Video therapy conferencing has been a lifesaver to mental health clients and clinicians during the COVID public health emergency. However, it does have limitations for those who either don’t have access to or don’t want to use the video format. Some rural areas don’t have access to internet services, and some don’t have access to technology. Providing phone therapy can effectively fill that gap.
Are Phone Therapy Practices Similar to Video Therapy Practices?
While it seems simple enough, some considerations are to keep in mind when performing an audio-only treatment. Clinicians need to keep in mind that they need to engage in the same ethical practices as in-person sessions, including informed consent and risk-benefit analysis, and be aware of the legal and ethical issues surrounding telemental health. As with videoconferencing, clinicians must determine whether or not phone-only treatment is the appropriate vehicle for any given client. It is also important to create a plan to manage emergencies and identify issues that may not be well suited to services rendered by telephone.
Phone Therapy Considerations
Other important considerations in providing phone therapy that differs from video conferencing include the following:
1. Privacy and confidentiality issues: Phone therapy by definition means you do not see the person; therefore, you can not tell visually if anyone else is present. That makes it more important to ask the client if they are alone in a private setting. Clients and therapists should also use a landline if possible and avoid using public or unsecured WiFi on other types of devices. The use of headphones and headsets also improves quality and confidentiality. However, speakerphones are not recommended, and other devices should be secured (see Protecting Your Personal Telephone Privacy).
2. Client identification and location: Because you cannot see the client, it is more important for the client to identify themselves at the start of each session and ask where the client is located in case of an emergency, whether mental or physical.
3. Distractions: Audio-only sessions are particularly vulnerable to distractions, not only for the client but also for the therapist. Encouraging clients to find a private space and free of potential distractions will improve privacy and enhance the client’s ability to concentrate on the session. Therapists must also take steps to create a distraction-free setting. For example, if using a smartphone, turn off any alarms, ringers, etc., that would be disruptive when heard. In addition, therapists must avoid the temptation to do any activity that is not directly supporting the call, such as reading texts or email, etc.
4. Attending to nonverbal communication: Because there is no visual cue available during a phone session, clinicians must be intent on listening for nonverbal cues such as differences in tone, pace, pauses, etc. Because you can’t see the client’s face, there may be more frequent times when you want to ask the client how they feel if you cannot detect it from their voice, such as when encountering long pauses. Because you cannot see expressions, emotion may be more difficult to interpret. More patience may need to be demonstrated as clients grapple with more difficult issues or emotions. As with all forms of counseling, it is important to recognize any cultural differences, especially in communication style. This is essential when doing telephone therapy since you cannot see facial expressions that might give you more accurate cues.
5. Documentation: Detailed documentation should be written for all telephone sessions. In addition to the usual session notes, elements, telephone telehealth documentation may need to include issues such as the time the phone session started, the geographic location of client/patient, interruptions or intrusions, and any events during the interruption/intrusion. For example, if someone’s spouse, roommate, or other party interjects information in a way that is audible to you, a decision must be made to address the intruder. Typically, the client/patient would be asked if they would like to include the third party, then the discussion would involve parameters to such inclusion. All this information could be noted. Other issues include whether or not the client/patient is wearing a headset or earbuds to limit the therapist’s voice into a room, thereby limiting access to the full content of the session to any eavesdroppers. Verbal agreements made by the client/patient regarding what they are doing and your assumptions based on the informed consent process you previously have in place, such as whether they are believed to be recording. Dynamic, informed consent may also be noted for any other digital interventions being used, such as apps, supportive websites, or digital informational/educational articles being recommended.
The therapist’s thoughtful and careful attention to the client/patient may be noted, as in a statement. Assuming the therapists is truthfully paying attention and avoiding distractions, the statement may be something akin to: “As the therapist, I was in a closed room with a locked door, only focused on the client/patient’s voice and taking notes. Distractions were eliminated, and I did not engage in multi-tasking.” (If distractions and multi-tasking have not been eliminated, the therapist may want to make it their business to eliminate those distractions ASAP to be offering professional care to their client/patient. Due consideration may particularly be needed by therapists engaging in other activities, such as strolling in the park, driving, or other multi-tasking, as these activities may be difficult to defend if questioned by any number of authorities. The evidence-based supporting such activities as part of a telephone telehealth treatment plan will most certainly be needed.)
As always, a proper telebehavioral informed consent process should be in place to prevent and better manage any potential emergencies, particularly with complex cases involving people who are prone to experiencing crises. Similarly, if the clinician has not yet taken enough telebehavioral health training to defend their telebehavioral health competencies, the therapist would be advised to obtain such training ASAP and fully document the training. Reference to any supporting telebehavioral health literature for the interventions being used by telephone is also to complete the telephone telehealth session note. For example, such reference might read as such, “As suggested by Peterson and Asim in 2020, this telephone telehealth intervention was used with Joe today. Joe responded positively, and so, another such intervention will be included in next week’s phone therapy session.”
Nuances Make a Difference
Providing therapy services over the telephone can be a useful tool for those clients who either cannot or choose not to utilize video conferencing. The same ethical standards apply to clinicians’ audio-only sessions as they do to services delivered in person or by any other delivery modality. Understanding some of the nuances one might face during phone therapy, a seemingly more straightforward approach, will improve clinicians’ ability to provide more effective and ethically grounded services.
Phone Therapy Reimbursement
Lastly, as with all therapy services, the wise clinician will stay abreast of changes in reimbursement policies for phone therapy services. For more information on reimbursement, see COVID-19 Telephone Telehealth Reimbursement. And even more recently, phone therapy reimbursement has become quite controversial this month. Please see Controversy about Eliminating Telephone Telehealth Coverage for details.
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