The COVID-19 pandemic exponentially increased counselors’ use of distance counseling and moved telebehavioral health from a lesser-used, avant-garde approach to a mainstream practice within the counseling profession, say Daniel G. Williamson and Jennifer Nivin Williamson, co-editors of the ACA-published book Distance Counseling and Supervision: A Guide for Mental Health Clinicians. There are both pros and cons that come with this development, but, most of all it affords an opportunity to refine and implement best practices for distance counseling.
“The COVID-19 pandemic quarantine will serve as a watershed event that ushered in the use of telehealth … It is remarkable how our profession rose to the occasion during this crisis,” say the Williamsons, who are both core faculty with Capella University and co-founders of PAX Consulting and Counseling in Texas. “It is an exciting new frontier for the field. The challenge in the ethical and legal aspect is that the technology and oversight are a moving target, and it is challenging for counselors to keep pace with the changing rules and regulations.”
Q+A: Distance Counseling and Supervision: A Guide for Mental Health Clinicians
Responses co-written by book co-authors Daniel G. Williamson, Jennifer Nivin Williamson, Marty Jencius, Susan Belangee, Stephanie Marder, Jeff Parsons, Angela McDonald, Jason Martin and Mykia Griffith.
From your perspective, what are some “pros” and “cons” that have come from counselor’s increased use of telebehavioral health?
Jason Martin: The clearest and greatest “pro” is definitely the increased availability of counseling that telebehavioral health brings. If someone has access to the internet, they can now access counseling services. People who live in more remote areas, have transportation issues, or health issues can now access counseling. Because of the hesitance some clients have about seeing a counselor within the community where they live and work, they now may access counseling services in other communities, thereby providing an additional layer of privacy within their home community. Above all else, these “pros” provide unprecedented access to care, and that impact cannot be overstated.
The “cons” are a bit more complicated. First, while the technology used for telebehavioral health continues to become more user-friendly, there are still many people who may struggle with the technology necessary to make it work. Some may not even have the devices needed to access telebehavioral health. Second, it also may bring insecurity to the counseling environment. No longer may the counselor be able to restrict who may enter the therapeutic setting because the client’s environment may not be secure or even private. Third, some clients and counselors may experience interacting through a computer screen to be less intimate and personal than meeting face-to-face, thereby affecting therapeutic rapport, and increasing possible distractions.
The circumstances of the COVID-19 pandemic have led to some clients never meeting their counselor in person. What are the nuances that counselors should be aware of and mindful of when treating a client 100% virtually?
Marty Jencius and Stephanie Marder: Counselors should be aware that a virtual presence is possible even when meeting with clients using telebehavioral health. Like many tools available for use by counselors, how a client’s outcome is impacted depends on how the counselor wields the tool. Clients can form a solid therapeutic relationship with a counselor online or over the phone. It may not be a counselor’s preferred way of working, but in response to the pandemic, counselors have had to embrace a change leading to a new way to provide client service.
Some insights gained from practicing online throughout the pandemic:
- Invest in a good microphone and earbuds so your client can hear you clearly and you can hear your client without distraction from outside noise.
- Consider your space and have good lighting when conducting video sessions. It is just as vital for the client to see you as for you to see the client.
- Have a plan for when technology is not operating properly.
- Pay attention to observable cues the client could potentially misinterpret or misread when meeting virtually (e.g., thinking the counselor is tearing up when they are scratching their eye).
- Create specific guidelines to prevent clients from being distracted or multitasking during appointments (running errands, driving, etc.)
- Try to wait an additional one or two seconds after you think a client has stopped speaking to avoid talking over one another due to lag.
- Working with younger children can still be a challenge; however, adolescents can often adapt to telehealth quickly.
- Do not automatically think older clients would be averse to using technology for distance counseling. Like many of us, they have developed a new comfort with video chat.
We encourage practicing counselors to seek continuing education opportunities as telebehavioral health counseling evolves.
What would you want counselors to know about navigating virtual sessions with a client who is not alone or in a private area (i.e. children are in the background, a spouse or parent is in the next room, or a client is at their workplace on lunch break, etc.)?
Daniel and Jennifer Williamson: Confidentiality is an ongoing concern in any counseling relationship, and one of the largest changes in the shift to telehealth is that the counselor has lost the ability to control many aspects of the clinical space. Educating clients about what constitutes an appropriate clinical space and how to be creative in finding appropriate meeting places is an important and ongoing conversation. We define being in a clinical space as being alone in a room with a door, the door is closed, and a “sound machine” is on. Clients can be creative in finding ways to create their own “clinical spaces.” Many have met in walk-in closets, parked cars, offices, bathrooms, and garages.
It is helpful when counselors remain aware of nonverbal shifts in attentions that indicate someone has entered the clinical space. It is important for the counselor to continue to explore informed consent surrounding the importance of clients protecting their own privacy. The ability to create a clinical space should be considered during the initial evaluation to identify if the client is suitable for this modality.
It might be prudent to establish a “signal” between client and counselor in the case that someone enters the client’s clinical space. A client might touch their nose or ear to indicate that someone has entered the private space and it is no longer safe to talk. Virtual services that constantly monitor for voice commands such as Siri, Alexa, Google, bluetooth connected devices, or gaming programs including Discord should also be considered, and clients should be informed about these potential breaches.
In the book, you mention that distance counseling will not be a best fit for some clients and that counselors must assess clients to determine whether it’s an appropriate medium. What are some “red flags” counselors should listen for that might indicate telebehavioral health is not a good fit for a client?
Daniel and Jennifer Williamson: While each client should be assessed individually, several considerations seem to signal “red flags” for the use of telehealth. Safety is a number one priority, and counselors must assess if the client is connecting from a place that is physically and emotionally safe. Clients in domestic violence situations or who are a harm to self or others might not be a good fit for the telehealth option. Emotional stability, trauma history, impulsivity, level of care, and ability to self-regulate are also considerations when evaluating clients for suitability.
It is equally important to explore the client’s comfort and skill using this type of technology. Many clients report enjoying the convenience and access that telehealth counseling provides while others miss the in-person human contact. Some clients have reported feeling stuck once the session had ended because they can’t leave the place where they explored difficult topics.
Counselors must assess the clients’ access and ability to navigate the hardware and software involved in telebehavioral health systems. Clients may not have stable internet access or updated technology for interfacing with the telehealth platform. Amber Hord-Helme created an assessment for evaluating clients for telehealth that is included in the book.
With vaccines widely available in many areas, some practitioners are opting to offer both virtual and in-person counseling. What would you want practitioners to know about managing this hybrid model?
Susan Belangee and Mykia Griffith: We are both currently doing the hybrid model, returning to the office one or more days a week and working virtually from the home office during the other time. One idea to manage this is to schedule clients who want to come in person on one day and any clients who wish to do sessions virtually can schedule on a different day. This can help to foster a rhythm to work depending on the day.
Is it best to have a client stick to one or the other (virtual or in-person)?
Allowing room for change allows for flexibility as well as opportunity for growth within the therapeutic relationship/alliance. Clients report that they appreciate the flexibility even if they tend to choose one option most of the time. Knowing that they don’t have to miss a session if they are unable to come into the office as planned seems to reduce stress. Life happens for everyone, and having the ability to maintain appointments through telebehavioral health will allow for continued work and continued progress.
During the pandemic, state regulatory boards and insurance companies broadened their acceptance of distance counseling (and telehealth as a whole). Where do things stand now – what would you want counselors to know? And/or where should they be looking for the latest updates and changes regarding insurance coverage and regulation of telebehavioral health?
Jeff Parsons and Angela McDonald: Prior to the pandemic, many state boards and insurance companies were ambivalent towards distance counseling. While some states had clear regulations around the practice of distance counseling, others did not. The pandemic spurred change in several areas. In an immediate sense, it allowed for the provision of distance counseling in most states; including registries that allowed for services across state lines. It also loosened restrictions, allowing for the use of technologies that would not traditionally be acceptable (e.g., phone, non-HIPAA software). In many cases, it opened up billing opportunities for distance counseling in states where this may not have been an option in the past. Finally, it encouraged states to actively engage distance counseling as a legitimate delivery model for counselors.
The long-term impact of COVID-19 on distance counseling will vary by state. Some provisions, such as interstate registries and loosened restrictions around phone/non-HIPAA compliant software, will likely be retracted once the state of emergency is lifted. However, it is likely that many states will (if they haven’t already) enact regulation around the provision of distance counseling, formalizing its place in our profession.
Counselors should continue to closely monitor their state(s) regulations and board activities for updates about distance counseling and supervision. Many states issued temporary changes that impacted healthcare practice during COVID-19 state of emergency declarations. As the emergency declarations expire and are lifted, boards will need to issue updated guidance to the public so that counselors can be certain that they are acting in accordance with the regulations. In some cases, boards may issue new interpretations of regulations that protect the public and attend to the expanded capabilities of safe practice in telehealth, and, in other cases states may pass legislative changes that make more permanent changes such as adopting the interstate compact for counselors or adopting broad telehealth regulations that apply in a state to many different regulated professions, all healthcare professions, or all behavioral health professions.
From your perspective, where does telebehavioral health fit in the future of professional counseling?
Jeff Parsons: Distance counseling is here to stay. It opens opportunities for services to a wider range of clients, including those who may have transportation or health issues. It also holds a convenience factor that may be appealing to counselors looking for flexibility in their schedules. However, its insertion into the everyday lives of counselors and clients has limitations. Confidentiality issues and video conference burnout are common complaints from counselors who have focused their practices around distance counseling during the pandemic. Likewise, distance counseling may not be ideal for all clients.
Long-term I think we are going to see significant growth in the creation of counseling agencies that focus on distance counseling. However, for most agencies, I think it’s more likely that distance counseling will be used as a tool that adds flexibility to the provision of face-to-face services. For example, counselors might use distance counseling with clients that are on vacation or have transportation issues. However, as this future unfolds, I believe states will be in a much better position to support the provision of distance counseling, as they develop much needed regulatory processes.
Angela McDonald: I am really excited to see telebehavioral health expand access to care, support continuity of care for mobile counselors and clients, and for communication skills in the tele-space to be strongly incorporated into standards for counselor education and supervision.
Susan Belangee: I think telebehavioral health is here to stay as a valid and effective treatment delivery option. The pandemic forced the profession to utilize virtual counseling options and this likely changed professionals’ opinions about how effective they could be using this method of treatment delivery. It will necessitate the development and revision of best practice guidelines as technology continues to evolve.
Mykia Griffith: Although telebehavioral health will never be able to replace the experience that comes with in-person treatment/therapy, telebehavioral health is essential for the future of professional counseling. The virtual method was previously just an option that left room for uncertainty. At this point in time, telebehavioral health has had an incredibly quick shift into our everyday reality and may prove to be fundamental moving forward.
Marty Jencius and Stephanie Marder: Telebehavioral health fits into the future of counseling by extending a counselor’s ability to reach clients when certain barriers exist (e.g., health, distance, inclement weather, global pandemic) which may have previously prevented a client from obtaining services. COVID-19 forced the counseling profession to use telebehavioral health tools more widely than ever before.
We may not need to use telebehavioral health tools as profusely as during the pandemic. However, the benefits of these tools have been demonstrated and their usefulness to the profession has promoted a willingness among counselors to explore these tools as viable options for providing counseling services.
Distance Counseling and Supervision: A Guide for Mental Health Clinicians is available both in print and as an e-book from the American Counseling Association bookstore at counseling.org/store or by calling 800-298-2276.
Proceeds from book sales will benefit Uganda Counseling and Support Services, a nongovernmental organization that brings counseling and mental health services, education, clean water, farming and medical services to rural Uganda. The organization was established by one of the Williamson’s former graduate students, Ronald Kaluya.
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.