Episode 30 – Starting an Online Therapy Practice – questions from Sue Bates

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Welcome to the Online Counselling Podcast. Exploring the practice of counseling through technology.  Here’s your host, Clay Cockrell.

Clay Cockrell: Hello and welcome to the Online Counselling Podcast. This is Clay Cockrell. Thank you so much for joining us as we explore the world of online therapy and coaching. First, I want to give a big shout out and thank you to Doctor Dave of Shrink Rap Radio. Last week, I get to talk to him on a show about online counseling and it was a real privilege. If you haven’t had a chance to subscribe to his podcast, I encourage you to do so. He really is talking to some incredibly interesting people about our field and how it’s changing and he’s just wealth of information. I think he’s up to or five hundred episodes. Really is a leader in the podcast industry. So, check out Shrink Rap Radio with Doctor Dave. He’s just lots of fun and interesting guy.

For today, we have a very special podcast. It seems every day I get an email from a therapist who says they are thinking of beginning an online counseling practice and want to know how to get started. Many of the questions are the same. Wanting to know what platforms to use. How does state licensure apply to them? What are the liability issues? I recently was talking to my wife Sandy how it would be great if I could have a podcast with a therapist who is in that position who is just starting out and just record that conversation so that everyone could kind of get the basics. Well today, that is finally happening. Enter Sue Bates out in Seattle. She’s been a therapist for over 40 years and has been listening to the podcast and thinking how she would like to add online therapy as part of her overall approach. She’s agreed to record our conversation and I have to say she had great questions. We get to cover all of the nuts and bolts of what people need to know and think about when considering this step. So, come along with us as we explore you what you need to know when starting out your online counseling practice.

Hopefully, we covered your questions but if you have more please let us know. You can email me clay@online counseling.com. If you are thinking of advertising your practice, you got an online counseling practice or maybe you just starting out, check out the directory. We are a service helping you advertise your practice. Very similar to Psychology Today. Our goal is to bring clients to you and educate you like this podcast on the ethical and legal ways of doing online counseling. So, check us out at onlinecounselling.com. Alright, ladies and gentlemen, here’s Sue Bates.

Clay: Hello and welcome to the Online Counselling Podcast. This is Clay Cockrell. I have a really interesting project that we are going to do today. I have therapists contact me all the time and say that they’re thinking about beginning an online practice and they have questions. Some questions they thought through and some they haven’t. And so, today, we’re going to talk with Sue Bates who is exploring beginning an online practice. The idea is that she’s going to go over some of the questions that she has about beginning an online practice. Maybe we’re going to be able to cover all of the concerns and thoughts of how do you get started and what you should be concerned about. So, I’m a thrilled to welcome to the show, Sue Bates. Welcome, Sue.

Sue Bates: Hi Clay! Thanks for having me. This is going to be really fun and I really do have some honest questions for you.

Clay: Good. Good. Good. Good. We’re going to get them all answered and maybe this can be a tutorial for everybody out there who is listening and thinking about doing this. First tell us a little about you. Where are you located and what’s your degree?

Sue: I’m in downtown Seattle. Like you, you might hear some sirens. I’ve been a therapist for forty years. I’m in my late sixties now and I want to semi-retire. I really have always wanted to travel around the country and may have been different places.  I think the way to do that is online counseling and I heard about you from Allison Puryear. She has Abundance Practice Building.

Clay: Yes. Love Allison.

Sue: She’s in my mastermind group and we’re friends and so I’m like, why doesn’t everybody do this when I started looking into it. My degree is a master’s in education about forty years ago.

Clay: Okay. So you’ve been in private practice for 40 years?

Sue: Really. You know there have been times I’ve moved back and forth between here and Denver and I’ve started again. I’ve had some jobs along the way. But pretty consistently, at least for the last 20 years or so.

Clay: Okay. And all face to face.

Sue: Yes. Yes.

Clay: What population do you specialize in?

Sue: Well, for the last 40 years, I’ve specialized in eating disorders and relationship issues. But the eating disorders are wearing me down. So I’ve changed to relationship issues and I’m getting a lot of clients for that. But my office is downtown Seattle and I’m like four blocks from Amazon.

Clay: Oh wow!

Sue: I’m filling up with people but they have insurance. So, I’m little concerned about the online because of the insurance.

Clay: Okay. So we’re going to get into that. Now, have you done any kind of online work?

Sue: Yes. Now and then I have a client on vacation or something and I’ll do that. Yes I used Skype because I didn’t know it was a really bad thing.

Clay:  I did too. We all start there.

Sue: Now I know what platforms to use. But yes, I have.

Clay: What do you think about it just a little bit that you’ve done?

Sue: I think it’s fine and I really like seeing where they live. Seeing their husband maybe there poppy on a little bit. But we make sure that the door is closed so the kids can’t come in. So I’ve really enjoyed it and not had much problem with it.

Clay: Great!  Alright. So, where should we begin on the questions?

Sue: Well, I would like to know, I signed up for your site onlinecounseling.com and I want to know more about… We’ll probably start with the basics. But what do you do? What is onlinecounselling.com?

Clay: I started putting this together because I was a therapist for about six years. Working online doing marriage counseling. When I needed to refer to someone, it was really hard to refer to another online therapist because I couldn’t check their credentials or I couldn’t find them period. And so, I thought wouldn’t it be nice if we had a… because Psychology Today does a wonderful job of creating a directory and they limit it your zip code. What if we could have a directory like Psychology Today but for therapists who are working online? I started putting that together and it became this massive thing and I started learning as I put it together that oh we got to limit it state by state because of the state licensure laws. There were so many people who wanted to become a part of it but they had questions. So I put together this podcast to begin answering those questions.

But what onlinecounseling.com is it’s an educational resource for therapists to learn how to work online ethically and legally. But it’s also a directory to help those therapists market their practices to people within their state or all the states that they’re licensed and international and to help clients around the world who are looking for a therapist to meet online. How do you find them? How do you say I want to meet with a female therapist that specializes in anxiety and works with teenagers? You put all those filters in just like Psychology Today. Up will pop a list of providers who we have checked their credentials, their training. We make sure they’re licensed. So it’s a safe listing of people that are going to be able to meet their needs. Now, clients at this time don’t meet with the therapist at my site. This is just a listing service like Psychology Today. You then have the freedom to go out and find whatever platform you like and that you feel good about and meet with them the payment, the scheduling. Everything happens someplace else. This is just an advertising directory.

Sue: Oh good. Okay. I’m glad you clarified the part about that you don’t see the clients through your portal.

Clay: Right.

Sue: That’s really helpful.

Clay: That maybe changing soon. I talked to someone who is pretty exciting to begin maybe have your entire online office with scheduling and billing and actually be able to meet in a HIPAA compliant platform on the side. We’re talking about it. But we’ll see.

Sue: You’re a great entrepreneur.  That’s a very good idea. Let’s start with basics of online counseling. I understand that some people might not that are listening to you. So how do you really define online counseling?

Clay: Great question. It’s interesting. There’s probably about 50 different terms for online counseling. There’s internet therapy. E-therapy. E-counseling. Online telemental health is a big one if you want to Google. Internet therapy. Internet counseling. So you have to use those terms back and forth. But all of it kind of comes down to the idea that you’re meeting online in a virtual way and that you’re connecting visually. This is how I think of it is your connecting visually and hearing auditorially. So it’s a video chat. Now, it can be expanded. Many people then do email therapy which is asynchronous that the client would send an email with their concerns and their thoughts and their issues, and then the therapist would respond in agreed upon manner and timeframe and they can go back and forth having sessions with text, with email. I don’t do that myself but I have interviewed people who trained that. Carol Francis Smith for example is wonderful in the UK. And so she’s been doing this and then there are some people who have counseling, via IM, instant messaging. That’s considered online counseling. These are things I don’t do but they fall within the world of online counseling. But I think generally what people think of is they think of visual, a video chat, a secure video chat like Skype.  Skype is the brand name. But of course we know it’s not HIPPA compliant.

Sue: Okay. So, the second part of this. Let’s talk about specifics like webcam, lighting, sound, those sort of things.

Clay: Great thinking. It’s the logistics are once you get them set-up, they’re really easy. You want to have a light that is facing you and not necessarily being back lit. Being back lit is let say you have a light behind you or you have an open window and it’s a sunny day, what happens is it your facial characteristics are going to get blurred or they’re going to be dark and you want to make a really nice connection. Many of the platforms out there you’re able to see yourself and kind of check on how am I looking here. So, the other thing is that it’s important to put the—and this takes a little bit of a maneuvering—but to put the computer at a certain distance from your face. I would recommend that you have a computer that has a camera built in to the computer instead of one that is clipped on to the top. You could do the clipped on to that the top. But what happens is you’re looking at the screen and you’re not really making eye contact with your client. Therapy is so much about making that eye contact I think. So that you want to really kind of keep the window of the client near at the top of your screen as close to the camera as possible so it looks like you’re making eye contact and yet you’re able to see them and get those visual cues. Because sometimes therapists will set-up like a free standing camera off to the side and they’re just seeing the side of the face. The client is seeing your side of the face and you’re not making that eye contact. So that’s an important one.

Sue: That’s very helpful because. Do you stare into the little camera?

Clay: Sometimes, but then when I do that, they’re seeing my eye contact but I’m just kind of seeing them at the bottom of my eyes.  So I’m not able to register and keep that connection and get those visual cues from them because I’m looking at a little green dot and that’s not helpful. So if you get a certain distance away from the computer and you’re looking at their eyes, it looks like that you’re making eye contact from their point of view.

Here’s a really cool thing and I haven’t explored it yet. But there’s a technology out there in beta testing called Eye Catch. It’s a plug-in that it adjusts. It does facial recognition technology and it grabs on to your eyes and adjusts them to make them look like they’re looking at the camera even though you’re looking at the screen. So, I’ve dreamed about that technology. I thought it would be cool or somebody can come up with this. Apparently these people have. They’re in beta testing so stay tuned. We’ll have more information about that.

Sue: That’s good. That’s very helpful.

Clay: Let’s say, a couple of other logistics. I always use ear buds with a microphone in them just like we’re using today. The microphone, most people get those free white ear buds that come with your iPhone. Those are excellent because the microphone picks-up your voice and hangs right there at your face and somehow it helps with the broadband connection. Because there’s a loop. There’s an auditory loop that it eats ups and echo can happen if you don’t use ear buds, if you’re just using the speaker and microphone from your computer. It can be a little tangy. You want to have that rich vocal connection with them. So using ear buds with the microphone attached to the ear bud is really helpful.

Sue: Okay good. That’s very helpful.

Clay: One final thing that I found is helpful is, shutdown also it’s a background windows that you may have that may be using the internet whether it’s Internet Explorer or Firefox or any of those things that are going to connect online. So you want to be able to shut those down and anything that might be taking, and not just x them out, but actually go to Force Quit or I think it’s Ctrl Alt Del on Windows and really shut them down completely so that the only thing that is using the broadband connection is the video platform that you’re using. That can be very helpful.

Sue: You said something about maybe closing doors, high-speed internet, placement of computer.

Clay: Right. Right. We want to make sure that you have a really good broadband connection. I don’t think anybody has a dial-up anymore, but you want to have a high-speed connection. What I was saying was just to shut down any windows that maybe using internet.

Sue: With the lighting, what I’ve learned is that you don’t have to have fancy equipment. You can light if you want to. But standing in front of the window’s very important. So you’re getting light on you.

Clay: That natural light is really helpful.

Sue: Right. Platforms. So we can’t use Skype. What do you recommend?

Clay: Onlinecounseling.com has a page called the Therapist Tool box. In there is also a really cool information. One of the pages is HIPAA compliant platform. Some really good once out there are WeCounsel, thera-LINK. Let’s see who else. Regroup is listed on there. I don’t want to forget somebody and someone’s going to call me and say, “Hey you didn’t mention me.” iCam is a good one. I’ve been hearing wonderful things about Doxy.me and Zoom. People in China particularly love Zoom. It’s got a really clean connection and the great thing, and I keep talking about Skype, is not just the HIPAA compliant issue. It’s that they are not buffering well. Many times the call will be pixilated. The audio will drop out or if it’s a busy day somewhere Skype will just all a sudden quit working and the call will be drop.

But these other platforms are designed for mental health providers so that they will buffer the signal. So that instead of an HD quality visual, it’ll reduce a little bit. You and I would never know. We don’t need HD quality. They will reduce that signal so that you maintain the signal and the connection. They buffer it down so that if it’s a cloudy day in Kuala Lumpur somewhere and the connection isn’t good, you still maintain that connection because it is frustrating I think to be in a therapy session and have somebody working on some really difficult issues and then the call get drop or you’re only hearing every third word. That’s why these other platforms are really good and they’re very affordable. Sometimes they’re free. Sometimes they’re $9, $14 a month.  You think about. That’s your office rent. I’m here in Manhattan and I’m paying almost $2000 a month for my office. If you’re only paying $14, $15 dollars a month for your “office,” that’s a pretty good deal. What you want to ask when you contact them is that if they will give you what’s called a business associate agreement. It’s just a form that keeps you HIPAA compliant and that they’re agreeing to keep the information encrypted and private and not use it and not record it and store it somewhere. It’s a business associate agreement and they’ll know what that means.

Sue: But if we’re using these platforms that you have on your site, we can just use them. We don’t have to call them about a business associate.

Clay: No. You’ll need to call them and make sure–.

Sue: Oh really!

Clay: You’ll need to make a contact with them and say, “Hey I am a therapist. It’s important for me to be compliant with HIPAA. I need to have a business associate agreement.” They’ll just email it over to you and you sign and you fax it back to them, and then you keep that on file and that keeps you protected. Even though these other platforms are encrypted, safe, secure, all of that, they’re listed because they offer a business associate agreement. That’s what going to keep you compliant with the HIPAA law.

Sue: I didn’t know that. Thank you.

Clay: Sure.

Sue: This is a good podcast. Anything else you want to add about that or?

Clay: I think that that’s mostly it. One other thing is that I think it’s important to make sure that you are in a secure environment that you’re sitting in an office that your wife or husband starts to be walking back and forth and your kids are going to be interrupting. You’re in a secure, confidential area that nobody’s going to overhear. God forbid a therapist would go and sit in Starbucks and have a session but maybe somebody else would do that. That’s not what we do. We want to keep it confidential. But also talk with your client because you want them to be in a confidential, private area with a closed door so that they need to protect their confidentiality. When they come to your office, they don’t have to worry about that.  But when you’re meeting in their home or maybe they’re using a conference room at work or something so that they are keeping their end of the conversation confidential.

Sue: Right. And if they might not be really aware of that so setting those boundaries for them will be really helpful, I think.

Clay: Very helpful.

Sue: So, back to me. I’m licensed in Washington State and I’m going to get licensed in Montana which is pretty easy, because you have to have fill out a lot of stuff but I don’t have to take the test because I don’t know if I could pass that test after 40 years. I’m not kidding. So, how do I market to other states?

Clay: That’s the great thing that we are doing here at onlinecounselling.com is that we list you in the state. Every state that you’re licensed in, you’ll be listed in. Once you get licensed in Montana, you just go back into your profile and click that you are now licensed in Montana. I think somebody has signed up and he has five states licensed in. So he’s marketing via our website to all of those five states.

Sue: Is he getting people clicking on him or working with him?

Clay: Yes.

Sue: Really? Okay.

Clay: That’s one way. I think that looking at… You may want to pay for an extra profile on Psychology Today because Psychology Today limits you to the zip code that you’re working in. That’s just kind of how they’re built, their face to face stuff. But on your profile on Psychology Today, you may want to list, by the way, I do online video counseling and you might want to put there parenthesis like Skype, because the lay person will think, they want to know, like Skype, they don’t care about the HIPAA compliant. So it’s like the brand name Skype. So you put that like Skype on your Psychology Today profile. And I’m able to see people in the following states.

Sue: I have to have a zip code. So I would just have one profile on Psychology Today but I would list the other states.

Clay: Yes.

Sue: But see, some when people are looking for a therapist in Montana, they can’t find me on Psychology Today.

Clay: Right.

Sue: I don’t like that. We got to do something about that.

Clay: That’s the way they’re built.  They have on their option to say a video call, you do video calls on your profile. But really what that’s about is it seems like more for a consultation. Not that you do video counseling, It’s just that you could set-up a video call for consultation that you could provide. That’s the way I kind of saw it. I can be wrong about that. Other option would be to create a whole new, and pay for it, Psychology Today profile in Montana and pick up large city in Montana and say, “I don’t have an office there but I can see you virtually in Montana.” That can be expensive overtime but you get more client from there and you probably will pay for it.

Sue: That’s good. So we can we have more than one profile on Psychology Today.

Clay: Now that I said that, I think so.

Sue: We’ll find out. I’m going to see about that for sure when I get the license. Okay. Marketing in another countries and how to market to expats. You’re doing that right?

Clay: So we push through Google ads, through Facebook ads. We are doing marketing for you internationally and nationally too. So that we’ve got ads rolling out all time for depression and anxiety or whatever their different specialties are. You are looking for counseling in Montana or Kansas or whatever. So we try to geo locate those ads. So we’re doing a marketing push for you. For expats, there’s some great sites out there. InterNations is great. Expats.com is great. There is a whole community out there geared toward helping expats  adjust because there’s a statistics out there that somewhere between 16-40 percent of international placements for jobs, those placements fail because of the stress living in an outside your culture living in international environment. The family sometimes have to be transplanted. It’s hard on the family, it’s hard on the individuals. So, there is a great need for expats to go through that counseling process and there’s therapists that specialize in working with expats to adjust to a new culture. So advertising within those online forms and communities is really important I think to reach those.

Sue: I didn’t know about those. That’s good. There’s something about hub, something hub?

Clay: There’s the private practice hub in the UK. Jeff Simons is a wonderful, wonderful guy. So he is also launching the Online Therapy Hub and that just came out this summer. And so it’s a lot of resources for people in the UK.

Sue: Good to know. I need a little help since we’re talking to me today. On my profile, on your site the onlinecounselling.com, is there something you advice for people to do to click on me more? Because I’m not getting any clicks yet.

Clay: There is a few things that you can do. When we developed this, we want it to be really a personalized page that you can kind of decorate. Very similar to Facebook. So you want to have an engaging professional headshot and that’s the smaller picture on your profile. But then you have a larger banner like the Facebook profile and that’s some place where you can personalize and maybe take a picture of your office or a beautiful forest or a meadow or something that’s

Sue: The big sky in Montana.

Clay: There you are. The big sky in Montana. Exactly. Some people put their logos up there on the large picture. Some group practices put a picture of all the therapists that work there kind of standing outside, with the arms around one another, so here’s our team, that type of thing. That’s a chance to bring a client in and show a little personality. And then of course you want to list all your specialties that you work with and we ask you to list your top three. So the search engine looks for those top three that you specialize in. But it also looks at everything that you do very similar to Psychology Today search engine. So, if someone is really looking for eating disorders and you are one of the top three specialists in eating disorders, you’re going to come up a little higher than somebody who just lists eating disorders as their all the things they do and not their specialty. That’s one thing.

There’s also to people out there that help clinicians personalize and write their bio. I think the bio is your chance to shine. You want to speak to the client, not just about yourself, and put yourself in the client’s shoes. Too many therapists say, “I am a cognitive behavioral therapist with twelve years experience and I specialize…” And they don’t care about that. You talk to them. Are you struggling with adjusting to a new culture? Are you depressed? Are you and your wife constantly fighting all the time? I know what that is like. I’ve worked with couples in similar situations. There is hope. Here’s how I work. I work to build skills. I help you communicate better, to rediscover why you’re in love, to embrace the challenges of expat living or whatever your specializing. I’m kind of throwing everything out there. So just if like somebody would call you and say, “I’m interested in working with you.” You talk specifically to that person and they talk about having an avatar. An avatar is your ideal client. She’s 35, single, wants to find the love of her life, struggling financially. You put that picture together. Even maybe give her a name. And then you talk to her and talk about how you can help and alleviate and how you work with similar people. And connect with that person. That’s going to personalize and I think bring more clients to you.

Sue:  I really like doing that. I really look at who I really like to work with. Because if you do that, I get people calling me all the time. They’ve seen my website and they say, “I think you can help me.” Who am I to argue with you? Because I really say who I am and how I’m different with other therapists. And I know who I’m talking too.

Clay: Alright.

Sue: I think that’s very important. Do you want to say something else?

Clay: Nope. I don’t think so.

Sue: Are you finding that other therapists are working completely online and how successful are they?

Clay: Some are. I think that they are minority. I think most people… I was talking with somebody the other day and seems like that people get in to online counseling because a client has asked them. A client is going off to college, a client is going to be travelling or the babysitter cancelled. So is there any way we can do it online session instead of or the roads are really bad. I talked with someone. Finally got someone from North Dakota to contact me. I’m so excited. I’ve been desperate to try to find a therapist in North Dakota. So I talked with her and she said people can live two hours away and they’ve be willing to drive. But sometimes the roads just won’t let them. So a client will go to a therapist and say, “Will you do this?” It pushes the therapist to get a little uncomfortable, do some research. That’s just when they find me and so they begin to go online because the client has asked them. And then I think some people say, “This might be a way for me to grow on my practice. Because I have an okay not completely full practice. This might be a way to fill up some those empty slots during the day.” So they have a part time online practice. I think it’s a smaller percentage of people who are all online, all the time, that’s all they do. They’re out there and I think in the next year or two, we’re going to see more and more people, they just have an online practice because like you, a lot of people want to travel, they want the freedom, they want the convenience. They don’t want to have to rent an office in downtown Seattle or something. They can work from their spare bedroom or home office. That helps cut down costs. I think this is the direction we’re going. But I think for right now, most people are sticking their toe into it trying to see if this is viable.

Sue: Good to know. You mentioned Facebook ads. Do you think Facebook ads are helpful or work for promoting online therapy?

Clay: I do. It kind of depends on your target audience. Any social media strategist will tell you, you need to know what your target audience is and then where are they in social media. Facebook is an older, more professional audience. I think it is kind of skewing toward male. Pinterest for example is very almost 80 percent female. Moms. Maybe working from home. Pinterest is highly female. Twitter is younger. Instagram is younger. So if you’re wanting to market to twenty year olds, you want to get on Instagram. If you want to market to 45 year old males, you want to do Facebook. So it’s figuring out where your market is. I think that the Facebook ads are relatively new compared to the Google ads. I think you could spin a fortune on Google ads. A lot of people don’t click on them anymore. Because they know people are paying to get there on those side slots or the first two slots and they’re looking for the organic. You want to improve your search engine optimization so you are ranking organic. Listing in directories can help with that. But I love the Facebook ads in that you can target so easily. You can target income, what the interests are and you can really drill down really well with the Facebook ads. We’re experimenting with them and learning. I don’t spend a lot of money. That’s my key. Say I’m going to spend two or three dollars a day maybe and play around with it, do some testing. Play with it until you go this is working over here whether its Google ad or whatever.

Sue: I found a good person to set up my ads. So that’s really helpful. I’m just starting those. So why would people do online therapy and who do you think would be appropriate to do online therapy?

Clay: Good question. There’s so many reasons to do online therapy. I think that there’s the convenience factor that even in New York there’ll be people down in financial district, it takes them depending on how the trains are running, good half hour to come up to my office at Columbus circle. And then you have a session and then you have to rush back. It’s hard to get around here in New York. We’ve got an incredible transportation system. But if you have to drive to your therapist’s office and fight traffic and then find a parking spot and then your harried by the time you walk in. I think the convenience factor is a big draw. I think the comfort factor. It’s to some degree more comfortable to sit in your own space at your own appointed convenient time and meet with your therapist. That’s a big draw. Millennials grew up with the internet. Anyone under thirty, they don’t see what the big fuss is. Of course I’ll meet with my therapist, just like I met with my coach or my tutor or college advertiser or whatever. They’re all meeting on Skype or somewhere online. They are really drawn to the technology and they’re comfortable with it.

I worked with this couple who lived in Dubai and they didn’t have any English speaking therapists that they could see. So their only option was to go online and find someone. There are couples who are living apart. Whether, somebody’s having an affair and they’re living in a hotel room or because of military deployment or job deployment overseas, they are living apart and the only way for them to meet is we pull up three screens and each person has a screen and we’re able to see and talk with one another. So that’s really helpful with marriage counseling. Those are some of the top reasons that come to mind.

Who’s appropriate? I think anyone who is appropriate to be in your office and engage in talk therapy would be appropriate for online therapy. You’ve got to look into what your state regulation says. Some says that teens would have to have permission from the parents, so you follow that rule. But if somebody is decompensated off their medication whether schizophrenic or bipolar, really would not benefit from talk therapy anyway until they’re stabilized. Then that’s maybe not somebody you want. And of course somebody who is either at risk for themselves or hurting someone else. That’s something I would caution against working with someone who is suicidal or homicidal.

Other people are much more comfortable with that. They work in crisis situations. They are wonderful online services. I don’t want to say this somebody who is suicidal shouldn’t have access to mental healthcare online. It’s just that as a therapist, you need to look at your comfort level and your risk level and what you would be willing to do and how do you protect them and protect yourself. Some people are putting in their informed consent that they want to have your address.

Sue: Oh yes.

Clay: They want to have an emergency contact number and they want to have the number of your local police department so that if you were to become suicidal during the session, me calling 911 in New York is not going to help you in Seattle. So you want to have that information available if you work with that population or if you fear that one of your clients may need those resources. Just to protect yourself and to protect them.

Sue: That’s a really good point about having a local police number. I really like that. Okay. So why would people have objections to do an online therapy?

Clay: Why would people have objections? I think that some people are concerned that you’re not able to have the same kind of therapeutic connection. I will say it’s different. It is a bit different. Sometimes different good, like we talked about the comfort factor. There is this phrase called online disinhibition. Some people are just disinhibited once they go online. You see the extremes are that with online bullying and that type of things, things that you would say in a form that you would never say out just by standing in front of you. But in cases of therapy, some people become more open and vulnerable and transparent and authentic in this type of relation. Sometimes, people just need to be in the same space though as their therapist, or maybe we as therapist just need that connection to be in the same space with them. So there’s a learning curve in what you’re comfortable with. But in my experiences, and I’ve been doing this really long time, that after doing it just for a little while, you kind of fall into a rhythm and you’re able to make those connections and read the person through the screen.

There’s some training out there that is quite good and they’ll train you on therapeutically how to do this. Online Therapy Institute, the Telemental Health Association. They’ll also train you on the legality and how to set up and make sure all your forms are correct and that you’re following with your state regulations. Training and there’s the distance credentialing, the distance counseling credential, The DCC. That can be very important to have. It’s not necessary although there are some states that say it is important. We mandate that you have online training before doing. Georgia is one of them. Who did I just talk to? Oh my goodness. I know the podcast listeners are screaming now and go “You just talked to that person and they said…” I forget there’s another one that says you have to have online training before working with their citizens.

Sue: I think you’ve kind of answered this question, but what has been road blocks for you? Things that clients have said they want or don’t like etcetera? You’ve probably answered that.

Clay: Road blocks for me? There are people who’ve contacted me that I’m just not trained or I don’t specialize on that particular need. There have been times where someone in domestic violence situation wanted to work with me. I didn’t feel comfortable. Of course that’s just me. That’s making my choice that I didn’t want to do that. There have been times where a person could not guarantee me that they were going to be in a confidential safe place. I felt like I couldn’t work with them in that situation. There have been times that there’s this one guy that was on the battlefield in Afghanistan. He had access to satellite for online connection and I worked with him for one session and just was so obvious that the satellite connection was not going to be helpful. I was hearing every third word. God bless him. He was having a difficult time in his relationship and I wanted to help. But I was able to redirect him to other services for the military that they may be able to get. I can’t do counseling if I’m not able to hear you or you’re not able to hear me. There are times, especially when now you’re working internally. People in third world countries where if you’re not having a good connection, you have to say, “I’m sorry this is just not working. I’m not going to take your money. I’m not going to try helping you when I can’t hear you.” We’re still growing as a technology and I think ultimately broandband is going to go everywhere. But right now, it’s hard.

Sue: On a battlefield. That’s wild. Okay. So do you know other states that are pretty easily to get licensed in if you’re licensed in another state?

Clay: That is a really good question. I don’t. Although there is. I talk to somebody the other day and his goal was to get licensed in every state. He was going through the process of finding out where he had parity or reciprocity so that you just have to show you’re licensed in New Jersey and you automatically got licensed in New York. I think you have to kind of go state by state on that.

Sue: There’s actually an online site that I looked at and all you have is click some links and they will let you know what the rules are. I’ll send that to you.

Clay: That would be incredibly valuable.

Sue: That’s what I’ve been doing.

Clay: But then you’ve got to factor in financially you’re going to have to pay for your licensed every year. Fifty licenses are expensive. Three or four they start to add up a little bit. And that’s

Sue: And that license application fee they’re like two hundred or three fifty or…

Clay: When you start looking at I’m going to get five, six, ten new clients in Montana or Kentucky or whatever, it might be worth it for you to pay for that license and also looking at where there aren’t a lot of therapist. I read the other day that there is the ratio. The ratio of therapist to people is highest in Maine. I think it’s one therapist for 700 people versus Texas is the lowest with one therapist for 3000 people or something it was like that. If you want to look where the need is, you might say hey I’m going to target Texas because there are fewer therapists, less competition and more need in Texas and I’m not going to go with Maine because it’s a glutted market.

Sue: Interesting. I was going to ask you something else about that but I forgot what it was. Liability insurance?

Clay: When I first started, I called up my liability, I’m a social worker so I called up NEASW provider at that time and said, “Do I need any kind of specialty insurance to be covered to do online work?” and they said no. Of course this was six years ago. Now, some insurance providers are learning that they can get a little extra money from us therapists by oh you need a special writer over here and it’s not expensive. But, you want to make sure that you covered. So call your liability insurance and say, “I’m covered here in my office. Am I covered to do online HIPPA compliant counseling, and if not what is?” and then shop around. That’s one of the areas that I see my podcast going in in 2017 is begin interviewing different insurance companies and finding out what’s affordable out there for us so that we’re covered.

Sue: Very good idea. Should my informed consent be adjusted for online therapy, I would think so?

Clay: Yeah. In fact Melissa Hall, who does wonderful, she just came up with an article and I’ll post this about how you need to have a special informed consent if you’re going to work online. So you want to make sure that that is mentioned, that I am licensed in the state. We’re going to be complying with my state license laws, etcetera. So you want to make sure that your client is informed.

Sue: What about prices for online therapy? Should they be different than what you charge regularly?

Clay: I get this question and it drives me nuts. You have to set that for yourself because the reality is that the market here in New York City is a certain level and it’s going to be different from my hometown of Mount Sterling in Kentucky. I’m not going to be able to charge New York prices in Mount Sterling in Kentucky. There are people who say I’m going to have a sliding scale fee or I’m going to have a reduced fee. But if you go with the idea of Skype is, I don’t know why their mentality is that you would charge less for Skype other than.  Some people, I’ve said why not charge more because it’s convenient. For the convenience of working online—I keep using the word Skype—but if you’re working online we had an added premium. Nobody does that. I don’t think that’s appropriate either. But to say, “This is my time. This is what I need to feed my family, need my budget, meet my expenses and that time whether you’re in my office or you’re meeting online should be the same.” Now that’s my choice. But there are other people that say, you know what? I’m going to reduce this for my online work. But I think that cheapens us a bit.

Sue: Therapists are so fast to cheapen or to charge less because we’re helpers and I think a lot of people feel guilty about charging for it. But I’m telling you in your late sixties. Let me tell you this. When I was 35, I was working in a women shelter. I was making $800 a month. And that was in whole locked in either. Until really the websites go and started going and you could market online and have a web presents, I never made a whole lot of money. I made the usual $40,000, $50,000 a year. And then a few years ago, I was able to start charging more and making more because of the online stuff. I’m telling you if you’re a woman or a single woman, you want to make sure you’re charging really good prices because you want some good retirement. So my input on that one. Few more questions. Time zones. How do we deal time zones?

Clay: Time zones. There’s a great website out there called world timebuddy.com. It allows you to put in your location here in New York and some else’s location, let’s say I got license in Montana, or somebody from Dubai contacted me and then there’s a little slider and it goes around the clock. You can see it’s three o’clock here New York. It could be six am in Dubai, I don’t know. So that wouldn’t be a good time. But if I move it to 5:00 PM and have the client, that might be right when they’re waking up. So that’s a great way of saying here’s some availability that I have in my schedule in your time zone and making it as convenient as possible for the client. Because many times people are not familiar with working across time zones. So you need to be. So when you contact them and say, “Yes I’d like to work with you. Here’s my availability in your time zone.” Worldtimebuddy.com is a great way of doing those calculations because I have messed up so many sessions at the beginning because oh I forgot. I missed calculated and I didn’t factor in the daylight savings time in your country is different than when daylight savings kicks in here, and so we are off an hour whatever or so. You want to use that website that could be very helpful.

Sue: That’s very helpful. I’ve never heard of that. One more question. How do you get paid and what currency do you get paid in?

Clay: Working internationally, we’ve talked about how working here in the states you want to work within your state that you’re licensed in. But when you branched out to international, you want to double check. Canada has some restrictions. But there are a lot of places that do not have restrictions so you’re able to see them. India, for example. Australia, New Zealand, South Africa. I was just speaking with someone in Nigeria. And they don’t have these regulations. Sometimes there’s English speaking people there and they want counseling. When working internationally, PayPal works lovely. They take a small little percentage. I think Amazon has a fee. That also they have like a PayPal thing. But I’ve been using PayPal and love it. I charge in US and so they pay in US from whatever bank or counseling, credit card they are using. So PayPal, convert that. They pay in US and then I get it in US. So they’re paying whatever conversion rate is for that.

Sue: It would be interesting for you to also do some podcast on what the rules are for different countries.

Clay: I don’t think I can fill up a podcast. There are other people out there that would say differently and we’re still learning. But the rule of thumb is here within the US you need to be licensed within your state. But licensure is really US concept. Outside of the US is more of a certification and being part of an association like the British Association of Counseling Professionals. You have to have a certain accredited education. You have to pass their test. But it isn’t state sanctioned license. It’s more of an accreditation. And so the laws restricting people from doing counseling are extremely limited across the globe, generally. But in the US, everybody’s very scared. My friends in the UK are very scared about doing counseling here. We’ve kind of created a walled world so nobody else is working within our population. But us going out and working outside of the US, it’s pretty wide open.

Sue: Good to know. Well, those are all of my questions. I’ve got a lot to do. One other thing I want to add is about getting license in other states. It’s not really as easy as you just send in your license and I’m licensed and so just license me. It’s a lot of paper works still and very detailed and they all want, they have different forms and you have to send their forms and so it’s a lot to do. It’s not all that easy. So anything else we need to know?

Clay: No. I think we’ve done a really good job of covering a majority of the questions that I get on a daily basis. I always say be informed. Learn this stuff.  Get yourself set-up just like when you set-up a face to face practice. Once you’re set-up and you feel comfortable, you can run with it. But it’s about getting set-up and being smart about the choice of what platform to use and where to advertise and marketing yourself, creating your profile, making it look really good. But I think we’ve done a pretty good job with answering most of the basic questions on how to get started.

Sue: Well you’ve really answered a lot of mine and I really appreciate you doing this. Because I just was going around on how do I do this and how do I do that. So I contacted you and say, “Why don’t you just let me ask you my questions?” So this is really very helpful for me. I really appreciate it.

Clay: I’m glad. Thank you for coming on the show, Sue.

Sue: You’re welcome.