Adopting Telemental Health in a Time of Crisis

The ongoing coronavirus pandemic has underscored the reality that the need for mental health services is not location or population specific—it is universal. Access to mental health care continues to be a critical issue for all counselors, and, at its core, telemental health is focused on access. With the internet becoming a more widely accepted platform for health services, telemental health is preserving and opening up access to mental health care in times of social distancing.

Availability of mental health services is often determined by a person’s location, insurance, or ability to access services. Telemental health opens the door to mental health care opportunities that may have not been available previously. These services can help clients who live in rural or underserved areas, clients who deal with stigma or significant anxiety, clients who have insurance limitations, or clients who want to skip insurance and pay for services out of pocket. In our current state of affairs, telemental health has also helped clients who want to continue receiving care but are limited in their ability to meet for face-to-face sessions as a result of pandemic-related restrictions. These services allow for continuity of care during unforeseen circumstances and provide a place to turn to for people who are experiencing mental health conditions for the first time.

Not everyone will find this type of service helpful, but for many people, it is an outlet or space that is extremely beneficial. Clients who have busy lives, live in underserved areas, struggle with stigma, want to see a specific counselor, or need to talk to someone immediately can see this as an important outlet.

I began my own telemental health practice in 2013 and have found that clients participate in online sessions at work, at night after children are put to bed, in the car on a lunch break, or before travel that is stressful or anxiety provoking. With more people at home, schedules have shifted and setting aside uninterrupted time to engage in a session can prove more challenging, especially for clients who live with others. But the flexibility, necessity due to safety concerns, and timing of telemental health has significant importance to clients and promotes growth, development, and wellness in their lives.

When I first meet a client online, there is an interesting process that occurs: connection. This connection is twofold. Initially, I must ensure that the client can hear, see, and respond to me via the platform I use; thus, I am engaged in technology connection and technology assistance. Then, once I gauge whether the client is secure in the technology platform, I can complete the informed consent process and establish the relationship connection. From the informed consent and initial session on, counseling online can progress essentially the same as a traditional counseling session.

One common myth of telemental health is that it decreases clients’ ability to connect or build a relationship with their counselors. In my experience, the opposite is true. Clients engage in online counseling in the safety and security of settings of their choice and at times during the day that they choose. In online counseling literature, this is called the disinhibiting effect of online communication¹ and this feeling of disinhibition can allow a client increased self-reflection and therapeutic expression.² Many people believe or worry that in some way online counseling is less of an experience than face-to-face counseling or that experiences or emotions can’t be seen or felt. Again, in my experience the opposite is true. Telemental health allows people to receive services in a safe and neutral space to express themselves.

One common myth of telemental health is that it decreases clients’ ability to connect or build a relationship with their counselors.

I have also been told that telemental health is only for individuals or adults. This couldn’t be further from the truth. Telemental health isn’t just online individual adult counseling. With parental consent, adolescents can benefit from telemental health. Similarly, family counseling and couples counseling are also possible on the advanced platforms.

There are a variety of reasons that led me to practice telemental health. Ultimately, client welfare and client demand propelled the process forward. I specialize in working with children and families. Today, families and parents are increasingly stressed and overwhelmed with responsibilities. Seeing clients in person, I experienced, like many counselors, clients who desperately wanted to come to counseling but had competing demands—work, school, extracurricular activities. Also, there were the challenges of clients wanting to see me as their clinician but who lived in a different area or felt a general feeling of stigma. Clients started requesting to use Skype or FaceTime or asking, “Don’t you do online counseling?”

That demand and the need to support overall wellness has increased during the COVID-19 pandemic. In my online private practice, multiple clients entered counseling for the first time. Anxiety and depression rates and experiences of life-altering stress are at an all-time high. I feel ethically obligated to say yes to taking on more clients than I had previously because of such demand for telemental health.

When considering telemental health, it is important to acknowledge the legal and ethical challenges. While telemental health provides wide access to mental health care, it can present issues of confidentiality and access to client records.

Not all online platforms are compliant with Health Insurance Portability and Accountability Act (HIPPA) standards, and not all platforms are secure when it comes to maintaining documents. It is important to do your homework and investigate the quality of platform compliance with legal and ethical requirements. This is even true during the COVID-19 pandemic when regulations have temporarily been loosened; the goal should still be to maintain professional, legal, and ethical standards.

Additional limitations and challenges emerge around emergency situations. What does the respective online counseling platform provide in case of emergency client situations? If you are a sole clinician providing telemental health, what are your emergency procedures when talking to a client online? Location of clients, ability to determine that location, and finding close emergency services are crucial factors in the success and potential failure of telemental health when presented with emergency situations. Similarly, understanding your state laws and rules around online counseling is crucial. Counselors should practice within the context of the American Counseling Association code of ethics (PDF, 4.9MB) and American Mental Health Counselors Association Code of Ethics whether online or face-to-face.

Preparing Clients for Telemental Health

There are a number of practical concerns that counselors must take into account as clients engage in or move to the telemental health modality, including:

• How to verify the identity of the client, particularly if this is a new client
• Where the client is located at the time of a counseling session
• How comfortable the client is with the use of technology
• What type of technology is best for the individual client
• How the counselor will reestablish connection if the technology breaks down
• Whether the client is in a private space where they can talk openly without interruption
• Whether there are other people in the presence of the client
• How multiple people or groups can change the dynamics of a session
• What to do in a situation where a client is experiencing a crisis

While telemental health may be new to some counselors and clients, this modality is helping fill critical gaps in services during a crisis. With this information, you can now explore telemental health options and decide if they are right for you.

Citation for this content: Counseling@Northwestern, the Online Master of Arts in Counseling Program from The Family Institute at Northwestern University.