Category: Therapy and the Internet

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.

To Skype or Not To Skype- Part One

I recently received a phone call from a former client in distress. We met for almost two years and ended our work together a few months ago because he was finishing his graduate program and moving out of state for a fellowship. It was good timing. He had been doing well emotionally for months, had transitioned off of medication with very little trouble and stayed stable, we had been meeting less frequently as a result and the upcoming move involved a great deal of excitement and happiness. He would be doing a prestigious fellowship at a well-known hospital and would be moving in with his partner after six years of long distance. As far as terminations (the therapy word for ending treatment) go, this one was a “web-gem.”

When he called last week, he was a few weeks into his fellowship, feeling very overwhelmed, afraid that he could not “cut it” in his program, was paranoid that he would make a mistake that would hurt a patient, was having trouble falling asleep, was waking up repeatedly throughout the night, and was having ongoing chest tightness. Not his best day. At the start of our conversation he stated he felt like he did when we first met, like all the work we had done flushed down the toilet and that he was back to square one. I disagreed. While he was most definitely having a flare-up of anxiety, which is pretty normal when someone with a history of anxiety makes a major change, he was not at square one. I reminded him that while physical and cognitive anxiety symptoms had returned, the coping skills (taking medication, regular exercise, talk-therapy, positive self-talk) he developed and used in the past were still in there, he just need to be reminded to use them. We discussed options, which included the possibility of finding local providers and resuming medication or talk-therapy. He was open to the medication suggestion, but was reluctant to find a new therapist,  “I’m not sure I want to start over with someone else, that I could connect with someone like I did with you. Maybe we could do phone or video sessions over Skype?”

Hmm… Maybe we could do sessions over Skype? Prior to this phone call, I had met a few clinicians personally and discovered many more on-line who conduct sessions via Skype, using the video conferencing feature. I found the idea interesting, but did not consider trying it myself. When my former client suggested it, I began more actively entertaining the idea. Could we do video sessions via Skype? More importantly, should we?

The issues of ending work with a particular therapist because of moving away or moving on,  client attachment issues, boundaries in the therapeutic relationship, ethical concerns, transference (the unconscious feelings in the client that are brought up and projected onto the therapist) and counter-transference (the unconscious feelings brought up within the therapist) all needed to be considered in this decision. I would do that, but before deciding whether or not I should provide psychotherapy using video-chatting over the internet I  needed to find out if I could. What are the laws for social workers providing therapy via internet video chatting? Are there any? Federal? State? What does my licensing board think?

So I began to research, like the good student that I always was….. and then I fell down a legal and internet rabbit hole, involving MA and VA social work licensing boards, the National Association of Social Workers (NASW) legal counsel, the NASW Massachusetts chapter’s ethics committee, and a non-profit called the Center for Tele-Health and E-Health Law. I got a few answers, still have a few questions unanswered and was left to ask myself even more questions.  I’m going wait for a few more folks to call me back, let all the new information marinate in my brain for a few days, make a decision and then post again. Stay tuned……

“Being An Adult”- Part Two

As I mentioned in part one of this post, I believe a big part of being an adult means doing things you don’t want to do. That means sucking it up and finding the motivation you need to get things done.

A good old dictionary.com search for “motivation” comes up with “to provide with a motive; incite; impel.” Digging deeper, the word motive  is defined as “something that causes a person to act in a certain way, do a certain thing.” The origin is linked to medieval Latin for “serving to move,” which is the part of the definition I find most helpful, providing the visual concept. People who are motivated appear to be in motion, convey a general sense of movement. They set goals, meet them, and do it all over again the next day. Sometimes the motivation is internal sometimes external, but often not related to a positive feeling. Fear, anxiety, the collection agency, the approval of others, and vanity all get some people to do things that are not intrinsically fun.

How do you become one of those people? What does one do about those day to day motivation struggles like flossing, finishing thank you notes after your wedding, or calling your grandma more often, like you promised? The basics are nothing new or mind blowing: set small and  measurable goals, track your progress, have someone or something to which you hold yourself accountable, reward yourself when you meet a goal. BLAH BLAH BLAH. We’ve all heard it all before and it sounds like a great plan, and we’ll get around to, but maybe later, because So You Think You Can Dance  is on right now, and we had a long day at work and besides, we’re grown ups and we want to do what we want to do, when we want to do it. So there. However, if your looking for a gentle nudge, coaching or a little forcing, there’s always the internet.

Most of the time people make resolutions or set goals related to losing weight or getting in shape. If that’s your goal, there are a gazillion women’s magazines, websites, and companies out there where you can log on, set goals, chart progress and feel alternately good and bad about yourself depending on the day. I decided not to research weight loss specific on-line tools for this post because I’d rather not fall down that rabbit hole on a Monday in the middle of the summer, nor do I want to drag you down there with me either. Instead, I decided to set a goal for myself unrelated body image and be the guinea pig. My goal was to “actively blog” and since that’s too vague, I quantified it as writing one new post a week. SPOILER ALERT!!!! It’s Monday night and my last post went up last Sunday, so you can guess how I did so far, but I’m not giving up that quickly on my dreams. Better late than never. Here’s what I found:

stickK (stickk.com)
After years of unsuccessful attempts, an econ professor at Yale decided to really get serious about his health and loosing weight, so he decided he would pay a friend $500 a week every time he failed to get closer to his goal. The contract continued when he met his goal, focusing on maintaining a healthy weight.  It worked for him because loosing 500 bucks a week was pretty painful, as it would be for most of us. He then decided to take this idea public and created an “online commitment store,” stickK. At stickK you sign up, set a goal, decide how much money you will loose, and pick a referee who checks up on you. You can donate your money to charity, which will randomly donate to a list of charities stickK supports. To make loosing even more painful, you can donate to an anti-charity, one’s who’s mission you don’t support, like the NRA or Planned Parenthood, depending on your politics. You also have the option of giving money directly to a “friend or foe.” I went with the no money down option and was reminded by a pop-up that putting money on it DOUBLES (their caps, not mine) my success. Basically it was a nice way of saying, “Are you really that serious about meeting this goal if you’re not willing to throw down the cash?” Touche. While I did not meet my once a week goal, I did get an email from stickK this morning, telling me to fill out my first “report” which will go to my referee. My referee then tells stickK how I did. I lied on the report and said that I met my goal, with the hopes that I would finish this post before my husband (my designated referee) checks my blog to verify. So although a day late on my goal and with a new lying habit, the report card and time crunch pulled me off of facebook and back to editing this post.

HassleMe (hassleme.co.uk)
The most humorous of all the sites I explored is HassleMe. The site’s tag line says it all, “Because sometimes in life you just need to be nagged.” You simply write in your “hassle, ” give them your e-mail and tell them approximately how often you would like to get a nagging e-mail related to your goal. The idea is that the site will be unpredictable with the timing of the e-mails so that you are annoyingly surprised. It is very easy to sign up and  beautifully simple. You can also put in your husband’s, teenager’s or roommate’s e-mail address and nag someone else about getting something done. I once had a client who put a sticky note on her husband’s mirror, reminding him to tell her that she is beautiful. This would be the digital equivalent. The website is also really entertaining, as it lets you read other people’s hassles (anonymously of course), which can be hilarious. I loved this feature, but it was basically anti-motivation, giving me yet another internet procrastination destination.

What fascinates me about stickK and HassleMe is that they go against basic behavioral treatment theory. The first and only thing I remember from the one day I studied behavioral therapy in social work school, is that rewards work better than punishments. Both sites actually operate against that theory, getting you to act to avoid punishment. StickK uses negative punishment, taking something you like (money) away from you, while HassleMe goes with positive punishment, giving you something painful or annoying (spam) until you change. Not sure how the sites are tracking their “success rates” but they could be challenging years of behavioral treatment theory.

Mint.com
Because financial savvy is both sexy and trendy, I wanted to be sure to include a site that helps with money management. Purchased by Intuit, the company that makes Quicken, around 2009 (proving the best way to beat your competition is to buy them), Mint.com gives you a web-based, free, money management system. You can’t see what Mint does until you log on, which means you must give them your bank account and credit card information right off the bat. Since my e-mail account was hacked the same day I started researching the post, there was no way I was doing this. However, a good friend who loves the site and was comfortable enough to let me see all of her financial information, walked me through a webinar, showing me her account.  If you take the leap of faith and let them have access to all your accounts, Mint tracks, categorizes and charts your spending for you. It will group expenses into categories like food, clothing, entertainment, and pet care.  You can also use it to help you set goals, like saving $200 a month, and it will track your efforts with a bar graph as the month progresses. Green, yellow, and red indicators tell you how close you are to going over budget on each category, and provide a nice visual. Because Mint is free it is ad supported, and the ads are cleverly disguised as financial “advice.” If you click on a link that says, “Learn more about controlling your credit card interest rates,” you will get an ad for a new credit card. Once you know that “advice” really means “advertisement” you can avoid them completely. There is no messing around on Mint; no underestimating how much you spend on cocktails last Friday and no denying that you bought a pair of Spanx off of Amazon your lunch hour. Like Santa it knows if you’ve been bad or good, down to the penny, and in pie chart form.

Hope that gets you started down the path of healthy life changes. Now put down that Ho-Ho and get back to the library.

BLOG?!?

I know, I know! “A therapist blogging!? Really!? Does she know what she is getting herself into?!!!”

I’ve been asking myself the same question since I set up my website. The ultimate goal of laurenschiffertherapy.com is to give current, potential and past clients a way to find out how to contact me, answer quick and easy questions they might have about working with me and get a general sense of how my private practice operates. Initially it was meant to only be a website, like any other business would have. However, the site host offers this handy blog feature and I was intrigued. Then I read this article by Keely Kolmes, PsyD, on psychotherapy.net, was even more intrigued and a bit inspired: A Psychotherapist’s Guide to Facebook and Twitter: Why Clinicians Should Give a Tweet!

My blog is intended to be a place where I share information about what I am doing professionally,  such as articles I’ve recently read, continuing education courses I’m taking, or my thoughts on current events in the behavioral health field. I will not be discussing clients and I will not be discussing my private life. The blog is intended, like my website, to give current and potential clients a general sense of what it would be like to work with me and a glimpse into my professional style and clinical approach.

It’s important to me that readers know this blog IS NOT therapy.  While the internet is a powerful tool for sharing information, it is not a substitute for treatment and should not replace direct medical, psychiatric, or psychotherapeutic care. This blog should also not be a substitute for treatment. It is BY NO MEANS my intention to dispense therapy via the internet. Reading my blog doesn’t make me your therapist and commenting on posts does not make you my client. If you are interested in working with me in individual therapy, that is through face to face sessions in my Cambridge office, please see the “Scheduling and Payment” section of my website.

Phew! Now that the dramatic part of this post is out there and it is clear what this blog is not, I want to end with a quote from Dr. Kolmes above mentioned article, which motivated me to add the blog feature to my website and describes my philosophy about therapists and their professional on-line presence better than I could myself.

“I see one’s professional online identity—so long as the interactions are professional and not personal—as a form of community outreach. I have compared it to working in a college counseling center and then visiting a class that your client may be a student in, such as when a community event affects the campus and you provide information or do a presentation. Sometimes we are visible in the community as mental health professionals and clients may see us acting in this role outside of therapy sessions. An online professional presence can be similar. Some of us are teachers, writers, and lecturers, as well as clinicians. This is our professional life. Perhaps we do not have to exist in a vacuum, only functioning as clinicians in our therapy sessions. Existing online does not have to mean we cannot hold the frame with our clients, nor does it have to mean we are incapable of boundaries or talking about the effects of our online visibility on clients, when necessary. But we are going to have to develop tools and systems to learn to take care of boundaries in new ways and be present to talk with clients about the effect our online lives have on the clinical relationship.”   -Keely Kolmes, PsyD http://www.psychotherapy.net/article/psychotherapists-guide-social-media#section-personal-vs.-professional-space