Greg Wright:
Welcome to Social Work Talks Podcast, I'm your host Greg Wright. Due to the coronavirus pandemic, many social workers cannot see clients in person, so they have turned to telehealth. However, telehealth is not a panacea. It has challenges as well. Today we are talking with NASW expert, Pat Spencer, about these challenges. Pat is a therapist in Highland Park, New Jersey, and has used telehealth for years. Pat, welcome to Social Work Talks Podcasts. It's really a pleasure having you with us.
Pat Spencer:
Thank you so much. It's a great pleasure to be here.
Greg Wright:
Our subject is telehealth, and I was wondering, how long have you been into this area of social work practice?
Pat Spencer:
I've been using telehealth off and on for approximately the past 10 to 12 years, but in my practice, like a lot of therapists out there, I really got into using it over the past eight weeks or so. But prior to my private practice, I worked at a nationwide call center for veterans doing... They had peer support. I was the clinical supervisor and we provided services remotely. So although not telehealth that they were doing, and certainly not therapy as it was peer support, we were using remote communication such as using telephones, chat, emails. And then previously I had worked at a psychiatric emergency screening center where I interviewed the patients in person, but they saw psychiatrist remotely. So a lot of our patients, we would first evaluate them then have them see psychiatrists using video webcams and whatnot. And that started about 10 to 12 years ago.
Greg Wright:
Wow. But we're in a corona pandemic now, so how has the attitude toward telehealth change? Has it been like a rapid thing?
Pat Spencer:
It certainly seems like it's been a rapid thing. It's been a rapid thing both with the practitioners but also with the clients. Ever since I started my private practice about three years ago, I've offered telehealth, but nobody, and I do mean nobody, has taken me up on it. But during the pandemic, obviously a lot of our clients have suddenly decided to start using. And in New Jersey, we have too. In New Jersey, we are in one of the hotspots of the pandemic. So again, approximately six to eight weeks ago, the governor issued the executive order that all nonessential businesses had to close, therapist are considered essential, but we all of a sudden wanted to make sure... Not all of a sudden, but we wanted to make sure that our clients and ourselves were kept safe. And so all of a sudden we had to use telehealth and quickly adapt and quickly make sure that it worked with both the clients getting more comfortable with it, but also with the practitioners becoming more comfortable with it.
Greg Wright:
Now, on the issue of making a client more comfortable with this, how is that done?
Pat Spencer:
Well, it depends on the situation, it depends on the person that I'm working with, it depends on their clinical issues. I happen to be in Highland Park, which is right across the river from Rutgers University so a good portion of the people I work with are college students. They were much more easy to adapt to it than my kind of working professionals, my 40 and 50 something year olds. So with the college students, it was just kind of second nature. Like, "Yeah, of course, we're going to talk to you online. No problem. We've been doing this for our entire life." With the 40 and 50-year-olds, it was kind of like, "All right, let's talk about what is it that you need? What type of software do you need?" But with all of the clients, whether regardless of their age, we did have a conversation, you're doing informed consent.
We had a conversation around how to maintain their privacy, how to maintain their confidentiality. What are some tips and techniques that they can do to keep themselves feeling safe in therapy? Because one of the things about therapy is that the clients come to our office and it's in our office that they get a chance to really process their hurts, their pains, their traumas. And they know that family is not in the next room, they know that the walls don't have ears here. So we had to have conversations around how to help you feel as safe as possible in whatever location you might be.
So some of the conversations we had were, "Where in your home or apartment would you be able to talk? Are there times of day that might be better than others," such as maybe later in the evening, if someone's a mother or a father and they have small kids at home. But we also had conversations like, "Maybe you want to talk with me out in your car." We also had conversations about the Wi-Fi and their internet access and how to make sure that they had the best possible hardware and software to support this. And then there was also the conversation around what happens if you don't have access to a computer or don't have access to Wi-Fi? What happens if you don't want to do telehealth? So those were also some of the conversations that we had.
Greg Wright:
Well, so it seems like a lot of work even before the first session using a telehealth portal. I'm sorry.
Pat Spencer:
Yeah, no, it's a lot of work, both for the therapist, but also for the client. You know, again, in our code of ethics we talk about informed consent, and with informed consent we want to talk about the risks and benefits and then how to make it work as effectively as possible. And I have those conversations in my office with clients when we're doing face to face. What are some of the risks? What are some of the benefits of doing therapy in general? telehealth just added a different layer and some other considerations to really discuss and to think about.
Greg Wright:
So we are wondering if you have a few tips to a social worker in order to make these sessions more effective. Just a few tips, possibly.
Pat Spencer:
Some of the tips are if you're living at home or if you're doing your telehealth at your home, so if you all of a sudden made your home your office, you want to set up a space that will allow you the therapists to maintain the client's confidentiality. So hopefully you have a room with a door. Even if you're home alone, I still recommend going into a room with a door, or at least having the client be able to see a wall or something that allows the client to really believe that there is that confidentiality. We do know that we really want to strive for that, and that's what we want. We need the confidentiality, but we also want the client to see and to believe it.
So for example, even if I'm home alone, I'm not going to leave the door to my office open because the way that my camera is set up, they can see the door to my office. And I don't want them to have any idea that their words might be heard outside of our session. Another tip is how and where you set up your computer and your webcam. I definitely recommend setting it up so you are not backlit. You want the lighting to come in front of you. So in my home office, what I have set up is my computer sitting next to a window and I face the window so the light's coming in on my face. And then I have two other lights on either side of the window just to make sure there's even lighting. Because I, as a therapist, don't want to be in shadows. I want the client to be able to see my face. I want them to see the reactions. I want them to see the empathy.
And if we're backlit, so in other words, if the light is coming from behind us, then they can't necessarily see that. If someone is able to, I'd also recommend getting a microphone, an external microphone for their computer, because it does improve the sound quality. And if at all possible to also get an additional webcam, it just again will improve the video quality that the client will be able to see.
Greg Wright:
I'm wondering, when a person is on a video online, is it harder to read their emotions, their expression? So in other words, is it different doing that virtually than if you are in an office with them?
Pat Spencer:
I find it to be different. Now, again, every therapist, every social worker is going to have different experiences, but when a client is on the webcam, literally all we can see is what they're showing us. And typically, it's kind of from mid chest up, so we're missing all of the nonverbal cues of what's happening with the client's hands. Are they clenching them? Are they releasing them? Are they ringing them? We're missing what's happening with their legs. Are their feet bouncing? Are their legs bouncing? Are they possibly physically agitated? But we can see their eyes. We do need to pay attention to that. We can see their face. We can see an awful lot, but there is, again, some that we're missing.
But again, this is where the therapist really needs to be attuned to the client and to really try to be paying attention to what they can and cannot see. And I do have conversations with my clients like, "Hey, I just noticed something, can you tell me what's happening in the rest of your body?"
Greg Wright:
What if you see a mess in their homes or a lot of personal items, should that influence how you are interacting with that client?
Pat Spencer:
So essentially what they're showing me is, I mean, they're in their home. And again, this will be part of the conversation that I would have with somebody before we even start the telehealth, is just to let them know that I can see what's around them. I'm not seeking it out and I'm certainly not going to violate our ethics and Google somebody, but I can't help but notice if they're sitting in front of a closet door and it looks like clothing is exploding out of that. And I would mention to the client, "Hey, look, I can see that. Is that something that you want me to see?" And we can certainly discuss it. But again, I try to have the discussion early in our telehealth relationship.
So thankfully, a vast majority of the people I've been working with, I saw in person prior to transitioning to telehealth. So these were parts of some of the conversations we had with folks was, "Just know that I'm going to be able to see where you are, and what is it that you want me to see?" And then the same thing actually goes for the therapist. We need to remember that the clients can see where we are, so we need to take into consideration what is it that we have in our background. Do we want the clients to see our family pictures? Do we want our clients to see our dog or our cat or our bird or whatever our pet is wandering through? So again, I have the same conversation with the client that I also am having with myself about what is it that I want to show them, and then what is it that I want to see?
Greg Wright:
A client can tell you, "Hey, you know, I don't want to see this. I don't want to see a dog or, or a parakeet." Like you actually set ground rules beforehand?
Pat Spencer:
I do. I try to, at least. And again, everything is going to be relationship based and it's going to be based on what the client is presenting with and what is it that they want and our relationship. So I have actually, I think a vast majority of my clients, I've met their pets at this point, which has been kind of fun. But I do have conversations about, just if they are married, for example, and their spouse is walking through the background, is that something that they want? So it goes into the confidentiality conversation that we had earlier about how can we maintain your privacy, your confidentiality? Are there parts of your home that you don't want me to see?
Some of the clients might have a hard time with my hoarding behaviors and they might not want me to see the extent of their hoarding behavior. So again, we're going to have this conversation about what is it that I see? Now, if I do see something, I am going to bring it up more than likely. I might say, "Hey, that's a cool picture in the background. Can you tell me a little bit about it or do you want to tell me a little bit about it?" So I do bring up what I see, but only if it's really clinically relevant.
Greg Wright:
Now, if it's a child, should a parent be there? I mean, if you're in your office, and I know that she work with college kids, but if you are working with a child, should a parent be there with them or not?
Pat Spencer:
It's going to depend on the age of the child and also what the clinical issues are and what we're working towards. So a lot of the work I'm doing with younger kids, I'm going to be working with the parent and the child together. But I do have a number of teenagers that I work with. And for them, what we do is we start off the session typically with the parent in the room, just checking in. Because usually what I do is I email the link to our sessions to the parent. That's the way all of them want it set up right now. So I email the link to the parent, the parent sets up the session, we do a quick little check in, and then I see the child typically alone. And then at the end of the session, I sometimes will see the parent again. But it is going to depend on the age of the person I'm working with and the clinical issues that are coming up.
So if I'm working with a 17-year-old, I might not be interacting with the parent as much. Whereas if I'm working with a 10-year-old, it is going to have a lot more parental involvement. Most of the kids that I work with though, the parents end up leaving the room to give the child some confidentiality. We have a session and then the last five, 10, 15 minutes, depending on the situation, the parents will come back in and we can have a conversation and wrap things up and maybe help the child say whatever it is that they needed to say to the parent.
Greg Wright:
So are there instances where telehealth is not advisable?
Pat Spencer:
There's not a diagnosis that I would say, "Don't do it with." Somebody can have schizophrenia and can do telehealth perfectly fine. If they are having... If some of their psychotic features are that the TV is talking to them, it's going to depend, again, on the client, our relationship, our goals, what we're working on. It may even depend on where we're living. Again, here in New Jersey, we're kind of in a hotspot. I work in Middlesex County, which has a lot of cases of COVID. So I'm probably not going to risk having that client come to my office for their safety as well as mine. So we might do telehealth but it might be, we might change it up. Instead of an hour long session, maybe we'll have a 15 or 20 minute session. Maybe we'll have some check-ins about what it's like for them to know that the computer is talking to them, but really it's me talking to them through the computer.
Actually, the very first patient I ever used telepsychiatry with at the emergency room was somebody with that exact presenting issue. He was brought into the ER, I evaluated him, he needed to see the psychiatrist. He was presenting with psychosis, one of the symptoms of which was he believed TVs were talking to him. And so I bring him into a room to have a TV talk to him. So beforehand, he and I actually had a conversation about, "Yes, this time the TV will be talking to you. I'm also in the room. I will also be able to hear it." So we tried to find ways to normalize it and to make it work for him. But again, that was an emergency situation, not ongoing therapy. But as the practitioner I have to weigh which is the greater risk? Seeing me in person, not seeing me at all, or doing telehealth? And so together, the client and myself would come up with a plan to find out what is the safest option for them.
Greg Wright:
I think that a theme that's actually running through our conversation is that there is a lot of give and take with a client, like an agreement's being made. So is that important, that everyone has a say and that it's equal and it's fair?
Pat Spencer:
Oh, my goodness, yes. I mean, that's the basis of social work, is that the practitioner is in no more power than the client is. They are coming to us for services, this is their treatment. They most certainly need a voice, and their voices is very, very, very important in this. And I need to be able to hear their considerations and their concerns. And again, some of my clients were very reluctant to transition to telehealth at the very beginning. And so until it was absolutely necessary, we did face to face for a number of weeks. But in conversation with the client, when talking about the executive orders and the increasing numbers of diagnoses, together, the clients and I decided when was the right time to switch to telehealth.
And at some point I did have to say, "Listen, I'm not going to be seeing people in my office after this date, so what is it that we can do to make this work?" But we did have to have a conversation about what is it that they want, what is it that they need? What can they do? What can't they do? Thankfully all of my clients have access to computers and Wi-Fi. I'm actually more concerned for the clients that do not have access to smartphones or internet or Wi-Fi. A lot of folks have used libraries for their computer access.
Well, after this pandemic, I certainly don't recommend going to the library to do telehealth on a public computer. So we as a profession need to look at how do we help those who do not have access to the internet or to smartphones or computers? How do we help them access the same level of care as others? And in all honesty, I don't have an answer for that. But again, thankfully my clients all had access to that, but it was certainly this conversation around what can they do? What are they comfortable with? And we also check in on a session by session basis. I've had several clients where at first they're like, "Yeah, meeting in my home is perfectly fine. It's safe, no problems. I don't care that my parents are in the next room." Well, now a few weeks in, when I start the session, I noticed that they're in their car because now they feel more safe in their car with a little bit more privacy.
Greg Wright:
We've been in this now going on two months now. Are clients getting more and more comfortable with it as time goes on?
Pat Spencer:
The clients that I see are getting more used to it. I also think that we, as a therapist and the practitioners are getting more used to it. A lot of my colleagues, we were all thrown into it six to eight weeks ago. And at first, the therapist was the one that had to get used to it. How do we find HIPAA compliant software? How do we make our home office as confidential as possible? How do we manage our own pets coming in and out? And as we got more comfortable with it, the clients also got more comfortable with it. And simultaneously, people are also dealing with the quarantine and all that comes with the pandemic, and I'm noticing a shift in how people are coping with that.
So the first few weeks, literally everything was new. It was new to the therapist, it was new to the client using the telehealth. What was also new was being home 24/7. It was also new not being able to run out to the supermarket anytime you wanted. Many of my clients are suddenly now they are teachers homeschooling their kids. Literally everything was new. And now six weeks into it, we seem to have developed some level of a flow, some level of a new normal for these not normal times. So I'm finding that my clients are getting more used to it, that we're actually starting to talk deeper to maybe delve into some deeper clinical underpinnings than what we were early in the pandemic.
Greg Wright:
Eventually we'll have a handle on this pandemic. At that point, is telehealth here now permanently or are we going to go back to how it was before?
Pat Spencer:
I wish I had a crystal ball to really be able to give you a straight answer. I do think that telehealth is here to stay. I do think we are going to go back to seeing clients in person. I know that many of the practitioners missing the clients in person. I know all of my clients miss coming and seeing me in person, but I do think we're going to be increasingly more comfortable with it. I think the software is going to be out there for us to be able to do it even easier. I think the insurance companies are going to have to make some changes, because one of the things that limited telehealth before was how insurance companies would or would not reimburse telehealth services.
When Governor Murphy here in New Jersey signed the executive order, the insurance companies were forced to cover telehealth. And as far as I understand, I believe most of them are only forced to cover telehealth until I think mid to late June. So we're not sure what's going to happen. I happened to take Horizon Blue Cross Blue Shield, I have no idea what's going to happen with Blue Cross' policy about reimbursing telehealth services when we go back to "normal," so once the pandemic has passed.
Greg Wright:
Pat, is there anything that we missed that you might want to add in?
Pat Spencer:
The one thing I always try to highlight to people is jurisdiction, that many states have it so you can only practice in the state that you're licensed, and telehealth is now allowing us to practice across state lines, but not every state allows that. So here during the pandemic, Connecticut, New York, Pennsylvania, New Jersey, they've all allowed licensed practitioners from other states to be able to practice in those states. So for example, I have a college student who goes to Rutgers but lives in New York, up until about two or three weeks ago, New York was not allowing out of state licensed people to practice so I had to stop treating her for a number of weeks. But once New York passed an executive order that allowed people licensed in other states to practice in New York, I was able to treat her again. So that we have to be mindful about where our clients are. So during normal times, if that client goes back to New York, I can't treat her while she's in New York.
Greg Wright:
Pat, thank you so much. This was a very fascinating conversation, and I want to thank you for the time.
Pat Spencer:
I appreciate it. Thank you so much.
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