Therapists in Tennessee have switched en masse to online meetings over the last few weeks to protect clients and employees from the new coronavirus, but regulatory confusion is making that harder.

Amy Mariaskin, the director of Nashville OCD and Anxiety Treatment Center in Brentwood, has converted hundreds of clients from office visits to video calls. Therapists at Brentwood Counseling Associates and and the Refuge Center in Franklin, along with many other clinics across Middle Tennessee, are also offering virtual consultations.

Lauren Ruth Martin, a therapist in Franklin, said she rarely used telehealth before the coronavirus outbreak. Now, she’s seeing all her clients via video.

“Telehealth for me has been a supplemental thing to use for consistency, like if they're traveling. It hasn't been used on a consistent basis for me, except for very extenuating circumstances,” she said. “To have this be the status quo for every session is definitely unprecedented.”

The switch to online counseling will allow clients to continue their therapy during a time of heightened fear and anxiety.

“The thing is there has never been a time when people need this more than we do today. We have got to find ways to continue to make it accessible,” said Amy Alexander, executive director for the Refuge Center.

However, many providers say the state and federal government haven’t provided clear guidance regulating the use of video calls for therapy. That confusion is making it harder to serve clients who need counseling now.

In Tennessee, licensed counselors can normally provide therapy via video, but they have to use software that complies with privacy laws.

Earlier this month, President Donald Trump issued an emergency declaration that loosened some privacy rules about telehealth software, but it’s not clear if that applies to therapists.

Lisa Henderson, the chief operating officer and founder of the behavioral health company Synchronous Health, said software that complies with privacy regulations is readily available and therapists should use it regardless of the emergency declaration.

A bigger obstacle is the status of therapists still in training. Students who have completed a master’s level counseling program and are working toward licensure can normally deliver therapy in the office of a licensed therapist, who provides some supervision. Students in counseling programs can also provide therapy with a higher level of supervision.

Under normal circumstances, state law prohibits that group from delivering therapy via video. Over the last several weeks, federal and state governments have issued emergency declarations loosening up restrictions on telehealth, but they don’t specifically mention therapists.

Henderson said the barrage of new information from all levels of government without specific guidelines for therapists is adding to the confusion.

“What are all the sources of authority? We've always had our licensing board, which is overseen by the state legislature ... Now we also have the federal government, and the department of health for each state,” she said. “I'm still working on piecing all that out and creating some sense out of that. That's a big part of why there's so much confusion. Who's really in charge here?”

Terry Casey, a licensed psychologist in Franklin who is consulting with therapists about the ethical and legal issues related to providing virtual care during the coronavirus pandemic, said therapists working toward licensure can represent a large portion of the staff at many offices. That means the typical restrictions on telehealth could limit access to care for many people.

He said the lack of clarity around regulatory issues puts many therapists in a difficult position. They feel like they have to choose between following the letter of the law and continuing to provide care for clients.

In an email, Susan Hammonds-White, the president of the state board overseeing licensed therapists, explained that the board only regulates licensed therapists and people who have completed a counseling degree and are working towards licensure.

She wrote that therapists working toward a license will need to email a staffer at the Tennessee Department of Health to request permission to provide therapy. Until they get that permission, they won’t legally be able to provide counseling.

That board doesn’t regulate the students who would normally be providing therapy to clients in person. Henderson, who also teaches at Vanderbilt’s counseling program, said an accreditation organization typically regulates student therapists. Since that organization doesn’t prohibit students from using video calls, she said it’s likely up to universities to determine if students can provide therapy remotely.

In many cases, that guidance hasn’t trickled down to individual therapists, who remain confused about what to do.

Casey said he hopes Gov. Bill Lee will clarify some of these points with an executive order so therapists will feel empowered to provide care for patients and free up more therapists to provide care via video.

Even if leaders can clear up the regulatory confusion, Casey said there’s still major operational obstacles therapists will have to overcome to provide quality care.

He said counselors need training to do it well. Some professional training organizations have deeply discounted telehealth training for mental health professionals, which usually takes a few days to complete. Henderson said most therapists could probably become proficient in telehealth with a few hours of training.

Mariaskin, at Nashville OCD and Anxiety Treatment Center in Brentwood, said her staff had received training in telehealth before the coronavirus outbreak. Her office is a specialty clinic that sometimes works with clients who are hours away. Still, she didn’t use it frequently.

“We've had that precedent in place to do that distance therapy, but we were pretty choosy .. about when and with whom we used it,” she said. “We work with anxiety, and a lot of times people with anxiety don't want to leave the house, or don't want to interact socially.”

The previous training, and in-house policies spelling out how clients consent to video calls, have allowed her business to pivot quickly to video sessions, but the switch was still abrupt. She sent an email to all her clients on March 20 letting them know that all sessions would move online by the following Monday.

“None of us had much of a chance to adjust, especially the people who had never used (video calls) before,” she said. 

Not all counseling centers are closing their doors. Therapists at the Refuge Center are still seeing some clients in person in addition to providing video sessions.

Therapists are only seeing clients one-on-one and the center has greatly reduced the number of clients and counselors coming into the physical offices each day. Executive Director Amy Alexander said she wanted to continue offering in-person sessions for clients that didn’t have access to video technology.

“We do have clients that have technological limitations or they don't have the right kind of computer or they have never used that and it feels very overwhelming,” she said. “We are considered an essential service and our goal has been to remove every barrier that might exist.”

Despite the confusion, and the logistical challenges of moving online, some therapists are also seeing a silver lining. Ruth Martin said that switching online is forcing her to learn a new skill that she will be able to use after the pandemic. She said she also hopes that the disease outbreak helps therapists better understand their clients.

“If anything it's reminding us of what it's like to be our clients sometimes … Clinicians are anxious too. We're managing it, but we're anxious,” she said. “Now that we're all doing this together, it can give a common humanity and maybe even improve the relationship between the therapist and the client.”

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