Mastering Telehealth in Behavioral Health: Ethical Considerations, Clinical Interventions, and Building Human Connection

This text-based course is an edited transcript of a live webinar presented by Ryan Kirk, PsyD.

This material is for educational purposes and does not replace clinical judgment or local policy.

Risks/Limitations

• This course provides foundational training but does not certify clinicians in EMDR or specialized trauma interventions.
• Clinicians are encouraged to seek further supervised training specific to EMDR protocols and advanced telehealth competencies.
• Due to diverse client populations, cultural competence strategies discussed may require tailored adaptations in unique clinical contexts.
• Participants are advised to consult state-specific telehealth guidelines for complete compliance.

Learning Outcomes

After this course, participants will be able to:

• Identify ethical considerations, diversity, equity, and inclusion (DEI) strategies, and best practices for culturally competent telehealth services.
• Describe strategies for effectively adapting trauma interventions, EMDR, and child and play therapy techniques for telehealth settings.
• Explain methods to establish and maintain human connection and therapeutic rapport during virtual sessions.

Introduction

Telehealth has undergone a profound transformation, particularly since 2020, becoming an indispensable modality in behavioral health. This shift, largely accelerated by global events such as the COVID-19 pandemic, has necessitated that clinicians across various disciplines, including those in primary care and behavioral health, integrate some form of telehealth intervention into their practice. This article aims to explore key insights for mastering telehealth in behavioral health, focusing on ethical guidelines, diversity, equity, and inclusion (DEI) considerations, and the adaptation of clinical interventions. Specific attention will be given to trauma treatments, EMDR, and play therapy, alongside a discussion of various virtual platforms and, crucially, techniques for fostering rapport and human connection in teletherapy.

The growth of telehealth has been exponential, offering unprecedented access to mental health services for individuals who might otherwise face significant barriers. These barriers can include geographical distance, transportation challenges, physical limitations, or privacy concerns. The ability to deliver care remotely has not only expanded the reach of behavioral health professionals but has also introduced a new set of complexities and considerations that demand careful navigation. This article will delve into these aspects, providing a comprehensive overview for clinicians seeking to enhance their telehealth practice.

Telehealth Behavioral Health Case Study

To provide a practical framework for applying the concepts discussed, we will follow a case study involving Daniel, an 8-year-old Latino male. Daniel's primary concern is increased anxiety and behavioral disruptions at school following witnessing domestic violence in his home. He was recently referred by his school counselor due to noticeable anxiety, a decrease in school performance, and aggressive behaviors towards his classmates.

Daniel's mother, Sofia, scheduled a telehealth session due to transportation barriers and privacy concerns that prevented in-person visits. The family resides in a rural community with limited access to mental health services, highlighting the critical role telehealth can play in bridging service gaps. As we proceed through the various sections of this article, we will revisit Daniel's case to illustrate how ethical considerations, DEI strategies, and adapted clinical interventions can be effectively applied in a real-world telehealth scenario.

Ethics Codes

Ethical practice forms the cornerstone of all clinical work, and its importance is amplified in the context of telehealth. Every major behavioral health profession has, to our knowledge, addressed telehealth within its ethics code. Clinicians are strongly advised to consult their specific ethical guidelines to ensure compliance and best practice. Resources for various professional organizations include:

• American Association for Marriage and Family Therapy (AAMFT)
• American Counseling Association (ACA)
• American Psychological Association (APA)
• National Board for Certified Counselors (NBCC)
• National Association of Addiction Professionals (NAADAC)
• National Association of Social Workers (NASW)

Additionally, clinicians must be aware of and adhere to their state-specific laws and administrative rules governing telehealth practice. These guidelines provide the foundational framework for ensuring ethical and responsible service delivery in the virtual environment.

Ethical and DEI Considerations – Brief Review

Ethical practice is foundational, particularly in telehealth. It is paramount to ensure privacy and confidentiality, which encompasses not only the use of secure video platforms but also safeguarding the virtual workspace. Clinicians must clearly communicate informed consent, detailing telehealth-specific risks and limitations. Proper documentation is essential to meet compliance standards and ensure quality care within one's organization or practice.

Diversity, Equity, and Inclusion (DEI) are equally important. Clinicians must be mindful of cultural differences and language barriers, which can be even more challenging to detect in an online platform. Strategies such as culturally sensitive communication and providing resources in the client's preferred language are crucial. Awareness of digital literacy levels is also vital. While some older individuals may need assistance with computer technology, younger generations, though comfortable with cell phones or tablets, may find these devices less ideal for telehealth interventions. The goal is to meet the patient where they are, understanding their typical interaction with technology.

Accessibility challenges related to disability or limited technological resources must also be considered. In Daniel's case, residing in a rural community with limited access to technology underscores the need for tailored approaches. Clinicians must always adapt their approach on a case-by-case basis, even when working with a general population, to ensure that telehealth services are accessible and effective for all clients.

Case Study: Diversity, Equity, and Inclusion (DEI) in Telehealth

Daniel and Sofia represent a diverse cultural and socioeconomic background, making the application of DEI principles in telehealth particularly relevant. Practicing diversity, equity, and inclusion in telehealth necessitates culturally sensitive communication, ensuring that language is both accessible and inclusive. It also requires understanding cultural views on mental health. How do Daniel and his mother generally perceive mental health practitioners or accessing therapy services? This understanding is crucial, as it adds another layer to how they might interact with technology and how these two aspects converge.

Acknowledging barriers to service access, such as their rural location, is vital. Openly addressing any cultural stigma related to counseling can foster greater engagement and trust. Several questions arise when considering cultural considerations in telehealth sessions with Daniel and Sofia. One might consider potential stigma surrounding mental health discussions and familial dynamics. Who is involved in the treatment, and who might wish to be involved? In a brick-and-mortar setting, one might anticipate meeting only the mother and child, but in a digital format, several additional relatives might wish to participate. How does this dynamic translate to a virtual environment?

Culturally appropriate methods of emotional expression also warrant attention. To what extent are nonverbal cues captured on screen? If the clinician is only visible from the shoulders up, how might this limit the observation of whole-body dynamics or nonverbal communication beyond traditional talk therapy? These discussions are essential for ensuring a comprehensive understanding of the client's emotional world.

Socioeconomic factors significantly influence Daniel's engagement and access to telehealth. Internet access limitations, including the speed required to sustain a video conference, and device availability are critical considerations. Clinicians must assess what devices the family possesses and how they interact with the clinician's chosen platforms. Offering practical solutions, such as phone check-ins or leveraging community resources, is paramount if reliable telehealth connectivity becomes an issue. For instance, an organization might set up a room with a computer in a different location within a rural community, allowing clients to access telehealth services even without home internet. This creative problem-solving is vital, while also being mindful of limiting solutions that involve public spaces, such as libraries, where full privacy may not be guaranteed.

Informed Consent and Client Autonomy

Informed consent and client autonomy are fundamental to building a strong therapeutic alliance, whether in traditional or virtual therapy settings. It is imperative for the patient to clearly understand telehealth procedures. This includes detailing the session structure, such as the expectation of using a virtual waiting room or preparing microphones and video before the session begins. Confidentiality measures must be thoroughly explained; patients may not fully grasp the security protocols simply by seeing a portion of the clinician's screen. Transparency about the measures the clinician personally takes to safeguard privacy is invaluable.

Data privacy is another critical aspect. Patients should be informed about whether sessions are recorded (typically they are not without explicit consent) and that data is generally not retained. A thorough discussion of the risks and benefits of telehealth compared to in-person therapy is also essential. If a clinician has reservations about telehealth ultimately benefiting a patient, it is best not to proceed with this modality.

When working with minors, as in play therapy or trauma therapies, obtaining informed consent from parents or legal guardians and assent from the child is crucial. The comprehension level must be appropriate for each developmental stage. For example, when conducting sand tray therapy, the clinician should explain how the virtual experience might differ from an in-person session where direct guidance or coaching is possible.

Best practices for informed consent include providing written documents that clearly detail telehealth-specific concerns, as recommended by APA guidelines. Ample time should be allocated for questions, not just at the intake or the beginning of treatment, but throughout the therapeutic process. This ongoing dialogue allows patients to express their comfort levels and helps gauge whether telehealth remains a suitable fit. Ultimately, ensuring that the client and caregiver clearly understand their rights and roles in telehealth services is paramount.

Confidentiality and Privacy

Confidentiality and privacy are paramount in telehealth. Practitioners must utilize secure, encrypted communication platforms that comply with HIPAA regulations. The era of using platforms like FaceTime for therapy is long past; secure options such as Zoom for business and healthcare, and other specialized platforms, are now standard. A list of hyperlinked resources will be provided at the end of this article, offering various platforms, some specifically designed for interventions like EMDR, bilateral stimulation aids, or group therapy modalities.

It is crucial to clearly communicate potential limitations of confidentiality in telehealth. This includes addressing accidental disclosures if someone enters the client's private space during a session. Clinicians should prepare for scenarios such as a patient attempting to find privacy in a public restroom, as this highlights the need for continuous assessment of the confidentiality of the client's environment. If a client is interrupted, any sensitive discussions should be paused to ensure no one overhears the private conversation. Particular attention must be paid to privacy issues in child and trauma-focused therapies, as sensitive disclosures may raise additional confidentiality concerns.

Best practices involve confirming that the client has a confidential and secure environment, free from disruptions, for each session. This might involve a virtual tour of the space. Regular reminders about the importance and limitations of confidentiality are essential, especially for minors and trauma survivors, ensuring they understand who has access to session content. Just as in traditional therapy, minors must understand that parents will be contacted in certain situations where confidentiality must be breached, clarifying that this does not mean parents will be brought into the video session without the child's knowledge.

Competence and Professional Boundaries

Ensuring professional competence in using telehealth technology and platforms is vital. This includes proficiency in technical troubleshooting and ethical decision-making within a virtual environment. It is advisable to conduct some of this troubleshooting during the initial intake to establish a safe environment, confirm good internet speeds, and ensure the patient is comfortable interacting on screen.

Clinicians must also recognize the limitations of telehealth in accurately assessing nonverbal cues, particularly in child therapy or trauma work, and adjust their practice accordingly. Patients do not need to be so close to the screen that only their head is visible. If an intervention involves bilateral stimulation or "butterfly hugs," a conversation should occur at the outset to determine the best setup for the technology, allowing the patient or parent to arrange it before the session. This proactive approach prevents the patient from feeling pressure to perform correctly while simultaneously discussing sensitive information. The goal is to avoid creating anticipatory anxiety related to the technology.

Maintaining clear professional boundaries in virtual interactions, especially regarding out-of-session communications, is equally important. Best practices include pursuing ongoing training and certification specific to telehealth best practices and ethical standards. For those engaging in specialty interventions, consulting the accrediting bodies or developers of those interventions for telehealth guidance is highly encouraged, as most now offer relevant literature. Establishing clear communication guidelines and protocols for session scheduling, rescheduling, and after-hours contact is also crucial. While the virtual format may make it seem easier for patients to text, email, or call, clinicians must clearly define these limitations, just as they would in standard therapy.

Trauma-Informed Ethical Practices

Applying trauma-informed care principles to telehealth practice is essential, prioritizing safety, transparency, and client empowerment. This guidance, derived from SAMHSA, emphasizes that patients must feel comfortable engaging in this modality, a comfort that may take several sessions to achieve. The aim is to ensure forward progress in the therapeutic journey.

It is crucial to acknowledge that trauma work via telehealth carries a risk of re-traumatization if not carefully managed. Clinicians must consider potential technological breakdowns, lag, or loss of connection during deep meditative states. These possibilities warrant upfront discussions with patients. A backup plan, such as a phone call to continue the session, should always be in place to prevent patients from feeling stranded during critical moments of trauma processing.

Best practices involve utilizing virtual grounding and containment strategies specifically designed for telehealth settings. These adaptations help patients remain grounded during sessions. Regular monitoring for emotional safety is also vital, requiring clinicians to adjust their therapeutic approach to reduce client distress and ensure supportive follow-up care.

Ethical Considerations for Child Therapy and Play Therapy

Child therapy and play therapy in a telehealth format often require significant adaptation. Direct physical interaction, as in traditional in-person sessions, is typically not possible. The primary goal is to maintain therapeutic effectiveness while upholding ethical standards. The Association for Play Therapy, in 2020, released recommendations for such adaptations, which clinicians are encouraged to consult.

Considering developmental appropriateness and age-specific confidentiality is paramount. Working with a 10-year-old differs significantly from working with a 3- or 4-year-old. The role of the parent or caregiver in facilitating the session may also increase, potentially involving more interaction between them and the child than would typically occur in an office setting.

Best practices include selecting age-appropriate virtual play interventions and ensuring caregiver involvement in creating a therapeutic space conducive to online play therapy. Clear communication of expectations and boundaries for both caregivers and child clients regarding interactions within teletherapy sessions is essential. For instance, clinicians might advise parents that while they can assist with setting up the digital format, they should not simply "pop in and out" of the session to maintain child confidentiality. A brief 5-minute start or close with parents, with the middle of the session dedicated solely to the clinician and child, can help maintain this boundary.

Ethics, Diversity, Equity, and Inclusion (DEI)

Ethically sound telehealth practice must actively consider diversity, equity, and inclusion by recognizing the multifaceted barriers clients face. These barriers can include language differences, which may necessitate a translator, similar to in-office settings. Cultural stigma surrounding mental health is another significant factor; clinicians must understand how patients perceive accessing therapy in general, and then layer on how they feel about accessing telehealth specifically. Socioeconomic constraints, such as the cost of devices and internet access, also impact access to telehealth. Clinicians should strive to level the playing field as much as possible, exploring creative approaches such as directing clients to community resources or designated office spaces where technology can be accessed.

Addressing potential implicit biases in telehealth interactions is crucial, as these can influence the therapeutic alliance or clinical judgment. For example, if a clinician expects a patient to maintain direct eye contact with the camera, but the patient's cultural background dictates a more deferential interaction style, the clinician must be well-versed in these nuances. Understanding that this is not a lack of respect but a cultural norm allows for appropriate adjustment of expectations.

Best practices involve actively engaging in cultural humility and seeking education on culturally responsive telehealth strategies. The growing body of research in this area provides valuable insights into interaction strategies for specific populations in telehealth. Providing equitable services is also paramount, which includes accommodating client needs through language assistance, culturally appropriate interventions, and flexible scheduling to address access barriers. This might mean adjusting session times to align with when community resources for technology are available.

Crisis Management and Ethical Decision-Making

Telehealth practitioners must anticipate and proactively prepare for crisis situations during virtual therapy sessions, especially when working with trauma and high-risk client populations. This guidance is reinforced by APA articles from 2017. It is crucial to clarify protocols for managing crises remotely, including suicidal ideation, threats of harm, or disclosures of ongoing abuse. When geographical distance is a factor, safety plans with nearby support systems may need to be established to assist at-risk patients.

Best practices involve creating and clearly communicating telehealth-specific crisis response plans. These plans should include immediate contact numbers, such as suicide hotlines or other interventions typically provided in face-to-face settings. Procedures for emergency intervention must be clearly outlined, including agreements to remain online beyond the scheduled therapeutic hour if necessary, to ensure the patient's safety and stabilization, and potentially arranging for a safe person to join them. Detailed, written crisis protocols outlining exact steps for both the client and clinician to follow in urgent situations are also essential.

Ethics Summary

Ethical practice within telehealth is critical for ensuring the delivery of effective, safe, and culturally responsive behavioral health services. By diligently adhering to established ethical guidelines, behavioral health clinicians can successfully provide trauma-informed care, implement child-focused interventions, and offer diversity-inclusive therapy services remotely. It is imperative for clinicians to engage in continuous professional development through regular training and to maintain familiarity with current ethical codes. This ongoing commitment provides the necessary foundation for sound ethical decision-making within the evolving landscape of telehealth practice.

Case Study: Best Practices and Ethical Considerations in Telehealth

Returning to our case study, as we meet with Daniel and his mother for their initial telehealth appointment, it is critical to integrate ethical guidelines and best practices. The first step involves obtaining clear and specific informed consent from Sofia regarding the nuances of telehealth sessions. This conversation must ensure she thoroughly understands the potential risks, the privacy safeguards we will implement, and the privacy measures she should also take. Additionally, a plan for addressing emergencies or technological interruptions must be established. Utilizing an encrypted, HIPAA-compliant telehealth platform and clearly outlining data security measures will enhance trust in the telehealth process.

To handle informed consent with Daniel's mother and ensure her understanding, a clear, age-appropriate explanation of telehealth, its functionality, and what to expect should be provided. Verification of understanding can be achieved by asking Sofia to paraphrase or recite her understanding of how the telehealth sessions will work, with this consent thoroughly documented.

To confirm confidentiality and data security with Daniel's family, it is essential to clarify that the platform is encrypted and to discuss privacy settings so they understand that session content is not shared with others. The clinician's unwavering commitment to confidentiality should be emphasized. Furthermore, providing a written detailed explanation or a frequently asked questions (FAQ) document can be a valuable resource, particularly if telehealth is a regular component of the clinician's practice.

Telehealth for Trauma Treatment and EMDR

We now turn our attention to Eye Movement Desensitization and Reprocessing (EMDR), specifically examining how this powerful, evidence-based trauma intervention can be adapted for telehealth settings. While early research and interventions for EMDR were primarily conducted face-to-face, telehealth has significantly broadened its accessibility, providing essential trauma treatment to clients who might otherwise face limited access due to geographic, physical, or logistical barriers. Shapiro's 2017 article, referenced at the end of this document, provides valuable insights into this expansion. Successfully translating EMDR to virtual environments necessitates thoughtful modifications, specialized tools, and careful ethical considerations to ensure both effectiveness and client safety.

EMDR Brief Summary

EMDR is an evidence-based therapeutic modality primarily used for addressing trauma and distressing experiences. Developed by Francine Shapiro, EMDR integrates bilateral stimulation, such as guided eye movements across the midsection, to facilitate the brain's natural processing mechanisms. This approach enables clients to reprocess traumatic memories, thereby reducing their emotional intensity and associated distress. EMDR has demonstrated high effectiveness as an evidence-based intervention for post-traumatic stress disorder (PTSD), anxiety disorders, and depression, often leading to a more rapid alleviation of symptoms compared to some traditional therapies. Its incorporation expands the therapeutic toolbox, offering a powerful resource for supporting clients on their healing journey.

How to Obtain Training

EMDR training is typically available to licensed behavioral health professionals, including psychologists, social workers, counselors, marriage and family therapists, and psychiatric nurses. The training process generally involves completing an EMDR International Association (EMDRIA) approved course. These courses consist of intensive workshops that combine didactic learning, live demonstrations, supervised practice, and consultation sessions. Training usually spans several weekends or a week-long intensive program, followed by substantial supervised clinical practice sessions to ensure competency. After initial training, ongoing supervision and consultation are crucial for therapists to refine their skills. Completing this comprehensive training equips clinicians with a robust, evidence-based therapeutic tool that significantly enhances their ability to work with patients experiencing trauma and anxiety.

Virtual Bilateral Stimulation Methods

Bilateral stimulation is at the core of EMDR treatment. Traditionally, this involves eye movements guided by a therapist in person. In telehealth, several virtual methods are utilized. Visual methods may include following a therapist's finger across the webcam or using digital platforms specifically designed for EMDR, some of which feature tools that facilitate back-and-forth eye tracking, such as RemotEMDR or BilateralStimulation.io. These resources are listed in the references section. Another common method involves auditory bilateral stimulation, where clients use headphones to listen to alternating audio tones, facilitated by specialized EMDR platforms. Clinicians may need to provide additional coaching to patients on setting up their virtual environment, including the use of headphones, to achieve this.

Tactile stimulation offers another avenue, involving methods clients can perform themselves, such as alternately tapping on their shoulders or legs, often referred to as a "butterfly hug" technique. All these methods aim to activate bilateral brain activity, which is essential for EMDR processing, while maintaining client comfort and engagement in a virtual format. It is crucial to clearly demonstrate and practice virtual bilateral techniques with clients before starting treatment. This proactive approach prevents the first exposure to these techniques from coinciding with the discussion of a traumatic experience, thereby reducing anticipatory anxiety. The goal is to ensure clients feel comfortable and competent with the technology before engaging in sensitive processing.

These methods have proven effective when clearly demonstrated, practiced, and discussed with clients prior to therapy sessions, as highlighted in Parnell's research. The therapist's role is to select the bilateral stimulation method most suitable for the client's comfort, preference, and technological capabilities.

Telehealth Adapted EMDR Protocol

Adapting the standard EMDR protocol, which typically includes eight phases—history taking, preparation, assessment, desensitization, installation, body scan, closure, and reevaluation—to a teletherapy format requires maintaining fidelity to the original methodology. While adaptations are necessary, the fundamental phases must still be followed, just as they would be with an in-person patient. Telehealth adaptations primarily focus on utilizing secure virtual environments to ensure privacy and compliance with HIPAA regulations. It is crucial to adequately prepare clients for what to expect during remote sessions.

Reinforcing the structure of EMDR virtually and thoroughly explaining each phase is critical. Adjusting the pacing of the session and transparently communicating these adjustments to the patient empowers them with information about the pros and cons of the virtual format. If a patient ultimately decides that an in-person approach is preferable, that wish should be respected.

Remote Resourcing and Stabilization

A critical component of EMDR therapy, especially when addressing severe trauma, is ensuring clients possess effective emotional regulation tools. In telehealth settings, this may involve guiding clients through virtual mindfulness exercises, grounding techniques, or guided imagery. Helping the client create a "calm place" and "safe place" virtually can significantly enhance their resilience. This is particularly important when discussing sensitive, trauma-related issues, as it helps reduce emotional flooding during processing and ultimately reinforces the client's sense of agency.

This process requires regular practice and consistent reinforcement of these resources at the beginning and end of sessions to help clients manage distress. When considering adaptations, it may be necessary to dedicate more time to ensuring the initial starting point or location is quiet and confidential, fostering a calm environment conducive to entering a meditative headspace.

Trauma-Focused Telehealth EMDR

When utilizing EMDR specifically for trauma-focused therapy via telehealth, special attention must be given to remote containment strategies, crisis planning, and any immediate safety measures that might be necessary if the patient experiences emotional flooding during the session. A clear plan must be in place to manage such situations and guide the patient back to a calm state.

During trauma-focused sessions, emotional activation is expected. As clinicians, we must carefully assess a client's readiness and stability before initiating EMDR online. Clear emergency protocols and crisis planning must be firmly established, and clients should be provided with explicit guidelines or frequently asked questions (FAQs) regarding crisis procedures. This might include providing resources such as the National Suicide Hotline (988) and establishing a specific telehealth safety plan to ensure immediate access to crisis interventions if needed.

Virtual EMDR Group Protocols

Virtual EMDR group therapy is an emerging and increasingly beneficial approach, particularly in scenarios involving shared trauma, such as natural disasters, community violence, or supporting healthcare workers during events like the COVID-19 pandemic. Much of the research in this area originated from the need to provide an outlet for highly fatigued and overtaxed healthcare workers to process shared experiences with peers.

Group EMDR protocols necessitate special attention to informed consent regarding confidentiality and group safety. It is crucial to ensure that the virtual environment is private, meaning that individuals in the background of one participant do not have access to the confidential information of other participants. This mirrors the in-person imperative to prevent information from leaving the group. Facilitators must ensure a secure environment, clarify boundaries, roles, and expectations prior to initiation, and continuously reinforce confidentiality, especially given the increased number of linked devices in a group format.

EMDR Telehealth Ethics Reminder, Resources and References

For further guidance on EMDR telehealth ethics, several key resources are available. The EMDR International Association (EMDRIA) provides specific guidelines on virtual EMDR, accessible through their website. Additionally, the American Psychological Association (APA) offers comprehensive telepsychology guidelines that are highly relevant.

In terms of specific EMDR telehealth platforms and tools, several options exist. RemotEMDR is a dedicated online EMDR therapy platform. BilateralStimulation.io offers a free virtual bilateral stimulation tool, and Easy EMDR provides an online platform for visual and auditory bilateral stimulation.

For client safety and crisis resources, the National Suicide Prevention Lifeline (988) offers 24/7 crisis support. The Crisis Text Line provides text-based crisis support by texting HOME to 741741.

Recommended literature for clinicians seeking to deepen their understanding and training in EMDR includes:

• Shapiro, F. (2017). Eye Movement Desensitization and Reprocessing (EMDR) Therapy: Basic Principles, Protocols, and Procedures (3rd ed.). Guilford Press.
• Leeds, A. (2016). A Guide to the Standard EMDR Therapy Protocols for Clinicians, Supervisors, and Consultants (2nd ed.). Springer Publishing Company.
• Parnell, L. (2013). Attachment-Focused EMDR: Healing Relational Trauma. W.W. Norton & Company.

These resources provide comprehensive information for those looking to pursue more training or enhance their EMDR practice in a telehealth context.

Case Study: Effective Rapport-Building via Telehealth

Returning to Daniel and Sophia's case, building rapport through telehealth requires very intentional efforts. Sessions can begin with engaging, age-appropriate icebreakers. For instance, asking Daniel about his favorite hobbies or inviting him to a "virtual show and tell" where he can share objects or activities from his home that he wouldn't typically bring to an in-person session can be highly effective. This might include introducing pets, which can be a powerful way to build rapport and bond with the patient.

Consistently maintaining direct eye contact, assuming it is culturally appropriate, involves looking into the camera and modeling how to interact on screen. This clearly demonstrates to Daniel that the clinician is focused and attentive, serving as positive modeling not only for children but also for adults, showing a high comfort level with the technology and a genuine presence.

To modify communication style for building trust and rapport online with a child client, clinicians should adjust their voice tone, utilize visual gestures, and employ expressive facial expressions. Incorporating interactive elements that foster emotional connection is also crucial.

Regarding virtual tools or activities that might engage Daniel effectively, the internet offers numerous possibilities. Shared online games, such as chess, checkers, or word games, can be beneficial, provided they are compatible with a HIPAA-compliant platform. Digital drawing tools and storytelling applications, akin to a journaling practice, can also enhance engagement and make sessions more enjoyable for Daniel.

Case Study: Trauma Therapy via Telehealth

In addressing Daniel's trauma from witnessing domestic violence, a trauma-informed care approach specifically adapted for telehealth is essential, guided by best practice guidelines. Before delving into traumatic memories, it is paramount to ensure Daniel is in a safe, comfortable, and confidential space at home. Virtual grounding exercises should be employed, teaching Daniel breathing or sensory grounding skills to manage distress. This foundational work and coaching, which might be more extensive than in face-to-face therapy, are crucial to ensure that if Daniel becomes overwhelmed by the additional element of technology, he can utilize techniques like deep breathing to regain presence in the session.

To adapt trauma-focused interventions for Daniel via telehealth, clinicians might use visual aids, such as a breathing exercise, and virtual grounding techniques like counting backward from 10. Each step should be clearly demonstrated over video to eliminate any ambiguity, ensuring Daniel does not have to guess how to perform the technique.

Telehealth-specific safety measures must also be considered. Working collaboratively with Sofia, Daniel's mother, to establish a clear safety plan is vital. This plan should ensure Daniel has access to supportive resources and emergency contacts in case of any distress he might experience during sessions, particularly given the potential for traumatic events related to domestic violence to arise.

Adapting Child and Play Therapy for Virtual Care

Child and play therapy necessitate creativity when transitioning to an online format. The integration of engaging, interactive virtual activities that align with the child's developmental stage is crucial. Encouraging caregiver involvement when appropriate facilitates meaningful therapeutic interaction, even in a remote setting. Examples of such activities include guided drawing, where a child might draw their family and describe its members, or a more specific prompt like drawing how they wish to be perceived by peers. Interactive storytelling or bibliotherapy can also be employed, perhaps through shared digital storybooks or collaborative drawing platforms. Virtual sand tray therapy, using digital tools that allow children to select and place symbolic objects, helps externalize internal experiences. Emotion-focused games, virtual puppet therapy, and mindfulness or virtual yoga sessions are also valuable options. Clinicians must guide parents in setting up a conducive therapy space at home to maximize effectiveness and ensure safety, potentially sending FAQs or emails in advance.

Modifying Therapy Techniques for Virtual Sessions

When transitioning play therapy to a virtual platform, careful selection of methods that are engaging, interactive, and developmentally appropriate is essential. Virtual interventions must be clearly structured and easy for the child to follow remotely. The principle of "less is more" often applies; steps should be easily digestible. It is important to anticipate and resolve any technology challenges. If additional interactions involving hyperlinks or navigation to other areas are incorporated, their number should be limited to avoid overwhelming the child or parent. Selecting virtual tools such as digital drawing platforms, online stories, and interactive games can significantly enhance engagement and outcomes, offering age-appropriate alternatives to standard talk therapies.

Integrating Caregivers Effectively

Caregivers, especially for children, play a crucial role in virtual therapy. Their involvement in teleplay therapy sessions is paramount, as virtual therapy takes place within the home environment, making caregiver support central to therapeutic activities. Clinicians can engage parents through phone calls or virtual video calls to outline session intentions and specific timestamps for their involvement. Gil's 2015 article provides good examples of how to prepare and converse with family members or caregivers. For instance, caregivers might set up a safe, comfortable therapy environment, assist with technology setup, and reinforce session activities. In a virtual sand tray therapy scenario, extensive coaching with the parent might enable them to facilitate the physical interaction that would otherwise occur in a face-to-face setting, with the practice extending as homework.

Tele-Play Therapy Examples

Several tele-play therapy examples can be effectively adapted for virtual settings. Guided drawing and expressive arts encourage children to express emotions through interactive drawing tasks. Clinicians might prompt a child to create a safe space or draw their feelings, then discuss these creations to gain insights into their emotional world. Interactive storytelling and bibliotherapy can involve digital storybooks or shared screens, allowing for collaborative drawing or storytelling. Virtual sand tray therapy, utilizing digital platforms, enables children to select and place symbolic objects, helping them externalize internal experiences safely. Emotion-focused games, such as feeling charades or emotion matching, promote emotional identification and expression. Virtual puppet therapy offers a unique dramatic element, leveraging the unseen space to facilitate safe emotional expression through puppets. Finally, mindfulness and virtual yoga, through simple exercises or brief child-friendly sessions, can help reduce anxiety and improve emotional regulation. Clinical judgment is always essential to determine the best fit for the child, their family's comfort, and their overall interaction and growth.

Family and Parent-Child Interactive Teletherapy

Family involvement through structured interactive teletherapy can be a powerful tool, particularly in addressing relationship dynamics. This approach can help strengthen attachment bonds and reinforce session outcomes within the home environment. Various methods can facilitate family interaction on screen, including joint art projects, collaborative storytelling, or structured emotion-sharing tasks. Anything that promotes effective communication and supports family wellness can be beneficial.

Trauma-Focused Approaches and EMDR Adaptations

Shapiro's 2017 article highlights the significant therapeutic value of integrating trauma-informed strategies, such as virtual EMDR or trauma-focused Cognitive Behavioral Therapy (TF-CBT), adapted for telehealth. The article specifically discusses carefully adapted trauma processing techniques, including virtual bilateral stimulation through guided tapping activities or "butterfly hugs," which support children in safely exploring and processing traumatic memories remotely. Clinicians engaging in these trauma-related processing techniques via telehealth are strongly encouraged to consult this article for comprehensive guidance.

Considerations for Diversity, Equity, and Inclusion (DEI)

Adapting child and play therapy techniques virtually also requires careful attention to cultural sensitivity, diversity, equity, and inclusion. It is paramount to ensure that all activities are culturally relevant, inclusive, and sensitive to the family's background. This necessitates an open discussion at the outset of therapy, prompting clinicians to thoughtfully consider the cultural differences that may exist based on the patient in front of them.

Ethical Considerations in Virtual Child Therapy

Several ethical considerations are paramount in virtual child therapy. Confidentiality and privacy are critical, requiring the exclusive use of HIPAA-compliant telehealth platforms. Informed consent is equally crucial; caregivers must be fully informed about telehealth specifics, potential risks, and their responsibilities during sessions. They need to understand the pros and cons of engaging in this format, as convenience alone does not guarantee suitability for their presenting problems or symptoms. Competence is another key ethical pillar; clinicians must continuously develop their skills related to virtual care delivery, ensuring familiarity with technological platforms and the utilization of age-appropriate virtual therapy methods. Finally, safety protocols are essential. Clinicians must have a clear safety plan and established procedures for implementation should a crisis arise during a session.

Adapting Child/Play Therapy to Telehealth Wrap-up

As we conclude this section, it is evident that teleplay therapy offers innovative, accessible, and highly effective avenues for delivering therapeutic services remotely. Clinicians are strongly encouraged to continuously expand their telehealth toolkit through ongoing professional education, consulting with experienced colleagues, and seeking guidance from professional associations that have developed specific guidelines, such as the Association for Play Therapy and the National Child Traumatic Stress Network (NCTSN), which are excellent resources for ongoing training.

For Daniel's case, to facilitate play-based emotional expression, specific virtual interventions could include utilizing virtual sand tray tools, guided storytelling, and drawing platforms. In this scenario, such approaches could encourage Daniel to open up more emotionally and be more willing to explore his experiences, thereby building stronger rapport. To monitor and maintain engagement and emotional safety during virtual child therapy, clinicians should regularly observe Daniel's emotional reactions, frequently check his comfort level, and use rating scales or check-ins and check-outs. This continuous assessment, not just at the start of treatment but at each subsequent visit, helps gauge his comfort and the effectiveness of the therapeutic relationship.

Building Human Connection Virtually

Establishing a strong therapeutic alliance remains paramount in a virtual setting, just as it is in person. This involves building trust and rapport, increasing emotional attunement remotely, and effectively managing any virtual crises. When patients know that their clinician has a plan for managing emergencies, it fosters a sense of security and trust.

Telehealth Best Practices: Key Takeaways

To recap the essential elements for mastering telehealth in behavioral health:

• Quick review of ethical guidelines: Clinicians must regularly consult their specific ethical guidelines and state regulations to ensure compliant and responsible practice.
• Cultural responsiveness in telehealth: Understanding and adapting to diverse cultural backgrounds, language barriers, and digital literacy levels is crucial for providing equitable and effective care.
• Effective virtual therapeutic techniques: Employing creative, engaging, and age-appropriate interventions, especially for trauma and child therapies, is key to maintaining clinical effectiveness in a remote environment.

Ultimately, the aim is to create compassionate, effective, and ethical care remotely. The resources discussed throughout this article, including specific platforms for trauma-based interventions like EMDR and general ethical guidelines from organizations such as the APA, ACA, and NASW, provide invaluable support for clinicians in achieving this goal (NASW, 2021).

Telehealth Course Resources

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Child and Play Therapy via Telehealth

• Virtual Sandtray Therapy: https://www.sandtrayplay.com
• Interactive Storytelling and Bibliotherapy: https://www.storybird.com
• Virtual Puppet Therapy: https://puppetools.com
• Online Playrooms and Interactive Games: https://toytheater.com
• Virtual Mindfulness and Yoga Activities: https://www.cosmickids.com

EMDR and Trauma-focused Telehealth Resources

• EMDR International Association (EMDRIA): https://www.emdria.org
• Virtual EMDR Platform: https://virtualemdr.com
• Trauma-focused Cognitive Behavioral Therapy (TF-CBT): https://www.nctsn.org/interventions/trauma-focused-cognitive-behavioral-therapy
• PTSD Telehealth Toolkit (Veterans Affairs): https://telehealth.va.gov

Telehealth Ethical Guidelines and Resources

• American Psychological Association (APA) Guidelines for Telepsychology: https://www.apa.org/practice/guidelines/telepsychology
• American Counseling Association (ACA) Code of Ethics (Telehealth): https://www.counseling.org
• National Association of Social Workers (NASW) Standards for Technology: https://www.socialworkers.org

References

American Counseling Association. (2014). ACA code of ethics. Retrieved from https://www.counseling.org/Resources/aca-code-of-ethics.pdf

American Psychological Association. (2017). Ethical principles of psychologists and code of conduct. Retrieved from https://www.apa.org/ethics/code

American Psychological Association. (2020). Publication manual of the American Psychological Association (7th ed.). https://doi.org/10.1037/0000165-000

American Psychological Association. (2021). Guidelines for the practice of telepsychology. Retrieved from https://www.apa.org/practice/guidelines/telepsychology

Association for Play Therapy. (2020). Play therapy best practices. Retrieved from https://www.a4pt.org/page/PTBestPractices

EMDR International Association. (2020). EMDR therapy and telehealth guidelines. Retrieved from https://www.emdria.org

Gil, E. (2015). Play in family therapy (2nd ed.). Guilford Press.

Landreth, G. L. (2021). Play therapy: The art of the relationship (4th ed.). Routledge.

Leeds, A. (2016). A guide to the standard EMDR therapy protocols for clinicians, supervisors, and consultants (2nd ed.). Springer Publishing Company.

National Association of Social Workers. (2017). NASW standards for technology in social work practice. Retrieved from https://www.socialworkers.org

National Association of Social Workers. (2021). NASW code of ethics. Retrieved from https://www.socialworkers.org/About/Ethics/Code-of-Ethics

National Child Traumatic Stress Network. (2021). Trauma-focused cognitive behavioral therapy. Retrieved from https://www.nctsn.org/interventions/trauma-focused-cognitive-behavioral-therapy

Norwood, C., Moghaddam, N. G., Malins, S., & Sabin‐Farrell, R. (2020). Working alliance and outcome effectiveness in videoconferencing psychotherapy: A systematic review and noninferiority meta‐analysis. Clinical Psychology & Psychotherapy, 27(6), 797–808. https://doi.org/10.1002/cpp.2456

Parnell, L. (2013). Attachment-focused EMDR: Healing relational trauma. W.W. Norton & Company.

Perry, B. D., & Hambrick, E. P. (2008). The neurosequential model of therapeutics. Child Trauma Academy. Retrieved from https://childtrauma.org

Shapiro, F. (2017). Eye movement desensitization and reprocessing (EMDR) therapy: Basic principles, protocols, and procedures (3rd ed.). Guilford Press.

Substance Abuse and Mental Health Services Administration. (2014). SAMHSA’s concept of trauma and guidance for a trauma-informed approach. Retrieved from https://store.samhsa.gov/sites/default/files/d7/priv/sma14-4884.pdf

Veterans Affairs Telehealth Services. (2021). PTSD and trauma telehealth toolkit. U.S. Department of Veterans Affairs. Retrieved from https://telehealth.va.gov

Additional Current References

These references were added as additional information on the topic for course participants; the presenter did not use them in developing the course.

Adedoyin, A. C., Wynn, S., Adunlin, G., Adegboyega, A., Holly, H., Makanjuola, D. I., Adedoyin, O. O., Bolaji, O., Olawoyin, E., & Makanjuola, O. E. (2025). Telehealth access inequality for african americans in rural areas: Interventions from an interprofessional education perspective. Journal of Human Behavior in the Social Environment. Advance online publication. https://doi.org/10.1080/10911359.2025.2470901

Choi, S., Hussain, S., Wang, Y., D'Aunno, T., Mijanovich, T., & Neighbors, C. J. (2025). Telehealth disparities in outpatient substance use disorder (sud) treatment among medicaid beneficiaries during covid-19. Substance Use & Misuse. Advance online publication. https://doi.org/10.1080/10826084.2025.2478603

Palfai, T. P., Kratzer, M. P. L., Taylor, J. L., Otis, J. D., & Winter, M. R. (2025). Addressing pain and heavy drinking among patients in hiv-care: A pilot study of an integrated telehealth intervention. AIDS and Behavior. Advance online publication. https://doi.org/10.1007/s10461-025-04660-8

Torres, V. A., Coe, E., Jackson, J., Leonard, K., Rostockyj, J., Swensen, K., Meyer, E., Gulliver, S. B., & Jones, S. (2025). Data‐informed selection of evidence‐based treatments for posttraumatic stress disorder and co‐occurring symptoms. Journal of Traumatic Stress. Advance online publication. https://doi.org/10.1002/jts.23133

Young, J. F., Jones, J. D., Schwartz, K. T. G., So, A., Dysart, G. C., Kanine, R. M., Gillham, J. E., Gallop, R., & Davis, M. (2025). Telehealth-delivered depression prevention: Short-term outcomes from a school-based randomized controlled trial. Journal of Consulting and Clinical Psychology, 93(4), 213–225. https://doi.org/10.1037/ccp0000913