Check in with your clients frequently to see if telehealth is something that is working for them, not just for you. Do not be afraid of the answer. Telehealth isn’t for everyone and it is paramount not to personalize, if a client moves on.
One of the consequences of the pandemic is the dramatic growth of Telehealth and Telemedicine. But how can doctors and providers best care for their patients when they are not physically in front of them? What do doctors with patients need to know in order to make sure they are getting the best results even though they are not actually in the office? How can Telehealth approximate and even improve upon the healthcare that traditional doctors’ visits can provide?
In this interview series, called “Telehealth Best Practices; How To Best Care For Your Patients When They Are Not Physically In Front Of You” we are talking to successful Doctors, Dentists, Psychotherapists, Counselors, and other medical and wellness professionals who share lessons and stories from their experience about the best practices in Telehealth. As a part of this series, I had the pleasure of interviewingDian Grier, LCSW.
Dian Grier, LCSW, is a clinical therapist who graduated in 1988 with a degree in business before moving onto her true calling as a therapist. She has a diverse background including grief work with hospice, crisis counseling with the fire department, addiction treatment and prison therapy. Her unique program development with prisoners has been nationally recognized and repeated at other prisons. She has spoken on panels regarding these unique programs that she has helped put in place. She now has her own private practice and writes for many online publications including newspapers in Bakersfield and Tehachapi, the National Association of Social Workers, Choosing Therapy, an online therapy platform and mental health resource site, as well as her own blog to assist individuals and share as much information as possible.
Thank you so much for joining us in this interview series! Before we dive in, our readers would love to “get to know you” a bit better. Can you tell us a bit about your ‘backstory’ and how you got started?
As a child I had difficulty in school. Looking back, what I remember is that I was always watching people when I was supposed to be listening. People fascinated me and watching interactions was a bit of an obsession. It didn’t help me in school early on, but I believe it has helped in my career. This career has been so fulfilling, it took me a while to find my calling, but I have been a psychotherapist for over 14 years now. In that time, I have had many paths within the field, from hospice, to crisis intervention with the fire department. I have had the experience of working with groups, and interestingly, I have worked with groups of just women in recovery, to groups of just men in prisons. Learning the differences between how men and women process trauma and learn, took time and research. I have great admiration for the men that are joining therapy and I feel fortunate to have the skills to work with men and women differently.
I have my own practice at this time and work strictly over telehealth with individuals, couples and families. I love the work and meeting people who are trying to create change. I am inspired by their courage and effort. Throughout the years, I have been asked to speak to panels regarding the innovative projects I started in the prison setting, including plays and ethics bowls. I do write articles and have been quoted on many topics from existential crises, to falling in love too quickly. I enjoy writing and sharing knowledge wherever I can. I feel grateful everyday for the work I am allowed to do and the trust of the people with which I work.
Can you share the most interesting story that happened to you since you began your career?
Working with the Fire Department, my job was to engage and assist people who were experiencing very difficult events. This enabled the police and fire department the ability to do their job, while the individuals on scene could have assistance with their crisis. I was once on a scene where there was a daycare in the home. There were probably eight toddlers that needed to be managed during the event. I had a police officer that was very young trying to help me wrangle them into a room. He looked very uncomfortable and confused about what to do. I asked him to sit down and read with the kids, but with all his gear, that wasn’t working so I asked him to stand at the door while I read to them. As he was standing at the door, one of the kids ran under his legs and took off. I remember him shouting, “We got a runner!” To this day it makes me smile. We got the “runner” back in the room without the use of force or handcuffs.
Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?
There are so many quotes from Joseph Campbell, who was a prolific writer and studied mythology, that it is hard to pick just one quote. The one quote I resonate with is “The warrior’s approach is to say “yes” to life: “yea” to it all.” The quote goes on to say: “Participate joyfully in the sorrows of the world. We cannot cure the world of sorrows but we can choose to live in joy.”
What I take from this quote is that life is a place of learning. Pain often teaches us more than joy and we are all on our own life path. To take a negative view of the world only causes the person internal pain and the world has always been full of sorrow and pain. To not push pain away, but to embrace both the good and the bad with a joyful heart is the true way to live, from my point of view. When we try and push pain away it also takes the ability to enjoy life to its fullest. If we numb one side of the experience it will numb the other. So, the idea in my mind is to do your best to stay present, and aware and let yourself have the full experience of life.
None of us are able to achieve success without some help along the way. Is there a particular person who you are grateful towards who helped get you to where you are? Can you share a story about that?
I cannot say that just one person influenced my journey. Teachers have shown up in my life when they were needed, whether that lesson felt painful or joyful. But when I think about the formation of my psyche, I have to attribute who I am and the ability of what I do to both my parents. I grew up in an unusual household. I remember family meetings on Sunday’s where we took turns reading psychology and self-help books, and then discussed them as a family. My Mother is the strongest person I have ever met and just wouldn’t allow me to back away from fear or allow negative emotions to stop me in any way. She modeled how to go for what I wanted in life without worrying about failure or fear. She would say, “Don’t take “no” for an answer if you want it,” teaching me perseverance. She was also the most perceptive person and able to read other people’s strengths and issues. I watched this and learned so very much from her knowledge. My Father and I felt like the best of friends. He has a curious, wondering soul and we connected at the deepest levels. Every weekend we would go out into nature to “notice” the beauty and talk philosophy. We often played and laughed in between the deep talks. My time with him felt so safe and soul fulfilling. He is a compassionate soul and gave me so much of himself. The two sides of my parents really created the person I am today and I have such gratitude for my parents and all they gave me. They both helped mold my personal success and the person I am today.
Ok wonderful. Let’s now shift to the main focus of our interview. The pandemic has changed so many things about the way we behave. One of them of course, is how doctors treat their patients. Many doctors have started treating their patients remotely. Telehealth can of course be very different than working with a patient that is in front of you. This provides great opportunity because it allows more people access to medical professionals, but it can also create unique challenges. To begin, can you articulate for our readers a few of the main benefits of having a patient in front of you?
It has been years of tradition in the counseling world, that the client shows up at our office, which we have created to feel like a safe space. They are free of distractions and both patient and clinician find it easy to connect, and stay distraction free. Emotions are something that are mostly read through body language and having a patient in your office allows for more information. If a patient is moving his or her foot up and down, it is obvious to the therapist that they are experiencing anxiety. They may not be saying they are anxious, but the body knows. Emotions are also something that are so palpable when in an office with a patient and clinicians who work day in and out with emotions can pick up on them with all their senses. It becomes almost second nature, to where the information coming at you is a language all its own. If a patient is experiencing powerful emotions, maybe working through deep trauma, just the fact that there is a person in front of them, who has access to them, gives the patient a sense of comfort. The therapist also uses body language to speak to their clients. Small gestures signal the patient on the most subconscious level. Perhaps leaning forward gives the patient the signal that the clinician is interested. Taking a deep breath can signal the client to follow suit so they will calm themselves after telling a difficult story. About 90% of communication is body language, and having a client in the same room gives the clinician a great deal of information.
On the flip side, can you articulate for our readers a few of the main challenges that arise when a patient is not in the same space as the doctor?
Since most communication is body language, telehealth has a few issues when a clinician is working with a client. One of the issues that has arisen several times is working with the elderly. Oftentimes they do not have the knowledge, training, or ability to download the platforms that we use in teletherapy. As much as I try to walk them through it, they often don’t have access to the technology or just can’t seem to figure it out. They grew up in a generation that didn’t work with technology daily and it is completely understandable. Another issue is technology glitches. Platforms and computers freeze at times and it may be at a crucial time in the conversation. Calming a patient over the internet can be more challenging because they cannot read the therapists body language. If they become angry, which sometimes happens, especially in couples counseling, my influence over the situation is reduced. The patients are in their own homes, with common triggers and it becomes harder to gain control of the conversation if they begin fighting while in session.
Another issue is sounds from the person’s home or where they have decided to conduct their session. At times I have seen family members walking around in the background during the session. This is not conducive to digging into deeper issues and the patient becomes distracted. There are sounds of barking dogs, trash being picked up, calls coming in, or someone on the phone in the next room.
Teletherapy platforms are all different and the clinician needs an encrypted HIPAA compliant platform. Not all of these platforms are created equally. I have tried 5 different platforms that are all HIPAA compliant and found many to have poor video or sound quality. When I have asked my clients what they feel the drawbacks are to teletherapy the only answer I ever receive is “technology glitches.” Overall, they have far more positives to talk about than drawbacks.
Fantastic. Here is the main question of our interview. Based on your experience, what can one do to address or redress each of those challenges? What are your “5 Things You Need To Know To Best Care For Your Patients When They Are Not Physically In Front Of You ? (Please share a story or example for each.)
As a mental health professional, most of us have concerns regarding patients with suicidal histories or potential. It is important to gather information from your patients to conduct a good suicidal risk evaluation during the first session. If a patient has had more than 2 attempts this puts them at great risk for future suicidal behavior. With any patient it is important to get contact information and consent to contact someone in their family or in their friend group, if you are concerned for their safety. Make sure you have a current address and update frequently in case you need to call the police for a welfare check.
Make sure you have a HIPAA compliant platform to use while meeting with your patients. Maintaining confidentiality is one of the most important parts of our jobs and part of our code of ethics.
Maintain goals with your clients, if you find that they tend to wander, bring them back to the goals you set when you began treatment. Sometimes these goals will change, so adapt and keep them working. One of the ways clients avoid dealing with feelings is to switch topics and start to chat. Gently redirect them to the topic at hand.
Watch facial expressions. Basically, this is now what we have to work with. Fortunately, the majority of communication is in the face and the tone. When in person, hand gestures tend to keep people’s attention, but this is difficult over the internet. Over time, I have found that I am much better at gathering emotional information from just facial cues and tone of voice.
Check in with your clients frequently to see if telehealth is something that is working for them, not just for you. Do not be afraid of the answer. Telehealth isn’t for everyone and it is paramount not to personalize, if a client moves on. Try your best to have a termination session if they decide to stop therapy. We want to make sure they are safe. They may just be choosing to change venues or therapists. Make sure that you provide at least 3 referrals if you stop teletherapy or they decide to change therapists. Once again, this is in our code of ethics.
Can you share a few ways that Telehealth can create opportunities or benefits that traditional in-office visits cannot provide? Can you please share a story or give an example?
I have spoken to many of my clients regarding the pros and cons of teletherapy. By far, my clients prefer teletherapy to traditional therapy. The reasons are many and I will share what I have been told.
Clients feel as if they can choose a therapist that fits their needs better. If they live in California, they have options of any teletherapist in the state.
They enjoy being in their homes where they feel comfortable.
If it has been an emotional session, they are already at home and feel safe letting feelings out.
They feel the scheduling is more flexible.
It saves them precious time not having to commute.
They enjoy getting therapy in whatever they want to wear, including P.J.’s!
It is much more convenient and possibly the only way for those with mobility issues to receive therapy.
There is no need to wear a mask.
It increases options for vulnerable populations.
It requires continual eye contact, which some feel is more intimate.
They find it convenient and can call from work, school, or sitting in their car.
Clients can hold their pets as they discuss difficult topics. Pets have been shown to lower blood pressure along with many other benefits. Therapy can be intense, and holding your own pet can add to the therapeutic benefit.
One of the funny aspects of teletherapy is that I have seen the inside of many cars. If someone is out running errands, they stop to attend therapy. If they need a space in their home for privacy but don’t have it, they go to their car. Jokingly, I’d like to call it car therapy. There might be a show someday!
One of my clients recently told me that she has such a busy life that she couldn’t continue traditional therapy with commute times. She stopped just because it was difficult to spend so much time going to and from therapy. She is very active and finds the flexibility and lack of commute to be a distinct advantage. When I asked her what the downside of it was, she just couldn’t find one. She said that teletherapy makes no difference to her because she said, “It is just about the therapist I am speaking with.” She has been a consistent client, made incredible progress and considers her therapy to be a form of self-care
Let’s zoom in a bit. Many tools have been developed to help facilitate Telehealth. In your personal experiences which tools have been most effective in helping to replicate the benefits of being together in the same space?
I think the most obvious one is video platforms. Obviously, teletherapy is all about video and sound. There are platforms specifically for clinicians that allow everything from booking online for customers to billing insurance, as well as maintaining notes. It can all happen in one platform. I feel that poor video quality is not acceptable and I have found a platform that offers the best sound, video and the least glitches. The name of that platform is Choosing Therapy. The better the technology the more authentic the experience.
If you could design the perfect Telehealth feature or system to help your patients, what would it be?
I’m sure this will happen at some point in the future but a virtual reality system, where we feel as if we are together and I can see the whole person, which would make a positive impact on the therapy. If I have more body language information, I can gather more information and respond appropriately. It would be great if we could meet in a virtual office of my design and it was so seamless that one could hardly tell that technology was involved. Of course, noise cancelling features would be an added advantage. Hearing dogs bark seems to be the biggest obstacle.
I also think it would be great if there were a platform that had pre-loaded worksheets and helpful articles that you could send from the platform during the session. Having many tools to help a client within one system would be great. I often give them homework to listen to audio-books or order a workbook. If all this could be done in one place during the session, I believe it would increase the effectiveness of therapy.
Are there things that you wish patients knew in order to make sure they are getting the best results even though they are not actually in the office?
I think it is important that clients spend the time to find the right therapist. Try and make consultation appointments with the therapist you are considering. If the therapist doesn’t offer consultations, move on! Not every therapist is the same and sometimes people just don’t click. You are the consumer and as the consumer you have every right to make sure you are getting your money’s worth. If a clinician just chit-chats during therapy, move on. You want someone who stays on task and actually helps you make the changes you are seeking.
Check your computer prior to your appointment. Make sure you have a video and speaker that works. Of course, there are other options, but those are the basics for teletherapy.
A therapist should never work harder than you. If you want the most out of therapy then put effort into the suggestions the therapist gives you. Try the homework. The clients I see who make the most progress take suggestions seriously and put them into motion. This applies to in office or out of office.
Speak up. If you don’t like something the clinician is saying or don’t like the direction therapy is going, let the therapist know. We are trained on many different approaches and your thoughts or beliefs need to be considered. Don’t just stop therapy, but talk to your therapist about it. If it can’t be resolved in the way you want, find another therapist.
The technology is rapidly evolving and new tools like VR, AR, and Mixed Reality are being developed to help bring people together in a shared virtual space. Is there any technology coming down the pipeline that excites you?
At this time Microsoft has won a contract with the Army for Augmented Reality Headsets. The concept is based on HoloLens technology which was originally designed for video games. The HoloLens projects contextual imagery and information is in front of the user’s eyes. The military is using this technology to improve situational awareness and decision-making skills.
I imagine this type of technology could be used in several ways for therapy. One type of therapy is called “Exposure Therapy” when someone has certain phobias. The idea is that you slowly introduce them, step by step to the phobia and over time, the mind and body learn that it is not dangerous. The other thought is that it could be used as a relaxation and anxiety tool. We ask clients to imagine a safe place or a relaxing place so they can calm their nervous systems when dealing with anxiety. This could make the experience more real and therefore more effective.
Is there a part of this future vision that concerns you? Can you explain?
I have been keeping track of new ways that therapy is being utilized. Some platforms use texting as a way to reach clients. I have concerns about this type of therapy as the therapist is not able to see the client and therapy is consistently interrupted. I had a client tell me they tried it, and found it difficult because each time the therapist texted them, they felt pressure to text back. This client did not find this type of therapy helpful.
There are also apps now that assist in calming a person. If individuals are relying solely on this type of technology it cannot be considered therapy. Real therapy gets to the core issues and beliefs a person is carrying around and adapts quickly when new problems arise. I do not think apps should be used as therapy but possibly in conjunction with therapy.
One other issue I have seen are the many mass marketed therapy platforms. Not all platforms are created equal. When I investigated the level of pay for the therapists, it was so low that I wonder who they are hiring and if these are quality therapists. We attend years of training and I see certain companies undervaluing what we do and the effort it takes to actually help people. I know I certainly wouldn’t accept what they are offering for pay and I do take clients on a sliding scale, based on their income, but they are paying these therapists even less than the typical sliding scale at its lowest rate. I’ve seen a growing trend of commercializing therapy which has positive aspects, but many negative aspects as well. I would suggest researching a company before deciding to use it. Of all the platforms I’ve seen Choosing Therapy is the best run organization I have worked with, and they have very high standards.
Ok wonderful. We are nearly done. Here is our last “meaty” question. You are a person of great influence. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger. 🙂
If I could inspire a movement, it is one that I believe has already started. I have quite a few millennials who use therapy as part of their self-care regime. To think of therapy as self-care is a wonderful idea. These are people who do not have significant disorders or even a diagnosis but want to continue to work on their self-growth. I don’t think therapy on a regular basis has ever been considered as part of self-care. It is so great to see how fast these millennials are growing and changing due to the effort they are putting into their personal growth. I believe they are bypassing years of figuring things out and then at age 40 saying, “Why didn’t I know this before.” They are possibly bypassing divorce and painful experiences by learning: how to stand up for themselves, what a good relationship looks like, what good boundaries are, and so much more. I think to myself, “what if I had done the work earlier on and avoided so much time learning on my own. I see them changing dysfunctional family patterns so much earlier than most people. I am continually amazed with millennials, which also includes the brave men of this generation, who do not view therapy as a weakness”. I hope they are teaching the rest of the world that therapy is not something that is only for the depressed or anxious but for genuine personal growth.
How can our readers further follow your work online?
I’m a contributing writer for Choosing Therapy, an online therapy platform and educational mental health resource site. You can check out my latest articles at ChoosingTherapy.com as well as my availability for therapy appointments at https://directory.choosingtherapy.com/therapist/dian-grier .
Thank you so much for the time you spent doing this interview. This was very inspirational, and we wish you continued success.