Considerations for The shift from in office to Telemedicine + Tele-play

These are definitely uncertain circumstances and uncertain times in the world at large, and the world of Play Therapy. When our clients are at their most vulnerable, we have decisions to make about the best ways for us to show up for our client’s and provide this service. AND these decisions are much more complicated than a therapist shifting their practice to virtual sessions under almost any other circumstances. 

Conversations with clients this week have been on a continuum of concern to sheer panic, but one common theme of uncertainty united them all.  Change of routine, as schools in Minnesota have closed, and much fear about underlying health conditions for children themselves, siblings, family members, and friends that may place them at risk should they be infected with COIVD-19.  Uncertainty of how long this will last, disappointment about cancelled events that young people have worked SO HARD for, such as concerts, sports seasons, and class trips, and frustration with not being able to see friends.  There has also been much confusion and difficulty understanding WHY things can’t be normal. In all this time of uncertainty the consistency therapy provides can be a safe harbor for our clients to begin to unravel all of these complex emotions.   

This week I have reflected significantly on what my clinical recommendations would be for clients as I transition my practice fully virtual in an attempt to do my part for both myself and the families with whom I work with to social distance. The great news is that all clients have autonomy over their mental health care at all times. I can offer what I believe to be the best recommendations for their mental health treatment, and they have the option to take it or leave it.

I in no way want to spread fear, as there is plenty of fear and panic in the world right now.  However, I do not want to be ignorant as I am watching the COVID-19 pandemic unfold across the world.  I think we need to get real and honest with ourselves and our clients.  This is not a one or two week break.  Schools are talking about being out of session until the end of the year.  And if I am thinking about the impact of this time frame on someone’s mental health services, this is a significant shift in their therapeutic care.

As I sat and thought about each of my client’s mental health needs, I reflected on the question – do I believe that our current pace of therapy is medically necessary? How would I (for any other reason) respond with therapeutic recommendations for a client that wanted to take a 2-3 month break from therapy?  What would be my ethical duties to inform them of what that might do to their mental health? For most of our clients, we would likely say that this amount of time without service would be detrimental to their mental health and progress. 

With the reality that some states have begun to require residents to “shelter in place” as well as social distancing recommendations, it is realistic to think that most clinics will be faced with the decision – virtual vs. no service.  In this decision I look to the American Counseling Association Code of Ethics which states, “Counselors assist in making appropriate arrangements for the continuation of treatment, when necessary, during interruptions such as vacations, illness and following termination.”  Read more about therapy interruptions and our ethical duties here.

Considering this information, for those that are not able to provide services virtually there needs to be a referral for clients to continue care elsewhere should you not be able to provide that service or significant resources put in place and a plan to receive services should they decide they want to re-engage in therapy and you are not able. If I think to my nine week maternity leave – SO MUCH planning and preparation went in to making sure each client was connected with another therapist for the interim or for those who elected not to continue a specific plan was made and a referral was given should they need to see a therapist during that time as I was not able to provide them therapeutic care.   
 
I strongly believe as a Play Therapy community, our leaders should be those who have expertise in this work and who have been doing it in the field with children and adolescents.  We can look to therapists such as Dr. Tillman, PhD of the Family Institute out of North Dakota who has been offering virtual Play Therapy services for 6 years to serve the remote families on her caseload that have difficulty with access to in office appointments and Lisa Dion, LPC of the Synergetic Play Therapy Institute who talks about her experience with virtual Play Therapy here and here and so many others that are offering trainings, materials, and adaptations. 

For those of you still taking a breath, getting clear, and deciding what is right for you, your clients, and your practice – that’s OK too! If you are not regulated and in your window of tolerance it’s ethically best to take a step back and get clear about the pros and cons of each as well as develop an action plan. So - here is the 1,000 foot view of what might go into this process as you make these decisions.

Get clear on the rules:
There are so many invested parties when you think about shifting your practice to Telemedcine/Telemental health.  The first is what does your specific state laws and licensing board say about what is needed to provide this service?  State law varies state to state for what is required to deliver this service.  AND licensing boards may vary across licenses within the same state! For my state of Minnesota as a Licensed Professional Clinical Counselor my board has different requirements for where a client needs to be in the present moment (“feet on the ground”) versus other boards.  Next is your malpractice insurance.  I carry my own malpractice insurance in private practice and the feedback I received was that I was covered whatever medium I choose to provide therapy.  However, this is policy and insurance company specific! Next consult your ethics code.  See about how I went through my ethical decision-making tree HERE! Lastly the client’s insurance company may also have specific requirements as well, so even if you are able to provide this service according to your state law, licensure board, and malpractice insurance your client’s insurance may not allow you to provider therapeutic services in this way.

Get Trained!
With anything new according to our ethics codes, additional training and education is required.  It is an amazing time to see the mental health community band together and offer FREE training of how to ethically and appropriate transition sessions to telemedicine. Some have CE Credit, like this PESI training below, and some are for your education as a therapist without CE credit. 

PESI is offering their course “Telehealth for Mental Health Professionals: 2-Day Distance Therapy Training” FREE with the code  TELEFREE at checkout! (usually $439.99).

Still feeling unsure? Think about getting supervision or consultation around this topic with someone who has provided this type of service!

Get Prepared
After your training you will likely know what resources you will need to pull together to ethically begin to provide this service to clients.  I write about more about what you need HERE and offer a free-mini course about how to get started.  Person Centered Tech also offers AMAZING resources HERE including forms, a free training video, and preparation checklists.

Give Informed Consent
Giving clients informed consent should be more than handing them a packet or sending them a form and asking them to sign at the end.  The informed consent, especially during the COVOID-19 pandemic, allows clients and their families to make decisions that are best for them.  My free course has the Telemedicine Informed Consent I use with clients.   

Collaborate with Clients
I talk HERE about how to have an Orientation Session with clients after they transition from in office to Telemedicine.  I include two free downloads of handouts to send to parents to help orient them to the technology and virtual platform. I also talk about how to brainstorm about how to make these sessions, within the home, safe, ethical, and confidential.

Modify
I strongly believe that providing therapy on a virtual platform for Telemedicine or Tele-Play is a modification of an existing skill set. I have provided therapy services across a wide range of settings including in office, schools, homes, and juvenile detention centers. Each of these settings needed special adaptations for me to ethically, privately, and competently provide services as a therapist.  Providing services virtually is another setting with its own unique set of challenges.  Much like in home we need to think about how to create a safe, private, and confidential space in their home.  The additional setting challenge includes how do you provide safety should a situation arise that the child is out of their window of tolerance and you are not able to use skills to regulate or they are a danger to themselves or others.  These structures should be built into every safety plan created with clients, may vary from client to client, but generally includes close and easy access to a parent and training the parent to engage in a safe ethical way when needed. 

​With these modification bumpers in place the heart of the work remains the same.  The relationship you have with the client, the core interventions, and your theory.
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Are you thinking about transitioning clients in your practice OR are you in the middle and finding it hard to become clear with all the moving pieces?  Grab this spreadsheet to ensure you have all the proper forms and communications in place with your clients.

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