Are We There Yet? Deciding When to Return to In-Person Sessions

Throughout the pandemic therapists have been engaged in social media debates about when/how to return to in-person sessions with their clients. I’m writing my article after watching a video where the Executive Director of CAMFT, Nabil El-Ghoroury, PhD, CAE weighed in about seeing clients in-person during the quarantine. He suggested we carefully consider the decision and cautioned his readers not to pressure themselves into making a hasty decision. El-Ghoroury stated that he planned to continue to see clients via telemedicine through Labor Day and would revisit his choice at that time. After watching his video, I took some time to reflect on the logistics of in-person sessions; my feelings about it deserve a separate blog post.

I knew I wasn’t ready to return yet, but I wanted to consider my options for the future and writing this post helped me gather my thoughts. The first question was masks. Right now, I wear a mask when I am out in public, except for my early morning runs when very few people are outside and the world seems almost normal. The thought of wearing a mask does not feel conducive to my work as a trauma therapist, where facial expressions help me attune to what’s happening inside of my clients and my face helps regulate their nervous systems. Some of my clients choose not to wear a mask, how would that work?

I’m concerned that my clients’ journey from their cars to my therapy room could be activating. We have seven offices in our suite and approximately twenty other suites in our large, three-story building. As I considered the entrance to the building, keypad, and elevators, I realized that on the way to my office my clients could encounter people who might not be wearing masks or practicing social distancing; I wondered how these encounters might impact their sessions, there would certainly be “grist for the mill.”

Antibacterial wipes would be available at the entrance to the suite. Once they made it to my office, clients could text me to bypass the waiting room and I could meet them in the outer hall. How would we handle it if another person’s client was walking out when I was escorting my client in? There is no way to stagger the schedules of seven clinicians, even if we all started and ended our sessions precisely on time, which is never going to happen.

Once we made it to my office, I imagined my chair being six feet away from my client, which feels way too far. To handle the credit card payment I’d have to roll my chair over to my client, and once they handed me the card I could swipe it, show them the amount on the screen and sign for them. Once I gave the card back, we could have another round of hand sanitizer. I realize I can keep a credit card on file, however, the fees are significantly more expensive, and it eliminates the chance to explore any potential financial transference as the client pays for their session.

I decided to ask my doctor for some recommendations, and she strongly recommended that I wear a mask at all times and require my clients to wear a mask. She advised me to wash my hands frequently and use antibacterial hand disinfectant with 70% alcohol. She told me to avoid touching my face and to wash my hands after touching any door handles.

Writing this article has helped me see that there is no magic business process that will allow me to feel perfectly comfortable returning to in-person sessions. We all have different opinions about this issue, and it can feel adversarial when colleagues communicate their judgment on social media. Writing this article has led me to decide to continue to practice telemedicine (via ZOOM) for now. Although it presents some challenges, I have been able to do important, clinical work during this time. Two weeks ago, I returned to the comfort of my air conditioned, quiet office, away from the many distractions at home and the noise of my neighbor’s bathroom remodel. I’m wearing my mask, washing my hands and using antibacterial wipes on the door handles. My doctor’s suggestions proved to be helpful as I navigated the reentry process, sharing a restroom and elevators with other people.

I will continue to reevaluate my decision as I learn more about the Covid-19 virus. I know there is no perfect solution, but it’s clear to me that I don’t want to do therapy with a mask on and I am not willing to risk my health or the health of my clients in order to see them in person. I’m interested in your ideas about this and would welcome a discussion.

Creating Your Professional Will

Last year, I decided to update my professional and choose new members for my Emergency Response Team, these are the people who would manage my business affairs if I became seriously ill or in the event of my death. When the coronavirus hit, I wanted my will to be current in case I got sick and could no longer care for my clients. Both people I contacted readily agreed and said they felt honored to be asked.

Creating a professional will is not difficult, the challenging part for me was calling my friends and requesting their help because I know it’s a big responsibility. Before you create your will, think about who you’d like to coordinate care for your clients in your absence. The colleagues I chose both specialize in addiction and trauma as I do.

I suggest you find at least two people. One of their main responsibilities would be calling your clients to inform them of the situation and providing them with referrals if needed. In the event of your death, your team would access to your office and any paper records. I maintain electronic records and my brother is my delegate for my password management software; he’ll be in charge of providing my friends with access to my records and managing any outstanding financial issues. If you use paper files, I recommend creating a list of your active clients and filing it with your professional will.

As therapists we have an ethical responsibility to our clients and our colleagues to keep our business affairs organized. I know it’s not pleasant to think about the possibility of getting seriously ill or our inevitable death, it’s comforting for me to know my affairs are in order during these uncertain times.

You can find professional will templates online and I’ve included the link to CAMFT’s template below https://www.camft.org/LinkClick.aspx?fileticket=8V-aZFCfl7s%3d&portalid=0

Choosing the Right Telemedicine Software

Choosing the Right Telemedicine Software
Due to the Coronavirus (COVID-19), many of us have moved our practices online to protect our health and the health of our clients. I have always offered online sessions to clients who travel or simply prefer not to drive in LA traffic. When I started doing video sessions I inquired with CAMFT about HIPAA privacy rules and video conferencing software for telemedicine. The first step in choosing the right software is determining whether you are a HIPAA-covered entity.

Here are three questions you need to ask yourself; you must answer yes to all three to qualify.

1. Are you a healthcare provider? The answer is yes for psychotherapists.

2. Do you transmit health information electronically?

3. Do you conduct covered transactions? According to CAMFT- “A covered transaction for HIPAA's purposes involves transmitting information between covered entities to carry out certain financial or administrative activities related to health care.” From David Jensen JD’s 2010 Article- “Are You A Covered Entity”CAMFT’s website and verified by phone

Since I am not on any insurance panels and do not transmit health information electronically, I answered no to questions 2 and 3.  I chose to use ZOOM, which is not HIPAA compliant.

When researching software choices, be sure to ask about the software’s privacy protocols.  Ask if the sessions are recorded and who has access to that server. If you are a HIPAA covered entity, check out VSee, one of the more popular HIPAA compliant platforms.

California law says we must maintain confidentiality and reasonable security when we conduct telemedicine sessions.  If you need more information about telemedicine, you can find it on CAMFT’s website www.camft.org.

The Language of Suicide

photo by Rod Long on Unsplash

One of my specialties is grief and loss, and early in my career I did an intensive training at a remarkable place called “Our House” in Los Angeles. During the training, we were encouraged to share our personal experience with grief and discuss our family traditions when someone died. The leaders emphasized the importance of using the correct language when talking to our clients about death.

We were taught to use the word “die” instead of “passed” and avoid saying someone “committed suicide”, because that phrase implies someone “committed” a crime. Instead they recommended saying someone “suicided”, died by suicide, or ended their life.

Last year I lost a close friend to suicide, she was the second friend who took her life in 2019. When someone dies by suicide, people are often unsure about how to respond.  Sometimes they’ll ask questions about the details of the death which is re-traumatizing for the grieving person. In our death denying culture, we need to find a way to get comfortable talking about suicide and listening to those who have suffered the loss of a loved one.

Didi Hirsch Mental Health Services https://didihirsch.org/services/suicide-prevention/ opened the first suicide prevention center in Los Angeles in 1958. Today their state-of-the-art facility offers a variety of support groups for the general public and specialized training for professionals.

California recently passed a new law requiring mental health providers to complete six hours of continuing education in suicide prevention. Those already licensed will be required to complete this one time training at the time of their first renewal that takes place on or after January 1, 2021, to learn more about the requirements of this law go to https://www.bbs.ca.gov/pdf/suicide_prevention.pdf 

Gratitude Season

It’s November and soon we’ll be celebrating Thanksgiving. It’s my favorite holiday, I love cooking and spending time with my family. My nieces are anticipating my questions about what they are grateful for.

I express my gratitude whenever I receive a referral from a colleague. I consider it an honor and a privilege for someone to have faith in my abilities as a therapist. (I’m not talking about the times where a therapist you don’t know sends you a difficult client without calling you first!). When I receive a referral, I send the person a handwritten thank you note in the mail. Several people have said that they felt pleasantly surprised when they received my note.

Dr. Martin Seligman is the founder of Positive Psychology. Seligman’s research supports the idea that practicing gratitude can increase your level of happiness. Dr. Seligman and his colleagues developed a practice called the Gratitude Visit. This is something you can share with your clients.

1. Close your eyes.

2. Take a moment and try and remember the face of someone who did or said something that had a major positive impact on your life.

3. Take some time to reflect on how that person impacted your life and notice what happens inside.

4. Write a letter to that person. Include specific examples explaining what the person did for you and why you are grateful for that person.

5. Deliver it in person

This can also be done using a person who is no longer living by modifying Step 5 in whatever way feels meaningful.

The research revealed that those who wrote the letters became much happier during and after the study. If you’d like to learn more about Dr. Seligman’s research go to https://ppc.sas.upenn.edu/research/positive-psychology-research