Telepractice extension: Family services

Telepractice potentially helps practitioners to do more to support families when and where they need it, using practices known as ecological momentary supports. Researchers focus on two key elements of these supports:

• ecological – they reach families in situ, in their natural environment
• momentary – they reach families at the moment when they need it.

Many clients already carry their smartphone throughout their daily routines and use it intermittently for activities like reading and responding to text-based messages, taking photos, and interacting with apps (Marzanno et al., 2015). These kinds of supports leverage the prevalence of smartphones in modern society.

The ecological momentary approach involves practitioners sending clients one or more prompts intended to help them progress towards their desired outcomes, in between more intensive contacts. They generally tend to aid approaches that have a behavioural element, that is, the client wants to do something in their daily life in order to achieve desired outcomes.

This approach shows great promise as when clients apply their learnings between sessions (sometimes called ‘homework’) it has been shown to significantly improve the effectiveness of interventions (Kazantzis, Deane & Ronan 2000).

However, simply telling clients that they should complete these between-session tasks is not always effective, and depending on the task and the family, they may find this difficult without support from a practitioner (Crawley et al., 2013). There is good evidence that family-focused services delivered by a practitioner and augmented with smartphone support are more effective than services without smartphone support (Lindhiem, Bennett, Rosen & Silk 2015).

The simplest way to use ecological momentary supports is to use a text-based or multimedia messaging service to send prompts and collect any responses.

Options include the standard short message service (SMS) offered by phone service providers, or a third-party app (e.g. WhatsApp, Facebook Messenger or Signal). You could also use email, but be aware many people may consider email messages less urgent, so you risk losing some of the ‘momentary’ benefit of the approach.

In designing ecological momentary supports in your work with families, you need to identify what sort of prompts are relevant to any particular family, and whether you want them to record and send you anything back in response.

Generally, it’s a good idea to look for skills they could practice or routines they could benefit from. For example, if a parent’s goal is to practice using mindfulness techniques to manage stress, your prompt could remind them of this objective, and ask them to consider when they might complete a 10-minute guided meditation. The message could also ask them to respond with their self-rated stress levels before and after the meditation.

Some types of messages you might consider:

• prompt – a message designed to promote an instant action (e.g. What is Sam doing right now? Is this an opportunity to give him lots of positive attention?)
• reminder – a message intended to help the client recall critical information (e.g. Looking after yourself is important. Have you planned a little something you can do for yourself to rest and recharge your batteries?)
• encourager – a message intended to provide emotional support (e.g. Jenny, I am so impressed with how you are looking after Liam! He is lucky to have you as his mum!)
• query – a message designed to capture information (e.g. On a scale of 1-10 where 1 is no stress and 10 is extreme stress, how stressful has today been?).

Your approach should be developed in consultation with the family. Discuss how many messages might be helpful, of which type(s), and what time of day might suit best. It’s also important to be pragmatic and consider sustainability – don’t aim to send multiple prompts per day for every client if this creates an unrealistic burden on your time. Investigate messaging software that will let you schedule or automate messages.

Remember to continually monitor and adjust your approach – you might start with one prompt delivered per week and adjust according to feedback from the client or your assessment of how helpful or otherwise it has been for their treatment goals.

Good prompts are concrete and specific and actionable immediately. They should be worded in such a way that the client can readily interpret them and respond – a prompt that requires the client to do a lot of thinking or to recall complicated information is less likely to be effective.

Good prompts should also be personalised. Use the client’s name, their child’s name, and anything specific to their lives or goals. However, note that you must also manage client expectations. It’s important to make it clear to clients that you won’t be available immediately in response to any messages they send to you.

1. Check and update any privacy and confidentiality protocols relevant to your receiving and storing information from clients across the apps and devices you’ll be using. This should be done by coordinating with relevant practice leaders and IT specialists in your organisation.
2. Identify what skills, behaviours or routines the family might apply between sessions.
3. In consultation with the client, design an appropriate prompt and agree on whether the client should send you anything in response.
4. Explain to the client that you intend to send them one or more prompts in between your direct contacts with them, the means by which you will send the prompt(s) (e.g. the app you’ll use) and whether and how they should respond. Choose an app or platform you’ll use in collaboration with the client that reflects their preferences. Make sure you understand the security status of this particular app and any safety risks entailed.
5. Discuss relevant boundaries, including how and when you might respond. Make it clear that although message apps might often be used for casual conversation, you intend to use it only in certain ways, as part of your professional role.
6. At the scheduled time, use the chosen app to send the text-based prompt. It’s a good idea to set yourself reminders for this, or even use software that allows you to schedule messages ahead of time.
7. Review the approach the next time you meet with the client, including discussion of any responses they sent you.
8. Update your approach to ecological momentary support as needed. Aim to gradually reduce the frequency of prompt you provide over time, to avoid creating dependency.

As a general rule, we all remember information better when we absorb it in more than one format. For instance, you’re more likely to remember the names of capital cities around the world if you study a map, look at pictures of landmarks, and have a friend quiz you, then if you spend the same total amount of time on just one of those activities. This is called the multi-modal principle of learning (Fletcher & Tobias, 2005). We can take opportunities to apply this principle while using telepractice.

How to use multi-modal support

Telepractice is well suited to the use of multi-modal learning. If there’s some key information a parent needs to take away from an interaction with you, look for ways to reinforce it across multiple modalities. You might explain, for example, key parenting information when you meet with them over teleconference, then share on your screen a video that gives some examples on raisingchildren.net.au. You might then also ask them a question to check their understanding or see if they can demonstrate their understanding in a roleplay.

On a related note, research also shows that retention of information is enhanced when it is shared multiple times across separate occasions (Donovan & Radosevich, 1999). This is called distributed learning, or spaced learning. Telepractice is well suited to take advantage of this principle. Using services like text messages means you can easily prompt clients to return to the same content across multiple occasions, such as revisiting previously shared links or conversations.

Steps to using multi-modal support

Here are a few ideas to experiment with:

• Podcasts
• Links to relevant websites (check which ones are endorsed by your organisation)
• An invitation to an online forum where the topic is discussed (such as a Facebook page or group run by the provider or another quality source)
• Books (or audiobooks)
• Visuals such as illustrations, diagrams and infographics
• A text message with a summary of the key points, which they can return to repeatedly.

Research into telepractice is still developing, including how people absorb information in digital formats. There are some indications that people may recall less of what’s discussed during a phone call, for example, compared to a face-to-face session (Car & Sheikh, 2003; Leclerc etal., 2003). Fortunately, researchers have also identified an effective solution, called teach-back (Morony et al., 2018). This is worth considering when using any technology to impart important information to parents.

How to use teach-back

The technique itself is simple. It involves explaining the concept you want the client to understand, then when you’re done, asking them to explain it back to you in their own words. Be mindful of how you react to the client’s teach-back attempt – if they get it wrong, remember to correct them in a supportive and confidence-building way. Identify and call out what knowledge, insight, or positive intention they have shown by putting the effort into responding to your query.

Steps to using teach-back

This technique can be illuminating because it will expose what the client is taking from what you are saying, which at times might differ from what you had hoped to impart (Dawson, R.W Taylor, Williams, B.J Taylor & Brown, 2014). It’s also superior to using general prompts (e.g. “does that make sense?”), because people tend to be reluctant to say they don’t understand. Remember when using this technique to allow a little extra time for the teach-back. It’s best not to rush it at the end of a session when you may not have the opportunity to follow through on re-explaining the topic if the client hasn’t understood it. It’s also best to do this in the same session where you explained the concept – waiting until later might risk the client feeling foolish for thinking they had understood precisely what you meant over the intervening period.

One way of doing this is by recording sessions conducted over videoconference. Most videoconferencing platforms feature a ‘record’ button, and after the session will produce a video file that can be shared via a secure messaging system (e.g. WhatsApp). The client can then review the session at any point in the future, at their leisure. They might revisit key points you shared with them about aspects of parenting, or a demonstration of a skill, or the point where you mentioned a useful website but they forgot to write it down. They might also return to the session some weeks later, when they need to remind themselves of something that has slipped from their memory. They may also want to review the moments where they felt particularly heard, or supported, or where your encouragement and warmth resonated with them.

You may also want to prompt clients to review aspects of a recording, or extract limited excerpts to share. This focuses the client’s attention on what is most important and makes the information more accessible due to a shorter time frame. It also allows you to avoid sharing any recorded content that you feel isn’t helpful.

Practitioners and services wanting to use this approach will need to invest in establishing the necessary clinical governance. This means that relevant policies and procedures will need to be reflected in documentation, informed by state guidelines and understood by all practitioners. Organisations will need to access information beyond this collection of techniques to do this. Further information can be found from relevant state departments, such as the Department of Human Services in Victoria, for example. Bear in mind that both practitioner and client safety must be supported.

Note that it is essential to manage consent and confidentiality carefully when using recordings.  For every session you wish to record, check the client’s willingness first. Undertake a thorough check of the security of the system you use for making and sharing recordings – ask your organisation’s IT support to assist. Inform parents about risks to their privacy by accessing recordings (will it download to their phone when they view it? Will it show up in their browsing history? Will it show up in other linked devices?). Where children are involved, make sure you are fully informed about relevant laws and ethical codes.

Also note that this is likely to be a new experience for both practitioners and clients. Clients may even be surprised (in a good way) that you’re willing to let them ‘keep’ part of your interaction.

Think about other products of your interactions that you wish to share with families as an additional support. Here are a few suggestions:

• A dot-point session outline, which you discussed at the beginning of the session, shared as a text message.
•  A ‘genogram’ that you drew on screen together using a shared whiteboard feature (e.g. in Zoom).
• A screenshot of a webpage that they found useful when you shared it on your screen over videoconference.
• The notes you took during a goal-setting exercise about what the client wanted to work on.
• A screenshot or short video of the client rehearsing a behaviour management skill to help them visualise how to do it between sessions.
• A screenshot or short video of you modeling or demonstrating something.

You could also consider whether you and the parent want to use these products or recordings as a way of connecting other family members to your work who may not be able to attend live sessions with you, such as other parents, grandparents or carers. Make sure to carefully check consent for this type of sharing on each occasion.

Record one or more video introductions to yourself and the services you provide. Many families are likely to experience a level of anxiety when engaging with a family services practitioner for the first time – more so if it’s a mandated engagement (Paige & Mansell, 2013). They are likely to be wondering who this person is that will talk to them about some of the most private aspects of their life, what it means to be a client of a particular service, and what will happen during sessions. They might be wondering if they can feel safe to speak to you, and perhaps what benefit they might get out of working with you. Some services may already make this information available in written form as part of induction or as general information on a website. But a video introduction may be a more engaging and informative method to share with new clients. This would fill a troublesome gap for clients – needing to trust someone they know nothing about.

You may consider preparing a general introduction video to be made available to all families referred to you. In addition, you could also prepare a personalised video introducing yourself to a new family, using their names and explaining your understanding of why they’ve been referred to you and how you might support them.

It may also be worth considering whether you could do outreach via webinars. Webinars have the advantage of being live and interactive, while still allowing the participants a level of anonymity. Webinars are generally suitable for topics that are important to many families and that include a significant teaching element. Examples could include behaviour management, supporting children’s early learning, family relationships and conflict management skills, or health and safety (amongst others). You may also be able to find examples of professionally run webinars produced by other organisations, to which you could refer your clients.

An added advantage of webinars is that they provide some efficiencies. You may be able to move some of the teaching content you typically deliver through individual sessions into a webinar format, freeing up the individual sessions for focusing on that client’s personal application of that knowledge to their daily life. Webinars may also offer other benefits through normalising engagement with family services, in that participants are made aware that other families are going through similar things.

If you are interested in making the most of telepractice, both now and into the future, consider whether it might be worth investing in an upgrade to the hardware you use. It would be hard to find a laptop or smartphone these days that doesn’t come with a built-in camera and microphone, and it’s possible to achieve quite a good level of audiovisual quality using these. However, you may be able to achieve a significant improvement by using an external, dedicated webcam and a dedicated microphone. The webcam will not only allow you to transmit a clearer image, but will also give you greater flexibility in how you position the participant’s point of view (such as making it closer to your eyeline).

As for the microphone, look for one that you can either clip to your collar (called a ‘lapel’ or ‘lavalier’ microphone), or one that sits on your desk right in front of you. These can achieve a clearer signal because proximity to your mouth means they can be more sensitive without being overwhelmed by background noise. A good quality headset can also achieve a good result. Bear in mind that these equipment upgrades aren’t for vanity – a higher quality signal will make it easier for clients to absorb your message.

Also consider ways you might support the client to get more out of technology. For the client, technology is not just a way to access your services, but an essential part of modern life. Are there ways that, while you’re connected by technology, you might take the opportunity to enhance the client’s technological proficiency? Two key areas you might wish to focus on are access to other services and connecting with peers. For example, if the parent regularly joins a videoconference with you via a smartphone, you could explore how well they understand the features of their phone. What other apps do they use? Can they use it to access their bank? How about Centrelink? Similarly, if they connect with you via a messaging service like WhatsApp or Facebook Messenger, or email, do they know how they might use these to connect with other trusted social supports, including overseas relatives? These sort of skills, which many of us might take for granted, can make a significant difference to a client’s life.

The eSafety Commissioner has published an excellent website that includes resources explaining many of these topics, including basics such as how to use different kinds of devices, through to more specialised topics such as how to do online banking. The resources include step-by step instructions in simple language, video demonstrations, translations into a number of languages and printable PDF versions. This makes them suitable both for practitioners to learn more about a particular piece of technology, but also makes them highly suitable for sharing with client families. The website can be found at https://beconnected.esafety.gov.au/topic-library.

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Crawley, S. A., Kendall, P. C., Benjamin, C. L., Brodman, D. M., Wei, C., Beidas, R. S., Podell, J. L., Mauro, C. (2013). Brief cognitive-behavioral therapy for anxious youth: Feasibility and initial outcomes. Cognitive and Behavioral Practice, 20, 123-133. https://doi.org/10.1016/j.cbpra.2012.07.003

Dawson, A. M., Taylor, R. W., Williams, S. M., Taylor, B.J., Brown, D. A. (2014) Do parents recall and understand children’s weight status information after BMI screening? A randomised controlled trial. BMJ Open, 4, e004481.

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Leclerc, B. S., Dunnigan, L., Cote, H., Zunzunegui, M. V., Hagan, L., & Morin, D. (2003) Callers’ ability to understand advice received from a telephone health-line service: comparison of self-reported and registered data. Health Services Research, 38, 697–710.

Lindhiem, O., Bennett, C. B., Rosen, D., & Silk, J. (2015). Mobile technology boosts the effectiveness of psychotherapy and behavioral interventions: a meta-analysis. Behavior modification, 39, 785–804. https://doi.org/10.1177/0145445515595198

Marzanno, L., Bardill, A., Fields, B., Herd, K., Veale, D., Grey, N., & Moran, P. (2015). The application of mHealth to mental health: Opportunities and challenges. The Lancet Psychiatry, 2, 942-948. https://doi.org/10.1016/S2215-0366(15)00268-0

Morony, S., Weir, K., Duncan, G., Biggs, J., Nutbeam, D., & Mccaffery, K. (2018). Enhancing communication skills for telehealth: Development and implementation of a teach-back intervention for a national maternal and child health helpline in Australia. BMC Health Services Research, 18, 162.

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