5 Things I've Learned from Providing Telehealth Counseling

On Monday, March 16, 2020 I took my private practice online into a fully Telehealth model in response to COVID-19 and social distancing rules and guidelines. As an early adopter to 100% Tele-mental health this transition came with some frustrations and struggles in addition to the unexpected tax on the entire Telehealth system that caused lags and delays. I am grateful to have the opportunity to have a portable job that allows me the flexibility to keep working and seeing clients though I am constantly humbled by the challenges of translating my very interpersonal, in the moment therapeutic style to an online space. I have taken note of some of the challenges and successes I have experienced over the past three weeks in hopes to serve as support and encouragement for those who are either struggling or those who are resisting transitioning fully to an online model.

First, some background about me. I am a Licensed Psychologist trained in a Counseling Psychology program. Online technology and teaching is not new to me as I did both work and research related to technology in education and mental health while in graduate school. I served as an Instructional Technology Fellow at the University of Minnesota for 6 years helping instructors integrate technology into the teaching within the College of Education. I also helped this same college become one of the first to integrate iPads within teaching and learning. And as a clinician I researched the ethical dilemmas of relationships between clinicians and trainees on Facebook. I am fortunate to be in a generation called Xennials (those born between the late 1970s and early 1980s). We are the generation of Oregon Trail, Mario (the original), and AOL, landline phones, cell phones and long distance calling, MySpace AND Facebook, and we also have the privilege of knowing records, cassettes, CDs, Napster, and Spotify. For this reason Xennials adapt REALLY well to new technology as well as have desire for "old school" ways of living. Why does this information matter? In regards to Telehealth I can both appreciate the efficiency technology has afforded us over the years though I also got to grow up and learn (and value) communication face to face. I love the ease but hate the always on, always reachable life! This makes me an asset to all generations in my opinion.

What I have learned from Telehealth

1. There is such a thing as too much screen time.

I will be the first to admit that I am definitely someone who has shouted from the roof tops that we should not be on screens all day. APA recently dedicated their last edition of the Monitor to all things about kids and screen time. Apple has integrated a feature calls Screen Time to help individuals and parents monitor and evaluate their screen time use. Some see Screen Time as a problem but when viewed to learn about your habits it is super helpful. Netflix has a pop up asking if folks are still watching. Some area annoyed by this but I'm of the camp, maybe this is a sign to get up and do something else. So I do come into Telehealth with this bias already, guilty, yes. However, now that my whole working world is online I can say without a doubt, there is such as thing as too much. Each evening I come home I am fatigued, I am tired, I am irritable. My cortisol levels must be through the roof. Screens are exhausting. It as helpful to learn there is a condition called Asthenopia which is fancy term for eyestrain or "ocular fatigue."

Asthenopia: It’s a common condition that occurs when your eyes become tired from intense use. Staring at a computer screen for long periods or straining to see in dim light are common causes.

Tips for Therapists Managing Eye Strain: I have found a couple of adjustments to help me manage the increase in screen time that I would like to share.

• I keep my sessions strictly to 45 min. And I’m informing my clients of that (when I can...I’m not perfect but keep learning week to week). Sometimes we stop at 45 and spend 1-3 more minutes in scheduling but this is necessary for me to get a break from the screen between clients.

• I schedule an hour for myself after two clients. It took a couple weeks but I learned that I do better in the day if I don’t “see” more than two clients in a row. Three clients makes me feel zoned out and spacey!

• Flexible scheduling. In private practice I have the flexibility to see folks outside of 9-5 which I like a lot right now. During COVID-19 social distancing and stay at home orders I am tethered to home and an empty office downtown with no social activities as I used to know them. Weekend plans and travel are at a minimum so my week is full of reading and puzzles and meals and Facetime calls. I do not mind scheduling an appointment or two on a weekend day as I have the flexibility to take off Fridays. I get to make my schedule work for me and given the exhaustion of a full 9-5 takes away any ability to enjoy my evening (because I’m toast), I would much rather see 3 clients on Wed and feel good Wed evening then one client Sat and have little impact on my week. I encourage all practitioners to find ways to be flexible if you can and find better balance.

• When using screens on your personal time consider reducing the brightness on your devices. This will help your eyes take a break. Also, on iOS devices (Apple iphones and iPads) there is a built in feature called Night Switch that reduces the tone to warmer light thus reducing eye strain and blue light features that interfere with the production of melatonin. I have this feature on all the time. Research shows that using Nigh Switch can contribute to improved sleep.

2. Silence is Golden. I was trained in counseling under what is referred to as a Humanistic Model of care. What does this mean in layman's terms? My work with clients is all about the relationship that exists between us. I emphasize techniques such as "here and now" processing (phrases such as "how does that make you feel" and "what's happening for you in this moment" are key to what I do). This type of work is central to individuals who are looking to understanding themselves and moving through struggles with shame, vulnerability, loneliness and grief. It also emphasizes movement toward change and growth over pathologizing symptoms.

There is an energy that develops in the therapeutic space when doing humanistic work that was challenging to find initially when transitioning to Telehealth. Thankfully my clients were very patient and engaged and the technology itself helped me with a valuable too. Trusting Silence. I felt so much anxiety with silence when on a screen as I had no idea what my clients were seeing. Was the screen frozen? An "is this thing on?" kind of feeling. Did the video skip? So much uncertainty and anxiety on my end. But when I slowed down and trusted, I was reassured. They are there. And they are waiting, and reflecting, and engaged. Patience and silence on both ends allowed for us to create a shared space, even at a distance.

3. Flexibility, Patience, and Compassion are key. No additional information needed here. There will be problems and issues along the way. Embrace them, expect them, be kind to yourself and others. We are doing the best we can.

4. Gratitude Goes a Long Way. This seems self-explanatory and I recently praised my clients, colleagues and Simple Practice on social media but it must be said over and over. Most of us did not sign up for online therapy. Not as clients and not as practitioners. We have all been afforded the gift of portability and I for one am grateful for all that have helped me do this. I encourage everyone to also be grateful. I'm grateful for the clients who know there is a pandemic and are wanting to use their time of unemployment or furloughing to invest in themselves. I am also grateful for those who are anxious, uncertain, scared and sad who are showing up to share their feelings. So much gratitude everywhere, we must express it and embrace it in all forms wherever it comes! If you don't see it yourself, put it out into the world!

5. If You Build it They Will Come. Are you a practitioner on the fence about Telehealth for therapy? Are you a client anxious and uncertain and not wanting a screen dividing you from your therapist? Are you uncertain if it is as good as face to face? Are you scared of your information not being private? If you feel any of these I am glad. Telehealth can be scary. What makes it less scary? INFORMATION. Inform yourself on ethical practices and guidelines. Inform yourself on your counselor's experience and knowledge to deliver mental health at a distance. Ask them questions like:

• What software do you use and how does it handle my information?

• Are these online sessions being recorded?

• What do I do if the connection breaks during session? Are there back up options?

For clinicians, I myself have been using a software called Simple Practice for over a year. Thankfully it integrates Telehealth seamlessly. It does not however offer multiple streams like Zoom. However, Zoom's session do not secure information in a similar way unless one is using their Zoom Telehealth option.

One thing that has been made clear to me over the past three weeks, clients still need help and therapists want to be helpful. If you are a client in need of help, trust that we are here to help you. Please call and reach out (and please be patient as we work diligently to return your call or email). If you are a clinician wanting to do online counseling well please pause first and get your paperwork, training and systems in place. Your clients will be there waiting and ready for you to serve them.

We are all in this together!

Please see my resource page for additional Telehealth references

A Beginner's Guide to Surviving a Quarantine: INTRODUCTION

Today is Wednesday, April 1st and this is not a joke. Here in Gainesville, FL we have been in our own version of "lock down," since the middle of March with each day becoming more and more grim. A couple days ago the state of Florida mandated all schools and non-essential businesses to cease operations until the end of April. There are many folks out of work. All students learning form home. Many individuals continuing to work from home. And all people finding a new normal in their lives as they get cozy in their home environments.

I have been fortunate to have a portable job and continue to see clients via Teletherapy either at home or in my office. Though I too miss social connection, miss continued engagement in my community and local activities, and I miss the normalcy of life I used to know. In an effort to reach more people and provide some fun in addition to increasing coping and well being in others I have decided to create this guide. It is a work in progress and the more we live our own version of a quarantined life the more it will take a life of its own.

This guide is not meant to be therapeutic advice. If you do not have a mental health professional you should find one (I myself am continuing to take clients as are other fabulous therapists in Gainesville and the country at large). This is also not meant to make light of the very serious situation we are in, some worse than others. Folks who know me know that I approach life from a realistic, sometimes pessimistic stance, yet, not I'm also a believer in a "not taking life too seriously" mindset. I work from a positive psychology approach with my clients which means I work with people on movement toward where they want to be over their self-identified barriers to happiness. We all experience trials and tribulations in life but its rare we can remove external forces. What we can do is keep moving and DOING.

So this guide is all about action and movement. Even if the action is stillness and the movement is internal. It's about intentionality. It's about taking from this experience what we can and what is meaningful and working like crazy not to be taken down by it.

Here is an overview of Stage 1: Preparation, The Beginner's Guide to Surviving a Quarantine

• Acceptance: First we must acknowledge what has happened and embrace what is. Because none of us can change it.

• Get Snacks: We all have made our initial good choices around essential supplies. But what about snacks? Toilet paper might be helpful but chips and candy are the things that make life really wonderful! I say nurture your soul! It's a quarantine, we gotta have something good!

• Do Some Nesting: You are now living and working from one environment (and some are also teaching and learning). Make sure your place is cozy and has opportunities for separation of work and life

• Get to Know Your Housemates: Look around...these are your quarantine buddies. You are now in a system and each of you has your own strengths and weaknesses. You will not survive this together if you do not work together. So get to know one another. Set some rules and expectations as well as boundaries. And be kind. You never know what the future may hold and you do not want to be voted off while quarantined.

I hope you will join me over the coming weeks. You can find videos and (mostly) daily tidbits on Instagram and Facebook. You will find longer posts here (linking to Facebook). You are welcome to email me through my website at affirmativecounselingpsych.com if you are looking for a mental health professional or a referral to one.

We are all in this together. I say why not have a little bit of fun on the journey!

Grieving Loss in a Time of Social Distancing

I built my practice with a vision of undoing aloneness and increasing connection with self and others. As a society and culture over the last couple of decades we have become more and more separate from others. Research supports that more than half of Americans feel lonely and lack authentic connection that make them feel loved, valued, and seen. Such loneliness can have detrimental effects on both emotional and physical health with youth and young adults being most at risk. Social distancing is putting a wrench in the challenges we are already experiencing to feel connected to others in addition to fear of what lies ahead. Jobs are being lost by the thousands. Graduations cancelled. Trips postponed indefinitely. And worse, family connections being ruptured out of desire and need to protect ourselves and those we love. As a society of people we are ALL grieving in the wake of social distancing.

Elisabeth Kübler-Ross discusses 5 stages of grief that we all go through in times of loss such as what we are presently being faced with. Newer models of grief have added on an initial stage of shock as well as a hopeful end involving finding purpose and meaning. No matter the stage of grief you are in please know that grieving is a highly individual experience and there is no one way how a person grieves or is supposed to grieve.

Stage 0: Shock - One's initial response to sudden loss. Symptoms can include inability to talk, move, eat or sleep. Physical pains such as stomach ache, headache, heart palpitations, jumpiness, and exhaustion.

Stage 1: Denial - Denial helps us to survive the loss. In this stage, the world becomes meaningless and overwhelming. Life makes no sense. We go numb. We wonder how we can go on, if we can go on, why we should go on. We try to find a way to simply get through each day. Denial and shock help us to cope and make survival possible.

Stage 2: Anger - Anger is a necessary stage of the healing process. Be willing to feel your anger, even though it may seem endless. The more you truly feel it, the more it will begin to dissipate and the more you will heal. There are many other emotions under the anger and you will get to them in time.

Stage 3: Bargaining - After a loss, bargaining may take the form of a temporary truce. “What if I devote the rest of my life to helping others. Then can I wake up and realize this has all been a bad dream?” We become lost in a maze of “If only…” or “What if…” statements.

Stage 4: Depression - After bargaining, our attention moves squarely into the present. Empty feelings present themselves, and grief enters our lives on a deeper level, deeper than we ever imagined. This depressive stage feels as though it will last forever. It’s important to understand that this depression is not a sign of mental illness. It is the appropriate response to a great loss.

Stage 5: Acceptance - Acceptance is often confused with the notion of being “all right” or “OK” with what has happened. This is not the case. Most people don’t ever feel OK or all right about the loss of a loved one. This stage is about accepting the reality that our loved one is physically gone and recognizing that this new reality is the permanent reality.

Stage 6: Meaning Making - Stage 6 is not one of the original stages of grief but rather a new addition to help individuals move forward and heal after a significant loss. Meaning making is about holding onto the love of the significant loss and finding a sense of peace and greater purpose.

Coping in the Beginning Stages of Grief

Grief commonly results in disrupted sleep, a loss of appetite and a lack of interest in everyday tasks — all factors that can affect your health and well-being. Be mindful of your health and daily habits. Try to get adequate sleep, eat a healthy diet and exercise regularly. You might find that including a friend in meal (possibly through Facetime) or exercise routines can keep you motivated.