What do you think when somebody mentions telehealth, digital practice or online therapy? Many families, service providers and clinicians are hesitant about what it involves, what the difference is, and if it really works. In fact, many people use the terms interchangeably.
At Umbo, we like to talk about online therapy or digital practice, because we believe that it leaves behind any baggage attached to traditional telepractice and practical or theoretical limitations.
Telepractice dates back to the 1920s and the pedal radios used by the Royal Flying Doctor’s Service, so working remotely is nothing new – especially for clinicians in the bush. And these days, there’s plenty of science to back the use of digital practice with babies, toddlers, schoolkids, older people, and everyone in between. As counterintuitive as it may sound, the most important factor that contributes to the success of digital practice is not technology; it is the relationship with the person, family, and community.
In that sense, digital practice is no different from in-person practice, and technology is merely a conduit. Umbo recognises that families value empathy and evidence-based practice over technology, and that’s why we use the person-centred approach.
What is the Person-Centred Approach (PCA)?
As allied health professionals, our primary goal is to improve quality of life. It’s what we’re trained to do. We aim to support individuals, families and communities to learn new skills and live their best life.
Many people use the term “person-centred approach” (or derivatives thereof) but an important point to remember is that the PCA is a well-defined and well-researched clinical framework, pioneered by American psychologist Carl Rogers. It is not an indistinct adjunct to our current service delivery models, but includes three core concepts: congruence, empathy, and unconditional positive regard.
Congruence is the matching of a clinician’s motivations and their outward expression, which gives the client a sense of “genuineness” or trust about the clinician’s expertise. Empathy is the clear identification by the clinician that the client is experiencing their own reality and difficulties, which contribute to the client’s motivations for change. Unconditional positive regard is the clinician’s expression to the client that they have good personal qualities, and that their goals are important and valid in their context.
In what we will call a prescriptive approach, allied health professionals seek to improve quality of life by identifying goals for someone, and then telling them how to achieve them. This approach is relevant in some clinical situations, but what clients, clinicians, and researchers have begun to recognise, is that the notion of quality of life is different for everyone. So this means that goals are different for everyone. And further, this means that clinicians could not possibly hope that families would fully identify with, or invest in, goals that were made by someone other than themselves. Families must be enabled to focus on their own goals and priorities, or they will simply disengage.
A prescriptive approach is when we assess (often with normed assessments), and then create somewhat arbitrary or decontextualized goals, arbitrarily based on typical skills that we would expect to see at a certain stage of life.
But why do we get to create the goals for the client? Well, many would argue that a therapist is the expert who knows what every person needs – we went to university to study this stuff after all! But whilst this can work (or be relevant) in some areas of practice, we need to remember that everyone is different, and has different preferences and motivations, so the same intervention or support won’t (and doesn’t) work for everyone.
The peer-reviewed literature supports this too. The PCA takes into account the goals, motivations and strengths of the focus person and their support network. Once we sit down and genuinely listen to clients and families (congruence and empathy), we often hear that they have vastly different goals than what we might’ve thought (unconditional positive regard).
It means that we build trust, and in being led by the family or focus person, we can achieve a truly individualised approach that sets out to improve the life of the client, family and community in the areas that they want to improve in.
Think of it like this: if you were a parent desperate for support from a speech pathologist because of the unexplained meltdowns your child has at dinner every single night, and the therapist says to work on ‘s’ sounds, what are you truly going to care about? What are you going to work on? The answer: not your ‘s’ sounds.
How does the Person-Centred Approach Help Clients of Online Therapy
Let’s use an example. A young child named Amelia (not her real name) lives with Autism Spectrum Disorder (ASD). Amelia is an active young child who loves unicorns and painting at preschool. Almost every weekday, Amelia has meltdowns – times of anxiety, distress and uncertainty, which are stressful and traumatic both for Amelia and for her family. Typically a very happy and relaxed child, each morning as Amelia and her family set out for the day, she will yell and scream, and she will hit and scratch family members who come too close, whilst refusing to get in the car.
Before I met Amelia and her family, they saw a visiting speech pathologist in their small rural community. It was a big relief because they thought they finally had someone to support with the meltdowns. The speech pathologist conducted a standardised assessment and found that Amelia, a minimally verbal girl, had a profound language disorder. They recommended some language stimulation activities and left a report with family, then left town.
The family was left without a solution, and now had more on their plate with all of the new therapy activities and a recommendation to see a therapist when in fact there was none within 3 hours’ drive.
I came across Amelia through a referring agency and got to know her and her family. I found out that Amelia likes unicorns, puzzles and is a strong visual communicator. I listened and empathised – eventually, Amelia’s family told me where their real priorities lay.
We completed a functional behavioural analysis in context (all online), and it allowed us to understand what might be behind Amelia’s behaviour during her meltdowns. We collected information about the meltdowns using an ABC analysis, and by sharing histories from the people who had seen the behaviour (parents and preschool teachers). Amelia’s mum was also able to send a video of what happened before, during and after the behaviour.
We figured out that the cause of Amelia’s meltdowns come from the uncertainty of knowing where she’s going each morning, due to an irregular routine that involves siblings and parents doing different things each day, and a mixture of mum and dad taking her to school. She needed to understand where she was going and what she was doing each day, so she didn’t feel so anxious about what was going to happen next.
We developed a visual schedule to use every morning, so now she knows where she’s going, and her parents give her her favourite unicorn to take on her journey, as a transition object. She is also immediately rewarded with a puzzle on arrival at preschool. Amelia doesn’t have perfect language now, and can’t say a nice clear ‘s’, but she no longer has meltdowns in the morning, and her parents now sleep soundly at night knowing that the next morning their little girl won’t be in terrible distress.
How Can I Use the Person-Centred Approach in Online Therapy?
Let’s recall that the three key elements of the PCA are:
- Unconditional positive regard
Firstly, show empathy. Acknowledge that the person or family has come to you for help, and that they have their own difficulties, goals and preferences. You don’t need to understand, simply acknowledge the situation and their feelings about it.
Secondly, be congruent. Make sure that your thoughts, actions, and language match up to create a sense of genuineness.
Finally, ensure that you provide unconditional positive regard. Goals, feelings, thoughts, actions, are all driven by our unique situation as human beings. This means that we can’t necessarily know the preferences, reasoning, and motivations of others, but we must still validate them, and be led by them. Any goal or feeling is valid and genuine, and the clinician should support the client as such.
To revisit our example case, in communicating with Amelia and her family, it was crucial to acknowledge their distress and sense of hopelessness, and also to realise that their priority was to resolve the meltdowns. In practice, this meant video/phone calls in the middle of meltdowns, so I could advise the family (and simply acknowledge the difficulty of that situation), and get a sense of context. It gave us a chance to conduct dynamic assessments to see what might reduce the severity of the meltdown. It also involved sharing video recordings of the behaviour, via Dropbox or Google Drive, so I could look at them in detail and provide ideas or feedback to the family at a later date.
In many ways, online therapy can enhance the process of achieving context-based goals. Getting the family comfortable in communicating with their therapist via technology can help parents to give a full, contextual account of the goal or issue.
How Do I Build Trust with Clients if I Can’t See Them?
My PhD case studies have shown me that clients and families really don’t care if you’re using technology or not. It’s not something that they tend to focus on. They’re looking for support from you, the clinician.
Talking and communicating by phone, video, email, or letter still gives us a great opportunity to develop rapport through sharing common interests, sharing a joke, or comforting someone in a time of need. Many people think that our physical presence is essential for building rapport, but you’d be surprised how many families you can connect with, without even having to video call!
At Umbo, we offer a free 15-minute consultation to all prospective clients, where they can chat with us, so we can understand them as people, before we get to know them as clients. Working on your own communication and active listening skills can be a great tool for building rapport with anyone.
The whole point of the PCA is that we’re putting the client at the heart of everything we do, just as their family does. If you feel it may help, don’t be afraid to share something personal with your client. It may be a hobby, a skill or a favourite holiday destination. If you think that sharing something will help to build trust and rapport in the relationship with your client’s family, then don’t be shy.
Through my 10 years of working as a speech pathologist, and 6 years working in online therapy, I’ve found that all of these techniques, tips, and theories boil down to one important thing: genuine care for the wellbeing and lives of the person or family you’re supporting. If you can constantly remind yourself that they are at the heart of everything you do, then you will be able to build a level of empathy, congruence, and unconditional positive regard with any client, family or community you come across.
Where Do I Go From Here?
If you’d like to learn more, Umbo offers a FREE training package about the principles of online therapy.
There are 5 modules to get you started on the track to being a great online therapist.
We also have a premium training package that covers topics like coaching online, and person-centred intervention principles online.
Umbo also provides bespoke consultations to help you or your business be the best digital practitioners you can be.