Tag Archives: Private Practice Management

Private Practice Management

Finding balance in counseling private practice

By Bethany Bray March 25, 2021

Managing a counseling practice takes strength of both heart and mind. To succeed, private practitioners must find balance between two roles: that of the caring, empathic and client-focused clinician and that of the shrewd business owner, which necessarily involves charging fees and making money.

Most people who enter the counseling profession do so first and foremost because they feel called to help others. At the same time, many counselors harbor dreams of one day owning their own practice, and that involves handling tasks that sometimes go against the grain of their helping instincts. Charging fees to clients who skip appointments or following up about nonpayment or a declined credit card can feel unnatural to counselor clinicians, especially after they’ve spent multiple sessions listening to the person talk about the painful life challenges they are facing.

“This is a tough area to navigate for many therapists, myself included,” says Dawn Altman, a licensed professional counselor (LPC) with a practice in Bryn Mawr, Pennsylvania. “It has been my experience that the most difficult area to navigate is my own money mindset and feelings of worthiness. … Most therapists come to this field with a sheer desire to help people work through emotional difficulties and live a more enlivened life. It feels somehow ‘sticky’ to ask for money for supporting someone who is struggling. The lines become blurred between what comes naturally to most of us — helping others — and requiring payment for our services.”

Money, money, money

One major aspect of maintaining balance between the heart and mind aspects of private practice involves setting — and enforcing — rates and fees.

When she first started her practice, Altman set her fees low because she doubted her own value. “Looking back, what came up for me was what is known as impostor syndrome — that internal experience of believing that you are not as competent as others perceive you to be. This is true of so many women in particular,” Altman says. “I had to get really deep with myself and ask myself, ‘Do you fear success as a business owner more than you want it?’ The answer was, of course, no, so I had to just rip the Band-Aid off and feel the fear and bill [clients] anyway.”

Now, after years in practice, Altman has found that her caseload feels balanced when she reserves three slots in her schedule for clients who pay on a sliding scale. If a potential client requests to pay on a sliding scale and those three slots are already filled, Altman has a list of practitioners to whom she can refer the client so they are not left without options. “I find that this system works for me because I can still provide a service to those who may not be able to afford my normal fee, but I don’t get resentful that I am working for pennies,” says Altman, a member of the American Counseling Association.

Norm Dasenbrook, a licensed clinical professional counselor (LCPC) with a practice in Rockford, Illinois, believes that counselors’ ethical mandate to keep up with self-care includes financial self-care. It’s not greedy to charge what you’re worth; it’s necessary, he says.

“If I’m thinking about how I’m going to pay the rent for my office when I’ve got a client in front of me, that’s not the best care,” says Dasenbrook, who also runs a consulting company that offers trainings and workshops on managing a therapy practice. “Charging what you’re worth is the best care for clients because you’re not thinking about that stuff when a client is in front of you. We [counselors] work hard and should get paid for that.”

Dasenbrook advises that private practitioners who are starting out should ask local colleagues about their rates to find the “community standard.” From there, they should decide on comparable rates and fees and stick to them. Private practitioners should also keep in mind that most clients are not going to shop around and choose a therapist based only on their hourly rate, he says. Rather, that decision revolves around many factors, from a practitioner’s area of expertise to their reputation.

From Dasenbrook’s perspective, the business and empathic sides of private practice are not mutually exclusive. Practitioners can find ways to accommodate clients with empathy while still getting paid, he says. For instance, with clients who are having financial difficulties, Dasenbrook will work out a payment plan allowing them to pay in small installments, or he will offer them half-hour sessions for a lesser fee. In other cases, he will refer clients to local charities or agencies that offer free or reduced-price therapy. These measures all ensure that clients are treated with care and continue to get the help they need, which is empathic, Dasenbrook says.

“To me, [the caring and business sides of counseling] go together. You’re providing a service and collecting a fee. There’s nothing mutually exclusive in there. You can do both with empathy,” says Dasenbrook, who has provided private practice consultations at the ACA Conference & Expo in years past.

Counselors in private practice who struggle with the idea of charging fees should look at how other service professions approach it, Dasenbrook says. He points out that plumbers and car mechanics don’t feel guilty about charging what a service is worth, and he stresses that counselors shouldn’t either.

“Don’t lowball your fees,” he urges counselors in private practice. “Think of other professions. A cardiologist that’s just out of school charges the same as one who has been working in the field for 10 years.”

Bethany Lato, an ACA member with two office locations in the Milwaukee area, also finds that the empathic and business sides of practice management can be interwoven through intentionality and commitment to purpose.

“One way I [incorporate empathy] is by maintaining a clear vision, purpose and foundation for what my business is and who it is for,” Lato says. “When focusing on tasks such as finances, sales and marketing, web presence and long-term business planning, I tend to wear more of the entrepreneurial hat. I think about it from the business perspective: What makes the most financial and business sense in order to achieve that mission?

“From there, I circle back around to empathy: How is this serving my clients and the people that I hope to reach? Am I making sure that I am taking care of my needs while also providing care to others? By beginning my work and concluding my work from a place of empathy, I aim to find that balance and never get too caught up in the business side or in simply making money. Sometimes this comes naturally, and other times it takes a conscious effort to maintain focus on the true mission and what feels truly aligned for myself and the clients I work with.”

Caseload questions

Determining caseload size and finding the “right” number of clients to see per day in private practice is an individualized decision. Counselors must charge high enough rates and take on enough clients to make money and stay solvent, yet still keep their caseloads and daily schedules from becoming so packed that they can’t give clients (or themselves) the time and attention they need.

It’s a balance that varies for each private practitioner and one that must often be determined through experience. Kristy Crump, an LCPC in Bel Air, Maryland, continued to work three days per week in an agency setting as she began her private practice in 2014. Within a year, she was fully booked and able to leave the agency, transitioning into private practice full time.

Finding the right balance was a matter of trial and error, she says. “You have to evaluate how you feel at the end of the day, at the end of the week. I was seeing 10 or 12 clients in a day and would be exhausted and struggling to keep up. It just took time to learn what’s right,” Crump says. “Now, my balance is six [clients per day]. I have some colleagues who say, ‘Four is plenty for me,’ and others who say they can do 10. You have to figure out [a schedule] where you still feel like yourself at the end of the day.”

Dasenbrook recommends that private practitioners start with an end goal in mind when determining their optimum caseload. Do they want to maintain a second source of income, such as teaching or consulting, while operating a private practice? How many vacation days do they want to take each year? Do they want to ease into semiretirement in a few years? Once private practitioners determine their long-term goals, they can work back from there to figure out how many clients they will need to see to meet (or to leave time for) those goals, Dasenbrook says.

Developing a reliable list of referral sources is also an important part of managing caseloads as a private practitioner, Altman notes. Over the years, she has discovered that she operates best when seeing fewer than 20 clients per week. This helps her maintain balance with other facets of her life, including time spent with family and her identity as a “lifelong student.”

“I quickly found out that seeing over 20 [clients] per week does not work for me. I feel pulled in too many directions, and my family life suffers, as does my own physical and emotional well-being,” Altman says. “I am very intentional about the type of client that I want to see, and while it is hard to turn people away, I now have a waiting list for those who want to wait specifically for me, and I have a list of five or six trusted therapists in the community to whom I refer when I cannot accommodate the client. … This alone has made a huge difference to me in my work-life balance because I enjoy each of my clients, and I am not burned out at the end of each week.”

Out of whack

Bryan G. Stare, an LPC and counselor educator who has experience working in private practice, is a critic of what they call the capitalist U.S. health care industry. Many of the decisions counselors who own private practices must wrestle with — whether to see fewer clients, whether to waive fees, whether to do pro bono work — have an effect on the bottom line of their business. This is an issue that often contradicts the counseling profession’s commitment to pursue social justice, Stare says.

“You’re put in a difficult position in private practice. You’ve paid a lot of money for this education, whether it’s a master’s or a Ph.D. To live comfortably, there’s often pressure to charge more for your services. But many of us have entered this profession because of a call to help or for social justice. … It does create some strife there,” says Stare, an assistant professor and director of the clinical mental health counseling program at the University of North Carolina at Charlotte. “We need to take care of ourselves and our business to take the best care of our clients. If I’m not doing that, I’m not able to create a safe space to care for my clients. If I’m spread too thin, I won’t be able to provide ethical and competent care to clients. [But] the system isn’t designed for that; it’s a profit-driven system designed to garner corporate wealth and leave people suffering.”

Navigating this balance requires that private practitioners keep consistent tabs on how they’re feeling about their workload. Only counselors themselves can recognize when their balance is out of whack and they’re spending too much time either on business tasks or client care.

For Crump, it comes down to how she feels at the end of the workday. If she’s irritable or exhausted, it means she needs to reassess her workload. “If I’m not at 100%, I’m not helping [clients] much,” she says.

Crump acknowledges this balance got thrown off when the COVID-19 pandemic caused her to shift all of her client sessions to a virtual platform. Crump specializes in anxiety disorders, and she says some of her clients became needier amid the stressors of the pandemic. In conducting sessions and other aspects of her practice from home, the boundary line between when she was working and when she was “off” began to blur. Crump says she had to check herself and take a step back to regain her balance.

“Of course I want to take crisis calls, but I would soon find myself three sessions over my limit [for the day]. It’s a struggle because you do have that control. You can say yes. I don’t have a front desk that will say, ‘Sorry, she’s booked for today,’” Crump notes.

Stare, an ACA member who counsels a small caseload of clients in addition to teaching and research work, agrees that emotions are a barometer. Private practitioners should recognize signs of burnout and regularly process their own feelings. Stare’s support circle consists of trusted friends, colleagues and mentors with whom Stare can consult.

Multiple private practitioners interviewed for this article say their bodies give them clues — such as feeling tired, worn out or achy — that indicate their professional balance is out of alignment.

“We teach our clients to do this, and we have to listen to our own body and our own needs too, and nurture ourselves as we tell our clients to do,” Crump says. “We have to take steps back and reflect. It gets very stressful. Some days are really hard. I’m a full advocate that every therapist should have a therapist — they can help keep you in check too.”

Lato notes that somatic cues tell her not only when her workload is imbalanced but also when things are going well. When her work is in balance, “I find myself genuinely excited about my business and my practice, rejuvenated by my sessions with clients, and with vivid dreams and visions of what the business can be in the future,” Lato says. “It is that vision that often gets me through the difficult, out-of-balance times as well. I spend a lot of time journaling, meditating and vision boarding around the future of the business and my practice, and find it is always important to know where you are heading. With this clear vision and direction, it becomes easier to recognize when things are out of balance.”

Put it in writing

The counselors interviewed for this article agreed that one of the best ways private practitioners can minimize the need to have difficult conversations with clients about payment is to offer clear, thorough communication about fees and expectations before any counseling takes place.

Crump provides a full explanation of her policies in the informed consent that clients sign at intake, but she also talks the policies through with each new client before they begin counseling work. “It took me a while to get a flow to be able to speak about that to clients,” admits Crump, an ACA member. “It’s hard to say, ‘Hi, hello, I have a cancellation policy.’ … [But] if you are genuine, you’ll get that in return. When I let [clients] know my boundaries and no-show fees, I’m being honest. I explain that it’s ‘housekeeping.’ It’s important to talk about it, get it out of the way and separate sessions into counseling and noncounseling work.”

Enforcing professional boundaries, such as imposing cancellation fees on a client who repeatedly no-shows, also models healthy behavior for clients, Crump adds. “I’m teaching boundaries to all of my clients, so I want to make sure I have boundaries myself,” she says. “I make sure to set boundaries with clients from day one. I’m direct, and if I answer a crisis call in the evening, I talk about how this won’t become a regular thing.”

Yet Crump acknowledges that she still finds it hard to charge fees, even after years in private practice. It presses on her empathic reflex, she says, because she doesn’t want to discourage people from seeking counseling.

“I hate having the conversation to this day,” she says. “It’s hard because we’re in a helping role. We’re here to help, and it doesn’t feel congruent with what we’re taught. You’re imposing a boundary on them, but unfortunately, that’s part of the business. There’s no one to enforce that but me. It’s easier [when] you talk about it upfront, instead of waiting until it happens and then springing a fee on them. It’s a necessary evil that you have to do. At the end of the day, you’re running a business, and you have to pay bills yourself.”

Crump and the other private practitioners interviewed for this article say that before enforcing a cancellation fee, they usually extend a one-time grace period for clients who miss an appointment. They also make exceptions for late or lesser payments from existing clients facing hardships such as an unexpected job loss. However, they agree that charging fees to clients who are chronically late with payments or repeatedly miss appointments is a necessity.

“I will usually say to the client, in writing, ‘Twenty-four hours’ [cancellation] notice affords me the opportunity to offer your appointment time to a client who may be on a waiting list or who needs an urgent appointment. I hope you understand that I must charge you for missed appointments,’” Altman says. “Being upfront about fees and payment options is crucial in setting up a good relationship with the client and [establishes] the clear boundary that therapy is a valuable service for which payment is expected.”

Enforcing fees not only helps to ensure that a private practitioner’s finances stay in the black. It also sends a message that counseling requires commitment and intentionality from both parties — counselor and client.

“At the end of the day, if I don’t set a boundary, I may not be acting therapeutically,” Stare observes. “If we’re not meeting regularly or semiregularly, depending on [a client’s] presenting concern, we’re not going to make therapeutic gains. Ethically, I can’t provide services that aren’t going to help.”

Dasenbrook urges private practitioners to spend time crafting thorough informed consent documents. Including details such as the hourly fee for services provided outside of counseling sessions (e.g., letter writing, filing court documents) ensures that clients are fully informed prior to being charged, he says.

Language centered on client consent, privacy laws and other practice issues varies from state to state, so private practitioners should seek training and consult with local colleagues and their state counseling associations when creating informed consent documents. “These are the people who are going to know the funky laws” in your state, Dasenbrook asserts.

The language in informed consent documents needs to be thorough and firm yet welcoming and calming, Dasenbrook adds. Clients filling out these forms are seeking therapy, so they may not be in their best mental state, he points out. They shouldn’t be made to feel as if they’re doing something akin to signing the seemingly endless number of pages involved in buying a home. Breaking informed consent into sections — treatment of minors, telebehavioral health, fee schedules, privacy laws/release of client information, etc. — makes things easier for clients to digest and allows counselors to remove sections that do not apply to particular clients. Per the 2014 ACA Code of Ethics, practitioners must include information about alternative/continuing service options should the counselor experience an emergency or pass away.

Ultimately, the time spent creating thorough informed consent documents should mean fewer confrontations with clients regarding fees and other policies down the line. “The business piece [of private practice] should be all taken care of in your informed consent,” Dasenbrook says. “It should be communicated upfront, before we even say, ‘What brings you here today?’

“Put it in writing, and get it all out ahead of time. … You want to take the money piece out of it [counseling] as best you can, and that’s why [I do it] all upfront.”

Getting down to business

The professionals interviewed for this article shared the following tips and insights on blending counselors’ caring instincts with the business side of running a private practice.

>> Maintain separate spaces: Stare uses an existential humanistic approach that recognizes the importance of feelings of place. With that in mind, Stare recommends asking for and accepting client payments in a space that is separate from the counseling room. If possible, keep a credit card machine or other payment mechanisms in another room and walk there with the client to take payment. Not sitting in the same chair and in the same room where therapy takes place to accept payment helps separate the two concepts for counselor and client alike, Stare says.

>> Pay first, talk second: Crump recommends taking payment from clients at the start of a session, before any counseling takes place. Crump didn’t always follow this process but eventually adopted the approach to avoid the awkwardness of having to transition from discussion of heavy, therapeutic topics to request for payment.

Keeping a client’s credit card number on file for automatic charging can also be beneficial if practitioners find it a good fit. Dasenbrook notes that private practitioners now have many convenient payment options, including apps such as Venmo and PayPal, compared with when he started in the profession three decades ago.

>> Stay on top of housekeeping: Tackling those unappealing tasks right away can be a benefit to private practitioners and their clients. For instance, Dasenbrook says, if a client’s credit card is declined, call them right away; don’t put it off or even wait until they come in for their next session. Addressing it immediately gets the issue resolved and is more likely to result in payment.

Similarly, Crump stresses the importance of filing insurance claims and paperwork as soon as possible after client treatment. This is especially important with new clients, to find out whether the private practitioner’s services are covered or whether the client has a deductible to meet. The sooner a practice owner knows there is a gap in a client’s insurance coverage, the sooner payment arrangements can be made, especially while the session is still fresh in the client’s memory. “Even though those case notes take longer, it’s worth it [to file right away],” Crump says.

Altman notes that a tough-love approach is sometimes necessary when tackling tasks that might go against a counselor’s empathic nature. “I used to offer monthly bills, which the client could then submit for reimbursement. However,” she says, “I found that several clients would simply ‘forget’ to pay. Their bills were racking up, and I was feeling resentful over both not being paid and the time it was taking me to have to rebill every few weeks.

“One client in particular would not pay me in a timely manner, and his bill would go unpaid for several weeks. I sent multiple reminders via email that he did not respond to. When the bill was a month overdue, I emailed him the bill one final time and told him that I was unable to provide the Zoom link for our next session until he had cleared up his account. He paid the bill immediately, and at our next session, I began with [talking about] the issue of payment. We agreed that moving forward, he would simply pay weekly, which he has done since that time.”

>> Play by the rules: Crump recommends that practice owners determine their “hard and fast” rules and endeavor to stick by them. For Crump, this includes taking Friday and Sunday off each week. She blocks those days off on her client schedule. In addition, although she doesn’t mind working in the evenings on occasion, she will build time into her schedule on a subsequent morning or afternoon to catch up on administrative tasks.

Another rule Crump has established for herself is never to send a client to collections for nonpayment. “I don’t see the need to cause unnecessary harm to those [clients]. If they could pay, they probably would have. It just doesn’t feel right,” Crump says. “Also, it [collections] is just one more thing to learn how to do and keep up with.”

>> Don’t do it all: One good way private practitioners can keep from becoming overwhelmed is to wield technology to their advantage, Dasenbrook says. This includes building a practice website with client intake and screening forms that ask for a person’s home address, insurance details, emergency contacts and other basic information. This negates counselors having to spend time asking for and transcribing this information in person or over the phone.

Dasenbrook also recommends that practice owners consider using software or hiring a professional to handle administrative tasks that they dislike or struggle doing themselves. That’s what Dasenbrook does with billing. “If there are tasks that you don’t like, then hire it [out],” he says. “You can try and do it yourself at first to learn and save money, but ultimately it makes sense to hire out if it causes a headache and takes too much time. Once your practice grows, start farming some of that stuff out.”

>> Seek and value supervision: “The No. 1 tip I would offer is to spend the money for high-quality supervision,” Altman says. “I had an incredibly gifted supervisor whom I worked with when I began, and it made a huge difference in the amount of time that I had to spend ‘winging it.’ Most of our supervision hours were spent on case discussion, but sometimes we talked [about] the business of private practice. It was enormously helpful to me as a business owner. Peer supervision is another great way to connect with others to share tips and insights and to just have a sounding board for cases or for life as a therapist in private practice.”

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Necessary skills

Private practice management demands a wide variety of skills, from overseeing scheduling and billing to determining one’s caseload size and handling client referrals. A successful private practitioner must also hone a number of skills beyond the nuts-and-bolts tasks of managing a practice, says Norm Dasenbrook, a licensed clinical professional counselor with a practice in Rockford, Illinois.

Dasenbrook considers the following qualities “musts” for private practitioners:

  • Clinical competency and excellence
  • Healthy self-esteem, self-awareness and the ability to set boundaries: This involves knowing what you’re good at and what you’re not, Dasenbrook advises.
  • The ability to know when you’re over your head professionally: This involves realizing when a client’s needs go beyond your skills and that you should seek consultation. Dasenbrook has been a counselor for three decades and still runs into issues for which he seeks consultation from peers. “It happens to everybody — when you’re sitting in session and you have no idea [how to help a client]. We’ve all been there. I’ve been there many times,” he says.
  • A business mindset and inclination for bookkeeping, scheduling, keeping medical records and other administrative tasks
  • Being comfortable with taking risks: “Sometimes we fail, but we keep on going,” Dasenbrook says. “You need to see yourself as an entrepreneur. Some things won’t work out, but you learn from it and move on.”

What skills would you add to this list? Post your thoughts in the comment section of this article, below.

 

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Action steps to learn more

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Pro bono: Yea or nay?

The 2014 ACA Code of Ethics encourages counselors to “contribute to society by devoting a portion of their professional activity to services for which there is little or no financial return.”

What role does pro bono work play for private practitioners who are trying to balance their empathy with the financial side of running a business?

Explore this topic further in an online companion piece to this cover story, “Pro bono counseling: How to make it work.”

 

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Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

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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.

Pro bono counseling: How to make it work

By Bethany Bray March 24, 2021

The 2014 ACA Code of Ethics encourages counselors to “contribute to society by devoting a portion of their professional activity to services for which there is little or no financial return.”

This is an important tenet of the counseling profession, and one that pulls at counselors’ empathy and call to social justice. However, counseling clients for a reduced fee or for free – pro bono – in a private practice setting comes with some caveats.

John Duggan, senior manager of continuing and professional education at the American Counseling Association, stresses that private practitioners who have any kind of third-party contract, such as agreements to accept clients from an employee assistance program, Medicaid or elsewhere, must take positive steps to avoid risk if they charge anything other than the same rate for service for 100% of their caseload. This is due to several reasons:

  • Charging different rates for services reimbursed by federally funded programs opens the practitioner to risks of fraud accusations or investigations by the U.S. Centers for Medicare & Medicaid Services (CMS). In general, Medicaid and other third-party insurance plans prohibit practitioners from waiving copays.
  • Insurance companies may be unwilling to honor a fee schedule if a practitioner charges different fees for the same contracted service to different clients.
  • Offering remuneration to clients is unethical and potentially illegal (see Standard A.10.b. of the 2014 ACA Code of Ethics). While there are exceptions, waiving copays/fees and underbilling are potential HIPAA violations.

Lastly – and perhaps most importantly – Standard C.5. of the ethics code prohibits discrimination in professional counseling. Offering different fees to different clients could potentially make a counselor’s health care business vulnerable to accusations of discrimination or lawsuits, Duggan says.

The only private practice scenario that would be exempt from the above points is if a counselor does not have any existing third-party contracts and treats 100% self-pay clients, without insurance, he notes.

“It is ethically essential to prioritize our work that’s pro bono,” says Duggan, a licensed professional counselor and licensed clinical professional counselor. “However, the bottom line is that professional counselors who manage a health care business should also operate as ethical businesspeople. Always consider ethical, legal and compliance issues before reducing fees, copays/fees or underbilling.”

Duggan points out that there are many ways a counselor can do pro bono work that do not involve counseling clients on their practice caseload. Volunteer or reduced-fee work in the community – anything from public speaking or leading workshops to mental health response during disaster situations – can be a rewarding way for counselors to give back.

There are also organizations and agencies that facilitate the counseling of clients outside of a clinicians’ existing caseload. Duggan points to the Pro Bono Counseling Project (probonocounseling.org) as an example. The Maryland-based nonprofit pairs clients with limited incomes who are uninsured or underinsured with volunteer practitioners for free mental health care.

When it comes to navigating the nuances of pro bono work, Duggan suggests counselors refer to ACA’s numerous resources, most notably the 2014 ACA Code of Ethics (including standards C.1. and I.1.b.) and The Counselor and the Law: A Guide to Legal and Ethical Practice by Anne Marie “Nancy” Wheeler and Burt Bertram, particularly Chapter 3 (available at counseling.org/store). Practitioners may also want to consult an attorney for guidance.

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2014 ACA Code of Ethics, Standard C.6.e.

“Counselors make a reasonable effort to provide services to the public for which there is little or no financial return (e.g., speaking to groups, sharing professional information, offering reduced fees).”

  • See the full ACA Code of Ethics at counseling.org/ethics
  • ACA members who have further questions can schedule a practice or ethics consultation with ACA’s counseling specialists by emailing ethics@counseling.org. 

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Pro bono: Opportunities

  • Remain cognizant of the potential for exploitation of clients, attend to their vulnerabilities, and consider their best interests in all professional decisions.
  • Look for opportunities to serve your local community by providing some pro bono services that capitalize on your unique interests and skills (e.g., speaking, teaching, mentoring, leading support groups, volunteering at a local nonprofit clinic).
  • Remember: Pro bono services are subject to the same rigorous ethical standards as all other counseling services. Practitioners offering clinical mental health services must also remain compliant with state and federal laws.

Source: John Duggan, senior manager of continuing and professional education at the American Counseling Association

  

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Read more

Counselors who enter private practice often find themselves confronting the push and pull between their desire to provide empathic, client-focused care and the need to turn a profit. Counseling Today will take an in-depth look at this topic in the magazine’s April cover article, “Finding balance in counseling private practice.”

 

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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.

Voice of Experience: Managing requests for client information

By Gregory K. Moffatt February 23, 2021

In nearly four decades of practice, I’ve experienced a number of attempts by various individuals to gain access to my client records. Here are a few of them.

  • Two police officers showed up in my office asking for records regarding a former client. They told me that the person was of interest in a very serious crime and they were trying to close that case. Would I please give them my records for that client? When I told the officers that I would be happy to comply with any order from the court, they pressured me. “Really! You are going to make us get a subpoena?” Yep.
  • An attorney sent me a very official looking letter that I believe was deliberately drafted to look like a court order. It was full of legal jargon and demands for information regarding a former client. I could have simply thrown it in the trash, but instead I called the attorney’s office. I knew the attorney would be waiting on my call. Sure enough, when I told the receptionist who I was, she immediately patched me through to his office. He answered on the first ring.

“I’m calling regarding your ‘request’ for information from me,” I said. Not waiting for him to make a comment, I continued, “I’m sure you know I cannot even acknowledge who my clients are without a court order or the client’s permission. Do you have either of those?” Of course, he did not. The call was polite and short. I never heard from him again.

  • A parent called my office seeking “any records whatsoever” I had pertaining to my therapeutic relationship with his son, who was a minor at the time. Ordinarily, I would have been happy to chat with a parent. However, I knew that this father’s custodial rights had been terminated by the court (my client’s mother had provided those documents to me), so the man calling me had no legal right to his son’s records. I declined his request.

Without experience, it might be easy to be intimidated by police, angry parents or clever attorneys. But you cannot be arrested (as I was threatened on one occasion) for following counseling ethics and HIPAA requirements regarding client information. In fact, you will likely be in greater trouble if you concede to these “requests” and thus violate our code of ethics.

To make your life a little less stressful, let me suggest three simple statements/rules that will help you know when to divulge information and when to stay silent.

First, never forget this line: “Who my clients are or are not is confidential information.” The two officers I mentioned above began by saying, “We are here to talk about M— S—, one of your former clients. Do you remember her?”

They were playing me. If I had acknowledged that I remembered her (as, in fact, I did), they would already have been on their way to pressuring me for more information. I simply delivered the line above and then shut my mouth.

Second, remember to ask, “Do you have a court order?” No court order is verbal. Police officers, lawyers and others have tried to tell me they had a court order and wanted me to provide information. I always state that I’m happy to comply with any court order that I receive. Unless a court order is provided to me, that is nearly always the last I will hear about a request for information.

Even if a printed order is provided, it must be signed by a judge. The lawyer who tried to scam me knew he couldn’t forge or fake a judge’s signature without risking losing his license and perhaps going to jail. I always first flip to the last page of the order to see what judge signed it. No judge’s signature, no information.

Finally, ask, “Who has legal right to this information?” Without a court order, that legal right generally lies exclusively with the client, but in the case of minors, those who have legal guardianship can request records as well. That can get complicated, as I indicated in the scenario above. If I hadn’t anticipated the question of legal guardianship, I might have provided client records to a person who had no right to see them.

If you have no experience with court orders, always consult with your professional organization or a trusted and experienced colleague. If you have questions about a court order, you can call the court to confirm or clarify.

One final caveat: I am not an attorney. I know some jurisdictions may have systems in place that differ from what I’ve described, so check with legal counsel in your area before you need it. You will then be prepared.

 

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Gregory K. Moffatt is a veteran counselor of more than 30 years and the dean of the College of Social and Behavioral Sciences at Point University. His monthly Voice of Experience column for CT Online seeks to share theory, ethics and practice lessons learned from his diverse career, as well as inspiration for today’s counseling professionals, whether they are just starting out or have been practicing for many years. His experience includes three decades of work with children, trauma and abuse, as well as a variety of other experiences, including work with schools, businesses and law enforcement. Contact him at Greg.Moffatt@point.edu.

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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.

Choosing your path wisely

By Lindsey Phillips September 30, 2020

Some careers offer a limited number of pathways and opportunities after a person graduates. The good news is that counseling is not one of those careers. Counselors can work in agencies, community health centers or hospitals. They can start a private practice. They can run a clinic. They can work in or with schools. They can teach or do consultant work. They can get a doctorate and move into counselor education. They can pursue licensure and specialty certifications. They can even use the skills they have developed to work in positions outside of the field.

The bad news is that these myriad options can leave many counselors feeling overwhelmed and unsure about their next professional steps. What follows are a dozen common questions that beginning counselors (and even, on occasion, established counselors) ask about possible career paths. The insights offered by several different American Counseling Association members with varied backgrounds can provide some guidance on deciding which path might be right for you.

With so many options, where do I even start?

Start with the end in mind. To put career goals into perspective, Norm Dasenbrook, a licensed clinical professional counselor (LCPC) and owner of the private practice Dasenbrook & Johnson in Rockford, Illinois, as well as the consultant agency Dasenbrook Consulting, recommends that counselors ask themselves, “Where do I want to end up?” Or, as he sometimes phrases it, “What do I want on my tombstone?”

Do beginning counselors ultimately want to teach or do research? Do they want to treat clients? Do they want to own their own practice? These questions can help people figure out their priorities and chart their own path toward that long-term goal, he explains.

Shannon Hodges, a professor of clinical mental health counseling at Niagara University in New York, says determining a long-term goal and thinking through the steps needed to get there requires that counselors engage in self-reflection: What is their true passion? Do they want to be a professor, run a clinic, work in an agency, be a consultant or open their own practice? Furthermore, what do they know about the responsibilities involved with that career path? What are the steps required to make that career happen?

LeTea Perry, an LCPC at the Bridges Wellness Group, a counseling practice with offices in Washington, D.C., and Hyattsville, Maryland, recommends that counselors first figure out what is important to them. Do they mind working in the evenings or on the weekends? What are their personal obligations? Do they like conducting research, teaching, consulting or public speaking? Do they like working with clients? If so, what populations do they want to work with? Do they want to open a counseling office in multiple locations? Do they want to become known as the expert in a particular knowledge area?

No matter how counselors answer these questions, the important thing is that they choose a path that makes them happy both personally and professionally, Perry adds.

How do I learn more about my career options? 

Hodges, a licensed mental health counselor and approved clinical supervisor, advises counselors to interview others in the field to learn about the responsibilities and realities associated with a particular job. Running a clinic or becoming a professor may sound like a great idea, but unless you talk to others who are actually doing the work, you won’t really know if it is a good fit for you and your lifestyle, he says. For instance, Hodges finds that counseling students who say they want to be professors have often neglected to talk with faculty members about what’s involved in that role. Many of these students don’t realize that professors are often promoted more for their research and writing; it’s not just about their teaching skills.

Judith Wambui Preston, a licensed professional counselor and owner of the private practice Centered Counseling Services in Chesapeake, Virginia, says that leaders in the profession can be great career resources. For example, a counseling student could contact the director of a mental health agency and ask how that person wound up in that position and what they do on a daily basis.

Mentorship provides another way for counselors to learn about career options. Perry stresses the importance of finding good mentors because beginning counselors don’t know what they don’t know. In her experience, professionals in the field are typically willing and even excited to share their backgrounds and wisdom. But beginning counselors have to take the initiative and ask.

Counselors should also strive to get involved with local and national professional organizations, where they are more likely to find mentors and be exposed to other professionals who have done what they want to do. Perry says most of her career opportunities have stemmed from connections she made by being a member of the Maryland Counseling Association and ACA and by being an alumna of Bowie State University and Argosy University.

Dasenbrook, a past president of the Illinois Mental Health Counselors Association, agrees that joining a professional association is worth the money. Twenty years ago, a colleague at a conference asked if Dasenbrook would host a workshop on starting a private practice because of his experience. Today, Dasenbrook presents this workshop at both the state and national levels. He advises counselors to get involved with their professional organizations by volunteering to be on a committee or volunteering at their annual conferences.

Supervisors also serve as career support, Preston notes. “The supervisor is the bridge between being a master’s student and entering the world of being licensed,” she says. Several supervisors have guided her through her career journey, and now, in turn, she serves as this bridge for new professionals.

Should I get a job if I don’t know what I want to do yet?

Yes. In fact, gaining practical experience often helps you figure out what you want to do.

Community mental health centers and state-funded or federally funded agencies are great places to learn more about the type of client populations and diagnoses that you want to work with, says Dasenbrook, author of After 40 Years in Therapy, What Have I Learned? and The Complete Guide to Counseling Private Practice.

Perry recommends that counselors make a career list and pick three counseling pathways that sound interesting to them. “You never know what you like or what’s your superpower until you try it out,” she says.

While getting her master’s degree, Perry worked with clients with severe mental health disorders such as bipolar disorder and schizophrenia as a case manager at a group home. To make a more informed decision about her career path, she decided to work with other populations before deciding between mental health and school counseling. So, she volunteered as a Girl Scout troop leader at a Washington, D.C., homeless shelter. The children in the shelter were the members of her troop, and this outlet allowed the girls to have fun and engage with one another. After being drained by work and school, Perry found herself excited to see this group of girls. That’s when she realized that she wanted to work with children. She went on to be a school counselor in southern Maryland for more than a decade.

By trying out different jobs, “You’ll find the populations you thrive at working with,” Perry says. “You’ll see how much [money] you can make doing that and if you want to get further certified to move up in the ranks.”

What can I do with a master’s degree in counseling?

Many graduate counseling students come out of undergraduate psychology programs assuming that they’ll need to obtain a doctorate to have a successful career in the counseling profession, but that’s not the case, Hodges says. To reinforce this point with his students, he shows them that master’s counseling students at his university have a 100% placement rate and only around 10% pursue doctoral degrees. So, unless a student wants to be a full-time professor, they don’t have to earn a doctorate, adds Hodges, who has written several publications, including The Professional Counselor: Challenges and Opportunities and The Counseling Practicum and Internship Manual: A Resource for Graduate Counseling Students.

Of course, this doesn’t mean the journey from master’s degree to counselor licensure is an easy one, Preston points out. In fact, it is often a long and costly process. In Virginia where Preston practices, counselors have to accumulate 3,400 supervised hours before they can take their exams and become licensed.

But counselors who are working toward licensure still have lots of career options. They can work in mental health agencies, community mental health agencies, detox faculties, hospitals, residential facilities (e.g., psychiatric inpatient facilities), correctional facilities, schools and university counseling centers, Preston says. They can also find places to work that will pay for them to get supervision, she adds.

“The great thing about a training program like counseling is that the skills go well beyond the profession,” Hodges points out. He’s had several students who have used their counseling skills in professions outside of the field. For example, one student decided counseling was not for her, so she became a professional coach. Another former student served as the assistant director of human resources at a university and used counseling skills to handle sexual harassment claims, mediate disputes and talk with employees who were being fired.

Hodges has noticed that many colleagues working in student affairs (e.g., residence life, the office of the dean of students, student activities) also hold counseling degrees. “In this era of severe mental health concerns among college students, a counseling background is very helpful,” he adds.

Dasenbrook found a niche applying counseling skills such as “I” language, reflective listening and empathy to business and industry. For example, he has coached highly technical people who lacked the communication and people skills needed in their positions as directors or supervisors.

What are the benefits and challenges of getting a doctoral degree?

After Perry finished her master’s in school counseling, she got a job in a school system. That same year, she received notification that because of budget cuts, she might lose her job.
She was upset and angry because she had thought a job in public education was safe.

Perry took one day to cry about it, and then she made a plan to never be in that situation again. She decided to return to school and get her doctorate to increase her versatility and stability and to have more control over her future earning potential. With a doctorate, more opportunities have opened up for her, she says. She teaches as an adjunct in a counseling program, works in a clinical practice, and provides trainings on social-emotional intelligence, ethics and other counseling topics for community organizations and universities. The knowledge and expertise she acquired during her doctoral program have also put her in position to earn more money.

Hodges acknowledges that getting a doctorate can open up more job possibilities, but counselors should first weigh the benefits with the cost, he says. That cost can be high, involving several additional years in graduate school and a large financial commitment.

If someone is considering pursuing a doctorate, Hodges advises them to seriously consider the following questions: Will a doctorate help you achieve your career vision? Do you have a support system (e.g., family, friends, an active self-care plan) to assist you in this pursuit? What value will the doctoral degree add? What is the return on the investment? Given the high cost of education today, manageable debt is one of the first things that people need to consider, he adds.

Perry recommends that counselors figure out their motivation — their “why” — before investing time and money in pursuit of a doctoral degree. For her, that “why” boiled down to anger, fear and uncertainty at the possibility of losing her job to budget cuts and the desire to diversify her career options.

For Preston, the decision to get a doctorate was a long time coming. She had entertained the idea more than once over the years, but the timing never felt right. Her kids were young, or she was busy with her own clinical practice. Plus, after taking out school loans for her master’s-degree program, she had promised herself that she would not pursue a doctorate unless she had financial help. (For more on Preston’s career decisions after graduation, see her contribution to Julius Austin and Jude Austin’s Surviving and Thriving in Your Counseling Program, published by ACA.)

Now, 15 years after earning her master’s degree, Preston says it is finally the right time for her. She just finished her first year as a doctoral student in the counselor education and supervision program at Old Dominion University in Virginia — with a tuition stipend.

What if I want to teach but don’t want to research?

There are ways to teach without having to research and publish. One option is to teach as an adjunct. Larger universities often require more research and publications, whereas adjunct faculty and some community college faculty positions don’t.

Conducting workshops is another way to teach others. Dasenbrook always wanted to teach, but because he didn’t have a doctorate, he knew it would be difficult for him to do so at a major university. Instead, he discovered that he could teach other counseling professionals how to improve their own skills and businesses through workshops. He has taught mediation skills for business and industry, and now he teaches workshops on how to start and build successful private practices. 

Hodges has noticed some universities are hiring clinical professors, which is a faculty position that focuses more on teaching and supervision. One of his colleagues at Niagara University was hired to oversee clinical placements and teach part time. She was drawn to the position because she doesn’t have any desire to do research. Hodges predicts there will be more options for clinical-type faculty in other university counseling programs in the future.

Should I get some work experience either before or during my doctoral program?

Preston thinks there is some value in having clinical experience before getting a doctoral degree. “When a professor is talking about a theory or technique in class, you’re coming in with another lens. You have familiarity with what that professor is talking about … because you have actually experienced it,” she explains.

But there is also a benefit in going directly from a master’s program to a doctoral program, especially because it can be challenging to readjust to academic life once you leave, she adds.

When Hodges was in graduate school, he wanted to get as much practical experience as he could. He did internships while also working at agencies and career centers. He also took two years after earning his master’s degree in counseling to work in the field. Then, when he started his doctoral program, he worked part time at an agency during the school year and full time during the summer.

This experience allows him to speak from a real-life knowledge base, not just a theoretical one, when he teaches. Students appreciate the practical examples he provides, he says.

Several of Hodges’ students have also chosen to work in the counseling field for a few years before returning to school to earn a doctorate. They say those experiences can help counseling students determine whether a doctoral degree is the right path to pursue.

Hodges believes that is a good plan. He often advises counseling students who aren’t sure whether they want a doctorate to get a job in a clinic and get licensed first. Then, they can teach part time in a counseling program and decide what the next steps for their career should be.

Do I need practical experience as an educator?

“Academics [often] have very little professional practice because they tend to be separate careers,” Hodges points out. “But it’s really an advantage to have several years of experience working in direct services or maybe even running programs because you understand practical, day-to-day issues.”

Dasenbrook thinks that counselor educators should be licensed in the field in which they are teaching, and Preston says that some universities prefer employing educators who are licensed. Having practical experience in the settings they are teaching about allows educators to discuss real-world examples, which benefits students who want to become clinical counselors,
she adds
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Being licensed also provides counselor educators with more diverse career options, Preston continues. Even with a doctoral degree, they need a license to practice independently; otherwise, they can see clients only under supervision, she points out.

Of course, having practical experience is not required to make someone a better professor. Preston says she has had plenty of professors without clinical experience who were wonderful teachers because they found other ways to increase their clinical knowledge, such as interviewing clinicians in the field and regularly attending trainings and conferences.

How do I balance being both a clinician and an educator?

Trying to juggle multiple professional roles at once can be challenging. For their own well-being, counselors must establish boundaries, and if they have too much on their plates, they have to be willing to let something go, Perry says.

Counselors should take on new projects in small doses to avoid overwhelming themselves, Perry continues. For example, if a clinician is working full time in an agency, they could choose to teach just one class on the side, or a full-time professor could start by taking on only a limited number of clients to see how that goes.

Although working in multiple roles undoubtedly expands the potential of increasing a counselor’s earnings, experience and expertise, counselors should take into account the possibility of a learning curve for each new role or project, she adds.

Hodges knows the struggle of shouldering too many roles at once. During his doctoral program, he was a teaching assistant for both the psychology and counseling departments, plus he worked part time in an agency off campus. This schedule didn’t give him a day off and pushed him toward burnout, so he eventually had to quit one of his jobs.

“Part of why [counseling] exists is to help people have balanced, healthy, rewarding lives. We have to make sure we’re doing that ourselves,” Hodges says.

At another point in his career, he realized that he wasn’t meeting that goal. He was driving an hour each way to work at an agency that he loved while also teaching, writing, researching and serving on journal boards. So, he made the decision to adjust his career plan. He stopped working at the agency and focused his energy on researching, writing, and taking international service trips to Africa and to remote parts of Australia during the summers when he wasn’t teaching.

What nonclinical skills do I need as a mental health professional?

When Hodges was in his master’s program, an alumnus came to talk to his class about careers. The man asked them, “Who wants to be a counselor?” Hodges remembers that all 30 hands went up.

Then the man asked, “Who wants to be an administrator?” Only five students raised their hands, but the alumnus predicted that in five years, most of the class would be administrators of some kind.

In Hodges’ case, that prediction came true. In his career, he has served as director of a university counseling center and as the clinical director of a county mental health clinic.

After getting some clinical experience, counselors often move up the career ladder to management and administrative positions. At that point, “Your management experience actually starts to supersede your clinical experience,” Hodges says. In these positions, counselors can find themselves negotiating with unions and outside agencies such as family services, jails or hospitals. And they often have to interact with vice presidents and CEOs of organizations.   

When Hodges ran a clinic in rural eastern Oregon, he had to interact with the state hospital, testify in court, handle frustrated county deputies, oversee prison contracts and deal with a counselor who had an inappropriate relationship with an inmate. Such administrative skills aren’t covered in most counselor education programs, Hodges says, so he had to learn them the hard way — on the job.

Hodges is thankful for one supervisor who pushed him to develop those skills by posing hypothetical situations. One time, the supervisor asked Hodges to write a correction plan for how to handle a therapist who was not doing a good job at work. The exercise forced Hodges to consider how he would help the employee improve their job performance, how much time he would give the employee to get better, and what reasons he would recommend for retaining or firing them.

Is private practice a viable option? How do I learn the business side of it?

“There’s this urban myth in a lot of counseling programs that you can’t make it in private practice,” says Dasenbrook, who, along with Robert Walsh, helped launch ACA’s Private Practice Initiative many years ago. “But if you’re good at what you do and you can get yourself out there, you’re going to do just fine.”

Counselors have the clinical skill set needed to open a private practice, he emphasizes. The problem often lies with the business aspect — marketing and billing, for example. Dasenbrook’s advice is to get a mentor and learn the business side of running a practice. That mentor doesn’t have to be another counselor; they can simply be someone who has started their own business, he says.

Workshops, trainings and college classes are also great ways to learn these skills. As an undergraduate, Perry got a concentration in business, but if she were to do it all over again, she says, she would minor in business or double major in business and a study field related to counseling.

“Business majors have a personality and mindset that counselors can acquire,” she says. “We are the helping profession and givers by nature, but we also need to be business minded. It is important for us to brand ourselves and look at things from a business perspective to monetize our gifts and talents effectively.”

What is the likelihood that my career plans will change?

Be prepared for career plans to change. Counseling students often start graduate school with preset plans, Hodges notes. He once had a student who said she would never work in the area of addictions. When her first choice for practicum didn’t work out, she had to go with a backup plan — a substance use treatment facility. She ended up loving the job so much that she continued to work with the agency after she finished her master’s.

“Perhaps tolerance for ambiguity is a real career asset,” Hodges notes. “You never really know how you will feel about a job or career until you embrace it.”

Dasenbrook’s own career journey has taken several turns. He dreamed of opening a clinic for sex therapy after graduating. While he was working in a community mental health center, he put together a small team — a counselor, a psychologist, a gynecologist and a neurologist — and made his dream a reality. But because there wasn’t a high demand for sex therapy in Rockford, Illinois, at the time, the practice lasted only six months.

Even though that career path didn’t work out as Dasenbrook had envisioned, he made professional connections through the venture, and the other doctors began referring clients to him.

“You never wind up where you start,” Dasenbrook points out. For that reason, he advises counselors to “be open to possibilities, to be open to something new.”

 

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Related reading, from the Counseling Today archives (2017): “A path well chosen

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Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist. Contact her at hello@lindseynphillips.com or through her website at lindseynphillips.com.

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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.

Making the ‘new’ normal: Five tips for providing teletherapy

By Andrea Chandler September 1, 2020

I awake, shower, dress and head into the office. I will see my first client of the day at 9 a.m., and I have arrived at my desk a half-hour early. I go to the office much earlier these days.

I start to ready myself and my space for work, spraying sage and lighting a palo santo stick to clear and bring in positive energy. I turn on my music, a surrogate noise diffuser, then close my eyes. Sitting in my high-back chair, I ask the universe again today to equip my mind, ears, eyes and words to support my clients in their healing journeys.

This is my new normal, but it is not so normal for me because my clinical office is now in my home. This is not a space that I originally set up to do private practice. Rather, it was a den I had designed for family escapism, reading, relaxing and spiritual grounding.

As I sit contemplating my schedule of clients for the day, I turn my attention to the bookshelves in the room. Among the different clusters of books sits a bobblehead doll of Jack Sparrow, a figurine of Ruth Bader Ginsburg, angel ornaments and angel sculptures. Also on the shelves, scattered and occupying space, are grounding rocks. Some are face-up so that I can see a word stamped on them from my vantage point: peace, calm, harmony, laughter.

I reflect on my past in-person sessions. At the start of sessions or during sessions, I would invite clients to select a grounding rock, hold it in their hands and set an affirmation, either verbally or silently, in harmony with the word on the rock. Or I would ask an anxious client to select a rock, and then I would guide them in a tactile grounding exercise. Most of my established clients know about the availability of the rocks — when they need to use them and how they will choose to use them. Among the comments I have heard from clients using a rock in session: “This gives me focus”; “It is comforting”; “I feel less anxious.”

On the table where the computer sits, there are writing pads I would previously give to clients to take home for journaling or suggest as a memory tool for those having trouble with remembering. In a corner of the sofa that sits along the far back wall of the den are several squeeze balls, which are great devices for releasing anxiety in session. In an off-white 5-by-6-inch box, sitting on the middle shelf of my computer workstation, are my business cards. These items all seem almost meaningless now because they are things I once provided for clients during in-person sessions.

Teletherapy vs. in-person

The reason that I now work completely from home, providing therapeutic services for clients by way of video and voice calling, is because I work with a population that is at higher risk for severe illnesses. This has been the protocol for many behavioral health workers for many months now. The current environmental situation dictates this change, and my obedience to moral and ethical obligations to clients guides me to protect and minimize harm.

I have found that teletherapy, telecounseling, telemental health and distance counseling — among other descriptives used to define the provision of remote mental health psychotherapy — takes a slightly different way of working with clients than does providing in-person sessions. I liken the two approaches to watching a movie versus reading a book of the same title.

An in-person therapy session, like watching a movie, involves the art of active listening. I am paying attention to what the client is saying while also focusing on their body language and behavior. The body language and nonverbal gestures can be picked up readily in in-person sessions.

On the other hand, I compare teletherapy with the way that written words in a book detail a story and convey information; it requires enhanced attentiveness to detail to see the full picture. I must use sharper observation to recognize the subtle messages of facial gestures and voice tonetics in teletherapy sessions.

Five areas of focus

Here are five areas of focus that have helped me make clients feel more comfortable and safer with the teletherapy process.

1) Distance counseling technology: Verification of a client’s identity and location are important. These things should be established before starting the first session and at the beginning of each session thereafter. Know that the person you are providing counseling service to is really who they claim to be and where they reside. In addition, know the definitions for the scope of practice and regulations for professional practice in both your state and the state in which your client resides because these items can differ between state licensure boards.

Ensure that the platform you are using for your teletherapy session is secure. Use applications that have an end-to-end (two-way) encryption capability. There are several good ones out there, but do your research.

Likewise, be careful not to use text messaging and email applications that are not compliant with the Health Insurance Portability and Accountability Act (HIPAA). Outside of the use of HIPAA-compliant text messaging applications, HIPAA does allow for texting clients on the condition that they have been informed of the risk of unauthorized disclosure and consented to communicate by way of text messaging. Both communication of the risks and consent from the client need to be documented.

Personally, I limit text messaging to clients to scheduling or confirming appointments. These text messages hold no personal client information, not even in the salutation. With email messaging, I never assume that the client has an internal email network with firewall protection. For this reason, all email correspondence that I send is by way of a secure messaging application.

2) Informed consent and confidentiality: In conveying aspects of the teletherapy process, counselors need to give clients a clear understanding of the therapy they are entering into and ensure that they feel comfortable and safe with the process. In this way, clients can make a choice to engage in therapy. The “consent for treatment” form should state the following at minimum:

  • Platform from which the counseling will be delivered (Zoom, Google, etc.)
  • Therapeutic modality that will be used (cognitive behavior therapy, solution-focused brief therapy, etc.)
  • Risks, benefits, confidentiality and boundaries involved in engaging in teletherapy, plus an acknowledgment that although measures will be taken to ensure the confidentiality of the session, there are no guarantees
  • Possibility of technology failure and alternate methods of service delivery
  • Location and setting of the practitioner, along with the practitioner’s credentialing and contact information

I have found it helpful before beginning sessions to show clients the confidential space in which I am working. I pan the monitor camera around the room so they can see the space I’m in is safe and free of distraction. Similarly, I encourage clients to use a quiet, calm space for their sessions when possible. It also helps for practitioners to be consistent with the counseling space location and background that clients see from session to session on their monitor screens. This allows clients to become comfortable with the predictability.

3) Technology slip-ups and client crises: Slip-ups inevitably happen, so it is wise to prepare as best you can before a session. First and foremost, test your video connection capability so that issues do not cause session delays. Unfortunately, some things cannot be anticipated, such as audio or visual problems in session. I have found it beneficial to address difficulties and concerns of this nature with clients in initial sessions and to plan together a backup alternative, such as having a phone session.

Just as with technology slip-ups, crisis situations can occur. It is important when conducting the initial client assessment that potential crisis situations for the client are discussed and a crisis plan is developed, documented and put in place. I ask an array of questions in considering the client’s risk for a crisis. As part of the crisis plan, it is important to have the client’s emergency contact numbers, local and national emergency crisis numbers, and language stating that the police could be called to provide a welfare check if the client’s safety is a concern.

A crisis can sometimes occur for clients at the end of an especially difficult teletherapy session. In these instances, I have used various techniques, such as relaxed breathing, having the person hold something in their hand and mindfully describe it, and the use of grounding exercises to help clients orient back to space, time and place.

4) Practical tips: At times, I have found myself focused on the computer’s video camera, checking my eye alignment so that I do not appear to be looking downward or too high upward. As a result, my awareness of the subtle movements and body language of the client has been obscured. Likewise, although I engage in active listening, I sometimes miss the tonetic detail of information being provided.

Some of the techniques I find most useful in keeping me attuned with the client in the therapeutic process draw on the principles of mindfulness practice. Having a moment-by-moment awareness of what is unfolding visually and tonetically allows me to help clients feel supported and understood.

When I mindfully remind myself to sit back from the screen, I see a wider area. I can better catch the slight facial expressions and eye gestures of the client and use these observations to reflect on helping the client gain awareness of the messages they are conveying. These days, I pay additional attention to noticing, understanding and noting what the client’s voice nuances, tempo, pitch and inflection are conveying. These hold equal importance with visual focus in creating a therapeutic alliance with the client.

5) Best self forward: Putting your best self forward begins with self-care. A great part of self-care is maintaining good boundaries, both inside and outside of client sessions. This includes establishing a clear line of demarcation between work time and personal time and creating a space of time between each scheduled client so that you are able to replenish your mind and body.

I like to replenish my mind through meditation and my body through movement. Meditation helps me create inner calmness and renews my focus. Fitting short exercise into my workday, such as a short cardio workout, walking the dog, and resistance-band exercise, helps me to reenergize. I also find great mental fortification in connecting with clinical colleagues with whom I can share challenges, problem-solve and get overall support.

In facing the changing times of our new normal, it is useful to know that we can move forward by being proactive in our thinking, preparation and approach. The more equipped we are, the fewer obstructions we will face. The fewer obstructions we face, the better we can be of service to our clients, upholding nonmaleficence, beneficence, justice and respect for the autonomy of the person.

 

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For more on the ins and outs of telebehavioral health, see the American Counseling Association’s resource page for counselors: counseling.org/knowledge-center/mental-health-resources/trauma-disaster/telehealth-information-and-counselors-in-health-care

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Andrea Chandler is a licensed counselor with more than 12 years of practice. It is her passion and privilege to serve individuals through counseling and advocacy efforts. Contact her at Achandler123@gmail.com.

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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.