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The Science of Observation Through The Senses

Do you feel like your therapist listens to you? Is there an appropriate time for a health care professional to touch you?

Listen to me, because I'm right here!

That’s an important question. In Washington State, touch between therapists and clients are limited to appropriate therapeutic touch, such as a handshake. However, I hold a license as a Registered Nurse, and there have numerous times when clients have shown me a wound that wasn’t healing, a mysterious rash on the arm, or presented with a cough that sounded more serious than the client was treating it [don’t worry: I always present my credentials, and ask a client if s/he would like my professional opinion on their medical question]. I might ask permission to touch near a wound to feel the temperature of the skin, or smell it to see if it is infected [or ask them to take a sniff if it’s within reach].  While I would never overstep the scope of my practice, I keep “Nurse Imei” ready for work when I’m in the therapy office, because it allows me to practice the best kind of medicine I know: the science of observation through the senses.

In an article posted on, Abraham Verghese MD, Professor of Medicine and Senior Associate Chair for the Theory and Practice of Medicine, Stanford University, wrote:

The truth is, I love and embrace technology, and have no desire to return to the pre-CAT scan and pre-MRI days of old. But I see no reason to let new technology make us lose the abilities we have had for over a hundred years to make sophisticated diagnosis at the bedside. Indeed, it should make us so much better.

I feel the same as Dr. Verghese. I too love technology and how it has enhanced medical practice. But it shouldn’t prevent or distract us from observing the client with out own eyes, ears, hands, and olfactory nerves. What does this mean for those of us who conduct therapy sessions over the phone, or handle triage in this manner?

If you are thinking of trying therapy over the phone or Internet, your therapist should be thoroughly trained to conduct sessions in this manner.  My telephonic nurse triage training gave me excellent experience in listening to patients because I could not see them. I can’t see a grimace of pain, but I can ask and help a patient evaluate their pain level using an appropriate pain scale. I can’t see if there is blood in their urine, but I can ask a client to describe a color or a smell. I can hear over the phone is someone’s breath is labored, or if their thinking is foggy.

If you are a client attending F2F psychotherapy sessions, it is important that your therapist look — or attend — to you. Attending is a developed skill, requiring hours of learning to observe a person’s normative behaviors, both physical and emotional, while they are describing issues that arise. Even if your therapist takes copious notes, a good therapist is watching body language, eye movement, changes in the tone or strength of your voice, the shifting of your body when you are uncomfortable with a subject, and even the presence of sweat and color changes to your skin. It’s not uncommon for a trained counselor to mention when s/he believes you’re not being honest about your problems.

As an RN, I feel exceptionally lucky to have additional tools of observation to bring to the table. Many of these help cast light on the overall picture of mental health. For example, knowing the complications of long-term sleep issues on the heart, as well as its connection to the incidence of depression, would lead me to prioritize a client’s complaint of poor sleep because his partner wakes him up when he snores. With more observation and interviewing, I could find out that the client has sleep apnea, a condition that contributes to depression, heart disease, and problems with a relationship.

I received a book as gift at Christmas, “The Naked Lady Who Stood On Her Head” by psychiatrist Gary Small and Gigi Vorgan. The stories highlight the many physical observations an MD notes, and they are often so many, I wonder how those without more medical experience (such as a physician or a nurse) function holistically in the mental health office. I must conclude that the best therapists I know rely heavily on observing through their senses, and documenting everything that seems unusual or unexplained. Anything falling the medical category gets noted and referred to a physician.

The corporate client who walks into an office with the smell of body odor and urine alert any therapist to inquire about the patient’s strong odor as a contrast to his normative grooming habits. But if you were trained to detect the smell of ketones on the breath of a diabetic experiencing the beginning of a sharp rise in high blood sugar, these are skills that can’t be as effectively used over the phone or Internet. And that is an important problem in the world of telemedicine.

When Telemedicine Isn’t Going To Work

A woman who has the smell of alcohol on her breath while going through treatment for alcoholism is not going to be detected if she contracts for telemedicine sessions. It is the practitioner’s responsibility to determine who should receive “old fashioned” health care in-office, and the convenience of telemedicine sessions should not be offered to everyone.

Technology has not caught up with our imagination. Some day we might have “smell-o-vision”, but as of today, we can’t smell through the phone. Someday, we’ll have more home devices that can measure heart rates and give us audio of a minute’s worth of auscultation (currently, there is an app that can do this for the heart, but it has not been approved for professional use). Until then, clients and providers should consider when therapy sessions are appropriate for phone and Internet, and when they should be seeing a helping professional face to face.

What do you think? What happens when clients leave the medical office saying, “My doctor didn’t listen to me, ” or “She barely even took a look at my symptoms”? How can we integrate crucial emerging telemedicine technologies with the need for old-fashioned observation?

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How Facebook Can Affect Your Insurance Coverage

How Facebook Can Affect Your Insurance Benefits
by Imei Hsu, RN, MAC, LMHC

With over 500 million users of Facebook worldwide, you shouldn’t be surprised who is on Facebook these days. Your dentist, your employer, your friends and family, and even your health insurance company may have a presence on Facebook. While it’s fun to set up events, get-togethers, and give your social network a slice-of-life status update a couple of times a day, you shouldn’t be surprised who is looking at your updates. Here’s how Facebook updates can affect your health insurance coverage.

What could your Facebook updates and photos be telling your insurer?

Enter Natalie Blanchard, a 30 year old IBM technician from Quebec. She has released her story The Los Angeles Times in 2009 about a medical leave she took in 2008 on the recommendation of her doctor. She was being treated for depression, and her doctor had suggested that she go on vacation. While on medical leave, had been receiving monthly disability benefits from her insurance plan, but these were severed without warning after the first year. Blanchard claimed that her insurance company had crawled her Facebook page, discovering pictures of her on her vacation. As you can guess, most vacation pictures include sunshine, smiles, eating and drinking, and what most of us would consider the “high life”. Her insurer considered her ready to return to work, and therefore benefits were terminated.

In the lawsuit that is scheduled to go to court in January 2012, Blanchard claims her insurer assumed this was a case of fraud based on her Facebook pictures and status updates, and that the insurer terminated benefits with studying the background of her benefits. She also claimed her doctor was not contacted before the benefits were terminated. If you don’t know this, it is standard practice in medical cases that the treating physician or nurse is contacted by an insurer case consultant (often times a medical practitioner) to determine the need for benefit based on the medical history of the client.

As a therapist, I find this trend alarming. But even if you’re not a clinician, you should be concerned. The original articles were released in 2009 and 2010, yet I consistently see people using their Social Media updates such as Facebook without an awareness of who might be tracking their posts. I also find it disturbing because disease and dysfunction does not follow a consistant pathway of suffering 100% of the time in ways that can be detected from the smiling face of a person on vacation.

Case in point: a friend of a close friend spent time skiing, running, and sharing meals with my friend all the way up to about a couple of weeks before she took overdosed in a hotel room. Her suicide note indicated that she had been planning her suicide for some time, but her friends and family were shocked. The months before her suicide had been filled with smiley-faced pictures of herself traveling around the world, a brief but intense romance, and dreams of the future. At her wake, the guests were still in a state of shock and grief, and to this day, I am sometimes haunted by her vibrancy and verve.

During the years of her struggle with depression, she had done what so many others do: they fight it, they get professional help, they try to live life the best they can, and when there are moments when the depression lifts, they go on vacations, eat and drink, fall in love, and struggle on. Those momentary lifts do not mean the depression is over and done with. Clinicians understand that a lift in depression can also be a time when a severely depressed person has just enough energy to plan a thoughtfully executed suicide.

While the insurer of Natalie Blanchard claims they did not terminate her disability benefits based on her Facebook status updates and photos, they are not denying that these updates and photos were viewed. What should you learn from this?

1. Insurers can and do look at your Facebook status updates and photos, and you cannot legally stop them from this practice. They have the right to search for evidence of fraud or foul practice. Any business can do the same thing. In January 2010, Mark Zuckerberg declared to the world that privacy in the online age was over.

2. You can change your privacy settings on Facebook to limit who can see your posts. However, you should understand that your Terms of Use on Facebook does not ensure your privacy, and Facebook’s position has never been to ensure your privacy.

3. Educate your physician’s office. If you are using insurance benefits for your healthcare and need special coverage based on a medical condition, discuss with your doctor your concerns. Your doctor should be directly contact anytime your benefits are increased, decreased, or terminated based on your medical condition.

4. Take a moment to consider what it is you are sharing on Facebook, Twitter, and other Social Media platforms every time you type. Notice what ads come up on your page when you type in keywords like cancer. At minimum, bots crawl your pages and emails on certain platforms, using keywords to generate ads that are sent to you. Test this: mention that you’re watching your weight, and see how many ads come up for everything from P90x to weight loss yoga. In a similar way, insurers can sift through your public posts to see what you’re broadcasting, and this can be used as evidence against you in a similar way lawyers are using this for divorce cases and employers are using it when interviewing a potential candidate for hire.

This post is not about scaring the bajesus out of you. It’s about educating users so that you can enjoy the best that the Internet has to offer while protecting your best interests. Now go: Skype, text, update, and post your photos. Only be careful, and if you’re not sure how something will be construed, save it for your private enjoyment.

For another link to the story about Natalie Blanchard’s case, take a look at this law blog.

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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.