 This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through all CEUs. Register at allceus.com slash counselor toolbox. I'd like to welcome everybody to today's presentation on using technology-based tools and behavioral health, best practices for improving access. This is actually based on SAMHSA treatment improvement, improvement protocol 60. SAMHSA Substance Abuse and Mental Health Services Administration, for those of you who aren't familiar. So you can, and a link to it is in the class, you can download the entire tip and read it. And, you know, it has a lot of really cool stuff in it. If you're into technology-based tools and that sort of thing. This is going to be a high-level overview. There was a whole lot more than I even imagined would be in that tip. So I didn't get quite as much detail in each chapter as I wanted to. But this will give you a good introduction. We're going to explore the benefits and drawbacks to using technology-assisted counseling. Learn about some of the different technology tools available. And I really want to encourage you to think, as I'm talking, and kind of brainstorm, ways you can use technology in your practice, whether you're an individual practitioner or you work for an agency, to enhance client success and be more culturally responsive. And some of you may be like culturally responsive. But we will be talking about the fact that a lot of millennials actually find it uncomfortable to be sitting in a face-to-face situation. And you can argue the pros and cons of that. But in terms of encouraging treatment compliance and that sort of thing to get them partway there, we will look at using technology-assisted care in terms of not only its accessibility, but in being more culturally responsive to those who grew up texting instead of talking. So why use it? Mobile devices are becoming universal in our culture. Ten years ago, you never would have made me believe that my mobile device would be an appendage that I couldn't seem to live without. But we have gotten in our culture where we almost demand instant communication. And I mean, it's things, it's not that I'm necessarily on it all the time. But for example, when I get in my car to go driving somewhere, I like knowing that I've got my mobile device. So if the car breaks down, I have the ability to call someone. Now, back in the day, you know, I would have walked three blocks to the nearest gas station and it wouldn't have been a big deal. But it gives me a sense of security now that I've gotten used to and kind of come to rely on a little bit. The use of electronic media and information technologies and behavioral health treatment is rapidly gaining acceptance. When you look at the studies, you're finding that there is a lot of support for the fact that technology-assisted care and e-therapy, tele-mental health, whatever you want to call it, is actually effective. So we want to look at ways that we can use that in order to reach more people for early intervention and prevention services to provide what we're going to call later therapist extenders. If you think of dialectical behavior therapy, how to have the coaching sessions in between, some technology-based tools will enable a client to log in and seek help when they're in the middle of an emotional episode so they can get help right there and then and start to learn how to apply the techniques that you talk about in your counseling session. But I'm getting ahead of myself. Technology allows alternative models of care to be offered to clients with specific needs that limit their ability or interest and hence on interest in participating in more conventional settings. Privacy. Think about it doesn't matter if you're dealing with depression or anxiety or substance abuse, there are certain people who wouldn't feel comfortable walking into a mental health clinic for whatever reasons. And from a cultural standpoint, it's not accepted or looked upon fondly of reaching out for help from a and you can consider it culture as well from an employment perspective, law enforcement, military personnel, certain professions like doctors and lawyers may not want to be associated with seeking help from mental health services. And, you know, we totally believe that mental health services are there to help people who are dealing with difficult times, you know, they're having normal responses to abnormal events, yada, yada. We don't see a problem with it, but we also have to respect their perspective that, you know, coming into a clinic, let alone sitting in group, maybe more than they're willing to do. People with ADD or ADHD who have difficulty sitting there for an hour and talking to you or sitting in group for an hour and, you know, paying attention and staying focused and sitting still can be very difficult. So it can accommodate certain needs like that. There are a lot of other issues that are not listed here. I'm just giving you some brief examples. People with chronic pain, if they have back issues, I've worked with clients in substance abuse treatment who had back issues. They were detoxing off their opiate medications. Their pain was really bad, so it was difficult for them to get comfortable. If they can find a way in their home where they can be comfortable, maybe they've got special chairs or beds or whatever that they can sit on that are more ergonomically appropriate for them, then they'll be able to focus better because they're pain free. So if we can provide the services remotely so they can be comfortable and still participate, it saves you from having to try to figure out how to help them get comfortable in your clinic. I know where I've worked before, our group chairs, with the exception of one facility, our group chairs were pretty uncomfortable. They were the old plastic stackables. And after an hour or so, even a person with no pain would start kind of wriggling around and time. Not everybody has the time. I mean, think about how much time it takes to drive to the clinic, wait for the program to start, sit through the program and then drive home. If they've got children to take care of, they've got, you know, got to tote somebody to soccer, whatever their time constraints are, they may have less time available for treatment and be unwilling or unable to make more time for it. So this helps with time constraints, even if it's live group therapy or live individual therapy, or what we're going to talk about with self-directed computer-based interventions and technology. People who are short on time, but still wanting help can start reaching out that way. Technology-assisted care or TAC can reach many people otherwise unable to access services. And thinking about the population that you deal with, whether it's a geriatric population, a cognitively impaired population, substance abuse, rural, you know, where one of the places I worked, you know, I was there for 14 years and we had our county, which was where the University of Florida was. So that wasn't rural. You know, there were a lot of services, public transportation. But we also served 12 other counties. One of those counties, the entire population of that county was less than 5,000. And so getting to services, getting all the way into Alachua County wasn't something that they were able to do. So how can we provide technology-assisted services? How can we reach out to them so they can benefit from mental health services, which brings us to where do we use them? In the home, we can provide certain services, whether it's self-directed services such as logging into a computer program that walks them through different activities, teaches them cognitive behavioral skills, whatever. That's one. Or participating in video chat or even text-based counseling or email-based counseling from their home with the therapist. Community organizations, OK, maybe we're not doing it to a home. Maybe we set up four computer banks at a place that's secure at the Local Boys and Girls Club or the library, where people can have some privacy. We don't want it out in the middle of everybody. But it is possible. And I actually have participated in some demonstration grants where we have set up computer banks where people could come in, log on and interact with their therapist or their psychiatrist from an organization, from a repository or whatever you want to call it, a central place in their community. So they didn't have to haul their behind all the way to where our clinic was. Schools, you can provide a lot of prevention, early intervention, likely you're not going to provide a whole lot of treatment services while the child or youth is at school. But there are a lot of things that they can participate in in terms of learning about wellness, learning about coping skills, education about substance abuse and prevention. And there's lots of stuff that we can provide to youth who are already at school, if the school district, if the school system is willing to allow us to provide, put computers and in the school and have the youth participate. Emergency rooms, you know, a lot of people go to the emergency room and they're under a lot of stress. Now, they could have a physical something, something going on. And that I get that. So they need to be at the emergency room. But if you've been in most emergency rooms, you don't get helped right away. So stress levels can go up, anxiety can go up. There can be screenings for depression, screenings for anxiety. So while the client waits for to see a emergency room physician, they can also be doing screenings for any mental health stuff that might be present so they could be referred for services in addition to whatever their presenting complaint was. Same thing is true in health care providers offices. If you go with SBIRT and I can't think of what that stands for, brief. It's brief intervention, but basically getting physicians to start doing screenings, brief screenings for substance abuse, depression, anxiety during each clinical visit. Well, if while the client is waiting in the waiting room, they can log on and take these assessments so the physician doesn't have to do it, you know, when they're face to face. The physician gets the print out, then they can make the recommendation. So expedites things and makes it more effective. And via mobile devices and online social networks. So sometimes people are going to want to log on. Like I said, they're at work, they go to a meeting, they get out of the meeting, they're really stressed out, they're wigging out, they're decompensating. Not to the point where they need emergency intervention, but they know they're feeling excessively stressed and they can log on to certain websites or use certain tools or apps that they've downloaded on their phone to help them get regrounded, help them use their mindfulness skills. You know, there's a lot of ways you can do it. You can also schedule texts to go out to your clients or they can schedule texts to go out to themselves to remind them to engage in mindfulness practices if they're diabetic. Now, obviously, we're not doctors, so we're not going to be treating diabetes. But if they're having difficulty with treatment compliance, they can set a text reminder to go out to themselves to remind them to check their blood sugar. I use it a lot for doing the mindfulness scans to encourage people to remember to do that. And maybe if we're working on health and wellness stuff, encourage them or remind them to log in and put in their food journal so they can see what they're eating and that sort of stuff. A lot of the apps that collect nutritional data will automatically prompt you if you miss your normal meal time and don't put anything in. Technology assisted care is often accessible on demand at the user's convenience, reducing barriers to access, including travel and transportation, time and childcare. Childcare is another huge one that a lot of our clients really want to participate in treatment, but they can't bring junior. And they don't want to bring junior and leave him in the lobby and we don't want him to do that either. So if junior is home from sick from school, spring break, teacher workday, whatever the case may be, and they're strapped for money so they can't afford additional childcare, you know, if the child's sick, they may not have anybody that they can call for childcare. There are a lot of reasons that people may not be able to attend a face-to-face appointment in a clinic. So if we look at ways we can accommodate them, you know, maybe you don't typically do video chat as your as your modality of choice with your clients. However, maybe you maintain that as an option if for some reason they can't attend a treatment session, that way they don't have to miss. But they're able to meet their other demands. If you do like total telemental health where you don't have to have an office and a physical structure, sometimes clinicians pass that reduced cost onto the client. Now there is cost that's associated with the telemental health services providing encrypted chat and setting up your website and all that stuff. So there are costs associated, but a lot of times they're a lot less than having a brick and mortar office. Technology assisted care also refers to anything that helps facilitate coordination of services and care management between providers. So you can log on to a secure chat and have a case meeting without the doc having to come all the way in or people having to meet in one place, which you lose billable hours when you got to travel. You can do that. You can also share if the health record is an electronic health record, you might be able to share portions of that as appropriate by HIPAA and high tech and all that other stuff. Do remember that millennials grew up communicating through chat and are most comfortable with those modalities. A lot of youth don't reach out for services, partly because they don't feel comfortable going to counseling. There's a lot of stigma associated with it, and it's not a mode of communication that they are necessarily used to using. So it's important to consider if you work in large part with millennials or youth or people who prefer online counseling to consider having that available. Several studies underscore the acceptability and appeal to youths of computer delivered interventions. That doesn't necessarily just mean the secure video chat. That can mean self-directed interventions. There are significant barriers to adolescence participation in addiction treatment, which can be addressed by internet-based addiction services. Addiction treatment often meets and the reason that it's singled out versus others. Addiction treatment often meets multiple days a week, which if junior isn't driving it, then you have to rely on parental unit to get them to and from treatment. They may have other things going on. They may not be comfortable in a face-to-face group setting. So they may resist going to group. There are a lot of reasons that you might want to look at considering it. And notice I keep hedging because it's going to be up to what is comfortable for you and what you feel is ethically appropriate and what you can manage to set up technologically. Because there is, as I said, an expense with getting set up with a HIPAA compliant system. Many youths report interactive computer learning environments preferable to traditional learning environments. So do remember that a lot of youth now are doing school, middle school, high school, even elementary school, online. K-12 was kind of behind the whole expansion into online public schools. But there are a lot of youth who've never sat in a classroom with 30 other students. They like computer-based learning because it allows them to solve problems actively and independently and receive individualized feedback when they're ready, instead of feeling like there's pressure on them, or instead of feeling like they've got to get caught up, they can kind of do it at their own pace. Another population that technology assisted care is really useful for is the elderly and aging, both for health promotion and to address cognitive difficulties. Computerized tools designed to enhance cognitive skills through exercises that target problem solving, attention, memory and abstract reasoning have been shown to have promise in populations with severe mental illness, as well as among individuals with substance use disorders. So for encouraging people to engage in activities, basically do mental exercise, it can help. It's not going to reverse everything and it's not going to solve everything, but there is a lot of research that if people can keep their brain active, it can slow some of the cognitive decline. Another reason to use it, it meets the needs of the adult learner, it can be portioned out, most adults have about a 10 minute attention span, and I know you're in here for an hour, so you're going, but well, yeah, we got to do an hour for CEUs in order to make it count. But technically, the research says that the adult learner typically has an attention span of 10 to 11 minutes, and then they start wandering, they come back, but technology assisted care can allow people to chunk what they're learning and really process it and digest it in a way that's meaningful for them. You can use it to provide comprehensive services, like I said earlier, clinician extenders. Patients can participate in online, moderated forums and groups, and all patients can access a web or app-based exercise activities and videos outside of session. So if maybe you're teaching DBT skills and you have your skills group and the client comes and it's wonderful, yay, they leave the next day that they're struggling, excuse me for a minute, the next day they're struggling with some emotional turmoil and they want to review what you went over, the skill you went over in group and they can go to your website, watch your video on radical acceptance or mindfulness to refresh what they learned the day before. It enables them to sort of touch base with the clinician. Now, they don't have any expectation that you're going to respond to them. This is them reaching out for a reliable resource that they can get something from. In moderated forums and groups, they may not be moderated by you. I'm trying to think. There are several online in the rooms is one and Dr. John Grohl has another one that is really popular. I can't think of the name of it right now. It's more for mental health. They moderate and they have moderators that moderate the different group chats. You can see where there and forum discussions. You can see where there might be some problems here, but we're going to talk about those when we get to downsides. Having clinician extenders available may encourage clients to reach out more often. If they're, you know, struggling and I'm not saying in the midst of a super bad crisis. The but I am talking about when they're struggling, they wake up, they can't get back to sleep, they get start getting frustrated. Well, then is the time if they can reach out and watch a video, they may be able to calm themselves down and get re-grounded as opposed to spiraling until 6.30 or 8 o'clock in the morning when the answering service can kind of get to them. Many online support forums are free and maintained by someone else. Now, if you think of it in terms of, you know, the typical brick and mortar clients that you see, a lot of us probably also refer those clients to support groups in the community. Same sort of thing, you know, we're not controlling what happens in the support groups. We have done our due diligence. We know that or we are thinking that it is a very good, helpful group, but we're not involved with it. We are saying this is a resource that you may want to check out. Same thing is true for support group meetings and online forums that are moderated by someone else. We're not controlling what happens there. So, you know, it may make you feel a little loosey-goosey. By the same token, we're also not saying or dictating that the client has to go there or providing it as a resource option. So the downside, you know, there are a lot of really positives to technology-assisted care, but it lacks the nonverbals even in video chat. If you are on even two-way video chat and one person doesn't have a super high-speed connection, there may be a delay in getting to the point of, you know, being able to understand what's going on. There may be a delay in matching the verbal, you know, you see their lips moving and then you hear the sound later or vice versa that freaks me out whenever I see that. But you don't get all the nonverbals even in video chat. So if nonverbals are particularly important, especially in the culture of your client, technology-assisted care might not be the thing. And we're going to talk about the differences in, let's see, today's Tuesday. In next Tuesday's lecture, we're going to talk about the differences in high-context communication cultures versus low-context communication cultures. But certain cultures, you get a whole lot more of an understanding of what they're saying from their nonverbals than from what they say. So if you're just listening to their words, like on the telephone, or if you're not getting that sync between verbals and nonverbals, you may miss a whole lot. There's a lack of immediate feedback when stuff is done asynchronously, such as through forums, email. I know a lot of people have started to try to do email therapy. If you've got a client that's doing that and they're in crisis and they send you an email and they say, I'm in crisis and you don't check that email for eight hours, there can be a problem. The client also may not get immediate feedback if they're struggling. You know, they're not in peril, but they are struggling. You may miss a window of opportunity because they're hoping you're going to check the email. So there can be a lot of hurt feelings, feelings of rejection, feelings of being ignored, that need to be addressed. We'll talk about this later in the class in the informed consent. Asynchronous interaction needs to be addressed in patient responsibilities and regularly reviewed for appropriateness. If you've got a client who's decompensating or who regularly makes veiled or overt threats in their texts or their emails, then the asynchronous interaction or in forum posts or chat room groups, then these types of technologies may not be appropriate. Additionally, and I hadn't thought about this, but clients who don't type well may find text-based interventions frustrating. Now, my old boss was, I mean, he's a brilliant man, but to this day, he is like a hunt and peck typer on the keyboard and when it comes to his mobile device, you might as well hang it up. He's not going to respond or if he does, it's two words. And it wasn't because he was trying to be dismissive, it's because he had such a hard time typing and I mean, he was a very big guy. He's like six, four and a half or something. So, typing on this little tiny keyboard and getting the letters right was really frustrating for him. When you have a client who's already stressed out, depressed, anxious, and they start having a hard time actually typing their message that can exacerbate their condition. Non-video-based methods of providing services can create legal and ethical issues when there's no ability to verify who the clinician is speaking to. Now, obviously, if you're doing live, face-to-face video chat, that's one thing. You can look at it and go, yeah, that's Jim Bob, but if you are doing telephone counseling or you're doing online chat or something where you can't verify the person you're talking to is who it is, you run into some potential ethical issues. Use secure logins, so they have to log into a website using a username and password that also where your system also records their IP address. That's an extra way of verifying on the back end, but I also have my clients use a secret phrase whenever we start talking and that phrase changes periodically. That way I know that the person who logged in is actually the person who I think it is. It doesn't prohibit the client from sharing that information with someone else. This is especially true in voluntary clients who may not want to come to treatment so they get somebody else to do it for them. Problem. Billability and that's not a word, but it is now. Some insurance will not reimburse and I spent about three hours looking for something that's current on that identifies which insurance companies will accept and which insurance companies will not accept telehealth services. I was not successful. In the document that's in your class, you obviously have these links here. In 2013 under Medicaid and Medicaid and Medicare actually seemed to lead the charge with acceptance of tele-mental health. 39 states covered telehealth services and they actually have specific CPT code modifiers for online tele-mental health services. They did cover individual psychotherapy, individual and group for assessment and intervention and smoking cessation. And that was 2013 so that was four years ago. Another article I found 19 states mandate some form of reimbursement for telehealth services including from private insurers. So they may not reimburse at the same rate or they may only reimburse for certain services like video. But there are some states that require it. Most providers will only reimburse for interactive video based counseling. So if you have your client and you do a two hour text chat, you know SMS chat, you're not going to get reimbursed for that. If you do a 15 minute consultation and it's not interactive video likely not going to get paid for that. So you need to talk to your provider ahead of time or the insurance provider ahead of time and ask them what is it that you cover. And that's the easiest most fail safe way to do it since each insurance provider can differ Blue Cross and Blue Shield in Tennessee may accept something that Blue Cross and Blue Shield in Florida does not. It's best to just call and ask and get it from the horse's mouth. I did link to the psychotherapy coding clarifications and code modifiers. If you're billing for yourself if you have a billing agency they should already be very familiar with the modifiers they need to put for tele-mental health. HIPAA and high tech compliance regulations including maintaining signed business associate agreements can be really cumbersome. So if you're using a lot of different services it's important just to be aware of what the regulations are. Honestly, I think it's best to pay a consultant to just help you get set up or get set up with something like VC that already has and that's V-S-E-E. I know they already have a tele-mental health and a tele-health suite set up that is compliant and they will sign a business associate agreement. Skype is not compliant, Gmail is not compliant and Second Life please Second Life is not compliant. None of these to the best of my knowledge with the normal accounts will sign a business associate agreement with you anyway. Even if you have a home office you have to maintain HIPAA and high tech security protocols. So it's important to set things up appropriately. If you're planning on getting rid of a brick and mortar office there are going to be some expenses around setting up a compliant home office setting that also has enough high speed internet to support video chat. Just kind of an FYI deducting the cost of a home office from taxes has historically been considered an audit flag and I did link to the website from Investopedia that tells you all about that. The same is not true for virtual services provided from a free standing business office. So just be aware, I'm sure your tax guy can help you figure out how to do it where it's safe and you don't increase your audit risk. So how to use technology assisted care. Email, that's one obviously it can be very asynchronous if you're emailing with clients you probably want to have time parameters set. So you tell them make a promise or whatever you want to say to check your email so many times a day or if they email you and they don't hear back within 24 hours or 48 hours to give you a call just to make sure that you got the email sometimes they get lost but if you're using a HIPAA compliant system a lot of that should go away. Smart phone and tablet applications or just your general apps that help people learn cognitive behavioral therapy dialectical behavior therapy wellness tools those can all be really useful they don't necessarily have to be apps that you've created if you find an app online that you really like and you think is useful you may suggest it to your clients as something that they can use in between sessions and that you can use as an adjunct to therapy. Online forums and targeted social networking sites now targeted social networking refers to not Facebook that everybody can join but we're talking about in the rooms for example where the people who go to that social networking site are all in substance abuse recovery there are targeted social networking sites for a variety of different issues and causes informational websites and blogs know which ones that you've looked at you've kind of proofed ahead of time that you can refer your clients to there's a dbtskills .com I believe is one that I refer a lot of people to that take the dbt classes because she the person who moderates the site has a lot of really good useful tools that are there there's no sense me reinventing the wheel and try to trying to put a bunch of new stuff up there because what she has is very useful you can however make your website an informational website or blog that walks people through different techniques and different steps that you think are important video and telephone chat are the obvious go-tos virtual reality or immersion therapy has been used a lot in the VA to deal with PTSD it's been used some in clinical trials especially to help people deal with phobias and fears there is some utility for this but it's one that I would really strongly caution you to make sure that you've got adequate training in handling it if you're using the VR in your office it's different than having the client use VR at their home and potentially decompensating so you do want to take into consideration how much control you have over it and make sure that the virtual reality system you're using is HIPAA compliant virtual art therapy this one was really cool I've just got to show you because I know some people really like doing art therapy with clients I am not artistic at all so I always look for good resources and the National Gallery of Art has a lot of different online activities where youth can go through anybody can go through and create sort of an art therapy project obviously this is not HIPAA compliant so we don't want them putting all kinds of personal stuff in it but a lot of times art therapy just helps them express themselves creatively make sure that if you use something like this you inform them even though it seems obvious inform them that it's not secure confidential and HIPAA compliant because it is through the National Gallery of Art not your clinical website Pinterest if it loads has a whole bunch of sites that you can use for virtual art therapy so if you've got clients who have an affinity for that you might even encourage them to go through this Pinterest board and find things that seem to fit for them okay several studies have demonstrated the feasibility, acceptability, and efficacy of using telephone-based counseling interventions targeting substance abuse among youth clients can participate in counseling sessions more if they're offered in a distance telehealth environment as an alternative or as an adjunct to in-person settings I really covered this a lot already but if you've got a client-based adolescent or you know not really interested in coming to face-to-face settings for privacy reasons time reasons whatever their reasons or maybe they're out geographically in a location where it's just not possible for them to get to your office once a week then telephone and video is something that you might consider obviously with telephone you lose all nonverbals self-directed web-based and computer-based therapeutic tools may have utility in specific settings where internet access is limited such as jails, other criminal justice settings and in certain residential treatment programs so if clients have access so they can keep a emotions diary or a feelings log or they have an app on there that reminds them every four hours to do a mindfulness scan and they're able to carry that around with them in whatever facility they're in that can be helpful or again if there's a computer bank somewhere where the clients can go access it if you've worked within a criminal justice setting especially a jail you know that them getting out and having internet connection to do interactive anything with a therapist is going to be almost impossible so we need to look at things that can be installed on the computers at the facility that will provide computerized feedback to the clients web-based self-directed therapeutic tools offer a number of advantages including the ability to update centrally and deploy content within a given program as needed on my website docsknives.com as I create new lessons I upload the videos I upload the worksheets and I upload the sheet that has sort of a therapist guide if you're going to try to cover this in group and as I create new content I upload it and anybody who accesses the website can access that so the self-directed tools having it even on a website is really helpful if you have it on an app or on a computer and it doesn't require internet access that every time that app updates whenever it logs on and actually updates itself you can deploy new information you can also track user activity within the program over time via unique login information so if you want to see if client Sam Jones signed in and participated or which clients were high utilizers you can do that and you can aggregate user activity data across client groups so looking and saying you know my adolescent population seems to really respond to this whereas you know these other people seem to respond to this so you can tailor and target your clients a little bit better they can be used for assessment and behavioral health services provision for things like diabetes, eating disorders substance use disorder prevention HIV and AIDS prevention and methadone maintenance treatment and we're talking about the social skills and the life skills classes that many many methadone clinics are required to provide obviously they're not administering methadone through an app the assessments we're talking about and a lot of times screening would probably be a more appropriate term because most clients are not going to do an in-depth assessment on the internet although I've seen it done thinking about taking the MBTI for example I mean that's a full assessment the Beck depression inventory that's technically an assessment not just a screening so you can look for certain things that clients can do online that you can access and see where they're at or facilitate the diagnostic process literature reviews underscore the effectiveness of these interventions in producing health behavior change so if people can log on to a self-directed site and we've all come across them and say you know take this quiz to see if you've got depression or take this quiz to see if you're gluten intolerant people log on they take the quiz they get results it provides them theoretically objective feedback and it gives them information on how to improve their health and quality of life and they found that people really respond to this they don't need another human on the other end explaining to them why it's important they just read why it was important so these can be helpful in terms of prevention if you're working in a capitated system so for example you get three million dollars to your agency every year to provide all necessary mental health counseling services to any Medicaid enrollee in your area you know so you've got to judiciously use your funding these can be helpful because they can prevent some people from getting to the point where they need to be high utilizers of like face to face services comparison of computer delivered interventions with person delivered interventions generally report comparable outcomes now obviously we're talking about similar things prevention early intervention if you've got somebody who's in the throes of a crisis probably not going to be comparable the literature in the tip was a little unclear on exactly what they were looking at but my guess would be they're looking at prevention and early intervention and educational services because we all need to help clients get the knowledge of what they need to do in order to address their depression and they have to get the knowledge of what caused their particular symptoms or problem computerized treatments for mental disorders have been most widely developed and extensively used for anxiety traumatic stress and depressive disorders they implement techniques such as cognitive restructuring relaxation trading and systematic desensitization oh some of the new generation scientists watches actually will monitor your health and your heart rate to detect levels of increasing stress and if it shows according to their logarithm that you have been under stress it will automatically prompt you to participate in a guided breathing activity or guided imagery so I thought that was kind of neat although I think it would also be kind of annoying sometimes so I'm not sure how I would feel about it but it's an interesting concept there is an interactive web-based intervention called the therapeutic education system which delivers CBT for individuals with substance use disorders and may be effective as traditional counseling let's see if I can get that bad boy to come on let's see okay this just takes you to the actual article that talks about it chat rooms typically refer to open rooms online in which individuals come and go as they wish and can communicate synchronously with any or all participants in the chat room I think we've all been in chat rooms so you know what they are many of the behavioral health chat rooms are moderated by a clinician who posts comments guides discussions and may screen comments before allowing people to post so you know when I moderate a chat room it may be mental health oriented or may go down that road depending on how well I know the people in the group I mean if they're all patients it's one thing if it's a general chat room I may want to reserve the right to preview comments before I allow anything to be posted just to prevent flaming and all kinds of other nastiness whether chat rooms are overseen by clinicians or by peers they typically include guidelines for participation with designated monitors who do monitor the content and we'll talk to people in private messages or offline if they become inappropriate online support forums are typically organized in a bulletin board format that allows users to post anonymous text-based communications you have your handle but you can make your handle whatever you want you don't have to use your actual name they online support groups enable asynchronous communication as do email lists now this website I thought was really cool it's called patients like me and people can log on and find other people who share similar issues such as depression and learn about what they've used what the people on the website have used to address their depression and explore different approaches and interventions it's worth going and just joining now it's free you don't have to do all kinds of personal information or profile setup or anything you can just get in and poke around a little bit and you can find that it can be really supportive let's see let's just go to diabetes type one because that's where I'm at so as far as symptoms of diabetes type one the fatigue what people are taking for it or to help them handle it parking permits this medication some people need a wheelchair in order to handle the excessive fatigue so it gives people ideas of accommodations they may be able to ask for it isn't an interactive board that I've found where people talk to one another you're just looking at other people's what they've done so basically their journal entries if you will about what has worked and what hasn't worked for them email and text chat email can be used for routine contact such as setting appointments following up on counseling sessions hey we had a great session yesterday I just wanted to remind you to keep your anger journal you can also send motivational messages encouraging clients to engage in specific therapeutic activities between sessions and or actually conduct some portion counseling I'm working with a client right now on some grief issues and I asked her to write a letter to the person that she lost technically just where she's at emotionally I could have had her submit that via secure email so I could read it before she got into session I didn't choose to do that in this particular case obviously if you're going to use email you need to make sure you're not going to cause the client to decompensate chat counseling in chat rooms or via instant messaging typically require more abbreviated interactions but are more real time services provided via mobile devices offer the opportunity to provide in the moment interventions which can be really impactful one-sided text messages from provider to consumer have shown considerable usefulness and promoting treatment compliance such as self-monitoring of health behaviors like healthy eating exercise that sort of stuff PTSD coach is an app created by the VA's national center for PTSD and helps users learn about and manage symptoms that commonly occur after a trauma it provides education screening tools easy to use skills that clients can use to help handle stressful symptoms direct links to support and help and continuous accessibility so clients if they're having a night terror can log on at 3 in the morning not just during office hours a search for virtual reality in the clinical trials search engines indicated that there were about 190 clinical trials in May of 2014 for using virtual reality in counseling and they used them for a whole host of different issues I would encourage you just to go to clinicaltrials.gov and look around and see what new ways people are trying to use technology in behavioral health online social networks can be problematic due to their general lack of HIPAA compliance if you've ever been in a facebook group for depression anxiety grief and loss whatever it is you know they're not HIPAA compliant so it can be problematic you can have people who troll which is you know they're just there to say nasty oppositional things and clients may post a little bit too much private information in public forums and then regret it later or you know find out that they probably shouldn't have done that for whatever reason but there's no way to take it back technology and therapy may be contraindicated for individuals experiencing significant emotional distress or complex situations such as domestic violence and you know my thought was well yeah use good ethical judgment all of your communications need to comply with HIPAA high tech and if you do any substance abuse treatment CFR 42 part 2 and some state laws which is again best just to have a consultant look at your protocol if not set up the whole thing text transcripts can be subpoenaed from providers or internet service providers because right now they're still not considered psychotherapy notes so another argument for not doing a whole session in text if you do it where it's encrypted point to point then they can subpoena the log but they're not going to get anything without having the encryption key health it dot gov offers a number of resources for health care providers related to using mobile devices in a way that helps protect and secure client health information so if you're thinking about using it to great resource it's written in layman's language essential elements of informed consent and I'm going to go through this really fast there is a whole bunch more information in the in the tip but it's I'm going to kind of hit the highlights make sure that you clients know the service process and alternatives whether the communications going to be at the same time or asynchronous what are the response standards and scheduling so you know what kind of lag can they expect how often are you going to interact if you're doing email counseling with somebody are you supposed to email once a week what happens if they start emailing you three times a day how is that going to be handled misunderstandings you need to talk about the risks with text and video based counseling for misunderstandings of nonverbals as well as verbals we all know how easy it is to misunderstand a text message or accidentally type in all caps alternative treatments to delivery approaches so if they don't like digital technology assisted care what are alternatives that they can explore who's going to have access to their clinical information and this includes technical staff who is going to have access to their IP address and depending on how your system set up may or may not have access to chat logs the potential benefits of the technology assisted service what the confidentiality of the records is going to look like what privacy risks exist because there are some there are even technology or privacy risks if you're just doing a standard old phone call so make sure they know what the risks are inform them of ways to protect their privacy including erasing cookies on their computer when they're finished with a computer session the roles and credentials of all individuals involved in the service delivery if it's not just you so if there's a moderator chat room that you facilitate that's not you what's that person's credentials what are emergency procedures if the client starts to decompensate and if for some reason the power goes out and you can't make that virtual connection what do you do how are how are charges and payments handled how do you handle service disruptions if the internet goes out in the middle of the session heaven forbid but it's happened to me so you have to have a plan ahead of time so the client knows what's going to happen and they don't feel like oh my gosh I was right in the middle of a moment and what regulatory agencies supervise telehealth care and where can they file grievances such as with the Department of Health and Human Services for perceived HIPAA violations telemental health is here to stay many self directed programs are extremely useful for all ages and a multitude of diagnoses especially for prevention and early intervention provide that information get them started enhancing their current coping skills and their processes the use of virtual technologies enables a clinician to individualize treatment to increase compliance accessibility and effectiveness there are many ethical regulatory and legal issues surrounding the use of electronic devices in any aspect of counseling so make sure that you run it past your attorney and preferably a very competent HIPAA high tech person there are so many ways you can use technology and as I kept saying it doesn't have to be just stuff you came up with it can be resources let me see if I can find that other website I was telling you about and if you need to get on to your next client you can feel free to log off and you know my feelings won't be hurt but if you want to stick around for a minute I'm going to try to get you to this other website that's a good example of a mental health psych central I don't know why I couldn't remember that he is actually one of the thought leaders in providing online screening and technology assisted care there are tons of links in the presentation as well as in the tip by somsa so feel free to download that it's free and you can look at some of these other resources I just didn't have enough time in the hour to cover everything possible but it is so exciting the different things we can do to make sure that our clients feel like they always have resources and always have support that's going to help them and they're not just going on the internet going well let me see if I can find something okay if nobody has any questions again you can go log in take your take your quiz and and be off on your merry way seeing your next client and all that happy stuff otherwise I will stick around for a couple more minutes because I know I skimmed over a whole lot of stuff and in response to a couple of the questions that came in and I think I answered him um in a way that you I said waited in a way that was meaningful but everything that's technology assisted care needs to comply with HIPAA and high tech if you're handling any sort of PHI now if you're just referring somebody to like dbtskills.com you know that's not going to be PHI so it's a little bit different um but you do need to make sure that anything that's going to have confidential information has all the extra walls and protections and for those of you who are still here I will try to find it um this afternoon and put it in the additional resources for your course I found an excellent handbook on learning how to read nonverbals uh that I've encouraged a lot of my clients who are more comfortable with technology to take a look at so they're more familiar with you know how to read people's body language in a face-to-face setting if you enjoy this podcast please like and subscribe either in your podcast player or on YouTube you can attend and participate in our live webinars with Dr. Snipes by subscribing at allceuse.com slash counselor toolbox so it has been brought to you in part by allceuse.com providing 24-7 multimedia continuing education and pre-certification training to counselors, therapists and nurses since 2006 use coupon code counselor toolbox to get a 20% discount off your order this month