Getting the Most Out of Telehealth

Join telehealth experts Melissa Douglass, MSW, LCSW and Pamela Surraci, LMFT as they discuss ways behavioral health professionals can make the transition from in-person care to a telehealth practice. 

Moderated by Dr. Ben Caldwell, this panel discusses what you need to know before starting your first telehealth session, how to work through technological difficulties, and how to combat screen fatigue while working from home. They also offer insights into how to adapt telehealth sessions for younger clients, and how to successfully market your telehealth practice. 

Whether you’ve been running a virtual practice for a long time or are just now considering making that transition, these expert panelists have the insight and advice you need to make sure you’re offering the best care to your clients—even when you can’t be together.

1. What are the most important details to know before starting your first Telehealth session?
2. How do you deal with telehealth fatigue when you’re on your computer all day?
3. How do you build rapport with new clients over Telehealth?
4. How do you engage younger clients (children and teenagers) through Telehealth?
5. Do you have any tips for going completely virtual?
6. What are some tips to best market your Telehealth practice? 
7. Are there any lessons you’ve learned about Telehealth and your practice during the COVID-19 crisis? 
8. What’s the best cadence when it comes to meeting with clients over Telehealth?
9. How do you handle a Telehealth session when you start to experience technical difficulties? How do you prevent it from affecting the work?
10. How are you collecting payments for Telehealth sessions from new clients? 
11. How do you stay engaged during a Telehealth session while taking notes?
12. Is it the clinician’s responsibility to make sure the client is in a private, quiet place before we start our Telehealth session?
13. What if they are unable to find such a space?
14. What are the laws about conducting Telehealth sessions across state lines?
15. If I’m licensed in one state, can I provide telehealth service for a client in another state?
16. What are the best practices of doing intakes for new clients via Telehealth? 

1. What are the most important details to know before starting your first Telehealth session?

Melissa: Before starting your first telehealth session, absolutely, some training. There are so many opportunities for training out there from many different places and sources, making sure that there is a sound understanding of what your state requires for yourself when participating in telehealth. We know that state to state, the requirements are so different. 

Although right now some regulations are lifted and there are a lot of exceptions that are being made, we still want to be very informed on how things should be because we know that there’s a very great chance that things will go back to being required the way that they were before. So, some training, knowing what the ethical requirements are, and what the legal requirements are when doing telehealth. 

You want to make sure that you’re assessing appropriately. Again, times right now are very different because everything has pretty much shifted online. But we want to make sure that we’re assessing for safety, with our clients knowing that if they need a more advanced treatment approach or possibly a hospitalization assessment, we want to make sure that we’re assessing for that before we’re jumping online. 

We want to make sure that we are covered through our malpractice insurance and that they know that we’re seeing our clients from a distance. Also, making sure that we are including telehealth requirements — the pros, the cons, the risks, our backup plans in case there’s any technological failure. That’s a huge one to know that they’ve fully planned that this platform or approach is going to work. 

We want to make sure that we have another platform or link that we can use just in case. We know with therapy, we are sharing some very sensitive information. We want to make sure that if we’re ever cut off that our clients know how we are planning to resume with them. 

We also want to be aware that we need emergency management plans. If we have a client that even if we don’t know in the assessment, but it comes out at some point in the telehealth session that they may have any thoughts of harm for self or to others, we don’t want to be making decisions on how to approach that in the moment. We want to make sure that we have a policy on that beforehand and that we communicate that with our clients.

Then making sure that we are identifying our clients. If these are new clients that we’re working with online, making sure that we are confirming their identity through some kind of identification card that can be held up to a camera. And this is just making sure that we’re being as safe as possible and sticking as close as possible to HIPAA guidelines and regulations.

Pamela: We always want to make our first choice the platform that is HIPAA-compliant and we are familiar with, especially if our clients are familiar with it. It’s possible that, for whatever reason, the platform that you’re used to using all the other times is not going to be available to you or it’s not working or whatever that is. That should always be your first choice. If that doesn’t work, then you can go to one of the ones that the regulations have been relaxed on. Always start with the one you’re familiar with and the one you know is compliant. 

Then the other piece is to help prepare your client for telehealth, particularly if you’ve seen them in your office. This is new to them and they want to have some background. If you’re a Simple Practice user, there’s a PDF that’s handy that you can just send out to clients. That makes a big difference for people coming in; they feel better prepared. 

And making sure that they know that it’s up to them to have a private space. If your clients are used to coming and seeing you in the office, you handle the privacy. When we’re seeing them in their home, in their offices, or in their cars, they are in charge of their privacy. We need to emphasize that with them. 

2. How do you deal with telehealth fatigue when you’re on your computer all day? 

Pamela: Well, it is more fatiguing for a couple of reasons. The thing is that if you’re working from home, you’re never really off duty. One of the reasons you’re fatigued is not because you’re doing telehealth, but because there’s this fuzzy boundary between work and home.

It’s really important that you carve out your schedule just like you would if you were going to the office. I learned how to do this years ago because I’ve been doing telehealth for a long time. That’s one piece of it.

The other piece of it is we were all extra stressed and we’re dealing with extra stress in our clients. So it’s natural that you’re going to be fatigued. That’s not because of telehealth. That’s because we are all concerned about the virus. We’re concerned about the economy. We’re concerned about our clients who are under extra stress. So there’s kind of that ambient stress. 

Then in terms of the mechanics, when I do a consult with a therapist, when they’re setting up their telehealth, I have them set up just like they would. 90% of the time, they’re sitting way too close to the computer. What that means is that you’re only being seen from the head and shoulders up. If your client mimics that, all you see are their head and shoulders, and that’s not how we look at people. So, you want to back up.

The measurement I use is I want a little bit of margin over the top of my head down to about my belly button. Then they’re seeing a whole person. They’re seeing me like they would see me in the office. In your office, you don’t stand right in front of somebody. You’re sitting back a little bit. I recommend that you have a really good chair and you have a backup chair. Don’t sit in the same chair all day, every day. You need to have a bit of movement and a bit of variety in how you’re sitting. 

I also tell people to get dressed for work. When you get up, get dressed, and put on your work clothes, you’re signaling your body and your brain that you’re going to work. If you put on your bunny slippers and your sweats and iron just the front of your shirt and just put a hat on because your hair is a mess, your body and brain are not ready for work. You’re kind of doing a foot in each boat and that’s going to exhaust you. 

Then the last piece is all the basic self-care that you need to do all the time—exercise, eating right, hydrating, making sure you’re sleeping, playing with the dog, calling your friends, making sure you’re reaching out socially. All the things you tell your clients to do for self-care, you also have to do. You have to get vigilant about it because it’s easy for it to fade away. I think there’s the big picture of what fatigue is about, but then there’s the technical part. 

3. How do you build rapport with new clients over Telehealth?

Melissa: One trick that I use is to be a little bit more expressive. In my face, sometimes I might just express a little bit more. I might speak a little bit more expressively just because there is a barrier through the screen. 

And some of it is the tech part, too. Making sure that the client got to the session comfortably, that it wasn’t confusing for them. Making sure that I’m checking in on my volume. I may think that I’m speaking in a very reasonable tone, but the client is having trouble hearing me, and that can be uncomfortable for them. Or if it feels like I’m shouting on the other end, that also can be uncomfortable. 

So, the basic human things that we know to do; to be courteous, to be kind, to make sure that there is comfort for our clients.

4. How do you engage younger clients (children and teenagers) through Telehealth? 

Pamela: The younger clients and teenagers especially love this format. Part of it is that they’re so familiar with it and they sort of get a kick out of being able to show us their life. There’s this different dynamic. They usually come to my office, and now, through the screen, I’m coming to their house. 

Sometimes it’s just a matter of checking with the parent and the teen in the living room. Then the teen will take the laptop, walk through the house, and go into their room for some privacy. I’m getting to see pets. I’m getting to see the kids’ rooms. I’m getting to see the artwork that they’re doing. 

In some ways, it’s a little bit easier. I think that when the dust settles and people can come back to the office, I think some of my teens are going to ask to stay on telehealth because they’ve done much deeper work in their environment. Part of that could be that there’s a lot to talk about because they’re at home with their families and there’s stuff that’s coming up. The younger clients are so familiar with this kind of format that they’re much more comfortable than adults. 

Melissa: Breaking up the sessions to be a little bit shorter helps because you’re just thinking of attention span. It’s very different when you are sedentary in front of a computer for talking-through sessions. 

I know many play therapists that talk through doing telehealth with their clients, outside of playing interactive games and online games with them, they’re also using the things that they have in their room. Maybe if they do have pets in the room, if there is artwork that they can come and show, or if there are pieces and things that they can bring to the session, not only acknowledging their surroundings but then using their surroundings and what they have on hand.

It’d also be helpful to send a message earlier to say, “For our appointment tomorrow, can you bring some crayons or pencils or markers if you have them and a notebook?” Or, “I would like for you to bring your favorite Teddy bear tomorrow because we’re going to talk about that.” Then it gives them a little bit of time to prepare and figure out what they want to have in the session too. 

5. Do you have any tips for going completely virtual?

Pamela: You can go completely virtual but I would make that decision carefully. Make sure that you get a good education. I recommend you get certified even if it’s not necessary for your state so that you feel very comfortable with it. 

Our work can also be very isolating. If you go completely virtual, it’s much more isolating. So, emotionally, you need to be ready for that. Make sure that you have a support system in place and that you’re getting together with people and colleagues. You would need that even more when you’re doing it completely virtual. 

It also means that your home is your office. That means that you have to have a dedicated space that is private. It needs to be a place that your kids, your pets, or your partner is not going to be interrupting in the middle of a session. You have to carve that out in your home.

There are a lot of benefits to going completely virtual, but there are a lot of things you need to be prepared for too. So, make this decision carefully, get certified, educate yourself, and walk through it.

Melissa: First, assess your current experience to see: where am I right now? How am I doing? Has my space been private at home? Has it been very disruptive? We owe our clients that privacy and confidentiality even if we’re working from home.

From there, identify the practice needs for yourself. That is linked to you just as a particular practitioner. What are the things that you like to do with clients in the office? How can you make that experience seamless online? Of course, there are going to be some changes, but how can you make it as close as possible? 

You also want to think about your fee structure and your marketing strategy. Marketing an online practice is different from marketing a practice that is brick and mortar in a community.  

Then plan for your long-term care. There’s going to be extended exposure to the lights on your computer, being pretty sedentary throughout the day, and feeling isolated. Make sure that you have self-care so that you can have longevity in your career.

6. What are some tips to best market your Telehealth practice? 

Melissa: You got to have a website. If you’re thinking about a telehealth practice, you have to have a home online. That website is going to need good SEO. Make sure that your website is strong, that it’s speaking to your target audience, and that it also has reach so that you can reach people outside of the zip code that your brick and mortar office was stationed in. 

You also want to look at web directories and other ways that you can connect and network with people such as blogging, podcasting, featured writing in different publications. You want as many things as possible to link back to your practice because their reach also impacts your reach online. 

Pamela: Just like you think about your brick and mortar, that there’s an audience that you serve, you can consider that you’re telehealth practice as another address. You don’t want to market that you’re a telehealth practice; you want to market the practice you do. For example, if you see couples, you want to market that you see couples, and telehealth is one way that you see them. You want to make sure that your potential clients know that’s what you do. 

People are not looking for telehealth; people are looking for somebody who can do what they need. Telehealth is secondary to that. People do telehealth for different reasons, but the main reason is they want to work with you. They’re not coming to you because you have a nifty telehealth platform. They want to talk to me because I work with therapists. 

So, don’t forget that you’re marketing what you do best. Telehealth is how you do it, it’s how you deliver your service, but you still want to focus on what makes you the therapist that you are and why you’re the right person for your clients to see. 

7. Are there any lessons you’ve learned about Telehealth and your practice during the COVID-19 crisis? 

Pamela: One lesson that’s really impacted me is the incredible resiliency of people in small businesses and how much we need to support them. That’s easy to forget when we can’t go to stores and businesses. But as doors open, please go to your local neighborhood restaurants and cafes, bookstores, and clothing stores because those people have really stretched to make themselves available. 

The other thing that I’ve learned is how much people rely on us. At the beginning of all of this, I sent an email out to everybody I’ve seen in the last couple of years, and I got a lot of feedback. Some people scheduled, but some people said it meant so much that they just heard from me. It brought back to mind how important we are. We have a big impact. Just the fact that we’re available is a really important thing for people. I want all of us to remember that as we go forward. We’re a huge impact at a time like this. 

The other lesson that all of us and our communities are getting is that mental health has long been ignored in crisis. This time, we can’t ignore it. The mental health crisis that comes out of this will out-distance the COVID-19 crisis by years. We all need to be, as therapists, prepared for that. 

Melissa: Just how crucial it is for us as a nation to prioritize mental health because this is going to be something that has such long-lasting effects. We’re still at the beginning, middle of it. Also thinking about the access and the equity that’s also needed in accessing mental health care. It made me think about how important it is for us to not only prioritize mental health as a country but also start to make some noise and advocate about everyone being able to access services in the same way. 

8. What’s the best cadence when it comes to meeting with clients over Telehealth?

Pamela: I think that it depends on the client’s needs. For some clients, it’s hard to even find the space once a week while some clients need more. We have to see where they are where we are. We have to measure how much we can do too and do good work. So, it’s very similar to what it is in a brick-and-mortar practice.

9. How do you handle a Telehealth session when you start to experience technical difficulties? How do you prevent it from affecting the work?

Melissa: I would say it is being very human. That can be as simple as picking up the phone and continuing the conversation. Just making sure that we are apologizing for any disruptions and checking in on how they’re doing. If it disrupted a thought or a very important place that they were in the session, making sure that we’re checking how they’re feeling in the moment. That compassion and that empathy help the work to be effective via technology. 

Pamela: The other thing is that you’ll be able to handle technical difficulties and the interruptions they cause a lot more confidently and smoothly when you know exactly what you’re going to do. So having those backup plans is important. 

10. How are you collecting payments for Telehealth sessions from new clients? 

Pamela: I have all of my clients set up a Stripe credit card on their portal. If they don’t want to use it and they want to mail me a check, they can, but I have to have that check within a week. Otherwise, I have to be able to charge their card. People are used to paying for things online so I don’t get any pushback with that at all. I have some clients who just prefer to pay by check. If they’re established clients, I’m not worried about that. They can just mail it. 

11. How do you stay engaged during a Telehealth session while taking notes?

Melissa: I am not a fan of typing through it during a session. I hold my notebook or whatever I’m writing on in my hand, with my hand rested on my desk and my notepad a little bit elevated above my keyboard. This positioning helps me to not break eye contact too much. I put my notebook within my peripheral vision because we know that when we’re looking down way too much or for too long in a session it could cause feelings of disengagement. 

I position my notebook where I don’t have to completely look down and I jot very quick notes so that I’m fully engaged with giving direct eye contact. I try not to break eye contact and not be distracted by anything else that’s going on outside. Just staying very engaged and making sure that we’re giving the most eye contact because online when we’re online, it can feel very disconnected. 

12. Is it the clinician’s responsibility to make sure the client is in a private, quiet place before we start our Telehealth session? 

Pamela: This comes up a lot with younger people who have roommates. One of the things that I front-load is we don’t know how deep we’re going to go. If there are people around, you’re not going to be able to get to those places that are sensitive because you’re going to be self-conscious whether you think so or not. 

I have people who go out to their garage and sit in their car so they have a little bit of space and quiet. I’ve heard people go to a neighbor’s backyard because the neighbor’s not home. At some point, we as clinicians are going to have to make the call. If the client says, “It’s fine, my roommate can hear everything,” we can say, “I’m not okay with that. We’re going to need to reschedule to a time that you can have privacy.”

We have to look out for our clients. We know how quickly things can get sensitive. Our clients don’t necessarily know that. We also know the value of that and how sometimes just pushing just a tiny bit further can get somebody a really big leap forward in progress. They’re not going to be able to do that if their roommates are walking around, or their parents are walking around, or their kids are walking around.

13. What if they are unable to find such a space? 

Pamela: We can get creative about timing. Is there a time that everybody else is out? Do they want a phone session instead? Can they walk down the street? 

We have to monitor how much our clients are going to safely do with the people around them. I don’t ever want to deny a client therapy, but I want to make sure they’re safe. If I know that they’ve had problems with the roommate in the past, I don’t want them talking about sensitive things with the roommate in the room or the periphery. 

So, if it was an emergency, of course, we’re going to see that client. We’re going to do everything we can. But when people start to get into the more sensitive things, we need to monitor their response to this. If they’re unable to find a space, then that’s probably something we need to talk about with them, too. 

14. What are the laws about conducting Telehealth sessions across state lines?

Melissa: You have to contact every state if you are considering this. There are some exceptions. We cannot just say that because I’m licensed in that state but I’m located somewhere else, I can just do it. We can’t make those decisions for ourselves. 

Even though some states have exceptions for it, first, think about your knowledge of that area that client is in. It’s part of the safety planning and emergency management plan if it was ever to be needed. Right now there are many states that we can work with people, but that also gives you the extra responsibility of knowing what the closest hospitals are or what community resources are in the area. So that puts some more responsibility on the clinicians to inform themselves. 

15. If I’m licensed in one state, can I provide telehealth service for a client in another state? 

Melissa: If you are licensed there or temporarily licensed there or get some communication in writing from the board in that state that there is some allowance, yes. But then you also have the additional responsibility of making sure that you’re informed of any resources that clients might need in an emergency.

Ben: There’s been a fair amount of misunderstanding of one of the Federal Emergency executive orders in the midst of the coronavirus. There was an executive order related to Medicare, allowing people to conduct Medicare services. I think the phrasing was “without geographic barriers”. It’s important for folks to hold in mind that that is not Carte Blanche for therapists to practice with anyone, anywhere, and any time. It was an exception specific to the Medicare population. It doesn’t impact services beyond that. 

16. What are the best practices of doing intakes for new clients via Telehealth? 

Pamela: I do the same intake in telehealth as I do in my office. I send out all the intake forms ahead of time and ask clients to fill them out so I have time to go over them. Then I can ask some specific questions. 

One of the reasons I do that is that it helps me to be more prepared. I’ve also had the experience of clients appreciating the chance to sit down and take their time to express what they’re coming into therapy for and what their goals are. They can sit with it and think about it. 

I have this experience of people who start talking and then they feel like they said too much. So, one of the reasons I like doing the intake online is that they can decide how much they’re going to tell me before they are in front of me. Then as they get comfortable with me, they can fill it in. 

Our clients are often afraid to tell us things. That intake, when they can take their time with it, soothes that discomfort. It allows them to decide what they’re going to say and how they’re going to say it. So, that intake is really important for telehealth. 

Part of the intake for telehealth is to make sure that your clients know how to get themselves set up. Again, that PDF that Simple Practice has is super handy and user-friendly. That’s all part of the intake so that their very first session is a good experience and not getting all choppy. We do everything we can to make that a smooth landing for them.