Just a few years ago, telebehavioral health was not a service that many counselors provided for their clients. Jennifer Nivin Williamson and Daniel G. Williamson, both licensed professional counselors (LPCs) and core faculty at Capella University, say that the use of technology in counseling before the COVID-19 pandemic was often considered “avant-garde” or a “fringe” practice.
The Williamsons note that telebehavioral health was seldom billable and often considered risky, with a few exceptions such as distance counseling for military families.
But the reticence toward telebehavioral health services in the mental health field changed when COVID-19 hit the nation. Because of the national public health emergency, the Department of Health and Human Services Office for Civil Rights temporarily eased the restrictions of the Health Insurance Portability and Accountability Act (HIPAA), allowing mental health providers to more easily provide telebehavioral health services. (For an update on the HIPAA compliance rules for telebehavioral health, see the Risk Management for Counselors column on p. 10.)
This meant a lot of counselors had to learn how to use telebehavioral health whether they wanted to or not. “When the pandemic-mandated general shutdown occurred, there was no other choice but to do it [therapy] virtually for most people. Very few therapists would risk going into the office,” says Sam Lee, an LPC at the McLean Counseling Center in McLean, Virginia. “Some therapists, mostly the older demographic, resisted [going] virtual. Some clients were unhappy about having to do therapy virtually, but it was that or none.”
Some clients missed the physical face-to-face immediacy of in-person therapy and others questioned if virtual, on-screen counseling would really work, he adds.
But the increase in people seeking mental health services during the pandemic made telebehavioral health a viable alternative to traditional therapy, and now telebehavioral health seems to be here to stay.
“Most people have gotten so used to the online interactions because of the pandemic that it is integrated into our everyday lives in a way it hadn’t been prior to the pandemic,” says Jessica Eiseman, an LPC supervisor in Texas.
And the majority of people who receive online health care have a positive view of online therapy. According to the COVID-19 Telehealth Impact Study, a collaboration between the American Medical Association and the COVID-19 Healthcare Coalition, 79% of the patients who were surveyed in 2021 said they were very satisfied with the care they received during their last telehealth visit, and 73% said they would continue to use telehealth services in the future.
Research has also found that telebehavioral health is effective in treating some mental health disorders. A meta-analysis published in the Journal of Anxiety Disorders in 2018 found that in-person, traditional cognitive behavior therapy (CBT), internet-delivered CBT and bibliotherapy have equally effective outcomes in treating people with anxiety and depression.
Although adapting to telebehavioral health has been easy for some counselors and challenging for others, it has caused many clinicians to rethink how they use clinical skills designed for in-person therapy and gain new skills when building the therapeutic relationship, assessing clients and using therapeutic techniques in an online environment.
Expanding the reach
Telebehavioral health has also made therapy an option for people who might have never entered a counselor’s office otherwise. Jude T. Austin II and Julius A. Austin, co-authors of the book Doing Counseling: Developing Your Clinical Skills and Style, published by the American Counseling Association earlier this year, say clients struggling with social stigma can use distance counseling as “a jumping-off point for more fulfilling social interactions.”
“We have both worked with clients who start off only doing phone sessions, then they gradually move to virtual sessions, then in-person sessions, then group sessions. Distance counseling makes counseling accessible,” says Jude Austin, an assistant professor and clinical coordinator in the counseling program at the University of Mary Hardin-Baylor. (For a discussion on possible issues with access and telebehavioral health, see Chris Gamble’s article, “Rethinking the accessibility of digital mental health” in the July 2022 issue of Counseling Today.)
Distance counseling can also be a first step in mental health treatment for people of color who may want to seek help but don’t have the time to visit a therapist. “We grew up in a community where counseling was very much a ‘white people thing,’” says Julius Austin, an assistant professor in the clinical mental health counseling graduate program at Grand Canyon University. “It was not that Black, Indigenous and people of color [BIPOC] individuals in our community didn’t value mental health or find processing through life important. It’s just that no one had [the] time or resources for counseling; not to mention that finding a BIPOC counselor when and where we grew up was difficult.”
“Distance counseling is a game-changer for populations who understand the importance of counseling but never had the time or struggled to find a therapist they felt comfortable approaching,” says Jude Austin, an LPC and licensed marriage and family therapist with a private practice in Belton, Texas.
It can also remove barriers that prevent some clients from taking the first step toward getting help, Jude and Julius Austin add. For example, they note that a queer quarterback who doesn’t want to go to the university counseling center out of fear of being stigmatized or a BIPOC individual who does not see themselves represented by the counselors in their area can decide to reach out to a counselor in a surrounding city by making a telebehavioral health appointment. Similarly, a construction worker who wants to save their marriage but can’t find the time to go to counseling can now have a Zoom or phone session with a counselor during their lunch break.
“There has been a lot of work done by ACA, counselors themselves and clients to lower the stigma of seeking counseling,” says Julius Austin, an LPC and the clinical director of a community-based private practice in Lafayette, Louisiana. “Distance counseling can serve the ‘let me just see what this is all about’ population of clients who think counseling can be beneficial but they don’t necessarily know if they will like it. They just want to explore counseling.”
Adapting to the technology
With so many counselors providing telebehavioral health for the first time during the pandemic, training became essential. Jennifer Hart, an LPC who provides hybrid services at McPherson Clinical and Counseling Services in Wyncote, Pennsylvania, admits she was not comfortable with using technology at the start of the pandemic, so she had a steep learning curve.
“I am a somatic-oriented practitioner, meaning I am very keen to body language and physiological responses when having sessions,” she says. “Not having in-person sessions really changed how I assess and [develop a] treatment plan. It was tricky. But with time and training, using technology to provide care became easier and easier.”
Hart received one hour of telebehavioral health training from a former employer. The training included how to use the practice’s telebehavioral health platform and how to use apps on iOS and Android devices. (For more on the use of mental health apps, read the Counseling Today articles “Mental health apps as therapeutic tools” and “Using apps to promote client safety.”)
When the pandemic began, the counseling practice Lee was working at provided training for the employees on how to use the technology for virtual counseling. “We were guided by emails by the practice administration on how to set up [a] virtual platform to restart seeing clients at home through telehealth,” he says. “There were trepidations, but at least for me, it was not really a hassle.”
Jude and Julius Austin have used some form of distance counseling in their work with clients since they each opened their private practices five years ago, but it became a primary modality during the pandemic lockdown. They both learned how to use telebehavioral health technology through various continuing education opportunities and from multiple conversations with the IT support staff working for the virtual platform and smart devices that the Austins use. For example, the Austins say they reached out to Zoom and Apple support to learn how to make a breakout room, how to create meeting templates and how to set up virtual private networks — all the technical things they didn’t have time to learn in graduate or doctoral school.
Sarah Barry, a licensed clinical professional counselor and owner of Mountain of Hope Counseling LLC in Butte, Montana, where she provides hybrid services for clients, says the specialized training on telebehavioral health that she received at the beginning of the pandemic helped her easily adapt the technology. She received nine synchronous video continuing education credits through the University of Holy Cross while she was living in Louisiana before the pandemic as a part of a state requirement to provide certified telehealth services.
Jennifer and Daniel Williamson, co-editors of the ACA book Distance Counseling and Supervision: A Guide for Mental Health Clinicians, say that before the pandemic, they only saw clients in person at their private practice, PAX Consulting and Counseling PLLC in Waco, Texas. But when their building closed for six months during lockdown, they had to rethink how they were going to see clients. They converted their practice completely to distance counseling using a HIPAA-compliant synchronous video conferencing platform, and they provided practice sessions and technological assistance for any clients who were hesitant about trying this new platform.
“Eventually, they [clients] began to love this approach because of the convenience. They were able to continue sessions when quarantined, especially when gas prices were hovering around $5 per gallon and [when] the weather was inclement,” the Williamsons add.
They say working in distance education and in other technical roles, as well as their previous experience with technology, made it easier for them to transition to virtual counseling. Daniel Williamson, for instance, has served as the webmaster for the School of Education at Baylor University and has experience working in electronic commerce.
The combination of counselor training, technology training and the implementation of counseling services using technology has been a huge help, the Williamsons note. They are currently completing the requirements for the board certified-telemental health provider credential, which covers the basics of telehealth and was developed in 2018 by the Center for Credentialing & Education, an affiliate of the National Board for Certified Counselors.
Now that their clients are comfortable with telebehavioral health, the Williamsons say they have no plans to return to a physical location.
Building rapport virtually
Forming a trusting and empathic therapeutic relationship with clients is “at the heart of counseling,” says Eiseman, founder and clinical director at Ajana Therapy and Clinical Services in Houston. The relationship is the “biggest influence on the effectiveness of counseling,” she stresses, adding that this is true no matter if the session is in person or virtual. “Our authenticity should be able to come across to our clients no matter the setting. I try to make my clients feel as comfortable as possible, whether I sit in the same room or on a screen,” she adds.
In a telebehavioral health session, it may not be easy for counselors to see a client’s body language, so Eiseman suggests counselors pay more attention to aspects of nonverbal communication. For example, counselors can watch to see if a client is holding their breath when they talk about a particular event. Are they holding their hand over their chest or heart while they are talking? Are they biting their lips out of nervousness?
“After building rapport with clients, you learn the micro expressions that can help you identify movements or reactions they may have throughout their sessions,” says Eiseman. “At times, you may even learn how to keep track of someone’s breathing patterns on camera, which can be very helpful in sessions, especially with somatic work.”
Lee says when he is working with a new client in distance counseling, he follows all the clinical guidelines he learned for treating in-person clients, such as assessing the client’s cognitive and emotional state at the beginning of the session. He also does a friendly check-in by chatting with a client to break the ice, and he makes sure he expresses empathy in areas where the client is focusing their emotions.
“I ask every new client if they had previous counseling experience, and if it was in person or virtual,” Lee says. If it is their first time in a virtual session, he explains the challenges (e.g., initial unfamiliarity/discomfort about virtual therapeutic interaction, internet connectivity issues, a potential for electronic security issues) and benefits (e.g., more flexibility with scheduling).
If appropriate, Lee says he may comment on the background decor of a client’s room or space, such as paintings and posters on the wall, and share his own similar taste in art or an experience from his life regarding the posters. Discussing common interests helps counselors make a personal connection with clients, he explains.
Barry finds that engaging in active listening, including repeating client concerns and making eye contact, helps develop a solid rapport with clients and makes them feel comfortable. “Eye contact during telehealth is extremely important so the client can know you are engaged in the session. Eye contact is a sign of active listening and displays attentiveness during the session, which helps build the therapeutic relationship,” she says. “I’ve had previous clients tell me [about] their frustration with other telehealth experiences in which they felt the provider was looking at their cell phone and/or toggling through webpages, which caused the client not to feel prioritized during the session and to seek out treatment from another provider. As helpers, we need to be engaged in the therapeutic process as much as possible.”
It is also important for the provider to be attuned to cultural differences in which eye contact may not be the strongest form of communication for the client or the provider, adds Barry, who is also an LPC in Louisiana.
Barry applauds new clients for their courage and bravery in taking the difficult first step to seek out treatment in a virtual space. “Positive reinforcement helps to develop trust,” she says. And “if my patients, whether through telehealth or in-person counseling, know I am cheering them on every step of the way, I feel this helps them to know I’m a human being just like them. I just happen to be on the other side of a computer.”
Another part of building the therapeutic relationship is for clinicians to talk about the nuts and bolts of conducting telebehavioral health sessions, particularly the security risks of meeting online, confidentiality, appropriate spaces to conduct therapy and the proper attire for a virtual session.
Lee says his practice provides new clients with the general guidelines for informed consent and therapy policy forms using the client portal on SimplePractice. The policies cover the benefits and disadvantages of telebehavioral health, as well as the risks of remotely meeting over a secure teleconferencing platform, the theoretical possibility of a security breach, technological malfunctions and the management of emergency situations. (For more on the specific requirements for informed consent for telebehavioral health, see the first chapter of Distance Counseling and Supervision).
Lee says his practice chooses not to include any formal dress code rules because he has noticed that the way clients dress for a telebehavioral health session can often provide insight into their social functioning.
“No one [has] ever dressed improperly for [a] session in my experience,” he continues. “I always present myself in professional and appropriate attire. [The] attendance and punctuality rules are all the same. I do ask if the client is in a secure setting to ensure privacy and confidentiality if they are at home or [in an] office area.”
Barry tells her clients to treat their telebehavioral health session as if they were going to the doctor. She says she asks them “to be dressed, out of bed and ready to address the issues that are taking place in their lives.”
So far she’s had only one client begin a telebehavioral health session inappropriately dressed: The client was lying in bed in their pajamas and was not fully awake. Barry told the client she was not able to continue the session unless they were fully awake and ready to begin. She asked the client to contact her when they were ready and logged out of the session. The client rejoined the session about 10 minutes later and apologized for not being prepared the first time.
Daniel and Jennifer Williamson remind counselors that they are obligated to provide the same standard of care online as they do in person. “We have heard horror stories of counselors trying to engage a client [who has the] video off while driving a car full of kids,” the Williamsons say. “There are many issues with that scenario. Creating a safe and trusting relationship must begin by creating strong clinical spaces for ourselves and helping our clients create clinical spaces within their own locations.”
For the Williamsons, a clinical space includes the following:
- Being alone in a room that has a door
- Having a door that is closed
- Using a sound machine
They recommend clinicians help clients be creative when defining what a clinical space means for them. When privacy is a challenge, for example, clients can use a closet, bathroom or even a parked car, as long as it is safe. And the “sound machine” could be a radio or television set or a white noise machine.
Defining a clinical space also gives clients emotional permission to advocate for their own privacy, the Williamsons add.
Assessing clients virtually
These counselors interviewed for this article acknowledge that assessing clients virtually can be challenging, but they also say that if counselors remain curious and use their interviewing skills, then virtual assessments can be done properly. In addition, they recommend clinicians consider using virtual platforms that provide tools for clients to self-assess.
Hart admits that assessing clients is one area that has been a learning curve for her. “Because I am a somatic-oriented, body-oriented practitioner, I had to learn how to be more attentive [when assessing clients]. I have a trauma-informed approach too, so at first, I had doubts that I would be able to assess,” she explains.
Hart has also learned to be more inquisitive and exploratory with the client and ask more questions. For example, instead of saying, “I notice that you …,” she now asks, “What do you notice about yourself and your body when you mention this symptom?’”
Hart says she takes a more Rogerian approach to assessments now because it allows clients to become an observer as part of a therapeutic team. “Instead of making first-person observations and verbalizing them, now I teach clients how to be more mindful of their somatic responses,” she explains. “It has worked out well and has created more mindfulness for clients.”
When doing virtual counseling, Lee uses all the same in-person modalities for assessing clients, including motivational interviewing and paying attention to the client’s facial expressions, tone of voice and speech patterns, and body language. And although he can see clients only from their chest up during a virtual session, Lee says he is not missing much in regard to nonverbal communication.
“I can tell enough nuances on face and shoulder postures and movements and can very well see the telltale signs of lethargy or agitation and interest or disinterest as well as I do in person where I can see the entire body,” Lee notes. “What is different in the virtual encounter is the close-up focus of video’s visual framing, which accentuates these clues while, at the same time, the client shows much more of their natural emotional and physiological state in their daily surroundings, unlike being in a doctor’s office.”
The presenting symptoms and the types of online assessment tools the counselors use will help determine the success of a virtual assessment, Eiseman says. She recommends counselors consider online assessment tools such as those provided by Pearson Assessments, which allow clients to assess themselves and submit the assessment for scoring.
Lee and Barry use the SimplePractice virtual platform to assess clients. The platform provides clients with a link to a HIPAA-compliant client portal where they can access assessment forms that screen for depression and anxiety. Clients complete the forms during the intake process and submit them using their own secure portal, and it notifies counselors when the forms are complete.
“It is also important to know the limitations of what you need to assess, as you may need to refer [the client] out if what is best for the client is an in-person assessment,” Eiseman adds.
Jude and Julius Austin say assessing clients often involves counselors using their sixth sense, which is easier to do in person. For example, during an initial intake assessment, a clinician may ask a client about their alcohol usage. “It’s the way they answer that make us intuit that there is something deeper to process in this area,” Julius Austin says. “It could be the heaviness of the client’s voice or the briskness of their responses or their lack of eye contact. Other times, it is the way their feet are shaking or [their] hands are wringing.”
But when assessing clients virtually, it can be difficult for counselors to use their intuition to determine when and if they need to dig deeper. The Austins suggest counselors use themselves as a tool and approach assessments with a “childlike curiosity.” For example, when virtually assessing a client who says they are struggling with anxiety, the clinician can start by examining the client’s choice to use the word struggle. In this situation, the Austins may respond by saying, “What does the word struggle mean to you?” or “What does struggling look like?” And then they would take the same approach with the word anxiety.
“We might share with clients things about their experience that resonate with us. We won’t go into great detail, but we use our experience to deepen the client’s connection to their emotional process in session. If a client feels insignificant, we mentally ask ourselves, ‘When have I felt this way?’” Jude Austin explains. “Instead of processing our experience, we think about the connective emotions and thoughts surrounding our experience, like insecurity, fear and anger. Then we use our experience [to] guide our reflections. As a distance counselor, being curious about our own experience and having emotional courage when sharing can help create the in-person atmosphere when distanced.”
The more counselors use themselves as a tool by sharing aspects of their own experience with clients and approach the process with curiosity, the more they will instinctively use their sixth sense or intuition in this virtual space, the Austins say.
The limitations of virtual therapy
Although proper assessments can help counselors determine whether a client is suited for distance counseling, the counselors interviewed for this article say clinicians should be mindful that some mental health disorders should not be treated using telebehavioral health.
“There are some serious ethical concerns to consider when moving counseling online, but the appropriateness of seeing someone with a serious mental health issue is more nuanced than [whether] in-person or online counseling is better for those clients,” Jude and Julius Austin say. “Nonetheless, we think most counselors can acknowledge that some clients struggling with hallucinations, delusions, self-harming, suicide or homicidal issues need extra considerations.”
The Austins stress, however, that counseling is now being done in “all sorts of nontraditional, personalized and practical ways.” As a result, they say whether a client with a serious mental illness can be treated online depends on the situation and the creativity of the counselor.
The Austins advise their peers to use their clinical judgment rather than a sense of fear as a guide when helping any client to gain the most from counseling.
Eiseman says counselors should look for aspects about their clients that may make virtual therapy more difficult, or even potentially harmful. “Even if a client tells you that they feel comfortable with virtual sessions, it is still our duty to assess that online therapy is right for the client based on our clinical opinion,” she stresses.
Therapeutic interventions in virtual sessions
Counselors can use many traditional therapeutic approaches without having to adapt them for distance counseling. “I don’t have to alter therapeutic techniques like CBT, dialectical behavior therapy, and acceptance and commitment therapy because they are empirically based theories that have existed for decades and therefore have more virtual resources available,” Eiseman says.
CBT is the backbone of Lee’s work. He says virtual clients learn to identify cognitive distortions and correction skills in the same way clients do in person.
One advantage in using distance counseling, Lee says, is the opportunity to see and interact with clients in their personal surroundings. Viewing clients on their “home turf” often gives him insight into their lifestyle, personality, socioeconomic status and even what kind of neighborhood they live in, and he says that these insights can help in a client’s treatment. For instance, he once worked with a married couple who were struggling with a hoarding issue. They initially came to therapy for relationship issues, but as the therapeutic trust was building, the clients were willing to show him their entire living space using a laptop camera, which allowed Lee to see the exact nature of their hoarding. He worked with them during their sessions in real time to catalogue the accumulation and their piling and storage patterns, and he helped them strengthen their reorganization skills so they could reduce their tendency to hoard materials while still being able to access what they needed. By being supported and held visually accountable through the virtual sessions to adhere to the treatment plan, the clients were highly motivated to implement both short- and long-term goals, which improved their standard of living and their relationships, Lee adds.
Barry says she uses the SimplePractice platform’s whiteboard to help virtual clients process feelings of anxiety or depression. She draws the CBT model on the whiteboard during a virtual session and works with clients to help them understand how their thoughts and behaviors work together to create an anxious or depressed state.
“The whiteboard really helps them to see a technique visually, so we are able to interact together,” she says.
Although most therapeutic approaches can be used with clients in person or in a virtual setting, some therapeutic techniques, such as play therapy, exposure therapy, brainspotting and ecotherapy, are not suited for distance counseling, Eiseman adds. Play therapy, for example, relies on the use of tangible items such as sand trays and toys. Although this can be done virtually, she finds it difficult to engage clients in the same way using virtual sand trays compared with in-person counseling. And brainspotting may require the client to have special equipment set up in their home to do it online, she says.
To stay abreast of technological advances and ensure that they are learning to properly integrate in-person counseling skills into virtual counseling, clinicians should continue to seek additional training opportunities. And graduate counseling programs must be intentional about including online therapy in their curricula.
“As this is a new modality for treatment and is gaining more attention and appreciation from both providers and clients, there is growing interest in bolstering educational training,” Jennifer and Daniel Williamson note. “Just prior to the pandemic, it was attended to as much as it now needs to be.”
Graduate counseling programs need to ensure that they train “counselors and supervisors to do distance work ethically and skillfully,” Jude Austin adds. “The more complicated answer is shifting the culture of distance counseling from convenience to a modality with just as [many] nuances as other modalities.”
As a counseling supervisor, Eiseman says all her students and employees are required to complete training on the best practices of telebehavioral health and HIPAA compliance. She also supports digital mental health training in graduate school programs.
“It is also my responsibility as a supervisor to stay up to date on any rules or regulations regarding digital mental health practices, as well as [to] model and teach appropriate practices,” she adds.
Because states may have different rules and regulations for the encrypted programs used in virtual counseling or for online communications and reciprocity, Jude and Julius Austin advise counselors to be aware of the rules their state licensing boards have for providing telebehavioral health services in other states.
In many ways, new counseling graduates are “stepping into a profession that might seem a bit like the Wild Wild West” regarding the guidelines for telebehavioral health, the Austins say. “States have different rules. Some have reciprocity; some don’t. Some are ‘duty to warn’ states and others are not. Some states make counselors wait what seems an arbitrary five years to get to a supervisor status; others have less time.”
The counselors interviewed for this article also say that as telebehavioral health continues to evolve, the counseling profession can play an important part in developing new technologies for its practice. Important legal, ethical and clinical standards of care will likely be left out of the equation if counselors aren’t involved in the decisions around telebehavioral health, Eiseman notes.
Jude and Julius Austin agree. “Counselors should be involved in innovation. Our trained ears, hearts and minds can help shape technology to suit healthy therapeutic relationships,” they say. “Being a part of innovation can also put us in a position to advocate for ourselves as some digital mental health platforms can be a bit predatory and unfair to counselors and clients.”
Hart also thinks that counselors can be the pulse of telebehavioral health in the future. “I think that compassion and empathy — these two very human traits — are rarely found in technology alone,” she says. “If we can bring about more ways to display these human traits within technology, that would be helpful.”
Preparing for virtual emergencies
Securing a client’s safety is a critical step when engaging in telebehavioral health sessions. After a counselor determines that distance counseling is appropriate for the client, they need to work with the client during the intake process to create a safety plan in case the client experiences a crisis during the virtual session. The plan should include the following:
- An emergency telebehavioral health consent form. This form outlines what would happen if a client had an emergency or crisis while being treated virtually, says Jessica Eiseman, a licensed professional counselor supervisor at Ajana Therapy and Clinical Services in Houston. It provides the counselor with an emergency contact and gives the counselor permission to call that contact in the event of an emergency.
- A list of emergency resources. Jennifer Nivin Williamson and Daniel G. Williamson, licensed professional counselors and core faculty at Capella University, say this list should include an emergency contact person — someone who is within 5-10 minutes of the client, the client’s doctors, the client’s medical conditions and the first responders in the area. Jude T. Austin II and Julius A. Austin, licensed professional counselors and counselor educators at the University of Mary Hardin-Baylor and Grand Canyon University, respectively, add that the list can also include a local hospital and police station and the name and contact information of a local counselor or other colleague who is willing to see the client in person, if necessary, during an emergency.
Eiseman reminds counselors to always verify a client’s location when they are in a telebehavioral health session. If that location is not a client’s residence, it is important to get the address of where they are during the session. The Williamsons also recommend counselors document the client’s location in the case notes for every online session.
Lisa R. Rhodes is a senior writer for Counseling Today. Contact her at firstname.lastname@example.org.
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.
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