The COVID-19 pandemic expedited the push to move mental health services to distance platforms. With providers ethically and legally bound to ensure their clients are not neglected or abandoned, state boards and federal regulators, such as the Health Insurance Portability and Accountability Act (HIPAA), relaxed their guidelines to support all providers in promptly changing how they were used to, and for many, even trained to provide counseling services. The Office for Civil Rights at the U.S. Department of Health and Human Services offered telehealth discretion during the COVID-19 nationwide public health emergency; penalties for noncompliance with the regulatory requirements under HIPAA would not be imposed against covered health care providers in connection with the good faith provision of telehealth during the pandemic. This enforcement discretion is still active with no known expiration date.
This increase in telehealth services has left many providers asking, “How do I actually implement my training of evidence-based interventions (e.g., empty chair, guided imagery) in an online setting?” Ethical and best practices recommend counselors implement evidence-based practices while being competent using the delivery platform (See Standards C.2. and H.1. of the ACA Code of Ethics).
Understanding how to implement counseling interventions using distance platforms is a necessity for counselors now. The purpose of this article is to support clinician understanding of how evidence-based practices can be creatively implemented with clients using a distance modality for a multitude of theoretical orientations.
I use the video conferencing platform Zoom for the technical instructions because it is a widely known and used platform and it offers HIPAA-compliant features. Zoom is accessible on a range of devices such as desktops, smartphones and tablets. Clinicians can use these techniques with other telehealth platforms (e.g., doxy.me, thera-LINK), but be aware that the terms and exact steps may change depending on the software used.
Before implementing creative approaches within the distance platform, clinicians should become comfortable and confident in the platform to ensure not only an easier implementation on the clinician’s end but also a clear and concise receipt of the counselor’s intention by the client. Furthermore, these guides do not replace the various ethical and legal implications a clinician must be cognizant of with their telehealth work. Some of these considerations include:
- Being up to date on state board requirements (Standard H.1.b.)
- Addressing issues related to the use of distance counseling in the informed consent (Standard H.2.)
- Verifying the clients’ identity (Standard H.3.)
- Ensuring electronic records follow security protocols (Standard H.5.)
When you feel comfortable with the ethical codes, legal standards, the modality of services and the platform, you are ready to begin to transform your talk therapy sessions.
Audio and video
There are ways to angle and position the camera when using Zoom to support both verbal and nonverbal exploration. I often ask my clients to move back from their screens so I can see their full body and gain a better sense of their nonverbals. Using wireless earbuds, such as AirPods, can also enhance this experience because not only can you hear when you are away from your screen but you can also freely dialogue while still being able to see the person in full screen. Additionally, you can use the closed caption button on the toolbar if either party prefers this accessibility option.
I’ve found this approach useful when implementing role plays with clients. Seeing the entire person on screen allows me to incorporate techniques I typically use in face-to-face sessions. With the empty chair technique, for example, clients can place an actual chair next to them, which gives clients the opportunity to imagine the person they are talking to is sitting beside them. The client could wear Bluetooth-enabled earphones with microphone capabilities (e.g., AirPods) and move their device, such as a laptop or smartphone, to show their whole body while doing this exercise.
If the client wants to have this conversation with the identified person for the empty chair technique via phone, I may ask the client to act out this scenario by taking their phone and sitting in the area where they would make the call. I would remain on screen and guide the client through this exercise. Clients have reported this approach makes them feel supported and empowered enough to take the next step and actually communicate with whom they desire. This exercise highlights some of the benefits associated with the telehealth platforms because I would not be able to have my client do this activity if we were meeting in a face-to-face setting.
Some clients struggle to imagine seeing this person and share that it’s intimidating for them to talk to an empty chair. So, I ask them to find a digital image of this person and share their screen during the video call, which allows them to talk directly to this image during the session. (Later in this article, I provide directions on how to share your screen to incorporate this intervention.) I can even remove myself from the screen, so the client simply sees themselves and the person with whom they are speaking.
Here are the technical instructions on using the audio and video functions on Zoom:
- Audio: To turn your audio on and off, click on the microphone icon in toolbar located in the lower left side of the screen.
- Video: To turn your video on and off, click on the video icon in the toolbar located in the lower left side of the screen.
- Remove video participant from screen view: To hide your own video, you can either turn your video off by clicking the video icon on the toolbar or by clicking the three-dot icon on the right, upper corner of the video thumbnail and selecting “stop video.” To hide the video of other participants, click the three-dot icon on their video thumbnail and select “hide video participants.”
Virtual backgrounds and filters
The virtual background tool in Zoom can support a number of therapeutic interventions such as mindfulness exercises, progressive muscle relaxation and guided imagery. For instance, I have had clients change their background to a color of their choice and then I have mirrored them by doing the same. Clients have reported that this has limited distractions for them; they simply focus on what we are doing in the present moment because they can only see me and themselves on screen without any distractions in the background.
I have had other clients select a background that offers them a sense of security, lightness or relaxation while we practiced progressive muscle relaxation. I either used the same background as the client or hid my screen, so the client could simply focus on themselves in this exercise. Clients have told me the background provides them with a sense of comfort, which helped them focus on the somatic work.
Some clients have told me that they find guided imagery easier to do in person because they can feel the counselor’s presence in the room, but with distance counseling, they find themselves opening their eyes to check if the counselor is still there, which distracts from the experience. To overcome this obstacle, I often have clients select a virtual background that resembles the one they are imagining. Then if they open their eyes during the exercise, the virtual background can help them regain focus and take them back to their imagined experience.
To use a virtual background:
- Click the up arrow beside the video icon on the toolbar.
- Select “choose virtual background.”
- Choose from preselected options or select your own by uploading an image.
Another option is to have clients use a virtual filter, which blurs the background and makes the client the main focus. This works well for clients who may be timid about sharing their background or if the clinician wants to truly focus more on the client’s nonverbals.
I have found the virtual filter to be especially helpful when working with dance and movement techniques because the filter allows the clinician to better explore the client’s shape, which informs the counselor about the client’s limitations and helps with treatment planning. Clients with a broader movement repertoire, for instance, tend to be able to better cope due to their ability to have alternate means to deal with stress, whereas someone with rigid movement is known to have difficulty relating to others. Ultimately, movement elements provide counselors with insight concerning how a client behaves. In a studio, the clutter that often fills our homes and offices is not present to distract from the experience of movement.
To use a virtual filter:
- Click the up arrow beside the video icon on the toolbar.
- Select “choose virtual filter.”
- Choose from preselected options.
The preselection options include color variants, which can be a creative way to have the client either share their personality or perhaps a bit of their emotion/mood in regard to the day, session or topic being explored.
Clinicians have the option to share their screen during a video call, and they can also give their clients access to share their screen. This tool can help support the client’s progression toward their goals, and as mentioned previously, sharing audio and video can support mindfulness and guided imagery interventions.
To share your screen:
- Click the share screen tool, which is an image of a box with an up arrow, located in the center of the toolbar at the bottom of the screen.
- Select the boxes “share computer sound” and “optimize screen sharing” (located in the lower left corner) for video clips.
- Ensure the file or video is open on your computer and select the application (e.g., YouTube Video, image) you want to share.
- Click “share” in the lower right corner.
Clinicians can use this feature to share psychoeducation services and information or to walk through something together with a client. In career counseling, for example, the practitioner could review jobs with clients or explore a client’s resume and help them identify and highlight strengths or gaps. Screen sharing can also support client accountability with homework assignments. Clients can share journals, charts, supplemental materials (e.g., ABC worksheets), drawings, research they completed, videos, pictures and narrative therapy letters. Counselors and clients can even use this tool to review treatment plans together.
This feature also allows clients and clinicians to collaborate through a virtual whiteboard. I often use a whiteboard when providing an individual check-in with scaling questions so clients can help me define the increments in the scale. This makes the scale more personalized and provides clients with a more active and engaged role in session. Clinicians can save the scale and reshare it in future sessions to modify the client’s feelings or progress or to highlight changes or patterns over time.
Counselors can use screen sharing to incorporate creative approaches with clients. This option allows both the clinician and client to explore a virtual sand tray together despite not being in the same room. (See onlinesandtray.com for a free, interactive sand tray you may want to use with your clients). They could also have the client create visual creations such as drawing on a whiteboard. Counselors can save and reuse these drawings or virtual sand trays at later times with clients if needed. These visual representations are also a nice way to document the session progress.
I often use these tools when doing exposure therapy remotely with clients. If a client has a fear of snakes, for example, then the counselor and client could first read about the fear- or anxiety-provoking item or experience. The counselor or client could share information related to snakes on the screen and together they could process the client’s feelings and reaction to the content. Next, the counselor could display pictures of snakes using the screen share tool. The gradual exposure and processing support a desensitization of the fear, and within time, the counselor could also introduce snake-related videos through screen sharing.
The counselor could even arrange for the client to take a virtual trip to the pet store or zoo. Eventually, the client could take a real-world excursion, and with the help of technology, the counselor could join them remotely. The client could take the device they use for telehealth services (e.g., tablet, smartphone) with them, and the counselor (who would remain on screen) would talk the client through the experience and process it with them in real time.
Telehealth can be much more than talk therapy via audio and video. I hope these guides help support my fellow clinicians in embracing the tools technology offers us to provide clients with enduring evidence-based approaches. Telehealth continues to rise in popularity both by counseling providers and with clients, so ensuring we as clinicians feel confident and competent in adapting our counseling interventions to align in a new platform will not only help us be successful in meeting our clients’ needs but also support the advancement of our profession.
Nicole M. Arcuri Sanders is a board-certified telemental health counselor licensed in numerous states, an approved clinical supervisor, and a counselor educator and supervisor. She supervises students conducting distance counseling, and she has participated in research, presentation, publication, and course development for distance supervision and telemental health best practices. She can be contacted at Nicole.ArcuriSanders@capella.edu.
Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.