by
Joseph Peters
| Aug 02, 2023
Announcer:
Welcome to the Voice of Counseling presented by the American Counseling Association. This program is hosted by Dr. S. Kent Butler. This week's episode is Distance Counseling and Supervision: A Guide for Mental Health Clinicians and features Dr. Jennifer Nivin Williamson and Dr. Dan G. Williamson.
Welcome to the Voice of Counseling from the American Counseling Association. I'm Dr. S. Ken Butler and joining us today are doctors Jennifer Nivin Williamson and Daniel G. Williamson, both co-authors, co-editors of the contributing book from ACA, Distance Counseling and Supervision: A Guide for Mental Health Clinicians. Daniel is a co-chair for the ACA or past co-chair for the ACA Policies and Bylaws Committee, and is a current member of the ACA International Committee. He is on faculty at Capella as a core faculty member and a co-founder of PACS Consulting and Counseling, PLLC.
Jennifer is also a co-editor in contributing often to the book and is also on faculty at the Capella. She has been the past co-chair for the ACA Ethics Committee and current member of the ACA Ethics Appeal Committee. So with that, I want to bring both of them on and see how they're doing. Jennifer, Daniel, what's going on?
Dr. Jennifer Nivin Williamson:
Dr. Daniel G. Williamson:
Happy to be here, thank you.
Dr. Jennifer Nivin Williamson:
Yes, thank you so much for having us.
Well, thank you for being a part of today's podcast. It's exciting to see you all. Can you kind of talk a little bit about what got you all so excited about contributing this piece to ACA and to our members of council?
Dr. Jennifer Nivin Williamson:
Yes, thank you. So it's exciting. We are old timers and we were in very traditional settings and in about 2017, I was co-chairing ACA Ethics and Dan was co-chairing Policies and Bylaws, and we were in an ACA town hall meeting. A lot of questions started coming up about the use of technology in counseling. So with ACA Ethics, we were saying, we defer to the state licensure board because most of the questions we were getting were legal questions and the person asking the question was very angry.
Dr. Jennifer Nivin Williamson:
He said, "I'm with the state licensure board, we defer to you." Someone else stood up, it was about 300 people in the room and they said we defer to you as well. So we realized that we were kind of playing a game of hot potato professionally with who was going to make this decision, this is pre-COVID. So Dan and I play a little game we're like, who would you invite to dinner to have different perspectives? We said who would we ask to sit on a committee next year?
Dr. Jennifer Nivin Williamson:
We had just a great group of people. I mean, I think really the strength of this book is the group of people that agreed to come together and we had a panel and then that panel turned into the book. But the first question on this panel was from a young person. And she said, "I'm doing text counseling with ... I don't know who the person is on the other end, do I need to keep cases?" There was this collective gasp from the group of people who were in that meeting. We realized that there just needs to be some guidance. So I think you articulate this very well.
Dr. Daniel G. Williamson:
Really and based on the questions because we did this, we had two different town hall meetings, two different conferences. And really we started to design this book as a way to help people do this well and not get in trouble doing it. Which was the goal, is how could you do this, protect the client, protect yourself, protect the profession and do this in a way where everyone wins and you minimize loss, you minimize risk.
Dr. Jennifer Nivin Williamson:
So we submitted the manuscript in February of 2020, and then COVID hit. So ACA sent it all back to us and said COVID's going to be a game changer. Then we started to kind of watch and learn and made changes and then it was published in December of that same year.
Dr. Daniel G. Williamson:
Well, and at the same time, we had a small private practice down here in Central Texas. And when COVID hit the building we were leasing our space is government owned, city owned. So they just shut the building down and they said you're welcome to use the building, but you have to manage the elevators. You have to come down three flights, you have to unlock all the doors to let people in. So for each client on the hour it was not going to work. We also had a lot of clients who were at the health risk, they were fragile people and so we didn't want-
Dr. Jennifer Nivin Williamson:
Saw a lot of clients who were actually being quarantined and so that was-
Dr. Daniel G. Williamson:
So we just shut down our physical location and we said since we generated the book on it, we might as well try ... Let's go into full time practice with this.
Yes, practice what you preach.
Dr. Jennifer Nivin Williamson:
Dr. Daniel G. Williamson:
Exactly. So we shut down-
Dr. Jennifer Nivin Williamson:
Absolutely, you need to walk it.
Dr. Daniel G. Williamson:
We shut down, went online, all of our clients came with us, stayed with us and since then we have gotten ... We are so busy with the number of clients that we actually have to refer people out because we don't have space to fit them.
Let ask you was working as faculty members at Capella helpful in that transition for you. What helped you kind of jumpstart that? Because I don't have that ability, as a faculty member for myself, I didn't do a whole lot of online. I did some things with supervision and things along those lines, but never thinking about doing it full time. So was that an easy transition to say that?
Dr. Daniel G. Williamson:
Actually it's really funny that you mentioned that because we onboarded with Capella about the same time [crosstalk 00:06:08].
Dr. Jennifer Nivin Williamson:
Dr. Daniel G. Williamson:
In 2019. Up until then, we'd been at brick and mortar institutions and then migrated to online stuff.
Dr. Jennifer Nivin Williamson:
I think it was a combination of things. I think one of the things we did is we really took a student approach to this and we talked to everyone that we could. And I think the group of people who wrote for this book were very ... They had great expertise in their little area. I think that's very important is that collective of expertise was really important. We learned a lot from our collaborators. We also ... Dan his background, he was the Director of Online Services for the School of Education for Baylor University while we were in our PhD program.
Dr. Jennifer Nivin Williamson:
And then prior to that, he did electronic banking and a lot of the electronic technology pieces of that. So it's that beautiful marriage of technology and counseling together. And then I think really trying to pull from all those different worlds and really talking to a lot of people, because I feel like that even at the regulation standpoint, this is a place where we don't really know what to do with it. We're all learning as we go. I think that really taking that approach that there are a lot of things we don't know. And so who has that expertise and who are we going to have a conversation with?
Dr. Daniel G. Williamson:
Well, clients have taught us a lot in a very short amount of time.
No, but you know it is a great marriage between that. I'll be honest. I was one of the ones that was kicking and screaming about telebehavioral health services.
Dr. Jennifer Nivin Williamson:
But I see now. I don't think ... I saw before the pandemic. I won't say the pandemic made me aware because I was doing supervision and some other things online. So I understood it, but I had some hesitation because I was really ... I'm like, I need you to be in front of me. I need to see all of you and really be there. How has that improved our counseling profession from your perspective?
Dr. Jennifer Nivin Williamson:
Dr. Daniel G. Williamson:
Well, in a couple of ways. Something we've experienced and I can speak just personally from my experience, because I also work with children and so play therapy's been challenging, like doing play online we've had to get very creative very quickly. But we have been able to continue seeing clients at their worst moments. Clients who are bedridden with COVID, isolated, they were quarantined, continued to have counseling sessions. Just like with us right now, I can see your upper torso, I can see your facial expressions. I can hear your voice. And sometimes when I'm working with couples or families, I'll have them back away from the camera so I can see even more of them.
Had I thought about that so much but yes.
Dr. Daniel G. Williamson:
You really don't lose as much as you might think you would lose. And I think-
It's really funny. I think at some point in time, we're going to probably have like studio we're having the Lavaliers on so we can see the whole body and everything. Lavalier mics.
Dr. Daniel G. Williamson:
Yes. Well, and part of it was our biggest concern was will people be okay with this?
Dr. Daniel G. Williamson:
Will they be okay seeing us? And so we have to make sure we're framed up. We have plenty of light. They can see our environment, we can see their environment. In this again, there are a few things that are lost, but the benefits in our perspective has outweighed what few losses we have experienced. I can't see the full body's presentation. No, I can't smell if they've got alcohol on them if they're coming inebriated. So I'm having to be mindful about what I'm watching for but we've learned new things about cues.
Dr. Daniel G. Williamson:
We've watched for social cues, because if someone enters the room, enters the space, if the there's something else going on, we've learned to notice things that we really didn't notice in an in-person session because we controlled the clinical space. Now we don't always control their clinical space and that's created a new set of skills for us.
Dr. Jennifer Nivin Williamson:
I think one of the big questions too, is to ask what are our options? What are our alternatives when we serve like client. One of our very first experiences with this modality was when we were working ... We were doing supervision for some students who were working on Fort Hood back about 2016, 2017. And they were working with the chaplain's office. They had a parent or a spouse that was in theater in Afghanistan and then they would have the rest of the family there on base.
Dr. Jennifer Nivin Williamson:
They would use telehealth to maintain the family bond, to help with the reintegration process once someone had returned. And so that was the first time when I was thinking this is something that wouldn't be possible if the technology wasn't in place. So I think that we're starting to see. That then when COVID hit, it was really a game changer because we all got a crash course in Zoom and I think that changed our culture as Americans and worldwide. We're seeing changes because of this experience that we have with this modality. So feel like that this has kind of been the watershed event that will change things.
So when you all came to be with writing this book, one of the things that you said, and you've been talking about are the key players or some of the folks that have helped you to kind of come along. I don't want you to be put on the spot with this, but are there are some of the key players who are a part of this project with you all, any particular chapters or anything that you want to speak to that are important for folks to really gravitate towards, to really make them go out and get this book?
Dr. Daniel G. Williamson:
Well, at the time that we wrote this book, we had the chair of the CACREP board, Jeff Parsons contribute. Angela McDonald who's the president of the State National Licensure Board Association.
Dr. Jennifer Nivin Williamson:
The two of them wrote a chapter together and I think that was really a powerful chapter because they had kind of a bird's eye view of some things that were happening. Marty Jencius and Stephanie Marder, they're both just ... Martin has been in the field really thinking about how counseling and technology come together for years. I think that they did a really nice chapter. Susan Belangee and Mykia Hollis-Griffith-
Dr. Jennifer Nivin Williamson:
They did a great chapter on looking at the cultural piece of millennials looking at digital natives versus-
Dr. Daniel G. Williamson:
Dr. Jennifer Nivin Williamson:
Digital immigrants and I feel like that's a great chapter.
Dr. Daniel G. Williamson:
We had the CEO of Motivo also write a chapter on distance supervision and what supervision elements. And we had also the founder of WeCounsel Harrison Tyner.
Dr. Jennifer Nivin Williamson:
You and Harrison did the-
Dr. Daniel G. Williamson:
Dr. Jennifer Nivin Williamson:
That's really neat because you're also showing the interconnectedness of us outside of the counseling realm, there are other facets of us as a profession that really support us moving forward in this endeavor.
Dr. Jennifer Nivin Williamson:
And then we have Jason Martin and Regina-
Dr. Jennifer Nivin Williamson:
Modiary that did some chapters and then we have great appendices and I think that if I were going to buy the book for nothing else, I think the appendices are great. Because Kenda Dalrymple is an attorney here in Texas who defends counselors when they go before the licensure board. And so she's a great person to say, don't do this because I don't want to have to represent you. And so she has some addendums in there that are kind of samples of some legal documents and then Amber Hornhelm who is a PhD from Lindsey Wilson College in Kentucky, did a checklist of things as far as like kind of considering the fitness.
Dr. Daniel G. Williamson:
Client fitness for the use of telehealth.
Nice, that's great. I'm going to pivot real quick. I got to ask you a question because it's just something that's on my mind. It looks like a propeller for an airplane and just behind you there, Dan, can you kind of give me the significance of this story because I got to know now why you have a wooden propel behind you.
Dr. Jennifer Nivin Williamson:
So that was actually in my bedroom as a child because my father was an aircraft mechanic during his career. So he had that as a kind of a souvenir and then he also-
Dr. Daniel G. Williamson:
Something he had picked up in his travels.
Dr. Jennifer Nivin Williamson:
So he's older and was trying to kind of make sure that each of ... I have five brothers and sisters, each of us got something that was significant from his life and that's significant.
Nice. That's a neat story. Thank you. I mean, it was compelling. I needed to ask that question. All right so back to it. So COVID 19 pandemic has impacted us especially the mental health field with regards to how people have been able to navigate through it. So there is this need for distance counseling and distance supervision. What are some of the things you want to bring to the table with regards to distance counseling and distance supervision?
Dr. Daniel G. Williamson:
I would definitely say one of the more important elements is identifying all the stakeholders. Because when we started really writing this book and thinking about it and also doing it, we realized we have licensing authorities, not just here, but in other states. In different states, they define residency, the word residency in different ways. So ensuring that where we are, where our client is, we're following all the rules. We also identify with the client, they're a stakeholder in this.
Dr. Daniel G. Williamson:
We need to make sure that what is being offered to them, number one they're appropriate for it. Number two, they know how to use it. And this is something that benefit them. The third thing we were looking at that really kind of caught us off guard was another stakeholder that we are now considering even more and more integrating into this are the insurance providers. They pay your bills.
Dr. Jennifer Nivin Williamson:
I think that's such an important point because what's legal to do and what's billable to do are very different things. And so making sure that you're in compliance with your governing bodies, but then also that each of your billing entities are going to have different rules and different guidelines.
Dr. Daniel G. Williamson:
I think it's important too to identify clearly that and I wrote this also, and this appears several places throughout the book, but we have our HIPAA standards and we have our purpose standards. We also have high tech standards.
Dr. Daniel G. Williamson:
The high tech standards are equally important. And so while there's a federal entity, state entities don't always follow what federal says. And so when COVID first hit the Department of Health and Human Services rolled back HIPAA requirements and said, use what you've got, we'll figure it out later. Texas said, I don't care what they say, you better be using HIPAA compliance stuff or you're going to be in trouble. And so states still recognize their independent authority to be able to enforce those rules and make sure that those privacy rules are in place. So knowing what your state's doing, knowing what the US government, federal government is wanting, there's a lot of balls to juggle, right?
Dr. Daniel G. Williamson:
I mean, you really, it's a lot of pieces in moving parts to it, but once you get your finger on the pulse of those different stakeholders, those different entities, it becomes easier just to follow up and stay with it.
Dr. Jennifer Nivin Williamson:
Dr. Daniel G. Williamson:
People need to be aware of that and open and adaptable to the fact that these things are coming down the pike. How do you help a person though who doesn't have that forward vision to kind of see that. How does this book support that?
Dr. Jennifer Nivin Williamson:
I think one of the things that we are seeing a lot and the trainings that we do, and the feedback that we're getting from readers is that when they look at this, they realize that there's so much that they hadn't thought about that they needed to know. And so much that we all still don't know. They realize it's a bigger question. Now, it's been also interesting. We've done a lot of guest lectures with universities and the students have identified that, okay, now I kind of have a ladder to kind of figure out some of these pieces.
Dr. Jennifer Nivin Williamson:
So I think that part of it is kind of an internal question about how comfortable you are with technology. I think that this is kind of going to be a really interesting modality. So I think that the book has done a nice job of kind of helping people have a primer about, okay, these are the things I need to attend to.
Dr. Daniel G. Williamson:
That's really a big part of the book that's kind of integrated woven throughout each chapter or what are the right questions to ask? And so if you're considering doing this, what should you be asking your licensure board? What should you be asking your other licensure boards, your insurance companies, what kind of technology? And so, in fact, in the technology chapter, I provide a couple of different checklists and some very interesting questions to ask all the varying providers that provide us our platforms and our networks to ability. So I get into some of the technology languaging just to kind of help people develop schema for it.
Dr. Jennifer Nivin Williamson:
Almost every chapter has a list of questions. Like these are things that you need to inquire about. These are things you need to know because we can put it in here and five minutes later, it can be different.
Dr. Daniel G. Williamson:
Really the book is about helping people ask better questions.
Now, is this your first edited book?
Dr. Daniel G. Williamson:
Dr. Jennifer Nivin Williamson:
What did you learn about yourself in the process?
Dr. Daniel G. Williamson:
That I'm a bigger nerd than I realized. I didn't realize, especially when I was writing the chapter on technology, because Harrison and I really get into the weeds about network integrity and ensuring that what you're doing is safe and the safety protocols that are required for your computer, because there's the responsibility, the burden responsibility falls back to the counselor, and you are also equally responsible for what your client knows or doesn't know about how to use the system.
Dr. Daniel G. Williamson:
So there's a little bit of training that goes in before you actually start the counseling process. Same thing for supervisors. Supervisors have to know what the counselors are using that they're supervising and what the end looks like for the client. So to build a schema around that, I'm trying start discovering I'm more of a nerd that I care to admit, but it really helped me even learn more about what I need to be attending to.
Dr. Jennifer Nivin Williamson:
I think also it reinforced the fact that we are so fortunate as counselors to work with amazing people in the field. I think that counseling has just some brilliant people and I think that was really reinforced with this collaboration is that we are really in ... Just we're so lucky to be in the counseling field.
Dr. Daniel G. Williamson:
I agree. I think that is so important to hear multiple voices. We get these textbooks and there's nothing wrong with them, from people who are just single authors and they did the work and they put their voice, but it's in their particular voice. But to have someone who is expert in this particular area write a chapter in this particular area and write another chapter, that really kind of lends to the wealth of information that people are getting, especially our students are getting when it comes to hearing from some of the salient voices that are out there in our community. So when all said and done, what is the most, I guess the thing that you're most proud of with this book that's entered into the counseling field?
Dr. Daniel G. Williamson:
Well, it's funny that you mentioned that because we've been on the international scene for a while. We started our work with working with the military and counselors who were military on family reintegration way back in 2011. And so we've been training counselors across the globe. About that same time we had a graduate student when we were still teaching at Lindsey Wilson College. A graduate student came in from Uganda And during our conversations with him, I asked him what do you want to do with this?
Dr. Daniel G. Williamson:
He ended up building one of the largest ... In fact it's now the largest NGO in Uganda, and he's built hospitals and schools, counseling centers, farms, and he's continuing to just take his and they're drilling wells and all this. And they've done this all over rural Uganda. And so we sit on the American side of the board of directors since the founding of it. So all proceeds from this book go to support that organization in Uganda.
Say that organization it one more time so people can hear it.
Dr. Daniel G. Williamson:
Uganda Counseling and Support Services.
Dr. Daniel G. Williamson:
Basically ugandacss.org and learn more about it.
That also talks about the caring nature of counselors. That's what we do. We are selfless and putting ourself forward the things that we are doing, our expertise that supports others. That's why we do what we do, right? Yeah.
Dr. Jennifer Nivin Williamson:
And the input that that community is having, they have integrated mental health facilitators into the community and it's helped in so many ways and educating young girls has given them so many opportunities to even delay marriage and make more choices about their lives. And so we're really excited that they're able to do that.
Nice. So I wanted to ask you with regards to tele behavioral health and client records and in supervisory records, what are some recommendations that you have when it comes to people in this new stage of development, this new evolution of counseling, how do they stay on top of their records?
Dr. Jennifer Nivin Williamson:
That's such a great question. I think everything that we do as counselors, all of the great pristine records that we are supposed to keep, all of that is the same. I think in addition, we want to document where we're connecting with that person each time. I think making sure that we know the location of the person in front of us is absolutely paramount. I think that's number one.
Dr. Jennifer Nivin Williamson:
And then number two is having connections to the emergency services in that area. And then three is having an emergency contact for that person that's within five to 10 minutes. So that if something happens, not just if they're all harmed to self or others, but also if someone has a heart attack or a medical condition during the session that we have a plan in place. And so having an emergency action plan, having thought through all of that, that all should be a part of the documentary from the very beginning.
It is till daunting and I would ask you ... I can see how it's so different from having a brick and mortar experience versus having this online experience. What do practitioners need to know going into that? How do they get there? Because what you just said, you just rattled it off. But there are people who may not be to know about all those different things. How do we get them up to speed on being able to know that they need to know about emergency services, that they need to be able to have maybe someone five to 10 minutes away that can go in and really intervene if there's a necessary need.
Dr. Jennifer Nivin Williamson:
Dr. Daniel G. Williamson:
Dr. Jennifer Nivin Williamson:
I was going to say, I think this is a specialization just like anything else. If you were going to work with clients who were experiencing trauma, you would go and get the very best training on that area. I think this is a specialization. So I think one of the things that we need to make sure that we're doing on an ongoing basis is that we're engaging in continuing education. I think that we're also trying to find new and better ways of integrating this into curriculum for new counselors.
Dr. Jennifer Nivin Williamson:
When we were in the midst of the pandemic, I told my students, you're the first generation of counselors who will be formally trained in this in their grad program. And I think that's something that we're going to need to continue to grow and develop. So I think that's the first part.
Dr. Daniel G. Williamson:
Well, the book also just talks about how to become more intentional about that. Intentionality is going to be huge. They can take resources from the book and create their own checklists. Then it becomes integrated into your routine. When I first get on typically with new clients on our website, we have a link on about telehealth and we have a list of things, it's a checklist for them to go through to help maintain control of their clinical space at home.
Dr. Daniel G. Williamson:
So once we go through that, then, "Hey, where are you today and what else is going on?" And so you learn to integrate those questions in at the very beginning, you're jotting things down just so that you can make sure those do it up in the case notes.
Dr. Jennifer Nivin Williamson:
Give the website for them.
Dr. Daniel G. Williamson:
In fact, nothing to us is ... We don't own it all. This has been a combination of things and so if they go to www.consultprax.com, that's our website for our practice.
Dr. Jennifer Nivin Williamson:
It has the list of things.
Dr. Daniel G. Williamson:
The list of items and it's interesting because it started out as five or six items and now it's up to 11 items. The only thing I ask is if anyone goes to that about telehealth link and they see things, if they see something that's not there, let us know so we can add it because we want this to be a resource as well.
I think that's a really good point. Can you kind of talk about that in terms of there's a time where people are afraid to ask questions, like what you're saying, and I know that has been on person to person face to face type of environment, that doesn't change and it is even that much more important to ask certain questions on an online platform. So maybe after the break, you could kind of talk about the importance of really stepping up and asking those very so difficult questions so that you do no harm.
Dr. Jennifer Nivin Williamson:
Good. So we're going to take a quick break and we'll come back after this break and we'll kind of delve into some of those topic areas. All right. This is the Voice of Counseling. I'm Dr. S. Kent Butler, we'll be back in a moment.
Counselors help positively impact lives by providing support, wellness, treatment. We are 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.
Welcome back to the Voice of Counseling. This is Dr. S, Kent Butler, and we're here with the Williamsons and we are going to talk a little bit more about what counselors need to know and how they can navigate working with their clients. We left off kind of talking about some of those questions that you ask, especially from an online perspective, that may not be something to has done face to face.
There's an importance of asking questions and sometimes new practitioners, students, especially are kind of hesitant to ask questions. Can you kind of talk about that and how they can get past some of that hesitancy when it comes to asking some very pertinent or very difficult questions?
Dr. Daniel G. Williamson:
Certainly. One of the elements I recommend establishing early in the relationship is letting the client know upfront if you're using telehealth services and this is your modality for them, but you're going to probably ask them some questions fairly regularly. If I notice something different about the space, if I notice a difference in you when we're talking, I might pause, I might stop for a second. And then I might ask you a question about that.
Dr. Daniel G. Williamson:
It's going to be about maintaining a greater situational awareness than you typically do when you're in a counseling session, because in a brick and mortar facility, you can have more control over the clinical space. Well, when you're doing telehealth, you have control over your clinical space but not theirs. And so, but-
Like asking about the propeller?
Dr. Daniel G. Williamson:
Yeah, exactly. Well, and with that too, it's a oh, I noticed you're in a different room today. So tell me where you are today. Because again, it's critically important to understand where that person might be.
Dr. Jennifer Nivin Williamson:
We even have a signal. I have some clients that we know that there are people who are ... The word his clients use are ear hustling. And so there's someone listening. So when we have a client who is in a situation like that, we even have a signal where they'll kind of pull their ear and that way they of convey to us someone's listening and so we need to kind of stop this line of questioning for a little while.
Dr. Daniel G. Williamson:
So working out some cues ahead of time, between, and just some nonverbal forms of communication.
Does that kind of play out with confidentiality?
Dr. Daniel G. Williamson:
It really helps preserve that confidentiality. Because with one of my clients, I have her do the old tag on the eye. Like someone just walked in the room and so I will stop asking or we'll stop the conversation that we're talking about at the time and we'll have tips. Sometimes we'll have a default conversation to turn to, and we'll turn back to let's talk about work again. And then once that person leaves, then they'll give me the clear, it's all clear now because that personnel has now left my space. We can go back and talk about what we were talking about.
And it makes me wonder, do we tell clients that they should be sitting with their back to the door so that we see the door if it opens or something like that?
Dr. Jennifer Nivin Williamson:
I talked to a counselor the other day and she does a beautiful thing. She works a lot with young people and she says let me see your room and she'll have them take the camera around the room so she can kind of ... And she's checking, she's checking to make sure that the client is alone, they're in that space and that there's not anything that is inappropriate. I think one of the things that we have to do is we have to be very clear about what constitutes a clinical space.
Dr. Jennifer Nivin Williamson:
So there's a great definition that comes out of an agency in Austin that says a clinical space is that you're in a room, it has a door, the door is closed and a sound machine of some kind is on. So that could be a proper sound machine or that could be a radio outside the door, something to drown out sound. I think even we've been very creative about this. So we have clients that will meet in bathrooms or in parked cars or in walking closets. I think that sometimes a clinical space, we think, oh, well, that's very fancy, I think it's about more functionality rather than about having to be pretty.
Dr. Daniel G. Williamson:
So the point there is it's about the relationship and getting this person through whatever they're going through, not the settings so to speak, that we should have to think beyond the setting, the traditional piece that we normally think we need to be in as counselors.
Dr. Jennifer Nivin Williamson:
Dr. Daniel G. Williamson:
And that really safety does become an issue as well. One of the things we ask of all our clients is if you are going to meet in the car, let's make sure the car's not moving. If you are in your home environment that you're safe. And again, this modality is not the best for all types of clients.
Dr. Daniel G. Williamson:
But the vast majority of clients that we do see with their presenting concerns, this works very well.
You maybe think of like someone who might be in a domestic violence situation.
Dr. Daniel G. Williamson:
Now you got me thinking back to five or 10 minutes away. No, maybe a minute away. Right? If something was to go down, that's really [crosstalk 00:34:50].
Dr. Daniel G. Williamson:
One of the things we take in, when we have clients fill out the intake paperwork is we ask for their emergency contact person and we have them fill out the appropriate release form. We also have them have a conversation with that person saying by the way you're my phone friend, in case something happens to me my counselor's going to call you because they're going to notice I just fell out of my chair. We get the person's doctor, whoever their doctor is, their physician, local hospital, and then law enforcement to do a wellness check.
Which is a different approach even there because in traditional can counseling, we typically try not to ... We try to keep our identity away from the fact that this person may be seeing a counselor. It shifts with the online component.
Dr. Daniel G. Williamson:
I had a client who fell out, I would just ... If I did call law enforcement. So if I were working with you, for example, and you fell out of your chair. And I said, "Hello, Dr. Butler, are you there?" And you're not responding. I already have your release and your permission by the documentation you signed and we've had a conversation about it. I'm going to call law enforcement or I'm going to call your phone friend and I'm going to say, "I was just on with Kent. Something happened. He fell out of his chair."
Dr. Daniel G. Williamson:
"He's not responding." I didn't have to tell him who I am. I'm just saying, I was just in a meeting with him. They fell out of the chair. They're not responding. Would you go check on him?
Dr. Jennifer Nivin Williamson:
Now I'm just being foolish right now but you may be think of those things that people wear around their neck that you get as advertised on TV, whatever have you. Somebody's going to steal this idea, right? So some counselor needs to have this little button that their clients have to wear when they're in the session with you that they push if they should happen to fall out of the chair. I fall and I can't get up type of situation.
Dr. Jennifer Nivin Williamson:
Dr. Daniel G. Williamson:
I heard that Butler button.
So I need to find a way to put that on ... What is it called? Copyright that?
Dr. Jennifer Nivin Williamson:
Dr. Daniel G. Williamson:
Patent it. That's the goal, really it's all about that safety piece, right? That safety, or can we help that client maintain their own safety.
Dr. Jennifer Nivin Williamson:
And knowing your client because maybe if they had had issues with enforcement, maybe EMS is a better place to call, kind of working out that safety plan ahead of time. And then part of the screening is knowing like, is this a client who struggles with emotional stability or impulsivity? What kind of level of care? We have a very moderate level of care agency. We're not going to work with someone who needs a really high level of care. So I think all of those considerations when we're evaluating a client for suitability, and then the other thing is that this isn't a one or kind of situation. More and more counselors that we know are doing some sessions in telehealth and some sessions in person.
Dr. Jennifer Nivin Williamson:
And so we have some other-
You talk about changing hats, that's a shift as well. Right?
Dr. Daniel G. Williamson:
If you think about everything you do in your traditional setting, you're still having to do all those things. Now you're adding some additional skills, additional things to make sure you do-
To be competent in what you're doing and to make sure you're doing no harm. So what are some special ways in which clients can benefit from telemental health?
Dr. Daniel G. Williamson:
They can be absolutely just bedridden sick and still have counseling session.
Dr. Jennifer Nivin Williamson:
Dr. Daniel G. Williamson:
I got to say that's that's number one.
Dr. Jennifer Nivin Williamson:
It was really interesting because Dan was working with a child and I was working with the parent and the child had been quarantined, but was the only member of the family who had tested positive. And so one of the things that we were able to do is work with them during quarantine to figure out how to interact. So I think during times when clients would normally just cancel, I think that continuity of care. And then the other piece of that is that being able to have accessibility, and I really feel like this is where this is a social justice issue.
The social justice piece. I was wondering about that. Especially with somebody who doesn't have the capability be online but needs your services.
Dr. Jennifer Nivin Williamson:
So Georgia Hope and the Christian Appalachian project are both areas that work in rural areas and have done a beautiful job of helping clients to figure out how to access this and to help them connect when they're in rural areas that wouldn't otherwise have access. I think that they've been a little creative. I think that a lot more people have mobile phones than they have internet and computers.
Dr. Jennifer Nivin Williamson:
It does some beautiful work in that area. I think the directors and counselors there have been fantastic.
Dr. Daniel G. Williamson:
The number of people I've even seen in the homeless population who have a cell phone.
Dr. Daniel G. Williamson:
If they have a cell phone, they can get to the counseling session.
That's interesting in of itself because it's one thing to be on a laptop in a stationary space. What do we need to know about working with somebody who might be in a counseling relation without using their cell phone?
Dr. Daniel G. Williamson:
I've had clients do that who were in transit. They were either moving or they were traveling around the state and they couldn't get a clear WiFi signal, but they could still get a phone signal. As long as we, and again, as long as we can try to help them find that space where they can have a private conversation with us. The protocol that we use, the program we use has an end-to-end encryption. So if anyone does intercept the signal, it's garbled, it doesn't make sense.
Dr. Daniel G. Williamson:
So some encryption, and really in that chapter in the book, I really go into the weeds about the technology part and things to consider. It's not just written from the high end user, it creates a vocabulary. It really helps define that vocabulary. So a person who has no technology experience could actually pick up this book, read that chapter and go that's what that means. Well then this is for the question I need to ask to make sure that if I do have a client who's using only a cell phone, that's a great question to ask whoever the provider is.
It leaves no questions unturned. People know from reading that chapter, just the various ways that things may come up.
Dr. Daniel G. Williamson:
Dr. Daniel G. Williamson:
Dr. Jennifer Nivin Williamson:
I think we're all learning. I think it starts the conversation. What noticed is that with programs like Siri and any kind of listening voice activation on your phone, any kind of listening device, like we have things like Discord that people connect with. I think any of that, no matter what your technology you have to be aware of and I think cell phones are probably even more complex because we're working with that voice activation every day.
Dr. Daniel G. Williamson:
We have to turn off and be aware of turning off those things. Alexa, Google Voice, all other things.
Because I've been in the middle of situations where I'm doing something and I don't even realize. I say something that's close to saying something and she'll chime in or whatever happened. Even with the online piece, there's sometimes distractions from little bells and whistles that kind of go off when a new text message or email comes in or something along those lines and how that could be distracting in some regards.
Dr. Daniel G. Williamson:
Well, and in our checklist on our website, that's one of the things we ask people that we remind them to do is go through ensure those things aren't turned on. Make sure they're turned off for temporary, just for a short period of time-
They have to be technologically savvy enough to be able to do it though. Right?
Dr. Daniel G. Williamson:
Dr. Jennifer Nivin Williamson:
Dr. Daniel G. Williamson:
Well, and most of our clients, because they have the technology in the house, because they have that Alexa, that Google device or whatever it is, they know how to unplug it or turn it off.
Well, I would have to go get my daughter. She's nine. In some cases, I'm being very honest. I sometimes don't have that capability. So what are summary the top four technical considerations that counselors need to address when offering tele behavioral health services?
Dr. Daniel G. Williamson:
Such a great question. Number one, HIPAA compliance, all the federal compliance requirements. So HIPAA high tech, if they are signing on with a company, and this is covered in the chapter in detail and whatever, whoever's going to be providing that service, whether it's an EHR, an electronic health record or a video conferencing platform, they need to make sure they get the BAA, the business associate agreement with that entity, because that outlines all the different levels of liability and vicarious liability-
Dr. Jennifer Nivin Williamson:
It's shared liability. Right?
Dr. Daniel G. Williamson:
Yeah, shared liability. It really describes what that means. Another thing I recommend that everyone get when they're talking about a reviewing or looking for a platform is to ask for the white papers. Now that's some language that a lot of people don't know about but white papers go in and describe HIPAA compliance, how they do it, their encryption, how they do it. And then what you do is you find a guy who's a tech nerd and you buy him pizza and have him sit down and explain it all to you because you want to understand how the technology works, how they maintain the HIPAA compliance, how they do encryption.
Dr. Daniel G. Williamson:
And getting your hands on that and then asking that provider, do you have a sandbox version that I can get and play with? And I can play with a colleague or a friend and see what both ends look like, know how to use that technology before you just jump in and start trying it. Network integrity is huge. One of the things I still recommend to a lot of people, I don't know how many people remember these an ethernet cable.
Dr. Daniel G. Williamson:
If you are not certain about your WiFi security in your place, wherever you're working, cable in. Cable in because then you're not worried about the WiFi signal. Cabling in with an ethernet cable helps eliminate some of that real-
This might sound like a crazy question, but I got to ask. If you use the ethernet and is it less chance of your WiFi going out? You know what I'm saying?
Dr. Jennifer Nivin Williamson:
Dr. Daniel G. Williamson:
In a situation where your WiFi might go out in the area, your ethernet may not?
Dr. Daniel G. Williamson:
Well, it depends on your internet service provider. If the internet's down for the area, then you can have an issue with just getting any.
Being hardwired doesn't really necessarily help you if the system has gone down in your area.
Dr. Daniel G. Williamson:
No, if the system's gone down the area. You're out of luck.
So the other question I have for you is you suspect that there might be some type of confidentiality breach or something along those lines. What do you as an online counselor do?
Dr. Daniel G. Williamson:
Well, if you have confirmation that there's been a breach either on your end or by one of the service providers, for example, your payment processor, whoever's providing the video conferencing platform, your EHR, you are mandated, you have to report that to your clients who their information has been used through that system. You have to make a mandatory report to them and everybody else.
Dr. Daniel G. Williamson:
I would definitely say, be mindful. This is not something we step into lightly. We want to make sure that those who are using, we are reviewing with them the last breach they had, what kind of security checks they do regularly for integrity. What does their regular reporting reveal because if you're using a platform that has been breached a couple times within the past couple years, you probably don't want to go with that provider. Because you don't want to have to call your client and say, "Okay, look, I know we've been using this, but now-"
Because then you're actually become more liable if you're using something that you already have been suspect of in terms of having some doubts about their ability. What's your recommendation for social media policy for counselors?
Dr. Jennifer Nivin Williamson:
I think everyone needs to have a social media policy for a couple of reasons. One is, I think there are legal issues involved, but I think even more so I think the relationship. We're so used to using social media that there are some cultural elements that we don't even think about that our clients as I'm meeting to social media use. So we have to make sure we clearly articulate in social media policy that I'm not going to accept a friend request and I'm not going to do certain things.
Dr. Jennifer Nivin Williamson:
I think we need to be very clear about that and help our clients to really understand that this is for their protection, not because it's rejection. Then I think also we have actually, I think there's a social media example in the appendices of the book that the attorney put out. And part of that is that we need to really be very clear that we're going to separate our personal online self with our professional online self. So those social media platforms are very separate when we're out there and that we never intermix that because it's a really, really easy way for us to breach confidentiality for our client unintentionally.
Dr. Daniel G. Williamson:
Well, and these policies really in our opinion should be baked into the informed consent right up front. Then another recommendation I make too in addition to that, so many of these different social media platforms cross communicate with your online purchasing apps. So you think Amazon, Facebook. If you ever are curious about it, open Facebook, then open Amazon, look for Bob Ross socks or something.
Dr. Daniel G. Williamson:
The painter guy and put in happy trees socks, and then watch your Facebook feeds. You'll notice the advertisements start to reflect those elements. There can be cross browser traffic and so one of the things we've been talking to a lot of folks about is if you have a computer you use to work, only use it for work. Don't use it for social media at all. If you have a phone that you use for work, use it for work. No social media, no other things.
Dr. Jennifer Nivin Williamson:
Wow. That's good to know. So listen, talking with the Williamson's goes by really quickly. We have come to the end of our time, but I have one more question that I want to ask you all. How do you stay up to date? How do we get counselors to stay up to date? You just mentioned that it's always evolving. Your book is out of date probably already now that it's in print. So how do we stay up to date?
Dr. Daniel G. Williamson:
Dr. Jennifer Nivin Williamson:
Dr. Daniel G. Williamson:
I would recommend reaching out to your state organization as well as your licensure board. See if there is a list serve that you can join to receive regular legislative updates. That's one of the things that I've been really proud of. Texas, there are a couple of different list serves that we belong to, that we get that information really, really quite quickly. Staying up with licensing laws, staying up with the federal standards as well and it just becomes a method of being intentional.
Dr. Jennifer Nivin Williamson:
Don't be afraid to engage in the conversation. Engage in the conversation officially through your professional development, but also engage in the conversation just like you would any other aspect of counseling. I think sometimes if we've been in the field for a while, we kind of stray away from technology conversations, don't be afraid to engage.
Excellent. Well, you heard it here first from the Williamsons and I thank you so much for being a part of the podcast today and sharing your wisdom. It's been great. It flew by, we try to make this a counseling hour and it flew by and so we already know that it works, that telemental health works and your book is phenomenal. We want folks to go out there and get it and start practicing in the best competent way possible as counselors. So thank you all for being here today.
Dr. Daniel G. Williamson:
Dr. Jennifer Nivin Williamson:
This has been the Voice of Counseling, I'm Dr. S. Kent Butler. We'll see you next time.