How can I safely reopen my practice and offer face-to-face counseling sessions during a global pandemic? Many therapists are grappling with this question.
Counselors, psychologists and social workers quickly switched to Telemental Health sessions in March 2020 when the dangers of the deadly new coronavirus (SARS-CoV-2) hit home in America. Telemental Health has allowed us to continue offering much-needed therapy to clients during this national crisis without risk of exposing ourselves to the virus or spreading it to our clients.
Many of us are opting to keep using Telemental Health until a vaccine for the virus becomes available. The American Psychological Association recommends psychologists continue using telehealth if possible. The National Association of Social Workers (NASW) reminds social workers they are “not professionally or ethically required to provide in-person services.”
It’s not just behavioral health clinicians who have made the switch to distance counseling. The CDC recommends all healthcare providers keep using telehealth if possible to “provide necessary care to patients while minimizing the transmission risk of SARS-CoV-2, the virus that causes COVID-19, to healthcare personnel (HCP) and patients.”
But not all counseling clients are comfortable with Telemental Health, and it may not work at all for young children or clients with attention deficit and other mental health disorders.
This is the dilemma for many therapists: How can you safely practice talk therapy when just opening your mouth to greet a client could mean sharing the deadly coronavirus? To be clear, talking for an hour in a closed room falls squarely within the CDC’s description of how the virus is transmitted:
“The virus that causes COVID-19 is thought to spread mainly from person to person, mainly through respiratory droplets produced when an infected person coughs, sneezes, or talks. These droplets can land in the mouths or noses of people who are nearby or possibly be inhaled into the lungs. Spread is more likely when people are in close contact with one another (within about 6 feet).”
If you are thinking about seeing clients in person again, you need to create a detailed plan before you unlock your office door. We’ve pulled together guidance from the major therapy-related associations and from government agencies:
Here are the key points for counselors to consider before reopening:
Do no harm Our first duty is to protect the welfare of our clients. Determine if an in-person session is necessary. Remember, your professional associations and the government are all recommending that you use Telemental Health if possible. If you decide to hold in-person sessions, document your decision and the steps you’re taking to protect client safety.
Laws, ethics and risk management Check with your state board and your liability insurance company to see if you can legally and ethically reopen your office. Talk to your liability insurance company to see if you need more coverage. Ask if you need to have clients complete a COVID-19 waiver. Work with a lawyer to make a plan for contact tracing if you or a client contracts COVID-19. Update your informed consent documents.
Clients Educate clients about the options for telehealth. They may get a false sense of security if you open your office. Make sure they know the risks of meeting in person and that you cannot guarantee their safety. Are your clients in a high risk group for getting severely ill if they contract COVID-19? Tell clients who are not feeling well to stay home. Make sure you give your clients a copy of safety protocols before their appointment. Post a copy of your protocols on your door so clients can read it before entering.
You, your employees, and your colleagues Make sure everyone in your office is well. Get tested for COVID-19. You can be a carrier even if you don’t have symptoms. Make sure everyone has been trained on your new COVID-19 protocols.
Supplies
Hand sanitizer Keep plenty available and ask clients to use it as soon as they enter the office.
Masks Masks save lives. According to the CDC, “masks are recommended as a simple barrier to help prevent respiratory droplets from traveling into the air and onto other people when the person wearing the mask coughs, sneezes, talks, or raises their voice.”
Make sure you are comfortable wearing a mask during multiple therapy sessions. Make sure your staff is comfortable wearing masks all day. Remember, germs exhaled by your clients may end up all over the front of your mask. Don’t touch your mask. Don’t touch your face.
Require masks for your clients and make sure they know your policy before their appointment. Will you provide masks to your clients, or do you want your clients to bring their own? Keep extras on hand for clients that forget to bring masks to the session (and some will). Do you want to charge them for the masks if you provide them? Remember, make sure you have told your clients about your policy on masks before their session.
Special notes on masks:
Clients who cannot or should not wear masks: Clients who are very young, or clients with intellectual and developmental disabilities may have challenges wearing a mask. The same goes for clients with PTSD, OCD, or clients who have suffered trauma. Think about how you will accommodate these clients if you reopen your office.
Clients who refuse to wear a mask: Masks are controversial. They have been politicized. Be prepared to offer telehealth for these clients.
Babies: The CDC does not recommend masks for infants, children under 2 years old, or anyone who has trouble breathing.
Clear masks: Consider a clear mask to help clients with hearing impairments read your lips.
Face shields: The CDC doesn’t know yet if face shields provide enough protection and the agency does not currently recommend using face shields as a substitute for masks.
Signs Add reminder signs to your front door so the clients know what to expect when they open the door. You can purchase professionally-made signs at many office supply stores.
Cleaning your office This isn’t your routine office dusting. You will need to make sure your counseling office has been thoroughly cleaned and disinfected before you open and that it stays clean. Follow the CDC safety guidelines for businesses and OSHA’s guidance for workplaces. The coronavirus can remain on surfaces for days and it can linger in the air for hours. It can be killed, but you have to use the right products. The EPA has compiled a list of disinfectants shown to be effective against the coronavirus. If you hire an outside cleaning agency, make sure the workers understand the extra cleaning that is required. You may want to share a printed version of the CDC’s cleaning guidelines.
Each time a client leaves your office, you need to clean before the next client arrives. Clean every surface the client touched including chair arms, door knobs, pens, clipboards, and play therapy supplies. If you open your office restroom, you will need to wipe down all touchable surfaces after each use. The same goes for your break room. Be sure to wear gloves and a mask while you’re cleaning.
Ventilation Does your office share a ventilation system with other offices? Do you have a filtration system to keep the virus from spreading between those rooms? Check with your building manager to make sure your air conditioner and heater aren’t spreading the virus.
Social distancing You’ve heard this many times by now, but remember – the coronavirus spreads by talking, coughing, sneezing and by touch. Is your counseling office big enough for you to sit 6 feet away from your clients? How about your lobby? If you have clients waiting together, do you have enough space for the clients to sit 6 feet apart? If not, you can arrange for clients to wait outside and to be called in one at a time. Do you share an office with other therapists? If yes, consider alternating days so that you don’t overlap. Remove magazines and other shared objects.
Remember, Telemental Health still is your safest option. Above all, do no harm to your clients, your self or your staff.
More resources:
American Counseling Association: What do I need to know about reopening my practice?
American Counseling Association: Counseling in a Time of COVID-19
NASW COVID-19: Practice Guidelines for Reopening Social Work Practices
APA: COVID-19: When is it OK to resume in-person services?
APA’s Telehealth Guidance State-by-State
The course was so informative and I was glued to my screen for the entire duration. I received so much knowledge concerning ethics in telehealth and I am greatly encouraged to read about all the standards and policies that pertain to my practice. Thank you!.