Lauren Schiffer, LICSW, MPH

The Power of Pants

Recently I’ve been thinking a lot about pants. I’ve been thinking about what they mean, what they represent and what they can do.

Often when clients are dealing with a crisis, loss, or just feel weighed down by their emotions, they will tell me they don’t know how they will get through it. This is understandable and common. When our negative emotions are so strong and raw, it’s hard to remember that we can feel differently in the future, or that we have felt differently in the past. When a client tells me they don’t think they can get through something, I often respond, “You already are getting through it. You’re breathing, you’re sitting, you’re here, and you’re wearing pants.” That last part usually brings some humor into the room, and while that is some of my intention, I’m not saying it just to be funny. Putting on pants, or a dress or a skirt for that matter, is important.

Asking about Activities of Daily Living, or ADLs, as they are often referred to in the mental health field, is an important part of the assessment process. Do you shower? Get your laundry done? Can you cook, keep your room or home reasonably clean, and get yourself dressed every day? It sounds basic, and some clients initially laugh when I ask these questions. However, for anyone whose symptoms have been so overwhelming and intense that they are not able to keep up with ADLs, it is no longer possible to take them for granted.

On top of ADLs, many people go to work, take care of children, hand in research papers on time, and remember to call their mother for her birthday, even when depressed, during crisis, or while managing intense anxiety. Despite the intensity of these emotions, things get done. These people, who would be classified as “highly functioning” by a therapist, doctor, or society, usually do not give themselves enough credit. I’m often reminding clients that despite how bad they might feel, every morning they get up, put on pants, and start the day. There is a power in this, The Power of Pants.

Anxiety, depression, grief, loneliness, an unhealthy relationship or a bad job can all have a way of waking you up early, yet make you feel like you cannot get out of bed and face the day. Stepping out of bed, getting out of the pajamas or sweatpants, and putting on pants is a powerful step. Even if the step feels very small, even if all you do is get into pants and sit on the couch to read, or go for a walk around the block to get coffee, you have taken that first step, which is the hardest one. The Power of Pants takes some of the power away from your symptoms, reminds you that symptoms do not have to define you, and shifts the narrative towards hope. Even if the shift it subtle, it is profound.

If nothing else, put on pants and see what happens.

Dinner On My Mind

As I write this post I am waiting to meet with friends for dinner. I am taking them to one of my favorite local restaurants, one they have been wanting to try. The place is tiny, so the atmosphere will be cozy, and the open kitchen window ensures that we will feel like a part of the preparation. The food, rustic Italian fare, will look, smell, and taste delicious. Finally, the mood will be joyous, as we are celebrating their engagement. All in all, the makings of a perfect evening.

There is only one problem: I am hungry, too hungry. So hungry, that I have been having trouble writing this post, switching from my work to rereading the restaurant’s web site and having an inner battle about whether I should have a snack before I go. Food, more specifically hunger, is taking over my thoughts. I am so hungry that when I meet my friends I will likely be distracted by my hunger, gazing at the plates of other people’s entrees as the come out of the kitchen, rather than fully listening to the story about their recent beach vacation and resulting proposal. I will likely grab a second and third helping of bread as I try to listen, becoming more impatient as I wait for my order. I will wind up eating so quickly that I will swallow my bites before I have actually tasted them. I wilI will be finished with my meal before I’ve even enjoyed it, feeling painfully full. This unwanted physical feeling will awaken upsetting psychological feelings and a potentially perfect evening in honor of my friends will be overshadowed by my own regret, guilt, and shame.

For too many people, regardless of their weight, shape or size, my scenario is all too familiar. Something happens, we feel out of control around food, and the process of eating becomes filled with negative emotions. Eating should be sensual, joyful, comforting, nourishing, delicious, but instead a plate of pasta or a piece of cheesecake turns into shame before we even swallow. What happened? In what reality should ravioli be a cause for shame?

There could be another outcome, a different scenario. I could be mindful. I could look up the menu before I go, carefully considering what I am in the mood for tonight, and getting a sense of what is on the menu that I would like to try. I could check in with my physical sensations and emotions to see if there are other feelings I am confusing with hunger, such as anxiety, bordem, fatigue or thirst and address them if possible. When we are at the restaurant, I could take a deep breath when the bread dish is placed in front of me, enjoying the aroma of fresh baked goods, choose a piece, and chew it slowly while I listen to my friends. When my meal arrives, before relying only on taste, I could engage my senses of sight and smell, appreciating the presentation, the way the food was artfully and carefully arranged on the plate, as well as the aromas, both thoughtfully considered when creating this meal. I could savor each bite, observing details often over looked while eating, such as texture and temperature, and think about how the food makes me feel, physically and emotionally. I could pause between each bite, asking myself if I want to experience the taste again, and before continuing, notice if I still feel hungry. Without discomfort and the resulting guilt or shame, the food can simply be pleasurable and the experience can be go back to being the joyous celebration we intended it to be.

I know, the second scenario sounds too good to be true, too perfect, inaccessible. But it doesn’t have to be. This fall I has the opportunity to attend week long seminar which taught mindfulness based meditation practices, how to integrate them with eating and food, and how to share these techniques with clients both in group and individual therapy settings. Mindfulness Based Eating Awareness Training, or MB-EAT, created by Jean Kristeller, PhD, provided me with a new approach to working with clients who want to change their relationship to food, particularly those struggling with Binge Eating Disorder or compulsive and emotional overeating. Many people are initially intimidated by the idea of meditation, believe that they are too impatient, imagine they will be forced to sit cross legged for hours chanting, or worry they will have to adopt a dogma they do not believe in. But mindful eating is not that complicated. Mindful eating can be as simple as taking a minute to decide what you would like off of the menu, taking five deep breaths before digging in to your meal, smelling the food before tasting it, or simply asking yourself, “Am I still hungry?”

Earlier this month I was excited to see an article by Jeff Gordinier in The New York Times, featuring mindful eating (http://www.nytimes.com/2012/02/08/dining/mindful-eating-as-food-for-thought.html?_r=1&ref=health). It’s a wonderful, straightforward article, providing a nice introduction to the topic. If you’re still curious after that, The Center for Mindful Eating (tcme.org) is a wonderful resource for both clients and professionals. Mindful eating techniques have made my clinical work more robust and I am always looking for ways to share them with clients.

Resolution Reality Check

As the first month of the new year draws to an end, I have been reflecting on resolutions. For many, New Year’s is a time to make resolutions, start fresh, eliminate a “bad” behavior, or lay the foundation for a major change. I have written about this idea a number of times, because I believe that at its core, psychotherapy is about making change. Healing from a trauma or loss, managing anger, improving communication with your partner, or advocating for yourself at work all require change, commitment and, of course, resolve. On this blog I have written about the importance of decreasing obsessions and their power over us, reviewed motivational tools, encouraged risk taking and even recommended reevaluating an over-scheduled life. I have repeatedly advocated for change. However, I did not do it at the New Year, and that was intentional.

I stay out of the New Year’s Resolution melee because usually it is focused on losing weight or dieting, and too often that focus feels like punishment or judgement on how we behaved in the holiday season. While less than a week or even a day ago, the media was encouraging us to spend, eat, and drink indulgently, on January first, the very same outlets begin selling us ways to undo or correct everything they just promoted. This mixed message is not only frustrating, it can be crazy-making, depressing, and rooted in shame.

I am in support of making healthy changes, but not when they come from a place of self-loathing. No matter how out of control, unhealthy, or unhappy you feel about your weight, body, or current eating habits, you won’t be able to change them if you hate yourself. Positive, long-lasting change comes from a nurturing and compassionate place. After a month of reflection and as we head into February, which is National Eating Disorders Awareness Month, I think the best resolution is to work towards loving yourself and viewing yourself with respect. When that happens the changes will follow. As the famous, humanistic psychologist Carl Rogers explains, “The curious paradox is that when I accept myself just as I am, then I can change.”

Ch-Ch-Changes

As I mentioned in a previous post, Lauren Schiffer Therapy is becoming a full time enterprise in 2012 and I’ve made a few changes to accomodate this growth spurt.

NEW DIGS! As of January 1, 2012 my office has moved. I will still be in Cambridge, but have moved from Harvard Square to Central Square. I am excited about the new location. It is cozy, is right off the Red Line, CT1 and #1 bus routes, has great views, tons of sunlight, and is handicapped accessible. My new location is 678 Massachusetts Avenue, 8th Floor, Cambridge, MA 02139.

NEW HOURS! I have also added an additional weeknight, am now seeing clients Mondays, Wednesdays and Thursdays and have slots available as late at 8:30 PM for all you night owls. Starting in February I will also have daytime appointments on Mondays.

NEW PAYMENT OPTIONS! I have recently been offered a contract to be a Blue Cross Blue Shield PPO and POS provider. The approval process is still in the works, but will likely be completed (fingers crossed) by February. That means that if you are a BCBS of Massachusetts customer with one of those plans, you may be able to use your insurance to pay for our sessions. I will post more details when I am officially an “authorized provider.”

Taking Lauren Schiffer Therapy full time has been a long-time dream, and I’m thrilled that 2012 is the year I start realizing it. I’m looking forward to the professional and personal growth this change will bring and am excited to share this with my clients.

The December Door Knob

After a year of talking, planning, debating, and ruminating, I recently decided to make a big professional move, leaving a full time job to focus more on my private practice and the professional world of Lauren Schiffer Therapy. I gave my notice on a Friday and met a close friend for brunch on Sunday. We had a lot of catching up to do. She had been sick for a few weeks, so we hadn’t been able to see each other, I had been too busy at work to write anything close to a thoughtful e-mail, she had a recent dating fiasco to share and we had plans and details of a mutual friend’s upcoming wedding to discuss. As we were waiting for the check, I told her about my resignation. She was extremely happy and excited for me, but was also a bit shocked and teased, “Next time, when someone asks you what’s new, you lead with that.” She was right. This news was big, exciting, important, but for some reason it took me all of brunch to get to it.

In psychotherapy this is casually referred to as a “doorknob,” a very important statement, fact, or topic that a client brings up right at the end of the session, often literally when their hand is on the doorknob. The therapy session is almost over, and there isn’t enough time to sufficiently address the topic. There are many practical and theoretical explanations for the doorknob statement. Sometimes the client is embarrassed by the topic and has been trying to relax, get comfortable or gain enough courage to address the issue. Other times the client knows an issue will be important information in their treatment, but might not be ready to dig too deeply, so brings it up at the end. This can be an enormous relief, “Phew, I got that off my chest,” without being too overwhelming. Whether conscious or unconscious, it can even be a way to test the therapist’s reactions and boundaries. “If I think she’s judging me, at least the session is over and I can get out of there.” “Will she extend the session longer than normal if something big comes up with only five minutes left?” “Will she remember this for next time, even if I say it at the very end?”

This can be exasperating, funny or even scary for the therapist, depending on the statement. While each response needs to be tailored to the client and their needs, when there are no safety issues, I often let my client know that I think it is an important topic, thank them for brining it up, mention that we don’t have enough time to discuss it today, and explain that since it is so important, we should start with it next time. Then I make sure to start with it next time. If this becomes a pattern with a client, I will point this out, see if we can explore why important things don’t come up until the end, and find ways to address it.

In addition to my private practice, I also work at the health and counseling center of a large university. In a college setting the doorknob not only happens at the end of a session, but also to the end of the semester, the December Doorknob. For most of the school, the last few weeks in December are a ghost town. Students hand in final projects, sit for exams and then get the heck out of there. It’s a time for faculty and staff to finish grades, reflect, plan for next semester and maybe clean off their desks, if so inclined. But right until the last day, my colleagues in the counseling center are humming along, business as usual. We even have intake appointments the week after final exams are over, with students coming to share all the difficulties they’ve been having this semester on the day, or even morning before they head home for a three week break.

The most memorable December Doorknob this year was a client who came in for an intake appointment hours before she would be leaving for home for winter break, and three weeks before she would be leaving for a semester abroad. I could not help but feel frustrated, wondering why she waited until the last minute, wondering what she expected me to do for her in a one-shot appointment. After some reflection, I had to admit that a great deal of my exasperation came from my own sense of helplessness. Knowing that our work together would not continue, and the entire therapeutic relationship would consist of only 45 minutes, I didn’t feel there was anyway I could help her solve her problem, or make any changes. But it was the client herself that helped me remember how therapeutic even getting through the door can be explaining, “I promised myself I would come in and tell someone about this before the end of the semester and I wanted to keep that promise.” In that moment a December Doorknob takes on a different symbolic meaning, it becomes a fulfilled promise, the start of change, opening a new door.

As the year draws to an end, what are your doorknobs? What it that thing you keep meaning to do? What do you need to say? What is the promise you made to yourself? Instead of waiting for the new year to make resolutions, to put off making changes until the calendar changes, put your hand on the doorknob and turn.

A Case of the Sundays

Recently, a college-aged client who has been dealing with homesickness told me he found a part time job at a small hardware store. He worked at one after school and on weekends throughout high school, and the job is a nice reminder of home. The narrow aisles crowded with lightbulbs, extension chords and paint buckets filled with screws are familiar and comforting. When I expressed concern that he might not have enough time to study, he reassured me. “It’s just one evening a week and on Sundays. You know, because Sunday is the hardest day.”

Sunday is the hardest day.

I’ve heard this sentiment many times from clients, regardless of their demographic or issue we were working on in therapy. Whether unemployed or working, single or partnered off, large social network or isolated, everyone is vulnerable to what I refer to as, “Coming down with a case of the Sundays.” Writing this post on the Sunday at the end of Thanksgiving weekend, I can feel it a bit myself. It’s is the feeling of dread that the weekend is almost over, even if there is still a full day left of it to enjoy. It can be the self-judgment that you did not get enough done around the house, in the yard, or on your dissertation. It can be as complicated as loneliness exacerbated by the misconception that everyone else is strolling the streets of your city’s trendiest neighborhood, drinking a latte and holding hands with their new lover, or as simple as the anti-climax of a great weekend drawing to a close. A case of the “Sundays” is when your negative emotions, whatever they may be, pull you out of the present, and prevent you from enjoying the end of the weekend.

For some the “Sundays” are a product of anxiety, and start creeping in just before bed, the “Oh God!” feeling as you are running down the to-do list for Monday morning. For others it is a depressed feeling right when they wake up Sunday morning, that the day will drag on, that there will be no one to share it with. Whether it is a day dedicated to church, rest, brunch, football, or dinner at grandma’s, Sunday is supposed to be different, special. There is a great deal of external pressure to enjoy Sunday, and when we don’t we feel even worse. We judge ourselves, saying things like “What’s wrong with me? Why can’t I just relax? Why don’t I have anyone to spend the day with? How did I let the weekend slip by?”

If you’re lucky, this feeling only comes up once in awhile, but if it’s every Sunday, it warrants some exploration. Do you have unrealistic expectations of your weekend that you need to let go? Are there Sunday traditions, like watching your daughter’s soccer games, that need to be replaced or reworked because your children are grown up? Were you raised going to church every Sunday and now don’t know how to replace that sense of community you felt every week? What is it about the upcoming week that is bringing up the dread? Can you make it go away? If not, can you make it have less power over you? There are so many areas you can explore to help you learn how to take back Sunday.

I used to refuse all invitations for Sunday evening activities, even if it was something I really wanted to do or with people I really wanted to see. My rationale was, that with my busy and stressful work week, I wanted to “start the week off on the right foot.” My plan for Sunday evening was to pack a healthy lunch, plan my outfit in advance, and get a good night’s sleep. But after a few months of feeling anxious starting around 7:30 PM, tossing and turning the whole night, spending most Monday mornings sleep-deprived, and wearing an outfit I really didn’t feel like putting on that morning, I realized planning the perfect Monday morning had too much power over me, and was giving me a bad case of the “Sundays.” I was wasting too much time planning and was missing out on being. Now whenever possible, I meet friends and play trivia Sunday nights. It’s not a monumental change and it doesn’t make my work week any less busy, but it keeps Monday morning to Monday morning, where it belongs.

Just Because You Can, Doesn’t Mean You Should

In a recent session a client expressed both concern and frustration with her social life. With a history of depression, she was worried that her lack of motivation to go out on weekends, her decreased interest in partying, and resulting social isolation might be warning signs that another depressive episode was starting. After going over details of her day-to-day functioning, trying to find recent changes, or identify any red flags, she reminded me that she is working 30 hours week and taking a full-time student course load of four classes. She is spending twelve or more hours a day out of the house, schlepping from home, to work, to class, to the library and back home, to wake up and do it again the next morning. Rinse and repeat.

By the time the weekend arrives she is exhausted, looking forward to lounging around in sweat pants, catching up on chores, and sleeping in. However, she expressed concern that she isn’t living the vibrant social life expected of an early twenty something. When I remarked that her schedule didn’t sound sustainable or healthy, let alone enjoyable, and that I thought the lack of motivation to socialize could simply be because she is tired, not depressed, she was skeptical. Initially she hadn’t even thought of mentioning her schedule because it was nothing new, and since it was something she was used to, she didn’t think it should be a problem. “I have been doing this for the past two years. It’s not like I can’t do it.”

Fair enough. She has been getting good grades and positive feedback from her work supervisors. Nothing is falling through the cracks officially, but she’s cranky, tired and doesn’t feel like her life is any fun. Surviving is not the same as thriving. Which is why my response was, “Just because you can, doesn’t mean you should.”

I think we all do this at some point – we put ourselves on a treadmill that we don’t know how to get off of, or push ourselves past a healthy limit because we don’t know how to say “no”. Sometimes we don’t know something will be bad for us until we are knee deep in it, and then it’s hard to get out without a “real” reason. Don’t get me wrong, at times it is good to test our limits, to push ourselves to see what he can accomplish. It’s not always a bad thing to see what you can do, rather than stick with a terrible status quo simply because the unknown is too scary.

The important thing when deciding between a can or a should is to ask yourself why. Are you trying to prove something to yourself? Trying to get someone to like you? Do you have an unhealthy need for a thrill? Did your parents teach you that it’s important to see something through to the finish and that’s a value you won’t abandon, no matter what? Are you afraid that if you change something, you’ll feel like a failure? Trying to keep your schedule so busy so that you don’t have time to notice you’re unhappy in your relationship? I could go on all night.

Getting to the why is the important part, where the therapy truly begins. Getting insight into behaviors, decisions, and emotions is what the work is all about. It makes the difference between surviving and thriving, and answering that one word question completely and honestly can help you decide if something is a can do or a should do.

Making Room

At the end of September I had the opportunity to attend a week-long seminar on mindful eating at a yoga facility in the Berkshires. The seminar was personally and professionally transformative, the setting was beautiful, and I plan to share and reflect on the experience repeatedly in this blog. The highlight of the experience was the interaction with other dedicated professionals in the mental health, nutrition, eating disorders, meditation and medical fields. It can be rejuvenating and inspiring to hear others talk about your field, from the practicalities of how they run their business to the philosophies that keep them excited about the work.

While in the gift shop/book store on one of the last evenings, a therapist I spent a good part of the week with was, at my request, making recommendations for my further reading, by pulling books related to eating disorders, mindfulness based mediation and psychology off the shelves and handing them to me. I’ve always been a sucker for books, so I walked out of the shop with a large pile. One of the books I purchased was When Food is Love by Geneen Roth and because my friend had gasped with delight, held the book to her chest before handing it to me and saying, “I loved this one,” I started reading it right away on the bus back to Boston and finished it in less than a day.

Roth has written a number of books on compulsive eating and women’s relationship with food, She made a name for herself with her book Breaking Free from Emotional Eating and its accompanying workshops. Roth writes from a personal, spiritual and reflective perspective, and helps readers explore their relationship with food on a much deeper level than weight or body image. Whether you have compulsive eating behaviors, bulimia, or have been on a diet, Roth’s books are worth reading. Roth captured me very early in When Food is Love:

“As I began spinning a world in which there were only two players, food and me, my capacity to be affected by other people diminished greatly…As long as my attention was consumed by what I ate…and what my life would be like when I finally lost the weight, I could not be deeply hurt by another person…When I did feel rejected by someone, I reasoned that she or he was rejecting my body, not me, and that when I got thin, things would be different.”

I cannot count how often the sentiment comes through in my work with women, and not just those with eating disorders. Life becomes about being on a diet. Identity is “Dieting.” Things like going to the beach, getting a message, having sex with the lights on are put off for “When I lose weight,” as if those activities are only reserved for women of a certain size and the only activity you are currently allowed is “dieting.” This world becomes very specific and very small.

Having an obsession, in this case food, shelters you from the truth. The truth could be a trauma history, an unhealthy relationship, an unspoken fear, anything. But instead this very important thing gets played out as being unhappy with what you eat, how much you weigh, and dieting becomes the distraction. Diets keep us focused outside of ourselves, allow us to ignore bigger questions about our values, what we believe in, how we make meaning in our life, the kind of woman we want to be, how we will connect intimately.

“It is not possible to be obsessed with food or anything else and to be truly intimate with ourselves or another human being; there is simply not enough room.”

Not enough room…

If you talk with someone diagnosed with anorexia or bulimia about how much time they think about food, the answer is usually, “All the time,” or “I don’t think about anything else.” When a client tells me this, I ask them to imagine what it would be like if they had all that time back, how much they could do with that space, and where they would transfer all that attention and energy. For some this idea is liberating, others terrifying. For a small group of clients I’ve asked, this question is ridiculous. They are so stuck in their current obsessive state that they can’t even imagine this possibility. Their world has become too small and there is not enough room for anything else, even fantasies.

For the rest of us, though, we can acknowledge that an unhealthy relationship with food, hating our bodies and an obsession with dieting are taking up too much space. We can make more room. What would you do if you had more room? I’m not talking about more time in your day to add in another chore, nap, phone call to your grandmother, or any other “should” you think ought to do. I’m talking about more room in your heart, head, emotions. Would you be more creative? More energetic? More successful? More fun? More interesting? Would you feel more love or gratitude? Would you find it easier to forgive? Would you finally be at peace with yourself? Would you be able to let someone in, allow yourself a closeness with someone else deeper than anything you’ve ever had?

Imagine the possibilities.

To Skype or Not to Skype- Part Three: My Reflections

I was pleased to see the article, “When your Therapist is Only a Click Away,” in the style section of The New York Times this week, highlighting clients and clinicians who use video chat for therapy sessions. I was excited because it made me feel trendy and cool, but more importantly because it shows that there are people out there thinking and talking about the issue.

In my last post I was able to share what I learned about the legality of video chatting a therapy session, explaining what I can and can’t do according to the law. While learning the law was the vital first step (that took about twenty sub-steps), I also did a great deal of additional reading and reflecting. Knowing what I can do got me thinking about what I should do, which got me thinking about what I would want to do.

Here’s What I Think:

Skype or other forms of video chatting can be a great way to provide individual or group psychotherapy to people in rural or remote areas, where access to clinicians is very limited, or where weather can make travel unsafe or impossible. Video chat can also be an ideal way to reach a client whose diagnosis, like Agoraphobia or PTSD make leaving the house or traveling to your office too anxiety provoking.

However, I don’t think video chatting should replace therapy sessions just because it would be more convenient. One could argue that the client is a consumer and we should cater to their needs, it’s their hour to use how they wish, or that for a busy client it’s better to have an on-line session than no session at all. But what about self-care, prioritizing yourself and that one hour a week you designate for therapy? What about having a time and place where you can get a break from the outside world, stop multitasking and dig deep into yourself to reflect, discuss and develop insight into your mood, personality and behaviors? In my opinion, for psychotherapy to be as successful and helpful as possible, both clinician and client need to be giving the session their 100%.

In the Times article they highlight a client sitting in a lounge chair by the pool and sipping a cocktail during a session. The same client discusses how great it is that she can take a break from a shopping trip to have a session. For me these scenarios raise red flags. First there is the boundary issue. If you are drinking cocktails, cooking dinner, or shopping during our session, there is a very high chance that you are going to forget my real role in your life. We are not friends or drinking buddies. I don’t give you advice, compare your experiences to mine, or share my personal issues with you like I do when I am out to dinner with my friends. Those choices are intentional, with the goal of allowing you to feel comfortable sharing your concerns without feeling like I will judge you, without worrying how your problems will impact me, and without wondering if my comments have an ulterior motive. In my work, I like to be accessible and approachable to my clients while maintaining boundaries.

Here are a few ways I conceptualize Skype’s place in individual therapy: Two feet of snow last night and the city hasn’t yet plowed your street? Yes. Raining and you don’t want to go outside and ruin your blow-out? No. Stuck in at the office because you left the lights on in your car all day, the battery is dead and you need to wait for Triple AAA? Yes. Stuck at work for the fifth session in a row because you don’t know how say no when your supervisor asks you if tonight is an okay night for you to stay late at work? No.

How I Plan to Translate My Reflections into Practice:

I plan on using Skype as an adjunct service available to clients I already see for in-person sessions. For example, if a client would like an urgent appointment for support or to discuss an unexpected issue, like a break-up, getting into a car accident, or a family member having unexpected surgery, and we can’t find a time at my office that works for us, I am comfortable using Skype. I will also be using Skype as an alternative to last minute cancellations, when getting to the session is just not possible, but a client still has the availability to meet privately for an hour. For example, if a nor’easter blows into Boston and it would be unsafe for the client or myself to travel I would use Skype. I would also consider using it for short term support while a client was dealing with a health issue, such as home recuperating from surgery, and unable to walk or drive.

Before I roll out this feature, I need to purchase a high-quality webcam for my desktop, if possible, one with enough resolution to allow me to recognize details such as blushing, sweating or shaking hands. I also plan on creating a separate informed consent document and treatment contract for clients who work with me in this way. I see the need for us to sign an agreement including things like, “I will never sign off or abruptly end the session intentionally,” and “I agree that neither party will record the session,” and to decide together how we will negotiate “eye contact” whether we will look at the camera or at the other person’s face on screen.

I will not work with anyone exclusively over Skype, nor will I use Skype sessions with people who are currently having thoughts of self harm or have any history of suicide attempts or psychiatric hospitalizations. There is just too much risk that a client in distress could log off before I am able to act to keep them safe.

I plan on charging the same rate and conducting my Skype sessions exactly like I would an in-person session, and I expect my clients to do the same. I will wear pants, sit in a room where privacy can be maintained, and do nothing else, except attend to the session.Whether or not we are in the same room, our work needs to be the priority for that hour.

Integrating technology into psychotherapy is both exciting and scary. As with any clinical decision I feel I have done my best to explore the clinical, legal and ethical questions, and can make an informed choice for my practice as a result. I may love this approach or I may hate it, but as with anything new, I can’t know unless I try.

To Skpe or Not to Skype- Part Two: The Legal Verdict

When I last posted, I was in the midst of an learning if I could legally provide psychotherapy ACROSS STATE LINES (I just felt the phrase needed caps for dramatic flair) via Skype and deciding if I should. My apologies for leaving readers hanging, but this question became much harder to answer than I ever imagined. Like any innovation, developing technology, or emerging field, there is little regulation and a lot of opinions.

My Google keyword search for “Skype therapy,” “psychotherapy video chat” and “online therapy” had me going in circles until I stumbled upon the word “telepsychiatry,” which then lead me to the Center for Telehealth and E-Health Law. CTeL (www.ctel.org) is a nonprofit in DC whose mission is “To overcome the legal and regulatory barriers that impact the utilization of telehealth and relate e-health services.” Jackpot! I had a chance to consult with Christa Natoli, a Harvard Law grad, who felt like a breath of informative fresh air after days of useless internet searches.

Christa explained that like our good-old Constitution, statutes are written to be flexible, and to allow room for interpretation. She explained that my specific question, “Can a social worker in Massachusetts provide therapy via video chatting to a client in Virginia?” would not be found specifically written into law and that I would have to be left interpreting something much more vague. First rule of thumb is that doctors must be licensed to practice medicine wherever the patient is. As Christa said, “If your patient is on the moon, then you must be licensed to practice on the moon.” However, things get a little confusing here, because laws pertaining to telehealth and e-health usually talk about practicing medicine, and no surprise, don’t specifically write social workers into the language of the statute.

Since licensing for social workers is regulated by states, it is the state that determines the “jurisdiction,” which means, the state (or commonwealth in my case) decides if treatment is happening where the clinician is or where the client is. Not many states have considered it enough to make laws about it. For example I now know that California believes social work treatment happens where the client is, so you must be licensed in California, whereas there aren’t any laws on Virginia that touch on this issue in anyway. When the state you live in or want to treat someone in doesn’t address the issue specifically, Christa told me it is best to go with the legal interpretation of your professional organization, in my case the National Association of Social Workers. Then she blew my mind, actually contacted the NASW legal counsel for me, and told me that….wait for it….. the NASW believes that a social worker needs to be licensed to practice in the state that the client is in to be practicing legally.

And there it is. Even if states don’t address this law, the folks who issue my license do, and I’m going to let their opinion make the decision for me. I will not provide Skype to clients who are not in Massachusetts, where I hold my only social work license. Should I ever move, or decide on a whim to hold multiple licenses from different states, I’ll reconsider.

Since I was on a roll getting Christa to answer my questions I asked her about within my own state. She told me I was good to go if I could answer yes to two questions: 1. Do you have a preexisting relationship with the client/patient? 2. Will your telehealth interaction meet the appropriate standards of care? As far as question one goes, I figured one is in the clear with an in person intake in one or two sessions. The second question came down to ethics, the rules of conduct recognized by my profession, social workers.

I contacted the NASW MA Chapter’s Ethics Committee and requested a consult. This is a great service, by the way, where a group of seasoned clinicians working a variety of social work jobs meets twice a month to discuss any issues brought to the committee. The service is free to all NASW members, but they don’t require that you give all your personal information if you’re not comfortable. Instead of staying up late at night wondering, “Could I lose my license by doing that?” or “Would other social workers think I’m crazy for doing this?” you can just call them and ask. The turn-around time is about a week or two, so that the committee members have a chance to review, conduct any necessary research, and discuss before providing consultation. Worth the wait, because one way to protect yourself from malpractice is to consult with colleagues and seek peer supervision when you have a question. One of the members called me back to let me know:

1. The NASW does not have any existing guidelines regarding video conferencing, “But it probably should.” That was a direct quote, by the way. 2. Committee members had all heard of and seen increasing numbers of clinicians using video chatting, so I would not run the risk of being a social work maverick. 3. The committee thought I should consider creating extra consent forms, addressing specific web-based confidentiality and informed consent issues. 4. They advised me to choose clients wisely when using this medium, especially to avoid clients with a history of suicidal ideation, previous suicide attempts or other unsafe or impulsive behaviors 5. They wanted me to keep in mind that, depending on the quality of a the web-cams used, important information about affect, such as blushing or sweating might not be as observable as it would be in person.

Good advice that I will certainly follow. I was disappointed, but not surprised, to find that National Association of Social Workers has not yet established formal guidelines regarding Skype, video chat or other web-based treatment. As a profession, social workers are leaders in civil rights, social welfare, policy development and advocacy. However, in my opinion, we are woefully behind when it comes to using technology, whether to assist us administratively or to market ourselves. As the ethics committee member mentioned, “they probably should” start creating guidelines for this communication tool that is not going away.