FAQ on online consultations

These frequently asked questions were put together by Nele De Witte, Sylvie Bernaerts, Eva Van Assche,  Sam Willems & Tom Van Daele of Thomas More University of Applied Sciences, in close collaboration with the EFPA Project Group on eHealth and several collaborators from around the world.

Different sources already provide relevant information about (online) mental healthcare in times of Corona. We do not aim to be another (competing) channel, but we want to bring together information from other reliable sources. We will do this specifically in relation to the concerns that were reported in the survey on online consultations by European psychologists. We will not be able to be exhaustive, but we will add new information when we can. Local guidelines and information that relates to the context of your country can be found on the websites of your psychological association. We have provided a list of links to their websites on the bottom of this page.

Here are some general sources that might be of interest

FAQ


Based on the ongoing survey on online consultations for mental healthcare, 8 recurrent questions were detected (for now). We will try to answer them here.

  1. Are online consultations appropriate and effective for different target groups (e.g., different types of mental illness, different age groups)?
  2. Are online consultations suitable for different elements or specific types of therapy?
  3. How to get a stable & secure connection for online consultations?
  4. Which software platforms can be appropriate and which ones are safe & GDPR proof?
  5. How to manage payments?
  6. How can we increase acceptance and help our clients with using online consultations?
  7. Can a therapeutic alliance develop online? And how can I promote connectivity and trust?
  8. For more specific information about your country, you can consult the website or contact details of your psychological association.

 

1. Are online consultations appropriate and effective for different target groups (e.g., different types of mental illness, different age groups)?

Evidence to date suggests that telepsychology/telepsychiatry is effective for diagnosis, assessment and therapy across different populations (i.e. children, adults, geriatric patients, ethnic groups), different mental disorders and multiple care settings (Hilty et al., 2013; Tuerk et al., 2018; Nelson & Sharp, 2016). Findings also suggest that the effectiveness of telepsychology/telepsychiatry is comparable to face-to-face care (Hilty et al., 2013).

In particular, recent findings have shown that telepsychology is safe and effective for anxiety treatment (Berryhill et al., 2018; Tuerk et al., 2018), depression (Berryhill et al., 2019; Tuerk et al., 2018), and PTSD (Bolton & Dorstyn, 2015). Although these conditions have been studied more frequently, the positive effects are not restricted to these conditions only.

Note, however, that these findings predominantly refer to short-term effects and effects of telepsychology when evidence-based practices are adopted (e.g., CBT). Evidence on long-term effects is – to the best of our knowledge – currently lacking. We would not recommend doing only online treatment with clients in acute crises but believe it can be an option in many other cases.  However, whether working online only, offline only, or blended is best for your specific client is something you will have to decide based or your clinical judgement. However, having to adhere to physical distancing in times of a pandemic is of course an extra incentive for online consultations. If in doubt, we would recommend you to discuss the case with a colleague.

 

2. Are online consultations suitable for different elements or specific types of therapy?

Although you are more restricted in your movements, online therapy does not have to consist of just talking. Most software tools have a whiteboard that you can use to work together on exercises, timelines, or drawings. You can also provide relaxation exercises online.

When working with children and youth a different approach, integrating elements of play could be appropriate. We would like to point your attention to some interesting resources in case you are interested in using online consultation in children & youth:

Specific work forms such as trauma treatment (including imaginary exposure and EMDR) are also performed online by experienced e-mental health practitioners. However, if you are not experienced or trained to do online trauma treatment, this might not be advised.

Concerning group therapy, evidence suggests that group videoconferences are feasible, given good IT support (see practical considerations below), and that they are highly accepted in different age-related and content-related groups (Banburry et al., 2018). Group videoconferencing is effective in overcoming multiple barriers for accessing face-to-face groups (e.g. the current corona crisis) and in replicating group processes in the online environment (Banburry et al., 2018).

 

3. How to get a stable & secure connection for online consultations?

Some suggestions to promote stable and secure video consultations:

  • Use Wi-Fi (but not public Wi-Fi for security reasons) and make sure you and your client have anti-virus software on your computer.
  • Try to position yourself within a good range of your router internet access point (and ask the client to do the same).
  • Have a steady power supply to your laptop/device.
  • The browsers Chrome or Mozilla Firefox seem to do better than the browsers Microsoft Edge or Internet Explorer.             
  • Create circumstances that promote good sound & video:
    • Use a private, well-lit room.
    • Don’t talk too fast (in case there is a lag).
    • Ask clients whether the sound is on & sufficiently loud.
    • Test the connection with a colleague beforehand.
  • In case you experience problems:
    • If the sound is bad, use a headset (if a headset is not needed, conversations without a headset might be more natural).
    • If a lag or instability occurs, you can try to call the client on the phone while leaving the camera on.
    • In any case: discuss with the client beforehand what will happen in case of connection problems.
  • Take the GDPR-rules into account
    • Use GDPR-proof software packages.
    • If it is not possible to use GDPR-proof software, you can consider suboptimal options (e.g., Dkype) if they are the only way to provide the necessary care to your clients within due time. However, clients should always receive information about the software that is used and give their consent. However, using these platforms for healthcare purposes is illegal in some countries (if they do not give exceptions for the pandemic)!
    • The client should agree to the procedures of the online consultations and the software that is being used.
      • Inform your client carefully about:
        • the tool that is being used;which data is being collected;
        • what happens to the data.
      • Have your client provide written informed consent (through e-mail).
        • Ask consent of parent when working with children.
      • Add the provided informed consent to the client record.
      • Interesting reading about informed consent procedures (guideline 3)

This information above is mainly based on a Belgian research project (SIMBA) by Philippe Bocklandt (Full source in Dutch: https://www.onlinehulp-vlaanderen.be/beeldbellen-in-coronacrisis/).

 

4. Which software platforms can be appropriate and which ones are safe & GDPR proof?

This is dependent on your national guidelines, so please consult their websites at the bottom of the page. According to the large online survey, Skype (including skype for business) is the most popular software platform, followed by zoom.us. We will give a brief overview of these 2 tools:

Skype (for Business)

  • We advise against the use of Skype for online consultation (but see also previous question).
  • Skype & skype for Business are not GDPR-proof and are not advisable for online consultations.
  • Not healthcare compliant.
  • Free (in case of Skype) and unlimited duration of calls.

ZOOM

  • Zoom.us is generally considered ok in terms of GDPR
  • The free tool is not healthcare compliant
  • Free, but limited to talks of 40 minutes when more than two people are involved
  • ZOOM for business & healthcare (two paying options) allow for a longer duration of calls and are more stable.


5. How to manage payments?

The APA states: “As part of informed consent, psychologists are mindful of the need to discuss with their clients what the billing documentation will include prior to the onset of service provision. Billing documentation may reflect the type of telecommunication technology used, the type of telepsychology services provided, and the fee structure for each relevant telepsychology service (e.g., video chat, texting fees, telephone services, chat room group fees, emergency scheduling, etc.). It may also include discussion about the charges incurred for any service interruptions or failures encountered, responsibility for overage charges on data plans, fee reductions for technology failures, and any other costs associated with the telepsychology services that will be provided.”  (guideline 3)

For your country-specific guidelines on managing payments and arranging possible remuneration, we would like to refer to your local psychological association (bottom of the page).

Two general practical suggestions about payment:

  • Have clients pay before the consultation by sending them a QR-code or your bank details, since it might not always be possible to track clients afterwards.
  • Explain the procedures for payment clearly beforehand and also clarify that clients will be reimbursed if the service cannot be provided (due to connectivity issues for example).


6. How can we increase acceptance and help our clients with using online consultations?

Some clients experience resistance to online treatment. According to Ebert et al (2015), potential barriers for internet-interventions Include “(a) low expectancies regarding its effectiveness, (b) worries about data security, (c) low comfort using such programs, (d) influence by important social contacts such as family and health professionals, (e) negative attitudes towards seeking psychological help in general, (f) low Internet experience, and (g) high Internet anxiety”. However, the study of Ebert also shows that providing information that addresses these potential barriers to primary care clients increases acceptance of internet interventions.  

It is consequently very helpful to address such potential concerns and it might currently also be relevant to address some corona-specific concerns:

  • Is it still possible to have real-life sessions (and which precautions do both parties have to take)?
  • If they switch to online sessions, what implications does this have?
  • What if you or the client gets sick?
  • What should the client do in times of crisis?

Resistance could potentially be worse now that private time and space have become scarce in many households. Hopefully, things settle down a little bit as time passes. It could consequently be a good idea to assess a second time whether a client still would not like online treatment after a week or so.

When a client agrees to online consultations, encourage them to find a comfortable and quiet space in the house (and try to make arrangements with other individuals in the house that they should not be disturbed during the consultation).

When performing online group therapy, you should also provide clear instructions to the participating clients:

  • Optimize group communication by providing clear communication guidelines to avoid participants talking over each other.
  • Highlight the importance of confidentiality, active listening and speaking slowly and clearly.
 

7. Can I work with non-verbal communication in online consultations?

It can indeed be more difficult to read the emotions and body language of clients online and to use your own expressions to support treatment.

A couple of suggestions that might help you:

  • You can exaggerate your facial expression a bit so that is more clear to the client.
  • You can state more explicitly what you see (or don’t see).
  • If the room, microphone, and situation allows for it, you can ask participants to sit a bit further away from the camera so that you can see their whole body. This can help you read non-verbal signals (e.g., agitation) better.
  • Silences are experienced differently online as compared to face to face, so you might not want to let silences linger for too long.


8. Can a therapeutic alliance develop online? And how can I promote connectivity and trust?

Although the amount of studies is limited, evidence indicates that clients report that the therapeutic alliance is equivalent to face-to-face therapies (Berger, 2015). Some relevant considerations:

  • Online consultations are not necessarily more impersonal, some people are more open and relaxed in their safe surroundings.
  • You can promote trust by being very transparent in what you will be doing and what they can expect.
  • It is important to let the client know in time when you are getting close to the end of the consultation so you can work towards a natural end of the conversation.


For more specific information about your country, you can consult the website or contact details of your psychological association


Scientific reference list

Banbury A., Nancarrow S., Dart J., Gray L., Parkinson L. (2018) Telehealth Interventions Delivering Home-based Support Group Videoconferencing: Systematic Review. J Med Internet Res, 20(2):e25. https://10.2196/jmir.8090

Bashshur R.L., Shannon G.W., Bashshur N., Yellowlees P.M. (2016) The Empirical Evidence for Telemedicine Interventions in Mental Disorders. Telemedicine and e-Health, 22:2, 87-113. DOI: https://doi.org/10.1089/tmj.2015.0206

Berger T. (2017) The therapeutic alliance in internet interventions: A narrative review and suggestions for future research. Psychotherapy Research, 27:5, 511-524. https://10.1080/10503307.2015.1119908

Berryhill M.B., Culmer N., Williams N., Halli-Tierney A., Betancourt A., Roberts H., King M. (2018) Videoconferencing Psychotherapy and Depression: A Systematic Review. Telemedicine and e-Health, 25:6, 435-446. https://doi.org/10.1089/tmj.2018.0058

Berryhill M.B., Halli-Tierney A., Culmer N., Williams N., Betancourt A., King M., Ruggles H., (2019) Videoconferencing psychological therapy and anxiety: a systematic review. Family Practice, 36:1, 53–63. https://doi.org/10.1093/fampra/cmy072

Bolton, A., & Dorstyn, D. (2015). Telepsychology for Posttraumatic Stress Disorder: A systematic review. Journal of Telemedicine and Telecare21:5, 254–267.  https://doi.org/10.1177/1357633X15571996

Ebert, D.D., Berking, M., Cuijpers, P., Lehr, D., Pörtner, M., & Baumeister H. (2015). Increasing the acceptance of internet-based mental health interventions in primary care patients with depressive symptoms. A randomized controlled trial. Journal of Affective Disorders, 176, 9-17. https://dx.doi.org/10.1016/j.jad.2015.01.056

Hilty D.M., Ferrer D.C., Parish M.B., Johnston B., Callahan E.J., Yellowlees P.M. (2013) The Effectiveness of Telemental Health: A 2013 Review. Telemedicine and e-Health, 19:6, 444-454. https://doi.org/10.1089/tmj.2013.0075

Nelson E., Sharp S. (2016) A Review of Pediatric Telemental Health. Pediatric Clinics, 63:5, 913 – 931. https://doi.org/10.1016/j.pcl.2016.06.011

Shore J.H., Yellowlees P., Caudill R., Johnston B., Turvey C., Mishkind M., Krupinski E., Myers K., Shore P., Kaftarian E., Hilty D.M.. (2018) Best Practices in Videoconferencing-Based Telemental Health April 2018. Telemedicine and e-Health, 24:1, 827-832. https://doi.org/10.1089/tmj.2018.0237