Parent engagement and therapeutic alliance in allied health teletherapy programs

[SarahLyon]

Read Full Text: Parent engagement and therapeutic alliance in allied health teletherapy programs (This is a paid article, but we still thought it was important to cover.)
Journal: Health and Social Care in the Community
Year Published: 2021
CEU Podcast: #45: Telehealth, Parent Alliance, and OT with Adam Griffin (CE Course)

As OTs, we believe that creating a therapeutic alliance is one of the most powerful vehicles to change.

But, we also know that there are many barriers to building transformational relationships with our clients.

Telehealth can feel like one of those barriers—but it doesn’t have to be!

The article we are looking at this week is a qualitative study exploring parent engagement and therapeutic alliance in teletherapy programs. The authors’ intent was to begin building a conceptual model to inform improved practice.

Next week on the podcast, we are excited to welcome Adam Griffin. Adam is an OT hailing from Dubai who has vast experience in both providing teletherapy and instructing fellow OTs in virtual care.

Quick intro to teletherapy and where the research stands

Allied health professionals around the globe are increasingly using teletherapy services.

But, teletherapy best practices have been under-researched thus far—leaving therapists with insufficient evidence to guide program design and service delivery.

The known importance of therapeutic alliance

Even with the dearth of research, we know that therapeutic alliance is crucial to the efficacy of teletherapy care—and in pediatric therapy, this includes optimizing parent/caregiver involvement.

Becker et al. and Butler & Titus have both shown that caregiver involvement has a significant impact on therapy outcomes in allied health.

Wait, what exactly is therapeutic alliance?

The concept of therapeutic alliance applies across the spectrum of allied health disciplines—including psychology, OT, PT, and SLP.

While the concept has evolved over the years, two main definitions are emphasized in this paper.

First, Plexico et al shares that therapeutic alliance is:

“A relationship between the clinician and the client or others involved in the therapy process, that involves trust, collaboration and agreement about therapy goals and the tasks required to achieve these goals.”

Pinsof adds that there are two essential aspects to therapeutic alliance:

1. Task Alliance: A collaboration that includes agreement on diagnosis, goals, purposes, and tasks.
2. Relationship Alliance: The development of rapport and trust.

Therapeutic alliance in teletherapy: what we know and don’t know

Other papers have examined therapeutic alliance in teletherapy, but they have mainly focused on the therapist’s experience.

While this perspective is important, the provider’s voice shouldn’t be the only one heard—especially in light of previous research showing therapists’ propensity to misjudge how clients and families view therapeutic alliance in teletherapy.

Which leads us to this paper…

What was the intent of this paper?

In order to clarify the factors that hinder therapeutic alliance in teletherapy, the authors aim to:

1. Investigate influences on parents’ engagement with a teletherapy program and their therapeutic alliance with the therapist.
2. Make recommendations to improve engagement and alliance during teletherapy.

What were the authors’ methods?

This study used a qualitative design.

Interviews were conducted with caregivers whose children had received teletherapy (led by an OT, PT, SLP, or psychologist). A thematic analysis was completed using the constant comparison method.

The themes were then used to develop a conceptual model of participants’ experience with teletherapy.

Who were the participants and what did the interview entail?

6 parents/caregivers participated in the interviews. 5 of the 6 families participated in teletherapy in a school environment. The remaining family participated in home-based teletherapy. The interview questions focused on therapy provided over roughly one semester. Each parent attended an average of 6.2 sessions.

The interview consisted of 23 scripted questions, including:

• Were there things about the program that made you feel comfortable?
• What things made it easier to work with the therapist?

What were the findings?

Three themes emerged from this analysis:

Theme 1: Initial engagement

Parents considered two main factors when deciding whether to engage with an offered teletherapy program:

1. Practical Advantages: These included reduced travel, reduced costs, and reduced inconvenience to the family’s schedule.
2. The Prospect of Therapeutic Rapport: Parents valued greater contact with the therapist compared to alternatives. Teletherapy allowed for access to the non-verbal communication between the key parties: parents, children, teachers, and therapists.

Theme 2: Collaboration

Parents sought evidence that the therapist was committed to a collaborative partnership. This commitment was demonstrated through:

1. Knowledge transfer from the therapist to parents and other caregivers
2. Inquiry into, and incorporation of, parents’ views and knowledge

Here is one example of a lack of perceived collaboration:

“I thought I would be asked more questions and maybe given a little more info at the end of the sessions.”

Theme 3: Rapport

Parents sought evidence that the therapist cared about, and/or understood how, the parent and child felt and might react. To confirm or revise their current view of the relationship, they looked for cues from the therapist’s:

1. Actual words
2. Facial expressions, body language, and manner of speech

Here’s an example of a parent feeling a deep sense of rapport:

“She (the therapist) had my child’s best interests at heart, which came across very well when she said, ‘This program isn’t working for your child. We need to tweak it, so we can get to the real issues."

Discussion/Conclusions/Implications

Using the themes above, the authors presented a conceptual model: The Parent and Caregiver Evaluation Cycle (PACECIT).

This model includes five evaluations made by parents in two areas:

In seeking collaboration, they evaluated the therapist’s:

1. Communication
2. Partnership (within and beyond the session)

In seeking rapport, they evaluated they therapist’s:

3. Words
4. Nonverbal communication
5. Manner of speech

Here’s a figure that merges these evaluations with relationship and task alliance:

See original image here.

The authors state that if allied health professionals providing therapy are aware of the PACECIT Model and systematically fulfill these caregiver expectations, they may be able to more efficiently develop a strong therapeutic alliance to improve engagement, therapy results, and stakeholder satisfaction.

Takeaways for OT practitioners

(Please note: These are my personal takeaways. They are not mentioned specifically in the article.)

1. I really liked the division of relationship alliance and task alliance.

This article hit home for me. In my practice with adults, there have certainly been times when I built good rapport. But, I wasn’t necessarily clear about goals and how our sessions were going to accomplish those goals. The figure above drives home how crucial both branches are to ensuring successful outcomes.

2. Goal alignment and parent engagement come up again….and again…and again in our research!

It feels like almost every article we look at underscores the importance of getting on the same page about goals and promoting parent engagement. I like how this article detailed what that looks like—and made us think about our communication from the parent’s perspective.

Next week on the podcast, I’m so excited to talk with Adam Griffin about using this model in practice. And, of course, I hope you share your experiences and questions about therapeutic alliance below!

Here’s the full APA citation for this article:
Fairweather, G. C., Lincoln, M., Ramsden, R., &; Bulkeley, K. (2021). Parent engagement and therapeutic alliance in Allied Health teletherapy programs. Health &; Social Care in the Community, 30(2).

Earn one hour of continuing education by listening to the podcast on this article!!

In this podcast episode, we dive even deeper into this topic, with OT (and Club member!), Adam Griffin. You may be eligible for continuing education credit for listening to this podcast. Please read our course page for more details!

What questions/thoughts does this article raise for you?

[Rsaltzgaber (Rachel Saltzgaber)]

I absolutely love to see this coming from the parent/patient perspective! With all the details of the evaluation and completing documentation after the evaluation, how many times do we go back and talk about goals and communicate expectations to be working on both with our pediatric clients and with our adult clients? I know I could use some work. and how much more with telehealth, really empowering parents to work with their kids!

As a parent of kids who have received therapy before, I’ve had to ask about goals. These are wonderful therapists who have built great rapport with me. I feel comfortable asking, but I’ve still had to ask. And continue to ask what they see and how to be working with my kids.

my thoughts go to “how could we do better communicating to parents and patients?” “How would understanding the goals, the building of the rapport, and comfortableness with the therapist lead to progress and joint effort toward the goals?”

“How can we as therapists get in to habits and routines of making sure to increase communication and rapport with our patients?”

Some of my thoughts for my current workplace include a fun welcome paper that everyone can receive that describes OT that can be given to the parents or emailed with telehealth. I know we describe this, but it would be a great reference for them to go back to. Potentially include a list of tips and questions to ask therapists that will help parents understand what their children are working on. For example, “what should we focus on in our play time this week?” And potentially attach a simplified list of goals such as “We will be working on tying shoes.”

I think this would be encourage and empower parents in so many ways!! Excited to see other thoughts and ideas!

[allison5 (Allison Doerpinghaus)]

A few thoughts here:

(1) I think so much of the emphasis during telehealth OT services - which, I think makes total sense and fully support - was on the parents/care partners. Telehealth was a really hard transition for a lot of kiddos (truthfully, for all of us!) but focusing OT services on empowering and engaging care partners allowed for continuity of services at home. I think this was one benefit to telehealth intervention and something that should continue in pediatric practice across all settings and domains.

(2) The inclusion of OT as a telehealth-approved intervention is a result of a ton of advocacy work by practitioners and the lobbyists who support the profession. Goes to show how successful and important advocacy is for our profession. While it’s great that telehealth is inclusive of a lot of families, I think it’d be a disservice if we didn’t mention how it is still exclusionary for a number of families, often families with low SES or living in rural areas. I think this continues to be an opportunity for continued OT advocacy - we know there are benefits to tele-services for both the child and the care partner, how can we continue to increase access to services for families who are not currently benefitting from this intervention approach?

(3) OTJR is putting out a telehealth-specific special issue so that’s exciting! I know my research lab has several papers coming out about telehealth and feeding interventions for autistic kiddos (both reporting out on the child/parent outcomes as well as impact on therapist). Just a shameless plug.

[cheryl2 (Cheryl Hall)]

Wow, this topic hit home for me as a therapist who does home visits and found Teletherapy very challenging during the initial stages of the pandemic.

I liked the visual with the breakdown of relationship and task alliance. Definitely a good reminder and made me reflect.

Relationship: As Dr. Bruce D. Perry is quoted “Relationships are the agents of change and the most powerful therapy is human love.” I have taken the first part of this quote to my practice. With parents, when there is a solid relationship, the children make significant progress because the parents listen, trust and implement strategies into their day. Parent/caregiver engagement is essential when working with children.

Task: It is important to relate what tasks and activities are being included into the sessions with the goals that were developed with the parents. This connection adds the next layer for follow-through and building relationships. I often have to go back and look at the goal documentation (parent driven) to make sure I’m on track.

Thank you for sharing this article! I can’t wait to hear the podcast as Adam Griffin has amazing ideas that I have incorporated into my practice.

[SarahLyon]

@Rsaltzgaber

Some of my thoughts for my current workplace include a fun welcome paper that everyone can receive that describes OT that can be given to the parents or emailed with telehealth.

I so relate to you, @Rsaltzgaber! This paper helped me realize that my strength is in rapport builidng—and I havent historially been great on goal alignment.

I love your idea about a simple welcome paper.

I also wonder how many OTs utilize a patient facing portal? And, how many of these portals have goal tracking options. (I’m thinking a portal would be a great shared place for the same content from your welcome paper idea.)

The patient portals I’ve seen all seem to have an exercise program focus. But, I’d love to see a more OT-centric one that facilitates goal alignment and tracking.

[SarahLyon]

@allison5

(3) OTJR is putting out a telehealth-specific special issue so that’s exciting! I know my research lab has several papers coming out about telehealth and feeding interventions for autistic kiddos (both reporting out on the child/parent outcomes as well as impact on therapist).

When is this coming out, @allison5 ? Do you know? I’m excited to see it!

[SarahLyon]

@ashley14, I’m so curious if you know what is out there as far as patient portals/patient journey systems that are more compatible with OT?

I know Therabyte has goal tracking, but can the patient see it?

[allison5 (Allison Doerpinghaus)]

Not sure - I just know that some of my colleagues submitted articles/abstracts for it. Will keep you updated!

[ashley14 (Ashley Reina)]

@SarahLyon Thank you for looping me into this conversation. I am SO PASSIONATE about this topic, to the extent that I build an EMR platform that is central to creating this relationship. Within Therabyte you can create treatment plans, share those goals to the client portal for the client/parent to view. There is also the option to share whole session notes (including goals), or just a portion of the session notes, with the option to enable commenting from the caregiver/client.
With the goals built into the session and documentation process, I have found it help me significantly with having goal alignment. The goals are transparent for everyone. Within my own practice I will often set goals that are caregiver focused and client focused. Here a short video that looks at including the goals as part of your session documentation process. I don’t have a video on what it looks like in the client portal…I’ll have to make that.

[SarahLyon]

I’m so glad you are in here, @ashley14!

When I look back on my sessions where there was a TOTAL failure on goal alignment, it definitely feels like a personal failure.

But, on the other had we did not have any systems that prioritized goal sharing and alignment. I have to think that client portals will become a standard part of practice in all practice areas over the next five years. Do you think that is true?

(Also, I would LOVE to see yours. Are you familiar with the CO-OP Approach? I always think it would be sweet for that approach to be built into an EHR, where clients can rate how they perceive themselves to be doing on their goals.)

[ashley14 (Ashley Reina)]

From what I can see in other systems and the push for transparency of data, I do think client portals will continue to become standard practice.
I am more familiar with GAS. Our current goal set up allows for trial data collection. I do love that idea of clients being able to rate their perception of their own performance. I can see that being important with adults and mental health clients.
This will give you an idea of what the client portal looks like, this is before we had the capability for goal sharing. https://www.loom.com/share/7ed60f8179314a4c8ca1cd694edc9212

[SarahLyon]

This is just the beginning of an idea for my ideal patient portal!

I’d love to have input from @helene1 Polatajko on CO-OP methodology for goal rating. @carlin and @catherine8, if every OT client had a portal, we could include access to maternal health/caregiver/lifestyle medicine screens.

[Rsaltzgaber (Rachel Saltzgaber)]

@allison5

impact

Yes!! I love the idea of using a patient portal. Where I work doesn’t have telehealth available at this time so I don’t even think about the possibility of patient portals! I think that would be such a great way to communicate.

[Rsaltzgaber (Rachel Saltzgaber)]

This is a great start!

[SarahLyon]

@Rsaltzgaber Would you use a simple client portal if it was available to you? Or would it feel like a hassle, if it wasnt connected to your doc/billing?

My gut says it could be a stand alone product. And, I’m feeling like this is my million dollar idea for 2023! But, I really want someone other than me to build it

[Rsaltzgaber (Rachel Saltzgaber)]

I think I would use either one because the parent/therapist connection is so important to me. However, I know that in the pediatric in-person world that schedules are packed and documentation is hard to keep up on. I know it may be challenging to add one more thing. In the telehealth world it may be easier. Any thoughts?

My children go several medical specialists such as the cardiologist and the pulmonologist through Cook’s Children’s in Fort Worth, TX. They have a patient portal where I can visit and review any visit info and the doctors’ notes. I had never connected what this would look like for us as therapists! I think it’s doable and exciting!

[ashley14 (Ashley Reina)]

I love this! love incorporating how each person see the progress of the goal.
Currently our is data driven… however you could use the same to be subject. We are working on the ability for the clients to submit data!