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COVID-19 and School Closures

Mayumi Y. Douglass, MS

I work as a licensed marriage and family therapist at a high school in Southern California. As an AAMFT Approved Supervisor, I had four marriage and family therapist (MFT) trainees completing their second-year practicum experience under my clinical supervision. The trainees and I provided school-based mental health services to high school students and their families who were referred by guidance counselors and teachers. Most of our clients are minors, and most have sought services on their own. Since our services are directly funded by the school through Title I grants, we do not seek reimbursement by health insurance plans. This allows us to see students who do not meet “medical necessity,” and we are not required to give a mental health disorder diagnosis in order to qualify for providing services. We also have the flexibility of providing mental health services as long as needed, based on client needs and not based on the number of sessions approved by a health insurance company.

I schedule weekly video or phone sessions with parents as part of my services to minor clients, and I have found that it is much easier to set up 30-minute conjoint video sessions, even if parents are still working outside the home.

On March 13, we were informed that as a result of the COVID-19 pandemic, the school would be closed starting the following Monday, and the length of closure was unknown, since it was based on federal and state mandates for decreasing the risk of infection from coronavirus. On that day, the team of trainees under my supervision and I had an active caseload of 63 students participating in school-based mental health services. Some of these minors have consented for their own services, and we had a variety of students who had just started services with us or were in the late stage of therapy. Students in our caseload who were presenting with severe symptoms of mental health disorders based on DSM-V (American Psychiatric Association, 2013) were already connected with outpatient mental health service providers to offer a higher level of care, if needed.

As a therapist

Before we were faced with the reality of the COVID-19 pandemic that caused the sudden and abrupt ending of in-person sessions, I had always thought of telehealth services as a last resort for providing mental healthcare. My clinical training in graduate school as an MFT emphasized “in-person” interactions as essential to create and maintain a therapeutic alliance.

This perspective has been reinforced by my continuous clinical training as a licensed marriage and family therapist, including the multidisciplinary integration of neuroscience and psychotherapy explained in the Brain-Based therapy model by Arden and Linford (Quinn, 2011). The quality of the therapeutic alliance is one of the four primary elements of the model, and it explains the neuroscience of in-person interactions, and their effect on creating and maintaining a strong therapeutic alliance and to practice effective therapy services.

When conducting a session by phone or video, information such as body posture, tone of voice, and other nonverbal cues are non-existent or very limited, which results in mostly focusing on what is emerging from the client’s left prefrontal cortex and temporal lobes, described by Arden and Linford (2011) as the speech centers that power the life narrative. However, my experience using both video and phone to continue mental health services has been more satisfactory than I anticipated. There are a few advantages I am noticing in comparison to in-person school-based services.

Increased sense of comfort

Clients have expressed feeling more comfortable participating in telehealth services because they are at home, in their own environment. Before, students would come to my office at the Guidance Center during school hours, but this change in service experience has brought to my attention that regardless of how cozy and warm I try to set up my school-based office, there is no comparison to participating in services from the comfort of the client’s own space.

Some of them prefer video, but I notice that most prefer phone sessions, stating they do not need to worry about their personal appearance and background. One client told me that using the computer for video sessions feels “colder,” since she already spends so much time in front of the computer completing school assignments, and that the phone is more “personal.” Another student shared that if given the option of continuing phone or in-person sessions, she would prefer phone sessions. She reported feeling more comfortable when she is not participating in person because, if she is not making eye contact, she may be perceived as not paying attention.

Increased opportunities for relational sessions

The limitations of bringing family members to participate in relational therapy during school and working hours have been significantly decreased by the shelter-in-place orders. Since my clients are mostly minors living with their families, I now have increased opportunities for engaging family members in therapeutic services. I schedule weekly video or phone sessions with parents as part of my services to minor clients, and I have found that it is much easier to set up 30-minute conjoint video sessions, even if parents are still working outside the home.

Self of the therapist reflections

As an immigrant from Mexico practicing as a therapist in California, I have always been aware of how my accent could be a barrier for people understanding me and forming an opinion of my professional competence. This experience has also been identified as doubts about the competence of the bilingual therapist as a result of the client’s view of professionals speaking her own language (Iannaco, 2014).

Part of the reason for my previous avoidance of integrating telehealth services as part of my clinical practice has to do with my own frustration with English as my second language, and the importance of not wanting to miss important details “lost in translation.” As multilingual therapists can attest, providing therapy services in another language goes beyond the proficiency that you have in both languages. There are critical elements of language that include the personal use of metaphors, sense of humor, and the emotional impact of certain words. The language of therapy itself is a unique language, and becoming proficient in the language of therapy in a second language is a very complex learning experience for multilingual therapists. As a bilingual therapists working with monolingual clients, I need to give additional attention to the extralinguistic and affective factors present in the therapeutic conversations (Javier, 2007).

The question, “What is it like for bilingual therapists to work with monolingual and bilingual clients?” was explored in a qualitive study to examine the identification and over-identification within a therapeutic relationship where English is the therapist’s second or subsequent language (Nguyen, 2014). Identification is usually described as seeing aspects of ourselves in others and the ability to identify with another’s feelings and needs. As a bilingual therapist, I agree with Nguyen’s statements that 1) identification is more likely to happen when, like the therapist, the client also is bilingual, and 2) the identification process is more difficult for a monolingual client with a bilingual therapist.

I had always preferred in-person sessions because the integration of verbal and non-verbal communication gives me a deeper understanding of the message conveyed by my clients. Not having the option of continuing in-person sessions, and with the opportunity to provide telehealth services, I have been forced to leave my comfort zone and engage in phone and video sessions, which add another layer of complexity as a therapist practicing in my second language. I can share that my experiences have been better than what I expected. Since most of my telehealth clients are former in-person clients, I had already reached a level of “therapeutic linguistic understanding.” I have not experienced a significant drawback from clients who were assigned to me to continue telehealth services. I do find video sessions more helpful for understanding the emotional content of clients’ words, but I have also noticed that paraphrasing and checking for meaning is very helpful when engaging in phone services.

As a supervisor

This pandemic created unique circumstances for all mental health providers. As a clinical supervisor, I needed to determine the options for continuing services to the 63 students who were actively participating in sessions with the MFT team under my supervision. These options were determined by:

Board of Behavioral Sciences (2020a; 2020b) statement about coronavirus disease, allowing MFT trainees to provide telehealth services
Decisions made by MFT programs regarding requirements for their MFT graduate students to participate in telehealth services (Monk, 2020)
The high school district and the school administration guidelines for providing telehealth services to their students
AAMFT’s Best Practices in the Online Practice of Couple and Family Therapy (Caldwell, Bischoff, Derrig-Palumbo, & Liebert, 2017).

Clients continuing telehealth services

The last two weeks of March were spent developing a system for trainees under my supervision to continue telehealth services in order to determine which students could qualify for these services. As a supervisor, the criteria I used for making this determination were based on the client:

Completing an intake session in person
Having an interest in telehealth services and access to phone or video communication
Having a legal guardian who is consenting for mental health services or is legally an adult and therefore can consent for one’s own services
Presenting with mild to moderate symptoms of mental health disorders based on DSM-V (American Psychiatric Association, 2013). If severe symptoms are present, the student is already connected with an outside provider who is monitoring outpatient mental health services and medication management, if needed
All interested students and their legal guardians are providing new telehealth informed consent before starting services

During the last two weeks of March, we attempted contact with all 63 students, and if we were unable to talk to them by phone, we left messages to let them know of the option to continue telehealth services, as well as provide referrals to the San Diego Access and Crisis Line and other mental health providers in the community.

Based on the criteria to determine which students could qualify for these services, we were given a new scenario for services: 18 students agreed to continue via telehealth; 14 reported no interest in continuing services; 5 students had severe symptoms and were already connected with outside services; 27 students and their legal guardians did not respond and their clinical charts were closed.

On April 20, 2020, the high school began distance learning, which resulted in increased access to students since they were checking their school email accounts again. We had some students who were former clients contacting us to request services via telehealth, and we also had new referrals from students who were experiencing high levels of stress and symptoms of anxiety.

As a supervisor, I had to modify my criteria for telehealth services to include new clients, with the following conditions:

Parent or legal guardian is consenting for services
Intake appointment includes a parent or legal guardian and is preferably completed in a video session
If student is presenting with severe symptoms of depression, we are coordinating services to access a higher level of care and crisis intervention services as needed

We also identified a need to offer an online weekly support group to connect students with their peers and discuss the impact of COVID-19 on their well-being and identify and implement coping skills to manage the resulting stress from these recent changes in their lives. We invited the 13 students who were already participating in an anxiety support group on campus and extended the invitation to students participating in individual sessions via telehealth.

MFT trainees continuing telehealth services

Alongside my role as a supervisor determining the options for continuation of services with our high school clients, I was also attentive to the impact of these changes on the MFT trainees under my supervision. There were unique circumstances that determined if they were able to continue telehealth services for their caseloads. These included health conditions, access to a private space at home, reliable technology to offer telehealth through a secure platform, and time to continue traineeship activities, as some trainees had also become full-time guardians for their children and homeschool teachers overnight.

Out of the team of four trainees, one was able to put aside 12 hours per week to continue her role. We continued providing distance services for the students who chose to continue, based on their preferences for frequency of sessions, either weekly or every other week, and through their preferred method of contact.

Telehealth supervision experiences

The greatest impact of the COVID-19 pandemic in my role as a clinical supervisor was losing my team, who I was expecting to supervise up until June 2020. I miss our group supervision sessions and the ongoing learning experience. I also miss the ongoing in-person collaboration with guidance counselors and other school staff at the Guidance Center. I did not have the opportunity to properly process the end of our supervision relationship, just as they did not get the opportunity to process the end of their experience with their clients. We all had to adapt to these rapidly changing circumstances to the best of our abilities.

We had some students who were former clients contacting us to request services via telehealth, and we also had new referrals from students who were experiencing high levels of stress and symptoms of anxiety.

Mayumi Yamanaka Douglass, MS, LMFT, is an AAMFT Approved Supervisor and Clinical Fellow, and lecturer at San Diego State University. She works as a mental health clinical supervisor and therapist at a high school in southern California. As other colleagues, she became a telehealth mental health therapist and clinical supervisor in response to the COVID-19 pandemic.

REFERENCES

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.

Arden J., & Linford, L. (2011, January/February). The rise and fall of PaxMedica: Welcome to the new era of brain-based therapy. Psychotherapy Networker, 34 (1).

Board of Behavioral Sciences. (2020a, March 13). Statement on Coronavirus Disease 2019 (COVID-19) and telehealth. Sacramento, CA, United States of America.

Board of Behavioral Sciences. (2020b, April 30). Updated statement on telehealth to reflect governor’s executive order N-43-20. Retrieved from https://www.bbs.ca.gov/pdf/updated_coronavirus_statement.pdf

Caldwell, B. E., Bischoff, R. J., Derrig-Palumbo, K. A., & Liebert, J. D. (2017, February 17). Best practices in the online practice of couple and family therapy. Retrieved from https://www.aamft.org/Documents/Products/AAMFT_Best_Practices_for_Online_MFT.pdf

Iannaco, G. (2014). A response to Nguyen’s article, Identification: A qualitative study of the experiences of bilingual therapists with their monolinguals and bilingual clients. Psychodynamic Practice, 20(4), 356-361.

Javier, R. A. (2007). The bilingual mind: Thinking, feeling, and speaking in two languages. New York: Springer.

Monk, G. (2020, March 12). MFT program contingency plan for COVID-19. San Diego, CA.

Nguyen, B. P. (2014). Identification: A qualitative study of the experiences of bilingual therapists with their monolinguals and bilingual clients. Psychodynamic Practice, 20(4).

Quinn, M. B. (2011). Brain-based therapy with adults; Brain-based therapy with children and adolescents. Psychiatry: Interpersonal and Biological Processes, 71(Spring 2011), 93-94.