Kerri Hopkins, a registered nurse at Prince David Kawananakoa Middle School in Honolulu, Hawaii, has another role in her school: She鈥檚 the aide who makes the school鈥檚 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鈥� consultations, Hopkins 鈥渉angs out鈥� in the background, but she knows her role isn鈥檛 just superfluous. 鈥淏eing an aide is a lot of extra work, but I realized that a lot of students won鈥檛 be able to access therapy if they didn鈥檛 have it at school,鈥� said Hopkins.
Sometimes things don鈥檛 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.
鈥淲e have students who鈥檝e 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,鈥� 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鈥攅specially 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.
鈥淚t 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鈥檛 have an infinite amount of space,鈥� 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 A representative from Presence said online therapists must also seek parental consent before recording sessions. Schools, meanwhile, must protect students鈥� personal health information which governs students鈥� 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鈥� small nurse鈥檚 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鈥檚 office. The school uses teletherapy for psychological evaluations and speech and language therapy. It prefers to do mental health counseling in-person.
鈥淢ost of our students attend the sessions on their own. But the psychologist鈥檚 room is within the student-support suite. It鈥檚 easier for us to monitor,鈥� said L鈥橳anya 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: 鈥淪tudents need to know they鈥檙e in a safe spot. They feel uncomfortable when they鈥檙e alone so an adult should be close by,鈥� she said.
Getting the right hardware
The Keyes Union school district in Keyes, Calif. first partnered with Presence twelve years ago, when it couldn鈥檛 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鈥檚 activity鈥攍ike 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.
鈥淭he computers can鈥檛 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,鈥� 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鈥攂ut 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鈥檛 being pulled out of class too often. And, sometimes they鈥檙e responsible for laying out all the therapy options to parents, if something comes up in their child鈥檚 psychological evaluation.
These aides can鈥檛 be passive observers, though鈥攅specially 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鈥檚 worked with principal support people with varying levels of training. 鈥淚nitially, you鈥檇 have them sleeping or reading in the corner of the room, and the kids crying out for help,鈥� 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鈥檚 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.
鈥淲hen you鈥檙e on-site, it鈥檚 easy to grab a teacher in the hallway and check on a student. This is much harder to do online,鈥� Florell said.
At Cain鈥檚 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. 鈥淲e also considered sending her recordings of our classroom,鈥� 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. 鈥淧rincipals can鈥檛 just check once a month to see how鈥檚 going. They need to appoint people to keep the system running. You won鈥檛 have a teletherapy program without their support,鈥� said Florell.
