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Establishing rapport in telehealth
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?
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:
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Positive outcomes correlated with whether the counselor demonstrated empathy and respect.
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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.
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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.
“I start from their world, with what's important with their world. Then I try to develop a plan with what works for them. Because I have joined in their world with them, there's a connection there.
“One of the things that works for me is that I participate with the person at their level. I explain it using familiar metaphors. I was talking to a security guard who was suicidal and sitting with a gun. I asked him, ‘If you have two alarms going off at the same time, how do you decide which one to respond to?’ He was able to put the gun away and focus with me on some solutions to his problem.”
Popenuk uses a lot of motivational interviewing skills and watches for anything the caller already does well. “The people we talk to live in hell holes sometimes. I honor their hard work. That comes off as real and not made up.”
Clarifying role confusion and conflicted expectations
Lisa Murdock, MA, who has worked at ProtoCall for two years, never expected to work with clients telephonically. “I imagined that it would always be like a crisis line. My expectations have mellowed. Some callers just need a level-headed person to bounce ideas off of.”
She perceives that some of the challenges to developing rapport are offset by the collaborative nature of the call center (in which clinicians can view prior calls). “Collaboratively, we can say, ‘I know about you. I've seen your history. I know what's helped before.’ That has been helpful.”
Murdock also pays attention to her speech. “I try to use smaller words to prevent misunderstandings.”
Murdock also suspects that callers approach telephonic counseling with even more transference than they do face-to-face counseling and with preconceived expectations based on media stereotypes. She also points out that callers present on the telephone much as they might in a hospital emergency room: They are more likely to be in crisis, making rapport more difficult due to heightened emotions and not necessarily due to the medium.
In response, she observes, “I remember that people are trying to do the best that they can. I remember that they are reaching out in the moment, when they may not be at their best or communicating as effectively as they might be in a regular session.”
Every moment is a teachable moment
Sally Van Meter, LPC, a former clinical supervisor at a busy HMO behavioral health clinic, has worked the swing shift at ProtoCall for seven years.
Like Murdock, Van Meter also worried about whether she would be able to develop rapport with callers. “I had some anxiety regarding whether I would be able to establish rapport. That didn't turn out to be the case. It's not that big a deal to talk to someone. We do that all the time in our lives. I think the biggest part of it for most people is having someone listen to them.”
She, too, finds that telephonic work offers a payoff regarding immediacy. In some cases, she believes that on-demand therapists can be more effective because callers call in the heat of the moment. She points to the difficulty in traditional therapy when a client may wish to discuss an emotionally intense subject but the experience can feel forced and artificial because he or she has to emotionally re-connect with the incident. “That would be like arranging to be upset,” she concludes.
Like Popenuk and Murdock, she struggles with callers' intense desire for immediate fixes. She reminds me that the fantasy of immediate recovery doesn't come true with telemental health interventions any more than it does in traditional therapy. “I think there's a lot of good to be done in telling someone, ‘It's OK, you don't have to fix it all right now.’”
Improved choice, extended access
Interestingly enough, I never actually find a single colleague or article that argues that sufficient rapport cannot be developed through telephonic or electronic mediums. Perhaps they are out there: As ProtoCall CEO Phil Evans has discovered in talking to colleagues, there is a certain set of beliefs that technology will be bad, maybe even disastrous, for the behavioral health industry. The people who approach him with these concerns fear that the benefits of face-to-face services will be lost in the rush to adopt what many see as simply cost-cutting measures. But Evans would be the last person to advocate for replacing face-to-face services with telehealth.
“The best scenario is that we open more doors to more consumers who may have otherwise not sought help early enough-or at all-if their only choice was face-to-face therapy. Telehealth is about extending the continuum of services by giving both providers and consumers more options to bridge issues of geography, time of day, personal preference, or even just convenience. Through technology, the industry can offer this larger menu of services without adding significant cost. And in doing so, an agency's ability to provide the more expensive face-to-face services can even be enhanced.”
When rapport is present, everybody wins
So, let's leave the discussion where it belongs-with a consumer.
Popenuk gets a call back from a frequent caller who is grieving a loss. But this time, the woman is not seeking support. She is calling to say “thank you” to all the counselors who have helped. She says, “Your line has saved me so many times. I want to say thank you to all of you. Bless you [counselors]. You got me through some really dark times. I'm alive and I almost wasn't.”
Ultimately, what really matters is that people's lives can be changed by the successful use of any medium-face-to-face, telephone, e-mail check-ins, or video chats. At the end of the day, what matters is finding a method that works for the people who need it most, when they need it most.
Julie Flaming has worked at ProtoCall Services for the past 11 years in roles that include counselor, supervisor, and writer/editor. She is the former editor of EAP Digest and Student Assistance Journal.References
- Bertera EM, Bertera RL. The Cost-Effectiveness of Telephone vs. Clinic Counseling for Hypertensive Patients: A Pilot Study. AJPH 1981; 71:6.
- American Telemedicine Association Evidence-Based Practice for Telemental Health. https://www.americantelemed.org/files/public/standards/EvidenceBasedTelementalHealth_WithCover.pdf. July 2009. Accessed September 6, 2010.
- Myers KM, Sulzbacher S, Melzer SM. Telepsychiatry with children and adolescents: are patients comparable to those evaluated in usual outpatient care? Telemed J E Health. 2004 Fall; 10 (3): 278-85.
- Monnier J, Knapp R, Frueh BC. Recent Advances in Telepsychiatry: An Updated Review. https://psychservices.psychiatryonline.org/cgi/content/full/54/12/1604. Accessed September 7, 2010.
- Manning TR, Goetz ET, Street RL. Delay Effects on Rapport in Telepsychiatry. CyberPsychology & Behavior. April 2000; 3 (2): 119-127.
- American Academy of Child and Adolescent Psychiatry Practice Parameter for Telepsychiatry With Children and Adolescents. J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, December 2008; 47:12.
- Barta P, Adventures in Telepsychiatry. https://adventuresintelepsychiatryblog.patrickbarta.com/2009/11/better-rapport-with-different-glasses/. Accessed September 6, 2010.
- Greenwood J., Chamberlain C. and Parker G. Evaluation of a rural telepsychiatry service. Australasian Psychiatry, 2004; 12:268-272.
- Mishara B, et al. Which Helper Behaviors and Intervention Styles are Related to Better Short-Term Outcomes in Telephone Crisis Intervention? Results from a Silent Monitoring Study of Calls to the U.S. 1-800-SUICIDE Network. Suicide and Life-Threatening Behavior, June 2007; 37 (3): 308-321.
