Dr. Norma Perez, a clinical psychologist at Lakeway’s Mind, Body, Life Connection, said she only recently switched to teletherapy due to the novel coronavirus pandemic.
“I started doing it just this week, in fact, out of necessity because that’s the only way I could reach people,” Perez said, adding by the week of March 23, she expects to be conducting only teletherapy sessions until further notice.
A March 17 policy order from Gov. Greg Abbott in response to the coronavirus has relaxed Health Insurance Portability and Accountability Act guidelines, and Perez said that has certainly helped mental health professionals as they make the shift to teletherapy.
The Texas Health and Human Services Commission's Civil Rights Office recently put out information saying that “during the COVID-19 national emergency, which also constitutes a nationwide public health emergency, covered health care providers subject to the HIPAA Rules may seek to communicate with patients, and provide telehealth services, through remote communications technologies. Some of these technologies, and the manner in which they are used by HIPAA covered health care providers, may not fully comply with the requirements of the HIPAA Rules.”
Because of this, the office is exercising enforcement discretion and will not impose penalties for noncompliance of HIPPA rules regarding telehealth policies.
With regard to the efficacy of teletherapy versus in-person treatment, Perez said there is research showing it can be just as effective, but it can also be more challenging for the therapist.
“We pick up on a lot of physical cues,” she said. “So like yesterday I was doing a [teletherapy] session with a couple, and when the spouse reached over to touch the other person, I wasn’t sure if it was to comfort them because they were tearing up, or if it was just a sign of affection, and so I had to ask the question. Normally I wouldn’t have to ask, ‘Are you tearing up? Because I can’t tell.’”
Adapting to the technology
Another issue Perez said she has been encountering involves the technology used to conduct teletherapy sessions. The couple she was helping this week through teletherapy did not have a great camera, she said, so that added to difficulties in her reading physical cues.
She said she has noticed different technological mediums for teletherapy have their own quirks.
“I had a phone session yesterday, and it wasn’t the greatest quality, but because it was a phone, she had the phone right up in her face so that I could see everything,” she said.
For a majority of therapists in the Lake Travis-Westlake area and beyond, Perez guesses teletherapy is a new endeavor. She said there might be some who have embraced the practice more fully before the crisis, but even early adapters likely have not been doing it for more than a year.
One speed bump Perez said she is noticing involves a slowed-down internet, which she guesses is due to more people being online for longer periods during the mass quarantine.
“In the [teletherapy] sessions I had yesterday, the first one [the computer] froze up three times, and the second one I think it only froze up once, but only for like one to two seconds,” she said. “So I think this is more like a global issue. So unless someone comes up with a higher-speed internet system, I think we’re all in the same boat. It doesn’t matter what profession you’re in. This is fairly new for all of us."
Patient access and cost
Therapists in the Lakeway and Bee Cave area have been networking with each other for about the last five years, Perez said, adding that has helped mental health professionals throughout the Lake Travis area have a more informed response to the situation through shared information.
In this time of crisis, Perez said many therapists are likely going to see patients regardless of financial resources, but in the long run, that is not sustainable.
“We’re really trying to get everyone to dedicate a large portion of their practice to anyone who needs it, whether they can pay or not,” Perez said, listing as an example a therapist in the Steiner Ranch area who said she would provide free 20-minute sessions to senior citizens during the duration of the coronavirus outbreak. “She’s saying she can do that for them but doesn’t think she can do it for anyone else, and she’s hoping that other therapists will also dedicate some time. That way it’s not too much of a burden for only a handful of us. That way, we spread out that need.”
She said another major ethical consideration for mental health professionals amid the coronavirus is making sure patients who are now receiving free or reduced-cost treatment understand regular rates will eventually resume.
Therapists are still responsible for their patients even if they are not paying, so it is imperative that those patients know what the agreement is from the onset, she said.
Sarah Cortez is a licensed professional counselor with her own private practice in Austin and Lakeway who said most therapists she knows, including herself, operate to some degree with a sliding fee scale.
“Every therapist should have a portion of their practice for indigent people or people who are having a difficult financial time,” Cortez said. “We should not be considered nonessential providers because mental health is every bit as important [as physical health].”
Cortez has been implementing teletherapy for the last two years and estimated that before the coronavirus, about 30% of her clients utilized the medium. This week it jumped to about 50%.
“I had several appointments today, and nobody canceled,” Cortez said. “But half wanted to do telehealth, and the other half wanted to come into the office.”
Provided the coronavirus subsides and global operations resume, Cortez said she believes telehealth, and especially teletherapy, will continue to see a substantial increase in use.
“We just have to get used to the internet and other electronic devices. Using that for psychotherapy, I think we’re going to be seeing this more and more,” she said. “I had a couple of clients say it feels better in person, and that’s understandable, but that doesn’t mean [teletherapy] is not as effective.”
Younger patients and teletherapy
Dr. Kristie Engel is a psychologist who operates a private practice called Hope and Wellness Rising east of Bee Cave.
Engel works exclusively with younger kids and teenagers. She had never conducted teletherapy sessions before the coronavirus but is planning to roll out teletherapy sessions for all of her clients starting March 23.
Regarding younger patients, Engel said it will be important to remember there are already differences in mental health treatment approaches compared with adults, and that will be no different for teletherapy.
Working with teenagers through telehealth, there are ethical and safety considerations that will need to be put in place, Engel said. For instance, protocols must be put in place for how to deal with lost connections, as well as how to respond when a client mentally disconnects from a teletherapy session.
“That’s true for any age client, but when we think about our teenagers, we are setting up those protocols not just with them but with their parents,” Engel said. “For me, I want to see a parent’s face on the screen before we get started with that appointment. They don’t need to be in the room for the appointment, but they need to be in the home somewhere where I can reach them by phone if I have a concern in the moment.”
For the time being, Engel said the most responsible thing she can do for her clients is to conduct sessions completely through teletherapy until it is safe to resume her normal operations.
Engel said she does have some concerns about switching to teletherapy, but she is also hopeful.
“We’re seeing such common community right now,” she said. “We’re all in this together, and we’re seeing such kindness, and I trust that will be part of this transition to telehealth as well. There are going to be bumps, and it’s not going to be perfect, but we’re connected, and we’re going to get through it.”