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SILER CITY — In early 2020, El Futuro’s mental health clinics offered primarily in-person services, save for a telehealth program they’d designed for farmworkers.
Now, in early 2021, it’s just the opposite: Thanks to COVID-19, the non-profit has pivoted to offering telehealth services only, with little to no in-person exceptions.
“If you would have told me a year ago that we would be able to function as a clinic doing telehealth, I would have said, ‘That’s not possible,’” said therapist Courtney Crawford, El Futuro’s clinical director. “It’s just amazing how it has become possible.”
El Futuro, a bilingual mental health clinic which serves the Spanish-speaking community, has two clinics — one in Durham and another in Siler City, located on 401 North Ivey Ave. It provides a bundle of bilingual services, including therapy, psychiatry, substance use treatment and case management, which refers clients to outside agencies to serve other needs, like paying rent.
A year ago, Crawford also wouldn’t have imagined telehealth as El Futuro’s ticket to expansion — yet, that’s what it might prove to be. While schools, community organizations and medical providers struggled with the digital divide and disengagement, virtual services allowed the not-for-profit El Futuro to expand its reach to those they couldn't serve before and to connect with clients in a new way.
“We’re excited — I’m excited — about getting back in person with people,” Crawford said, adding, “But we’re also excited about thinking about the possibilities for the future. ... One of our main goals is to increase services, so provide more mental health services to more people, and telehealth might be a way that we can do that.”
In March, COVID-19 forced El Futuro to close its clinics and go virtual — and within months, everything changed. Services went online, demand skyrocketed and the pandemic brought clients stresses they perhaps hadn’t dealt with before.
More people began coming in with heightened anxiety, depression and feelings of isolation, especially teenagers, said Crawford and another El Futuro therapist, Victoria Romero. Others have been grappling with loss — and especially an inability to travel to be with family in different countries. Others have seen intermarital and family dynamics suffer, too.
“I think that is something that we’ve seen, instead of having that reprieve of during the day ‘I’m not with you,’ it’s like, ‘Now, I’m with you all the time,’ and that can be trying for anybody,” Crawford said. “But particularly, I think, in this (Latinx) community, there tends to be more people at home.”
According to Crawford, the Siler City clinic served an average of 50 people per month last year, and not all of them lived in Chatham County. On average, they’ve also begun to see clients for longer periods of time.
“More people are coming in for our services, are requesting our services,” she said. “... Those are two areas of need that we’re seeing, both in just sort of getting into services and then when you get into services, often there’s higher need once you’re in there, too.”
The pandemic especially touched El Futuro’s case management program, said Romero, who spends about 50% of her time running that program. During COVID, she said they’d been referring people now more than ever to partner organizations for basic needs, including food, rent and utilities.
“Whereas before COVID, we had more of an array,” she said. “We would have that of course, but we would also have more clients may be seeking legal help or may be interested in job skills. But because of COVID, it’s like those are extras now. We’re starting to see that change a little bit, tiniest bit after a year.”
Switching over to telehealth was a bumpy ride at first, Crawford recalled. Staff had to work to adapt face-to-face services for telehealth, find HIPAA-compliant Zoom lines and switch their clients over to videoconferencing, too.
Even therapists’ toolkits changed: Instead of playing games with children, for instance, therapists had to substitute online methods, like drawing on a Zoom whiteboard or a virtual show-and-tell.
“You go find something and I’ll go find something and we sort of bring it back together,” Crawford said as an example. She added, “And so those first couple of weeks were really intense.”
But after a year, El Futuro’s telehealth system now works like a well-oiled machine — and has reaped some unexpected benefits.
Thanks to telehealth, El Futuro has been able to expand its hours — and even days — of operation and accommodate clients.
“Previously, we were open three days a week in our Siler City clinic and five days a week in Durham,” Crawford said. “But now that we don’t have to staff a physical clinic separately, we actually can see Chatham County (or) Siler City clients any day of the week.”
Romero said she’s even been able to see clients later at night, which she rarely did before.
“I have a little bit of a commute, and I didn’t like to stay too late at the office,” she added. “Now, because we are 100% teletherapy, I have no problem with that.”
Better yet, both said, their clients haven’t really had problems using telehealth technology. To preempt technology barriers, El Futuro employs a team of bilingual administrative assistants who teach clients how to download, install and use Zoom on their smartphones or computers.
“We’ve created videos that we send to the client that walks them through it, and then they’ll actually practice with the client,” Crawford said. “So in case, you know, audio is an issue or something like that, they can sort of troubleshoot that.”
On certain days, El Futuro also invites clients without internet access to come to their clinics, where staff will set them up with company computers to attend their appointments. Some psychiatrists, Crawford added, are also beginning to see some people face-to-face when it’s necessary.
“There is a small percentage of clients that don’t have access to Wi-Fi, but that’s a very, very small percentage of clients,” Romero said. “I would say by far, most of our clients have adapted incredibly well to getting on Zoom.”
According to El Futuro’s surveys, the system has worked out well for nearly everyone, too, Romero said; surveys found telehealth treatment “outcomes” and improvement levels are similar to those measured when people came to the clinics in person.
“What’s interesting is it’s almost increased access, because as you can imagine, if somebody, say, a mother has children at home, but can’t find childcare, she might have had to cancel her appointment,” Crawford said. “... But now, since you can just call us on your cell phone, she can like go in the other room and have her appointment.”
Romero said she's been able to see clients via telehealth that she couldn't have in her office.
"It was too difficult (for one client) to get to the clinic," she said, adding now, "She's able to have therapy, and it's been wonderful for her. It's been wonderful for me to get to know her and work with her, and that would have never happened had teletherapy not come on the scene."
Ironically, telehealth has also allowed therapists to connect with their clients on another level. Before, Crawford said, she may have only heard about a client’s stress with his or her spouse; now, she actually can see it.
“People are inviting us into their worlds,” Crawford said. “... So in some ways I can imagine that might be something that I miss about telehealth — learning a little bit more about somebody’s world by seeing it rather than just hearing about it.”
Romero has seen clients in their cars, bathrooms, stairwells at work and even in break rooms, which she said has also given her “a window into (her) clients’ lives.”
“It’s been so fun,” she said. “I think that most of us who see kids will say, ‘Can you show me your favorite object in your room? And can you show me something in your house that you’re really proud of?’ Or something like that, and we get walked around on the computer.”
As such, she even said telehealth has helped her break her stereotypes about her clients.
“It’s our implicit racism that we all have and even as a Latina, definitely, I own that and see some of my clients are very financially well off,” she said. “I don’t think I had realized that, like, they’re really living in a nice house, and I could see it’s very nice.”
Yet in some ways, Romero and Crawford said telehealth just doesn’t compare to in-person therapy.
“It’s amazing the information that we give and receive through our bodies,” Crawford said. “And so shifting in a chair, or leaning forward, or something like that — that can communicate a lot, and I miss that. I miss receiving that information. I think that can be really good information.”
She also misses giving that same information to her clients.
“Like, ‘I’m concerned with you, so I’m going to lean forward,’ or things like that,” she said, adding, “We all sort of know that we use body language ... I find myself limited in sort of being able to communicate fully. Telehealth is a wonderful tool, and I’m so grateful for it, and I do think that there are some things that feel different about it.”
It’s also harder for therapists to maintain confidentiality and keep their clients safe when they no longer share a space, Romero said. Some clients may be logging on from work; some may have really thin apartment walls.
“So I will make sure with clients at the beginning, are you in a place where you feel comfortable talking right now?” Romero said. “And sometimes they’ll say yes, and then sometimes, ‘No,’ they’ll say, ‘Other people can hear me.’ So I will judge from there where to go.”
Sometimes they’ll end up rescheduling; other times, sessions won’t go as “deep” as others to ensure clients won’t have private emotional reactions where others can hear them.
“If we’re talking about a trauma, the client is in front of me, and I’m able to use my clinical skills to keep that client clinically, emotionally, within a window of tolerance,” Romero said. “However, when that client is in another room ... it’s scary for me, because I don’t know what that client can do.”
Crawford and Romero also just miss sharing the same room with their clients.
“It’s just sort of like a fatigue of, ‘Gosh, I wish that I could just be in person with you,’ because it doesn’t feel the same,” Crawford said.
“Being able to engage the person with their whole being, I really miss that,” Romero added. “And then of course, the kids — I really miss all of that, just engaging them completely with activities and making it so much fun, as opposed to sitting in front of a computer.”
That’s why she’s looking forward to going back to her office — though she’s not yet sure when that’ll happen.
El Futuro is still planning when and how to reopen, Romero said; so far, she added, they’ve been considering a move into a hybrid schedule, a combination of in-person therapy and telehealth. Surveying their clients, Crawford said, has shown them that the majority of clients prefer to have in-person appointments once it’s safe.
“But it’s hard to determine when that might be,” she added. “So we’re excited about continuing with the possibility of telehealth. Time will tell what that will look like in our service provision.”