If you live in a large city, it’s likely you have already had your first experience with telemedicine.
Suppose on Day Seven of a nasty cold or flu, you decide it’s time to see your doctor. You call up your medical practitioner’s office and request an appointment. In smaller stand-alone practices, you would speak to a receptionist or scheduler, and you would be offered an appointment with your doctor based on his/her availability. In larger multiple-practitioner offices, you might be offered the option of seeing a different doctor other than your primary doctor if you wished to be seen sooner. Yet by phone, you’ve been triaged and placed into the schedule.
Most medical centers began using telephonic triage nurses to help patients get effective medical care in a timely manner, and also keep those who actually did not need to see their doctor from spreading colds and flus to others in a waiting room. Seattle is no exception, and I had the opportunity to work as a Telephonic Triage Nurse in 2011 and 2012. I am happy to report that I learned a lot about the effectiveness of telemedicine during that time!
Telemedicine, particularly in behavioral health settings, is an exciting option for those seeking counseling therapy. Yet perhaps you wonder, as I do, why more people aren’t using it more. Less than two percent of the inquires I receive from potential clients include a request for telemental counseling services (that is, sessions provided over an Internet connection using a HIPAA compatible video conferencing platform, or services provided over the phone).
Until last month, that is. I received an unprecedented number of inquiries about access to counseling sessions either by phone or by video conferencing. And I actually think this is very good news. Read on to find out why.
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.
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.
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 Speedtest.net. 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.