In-Person versus Telehealth Care
As COVID and quarantine became everyday phrases, telehealth also became a familiar term. Prior to 2020, telehealth (the use of 2-way communication devices to access health care services), lacked clear guidelines as far as insurance reimbursement, HIPPA compliance, and ethical considerations. In response to the COVID 19 Public Health Emergency, Health and Human Services empowered and encouraged providers to serve patients through telehealth. Medicare coverage of telehealth services was vastly expanded. Out of necessity, telehealth quickly moved from the wings of health care to center stage. This included not only medical services but mental health services and coaching as well.
Clearly this expansion was an essential part of the national response to the COVID crisis, serving to protect both patients and providers. A possible unforeseen benefit has been the improved delivery of services to patients who are homebound due to limited mobility or compromised immune systems. Telehealth in counseling, psychology and coaching, certainly has a place. However, I think the adoption of telehealth as the norm, rather than the occasional exception to in-person appointments is short-sighted. An important conversation about the benefits of in person appointments has been noticeably absent.
After 20+ years in the mental health field, practicing as a therapist and coach, I strongly believe that in person appointments should be the standard of care, barring exceptional circumstances. The wealth of data gathered from the physical presence of a client is substantial and cannot be recreated via Zoom. In my own practice, these examples come to mind;
The front desk staff let me know that my client in the waiting room had accused the staff of whispering and making fun of her while she was waiting. Being able to address this with my client and learn that she was experiencing other paranoid thoughts was essential in our work. While the issue likely would have presented itself eventually, in-person appointments brought it to my attention quickly.
I met with a client (who had recently begun taking Wellbutrin) for the 2nd time. I noticed a tremor that I hadn't observed the first time we met and was able to alert his physician to this potentially serious medication reaction before it progressed to a seizure.
In person appointments allow me to notice the smell of alcohol or pot on my client and give us the opportunity to discuss it. A client may also present as malodorous and while this can be unpleasant, the information that a client is not showering regularly or perhaps not wearing clean clothes is critical information when treating any number of mental illnesses or practicing social skills.
In person appointments allow practitioners to more readily identify and address sudden weight gain or loss and scars from self-injurious behavior.
Lack of eye contact, body language and tics, are all more easily observed and addressed in person.
As important as it is to note the presence of these issues, it is equally important to have the opportunity to note their absence. The past two years have shown us how much easier it is to turn on our computer at 8:55am than it is to make it to the office by 9am. However, the ability to keep an appointment, arrive on-time, showered, dressed appropriately and sober is not a skill that everyone possesses. This ability represents essential areas of executive functioning such as time management, organization, and planning. Knowing if your client is capable of this on a regular basis is imperative to gauging their level of functioning. Additionally, for a client with depression or social anxiety, the act of showering and interacting with others while enroute to an appointment and the appointment itself can be an important part of treatment. An appointment with a therapy provider may be the only in-person contact some isolated individuals have on a regular basis. It is a huge disservice to our clients to remove that lack of contact without a compelling reason.
Phone-a-therapist businesses are popping up and like many others, I am frequently recruited to join their provider list. I am disappointed by the number of mental health providers limiting themselves to virtual appointments even though the threat of COVID has seriously abated. I'm concerned that some providers are taking advantage of a policy that was meant to provide coverage during an emergency without recognizing the value of in-person appointments for their client. We have a sacred obligation to our clients to show up; physically, mentally and emotionally. By entering the relationship we make a commitment to be fully present with them. The ability to conduct appointments virtually should be used thoughtfully when circumstances dictate, but not as a default.
Jacqueline Sweeney, MA
JS Consulting, LLC
