Technology, Telehealth and Professional Practice - S1E9

Dr. S. Kent Butler: Welcome to The Voice of Counseling from the American Counseling Association. I'm Dr. S. Kent Butler, and joining us today is Dr. John Duggan. John is a practitioner, educator, and he's ACS staff lead on developing multimedia educational experiences for our profession. Today, we're going to be exploring technology, telehealth, and professional practice. 

In this conversation, we'll learn about practical use of technology and get some helpful tips on the use of telehealth as the landscape changes in the era of the COVID pandemic. Dr. Duggan is an ideal practitioner, and he's going to share his insight on these particular issues. Welcome to the conversation. How are you doing, Dr. Duggan? 

Dr. John Duggan: Dr. Butler, good morning, and good day. It's good to be with you. Thank you for the opportunity to be with you, Kent. 

Dr. Butler: Good to be with you as well. Look at that bright smile you have on your face. Where was that eight minutes ago? I'm just kidding. I'm just kidding. We've been on-air waiting to start this podcast. I hope all is well. How have you been? 

Dr. Duggan: It is. We've been a little bit of rain up here in DC, but it's kind of fall. 

Dr. Butler: Yes, that's what it is. That's what it is. Well, that's where you chose to live, so I don't know. How has life been for you as you've been dealing with the last two years of this COVID pandemic? 

Dr. Duggan: I'm good. I'm grateful to be healthy and doing things to take care. It has been very difficult also in that-- There's just been a lot of hurt and angst. We have multiple pandemics that are going on. I have involved in education and working and school counseling and clinical mental health counseling education and working to focus on anti-racism and helping practitioners understand the xenophobia, the xenonegativity, trans negativity. There's just been so much you've been exploring in these podcasts that has been weighing on me and on us, my family here. 

Also, just taking it in, it's just like almost 23 months of staying very close to home and seeing family once over that period of time. It's been an adjustment. What it reminds me of, and this comes into one of our first questions is the wisdom that has helped me get through the first part of the pandemic, and we can lean into that. I'm doing okay, given what is. How are you? How are things going for you? 

Dr. Butler: I'm leaning in. I'm doing what I can to stay-- To be honest, I've said this a couple of times, I am definitely an introvert. The pandemic hasn't messed with me the way that it has messed with individuals who like to be out there, out and about. I've been able to maintain and stay relatively calm, and then buy into what's happening in my life. Just being close to family here, FaceTime and Zoom has been helpful. I'll be honest about that. I'm glad we're going to talk a little bit about what this might look like from a telehealth-type situation. 

It's been really a bit a long time. I think I'm ready to get out. I would love for this pandemic to be over. I don't think anybody wishes it more than I do at this point in time. What it may do when I'm out and about, though I'm masked up and taking care of my health. That's where I am right now. It's been an interesting ride. I'll leave it at that. When you think about telehealth and all the things that are going on in our community of counseling, what are some of the things that stand out to you? What do you think off the bat, we as counselors need to know about how we can maintain and do the work that we do in this telehealth environment? 

Dr. Duggan: Well, I think one of the important things for us to consider, and this goes for our students, new professionals, as well as the advanced practitioner, so across the spectrum is that this is a changing landscape, and it has not, using technology, using telehealth, in general, has not settled, if you will. I personally would recommend using a legal ethical decision-making model to really think about when it is appropriate to engage in telehealth and what types of practices that we're doing, because it's not as easy as just going based on licensure and those things. I think there are other issues that we can talk about, but the landscape is changing, clearly the pandemics that we're experiencing, and I'm using that poorly because there are just multiple needs that are going on. 

We're looking at hospitals that have been closing for decades, parts of the country where there are no healthcare practitioners, and, folks are needing the support. We're looking at interventions within the school systems and having clinicians that are supporting school counselors, and finding ways to help the various needs that are going on. A lot of that is going to, I think come from technology, and what we've learned through the pandemic is that there are just so many opportunities that I think folks were holding back on in terms of the approval process. That's going to I think continue to expand. 

Our struggle is, as a profession, we often come from schools of education, and so over the years and soon you'll have another interview on looking at Medicare and things like that with some other folks from ACA, but we really need to also look at ourselves as healthcare practitioners, and with that comes all of the other stuff that applies to, physicians, dentists, and so on. I think it's important for us to take these different variables, and bring them together and find a way to make it a meaningful intervention, a meaningful use of technology, and engage in it ethically and remember that we are also healthcare practitioners who need to step into it from that perspective. 

Dr. Butler: How do you wrap your head around that though as a health care professional, you know that you have a job to do, but how do you come to grips with all of this? 

Dr. Duggan: Sure. Well, I think one of the important pieces is becoming knowledgeable about the technologies that are available, paying attention to our standard of care, which is the 2014 ACA code of ethics and how it is that we would normally protect client, student privacy and confidentiality in the physical setting, right? Then think about how we then expand that into the settings where we're using technology. 

One of the things that I think is going to be important for our profession, and it's evolving is that, Kent, there were 30-plus names for the use of telehealth and technology that are out there in the literature. It's 35 or 40 names. Our code of ethics when it was written was calling it distance counseling, and other practitioners and I have clearly had the experience where we're having groups, and people are using technology to securely send us messages in the group setting in the same physical space, and what that means is that there is no distance. We've been physically present before the pandemic, and people are, especially teens and young adults, they're sending that stuff through an encrypted telehealth-type platform, although it's mostly messaging. 

What we really need to remember is that it is no longer just about distance, it's about the use of technology. That's one of the things I really enjoyed the book that we have from ACA is talking about using technology-assisted distance supervision. Remembering that this is about the use of technology. 

How I wrap my head around it, though, is that we need to continually be seeking and engaging supervision and training. Our supervisors need to be trained in the intervention of using technology and telehealth services and really getting some different types of feedback in terms of what is working and what doesn't, and also being attentive to who's appropriate. Now, I understand that in the pandemic, we don't have much of a choice. I get that. I don't want folks to hear this and go, "What the heck is this guy saying?" 

Over the years of clinical practice, I've worked with folks from different diverse social identities and backgrounds, some who did not have bank accounts, let alone able to have technology and internet service, as well as folks who have bipolar spectrum psychotic disorders. I became a specialist with dissociative identity disorders and people who had adverse childhood experiences or who actually were asylees to the United States and had experienced periods of torture. 

For some of those individuals, using telehealth services, audio and video, can be helpful for them to remember who John is as a counselor. Because someone who has that type of an experience can, after a couple of weeks, forget who you or I are. That sense of identity can fade away. We have to make sure that the person is appropriate and is going to be well served through the use of technology. My hope is that as we look at the use, we just don't have a one-size-fits-all approach as the pandemic recedes. 

Dr. Butler: Can you talk a little bit about it from the ethical point of view then? Because that sounds like it feeds right into how counselors can stay above the grade and make sure that they are not doing harm, especially from an ethical point of view. 

Dr. Duggan: Exactly. We need to pay attention to really our use of an assessment. Part of it also, as you had asked earlier, was you need to also look at your scope of practice and your licensure or regulation. For example, I'm here in Maryland, there are very specific things that need to happen in order for a counseling relationship to begin. There needs to be a thorough assessment, there needs to be certain things in the documentation and all of that. Ethically, we need to make sure that we're doing that. There are some services or platforms that will allow one to initiate a telehealth. 

I call it a counselor on retainer type thing where the counselor is into this service, they're getting paid a certain amount, they get certain clients and there may not be really the ability to do a visual and a thorough assessment to determine, well, is John experiencing bereavement or is it a depression or is it a thyroid disorder or is it sleep apnea? What's going on? Somebody can conditionally say, "Hey, I took this assessment online and I think I have depression. This is what it is." Okay, but we need to engage ethically in a thorough assessment. We need to ethically do interdisciplinary care. 

Remember that when we're looking from the clinical side of things, the diagnostic processes, you do a rule out for any type of substance, any type of environmental factor that may be influencing. I've had times where I've worked with clients who are referred to me for panic disorder. The panic comes when they're putting their head down to sleep on the pillow. The assumption can be, "Oh my gosh," there's panic because of something that's related to where they're sleeping. 

When you're following the rule-out process of first looking at the environment, the substance, any substances, and that could be over the counter medication too. Then looking at the medical issues, getting a full diagnostic from a physician to rule out any organic or metabolic issues, then you can start to figure out, "Well, okay, what else is going on? How am I ethically engaging in counseling with this particular person?" Kent, in the scenario that I just laid out for you, one particular client who maybe is having panic when they're going to sleep, it actually turns out to an allergy. 

There's still issues that can be worked out in the counseling relationship, and those can be addressed in telehealth. The key factor that I want to point out is ethically, we need to make sure that we're following all of the steps that are part of the standard of care. I'll add, not just doing evidence-based interventions for the sake of doing an evidence-based intervention. 

Dr. Butler: How can you ensure that you're doing the right thing for your clients? Because this is a big mixed bag of a whole lot of things that are coming together, that we have to sort through in order to ensure that we are doing the right thing. You're talking about these assessments. You talked a little bit about how that's different than if you are face-to-face with a client. Also, what do we need to know as counselors that help us to take that into consideration? How does that look different? 

Dr. Duggan: Sure. This is anecdotally, from my experience, it takes much more time, and it takes patience, because sometimes maybe things that folks might have been familiar to do on a paper or in an office setting while they're waiting, they may forget to do if you have an online assessment. One type of way of approaching it is a screening instrument where you're tracking, not necessarily a diagnostic exam, so it's not an advanced appraisal, but you're having some sort of a service that's set up, and sometimes they can be reimbursable, if a counselor is billing health insurance, submitting claims, and you can track symptom. 

You can rule out if there is any report, and this is a self-report of something that is related to misuse of a substance or if there are markers for PTSD. I think also at the same time when we're going through these instruments, and being patient, because it's not as easy as doing it in the office setting, sometimes people are going to need help to navigate these items. To also then make sure that you have a good physician or three that are in your field, on your team, and you can make those referrals so that somebody is also getting a good quality medical checkup along the way. 

It's really helpful when the nurse calls or when the physician calls or sends a report over securely and says, "You know what, what you're experiencing is most likely not related to obsessive-compulsive disorder, what you're seeing is Lyme's disease. This is a neurological issue, and so we're going to refer them to a neurologist. Here are some of the interventions that you can help with." 

We can make some quick assumptions based on these symptomatology measures and instruments, but we need to then collaborate with other disciplines, and make sure that they're in the person's welfare and interests, that we're not stepping outside of our own scope of practice, but that they're also culturally appropriate that not every intervention is going to be right just because the book says this is the best thing. 

Now, I'll be downright honest with you, I was trained by Dr. Courtland Lee for both my masters and my doc studies. I have had the opportunity to engage with folks and really become familiar in evidence-based practices, and then recognize that for some people, they don't fit, they're not the right size. I'm going to identify myself, I'll be very honest to say, I'm a humanist, I'm humanistic existentialist, and so that is one of the basis. It allows me also to bring in a multicultural, social justice advocacy framework, because I want to make sure that, ethically, we're doing those things to make sure that somebody is really getting the best care that they can. The challenge is, Kent, it takes time. It is a lot of work to pull this off. 

Dr. Butler: A lot of work because we're doing it online or a lot of work because we are doing it because we're counselors? 

Dr. Duggan: It's a lot of work because we're doing it as counselors. Remember, we also ethically need to be monitoring the effectiveness of treatment. This is part of one of my research areas, where, looking around, it's like I ask practitioners, "Well, how do you check, how do you monitor the effectiveness of treatment?" Most everybody, I would say 95% responses were, "I simply ask, 'Is this helping?'" 

What we know is that is not a really robust way to get that information, to check about the alliance, and then to see if those interventions are actually helping. Somebody may be saying, "This is helpful," when actually they're tanking. Maybe they're experiencing non-suicidal self-injury, and they're not disclosing that to us. I think it's challenging as counselors, but it's also perhaps, at times, it requires a little more technology and work because we're doing it virtually or using technology. 

Dr. Butler: When you think about what we're doing virtually, and you look at licensure laws, and you look at ethical practice, and you look at lack of education, lack of awareness, lack of opportunity to do this, where, like you said, during the pandemic, this is coming into view for a lot of people who have never ever thought about counseling in this manner, who went kicking and screaming into technology in the first place, so what are some of the things, what are some of the things from your perspective that counselors can do to bring themselves up to speed on how to best navigate these new horizons that we're a part of? 

Dr. Duggan: Good question. I think constantly being curious and critically curious. Not just taking the first information that comes across the website on a web search, but being critically engaged in your curiosity and learning as a practitioner and engaging in those trainings, reading articles and literature on where distance counseling or telehealth is going. I was trained 15 years ago in telehealth, and I look back at that manual, and I'm like, "Wow, things have really changed." 

Dr. Butler: That's because technology has changed, though, right? Was it correct back then, and for the time that it was in, or were we getting it terribly wrong at that point in time too? 

Dr. Duggan: I don’t think it was we were getting it terribly wrong. I think that the technology has changed and it's become better. Not everybody has access to it. There's still that issue that we need to be attentive to. Also, some of the stuff related to who might be appropriate and how do we go about some of these interventions are problematic. 

The other piece, I think, Kent, is sometimes people, in order to pay the mortgage, if you're a counselor and you're running your own practice or that type of thing, you've got to have a certain amount of clients available to provide services to. There's this business side of things. One of my fears is that we've looked at wellness through ACA. One of my fears is that people are burning out, because when you go from one telehealth session to the next, to the next, it can be a little different than having somebody who's sitting in a waiting room or is then coming into your office. 

Dr. Butler: Speak to that. In what ways do you see that as being different? In what ways do you take care of yourself in regards to that? 

Dr. Duggan: I think physically, there is a break that one experiences after a session. You close the door, you get a couple of minutes, you get that glass of water, and then you go greet somebody. I think the temptation can be for folks to go from one Zoom session or, I'm using Zoom as an acronym, I guess, but one telehealth visit to the next, to the next, to the next. 

What happens, I think, is that without actually scheduling in and being self-aware and saying, "Wait a minute, I have to do things that are going to take care of myself in this process." If you're in an agency setting, I don't know that, that's advocacy from a supervisor's level. That's really the intervention to say, "Wait a minute, we have got to measure this out in such a way that folks are going to be able to get that break and slow down." 

Dr. Butler: I was going to ask you a little bit about accountability, not just from a supervisor's point of view in this case where you just spoke to but accountability in general. In some regards, it seems safer to go into a location and receive counseling services. There's a little bit of an unknown when you're online. How do we hold counselors accountable for doing the right thing and not causing harm to their clients? 

Dr. Duggan: It's a good question. I think that it is about consultation groups and supervision. I think that one of the challenges is, a lot of times after an individual becomes licensed, it's like, [whistles] [laughs] "I've arrived. I'm finally licensed. I have finished the master's degree. I've gone through all of these different steps." Let's face it, getting licensed is not an easy process. It takes a lot of work. I think it's challenging for a new professional who finishes up and goes, "Okay, now it's like I got to do another master's degree to-- 

Dr. Butler: I'm trying to read through your lines what you're talking about. Are you saying that when they get their license or they are licensed at that particular point in time, then maybe the imposter syndrome goes away and they feel like they could do all things? Is that where you're going with that? 

Dr. Duggan: No. I think where I'm going is, is that there is this sense of, "Oh my gosh, I don't need to really consult into what--" The imposter syndrome may go away, but I think it's more about the sense of, "I don't need to check in with somebody who's going to be a supervisor," or some folks may call them master practitioner, clinician consultant, "to have those ways to check in and get feedback because I may actually have a blind spot." 

Dr. Butler: Do you feel that most counselor education programs lead new counselors to that kind of end? Do you think that there's some kind of conversation in the teaching or in the programs, curriculums that we have that help people understand that there's a need for added consultation and supervision throughout the lifespan of a counselor? 

Dr. Duggan: I hope so. Some of my experiences in teaching have included that, and I see some programs, but I can't speak universally. My hope is that, yes, but I would say that it's going to get a little over the top with the cognitive bias type codex, but one of the things is called the Dunning-Kruger effect. What it means is that at any point in our professional lifespan, we're going to have gaps in knowledge and then make assumptions about others even at the same point or at other points, and so we need to constantly have feedback from other practitioners who can help us engage in good practice. 

Dr. Butler: Right. That's what I think I love about the multicultural social justice counseling competencies in that it's about becoming a lifelong learner, understanding that things are going to always have an impact on not just ourselves but on our clients. We need to be self-aware enough to be able to do that. When you think about it from the perspective of someone coming in and saying, "Okay, I have arrived. I am what--" 

When you look at some of these racial identity models, you see someone who has self-actualized. It has come to this particular point, but in a very real sense, we should never get there. It should always be an aspirational goal that we should always be lifelong learners as we are moving forward. 

Dr. Duggan: Exactly. I would frame it as I'm arriving, and so it's always an I-N-G, it's a gerund. It's I'm arriving, I'm becoming, I am continuing to grow and to learn. For me, it's a quick sidebar. I had the chance years ago when I was in my Masters of Theology program, I got to meet Dr. Jerry May, who was the younger half-sibling of Rollo May, the American existentialist. Jerry focused on the stuff of willingness, the openness, the willingness to understand, the willingness to be understood, as opposed to being willful and saying, "This is the way it's got to be." 

That moved me so much in my early career to have that encounter and really just to experience it. Then the sense of genuineness to be willing to say, "Gosh, I have got to learn more about this." Training 15 years ago, gosh, the research has changed, the models have changed, the technology has changed, but the need is still present and more so. How is it that we can move it forward? 

Dr. Butler: Wow. That looks like a great spot for us to take a break real quick, and come back and talk with you some more about what telemental health is and what us as counselors, especially American Counseling Associations affiliated counselors can be doing to move the needle on what we're doing as counselors for our clients. I'm Dr. S. Kent Butler, and this is The Voice of Counseling from the American Counseling Association, our conversation continues in a moment. 

Narrator: Counselors help positively impact lives by providing support, wellness, treatment. We're working to change lives. We are creating a world where every person has access to the quality, professional counseling, and mental health services needed to thrive. 

Dr. Butler: Welcome back. I'm Dr. S. Kent Butler and we're continuing our conversation with Dr. John Duggan. It is phenomenal that we've gotten to this point. We talked a little bit about telemental health and how it has really impacted our lives here during this pandemic. Can you give us some recommendations? What do counselors need to start looking into those who have not necessarily navigated this pathway yet? What are some things that you would share with them that will help them in their journey? 

Dr. Duggan: Sure. First one I have, Kent, is just because you can, doesn't mean you should. Now, I understand that we are in a global healthcare pandemic. The script has been flipped, the table has been turned, we need to come up with new and creative ways to be helpful. I also want to give the just because you can doesn't mean you should. What does that mean? 

In clinical practice, just because I'm working with a student at, let's say, the University of Maryland, just down the road for me. Maybe they're starting bipolar medications or something for seizure disorder or something like that. They're local, they're close, I know the resources, I'm licensed in Maryland, it's 20 minutes away if that. I'm able to provide ethical and appropriate services within my scope of practice. I'm licensed to do that, collaborate with their caregivers. 

Now, let's imagine that that same student chooses to move to the eastern shore or Western Maryland. I know nothing about that community. I don't know the physicians, I don't know the practitioners there. They're starting a whole new school program. There could be a lot more psychosocial stressors and environmental issues. Just because I can work with them, I'm license to, doesn't necessarily mean I should. Maybe there's the need to actually transfer the care or to get greater supportive services from somebody who's in the local community. 

Dr. Butler: Which goes back to what we talked about earlier, the reason why you need supervision and consultation with others. Because a lot of times I would think that you don't want to give up that practice or that client because it means something to you in terms of maybe your cash flow, the money that you're getting from having that person as a client, and also just a lot of times people just don't want to give up on someone that they've been working with. How do you get through those types of things and how do you move forward in that regard? 

Dr. Duggan: Consultation, working with others, being honest. One of the foundations of our code of ethics is veracity. We've got to be truthful, we've got to speak truthfully, appropriately to one another, and be truthful with our clients and all the others whom we may serve, our students. We've got to be truthful in, "You know what, maybe it's not about me," maybe I need to step back and say, "I need to be able to make sure that this client gets the best type of care that they can." 

Dr. Butler: That also means that the person has to really go through their program, and the remaining of their career being able to take critical feedback and listening and understanding and having some discernment when it comes to how they move forward with each and every client that they have. A lot of times, people think that they can, like you just said, and don't really have the skillset to do so, and then what that does is cause really maybe irrevocable harm to a client. 

Dr. Duggan: Absolutely. There can be times where it's not the right skillset and I can go and seek more supervision and training and move into it, and there may be other times where the interventions aren't being helpful and maybe actually hanging on and saying this is the client that I've worked with for 5 or 10 years and so therefore, I'm going to continue it because we've always had this wonderful relationship. Well, part of the counseling experience, if I want to borrow some stuff from Becker Irvin Yalom is being able to engage in a transition, being able to say in a healthy, good way "goodbye". 

Dr. Butler: You said something that was really interesting just now, you said, sometimes you've been with a client for five-plus years. Is there a time limit? Is there a time when you maybe feel as though-- I understand that there's maintenance in this room, somebody is coming in, they're just staying with us so they can maintain and things along those lines, but is there a certain point in time when you're working with a client, whether it's telementally or whether it's in-person where you have to say, you know what, maybe I've reached my breaking point with what I can do with this particular client. Perhaps I need to either refer them on to someone else or maybe the person is needing to really step away from housing experiences for a while so they can see what life is like for them on the other side. 

Dr. Duggan: Absolutely, and that's where consultation, and we're kind of moving for the telehealth, but it's where consultation and monitoring the effectiveness of treatment come together. I view it, Kent, as part of informed consent. I'm always already bringing that back in, "How are things going? What is our relationship looking like? How are you experiencing this beyond these 45 minutes that we have that insurance, maybe somebody is working with managed care, these 45 minutes that we have to work on something? Maybe it's 16 minutes? What is life like after we move apart? What does it look like when we take breaks?" 

I just want to clarify that when I say five years or longer, I'm talking about usually the-- I was a specialist in working with dissociative identity disorder, those are kind of a complex experience where folks maybe are coming for two times a week, three times a week, and it may be over the course of many years and then they transition from one specialist to another and also checking in with neurology and stuff like that. 

Dr. Butler: Understood. When you think about the work that we're doing as counselors especially when we are looking at somebody on the screen, are there ways that you would want counselors to position themselves or position their clients so that they can-- when you're in the room with a client, you can see the full body and you can see what they're doing and you can pay attention to maybe some things that maybe seem a little out of order with regards to that. Is there something in your mind that we can do as counselors when we're looking at them on the screen? Would it be wise to watch them from a full-body experience or is that just too far away? 

Dr. Duggan: It could be. I think, for me, the most important thing is remembering. I'm talking to a human being. I'm not talking to-- you see my humanism coming through here. I am not talking to a screen. This is a living, breathing, loving human being. What can I do if we're going to focus on our code of ethics to promote their wellness and dignity? If you have to put that up on a sticky note on your screen to remind you that, by the way, this is not just another meeting, these are a group of people who have thoughts and feelings and they're coming to you for a reason, then do it, do what you need to do to remind yourself. 

Dr. Butler: Again, that's why I get that. Also, like I said, there are some things that actually when I'm working with a client and I watched them twitching and I see them having some things that are going on when we talk about a certain subject and I can visually see that, are there some cues that we should be on the lookout on the screen when we're just seeing somebody who is having showed us? 

Dr. Duggan: Well, yes. We're certainly going to become more cognizant and more aware of twitches or body movements or behavior, but also it's important to check in. Answer appropriate. I don't want to make somebody feel like they're under a microscope. It's like one client used to say, "I really enjoy being with you because I don't feel like the counselor or the practitioner has the high beams on me." They're constantly scrutinizing everything, but I think that, yes, we can [crosstalk] 

Dr. Butler: What does that look like? What kind of questions might we ask to check in with someone? 

Dr. Duggan: I've noticed that one of the things that I may do is I may have a certain move or the way that, "Is everything okay. Talk to me about what's going on." Even before I would do those typical things that we would outline in our skills class, I want to make sure that I have training and understand what it's like to be in the client's home environment, which is different from having them show up in our professional practice. 

There are a whole other set of issues that'll come into play. I used to do home visits. The program that I oversaw for our county was one where we actually went into the home setting. You've got to have a sense of that. You've got to have a sense of the cultural and the family experience. Also if we're working with technology, you need to make sure that somebody is actually in a secure, safe environment, rather than have a way to check that this is somebody-- there's a code word, so that somebody can say to you, "I'm safe" or "I'm actually in harm's way". 

Dr. Butler: Exactly, exactly. I like that. There's so many different things, so many questions are coming up for me. I'm going to pop some questions at you and maybe you can come back with some quick responses. You work with somebody who has weak technological skills. The internet goes out while you're in the middle of session, what do you do? 

Dr. Duggan: Have a backup plan, always have a backup plan. I always make sure that I've got somebody's phone number or some other way to follow up if at all possible. If there is a weather outage or something like that, I want to have a contingency plan. They can text me or something. I usually will not do text because it's not safe and secure, but I want to know that somebody's okay and that will have a way to check back in. 

Dr. Butler: A counselor is working with somebody and there're people in the background and maybe not a person with headphones. What's your first response to your client? 

Dr. Duggan: This is one of the things is you always want to check the background. What I'll do is I will show where I am and I'm not moving my camera now, but my office space or wherever. I'm usually wearing earbuds and I will let them know that I am and I want them to do the same thing. I want to know. Tell me, where are you if there are other people in the background, tell me what you can do to go to a private safe space. If that means that you've got to sit on the edge of the bathtub, then you know what, I want for you to have a quiet safe space for a little bit where you can actually talk to me and we can have a sense of privacy and confidentiality. 

Dr. Butler: They insist that there okay where they are, what do you do? 

Dr. Duggan: Again, it's going to depend on cultural and geographical factors. There may be some areas where it's culturally and geographically considered appropriate or that's all that they have. Then what I'm going to do is ask them and make sure that I follow up in a private, secure conversation. Is that really what is going to work for you or do you feel as though you are being threatened or intimidated, is your privacy being jeopardized, and as our ability to be effective lessened because you have other distractions for people around you? If the answer is yes, then I want to brainstorm with them on how it is that they can change the game up and do it so it's confidential and securely. 

Dr. Butler: When your client doesn't come online when they're supposed to in terms of the time that you have set up, what are some of the things or approaches that counselors can do to ensure that everything either okay or that the person is not just missing their appointment, right? Sometimes it could be over multiple weeks or multiple times that they're supposed to get together. How do you account for someone who is being tardy and/or maybe not necessarily showing up for their sessions? 

Dr. Duggan: Yes. That's in your informed consent. You really need to have a communications plan and a backup plan. Informed consent is not a one-time process where you just do a form, you sign off on it and away it goes into an electronic chart or a filing cabinet, no, you continually talk about it. If somebody has a missed session or something like that, I'm calling them up or I'm probably going to send them, I'll have a secure portal rather than an email, which can be hacked and things like that. I'm going to try to reach out to them on that. 

If in the informed consent and the communications policy I have something that talks about the innocuous texts, so it's like you're waiting at the door or if something has happened and some happenstance has come along and it's not personal information, all I want is an initial so I just know who's sending this text because I'm not keeping your phone number in my phone. What I may do is just say in those instances, "I may reach out to you by text and say, is everything okay?" 

I have to keep in mind that the individual that is my client may not be responding to that text. Especially if you work with folks who have interpersonal violence, you have to take all of these other variables into consideration. I'm definitely reaching out on them. Two weeks, no, I want to find out what's going on. I want to have a conversation with them. 

Dr. Butler: Before you terminate a client-- 

Dr. Duggan: Oh, yes. 

Dr. Butler: You would just find out that there's something that's going on in terms of that. Okay. How do you help someone who's doing telemental health and billing and insurance things? Is there any feedback or recommendations with those who are now venturing into telehealth and need to look at how they are compensated for their services? 

Dr. Duggan: Sure. You want to make sure that you are billing. Tracking those claims, usually if you're using telehealth services, you're going to be engaging with some sort of a vendor that hopefully is engaging with secure and encrypted practices. You want to make sure that your billing is clean, so they call it a clean claim that you're submitting them regularly. This is not the area to procrastinate where it's like, gee, I think I want to wait to write this next chapter or something. No, no, no. You've got to get these claims out regularly, got to have a system in place. 

Then you want to check the electronic remittance. If someone has two insurance plans and they're doing telehealth and one is primary and one is secondary, you've got to do verifications and check all of that on the front end. You've got to make those phone calls or have somebody who is a business associate agreement is what we call, so business associate. You've got to remember that if you're submitting these claims and you're using types of technology to transmit this information, congratulations, you are a part of the HIPAA club and there is no way to talk your way out of this. It's-- 

Dr. Butler: One other question, there is a licensure and then legislative actions that are in play, especially when it comes to telemental health, are there any things that you would suggest to counselors that they can do to strengthen the resolve of counselors in the eyes of licensure boards when it comes to telemental health and to legislators, especially when we think about the interstate compact and the fact that people are going to be counseling across borders? 

Dr. Duggan: Reach out, advocate, go to licensure board meetings if you can, or join them virtually. Remember that the board is actually the professional members when they gather and they gavel drops and they have their meeting. It's not the regulators, the regulators are the ones who take what the board is deciding or through the Department of Health, and then enacting it. 

I would say, if for those that are doing advocacy, and maybe they're using a temporary license in another state because of the pandemic, a governor may rescind that, and so if that's the case, you need to be checking, we all need to be checking board websites. I have my students doing it every 60 days because regulations can change and it is not a defense ethically. I'm not a lawyer so I can't speak legally, but it's not simply not a defense to say, "Gosh, I didn't know." 

The other thing, Kent, I would add is do not change the name of the game. If you've been doing professional counseling with somebody, and it's in a different jurisdiction, and you're doing something to help them out and you're working on a temporary license, and then the governor rescinds that, don't change the name and simply say, "Oh, we're doing professional coaching now." Most likely it is not going to fly, it's going to get you into hot water. Stay truthful, stay honest about it, and do what needs to be done, do the good work and do it well. 

Dr. Butler: Stay true to who you are in your professional identity. That sounds like a phenomenal place to end our conversation today. John, thank you so much. It's been great talking with you, especially when we have to expand our horizons about what we're thinking about and talking about when it comes to telemental health. I think you've provided us with great ideas and great opportunities to move and explore how we can even make our profession that much even better. 

Appreciate you. Thank you for taking time out today to be a part of the podcast. This is the voice of counseling coming from the American Counseling Association, Dr. S. Kent Butler telling you to have a great day and enjoy the view. Enjoy all those things that are going on in the world and we'll be back with another episode next week. Thank you. Have a great day. 

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