…Before the session, I remind my client to be in a settled private, quiet and comfortable environment. Free and clear of any distractions such as noise, telephone, tablets, family members, and the space to be uncluttered with proper lightening.
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 wish patients knew 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 interviewing John P. Carnesecchi, LCSW, CEAP of Gateway to Solutions.
For the first time in decades, there is a new choice, a better way to help people live and work well. Gateway to Solutions empowers individuals, couples, families, and organizations to prosper and thrive; it’s wellness in a whole new way. With over twenty-five years of experience, John P. Carnesecchi LCSW, CEAP, is the founder and clinical director at Gateway to Solutions — an emotional wellness group practice based in the Financial District of New York City that provides teletherapy worldwide. John and his team collaborate with clients providing goal-oriented psychotherapy, couples counseling, career and leadership coaching, organizational consulting, and divorce and family mediation.
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?
A few words describe who I am; I am a cultural nomad, music enthusiast, clean eater, and avid jogger. I’m married to my husband of 23 years; we have a 12-year-old daughter and a 2-year-old cockapoo. I identify as an Italian American. I recently received my birthright citizenship in Italy and Europe that extends to my family. I successfully achieved my college aspirations by building my own mental health private practice with the passion of helping individuals and mentoring many clinicians for the next steps in their careers. I love to travel the world and experience culture firsthand. I remind myself there is always a better way to do things, a better way to live this life, seek it out and enjoy the journey.
Music means the world to me. Music is a very much part of our lives in Park Slope, Brooklyn. Growing up, I learned to play the piano. I played for continuous hours on end. Although I do not play like I use to, I can enjoy piano tunes through my husband and daughter trained in the Suzuki piano method. We have music on practically all the time. We wouldn’t mind taking away the television and leave the speakers for music. In my line of work, we train to practice self-care for ourselves. Our wellness is crucial to positively and effectively help individuals. Jogging and clean eating are a part of my self-care. I enjoy feeling healthy, eating clean, and feeling energetic and alive. Each one of these characteristics is attributing to my overall well-being. I’ve learned to take my pleasures and apply them to my everyday living for a healthy balance mentally and physically.
Can you share the most interesting story that happened to you since you began your career?
When I was in Ithaca College, I studied Business and Applied Psychology, double major. When I graduated, I did a project on a Fortune 500 company. I sent my human resource management business project that I did in my last year of college to an Executive Vice-President for the world office in New York City. During my previous two months as a senior at Ithaca College, they called me down for an interview. They offered me a job as a marketing analyst to help develop, through market research, fragrances for Armani, Calvin Klein, and top fashion fragrance companies. I was choosing a career for fashion and fragrance using my business major. After three months, I realized it wasn’t fulfilling.
People were unkind in this industry. During my high school years and my summers in college, I volunteered at a long-term care facility for those dying, the elderly, and the chronically ill. On my third month at the Fortune 500 company, I witnessed the Vice-President yelling at the staff to get their work done. I said to myself, “When they yell at me, that will be my last day.” My sentiments validated myself I was not being fulfilled by this career choice, even though a prestigious company employed me at their world headquarters. It was on that very day the Vice-President came to my office yelling at me, “We are not here to recreate the wheel!” I just looked at her and took it like a champ. After she left, I handed in my resignation. I came home and cried, thinking what will I do now. The following day, I walked to the long-term care facility I volunteered in the past and asked for my first job as a medical social worker at 1/3 of the pay. I was the happiest ever since then. Thank God I double majored; I knew I could have business skills, but I needed to be front and center in helping people.
Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?
My favorite life lesson quote is, “The definition of learning is a change in behavior.” As a Cognitive Behavioral Therapist, I firmly believe we can spend our time learning and inquiring as many insights and moments as possible. But, if we do not take and apply (and the keyword is “apply”) our new insights to our behaviors and “how” we live this life, we haven’t learned a thing. It is the marriage of wisdom with our behaviors that make us whole and authentic. This marriage celebrates who we are, and we begin to evolve. This quote is highly relevant to me and my life. I’ve helped thousands of individuals in over twenty-five years in the human services field, consultancies, and organizations. I have journeyed with people on their evolution. Clients come to me because they are ready to deal with, for example, a childhood trauma as a victim; they want to heal and grow. I get to have the privilege of being invited into their lives as a stranger, in the beginning, then a very close confidant a few sessions later and often to years. There are plenty of stories work-wise, allowing me to witness the evolution of people wanting to move forward, which I will never take for granted. To every client that comes to us at my practice, in their first intake session, I often say, “Before you tell me your story, I know you are coming to me to move forward in something. In that, it is my privilege to partner with you, and you are in the right place.” We must have a positive, psychological approach. Our therapeutic process has to embrace that we are evolving, and we all have a unique story to be told and work through for us to get to our next step. I think of no other more extraordinary privilege for someone to ask me to partner with them in this way. That’s how my work informs this valuable “life lesson quote.”
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?
At my first medical clinical social work job, I had a clinical mentor, the Director of Social Services and Counseling, named Emily. She was the director of social services and counseling in a 700-bed facility. She took a chance on me. I volunteered for a few summers in high school and college, being a friendly visitor to people who are dying, the elderly, and the chronically ill. I came to her asking for an entry-level job because of my previous job experience entertaining the business part of my double major undergraduate. Under her mentorship, she allowed me to run clinical support groups for family members and patients to learn how to cope with multiple sclerosis. I crafted this as a specialty dealing, which still serves my career 25 years later. She allowed me to do fundraisers, like creating a customized cookbook to help the Multiple Sclerosis Society. She endorsed me to take on policy writing, psychotherapy, my graduate internships at New York University at the facility. She gave me ALL of herself as a mentor. She has all the qualities of a good listener, sounding board, and flexibility. She values diverse perspectives; she’s non-judgmental and able to give constructive feedback. She rewarded me along the way many times, not just in her energy and knowledge but also through my facility role. She often put me front and center with administration and outside agencies as the face of the department. I lost some confidence in myself with my first job after college that entertained the business aspect of my double major, then Emily instilled confidence in me. I owe her a lot.
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?
In my field, as a mental health provider, I advise against teletherapy as the first choice form of psychotherapy. Due to the unprecedented times of the COVID-19 pandemic, we had no choice but to continue to treat our patients through a virtual setting. In this, I am thankful. However, I do not feel it is as effective as in-person psychotherapy. In-person psychotherapy sessions provide optimal management, especially for severe conditions. There are several benefits to in-person therapy sessions that I believe outweigh the benefits of teletherapy. Meeting your therapist at a specific time and place removes you from the outside world. The office one-on-one setting eliminates the distractions providing an intimate environment which we call “the clients safe space”. Patients can focus easier on the therapist. Having a real-time conversation opens the door to trust, connection, and insight in a safe and private venue. It takes more than words to understand better a patient’s thoughts, moods, behaviors, and feelings. Facial expressions, body language, and voice tones help decipher what is beyond the meaning of the words. Virtually, if I cannot see the person’s body of a leg is shaking, or hands are frigidity, the words may contradict what the body is saying. Neurologically, virtual sessions are more fatiguing for both the therapist and client.
It is challenging to help a patient in a time of crisis. If a patient is suicidal in the office, the patient is there to feel safe, wants my help, and won’t leave. In a virtual setting, a therapist would not respond as fast, and the lack of timely response would compromise the treatment. Now, technology — as great as it is, we can also bear the burden of technology. It is not reliable. We are at the mercy of internet services. Service outages, bad connection, poor phone signal. We have all been there. In-person, there is an appointment time and specific place. HIPPA standards for in-person therapy apply for teletherapy using a secure link. Although, many clients have still expressed concern about their information being cyber hacked and shared. In a private office, there aren’t any privacy concerns. Lastly, it is essential the patient feels supported and encouraged. It is tough to feel positive energy through a screen. The intimacy of the therapy setting is critical to developing the therapist-patient relationship. The most ideal, effective treatment plan is best in person while virtual is a good “plan B.”
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?
Several challenges make it difficult to provide effective psychotherapy treatment fully. It is very challenging to help a patient in a time of crisis. If a patient is suicidal in the office, the patient is there to feel safe, wants help, and won’t leave. In a virtual setting, the therapist would not respond as fast, and the patient is in harm’s way.
Now, technology — as great as it is, we can also bear the burden of technology. It is not reliable. We are at the mercy of internet services with service outages, bad connection, poor phone signal. We have all been there. A patient can lose part of the session time or possibly miss the appointment. There is no guarantee.
Privacy has become a challenge through teletherapy. HIPPA standards for in-person therapy apply for Telehealth. However, patients have still expressed worry about their information possibly being cyber hacked and shared. In a private office, there aren’t any privacy concerns.
Distraction is a big problem. A patient is not as focused when they are not in the therapeutic setting. Phone’s ringing, interruptions, family sounds in the background, children fighting, dogs barking, and just distracted by the personal things in their environment. I have seen this one too many times. It is not ideal for a patient to focus on oneself, grasp the purpose, and engage with the therapist.
More importantly, the biggest challenge is reading my patient’s body signals and cues. As mentioned in the previous question, body language, facial expressions, and voice tones are significant to understand what the patient is truly feeling. Virtually, I cannot see the person’s body or clearly hear; possibly the leg is shaking, hands are frigidity, distortion in the background. Teletherapy is impersonal. It is imperative to build a personal connection and build a strong foundation of trust.
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.)
It has been a trying year and lots of learning curves for the new way to treat my patients. There are five things I confirm before and techniques used to the start of a teletherapy session with the patient and me:
First — Before the session, I remind my client to be in a settled private, quiet and comfortable environment. Free and clear of any distractions such as noise, telephone, tablets, family members, and the space to be uncluttered with proper lightening.
Second — My client must be using a compatible device to the HIPPA compliant platform. Ensure their internet connection is solid and stable. The microphone is clear and integrated with their device, the camera is focused, and if they are in their home environment, to use headphones or air pods if there are other people in their home.
Third — I need to see my client. Although it is impossible to see their entire body, I ask they are facing the screen. Their body language, facial expression, voice, and other cues are a great indication of how my client is feeling.
Fourth — Before we begin, we break the ice and reconnect for a few minutes. Simple chat about their week or anything light before we get into the deep issues. Small chit-chatting is easier to start the dialogue and then jump into our goal-oriented treatment plan.
Fifth — Some patients feel uncomfortable, nervous, or anxiety-driven with the change of their therapeutic environment. These reactions are prevalent. I like to begin with some grounding exercises, like deep breathing. To get the most out of the session, they must be centered and mindful of the present moment.
Can you share a few ways Telehealth can create opportunities or benefits that traditional in-office visits cannot provide? Can you please share a story or give an example?
Telehealth does have some benefits that in-person psychotherapy cannot provide. Accessibility is the most highly rated benefit. Teletherapy is about convenience, anywhere, as long as there is a stable internet connection. Individuals with barriers or limitations, such as chronically ill, bedridden, disabled, and mobility issues, can still easily have therapy in their virtual setting. Their treatment will have continuity regardless of the circumstances. For a patient who is in a wheelchair and the office is not wheelchair accessible, teletherapy is a great opportunity. For a chronically ill patient or hospitalized and needs to continue therapy to get through these times, teletherapy is the way to go. Based on someone’s circumstances will determine if teletherapy is most beneficial.
Many individuals feel reluctant to start therapy thinking about the anxiety of walking into an unfamiliar office, sitting in a waiting room, and meeting an unknown person, their new therapist — the thought of seeing an acquaintance and their breach of privacy. Teletherapy is in the privacy and comfort of an individual’s home. The comfortable setting can make it easier to begin the therapy process, followed by emerging into in-person sessions.
The mental health crisis among college students has dramatically increased. The influx is too demanding for campus counseling services. They cannot accommodate the overload of students. Teletherapy allows college students to seek help using any provider of their choice, whether from the college’s surrounding area or one from their hometown. Teletherapy provides more options for therapists from any location.
Teletherapy removes time barriers. Meaning, individuals may rush from work/school/home to get to their appointment, stuck in traffic, running late, child-care issues, last-minute cancellations, consequently starting their session overly anxious and flustered. Finding a quiet place in their home without any pre-aggravation is an excellent start to the therapy session.
Mentioning just a few benefits ultimately comes down to a personal preference for how the patient feels most comfortable.
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?
It has been a creative time to replicate in-person therapy through a virtual setting. Before a teletherapy appointment, I email my clients with a few tips to clone, the best as possible, our in-person therapy sessions.
- Find a quiet, clean, organized, and private space removed from distractions. Perhaps your bedroom, bathroom, and even your car.
- Get dressed as if you were coming in person.
- Inform everyone you will be unavailable and do not disturb.
- Take your materials or items you would typically bring, like paper, pen, water.
- Do not multi-task. Focus on your therapist and eliminate any outside distractions; television, phone, tablets, music, pet, etc.
- Focus with direct eye contact on the therapist
- For the utmost privacy, use headphones/earbuds
Besides staging your environment, some therapeutic approaches require physical resources, such as worksheets and handouts frequently used in therapeutic development. They are great tools for visual learners. There are new platforms, like TheraPlatform, that allow screen sharing in a real-time virtual session. The patient can draw, type, and annotate on the worksheet. TheraPlatform can show PDFs and videos during the virtual session through screen sharing.
Therapists worldwide have become innovative to create compatible settings for their patients to get the most out of their treatment.
If you could design the perfect Telehealth feature or system to help your patients, what would it be?
Ahhh, great question! The ideal Telehealth system for teletherapy purposes would include text or email reminders; 24 hours and 15 minutes before the appointment. Confirmation texts. A platform that allows the patient to choose a virtual background for me. Options would include a peaceful scene or maybe the ocean, beach, flowers, rainbows — something serene. I love to use imagery techniques during my sessions. The patient can choose a video clip of a place they would love to travel or have visited that they loved so much. A destination that brings joy, adding soothing music in the background. The patient would use the video to decompress using deep breathing techniques to go into a mindful state at the start of the session.
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?
The beginning phases of teletherapy were cumbersome. Many kinks needed to unraveling between my patient and me. It was a trial-and-error process. Teletherapy wasn’t standard practice for me. My colleagues and I quickly found the appropriate video platform with HIPPA compliance standards, proper state licensing for video conferencing, and multipole capabilities.
For me, being organized is essential. I felt a bit overwhelmed having my patients established before their session. After a couple of weeks in, I created an email to my clients to prepare for their teletherapy. First, make sure their environment is private, comfortable, removed from any distractions. Secondly, ensure their internet connection is solid and stable. Thirdly, make sure their electronic device and web browser are compatible with the virtual platform I was using. After implementing these three things, my sessions were seamless if there was only a template to be issued in the early stages of development.
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?
Yes, there is! I would love Augmented Reality (AR) technology for psychotherapy as an additional tool to a therapeutic approach. AR is an interactive experience bringing an enhanced version of the real world with computer-generated elements and multiple sensory modules. I have mentioned a visualization technique I use with my clients. The AR headset can simulate a real-world scenario designed by the patient to overcome fears that trigger sensory overload, practice mindful techniques, simulate scenarios, and much more! It would be a creative way to enrich the psychotherapy experience.
Is there a part of this future vision that concerns you? Can you explain?
I worry that technology will replace the personal connection between individuals. It has become a world of digital loneliness and increased physical ailments. Every day, rapid advancements in technology reduce human interaction, online grocery shopping, online banking, Telehealth, virtual learning, video conferencing platforms, virtual workouts, etc. I am a firm believer in physical human interaction. It is vital to mental and physical growth development. We need socialization, human touch, real-life experiences, interactions, daily functioning responsibilities, in-person learning, new sensory stimuli to grow, to embrace kindness, empathy, and compassion. I’m concerned the simple emotions we feel would dissipate and the beginning of the loss of humanity.
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. 🙂
I would create a national government program in developing countries where children have to work to provide for their families instead of school. India and the Philippines, to name two, are countries suffering economically with a substantial poverty class. This policy would have the government pay for the children’s breakfast and lunch, which is cents on the dollar per child in those countries. For that reason, the family would not need to provide those meals, and it would be an incentive to send their children to school versus keeping them at home to work. Many families can’t afford to feed their children. If they received breakfast and lunch, families might be more inclined to send their children to school. Providing those two meals would incentivize the children to go to school, get an education, and a skill. It would monetize and elevate the developing countries’ economic status to create a stronger middle class, creatively improving poverty with a ripple effect. Thinking about their base needs of poor developing countries and how they function, how we can globally improve economies which ultimately will improve healthcare, education, job opportunities, and people’s futures for generations.
How can our readers further follow your work online?
Readers can follow and contact me through many social media platforms and website to my private practice –
LinkedIn: @John P. Carnesecchi
Thank you so much for these fantastic insights!
It has been the utmost pleasure to be interviewed and assist with your article.