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!