Definition, viability, effectiveness, facilities needed, enablers and barriers, privacy, preparation, conducting the session, extending the session, telehealth with groups
This page has three sections:
Background Material that provides the context for the topic
A suggested Practice Approach
A list of Supporting Material / References
Feedback welcome!
Background Material
Definition
Telepractice (or telehealth or telemedicine) refers to the use of telecommunications technology – including voice calls and video conferencing – to assess, triage and provide therapeutic and other supports to clients, enabling clients and social workers to meet despite being in different physical locations (Joshi et al., 2021; Parenting Research Centre, 2021a).
Note: Research about telepractice is in its infancy and robust conclusions should not yet be drawn. There is no conclusive evidence on whether telepractice produces better client outcomes than traditional face-to-face delivery. There are gaps in research, where future research could be directed. (Joshi et al., 2021).
Digital technology use in Australia (Digital Inclusion)
Being able to use technology effectively has three aspects: (i) having access and in different locations, (ii) being able to afford access, and (iii) being competent users of the technology, i.e., using technology to enhance quality of life, for education, and to promote economic participation and wellbeing (Barraket et al., 2021).
In Australia, effective use of technology - digital inclusion - varies from state to state with the ACT the most digitally included state or territory in Australia while Tasmania and South Australia are the least digitally included. Also, there's a pronounced country city divide in digital inclusion and a pronounced country-city and rural-remote divide (Barraket et al., 2021).
Digital inclusion varies considerably by age, education levels, income levels, employment status and cultural and linguistic diversity.
The gap between low- and high-income earners has widened since 2014.
The education gap also remains significant, e.g., people who did not complete secondary school scored 49.4 in the last Digital Inclusion Index measure which was 17.2 points lower than the national average.
People aged 65 plus are the most digitally excluded group in Australia in both affordability and digital ability.
Four million Australians access the internet solely through a mobile connection and these people have lower digital inclusion overall largely due to the affordability issues of accessing the internet only through a mobile phone. That's quite important in terms of services delivery because mobile only users in Australia tend to be people who are experiencing other forms of exclusion: homelessness, young people and people in remote communities tend to be using mobile only technology more than others.
Therefore, it is important to realise that those groups social workers seek to serve often have the least access to the technologies through which we're now providing quite a lot more services than we have in the past (Barraket et al., 2021).
Is telepractice a viable option?
Telepractice has a place in the continuum of care. It's not an either-or situation, but it must be embraced as one option. In assessing whether telepractice is right for a practice consider (Cousins & Owen 2020):
Client safety
Does it meet the clinical needs?
Effectiveness for your client
Client preference
Location of your practice
Equipment required – hardware and software
Adequate internet data – optionally 500 MB per hour session at both ends, i.e. for you and the client.
Budget requirements
Other issues to keep in mind (Barraket et al., 2021; Parenting Research Centre, 2021a):
Lack of access to devices and sufficient data (but cheap tablets (<$100) are available and Telcos often have good plans)
Low literacy, both general and digital. Useful resources that may help:
Be connected website: https://beconnected.esafety.gov.au/
Digital Springboard: http://digitalspringboard.org.au
PRC Telepractice Toolbox: http://parentingrc.org.au/telepractice-in-parenting-support
Trust and privacy issues
Gaps that can occur in service provision for
Aboriginal families, e.g. due to access to phones, having proper spaces available, people sharing phones
People with disabilities, e.g. making sure we are adapting our resources so they're easy to understand and easy to read (removing complex instructions)
CALD families
‘Invisible families’ who have neither access to digital devices nor are able to physically travel to services
The Parenting Research Centre has developed a form that social workers can use to decide whether telepractice is viable and/or preferred. It is available at https://www.parentingrc.org.au/wp-content/uploads/Form-digital-1.pdf and has 35 questions including the following (Robinson, 2021).
Client focus questions
Will a telepractice option provide welcome savings for the client (e.g. by avoiding transport or accommodation costs associated with in-person services)?
Does the client experience any issues that may make engaging with in-person services problematic (e.g. social anxiety, agoraphobia)?
Social worker focus questions
Is the travel time associated with the type or purpose of visit excessive?
Are there safety concerns around visiting the client in their own home (where applicable)?
Technology focus questions
Do the client and social worker have reliable connectivity?
Do the client and social worker have familiarity with the platform being used; for example, Skype, Zoom?
Service/program focus questions
Does telepractice increase your ability to offer the service or programs in locations where there is a shortage of workers or services, or where low levels of in-person engagement mean a program won’t go ahead?
Is telepractice effective?
In a 2021 review of telepractice in the family and relationships sector, Joshi et al. found telepractice was an acceptable service delivery model when accessible and easy to use. Areas with positive responses included: intimate partner violence prevention, early intervention parent counselling, family counselling for treatment of challenging behaviour, domestic violence and sexual assault therapy, couple/family therapy, parents receiving training to support their children with challenging behaviour. Cousins and Owen (2020) add anxiety, stress, and depression to this list. They also suggest social workers look at a client’s preferences and goals. They remind us that some people don’t feel confident with technology, and this can increase stress levels. On the other hand, telepractice enables different family members to be linked into the same conference, or clients can be linked to service providers. Services can be provided across geographical boundaries.
Joshi et al. (2021) also found parents preferred a hybrid model incorporating telepractice and face-to-face delivery. In addition, they suggested telepractice may suit people with higher rather than lower incomes because the former are more comfortable with technology.
Benefits of telepractice (Joshi et al., 2021; Parenting Research Centre, 2021a)
Telepractice provides benefits that work well as an addition to, and not a necessarily replacement of, face-to-face consultations.
Convenience: travel reduced (time and cost savings), beneficial for people with mobility or health complications, reduces inconvenience for carers, family members, parents, etc.
Access to services: can fit services around participant’s day, choice of environment, extend support beyond office hours, assists those in rural and regional areas
Participant choice: reduce feelings of stigma, can help for those uncomfortable with face-to-face interactions
Quality of care: can assess and support participants in their natural environment, can offer shared care through consultation and collaboration with specialists
Winkler (2022), in a short article summarising research findings around child mental health and telepractice, suggests telehealth is effective for delivering mental health support to children and families; and is improved through practitioner preparation and skills training. Winkler further suggests evidence demonstrates that a hybrid model of care providing families with choice and flexibility is more likely to be acceptable and effective in child mental health practice. Hybrid models of care combine different forms of service delivery including in-person support, telehealth and independent online learning, to deliver mental health support to families. Hybrid models typically combined phone and/or videoconferencing with home visits (or webinars as a ‘soft’ entry point to further face-to-face support).
What facilities are needed?
Appropriate hardware with built-in or external audio-visual capabilities (e.g. laptop, computer, tablet, smartphone) and a consistent, high-speed internet connection are essential. Free applications allow video conferencing but may not meet privacy and security standards. Zoom is very popular (65%), followed by Skype, Microsoft Teams, FaceTime, and WhatsApp (Joshi et al., 2021).
Consultation space set up that is quiet and fit for purpose. Have an adequate microphone and speaker system. Smartphone headsets can work. Check out the quality with colleagues. Plain décor, good lighting but not high intensity. You can mute sound and you and your client can talk on the phone but still see each other (Cousins & Owen, 2020).
Providing telehealth consultations
The principles and procedures for conducting these sessions are the same as for personal consultation; you need to adapt these for video conferencing.
Enablers of telepractice (Cousins & Owen, 2020; Joshi et al., 2021)
Provide detailed information so that the client can make an informed decision—rationale for video conferencing, costs, need for a support person, parent to always be with children. Let the client know how we’ll protect their privacy and will be using secure video conferencing, not recording it and ask the client not to record the session.
Social workers need to be confident, skillful, and adaptable to successfully implement telepractice. Practice, interactive peer meetings, training and understanding the logistics of the platform can help with this.
Being flexible to accommodate client preferences is important: hold an initial face-to-face session to build rapport and make sure the client is comfortable with the telepractice approach. Check if a mix of telepractice and face-to-face would facilitate better engagement.
Establish a back-up plan if technology fails, e.g. use the phone.
Barriers to telepractice (Joshi et al., 2021)
Inequitable digital access, e.g. slow-speed internet.
Video freezing.
Older adults may have more difficulty than younger in accessing technology.
Loss of non-verbal cues and limited ability to build trust, leading to difficulty in accurately assessing clients or conveying empathy.
Concerns about privacy. Platforms need to be secure.
Clients may become distracted at home.
No control of the treatment space, e.g. a child could leave.
Victims of family and domestic violence are particularly vulnerable.
Privacy, risk management and insurance
Social workers can maximise privacy and confidentiality by implementing some simple measures (Parenting Research Centre, 2021a).
If working from home, check that there is no identifying information visible about you, your family or other clients.
Have separate devices for private and professional use
Ask parents who else is nearby and how they feel about them seeing or hearing the session.
When videoconferencing, both social worker and parent should close any documents/windows that are open to avoid accidental sharing.
With telepractice technology it is easy for all participants to record sessions. Discuss issues relating to recording sessions, and the importance of keeping any recordings secure and confidential.
Professional indemnity insurance—confirm you have enough insurance to cover video conferencing.
The use of telepractice in Family and Relationship Services Austraia (FRSA): A focus group exploration
This report (FRSA, 2022) presents the outcomes of focus group discussions held with FRSA members to explore experiences and perspectives on the use of telepractice in the family and relationships services sector. The key findings from this research are:
The use of telepractice has increased accessibility of services to some people who would otherwise be unlikely, or unable, to access services including people who live at a distance from face-to-face services, time-poor parents and people who have difficulty leaving the home due to physical or mental illness/disabilities.
FRSA members will likely continue to use telepractice into the future as a part of multi-modal service delivery that includes face-to-face service delivery. It may be used in a mixed model of service delivery with the client(s) receiving both face-to-face and telepractice sessions.
The use of telepractice must be client-led and the client’s suitability to engage in telepractice must be determined through a robust assessment process that includes an appraisal of safety risks. The client’s preference and the client’s best interests should guide the use of telepractice.
Telepractice is better suited to clients who would otherwise be unable/unlikely to access services (as described above). There is also some indication that telepractice may feel less confronting or exposing for some people (particularly men), enabling them to engage more readily in the service.
Telepractice is perceived as less well-suited to children (particularly young children), people experiencing communications issues (language barriers, people with hearing or visual impairment), and people with low technological literacy and/or limited access to devices or internet.
Telepractice is perceived to deliver comparable (sometimes better) transactional outcomes – that is, outcomes involving the exchange/transfer of information, knowledge and support and/or the negotiation of tangible outcomes such as property division following separation.
Telepractice is perceived to deliver transformative outcomes – that is, enduring therapeutic outcomes such as shifts in self-awareness, self-concept and agency – less successfully.
Practitioner challenges include screen fatigue, low technological literacy and practice philosophy. Professional development and technical support for practitioners delivering services via telepractice is therefore instrumental. Regular breaks between online sessions and if appropriate, shorter sessions, may reduce screen fatigue. Organisational consideration of practitioner preferences may be advisable.
Telepractice with groups
Telehealth can be used effectively with groups. The following strategies may assist social workers with group-telehealth sessions (Abdi, 2023).
Key messages
Group telehealth is a viable option for many practitioners and their clients, with high rates of satisfaction reported.
Preparation ahead of the session and experience delivering group sessions are linked to successful delivery of telehealth groups.
Practitioners can take advantage of approaches that work better online, such as visual and tech features, use of the client’s home environment, and flexible scheduling.
Reflective practice along with inviting feedback from group participants can help refine practitioners’ approaches for more effective delivery.
Why use telehealth to run groups?
Video telehealth groups have been found to be as effective as in-person groups, and participants in these groups typically report high rates of satisfaction. Virtual group sessions can be particularly beneficial for improving participants’ mental health outcomes such as depression, stress and anxiety and overcoming a fear of meeting new people.
The online platform used can minimise the impact of barriers such as time, distance and mobility. Families may feel more comfortable communicating from their own home thereby supporting families’ and child mental health.
Group telehealth sessions do not have to be an all-or-nothing approach; groups can instead adopt a hybrid model, i.e. a combination of both telehealth and face-to-face sessions, depending on the preferences of the practitioner and the group. It is important to find what works for the group: in-person, online or a mix of both.
Be sure to check participants technology in advance to avoid disruptions in the session, and it can be a way to build rapport.
Design recommendations
Keep the group small (e.g. 5 to 15) to ensure participants have sufficient opportunity to discuss and contribute. Adjust the numbers in a group depending on personal preferences, group dynamics and goals of the group.
Reduce the length of sessions The length of a group session is shorter than that of an in-person session to optimise engagement and attendance. Keep sessions to an hour. Adjust sessions further with children if engagement is dropping.
Aim for consistent membership of the group Send reminders via texts or emails. Consistent membership helps create a safe and supportive environment, promoting families’ mental health and broader wellbeing.
Work to establish a warm and trusting relationship with participants With telehealth it can take longer to establish connections with participants. One way to do this is via one-on-one meetings with each participant before the first group session—build rapport, learn a little about the family and establish expectations for the group.
Reduce the amount of content presented during each session Too much content presentation will lead to disengagement and may cause issues for future group attendance.
Have a conversation about confidentiality and privacy so participants are aware to check who is present in their space during the session.
Delivery strategies
Incorporate visuals and tech features Sharing the screen and uploading images can enhance sharing information and engagement.
Establish methods for turn-taking For example, ask participants to stay on ‘mute’ and send a text message when they would like to contribute (e.g. “I have a thought on that” when someone else in talking), or use the ‘raise hand’ button to indicate a desire to contribute.
Invest in participants ownership of the group Avoid participants sitting back and waiting for the facilitator to lead by deliberately encouraging a sense of group ownership in participants (for example, ‘What would you like to do next?’) and defer to the group whenever appropriate.
Take advantage of activities that work better online For example, demonstrate how to access various websites or apps by sharing the leader’s screen and showing the process step-by-step in real time.
Engaging different participants
Strategies to engage parents and facilitate group interactions
Use reflection statements: “So I’m hearing there has been a lot going on for your family this week.”
Encourage the asking of questions or sharing of thought via the ‘unmute’ button or chat function.
Allow silence.
Check periodically for any comments or questions in case someone has something to share and just needs prompting.
Strategies to engage children
Set realistic expectations about what can and cannot be accomplished in a session; adjust the length of the session or the amount of content covered.
Build rapport with children: include questions such as, ‘What is your favourite colour?’, ‘What is your favourite TV show?’, ‘What is your favourite food?’ and so on. Art can be an effective way to keep children engaged in the session.
Encourage parents to have quiet toys for children to play with.
Use technological features such as online drawing tools, eye-catching screen backgrounds and online games.
Learn by doing, and adapt
Research suggests that practitioners and participants alike initially found virtual group sessions challenging, however this typically improved after a few sessions. After a session, evaluate what worked well and what didn’t work so well.
Seek feedback from participants. This can be done informally, through casual conversations with participants or noting observations as groups are running, or more formally by using feedback surveys and/or outcome measures.
Use a collaborative approach and ask participants if they would like to approach something in a different way, or if they have thoughts about how the group could function differently.
Practice Approach
Preparation
In deciding about the appropriate telepractice approach and preparing for sessions Brown and Hopp (2021) suggest the following:
Telepractice should be conducted in a manner consistent with the AASW Code of Ethics.
Respect the client’s self-determination around telepractice. As the information about digital inclusion in the background material above indicates, some may be more at ease with telephone than video. Explore the issue using a person-centred, empathetic approach.
Documentation should specify that services were provided by telepractice.
Use a secure platform, e.g. Zoom.
Dress, present, and conduct yourself as you would when providing services in person.
Make sure the client’s view of your personal space reflects professionalism and a minimal amount of personal information about you, and your living situation.
Brainstorm with clients possible ways to establish privacy so the conversation is not overheard by others, e.g. sitting alone in a car, sitting outside on a porch or in a yard, going for a walk while on the phone, going into the bathroom or down to the basement.
Have a back-up (e.g. telephone) in case the video fails.
The Parenting Research Centre (2021a) suggests disruptions can occur during sessions, including
personal interruptions from family members or work colleagues
visual distractions (e.g. sunlight glare or technical difficulties)
technological factors (e.g. internet disconnection or lagging)
objects in environment capturing attention
The Centre suggests strategies that can overcome some of these disruptions.
Strategies that can help manage disruptions in the client’s environment:
Set up expectations with families before a session – together, explore solutions to potential barriers (e.g. ensuring that their device (mobile/laptop) is charged).
Organise session times around parents’ schedules to minimise likelihood of interruptions (e.g. child’s nap time).
Consider session times – studies suggest the ideal length for virtual sessions are shorter than face-to-face session lengths, as people are more likely to disengage or become fatigued.
Address a disruption when it occurs and deal with any challenges together (e.g. “I can see something is happening there, do we need to take a break?”).
Use an interruption from a child as a learning opportunity to model positive interaction with the child (e.g. smile and praise child, encourage them to tell you something).
Strategies that can help manage disruptions in the social worker’s environment:
Choose a room with plain décor to help reduce participant distraction.
Try to avoid having intense lighting above or behind you during video calls to reduce the impact of glare or reflective light, which may distract the client(s).
Strategies that can help manage disruptions for social workers and clients:
Turn off/silence mobile phone.
Work from a quiet room where you will not be overheard, ensuring your full attention can be on the client(s) and vice versa.
Put up a sign or notify people in the home or office that a telepractice session is underway.
Building the relationship
Use similar strategies as you do in person. Also, the client often gets to the point more quickly than in an in-person session. And different personality types can find video conferencing better or worse. It can feel clunky and can be a struggle. Practise is the best way out of that.
Conducting the session
Tips for using digital technologies (ACRM, n.d.; Barraket et al., 2021):
Make more rather than less eye contact with the camera
Use more expressive body language
Keep group sessions shorter to reflect attention spans online
Check people can hear and/or see you adequately first
Let the person know when you are taking notes or reading something – silence is okay
Pauses should be considered. We use them all the time in-person, but this requires a bit of a shift in telehealth. We have to say what we are doing, e.g. “I’m just going to give you a moment to have a think about that” or “I’m going to take a moment to think about what you just said”. Otherwise it can seem as if the technology has failed (Cousins & Owen, 2020).
In a group session, you may have to direct traffic—“I’d like to hear from you now”—rather than using body language as you would in a ‘normal’ session (Cousins & Owen, 2020).
Boundaries have been changed by the COVID experience. Home learning/working might be going on in the background. People can see into the home environment. Because of this, there can be a temptation to over self-disclose. So, before self-disclosing, ask: “Whose purpose is this for? Is there a benefit for the client from this discussion?” (Cousins & Owen, 2020).
Finishing the session
At the conclusion of the session (ACRRM, n.d.):
Summarise key points and what happens next – who will do what & when.
Ask the patient if they need anything clarified.
Confirm and record if the patient is happy to have a remote consult again.
Extending the session
The Parenting Research Centre (2021b) suggests social workers can extend a session with a client by using technology, i.e. sending clients one or more prompts intended to help them progress towards their desired outcomes. These prompts generally tend to aid approaches that have a behavioural element, that is, the client wants to do something in their daily life to achieve desired outcomes. Options include the standard short message service (SMS) offered by phone service providers, or a third-party app (e.g. WhatsApp, Facebook Messenger, or Signal). Identify the prompts relevant to the client.
Some types of messages you might consider:
prompt – a message designed to promote an instant action (e.g. What is Sam doing right now? Is this an opportunity to give him lots of positive attention?)
reminder – a message intended to help the client recall critical information (e.g. Looking after yourself is important. Have you planned a little something you can do for yourself to rest and recharge your batteries?)
encourager – a message intended to provide emotional support (e.g. Jenny, I am so impressed with how you are looking after Liam! He is lucky to have you as his mum!)
query – a message designed to capture information (e.g. On a scale of 1-10 where 1 is no stress and 10 is extreme stress, how stressful has today been?).
Your approach should be developed in consultation with the family. Discuss how many messages might be helpful, of which type(s), and what time of day might suit best. But don’t take on commitments you can’t manage; you may be able to use messaging software to schedule prompts.
Good prompts are personalised, concrete, and specific and actionable immediately. Use names. And make clear to clients that you won’t be available immediately to respond to messages they may send.
Self-care
Because of COVID some social workers may already have high stress levels, so self-care may be in high need. Review self-care strategies. The transition from work to home has ceased for some. Picking up a coffee, going to a movie. So be more deliberate about self-care strategies and what might need to be put in place. For example, go for a walk, take a shower, do something to create a break from work and home.
Note: there is a section in the Suicidal Behaviour topic that deals with assessing and preventing suicide during pandmeics when conducting a telehealth session. It is located at the end of the Practice Approach section.
Supporting Material / References
(available on request)
AASW: Australian Association of Social Workers. (2016). Providing social work services online/remotely. Retrieved from https://www.aasw.asn.au/document/item/6473
Abdi, A. (2023). How telehealth can be used in group-based supports. Emerging Minds. https://emergingminds.com.au/resources/how-telehealth-can-be-used-in-group-sessions/
ACRM: Australian College of Rural and Remote Medicine. (n.d.). How to do a high-quality remote consultation. Retrieved from https://www.acrrm.org.au/docs/default-source/all-files/how-to-do-a-high-quality-remote-consultation.pdf?sfvrsn=86d02be8_2
Barraket, J. (8 September 2021). The digital divide in telepractice service delivery. CFCA News & Discussion. Retrieved from https://aifs.gov.au/cfca/news-discussion
Barraket, J., Michaux, A., & Bannister, K. (2021). The digital divide and remote service delivery. CFCA webinar, 24 February 2021. Retrieved from https://aifs.gov.au/cfca/webinars/digital-divide-and-remote-service-delivery
Brown, S. & Hopp, F. (2021). Tips and practices for providing telephone and video conferencing mental health services. Wayne State University: School of Social Work. Retrieved from https://socialwork.wayne.edu/coronovirus/socialwork/telehealth
Cousins, C. & Owen, N. (2020). Social Work, Telehealth and You. AASW Webinar.
FRSA: Family and Relationship Services Australia. (2022). The use of telepractice in Family and Relationship Services: A focus group exploration. https://frsa.org.au/wp-content/uploads/2022/05/FRSA-Report-2022.pdf
Joshi A., Paterson, N., Hinkley, T., & Joss, N. (2021). The use of Telepractice in the family and relationship services sector. Child Family Community Australia (CFCA) Paper, 57. Retrieved from https://aifs.gov.au/cfca/publications/use-telepractice-family-and-relationship-services-sector
Parenting Research Centre. (2021a). Telepractice hub: Telepractice basics. Retrieved from https://www.parentingrc.org.au/telepractice_hub/
This resource has an extensive bibliography that may be useful for further investigation around telepractice
Parenting Research Centre. (2021b). Telepractice hub: Telepractice extension: Family services. Retrieved from https://www.parentingrc.org.au/telepractice_hub/telepractice-extension-family-services/
This resource has an extensive bibliography that may be useful for further investigation around telepractice
Robinson, E. (2021). Client-centred telepractice in community services. Retrieved from https://aifs.gov.au/cfca/search/site/Telepractice
Winkler, L. (2022). Telehealth for supporting child mental health. Emerging Minds. https://emergingminds.com.au/resources/telehealth-for-supporting-child-mental-health/?audience=researcher