Client-centered Therapy eTherapy How to

Ten Things To Make You Whistle While You Work

Congratulations! You survived Labor Day Weekend, and off to work you go! After posting for the umpteenth time, “I love my work!” to my various Social Media platforms, I realized I had a blogpost bubbling up inside of me. Do you know how many hours of your life you’ll spend in the world of work? Someone did an average calculation for you on

A man expected to live to age 78 will have lived a total of 683,760 hours (counting 20 leap days). If he starts work at age 22 after college, works 37.5 hours per week until age 65 with three weeks vacation per year, he will work a total of 106,575 hours during his lifetime, or roughly 15.5 percent of his life.

You too can whistle all the way to work with these tips to keep it happy.

If you are in a startup, work a corporate job with long hours, have an entrepreneur position on the side, or combine business travel with leisure, you can see how some people will work more than 20% of his or her life. Adding on the fact that many people are financially unprepared to retire at age 65, work ends up being a quarter of your life spent. In light of this, here are my top ten things you can do to make you whistle while you work.

Ten Things To Make You Whistle While You Work

1. Select and stay in jobs that allow you to do what you love. As a job evolves, pay attention to if and when it morphs into something you do NOT love. If you have the choice and means to change your job, do it.

2. Know when a job isn’t worth staying at, and have an exit strategy. When you can’t figure out the benefit of staying, carefully plan your exit strategy, including money saved for time off, a few month’s rent or mortgage prepered, and lining up another job or return to school for more education.

3. Consider eating healthy part of your work day. When the job is great, eating healthy makes a difference to the enjoyment of the world of work. If you eat alone, try eating with others once a week. If food is greasy or fatty, look into higher fiber and lower fat options that keep you satisfied but not sleepy.

4. Don’t sit all day. Last time I checked, our bodies were not made for sitting all day. Plan in times to stretch, walk, stand, or even lightly exercise during breaks. [I am a big fan of air squats and crunches, thus the yoga mat stored in my office].

5. Shorten or change your commute. If driving makes you batty, look into rideshares, public transportation, or working flexible hours that move your commute out of the worst times of day. [My commute is short, but I recently added bicycling to work for a change of pace].

6. Make it social. Many employees note that one of the most satisfying elements of their work are the friendships made. Lost friendships is also a common complaint when people either lose their jobs, retire, or resign. Where appropriate, get to know other employees on a more social level.

7. Take your vacation, and use sick leave appropriately. Sometimes a “mental health day” is a good choice! Just know you can’t declare your need of one in the midst of a big company project or deadline. Sit down with your calendar, loved one, and a list of “black out” days, and plan ahead.

When you are sick, you are… SICK. I have watched sick clients drag themselves to work, exhausted, worthless in terms of productivity, and primed to share their virus with others. I admit that I’ve seen and experienced this first hand in medical clinics, and the risk is severe. Last year’s flu season, while late, was very long. If you’re sick, stay home. Don’t teach your brain to associate work with the sacrifice of your health and risk to others.

8. Use your benefits. If you don’t have any, set aside money from your paychecks for the express purpose of paying for services you need to feel good. Benefits may include chiropractic work, massage, acupuncture, and behavioral health visits.

9. Transition to and from work. If possible, listen to music, refrain from jumping into work from home, leave house woes at home, and limit personal conversations to breaks. Give respect to your body: it isn’t a pinball machine. Gentle and gradual transitions work better than abrupt changes.

If you work from home, be creative about creating transitions and marking off workspace that identifies when you are working and when you are not. While working from home can be enjoyable, it also has its downfalls. For a humorous look at the perils of working from home, check out Matt Inman’s adorable comic on the subject.

10. Grow with your job, and become a life long learner. Anything missing along your job path? Are there goals at the end of your work path that would help you feel a sense of achievement and satisfaction if they were met? While you may have done your job for 5,10, and 15 years, it may not be too late to add other dimensions to your work.

One change I am looking forward to: becoming a supervisor to another emerging clinician. Recognizing my love of teaching, writing, and mentoring, I’m going to be earning my CEU’s to beome a state-approved supervisor. I’m also working on a book, and preparing to become a speaker on a couple of topics for CEU courses in my field. By adding on, my love for my work continues to grow, and my investment in others gives me a sense of accomplishment and satisfaction.

What makes you whistle while you work? Feel free to share your comments, or send an offline response to for anonymous posting.

Counseling eTherapy Health care How to

How To Pay For Therapy Sessions

by Imei Hsu, RN, MAC, LMHC, RYT

How To Pay For Therapy Sessions

Going to psychological therapy sessions for the first time can be a little unnerving. But if you know you (or a loved one) really need to get a jump on some challenging issues, you’ll need to contact a therapist. Part of setting up your first appointment involves some important decision-making about how to be financially responsible for payment. While paying for services rendered should be a piece of cake, many of you know that paying for medical services isn’t always straight-forward. How many of you have whipped out your insurance card for a medical visit, only to receive a bill with unexpected charges a few weeks later? The more you know about how you will pay for your therapy sessions, the more satisfying your experience.

Using Health Insurance

Get the skinny on paying for counseling BEFORE your first session.

lIf you find using your employer’s health insurance benefits for outpatient medical visits to be confusing, you’re not alone. I have many corporate clients who breathe a sigh of relief when they tell me, “I really don’t know how my insurance works.” These are intelligent people. Often times, understanding their benefits doesn’t get but a few moments of explanation during new employee training. Retrieve your employer’s benefit material, and start looking for medical benefit coverage. Also, have the insurance company’s customer care phone number ready. You might need to make a quick call.

If your employer offers benefits that include outpatient mental health (a.k.a. behavioral health visits), find out how many sessions are covered. While the State of Washington has a parity law requiring health insurance companies to allow participants the same number of medical visits as behavioral health visits,  that doesn’t mean all your visits are fully covered. For example, a company covers your first six visits with a low copay. After the first six visits, the subscriber must meet a high deductible in the calendar year (let’s select $2500 as an example). After the client has paid out-of-pocket the deductible (about 23 sessions on average), the insurance kicks back in at 70% (client pays 20%). For many subscribers, that deductible looms on the horizon. But for therapists who accept insurance payments, it places them in a difficult position. We have to explain to clients that six sessions is not going to solve problems that might have taken years to develop. Yet, we don’t want our clients to terminate too early, only to conclude that therapy didn’t “work”.

In other cases, your employer may offer benefits that are more comprehensive, with no deductible, and a low or non-existant copayment per visit. In this case, the client should consider whether s/he wishes to have behavioral health visits on a legal medical record. While it is against the law for your employer to view the contents of these records (because of HIPPA), you should weigh the costs and benefits of your employer (via Human Resources) knowing you have been in session with a licensed therapist, psychologist, or psychiatrist. If you are unsure about what these costs or benefits could be, I highly encourage you to ask a therapist during the consultation period (i.e when you are selecting a therapist).

Paying Out Of Pocket (OOP)

Paying out of pocket for medical services may not be as hard as you think.

While therapists should not run their practices as a charity, we are a compassionate lot. We see first-hand how the economy has affected individuals and families. But when a caller once shouted, “You therapists should be providing services for free!” I bristle. If that were true, we therapists should have been given a Master Degree education for free, books for free, continuing education units for free, and liability insurance for free. While we’re at it, how about a professional office, donated and maintained, for free?

Our services are valuable, and they need to be honored like the services you receive in any other medical office. Some medical offices do provide financial assistance, but that is usually on a case-by-case basis. If a therapist cannot assist you with lower-cost services, s/he may have local resources, or know of an agency that can provide lower-cost services. If s/he can assist you financially, take a moment to understand what is being offered.

* Low income — a sliding scale may be offered in cases of low income. Low income is considered at or just above poverty level. You may be asked to provide a pay stub as proof of your income level. The exception is for students with catastrophic-only insurance, and no outside support from family. Often, low income sliding scales are provided only at state agencies that receive assistance.

* Hardship —  this includes women and children in situations of domestic violence, those in rehab, and unemployment, and chronic transition that has devastated a person’ s finances, such as death of a spouse, job relocation followed by a layoff, and divorce.

*Scholarship — your state may provide money to single women who qualify. They qualify by income, the type of work they do, or the number of people in their household they support.

* Pro bono — a therapist may choose to offer services pro bono when extreme hardship makes even $10 a session hurt.

Traditionally, therapy offices did not provide the means of paying by credit card. Today, more therapists are joining the 21st century by providing credit card services. The one used at Seattle Direct Counseling is Therapy Partner, which remains HIPPA compliant. Others use Paypal, Square, or bank-supported options over the telephone to assist you in paying. Be aware of any Terms of Use with any of these services.

When You Can’t Use Your Insurance

There are some cases when you can’t use your insurance, and these cases are usually stipulated in your explanation of benefits. These may include treatment for sexual dysfunction, biofeedback, alternative therapies, and couples (conjoint) therapy. Additionally, you may select a therapist you really like, only to find out that s/he does not accept your employer’s third-party payer. Things you should know:

*Ask why your therapist does not take your insurance. In the case of my practice, I “fired” or chose not to renew certain payers because the payouts were some of the lowest in the region. What this means is that the payer determined a low value on psychological services, and then either expects the Provider to suck up the cost, or shafts the patient. Sometimes, it’s a combination of both.

*Your insurance benefit has run out for the calendar year. You must decide if it makes more sense to pay for services OOP, or wait for the next calendar year. If you determine your condition or relationship will worsen without treatment, it’s better not to wait.

In this case, clients cannot ask for a sliding scale, nor can they pay at the level of the Payer (i.e. 70%), and expect to continue using the limited benefit at the start of the next calendar year. This is considered a breach of contract with the Payer, and it could result in loss of paneling with the Payer. Translation: the Payer can fault the therapist by declaring his or her billing as fraudulent.

*Conjoint (couple’s therapy) can be billed under individual insurance only when the identified client has a qualifying diagnosis. When the diagnosis code indicates this, your case can be fully investigated by the third-party payer for validity. A therapist can lose his or her contract with the payer (and be accused of fraud) if s/he bills conjoint therapy as individual therapy simply to save a couple money. [At Seattle Direct Counseling, I do not bill individual therapy for couples. If there is an identified client with a qualifying diagnosis, the partner/spouse can be asked to present in the therapy sessions, but the focus of the therapy must remain on the identified client].

Why Your Insurance Might Not Be Accepted

Over the past couple of years, I have purposely chosen not to renew with specific insurance companies, such as Cigna and Aetna. I am currently making a decision to pursue Group Health for paneling.

While I was about to draft a sample letter to clients explaining why I do not carry certain third-party payers, I was sent one from my dentist that explains this beautifully. I have obtained his permission to reprint the letter,in part or in full, to help educate you as to why many therapists are doing the same [a link will later be provided on the website]. What it often comes down to is a compromise in care. When insurance companies determine a low value on our services, it forces providers to increase their client loads. And in my case, I determine pro bono cases when my client load supports the ability to manage a few clients with no ability to pay. While I have no employees and low overhead costs as compared to a medical office, I still have liability insurance and rent to pay, and both of these costs will increase when: 1) my client load increases above a certain thresh hold, and 2) I move to larger office (which will likely happen very soon).

Be Responsible and Proactive With Payment

Therapy practices are not equipped to be used as a bank if you default on payment. Most therapy practices will not charge you interest if you take more than 90 days to pay. It is advisable that you not attempt to keep a balance in an account of what you owe your therapist by promising to pay at a later date. Instead, discuss your means to pay for visits at the beginning of therapy. This discussion is part of the therapeutic process, and it addresses your ability to communicate, relate, and deal with adult issues of responsibility.

If your financial situation changes in the middle of your therapy process, make sure you discuss that with your therapist. I can’t speak for others, but in my own practice, I fight hard to make it work in your favor to continue therapy while being responsible with cost. Many of my clients can vouch for my willingness to help when the going gets tough.

Do you have a question about how to pay for therapy sessions? Have you had difficulty with your insurance company? You can send an offline email to, and give permission to reprint your comment without identifying information, so that everyone can learn from your experience while remaining anonymous.















eTherapy How to Online Therapy Relationships Seattle Therapy Washington

How To Conduct Sessions Online

How To Conduct Sessions Online
by B. Imei Hsu, RN, MAC, LMHC

Note: The following post is for therapists and clients, but I’m writing primarily with the client in mind.

You’ve probably already heard about traditional talk therapy moving to the telephone, a.k.a. teletherapy or telemedicine. The same session you have face to face (F2F) with your therapist is the one you have over the phone, and in many ways, these sessions can be more intensive as the therapist and the client listen carefully to each other is ways that we take for granted when in the same room together. With the advent of popular VOIP (voice over internet protocol) and Internet-based applications such as Skype with improved video quality, many therapists and clinicians like myself have been providing professional counseling and coaching using VOIP clients and Internet applications for video for a couple of years. While it seems like a convenient alternative for almost anyone, you can have a session fail if you don’t know how to prepare for VOIP and online sessions. Here’s what you need to know about successfully conducing sessions online.

Do you know how to conduct a telephonic or online counseling session? (Hint: don't call from a phone booth)

Photo used by permission. 206 Gallery, Pioneer Square Artwalk

After checking with your state or country’s guidelines on Internet-based therapy sessions, a successful online or telephonic session involves these quick and easy steps and considerations:

1. Cover all benefits and limitations with your clinician. Cover ground rules such as confidentiality and privacy as it relates the Internet-based program you will be using, as well as use of a private room, and protocol for “showing up” to a session. I have my clients sign in five minutes before a session time, and I will indicate when I am ready to receive their VOIP call or video call. I tend not to use a mobile-to-mobile call, mostly because this is costly to the the health provider if the client is not using the same cellular carrier.

It’s a good idea to take time to breeze through the Terms of Use Agreement of any Internet program you use. For example, Skype’s terms indicate in no uncertain wording that they are not responsible for the content you receive on its platform. Therefore, if you post profile information (i.e. contact info) that is seen by others, this behavior is your business, not theirs. That also means that you may receive content you did not ask for, including lewd, violent, or suggestive messages. If you ever receive harassment from another user, I would suggest taking a screen shot of the messages and reporting it.

This has important ramifications for therapists and clinicians, as our conversations with clients often cover sexual behavior, domestic violence, and abuse. I write it into my signed contracts with my clients that I do not — and the client cannot — record any sessions in person or online. Period. Reason: to protect the client. Skype and Google Voice and Video may someday provide these features, but even if they do, I would highly recommend that sessions not be captured and archived digitally. Of course, clients and therapists are free (and the therapist is required) to take notes during and after a session.

2. Get up to speed. If you will be trying a video call for the first time over the Internet, make sure you have Internet speeds of at least 128Kbps upload and 500Kbps download. These are the speeds recommended by Skype, one of the more popular Internet-based VOIP and video calling programs available (and recently acquired by Microsoft).

One of the easiest ways you can find out what your computer’s upload and downloads speeds are involves a test on sites like If you set up an account, you can also track your Internet speeds over time, and learn how to improve speed with the program’s helpful information. You can even brag about your high speeds by sending it out to others via Social Media platforms.

If your Internet connection doesn’t achieve these minimum speeds, what you will get is a heavily pixilated video image and distorted vocalizations out-of-sync with your clinicians speech. In my case, I would cancel a scheduled session, and require the client to improve their upload and download speeds before initiating another session. I usually buffer in an additional ten minutes to the first Internet-based session in order to address technology issues and challenges.

3. Fly and be free. Some of my clients travel for work, and therefore they are using mobile devices and hotspots. Skype has a mobile app that works beautifully. All you need to make sure you have is a solid wireless connection and at least 50% signal strength on the device.

4. Enhance the senses. Not all computers, laptops, or mobile devices have good built-in microphones or peripheral webcams. There are reasonably-priced webcams you can purchase, such as ones by Logitech, as well as headset microphones under $50 that provide clear video and superior sound while blocking out distracting noise.

Make sure there are no shadows casted on your face. My personal preference is to not have natural sunlight shining behind the client; drawing the shades and using a lamp bouncing soft light towards you appears more natural and less glaring, and it will make it easier for me to see your body language as part of the therapy session.

Don’t have the camera pointed only towards your face. Your hand gestures and body language are important elements of the online session. It also may help your camera to focus on you if you don’t have a lot of distracting objects behind you. A blank wall or screen is a plus.

5. Remove distraction. Just like you would not expect your therapist to be doing her laundry while you talk, the therapist needs your undivided attention. If there is a child in the home (and is not a part of the therapy hour), the child should not be awake and active with you during an online session. Dishwashers, washing machines, and loud equipment should be not be running if the session is conducted from home; noisy computer fans in an office can also interfere with a session (a headset microphone will usually take care of that problem).

If you are at home during your online session, and other household members are at home, use a private room. Indicate that you cannot be disturbed during your session time. However, online sessions are marvelous for in-home tours and whole-family meetings. There are a lot of great applications for home-based online sessions that are yet to be explored.

Important: I do not encourage working professionals to use job-related computer equipment for the purpose of conducting an online session, nor to conduct those sessions at their worksite. If the session occurs on a lunch break, it is more prudent to remove yourself from your corporate setting and use your personal devices.

6. Use all the tools of the trade. With programs such as Skype, you can use the chat box to text related links, titles of books, or share related CBT (cognitive behavioral therapy) exercises. I try to activate multiple modes of learning and idea acquisition to mobilize my client’s activity towards their goals. You can also use the screen share mode to share what you are working on with your therapist (but ask permission first).

Other Question You Might Have About Online Session
Recently, a friend asked if I preferred Apple’s FaceTime (used over a WiFi connection) over Skype. While I am unabashedly an Apple product user (and a relatively happy one!), I don’t see much difference between using FaceTime and using Skype, with the obvious point being that not everyone can use FaceTime. I do, however, prefer the visual clarity overall when using Facetime. This is a personal preference, based on the warmth of the video and audio quality, though I am expecting both to keep improving over time on all competing video calling programs.

Here’s another question I was recently asked: does the expense of adding on the equipment mentioned above (increasing Internet speed, purchasing a webcam and/or microphone, using a mobile device’s minutes) make sense if you live in the same city as your therapist? I have found that local clients have also requested online sessions for a number of reasons:

Inclement weather. While it might not be snowing in my area, snow and ice could easily affect another neighborhood just 10 miles away.

Commute time. All it takes is a baseball game or a large event, and traffic snarled for miles. Ditching the commute by converting a F2F visit to an online one can over mean less stress.

Change in work schedule. Sometimes a last minute meeting at work gobbles up your buffered time for a F2F visit.

Dodging a late-cancel charge. I allow clients to convert what would otherwise be a late-cancel appointment to an online session at no charge.

Home visitation can be done at the same billable category. Some clients require home visitation because of dual diagnosis. With an online session and a mobile device, I can see what is going on in your home, but I don’t charge the extra fee for time and miles.

Family sessions can be more easily accommodated. Sometimes it’s hard for the entire family to schedule an in-office visit, so an online session may be a more practical solution. There may be additional benefits for marital counseling and relationship coaching as well.

If you already have the main pieces in place (computer or laptop, Internet connection), the smaller expense of a webcam and microphone could easily offset the cost of time, inconvenience, the cost of gasoline, parking fees, and late-cancellation charges, especially if you are seeing a therapist for weekly sessions.

What are your thoughts on conducting therapy and coaching sessions online? What do you think therapist and other clinicians should minimally provide for clients who wish to convert their sessions from F2F to online? What ramifications do you see for clients who are highly mobile, such as businessmen, students, and young professionals)?

Note To Therapists: it is YOUR ethical and legal responsibility to provide a method for clients to show informed consent concerning electronic communications via the Internet, especially regarding privacy and security. Before starting any online session with your clients, check your state or national counselor association’s ethical guidelines, and do due diligence in providing that information to your clients.