Kerri Hopkins, a registered nurse at Prince David Kawananakoa Middle School in Honolulu, Hawaii, has another role in her school: She’s the aide who makes the school’s teletherapy model work.
She has to pull students out of classes for their sessions, manage a crowded schedule, ensure privacy, and be around to make sure sessions go smoothly. During the students’ consultations, Hopkins “hangs out” in the background, but she knows her role isn’t just superfluous. “Being an aide is a lot of extra work, but I realized that a lot of students won’t be able to access therapy if they didn’t have it at school,” said Hopkins.
Sometimes things don’t go to plan. This week, a sixth grader sent to her room for his teletherapy session froze up in front of the computer. He refused to talk to her or the therapist online.
Still, despite the hiccups, teletherapy in schools has grown at a rapid pace since the pandemic, especially in rural districts that find it hard to employ, and retain, full-time school counselors and psychologists. In addition to regular evaluations and case management, there are diversifying mental health needs that schools now must manage.
“We have students who’ve just moved to a new island. Fifty percent of them are economically vulnerable and suffer from academic anxiety or depression. These kids need immediate help,” said Bebi Davis, the vice principal at Prince David.
Schools now meet at least some of this growing demand for mental health interventions by contracting with for-profit service providers like Hazel Health, the provider Prince David uses, and Presence. The platforms cater to specific district licensing and training needs and provide a variety of mental health professionals, from psychologists to special education experts.
The ingredients to get teletherapy off the ground seem simple. A school needs a few working computers, a good internet connection, and a coordinator on-site to make sure that students get to their appointments. Getting all these elements to work together, though, is far more complicated—especially because different students have different needs from teletherapy.
Quiet, but not isolated
First, schools must secure a quiet location for the sessions, but one that can still be supervised from a distance. Dan Florell, a school psychologist who works with urban and rural schools, has a definite ask.
“It should be the smallest room they [the school] can find. The bigger the space, the more the chances that therapy gets bumped in favor of other meetings. Schools don’t have an infinite amount of space,” said Florell.
This configuration of quiet but not isolated is a hard one to crack, especially in a mental health counseling session, where students talk about their feelings of anxiety, depression, or loss. Students should be alone in the room which should ideally have a white noise machine to mask the conversation for anyone outside the room.
Schools must also navigate complex privacy regulations for therapy. Providers need to be compliant with HIPAA, the federal privacy law governing health information. A representative from Presence said online therapists must also seek parental consent before recording sessions. Schools, meanwhile, must protect students’ personal health information under the FERPA law, which governs students’ education records.
This requirement changes when students come in for speech and language, or occupational therapy. For younger students in speech and language therapy, for instance, there is usually an aide present in the room, either to help log in or do warm-up exercises with them.
At Prince David, the sessions take place in Hopkins’ small nurse’s office, tucked away in the back of the library. The sessions happen behind a room divider, where Hopkins sets up the iPad and headphones provided by Hazel Health.
Other schools have fewer dedicated spaces to spare. At the Alfred G Waters Middle School in Middletown, Del., sessions are either held in a conference room, or the part-time school psychologist’s office. The school uses teletherapy for psychological evaluations and speech and language therapy. It prefers to do mental health counseling in-person.
“Most of our students attend the sessions on their own. But the psychologist’s room is within the student-support suite. It’s easier for us to monitor,” said L’Tanya Cain, an assistant principal at the school. It can be a challenge to get some students out of their classes for a teletherapy session, Cain said, so the proximity sends an important message: “Students need to know they’re in a safe spot. They feel uncomfortable when they’re alone so an adult should be close by,” she said.
Getting the right hardware
The Keyes Union school district in Keyes, Calif. first partnered with Presence twelve years ago, when it couldn’t find a qualified therapist to join on-site. Initially skeptical, special education curriculum director Cyndi McDaniels said Presence now provides speech and language therapists for all three schools in the district.
The setup for speech and language therapy looks different from the type of mental health counseling that goes on at Prince David, with multiple computers in a small room, as well as headphones with splitters, to allow the principal support aides to listen in if needed.
If students are doing occupational therapy online, schools must devise an additional camera setup that points to the day’s activity—like writing practice. This two-camera set-up can be pointed at the student if they need to move around as part of a warmup activity with the therapist.
Therapists have their own preferences when it comes to hardware. Cindy Hollmann, the Presence therapist for Keyes Union, says desktops with an ethernet cable have a better internet connection than those relying on wireless.
“The computers can’t be cast-offs from the computer lab in the school. The school leaders play an important role here because they have to advocate for all this new hardware,” she said. During the COVID-19 pandemic, for instance, the number of headphones needed at Keyes Union went up from three to fifty.
Coordinators are the glue—but they need training
The principal support person on-site helps to coordinate a lot of moving parts.
Their duties involve getting each student out of class, setting up the device with cameras and headphones, and being available during the session to make adjustments when necessary. They also manage the schedule of these appointments, so that students aren’t being pulled out of class too often. And, sometimes they’re responsible for laying out all the therapy options to parents, if something comes up in their child’s psychological evaluation.
These aides can’t be passive observers, though—especially with younger students who might need cameras repositioned, or need to find the right tools for their therapy. Presence advises its therapists to stay connected with the aide through the app or over a text thread. Training on privacy and how it differs based on the kind of therapy being provided is important, too.
Hollmann said she’s worked with principal support people with varying levels of training. “Initially, you’d have them sleeping or reading in the corner of the room, and the kids crying out for help,” said Hollman. That has improved over the last decade.
Hopkins, the registered nurse at Prince David, is now training a health technician to deal with the increasing caseload of students.
Integration is key
A final pillar of the teletherapy structure is ensuring an online therapist is integrated with a school’s culture. Without constant communication with school leaders, or staff appointed to deal with student well-being, important information about students can fall through the cracks.
“When you’re on-site, it’s easy to grab a teacher in the hallway and check on a student. This is much harder to do online,” Florell said.
At Cain’s school in Delaware, the online therapist comes to the school site frequently to observe students in their classes, and pick up behavioral clues on students from their teachers. “We also considered sending her recordings of our classroom,” said Cain.
Schools need to ensure that therapists are seen as part of the team: They should be involved in the meetings to set Individualized Education Program goals, have access to the kind of social-emotional learning curriculum being taught in the school, and participate in school culture.
It ultimately falls to the school leader to create space for the online therapist in the school. “Principals can’t just check once a month to see how’s going. They need to appoint people to keep the system running. You won’t have a teletherapy program without their support,” said Florell.