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Online Therapy: The Brave New Frontier?

With the onset of the COVID-19 pandemic, the world of behavioral health has been catapulted into a mode of treatment that, while not necessarily new, is being utilized on a scale like never seen before. Telehealth is now the norm and not the exception.

In the course of just over 6 weeks, virtually every behavioral health provider in the Western New York region (and most of the U.S.) has nimbly pivoted to offering some mode of telecounseling to meet the needs of their existing patients, as well as attract new ones.

There are particular challenges and opportunities associated with this method. So, I reached out to three clinicians: Lisa Prefontaine, L-MHC who is in private practice and also conducts web-based training with the University at Buffalo School of Social Work Continuing Education Program and Shallowhon Consulting, Adam Giancarlo, L-CSW-R,who is in private practice and works for Venture Forthe. and Megan Quinn, Director of Behavioral Health at the Community Health Center of Buffalo, Inc. 

The first question I posed centered on any previous experience with telehealth:

Megan Quinn: Behavioral Health offers telepsychiatry service since November of 2019. A lot of care coordination services prior to COVID-19 were conducted via telehealth phone calls. We are, for the first time, providing virtual therapy sessions since COVID-19 started.

Adam Giancarlo: No

Lisa Prefontaine: My first webinar for the University at Buffalo was a crash course on telehealth sessions because I have been doing them since 2011. As a LMH-C and taking private fee only, I was able to do online Skype sessions (informed consents with clients) with clients over the years, so I have familiarity with telehealth overall. Also, when I left Horizon Health Services in June, 2019, my 5 year plan was to be solely online (and consultation and training either online or in person) exclusively..

How has the transition been for you? For your patients?

MQ; The Behavioral Health Department has faced challenges and difficulties switching to virtual therapy visits. It is difficult finding a platform that is conducive to all patients and staff. It felt like we were creating a whole new program for the Behavioral Health Department. Our patients seemed hesitant at first to use the virtual platform because it was different for them. It can be difficult for individuals suffering from mental health concerns to adjust to changes. It causes uncertainty and increases anxiety. Also, an important part of mental health therapy is building a rapport with patients which starts immediately during a face to face, in-person visit. The dynamic change when you are not in the same room and having to utilize technology.

AG: The transition has certainly been an adjustment for both myself and my clients. Some clients have chosen not to participate in telehealth, seemingly because they feel more comfortable in person. That is their preference. Some others have voiced that they do not like talking on the phone in general, and have a hard time with it. For some, it has been a relatively smooth/natural transition, particularly those who are comfortable with technology. There are also some clients of mine who started more recently, and so they have been telehealth clients for the duration of their treatment so far. Some of those clients have experienced face-to-face counseling in the past, and others of those have not. Basically it seems that most, if not all, of the clients would prefer face-to-face contact/sessions, but everyone seems to be at least trying to make the most of the current situation.

LP: Although I had prior experience, it was never (with) more than a handful of clients at any given time online so an entire caseload has had it’s pros and cons. Transitioning was initially not as difficult as anticipated but online sessions feel more emotionally draining. Many clients have familiarity with Zoom and web meetings so again transition seemed ok but challenging to have privacy at times for clients. 

Are you dealing with any particular challenges when delivering your counseling services to your patients?

MQ: There are some challenges. Sometimes technology acts up or internet access shuts down. This has interrupted sessions on occasion and there has to be a change in the original plan while in mid-session with a patient. There have been times when a patient is not able to connect virtually with the mental health provider and the patient starts to feel frustrated and irritable. We also work with individuals who are not familiar with technology, are uncomfortable with innovative technology, or do not have a smartphone to use.

AG: Sometimes technical difficulties have presented themselves, but those have been surmountable. There are certain aspects of a Mental Status Exam that require observation of the client’s physical appearance, and that is obviously impossible to do over the phone. You are unable to observe facial expressions or gestures over the phone. Sometimes clients do not have enough to talk about over the phone for an entire 45-minute or 60-minute session, and sometimes clients can talk/feel like talking for more than an hour. Length of session is a bit easier to control and manage in person than over the phone for those reasons, although a therapist could run into those kinds of issues in person as well (it seems to be less common in person for some reason).

LP: Each session has been more unique versus a streamlined treatment plan because each week is a different stage during this pandemic. Survival mode affects both client and clinician in different ways. 

What have your patients been saying about the experience? Are you seeing a change in the show rate?

MQ: We have seen a definite change in show rate, (The) Behavioral Health department productivity has increased and will continue to increase. Once our patients are set up with the virtual visit and become comfortable utilizing the technology, they have nothing but great things to say about it. I find that I am talking with my patients more often and seeing my patients more often (virtually) because we do not have to worry about schedule conflicts, transportation issues, childcare, or waiting periods. My patients now say they want this to continue even after COVID-19 pandemic ends.

AG: Clients actually find telehealth to be helpful and useful, once they give it a chance. I have been able to build rapport/a trusting therapeutic relationship with clients through the use of the phone and other video technology. Clients really mostly need someone to talk to who will listen to them without judgment and support them through whatever trials and tribulations they may be going through. And everyone is going through trials and tribulations right now (some people definitely more than others), so there is a sense that we are all in this together, and these therapeutic relationships help reinforce gratitude for what we do have on both sides – the side of the client and the therapist (especially as pretty much all clients are asking me how I am doing through this time, with genuine concern and caring). Show rate has been about the same. I generally have good show rates, but there have been some times when I’ve called clients and gotten no answer/voicemail because they forgot about the appointment. I suppose that could happen with in-person sessions as well, although I have been doing Home and Community Based Services (HCBS) in the form of Community Psychiatric Support and Treatment (CPST), so it is less often that clients do not show when you come to their home (although that has happened as well).

LP:  In many ways the show rate has improved because of availability. Clients, though, are feeling fatigued for many reasons here and there and have asked for a break here and there. Many clients really like being online and almost open up more because of a different level of safety. Only a few have decided to wait until in person sessions can resume. 

How do you find telehealth affecting your practice? How have you had to adapt your counseling style to accommodate your patients?

MQ: I feel creating a safe and comfortable environment for the patient takes more time due to the virtual visits. I feel it takes some time to help the patient become comfortable and build the therapeutic rapport. This is a huge change for the therapist, as well, and the therapist must work on feeling comfortable using virtual platforms. I believe telehealth has impacted (my) practice in such a positive manner. In my opinion, the pros outweigh the cons and it is worth the small extra challenges/obstacles that happen in the beginning because the outcome is very beneficial to our patients.

AG: Aside from what I previously mentioned, telehealth is actually a fairly efficient and practical method of providing therapy. It eliminates the issue/problem of transportation, which can be a major barrier/obstacle for clients in accessing services. Clients have been saying that they appreciate the sessions, find them helpful and useful despite the fact that they are not in person, as they would prefer. My counseling style is similar whether using telehealth or not. I use Feedback Informed Treatment (FIT), am outcome-informed, client-centered/client-directed, solution-focused, and strengths-based in my approach to counseling, regardless of the situation. This is what works for my clients and me.  

LP: I have had to pace myself in sessions versus filling each minute, take longer breaks in between clients to combat screen fatigue and regroup to basic grounding strategies. 

Do you see yourself continuing to offer telehealth as an option for your patients, if possible, once physical distancing guidelines are loosened?

MQ: Absolutely, we see telehealth as a very beneficial addition to our Behavioral Health Department. I believe telehealth has eliminated a lot of barriers to care and individuals will be better able to receive the treatment that is needed in our communities.

AG: Yes. It will be up to each individual client what they would prefer (in-person sessions, phone sessions, or video sessions).

LP: Yes and still hoping to be exclusively online instead of 5 years down the road, maybe 3….

As you’ve read, Megan, Adam, and Lisa all have their unique perspective on telehealth, but overall see it as something that is here to stay. In my own opinion, the opportunity to eliminate barriers to treatment and provide individuals with greater access should be the goal and telehealth can do that. 

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