How telehealth can be used in group-based supports

Video telehealth groups have been found to be as effective as in-person groups, and participants in these groups typically report high rates of satisfaction (Gentry et al., 2018). Virtual group sessions can be particularly beneficial for improving participants’ mental health outcomes such as depression, stress and anxiety and overcoming a fear of meeting new people (Banbury et al., 2018).

Practitioners can deliver therapeutic and support sessions via an online platform, which helps minimise the impact of barriers such as time, distance and mobility (Banbury et al., 2018). In these groups, enrolled families can come together and benefit in a range of ways from interacting with the facilitator, the session content, and each other.

Virtual groups can be valuable for families’ mental health and wellbeing, as they may feel more comfortable communicating with practitioners from the comfort of their own home, which can reduce their anxiety and stress. Group telehealth sessions can also be a valuable way to support child mental health.

This paper explores some of the strategies you can incorporate into your sessions.

Group telehealth sessions do not have to be an all-or-nothing approach; groups can instead adopt a hybrid model. This model involves a combination of both telehealth and face-to-face sessions, where some weeks groups may be held in-person and other weeks they can be held online. This is flexible, depending on the preferences of you and your group. So, for example if a circumstance arises where several group members are feeling unwell and would prefer an online session, you might organise a telehealth session for that week. Find what works for your group, whether that is predominantly in-person meetings, mostly online sessions, or a mix of both.

When using telehealth to deliver group sessions, you have a few things to think about to optimise your delivery. The adaptations and recommendations in this paper are presented as follows:

• Set up recommendations
• Design recommendations
• Delivery recommendations.

Below are some implementation features you can incorporate to give your group telehealth sessions the best chance at success.

Check participants’ technology in advance

Participants are likely to benefit from some basic assistance in making sure their technology set up is adequate to access and participate in the telehealth group. This is also an effective way of building rapport with a family and may lead to better attendance and engagement with the group in future. Because dealing with technology issues can interrupt a group telehealth session, it is important to deal with potential issues in advance as much as possible.

These technology checks might include educating participants about the software to be used, and prompting them to check what device they’ll be using and the quality of their internet connection. You can also check that the participant knows how to use the basic functions of their device and ask them to connect to the videoconferencing platform being used, so that they can test the functions that will be used during the group. You may also assess the quality of the audio and video being received through the device and give recommendations about positioning to improve these if necessary.

For families in your group who may have difficulty accessing technology and virtual services, it is important to offer support to address this barrier. Ideas to guide practitioners in assessing and responding to client suitability for telehealth can be found in PRC’s resource on telehealth basics.

The Emerging Minds guide to telehealth for parents can be a useful resource to share with parents to help establish their expectations and support them to prepare for a virtual meeting.

Think about having support from a co-facilitator

It may be helpful to have a support person present with you in your group sessions. This person can assist with the smooth running of the session, particularly if you’re working with people with additional needs. A co-facilitator can help to manage risks that arise during sessions and support you to manage the group dynamics you may have to facilitate. For example, if a participant shares a concerning story or is behaving in a way that raises some red flags, the co-facilitator can privately message them in the chat to invite them to a breakout room. In this breakout room, the co-facilitator can have a chat with the participant, asking questions such as:

• ‘Do you need a break?’
• ‘Are there any struggles you would like to speak about?’
• ‘Do you feel comfortable to return to the group?’

Offer flexible, family-centred participation

One of the major limitations that participants report in relation to traditional, in-person groups is difficulties with accessibility and inflexibility, due to the logistics involved with running and participating in an in-person group (Kohlhoff et al., 2020). To really get the most out of telehealth for groups, it’s best to take full advantage of the flexibility that different modalities provide. One way to do this is through a hybrid approach to group telehealth.

A hybrid approach to group telehealth might involve some engagements being held via live group videoconferencing and some via other means such as group text-based discussions, sharing multimedia via email, or individual phone calls for skill rehearsal and troubleshooting. This allows you to take an individualised, family-centred approach.

Each family might prefer a different mix of the various modalities employed – one might want less participation in group video calls while benefitting from resources shared via email, while another feels more comfortable with text-based interactions with the group via Facebook or WhatsApp. This flexibility can be particularly valuable for families with a child with mental health concerns who may have specific needs, as it allows you to accommodate those needs as much as possible and find a process which works.

Below are suggestions to consider when planning for telehealth groups, or to apply to your existing groups.

Keep the group small

Keep the group size relatively small to ensure participants have sufficient opportunity to discuss and contribute. A smaller number of participants allows you to manage the group more easily, as you can facilitate conversation and engagement from everyone. The number of people for an online group session can vary between 5–15 participants (American Psychological Association, 2019) but you can adjust the numbers in a group depending on your personal preferences, group dynamics and goals of the group.

Reduce the length of sessions

The ideal length of a telehealth group session is shorter than that of an in-person session to optimise engagement and attendance (Butt et al., 2022), although session lengths do vary in practice. Shorter group telehealth sessions typically work better as the use of audio-visual setups such as small screens can strain the senses and cause loss of focus and fatigue. Therefore, it is recommended that sessions be kept to about an hour in length.

If children are participating in your group, their age and developmental level can also help you determine the length of the session (Campbell et al., 2020). If you are having trouble keeping the children in your telehealth group engaged, it is important to adjust your expectations of how long your session may last, particularly for the first few sessions. Children’s satisfaction with telehealth usually increases with use (Lopez et al., 2020), so any initial disengagement impacting the length of the session will likely reduce over time.

Aim for consistent membership of the group

Encourage group participants to attend each week, as this creates greater cohesion between members. You can facilitate this by establishing a set day and time for the group session each week or fortnight to establish the habit in participants. You can also send reminder texts or emails to participants ahead of the session time. Consistent membership helps participants to feel more comfortable with one another and also helps in the creation of a safe and supportive environment, promoting families’ mental health and broader wellbeing.

Work to establish a warm and trusting relationship with participants

With telehealth, it can take a little longer to establish connections with participants than it does with face-to-face sessions (Banbury et al., 2018). Therefore, it’s important to consider your relationship with participants before addressing the topics of interest for your group, particularly for more sensitive topics which may touch on mental health and wellbeing.

Take some time to build rapport and establish a sense of trust with participants prior to bringing up certain group conversations, to reduce the risk of disengagement and feelings of discomfort. One way to do this is to undertake one-on-one meetings with each participant before the first group session to build rapport, learn a little about the family and establish their expectations for the telehealth group.

Reduce the amount of content presented during each session

Participants may struggle to concentrate and absorb information for an extended period during a telehealth group session, so it is advisable to reduce the amount of information presented. This may present a particular challenge for groups where the aim is educating participants about a particular topic.

Participants may become disengaged if you spend too long in one-way delivery of content (which is when you are sharing information and participants are listening). This may cause issues for their future group attendance and may also lead to them not retaining much of the information shared. Therefore, it is important to be realistic about the amount of content you aim to include in a telehealth session.

You may decide to deliver some content via another modality, such as email or text messaging, rather than in the live interactive group. Or it may be feasible to schedule shorter group meetings more frequently, thereby covering less content per meeting but a similar amount of content overall.

Raise topics in a way that makes sense for the group

Depending on the nature of your telehealth group, you may vary the extent to which you structure each session in terms of the content to be delivered. If it’s appropriate for your group to discuss participant experiences of child mental health or wellbeing concerns, it can be powerful to have participants guide the chosen topics.

Online group sessions with families can be a valuable opportunity for you to address aspects of children’s social and emotional wellbeing in a family’s own environment and can promote valuable conversations. At other times, you can share information you think will be useful for the group about topics such as children’s behaviour, growth and development; how to promote positive interactions in the child’s life; or how to help children feel confident and develop their self-esteem.

It may be more appropriate to use terms such as ‘social and emotional wellbeing’ over ‘mental health’ for a softer entry point into the conversation (Australian Government, 2019).

Have a conversation about confidentiality and privacy

Joining a virtual group session comes with its own set of unique challenges relating to privacy. When participants join a virtual session, it can be unclear who else is present in the space and able to hear the conversation.

You can lead a discussion about being overheard at home and convey to the group the role they play in protecting their own and respecting their fellow participants’ privacy and confidentiality. You might encourage group participants to use headphones and attend the session from a private space.

Ensuring privacy and confidentiality is upheld in telehealth sessions can be particularly important for children with mental health concerns to share their experiences in a safe and private environment.

Plan how to deal with potential technology issues

When using telehealth, some common technological issues that may arise include internet disconnection, poor quality of video or sound, and lagging. You can prepare in advance to deal with technological issues that may arise for you or your group participants. This planning can help minimise disruptions and maintain a smooth flow to the telehealth group session.

For example, you may suggest at the beginning of the session that if someone’s video or audio drops out, they call in and resume the rest of the session via their phone. If you would like to share some tips with participants prior to a group telehealth session, you can share brief instructions in an email or text to group members. This can include, for example, a reminder for people to check that their device is connected to the internet or a reminder for the group to charge their device prior to the session time.

Take advantage of more flexible scheduling

One of the benefits of group telehealth sessions is the capacity to be more flexible with scheduling. Telehealth sessions typically have fewer logistical challenges compared to in-person groups, such as venue scheduling or catering considerations. You can use this to your advantage by scheduling the group sessions in close succession, as there is no need for packing down and setting up your space with a virtual session. This can provide you with the advantage of running more groups via telehealth than you could in person, expanding your reach to more families.

You can improve your session delivery to ensure you and the group participants get the most benefit, by using these strategies during the virtual group.

Incorporate visuals and tech features

Using visuals in telehealth groups promotes participant engagement, particularly for families of children with disability (Angell et al., 2023). Most modern videoconferencing platforms allow you to share your screen and upload images or PowerPoint slides. This can be a great way to share information and engage families. You can experiment and ask families for feedback on which visuals work best for which activities.

Establish methods for turn-taking

In group sessions, it can be helpful to manage how participants take turns speaking in a session. Many videoconferencing applications have visual indicators that participants can use to show when they wish to contribute to the discussion. One option is to use the ‘mute’ button that is present in most platforms. Generally, when a participant is muted, this is shown on the screen for other participants to see, in the form of an icon. You can instruct the group to stay on mute until they have something they want to say. Then, participants can take themselves off mute before the previous participant stops speaking, to indicate that they are waiting to speak. Of course, participants will need to be reminded to watch other participants’ mute indicators to keep track of who’s keen to contribute at any given point in time. This method also fits with good online practice in general, in that when a participant is not talking, they are on mute, preventing any background noise from being transmitted to the group.

Another option is to use text-based chat in the background while someone is talking. Most videoconferencing platforms allow text messages to be sent live to the group, which then displays an alert each time a message is sent. You can encourage participants to send a message to the text chat such as ‘I have a thought on that’ or ‘could I say something?’ while someone else is talking, then invite that person to speak next once the current speaker has finished. Your videoconferencing platform may also feature the ability for participants to select a ‘raise hand’ button, which then displays a raised hand overlaid on their video feed and/or next to their name. This can be another way for participants to let others know that they’d like to contribute to the discussion.

Another related issue that may contribute to awkwardness of turn-taking is the amount of time for which each participant speaks, especially in very active groups. You may wish to institute a rough time limit for each contribution, which can help to keep the conversation flowing. Of course, this will need to be explained to the group at the beginning of each session, and you may need to provide reminders and facilitate the conversation throughout.

Invest in participant ownership of the group

Participants in online group sessions may take a passive approach, where they sit back and wait for the facilitator to lead every interaction. This can detract from the kind of engagement your group aims to achieve, so it is important to avoid this by deliberately encouraging a sense of group ownership in participants. Use language that emphasises participant control (for example, ‘What would you like to do next?’, ‘I noticed we don’t have much to say for some of the activities, what should we do about that?’) and defer to the group whenever appropriate. If a participant asks a question, you can ask what the group’s response is instead of answering directly. You may already be familiar with these techniques from running in-person groups, but they are even more crucial in telehealth sessions.

Another option is to appoint an informal host to run one or more aspects of the session, rotating amongst the participants each meeting. Participants are more likely to contribute actively to a discussion if they feel they are helping one of their fellow participants to make the activity run smoothly. This group cohesion can be harder and take longer to establish online (Lopez et al., 2020; Weinberg, 2021) so keep in mind that participants may initially connect more with you as the group facilitator; however, this allegiance can shift to the other group members as more sessions are held (Yalom & Leszcz, 2005).

Take advantage of the activities that work better online

Telehealth sessions can be a great time to teach or practice activities that you wouldn’t be able to do in person. For example, you may wish to demonstrate how to access various websites or apps by sharing your screen and showing the process step-by-step in real time. This could be particularly effective for families who have additional needs and must access a variety of services, or for those with low literacy in English.

The fact that participants can access the group remotely from their home environment may also have some advantages that you can explore. If appropriate, invite participants to share any mementos and associated stories, parenting approaches they’ve been using (such as reward charts stuck to the wall for managing behaviour), or some food they’ve been cooking that is relevant to their culture.

Recognise opportunities to integrate mental health into your telehealth group

As addressing child mental health and wellbeing is a process as opposed to a one-off event, you can create a habit during your group of checking in with parents and children about how their week has been (if this is appropriate for your group). You can ask questions such as, ‘What was easy/has gone well for your family this week?’ or, ‘What was hard for your child this week?’ This can be a great way to open up discussions about wellbeing for their child. You can talk through topics or issues that parents raise as a group, encouraging discussion and sharing, and you may suggest places to seek further advice if appropriate.

Different considerations need to be made, depending on who is attending your group session. Working with children and parents respectively comes with its own specific challenges and opportunities, as does working with both groups. In the following sections, we explore how you can engage the different participants you may have in your group.

Engaging parents and facilitating group interactions

Parents may be more passive in online group sessions than in-person ones, potentially due to a lack of familiarity with the platform, feeling less immersed in the group environment, or simply being unsure of their role in the group. Consider these strategies to maintain parents’ engagement throughout the group session:

• Try to limit the use of a question-and-answer approach, which if overused can establish an interview-style tone in the group. If that happens, participants may become more focused on sharing acceptable, efficient responses rather than the true reflections you might be after. Instead of asking direct questions, try to share a reflection which can encourage others to do the same. For example, if someone shares that this week has been stressful for their family, you can repeat this back: ‘So I’m hearing there has been a lot going on for your family this week.’ This type of response can prompt further elaboration.
• You can encourage participants to un-mute themselves and ask questions or share thoughts during the session. If you find that they are uncomfortable doing so, you can suggest they write questions or responses in the chat function. Every so often, remember to check the chat function and share what has been commented, thanking the writer for sharing.
• It may feel instinctual to jump in when no one is speaking during an activity, but instead you can use the silence strategically. Leaving a little extra time to sit in the silence strongly conveys to the group an expectation for a response. Remember to show with your body language that you are comfortable waiting in silence for a moment and adopt a facial expression that shows anticipation.
• It can also help to periodically check in with participants throughout the session for any comments or questions, in case someone has something to share and just needs some prompting.

Engaging children online

Some children, particularly those with cognitive difficulties (World Health Organisation, 2021) can find it difficult to sit in front of a screen and concentrate during a group telehealth session. It can be helpful to take some time to think about how you can maximise children’s engagement.

• Firstly, set realistic expectations with yourself and caregivers about what can/cannot be achieved during the session; if required, adjust the length of your sessions or the amount of content covered.
• You can open conversations with children by asking questions to establish rapport and increase their comfortability with you and the other group members. This can include questions such as, ‘What is your favourite colour?’, ‘What is your favourite TV show?’, ‘What is your favourite food?’ and so on, where they can share their interests and preferences. You can also do this activity by asking children to draw their favourite food or animal on their device, and use screen-share or send the image in the chat to share it with the group. Art can be an effective way to keep children engaged in the session.
• Encourage families to have toys in the room they are streaming from – ideally quiet toys which children can play with. This helps to prevent children from getting bored and increases their likelihood of maintaining engagement for the duration of the session.
• You can also use technological features such as online drawing tools, eye-catching screen backgrounds and online games to increase and maintain children’s engagement during a session (Montague et al., 2014).

It is important not to give up or become frustrated with running groups via telehealth too soon after starting. Research tells us that practitioners and participants alike initially found virtual group sessions challenging, however this typically improved after a few sessions (Weinberg, 2021). Your proficiency in using telehealth will improve as you go, and a good way to promote this is to be mindful and reflective after your session.

An important aspect of reflection is for you to take some time after a group telehealth session to think about what worked well in the group and what didn’t work so well. For example, you may feel that a certain activity didn’t have as much collaboration from the participants as you had hoped for. You can take note of this, along with potential gaps in the activity (maybe you didn’t share the content with participants ahead of time, or you felt rushed and didn’t sit in silence long enough to allow people to jump in) which you can consider in the next group to do things a little bit differently.

Another way of assessing what works well in telehealth groups is to seek feedback from participants. This can be done informally, through casual conversations with participants or noting observations as groups are running, or more formally by using feedback surveys and/or outcome measures. You can send these surveys out after each session, or every few sessions for participants to complete. There are other relevant metrics you might like to consider as well, such as rates of attendance.

Reflect regularly on the feedback obtained. This can be done in a group setting with colleagues, individually, or both. Form hypotheses about why a particular approach or practice worked or didn’t work, and in cases where there are questions, try a different approach and see if that works. It may be useful to involve the participants in the process – you may share with the group that you noticed one activity or feature of the group wasn’t so successful, or that the participants didn’t get so much out of it, and ask if they would be happy to try approaching it differently. This kind of collaborative approach will also help participants to appreciate that the telehealth group is a work-in-progress and that any aspects that are less than ideal for them might realistically improve in the future.

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