Patricia Carl-Stannard, LCSW, MSW, is a licensed clinical social worker with over 40 years of experience. She is a clinical associate professor of social work at Sacred Heart University. For the past two years, she has served as the university’s acting director of the school of social work. Balancing her duties as an educator with her work as a private practitioner, she specializes in developmental issues in children, adolescents and adults. She’s also well-versed in treating anxiety and depression disorders along with what she terms “life-transition” issues, such as grief and divorce.
Like so many of her peers, Carl-Stannard relishes the opportunity to foster long-term relationships with clients, often counseling young children until they reach college age. Until recently, those relationships would predominantly blossom within the confines of her office in Branford, Conn.
As with so many aspects of everyday life, the COVID-19 pandemic disrupted the rhythms of Carl-Stannard’s practice. But when she began offering teletherapy counseling services, she witnessed a surprising shift in the patient-practitioner dynamic. Relegated to practicing out of her home and using videoconferencing tools like Zoom, Skype or FaceTime to conduct individual and group therapy sessions, Carl-Stannard saw her patients make great strides in treatment thanks in no small part to their surroundings. They took solace in a favorite blanket and cozied up on sofas, letting their guard down and allowing a more productive dialogue to take place.
Likewise, Carl-Stannard feels more comfortable with her new surroundings. She is often accompanied by her dog, which can lead to the occasional disruption. But those, too, have the effect of deepening connections from afar rather than making the distance feel starker.
Sharing her perspective on online therapy and the clinical social worker, Carl-Stannard said of her frequent home-office companion, “He’s attached to my hip. He’ll bark and I’ll say, ‘Excuse me. I’m sorry.’ But I think it humanizes me for my clients. I, too, have a life. It’s not just being this professional therapist. Here’s how I cope.”
What is Telemental Health?
The National Association of Social Workers (NASW) defines telemental health as “the practice of delivering clinical healthcare services via technology-assisted media or other electronic means between a practitioner and a client who are located in two different locations.” Instant messaging apps can facilitate a live chat for patients who may not be comfortable with visual components, but telemental health services were available remotely well before the advent of the iPhone. Some of the earliest examples were crisis hotlines for suicide prevention and addiction.
One of the benefits of social work teletherapy enjoyed by both patients and clinicians is flexibility. The social worker can serve as a “lifeline,” as Carl-Stannard puts it, available at a moment’s notice to FaceTime with a patient calling from a grocery store parking lot. It also lowers the barrier of access to teletherapy psychotherapy for people in isolated areas. Social workers who are licensed in telemental health can effectively “broaden their availability,” Carl-Stannard said.
“There’s almost a feeling that we’re making a house call,” Catherine Monk, a professor of medical psychology at Columbia, said in a New York Times column published in May 2021. “We go with the patient; if they’re picking up their child at school, if they are in the car, we are there. And it adds to the role we are in because ultimately we want to know how to be useful.”
Of course, there are some logistical hurdles to clear. Technology tends to move faster than state legislatures, thrusting governing bodies such as the NASW and its local chapters into a complex ethical conversation. Regulatory issues such as licensure portability (which would allow practitioners to treat clients outside of the state where they’re licensed) and insurance jurisdiction were temporarily relaxed but still need to be addressed on a long-term basis.
Measures must be taken to ensure that teletherapy counseling sessions are HIPAA compliant and that discretion is exercised — even if it means employing encryption software to keep hackers and malware at bay. Additionally, Carl-Stannard and many of her peers require patients to sign a separate consent form for the virtual environment, acknowledging its inherent limitations. She devises safety plans for high-risk patients that task family members with intervening if necessary.
Despite these complicating factors, it seems there isn’t much debate in the social work community over online therapy vs. in-person therapy. Both have value, and practitioners will likely adopt a hybrid model going forward. In an extended interview on social work teletherapy, Carl-Stannard was a proponent of this method.
The following Q&A was excerpted from that interview. It has been edited for length and clarity.
Sacred Heart University: What were your initial impressions when you first started practicing teletherapy counseling?
Patricia Carl-Stannard: One of the things I noticed — it was interesting to me — after about the second or third telehealth session, my clients were completely relaxed and very focused on what their issues were. What I sensed was it was very different for them to speak with me from the comfort of their own home rather than coming to my office, which feels much more professional or perhaps even stigmatizing. Somebody walks into my office and my name and my license are on the door.
It’s not that it took on the quality of a friendship in the virtual environment; it was just more relaxed. I didn’t expect that, and in fact, I thought people would struggle.
SHU: Were there any technological growing pains?
PCS: Because of my academic experience, I had an upper edge. I had been accustomed to working online. For other colleagues, there was a learning curve. Finding the HIPAA-compliant program that would allow one to treat virtually was one challenge. Following the information that was coming out of the state, the governor’s executive orders, NASW insurance about the ethics around this — those were all additional challenges. We had to have a virtual system that was protected, that was “hack-proof.” A system with a password.
And then there was just the matter of really understanding the limitations. What do you do as a practitioner if you’re online with somebody who is expressing suicidal ideation? That’s really scary. Practitioners should have a discussion about the limits of telemedicine, telehealth. And they should have their clients sign a consent form that acknowledges those limitations. When I was working with someone I would consider a high-risk client, what I began to do was to get contact information for a significant other. If somebody is expressing suicidality, and I’m engaging them in trying to have a safety contract, but my gut sense is telling me “this is really possibly going to happen,” and the person gets off the call, I’m pretty helpless unless I can dispense somebody to that person’s home. It’s challenging.
SHU: Is it difficult to pick up on certain visual cues or facial expressions virtually — particularly when it comes to high-risk patients?
PCS: If I’m sitting in my office, I have a full view of the person. Not only facial expressions, but whether their leg is moving, their foot’s tapping, their hands are anxious. I’m only seeing from the chest up on Zoom. It heavily relies on facial expression, tone of voice, the pace of language, cadence. It’s partial information as opposed to full information, so there’s more pressure on really interpreting that virtual presentation.
SHU: Can you share an example of a relationship you had with a client that benefitted from teletherapy counseling?
PCS: A woman who is now 76 came into treatment two years ago because she lost her husband of 40 years. This was a very complicated bereavement because three months prior to losing her husband, her daughter lost her husband. So this was a family hit very hard by serious illness and death. The issue that came out was that she was very dependent on her husband. This was a very traditional marriage. Her husband had his own business and took care of all the finances and all the major issues around the house. And suddenly, she’s it. She had no confidence in being able to do those things. Our treatment centered around helping her tap into the idea that these are learnable skills. Yes, her grief is overwhelming, but within that grief, she can begin to become her own person and learn to manage. Over the two years, she did. My work is helping her see “yes, you’re alone in the sense that your husband is gone, but look at all these other people in your life you can tap for help.” It’s healthy to reach out for help. She’s really grown through all of that. About three months before the pandemic, she sold her home, bought another home — and of course, there was a resurgence of the grief because she was moving by herself. With telehealth, a lot of our sessions were looking at how those feelings were being compounded by the isolation of the pandemic.
Prior to that, she had really begun to get out into the community. She joined a yoga class and joined the local Y and was going to classes every day she wasn’t going to yoga. She had a group of friends that met every Saturday after a long group walk and went to McDonald’s for breakfast. This was a group of women that loved each other. All of that stopped with the pandemic. So again, you had all these layers and cutoffs. We started talking about how, “yes, it might feel artificial, but you can Zoom with me. You can also Zoom with others.” She started Zooming with family members out of state. She started Zooming with women from her friend group, and she joined a Zoom yoga class. So she found ways to cope. In recent discussions, there’s a sense of hope and light.
SHU: Has telehealth become a point of emphasis in your career as an educator?
PCS: All of our students complete field placements, which means they’re assigned to agencies and they’re working with clients. What happened in  was we had to pull everybody out of field placements. Agencies were shutting down. They couldn’t guarantee safety. We have a responsibility to keep our students safe. It created quite a crisis and a dilemma because our students need a certain amount of field hours so that we’re meeting our accreditation requirements. We’re accredited by the Council on Social Work Education. That accreditation body modified and reduced the required hours in order to keep schools open and to enable schools to place their students, so that was helpful.
What our field office had to do was assess which agencies could give our students field placement opportunities using telehealth. We have many students who actually were trained by agencies and who were engaging clients in assessment and conversation and providing resources vis-à-vis telehealth. Not all of our students had that opportunity, but some did. Students who at least got to wet their feet in the idea and provision of telehealth or telebehavioral health. It is not yet formally in our curriculum, but we actually have been approached by an agency that provides training and certificate training for practitioners in telehealth, and it’s something I’m looking at. It depends on how this particular company would relate to our school — there’s a lot involved. But ideally, it’s a certificate opportunity I would like to be able to offer our students. It’s a tool in their toolkit. It would be wonderful for them to be able to have it on their resume.
SHU: If you had to give a social worker advice about how to incorporate teletherapy counseling into a new private practice they’re starting, what would it be?
PCS: I’m the chair of the clinical social work network committee for the NASW Connecticut chapter. And for the past seven years, I’ve done a seminar for private practice folks, or for people in agencies looking to transition into private practice. It’s called The Business of Private Practice, and one of the topics I discuss is telehealth. What it means, what the regulations are, what the ethics of it are. I can advise people on that.
The next time I give this seminar, one of the pieces of advice will be that they could consider it as a full-time way to deliver their practice. Or they could have a hybrid, with some in-person and some virtual sessions. But as we go forward and it becomes a regular part of the profession, I would advise that private practitioners get certified in telehealth. I’ll do some research about who’s offering it because it has to be legit. Part of their intake packet will be to have the client sign a telehealth consent form in addition to the regular consent form. They will clearly need a HIPAA-compliant system by which to conduct the sessions. Telehealth will be the wave of the future. It will remain a part of private practice. And it will be a part of agency practice, I believe.
This is anecdotal, but what I’ve found is that people who have been in the field for a very long time, who are seasoned practitioners, struggle more with this than the younger people in the field. The younger people have all grown up with digital technology. They are digital natives. But the good news about neuroscience is that the plasticity of the brain allows those of us who are not native to digital life to easily learn it. It’s all learnable.
SHU: What sets Sacred Heart’s school of social work apart from other programs?
PCS: I’ve often thought if the younger me were looking for a program, this one is so different from the one I went through years ago. The accreditation standards are different than they were back then. But I think what differentiates our program at Sacred Heart is we focus on integrated practice. So for example, many people go into an MSW program because they want to be a therapist. And that’s a fine goal. But that’s not how we approach it. We’re not purely, intensely clinical. We are integrated into that, yes. We are very focused on the micro, meaning the individual experience and understanding people as individuals, assessing and intervening and treating them as individuals, but always keeping in mind that they are functioning in the macro. So in other words, how does their community impact them? How does the culture impact them? How does local government impact them? How does federal legislation impact them? We look at the impact of the macro on the micro and the impact of micro on the macro. The micro to macro would be the role of social work in advocating for policy because they’ve experienced peoples’ lived experiences and what the dilemmas are, and what the barriers are. It’s about trying to make changes on a systemic level.
We have our students take a look at the entire spectrum of experience. Some may want to specialize in policy and program and legislative issues, and that’s great. But they understand what’s happening for the individual. Others will go into private practice, but they can always look at their client system — whether it’s an individual, a couple or a family — and understand how the greater experience is impacting them. That’s unique to our program as opposed to the clinical track at other programs. Those are more narrowly focused and specialized.
The Teletherapy Revolution is Here to Stay
By and large, the benefits of teletherapy counseling outweigh any drawbacks. Industry professionals sense that a tide is turning and that changes born of necessity in 2020 will be permanently implemented. Seasoned clinical social workers like Carl-Stannard have embraced the medium, and it’s easy to understand why. A November 2020 study conducted by the American Psychological Association found that 44% of the approximately 1,800 practitioners surveyed reported fewer cancellations or no-shows in the teletherapy environment.
Telehealth apps like betterhelp — whose tagline is “therapy from your couch” — and Teladoc are attracting new clients in droves, nullifying the obstacles (such as access to transportation or childcare) that previously discouraged them from seeking treatment. In a May 2021 New York Times column entitled Has Covid Remade Psychotherapy for Good?, author Ginia Bellafante wrote, “Convenience has spurred a greater sense of commitment among some patients, and in some instances the virtual experience might not just rival the paradigm of two people physically together in space but also surpass it, however blasphemous that might sound. If the first step to successful therapy is showing up, the digital approach has been invaluable.”
Above all, teletherapy counseling lowers barriers to access, bringing these vital services to communities that have previously been underserved. Sacred Heart University’s CSWE-accredited online Master of Social Work program equips students with cutting-edge skills and invaluable field experience. And a rigorous curriculum taught by expert faculty is being tailored to meet the demands of an industry in transition.
Learn more about Sacred Heart University’s CSWE-accredited online Master of Social Work (MSW) program.