Providing Ethical, Effective and Warm Video Based Therapy: Our 10 Best Tips

Providing Ethical, Effective and Warm Video Based Therapy: Our 10 Best Tips

IN THIS VIDEO:

Angela Krumm: Good morning, welcome.

We're happy to have you here for our webinar this morning. I'm Angela Krumm, and this is Maor Katz. We're both from the Feeling Good Institute, and we're excited to talk with you today about ethical, effective, and warm tips for doing video-based therapy.

Before we jump in today, I'm going to provide a little bit of information about the continuing education units as well as the technology. So first of all, if you are licensed and listening to the broadcast live and would like to receive continuing education units, then you do need to be here until the end of the hour. So we will be taking attendance, and if you leave early, unfortunately, we cannot give you the one free CE credit. If you do complete the broadcast live, then within a couple days after today, you'll receive an email from Feeling Good Institute, and that will have a survey, which is required before you can get your continuing education certificate. So look for the survey within a couple days, fill it out, and that will initiate you getting the completion certificate. Unfortunately, CE credit is not available to folks who watch the recorded broadcast after the fact.

Next, I want to orient you just briefly to GoToWebinar, in case this is your first time participating, to the right of your screen, hopefully you're seeing a control panel, and you'll notice that about halfway down the panel, there's something called the chat box. And this is an opportunity for you to engage and participate with us during the presentation. You can pose questions by typing into the chat box and choose whether it goes to the whole audience or just the presenters. Unfortunately, we won't have a lot of time for questions today because we do feel excited to get through the 10 tips with you, but we'll do our best to attend to ones we can. And you may also hear from our telehealth clinicians around the U.S. and Canada who can help answer some of your questions via the chat box.

Maor Katz: Maybe someone can help us by putting a message in the text box.

Angela Krumm: To test it now? Yeah, great, so someone be a helper and see if we can see a chat, if you're willing to try a chat box and send it to us as a tester, thank you. We'll look for that in just a moment. The last thing I wanted to tell you about is that you should also see halfway down your screen an orange P and the P clicking on it will help you access the PowerPoint slides for today's presentation. So go ahead and open up that now if you'd like and after the presentation, even if you're attending live, you will receive a recorded version of the webinar today. So we're still not seeing anything in the chat box. Maybe everyone's feeling nervous to type.

Maor Katz: But maybe no one is listening to us.

Angela Krumm: We're talking to no one. We'll assume that it's, we'll probably move forward anyway.

Maor Katz: We should move forward?

Angela Krumm: Yeah. Okay, give us just a moment here as we kind of settle in. Okay, great, so just briefly wanted to share with you our clinicians who are spread out throughout Canada and the US who do teletherapy for Feeling Good Institute. I won't have time to introduce all these folks by name, but on the second from the top left, you'll see a picture of Mike Christensen in Canada. He's our lovely clinician who leads our telehealth clinicians and provides them consultation. Just a wonderful, warm guy who provides services throughout Canada. You see a handful of other folks we have here in California, Florida, Kentucky, Ohio, Michigan, Oregon, New Mexico, Illinois, and New York. So we're excited to have all these folks. Many of them are participating live with us today as well. Great, and it looks like we are seeing some greetings here from folks who are with us today. Robin, John, Debbie, thank you to those and others who are saying hello and greeting us today. It's great to see you all there. Lots of folks.

Maor Katz: Thank you, Angela. So I wanted to say just a few words of thank you for creating this presentation, this webinar with us. The way that it came to be is with us asking the community of therapists, really what are some challenges in video therapy? What would be some concerns? And as you probably all know, we had a lot of responses, which was really thrilling to see. We got hundreds of support emails and dozens and dozens of suggestions. And then we were kind of sifting through it to help make this webinar helpful for people. And it's been a learning process for me, kind of distilling these questions into answers and ideas of how to make your experience better using video therapy. So I wanted to thank all of you that answered and as we were looking at the responses we received, it became clear to us that there were kind of clear issues that people had that wanted answers.

One is connection. Can we create a warm human connection with our clients? Can there be a meaningful, as meaningful connection online using technology and the obvious kind of technical barrier to the human connection? So this is one thing. And then the other is, how can we do this ethically and legally? How can we provide therapy to people very far from us legally and ethically? And what are those concerns and how can we answer them best? And then maybe the third topic is, how can we be effective doing this? Can this be effective? There's no question. And if you look at the literature, that it is as effective as therapy in person. That's been shown. But that's, we wanted to go beyond it. How can we make this experience really effective for our patients? And this was kind of the third theme. So hence kind of our topics for the webinar. And all of our tips would be basically directed at these three themes of connection, warmth, being effective, and also the legal aspects and ethical aspects.

And before we dive in, I just wanted to share with you a little bit about Feeling Good Institute, what we do. We are an organization that's dedicated to improve therapy, to make therapy better. We wanna have high standards of effectiveness and connection. And we wanna participate in anything that makes therapy better and more effective. And we all have been trained with the wonderful Dr. David Burns, using his approach to making therapy better, which is called, he coined it as TEAM-CBT. What we do at Feeling Good Institute is we train therapists. We do training, we do treatment, but the training part is a lot of what we do. And we also help therapists progress in their training through a certification program in TEAM-CBT. We've developed systems and treatment centers, both in California and Mountain View, where we're coming to you right now, and Silicon Valley, as well as New York City. And we've also created, not super long ago, the video therapy program, with the intention of making effective therapy accessible to people from anywhere. We're also developing some electronic tools to help make therapy more effective. And yeah, maybe most recently, we've been kind of trying to think of other ways as well. But training hundreds and hundreds of therapists per year, in these kind of measures. And specifically with video therapy, as I said, we want to make it accessible. And our video therapy program has been developing really nicely. We have really high standards. We want our therapists to be really awesome. So we don't want it to be kind of ineffective therapy, accessible to all. We want it to be kind of kick-ass therapy, accessible to all. And so we're really cherry-picking our therapists through the program, and only therapists who have reached a certain advanced skill level in TEAM-CBT, in our certification system. And also, we kind of vet them with, we want people to be very highly regarded by their teachers. And then we invite them to participate in a video therapy program in different states. And so this way, we've been able to develop this video therapy program as a treatment center, online, in multiple states, in California, in New York, in Florida, in Michigan, in Illinois, in Ohio, in Kentucky, in Oregon, in New Mexico. And from a kind of teaching perspective, it's led by Mike Christensen over in Canada, who provides treatment in Canada. So if you're interested in learning more about that, please let me know. If you feel like you'd be a good fit, we'd love to hear from you, if you want to be a provider for us as well. And we'd also wanna, some of your questions will be answered today by our video therapy team. So as we're diving into our content here, I wanna ask you, do you use video-based therapy? And I'm gonna pull up this poll, if I figure out how to do that real quick. So you're gonna be able to answer this question right now. The poll has been launched, and we're gonna give just a few seconds to answer this question. Do you, what's your experience really with video therapy? Just to kind of understand our audience today. Have you ever engaged in it, or really super rarely, or fairly regularly, or kind of all the time? And we're gonna give you just a few more seconds here to answer.

Angela Krumm: It's really fun to watch the numbers come in. It's like a video game popping up with.

Maor Katz: Yeah, who's gonna win? So cool, so maybe.

Angela Krumm: Looks like 80% have voted, maybe that's as good as we'll get, in terms of maybe not enough.

Maor Katz: What about the other 20%?

Angela Krumm: We'll hold out for those 20% who are busy drinking their coffee.

Maor Katz: Or figuring out where to answer this. So yeah, I'm gonna count to five and close the poll. How about that? So I think I'm up to five. So I'm gonna close the poll. And I see about 88% answered, so that's not bad. So I'm gonna share the results with you. And I think you can see the results on the screen. And you can see that really the majority, the vast majority of our audience today, really has either rarely or never have done video therapy. So I'm so kind of thrilled that we get to give you some pointers to make it feel easier and more accessible to you. Because I think there's no doubt that it's gonna become more and more part of everyday practice in modern therapy. So, and I do see it too, that there is like a 9% that do it all the time, which is a small number. But hopefully we'll have some pointers to you too. And I wanna encourage all who have experience to share their experience in the chat box. If you have some ideas of something that we say, kind of encourage, I want you to feel encouraged to share in the chat. Things that ring true to you, you wanna add from your experience to it as well, to our presentation. Angela, I think you know how to do this.

Angela Krumm: Okay, let's see, next slide.

Maor Katz: Awesome. So I'm gonna start with tip number one. And our tip number one, I think, as I was thinking about this webinar, I think it's really the most important thing that I've learned in my experience in video therapy. And I've done video therapy for a few years now, and it seems like it's becoming a larger and larger part of my practice. And I think the most important thing that I've learned is to really insist on having an awesome connection. And by that I mean technologically. So I also think the setting is gonna be very important to insist on. Insist that your clients meet with you from a private room with great Wi-Fi using a laptop or a desktop. Sometimes maybe like an iPad type thing is okay. iPhone, never okay. Outside, never okay. Not having privacy, never okay. And this involves some challenges because you'd think I'd learn how to change the slides by now. Thank you. So I'm repeating this here. You want to insist, you're going to insist this because you're going to face some situations where it doesn't happen. You're gonna be shocked because once the room, the physical place evaporates, all sorts of other places can seem reasonable to some of our patients. And so here's just some examples of my experience of places where it was inappropriate to meet that I just kind of found myself, a patient kind of logging into our therapy session. It was a subway station. By the way, there are no subways in California. So you also know that it's actually out of state. And then there was a bus station. There was the beach. Several times, college campus lawns. Seeing like people think, yeah, I'm with privacy. They're having earbuds and they're on, there's sidelines of the highway. I had a patient drive from San Francisco area down to LA and pulled over on Highway 5 and she was late to our meeting and wanted to meet that way. Dashboard of a car just in the parking lot. Someone left their office space and went to their car at work and wanted to meet from their college dorm, from their room, just kind of wearing PJs, just clearly just woken up. And I had even someone meet with me from a closet where she felt like she would have some privacy from her roommate.

So with all of those situations, I had to overcome my anxiety and my fear of confrontation and saying to my patients, I'm so sorry. I really have to insist that we figure out a way that we find a way to meet with a good wifi, private room where you're comfortable and completely in privacy and using a really good connection and a good device so we can have that connection, so we have a chance of actually having this warm connection. So I wanna encourage all of you to overcome that anxiety that comes up whenever something like that happens. So no matter how many times you'll tell your patients ahead of time that that's how they need to meet with you in person, or I'm sorry, from a room in private and all that, these situations will occur to you and it's okay. It just means be prepared to be insisting and be ready to reschedule. And 100% of my patients with all those situations understood that the reason that I'm kind of insisting on that is not because I'm being unreasonable, it's because I want to have a meaningful connection with them and I want to have a warm, meaningful connection with them that can be effective and conducive to good therapy. So that's my first step and I wanted to ask you guys too to put in the chat box any situations that you had that, or you can maybe sometimes it's easier to put in just in a question box in the form of a statement, situations that you had that you encountered being in kind of weird places. And I see Raphael's putting the bedroom and car driving. That's a good one. Yeah, right. So these are true to life and they seem so clearly absurd to us, but they happen to all of us all the time. And so we want to say once that you be prepared, be prepared to just insist on a setup for a therapy that can be conducive. Angela, does any one of those other ones pop up to you?

Angela Krumm: I see a question that looks like it got raised a couple of times, which is asking you more to elaborate on why is a car a problem? For example, folks are wondering, maybe they're thinking it could be private, it could be quiet if they're parked somewhere. Can you speak to that for these folks?

Maor Katz: It's up to you. If you feel comfortable with a car, that's okay. In my experience, cars are not really private. Cars have large windows. Also, what I want my therapy, I want my patients to be able to write. I want to be doing some really kind of intense thought and emotional therapy exercises with them. And being in a car doesn't allow you for that. I think ideally for me, for my kind of therapy and my experience to be effective, I also don't want it to be on a couch. I want their hands to be completely free. I want there to not worry about anything happening around them, have at least distractions. I have a little bit of ADD. I'm sure a lot of my patients have that too. I can be easily distracted. So I want to kind of have the most, the best connection I possibly can and one that allows for us to actually dive in and do meaningful, emotional work. And I think a car, to me, doesn't cut it. But if you have different experience, I don't know, maybe an RV, I'm not sure, could work. But that's my recommendation to you for sure, to insist on that.

Tip two. Sure. So I want you to think about ways, and this is the tip, to create rapport in spite of the technology. So later in the webinar, I'll share with you things that you could do to get the use and aid of technology. But here is kind of in spite of technology. And when we asked our video therapy clinicians what would be some good ways to, what's some good tips that they've learned, and then Mike, that I mentioned to you from Canada, mentioned something that I think is a really good tip, which is to position your incoming video on your screen up near where the camera is. And so like I'm doing right now, your experience, I hope that your experiencing me is more engaged with you and more engaging because I am looking directly at the camera.

Angela Krumm: Versus this, or this. Maybe you often see a client where you just see like this much of their face.

Maor Katz: Right, totally. So you can position their video feed, just drag it, you click on it and drag it in most systems that their face shows up right underneath your camera. Sometimes automatically it shows up like on the far right or on the far left, and then you just need to drag it and then they have the experience that you're looking straight at them. And that makes a big difference. So thank you Mike for that. And then Julie also mentioned, Julie Simmons who does our video therapy over in Florida, mentioned the point of always having your client's phone number, having your own phone right there, having your earbuds ready. So if something goes wrong with technology you can kind of sort it out really quickly because it can be very frustrating and you can feel kind of hopeless and annoyed when, and so with the patient, if something kind of goes wrong, and oftentimes it's not rare that initially in the beginning, like things are a little off and then you kind of establish connections. So be prepared that it's technology, like we had some technology problem this morning. Like we couldn't figure out how come this GoToWebinar system is not working for us and we had backup. So we're actually talking to you from the backup as well. So that's a good idea. So my tip to finalize maybe tip number two is figure out, kind of think of ways to create rapport with your patients, kind of understanding what their experience is dependent on. And so you can do some steps to help their experience. My next step that I want to share with you is about you doing your part or us therapists doing our part in the connection. And this has kind of multiple layers to it. We want to create warmth, right? This series of tips that I'm mentioning to you are all about creating warmth and connection. And it's not only our patients that can do less than ideal things. Like I find my mind being distracted sometimes. What if I have notifications coming in and it catches my eye? And what if sometimes I'm really kind of nervous about something that I'm expecting or on my phone. So think about what is it that you need to do in order for you to be fully present given that you will also be kind of seduced, kind of tempted with different aspects in your life while you're in front of this amazing machine, you know, the computer. And so one thing that I would recommend to you is to avoid your own distractions. Make sure your connection is really good. You're turning your own notifications off on your screen. One thing that I noticed is that if I show my hands to some degree on the screen, on the view of the patient, then that's a guarantee that my hands won't be doing anything else. And so it also serves as a way, because we also gesticulate and that's another way to connect and to converse in nonverbal ways. And also it's a way for me to make sure that I'm not letting myself be distracted by anything. I also would recommend to you to, since there's something about the patient coming into our clinic, into our home, whatever, homey clinic, a warm and brown colored clinic, and that experience is meaningful.

And some of you had questions about that, of the patient to come into the space that is kind of a little sacred and is a space that is more emotionally present and kind of means slowing down and diving deep and getting some emotional connection and relief. And make that easy for them, for your patients, also using technology, have a nice backdrop that conveys warmth and connection and humility and presence. And also I would recommend to say a little bit about yourself, like of course in an appropriate way, but where are you coming, where is your office located? Where are you coming from to them today? Say a tiny thing about your surroundings that would make it feel more human and less kind of remote and technical. A lot of us work in clinics, and so my therapy clinic is, because I do some video therapy and some in person, sometimes I can have a regular session and then I turn to my desktop or even my laptop situated appropriately and do a video therapy session. So you might be sharing the connection. Sometimes I work from my home office, my home clinic, and then my kids might be on their own, YouTube, etc, and kind of on their own devices. So make sure that your connection isn't shared with other people. Have a dedicated connection to your video therapy clinic because that could create a lot of chalkiness and that's very frustrating and takes a lot out of the warmth and connection as well. So, and again, if people wanna share some of their ideas about how, you know, there's some kind of tricks about how to create warmth and connection and do kind of our part here, I'd recommend that you do that. So I think with that, I'll pass the baton a little bit to you, Angela.

Angela Krumm: Sounds good. Yeah. Great, so for tip number four, we're moving actually into kind of the second of three parts that we're focusing on. So we're talking about empathy, ethical parts, and effective therapy. So we're gonna move now into the ethical region and that word is used broadly here to cover a number of things that are related to picking clients, laws and legal pieces. We're kind of using that broadly here. So tip number four is about screening who is the appropriate client for video-based therapy and of course, who is not as appropriate. And as we start this tip, go ahead and add to the comment box if you are thinking already of rule-outs that you have for video-based clients. So if you're someone who already does this, are there specific presenting concerns or things you're thinking about that might tell you someone's not an appropriate fit? So the truth is, there's not sort of a hard standard that I can give you that says, these are exactly the folks you should see and the people you shouldn't see because of course, this is gonna depend largely on your own clinical expertise, your own clinical decision-making and comfort level with different types of clients. So instead, I'll pose some thought questions for you today to help you come up with these decisions. Initially, surely I wanna encourage you to have a very specific screening process that allows you to learn about the patient before you first start like a video intake with that, right? You want to figure out what will be your method of talking with these folks in advance. So we like to actually do it over video. So we do a free 15-minute video-based conversation as a way to gather a little bit of information about goodness of fit. And we also collect then of course, pretty substantial intake information where the client fills out electronic forms that tell us quite a bit. So given those two pieces of information, we feel pretty good that we know enough to be able to decide if we think we can be helpful for this person in general and over video. So some questions you might consider would be things like, would you feel comfortable working with someone who has active suicidality? Or is that something that you might need to see the person face-to-face to do a good job, the more thorough job with your assessment? What about access to diagnoses? And I don't mean that you would consider ruling out all of them, but simply being thoughtful about what struggles that exist for our potential clients may get in the way of their ability to be open or honest over video. If you don't get to read the scene, the demeanor and all of the non verbal ads easily. You know, if there were cognitive barriers, what about working with younger folks and your ability to kind of get parents involved or have consent from parents? Those would be parts you need to work through, right? Surely people do video therapy with youth, with thought, right, and planning. So there's different things you might consider. One thing, you know, other thoughts that I have about this are folks where you really do need to lay your eyes on the person. So for example, if someone has been engaging in cutting and you need to see the cuts in order to be able to, you know, diagnose severity, how would you handle that over video, right? So these are parts that you wanna think through in your practice that can lead you to decide where's your comfort level. And of course, with higher risk clients, we'll talk later about safety planning and how you have a local support team. And so if you are going to work with higher risk clients over video, you'll wanna be even more thoughtful about what the safety plan would look like to make it really effective and to give your best care to these folks. So you're probably seeing from each other other ideas too, you know, about what folks might, how they make these decisions about rule-outs. And again, there isn't sort of a one standard that you can follow, but wanting to get you thinking about what would feel right and comfortable for you.

Maor Katz: Can I say something about that?

Angela Krumm: Yeah, please.

Maor Katz: I think you'd want to, since this is kind of an ethical guideline, you'd probably wanna put in your notes that you considered that. That you consider the appropriateness of video therapy for this patient, and then that you found that you believe that this person would be appropriate. And just you documenting that would kind of fulfill a certain requirement. If you don't document it, it's kind of like it didn't exist. So I would suggest not only thinking about it, but documenting that you thought about it.

Angela Krumm: Yeah, great. So I did see a comment in the question box that some folks are not seeing other people's comments, and we'd love for you to be able to do that. Take a look, are you entering your comments into the chat box, and then choose the option that allows you to share it with all attendees, I believe is how it's framed. And that would help folks to see your comments if you wanna share them beyond just with the presenters here. Okay, great.

So tip number five actually includes quite a few points because the folks who submitted questions in advance had lots of questions about laws and HIPAA and practicing across state lines. And so I wanna preface this with acknowledging I'm gonna hit on five topics here and really just provide kind of an overview of each of these with the idea that I can refer you to more information where you can learn more. So these are the five points that we'll kind of briefly touch on. And again, each of these topics are complex and could use a whole hour just to itself. So we'll do our best to give you a little overview today to get you started. So let's first talk about HIPAA compliant systems. So before I go to the next slide, let's do a thought question. How many of you are using Skype or FaceTime with your patients, right? And you don't even have to disclose, just answer for yourself because what you're gonna see on this next slide is that I say as of my last check, and I say that purposely with a little disclaimer because the technology changes so fast, but as of my last check, your standard access to Skype and FaceTime are not considered HIPAA compliant. And so really we should not be using these for any patient related work we do. Now, meeting HIPAA compliance is a complex bag of requirements, right? And you have to have a business associates agreement, it has to be encrypted, all these different levels. So up top of this slide here, you see a handful of examples of programs that claim to be HIPAA compliant and will sign what's called a BAA or a Business Associates Agreement with you. And so they're ones that many therapists who are doing video based therapy are using. Now, your clients will ask you to do Skype or FaceTime because it feels easiest for them, right? Mostly because it's familiar and it is important that your client feels comfortable with the technology. So again, this requires you to plan in advance, pick a system that's HIPAA compliant and then help your clients understand why those are necessary and why you would not wanna put them at risk by using these other systems. So always double check because as I mentioned with how quickly technology changes, I can't guarantee by the time you watch this recorded that something won't be different. But many of the systems listed that are quite user-friendly and easy to use and actually fairly affordable. So it doesn't need to be a barrier, you don't need to be held back by the technology. So here's our second poll. And this is related to practicing across state lines. So for those of you who are coming in today from out of the US, this question may not feel as interesting or relevant for you because international laws do differ. But the question says, so if you are a US practitioner and you're licensed by the state of California and really you can replace California with any other state you want, and a client from New York requests video therapy because you have specialization in treating his type of problem, can you provide him services? So go ahead and we'll launch the poll now and I want you to answer questions, option one, two, three or four. Yes, because I have this specialization. Two, because I have practice and expertise in doing video therapy. Three, no, it would be breaking New York law or no, for item four, it would be breaking California law. We're seeing lots of variety of answers come in, which is always fun. Okay, you see our eyes honing in as we see this.

Maor Katz: We see about 60% of people answered, yeah.

Angela Krumm: We should have put a, I don't want to answer because I really don't know because my guess is a lot of non-responders will be saying, I'm not sure, right? Because this is such a confusing question for folks and probably the most commonly asked question among clinicians on listservs and discussion groups all the time. And the answer is complicated as we'll talk about in just a moment. So I'll just give five more seconds and we'll move on realizing that many folks may not feel confident answering.

Maor Katz: Yeah, maybe those who don't feel comfortable answering and try to still guess something.

Angela Krumm: That's a great point.

Maor Katz: Because being wrong will teach you.

Angela Krumm: Yeah.

Maor Katz: Make sure you learn.

Angela Krumm: Yeah, there's no consequences for wrong answers here.

Maor Katz: Anonymous.

Angela Krumm: Okay, let's do move on because I want to be attentive to making sure we get.

Maor Katz: So I'm closing the poll. And I'm going to show the results.

Angela Krumm Great. Okay, so by far the most folks said that their belief is they'd be breaking California law by practicing. So again, this is a clinician who's licensed in California and practicing with a client who's located in New York. So most folks thought they were breaking California law. The second most popular was the idea that actually you're breaking a New York law. And then we have just a few people coming in on those ideas that it's more about specialization in either an area of need or in video therapy. You can close that out and I'll go to the next slide. So the most correct answer here actually is that we'd be breaking New York law, okay? And this again, confuses a lot of people. And the rationale here is that when we are licensed by a state, we're licensed to practice with clients in that state. So as a California provider, I'm only licensed to work with folks in the state of California. Now, California law actually doesn't explicitly state that I can't practice at a state, but what New York law says is that no one without a New York license can practice in New York, right? So we're actually in trouble by the state where the client is because it looks as if we're practicing in their state without a license. So it'd be as if you got your degree in one place, you moved to a new state and just opened up a shop and started practicing, but you don't have a license in that new state. And that's how conservative interpretation of law is dictating telehealth, okay? Now, the laws are changing rapidly. There's definitely organizations right now that are fighting for interstate licensing laws that would open this up to broader practice, which if you are someone who wants to be involved in advocacy and you want telehealth to expand, it's a great thing to get involved with. In the meantime, I do encourage you to consult with experts and inquire with the state that you're interested in doing telehealth, right? There is this website down here at the bottom that's also listed in our additional resources at the end of the handouts that actually discusses state policies and punishments for practicing in each state without a license.

So if you need, if you're someone who's motivated by a little information and maybe a little fear, you might take a look at what does New York say they would do with someone who was practicing there without a license? Now, let's expand on this for just another minute and think about, so why do so many clinicians take this risk? Because if you're like me, you could rattle off a whole bunch of people you know who are doing this anyway, right? It's actually very common that folks are practicing across state lines and even internationally. So it's maybe, and this is a theory from reading I've done, is that it's possible that folks are taking the risk because it's very rare that states actually pursue legal action against clinicians who are crossing state lines, okay? What is more likely to happen actually is if you were to go to court for some other problem, let's say there was some other accusation of malpractice, right, that then upon being brought into a court process, it would be added acknowledgement that you were actually practicing in the state without a license. So I think many clinicians tell themselves, well, I'm not gonna get in trouble for anything else because I'm so careful and ethical and legal that they feel pretty comfortable doing this. Now, and internationally, it's also a lot of folks take the risk because many international, many countries outside of the US have less stringent licensing laws to begin with and may not have any laws indicating whether it's okay or not to practice within that country without a license. So what you need to do is do your due diligence. If you wanna practice in another state or country, you need to find out what's allowed in that state or country and document.

And then of course, consult with your liability coverage, right, because you'd wanna explicitly say to them, if I was practicing in this other state and there was a problem, would you cover me? You wanna explicitly have that in writing to find out if they might drop you because they could argue that you had broken the law. Okay, just one word about this and you can read the details later. A lot of folks will then ask, well, what about short-term? So what if my client is just traveling to another state on business or vacation and I need to do short-term work? And the conservative interpretation again is that you really should not do that because you're crossing state lines. If you're going to do it, you would wanna very clearly document in your session note why you made that choice. For example, if the risk of not seeing the person is higher than the risk of seeing the person, then you might document how you came to that conclusion. And you can also consider getting short-term approval to practice in the location where the client will be. So for example, I one time did a round of intensive therapy with a client from the state of New York who came to California and worked with me for a few days. And when he went home, I got approval from the state of California to continue seeing him. They authorized up to, I think it was 15 or 20 sessions that I could work with him on telehealth because I wrote a letter arguing why he needed this follow-up care and why he couldn't get the exact same type of treatment in state at that point. So given.

Maor Katz: I'm sorry, Angela, you said the state of California was your approval?

Angela Krumm: I'm sorry. Wow, thank you for the catch there. Thank you. Of course I needed approval from the state of New York. That's who I was appealing to or applying to.

Maor Katz: Because that client flew back to New York where they lived.

Angela Krumm: Right. So I wasn't breaking New York locks. I had this documentation saying I could practice short-term. So that's something you could pursue. And of course you can also consider getting licensed in the state where you might wanna see folks. For example, Amy Hoyle, one of our clinicians, is licensed in both Ohio and Kentucky, kind of border states there. She can see people face-to-face in both states as well as do telehealth then in two states. So it's another option to consider. So I know that was dense and a lot of information. And we're gonna move on and know that you have these additional resources in the handouts to learn more about those parts. Just briefly, other folks asked about, do you have to code? Do you have to use different billing codes when you do telehealth? And the simple answer is yes. It is your responsibility to code accurately. And so especially if you're doing Medicare or Medicaid, you wanna actually get the information directly from them about how they want you to code telehealth. But in short, it is considered insurance fraud if you just list 90834 as your 50-minute session, that implies it was a face-to-face session. And insurance may or may not have a different coverage for telehealth. Most often now folks are asking us to use these, what's called a GT code that indicates it's telehealth. I always say, heck, when in doubt, just add an asterisk or a parenthesis that says video therapy, right? It would be absolutely clear so that it's never, no one can ever say you were trying to mislead the insurance or Medicare. There's also a resource in your handouts about learning more about coding. And then lastly, let's see, in brief here, oh gosh, I have two more in this section. I'm taking way too much time, aren't I? We'll power through. Regarding informed consent for video therapy, folks ask, what do you have to inform your clients up front, right? What is important for them to know? And the basics is that your informed consent documents should add a statement that talks about the risks and benefits of telehealth, right? So many folks in their informed consent documents will include risks and benefits of counseling in general. You would wanna add the risks and benefits of telehealth. And there's so many good research studies that talk about the beautiful parts of telehealth that you can cite. And then of course, you can refer to sites that show potential limits of it, right? You also would wanna discuss this and document that in your note that you discussed it and made a decision together with the client that video therapy would be helpful for them. And of course, you can do this in your intake paperwork so that you don't have to just rely on the verbal conversation. The last thing that I'll add around kind of this legal ethical part here is that every licensing board, so whether you're a social worker, a medical doctor, a psychologist, etc has their own ethical statement regarding telehealth. And here I've provided the website. I would add to your to-do list this week that if you have not yet read the ethical statement of your licensing board, that's a great place to start, right? And an important, important part to do. So we'll move on to one final tip before I hand things off to Maor for a bit.

And that's related to making a plan for contact between sessions. You want to be thoughtful about how often will you talk with patients? And will that be different than what you do with your face-to-face clients? I list some examples here of things to think about, right? And we'll have you do that, kind of add that to your to-do list as well. And as with anything, decide your policy in advance, discuss it with the client, document it, and then just be consistent is what I recommend. So Maor, why don't you take on with tip number seven?

Maor Katz: Thank you, Angela. And it really is striking how kind of challenging this, I noticed that your poll question was really difficult to answer. And I think I want to say also, those who answered that the California clinician cannot practice with a New York person because of breaking California law, I don't know that it's completely wrong because there is this kind of question of scope of practice that could be argued. And we could leave that go, but I wanted to also just talk for a minute about logistics. First, you've noticed that we've been talking about video therapy and telehealth. In my mind, telehealth feels like a mouthful and feels a little more technical. That's why we chose to call it video therapy. But sometimes officially it is called telehealth in other places. So we use these terms interchangeably. Usually with my patients, I call it video therapy. And then I wanted to say something also not related, but maybe important to some of you. You have the handouts to this presentation. So there's a lot of what Angela has said, I think you might want to go back and review. And if you want to use those handouts, you're welcome to it, but they're only going to be available to you during the time of the presentation to download. So for those of you who are attending this live, between now and the end of this session is your opportunity to download the handouts if you want them. They're all available to you in PDF form. The orange P. The orange P. We should move on then. So next we're going to this kind of section, we're kind of wrapping up with connection and warmth. And we've wrapped up with that. We're wrapping up now with the legal and ethical parts of our session today. And we want to talk to you about how to make it more effective. And remember I gave kind of a clue that the idea is that technology is not only limiting in video therapy is like warmth and connection. It's actually can be used as enhancing. And this has been really exciting for me as a video therapy clinician, as I'm developing in this field, it's been really exciting for me to kind of realize that, that there's this like a whole new kind of ballgame where we have different things under our disposal that we previously wouldn't. And you wouldn't think much of it before actually starting to practice on video.

So I want you to think about how can you use technology to improve the effectiveness of therapy. It's not only something that is a barrier to connection, it's actually could be something conducive to effective therapy. So here's some tips about that. Once you start thinking about it, you'll think about it yourself and figure out what works for you. But I want to encourage you if you feel comfortable, there's the HIPAA question and all that stuff. But think, is there a shared document that you can have on Google Docs or something like that, that you can share with your patient? Maybe your patient can kind of create, write their homework on it and give it to you at a certain time so you can see and that serves as an accountability and kind of a shared document that otherwise you wouldn't have as easy access to. You can share your screen. Sometimes I often share my screen with my patients when I show them, we have a symptom measurement tool, like a measurement of depression and anxiety and other skills. I can share with my patient how I can see session by session how their symptoms have been doing and we can see, are we making progress here? Are you stuck somewhere? Emma, is this kind of skill appropriate and does it seem to be kind of saying something that's true about what's going on for them? So kind of using it as an enhancement of their own awareness to how therapy is going, how they themselves are doing. Have them share their own screen with certain things. One time, I just give it as an anecdote, I had a session with a patient who we were in Silicon Valley, he was in San Francisco and he was struggling with social anxiety. So we decided to do the smile and say hello technique and I encouraged him, why don't you do it now? So he left the desktop, the desktop that he was connecting with me from. We went on the iPhone and that's one situation that I would encourage it. He was with earbuds in his iPhone, I was right there. He's in the streets of San Francisco, I'm in Silicon Valley, 50 miles away and he's walking down the street and he's kind of showing me what's going on around him and I could say to him, why don't you go and smile and say hello to this person? And he went to smile and he smiled and said hello and then I said, how about you now say, how are you? Smile and say, how are you? Because that kind of encouraged the other person to actually answer back, which was even more intimidating. So this lovely young man was super bright and wonderful, was struggling with social anxiety and I was able to really be there in a much easier way, kind of get out of the office in a much easier way and support him while he's kind of doing alone some exposure work to overcome his anxiety. Other options that you have that I wanna encourage you to do and Richard Lam, who is a wonderful therapist here in California and he does a lot of video therapy with our California folks on a video therapy program, suggested using just simply the chat box. They can, you can use the chat box if you're doing different things to actually just type in exactly what they're saying and then they can kind of look at it and face it. Sometimes we do all sorts of practice of communication skills with our patients and you can type exactly what they say and then they can read it and say, oh, here's where it worked, here's where it didn't work. Creates a nice addition to the therapy. Taylor Chesney reminded me, reminded us that there is the option to record. Taylor is a New York clinician, she heads our New York office and also does video therapy there. And she was saying, look, if you feel comfortable with it, if you have a patient kind of signs the consent for it, you can record the sessions and use them and then they can review them later. So these are things for you to decide. You're the licensed clinician, you can decide, do you feel comfortable with patient recording session or not, etc.. So make use of technology. Another way to making it effective is, I mean, Angela's gonna talk about it.

Angela Krumm: Yeah, so we'll talk briefly about safety planning. I know we're coming to the end of our hour here. So in sum, with safety planning, the key is to collect lots of information upfront, right? And you can take the pressure off yourself by doing this in your paperwork. Remember that really a safety plan in telehealth requires you to be 100% confident that you can access help for this person if there was an emergency, meaning if they were actively suicidal, if they had a heart attack as they sat on screen with you. And of course, these are very rare things, but that's what you need to be prepared for and hope you'll never have to use them. So simple things you see in the middle of your screen that you can add to your intake paperwork include asking the patient to do the research. What is the local hospital or emergency room? Who is a local emergency contact, someone that is nearby that could help? Who are their local medical or mental health providers, right? It'd be wonderful to have a team feel of having someone, even if it's a primary care doctor, on the ground in the local town, right? And those you could collect upfront, and that way if there is an emergency, you're one step closer. Also keep in mind that dialing 911 internationally is not going to be effective. Dialing 911 for someone in another state can be effective, but takes longer. They'll essentially research for you how to access the local providers. And so if you really felt someone was high risk and you were already doing video therapy, you might want to work ahead to come up with what's the local police phone number that you could call directly. Okay, Maor. Oh, this is mine too, isn't it? I'm sorry. We actually really already addressed this. Maor talked quite a bit at the beginning, about the importance of having your clients be in a position where they could take notes, that it really solidifies having them be present, be focused, taking the session really seriously. So let's move on to your point number 10 then.

Maor Katz: So one final tip here is thinking about ways, how can you kind of dive in in the start of a session? I think making a therapy session more effective has a lot of times to do in my experience, and I'm sure you can share that experience too, is that there's kind of time that lapses between the time that session starts and the time that meaningful emotional connection and work is being done. And I want to think with you, and this is a tip that that's the way I use, I want to share my system with you, so you can think if there's something of it that you'd want to take for yourselves, that helps shorten that time. I don't want a 50 minute session to be wasted 10% of that, or I'm sorry, 10 minutes, or 20% of that 50 minute session to be wasted on like a patient sharing with me what happened to him during the last week and things like that, that sometimes can be valuable, but sometimes can feel like just a warmup. And I want that warmup to be, if possible, shorter. And I think there are ways, and this is one tip for it, to dive right in the start of the session. So I just wanted to share my system with you. What I do is I think about two things. I want to first make sure that I get the chance to connect with my patient quickly about how they are feeling. I want to hear how they're feeling.

I want to give them a chance to tell me specifically how they're feeling, not what they're thinking so much, not what's going on for them, but really how they are feeling, kind of connect with some feeling words. And then I want to also bear in mind kind of that, I don't know, it's kind of a lame two punch kind of idea, but the first punch is getting kind of into the emotions, and the second is insisting on reviewing homework, because we know that homework, doing homework, doing things between sessions is so important, at least to me, for making therapy effective. And I don't want to get the session to take too long about talking about other stuff that could be important, and as a result of it kind of missing out on really keeping the patient accountable, patients seeing that I'm taking their homework very seriously, and that would encourage them to do it. So first, connect with emotion. Second, I want to review the homework. And so what I do is I use technology for that, giving you here an example of our system for mood survey. So we start the session with reviewing how a patient is feeling, and I can now come very quickly and say, hey, Jack, whoops, I said, hey, Jack, I noticed that you're feeling kind of somewhat down today. I see that you're feeling kind of fairly down in the dumps, and you're feeling kind of your low self-esteem is more pronounced and not very motivated. Is that true? Does that kind of depict how you're feeling right now? And then I stop and I listen for a minute or two, and then I say, so now I feel there's connection. Let's share this Google Doc and see, tell me about your homework. Let's review your homework, and here's an example of a homework that I actually gave to someone not so long ago about how you need to write an essay about how hopelessness becomes a self-fulfilling prophecy, and then he was also, like the other example, doing some smiling, saying hello technique, and he was recording it. So we can review it using the Google Doc that's right there, and I find that it cuts down tremendously on this kind of wasted time in the beginning of session. So I hope you can take something out of it for you to use in your practice. So this is you, Angela, right?

Angela Krumm: Yeah, awesome, yeah. So here's the slide where I list a number of websites.

Again, hopefully you've clicked on the orange P button to download these handouts, so you can refer to these later. These are opportunities for more learning that we hope are helpful to you. Wanted to let you know our contact information.

Of course, Maor and I would love to just be in touch and connect with you all in the future and you know be support in whatever version maybe helpful and of course we want you to know how to find these clinicians we have mentioned who are these excellent CBT or specifically TEAM CBT, model of CBT clinicians who are spread across Canada, in the US as you see you can have a potential client schedule of free 15-minute conversation with one of them and by going to our website which is videotherapy.live, you click on the appropriate state or country and it will help you schedule the free 15 minute consultation, we hope that’s easy. If you were wondering how to access those people and the other thing we want to make you aware is again that this recording will be sent out within a few days along with a CE survey if you attended the whole presentation live today, might take a few days to get that once you do the survey which is required. You’d receive a certificate and also want to know that the recording will be available on our YouTube channel and how do they find our YouTube channel, just Feeling Good Institute is a great way to find and there’s other wonderful resources there, if you’re interested in seeing other educational videos. So, we hope this was valuable for you today. It was fun for us to connect with folks in this way. We hope to have a connection again in the future.

Maor Katz: Thank you again for making this happen and asking questions that made this webinar possible.

Angela Krumm: Yeah, best wishes if you decide to launch into video therapy yourself. Bye.