To protect adolescents' privacy and keep them engaged during therapy, I use the "Visual Red Flag Signal" technique to set boundaries for adolescents who live in crowded homes. At the beginning of each session, the adolescent chooses a special object, such as a stuffed animal or toy, and places it in front of the camera so I can see it when a family member enters the room or is within hearing range. This nonverbal cue allows the adolescent to let me know that someone is within earshot without having to say anything, which is essential for keeping the adolescent actively involved in the session when they feel observed. In addition to the "Visual Red Flag Signal" technique, I have implemented a headphone-only policy and a chat-triage protocol on the telehealth platform that I use for therapy with adolescents. The headphone-only policy requires all adolescents to wear headphones throughout the session, which allows me to keep my prompts and questions confidential. If the adolescent feels a topic is too private or sensitive to discuss aloud, we have agreed to switch to the encrypted online chat function on the telehealth platform. I recently worked with an adolescent who was able to work through a significant interpersonal conflict exclusively via the chat function with family members present in the room, allowing for deeper therapeutic engagement than would otherwise have been possible due to a lack of physical privacy.
In telehealth, especially with adolescents lacking private spaces, maintaining confidentiality and engagement is essential. The safe word protocol is an effective boundary-setting technique, allowing adolescents to use a predetermined word or phrase to signal discomfort or the need for a break during sessions. This empowers them to manage boundaries and exercise control without the pressure of directly expressing their feelings, especially amid potential distractions.