Last year, the safety precautions and restrictions of the COVID-19 pandemic came to an abrupt halt in the personal interactions of most consultants with customers, colleagues and students. To continue treating clients, many clinicians switched to counseling sessions via video or other digital media. For some practitioners (and clients too) it was a like or dislike change with a steep learning curve, especially if they had not offered telebehavioral health services prior to the pandemic.
Now some consultants are starting to return to face-to-face meetings or a mixture of in-office and virtual meetings. What have practitioners learned about themselves and the counseling process over the past year as they harnessed and adapted to the health of tele-behavior? Have consultants picked up something that they could use in face-to-face work with clients when they return to a traditional office setting? From zoom fatigue to eye-opening lessons on resilience and humility, there are stories to tell.
Counseling Today recently gathered evidence from members of the American Counseling Association who have used telemedicine over the past year to provide partial or full counseling to clients. Read her thoughts (in her own words) below.
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Gale Brunault is a Licensed Mental Health Counselor (LMHC) with a private practice in Amesbury, Massachusetts.
When the pandemic first hit and all physical contact with the outside world stalled, I remember asking myself, "How will I continue to serve customers in a meaningful and productive way?" After all, I only knew one way to do business and that was face to face.
The initial use of telemedicine and / or telephone calls as an aid for customers was extremely difficult at first. I no longer had the physical presence to watch the individual, which meant that I could not effectively "time" my response. Between and dealing with technical stress, my focus shifted and I was distracted by problems that had nothing to do with customer needs. Not only did it become a challenge for me to stay at work, but I used up more energy than I wanted for each session.
Over time, the program I chose became more efficient and user-friendly, which allowed me to focus more on improving my skills. I no longer had any concerns about telemedicine diminishing the client-therapist relationship. In fact, the process turned out to be encouraging.
The use of telemedicine taught me that anything is possible. Although I initially had concerns that it might not be a cheap way to deal with grief and loss, telehealth has proven to be a solid addition for those unable or unwilling to leave the house, especially after a big one Loss. One of the most difficult tasks for a bereaved is to live in a world without loved ones. Staying at home and being able to receive therapy can be extremely helpful, especially if you just want to isolate and hide at first.
Many of my customers have asked to continue using Telehealth. Some look forward to getting back to the office. In any case, I will be available.
Since I've been using telemedicine, I have learned, among other things, that the body reveals a lot about a person, but so does the face. There is some level of intimacy in just focusing on one person's face. I became more attuned to a client's eye movement, the pauses they take, how they play with their hair, the thought process and choice of words, etc. Although all of these parts were obvious and fewer in the face-to-face time can deepen the observation and evaluation of customer patterns and behavior.
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Julie Hine is a licensed professional clinical advisor in a private practice in Albuquerque, New Mexico.
Having been in the counseling field for nearly 30 years, not only does telebehavioral health offer another opportunity for professional and personal growth, but I also believe that it can act as a catalyst for breaking down barriers to access to psychiatric health Services. While a whole world lives on a pandemic, common issues have surfaced in almost everyone. People experience a wide variety of emotions, often while feeling alone and alienated from loved ones and the world around them. People feel hopeless and helpless, full of nervousness. So what happens when the whole world feels this way? Telebehavioral health (or telemedicine) has provided an answer.
Telemedicine has given everyone in whom [they] lives access to psychiatric services. Especially in rural communities like New Mexico. Many people living in smaller communities or on reservations do not always have access to mental health services, whether because there are no counselors in their area or because they have no regular access to an office. Telemedicine has opened the doors for people to access services regardless of where they live, whether they have a car or whether they have gasoline for that car. If a person has access to a phone or a computer, they can get personal help without actually being [there] personal. I can now advise someone who lives four hours away without leaving my home.
Throughout all of this, human communities have come to realize the importance of positive mental health, and I have come to realize that self-care is a crucial gift for us as counselors. If you are a telemedicine advisor, remember to get up often, sit upright, take breaks, rest your eyes, eat healthy snacks, and most importantly, be kind to yourself. During the sessions, encourage your clients to be kind to themselves as well. The emotions are heightened so remind them not to analyze everything, ask for support when needed, learn to be proactive instead of reactive, and remember to laugh because nothing is permanent and we will get through this . People are resilient.
As a clinician in the mental health community, I plan to continue providing telehealth services even as returning to an office becomes a reality. In this way, I can continue to help individuals regardless of the circumstances. However, I have to admit, I look forward to getting out of the chair in my home office and being face-to-face in the same room with the people I serve. Nothing beats human contact and a smile of hope.
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Justin Jordan is a Licensed Professional Counselor (LPC) and Certified Substance Abuse Advisor treating mental health issues and substance use in his private practice in Salem, Virginia. He recently received his PhD in counseling and supervision from Virginia Tech and will attend the Mental Health Faculty at the University of Wisconsin-Parkside this fall.
The transition to telecounseling in spring 2020 was an easy decision due to the situation of my family. I learned very quickly that my prejudices had limited my ability to see the potential of telemedicine software for connecting with my clients and removing barriers to attending meetings [prior to the pandemic]. I never intended to use telemedicine software for counseling and I strongly believed that being face to face with clients is essential to the relationship and serving my clients' needs. Although I would still prefer to be safe in their presence, I now see that with the loss of presence there is flexibility gained in the personal / work life of the client and the counselor and the ability to see clients wherever they feel most comfortable.
In the context of COVID-19, customers felt more secure online, and so did I. Beyond the context of the pandemic, customers with children [fewer] had obstacles [for] to adjust their childcare for meetings. It was easier for customers to meet at work during their lunch break without commuting. And some customers who were very eager to get out in public could be seen from the comfort of their homes. Many of these benefits will apply when physical distancing becomes less of an issue. So if I didn't close my practice to open a faculty position in the fall, I would continue telecommunications.
In addition, as a humanistic advisor, I have always tried to reduce the power dynamic and build relationships with my clients that are based on reciprocity. Telecounseling taught me that asking customers to enter my office [in person] is always associated with a certain authority, since logging into meetings from my office / bedroom, often with the sounds of small children in other parts of the house, is the [imbalance] extinguished]. I had to break some of the boundaries I worked hard on with my physical counseling space, which came with discomfort but also a beneficial humility on my part that I had less control – over technological glitches, distractions in my home and in the state of the world. I also see that my clients often feel freer meeting me from the comfort of their own sofas or other parts of their home. I kept getting feedback from my customers that there are aspects of telecounseling that have improved the process.
One of my main suggestions for consultants and students who must decide to incorporate telecounseling into their practice is a solid plan for backup communications when technology issues arise. Note that host platforms can sometimes have problems, the clients' hardware can have problems, your hardware can have problems, and software or Internet connections can crash. Also, many clients need training in how to properly use the technology and have access to a usable digital device (which most clients do in my private practice).
I also think that humility, honesty and authenticity remain important advisor characteristics in telecounseling, which means recognizing when technology creates a barrier or problem in communication.
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Stephanie Brookins is a private practice LPC in Columbus, Georgia that specializes in the treatment of post-traumatic stress disorder (PTSD).
At first I was resistant to the idea of telehealth and would not have imagined that it could become an integral part of my practice. I now realize that a large part of my negative outlook was shaped by the discomfort of the unknown and hadn't thought about how the initial stress might dissipate. My first experience with telemedicine was a few years ago with a client who had temporarily moved to another part of the state and wanted to continue individual therapy with me. Privacy and internet connection issues and general inconvenience with the technology resulted in a negative experience for [me] and the customer, and I referred them to another vendor.
What I've found over the last year is that after initially adapting to technology and change, it's relatively easy to forget that we connect through technology. However, this is not always the case. Due to the closure of schools, some customers have problems with childcare and have to interrupt their session to help their child with school or to deal with a parenting crisis. Other customers have plumbers or pets who want attention. Initially, some clients attended telemedicine sessions in bed, half awake and in their pajamas. This required discussions about boundaries and structures that could be uncomfortable.
There were some unexpected benefits to telehealth. Clients with chronic health problems and periodic outbreaks have had to miss appointments in the past [because] when they could not drive and physically miss appointments. Now we can meet online and limit the time if necessary. This has resulted in a drop in last minute cancellations. Some customers can now access care if transportation or time has been a constraint on them in the past.
As a certified therapist for desensitization and reprocessing of eye movements, I had to adjust the bilateral stimulation mode used during processing. I was surprised at the work customers could still do, [with us] being physically separated and using self-tapping instead of eye movements or therapy tapers.
With precautionary measures for environmental safety, I was able to maintain personal advice as an option for customers over the past year. Some people are unfamiliar with the use of technology, need the human connection to see a therapist face-to-face, or don't have a reliable internet connection. It was therefore important to me to continue to offer this option. I can imagine that I will continue to adapt to my clients' needs and continue to offer both telemedicine and personal therapy.
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Nicole Sublette is a licensed clinical mental health consultant and certified hypnotherapist who also serves as a social justice advocate, public speaker, and anti-racist educator for the state of New Hampshire.
I have learned that telemedicine makes treatment more accessible to people who may not be able to undergo treatment due to timing or distance. In my practice I haven't noticed too many differences between telehealth and personal [counseling]. However, I will be more grateful for face-to-face meetings in the future. There won't be any audio or video issues. There will be no interruption in the flow of therapy due to technical difficulties.
In the last year I learned something about my own resilience and adaptability. This was of great importance to me, especially in these uncertain times. So far, I wouldn't qualify as tech savvy. The use of telemedicine and adapting it to an online format for treatment have pushed my growing limits and helped me to rely on my own capacities as well. In uncertain times, it also helped me to learn my strengths and adaptability. Techniques that I previously thought could only be done in person, such as cognitive processing therapy for PTSD, can also be done through telemedicine.
I adjusted [to telebehavioral health] by asking the clients more somatic questions and discussing how the body deals with symptoms. Asking questions about what I had previously observed with my eyes opened the dialogue in ways I would not have imagined. Asking raised questions can decrease the avoidance potential for both the therapist and the client.
For my fellow counselors, I would say that holding telemedicine sessions becomes easier over time. Using the same rapport techniques that are used in person can be very helpful in telehealth, e.g. B. Asking open questions and conveying authentic curiosity. Also, contact the elephant in the room if you have any complaints for both the therapist and the client. Share how you can learn together. Work through any inconvenience associated with using telemedicine, then work together to create a discomfort relief plan. Humor is also a great way to relieve tension.
I definitely plan to use telemedicine in the future. I hope to make a mix [of telehealth and in-person counseling]. I am currently one of the few BIPOC (Black, Indigenous and People of Color) therapists in my state. National BIPOC [constitute] about 4% of practitioners in the mental health field. Telehealth has made BIPOC populations across the state accessible for therapy. I can treat customers who would otherwise not be able to travel to my office due to the distance. In view of the ongoing escalation of police brutality, the BIPOC therapy was very critical.
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Laura Sladky is an LPC and licensed chemical addiction consultant working as a school counselor in Dallas.
Through video / telemedicine as a school counselor, I learned that being able to literally look into a person's world provides such insight into the way they organize and run their daily life (pets, plants, family relationships ) as well as their self-confidence. In short, telemedicine is an opportunity to know customers differently and accidentally know their world outside of my office.
During the past year I have been very conscious of my sense of justice and my desire for equality. Of course, these qualities are important when it comes to developing a therapeutic alliance and giving unconditional positive consideration to a client, but on a systematic and global level I have become painfully aware that individual problems do not exist in a vacuum and that change requires advocacy. Overall, this year was the portrayal of many theoretical concepts such as Maslow's hierarchy of human needs in “real life”. People cannot be thoughtful, insightful, and self-reflective when their basic needs (food, shelter, security) are not met. The individual's autonomic nervous system is activated under threat and chronic stress (winter storms, unemployment, death of a loved one, fear of illness) and, consequently, higher-level thinking at the level of the prefrontal cortex is inaccessible. In addition, I learned the inseparable connection between humanity, trauma and the imperative nature of sensory integration. While the past year has been exceptionally disruptive and devastating in many ways, our ability to understand our experiences and make pro-social connections predicts our ability to recover through our experiences – and not be further traumatized.
This year, given the social / political climate, I asked more targeted questions about media coverage / social media and how this has affected the people I work with. Whether we are aware of it or not, our brains easily become biased. Hearing a negative headline can start a downward spiral, and before you know it anything can seem awful. It helps me understand how much I know how much screen time people are exposed to.
In addition, helping individuals sift what is and what is not in their control (control vs. change skills) and take actionable steps to alleviate hardship has been of paramount importance. Asking questions is so important because you don't know what you don't know. In the same way, it can affect non-verbal cues (leg bounce, posture, etc.) if the client is not fully in view. However, it reiterates the importance of following the body, asking questions and helping it become aware of its body / feel safe in its body.
It is so refreshing for those we work with to understand that we are also experiencing undesirable situations (zoom errors, our pets interrupt calls when we miss the customer's point of view) and how we are dealing with them in the moment. Radically open dialectical behavior therapy tells us that mistakes are pro-social, help us to feel connected to others, and take the strain off our nervous system. For consultants working to network or find this challenge, I think it helps if you briefly disclose your own minor inconveniences in order to build a relationship with clients.
Our life was unceremoniously troubled, so we had to deal with grief and ambiguous loss every day, and in fact it is strange even after a year. However, strange does not mean inherently bad. One of the best ways to tackle the craziness of zoom life is to acknowledge it. This allows advisors to validate that experience, name it (awkward, different, etc.), and make it easier for clients to manage those feelings.
I think that offering a variety of therapy media is the future of our profession and I plan to make myself accessible through a variety of settings.
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Michael T. Greelis is an LPC, Licensed Marriage and Family Therapist, and Licensed Clinical Supervisor in private practice in Herndon, Virginia who has seen adolescents and adults with mood and anxiety disorders and other life problems for 25 years .
On March 17, 2020, I made a complete transition from face-to-face, face-to-face [counseling] to video conferencing for my practice – about 30 sessions a week. The change was immediately possible for all customers from March 18th. Based on the statements of the Centers for Medicare & Medicaid Services and [National Institute of Allergy and Infectious Diseases Director] by Dr. Anthony Fauci, we have either switched to virtual visits or put our health and that of our customers at risk by continuing face-to-face meetings. I've seen my clients and colleagues place a high value on treatment by making this full transition on very short notice. I've learned that with dedication and flexibility, therapists and clients can make an important transition, and that the work itself – face to face or on video – is important.
I immediately tweaked my approach to focus on the content rather than the medium, avoiding false assumptions (some cognitive behavioral therapies on my part). I assumed that my clients and I would get teletherapy working and that we would pick up on the requirements for it. What works is a focus on substance over style and developing the style as needed.
My overall impression of video conferencing for therapy (we call it teletherapy in Northern Virginia) is very positive. Before the COVID-19 crisis and the immediate measures, I was skeptical. On March 17th, 2020 it was clear that I would either have to switch to teletherapy entirely or stop practicing. My ability to adapt to this change and my clients' receptiveness to make the change had a positive effect on each other. Every client in the transition phase remained in treatment, and clients who began during the virtual-only phase followed a course of treatment similar to that expected in personal times.
After COVID-19, I am planning a hybrid approach combining personal with teletherapy based on the client's conditions and needs. This is both my preference and the one that is expressed very clearly by my clients.
My advice to fellow counselors is to focus on the work and the client's needs, give special consideration to your video conferencing experience at the beginning with each client, and ask clients how they think the treatment is progressing. Make use of the special features of the medium. I'm always surprised to see that none of my colleagues use a green screen to project backgrounds that are more appealing to any meeting than the same wall, office, etc. I push myself to have a series of images, videos, and passages of text on hand to have [to use in sessions] when they are an advantage. And I learn how to insert materials from the Internet or from my files in real time during the sessions.
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Rob Freund is an LMHC and Assistant Professor at Nova Southeastern University in Davie, Florida who also works in private practice with couples and individuals.
Before the pandemic, I had received training in telemedicine counseling and conducted it across state lines in Florida and New York, where I received a double license. So the format wasn't particularly strange to me, but the frequency of use was more difficult. Like many others, I have experienced “zoom fatigue” from using only telemedicine communication platforms. I learned that despite the pandemic, I had to separate myself more than usual from my work area and deeply and consciously care for myself in order to bring my best self into the therapy room. Spending time meditating and communicating with nature became essential for me. I also realized the value of turning off the computer and disconnecting it so that I could better reconnect with my clients.
One aspect of this work that I would like to incorporate into my personal therapy is the use of technology in the therapy room itself – using my tablet, materials for discussion and sharing of resources in real time. Using digital drawing tools to collaborate with to present and invite the customer. It has been an opportunity to further develop the tools that I bring into the room.
We rely so much on being in the room with customers that the lack of much shared experience with the room – behavioral traits when seeing the whole body, the ability to have natural eye contact patterns, smells and other sensory cues – is sometimes disoriented. It is fascinating to experience human adaptability. I found myself starting to pay attention to the sensory information I had access to – facial features, speech patterns, and non-verbal cues – and adjusting my work accordingly. We can be remarkably resilient, and I found the customers to be the same.
I think there are specific things that counselors can do to make it easier to adapt to this new model of therapy leadership. First, it is important for the clinician personally to develop grounding strategies and prep work for before and after the session, especially if you work / live in a smaller space. Second, I encourage counselors to train in emotional communication and recognition of non-verbal behavior. The Paul Ekman Group has excellent educational resources on Recognizing Micro- and Subtle Expressions, as well as books such as Unmasking the Face: A Guide to Recognizing Emotions Using Facial Expressions (by Paul Ekman and Wallace V. Friesen), Emotions Uncovered: Recognizing Faces und Gefühlen zur Verbesserung der Kommunikation und des emotionalen Lebens (von Paul Ekman) und was jeder Körper sagt: Der Leitfaden eines Ex-FBI-Agenten für schnell lesende Menschen (von Joe Navarro und Marvin Karlins) eignet sich hervorragend zur Erweiterung des nonverbalen / emotionalen Scharfsinns.
Wie jedes Tool hat auch die Telegesundheit ihre Vor- und Nachteile. Die Portabilität und Abwesenheit von Pendlern kam [me] und meinen Kunden oft zugute. Ich bemerkte jedoch, dass es für einige einen höheren Wert hat, eine Therapie außerhalb der häuslichen Umgebung zu erleben.
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Grace Hipona ist eine LPC am NeuroPsych Wellness Center P.C. in Fairfax, Virginia, der in Beraterausbildung und -aufsicht promoviert hat.
Die Pandemie hat mich herausgefordert, den Beratungsprozess aus einer anderen Perspektive zu betrachten. Es hat mich herausgefordert, flexibler zu sein und meine eigenen Bewältigungsstrategien zu überdenken. Es hat meine Widerstandsfähigkeit und Fähigkeit getestet, anderen weiterhin zu helfen, während ich durch meine eigenen Umstände navigiere. Der Prozess hat mir die Möglichkeit gegeben, wirklich mit Kunden in Kontakt zu treten, da wir alle gleichzeitig von der Pandemie betroffen sind. Auch wenn wir die Pandemie möglicherweise nicht direkt diskutieren, bin ich mir bewusst, wie wir betroffen sein können. Ich bewerte und überwache auch weiterhin meine eigenen Gedanken und Gefühle, sodass die Perspektive des Klienten in erster Linie im Vordergrund steht, und ich unterstütze sie auf der Grundlage ihrer gelebten Erfahrungen.
Vor der Pandemie waren meine Gesamteindrücke von der Gesundheit des Televerhaltens neutral bis negativ. Seit März 2020 nutze ich jedoch nur die Televerhaltensgesundheit, um Beratungsdienste anzubieten. In dieser Zeit habe ich meine Gedanken und Gefühle verändert und habe jetzt eine positivere Einstellung zur Gesundheit des Televerhaltens. Ich schätze die Bequemlichkeit und Flexibilität, die es bietet. Meine Klienten scheinen ähnliche Gefühle und Gedanken über die Gesundheit des Televerhaltens zu haben. Ich habe mehrere Erwähnungen erhalten, dass sie wahrscheinlich nicht an der Beratung teilgenommen hätten, wenn diese Gelegenheit nicht verfügbar gewesen wäre.
Unsere Praxis bewertet und bewertet weiterhin die Rolle, die die Gesundheit des Televerhaltens in der Beratung spielt. Wir haben mindestens einmal im Monat ein Anbietertreffen und seit Beginn der COVID-19-Pandemie berücksichtigen wir alle Vorteile und Herausforderungen. Wir haben jedoch keine langfristigen Entscheidungen über die Rolle der Gesundheit des Televerhaltens getroffen. Die Möglichkeit, mit Krankenversicherungen zusammenzuarbeiten, wird ein entscheidender Faktor sein. Wenn die Krankenversicherungen weiterhin die Gesundheit des Televerhaltens abdecken, bietet dies Flexibilität. Ich glaube, dass die Schaffung von Möglichkeiten für eines oder beide [in-person and telehealth] in Zukunft eine der bleibenden Auswirkungen der Pandemie sein wird.
Um besser mit Kunden in Kontakt zu treten, hat sich mein Beratungsansatz im letzten Jahr dahingehend verschoben, richtungsweisender oder unkomplizierter zu sein. Mit anderen Worten, wenn ich mir nicht sicher bin, wie ich die Gedanken oder Gefühle eines Kunden interpretiere, frage ich direkt. Zum Beispiel sage ich: „Ich bin mir nicht sicher, wie Sie sich fühlen oder was Sie gerade denken. Hast du etwas dagegen, es mir weiter zu erklären? “ Im Allgemeinen haben Kunden die Möglichkeit geschätzt, ihre Perspektive zu klären.
Um Sympathie, Empathie und Verständnis zu vermitteln, verstärke ich meine Mimik, nonverbalen Hinweise und verbalen Aussagen im Allgemeinen. Aus diesem Grund glaube ich, dass Fernberatung anstrengender sein kann. Reflexiv bemühe ich mich mehr um die Selbstversorgung, damit ich mich erholen und für zukünftige Sitzungen auftanken kann.
Die Verwendung formaler Bewertungen oder Bewertungen ist auch in meinem Beratungsprozess integraler geworden. Abgesehen von der anfänglichen Aufnahme fand ich es zeitweise vorteilhaft, formelle Kurzbewertungen zu verwenden, um meine Kunden zu unterstützen. Ich bemühe mich auch mündlich konzertiert, bewertungsbezogene Fragen zu stellen wie „Wie geht es Ihnen heute – besser, schlechter oder ungefähr gleich?“
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The future of telehealth
Insurance coverage has expanded and regulations regarding telebehavioral health have been relaxed in many states out of necessity during the COVID-19 pandemic. Will these changes remain as pandemic restrictions are loosened and many helping professionals return to in-person office settings? Find out more in our online article “The future of telehealth: Looking ahead.”
Also be sure to read this month’s “Risk Management for Counselors” column on page 8 of the print version of Counseling Today‘s May magazine, available for ACA members to download here.
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Action steps to learn more
Read Section H, “Distance Counseling, Technology, and Social Media,” of the 2014 ACA Code of Ethics at counseling.org/ethics.
Search for articles with the tag “coronavirus” at ct.counseling.org.
Browse ACA’s continuing education offerings by topic, including telebehavioral health, at aca.digitellinc.com/aca/.
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Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at [email protected].
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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.
