HEALING ON-LINE: HOW THERAPISTS CAN … THERAPISTS CAN ETHICALLY & EFFECTIVELY SUPPORT CLIENTS ... technologies when delivering services to clients/patients ... ¨ Clients can’t

HEALING ON-LINE: HOW THERAPISTS CAN ETHICALLY & EFFECTIVELYSUPPORT CLIENTS IN THE DIGITAL WORLD

www.TheCounselorsCoach.com

MARI A. LEE, LMFT, CSAT-S

Presentation Outline

¨ About Mari¨ Managing Expectations¨ What is Telehealth?¨ Training & Scope¨ Common Misconceptions¨ Best Business Practices¨ Best Clinical Practices¨ BAA Info¨ HIPAA Reminder¨ Pros & Cons¨ Attunement & Attachment¨ Forms & Resources¨ Q & A

About Mari A. Lee, LMFT, CSAT-S

¨ Licensed Marriage & Family Therapist ¨ Certified Sex Addiction Therapist & Supervisor¨ Certification in Telemental Health ¨ Founder of Growth Counseling Services Center in Glendora, CA¨ Co-author of, “Facing Heartbreak: Steps to Recovery for Partners of Sex

Addicts” ¨ Author of, “The Creative Clinician: Exercises and Activities for Clients and

Group Therapy”¨ National Speaker on Partner’s Trauma, Resiliency & Healthy Rebellion,

and Developing Multiple Income Streams in Private Practice¨ Founder of The Counselors Coach¨ www.TheCounselorsCoach.com¨ www.GrowthCounselingServices.com

Managing Expectations…

Who I am not…

I’m not a super tech geekI’m not a HIPAA expertI’m not an Internet GuruI’m not a crystal ball readerI’m not going to cover everyaspect of this topic

I am also not an opera singer, eater of lima beans, or a lion tamer…just in case you were wondering.

Who I am…

Dedicated to ethical client care for clients interested in on line therapy

Enjoy learning new platformsLove sharing information

with colleaguesA coach who stays on top of trends and tech

to assist my therapist coaching clients

I am also an animal advocate, nature lover, and enjoy hiking, dancing, music, especially

Prince, Led Zep and funk.

Please Hold Questions until the Q&A

I will provide time before we wrap up for Q&A.

What is Telehealth?

Telepsychology or telemental health: The provision of behavioral and/or mental health care services using technological modalities in lieu of, or in addition to, traditional face-to-face methods (e.g., provision of therapy using the phone, diagnostic interviewing via video teleconferencing, use of applications to track mood states, consultations via email).(Source: American Psychological Association)

Did you know?¨ There are more than 45 terms used in the marketplace and professional

literature related to the mode of TeleMental Health, such as e-therapy, telehealth, on line counseling, digital therapy and so forth.

¨ At least thirty-eight (38) state counseling boards now have policy regulating online counseling for the citizens of their state.

¨ Most state counseling licensing boards include the requirement that the counselor is licensed in the state in which the client resides. Arkansas has gone a step further in requiring a special license.

(Source: American Psychological Association)

Forms of Telehealth

¨ Technology may include phone, email, webcams, mobile apps, webpages or adaptive and assistive equipment.

¨ Working with a psychologist or clinician may take place in real time (via webcams or phone) or it may be time delayed (via email).

Is Training Required for Telehealth?

¨ Training is not “mandatory” as of this date, however…¨ As telehealth continues to gain popularity, regulations

will likely change re training¨ Important considerations for seeking training:

¤ Clinician’s level of understanding law & ethics of telehealth¤ Clinicians competence utilizing telehealth platforms¤ Client Confidentiality ¤ Affordable and up-to-date training that includes CEUs and

a certification that is recognized by your board¤ Selecting HIPAA compliant platforms for Telehealth

What do our Professional Associations have to say about Training and Certification in Telehealth in 2017?

American Association of Marriage and Family Therapists:6.6 Training and Use of Current Technology.Marriage and family therapists ensure that they are well trained and competent in the use of all chosen technology-assisted professional services. Careful choices of audio, video, and other options are made in order to optimize quality and security of services, and to adhere to standards of best practices for technology-assisted services…American Association of Marriage and Family Therapists Code of Ethics, 2015


American Psychological Association:Psychologists who utilize or intend to utilize telecommunication technologies when delivering services to clients/patients strive to obtain relevant professional training to develop their requisite knowledge and skills. Acquiring competence may require pursuing additional educational experiences and training, including but not limited to, a review of the relevant literature, attendance at existing training programs (e.g., professional and technical) and continuing education specific to the delivery of services utilizing telecommunication technologies.American Psychological Association Guidelines for the Practice of Telepsychology, Competence of the Psychologist, Application, 2013


National Association of Social Workers:NASW’s code of ethics does not explicitly address competency in the practice of telehealth, however the NASW’s is currently writing new guidelines for technology in social work:Standard 4. Technical CompetenciesSocial workers shall be responsible for becoming proficient in the technological skills and tools required for competent and ethical practice and for seeking appropriate training and consultation to stay current with emerging technologies.NASW and ASWB Standards for Technology and Social Work Practice, 2005


National Board for Certified Counselors:While the NBCC’s code of ethics does not explicitly address competency in the practice of telehealth, it does address that NCCs must practice within their scope of competency NBCC addresses training in the Policy Regarding the Provision of Distance Professional Services:

“2. NCCs shall provide only those services for which they are qualified by education and experience. NCCs shall also consider their qualifications to offer such service via distance means.”

National Board for Certified Counselors, Policy Regarding the Provision of Distance Professional Services, 2012

Clearing up Common Misconceptions

Common Misconceptions & Myths

¨ It is illegal to provide counseling via teletherapy

¨ A therapist can provide on line therapy services to a client who is out of the state they are licensed in

¨ A therapist can provide teletherapy via SKYPE

¨ Group or couples tele therapy is not effective

¨ Clients can’t attune and connect with the therapist via teletherapy

¨ You must lower your fee for teletherapy

(Nope to all of the above)

More Common Misconceptions & Myths

¨ Every client is the right fit for teletherapy¨ Every therapist is a good teletherapy provider¨ You have to be a “techie” to provide teletherapy¨ It is A-OK to transition an out of state therapy client to

a coaching client and provide therapy services

¨ It is A-OK to provide therapy to a client on vacation, location or tour outside of the state you are licensed

¨ It is A-OK to provide therapy services to coaching clients and visa versa

(Nope to all of the above)

Best Business Practices for Teletherapy

¨ HIPAA Compliant Platform with encryption and back up

¨ Business Associate Agreement in place with platform and others

¨ Out of session boundaries and policy (email/texting)

¨ Client Forms accessible (including reporting, consent, limits of confidentiality, risks, etc.)

¨ Specific teletherapy info. on client forms

¨ Assessments (bio/psycho/social)

Best Business Practices:Pre-Session Internet Check List

We can’t control all Internet glitches and snafus, but we can greatly reduce dropped session calls and video platform freezes by doing the following:

1. Quit (not just close) all other non-therapy programs before the session, such as Google drive, Drop Box, Facebook, SKYPE, websites and web connections not related to your session.

2. If your connection is week (less bars), move closer to your Wi-Fi connection. This will ensure the best connection so that your Wi-Fi doesn’t have to work so hard at keeping you and your client connected.

3. Double check that your antivirus program and system software updates aren’t scheduled to run during the session. Otherwise it will suck the juice from your session and could create dropped calls or frozen screen time.

4. Have a backup plan! I purchased a little Wi-Fi hotspot that uses the same 4G LTE cellular service that my phone uses. It works as a backup for my main Internet.

TIP: BOTH YOU AND YOUR CLIENT NEED TO DO THIS ON BOTH SIDES

Best Business Practices for Teletherapy

¨ Drop calls/frozen screen -how is this handled?

¨ Reduce interruptions/Have a plan if interrupted

¨ Professional Backdrop Environment¨ Reducing noise (dog, baby, traffic,

doorbell)¨ Dress Code for therapist¨ Encrypted and secure email¨ Headset

Best Clinical Practices:Confidentiality and Crisis Policy

¨ Verifying where client is located during session including verifying address, making note of the address, city and zip code of client.

¨ If meeting via phone, verify ph. number for client if shows as restricted.

¨ Verifying there is privacy for you and client. No one is present in your space or client’s space while conducting session. Client nor therapist is driving at time of session, nor is there a driver present.

¨ Client may not be under the influence of drugs and alcohol or drinking alcohol at time of session.

¨ Client is a resident of and located within your state of licensure at time of session

Best Clinical Practices:Confidentiality and Crisis Policy

¨ Client understands and has signed client forms on mandated reporting, Tarasoff and duty to warn, and crisis intervention for suicide.

¨ Referrals for client in their area if therapist (or client) feels traditional in office therapy would be best and driving to therapist’s office would create a burden for client.

¨ Available office for important in office meetings such as Formal Disclosure, or other important parts of treatment that may require in office contact.

Best Clinical Practices:Important Tip for Treatment Notes

Helpful language for treatment notes:

¨ “This therapist verified that the client (name) was located at (address, city and zip) on (session date) during the hour of (treatment hour).”

¨ “This therapist verified that the client was alone in their space with privacy, was sober, and to the best of this therapist’s ability, confidentiality was in tact on the client’s side by this therapist asking client, and having client scan room with (device).”

¨ “Crisis intervention assessed. No life threatening crisis was noted during session with client.”

Then proceed with symptom, intervention, response and plan per normal treatment note protocol.

Best Business Practices for Teletherapy:A Business Associate Agreement

BAA Basics:¨ HIPAA covered entities are responsible for protecting their clients’

information.¨ The people we hire to support our practice who may have access to client

information must do the same. In order to ensure this, we employ what is called a “Business Associate Agreement.”

¨ Who needs a BAA? HIPAA defines this as people we hire to handle personally-identifying client information. For example: billing services, assistant, VA, accountant, temp, data back up storage, etc. as “Business Associates.”

¨ HIPAA states in the Administrative Simplification that we can work with such services if we “…obtain satisfactory assurances that the business associate will appropriately safeguard [personally-identifying client information.]“

¨ That “satisfactory assurance” is required by the law to take the form of a contract called a Business Associate Agreement, or “BAA” for short.


BAA Basics:¨ A BAA is a form that, in a nutshell, is a legal promise from the

Business Associate that they will secure and treat your client information in the same ways you as a covered entity are required to do.

¨ Business Associates must inform you if they suffer a security breach that impacts you and/or your clients.

¨ Does your cloud and email need a BAA. Yes, because if you are sending and receiving client emails, if you do on line payments or back up data on line, or schedule on line, you must have a BAA with your service provider.


BAA Basics:¨ Remember, whether it is a huge company that provides your

Google suite, or your one person bookkeeper, or a virtual assistant, the similarities is that they all use their own resources to handle our information.

¨ We who use those services do not have control over how our client information is managed and kept secure because the outside individual or company uses their own set of procedures and polies vs. ours.

¨ Thus HIPAA requires that we get written contract that they will secure and handle our patient information to HIPAA standards by having a Business Associate Agreement contract in place.


Who is exempt from a BAA?

¨ As a business coach I am often asked if cleaning services, interior designers, plumbers, or electronic repair people are also Business Associates because they may be near our client information.

¨ However, using the office cleaner or tech person as an example, this kind of potential contact with client information is what is categorized as “accidental or incidental” so they are not considered a HIPAA Business Associate.

¨ Currently you do not need a BAA from your bank, as banks are exempted from the HIPAA rules when performing the basic functions of processing payments.

¨ Tip: It is always wise to weigh the risk with your business and decide if having a confidentiality agreement in place would be a smart idea. I know if I were a client I would appreciate that extra step!


SAMPLE Counseling Office Office Cleaning Confidentiality AgreementI, ________________________________________________, understand that should I come across any private patient information, patient forms, files, mail or other private clinical patient information in my role as office cleaner at (address) that I will treat this information as confidential and agree not to discuss, share, or otherwise compromise the identity of any patient and/or patient information that I may come across while performing my tasks within the counseling offices at listed address.

Date: _____________________________

A brief reminder about HIPAA

¨ HIPAA: Acronym that stands for the Health Insurance Portability and Accountability Act, a US law designed to provide privacy standards to protect patients' medical records and other health information provided to health plans, doctors, hospitals and other health care providers.

¨ The Administrative Simplification standards adopted by HHS under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) apply to any entity that is:

¨ A health care provider that conducts certain transactions in electronic form (referred as a “covered health care provider”)

¨ A health care clearinghouse, or ¨ A health plan

A brief reminder about HIPAA

¨ An organization or individual that is one or more of these types of entities is referred to as a “covered entity” in the Administrative Simplification regulations, and must comply with the requirements of those regulations.

¨ HIPAA covered entities (entities simply mean health care providers in the US who meet certain requirements) are responsible for protecting their clients’ information under the HIPAA laws.

¨ Not sure if you are a HIPAA covered entity? Then take the 20 second free assessment to determine if you as a person, business, or government agency is a covered entity:

¨ https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/HIPAA-ACA/Downloads/CoveredEntitiesChart20160617.pdf

Benefits and Challenges of Teletherapy

¨ Disabled clients¨ Elderly clients¨ Access to therapists who speak your

language¨ Access to therapists with particular

specialization¨ Access to therapists who provide sign

language sessions¨ Access to more diverse therapists¨ Chronically ill clients¨ In office clients who are ill¨ When you are contagious ¨ New parents¨ Can schedule in office as needed

¨ More flexible scheduling¨ Model boundaries on line for SA

clients ¨ Clients who cannot drive¨ Clients who have bonded with you

but have moved to another part of the state and prefer to continue

¨ Clients in metro high traffic areas¨ Clients who have busy professional

or academic schedules¨ If office is compromised ¨ Convenience ¨ Client who is running behind ¨ Overhead reduced for therapist

Benefits

Benefits and Challenges of Teletherapy

¨ Internet glitches¨ Dropped calls¨ Power outages due to

natural disaster¨ Potential risk to

confidentiality¨ Client fear of technology¨ Therapist fear of technology¨ Not all clients can afford

technology¨ Expense of teletherapy

platform for therapist ¨ Client records session

¨ Client feels more isolated ¨ Client is less inclined to lean in to

challenging interventions (like ERP therapy for OCD)

¨ Client is not honest about privacy ¨ Client is not honest about location¨ Client is not willing to give

address location during session¨ Client becomes anxious without

seeing therapist in person¨ Client feels a lack of attunement

and attachment

Challenges

Thoughts on Attachment & Client Attunement via Teletherapy

¨ Siegel termed "interpersonal neurobiology"—the idea that social relationships fundamentally shape how our brains develop, the way our minds construct reality, and how well (or badly) we adapt to psychological stressors throughout life.

¨ According to Siegel, the particular clinical model or approach we use is much less important than the attunement of the therapist to what he calls the "critical micromoments of interaction” with the client.

¨ This includes tone of voice, facial expression, posture, motion, eye gaze that "reveal otherwise hidden states of mind."

¨ The right brain/limbic (unconscious, emotional, intuitive) interaction of the psychotherapist and client is more important than cognitive or behavioral suggestions from the therapist.

Source: “Does attachment theory really matter?” by Mary Sykes Wylie and Lynn Turner

¨ The psychotherapist's emotionally charged verbal and nonverbal, psychobiological attunement to the client and to his/her own internal triggers is critical to effective therapy.

¨ Reparative enactments of early attachment experiences, co-constructed by therapist and client, are fundamental to healing.

¨ Excellent article on determining eye gaze, distance https://personcenteredtech.com/2016/11/02/making-eye-contact-over-video-in-telemental-health-services/

Ethical Marketing

¨ Clearly list the way you provide teletherapy on your website and forms

¨ Clearly list your fee on your forms, and discuss before first session

¨ Scheduling: make the process as confidential and clear as possible

¨ Forms: credit card forms,confidentiality, rules for safety

¨ Legal/Ethical: Limits of confidentiality

¨ Referrals for in office therapists

Digital Platforms

¨ https://www.adaptivetelehealth.com

¨ https://doxy.me

¨ https://vsee.com

¨ https://carepaths.com/telepsychiatrytherapy/

NOTE: I do not get paid to endorse the following companies and have no affiliate relationship with them. The following companies claim to be HIPAA compliant. Do your research:

ResourcesNOTE: I do not have an affiliate relationship with any of the following. I am sharing my favorite resources, not endorsing a particular company or organization:

1. Training: Zur University : http://www.zurinstitute.com

2. Blogs: Roy Huggins, Person Centered Tech -https://personcenteredtech.com

3. Teletherapy Forms: Mari A. Lee, LMFT www.TheCounselorsCoach.com

4. Am I a Covered Entity? 1 Minute Assessment:https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/HIPAA-ACA/Downloads/CoveredEntitiesChart20160617.pdf

5. Notice of Privacy Practices Sample Form:https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/model-notices-privacy-practices/index.html

Resources

6. Article: http://www.apa.org/practice/guidelines/telepsychology.aspx

7. Book: Basics of California Law for LMFTs, LPCCs and LCSWs by Benjamin Caldwell

8. Coaching: Mari A. Lee, LMFT, CSAT-Shttp://www.thecounselorscoach.com

]

10. Further Information:http://www.apa.org/pi/disability/resources/publications/telepsychology.aspx

References

1. The Future of Online Therapy; Yair Amichai-Hamburgera, , , AnatBrunstein Klomekb, c, Doron Friedmand, Oren Zuckermane, Tal Shani-Shermana

2. The Therapeutic Relationship in E-Therapy for Mental Health: A Systematic ReviewMadalina Sucala, PhD, 12 Julie B Schnur, PhD,1 Michael J Constantino, PhD,3 Sarah J Miller, PsyD,1 Emily H Brackman,1 and Guy H Montgomery, PhD1

3. Exploring Mental Health Providers' Interest in using Web and Mobile-based tools in their Practices; Stephen M. Schueller, Jason J. Washburn, Matthew Price

Thank you, it’s been a privilege…

Q & A Time

SASH SPEAKER DISCLOSURE

¨ I am not being paid by SASH or any other organization to speak at the 2017 SASH conference.

Documents

HEALING ON-LINE: HOW THERAPISTS CAN … THERAPISTS CAN ETHICALLY & EFFECTIVELY SUPPORT CLIENTS ... technologies when delivering services to clients/patients ... ¨ Clients can’t