Evaluation of the rapid implementation of telehealth during the COVID-19 pandemic: a qualitative study among adolescents and their parents

20 participants met inclusion criteria: 10 adolescents (mean age, 15.8 years; 70% female) and 10 parents (mean age, 42.9 years; 80% female). Only three mothers of interviewed adolescents participated (P1, P5, P6). The adolescents of the other seven parents were not interviewed. See Tables 1, 2. Their experiences were captured in three main themes: (1) facilitators for moving from in-person to teleconsultations; (2) distance from the therapist’s gaze and its consequence; (3) awareness of the value of the in-person therapeutic space.

Table 1 Characteristics of the adolescent populationTable 2 Characteristics of the population of parents of adolescents receiving therapyTheme 1 facilitators for moving from in-person to teleconsultations

This theme covers three types of facilitators mentioned by the participants for changing from face-to-face to teleconsultations.

The health emergency

The participants, both adolescents and parents, reported an initially negative attitude toward teleconsultations.

I was afraid that it would be a little annoying because of the distance and because we only see each other through a screen (A10).

Nonetheless, the use of teleconsultation developed rapidly among patients due to the health emergency and the lockdown. The adolescents’ symptoms deteriorated, and the parents felt extremely helpless at home; the need to have conversations with the healthcare professionals became more important than their medium.

It was extremely complicated to be in a permanent state of vigilance, always wondering what could happen, how, when, what would be the next crisis (P7).

This emergency situation finally pushed the participants to accept teleconsultation to maintain continuity in their care.

They couldn’t leave us alone in the wild like that. With what we’re living through, what we’re going through, from a medical point of view, it would be pretty dangerous to not keep seeing us (A3).

Integration of parents in the treatment

Some adolescents reported a reshaping of their parents’ place in their care due to the implementation of the remote consultations. Several expressed the feeling that their parents were better involved in this care. They perceived a positive impact that encouraged them to use teleconsultation.

[Teleconsultation] made it possible to have other contacts with my father. It makes it possible to have talks with him, because otherwise it would be kind of complicated for him to come to each session (father living abroad) (A2)

Choice between telephone or video consultations

Each participant appreciated being able to choose the medium for remote care: telephone or videoconferences. All the parents questioned preferred videoconferences for access to an image, especially when they had never met these professionals earlier.

In particular, in these circumstances, seeing the face of the people who are taking care of your child is important, after all (P8).

The adolescents were more divided in their choices. Those who chose videoconferences underlined the importance of being able to have access to the professionals’ gestures and facial expressions, but also being able to be seen and better understood.

I think it’s clearer when you can see the expressions on their face. I talk a lot with my hands with gestures too. I think it’s clearer when you can see the expressions on their face (A5).

On the contrary, several adolescents stated their discomfort about the use of video during sessions.

There’s more contact, finally you see us more and ⋯ it’s more complicated to hide (A2).

The participants thus raised the question of the relation to the body during the remote meetings they had with the therapist.

Theme 2 distance from the therapist's gaze: consequenceAn obstacle to deciphering clinical nonverbal communication

The experience of televisits showed the importance of the nonverbal communication between the adolescent and the therapist. The adolescents reported how much they relied on this nonverbal expression to transmit their emotions during their psychotherapeutic work. They realized during televisits that their therapist could no longer “decipher” them unless they verbalized what they felt.

Being physically there, it would have been simpler⋯ to express myself, being face to face, than by telephone. So that [the therapists] can guess things a little, by seeing me, from my expression (A6)

For some adolescents, in particular those with anorexia nervosa, distancing themselves from the therapist's eyes reassures them and helps them to let go as care proceeds.

I feel more sheltered because she [the psychiatrist] doesn’t see me and she can’t necessarily interpret how I feel when we're talking (A4)

For other adolescents, in particular those with depression and/or anxiety, this distance from the therapist’s gaze during sessions destabilizes them by requiring additional effort to make up for the absence of non-verbal communication:

⋯ it’s often easier to say something when there’s a facial expression that goes with it, it’s more understandable, and so in teleconsultation, you have to think more about what you’re going to say and say the right words; all that, it’s not easy (A5).

Some adolescents thus have the feeling that the therapist can no longer either guess their emotions or decipher their gestures.

When my doctors saw me, they could feel things without me having to talking about them. They could guess a little when things were ok, when they weren’t ok. I didn’t need to put them into words (A6).

Effectiveness depends on the severity of the adolescent's symptoms

Adolescents and parents both perceived the effectiveness of the adolescent's psychiatric care by teleconsultation to depend on the severity of the symptoms. On one hand, the patients who were stable or in the process of clinical improvement on the whole accepted the teleconsultations very well. They mentioned that their relationship with their therapist was unchanged and that they felt supported in their clinical improvement or during passing moments of emotional instability. They perceived the continuity of care via teleconsultation as therapeutic.

The relationship and the care I have hasn’t changed. In any case, the doctors are present the same as always and aren’t any different with me (A5).

The parents also perceived teleconsultation as a means of participating in some sessions, despite their work constraints, and thus felt more included in the care. The “routine” sessions for their adolescent who did not present any particular decompensation were particularly interesting for them.

For adolescents with acute or worsening, teleconsultation was perceived as an essential support for continuity of care and as essential aid, given the severity of the situation.

Truly, I’ve found it a real comfort to be able having this bond; it’s extremely reassuring, and especially with a child in a truly fragile condition (P3).

Nonetheless, in situations of major instability, some adolescents found it impossible to use teleconsultations, while several specified that their ability to use teleconsultation depended on the severity of their symptoms. A8 reported both:

At the very beginning when I felt really bad, it was impossible to do it by video⋯I think that there are people for whom it is not possible. There are people at different stages of their disease different, and depending on that, I think for some it’s impossible (A8).

Effectiveness depends on the previous quality of the therapeutic relationship

The participants linked the effectiveness and continuation of teleconsultation to their alliance with the therapist. When it was established before teleconsultation began, the transition to remote sessions was better accepted by adolescents and parents. They then perceived the continuing care to be as effective as in-person sessions.

We were used to it, we know each other well, we trust each other⋯ Starting from a relationship that already exists, it’s easier to switch to talking on the telephone or by videoconferences. It’s doable when there’s already a solid relationship (P4).

Inversely, some adolescents quit their treatment by teleconsultation. This was especially true for those who had only recently begun therapy. Their fragile pre-existing bond with their therapist at the start of teleconsultations did not allow a satisfactory continuation of their care.

Especially if I have to see for example someone who I’ve never seen before, I’m not going to be really at ease in front of the screen (A8).

The adolescents and their parents both perceived the quality of the therapeutic alliance as a decisive factor in the success of teleconsultations.

Theme 3 awareness of the value of the in-person therapeutic space

In switching suddenly from in-person to remote consultations, the adolescents, like their parents, became aware of some aspects of the therapeutic space, in particular, its neutrality and its confidentiality.

The need for a neutral therapeutic space outside the home

In having to find a physical space for their teleconsultations, the participants became aware of some aspects of the therapeutic space that they had previously considered earlier about the framework of their care. Many missed the reassuring, neutral setting of the therapist's office, the ritual of going there, “escaping” from home for several hours.

[My appointment] gets me out, and then for two hours, I escape from home and that’s good for me (A7)

To adapt and create a neutral space for the consultation, the youth found creative strategies for their remote sessions. For example, one patient chose to have her video visits in a car:

Now, I do the appointments in the car. That way, I have more privacy and that makes me go somewhere else (A5)

Parents agree with these perceptions and report their sense that the setting of a teleconsultation at home limits their teen's trust and privacy.

Having her psychiatrist, or any other therapist, come by Skype, into her private space, it's complicated for my daughter (P4).

The need for a therapeutic space that is confidential

The participants were able to express their sense of a lack of privacy and confidentiality compared with the therapist's office, which they associated with neutrality, a space devoted exclusively to them and to care.

I won’t be in neutral territory, that’s for sure. Because my parents are right there, well, my mother is. I would feel more free to talk outside of my house (A2).

The setting of the place where the teleconsultations takes place can no longer guarantee the confidentiality of the conversations. This was the case, for example, for participants living in small spaces, with large families.

I’m always afraid that someone nearby will hear me, because we're in a house, and everyone hears everything (A1).

Perspectives envisioned for the future with willingness for a flexible return to in-person visits

The COVID-19 health emergency required the compulsory and hasty use of teleconsultations, without sufficient preparation. Several factors were perceived as obstacles to the effectiveness of this care, including but not limited to problems of confidentiality, severity of the adolescent's disease, and an inadequate therapeutic alliance. Despite the essential nature of continuity of care, it appeared that all participants, adolescents and parents, wanted to return to in-person care.

⋯anyway, there’s the real aspect, which is nice. When I say nice, it’s that it’s more agreeable to see the person in front of you and to talk to him, rather than be behind a screen (A10).

On the basis of this unprecedented experience, participants proposed that teleconsultation be used occasionally, depending on the situation. For example, some parents suggest that it might be a supplementary way of including them more in routine care despite their work constraints or traveling.

For very practical organizational reasons, I think that we could keep a mix of the two, between in-person contact and teleconsultation (P3).

Finally, teleconsultation is also an interesting means of care for adolescents unable to come to the therapist's office, precisely because of the disorder. Depending on the adolescent's disorder or clinical stage, teleconsultation could be a supplementary means of continuing care. One mother pointed out:

Inability to face the outside world, I would say, is a part of her disease, in fact, she misses an enormous number of appointment that she couldn’t go to because she couldn’t move, couldn’t get out of bed (P4).

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