Remote Service Delivery

Introduction

As a result of the COVID-19 pandemic and associated stay-at-home orders and physical distancing recommendations, students may need to seek a variety of health services remotely. Telehealth describes “the use of telecommunications and information technologies to provide access to health information and services across a geographical distance” (Glueckauf et al., 2003, p. 160). The United States started building its telehealth infrastructure as early as the 1940s, and telehealth has grown exponentially since the 1990s (Nesbitt & Katz-Bell, 2018). The healthcare field, therefore, has a substantial history of providing services through telehealth. Telecounseling refers to psychological services conducted virtually through digital communications software by a trained counselor from a remote location rather than in a physical office space (Lau et al., 2013) whether over the phone, through video conferencing, or more recently, through textbased platforms. Telecounseling was initially popularized to connect with “hard-to-reach” populations, including those living in rural communities and those without transportation access (Thomas et al., 2005; Weiss, 2018; Steinmetz & Gray, 2016; Fletcher et al., 2018; however, due to the health risks of meeting in-person during the COVID-19 pandemic, telecounseling has rapidly grown as a popular counseling format. This guide shares best practices for victim/survivor service providers to offer remote services using video conferencing. It begins by highlighting both the challenges and opportunities associated with telecounseling. It then describes platform considerations and concludes with resources that provide more details on each of these topics.

Opportunities of Telehealth Counseling

Although providing virtual counseling may initially pose new challenges, it can ultimately lead to quality services. A systematic review of research revealed that mental health clinicians and clients were overall satisfied with counseling through video conferencing (Reay et al., 2020). Also, this may allow for increased flexibility for counselors (Shaw et al., 2016) who may need accommodations due to COVID-19 restrictions. Virtual services can also increase accessibility for students. For example, some virtual platforms offer real-time translation services, which may allow Deaf students or students who speak another language to receive more consistent, appropriate support (Luxton et al., 2014; National Network to End Domestic Violence, 2019a). Students with mobility restrictions may also prefer virtual services, as these services pose fewer barriers to physical accessibility than in-person services. Students who commute to campus may also benefit, as arranging transportation is a significant logistical barrier to attending in-person services (Steinmetz & Gray, 2016; Boykin et al., 2019). Those with anxiety may more willingly seek out online services for treatment (Gordon, 2020), which reduces missed appointments (Reay et al., 2020). Online services may be more private, and thus reduce students’ fear of stigmatization and judgment for seeking counseling, which can lead to better treatment outcomes (Constantino et al., 2015). As of this writing, telecounseling is currently the only safe counseling option due to COVID-19, so it is important to embrace these benefits.

Challenges and Best Practices for Telecounseling Providers

There are many challenges that victim/survivor service providers must consider when determining their telecounseling protocols, including:

1. Preparing the client
2. Working from home
3. Addressing client privacy and safety
4. Maintaining quality of service
5. Licensing
6. Obtaining informed consent
7. Provider training

Practitioners with experience in telecounseling and other forms of telehealth have documented best practices to provide high-quality services.

Preparing the Client

First, victim/survivor service providers should determine what form of counseling is appropriate for each client on an individualized basis, as telecounseling is not recommended for all clients. Clients with severe mental health issues, for example, may not be suitable for telecounseling due to safety concerns, as telecounseling limits providers’ capacities to conduct full mental status examinations and assess for safety (Alessandria et.al, 2019; Luxton et al., 2014). If telecounseling is advised, the victim/survivor service provider should determine if the client prefers services by video or by phone. Providers should keep in mind that services by phone limit observation of affect including clients’ facial expressions, motor activity, and overall body language. Communication-related barriers should also be addressed, for instance, being able to observe affect is limited in an audio-only format. It is important that before initiating sessions with a client, victim/survivor service providers take the proper steps to prepare the client for success. This includes explaining and obtaining informed consent for virtual services, reviewing how confidentiality and privacy will be maintained, and teaching the client how to use the technology outside of their official session. Clients and providers may find it useful to have a “test session” to ensure that the technology and communication run smoothly (Colorado Coalition to End Sexual Violence, 2020).

Working From Home

Providing victim/survivor services from one’s home instead of an office poses significant challenges in maintaining professionalism (Colorado Coalition to End Sexual Violence, 2020). If working in an office is not an option, it is important for clinicians to consider how they will maintain professionalism and prevent unintentional self-disclosure. For example, clinicians should consider the parts of their homes that are visible onscreen and whether they are distracting or reveal personal information about themselves that they might not want to be shared with clients (Colorado Coalition to End Sexual Violence, 2020). When possible, it is ideal that the victim/survivor service provider uses a work computer instead of a personal computer, to ensure any client information remains secure and private (Colorado Coalition to End Sexual Violence, 2020). Telecounseling also introduces unique privacy concerns. Victim/survivor service providers must consider if anyone in their home can overhear their sessions (Luxton et al., 2014). Solutions include using a sound machine and headphones and locking the door, so others in their household cannot overhear sessions with clients (Colorado Coalition to End Sexual Violence, 2020).

Privacy and Safety Planning

A client may live with family, a partner, or roommates who are unaware of their victimization or counseling. Victims/survivors currently living with an abusive partner may have difficulty taking video calls from their homes. If a client is in an abusive relationship, it may not be feasible to discuss the relationship in a shared space. If an abusive partner discovers that abuse is being discussed, this may lead to perpetrator retaliation and additional violence. If a client is in an immediate crisis or needs emergent medical attention, the service provider cannot offer help in person.; therefore, it is crucial to develop a safety plan in case a client is in immediate danger (Luxton et al., 2014). Victim/survivor service providers should begin every call by asking their client to confirm their location and address in case they need to call emergency services (Colorado Coalition to End Sexual Violence, 2020) and determine ahead of time what those emergency services may be (Luxton et al., 2014). Providers should also ensure they have correct backup phone numbers in case the call is disconnected (Luxton et al., 2014), and verify with clients that no one else can overhear the session (Colorado Coalition to End Sexual Violence, 2020). Victim/survivor service providers can work with their clients to determine a code word so clients can discretely alert them if they are not in private (Colorado Coalition to End Sexual Violence, 2020). They may also need to increase the flexibility of meeting times, so clients can communicate safely, such as when an abusive partner is out of the house or asleep (Jarnecke & Flanagan, 2020). These measures will help ensure that the client’s privacy and safety are maintained.

Maintaining Quality of Service

Some victim/survivor service providers may find it more difficult to offer the same level of support to clients through telecounseling and may feel the conversation is less natural than in-person conversations. There are also details about clients that a service provider may not notice in a virtual setting; for example, clinicians cannot easily detect if a client is under the influence of alcohol or if they have a new injury (Luxton et al., 2014). When care is virtual, victim/survivor service providers may feel tempted to change their practices regarding provider/client interaction; however, it is important that virtual services mirror in-person services as closely as possible. This includes only taking scheduled calls and sending appointment reminders or checking in with clients as they normally would (Colorado Coalition to End Sexual Violence, 2020). Ensure that your organization has a clear written policy regarding communication by phone, email, or text message between sessions and the privacy and confidentiality risks of clients using text message or email communication for purposes beyond scheduling appointments. Victim/survivor service providers should pay extra attention to building rapport with clients, which may be more difficult in virtual settings (Colorado Coalition to End Sexual Violence, 2020).

Licensing Restrictions

Not all state licensing boards allow New Jersey licensed counselors to practice in their state (Colorado Coalition to End Sexual Violence, 2020). In many cases, licensed counselors need advanced permission to serve clients in other states (Colorado Coalition to End Sexual Violence, 2020). This poses a significant challenge to victim/survivor service providers during COVID-19, who are often serving students who have moved back home, out of New Jersey. The resources section includes an updated list of state licensing laws, which have changed in response to COVID-19. When providing in-person counseling services, the victim/survivor service provider typically must focus only on the laws of the state in which they practice. However, when serving out-of-state clients, it is essential that counselors be aware of the laws governing the states in which their clients live. This includes the licensing requirements to practice in those states, and state reporting laws, should they believe that a client may become violent (Alessandria et al., 2019). Counselors may also consider obtaining malpractice insurance for the states in which their clients live (Alessandria et al., 2019).

Obtaining Consent to Share Information

Victim/survivor service providers are required to obtain consent from their client to share confidential information. The Health Insurance Portability and Accountability Act (HIPAA), the Violence Against Women Act (VAWA), the Victims of Crime Act (VOCA), and the Family Violence Prevention and Services Act (FVPSA) all require written, informed consent to share information. While HIPAA allows for failure to object (i.e., implied rather than explicity expressed consent) or verbal consent to constitute legal consent in extenuating circumstances, VAWA, FVPSA, and VOCA do not, so navigating consent procedures ethically and responsibly is essential (National Network to End Domestic Violence, 2018). Service providers must work with clients to determine if the best way to meet their current needs is by disclosing personally identifying information (PII) and to ensure clients are aware of the pros, cons, and alternatives to sharing their informational digitally (National Network to End Domestic Violence, 2020a). The victim/survivor service provider should determine with their client if they have the time and ability to complete a traditional written, signed consent form either in-person or via mail (National Network to End Domestic Violence, 2020a). The provider should confirm they are communicating with the victim/survivor whose PII will be disclosed and has clear written instructions about what can be disclosed, to whom the victim/survivor wants it disclosed, the method by which it will be disclosed, and the time limit for making the disclosure. It is important that the provider has a record that the victim/survivor has approved the instructions. More information is included in the resource list below.

Necessary Training

Victim/survivor service providers will likely need training to best support their transition to virtual services and to maintain quality of care. Valuable training topics include using technology, guidelines, and protocols, information on consent, safety planning, building rapport, and any of the other topics included above (Ford et al., 2012). Service providers should regularly check-in with each other to troubleshoot any challenges and problem solve together.

Platfrom considerations and recommendations

Data Security and Privacy

As mentioned earlier, many victim/survivor services are bound by the confidentiality requirements of HIPAA and VAWA/VOCA/FVPSA. There are two main differences between these policies. First, HIPAA allows for greater information sharing than VAWA/VOCA/FVPSA do without seeking permission from the person to whom the information belongs, such as sharing with other medical providers and families (National Network to End Domestic Violence, 2018). This is never allowed under VAWA/VOCA/FVPSA. Also, under HIPAA, losing or destroying information is as serious as having information stolen or misused (National Network to End Domestic Violence, 2018). However, at appropriate times, victim/survivor service providers may need to destroy information as part of victim/survivor-centered services. (National Network to End Domestic Violence, 2018). Some platforms may advertise that they are “HIPAA compliant,” yet do not comply with the laws that govern victim/survivor service providers. More details on confidentiality are included in the resources section later in this toolkit. It is also important to note that there are no formal certification platforms to become HIPAA compliant, so before choosing a platform, victim/survivor service providers must investigate the basis for that label. A detailed list of questions to ask vendors is included in the resource list, and here are some basic questions (National Network to End Domestic Violence, 2020b):

1. What do you mean by HIPAA-Compliant?
2. What security features do you offer that protect confidential information?
3. Who in your company would be able to access the information we enter into your system?
4. Here is the information about the laws governing our work (i.e., VAWA/VOCA/FVPSA). The privacy standards in VAWA, VOCA, and FVPSA do not have an exception for sharing with business associates. How does your system meet these higher standards?

Data security and privacy are important aspects of client confidentiality. Many platforms automatically capture user information such as phone numbers, IP address, usernames, or even the content of the conversation (National Network to End Domestic Violence, 2019c). It is important that victim/survivor service providers use vendors that only collect information they actually need and allow users to control what information the vendor receives (National Network to End Domestic Violence, 2019c ). It is important to review the vendor’s privacy policy and ask what information the vendor collects, stores, and can access (National Network to End Domestic Violence, 2019c).

Customer Service

The vendor must offer quality customer service to help troubleshoot problems that arise with the platform. When selecting a platform, victim/survivor service providers should consider the quality of the customer service team by reading reviews and asking questions on the types of support the vendor offers before purchasing (National Network to End Domestic Violence, 2019c). Service providers should also determine if their universities’ IT department can assist with any technical difficulties (National Network to End Domestic Violence, 2019c).

Additional Features

Victim/survivor service providers may want to consider other features that platforms offer. For example, they should consider if translation service features are built into the platform if their clients need such services. Also, if group counseling is of interest, the victim/survivor service provider may want to explore platforms which offer group conferencing. Finally, it is ideal if victims/survivors do not need to download anything to use the platform, which makes the experience simpler and safer (Colorado Coalition to End Sexual Violence, 2020).

Platform Suggestions

While Zoom is a familiar option, it presents many challenges, including security concerns and a price which may be too expensive for victim/survivor service providers. The Pennsylvania Coalition Against Rape (PCAR) recommends the platform “doxy.me” for virtual services, which labels itself HIPAA Compliant and is also free. The National Network to End Domestic Violence (NNEDV) recommends Gruveyo and Cyph as alternatives (Colorado Coalition to End Sexual Violence, 2020).

Summary

Telecounseling is a safe and popular alternative to in-person counseling during the COVID- 19 pandemic. Service providers should consider the benefits and limitations of telecounseling and how to maintain their own competence in providing counseling in this format. Most importantly, service providers must ensure clients can provide informed consent for telecounseling and privacy, confidentiality, and safety are maintained while using these platforms.

Overview

Text-based counseling services have been utilized since the widespread use of the internet in the mid-1990’s (Maheu & Gordon, 2000) and include synchronous (e.g., live chat) and asynchronous (e.g., email) formats. Textbased services may be offered as a replacement for face-to-face or telephone counseling, or as an adjunctive treatment. Some text-based services involve one-way communication; for example, Text4Mood, introduced in Alberta, Canada, was designed as an adjunctive treatment to improve subscribers’ depression and anxiety symptoms (Agyapoing et al., 2016). Agyapoing and colleagues (2016) found that subscribers to Text4Mood felt connected to supports and hopeful and in control of their ability to manage mental health symptoms. There is limited research on which types of clients and their presenting problems benefit most from text-based counseling services and differences in effectiveness based on format type. However, research has demonstrated benefits and limitations of text-based counseling services.

Benefits

• Increased sense of privacy and anonymity by users
  • One systematic review found that these factors were related tohigher levels of self-disclosure and discussion of more intimate topics
  • However, other research has demonstrated the opposite: that morecomplex and sensitive topics necessitate richer communication formats, such as face-to-face psychotherapy
• Reduced stigma discussing mental health
• Feelings of safety and comfort with text-based communication, especially for younger clients
• Accessibility and flexibility of chat-based communication
• More control over sessions for clients/service users
• More time to reflect before responding Improved mental health outcomes compared to waitlisted study
• Improved reach to underserved populations

Limitations

• Users’ discomfort with this type of technology
• Connectivity issues can disrupt communication
• Slower responses can inhibit goal-setting
• Difficulty perceiving client affect
• Differences in strength of therapeutic alliance in text-based vs. face-to-face counseling
• Too many opportunities for miscommunication
• Lack of adequate research on culturally competent text-based therapy

Text-based counseling services increase the availability of counseling to those whomay not want or have access to face-to-face counseling services. However, thelimitations of text-based communication should also be considered when providingthis type of service. Additionally, victim service providers should consider whether to include text-based counseling as an additional communication option for crisis hotlines and warmlines (single session), or whether text-based services will be offered in an ongoing format (multiple sessions).