PCAR Technical Assistance Bulletin Telecounseling for Survivors What is telecounseling? Telecounseling offers counseling and support services using interactive video conferencing via the internet. If discussed in advance with clients, telecounseling can be used in the event of inclement weather or during other unprecedented times (like a pandemic!). Telecounseling should be used for scheduled sessions only – not for emergencies. If a client needs to talk outside a scheduled session, they should call the hotline or 911, or follow your agency’s protocols. Can we do telecounseling over the phone? Yes. We recommend using video conferencing if possible because it more closely resembles an in-person session. But if the client prefers to use the phone, or there is an interference with video conferencing, using the phone is a great alternative. Why would we want to use telecounseling? Telecounseling is a tool that can help improve access and continuity of care for survivors. Engaging in counseling services from a distance can reduce travel costs for both clients and centers and provide an alternative option for clients who have scheduling challenges or are unable to travel. If discussed in advance with clients, telecounseling can be used in the event of inclement weather or during other emergencies. Who can use telecounseling? Telecounseling is appropriate for most clients, especially those ages 14 and above (check with your state coalition for more information about age of consent for services). As long as clients have access to the required technology, they can use it. We recommend doing a test session with a client to make sure the technology works. Telecounseling could work well with clients who are incarcerated or living in residential facilities, but you’ll need to make arrangements with the facility. Can we utilize telecounseling with children? For more information on utilizing telecounseling with children, check out PCAR’s resource here. (https://pcar.org/sites/default/files/resource-pdfs/telecounseling_with_children_and_teens_508.pdf) What are the drawbacks to using telecounseling? There can be some challenges to using telecounseling. Technology can malfunction or connectivity can be lost during sessions, and that can be frustrating or disruptive for both the counselor and the survivor. Go-to practices that work well in-person may be less effective or impossible when providing services remotely. The good news is that with creativity, transparency, and planning, many of these challenges can be overcome. For example, be honest with survivors about the limitations of telecounseling, and work together to identify solutions. Create a plan for when technology or connectivity fail. Identify new and creative ways to engage with survivors. To guard against misunderstandings, practice your best reflective listening skills, and make the effort to check in more frequently with survivors to confirm understanding. Telecounseling may require counselors to think about and integrate new self-care strategies into their practice. For example, sitting in front of a screen for longer periods of time may increase eye strain, headaches, and/or fatigue. Consider ways to incorporate more breaks into your day, adjust your screen settings or your lighting, or make conscious efforts to get up and move your body. Reduce screen time by having phone calls with colleagues, instead of videoconferencing meetings, if necessary. Platforms & Technology How do we choose a platform? You want to choose a platform where no identifying data is recorded, the vendor cannot see or access personally identifiable information, the survivor doesn’t need to download anything, and the platform doesn’t require an account, profile, or username. PCAR recommends the resource created by the National Network to End Domestic Violence (NNEDV, 2020), Video Conferencing & Digital Communication Platforms Comparison Chart (https://static1.squarespace.com/static/51dc541ce4b03ebab8c5c88c/t/5e7e62a25ed80a4219adad77/1585341091261/NNEDV_Communication+Tools_Handout.pdf), which compares Cyph (https://www.cyph.com/), Gruveo (https://www.gruveo.com/), doxy.me (https://doxy.me/), Zoom (http://www.zoom.com/), and ResourceConnect (http://www.resourceconnect.com/). Learn more about how to choose a platform using NNEDV’s Vendor Checklist (2020). Why shouldn’t we use Skype, Zoom, Facetime, or social media apps and chat features? We do not recommend these platforms at this time due to privacy concerns. They are not Health Insurance Portability and Accountability Act (HIPAA) or Violence Against Women Act (VAWA) compliant. Secondly, these platforms keep record of the calls, making it easier for abusers or others to access this information (especially on shared devices, like family computers). The same is true for texting or chat apps that store this data (for the same reason we wouldn’t put confidential information in an email). Zoom has a HIPAA compliant version but it’s much more expensive (currently $200/month). Skype for Business is not HIPAA compliant and not more secure than the free version of Skype from our standpoint. However, if a survivor understands all risks involved and prefers to use one of these platforms and provides informed consent, the decision is theirs. In terms of devices (computers and phones) should staff use personal or agency devices? Ideally, staff should not use their personal devices to communicate with survivors; it is best to use agency devices because the proper security features should be installed. However, in situations where staff must work from home, some might have to use their personal computers as there may not be enough agency laptops for everyone. If this is a device you share with others (i.e. family computer), take extra security precautions by setting a password to access your profile and making sure you have logged out of the platform you use to communicate with survivors. If you are using a personal phone, you can dial *67 before you dial the survivor’s number; this will block your number so that they do not have access to your personal phone number. What should we use for group sessions or peer support groups? Check out NNEDV’s Video Conferencing & Digital Communication Platforms Comparison Chart (2020) for guidance on what platforms support group calls. Survivors participating in group sessions must understand the limitations of the platform’s security, as well as how confidentiality might be compromised when members are participating in the group remotely. What should we do if the technology stops working mid-session? You should prepare a back-up plan with clients in advance. Make sure you have the client’s phone number and confirm that it is okay to call that number if you lose connection. Confidentiality What is being done to address confidentiality issues? First, use a secure platform (see NNEDV’s Vendor Checklist [https://www.techsafety.org/digital-services-vendor-checklist]). A platform that is HIPAA compliant may also meet additional VAWA regulations. VAWA regulations clarify that grantees must not disclose, reveal, or release any personally identifying information regardless of whether the information has been encoded, encrypted, hashed, or otherwise protected. Additionally, VAWA regulations require grantees to make reasonable efforts to prevent the inadvertent disclosure of identifying and individual information, especially when making use of any third-party database, or internal database managed by an outside company (NNEDV, 2016). For more clarity on what confidentiality regulations to follow, check out the Safety Net Project’s Confidentiality Toolkit (https://www.techsafety.org/confidentiality-in-vawa-fvpsa). Do we need to follow HIPAA regulations, too? To figure out if you need to follow HIPAA regulations, check out this resource (https://www.hhs.gov/hipaa/for-professionals/covered-entities/index.html) about Covered Entities and Business Associates (U.S. Department of Health & Human Services [HHS], 2017). How do you explain or reassure clients about the confidentiality of the platform? Talking through the benefits and drawbacks of telecounseling is essential before trying it with clients for the first time. While there will always be privacy concerns, assure the client that there are additional steps you can take. For example, they can choose a fictitious name to use on the platform when asked to enter their information to join the session, as an extra layer of keeping their information confidential. Clients, counselors, and group members will be asked to not record the session via audio or video, or take screenshots with their cameras. What are best practices for maintaining confidentiality while working from home? Maintaining confidentiality at home looks similar to when you are in your office. You want to have a private space to hold the session. At home, that might mean locking your door so that other people and pets don’t disrupt the session. Using headphones and setting a sound machine outside your door can help maintain privacy of what is being shared. Counselors should ask clients at the beginning of each session to inform them of their location and if anyone else is nearby that may be able to hear their conversation. If clients are worried about partners or family members sitting in the room off camera without the client’s consent, counselors will be advised to create a code phrase that informs the counselor to end the session in a discreet way. This resource, Protecting Survivor Privacy When Working From Home: A Guide for OVW-Funded Victim Service Providers (https://mcasa.org/assets/files/Privacy_When_Working_at_Home_VRLC.pdf), from the Victim Rights Law Center (VRLC, 2020) provides additional tips and information. Can you share information about FERPA (campus-based confidentiality) compliance with any of these tools? The Family Educational Rights and Privacy Act (FERPA) only applies to school employees. Unless you are employed by a federally-funded educational institution, FERPA does not apply to you. For example, campus-based advocates who are paid by rape crisis centers do not fall under FERPA. This webpage (https://www.hhs.gov/hipaa/for-professionals/faq/514/does-hipaa-apply-to-school-student-health-records/index.html) explains the difference (HHS, 2013). For more information about telecounseling in college settings by campus employees and various privacy considerations, check out this resource from Higher Education Mental Health Alliance (2019). (http://hemha.org/wp-content/uploads/2019/01/HEMHA-Distance-Counseling_FINAL2019.pdf) Obtaining Consent for Services How do I obtain consent from a client to use telecounseling if we cannot meet in-person? Ideally, during intake or a previous in-person session you would have discussed telecounseling as an option and obtained written consent. If you cannot meet in person, you can utilize an electronic signature service. You can also email the informed consent page to the client to review if there are no concerns about safety or computer privacy. The client can print and sign the form and send it back to you (via text, email, mail, or fax), or reply to the email indicating their consent. If you cannot obtain written permission, the client can provide verbal permission – though, you must document this in their file with the date and time. At the start of telecounseling sessions you should secure verbal informed consent, even if you have a signed document. What needs to be included in an informed consent form for telecounseling services? You can find an example of an informed consent form for telecounseling here with talking points. (https://pcar.coalitionmanager.org/resourcemanager/resourcefile/details/45) What electronic signature platforms are HIPAA compliant? You can read more about HIPAA’s rules around electronic signatures here (https://www.hipaaguide.net/hipaa-e-signature-requirements/) (HIPAA Guide, 2017). You can read about DocuSign’s HIPAA compliance here (https://www.docusign.com/sites/default/files/DocuSign_HIPAA_Compliance_Overview.pdf) (DocuSign, 2020). To be HIPAA compliant, you need to enter into a Business Associate Agreement (BAA) with the company, which usually requires a paid subscription. Please read all terms of service before using a platform. What if a client doesn’t want to participate in telecounseling? What if they won’t sign a consent form? VAWA states that consent to release personal information cannot be a condition for services. Therefore, if a client does not want to participate in telecounseling due to concerns about the technology or platform, you still must provide them with services in another format (i.e. the phone or in-person). If they will not sign a consent form, you cannot proceed with services, but may be able to provide the survivor with referrals or other resources or information. Licensure Do I have to have a certain license to use telecounseling? No, but if you are licensed or working towards licensure, you should check your state licensing laws to make sure you are practicing legally and ethically. Can we provide telecounseling services to a client in another state? What if the client has temporarily gone to a different state because of the pandemic? It is illegal for licensed professionals (i.e. LSW, LCP) to practice when a client is in another state (without advanced permission from the licensing board of that state). If you are licensed, or working toward licensure, reach out to your licensing board for more guidance (many restrictions have been lifted for those with licenses due to COVID-19). Due to mandated reporting laws varying in each state, and sexual assault counselor’s confidentiality statute, it is not in a client’s best interest to receive services while they are in another state. However, if the sexual assault counselor is unlicensed and is in the home state, while the victim/survivor is in another state, confidentiality privilege should apply, and any attempts to challenge the home state absolute privilege should be fought with the help of legal counsel. Safety Issues What is done to address liability and safety issues (i.e., a client says they are going to self-harm and then disconnects the call, or actually does self-harm in front of the counselor)? Ideally, before clients use telecounseling, they would meet with their counselor to discuss this method of counseling in-depth and sign an informed consent form. Part of the informed consent form states that if a life threatening medical emergency were to occur, a counselor has the right to disclose information related to the medical emergency. In this situation, a counselor would call 911 and give the address of the client’s location. In regards to self-harming behaviors, the informed consent form also explains that the center is governed by laws of the state with regard to counseling, mandated reporting, and confidentiality. Each center should already be explaining the limits to confidentiality during intake, including exceptions to confidentiality being made if a client is a threat to themselves or others. If self-harming behaviors were to occur during the session, counselors would follow the same protocol they have at their centers by contacting the appropriate authorities. During intake, or over the course of the counseling relationship, if the counselor feels telecounseling is not in the client’s best interests (due to self-harming behaviors.) Other than checking their location, having the right address, phone numbers, what are other things to think about how to best respond to crisis situations? While this may not be an exhaustive list, and you’ll always want to consider each client’s unique situation, here are some suggestions: 1. Confirm and/or obtain the client’s geographical location, in case of emergency, so that you can provide an address to first responders. 2. Make sure you have your list of crisis numbers on hand - if you’re working remotely this may not be something that’s as easily accessible to you right now. Write them down and keep them nearby. 3. Use the skills you would use in any other crisis situation, follow your protocols, but be flexible and adaptable. 4. For clients ages 13 and under, arrange for an adult caregiver to be “on call” during the session in case of emergency or crisis. This person does not need to be in the room, but should be on site. Obtain this person’s phone number so that you can call them or text them, if needed, during the session. While this may be a good practice in some cases with other clients, as well, it is important to consider and explain the impact to the client’s confidentiality. Accessibility How does interpretation work with these platforms? Some of these platforms will have built-in services to easily add an interpreter. You can continue to use phone interpretation during video counseling; mute the video on your device and use phone interpretation. If you have questions about this, the interpretation company you use should be able to help navigate this with you. What recommendations do you have for folks who do not have phones, and are only able to use Wi-Fi and Facebook? If the person has access to a secure Wi-Fi connection, they should be able to use the device to access Wi-Fi to participate in these sessions. If they do not have access to a phone, continue using whatever method they would typically use to communicate with the center. Ideally, we would not recommend using Facebook as a form of communication with clients due to privacy concerns. However, if the client understands all risks involved and still wants to use Facebook and provides informed consent, you can. It is important to remember and explain to clients that using public Wi-Fi puts confidentiality at risk. Intakes Prior to scheduling a telecounseling session, is there usually an initial in-person session to sign consent and to complete paperwork? Ideally, yes. But during this time, you should first get the consent for services form signed (see other questions about obtaining consent), and then you can conduct your first session via telecounseling. Once we are able to provide services in the office again, this is something that centers and coalitions will likely have to determine for themselves. There may be some clients who are unable to come in for an intake or would prefer to do it via telecounseling - how can your center accommodate that? Has there been any guidance on doing assessments or screenings via telehealth? In an ideal situation, initial intakes and assessments would be done in-person to determine if telehealth options would be the best way to meet the client’s needs. Conducting the initial assessment remotely is the next best option. In some cases, this can be done via teleconferencing. In other cases, it may need to be done over the phone, depending on the client’s access to technology and connectivity, or their comfort level with using the videoconferencing platform. As you would during any intake or assessment, be prepared to make appropriate referrals if the client’s needs extend beyond your expertise or area of practice. Making a referral may result from the extent of the client’s needs or your comfort in effectively addressing their needs remotely. Always be honest with clients about their options and your reasons for recommending a referral. If you haven’t already, contact local providers to assess their ability to serve as a referral source, particularly during high-stress times, such as we’re experiencing right now with the pandemic. Create a referral list of counselors and therapists in your area that can help to meet clients’ complex needs. Be sure to include professionals who are competent at providing remote services. References DocuSign. (2020). DocuSign esignature for HIPAA compliance. https://www.docusign.com/sites/default/files/DocuSign_HIPAA_Compliance_Overview.pdf The Health Insurance Portability and Accountability Act (“HIPAA”), 42 U.S.C. § 201 et seq. https://www.govinfo.gov/content/pkg/PLAW-104publ191/pdf/PLAW-104publ191.pdf Higher Education Mental Health Alliance. (2019). College counseling from a distance: deciding whether and when to engage in telemental health services. http://hemha.org/wp-content/uploads/2019/01/HEMHA-Distance-Counseling_FINAL2019.pdf HIPAA Guide. (2017). What are the HIPAA e-signature requirements? [Webpage]. https://www.hipaaguide.net/hipaa-e-signature-requirements/ National Network to End Domestic Violence. (2020). Confidentiality toolkit [Webpage]. https://www.techsafety.org/confidentiality National Network to End Domestic Violence. (2020). Resources on the response to the Coronavirus (COVID-19) [Wedpage]. https://nnedv.org/latest_update/resources-response-coronavirus-covid-19/ National Network to End Domestic Violence. (2020). Selecting a digital services vendor checklist [Webpage]. https://www.techsafety.org/digital-services-vendor-checklist National Network to End Domestic Violence. (2020). Video conferencing & digital communication platforms: Comparison chart [Webpage]. https://static1.squarespace.com/static/51dc541ce4b03ebab8c5c88c/t/5e7e62a25ed80a4219adad77/1585341091261/NNEDV_Communication+Tools_Handout.pdf U.S. Department of Health and Human Services. (2017). Covered entities and business associates [Webpage]. https://www.hhs.gov/hipaa/for-professionals/covered-entities/index.html U.S. Department of Health and Human Services. (2008). Does FERPA or HIPAA apply to elementary or secondary school student health records maintained by a health care provider that is not employed by a school? [Webpage]. https://www.hhs.gov/hipaa/for-professionals/faq/514/does-hipaa-apply-to-school-student-health-records/index.html Victim Rights Law Center. (2020). Protecting survivor privacy when working from home: A guide for OVW-funded victim service providers. Victim Rights Law Center. https://mcasa.org/assets/files/Privacy_When_Working_at_Home_VRLC.pdf © Pennsylvania Coalition Against Rape 2020. All rights reserved. www.pcar.org