Friday, June 11, 2021

The New World of Telehealth: The Challenges and Benefits.

By Janet DiGiorgio-Miller, Ph.D.

Whether you have decided to take a hybrid approach or do all virtual therapy sessions you have come to find that there are challenges as well as benefits to telehealth. I moved out of my office on July 31st, 2020 after 18 years. It was a three-room, third-floor office space in a 1929 building with beautiful big windows in a bustling little town in New Jersey. It felt like a safe and secure place for my clients and for myself.

While I missed that office, I soon came to appreciate my home office with my furniture and my paintings and all the benefits that come with staying at home during the day. As my practice became totally virtual, I thought that I would begin to write down what worked and did not work. I also asked my clients. The following are the challenges and benefits of virtual therapy. Please feel free to continue this blog by posting your thoughts.

Challenges:

Telehealth presents challenges for both the provider and the client. Probably the most challenging issue is working with young children. It is difficult to keep their attention by just talking. Usually, when you are working with a child you have some play materials to assist in the conversation. This is a task that is exceedingly difficult to replicate virtually. In addition, teenagers may be viewing more than one screen at a time or multitasking. When this issue presents itself, it is good to address it and ask the client if they are attending the session. Another issue that I found is that you cannot see the whole person’s body and sometimes cannot tell if they gained weight/ lost weight or are fidgeting and or distracted.

The biggest challenge for some clients is to have a private conversation and worry if they are being overheard. This concern has led some to clients doing sessions in their car.

Another challenge is that parole officers will not allow a client to use the Internet to have a virtual appointment. Some clients have had their attorney lobby for this privilege and other clients must use the telephone to have appointments.

As we all know, you can have technology/internet issues. It is helpful to watch YouTube videos of the technical issues and find tips there. It is also helpful to remind ourselves that we as well as our clients are learning more and more about technology. So, I tell myself to be patient (with myself and others) which is one attitudinal foundation of mindfulness.

Benefits:

The biggest benefit by far is the convenience for clients. Therapy is now available for any client who has 45 minutes to take out of their day. Previously a client would have to find a therapist in their area, drive to the therapist's office, park and/or pay, find the office or suite, and then drive back to home or to work. Instead of taking 45 minutes to find a private place to talk clients have to take at least two hours out of their day to have a therapy appointment. It is easier for clients who work a regular job or work overnight to find 45 minutes. It is also easier get approval from their supervisor to leave for 45 minutes as opposed to two or more hours. They also save money on gas and parking. In addition, if a client forgets their appointment, I can text them and remind them and we can have a session instead of missing an appointment. I can also text clients to remind them of their appointments. Or if the client cancels an appointment at the last minute, I can fill the slot with someone who is waiting for an appointment. Another benefit is that client does not have to find childcare to attend their appointment. I had one client turn the camera away and breastfeed a baby while she was speaking in therapy.  

Teens and millennials are extremely comfortable using the computer as a forum to talk. Many times, I see adolescents and young adults in their hoodies, on their beds with a cup of tea talking. In fact, some people eat their breakfast and lunch because they are in a hurry to get to work or to get back to work. I have noticed that you can see a person’s personality when they are talking from different parts of their home. You can ask them about their surroundings to get to know them better. It is also a perfect forum for clients who have been in your care and then go off to college in a different state. They have continuity of care since telehealth. You can also invite other family members to join a session.

Another benefit is you can see different people throughout your entire state/territory as opposed to having geographical limitations regarding clients coming to your office. That means the expertise is spread throughout the state or territory. This is extremely helpful since therapists with expertise in treating sexual abusers are few and far between. Another benefit is that you can evaluate and treat clients in a safe place.

Telehealth is ideal for anxious clients. Clients who have anxiety are worried about getting to the office, finding parking, being on time, and then having to settle down to discuss their anxiety in therapy.

You can still use certain tools such as reading cards, sharing screens to test clients, and showing books to suggest that they read. You can also meditate virtually. You can do your progress notes while talking to a client in a discreet manner. You can also refer to the last session notes to have a point of discussion if needed.

One unexpected benefit is that the US government is supporting telehealth by waiving copays for mental health for most insurance companies

Clients Perspective

Some clients find telehealth extremely convenient and useful however some clients indicated that they like in person sessions because it is a space for them to feel safe talking about their issues. One client told me that on one hand “It is a designated safe space to have a conversation however due not having it, it allowed me to work on several safe spaces (in and around) my home to talk.”

My/Therapist Perspective:  

It is nice to be able to eat healthy food and have no commute. It also a pleasure that my husband is home more often. I can come down to my office at any time to do my work instead of having to drive anywhere. All my documents are in one place. I have more time to balance my work and self-care.

To summarize, I have found that telehealth primarily benefits clients. I do not see a difference in live or virtual therapy regarding rapport with clients or having them open up to discuss their issues. In fact, they seem more comfortable in their own home discussing personal issues. In addition, they do not have to worry or stress about getting to an office. Regardless of the shift of their work they can find 45 minutes a week to be available for a therapy session as opposed to over 2 hours if they would have to leave their home and go to the office.

I have chosen to continue doing telehealth as it is the best option for clients and has the added bonus of being home. Another major advantage of staying home is saving money by having no rent or additional expenses related to having an office, and less wear and tear on my car.

The lack of commute is a definite bonus.   

I think telehealth is convenient, benefits clients, and is here to stay. So, embrace the change, notice the benefits, and enjoy.

 

Tuesday, June 1, 2021

Double Standard, Human Rights, and beyond?

 By David S. Prescott, LICSW and Kasia Uzieblo, Ph.D

The week before last we wrote about the apparent double standard involved in a European singer’s affair with a 15-year-old. We took note of how many in society condemn sex with underage people even as they seem to make exceptions for those who are well-to-do and/or celebrities. Within hours of its publication, we learned of a related news item in the USA. In this case, a state senator seeking to replace a member of the US House of Representatives openly acknowledged impregnating a 14-year old who he later married (and divorced).

Recognizing that sexual misconduct is not the province of any one political party and that it has often appeared to be rampant in some governments, it was hard not to notice the shifting of blame in this case. The person involved blamed the political status quo. To some, his account may seem familiar:

"Everybody has something in their life that they did ... We’ve all had these problems. Why is this a big deal?" .... So, bottom line, it's a story when I was young. Two teenagers, girl gets pregnant. You've heard those stories before. She was a little younger than me, so it's like the Romeo and Juliet story," he said.

The news account further states, “He said he tried to ‘do the right thing’ and told the paper he married the girl when she was 15. They later went through what he described as ‘kind of a bitter divorce,’ … the ex-wife died by suicide when she was 20.” There is no description of her motivation to take her own life and so readers can only speculate. The aspiring politician says he tried to do the right thing but never says what the right thing is. Strikingly absent is the perspective of those who have other perspectives, in particular those with less power

It’s been the authors’ experience that some readers comment on how men marrying adolescent females has, at times throughout history, been commonplace. Many of these marriages end up being described and/or remembered as happy. We don’t doubt that this is the case; happiness and fulfillment can occur under all kinds of circumstances. Even in cases of chronic abuse, victims are struggling with the fact that they sometimes also experience positive emotions toward the person who abuses them – which confuses them even more. These observations, in turn, lead to further questions which are worthy of reflection for all seeking to prevent abuse from (re)occurring.

The first question is whether there are bright lines discerning abuse from non-abuse in situations like this and the celebrity we discussed last week? We suspect that there will always be situations that don’t fit into neat categories. Humans, and the lives we lead, tend to be too complex for that.

Still, the question that follows from there is what price young women pay when married off at an early age. Were they able to provide anything close to informed consent? Are the cases we hear about situations in which people made the best of circumstances that didn’t go their way? Did anyone ask the young women involved whether they saw or preferred other options? Did the young women have the opportunity to ask what part of their full potential they would not live up to through sexual behaviors and/or marriage in mid-adolescence?

Given the stakes involved in this recent news item, where the wife took her own life at the age of 20, we are reminded that the outcomes of sexual relationships in early and mid-adolescence are never entirely known. Whatever has unfolded in the past, it seems that all young people should have the chance to make these decisions in a fully informed way as well as in accordance with the law. Our collective years in working to prevent abuse has led us to conclude that unless we are working to uphold others’ autonomy we may be preventing them from living up to their full potential.

These cases highlight how far we’ve come as a society and how far we still have to go. The first author (David) had a great-grandmother who was considered “insane,” in large part because she insisted that her brother had forced her into having sex; this did not fit with her family’s wishes. Her circumstances would, hopefully, have been far more fortuitous today. Nonetheless, the news item described here, in which the voice of the young wife who killed herself is absent, reminds us how important it is to listen to our most vulnerable members of society outside the often implicit paradigms that belong to the past.