Catching Our Breath To Evaluate Telehealth Best Practices

by Susie Kim-VanderGriend, MSW

     The unprecedented global pandemic of the COVID-19 outbreak brought life as we know it to a standstill. Many state governors implemented shelter-in-place or stay-at-home orders, suspending all activity that is “not necessary to sustain or protect life” (Michigan, 2020). In response, social workers continued to provide essential mental health services to clients in need. Many quickly transitioned to telehealth to meet the needs of current clients and prepared to serve the growing population of people who need mental health services in the wake of this crisis. It is worth noting that there are various forms of telehealth, but for the purposes of this article, the focus will be on video conferencing psychotherapy (VCP).

     Online VCP brings a different set of challenges, including new considerations for self-care, technology, space, and ethical behavior. Despite the quick run-up to providing services, it is worth stopping to catch a breath and consider how we are doing. Even as services are already under way, it’s important to take a look at the National Association of Social Workers (NASW) Code of Ethics (NASW, 2017a), along with the Standards for Technology supplemental guide (NASW, 2017b) for guidance for providing high quality telehealth services.

     One more note before jumping into the practical elements is the good news for those already providing telehealth services - research has shown telehealth to be an effective delivery method for various evidence-based practices (EBP). Across multiple EBPs addressing various psychiatric disorders, such as anxiety disorders, depressive symptoms and suicidality, eating disorders, trauma-related symptoms, and addictive behaviors, clinical outcomes were roughly equivalent between telehealth and traditional in-person treatments (Gros et al., 2013; Backhous et al., 2012).

Best Practices To Consider

Self-Care

     Self-care is an important consideration for social workers during a time like this. The age-old adage to put on your mask before helping others with theirs aptly applies here. We are all experiencing elements of the pandemic, so it is crucial to heed and attend to symptoms of fatigue or even secondary traumatic stress. There may be boundary confusion with an online medium that brings therapists into clients' homes, and for providers working from home, it goes both ways. Being able to leave work at work may become more difficult. If using a part of your bedroom space, there may be discord when trying to use that same space for rest or sleep. It is imperative to implement self-care practices with these factors in mind. Another area of boundary confusion that requires ground rules is around therapist personal space and clients’ questions (NASW, 2017b). Therapists should maintain clear professional boundary guidelines for themselves and for clients while engaging in VCP sessions.

Pre-Screen Clients

     Accessibility may vary widely among clients, so it is good practice to get a pulse on each client's resources and needs when transitioning to VCP. The Medical University of South Carolina (MUSC) has a tip sheet that includes questions to ask clients regarding their willingness to be seen by telehealth, access to technology, and privacy in the home (see MUSC tip sheet).

     It may also be helpful to know if clients have access to a printer for forms or supplemental materials to be used in sessions or a computer so screen sharing can be done effectively. When using VCP, the client needs high speed internet; otherwise, the images and sound may freeze, causing disruption in the session. Finally, ongoing discussions with clients are needed to check in as expectations may change with services during treatment via VCP.

Professional Competence in VCP Services

     The pandemic crisis emerged so quickly that many social workers have had to engage in professional training concurrently with providing services. Continuing relevant professional training to understand VCP and get ideas for variations on treatment can enable social work professionals to provide a higher quality of care. Many organizations have graciously offered free online trainings and resources during the COVID-19 pandemic. Additionally, social workers providing VCP should continue to explore the specific system they intend to use, if possible, before beginning any sessions with clients, to get familiar with the technology and the changing adaptations. Guidelines and tutorials for clients to get familiar with the platform may be helpful to clients who are uncomfortable or unfamiliar with technology. Be ready to troubleshoot technology issues with clients, and have a backup if the first plan fails.

Informed Consent

     Informed consent specific to VCP services entails providing clients with an understanding of the risks and benefits of the new telehealth service. A significant benefit of VCP is the ability to continue therapeutic services despite the COVID-19 stay-at-home orders, but there are also risks such as technology failure and breaches in confidentiality. It is important to obtain and document a written informed consent form for both parties to sign. The NASW offers a free template for use: NASW Consent.

Confidentiality

     Because of a higher potential for confidentiality risks when using technology, social workers should establish new confidentiality policies that relate to the use of online VCP technology. As providers, social workers need to ensure that communication occurs on a secure network and the transmission of information is encrypted. Although HIPPA requirements have been loosened during the pandemic crisis, it is best to use a HIPPA-compliant system to deliver telehealth services, if possible. In addition to electronic privacy, physical privacy can be challenging and is compounded by the shelter-in-place orders keeping almost everyone home. Multiple people may be home with shared spaces or only thin walls separating them from each other. Providers need to ensure that their own space maintains confidentiality by employing sound machines outside their doors and/or wearing headphones so client conversation cannot be overheard.  

Safety

     As a result of the physical distance created in VCP, social workers should consider and create safety protocols for sessions with clients (MUSC, 2020). This may include confirming the client’s current location and phone number in case of an emergency. In the case of new clients, verifying the client identity with a photo ID may protect against fraud. It may also be worthwhile to provide access to you, the provider, via an alternative method in case something happens during the teletherapy session. Creating a Google Voice number is a useful option to avoid giving away personal phone numbers. Also, discuss emergency procedures with your clients, in case something arises (MUSC, 2020).

Additional Etiquette Tips To Consider

The Space

     A big change for telehealth professionals during the COVID-19 outbreak is that not only are clients home, but providers are also home.  According to Teresa Iafolla’s telemedicine tips, setting up a private, professional space, free of distractions, is crucial to providing care. Iafolla (n.d.) goes on to recommend making sure the location is quiet and clean and checking what is in the patient’s field of vision before beginning any sessions with clients. The MUSC further recommends creating guidelines for clients to be in a private location with a door, and if a bedroom needs to be used, that clients not be on their bed but instead sitting at a desk or table, if available. A noise machine set outside the provider’s door is also recommended for greater client confidentiality (MUSC, 2020).

The Attire

     Setting the tone with clothing is an easy way to maintain professionalism. It is important to be dressed professionally, even though one might be working from home. A good rule of thumb is to dress however one would dress if the session was in the provider’s office (Iafolla, n.d.) or dress in business casual attire (MUSC, 2020). Similarly, clients can be asked to be dressed as they would be coming into your office.

The Communication

     Telehealth has some limitations that require adjustments to communication styles and increased verbal communication. Providers and patients may need to use a slower rate of speech to adjust to the audio via VCP (Gros et al., 2013). Keeping lag time in mind, wait about two seconds to allow your client’s last words to come through before speaking (Iafolla, n.d.). Increased verbal communication may be necessary to indicate a physical action, such as letting a client know that as a provider, you are looking down to write notes (Iafolla, n.d.). When body language and hand gestures may be hard to see or interpret, greater verbalization or direct questions and answers may need to be exchanged (Gros et al., 2013). 

Conclusion

     During challenging times throughout history, social workers have risen to the call to help those in need. The COVID-19 pandemic brought a surprising and abrupt change for people everywhere, social workers included. Although the technology is not new, the broad use of the application in place of traditional face-to-face therapy is unprecedented and can compound problems for clients, so social workers need to be mindful of potential issues for themselves and their clients. So, now is the time to take a breath from the rush of transitioning to VCP, make sure you have your mask on, and double check to ensure you are providing the most ethical work possible.

References

Backhaus, A., Agha, Z., Maglione, M. L., Repp, A., Ross, B., Zuest, D., . . . Thorp, S. R. (2012). Videoconferencing psychotherapy: A systematic review. Psychological Services, 9(2), 111-131. doi:http://dx.doi.org.proxy2.cl.msu.edu/10.1037/a0027924

Gros, D.F., Morland, L.A., Greene, C.J., Acierno, R., Strachan, M., Egede, L.E….Frueh, B.C. (2013). Delivery of evidence-base psychotherapy via video telehealth. Journal of Psychopathology Behavioral Assessment, 35, 506-521. DOI 10.1007/s10862-013-9363-4

Iafolla, T. (n.d.) 10 telemedicine etiquette tips to deliver professional care. eVisit. Retrieved from: https://blog.evisit.com/10-telemedicine-etiquette-tips-deliver-professional-care

Michigan. (2020). Executive Order 2020-21 (COVID-19). Retrieved from: https://www.michigan.gov/whitmer/0,9309,7-387-90499_90705-522626--,00.html

National Association of Social Workers (NASW). (2017a). Code of ethics of the National Association of Social Workers. NASW Press.

National Association of Social Workers (NASW). (2017b). NASW, ASWB, CSWE & CSWA Standards for Technology in Social Work Practice. NASW Press.

Medical University of South Carolina (MUSC). (2020). Guide for transitioning to telehealth delivery of mental health: Addressing barriers during the COVID-19 outbreak. Retrieved from: https://learn.nationalchildrensalliance.org/covid

Susie Kim-VanderGriend, MSW, is a 2020 graduate of Michigan State University with specialized training in evidence-based trauma treatment and advanced clinical skills with couples and families. She is a contract therapist with the Children's Advocacy Center of Kent County.