Reviewed by: Caitlin Kingston, LCSW
Updated: April 30, 2021
The traditional counseling setting, where clients visit a therapist’s office in-person, has evolved over the years, especially with the rapid adoption of telehealth during the pandemic. It’s not necessary to sit in an office with a patient to deliver effective therapy. Many counselors are embracing virtual visits as a way to continue care for patients who are more comfortable and receptive to receiving help from the comfort of their homes.
“There are different ways to meet and communicate with people, and it doesn’t have to be in the same room,” says Ray Barrett, a behavioral health counselor and founder of the Telehealth Certification Institute, which he started in 2014 to provide practical training to counselors starting or currently operating online practices. “Clinicians go to graduate school and receive supervision to hone skills on how to provide services when they are in the same room as the client, but they are not necessarily prepared to do telehealth. There are competencies they should be aware with when providing telemental health.”
Technology, administrative processes and a professional office setup are a few considerations online counselors need to effectively run a telehealth practice.
“The number one thign that can make a virtual visit go well is when a counselor is comfortable with delivering care online, can use the tools they have selected, and can put the client at ease—nothing else matters more,” says Lisa Henderson, licensed professional counselor, COO, co-founder and president of Synchronous Health, Inc. Henderson is past-president of the Tennessee Counseling Association and southern region past-chair of the American Counseling Association.
Why Start an Online Counseling Practice?
Online counseling can be beneficial for clients and therapists, and there are a number of reasons a counselor would want to offer virtual visits. As the practice management software company TheraNest points out several advantages for therapists: flexibility, convenience, greater access and increased income.
Barrett initially started his online behavioral health practice 15 years ago. “My very first client wanted phone sessions, but i didn’t learn about how to deliver therapy this way in graduate school, so I had to go looking for answers,” he says. “The more answers I got, the more questions I had. I enjoyed working from home, so I focused on [virtual visits] from day one.”
He discovered a need for comprehensive, practical training to give counselors the necessary tools to effectively deliver visits in ways other than in-person. This is what led him to start the Telehealth Certification Institute. “For counselors, the decision to offer online therapy depends on how they like to work with people,” he says, relating that just as some clients prefer virtual visits, some counselors would rather work this way, too.
Barrett has been able to balance his business while being around for his four younger children since he works from a home office. He doesn’t have to commute, he can see patients during hours when an office building might not be open, and his services are accessible to people who might struggle with transportation, challenging schedules, childcare or a self-conscious hesitation to go to a therapist’s office.
“Telehealth counseling is a way to be effective and also client-centered because for some clients, it’s more taxing to go to an office than to just stay home,” Barrett says.
Access is a huge factor driving online counseling. Clients might seek help sooner if they can do so privately from home. Telemedicine knocks down geographic barriers, for the most part. (That said, counselors must be licensed in the states in which they’re delivering therapy to clients. We’ll get into that later.)
Counselors can realize financial benefits from offering telemedicine by adding hours of availability and scheduling appointments during non-traditional times such as weekends or evenings.
From the client perspective, they can gain more privacy from online counseling sessions, as long as they prepare for a visit by finding a quiet space at home where they will not be interrupted. “Logging in for a session is even more discreet than parking your car at a counseling center,” Henderson points out.
Is Online Therapy a Legitimate Practice?
While there can be some perception that telehealth is not as effective as in-person therapy, that’s not the case. “In reality, as long as the counselor can be as focused on the client during the session online as they are in person, there is no difference between the two,” Henderson says. “Where things get tricky for counselors is when they get distracted with other screens or notifications on their computer, or if they struggle to set boundaries with clients who may be getting distracted on their devices.”
Also, behavior cues can look different online than in person, Henderson points out. “In person, someone may be tapping their foot, giving the counselor a behavioral cue to follow,” she says. “Online, you can’t see the foot tapping, but you may see the screen bouncing slightly or see a pen twirling at the edge of the screen. These are important cues not to miss, just as the foot tapping is in person.”
Some counselors might struggle with transitioning from one client to the next online, Henderson says. In an office, a counselor walks a client out to the waiting room, welcomes the next client, returns to his or her office, and begins the next session. “We get used to our own mental compartmentalization strategies so that we can be present with the person in the room, not the one who just left,” she says.
“With telehealth, the automatic compartmentalization is gone, but there are still opportunities to compartmentalize,” Henderson continues. “We can create new habits and hold space for the one we’re serving in the moment we’re serving them, even if it’s as simple as taking 10 deep breaths between sessions.”
The same mannerisms used in an office, such as making eye contact, using body language, mirroring and using a clear voice are important in-office and online. “So, if you are using video, you want to make sure you have good eye contact and you’re looking toward the camera, and you want to use your affect on your face, so clients need to be able to see your face well and hear you really well,” Barrett says.
Reducing background noise in the therapists’ and clients’ environment is critical. “You want an area that is private so clients will get the most out of the session and feel they can trust the situation,” Barrett says.
How to Start an Online Counseling Practice
While starting a telehealth practice is not complicated, there are many practical steps a counselor must take to assure privacy, safety, compliance and an overall smooth workflow that allows sessions to be productive. Here are the basics tools a private practice counselor needs to get started:
- Working hardware
- Reliable internet connection
- Inter-office best practices
- Clear audio
- Effective lighting
- A HIPAA-compliant platform
- Emergency plan
- Legal and licensing
- Scheduling tools
- A quiet space to conduct therapy
The equipment and devices you own for personal use might not be sufficient for managing a counseling private practice online. Rather than relying on a smartphone, which can make it harder to stabilize a camera, as Henderson points out, use a laptop or tablet that is compatible with the telehealth platform you select. “This way you will have the screen space to have the client at the right size on your screen, adn see anything in the record at the same time,” she says.
The Center for Connected Health Policy (CCHP) lists the following important tools for conducting telemedicine:
- Computer, phone or tablet with integrated speaker, microphone and camera
- External microphone if your device lacks a high-quality integrated one
- External camera if your device lacks a high-quality one
- Headphones for more privacy
Reliable Internet Connection
“It’s guaranteed to happen, but lagging video, frozen screens and robotic voices shouldn’t be the norm,” Henderson says. CCHP suggests using Google’s speed test to check your internet quality. If your speed is less than 3Mpbs, consider an upgrade. Another tip is to close all extra browsers and windows before conducting an online session to maximize the internet speed you do have. A wired Ethernet connection is preferable, CCHP says. It tends to provide a more stable connection than WiFi.
Inter-Office Best Practices
Do Not Disturb! How will you let others in your environment know that you are working privately with a client and cannot be bothered? Establish boundaries and expectations for your online counseling time so you can give patients your full attention. “A closed door is often not sufficient,” Henderson says. “We’ve all seen those videos.”
Barrett adds, “Sometimes, counselors can set their standards aside when they do telehealth. If you are in a home office, make sure there is no background noise, you won’t be interrupted and that your office is secure.”
Check the Audio
Before you conduct a telehealth counseling session, test your audio and video. Will you need headphones with a microphone? “Also test the audio of the room so that voices aren’t carrying outside the door,” Henderson says. “Computer audio travels differently than human voices in person, so don’t assume that if people can’t hear your in-person sessions that means they can’t hear you on telehealth sessions.”
Proper lighting and camera positioning is critical for conducting an effective online counseling session. Clients need to clearly see therapists’ facial expressions. “That’s how clients get comfort when they are inching toward something difficult,” Henderson says. “Our unflappability, non-judgemental or mirrored response to their words is what gives them the courage to proceed. If the client can’t read that on the counselor, they clam up and progress is inhibited.”
A HIPAA-Compliant Platform
Select a HIPAA-compliant video conferencing system. CCHP says Facetime and Skype are not suitable. That said, most major providers offer HIPAA-friendly video clients, including Google Meets, Zoom, GoToMeeting and Microsoft.
Find out if the software provider has a HIPAA Business Associated Agreement. Counselors have to conduct a risk analysis of the technology and put a risk management plan in place for those risks, Barrett says. “They must have reasonable assurance that the technology vendor is complying with HIPAA law,” he says.
Be sure to put in place client verification, especially if you are billing third parties. “Otherwise, you could unwittingly commit insurance fraud,” Henderson says.
Counselors need an emergency plan if a patient they see online seems unsafe. Henderson points out, by calling 911, emergency responders will be routed to you and not the client in need. Be sure to ask for the client’s location before the session begins so you know where to send help if required. This information also should be kept on file.
Legal and Licensing
Know your state’s rules and regulations. TCI has a database of federal and state telehealth rules and regulations that is comprehensive, authoritative and regularly updated. It also includes a registry of codes of ethics to guide telehealth best practices as a single source for accessing information for professions ranging from social work to counseling and psychology.
For clients’ convenience, online counselors should offer some self-scheduling options through an online calendar. This can be a feature of an electronic health record, which also allows counselors to maintain clients’ paperwork, session documentation, billing and other functions, Henderson says. “Text reminders of appointments and bills can also be set up and automatically delivered through electronic health records.”
While online counseling offers flexibility and convenience for therapists, they need to take their environment seriously because it will make the difference between a comfortable, effective session and one that is less than adequate. “Set up your virtual office and go through a thoughtful, intentional process of creating a space that is conducive for seeing patients online,” Barrett says.
CCHP recommends an area free of clutter and neutral walls that will not distract clients. Avoid spaces where noises from outside, doorbells, TVs, radios and other conversations could impede on the virtual counseling session. And again, make sure no one else can hear what you and the client are talking about.
How to Do Online Counseling—Develop a Telehealth Workflow
Setting expectations for how an online counseling session works helps clients understand their responsibilities before the virtual visit. It’s really no different than the orientation a counselor would conduct before a first-time patient attended an in-person counseling session. “You tell them how to get there, where to park, they’ll walk into the lobby and sign in,” Barrett says.
“So, give clients basic instructions on how an online session will take place so it’s a smooth process,” Barrett continues. Telehealth procedures should include:
- Signing a consent form
- Gathering necessary insurance information
- Setting expectations for online visit behavior, such as meeting in a quiet place without interruptions
Private Practice Online Counselor Resources
Counselors building an online practice can tap into a wealth of resources related to technology, software platforms, compliance and the basics of how to conduct a therapy virtual visit. Here are some helpful resources
Telehealth Certification Institute
The Telehealth Certification Institute provides comprehensive telehealth training and consultation to more than 20,000 healthcare organizations and professionals. Founded in 2014, it offers online courses, certificate programs, training for groups and communities, and other services. Its resources include states’ codes of ethics and a listing of telemental health physicians. Also, the institute holds an annual summit.
The American Counseling Association (ACA)
On counseling.org has a knowledge center that includes telebehavioral health information for counselors in private practice and healthcare organizations. It answers frequently asked questions, and provides information on licensing and liability insurance, ethical standards, insurance billing processes, effective remote counseling and telebehavioral health technology. You can also review the ACA’s state actions on telebehavioral health.
TheraNest is practice management software for behavioral health professionals. In addition to its telehealth technology platform and solutions, the company provides guides for billing, telemedicine, and free private practice email templates.
American Psychological Association (APA)
Download practice guidelines for telepsychology from the American Psychological Association, which says its guidelines are informed by APA standards, including following: Ethical Principles of Psychologists and Code of Conduct.
The NextGen electronic health record (EHR) platform is designed for small, cloud-based practices and larger healthcare organizations. Its features include workflow tools like e-prescribing, practice management tools for medical billing and staffing, and reporting and analytics. There are a range of EHM platforms available, and this is just one of the options.
AthenaHealth EHR software provides telehealth services that allows practitioners to complete a virtual visit from scheduling to billing. Capabilities include a group video conferencing option, billing support, patient outreach, and patients can join visits from any mobile device.
AthenaHealth is listed on ERM Finder as a best electronic health record platform for small practices. The resource also named these electronic medical record platforms as solid software solutions for private practices: AdvancedMD, drchrono EMR Software, Practice Fusion EHR Software, Kareo Clinical EHR Software, eClinicalWorks EHR Software, PrognoCIS EHR Software, ChartLogic EHR Suite, SammyEHR by ICS Software Ltd., Epic EHR Software.
Ray Barrett, a behavioral health counselor and founder of the Telehealth Certification Institute
Lisa Henderson, licensed professional counselor, COO, co-founder and president of Synchronous Health, Inc., past-president of the Tennessee Counseling Association and southern region past-chair of the American Counseling Association
- Telehealth Certification Institute Last Accessed April 2021
- Synchronous Health, Inc Last Accessed April 2021
- American Counseling Association Last Accessed April 2021
- TheraNest Last Accessed April 2021
- Center for Connected Health Policy (CCHP) Last Accessed April 2021
- U.S. Department of Health and Human Services HIPAA Business Associated Agreement Last Accessed April 2021
- American Psychological Association Telehealth Resources Last Accessed April 2021
- NextGen Last Accessed April 2021
- AthenaHealth Last Accessed April 2021
- ERM Finder Last Accessed April 2021
- AdvancedMD Last Accessed April 2021
- drchrono EMR Software Last Accessed April 2021
- Practice Fusion EHR Software Last Accessed April 2021
- Kareo Clinical EHR Software Last Accessed April 2021
- eClinicalWorks EHR Software Last Accessed April 2021
- PrognoCIS EHR Software Last Accessed April 2021
- ChartLogic EHR Suite Last Accessed April 2021
- SammyEHR by ICS Software Ltd. Last Accessed April 2021
- Epic EHR Software Last Accessed April 2021