Group telepractice guide
Telepractice is the use of telecommunications to deliver parenting support and other services remotely. It draws upon experiences in the delivery of telehealth and can include synchronous (e.g. virtual home visits) and asynchronous (e.g. email, text) approaches.
We use the term telepractice rather than telehealth to avoid the perception that these modes of service delivery are restricted to healthcare settings. Other commonly used terms in health care include eHealth (referring to the use of internet technology) and mHealth (encompassing mobile and app technologies).
Telepractice has the potential to offer practitioners and the families they support significant benefits in accessibility, safety and flexibility. Research shows that online sources are where most parents turn for parenting advice, so telepractice offers the opportunity to meet parents where they are.
This resource provides recommendations for practitioners who are running, or intend to run, group telepractice supports for parents and families. These recommendations come from two sources.
- Firstly, the Parenting Research Centre has been closely involved for some time in supporting practitioners who run group supports for parents, including telepractice groups, and have collected their insights into what works and relevant challenges.
- Secondly, to see if we could find any recent evaluations, we conducted a brief search of PsycInfo for publications dated 2016 onwards on online groups for parents, including telehealth, videoconferencing, e-therapy and other technology-based flatforms. While telepractice has been used for some time in the field, the state of the evidence is still a work in progress.
Practitioners who are used to running in-person groups with parents might be used to one main form of support that you offer to parents in that role – the group sessions themselves. This is where the action is, so to speak – a number of enrolled parents come together and benefit in a range of ways from interacting with you, any session content, and each other. There are most likely other activities you do as well, depending on your work context, such as administration in setting up groups, and following up with parents and colleagues about a range of related issues, but these would mostly be in aid of helping run the group itself.
Given this, it would be natural to default to running telepractice groups in the same way as they are run in person. If you run four three-hour parent groups per week with 8-12 parents plus their children in each, then you might intend to run four three-hour online live video calls per week with the same 8-12 parents plus their children participating. This might work in some cases, but research plus parent and practitioner feedback tell us that most of the time, live online connections (where all participants are joining in at once, in the same online platform, in real-time) work best when we use them somewhat differently to in-person interactions.
The adaptations and recommendations in this resource are divided into three domains. These are:
- Design decisions to be made in the process of setting up telepractice groups, or to be applied to existing groups
- Practices that can be used in the moment while engaging in group videoconferencing with parents
- Implementation features that give telepractice the best chance of being successful and effective in your context.
Supported by the Victorian Government Department of Health and Human Services.
- Reduce the length of sessions
- Reduce content presented during each session
- Blend delivery across a range of methods
- Take advantage of flexible scheduling
- Train participants in technology use
Studies of telepractice effectiveness and practitioner feedback indicate that the ideal length of a telepractice group session is shorter than that of an in-person session. The reason for this is not established, but it seems participants find it harder to concentrate for an extended period of time during a telepractice session – perhaps due to the novelty of the experience, or the use of audiovisual setups that strain the senses (such as small screens).
For this reason, it is recommended that while in-person groups might successfully run over a number of hours, telepractice versions should be kept to about an hour. This isn’t a firm recommendation in terms of the precise amount of time that works best, although some researchers suggest that two hours is too long.
Practitioners should monitor parent engagement throughout sessions and adjust the duration of future sessions accordingly. It is also important to note that many practitioners find that many activities take longer in telepractice group sessions than in their in-person counterparts. Things like group interactions and discussions need more time allocated to them, which means carefully planning and reviewing session structure is necessary.
Because there are indications that participants struggle to concentrate and absorb information for an extended period during a telepractice group session, it is advisable to reduce the amount of information presented. This presents a particular challenge for those groups where the aim is educating parents about effective parenting practices.
Spending too long in one-way delivery of content may risk parents becoming disengaged, which may cause issues for their future attendance of the telepractice group, and may lead to them not retaining much of the information shared anyway. Therefore, it’s important to be realistic about the amount of content you aim to include in a telepractice session. Unfortunately, there are no firm guidelines yet available that can be offered about the precise amount of content that should be included.
Some practitioners may feel skeptical about the feasibility of running telepractice groups for their respective programs due to this need to restrict the amount of content imparted during a given session. However, there are a number of options that may help here. Content can be moved out of the live interactive group and into other modalities, such as email or text messaging. Or, it may be feasible to schedule shorter group meetings more frequently, thereby covering less content per meeting but a similar amount of content over all.
Telepractice has the potential to offer flexibility that cannot be achieved with traditional, in person delivery. There is emerging evidence that in many cases, approaches like blended delivery can lead to better engagement and outcomes than programs that stick to one mode of delivery.
In designing your approach to telepractice for groups, it is important to analyse the key activities and outcomes you aim to achieve in running parenting support groups, then choose telepractice methods that achieve these.
It’s likely some activities can naturally be moved out of the live group interaction and into other telepractice modalities, leaving space in the live group for the activities that benefit most from that format. For example, rather than spend 30 minutes at the start of a group session presenting a strategy for managing behaviour, you might share this as a pre-recorded video ahead of the session, then provide a brief recap at the start of the live session before launching quickly into group discussion or rehearsal (the parts that need to be done interactively).
Hopefully, the time saved by reducing the duration of live interactions with families in group settings will enable practitioners to invest in engaging parents via one or more of a range of other modalities. Some of these modalities are listed below, along with suggested uses in supporting group telepractice with families.
- Multimedia asynchronous messaging: Modalities such as email and social media allow practitioners to share a whole range of content with participants, and collect participant input and feedback directly. This can be a great way of sharing resources or information about parenting or local services, through text, documents, videos etc.
- Rapid text-based chat: There are many applications that allow participants to chat in real time or close to it via applications or websites, such as WhatsApp. Practitioners can send discussion prompts to a group text chat and can share their own views and experiences in response, and observe and react to other participants’ responses.
- Synchronous voice chat: There are a range of ways to connect participants via voice, including via telephone calls, or via a videocall with the camera turned off. Many videoconferencing services enable participants to dial into a videoconference via phone, which means they won’t be able to see other participants or be seen, but this is a good way to involve participants who have limited internet access.
Running traditional in-person groups for parents presents a range of logistical challenges. They may need to be scheduled when communal facilities are available, when transport is convenient, when catering can be organised, outside of naptimes and when older children are at school.
In many cases, telepractice may provide opportunities to circumvent these issues. In designing telepractice services, consider broadening the range of scheduling options offered. This may present opportunities to increase family engagement. It may also enhance flexibility for practitioners. Consider whether it may be beneficial to offer groups in closer succession due to the reduced need for cleaning up after one group and setting up before another.
Practitioners may be wary of parents not engaging with telepractice groups due to the barrier of unfamiliarity with the technology involved. If parents struggle to use devices, or aren’t familiar with the apps being used, or aren’t used to seeing themselves or others on camera, they may feel reluctant to participate; if they do participate, they might be less able to benefit from the session if a significant amount of their attention is occupied by thinking about the technology rather than the interactions within the session.
Consider the role of the practitioner in helping to build parental confidence with technology use. A relatively small investment of time in helping parents to understand the technology being used may not only help parents engage successfully with the telepractice group, but with other areas of their lives where technology plays an important role. Just as a parent experiencing social anxiety may need additional supports to attend a traditional in-person group for parents and also benefit greatly from the support and validation they find there, so might a parent who is not confident in using technology benefit from patience, instruction and encouragement in accessing digital services. Fortunately, there is some research to show that while parents may indicate a level of discomfort with technology for the first few telepractice sessions in which they participate, for many this improves significantly over subsequent sessions.
Good ways of training participants in technology use involve an individual phone call before the first telepractice group session to check their understanding of what’s involved and explain the setup, then running through how to use the telepractice platform at the start of each group session and having the participants test the features. It has also been recommended to have a second facilitator available expressly for troubleshooting technology issues during telepractice sessions.
Supported by the Victorian Government Department of Health and Human Services.
- Establish methods for turn-taking
- Invest in participant ownership of the group
- Get participants talking and contributing
- Increase use of visuals
- Take advantage of activities that work better online
Practitioners and parents report that turn-taking can be somewhat clunky in telepractice groups. Fortunately, there are some indications from the literature that this improves after a number of sessions. Nevertheless, it is advisable to implement some strategies to alleviate this.
Many videoconferencing applications include visual indicators that could be used by participants to show when they wish to contribute to the discussion. One option is to use the ‘mute’ button that is present in most (if not all) platforms. Generally, when a participant is muted, this is shown on the screen for other participants to see, in the form of an icon (often a microphone with a line through it, in red). The group facilitator can instruct the group to remain on mute, until they have something they want to say. Then, if they take themselves off mute before the previous participant stops speaking others will be able to see that the next participant is waiting to speak. Of course, participants will need to be reminded to watch other participants’ mute indicators to keep track of who’s keen to contribute at any given point in time. This method also fits with good telepractice in general, in that when a participant is not talking they are on mute so that any background noise is not transmitted to the group.
Another option is to use text-based chat in the background while someone is talking. Most videoconferencing platforms allow text messages to be sent live to the group, which then displays an alert each time a message is sent. The group facilitator can encourage participants to send a message to the text chat such as “I have a thought on that” or “could I say something” while someone else is talking, and then invite that person to speak next once the current speaker has made their contribution.
A number of videoconferencing platforms also feature the ability for a participant to click a ‘raise hand’ button, which then displays a raised hand overlaid on their video feed and/or next to their name, letting others know that they’d like to contribute to the discussion.
Another related issue that may contribute to awkwardness of turn-taking is the amount of time for which each participant speaks. Especially in very active groups, if a participant talks for a long time it’s likely more and more of the other participants will think of their own contributions to make while that person is talking, and probably become increasingly impatient, leading to multiple participants trying to jump in to the conversation when they see the chance. Practitioners may wish to institute a rough time limit for each contribution, which can help to keep the conversation flowing. Of course, this will need to be explained and understood by the group at the beginning of each session, and reminders are also likely to be required.
Participants who are not experienced in using technology to interact may feel that the telepractice platform does not ‘belong’ to them. This can lead to participants sitting back and waiting for the practitioner to lead every interaction, which detracts from the kind of engagement parenting support groups generally are aimed at achieving.
It may be possible to circumvent this by deliberately encouraging a sense of ownership of the group in participants. Use language that emphasises participant control (“what would you like to do next?”, “I noticed we don’t have much to say for some of the activities, what should we do about that?”) and defer to the group whenever appropriate. If a participant asks a question of the facilitator, they can ask what the group’s response is instead of answering directly. Many experienced facilitators will be familiar with these techniques from running in-person groups, and they are even more crucial in telepractice.
Another option to consider is to appoint an informal host for each session (from the participants) to run one or more aspects of the session, rotating amongst the participants each session. Participants are more likely to contribute actively to a discussion if they feel they are helping out one of their fellow participants to make the activity run smoothly.
It’s been reported that participants may tend to be more passive in a telepractice group compared to an in-person group setting. This could be caused by a range of issues, such as being less familiar with talking into a screen compared to talking to a person, being less immersed in the environment of the group while being at a remote location, or just being less sure of their role. Regardless, it’s likely telepractice practitioners need strategies for increasing the level of engagement and contribution of participants. Some of the techniques below, which are relevant to both in-person and telepractice groups, may be particularly helpful given these circumstances.
- Avoid the ‘question-and-answer’ trap. Instinctively, if we don’t get much a response, we may probe for more by asking follow-up questions. Unfortunately, this establishes an interview-style tone to the group, where participants will focus on giving acceptable, efficient responses to the practitioner’s questions rather than thinking about how they can contribute or learn from the process.
- Building on the strategy of limiting the use of questions, increase the use of reflections. This involves simply stating what you’ve heard, or making an observation about it. There’s good evidence to show this technique often prompts elaboration from the person who made the original remark.
- Where appropriate, practitioners may also consider sharing their own contributions (self-disclosure). This functions as a form of modeling – providing an example to the group of what an appropriate contribution looks like, and gets the ball rolling for other to follow on from. Anything that a practitioner shares is likely to prompt participants’ thoughts on that topic or bring to mind their own experiences.
- Finally, consider using silence strategically. In group settings many of us have an instinctual aversion to silence, and a practitioner may automatically step in to ‘save’ an activity where no one is speaking by speaking themselves. While this may be necessary at times, leaving a little extra time to sit with the silence conveys a strong message of expectation for a response. Sometimes a participant will make a contribution just to break the awkwardness of sitting in silence. Note that the practitioner should show by their body language that they’re comfortable with waiting in silence for a moment and adopt a facial expression that shows anticipation.
A number of studies indicate that increased use of visuals in telepractice groups achieves better engagement from parents. Fortunately, this is generally quite easy to achieve in telepractice as most modern videoconferencing platforms allow a practitioner to share their screen, or upload images or powerpoint slides to display within the application.
It is not yet clear from research exactly what visuals work best for which activities in telepractice for groups, so this is an area in which practitioners should actively experiment and monitor the results. Some examples include:
- one or more key words related to the topic of discussion
- images of families engaged in relevant activities
- video demonstrations of particular parenting practices
- you could also consider opening a text document that you share on your screen with the group and noting down participants’ various contributions during a group discussion
- Another good option would be to use the ‘whiteboard’ feature that can be found in some videoconferencing platforms, which allows you to type onto a space that all participants can see, or draw if with a mouse or stylus, and even invite participants to do the same.
Some activities that you may wish to undertake in a group setting work better in a telepractice setting than in a traditional in-person setting. Generally, the fact that all participants are situated in front of an internet-enabled device means that this is a great time for teaching or practicing activities that use these. You may wish to demonstrate how to access various websites or apps by sharing your screen and then showing the process step-by-step in real time. This could be particularly effective for families who have additional needs and must access a variety of services, or for those with low literacy in English.
The fact that participants are able to access the group remotely from their home environment may also have some advantages that practitioners can explore. If appropriate, participants could be invited to share any mementos and associated stories, or parenting approaches they’ve been using (such as reward charts stuck to the wall for managing behaviour), or some food they’ve been cooking that is relevant to their culture.
Supported by the Victorian Government Department of Health and Human Services.
- Undertake facilitator training and rehearsal in advance
- Undertake participant technology checks in advance
- Reflect on reactions to telepractice and technology
- Learn by doing and adapt
- Offer flexible, family-centred participation
One consistent message from research and practitioner reports is that it takes experience to become confident and effective in using telepractice for parent support groups. Or, to put it another way, the typical experience is one of being uncomfortable and possibly even skeptical about telepractice groups for a number of sessions when first using the modality. For this reason, it is strongly recommended that practitioners are given opportunities to build their familiarity with the format in a suitable and safe way.
Ideally, services running telepractice groups will be able to connect multiple practitioners who are or will be involved in running telepractice groups, who can then run practice groups with their colleagues as participants. It is recommended that this is done more than once. This is because the first practice group is often spent in discussion of the particulars of the technology and practitioners’ feelings about how well it is functioning. While this is an important discussion to have, it is also important to progress to preparing particular group facilitation strategies, and especially some of those most relevant to telepractice, such as are discussed in this resource.
Furthermore, learning is likely to be maximised with opportunities for some sort of actual rehearsal. In cases where a practitioner is able to participate in group rehearsals with multiple colleagues, a good idea is to use some role-play activities, where one practitioner will act as facilitator and the others will role-play as parents participating in the group. This is likely to feel awkward for many practitioners, but is perhaps the best way to build practitioner confidence and to help groups run more smoothly and effectively with real clients.
Most practitioners are keen to avoid being IT support consultants for their client families. Nevertheless, many families are likely to benefit from some assistance in making sure their technology set up is adequate to access and participate in the telepractice group as fully as they can.
Because dealing with technology issues can interrupt the activities a practitioner really wants to focus on during a group telepractice session with parents, it is recommended that these are dealt with in advance as much as possible. Therefore, practitioners should contact each enrolled family in advance of participating in their first telepractice group. For newly-enrolled parents, this contact should be an integral part of the intake procedure. For parents who are enrolled in other supports or have previously attended in-person groups, it is a necessary additional step.
These technology checks should not only educate the parent about the software to be used, but also check what device they’ll be using and the quality of their internet connection, as well as any data caps. The practitioner should also check that the parent knows how to use the basic functions of their device, then ask them to connect to the videoconferencing platform being used so that they can test the necessary functions that will be used during the group. The practitioner should also assess the quality of the audio and video being received through the device, and give recommendations about positioning to improve these if necessary.
While this may be time-consuming, the time invested early is likely to save more in the form of troubleshooting later. Showing this kind of personalised interest in a parent’s experience of the technology and their ability to get the most out of the telepractice group is also an effective way of building rapport with the family, and may lead to better attendance and engagement with the group in the future.
An interesting finding from the literature on group telepractice parenting supports is that while many participants and practitioners found them clunky initially, this generally improved by about five or six sessions into their experience. In fact, after about 10 sessions, parents provided high ratings of acceptability of the platform. Indeed, anecdotal feedback indicates that many parents in fact prefer telepractice groups to their in-person versions, for a variety of reasons.
This indicates that it’s important not to give up on telepractice for groups too early in the face of initial challenges. Some practitioners may be reluctant to persist with telepractice through this developmental period due to a broader skepticism about technology and its ability to enhance their work. Practitioners who have become proficient in running in-person groups and have seen good results from doing things this way might not wish to vary this formula. In these cases, supportive supervision and reflection may help practitioners explore their views on telepractice for groups and its relative strengths and weaknesses.
Practitioners should also be mindful of the need to support and encourage parents to attend telepractice groups even if they are initially reluctant. Again, research shows that the parent experience often improves over the number of sessions attended, so in order to achieve the best outcomes for their clients, practitioners need to work to engage families with groups and not be too quick to concur with the view that the telepractice group isn’t the right fit for a given family.
Telepractice for groups is a new or relatively new mode of work for many practitioners in family services and similar roles, and is increasingly utilised across the sector. This means that while the evidence about which practices work best is still emerging, there are constantly opportunities to improve services by learning through experience and making adjustments accordingly.
One way of assessing what works well in telepractice groups is to seek feedback from clients. 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. Consider other relevant metrics as well, such as rates of attendance.
Practitioners delivering telepractice groups should regularly reflect on the feedback obtained. This can be done in a group setting with colleagues, or individually, or both. Form hypotheses about why a particular approach or practice worked or didn’t work, and in cases where there are questions, try a different approach and see if that works. While doing so, it may be advantageous to involve the participating parents in the process – a practitioner may share with the group that they noticed one activity or feature of the group wasn’t so successful, or that the participants didn’t get so much out of it, and ask if it would suit them to try approaching it differently. This kind of collaborative approach will also help participants to appreciate that the telepractice group is a work in progress and that any aspects that are less than ideal for them might realistically improve in the near future.
One of the major limitations that parents report in relation to traditional, in-person groups is difficulties with accessibility. Because of the logistics involved with running and participating in an in-person group, they tend to be inflexible. Parents need to be able to attend at a certain location at a certain time and in a certain way or they won’t be able to at all. To really get the most out of telepractice for groups, it’s best to take full advantage of the flexibility that the modality provides. Some suggestions are provided below, the suitability of which will vary depending on local circumstances.
- We recommend a blended approach to group telepractice, with some engagements being via live group videoconferencing and some being via other means such as group text-based discussions, sharing multimedia via email, or individual phonecalls for skill rehearsal and troubleshooting. If this is adopted, it has the additional advantage of facilitating an individualised, family-centred approach. Each family might prefer a different mix of the various modalities employed – one might want less participation in group videoconferencing, but get a lot out of the resources shared via email, while another feels more comfortable with text-based interactions with the group via Facebook or WhatsApp, etc.
- By removing restrictions around geography, limitations around finding a time that suits can also be better accommodated. Whereas with in-person groups a parent would have to be able to attend at a time that is also convenient for other people in their local area, this doesn’t apply to telepractice groups. Services may wish to offer their clients the option to attend any time slot where there is capacity, rather than one that others from their local area are attending.
Supported by the Victorian Government Department of Health and Human Services.
Banbury, A., Nancarrow, S., Dart, J., Gray, L., & Parkinson, L. (2018). Telehealth interventions delivering home-based support group videoconferencing: Systematic review. Journal of Medical Internet Research, 20, e25.
Martin, S., Roderick, M. C., Lockridge, R., Toledo-Tamula, M. A., Baldwin, A, Kinght, P., & Wolters, P. (2017). Feasibility and preliminary efficacy of an internet support group for parents of a child with Neurofibromatosis Type 1: A pilot study. Journal of Genetic Counselling, 26, 576-585.
Rayner, M., Dimovski, A., Muscara, F., Yamada, J., Burke, K., McCarthy, M., Hearps, S. J. C., Anderson, V. A., Coe, A., Hayes, L., Walser, R., & Nicholson, J. M. (2016). Participating from the comfort of your living room: Feasibility of a group videoconferencing intervention to reduce distress in parents of children with a serious illness or injury. Child & Family Behavior Therapy, 38, 209-224.
Shah, R., Chakrabarti, S., Sharma, A., Grover, S., Sachdeva, D., & Avasthi, A. (2019). Participating from homes and offices: Proof-of-concept study of multi-point videoconferencing to deliver group parent training intervention for attention-deﬁcit/ hyperactivity disorder. Asian Journal of Psychiatry, 41, 20-22.
Vismara, L. A., McCormick, C. E. B., Wagner, A. L., Monlux, K., Nadhan, A., & Young, G. S. (2018). Telehealth parent training in the Early Start Denver Model: Results from a randomized controlled study. Focus on Autism and Other Developmental Disabilities, 33, 67-79.
Williams, L. K., McCarthy, M. C., Burke, K., Anderson, V., Rinehart, N. (2016). Addressing behavioral impacts of childhood leukemia: A feasibility pilot randomized controlled trial of a group videoconferencing parenting intervention. European Journal of Oncology Nursing, 24, 61-69.