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Getting Paid: Teletherapy Survival Tips for Clinicians

5/23/2020

Teletherapy . . . Telehealth . . . Telemedicine . . . Telemental Health . . . Telepractice . . . Televideo . . . Internet Therapy . . . Online Therapy . . .

Teletherapy is everywhere. Like it or not, telehealth is here to stay during the current crisis—and is likely to stay in some form after it ends.

What’s a therapist to do? How can a therapist survive, and better yet, thrive, while doing so many live teletherapy sessions with clients?

Many therapists are now working from home for the first time doing therapy with clients using online video or telephone platforms in place of in person sessions. While working from home as a Teletherapy provider allows therapists to have a flexible work schedule and many other conveniences, the shift to virtual comes with many new challenges and stressors as we're adapting to what’s going on in the world and to this new setting and medium.

While Teletherapy is still therapy, it has idiosyncrasies. When doing a remote session it’s a much more exacting, labor intensive process for a skilled therapist to work effectively with the same things they do in person. Facilitating therapeutic communication and interaction is definitely different when you and your client aren’t in the same room—it requires another kind of focus, concentration, and energy. Add to that the fact that most therapists are now juggling a work-from-home therapy practice alongside home and family life while everyone's at home, too. The result? Therapists are reporting how exhausted they are after providing Teletherapy services to clients.

Teletherapy exhaustion, burnout, and fatigue are real.

Why is delivering Telehealth services so tiring? Conveying professionalism through a Teletherapy portal in your home requires that we develop and utilize a therapeutic telepresence and a “web-side” manner while conducting sessions through a screen—and that’s very fatiguing. Therapists are also finding that Telehealth delivery does not lend itself to the same type of marginless in-office scheduling where clients are seen back to back without any breaks.

Teletherapy is a much more strenuous delivery system than in-office therapy. That shouldn't be surprising since it’s well documented that sustained and prolonged use of digital devices—computers, tablets, smartwatches, smartphones—for video sessions and meetings leads to exhaustion, computer eye strain, dry eyes, focusing fatigue, and neck, shoulder, and back pain.
Here are tips for reducing the fatigue, stresses, and challenges of telehealth and conducting video therapy sessions, groups and meetings. Think of these tips as a menu of options. Try the ones that suit you, discard the ones that don’t.

Teletherapy Survival Tips for Clinicians
1. Teletherapy relies on a strong internet or phone connection.
Poor internet or phone quality is one thing that not only makes clients upset, it negatively impacts therapeutic communication, the therapist client connection, and the outcome of therapy. Anytime video gets glitchy and skips, sputters, gets pixelated or freezes the image—or the audio stops, develops, an echo or keeps cutting out—it becomes difficult to maintain therapeutic communication and the therapeutic connection diminishes.

Therapists need the best, most reliable internet connection—and Telehealth delivery platform—that they can get. Whether poor quality is on the client or therapist side, the experience of therapy deteriorates without solid audio and video. Poor internet or phone quality definitely interferes with progress, the outcome of the session, and the the therapeutic alliance.
Before scheduling a session, be sure to check whether the client has a good enough internet or phone connection, and the right type of equipment/device for video sessions, otherwise a different type of Teletherapy is needed.

2. Create the right environment for you.
Just as your office set-up is a key part of your in-person practice, how you arrange your remote office can make a big difference in your sessions.

Make sure you are in a space private enough and secure enough from other people interrupting. Close doors and windows for privacy
Consider silencing anything that can be a distraction or that will make it difficult for the client to hear you clearly--background noise, barking dogs, phones, etc.
Position and adjust your desk and chair. Make sure they’re at the right height, with your back supported and your feet on the floor. Save yourself from the physical strain of poor posture caused by less that ideal set-ups.
Use the largest screen you can for video as this diminishes eye strain, fatigue, and muscle tension. Position your computer or device so the video screen is at arm’s length. Make sure the height and center of your video screen is in a comfortable position for your eyes, head, and neck.
Have the right lighting. Make sure your computer is in a place to avoid glare.
Turn off email and any other application running in the background.
When working on the computer make text bigger so you can comfortably read from a distance.
Adjust your computer display settings for comfort—brightness, text size, contrast, etc.
If you must type notes during session, consider muting your audio. Keyboarding is loud, especially when both therapist and client are using headphones.
If you decide to use headphones, consider those with a noise-canceling feature. Headphones are a good idea for maintaining client confidentiality, too.
Test your equipment, links, and Telehealth platform before each session. Consider what clients will see by testing out your camera set-up and lighting.
Have ALL your materials ready—and have a backup plan for technology glitches.

3. Create the right environment for the client.

Inform your client about what they can expect during their Telehealth session. Let them know what platform you use for sessions. Inform them ahead of time if they need to download any additional applications.
Consider offering new clients a free short session to test everything and to briefly educate them about how you will conduct the session.
At the beginning of the session make sure the client is not driving and is in a space private enough, and secure enough, to ensure confidentiality —and so they will not be interrupted. Make sure that there are no children or adults in the room unless they’re part of the therapy.
Verify and document the client’s current address/location in case a crisis is disclosed and you need to respond by getting client help from emergency responders.

4. Ways to reduce exhaustion and minimize fatigue, dry eyes, computer eye strain, focusing fatigue, and back, neck, and shoulder pain.

Take a moment for yourself before opening the session. Allow yourself some time—a few minutes—to stretch and prepare for the client. Then, just like you would in your office, take the time to greet your client with your full attention.
Periodically exercise your eyes during video sessions to reduce eye strain. Ease your visual focus on the screen and look at something far away, then something close, then something far away again. Do this a few times during each session.
In between sessions stand up, move around, stretch your arms, legs, back, neck, and shoulders to reduce tension, muscle fatigue, and pain.
Take regular screen breaks to keep from tiring your eyes. Constantly looking at the screen and using your eyes for long periods of time without resting them causes Focusing Fatigue and increases eye strain. Consider wearing computer glasses to reduce your eye strain.
To reduce fatigue, if you can arrange to, take some kind of break for a few minutes between sessions to walk around or stretch. Getting your blood flowing reduces the mental fatigue that's caused by the physical fatigue of your muscles.
To keep from getting computer-related dry eye, keep your eyes moist by blinking regularly or using eye drops. Drink enough water so you don’t get dehydrated.
Schedule short gaps (5-10 minutes) in between sessions. A zero break schedule can leave you incredibly drained at the end of a full day of clients or meetings. Building in transition periods with a few minutes of movement and a mental break between sessions can refresh you. Consider scheduling a longer break after three or four sessions.
When attending meetings or conducting groups, choose “speaker view.” Direct your attention primarily to whoever is speaking—so the person speaking has more of your attention and the others are more peripheral.

5. Consider using phone sessions.

Think about and assess whether video is really the best option for you and the client. Sometimes a phone session is better.
Being on a phone session can also be a better choice/method/platform for a client who wants to talk to a therapist but isn't comfortable being on camera.
Phone sessions can also be especially helpful for those clients or therapists who have slow internet speeds or when there are online or mobile video glitches.

While many therapists have made the switch to offering Telehealth services, the transition to Teletherapy takes getting used to! Although we miss the rhythm of our usual practice, our clients, and our office, we recognize our good fortune in having jobs and being able to continue to provide therapy.

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Getting Paid: Telehealth & Keeping Your License: Things to Remember from the BBS

5/23/2020

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Today, during the COVID-19 public health emergency, the majority of licensed and registered mental health professionals in California have shifted to providing psychotherapy services using telehealth. Most are new to telemedicine and what’s required by the California Board of Behavioral Sciences (BBS). Questions abound . . .

What telehealth platforms can I use during the COVID-19 public health emergency? What communication technologies are still prohibited? What communication products or technologies can I use if I want a HIPAA compliant telehealth platform for my practice? What things am I required to do with each client when I begin telehealth services? What am I required to do with clients at the beginning of each telehealth session?

The answers to these questions and more are in the three following BBS telehealth documents presented here in full for easy use and reference—with links to the original documents.
Read them. Comply with them. Keep your license, and yourself, free from unprofessional conduct and disciplinary action.

1. BBS: Standards of Practice for Telehealth California Business and Professions Code
All persons engaging in the practice of marriage and family therapy, educational psychology, clinical social work, or professional clinical counseling via telehealth, as defined in Section 2290.5 of the Code, with a client who is physically located in this State must have a valid and current license or registration issued by the Board.

All psychotherapy services offered by board licensees and registrants via telehealth fall within the jurisdiction of the board just as traditional face-to-face services do. Therefore, all psychotherapy services offered via telehealth are subject to the board's statutes and regulations.
Upon initiation of telehealth services, a licensee or registrant shall do the following:

Obtain informed consent from the client consistent with Section 2290.5 of the Code.
Inform the client of the potential risks and limitations of receiving treatment via telehealth.
Provide the client with his or her license or registration number and the type of license or registration.
Document reasonable efforts made to ascertain the contact information of relevant resources, including emergency services, in the patient's geographic area.

Each time a licensee or registrant provides services via telehealth, he or she shall do the following:

Verbally obtain from the client and document the client's full name and address of present location, at the beginning of each telehealth session.
Assess whether the client is appropriate for telehealth, including, but not limited to, consideration of the client's psychosocial situation.
Utilize industry best practices for telehealth to ensure both client confidentiality and the security of the communication medium.

A licensee or registrant of this state may provide telehealth services to clients located in another jurisdiction only if the California licensee or registrant meets the requirements to lawfully provide services in that jurisdiction, and delivery of services via telehealth is allowed by that jurisdiction.
Failure to comply with these provisions shall be considered unprofessional conduct.

2. BBS statement on HHS Telehealth Announcement of Enforcement Discretion
U.S. Department of Health and Human Services (HHS) Announcement
of Enforcement Discretion for Telehealth Remote Communications
The Office for Civil Rights at the U.S. Department of Health and Human Services (HHS) has announced that it will exercise its enforcement discretion and will waive potential penalties for HIPAA violations against health care providers that serve patients through everyday communication technologies during the COVID-19 public health emergency.
During this time, covered health care providers subject to HIPAA may provide telehealth services, in good faith, through remote communications technologies that may not fully comply with HIPAA requirements. This applies to telehealth provided for any reason, whether related to health conditions related to COVID-19 or not.

What Telehealth Platforms Can I Use?
HHS states that covered health care providers can use any non-public facing remote communication product that is available to communicate with patients. This includes popular applications that allow for video chats, such as the following:

Providers are encouraged to notify patients that these third-party applications potentially introduce privacy risks. Providers should enable all available encryption and privacy modes when using these applications.

What Platforms Are Still Prohibited?
HHS still prohibits using communication products that are public-facing. Therefore, do not use these types of platforms. Examples of public-facing communication products include, but are not limited to, the following:

Facebook Live
Twitch
TikTok

I Still Want to Use a HIPAA Compliant Telehealth Platform For My Practice. What Are Some Examples Of These?
HHS provides some examples of products that are HIPAA compliant and will enter into HIPAA business associate agreements (BAAs) in connection with the provision of their video communication products. (They stress that they have not reviewed the BAAs for the below entities, and that this is not an endorsement, certification, or recommendation):

Skype for Business (Now called Microsoft Teams)
Updox
VSee
Zoom for Healthcare
Doxy.me
Google G Suite Hangouts Meet

HHS Notes That HIPAA Applies Only to Covered Entitles and Business Associates. How do I Know If It Applies To Me?
HHS provides the following bulletin HIPAA Privacy and Novel Coronavirus. This topic, HIPAA Applies Only to Covered Entities and Business Associates, is covered toward the end of Page 5.

Where Can I Find More Information?
You can use the following links for more information from HHS:

3. Telehealth: BBS General Information & Requirements for Licensees & Registrants
About Telehealth

Under law, “telehealth” is the mode of delivering health care via information and communication technologies, including, but not limited to, telephone and/or internet
Licensees may deliver health care, under their scope of practice, via telehealth, under certain conditions
Licensees are responsible for understanding all applicable laws, to deliver health care via telehealth
Failure to comply with any provisions regarding telehealth may be subject to disciplinary action by the Board

Comprehensive Requirements and Applicable Laws
Detailed explanations regarding telehealth requirements, for licensees and registrants, are contained in the following statutes and regulations:

California Code of Regulation Title 16 §1815.5: Standards of Practice for Telehealth
Business and Professions Code §2290.5

Clients in California
This section applies to clients who are physically located in California.

Individuals providing psychotherapy or counseling, either in person, via telephone, or via internet, must be licensed in California.

Clients Outside of California
This section applies to clients who are physically located out-of-state.

California licensees or registrants who wish to engage in telehealth with a client located in another jurisdiction need to check with that jurisdiction to determine its laws related to telehealth, and if licensure in that jurisdiction is required. Several states currently consider a client located in their state to be under their jurisdiction. Therefore, a practitioner needs to comply with that jurisdiction’s laws in order to avoid any potential violations of those laws.

Inform and Consent
Prior to the delivery of health care via telehealth, the provider initiating the use of telehealth shall:

Inform the patient about the use of telehealth; AND
Obtain, and document, verbal or written consent from the patient for this use

Confidentiality

All laws regarding the confidentiality of health care information and a patient's right to their medical information shall apply to telehealth interactions.

Additional Info
Additional information regarding telehealth is contained in the following statutes and regulations:

California Code of Regulation Title 16 §1815.5: Standards of Practice for Telehealth
Business and Professions Code §2290.5

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Getting Paid: Tips for Getting the Word Out About You, Your Practice & Your Expertise

5/23/2020

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Getting the word out about your therapy practice is important. To be successful in private practice, you need a steady stream of clients—QUALITY referrals that are a good match for you and your practice. Letting people know what you do therapeutically and how you can help them, not only helps fill your practice, it helps you help more people.

The more people who know about your therapy services and expertise, the easier it will be for those who need your services to find you and get the help they need. Consider the ways you can let colleagues, prospective clients, and referral sources know about you and your services.

1. Getting the word out about your practice is a community service.
Getting the word out about your therapy services and expertise is really about letting people in the community know about you, your practice and your services. It’s educating those in your community—your peers, prospective clients and referral sources—about what therapy is, who you serve in your practice and how you help them.

Tip: When clients go to your website, directory listing, and social media pages, what they are really looking for is: Who are you? What can you do for me? How can I contact you? Make sure your content on your website, directory listings, and social media pages gives them that information clearly and easily.

Tip: It doesn’t matter what you do to get the word out about your practice and services but you have to do something. Since you have to do something, ONLY do the things you like.

Tip: Remember, only do what fits or makes sense to you to get the word out—and always within legal and ethical guidelines! It’s okay to make things up to do that you like. However, you will have to try things out to see what you like.

Tip: Be sure to make the act of promoting yourself and your skills and services energy producing instead of energy draining.

2. Getting to know people in your community and letting them get to know you, the services you offer, and the type of work you do, brings in quality referrals.
People who already know about, like, or trust you are more likely to refer to you than anyone else. People trust their friends and people they know so that’s why word of mouth,whether in person or online, is the most valuable source of referrals for your practice.

Tip: Connect with local businesses. Introduce yourself to other local business owners who are your neighbors. One therapist I know who moved into a new office went to each one of the businesses around her—introduced herself, met and got to know the business owners and or those who worked there, found out about their businesses and gave them her business cards and brochures.

Tip: Join a professional organization or association. Attend meetings of professional groups, associations or organizations to get known in your community. Become a member. Volunteer. Register and attend a conference.

Tip: Post your professional and or practice information to a directory. GoodTherapy, Psychology Today, LinkedIn, etc. Remember that Linked In is social media for professionals, and is a trusted source for professional services and referrals.

Tip: Either donate products or volunteer your services to a worthy cause and get your name and the name of your practice out there to new people while doing a good deed.

Tip: Consider getting some promotional products with your name, website, phone number, email, and or practice specialties on them to hand out. Pens, notebooks, notepads, post-it notes, shopping bags, led flashlights, etc., are all favorite types of promotional swag that people appreciate.

3. Tapping into existing relationships is the fastest way to fill and grow your practice.
People trust other people and the experiences they have so that’s why when people hear from a friend, someone they know or a professional they trust, about a service or product they choose that one over others. For therapists, the first few referrals after you open your private practice will usually come through in person connections and relationships you’ve already built.

Tip: Build an email list. Who should you put on it? Include those you meet while networking but don’t stop there, add close friends, acquaintances, family members, extended family; neighbors, acquaintances. Professionals you have personally used—medical professionals such as doctors, physical therapists, psychiatrists, dentists, dental hygienists—as well as business professionals who are lawyers, estate planners, financial planners, as well as nutritionists, doulas, Lamaze instructors. Personal trainers, Pilates instructors, meditation instructors, massage therapists, aestheticians, hair stylists. Those who attend your church or who worked with you in the past as well as elementary, middle and high school teachers and coaches. Mentors, past clinical supervisors and professors, classmates and supervision group members. teachers, guidance counselors.

Tip: Send regular emails to your list to keep them informed of what you are doing in your practice—do this at least three times a year. Or start a free monthly email newsletter and send it to your email list.

Tip: Utilize Your Email Signature. Make sure your email signatures contain contact information for your business—links to your website, upcoming workshop, new book or audiobook, podcast, video, YouTube channel, etc. This makes it easy for people to know more about you and what you offer.

4. Consider using some type of social media to get the word out.
Today there are a lot of people who are looking for help—and most of them aren't asking their friends or family for referrals. They are looking on the internet at websites, social media platforms (Facebook, YouTube, Instagram, Messenger, Snapchat, Twitter, WhatsApp,LinkedIn, Tumblr, Tik Tok, Viber, Pinterest, etc.) and closed groups, discussion groups or forums (Quora, Reddit, etc.).

Because social media helps you build relationships, using social media to get the word out about your services allows you to showcase skills and expertise and to build relationships with existing and potential clients and referral sources.

When you post a variety of content on social media (blogs, articles, videos, quotes, podcasts—your content as well as other’s), you can build recognition, connect with your peers, referral sources, and potential clients to show them that you are trustworthy. You’ll definitely get some interest in your work from this—people will love your content and want more.

Tip: Not all social media platforms may be suitable for your business. Different customer segments frequent different social media. There's no point in spending time and money on promoting your business on a social network that your customers don't use.

Tip: When you blog or write articles regularly, social media is a great place for you to share that content. You can also share articles that you find interesting, inspirational quotes, podcasts, and videos that you think those following you would enjoy. All these are great relationship builders.

Tip: Record a video blog post and put it on your website or upload the video to YouTube. Record a Facebook Live or Instagram Stories short video. People love this content and enjoy getting to know you through what they see and hear on the videos.

5. Track what’s working and then do more of it.
Know the results you get from each thing you do to get the word out and repeat what works. Quit what doesn’t work.

These are all fairly low cost and not too time consuming tips for getting the word out. See which ones you enjoy doing and that work best to fill your practice.

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Getting Paid: Teletherapy Survival Tips for Clinicians

Getting Paid: Telehealth & Keeping Your License: Things to Remember from the BBS

Getting Paid: Tips for Getting the Word Out About You, Your Practice & Your Expertise

Lynne Azpeitia, LMFT

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