectations for remote counseling. As you would with all clients, ensure they understand the policies for session attendance or duration of appointments -Establish boundaries around the use of technology. For example, if you choose to email with clients, let them know the timeframe of when they can expect a reply, and what to do if they need a more immediate response. -Be mindful of what can be seen in your camera view. This can be especially important if you are working from home. Consider what personal information might be disclosed by what can be seen in your background. -Remove audible or visual distractions. For example, pets entering the view can pull a child’s or teen’s attention away from the work that you are doing in your session. -Maintain the same level of professionalism as you would if you were in-person with a client. Simple things like dressing appropriately and not eating during sessions are easy and important ways to show clients you respect the importance of their time with you. Tips for success Telecounseling can provide an effective alternative to in-person services; however, it requires careful planning and preparation. While it can be very effective, it is not appropriate for everyone – not for all clients and not for all counselor-advocates. Sexual Assault Centers that are interested in exploring or engaging in this option should provide training and resources for staff to ensure their comfort and competence with providing services remotely. Additional tips include: -Be sure to review PCAR’s telecounseling resources (https://pcar.org/telecounseling), webinars (https://youtu.be/AuZkXXu0opw), and the sample Informed Consent for Telecounseling form (https://pcar.coalitionmanager.org/resourcemanager/resourcefile/details/45). -Plan ahead and be creative. Adapt activities and materials to be delivered in a virtual format. Ensure clients have access to the supplies they need to complete activities. Mail or email session handouts and supplies to clients, if necessary. -Strategize ways to boost interactivity. Utilize tools within the platform to allow clients to use different features, such as chat functions or symbols, to express themselves and to engage with you. -Explain expectations and how the sessions will work as you would in in-person sessions. Be sure the child or teen understands how to use the platform and is empowered to actively participate. -Create partnerships (with consent, of course!) – with parents and caregivers, schools, and other agencies where children might be receiving services. Collaborate with other caring adults to help facilitate setting up appointments, to serve as the emergency contact person, or to help reinforce concepts covered in counseling in other settings. -Engage in creative, ongoing, and active problem-solving to address issues or roadblocks along the way. Recognize and respect the child or teen client as your partner in creating a meaningful telecounseling relationship. Resources and activity ideas -Practice Relaxation Activities and visualization. https://www.mc.vanderbilt.edu/coe/tfcbt/workbook/Relaxation & Affective Expression/PMR Script.pdf -Watch tele-play therapy videos on YouTube for ideas (Check out videos by Tammi Van Hollander. This link will take you to the first of the series. Each episode covers a new topic.) https://www.youtube.com/watch?v=D9hEcN8tgnc -Introduce your clients to NSVRC’s Grounding Tools E-learning Resource in English and Spanish. https://www.nsvrc.org/elearning/grounding-tools -Adapt creative expression activities for use in tele-counseling. https://www.psychologytoday.com/us/blog/arts-and-health/201406/creative-arts-therapy-and-expressive-arts-therapy -Read the blog Interventions for Online Therapy with Children and Youth by Ariel Landrum. https://www.guidancett.com/blog/interventions-for-online-therapy-with-children-and-youth-2020 -Read and discuss books together. Contact PCAR’s Librarian for suggestions! https://pcar.org/resources/library -Create or adapt games to play virtually. https://www.pinterest.com/pin/320459329706767004/ -Design art activities using craft supplies or technology. Color pictures or create videos. -Use music to prompt discussion or personal expression. Listen, discuss lyrics, or dance! https://www.counseling.org/docs/default-source/vistas/the-use-of-song-lyrics.pdf?sfvrsn=d3db432c_4 -Be sure to review Practice Guidelines for Telemental Health with Children and Adolescents by the American Telemedicine Association for additional guidance. https://higherlogicdownload.s3.amazonaws.com/AMERICANTELEMED/618da447-dee1-4ee1-b941-c5bf3db5669a/UploadedImages/Practice Guideline Covers/NEW_ATA Children & Adolescents Guidelines.pdf -Review the Victim Rights Law Center’s Protecting Survivor Privacy When Working From Home: A Guide for OVW-Funded Victim Service Providers. https://mcasa.org/assets/files/Privacy_When_Working_at_Home_VRLC.pdf -Read the National Network to End Domestic Violence’s resource, Digital Written Consent to Share Information, for more information about obtaining informed consent remotely. https://www.techsafety.org/digital-written-consent References Boydell, K. M., Hodgins, M., Pignatiello, A., Teshima, J., Edwards, H., & Willis, D. (2014). Using technology to deliver mental health services to children and youth: A scoping review. Journal of the Canadian Academy of Child and Adoclescent Psychiatry, 23(2). 87-99. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4032077/ Jones, A. M., Shealy, K. M., Reid-Quiñones, K., Moreland, A. D., Davidson, T. M., López, Barr, S. C., & de Arellano, M. A. (2014). Guidelines for establishing a telemental health program to provide evidence-based therapy for trauma-exposed children and families. Psychological Services, 11(4). 398-409. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4079762/ Stewart, R. W., & Orengo-Aguayo, R. (n.d.) Telehealth: What you need to know to get started. [PowerPoint slides.] Medical University of South Carolina. Stewart, R. W., Orengo-Aguayo, R. E., Cohen, J. A., Mannarino, A. P., & de Arellano, M. A. (2017). A pilot study of trauma-focused cognitive-behavioral therapy delivered via telehealth technology. Child Matreatment, 22(4). 324-333. https://doi.org/10.1177/1077559517725403 Stewart, R., & Wallace, M. (2020). Guide for transitioning to telehealth deliver of mental health: Addressing barriers during the COVID-19 outbreak. Medical University of South Carolina. https://socialwork.msu.edu/documents/COVID-19/Telehealth-Guide-MUSC-English.pdf © Pennsylvania Coalition Against Rape 2020. All rights reserved. www.pcar.org