AARON, thank you for your timely post. I have suspended my groups for two weeks, but I know this will last longer than 2 weeks. I wonder how to do groups using Doxy.  I will check with them and see. Thanks for the resources you have provided.

"The chief task in life is simply this: to identify and separate matters so that I can say clearly to myself which are externals not under my control, and which have to do with the choices I actually control." 

-Epictetus, Discourses, 2.5.4-5

Hello, SMHCA family!

I'd like to reach out and offer what I hope are some helpful resources for counselors in relation to the COVID-19 pandemic.  I think there is some important information that can help us create and adjust to a "new normal" in our counseling practices.  

Some of the unique challenges counselors face include how to reduce risk of transmission in the counseling setting, how to address anxiety, questions, and concerns of clients, how to address possible reductions in appointment attendance as clients engage in "social distancing," how to conduct telehealth sessions legally and ethically, etc.  Personally, I think it is wise to address the issue with a balance of reasonable precautions and a tone of optimism, focusing on what is within our control rather than what is outside our control.

To this end, I have assembled some resources that may be helpful:

Telehealth sessions are an opportunity for many clients with adequate internet access to continue with their therapy but also minimize exposure possible exposure to the virus.  I don't think it is in our clients' best interests to discontinue therapy because of the pandemic, and technology provides a resource to this end.

Telehealth Platforms

When using telehealth, it is illegal to use resources such as Skype, FaceTime, etc. that are not HIPPA/HITECH compliant.  Instead, get a free account with Doxy (https://doxy.me), or spring for the $35 per month fee if you want the "pro" version, which includes the ability to screenshare with clients (if you want to show them something on the screen) and to conduct group sessions.  Many counselors get a free Zoom account, having heard that Zoom is HIPPA-compliant, but unfortunately a free Zoom account is not HIPPA-compliant.  Zoom Healthcare is, but it costs $200 a month (for up to 10 users) and therefore is a tool of preference for agencies vs. individual practitioners (although you can sometimes talk Zoom sales reps into reducing the cost to as little as $100 per month).  Many electronic practice management systems and counseling website vendors, such as Simple Practice and TherapySites, also have options of adding telehealth platforms, so if you already have a practice management system, you may want to consider adding that feature.

In summary, I recommend Doxy for sole practitioners and Zoom Healthcare for agencies/groups, unless you have a practice management system that offers a telehealth feature.

Understand that no platform is compliant with the law unless you have signed a business associate agreement (BAA) with the tech company, so make sure you get that document signed and saved as soon as you secure your platform.

Telehealth and Ethics

Once you have an appropriate platform, your next task is to ensure that you are abiding by good ethical practice and by legal guidelines when using telehealth.  Ethics Rock is providing their $599 training on ethics of telehealth for free until 3/23/20 and might be a good resource to learn more (https://ethicsrock.com/services).  I also recommend reading section B6 (on the use of technology supported counseling and communications) of the brand new AMHCA Code of Ethics (2020 edition).  Client access to internet, familiarity with technology, privacy concerns, etc., are all issues to be addressed with the client, and appropriate informed consent must be procured.  

Telehealth and the Law

If you and your client are physically in two different states at the time of a telehealth session, you have to ensure that it is legal in both states for you to conduct the session.  The free telemental health app enables you to learn what the laws are state-by-state for counselors conducting telehealth (https://www.ebglaw.com/telemental-health-laws-app/).  

Additionally, many counselors (even if unknowingly) are violating the law when submitting claims for telehealth.  There are numerous cases of 491 board sanctions taken against counselors who were criminally prosecuted for insurance fraud for this reason.  My understanding is that you must use location code 02 (telehealth) vs. location code 11 (in office) when submitting claims for telhealth sessions.  Some insurance policies cover these sessions, and others don't.  You should contact provider relations for each insurance carrier and EAP that you work with to ensure that your contract/agreement covers telhealth.  If it doesn't, ask how you can have it added.  For example, Cigna requires each counselors to sign a contract addendum with specific guidelines for telhealth, and sometimes the reimbursement rate is different as well.  If a client's policy doesn't cover telhealth, then you may wish to consider reduced rate out-of-pocket telhealth sessions as an option if necessary.

Telehealth and Clinical Considerations

The clinical considerations for telehealth are too numerous and nuanced to address in a brief post like this, and some of them are less of an issue in the context of a pandemic (like, for example, the question of whether a client with social anxiety is avoiding in-person sessions and, if so, whether this is therapeutically in the best interest of the client).  I'll keep it brief and just say that some clients will prefer in-person appointments for a variety of reasons, some will prefer telehealth sessions, webcam sessions can "feel" very different vs. in-person appointments, and some clinical interactions simply cannot be conducted via webcam, such as substance abuse evaluations for DOT violations (which by federal law must always be in-person, in part so that the evaluator can detect the odor of alcohol, body odor, etc. as part of the evaluation).   Counselors should consider whether it is in the best interest of the client to use a telehealth platform, but I would wager than many will consider the best interest of the client (in terms of reducing exposure to COVID-19) a priority over some of these clinical concerns.  

I recommend reading Section E on Technology-Supported Counseling and Communications on pages 23 through 25 of AMHCA's newly-revised Standards for the Practice of Clinical Mental Health Counseling before providing telehealth sessions to gain an appreciation of the many different considerations involved when providing telehealth sessions.  Also, I suggest reading pages 38 through 40 of the Fall 2018 issue of AMHCA's The Advocate Magazine, which contains an article entitled, "Therapy Inside the Box: From My Computer to Yours" by Dr. Susan Meyerle, a telehealth expert, who provides an excellent overview of some telehealth considerations.  

2. COVID-19 and the Counseling Office

Personally, I intend to continue seeing clients in-person each day just as always.  I think that is important for me and my clients.  However, I understand that other counselors may not choose to do this for various reasons.  As long as your doors are open, I think it is important to develop a plan in your counseling practice for reducing exposure in the office.  Here are some of the strategies that I am personally using in my office:

1. I have stopped shaking hands with clients for now.
2. We are disinfecting commonly used surfaces such as doorknobs twice a day using Clorox wipes, Lysol wipes, and/or a rubbing alcohol solution.
   
3. We have posted a reminder and a friendly graphic of how to appropriately wash hands in our bathrooms.
4. I am washing my hands for a minimum of 15 seconds (humming to the tune of the Happy Birthday song pretty much does it) with appropriate friction between sessions.  I also use a single-use paper towel to turn off the facet and open the bathroom door after hand-washing.
5. We have created a flyer for clients explaining the precautions we are taking and letting them know about telehealth options.
6. We have posted a notice outside our office informing clients that if they have flu-like symptoms they should not enter the office and should instead call their physician and notify us afterwards.  We have also chosen to be more flexible about our late cancellation policy for these scenarios.  
7. I have expanded my availability in anticipation that my cancellation/no show rate may increase in coming weeks/months, compensating for the loss of revenue.
8. My office furniture is arranged so that there is always more than a 3-foot distance between me and my clients.  Clients also do not have handle the doorknob to my office.

There are many other good options and precautions available, and for a more thorough read on this matter I recommend reading Miranda Palmer's COVID-19 Plan for Therapists: Questions, Answers, and Guidelines.  I found it very helpful, and you will read strategies there the I did not post above.

The COVID-19 pandemic raises particular challenging questions for those of use who are treating clients with OCD and anxiety disorders.  I have two resources I would like to suggest for those of us (which probably is most or all of us) working with such presenting problems:

• International OCD Foundation: COVID-19 & OCD: https://iocdf.org/covid19/
• Vox article:  "I have OCD. Here’s how I’m dealing with coronavirus fears."

3. You All Know More than I Do, So Reply With Your Ideas!

I can confidently say that collectively we know more than any one counselor (like myself) does, so I'm sure some of you have better/additional ideas, tips, and resources than I have offered above.  For example, Joel Miller, the E.D. of AMHCA, recently posted an update about what AMHCA is doing in response to COVID-19 with some additional resources (read here).  Let's keep this conversation flowing!  I'd like to invite you to reply to this thread with additional ideas, rips, and resources that you know about.  I think the pandemic will affect us for months to come, so we have to create a "new normal," and I think we can do this in a reasonable, safe, and productive way if we put our heads together.