Thanks to stay-at-home orders, mid-March 2020 may mark an abrupt change in social work—from in-person meetings to a vast, fast leap into telehealth, including video conferencing, phone and text. The MyNASW online community lit up with questions about telehealth platforms, including which complied with health-privacy regulations, which were the least costly and least likely to drop connections as well as billing and co-pays. But therapists who had never worked remotely rose to the challenge.
With many questioning not only returning to in-person sessions, but also seeing advantages in distance practice, telehealth services appear to have made inroads. But how to make the most of this new “treatment delivery modality,” as veteran telehealth social worker Melissa Douglass puts it, and minimize the snags while developing an even better practice?
Newfound Intimacy—and Ethical Considerations
In mid-March, the U.S. Office of Civil Rights, Department of Health and Human Services, announced that during COVID-19, it would ease health-privacy and telehealth enforcement under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), as amended by the Health Information Technology for Economic and Clinical Health Act. This meant therapists could use non-HIPPA-compliant platforms, such as FaceTime. But many did not want to rely on eased regulations only to have to readjust later.
Marni Millet, LCSW, CASAC, Syracuse, N.Y., opted for HIPAA-compliant Zoom for Health Care and Doxy.me. (Both work with her four-year-old computer; calls may be unstable for older models.) She had been exposed to telehealth information through emails and listservs as well as having gained knowledge of health-privacy compliance from macro-level work. She was already familiar with certain technologies because her in-person practice involved videotaping patients, who watched the video to see what she saw. But she wasn’t comfortable continuing to work in that way with most clients through a screen.
Three patients told Millet they had appreciated the process of physically getting ready, going to their appointments and meeting in person with her. She had not heard that before. “People who value it like that are missing that face-to-face,” she says. “It’s a small number, but that number touched me.
Millet, who has an elderly father, will not meet in person for the time being, however. “I have to choose my dad right now,” she says. She also can’t envision working with patients wearing a face mask. “With therapy being based in attachment, masks create a barrier to really being seen.” A few patients won’t do phone or a video and “that’s a struggle,” she says.
Still, she quickly found an upside: In person, she might set chairs 4 feet apart to be close without violating the frame. In that setting, patients might look around the room. But through telehealth, there’s a sense of being 12 to 18 inches apart and being much more deliberate about looking at the other person and being seen. “Attunement is increased,” says Millet. “We’re able to pause and really talk about what is it like to be seen and not be defensive.”
She’s also been pleasantly surprised by how seriously people are taking treatment. They can, for example, name a defense—as in “I want to close this laptop right now”—and then move into steps to regulate anxiety and identify their feelings.
The subject of seeing something in patients or in their home has also been a key topic among social workers not used to making home visits. This could include witnessing family discord or other aspects of patients’ lives not seen in person. Millet might say to them, “I see this happening. How is this related to your goal?”
Frederic “Rick” Reamer, PhD, a professor in the School of Social Work graduate program at Rhode Island College, says insight into a person’s circumstances is as old as social work itself.
“Social workers have always been sensitive to patients’ privacy, including the fact that social workers may learn things about their private lives that introduce complex ethical issues,” he says. Working remotely raises two issues for social workers: privacy/confidentiality and boundaries. Social workers need to address or re-address these for telehealth, he says.
“Social workers now have a responsibility to revisit privacy and confidentiality—not to depend on a speech they gave a year and a half ago, but to talk about privacy and confidentiality in the new reality,” Reamer says. For boundaries, it means talking about the implications of seeing into patients’ personal spaces, including how the patients feel about that, how that knowledge may segue into difficult issues and obtaining informed consent for working in that way.
Millet has addressed these with her patients. If patients use a monitor or tablet for the meeting, she has their phone number in case the connection drops. She also knows the address, in case the possibility of self- or other-harm arises as well as contact information for local law enforcement. Together, she and patients create action steps: “If this were to happen, what’s our plan going to be?”
Douglass, LCSW, BC-TMH, founder and virtual clinical director of Goal Driven Counseling LLC, in St. Louis, works with patients to ensure they have privacy—whether they’re sitting in a car because they have a house or apartment full of people or in an oversized closet. Even if the patient says they’re OK having someone else present, Douglass and the other six practitioners in her teletherapy-only practice convey the importance of having the feeling of safety, security and freedom of expression that come from privacy.
Douglass also stresses she is a guest there. Maybe patients have some artwork they’d like to share—something they’re not going to lug into an in-person session. Maybe they want to introduce their dog or cat. The open view into someone’s home environment can present a therapeutic opportunity.
Lael Telfeyan, PhD, LCSW-R, would normally see patients in her offices in Manhattan or in Great Neck, Long Island, but hasn’t since about March 16. She’s been working remotely and exploring various telehealth platforms, though she has yet to settle on one she really likes.
The biggest impacts she’s seen on patients are fear of exposure, including an attendant hyperfocus on physical symptoms; adjusting to new restrictions; changes in basic work and life routines; and isolation. “Restrictions on seeing or being close to family members has been a tremendous void,” Telfeyan says. Clients also struggle to deal with conflicting information from political leaders to medical people.
Telfeyan has helped some try to cope with obsessive-compulsive disorders that prompt them to clean everything and repackage food. She’s helped others who’ve been diagnosed with COVID; one of her patients, who had many comorbidities, died. Plus, she says, many patients are having unsettling dreams or nightmares. Sessions now revolve around new routines—how are patients coping, sleeping and eating? She’s suggested that they not listen to things that will upset them, avoid the news before bed and eliminate things that make life more challenging.
For Millet, COVID-19 meant referrals ceased, but she has the same caseload—yet from 9 a.m. to 9 p.m. “It’s harder to do telehealth,” she says, echoing the sentiments of countless social workers. “My eyes are looking at a screen and I have to spread it out,” she says of the therapy sessions. The 12-hour days include breaks, when she can do things like walk her dog, enjoy a cup of herbal tea, and practice yoga and meditation.
She made an appointment with her eye doctor, has invested in lubricating eye drops, sets the computer monitor to night mode and uses blue-light protectors. She dresses for work and patients get to see the inside of her house—something she didn’t know whether she’d like, but doesn’t mind. The screen view—her dog may wander in and she’s surrounded by house plants—invites a more humanistic sense. But Millet also maintains her boundaries. It’s easy to become porous as anyone who works from home can attest. But she says she takes herself seriously and holds to a schedule, which includes not offering additional sessions in a given week.
Telehealth as Practice
Douglass launched Goal Driven Counseling in September 2017. Thanks to her expertise and experience with delivering counseling that way, she was able to help fellow social workers new to the format with the ins and outs during the COVID-19 emergency—and continues to train them.
Douglass’s previous job in social work was in management for local government. That work gave her further insight into systemic inequality, but she wanted to get back to direct work with patients, without the bureaucracy and the red tape, she says. She and her husband, who works in information technology, had often discussed her creating a virtual practice for telecounseling. She wanted to appeal directly to the people all too often disadvantaged by programs ostensibly created to serve them: African-Americans.
Douglass figured she would stay in her full-time position and build the practice over time, but four months in, she was at capacity and chose to move fully into telecounseling.
Today, she and six fellow practitioners work with patients in Missouri, Illinois and California w through telehealth, with plans to expand to more states soon. Some 98 percent of the patients are African-American and see practitioners from their homes, jobs, cars or while out for a walk. Many are seeking therapy for the first time, and anxiety—especially around life transitions—is often the driver, says Douglass, though grief, depression, trauma, overwhelm and stress also can be present.
Douglass has developed even deeper relationships with patients through screens. The learning curve? The need to put more energy into engaging more fully because of distance.
“I notice myself being more expressive and observant—facial expressions are more pronounced, inflections in my voice are more intentional, maintaining eye contact is a consideration, and more attention is given to scanning my clients’ verbal and nonverbal cues for full clinical observation and assessment,” she says. “It takes a little bit more from you, but you also get great return from that in the relationship and rapport you develop with the client.”
Douglass offers the following suggestions for social workers new to telehealth: Choose a platform with features that would make your and your patients’ online experience as similar in feeling as your in-person experiences. If you use worksheets, share videos or share assignments electronically. Douglass has used Simple Practice since late 2018, because she wanted a complete electronic health record that lets patients electronically sign/upload documents, schedule appointments, securely message her, screen-share, and access billing info.
The platform also lets her see progress notes and run reports across the team, which meets monthly and can provide consultation to one another. The platform accommodated their recent shift from private pay to insurance acceptance.Create a dedicated workspace to ensure work-life balance.
“It’s easy to get distracted by home when you’re working and easy to get distracted by work when you’re home,” she says.
Keep your work in that dedicated space—don’t bring your notes or computer to your living room or bedroom. If family is home with you, ensure your conversation with clients is confidential on your end by communicating when you are in session with a sign, by locking the door, or disabling listening devices like Alexa.
Project confidence and competence in your sessions, including by ensuring ideal lighting and sound, communicating backup plans in case of technology failure, and regularly checking in with clients on their care as they navigate tech platforms and the therapeutic experience in their natural environments.
Continue to seek education and maintain contact with colleagues. Working from home can be isolating, Douglass says, so host or take part in virtual coffees, in-person events, conferences, community-based initiatives, and share honest experiences, as well as resources and ways to stay connected. Take frequent breaks and diversify your self-care. Don’t schedule too many clients back to back to give your eyes a break. Stretch periodically and move around. Hold time to get out of the house and go for a walk or ride a bike.
All of these set the tone for more effective work with patients. Consider how you might become more financially accessible to clients through online services. If only private pay, consider a sliding scale. If accepting insurances, determine which plans feel best and fair for your practice. Consider opportunities for collaborations and partnerships with nonprofits and businesses seeking to provide mental health support to the populations they serve that align with your target population.
With various closures, COVID-19 exposed a wide variety of system-wide inequities, from access to computers and Internet for school children to disparities in access to mental health care and health care.
“This is something that is really important to me at this time,” Douglass says. “When temporary allowances due to COVID are over and regulations are tightened, we can’t revert back to large underserved and rural populations of people not having access to the technology, the adequate Internet access, or telehealth benefits through their insurance policies again. This is a prime opportunity to advocate for everyone to have equitable access to mental health care.”