Apr 4, 2022
Curt and Katie chat about non-traditional therapy settings like outdoor walk and talk therapy as well as home-based counseling. In the second of a two-part, continuing education podcourse series, we look at law and ethics, accessibility, informed consent, navigating confidentiality, dual relationships, and what therapist might want to consider before getting started.
For our fourth CE-worthy podcourse, we’re looking at the laws and ethics of bringing therapy into non-traditional settings, including walk and talk therapy and home visits. We cover a lot of topics in this episode:
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Today’s episode of The Therapy Reimagined podcast is brought to you by Melissa Forziat Events & Marketing. Melissa is a small business marketing expert who specializes in marketing advice for businesses that have limited resources.
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Hey modern therapists, we’re so excited to offer the opportunity for 1 unit of continuing education for this podcast episode – Therapy Reimagined is bringing you the Modern Therapist Learning Community!
Once you’ve listened to this episode, to get CE credit you just need to go to moderntherapistcommunity.com/podcourse, register for your free profile, purchase this course, pass the post-test, and complete the evaluation! Once that’s all completed - you’ll get a CE certificate in your profile or you can download it for your records. For our current list of CE approvals, check out moderntherapistcommunity.com.
You can find this full course (including handouts and resources) here: Walk &Talk and Other Non-Traditional Therapy Settings Part 2
When we are airing this podcast episode, we have the following CE approval. Please check back as we add other approval bodies: Continuing Education Information
CAMFT CEPA: Therapy Reimagined is approved by the California Association of Marriage and Family Therapists to sponsor continuing education for LMFTs, LPCCs, LCSWs, and LEPs (CAMFT CEPA provider #132270). Therapy Reimagined maintains responsibility for this program and its content. Courses meet the qualifications for the listed hours of continuing education credit for LMFTs, LCSWs, LPCCs, and/or LEPs as required by the California Board of Behavioral Sciences. We are working on additional provider approvals, but solely are able to provide CAMFT CEs at this time. Please check with your licensing body to ensure that they will accept this as an equivalent learning credit.
We’ve pulled together resources mentioned in this episode and put together some handy-dandy links. Please note that some of the links below may be affiliate links, so if you purchase after clicking below, we may get a little bit of cash in our pockets. We thank you in advance!
Cooley, S. J., Jones, C. R., Moss, D., & Robertson, N. (2022). Organizational perspectives on outdoor talking therapy: Towards a position of “environmental safe uncertainty.” British Journal of Clinical Psychology, 61(1), 132–156. https://doi.org/10.1111/bjc.12315
Boland, K. M. (2019). Ethical Considerations for Providing In-Home Mental Health Services for Homebound Individuals. Ethics & Behavior, 29(4), 287–304. https://doi.org/10.1080/10508422.2018.1518138
For the full references list, please see the course on our learning platform.
Curt Widhalm is in private practice in the Los Angeles area. He is a member of the California Association of Marriage and Family Therapists ethics committee, an Adjunct Professor at Pepperdine University, lecturer in Counseling Laws and Ethics at California State University Northridge, a former Law & Ethics Subject Matter Expert for the California Board of Behavioral Sciences, and former CFO of CAMFT. Learn more at: www.curtwidhalm.com
Katie Vernoy is a Licensed Marriage and Family Therapist, with a Master’s degree in Clinical Psychology from California State University, Fullerton and a Bachelor’s Degree in Psychology and Theater from Occidental College in Los Angeles, California. Katie has always loved leadership and began stepping into management positions soon after gaining her license in 2005. Katie’s experience spans many leadership and management roles in the mental health field: program coordinator, director, clinical supervisor, hiring manager, recruiter, and former President of the California Association of Marriage and Family Therapists. Now in business for herself, Katie provides therapy, consultation, or business strategy to support leaders, visionaries, and helping professionals in pursuing their mission to help others. Learn more at: www.katievernoy.com
Our opinions are our own. We are only speaking for ourselves – except when we speak for each other, or over each other. We’re working on it.
Our guests are also only speaking for themselves and have their own opinions. We aren’t trying to take their voice, and no one speaks for us either. Mostly because they don’t want to, but hey.
Voice Over by DW McCann https://www.facebook.com/McCannDW/
Music by Crystal Grooms Mangano http://www.crystalmangano.com/
Curt Widhalm 00:00
This episode of ModernTherapist's Survival Guide is brought to you by Thrizer.
Katie Vernoy 00:04
Thrizer is a modern billing platform for private pay therapists. Their platform automatically gets clients reimbursed by their insurance after every session. Just by billing your clients through Thrizer you can potentially save them hundreds every month with no extra work on your end. The best part is you don't need to give up your rate. They charge a standard 3% payment processing fee. By using the link in the show notes, you can get a month of billing without processing fees just to test them out for your clients.
Curt Widhalm 00:30
Listen at the end of the episode for more information.
Katie Vernoy 00:34
This episode is also brought to you by Melissa Forziat Events and Marketing.
Curt Widhalm 00:39
Melissa Forziat is a small business marketing expert who specializes in marketing advice for businesses that have limited resources, including the very special course How to Win at Social Media, Even with No Budget. Stay tuned to the end of the episode to learn how you can get the most from social media marketing, even with little to no budget.
You're listening to The Modern Therapist's Survival Guide where therapists live, breathe and practice as human beings. To support you as a whole person and a therapist, here are your hosts, Curt Widhalm and Katie Vernoy.
Curt Widhalm 01:15
Hey modern therapists, we're so excited to offer the opportunity for one unit of continuing education for this podcast episode. Once you've listened to this episode, to get CE credit, you just need to go to moderntherapistcommunity.com, register for your free profile, purchase this course, pass the post test and complete the evaluation. Once that's all completed, you'll get a CE certificate in your profile, where you can download it for your records. For a current list of our CE approvals, check out moderntherapistcommunity.com.
Katie Vernoy 01:47
Once again, hop over to moderntherapistcommunity.com for one CE once you've listened. Woo hoo!
Curt Widhalm 01:54
Welcome back modern therapists. This is The Modern Therapist's Survival Guide. I'm Curt Widhalm with Katie Vernoy and this is our second in a two part episodes for our CE content on doing therapy in non-traditional therapy settings. Part one was a lot about the logistics and clinical concerns. Part two, we are looking more at law and ethics concerns. We had made reference to a number of things as far as precautions to take. And if it's not written down, it's probably not something that you had thought about ahead of time or so the lawyers who are suing you would say. So, some of the concerns and stuff that we're going to talk about here today is about, you know, avoiding any liability, minimizing liability that we can take into this episode. So Katie, what are the most important things for us to talk about now? What are you hearing from some of the people who are consulting with you? And let's dive in from there.
Katie Vernoy 03:05
Sure. And just to clarify for folks that this is the first one I would recommend going back to the previous CE episode, it's kind of a 101 on what walk and talk and home based therapies are and clinical considerations, benefits and how to do it. So definitely check back to that one. The most important thing is that we think about what we're doing ethically. And that's kind of what this conversation is going to be about. But I think the first place to start is to look a little bit at why there's been such a hesitation around employing especially therapies like outdoor walk and talk kind of therapies. I think home based has been around for a while, but there's been hesitation just in any kind of non-traditional setting. And part of it really stems from provider anxiety, or kind of the rigidity that we can have around what therapy looks like. Is it just in my office in the safe space where I can control everything? And I think there's a lot of stereotypes around what therapy is. And one of the articles I was reading Cooley et all 2021 put together an article 'Organizational Perspectives on Outdoor Talking Therapy' in the British Journal of Clinical Psychology. Cooley's done a lot of these things. In looking at the systemic pushback on this, what they really posited is that we need to get to a place of environmental safe uncertainty. And what that means it's a position of openness, curiosity and collaboration regarding the therapy environment, including the possibility of other environments being more conducive to therapy, other environments meaning not the office. And that leads me to kind of the first point which is: Is it unethical not to consider these environments because they maybe more conducive to treatment, then sitting in your nice little office?
Curt Widhalm 05:06
We have talked about in some of our previous presentations about how much of our field is modeled around clinician comfort and clinician principles, rather than necessarily what's best for clients. And some of those are logistical concerns, you know, we can't always just, you know, stack six or seven clients in a day back to back if it means that we're having to also travel to different parts of a city or county or, you know, much further if you're working in rural practices. If what we're going to is kind of the core principles of have the first stance of like, do no harm, but our second stance is do good.
Katie Vernoy 05:47
Curt Widhalm 05:50
And, you know, this is that push pull between those two concepts. Is the environment of our office is one that is hopefully set up best for do no harm. And it's kind of in that good enough for like, doing good. Now, what I'm hearing is the aspirationally, doing best is doing therapy, where it's going to most benefit the client.
Katie Vernoy 06:18
Curt Widhalm 06:19
And we do have, you know, some examples of this that, you know, for instance, Italy, as an example, here is a country that does not have mental hospitals. That it is about being able to work with people with mental illness, in the environments that they live, that kind of thrusts them into needing to have the right approaches to clinical intervention that leads them best into their day to day lives. On the other hand, we have America where we throw people in jail and ignore that mental illness might be a factor. And that's not today's episode.
Katie Vernoy 07:01
No, no. But I think that that really hits at the crux of the argument here, which is, there are people for whom home based or walk and talk therapy is the best form of treatment. And so the best way we get to a system that supports it is holding this environmental safe uncertainty, which is being able to be open and safely open to the idea that we can be in an uncertain environment. Another systemic concern, which I think gets in the way and dances around with some of our our ethics and laws, is payers and payment. Now, insurance coverage, you know, Medicaid, for those of you in the United States, oftentimes covers a lot of this stuff. But there are concerns around driving time, and is that billable? I know, we had a huge argument around that when I was completing mental health but if you are a private practitioner, and you're needing to then charge extra to drive to a client's home, for example, or do you on the flip side, decrease your fees, if you let go of your office, and you're only seeing people in these non traditional spaces. And it really puts this thing of around payment of are we being limited by payers, whether it's insurance payment, or how much someone can afford to pay on what treatments we can offer. And we at least there's a CAMFT ethics code three point eleven or 3.11, that says we actually have to tell people about options for treatment, even if their insurance company doesn't cover it.
Curt Widhalm 08:47
So much around payment is going to be in the: we charge for services that we actually provide. We let our consumers know what we're actually going to provide. So that way, they can opt into what is best for them. And that's going to take a couple of different forms here. Like you know, on one hand, you're talking about, you know, managed care system, but keep in mind that these ethics codes are written in a way that helps to maybe hit kind of the best catchment of every type of practice in being able to write them. And so, I'm going to start not with managed care systems here first, I'm gonna start with, you know, those private practices that are all cash payer or doing super bills. You might, you know, have a client where you say, alright, I can go and see you at your house. But it's also going to take me time to drive there. And this is roughly how long it's gonna take me to drive here. Here's my driving fee. You cannot put that driving time as session provided time on something like a super bill, those are actually two separate line items. And so this is that recommendation of charge appropriately for the services that you're providing, out what you're speaking to, and going back to the manage healthcare part of it is that drive time isn't an option. And so therefore, it kind of thrust some of the business practices to, if they're going to operate efficiently, maybe not allow for that kind of time to sit there in the middle. It is a possibility with maybe things like, you know, a private health insurance company that you can still tack on that drive time to those clients, that's just being able to get to a different service, insurance probably isn't going to reimburse it. But I think that, you know, in my limited knowledge of some of the federal health care systems, I don't think that that's going to be an option there.
Katie Vernoy 11:01
Well, and I think with some of the the systems that require those things like Medicaid, Medi-cal, Medicare, you know, some of those payers, they're gonna have their own rules, and whether drive time is billable or not, I think is something that you want to pay attention to. I think the challenge is, is when it's your own private practice, and do you have it as a separate line item? Or do you just charge more for the service? You know, is there is there an issue with saying, I'm going to raise my fee, X amount, and I'm going to spend 30 minutes driving to client a, and zero minutes driving to client B, but they're both point paying the same amount? Is there a concern there?
Curt Widhalm 11:49
Yes. And it's gonna fall under those usual and customary amounts. And, again, there's probably going to be people who do this kind of stuff anyway, and just kind of all lump it into one sort of payment and don't pay much mind to it. But when clinicians are being examined for what is your actual usual and customary be prepared for questions like how do you figure that out? If somebody is to look at client A where it's alright, you've got this 30 minute drive time incorporated into this fee? What's the justification for the exact same type of services just being provided in your office having a completely different fee? And you need to be able to reasonably and prudently explain the differences between those two, because when it comes to what your usual and customary fee is, it's also the justification for those fees that needs to be explained.
Katie Vernoy 12:48
And I think the equity and the ability to do a fair payment for all clients, there's arguments in both directions in that if, if on average, I spend X amount of time driving, and I don't charge individual clients for driving, you're saying that's not okay.
Curt Widhalm 13:07
Katie Vernoy 13:08
If I go, if I go all over town, and client a is typically a 30 minute drive, sometimes they're a 90 minute drive, client B is usually a 10 minute drive, but sometimes they're a 40 minute drive, I need to charge them differentially is what you're telling me.
Curt Widhalm 13:22
You need to charge for what you're actually doing. And you need to do that appropriately. And you need to have that kind of stuff set up, up front.
Katie Vernoy 13:32
Curt Widhalm 13:33
And especially with our no surprises act being introduced in America here in 2022, is there's a potential that if you're having kind of these traffic concerns, as you're describing, that it's a separate line item that you're going to need to put in your good faith estimates to clients. Because the whole point of this is that it's not to surprise clients with your billing. And the best way of protecting yourself on that is putting that information in writing ahead of time and having clients see it and agree to it.
Katie Vernoy 14:13
Yeah. And I think there's there could also potentially be an argument just having a specific fee for home based services. So here's the session fee. Here's the home based services fee. But you're saying if somebody is further away, I got to charge more.
Curt Widhalm 14:30
Saying that it needs to be commensurate and clear with your policies.
Katie Vernoy 14:34
All right. All right. All right. We don't want to get stuck there.
Curt Widhalm 14:37
That results in a higher fee, then that's commensurate with whatever policies you have.
Katie Vernoy 14:43
All right. So there may be some fee stuff to sort out if you're doing this, especially if you're driving a lot of distance most days. Some of the recommendations that I've given to folks in the past is setting up what I would call catchment areas. So on Monday, I'm in this area of town On Tuesday, I'm in this area of town on Wednesday, I'm this area of town. And on Thursday, I'm at the walk and talk location by my office or whatever, right like you, you know, just so that you diminish those differences. However, regardless of setting that up, and potentially putting systems in place, there is still going to be unpredictability. And that can be due to a lot of different things. So you've got the unpredictability of the environment, which we talked about in detail in our previous episode. But there's also this unpredictability on, if you're outside what the weather's like. If you're going to someone's home, if they have visitors. And I think there's those types of things where when you have so little control, the system says, "No, don't do this, don't do this. This is scary."
Curt Widhalm 15:50
So as a resident of Southern California, where our weather is usually 75, and sunny, I don't find myself traveling to other places in the country, sometimes where I forget that weather is different. Like...
Katie Vernoy 16:04
There's... weather is a thing in places Curt. I know, it seems weird to us, but there's actually weather in other places.
Curt Widhalm 16:11
So, my informed consent is being cognizant that people are not fragile little beings, and that they can make their own decisions about things. So it does make mention of weather does happen, and it's your responsibility to be dressed appropriately for it. And that's at least, like this is a foreseeable thing that can happen.
Katie Vernoy 16:43
Yes, we'll go into more of this and the informed consent section, because we could dig into this very deeply, especially the the fragile little beings. But, um, but I think just as far as kind of the overarching systems concerns, just to close this out, I think the other pushback that often happens is scheduling and getting permission for the services that are provided. Whether it's getting permission to go into someone's home, school or office. Whether it's scheduling to get to a certain location, I know I've had to shift clients by 15 or 20 minutes to get to walk back to my office between sessions. And I think the difficulty with that means that you have to be able to navigate those things with your clients. Because, well, if we're in the office, it'll be at this time, if we're at the park, it'll be at this time. And if we're in video, it'll, you know, like, it's, it's something where navigating those concerns, I think, can be very hard for some clients, because they want their exact time, every single week.
Curt Widhalm 17:46
And as we mentioned, in the first episode, this is a little bit more of that dynamic practicing that you need to be able to respond in any sort of given situation and, and it's having backup plans, you know, in the days where there is inclement weather, it might change that, alright, we're not meeting at the park, we're actually meeting at an office instead, or, and...
Katie Vernoy 18:10
We're doing video, doing telehealth.
Curt Widhalm 18:12
And that might affect a start time. And I think it's prudent of therapists to make sure that we revisit that as a possibility fairly frequently with our clients so that way, it's not a surprise when and if it does come up.
Katie Vernoy 18:29
Yes, yes. And I think just allowing for that in the conversation. So. So that's kind of the high level systems concerns. I think we've addressed those well enough. I think that the brunt of our conversation is really going to be around the legal and ethical concerns that a lot of people bring up that are kind of more individual with your client, the things that you have to grapple with not just as a system, can we say it's okay to do this thing. Some of the thoughts I am sharing are from an article, Boland 2018, 'Ethical Considerations for Providing Home Based Services for Homebound Individuals.' It's obviously there's some specific things to folks who are homebound. And I want to mention those things. Because if you're doing home based therapy, it could be for someone that is homebound for mental health reasons or physical reasons. But it also talks I think sufficiently around the types of things that you might encounter in an environment that is not yours that you don't control. Accessibility, I think is is one of the reasons that people say to do this to go to people's homes, meet them where they're at, they don't have to, to drive, those kinds of things, but it's also a complaint, especially around walk and talk therapy. And so there is a value in a lot of the ethical codes around accessibility, about providing therapy across the board and in my thoughts, you know, like there's physical abilities and accessibility that you want to make sure if you're doing a physical activity together, you know where we can make sure that you're able to walk together or if you if someone is not able to walk that, that, if they would like to be outdoors, you can provide them space to do that, whether it's in a wheelchair or in other types of settings or primarily sitting outdoors, those kinds of things. But it is, I think, a harder concept around, okay, if I've got someone who is disabled, or who has another challenge that outdoors might not work for, this may not be an accessible modality for them. There's also just the physical concerns. And you'd already mentioned, like they need to wear the right clothes and to do the things but but there is making sure that when they show up, they can access the service. So I wear a hat. And oftentimes during the summer, I wear sunscreen, and you know, I make sure that I've got the right shoes on. And so one of the things is looking at if someone comes unprepared for what you're signed up for, what do you do with that? I mean, you kind of just said, I leave it up to them.
Curt Widhalm 21:00
So I'm looking at the American Counseling Associations Code of Ethics here. And this is A6C documenting boundary extensions. And I'll paraphrase this, but it's if counselors extend boundaries, they must officially document prior to the interaction when feasible, the rationale for such an interaction, the potential benefit and the anticipated consequences for the clients. When unintentional harm occurs, the counselor must also show evidence of attempt to remedy such a harm. And I think that this is a really good and dynamic ethical code here because it says that what we talked about in the last episode and and what we're going to get into with our informed consent discussion here in a little bit, is that we need to anticipate what the consequences of situations are. But these are also things that are going to be dynamic, that if a client is showing up doesn't have the right footwear, for example, you know, is going for a walk on a trail in flip flops is going to be something that is doable for them is you need to then document that you're having that conversation. And that it's up to them to be able to continue to opt into it. And if they do end up getting hurt, you do need to document like, what it is you're doing. So you can't just be like, "Well, alright, if you want to walk in flip flops that's on you," like, really, like you don't, there's just there's a potential, like there's a long walk, these might not be stable enough shoes, you know, the person gets a blister halfway around the loop, like, you know, you gotta be like "You need me to get your band aid?" like "You want to wait here until, you know, you paramedics come?"
Katie Vernoy 22:59
I think it's I think all of those things are really important because to me, there's also the other element, when you talk about extending boundaries, just the element of I'm wearing those kinds of clothes, I may be in not as good physical shape as my clients as far as how fast I can walk, how long I can walk, I fell once and my client helped me up. We'll talk about that in dual relationships a little bit later. But I think it's it's something where this is a little bit harder to, to kind of cleanly say is that are these forms of treatment accessible or not? And so the the question I have here is, do you need to be able to provide these options for all people?
Curt Widhalm 23:47
Going back to what I said at the top of the episode, is that sometimes you're going to provide therapy that is just based on clinician preference to. You know, what, when we talk about accessibility sort of things, we, as individuals, and especially in private practices don't need to absolutely make ourselves 100% available in every single direction for every single possible type of client. And this is where we do the good enough approach. And we take steps to address situations that are more accommodating as those situations arise. And it may not be immediately, you know, you're talking about clients with disabilities or something that might affect mobility. Well, that might be a consideration that you look at as far as your office building or whether or not you participate in therapy outside of the office. Some of these situations are also going to come up with some of our able bodied clients. You know, if you have have a client who breaks their ankle in between sessions that this is now something where you may not be prepared for that. What you're going to want to do is then stop, evaluate the situation, go through what the new risks and consequences of things are. We like, 'Alright, man, like, you got to hobble along on your crutches faster along with me. So that way we...' Probably not a good recommendation there. But it's, you know, all right, we might not be able to have a full, you know, loop of sessions, you might be like, left out there, would you rather sit on a bench instead?
Katie Vernoy 25:41
Or would you rather meet via video? There are those types of accessibility. And then I think there's also some of the things and we started talking about this in the last episode, but for home based clients, where do we only provide these things for folks living in certain neighborhoods? Where we feel safe? You know, do we only provide home base for people that have a specific payer? I mean, or who can afford it? You know, I think it's, it's something where I agree with you, I think we do the best that we can. And some of it has to have some boundaries around our own needs, you know, we can only afford what we can afford to, as far as, you know, lowering fees, we can only do what we can do around our own safety, and we want to protect our own safety. But I think there's that element of being aware, are you providing a service that is inaccessible in a way that is discriminatory? And I think in this situation, I think it's very much case by case. And I don't think that this is a reason that you would not consider using these ever. I think, I think accessibility issues are pretty navigatable in this situation.
Curt Widhalm 26:56
Sure. And to be a little bit more open about this. There's a couple of citations here that I want to point out, Lazarus all the way back in 94, said one of the worst professional or ethical violations is that of permitting current risk management principles to take precedence over human interventions, and very much advocating for we should take these considerations into account. And that it may be unethical to not open our practices to being able to serve in a wider variety of communities. And the goal of this is to free therapists to intervene with client's specific situations in presenting problems, rather than just kind of sitting back and playing it in the safest way possible.
Katie Vernoy 27:55
Exactly. But speaking of being safe, I think it's time for us to jump in to the informed consent, because I think it's truly important. I think all of the ethical codes, talk about informed consent, and we definitely in these situations needs a very strong informed consent.
Curt Widhalm 28:12
Katie Vernoy 28:13
So I think first off, we want to look at making sure that this is truly the client's choice. That the plan is created together. I know, there were times at least during the pandemic for me, when I was ready to be face to face with folks, I was not ready for being in the office. And so I started doing walk and talk. And there were some clients that I told it to. And after I set it, I was like, that was just for me. We did not end up doing walk and talk, I will I will put that out there. I was able to dial it back. But there was something was like, Hey, you want to meet me at the park? And they're like, "Umm, that seems weird." And so to me, because we've talked about in the previous episode that there was clinician benefit for being outdoors and walk and talk, mental health, wellbeing all that good stuff. And, and also efficacy because you're more creative and your brains working better. But that is not a reason to do it. Like it has to actually be co-created. And the treatment plan needs to be collaborative. And I think that's something where it can be very easy to say, well, this is my new thing, and we're all doing it. Or this is the only thing I do and you're gonna do it versus let's see if you're a match and I'll refer you out if I don't do other forms of therapy.
Curt Widhalm 29:33
So there's two things that you're talking about here. One is the creating the plan together. And some of this is also going to be based on clinician competence and actual services offered that, you know, the client may come in with ideas of what they want out of therapy, but if it's not something that you provide, you are still free to say no.
Katie Vernoy 29:56
Curt Widhalm 29:58
And so I don't want anybody to feel like they have to absolutely twist themselves into knots in order to do something, if it's not something that you yourself are comfortable with. And you know, as far as the place where you provide therapy, you're free to say like, you know, I only work out of the office, or I'm only doing virtual sessions right now. And giving those referrals like Katie's talking about.
Katie Vernoy 30:24
And I think the point for the informed consent is to be very clear within the informed consent, how you're doing treatment and making sure that the client is opting into that, versus what they imagine therapy to be because you if you don't know how to describe it, how can they really know what they're opting in for? The other thing too, is, especially with some of these more non-traditional therapy spaces, they really need to recognize it's voluntary. And that they can opt out at any time. And I think... what it seems obvious, you know, to us, but there is the power differential. And I think there's also this element of when someone's doing a treatment that's specifically aligned to their location: ERP, desensitization, all the different kinds of things where somebody's kind of walking through something really challenging with their therapist, they need to know that they can opt out that they have some control.
Curt Widhalm 31:22
That's just good therapy and not abusive therapy in the first place.
Katie Vernoy 31:29
Of course, I mean, some of this is going to be like,duh, this is the normal thing that we would do in an informed consent, it just is, it's a bit different if you and your client are on a trail, and letting them know, you can opt out and walk back. And I will, I will finish the loop or I will follow you back. You know, whatever it is, I mean, I think people need to know that they have control and autonomy, and this is their treatment and not the clinicians dictation of what's going to happen.
Curt Widhalm 31:58
And in addition to that, you as the therapist leading the conversation on 'how is this working out for you?' that extends that action to not just waiting for clients to then passively opt out and just like leave you standing in a park the next week when you're supposed to be meaning there.
Katie Vernoy 32:18
Sure. Yeah. Specifically to the outdoor therapy, there are the health issues. And I think one of the things I looked at, talked about doing a health screening questionnaire, I feel a little concerned about scope of practice there, potentially a physician note or some sort of approval. But I've also seen consent for treatments that just have an attestation that I'm taking my own risks, and I'm healthy enough to do this. Where do you stand on that, Curt?
Curt Widhalm 32:47
I think that it's important that considerations be factored into it. And again, where I'm always a little weirded out that our profession treats people as both incredibly fragile and capable of making every decision in their life at the same time. So I like that the informed consents have: you're opting into this and you're taking care of your physical health as part of that consideration. It at least speaks to us thinking of, well, this could be a risk, and especially in more litigious areas, you know, if you're gonna get sued by somebody, this is again, reducing liability, because you can always imagine that opposing counsel in a deposition saying, "Well, why didn't you consider that this client might be not a good candidate for getting physical exercise?" So it at least is something that allows for you and your attorney in that situation to say, they attested that they could and that they were medically cleared for it, you know. Oddly, I see the same kind of language in things like sporting events like marathons and 10, Ks and five K's where it's like, you've you physically fit person, theoretically have cleared that you're medically okay to come in and do this. At worst, it's a line to check off in your informed consent. And at best, it's something that really does help to limit some of that liability for you.
Katie Vernoy 34:30
Another element with that is potentially like someone who is allergic to bees, or to bee stings or or some of the things that you may want to be aware of if you're outdoors with someone. I feel like that could be a separate conversation and/or something that goes into the informed consent. I have mixed feelings there.
Curt Widhalm 34:53
There's always going to be, no pun intended. There's always going to be something that inevitably gets left off of a list like that, you know, and there's got to be a natural line, like, you know, how specific you have to be with things like allergies, like, you know, you're going to be exposed potentially to tree pollen and, you know, if you're walking by a dog park, you know, animal dander say. So I like that there's at least something that points to you attest to, you know, if you're speaking to a client, you attest to that you are medically and physically capable of being in these environments as cleared by a medical professional. And you accept all risks that go along with being outside where you're potentially exposed to nature.
Katie Vernoy 35:48
I would almost add and this was this was something suggested in one of the things I was reading is that you kind of encourage them to tell you if there's anything you should know. I think if someone's allergic to pollen, and it's spring, I think, okay, I don't need to know that. But if someone is deathly allergic to bees I want to be aware of that. So that I know to call the ambulance when/if someone gets a bee sting. Now, granted, they could tell me that in the moment. But I don't know if I raise my liability if I'm aware that they have that concern.
Curt Widhalm 36:26
Most attorneys will do a very good job of finding some way to make you know, that you should have been aware. And, you know, so it's kind of that naivete is not a protection, and especially intentional naivete. So, yeah, it's a basically a longer version of the question that you asked: any concerns about you being outside and walking around physically, you know, that this is the kind of terrain that we're going to walk on, generally, well maintained sidewalks, at times, sidewalks with cracks in them, you're potentially crossing the streets in a couple of areas, or walking on the street for sections without sidewalks. If you're walking on a trail in a park, it's unpaved, maintained grounds that, you know, has potential tripping hazards. You can put some of those language things in there that, again, you're going for reducing liability, you're not going to be expected to protect against everything here.
Katie Vernoy 37:36
And I think just for to close that one up, I think I would put something to the effect of you're attesting that you're fine medically, and that you will inform the therapist if there's anything they should know.
Curt Widhalm 37:49
Katie Vernoy 37:50
So another thing that should go into the informed consent are confidentiality challenges and how you're going to manage those. But we're going to do a whole section on that. So I want to skip that one really quickly. And go to clinician safety, because I think this is one that I was surprised in reading through the informed consent suggestions, that clinician safety was there. I don't concern myself with this prep for walk and talk therapy, I think that probably is something where I'm having at least a little bit of control over the environment and so I'm opting in. This is more for home based, where you're contracting basically, with your client, if there's anything that they need to manage for clinician safety, so this: is locking up pets, this is: potentially if there are family members that are very much against treatment, and maybe have even threaten the clinician, or if there's or if there are family members that just are going to be mean... I don't know. But that there are some safeguards in place, and talking about how the clinician is going to be remaining safe in those situations.
Curt Widhalm 39:05
And I think that the more clear that you can be with any of these things, the better because, again, you're looking for an open collaborative process here. In order for me to be able to help you know, again, coming back to like allergies, things for clinician has a strong allergy to something like perfumes, that might be a barrier to treatment when it comes to a clinician visiting someone's household. Yeah, and these are the things where yeah, you move up to having pet secured, if there has been a threat from a family member, you're gonna have to address that with your clients as far as "alright. I can't be in that environment and provide you therapy. We need to find something else to do." So again coming back to that problem solving alleviating this the the part of the problem and developing a new treatment strategy from there.
Katie Vernoy 40:07
And I think exactly what you said, I think that the biggest piece of that is maybe not even delineating all the clinician safety concerns. I mean, if there are specific ones, like I have these kinds of allergies or whatever, you may want to have that in there. But even just say if the clinician is not able to ensure/secure their own security, the session may be discontinued. I know for myself, it seems obvious. And I think this is something that actually is good both for kind of newer clinicians or clinicians under supervision as well as clients to think about this. But if you're in a client's home, and something happens, where you feel like your life is at risk, or if you feel like you're in danger, you should leave. Immediately.
Curt Widhalm 40:57
Katie Vernoy 40:59
Whether or not the client is in a high state of risk, whatever, the clinician must protect their own safety immediately. And I think clients should, should know that, that they this is what they can do to mitigate the risk for the clinician. And if that risk is not sufficiently reduced, or if there is a risk there that the clinician is not comfortable with adult in the session, and/or suggests an alternate location to have that session.
Curt Widhalm 41:23
Because no matter how ineffective you may be, you will be more ineffective if you are dead or incapacitated.
Katie Vernoy 41:36
True story. And along the lines of plans, I think it's also important to have whatever plans you know for you know, that you can have for handling known risks for me COVID precautions, I've definitely incorporated those into all of my informed consents. And so, if you are only doing home visits for folks who wear masks, or only have certain levels of vaccination status, or whatever, I think those things need to be very clear. I think that there's the plans around the uncertainty of the weather, backup plans, and then I think a big one that I think all of us have been playing around with our cancellation policies. I know that many of us have shifted our very stringent cancellation policies to basically say, if you're sick, do not come and see me in person. But I think other cancellation policies around rain, you know, or if it's raining, we will switch to video. If you've got a visitor, what are you going to do, I think being able to talk about ways that you can minimize the negative impact on the practice, because we are businesses, we need to be able to run and we need to make our money. But also that makes sense and that are clearly stated in your informed consent.
Curt Widhalm 42:58
And one thing that I noticed with some of my clients that I was seeing outside of the office, is what you do when the time changes, and it gets dark way earlier and is... an appropriate place. So again, this all falls under that foreseeable consequences and adapting to them and documenting that these processes have happened all along.
Katie Vernoy 43:23
Yeah, yeah. And I think all of that stuff is, is really important to be in the informed consent just to kind of run through just for for those of you who are taking notes, you want to make sure that they're aware of voluntary participation, that they're actually consenting for treatment. And actually, you may need collateral participation, consent for treatment. If you're doing stuff in home, if like a sibling or a fit parent or another family member is going to pop in time to time, making sure they know what they're opting into, health statements and potential plans around taking care of that, confidentiality and how to handle it, which we'll go into more detail on, clinician safety. Any plans for handling known risks. I think those are really important. There may be other things, but those all need to go into informed consent. And I think the question on this topic that I think, well, the first one was: Can people really know what they're opting into? And I think we've talked about Yes, I think we need to understand it and explain it to them. Yes. But you talked about kind of being left standing, the therapist, you know, kind of forlornly standing in the park by themselves and the client doesn't show up. And that's called passive termination. Right? The client just ghosts the therapist.
Curt Widhalm 44:45
Katie Vernoy 44:46
But the interesting thing, and this was in the article around the homebound therapists or homebound clients where that if you were going to a client's home, they cannot passively terminate because: She just keeps showing up. I mean, I guess they could not answer the door. And I'm sure you had those. I've definitely had those long ago or they could not be there. But it's very hard, especially for someone who is completely homebound and cannot leave to passively terminate services. And is that, okay?
Curt Widhalm 45:18
We have a responsibility as therapists to ensure that the services that we're providing are effective with our clients. And one of the best ways of doing that is talking with our clients about it. And well, the situation that you're describing may not allow for that passive opting out. There should be some sort of approach that therapists are taking to regularly evaluate how the treatment is going. For my feedback informed treatment listeners out there, this is already built into just about every session that you're doing things. But for those who aren't engaged in that, we do have the responsibility of coming back and evaluating how are we doing on our goals? How's our treatment plan looking? And that should be done with some regular sort of interval, whether it's time based, whether it's number of session based, that if we're aware that clients can't passively opt out of sessions, we should take on some of that responsibility of giving them more of an active opportunity to opt out of sessions.
Katie Vernoy 46:37
Absolutely. And I think the other piece is also for us to continue to assess appropriateness, because another thing mentioned in there was that they may not want to terminate due to loneliness. And so we have a responsibility to make sure that treatment still necessary and that we're providing them with only the services that they need. And not just being a buddy that comes to see them every week. So moving on to bigger stuff. But that was kind of what needs to go what kind of the issues around informed consent. But now looking, I want to spend a little bit of time on confidentiality, as well as the potential for dual relationships. Because I think those are the big things. When we think about these types of services, I think those are the big things that are the big juicy things that we should be paying attention to. And starting with confidentiality, I think we cannot completely guarantee confidentiality, I don't think. But I think there's a lot of ways we can mitigate the risks. And so what are some of the things that come to mind when you think about confidentiality in either these public spaces or in someone's home?
Curt Widhalm 47:45
So the biggest things, and again, looking at it from limiting your liability standpoint, is talking about the potential risks and benefits of what this is. And so the risks are other people can overhear what we're talking about, we might need to speak in a more coded way. And really talking about that the limit of confidentiality, much more fluid when it's outside of the office, and when it is inside the office, because there is just that potential of being overheard.
Katie Vernoy 48:19
And I think what can compound that at home is that you might be overheard by the person that you're talking about. Or they may come in, or they may do the things, or you may want to introduce them, or there may be, you know, kind of a fluidity of them coming in and out of sessions. And so I think just being very clear on that, but I think as far as the cya elements of it, I think if they're going to be part of treatment, you do the collateral consent form. But I think making sure that if there are folks that are going to regularly be interacting, you want to get release forms. You can't obviously, you're not going to do that for the folks at the park, those people are just walking by. But like people in the home, you know, you may want to consider that.
Curt Widhalm 49:00
Well, and it's also part of what we're talking about into, be specific about it. Is asking our clients how they would want us to handle those situations where there are other people in the house, or where we are walking by other people outside. Help the client be able to make their own informed decision of and take some ownership over those situations as well.
Katie Vernoy 49:27
Absolutely. The big pieces outside, I think clients don't necessarily know and don't have the experience to think about how they want to handle it. Because it could be just let's, you know, we'll just pay attention. If somebody walks by maybe we either speak more in a more coded way or we break for a second and then pick back up once we pass these people or whatever. But I think if someone comes up to you or to your clients, people they know or people that know you, actually having the conversation is if someone comes up and talks to us, what are we going to say? You know, and I've heard you know, like, you can say this as a colleague, this is someone I work with. It can, it can be a lot of different things. Maybe it can be this as my babysitter, or this is my teacher, it could be this as my therapist, "Hey, meet my therapist." I mean, they get to decide. But I think if you have some ideas around how to manage that, then it can feel a little bit a little less daunting for them. Because I don't think that they necessarily immediately like, oh, yeah, I live in this community. And I'm walking around with my therapist. Oh. Oh, now I have to think about I don't think that's the first thing they think of when they commit to walk and talk therapy.
Curt Widhalm 50:42
And I've noticed this kind of trend change. And again, I work with younger population teens. Earlier in my career, it was just kind of like, oh, I, I don't want to necessarily, you know, let people know that I'm getting help. And teens these days are just kind of like, you're basically shouting out like, "I'm with my therapists," like this, "You need help this guy's great." Like, I point this out that there has been kind of a lot of these principles and guidelines that were written when therapy was a lot more hidden in the shadows. And I think with a lot more emphasis on mental health, that it's still important for us to have these conversations. My experience and the experience of a lot of the colleagues that I know has been that it's less and less of a concer. We still need to ask the questions, but people aren't is shamed by it in the general population. I know that there's still some cultural considerations where still getting therapy, in some cultures is going to be a sign of mental illness. That's why we still ask, but the trends are pretty positive on this.
Katie Vernoy 52:04
And I think that's very fair. And I think that there are going to be different things based on age differences, on what your role in the world is, I think some folks are fine saying that they're in therapy, but maybe not like "this as my therapist." And so I think, definitely ask, and I think the other element of this is, the confidentiality may be lost more passively. So it's not just somebody coming up to you, but maybe someone noticing that you and your therapist are walking the park every week at the same time, or you're coming to their home every week, you know, in your particular car with your particular, you know, kind of characteristics. And so it's something to consider, because people will be will need to be aware of the types of confidentiality that they're losing by having these types of services. But I'm sure that people that go into your building, most of the people sitting around and going like they're going to therapy, because like how many therapists are in that building? Like a bazillion.
Curt Widhalm 53:09
Katie Vernoy 53:10
And so people may lose confidentiality by going to their therapists office. And so I think the location thing I feel a little less concerned about, but I do think it is something to be aware of, and for clients to be aware of, as well.
Curt Widhalm 53:26
And a lot of the confidentiality factors, as a reminder to our clinicians, and to any clients who are maybe hearing this is, confidentiality is only the strongest where you have the expectation of not being seen or heard by a third party. And our discussions up to this point are really that even in the waiting rooms of therapy offices, there's not an expectation of privacy there. So you know, your points of even walking into the building or or walking around, we can point out like, hey, there's not that guarantee of confidentiality, like if we were in my office.
Katie Vernoy 54:11
Sure. I think the other thing and this is kind of a juicy question for us to dig into for a minute or two is boundaries versus confidentiality, and walk and talk maybe you're you're standing closer than the COVID guidelines were and that kind of stuff so you can keep close but really the one that I think is the toughest is if you're going into a client's home, they don't live alone. And I guess if they live alone, there's a whole other thing but the the option for meeting privately is in the client's bedroom. And I think that becomes very complex. It also speaks to the next one we're going to, the next section on dual relationships. But I think this is a really it's it depends for me on the client, sometimes it'll be a meeting with the client in their room, but with the door open, and we're talking quietly, so there's a little bit of space, sometimes it's I'm in the room with the door closed, you know, I think it really is client by client and the type of boundaries that need to be held. But I think there's a lot of a lot of risks that could be in this particular negotiation, because you're either like, hey, we have to be in a public space, and everyone can hear us, or we're in your bedroom and the door is closed.
Curt Widhalm 55:27
And this is also got a whole lot of needing to negotiate things with clients, potentially with parents. And that is something where, you know, being in a child client's bedroom and doing play therapy on the floor, sounds a lot more reasonable. But being behind a closed door with the child's might also be something where their poses risks. So this is not just a matter of any one particular characteristic of a client. And it's something that you need to thoroughly evaluate every single time that you do it and take and document the proper precautions. Document people. Document.
Katie Vernoy 56:12
Just document. And I think the other thing, if there are more than one private room, I think if you can be in a room with the door closed without a bed in it, I think that actually is quite helpful. I think it is a little strange sitting on a client's bed, if that's the only place to sit and you're with an adult client. It just it gets really complicated. And so I think being really aware of what the situation is, documenting it, and if you can't find a good space inside, maybe you just kind of, your head outside. But dual relationships: clearly do not have sex with your clients, there is no sex in professional therapy, or professional therapy does not include sex. That is obvious. That's one of the things about you don't sit on the client's bed, you don't even want to get close to that right. Or maybe you do but you document why it's okay to do that. But we've talked about this before, you also cannot become your clients friend, which can feel very easy if you're hanging out at the park, there's a nice breeze and you're, you know, shooting the breeze and or you're you're hanging out at their house, and they're serving you up a little bit of tea and crumpets. I don't know, there was a lot of British articles when we were reading this, but like, there is a lot of ways where we become very casual, and it can feel very much like a friendship if we don't watch out. And that's, that's potentially a very unhealthy and harmful dual relationship.
Curt Widhalm 57:46
Yeah. And I see this from time to time. And it's really when the therapist stops holding the boundaries. It is not coming back to talking about therapeutic goals, it's relying a little bit too much on the personal shared experiences, rapport building in session, 78, that's, you know, already been well established. That makes it very hard for clients to be able to really differentiate what actual therapy is happening there.
Katie Vernoy 58:27
As we've said before, not all dual relationships are problematic. Of course you don't, you cannot avoid all dual relationships. And in this case, you're going to have some dual relationships that you just have to make sure to navigate becoming their friend or having sex with them, No! But you will be a fellow travele, a fellow walker down the path. You will be potentially in their home. And there may be some host-guest dynamics that you end up having to navigate there. Those things are not necessarily harmful. There's certainly things to pay attention to. And there's a humanity that comes into it. It's just you have to keep coming back to the therapeutic alliance, the professional relationship and the treatment goals. One other thing before we move on is that there are specific needs I think, for folks who are homebound due to medical reasons. And one of the things that they were paying attention to were if you're with a client and doing a therapy session, and they need to roll over and they can't do that themselves, or if they have any other physical needs. There's that that confidentiality boundary thing again, it's like do you keep their home health aide in there with them? Or do you not? And you, you roll them over or you plump up their pillow or those kinds of things. And I think really being comfortable with being a human and holding that with your professional identity I think it's really helpful. I worked for a while with folks who had HIV and AIDS and there were definitely times when, if they were very sick, the relationship by nature needed to shift. And so when I was sitting with them at their bedside, it was going to be something where I might help, I might fluff up their pillow. And it felt particularly connecting, rather than a boundary crossing.
Curt Widhalm 1:00:18
A lot of our traditional advice in this particular area of practice has been, don't do something that is not part of your role. And that's most of, most of the time still going to be the best advice to follow here. And, again, it's consults, it's being able to not take the sole responsibility of these decisions. It's being able to document those boundary crossings and what the effects of them were. But in some of these healthcare type situations that you're talking about, it may end up being where you also then need to advocate for the client to get the kind of help that they need. That is just falling upon you, because you may be the one who's visiting them at that time.
Katie Vernoy 1:01:10
Sure. And I know we talked about when I fell and a client helped me up. But I think if your client falls... Well, I can't touch them. There's no physical contact NASW 1.10 says no. I mean, like, I think we we can be humans and helps up as well. And we can help them across to a curb or something. I mean, I think that there are things that are going to be a little bit different. And I think, certainly consult, don't sit in this in isolation and document. But I think it's more harmful not to be a human in the space, than it is helpful to stick with these really harsh, strong, professional boundaries. As we're running low on time, I want to just mention some therapist concerns, things that we should really consider before getting started. Because I think, you know, that's kind of the last piece. And as we said, we'll we'll make sure that we can put together some ideas around informed consent. And we'll include those in the course that you can get over at moderntherapistcommunity.com. But truly, you want to check on your malpractice insurance as well as liability, make sure that your insurance coverage is complete, so that you can do what you need to do. We've talked about kind of your own logistics around commute or those types of things. Make sure that you think about those things so that you're not unduly burdening yourself or your clients. Certainly make sure that you are doing this for the client's benefit and not solely yours. And truly make sure that you are competent to do these services. It means dig into what we did here. But there's a lot more that can be, can be said about doing these types of services. But also make sure that if part of the reason you're doing these services is due to them being home based, there may be a different different diagnosis, a different type of thing that's happening. And so really consider all the comorbidities, all of the co-occurring disorders. And again, training, consultation, supervision, make sure that you're really doing what you need to do to show up for you in the ways that you can fit these clients.
Curt Widhalm 1:03:20
And document all of your decisions. Continue to consult even if you think that you are an expert in all things non-traditional therapy settings. Don't go at it alone. And check out our show notes. You can find our references there at MTSGpodcast.com. And follow us on our social media, join our Facebook group, The Modern Therapists Group, and listen just a little bit longer. You'll find out how to get your CEs for this episode if you desire. And until next time, I'm Curt Widhalm with Katie Vernoy.
Katie Vernoy 1:03:58
Thanks again to our sponsor, Thrizer.
Curt Widhalm 1:04:02
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Katie Vernoy 1:04:41
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Curt Widhalm 1:05:22
This episode is also brought to you by Melissa Forziat Events and Marketing.
Katie Vernoy 1:05:26
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Curt Widhalm 1:05:56
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Katie Vernoy 1:06:29
Just a quick reminder if you'd like one unit of continuing education for listening to this episode, go to moderntherapistcommunity.com, purchase this course and pass the post test. A CE certificate will appear in your profile once you've successfully completed the steps.
Curt Widhalm 1:06:44
Once again, that's moderntherapistcommunity.com. Hey everyone, Curt and Katie here. If you love this longer form content and would like to bring the conversations deeper, please support us on our Patreon. For as little as $2 per month we're able to bring you more content, exclusive offerings and more opportunities to engage in our growing modern therapist community. These contributions help us to expand our offerings for continuing education, events and a whole lot more.
Katie Vernoy 1:07:13
If you don't think you can make a monthly contribution, no worries. We also have a Buy me a Coffee profile for one time donations. Support us at whatever level that you can today it really helps us out. You can find us at patreon.com/MTSGpodcast or buymeacoffee.com/moderntherapist. Thanks everyone.
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