Thank you so much, Dr. Felker, for that lovely introduction. Thank you to BHI for having me here today. And thank you for spending some time with me to speak a little bit about clinical engagement over telehealth. I'm Sara Smucker Barnwell. And as Dr. Felker mentioned, I'm a clinical psychologist. 

And I've had this fun and fortunate career in telehealth, had the opportunity to work in diverse environments and really see firsthand the impact that telehealth can facilitate when we bring the care that patients need to them in a way that's accessible and meaningful. 

So I'm excited today to talk to you a little bit about this topic. And as you know, I'm a telehealth enthusiast, and so I hope I can share my enthusiasm for this modality and perhaps recruit some of yours as well. 

So we have some learning objectives today. We're going to identify three factors that improve clinical engagement, inclusive of some of the environmental factors that can help us really connect with our clients, deliver care, and identify those behavioral factors that also enhance engagement. 

So let's dig in. Let's talk a little bit about clinical engagement in telehealth. So we're going to spend our time today, divided among four areas of discussion. First, we're going to talk a bit about definitions and examples. 

Telehealth, and I would say many of its associated technologies, they're no stranger to jargon and acronyms. So we'll spend a little bit of time operationalizing and thinking very concretely about what do we mean when we talk about telehealth and specifically telemental health. 

We're going to speak a little bit about clinical engagement and just what is this construct, how do we think about it, how do we measure it, how do we know when it's working and when it's not. Then we'll think about those environmental factors that can help enhance clinical engagement, as well as some of those behavioral factors. 

What can you and I do to really help facilitate that connection and engagement with our clients? OK, let's dig in. Definitions and examples. So the term telehealth is so broad, it's almost meaningless, frankly. 

Telehealth is referring to any type of clinical services that are delivered through telecommunications technologies. So this is inclusive of telemedicine. When we provide education to patients and clients, when we have meetings with patients or our colleagues, when we're training our trainees or attending trainings ourselves, all of this can fall under the rubric of telehealth. 

If we dig down a little bit, we can focus on telemedicine, and that is diagnosis and treatment, more of an intervention focused application of telecommunications technologies. And then, of course, telemental health refers to mental health care delivered through telecommunications technologies. 

And from here, we'll see even further distinction. Telepsychology. Telecocial work, telenursing, telepsychiatry, you name it. And the prefix can be aptly applied. And often I'll mention, when people say telehealth, a lot of times they're referring to video conferencing. 

And this is relevant today because we're going to get into, what are those features we can impact, and influence, and thinking about the technologies we use. But frankly, any way that we engage with our clients, is inclusive of telehealth. So it could be a telephone call, a video call, it can be an asynchronous message. All of these are applicable. Heck, we can send them a fax. 

In each of these instances, we're going to be thinking about clinical engagement, enhancing that rapport, that therapeutic alliance that makes our relationships with our clients really special. And we know from data that clinical engagement matters. It impacts patient outcomes. We see this across different demographics of patients, across different clinical diagnoses that our patients may possess, and across the different interventions and treatments we may deliver. 

We know that clinical engagement matters. We see improved outcomes. We see improved completion of treatment. We see reduced attrition when we have clinical engagement. And we know that impacts provider outcomes as well. 

When our providers feel connected to the clients they serve, they report feeling greater work satisfaction. We see more fidelity to treatment manuals and treatment protocols, and we see less burnout. Folks stay in the work. This is hard work, we all know. 

And so finding ways to feel connected and engaged in our work is really important. We're going to stay the distance and keep delivering that care that matters. OK, we talked a little bit about what some of these constructs are. Let's talk about when it's not happening. 

Oh. Hello. I didn't expect to get a person. Hi, there. 

Hello, new client. How are you today? 

I'm well, I was hoping to get some information about telemedicine. 

You've come to the right place. I'm really excited that you're ready to begin telemental health therapy with me today. I know that regardless of what's going on, regardless of whatever issues may have come up in your life, whatever your history may be with treatment in the past or really whatever your goals are for the future, I know I'm the right therapist for you. So are you ready to tell me about your mom now? 

Whoa, I didn't think it would go this quickly. I'm not even sure where I am. Is this-- is this secure? 

I mean, did you close the door? Yes, of course. It's secure. We're on the internet, where we know everything is always really safe and secure. There's a lot of technical gizmos and doodads that keep us secure. 

I think what's important is that it's video conferencing. And we know a video conferencing call could never be overheard, or intercepted, or really interrupted in any way. So it's nothing you have to worry about. And in fact, I know that you clicked on this, and it took you to this entirely off brand video conferencing product. But just because you've never heard of it doesn't mean that it's not a totally legitimate way to get your health care. 

OK, well, I don't even know exactly who you are, but I guess what kind of doctor are you? 

I'm the really good kind. I mean, I'm the kind that you find on the internet, where you always know that health care quality is assured. That's where you get all the best information about your health care. And you needn't ever double check or really do any sort of fact checking on things. 

I think what's really important right now is that we think a little bit about your treatment and securing perhaps a prepaid package, perhaps 12 sessions or so, that really come together in a therapeutic dose of treatment. That would probably be what I'd say our next step is. 

You mean like an Arthur Murray dance prepaid program? Is that the kind of-- 

Yeah, but for feelings, yeah. I think what's most important here is that you feel well informed in these next steps, where to put the credit card, how to process the payment. And these things we can facilitate online. 

Well, speaking of informed, like shouldn't we have some kind of understanding of what this is and what you're going to do with my information? And I-- 

Like an informed consent document? I figured you're pretty smart. So like, I'm not so worried about that. Like, yes, typically an informed consent document would review things like risks to your privacy and confidentiality, the benefits of the modality, what we would do in case of a technology disruption, what we would do in case of an emergency. 

What we would do in terms of payment or missed appointments or cancelations. But like, honestly, I trust you. I can just see you're good people. So I don't think we need to really, futz with all of that. 

So you mentioned, OK, so what would happen in an emergency? You should probably get a doctor then. Yeah. No, I mean, some people would do it where you have an emergency plan, where we'd send emergency services to your house and really secure, make sure everything's OK, and that I could ostensibly stay on the line with you. It sounds like a lot of hard work to me. 

I tell you what, I think the most important thing right now is that you go get that credit card. And then you click on this link again, and we'll sign you up for those 12 prepaid sessions. And then I think we're really going to be ready to start some healing. OK. 

Yeah, I'm going to go do that, and I'll be right back. 

OK, I'll wait here. 

OK. So that's what it's not. I think we have-- I'll show you some videos throughout this presentation. And in my life as a presenter, I have a lot of how not to videos. They all come from somewhere. 

And I think the more we can be credible, the more we can deliver reassuringly steady, solid, best practice based care that stays within our scope of practice and adheres to our highest ethical standards. The more we really facilitate clinical engagement as a construct and really help our clients to understand that we're here to help. 

So let's think a little bit about clinical engagement. As I mentioned earlier, clinical engagement matters for care. We know that providers and patients ranking clinical engagement at high rates predict symptom improvement from session to session for clients, predicts reduced treatment attrition. 

We see less dropout, greater rates of completion, and we see clinical outcomes improving when we have clients reporting simultaneously high levels of rapport and engagement with the provider and with the treatment. We see that clients are more willing to disclose difficult information. We see that they're more willing to do what they're asked, whether it be take a medication as recommended or whether it is to engage in treatment and show up consistently, do the homework that we suggest. 

All of these, I think it's pretty common sense to me. The more we trust, the more we feel connected, the more we feel seen by and understood, the more we're likely to do what's asked in our partnership with our providers. 

So we see that clients are a little bit more likely to be candid when things don't go quite right, or maybe they haven't been exactly doing what we discussed. And I think the more we can lean into that rapport, that engagement that we have with our clients, the better positioned we are to facilitate some of the difficult conversations we need to have. 

This is especially important in telehealth. In telehealth, we have an environment that can be a bit impoverished. I don't see all the data that I see when I serve a client in my in-person office. So the more I can ask questions and reliably trust the answers I receive, the more I feel permission from my client to be inquisitive and curious, the better positioned I am to deliver care that enjoys all those benefits that we just reviewed. 

OK, how do we think about promoting clinical engagement? What does this look like? We know from research that things like eye contact, looking our clients in the eye, expressing empathy, really making sure that someone feels heard by us that we are doing thoughtful, active listening, reflecting back, we are being emotionally resonant. 

We're not stone faced listening to the saddest day of someone's life, but rather we're being responsive and thoughtful. And the more we are being candid and human with our clients, we know that these are clinical tools and skills we may use to promote clinical engagement and to see those clients really willing to take the risk of doing the work with us. 

Now, why does this matter in telehealth? These are all areas that can struggle in a remote context. We're talking a little bit more today about video conferencing in some ways because I'm not quite sure how you make eye contact over the telephone. But even within a video conferencing environment, looking here is different from looking here. 

It shows up. And so these small things are really important. And I think when we're meeting remotely with clients, we need to lean in a bit. I've had the experience of working with trainees in the telehealth modality. Lovely, warm people who, when you sit with them in a room, just the nicest people you care to meet. 

And when you put them on camera, they look like stone-faced killers. It's true. There's this reality that when we are in this modality, we lose a little bit. So we want to be really thoughtful about how to bring that warmth and that empathy to this environment. 

I've heard it said that it's valuable to even overexpress a little bit in service of trying to get across the empathy that we want to communicate. Similarly, being candid and being honest, I think there are moments that I don't know what's going on. I can't see my patients, excuse me, small gestures with their hands or a tapping foot. 

I may not have that opportunity. I might have to ask, how are you feeling in your body today? What's this like? I may have to be more inquisitive and slow things down. So how do we think about promoting this type of engagement? 

So again, we do this active listening. We're repeating back what we hear. We're using those good one on one clinical engagement skills that we learned probably the first few weeks of becoming care providers. 

We mirror affect, and we really try to show up in our face. Because again, really lovely, warm people can sometimes seem really subdued in a video conferencing context. So in the context of meeting with clients, we try to make sure that however we're feeling authentically, however we're responding, we show up, and we show it to our clients. 

And we do this by mirroring it physically. And this gets a little interesting in terms of how you want to show up on your video. Right now, I'm very close to my screen. That's because I'm very small on your screen today. 

And so I wanted to be sure to capture some of those facial expressions and some of the minute kind of moments by having my camera up close. Now, were I to back off my camera, you'd have a little bit more of my physicality. You'd see when I would lean in close to you, you'd see when I would back away. 

And that's just fine. You're going to miss things, and you're going to gain things. We'll have a demonstration video a little later. But I want to invite us to think about what am I trying to communicate and how do I create my environment in such a way that is conducive to that? 

The loss of physical presence impacts the ability to easily mirror to easily catch small details that you're going to normally have in the in-person environment. And inasmuch as that's true, we want to be thoughtful about recreating that as much as we can in a remote circumstance, particularly in video conferencing. 

OK, so we're responsive, we're reliable, and we're professional and confidential. And again, all of these are things I know we know how to do. These are cornerstones to being a clinician. And I want to acknowledge, we had the silly video a moments ago. 

There are practitioners out there in the world that are not adhering to these tenets, and I think most clients are aware of that. So I encourage us to be even more boundaried than we might usually be. We're warm, we're engaging, we're kind, but we're also really thoughtful. 

When we're going into someone's home, potentially, they're coming into our home office. If that's where you happen to have your clinical office for telehealth, there's a lot of opportunities for a small degradation of boundaries that we may not be cognizant of. So the more we can really show up in a professional way, we're crisp on our timing, for example, coming five minutes late to an in-person meeting when your client is in the waiting room. 

Well, the clients in the waiting room. They probably have seen people coming and going. They know people are in the office, or perhaps they've seen you coming and going. They know you're in the office. 

It's a little bit different than sitting on a Zoom room. We've probably all had the experience of wondering if someone's coming to that video conferencing meeting. So we want to be really thoughtful about these sort of nonspecific things that are going to happen in the video environment that might not be reassuring in terms of our professionalism, our reliability. 

So we're responsive, we're timely, we answer emails and calls quickly, and we're really thoughtful and conscientious about communicating confidentiality and the steps we take in a technology-enabled environment to ensure those things. Again, these are things we all do, and I'm certainly cognizant of that. 

And I think in the telehealth modality, when we're trying to be thoughtful about gaining people's trust and helping them feel comfortable and reassured in potentially a novel circumstance, but often a novel circumstance for receiving their health care, we want to just be a little bit extra, a little above and beyond to help them feel that confidence that we know enables all of those good outcomes. 

So our challenges. Our eye contact. It is so easy to look somewhere else in a room. I happen to have a two screen solution on my desk here. And so, I look over here, and I see the medical chart. So I might be looking there. I might be looking over here referencing a note I've seen. 

I'm doing things related to my client's care. They don't know that. And so for me, when I have to look somewhere else, I say aloud. Well, I'm going to look over here at the chart for a moment. Excuse me. 

It's no amazing remedy that I'm offering as much as acknowledging that I'm looking elsewhere, which gives you the impression I'm not looking you in the eye. And I want you to know that I know, and I'm coming back. And I think when we are actually sitting with the camera, being thoughtful about seeing our own self-view, I know nobody likes looking in the self-view all day, but I really encourage you before you start your telehealth day and throughout the day, spend some time with it. 

Are you looking close enough to your camera to give people the impression of looking them in the eye? Or is your gaze all over perhaps necessarily? And how are you going to think about that during the session? 

Are you really, really close to the camera? Are you really, really far away from the camera? All of these things are impactful. And again, it's not that I'm thinking there's a right or wrong as much as we want to be thoughtful about what we're trying to communicate and communicate that. 

And again, we miss little details. When I am sitting in front of a camera, yes, you will see my face, but there's just small moments, I think they call it limbic resonance, that you do miss out on. 

I say this as a career psychologist. I love the modality and I acknowledge, there are things I don't catch. If you have psychomotor agitation. And you're twiddling your thumbs, and you're tapping your foot, as I mentioned before, I'm just not going to see it. 

Olfactory data, I think I mentioned in the next slide, is real. We miss things when we're not in person. So we really try to have clear, crisp expression. And when we don't think we're communicating it non-verbally, we're really explicit to do it verbally. Technology lags, interruptions, whether or not we have reliable technology, all of these things, specific to the telehealth modality can be a notable impairment. 

I think many of us have had the experience of being in some manner of video call, or a telephone call, or even a text exchange, where there's just tech disruption. And it's frustrating. And we know it's no one's fault. We know no one's intentionally making our call drop. 

But I don't know about you, I can get annoyed. I can be a little less present in the moment if I've had a call drop four times. I'm probably not in the best space to have a more in-depth conversation. So inasmuch as this is the case, as telehealth practitioners, we want to really be thoughtful about, those challenges. 

What type of technology challenges am I going to face, and how can I mitigate those? How reliable is the technology that I possess, and how can I invest in reliable tech? Again, we want to be really conscientious about acknowledging concerns about confidentiality and really show up in our most professional way possible. 

And in doing this, I encourage everybody to invest. So invest in duplicate redundancies for technology. So if I have one video conferencing program seems pretty reliable, I encourage everyone to be aware of at least two. There are many good free HIPAA compliant options in the marketplace. 

They typically don't have all the bells and whistles, but there are great backup if you need it. Make a plan with our clients. If our video conferencing is unreliable on a given day, I'm going to have a telephone appointment with you. Is it optimal? No. 

But it's better than having a call drop 10 times and having someone feel interrupted over and over. Personally, I have two to three different internet options in my home at any given time. That's because if I don't have internet, I'm going to miss a whole day's work. 

So I try to make sure that I have some redundancies. I do a lot of telehealth. So for me, that investment is really worthwhile. Each of us will have to decide to what extent, investing our resources makes sense for our practice. But I encourage you, if this is going to be meaningfully in your practice. 

Think about the impact of a reliable connection with your client on that clinical engagement, on your ability to do the work and invest accordingly. So again, we're planning in advance, and we're investing. So we want to think about, what can I do up front that's going to set me up to succeed? 

Whether that's having a test call with a client. If I have a client who is maybe uncertain about meeting this way, perhaps they've done it socially, but they've not really meaningfully had healthcare and not mental health care over a different modality. 

Perhaps I do a test call with them. We can introduce the construct, see what they think of it. And I really encourage everybody, I say this as someone who talks very quickly, we want to slow down. And I mean that not only in actually speaking a little more slowly, but I also mean don't make assumptions. 

When someone comes into my office, there's just more information. I can see their gait and posture. I can smell whether they've been smoking outside or not. Maybe there are little non-specifics that I'm going to catch, secondary to sharing a physical space with them that I will not have. 

Now, take that even farther. Let's say that I'm meeting with someone over the telephone and not video conferencing. I'm losing all that visual data. I'm going to have to slow it down and ask more questions. And I encourage providers to give yourself the time to do this work. 

My intakes when I meet over video conferencing, typically, I allocate myself probably about 1.5 the amount of time I do, as in person. And over telephone, 2.0. I just need more time. I have to ask more questions. I have to be more curious. Because I can't rely on the other data that I would receive in person, or in the case of telephone by looking at someone. So I'm going to have to really slow it down and not assume. 

Let's talk about body, gaze, and hands. These are small ways that in our in-person sessions, we help build therapeutic alliance. We look our client in the eyes. We reflect and mirror their physical posture with our own. 

Perhaps if you're like me, you're a hands talker. We use our hands to help communicate and emphasize points that we are making. These aspects of rapport and alliance are impoverished somewhat in the telehealth modality. So we want to be thoughtful about how we're going to bring to life these important aspects of clinical engagement through the distance milieu. 

So, as I mentioned earlier, gaze is one that's often talked about, and it is the case that when I'm looking at where my client appears on the screen, I'm looking downward. And when I look up toward the camera, I'm giving the appearance more of looking someone straight in the eye. 

Of course, the challenge of this is that if I stare in the camera for the entire session, I would miss what my client was actually doing. So I want to talk a little bit about different options we have around this. I've jokingly said I'd like to train my eyes like the chameleons from Madagascar have one eye up and one eye down, which I'm sure would be more disconcerting than what I'm currently doing. 

I think for many of us, we mostly are looking at where the client is on the screen. It is my recommendation every once in a while, and it's a strange habit to get into? Look up at the camera. I think it gives the impression of looking more closely. 

It's a funny thing, but play with it a little bit. And in all of these instances, I'm going to really recommend that you record yourself. There is no proxy for it. It is a significant difference to sit and have a conversation with someone like this, which is a perfectly reasonable thing to do in person, versus to have a little bit more engagement in our face, in our body, and with our hands. 

In person, this is felt with less-- I think with less intensity, I think it's a less prominent aspect. However, when we do it in the telehealth modality, maybe a perfectly reasonable way to be interacting with one another in person, but it comes across as more flat and connotes less emotion to the client. 

So I think there's this opportunity for us to record ourselves. I've had the chance to do this work with lots of folks, and people are genuinely surprised about the discrepancy between the emotion they're intending to communicate and what they actually are communicating. So I want to really encourage you, set up your mobile device, set up your laptop likely has a recording function, and give yourself a little bit of a chance to see exactly what your client is going to see, in terms of your posture, in terms of your facial expressions, in terms of where your hands go. 

I will tell you that I'm a hands talker, and it's a challenge. It actually can be quite distracting. So at times, during a therapy session, I will have to hold a pen because it's the only way I can really stop myself. But I think in doing this, we get to know ourselves a little bit better, and we get to make some decisions about how we want to show up in this modality. 

I recall taking a training many years ago that said, you want to demonstrate 110% of your usual facial expression and emotion. I'm not sure quite how we quantify that, but I think there's something to it. Our usual facial expression is well served to be a bit more pronounced. 

We're relying more on our face. So if we can, as we watch that recording, decide how much we want to turn it up versus turn it down and practice that, it's going to give you an opportunity to make sure that you're doing all you can to create an environment that is conducive to rapport, engagement, and connection with your client. 

So let's think a little bit about what we can do in the clinical environment to help promote that clinical engagement that we want to see. So I want to encourage us to think about our office environment as having three distinct offices. So what are your three offices? 

There's your environment, the environment of where you're seeing the client from, there's the environment that the client is in, and then there's the technology environment. All of these are going to influence our ability to connect with our clients and to have a more, quote, unquote, "normal interaction" with them. So let's think a little bit about the research again. 

And again, I'm giving such short shrift to this. We're just there's a whole lovely and robust body of the extant literature, but we're just kind of zooming through it. We know that therapeutic alliance typically is highly regarded in telehealth. Patients and providers both typically are going to rate therapeutic alliance pretty highly. 

Client satisfaction also tends to be pretty high in telehealth modalities, video conferencing and telephone. And we see comparable clinical outcomes to in-person modalities. And what we see in the research is that the environment matters. You're going to see those higher ratings of satisfaction, those higher ratings of rapport. 

When things feel more professional, they feel a little more formal. And you don't feel like you're meeting from the back seat of someone's car while they jostle around. Inappropriate patient environments impact treatment adherence. We see higher patient attrition, and we see reduced clinical outcomes. 

And that, to me, is very sensible. If someone's seeing me from a space where they don't feel that they have confidentiality and privacy, or frankly, there's just a lot of distraction, and they can't pay attention, all of these are going to roll up to having a negative impact on their ability to be with the clinical work we're doing together. 

In appropriate provider outcomes, and there's a little less research here. But typically, we know that it negatively impacts patient perception, and that therapeutic alliance, and through these the outcomes. And again, that feels very sensible to me. I want to feel like I'm meeting with my provider. 

If I went into the physical location for my primary care doctor today, and it was unprofessional. There were personal items everywhere. It was messy. It didn't look like a place I usually receive medical care. 

It's going to set off some alarms for me. I'm going to be a little-- I'm going to be attending to that more than I am going to be attending to the meeting. I think this is even more of a pronounced issue in behavioral health, where we ask folks to disclose very personal topics, where we ask them to trust us with secrets often. 

And I think in that context, we want to be sure that we are being respectful and that we are creating an environment that is maximally conducive to their comfort, their disclosure, and their really sensibility that this is health that they are receiving. This isn't a chat with a friend while they go grocery shopping. This is your health with your trusted provider. 

And of course, this is always a balance. I think in 2020, a lot of us had the experience, if you were practicing at that time, of expanding our definition of where we saw clients, I cannot say I saw people in their cars too often before that year and after that time, we were trying to find any place, that would work. 

Now, I'm never going to see someone in a moving car. That's not safe. And I'm not going to see someone in a car when someone else is in the car. That's not confidential and private. But if someone were to say, I'm in my car, it's parked in a driveway. 

Here's the address in case we need for emergency circumstances. But this is the only place I can be where I won't be overheard and I can have a private conversation. I'm actually going to be more flexible on that. Now, is it my favorite? 

No. But I think we're always trying to find this balance between what I, as a provider, mean. I need confidentiality. I need safety. I need the ability to be enough, lack of distraction, that we can have a coherent conversation. And then, of course, what my client needs. 

They may not have the luxury of having tremendous numbers of spaces that they can go and enjoy privacy and confidentiality. So we're always finding and maintaining this balance. And I think because we think we see that clinical relationship varies as a function of comfort. 

And we know from the well-known match study many years ago that outcomes vary as a function of clinical engagement. And I'll note that there are few codified requirements. So you're not going to open up we just in 2024 have revised telepsychology guidelines, for example. 

And you're not going to find as many-- that many requirements to say, well, you have to be in exactly this environment to receive telehealth care. Instead, we see guiding principles confidentiality, privacy, physical comfort, the ability to observe one another, a lack of distraction. So it's more of a first principles than it has to be exactly here in this environment or that environment. 

And again, the relationship is the focus, not the tech. So the more the tech, it's becoming about the tech or fussing with things, I think the more it's detracting from our ability to engage with our clients. We're balancing high quality care, risk management, and frankly, just what's practical for both patient and provider to have a really good meeting. 

I don't want to make the requirements for meeting with me so stringent that no one can do it. So let's talk a little bit about your environment because that's one of our offices as well. Perhaps the most traditional conceptualization of your office is where you're sitting. 

However, in the telehealth context, a lot of us had to be creative about thinking where we are going to meet and how we're going to have a sustainable, reliable place to see our clients. And again, in a way, that's confidential, and private, and appropriate. So I think it's notable here to make a distinction between home offices and then professional space offices. 

Interestingly, I think for me at least, when I worked in a large hospital system, it was harder for me to have privacy in my professional office. There have been times in which I had to share an office with other providers. So having a private independent space to meet with clients was actually a challenge. 

When I started doing telehealth, working from my home office, was actually more conducive to privacy. That being said, traditionally, when we're thinking about home offices, we're acknowledging that there are more potential impediments to that privacy and confidentiality, that professionalism necessary to have that clinical engagement that we need. 

And in my home office, I have to have the same standards as a professional office. I have to have a door that closes. I have to have reasonable soundproofing. My home has pets, and kids, and things happening in it. 

And I need to make sure that there's no intersection of that world and my professional life. I can't have people coming and going from here as they might in another room in the home. So I think that we need to be really thoughtful. 

Particularly, I think this is true for students and trainees in their earlier days, may not have access to an entire office in a home that's luxurious and that may be something that is valuable later in life, but not earlier. And so I think we have to be really thoughtful about what is practical for a sound home office. 

And this isn't just for reasons of protected health information or PHI. We don't want to have sensitive information. Of course, sitting around a home office or really sitting around anywhere, but we want to treat all that information with the security it deserves. 

But I think it's more than that. Because we're also acknowledging we want to maintain those standards of professionalism and really communicating to our clients that they are having a health care appointment. So I think a way in which we can think about that is just distraction. 

I think there is this balance to be maintained when we have a more austere, cold, clinical environment. It is professional in some ways, pretty straightforward. It's not cluttered. It's straightforward. But maybe we want to have something a little more warm. 

I've been working on this one for a while I don't know. We're getting there. We have some flowers. We have a picture. It's a little warm. And you'll notice, I don't have family pictures. I don't have anything indicating political affiliations or religious practices. 

I don't have anything that's too personal. The idea being that it is of benignly pleasant and professional without disclosing too much necessarily about my life, that wouldn't be appropriate in a clinical relationship. I want it to be consistent with health care. 

Because I'm a psychologist, I like things to be a little on the warmer side. That's my style. I think each of us are going to have to find the environment that reflects our own unique styles. I want it to be relatable, accessible. 

I'm just going to come out and say, I really hate blurred backgrounds. Sometimes they're necessary. Sometimes we might not have a space that's really conducive to health care, and that's OK. I also am just going to vigorously opine that I don't like them, and I don't like them, because I think they just give this sensibility that you're not seeing things. 

I actually request that it never happens on the client side because I think that I'm missing data. If your house is messy, I want to know. If there's clutter everywhere, that's actually clinically interesting. I want to know. 

Part of the best things that happen, when we go into someone's home, when we go into the space that they occupy, is we get to see how they live. And that's something we're not going to get in an in-person environment. I don't want to miss that data. 

So again, what's disclosed in my space? Do I have my original Van Gogh hanging in the background. I obviously don't have an original Van Gogh. I don't necessarily want pictures of my family or the composition of my family. 

There's-- I guess you could guess from looking at this that I like flowers. Things are they're sort of vaguely feminine in here. You could make some assumptions from that, but I'm trying to keep it pretty generic so that the focus remains on the clinical relationship, and we're not necessarily chit chatting about anything in particular. 

That being said, I'm now going to point out that I have a mural behind me, and I once had someone ask me if it was a projective, and if they were to select which animal they were in the picture. I'm going to tell you, I didn't even know there were animals in the picture. I hadn't really attended that well to it. 

So whatever you put there, somebody might have something to say about it. It was a pretty funny conversation, actually. But this was a colleague, by the way. So I think that we will find our way to figuring out what the right balance 

Is. And then for your own appearance, what degree of formality feels right? So I was presenting to you all today. So I put on my snazzy jacket to try to look a little more professional. And I often actually do that with my clients. I tend to dress up a little bit for my telehealth appointments. 

That makes-- I feel like I'm communicating something where I hope it's reassuring. I hope they know they're seeing a provider, but that's a personal decision. I would encourage you to go a little more formal, a little more professional than you would in your in-person office. Because again, we're at a bit of a disadvantage in these telehealth environments of what we're able to communicate succinctly. 

So the more cues we can give, give the affect that we're attempting, the better. Your office. So we want to get that replication of an in-office feel. This can be really hard in home environments. And we're finding this balance between the professional and the personal. 

I'll mention that in my office, at any given time, I probably have 10 different light sources. I'm not using all of them. I'm going to put one on right now. OK, so here's me just with some overhead lighting. And then I have a few lamps. I also have some ring lights we're going to put it on 

OK. I think this looks a little bit like I'm being interrogated. So I don't keep it on all the time. But I encourage you to consider what type of lighting-- what type of technology investments for your office is going to help give you the experience you want to have. 

And toward that end, think a little bit about, who do you serve? What type of services do you provide? Now, I typically do talk therapy. So for me, a high quality video conferencing program is going to do the trick. 

I have colleagues, however, who perform clinical assessments. They need more. They need technology programs that have whiteboards or facilitate better screen sharing. They have online assessments that they're administering in session. 

They're going to need a little more facilitation for the types of services they offer. We want to think about your usual affect and rapport. When you meet with someone, what's your style, and have it show up in this modality, and how are you going to best partner with your clients in order to recreate that experience in your remote office as you would in your in-person office. 

And I want to just a word about noise. Because especially if you have a home office, but it's also true if you have an office in traditional professional building, it is more strange to encounter background noise when you can't see the source. 

So when I am in my office in person with a client, and we hear a dog barking outside, we both can echolocate where it's coming from. Maybe it's not echolocation exactly. We can hear where it's coming from. And we can look that way. 

It's pretty straightforward. We know the dog is barking. There's a window right there. It's coming from there. It's a different experience than when someone hears a dog barking in my home, and they don't know where it's coming from. 

Is the dog in the room with me? They don't have that information. So we want to be thoughtful about mitigating those noise and distractions as much as we can. We want the Alexas out of there. We want the series out of there. 

We want-- first of all, they have tremendous issues with confidentiality and recording, but they're also potential impediments. And they give this sensibility of their distractions in the space. I will mention that most video conferencing softwares, these days have pretty competent noise gates that will reduce a lot of that distracting noise. 

But we wanted just a little bit of investment in thinking about the space you're in. So if you have one space that's next to a window, where there's tons of traffic and one space that's at the back of the house, even though it's probably less beautiful, I'd go to the back of the house to that quieter space. 

Again, we want things to feel professional, and they're having a usual experience with a trusted provider. And again, investment. Telehealth is here to stay. It's not going anywhere. If you think this is going to be a meaningful part of your practice, then I really encourage you to invest in yourself. 

So lighting, sound. In this office, at any given time, I have about three different microphones. There's a bunch of them in here, varying quality. I have different lighting in here. I have invested in a lovely chair. 

It feels nice. They say sitting is the new smoking. But personally, I sit a lot. I don't smoke, though. Sitting here, I think is-- it's hard on the body. And so, some people have a standing desk that they're working with, figuring out what works for your body and what will allow you to do this comfortably for the duration is valuable. 

Again, having those redundancies in your technology, even if you have to pay a little bit for them, I think is an investment in your practice and in the longevity of doing this work. And again, if you're a trainee, if you're just getting started, sometimes in the beginning we make do. 

We do our best with what we have. As you get into your practice, however, I encourage you to consider as among your business expenses, investing in these types of accommodations that allow you to be as present as possible, as comfortable as possible, and frankly, to model the type of ease that you want to see in your clients. 

So let's talk about that client environment. This is trickier because I can control my office to some extent anyway. I can choose what type of lighting I have. I can choose my seat. I have a little bit more say than I do in the client environment. 

And I think, again, we're always balancing what's appropriate and what's practical. And we want to in the beginning of any telehealth relationship, and I'm sure other folks in the series will talk about this, think about an initial assessment of is this technology appropriate for the type of care I seek to deliver? 

And as part of that appropriateness assessment, we're going to be thoughtful about what environment does the patient have access to in order to meet with me. And I'll say, I've worked with clients who have, I think, difficult circumstances in finding that an optimal environment. 

I work with plenty of folks who are unhoused. I've worked with folks who are their work takes them all over on long distances. It gets into some tricky interjurisdictional stuff. I work with folks who have a lot of fluctuation and challenge in their environment. 

So we always want to prioritize patient access to care. But I think given that we have much less capacity to dictate our client environment, we want to be communicating with our clients about the importance of this and maintaining a weather eye on what is appropriate, what are our need haves, and what are our nice to haves. 

So here are some of our need to haves. We need to have an environment that is private and confidential. You'll note I'm not saying in a locked room with two feet of soundproofing. That's optimal. That's what I'd prefer. 

But we need to find a place that won't be interrupted, and that is conducive to a professional health interaction. So sitting in a group of friends, hanging out with the parents at Starbucks, these are not appropriate Will I sit in someone-- with someone in a car? Absolutely. 

Have I been outside with folks when we have done a little bit of a camera scan and looked around the environment to see if anyone else is there? I have. It's not my favorite. I'd rather be in a locked room. 

But I work with what I can. And in each of these instances, if I perceive that there is additional risk to confidence and privacy, I'm thinking through my willingness to work with that, and I'm communicating that risk to my client. 

Because for a client to really give informed consent, they need to understand the balance of risk and benefit of meeting thusly. And patient environment is a significant impact, has a significant impact on that balance. In the client environment, we want to be thoughtful about scheduling. 

Will this space be reliably available? So sometimes, I've had clients say, well, I can meet with you this one time. The living room is going to be free, and no one will be in the house. That's great. Let's do it. 

And how are we going to have our subsequent meetings? So part of that initial telehealth assessment is like, are we reliably going to be able to meet in a way conducive to health care and free of interruptions? I encourage folks to, again, ask their clients what the demands of the situation are. 

I work with plenty of folks who have kids, and so they may need to take some breaks during our meeting. Normally, if they were sitting in my physical office, they wouldn't say, excuse me, I need to step outside and check on my baby. But if they have a napping baby in their home, I work with a fair number of postpartum moms, it may be the case that they do need to take a moment, take a break, step outside, and check on things in their home. 

And that's fine. We want them to be comfortable, and we want them to be not distracted. It's a balance. Now, if the baby's crying the whole time, they're having to keep going and figure that out, that's not optimal either. So we're trying to find the balance. And all of these situations, again, as part of the informed consent process. 

We want to be thoughtful about when we don't find the balance, who is responsible? So let's say my client did want to meet with me. And it was just not a good day for childcare. The babysitter couldn't come. The kiddo was there, and they were crying. 

And they're trying to figure out. Of course, I'm going to be understanding. Who's financially responsible for that meeting? It's the type of thing we should talk about in advance. I'll share with you, just anecdotally, not that this is what anyone else has to do. 

I have a policy that if there's something going on environmentally that requires a reschedule, if we can do it within that calendar week, I don't assess a fee. Of course, if there's an emergency or something, I'm not draconian and cruel. But if this is happening somewhat reliably, I want to figure out the balance of if I can reschedule them within the week, and we can figure out something reasonable, I never assess a fee. 

If I can't then we figure something out. And all of this has been discussed beforehand, and all of this is documented and informed consent. OK, let's talk about client environments. 

Hi, Jason. 

Hi, Dr. Smucker. 

How are you today? 

I'm doing OK. 

Great. Well, thanks for being here. I wanted to check in and creating our agenda today, which we do at the beginning of every appointment. We had some homework this week. We were going to have you watch some videos of insects, and we're going to watch those repeatedly, and you are going to log your subjective units of distress, scale, your suds scores as you continued watching those. And I wanted to check in on how that was going. 

It's going OK. 

Did you have a chance to watch the videos I sent over the portal? 

Yeah, yeah, I watched the videos. Yep. 

Great. How many times did you get to it? 

I think I watched them twice. Yeah, twice. 

And any change in those sub scores as you went along? 

Yeah. They got better. They got better. Yeah, OK. 

Jason, I'm noticing something today. I'm noticing today-- I'm noticing you're looking down a fair bit and a little more constricted in your body posture. And I want you to know that's fine. We can be however we are together. 

I also want to acknowledge that's different from some of the ways in which we've interacted in the past. And if you were in my office, I have a strong suspicion, I would just have a better sense, perhaps, of how you're feeling today or what was going on, one of the challenges of meeting this way is that I can't always tell. 

And so, at the risk of making it super awkward, I just want to pause here and check in, how are you today? How are you feeling? I just see you looking down. And I'm wondering what you're thinking and feeling in this moment. What's going on? 

Yeah, there's just some crazy stuff going on at work. And yeah, I'm sorry. It's just being really distracting. And I'm-- you're right. I don't think that I'm fully present. But. yeah, it's got me-- it's got me pretty stressed out. 

It's really hard to be present. I mean, I know this space is also your office for work. So I'm guessing you have all the reminders, and all the interruptions, and all those things from work that can be really stressful. 

Yes. 

Yes. So, Jason, I guess, I want to offer if you need to take a moment, if you think that it can fit appropriately within the timeline we have today, if you need to take a moment to respond to something. I'm happy to pause and allow you to do so. 

And then I would ask if you feel able to continue today, for us to really come back together and try to resolve things to a point where you can really be present, and we can do some of this work in the spirit of helping you along with your goals. Does that feel OK? 

I think that'd be great. If really just 30 seconds to respond to this, I think my mind will be cleared, and I'll be ready to be present, and focused, and engaged. And I won't have to keep coming back in a distracted way. 

All right, Jason. Why don't we pause for 30 seconds, and then we're going to resume our session. And I might ask you to silence those devices and close those tabs. And if you feel you can do that, to really, really keep us present here together today. 

Can do. 

All right. Thanks, Jason. OK. I think we've all had the experience, where we're talking to someone, maybe over distance, maybe in person. They're looking at their phone, they're not paying attention. We are so divided, these days in terms of the demands upon our attention. 

And this goes back to those candid, courageous conversations we have with clients. If a client was in my office sneaking looks at their phone, I would be curious. What's going on? Like, I'd want to know the reasons I'd want to understand, and I'd want to gently bring them back to the clinical relationship. 

We're here to work on something together, and we're probably not going to get very far if far. If we're not really paying good attention. We want to be compassionate and also boundaried. Again, finding that balance. And I will say, as part of my getting started with the client, if we are working from a space that they're on their laptop or their phone or something, well, they're always going to be on their laptop or their phone. 

They're on some place that receives their work as what I really mean to say. If they're on a device that is also used for professional purposes, we talk a little bit about how we're going to maintain those boundaries. I don't know about y'all, but I hear that little knock, knock, knock, of slack quite often when I'm in a video call with someone, and I'll address it and say, gosh, we're really trying to be present with each other. 

And sometimes, folks will say, no, I can't do that. And then we have to figure that out together. And again, we're finding balance of boundaries, while also being practical within someone's life. I'm a little more forgiving if you have a baby monitor, and you have a baby somewhere, you need to pay attention, then I'm worried someone's going to Slack me, and it's going to make me anxious. 

Well, that might be a clinical issue. So we're always trying to find the balance and how to be most helpful to our clients. Let's talk a little bit about the environment that the technologies we use create. So what are some of the factors that influence that technology environment? 

Internet stability, connection quality drop calls. We've talked a little bit today already about redundancy backup and advanced planning. Excuse me, advanced planning. All of this, again, rolls up to these factors that can meaningfully impair clinical engagement and really take us off topic when we're really trying to be focused on the work that we do with our clients and not the vehicle to deliver that work. 

So I encourage folks, when you're choosing technology products, to really think about the features that are going to be most conducive to that engagement, that rapport for the work that you do. I really like picking something that's easy to use and something that has good customer support. 

Personally, I never buy a technology product. Really, any technology product before I try contacting their customer service, if they'll do a test call with me for a video product, all the better. But I want to see it in action, and I want to see how they handle problems. 

I, for my work, I like to make sure I can have a self view, I can see myself. I want to configure it in different places around the screen. I personally like to have a screen share, a whiteboard. 

Some of those things are nice to haves. Need to haves, but I do prefer them. I want to focus on the content of the discourse and not get tangled up in the tech. I also want to be sure that it's something easy for my clients to use. 

I have some clients who are vastly more facile with technology than I am, and others who are not. And so I want to make sure that my products are products that are good for a diversity of clients. I want to have a messaging platform that's easy to use. I like to do some asynchronous messaging with my clients. 

And some of them have great front end encryption and great password protection, but they can be prohibitive to ease of use. So again, finding that balance, I want an easy way to exchange documents. Homework back and forth, an easy way to collect payments and send. 

Super bills to my clients, all of these are going to be little facets of technology that make an experience more professional, and easier, and frankly, enable that trust and that confidence that we want from our clients. Finally, let's talk a little bit about some of those behavioral factors. What can we be doing to help really encourage clinical engagement? 

We've talked already today about gaze. We've talked about body position. We've talked about hands. It is-- I will also mention, the more frenetic we are on our video calls. The more data we have in our backgrounds, the more burden we place on the call. 

So I think we also have to think about the internet connectivity of the people we serve and our own connectivity. When I have worked with folks who have less stable video calls, it's more challenging to move all around. It's more challenging to have a lot of data in the background. So sometimes, out of necessity, we keep things more austere in order to facilitate less burden on the system. 

Again, I really encourage, if you do one thing after this presentation, go to your self view and record yourself. Play around with it a little bit. Speak how you normally speak. Just imagine yourself speaking to anyone, and then imagine yourself with a slightly more performative kind of affect on the screen, and record it, and see what you like better. 

Watch that self view. Make sure you're not drifting, out of the frame. And make sure that you are happy with what you see. We want to be thoughtful about what are the options for our clients, and how are we thinking about serving them in their environment? 

I think that-- we can think about it different ways. Like many people will want to see someone over a laptop or a computer over a mobile device. They have a preference. And this gets many times complicated. 

If you're working with large groups of people, let's say you're doing group therapy or group education versus one, then you have all types of devices connecting, and some are very steady, some are moving all around the room. It gets a little confusing. I want to note that all of these things are a bit intersectional with privilege. 

People having multiple devices to choose from, well, these cost money. And so that may not be an option for our clients. And we may have to meet them where they're at. Again, we're always finding balance, what is optimal and what is available. 

But we're kind of trying to find, these configurations that are just most conducive to the type of care we want to give just a few words about pediatric clients. Because I think there's a different set of challenges for this population. 

So we're probably going to need some different behavioral strategies for clinical engagement. For younger children. Having a support person in the room can be incredibly helpful, especially if you're young enough that they're just going to get up and wander away from the camera. That's not terribly helpful. 

Of course, anytime we have someone in the room, there's a notable impairment confidentiality. This is especially tricky if we're doing any type of assessment, and we're concerned about the impact of third party monitoring or the presence of another person. So in these instances for assessment, particularly, we're revisiting the reason of why are we doing this, what is the reason for referral. 

Is this technology a good fit for what the client needs? With kids, I encourage us to have more brief sessions. Use screen share. Use other things to keep it interesting. It can be just sort of dry to just sit and look at my face and talk. 

A lot of pediatric providers, I know will bring in little video clips or things that are engaging and fun to try to just increase engagement and keep it interesting for the kiddo. And again, do that test call. Make sure that this feels OK to the kiddo. Introduce yourself and ease into the relationship instead of expecting a child to start having a 90-minute appointment for intake with you. 

Just one on one. I would invite doing that a little more slowly and thoughtfully as the circumstance permits. And then working with older clients. Psychologists, who work in the telehealth modality have, I think, a lot of great accommodations that they use assistive technologies for hearing, for vision challenges when they can help our clients. 

If our client is less facile with technology, helping use that first session dedicated to really comfort, engagement, reviewing the technology, answering any questions. And again, we slow down. Consider expanding the intake process for those clients of any age, really, for whom that technology is not really familiar. 

And again, here a test call can be very useful. So let's talk about when things go wrong. Hopefully, we've documented upfront when-- you know, what we're going to do in case of things going a bit off the rails as part of our informed consent. We keep calm, we carry on. 

We disclose to folks when we're having a challenge. And we try to maybe do it with some levity and some light. Personally, when I find that in a session, I feel that something is amiss with our engagement. Someone's they're elsewhere or something just feels funky in the relationship. 

That's the clinical term funky. I slow it down. I ask questions. I might share with them. Today, something feels different. What's going on? Do you feel that, too? 

Asking a lot of questions, being non-judgmental and curious. These are basic clinical skills. But I think they really serve us in these moments. And how about when things go right. Again, when we go into someone's home, when we're delivering care where they are. We can see their environment. 

It's easier to gain collateral reports. And there is a much less vigorous argument for avoiding your care. So in some ways, I do worry that telehealth can facilitate clinical avoidance in some circumstances. I'm thinking of clients with social phobia or agoraphobia. 

And if you know this was interfering with them getting to care whatsoever, this can be a bridge or this can be a way to get them engaged with care. So some homework for all of us. We're going to find a device that records. We're going to record ourself, introducing ourselves to a new client, what that looks like. 

And we're just going to tinker. Our posture, our expression, our space, the light, the sound, all of these things. And we're going to think about how we want to show up and what we think is going to really best support the type of clinical engagement we want to have with clients. 

Thank you so much for spending some time with me today. I'm very appreciative. Thank you to And if you ever have a question, please reach out. And thanks so much for the great work you do. Take care.