Dr. Greg Fritz (Host 1): Welcome to Mindcast, a podcast from the mental health experts at Bradley Hospital. I'm Dr. Greg Fritz, and I'm here with my co-host, Dr. Tanuja Gandhi. And today, we have Dr. Molly Hedrick with us. She's a psychologist at Bradley Hospital. And she's been at the forefront of our Virtual Partial Program for teens, which we call Bradley REACH.

Dr. Tanuja Gandhi (Host 2): Dr. Hedrick, thank you so much for joining us today.

Dr. Molly Hedrick: Thank you for having me. It's a pleasure to be here. I can introduce myself briefly. I am a psychologist and team lead for the Virtual Adolescent Partial Program, or REACH, at Bradley Hospital. Prior to that, I was at the In-Person Adolescent Partial Program, and I also have a small private practice in the community. So, I'm excited to be here to talk about telehealth.

Host 2: So, we've seen a huge shift to virtual therapy since the COVID pandemic. I think before that, it was already hard to get connected to mental health services for children and teens. Since then, it's become a tad bit easier because you have the options of virtual therapy or telehealth, right? Can you tell us a little bit about your experience with telehealth, especially with teens who seem to have embraced it so easily?

Dr. Molly Hedrick: So, I always tell people that I'm a telehealth convert. I had colleagues that were kind of dabbling in telehealth even before the pandemic, and I just really wasn't buying it to be honest. I was always trained that that face-to-face interaction in a therapeutic space that you have control over in terms of privacy and distractions was pretty fundamental to the treatment process. So, I just didn't even want to go there. I guess it was out of my comfort zone.

But then, the pandemic hit and I had to move my private practice and we moved the partial program to a virtual modality in a very short period of time. You know, and it was certainly a learning curve, but we did find that there were benefits. We were able to see teens that we would never have been able to see if they were required to come in person because it reduced that transportation barrier. Our attendance really improved. Teens just rolled out of bed and joined via Zoom versus arguing with their parents to get to the in-person program. Family engagement improved. Different family members could join at their lunch break from their car to participate in a family meeting that wouldn't have otherwise been able to come to campus. And that information was really invaluable.

We were able to really meet the needs of the teenagers in their home environments and intervene in the moment, rather than try to explain what happened during the program day. If something's happening, we can problem solve in the moment. So, it was almost like home-based therapy to be honest. Teenagers really seem to have an easier time with it than the staff. Teenagers were already used to relating to each other virtually. They were already comfortable with that virtual relationship that the staff were in. So, I say it kind of brought us along to this new way of delivering health care.

Host 1: That's such a good point. And I think it's interesting that you're a converted skeptic.

Dr. Molly Hedrick: Yes.

Host 1: So, you have seen both sides of the issue. And I know when transportation and finances or even geography were barriers before, during the COVID pandemic. Virtual care has really stepped in as a solution. Can you talk a bit more about the impact that telehealth has had on improving access to care?

Dr. Molly Hedrick: Yeah, absolutely. And especially in rural areas, I would say, I think the percentage is something like 80% of rural communities have zero access to a psychiatrist and 75% have limited to no access to other mental health providers. So for rural communities in particular, telehealth can be life-changing.

And even in urban communities, like I said, we were seeing teens that we couldn't have seen because of transportation issues or, you know, financial barriers. It's expensive, right? Gas and getting people to where they need to be and taking time off out of work. For a lot of families, that's just not realistic. So, it's really opened the door for a lot of teens and families that won't otherwise have access to mental health services. So, it's really about reducing barriers and increasing access to care.

 And right now, we're having issues with, you know, traffic. You know, and there's a lot of emphasis on family stress now too, right? Like, how do you get your kids to where they need to be and get yourself to work and engage in treatment all in a given work week. It's just really difficult. So, this can really reduce a lot of parental stress as well.

Host 2: I imagine it also gives you a unique insight into the home environment. As clinicians, usually, we don't get to see what the home environment is like. And I'm wondering how this affects the way you approach treatment.

Dr. Molly Hedrick: I have to admit that in the beginning it was hard, because you don't really have any control over the home environment. I could control my environment. But sometimes, there's some chaos in every home, right? So, you have dogs barking, you have siblings coming and going, a teen is going to get a snack in the middle of family therapy. it's really hard to contain some of the chaos sometimes. But I think once I let go of a little bit of control, I kind of saw the joy in that and also the opportunity to intervene at times. "Oh, well, how can we make this a little more focused or a little more structured? How can we use the strengths and weaknesses of your home environment? Or how can I empathize with some of these teens and families that might be really struggling in a home environment?" Right? It gives you a really unique window into what's going on in the home. And so, it's almost like a middle ground between home-based and outpatient therapy. So, I can make interventions in the moment in the home. But also, you know, I'm separate. So, it's really interesting in that way. And I feel like there's opportunities to connect in different ways.

So, one of our favorite things to do in the partial program and also when I'm doing outpatient therapy with teens is "Show me your room. Let's do a room tour. What are you excited about in your room? What are you passionate about?" It's a different way of connecting with the teens or my other favorite part of doing family therapy online is you get to see the animals in the house. And they almost always, without fail, want to join the family therapy process, whether it's a rabbit, a hamster, dog, cat, we've had it all and you can just kind of see what's really important and what the family values in that way too. So, it's just kind of unique and fun and it's a good, exciting challenge.

Host 1: Well, it seems like this approach allows for real time adjustments that might not be as effective in an office setting. But we're wondering also about the different levels of care that telehealth can support? We've mentioned mostly the partial program to make sure everybody knows what that is and then what other levels of treatment can be in telehealth.

Dr. Molly Hedrick: So partial, I think I take it for granted that everybody knows what partial level of care is, but most communities across this country don't have access to partial levels of care. So, partial levels of care include intensive day treatment, usually for a week, about six to seven hours a day and provide group therapy, individual therapy, family therapy, milieu-based treatment, and psychiatric treatment. So it's very comprehensive, but then the teens go home at the end of the day. So, it's kind of like a middle ground between outpatient and inpatient levels of care. It's either a step up from regular outpatient therapy, maybe a teen needs more help than regular outpatient therapy once a week is providing them, or a step down from inpatient. They've been at inpatient, they're okay to go home, but they may not be ready for just weekly therapy or to continue in school. So, that's where the partial level of care fits in the continuum of care.

And again, I didn't think it would be amenable to virtual care, but we have found that it is quite effective. All our research has found that it's just as effective as our in-person programming. And, like I said, people have been experimenting with telehealth and outpatient levels of care for quite a while, and they have found that it is just as effective as in person in most cases. And there's also other levels of care like intensive outpatient programs that are maybe several days a week, but not as many hours or it's just similar to partial but not as intense. Several of our programs at Bradley have remained virtual, even after in-person programming resumed.

So, we have an After-school Intensive Outpatient Program that's virtual, a Co-occurring Disorder Program that's virtual because families seem to like it better. And it's also amenable to different treatment modalities, so Psychiatry, Group Therapy, Individual Therapy, Family Therapy. I work with an amazing interdisciplinary team, including psychiatrists and social workers, psychologists, nurses, behavioral health specialists, and we're all able to provide virtual treatment in an effective way for families. So, it's really just about figuring out what works best for whom.

Host 2: So, that flexibility seems like a critical aspect of providing treatment. And it's so important. We've noticed that in some cases, virtual therapy can reduce wait times for all the reasons that you mentioned. And I wonder if that also prevents the need for higher levels of care later on, that is like preventing hospitalizations or increasing severity of the problems that children are facing.

Dr. Molly Hedrick: Absolutely. I think the sooner you can get in to see someone when you're having a problem, the less chance you have of needing a higher level of care. And because telehealth has kind of taken off, there's all these national companies now that hire providers that are willing to provide telehealth across state lines as long as licensing is taken into consideration.

And so, because you have a wider provider pool, you can often get in to see someone much quicker if you're willing to do it via telehealth. You know, our local wait lists tend to be really long, because people, still, I think, are more used to in-person models of care. So, they really want to get in to see someone in person, which is great. But if you need immediate assistance and there is an equally effective treatment modality that's immediately available, why not give telehealth a chance?

And also, I'm sure you remember, during the pandemic, the emergency rooms were overflowing with teens waiting for inpatient beds. And so, telehealth and the availability of telehealth was able to divert some of those teens from an inpatient hospitalization because there were no beds, right? So, let's get them intensive levels of care without having to go to an inpatient program. And then, we could work on the crisis and help stabilize teens and families so that they could then go back to an outpatient level of care. So, it absolutely can prevent escalation in care.

Host 2: I'm sure it helps with some of the hesitation that people feel with seeking mental health services given the stigma around having mental health problems and needing treatment, especially when you have families who might have like a long history of mental health problems or are challenged in terms of resources and really want the help but don't know if this is what they really want to do, I want to go to a psychiatric hospital or an emergency room. This might be a way to actually get into treatment and get a feel for what mental health treatment is about.

Dr. Molly Hedrick: Oh, absolutely. In a private and confidential way, right? I think you're right on in terms of the stigma still, especially for higher levels of care. And it's scary, right? It's scary for children to be separated from their families. So, you know, we would like to have them do the treatment at home if the safety is such that that's possible.

Host 1: So, we also know that telehealth isn't without its concerns. One of the big ones is privacy and security. Have you had families express concerns about these sort of issues?

Dr. Molly Hedrick: Oh, absolutely. And it's one of my primary concerns. Confidentiality is the hallmark of effective therapy. People need to know that they can trust you in order to open up to you. So, what I can do on my end is make sure that my environment and where I'm providing the telehealth from is safe and secure. My kids aren't knocking on the door or walking in or there isn't people coming in and out of the background. So, I can control that on my end. And then, we set the expectations for the families that, "Okay, on your end, this is what we need." And so, everyone feels comfortable. We need your teen or you to have a private space in which to join the program. Headphones are recommended. There should be nobody walking in and around during group times or during other times. We just have to really make sure that confidentiality is the priority. And then, otherwise, you know, I'm not a tech expert at all, and I'm lucky to work for an organization that has skilled people that can look at the security issues. But we live in a digital age, right? So, security is really important and we need people to keep working on which platforms are the most secure and HIPAA-compliant that will protect families, protect health information, and prevent any sort of security breaches. I need to talk to other colleagues on how to do that on an outpatient basis. And I think it's our responsibility as a mental health community to really find solutions to some of these concerns as we become increasingly reliant on digital resources.

Host 2: Another concern we often hear from families is engagement. Like the questions around, "Well, will my child be able to engage with someone if it's virtual than in person, one to one?" What's your take on that? What kind of things have been helpful, challenging?

Dr. Molly Hedrick: I often say that the hardest part of engaging parents is just getting them to agree to telehealth in the first place, because we are still kind of living under the ghost of virtual school that really wasn't effective for a lot of families and their children, my children included. So, I get a lot of feedback, "Oh, virtual isn't going to work for my kid. It didn't work in virtual school. So it's not going to work for virtual therapy." But if we can give them a little psychoeducation on what it's like, what is our structure, let's try it, see how it goes, once we get them in the front door and, you know, really engage with them on how to engage in therapy virtually. Like, "Okay, let's get the teen in a chair away from their bed so they're not falling asleep. Let's have them fully on screen so we can actually interact with them. Let's just make sure they're not on other devices while they're engaging in therapy." They're teenagers. They're going to push limits. That's what makes it fun. But if we can set those expectations for their level of engagement, then we can step in. And I have to say, "We don't have problems engaging teams because of our staff. And I feel like the structure of our program is built to be fun and variable." So, we do group therapy, we do individual therapy, we do family therapy, and we like to have a lot of fun. So, we do team building exercises, we have music therapy. We are constantly trying to find different ways of engaging the teens.

And, you know, ultimately, the goal is the same virtually versus in person, right? You want to create a space where teens feel connected and they belong. And if you can do that, it doesn't matter if it's virtual or if it's in person. If they feel safe and connected, they will do the treatment. And so, it's really just about being creative. I find especially in an outpatient basis, just one on one with teens, I have to amp up a little bit. Like It's a computer between me and this team, how can I be a little more enthusiastic? How can I make sure that they know that I'm here with them, even if there's a computer between them? So, it's just about being creative and learning from the teams and the clients that we see every day.

Host 1: That makes a lot of sense. One thing we haven't touched on yet is how people worry that telehealth or technology and screens in general are going to take over real-life relationships. Have you come across this kind of concern with parents that this might be part of the problem rather than part of the solution of screens?

Dr. Molly Hedrick: Yeah. Even more than from parents, I think that was one of my primary concerns, right? The therapeutic relationship in person is so key. And I worry about how AI and things like that is going to affect that, and parents are concerned about their teens, you know, playing video games in the basement all day anyway. And now, we want them to be on the screen more, that's totally valid. So, I guess I don't see it as either-or or one is better than the other. In my own life, what I found is that telehealth or Zoom or virtual modes of relating can complement in-person relationships. So for example, my cousin lives in California, and we started a family book group during the pandemic. My extended family is large and they're all over the country and I can maybe see them once every two years, if we're lucky, right? But now, I get to see them every month during our book group discussions, and I feel even more connected to them than I did before. Because I see them and talk to them more, even if it's through a screen. Or the people I work with in my interdisciplinary team, they're amazing, and I feel just as connected to them as I did to my in-person team.

And so again, I really just tell families, skeptics, and anyone that it's not that telehealth or virtual is worse or better than in-person therapy and relationships. It's just a little different and we can have both. And really, what we want to do is make sure people get into treatment when they need treatment with as few as barriers as possible. And how that comes about is not as important. The modality isn't as important as the quality of the care.

Host 2: So, it sounds like telehealth is here to stay. We've gotten accustomed to it. Some people really like it. Some people are still preferring in person appointments, but this has become a part of our treatment options nowadays. What do you see as the future of telehealth and mental health care, especially for children and teens?

Dr. Molly Hedrick: Well, I think we're hoping that telehealth can continue to expand to meet the needs of the community in a way that is effective, again, and that preserves the quality. Like I worry about growing too big too fast. And then, are you sacrificing the quality? I mean, there has to be some intention to how you're delivering telehealth that's different than just seeing someone in an outpatient practice. So, I think as long as we can keep an eye on regulations and safety and confidentiality and privacy and quality of care, the expansion of telehealth can only be a good thing with the understanding that also there will always be a need for the in-person connections as well and in-person therapy.

Host 1: That's a great way to put it. It's about creating more opportunities, really, for people to get the help they need, whatever way works best for them.

Host 2: Dr. Hedrick, thank you so much for joining us today and sharing your expertise on telehealth. I think what I've learned today is that this modality of treatment or providing care is clearly here to stay, is more accessible, flexible, and hopefully is addressing the mental health stigma that's out there in communities, and making people a little more open to seeking care when they really need it. And this is one way to get connected to that kind of care.

Host 1: Yeah, we really appreciate your insights. It's been fun and lively. And for our listeners, if you're considering telehealth for your child or teen, remember, it's an option worth exploring, especially if barriers like transportation or geography have been an issue.

Thanks for joining us on this episode of Mindcast. Stay tuned for more discussions on child and adolescent mental health.