As essential workers, social workers are doing their very best to provide caring services to their clientele during the COVID-19 pandemic. For many, it means working in new ways with telemental health by phone or video conference. The Wayne State University School of Social Work wants to help you with the transition and our expert faculty, Associate Professor Suzanne Brown and Associate Professor Faith Hopp, have compiled the following list of tips and practices for you to consider as you begin working in this new environment. 

Ethical and legal considerations

• Social work practitioners should ensure that their telemental health practice is consistent with the social work code of ethics. Respecting the dignity and worth of persons, recognizing the central importance of human relationships, and behaving in a trustworthy manner apply to tele-mental health sessions as they do for in-person sessions.
• Social work ethics also require us to respect the clients' self-determination with respect to telemental health services. Some clients will not feel comfortable with the video mental health environment but may feel more at ease and familiar with telephone sessions. Others may become more comfortable with video conferencing technology over time but will need support and encouragement as they learn to use new technologies. Social workers should explore potential technology modalities using a person-centered, empathetic approach. 
• The standard of care is the same in telemental health services as it is when providing services in person, and all practitioners should abide by the clinical practice guidelines in their field.
• Practitioners should become familiar with the telemental health regulations established by their own licensing boards. Both NASW and APA websites offer information regarding regulations.
• Documentation of the services provided should specify that services were provided via tele-mental health rather than in person
• To maintain client privacy, HIPPA compliance, confidentiality and security, it is best to use HIPPA compliant and secure platforms such as Zoom for Healthcare, Doxy.me, and TheraPlatform.
• However, during the COVID-19 crisis clinicians will not be held to the same expectations regarding the use of HIPPA compliant platforms for the time being.

Preparing your environment

• Dress for the office: Practitioners should dress, present, and conduct themselves as they would when providing services in person.
• Arrange your physical environment to reflect professionalism. Before using video-conferencing test the angle of your camera and be aware of what in your personal space clients will see. Make sure the client's view of your personal space reflects professionalism and a minimal amount of personal information about you, and your living situation.  Consider using a 'virtual background' for your video call that enhances your professional environment.
• Clients are entitled to the same level of privacy during telemental health meetings as they would receive during in-person meetings, and the practitioner is ethically obligated to maintain client privacy. Therefore, it is imperative that you as practitioner conduct telemental health meetings in a private location where client privacy is assured and where the meeting will not be overheard by others in the practitioner's environment.
• Test the strength of your internet service before meeting with clients via video conferencing to ensure that you can maintain a video conference without signal loss or interruption.

Clinical considerations

• Consider your client's culture, age, and the impact of those on their capacity to utilize the technology required for video or telemental health services.
• Consider the cognitive capacity of the client, their history of cooperation with treatment providers, their history of substance abuse, violence, and self-injury, and establish protocols to assess and manage these within the telemental health setting.
• The practitioner should discuss and clarify with the client any potentially necessary emergency protocols. For example, if the client reports suicidality what will the protocol for engaging emergency services be?  These protocols should be established between practitioner and client at the start of engaging in telemental health services.
• The practitioner should clarify the address of the client during each meeting and have information about the emergency services and local crisis services available in the geographic area of the client.
• Clients should be informed that if the practitioner feels that services can't safely be delivered in a telemental health format, then services will be discontinued.

Teach your clients the rules of engagement

• Never assume that clients know how to engage via telephone or video conferencing meetings
• Consider developing a list or information sheet for clients that identifies client responsibilities during telephone or videoconferencing meetings
• Provide information on low-cost internet services in the community for clients with limited incomes who do not currently have internet services in their homes.
• Clients should be reminded that they must remain fully clothed (Yes, for some clients this reminder is necessary), and that they should engage in telemental health meetings in clothing that they would wear to in-person meetings (i.e. not in pajamas)
• Clients should be instructed to find a place that is free of distraction, where they will have privacy, and where their meetings will not be overheard by others in their environment.
• Clients may need coaching from the practitioner regarding how to create boundaries in their home to establish privacy for their tele-session
• Brainstorm with your client possible ways to establish privacy for their meetings. Solutions may include sitting alone in a (non-moving) car, sitting outside on a porch or in a yard, going for a walk while on the phone with you, going into the bathroom or down to the basement. Encourage your client's creative thinking to identify solutions to the lack of privacy.
• Parents may not have anyone to supervise children so it will be difficult to have a private, undisturbed telemental health session. You may want to explore shorter, more frequent meetings (i.e. instead of 50 minutes weekly, can you meet for 25 minutes twice weekly?).
• If parents can't find a private time/space away from children, consider with the client changing the treatment plan to incorporate children into a family session rather than sticking with the individual session modality (only if this aligns with the client's treatment goals). 
• While we don't like to encourage using electronics as a "babysitter", it may be beneficial to encourage the use of electronics to preoccupy children for the 45 minutes of privacy required for a telemental health appointment.
• Remind clients that although they are in a more comfortable setting than your agency, this is still a clinical appointment and the focus of your contact will continue to be their treatment goals. This sets the boundary that this is not a friendship but a professional relationship.

Resources

1. National Association for Social Workers - Telehealth Information
2. American Psychological Association - Guidelines for the Practice of Telepsychology
3. Luxton, D.D., Nelson, E.L., & Maheu, M.M. (2016). A practitioners guide to telemental health: How to conduct legal, ethical, and evidence-based telepractice. American Psychological Association.
4. Low-cost internet services: Comcast and AT&T