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“Normal” Psychotherapy: Past, Present, and Future

12 May 2020 4:40 PM | CSWA Administrator (Administrator)

by: Laura Groshong, LICSW, CSWA Director of Policy and Practice

May 12, 2020

Just as we are settling in with videoconferencing and (thank you, CMS!) audio psychotherapy, the possibility that we will no longer be forced to maintain the distancing that led to these forms of practice is beginning to emerge in some states . What we can expect in the near to later future is at best likely to vary from state to state and region to region. The range of options for how psychotherapy is conducted is likely be forever changed, as well as the reimbursement that goes with the different options.

LCSWs are flexible and we can process and make choices about all the new information we are getting that affect our practices. We can integrate the changes that we need to make to our well-honed skills to protect ourselves and our patients. Here are the issues (not exhaustive) that seem most important to consider at this point in time, whether you are planning to hunker down with your computer screen for a while, itching to get back to seeing patients in your office, or both.

Dealing with Insurance Issues in the Here and Now

I think it is safe to say that, while LCSWs used to feel frustrated by low reimbursement rates, lack of coverage for more than once a week treatment, and treatment reviews for psychotherapy that lasted more than a year, we now have a whole new set of frustrations.

Among these new frustrations are the variability of private and public insurance policies: first they agree to cover the co-pays, then they don’t; first they will pay the same amount for distance therapy as in-person therapy, then they won’t; first they ask us to use a certain POS code and modifier, then change them without notice while denying claims; and more. Spending hours tracking down provider liaisons about why our claim was denied, or paid at a lower rate, is painful and even scary. One remedy is to engage our patients in the process of finding out what their current co-pay coverage is. Another recommendation is to keep a list of POS and modifier guidance as it comes out, by insurer, and keep it updated. If you find inconsistencies, let your insurance commissioner and attorney general know. This is the best way to get action on insurers’ failure to pay us what they have agreed to when we have complied with stated policies.

Telemental Health Changes and Challenges

I have heard from clinical social workers from all over the country in the past 4 months: the vast majority tell me that they have moved from doing in-person psychotherapy to doing psychotherapy through videoconferencing and telephonic means. Most LCSWs struggled at first with the loss of the in-person office setting and the intimacy that usually goes with it. Staring at a screen for 5-8 hours a day is tiring as we try to maintain the level of empathic attunement that is optimal with what can feel like less emotional information coming through the screen for both patients and therapists. The good news is that the process becomes more ego-syntonic over time and many LCSWs report that they have adjusted to videoconferencing after about two months. Many have gotten training in telemental health (see CSWA website for training by Marlene Maheu of TBHI at www.clinicalsocialworkassociation.org in the Members Only section).

LCSWs have put in the time to explore the best videoconferencing platforms which have good connectivity, reasonable pricing, and adequate confidentiality. Similarly, many LCSWs want to find a different payment system since checks or cash can’t translate well to distance treatment; again, much information on the CSWA website home page – click the red bar.

Others wonder if they can wait the possible 3 months, 6 months, 12 months, or two years, all of which have been suggested as the amount of time it will be take to be safe from COVID-19, to return to office practice. Safety will be based on having ‘herd immunity’, e.g., most people have had it and are immune, or a vaccine has been found; most epidemiologists see this as a 12-18 month process at best. The lack of knowledge about how to plan our lives is anxiety provoking as is the thought that it could be 2-3 years before we can safely return to doing in-person psychotherapy.

CMS has given LCSWs the options to use videoconferencing and audio only psychotherapy to be covered at the same level as office psychotherapy, after much prodding by CSWA and other mental health associations. CSWA is looking at the widespread discrepancy that still exists among private insurers and ERISA plans in covering videoconferencing and audio psychotherapy at all; which insurers and ERISA plans are covering co-pays; and which insurers and ERISA plans will pay for videoconferencing/audio therapy at the same rate as in-person therapy.

What will our practices look like in another 8 weeks, in 6 months, in a year, or maybe three years from now? We have no idea. Different states are following different trajectories based on the way COVID-19 is impacting the people who live there. Some states are coping both with “Hot Spots” and with areas which are lowering the curve and returning to an acceptable level of infection (less than 1:1 increases). The devastating impact of the 15% unemployment rate, higher in some states, affects many of our patients. Fortunately, the Affordable Care Act is still in place so that patients can find insurance if they need it when they lose their jobs.

So far, our state and local governments have been trying to create guidelines that will protect as many people as possible, mainly through physical distancing, hand washing, wiping down all high touch surface, and masks. While this is the legal “frame”, all LCSWs still have to determine what we think is safe in doing our work in the present and moving forward.

Types of Psychotherapy Delivery

There are many questions to be answered by LCSWs as individuals to decide how we decide to practice from month to month and year to year as the pandemic runs its course. The answers may change depending on where we live, state restrictions, our own comfort with telemental health or audio therapy, coverage of these delivery systems and much more. Here is a list of considerations for making these decisions:

  1. Comfort with Telemental Health – the surprise for many LCSWs is that telemental health is much more successful than they thought it would be. Some patients prefer it to in-person treatment, as do some therapists. Deciding whether you want to continue providing psychotherapy through telemental health is a decision that each LCSW will make as an individual.
  2. Regulations by State – many state insurance commissioners and governors have required private insurers to cover telemental health and even audio therapy. It is unclear what will happen if and when COVID-19 is controlled by herd immunity or a vaccine. These solutions are likely to take 12-18 months. The longer that alternatives to in-person therapy continue, the more likely it is that they will be to covered when in-person therapy again becomes a viable option. Until then, following the restrictions of our states is a necessary part of how we practice, i.e., sheltering in place, even if we think we are safe to see patients in-person.
  3. Regulations from Medicare – CMS has been a leader in covering telemental health and audio therapy. The same conditions apply to the continuation of these delivery systems as in the states. Whether we want to use these options will be a personal decision for each LCSW when it is safe to return to in-person therapy. Hopefully, CMS will collect data on the qualitative differences between in-person, videoconferencing, and audio psychotherapy and realize that there is a strong basis for continuing all three options.
  4. Intersection of Diagnoses and Psychotherapy Delivery – there may be a difference in the success of psychotherapy delivery depending on the presenting problems, diagnoses, treatment method used, and length of treatment. There will be much more research into these topics. Each LCSW should consider the intersection of these items when deciding whether to see someone in-person, audio therapy or through videoconferencing.

Confidentiality Issues

CSWA has had several articles about the potential confidentiality problems with using telemental health (see https://www.clinicalsocialworkassociation.org/sys/website/?pageId=18219 for complete list). The use of video platforms that are not HIPAA compliant has been relaxed but this should be taken with a grain of salt; state laws may still be more stringent than Federal laws and therefore apply.

Another confidentiality concern comes into play if and when we are see patients in-person. If, in spite of our best efforts to maintain a COVID-19-free office environment we discover that a patient has been infected, we will need to do contact tracing and notify every other patient who has been in our office within 14 days. Confidentiality is affected by COVID-19 in ways that are not usually a concern in the consultation room.

Safety of In-Person Psychotherapy

There has been increasing discussion about returning to in-person psychotherapy as some states begin to relax sheltering-in-place regulations. Many LCSWs understandably miss seeing patients in-person and are anxious to return to the office. Here are some safety issues to consider in making this decision. It goes without saying that LCSWs should comply with any state or federal laws about sheltering-in-place.

  • Office sanitization of doorknobs, chairs, tables or any other surface between each patient
  • WHO safe distance of 2 meters/6 feet
  • Negative pressure ventilation (if possible)
  • Antiviral cleaning of any areas touched by patient in waiting room or restroom
  • Virus air filtration (if possible)
  • Office ventilation (if possible)
  • Screen for any flu or cold symptoms
  • Removal of porous objects such as stuffed animals, pillow, blankets
  • No waiting area/limited waiting area
  • Hand washing before entering
  • 80% alcohol sanitizer in dispenser in office
  • Patient and therapist wear face masks
  • Self-quarantine if exposed to patient with COVID-10
  • Notify any other patient who has been seen the same day that a patient with COVID-19 has

DO NOT see patients who:

  • Have returned from international travel or from hotspots within the U.S. within the last 14 days
  • Have a fever of 100.4°F or greater (consider taking temperature of patients)
  • Have a cough, difficulty breathing, sore throat, or loss of taste or smell
  • Had contact with a person known to be infected with COVID-19 within the previous 14 days
  • Have compromised immune systems and/or present with chronic disease
  • Refuse to abide by social distancing

Clinical Implications of Changes to In-Person Practice

While the changes we make to our practices, in-person or distance practice, are based on the real dangers we face, LCSWs need to be aware of the emotional meaning to our patients of such changes. Seeing patients while the LCSW and the patient are wearing masks may have a chilling effect on the office being a safe environment. Use of hand sanitizer and all the other preventive measures may similarly feel like an intrusion into the safety of the therapy setting. Nonetheless. to keep ourselves and our patients safe, we may decide to continue conducting distance therapy, no matter how frustrating it may be. The feelings that patients have about the changes that we make will be ‘grist for the mill’ as always. Of course, we must strive to process our own feelings about the pandemic enough to be able to somewhat objectively help our patients process theirs.

In short, use your own judgment about what form of psychotherapy feels safe for you and your patients. Keep letting insurers know that they need to be consistent and cover videoconferencing and audio therapy. And most of all - stay tuned.

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