How Can I Safely Reopen My Practice?

Five Clinicians Weigh In

Psychotherapy Networker

Thank you to everyone who responded to our July Clinician's Quandary. Here are some of the top responses! Submit to next month's Clinician's Quandary here.

July 2020 Quandary: My area of the country is starting to be open back up from COVID-19 lockdown measures, but I’m still worried about the risk of seeing clients in person again although many of them are asking for that. We can sit six feet apart, but what if my client sneezes or coughs? Therapy with masks on doesn’t feel right, but I don’t even go to stores without a mask these days. What are some ways I can ease back into seeing clients in my office that ensures everyone is safe? Any tips on managing my own anxiety around coronavirus, especially as I try to ease the anxiety of my clients?


1) Practice the Essentials

I want this therapist to know she’s not alone.  Many of us carry anxiety about easing back into in-person therapy during these bizarre times. My best advice is to, first, inhale deeply and exhale. Then, we can get to planning.

As part of our reopening plan, my colleagues and I have taken the step of keeping our waiting room off limits. Clients text when they’re in the parking lot, and we’ll greet them outside and walk with them into the office, socially distancing all the while. We sanitize all doorknobs and surfaces before and after each session. My colleagues and I are also clear with each other about when we’re scheduling sessions so they don’t overlap. Clients and therapists have separate tissue boxes that they keep beside each other. I also wear two masks while doing in-person therapy: one disposable one and another, professional-grade mask on top.

Here are a couple other options for this therapist to consider: Is it possible for her to sit outside with some of her clients? I realize this sounds a bit unusual, but several of my clients have found time in nature to be quite soothing. We've watched birds at the bird feeder together and felt safe in the fresh air. It’s so nice to be able to relax about breathing deeply. Even an office courtyard might be comfortable.

If you’re working with children, I’ve found that they can enjoy decorating the mask with paper, drawing emotional expressions on them or pictures of what's going on underneath the mask. For an adult or teen, this activity can provide some comedic relief.

As far as soothing your own anxiety goes, I recommend movement, somatic therapy, art in whatever form you enjoy. Get plenty of sleep, practice good nutrition, meditate, exercise, and take time in nature. I’m an avid journal writer, which I’ve found very helpful. Also, make sure you have colleagues you can process feelings with. When I talk with my therapist friends, we laugh and cry.

We therapists are purveyors of hope. I believe this has never been more true than right now. We must find our own sources of light and optimism so we can impart it to our clients. We’re being called to explore our own creativity about how to provide services while remaining safe and healthy ourselves. I hope this advice serves as a life raft as we navigate these choppy waters together. Here's to much smoother waters ahead.

Didi Rowland, LCSW
Austin, TX


2) Take Safe, Gradual Steps

I work in a university counseling center, so we’ve had some time over the summer to prepare for students returning to campus in the fall. We plan to continue to see most of our clients remotely, but we know that some clients—and more than a few counselors—are tired of Zoom meetings and want to meet for in-person sessions. We’ve opted not to wear masks, since we know how important facial cues are, as well as how difficult it can be for clients who cry during sessions to do so while wearing a mask. Instead, we’ve decided to hang clear plastic shower curtains in each counselor's office, between where the client and therapist sits, so that there’s a protective barrier separating them. In addition, we’ve going to have clients and therapists sit six feet apart at all times. As an added layer of protection, we’ve also got a large supply of washable, reusable face shields for both counselors and clients.

I’ve practiced talking to colleagues through the curtain while wearing the face shield, and it works so far, but we haven’t opened the counseling center to clients just yet. I don’t know how well our plan will work, but we’re hopeful!

Angie Trzepacz, PhD
Murray, KY


3) Get Outside

In considering how I might start seeing clients in person again, I think meeting in an outdoor space might work well. There’s a nearby space with a beautiful spiritual ambiance and energy that complements my hippie tendencies. It’s next to a synagogue, which is next to a convent—a peaceful oasis in a bustling city. As we return to face-to-face counselling, creating the right space matters. If we are calm and in a good physical place, it will put our clients at ease, reduce stress, and strengthen our new therapeutic relationships going forward.

I’m also thinking about meeting clients for walk-and-talk therapy. In the city where I live, we have lochs, forests, and beaches, all not too far from my doorstep.! I’m learning the best way to work with clients outdoors, taking their lead and adapting each walking session to suit their needs, considering the terrain, accessibility, and, of course, the Scottish weather! From what I’ve read, therapists who do walk-and-talk therapy see clients in all types of weather, in all seasons.

During this pandemic, I’m learning to let myself be open to possibility. I’ve just started my own private practice, and it goes without saying that doing so in the middle of a global pandemic is challenging. Nonetheless, I am ready to adapt.

Paula Benhaddad, Counsellor
Fife, Scotland


4) Meet the Needs of Others

Our region has been open for a while, and I’ve found that clients are equally concerned about maintaining their safety and mine. Before setting up appointments, I discuss COVID-19 measures with each of my clients. Through email, my practice acknowledges the potential for legal disclosure to health authorities should either party be found positive for coronavirus. There are also posters in my office visible to clients at all time that remind them of the importance of social distancing and wearing a mask.

We also offer disposable masks, sanitizers, and wipes in three locations in our one office. This room is very spacious, allowing clients and I to sit further than six feet apart. There are also tissues within reach of all seats, and three waste baskets that I empty regularly.

Because masks are required in so many settings, almost every client I see has arrived with their own. Some clients prefer to keep masks on, in which case I do as well. But if the client is comfortable doing so, we take our masks off.

Still, easing back into in-person therapy hasn’t always been easy. When working with clients who prefer to keep masks on, sometimes either myself or the client has to ask the other person to repeat ourselves. But I’m finding creative solutions along the way. I know a hearing and ASL specialist who’s going to bring me a see-through mask that doesn't fog up.

I believe I must do everything possible to help ourselves and clients maneuver through this pandemic, while being as sensitive to other people’s wants and needs as possible. One of my colleagues is in a high-risk category, never takes her mask off, and asks clients to do the same. So far, this hasn’t been a problem, even our rural, mostly conservative community.

To clients and therapists, I offer this piece of advice: do your best, listen to the experts, and be yourself.

Karla Forgaard-Pullen, LCSW
Ontario, Canada


5) Give Your Clients the Power of Choice

As a therapist who recently had a heart attack with stent placement in February, I was very cautious when the pandemic hit and stopped seeing all clients in person at the beginning of April. I moved to strictly seeing clients via telehealth, and had almost half of my clients opt out of therapy due to their discomfort or unfamiliarity with online platforms. We made tentative, in-office appointments a couple months out and have kept in touch, but it hasn’t felt like enough.

In June, I assessed the local pandemic conditions, and reassessed. I decided to see a few clients in my office with the caveat that they had to be healthy and symptom-free, as did I, and that we’d both be wearing masks during the entire session. Clients who weren’t comfortable with telehealth readily agreed.

I’ve adopted other safety measures too, like pushing the chairs in my office six feet apart, and asking clients to use hand sanitizer upon entering the space. I’ve also created 90-minute gaps between sessions so that I’ll have time to wipe down the chairs, doorknobs, and light switches in between clients.

Perhaps the most effective strategy I’ve found is offering clients the choice of telehealth or in-person therapy with masks. At this point, about half of my clients have opted for telehealth, the other half for therapy with masks. Giving them choices, I think, gives them a small sense of control at a time when having control over things is rare.

In the midst of this pandemic, I’ve also found a new kind of courage, a way to use my own feelings of vulnerability and uncertainty to identify with those of my clients. It’s allowed me to find new ways of coping with a pervasive sense of loss that is affecting all of us.

Kim Charron, LIMHP
Grand Island, NE

***

Next Month’s Quandary: Week after week, my client’s sessions focus on her issues with her partner, who dismisses her feelings, refuses to work on the relationship, and even seems emotionally abusive at times. Since she doesn’t want to leave the relationship, I think couples therapy would be tremendously helpful, but the partner refuses to go and gets angry when she suggests it. I worry she’s just spinning her wheels in individual therapy, since all she talks about with me are the changes she wants to see in her relationship. What should I do?

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Topic: Professional Development

Tags: 2020 | Clinician's Quandary | Illness | Illnesses | Personal & Professional Development | Professional Development | Anxiety | client relationship | Client relationships | clients | Collaboration | therapist's office

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5 Comments

Monday, August 10, 2020 12:49:16 AM | posted by Andre Lampa
I get why a therapist like Karla above may want to follow a client's lead in wearing or not wearing a mask. This is going to make a client feel more accepted when the therapist follows their choice. However, it is of course more risky for both to remove their masks than if at least one mask were to remain worn between the two. Ironically, the safest course is for the therapist to do the opposite of the client who removes their mask, and retain their own. It is not only safer for the wearer, but most courteous to the other to continue to wear a mask. Keep in mind that masks are more effective at preventing disease transmission from the wearer than preventing transmission to the wearer. If humans were logical in nature, we would realize and appreciate that others wearing masks are protecting us more than themselves. Nevertheless, I suppose this explanation would not go too far in comforting a client. I think we would both feel pretty badly if either I or my client were to get sick following a session, even if the session was probably not the cause. For now, I'm sticking with video sessions.

Saturday, August 8, 2020 7:49:18 PM | posted by Michael McCarthy
Are any of these contributors trained in medicine.

Saturday, August 8, 2020 5:19:59 PM | posted by Susan Hartman Brenizer
I, too, am horrified by the answers of most of these clinicians. I have been practicing for 40 years and most of what has been said applies to many circumstances: not this one with a novel virus that has no cure and no vaccine. I have three infectious disease doctors in my family (one of whom worked hard in Africa with the Ebola virus and he says this is much more scary as it can hang in the air in "droplet form" for quite some time). I am more scared for younger therapists reading this piece and the advice given. No amount of "journaling, deep breathing, talking to other therapists, allowing your clients to make the mask choice, or getting good sleep and nutrition" is going to protect oneself if you are exposed to this virus. This is BIOLOGY, not psychology this time, and to say "I'll allow the client to decide" is irresponsible, at best. Many people are asymptomatic at time of transition of Covid-19, so what do therapists do to protect themselves and model this for clients, as well? Even with multiple mask wearing, our clients often cry in therapy, as well. What happens when clients cry? Naturally, they take off the mask to blow their nose, putting the viral load further into the air in front of therapists. I have a very active caseload, and I have made the most difficult decision to go to telehealth until there is a vaccine. I believe it is irresponsible to do anything else at this time. We must protect these beautiful therapists as well as our vulnerable clients.

Saturday, August 8, 2020 4:00:49 PM | posted by Lorraine
Thank you all for your responses. I was wondering why no one has utilized Newest Infrared Non-contact Thermometer Forehead Thermometer Instant Read Fever Indicator. This would be a way also of finding out if anyone has the virus actively. People may come to the office sick. In addition asking clients questions regarding their exposure in the past week. If any family member has had the virus and if they have been quarantined.

Wednesday, August 5, 2020 12:35:47 PM | posted by Bill Dearing
I am horrified to read Dr. Trzepacz's thoughts that an air-born disease will be controlled by shower curtains in her office. It's my understanding that curtains are not allowed in dialysis centers for the very reason that they catch and hold germs. There's nothing about her setup that sounds safe to me. Most offices are sealed in winter and use recirculated air. I do not see how a shower curtain will protect anyone from an airborne disease. Masks, while hiding our faces, also catch the particles coming out of our respiratory systems before they can enter the air. A shower curtain won't stop air from circulating within the room and entering someone else's lungs. I am very worried for both Dr. Trzepacz and her clients. I don't think that her decision is well reasoned and hope she reconsiders it.