We’re in the midst of a global pandemic.
It’s a big deal.
But it doesn’t change the fact that teenagers all over the country still need intensive treatment for mental health and substance use disorders. In light of the current regulations, most therapists have shifted over to teletherapy. Likewise, since adolescent intensive outpatient programs (IOP) and partial hospitalization programs (PHP) have been forced to close their brick-and-mortar locations, many have shifted to online platforms like Zoom to continue treating clients.
As any therapist might tell you, the transition from in-person to virtual therapy comes with its share of challenges. Especially when you’re the clinical program director of an IOP or PHP (or both!) and you’re dealing with multiple group sessions, a full staff of therapists, and a group of clients slated to receive three to seven hours of treatment every day.
Which means that people like Matt Metcalf, LCSW – Clinical Program Director of Partial Hospitalization and Intensive Outpatient Programs (PHP/IOP) for Evolve Treatment Centers – had their work cut out for them from the start. Metcalf has spent days researching best practices for telehealth and training his staff on new procedures. Like most PHP/IOPs, Evolve’s outpatient programs have also shifted to online platforms.
Here, Metcalf shares some insight on the lessons learned so far. He also provides helpful tips for other clinicians shifting from in-person to virtual treatment.
Lesson 1: No More Home Field Advantage
First and foremost, Metcalf says, there’s one fundamental difference that therapists need to understand about teletherapy: you don’t have the home advantage.
“Therapists are used to playing a lot of home games,” he says, using a sports metaphor. “Now we’re exclusively playing away games.” In other words: if you’re a therapist, your work just got harder, since you’re not on your own turf anymore.
In traditional therapy, clients come to the therapist’s office. It’s their responsibility to create a structured, therapeutic environment in that space. Clients wait in their waiting room to be called in. They sit in their usual place, and abide by certain norms and routines.
Now, the shoe is on the other foot.
“As therapists, we’re now going to our client’s homes and playing by their rules,” Metcalf says. You’re talking to them while they’re at home in their bedroom or living room. Clinicians have to work harder to recreate that same therapeutic environment they had when they controlled the space.
And if your clients are teenagers or millennials, they may have double the advantage. The virtual world is largely their world. Older clinicians might experience a slight learning curve navigating the technology that, for their teenage patients, comes naturally.
Lesson 2: Discuss Rules During the First Session
Don’t discount the importance of the first session, because that’s when you set the tone cor the new virtual relationship. Everything follows from that first session.
Metcalf says that the first therapy session should establish the rules of teletherapy. Every therapist in private practice or outpatient treatment center should spend time orienting their clients and staff to the specific technological rules and procedures you’d like them to follow.
“If you set the right table, you have the right meal,” Metcalf observes.
Ensure patients sign consent paperwork regarding telehealth before the first session
Discuss the need to remain in a private room for the duration of each session, how to set up a camera appropriately before the start of a session, and what to do if someone walks in in the middle of a session. Answer: immediately announce their presence to the therapist or the entire group. Therapists in private practice might also discuss logistical issues like cancellation policies.
For PHP/IOP programs, directors also need to talk about attendance. What happens when a client doesn’t arrive to a session? Or comes late?
Answers to these questions should all be discussed with the group.
Lesson 3: Create Routines. Lots of Routines.
Outpatient programs looking to shift to telehealth need to create and implement routines and procedures to keep organized and maintain structure.
“If a client isn’t going in to your office or program in person, there has to be certain routines that happen every day, or else clients – especially teen clients – are going to have a hard time even feeling like they’re actually in treatment.”
For example, every Friday, families receive a comprehensive schedule in their email with the Zoom links for every single session taking place the following week. This ensures that everything is organized in advance, and there’s no last-minute scrambling to send out a Zoom link one minute before a session starts. Metcalf customizes each email for his patients and their parents, taking into account the scheduled times of their individual therapy, family therapy, psychiatry, and group sessions.
At Evolve Treatment Centers, teens in PHPs participate in seven group sessions a day, while teens in IOP participate in three. Parents also participate in three hours of treatment a week: parent support groups, family therapy sessions, and multifamily sessions, all at times scheduled in advance.
Lesson 4: Establish a Sense of Community
Another routine Metcalf implemented?
Every day of treatment, at an appointed time, Metcalf and his staff hop onto a joint Zoom meeting and take turns calling each teen in the program on speakerphone with a cheerful morning greeting. These calls go something like this:
“Hi, this is Matt, your therapist, and I’m calling with the entire team at Evolve.” Then the teenager hears a chorus of “Hello!” from the entire staff.
Why do they do this?
“Psychologically, it’s extremely beneficial to hear four people on a phone line saying hi to you at the same time. Plus, it prepares them verbally and emotionally for the day of treatment coming up.”
This kind of formal greeting, of course, wouldn’t normally happen at an in-person PHP or IOP, where a teen would walk into the common area, see the staff, the rest of the group, and greet them as usual. However, in a virtual program, clinicians need to go above and beyond their usual routines to organize a more structured community environment. With teens not leaving their house most days, there needs to be a clear, delineated difference between a treatment day and any other day.
An early morning greeting creates that positive element of community for them.
Lesson 5: Accountability
Metcalf has a secret to his impressive 95% attendance rate: hold patients accountable.
At the start of every group session, the clinician checks to see if anyone is missing. If a patient hasn’t shown up within four minutes of the start of the session, the clinician doesn’t continue the group. Instead, the absent teen receives a call on their personal cell phone asking where they are. If they don’t answer, their parents receive a call. This typically clears things up within a couple of minutes.
Of course, there was a learning curve at first. Everyone had to figure out how Zoom was going to work for them, and iron out all the small and potentially disruptive glitches.
“But by the time we had our fifth group, we’d go on a meeting at 5:58, and within a span of four minutes, every teen would pop up on the screen, present at the group session.”
And that still happens, weeks later.
“Humans always pick the path of least resistance,” Metcalf says. “You have to make attending session easier than not attending.”
Of course, teens still miss sessions, sometimes. They may miss for mundane reasons. They oversleep. Or have internet issues. But they may miss a session because they’re in crisis and don’t want to log on and have everyone see them crying.
Whatever the case, a personal phone call is often a fast and efficient fix.
“If you keep clients accountable and they’re expected to perform, when they don’t perform it’s either because of a logistical problem or a personal issue. Both are in our best interests to resolve.”
Lesson 6: Adapt Goals to COVID Struggles
With COVID closing schools around the nation, Metcalf says the focus of treatment in PHP/IOPs should change as well.
Whereas programs might have previously focused on social skills and interpersonal relationships with peers and classmates, Metcalf says the focus of treatment in the programs he supervises has shifted to independent functioning, decision-making, and self-management skills. Patients learn how to create schedules for themselves every day, stay productive, and show themselves compassion. While these skills are always important, they’re especially vital during the coronavirus pandemic, when all teens are home.
Structure, Stability, Consistency
Prior to COVID-19, outpatient treatment centers had the responsibility to create a structured environment for teens and families that felt safe and therapeutic. The physical space and community largely contributed to that. Walking into the same dedicated rooms every day, seeing the same counselors, having separate areas for group sessions, individual sessions and downtime created a sense of permanence and solidity. Leaving your house or school and coming to PHP/IOP meant something significant. It was part and parcel of the therapeutic process. Now, outpatient treatment centers have the burden of trying to recreate that experience, and therapeutic impact, online.
That’s one of the many challenges mental health professionals like Matt and his clinical team at Evolve Treatment Centers meet and overcome every day. They do it because they’re committed to helping their patients in any way they can. For Matt and his team, it’s part of the new normal. No one really knows how long it will last, but one thing is certain: teens still need treatment during this pandemic, and the professionals who treat them are doing everything they can to get the treatment they need.