Establishing rapport in telehealth

September 30, 2010
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Counselors translate “attending” skills to media beyond the traditional face-to-face session

Most new hires at ProtoCall Services' AAS- and CARF-accredited crisis and information call centers in Portland, Ore., and Grandville, Mich., watch an unusual training video. In it, comedian Phil Hartman gets “customer service” from a rude, disinterested character played by Rosanne Barr. The late Hartman blithely interprets Rosanne's disrespectful remarks as signs of interest, support, and caring, even as she files her nails, chews gum loudly, and ridicules him.

This film gets some laughs, but it makes us uncomfortable. As a sub-contractor of crisis line, intake, and mental health support services, ProtoCall and its clinicians take the issue of rapport very seriously, and these trainees will spend months being mentored as they learn to provide telemental health services in acute scenarios.

When I began working at ProtoCall in 1999, the idea of counseling over the telephone felt exotic, especially for any non-crisis interventions. Today, clinicians work with clients in a broad variety of settings; my smart phone, for example, has an app for completing Mini Mental Status Exams.

But the discussion continues to circle around the same old questions: Isn't something lost in offering telephone support, e-mail check-ins, or a video session? Can rapport occur when we are not in the same room?

Counselors at protocall services, a crisis and information call center, give consumers an option for care beyond the standard, face-to-face therapy session
Counselors at ProtoCall Services, a crisis and information call center, give consumers an option for care beyond the standard, face-to-face therapy session.

Much has been written on this topic. Telehealth options have been a source of interest for quite some time due to their cost-effectiveness and increased ease of access for rural populations and others with transportation barriers.1

The American Telemedicine Association (ATA) and individual researchers have concluded there is extensive evidence to support that adequate rapport is developed between therapists and clients for accurate diagnosis.2,3 Additional efficacy studies indicate that, in fact, many clients prefer the reduced stigma and easier access offered by telemental health options.4

Environmental factors and cultural competencies

Environmental factors, such as the apparent sterility of the office or the angle of a webcam lens, play a role in rapport-building, according to several studies and a recommendation of best practices by ATA.5,6,7 The guidelines also cautioned clinicians to consider cultural and other issues such as native language, age, literacy, and the presence of dyslexia.

Not all clients prefer remote options, but most find them satisfactory. Australian researchers discovered that rural populations preferred face-to-face therapy when available, but found telepsychiatry services adequate.8

Measuring what works

Researchers Brian Mishara et al monitored clinician behaviors within the 1-800-SUICIDE network of suicide prevention hotlines. Some of their findings included:

  • Positive outcomes correlated with whether the counselor demonstrated empathy and respect.

  • Measurable behaviors that were connected to good outcomes (and to rapport building) included validation of emotion, offering moral support, reframing, talking about clinician's own experience (which researchers believed would compensate for the loss of in-person contact), and offering follow-up.

  • Adopting a collaborative problem-solving style was also viewed as vital.9

How do real telehealth practitioners put these values to work? I talked to several ProtoCall counselors to gain some perspective.

The crucial first minute

Shawn Mathis, MS, a Senior Clinical Specialist who frequently mentors new staff, says, “An important aspect of developing rapport over the phone is having a professional, confident tone. If the clinician is anxious, unsure, hesitates awkwardly, or has an informal tone at the beginning of the call, then the caller doesn't trust the clinician with his or her personal thoughts and feelings.

“After that, a clinician should be warm and open. One of my favorite phrases is, ‘Sure! I'll be happy to help you with that.’ In addition to being warm and open it also implies I know what I'm doing and am prepared to help, even though I don't always know for sure what I'm going to do. I have confidence I'll figure it out. Then, pre-education solidifies that trust as it lets the caller know what to expect during the call. It's a matter of respect to keep the caller on the same page.

“All these things happen within the first minute of the call and may continue throughout, sometimes evolving through the call. For instance, a clinician's tone may start out as strictly professional, but may be more informal near the end of the call, which is natural in the rapport process.”

Honor the client

Priscilla Popenuk, MA, a veteran case manager with many years of face-to-face service thinks that working by phone actually allows her to develop better rapport with many callers:

“I tend to be visual on the phone. I attend to what I hear in the background, what I hear in the voice, I imagine what's on their face. I can tell when they are crying. I stop paying attention to their socioeconomic status and that kind of thing.

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