Private practice: What you need to know about practising online

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Therese Mascardo, a psychologist who got her start in California, talks about how the conventional therapist can evolve using modern technology.

Summary points

  • Research supports that online therapy, for example via video conferencing, email and text, appears to be just as effective as in-person therapy.
  • Psychologists are switching to online therapy because it saves time, money and resources.
  • Providing online therapy can be a way of removing commuting time and achieving a better work–life balance to avoid burnout, as well as the opportunity to live or work in your chosen location.
  • Online therapy offers more accessibility to clients.

Being a therapist can be a tough job. Being a therapist in traffic-congested Southern California is something different entirely. In LA, it’s not uncommon for a commute of a few miles to take upwards of one and a half to two hours in just one direction. For someone who hasn’t experienced it before, it feels like a cross between The Hunger Games and The Fast and The Furious, only without the entertainment value.

By the time you’ve made it to the office, you feel like you’ve already been through battle.

I’ve been an online therapist for over five years. At first, it started out of a pragmatic need. I was living in LA and most of my clients were hours away in Orange County, and I could not manage to make the commute every day, but I wanted to keep seeing my clients. What started out as a way to bypass traffic and increase my available client hours has become one of the best decisions I’ve ever made, and my primary means of delivering therapeutic services.

In that time, I’ve seen the number of online therapists go from hardly any, to a proliferation of thousands. Platforms like TalkSpace, BetterHelp, and others have focused on providing mental health services via digital means (mostly video conferencing, email and text) and show no signs of slowing down. And my fully online practice, which I was worried at first would not thrive, has been full with a waiting list for months.

Here’s what we know

Research supports that online therapy appears to be just as effective as in-person therapy (APA, 2017).

In some studies, clients who received online therapy reported doing better than clients who saw their therapists in person (University of Zurich, 2013).

As the popularity of switching to online practice skyrockets, the landscape of private practice is changing. A decade ago, my practice was 100 per cent in person. Now my practice is 100 per cent online. I have received more inquiries about how to start an online practice in the past year than I have in the four years prior.

What are the major reasons many therapists want to expand to online practice?

Online therapy saves time, money and resources (in a nutshell).

  • Money. Without the need for a bricks and mortar office, complete with furniture, receptionist, waiting room with soothing music and magazines, and so on, online therapists save thousands of dollars each year.
  • Time. There are also gains in time. A full-time therapist in LA with a 1.5 hour commute each way might save approximately 750 hours each year by going online – that’s over 31 days saved by eliminating the commute. It’s hard to place a monetary amount on time, but it’s arguably priceless, as it allows therapists to spend more of it with loved ones, travelling, and doing the things that help them invest in their own health and wellbeing.
  • Reduced carbon footprint. The environmental impact of online therapy is especially noteworthy. I calculated that commuting 30 miles each way on weekdays in my Volkswagen sedan creates approximately 12,000 lbs of CO2 emissions per year. (You can check out TerraPass to calculate your own commute’s carbon footprint – see ‘Further information’.) That’s 12,000 lbs of CO2 that isn’t being released into the air now that I offer therapy online.
  • A level playing field. Online therapy levels the playing field by allowing therapists with different ability levels to tailor their practice to meet their health needs. Therapists who struggle with illnesses are able to maximise their time in a way that works for them.

These are significant gains for online therapists, which help to reduce burnout and help them to thrive. And when therapists thrive, we are equipped to serve our clients better.

What about clients?

Clients also see major benefits from working with an online therapist.

  • Time, money and the environment. In addition to reducing their carbon footprint, clients save time (by not commuting) and money (by not using fuel) that can then be reinvested elsewhere. Clients may benefit from reduced prices offered by therapists and platforms, perhaps due in part to reduced overhead costs.
  • Convenience and privacy. Clients have the convenience of being able to access their therapy wherever they are located. Clients have more control over their privacy and anonymity since they don’t have to show up at an office and sit in the waiting room. I’ve had clients contact me from their offices, dorm rooms and cars.
  • Accessibility. Clients with physical disabilities and illnesses can call their therapist from bed. Deaf and hard of hearing clients can go online to have more access to therapists who are fluent in Sign Language. Clients living in remote areas are able to see therapists who would normally not be able to serve them due to geographic distance. For clients who are not able financially to take on the burden of owning a vehicle and paying for fuel, online therapy may be a lifeline to get the services they would otherwise be unable to access.

Limitations: ‘But doesn’t it feel different?’

This is probably the most frequent question I’m asked, and my answer is, yes and no. Of course, seeing someone on a screen is inherently different from being physically present with them in the room. It’s more difficult to see micro-expressions. It’s more difficult to see the details in people’s eyes, the texture of their skin. You can’t smell alcohol, perfume or body odour (in the case that a client struggles with maintaining proper hygiene).

I don’t recommend online therapy for every population, and it’s best to really assess appropriateness for children younger than 12 and for people who have ADD (who may struggle more with attending to a screen versus someone in person). Interventions that involve playing games, drawing or painting require a bit more planning and preparation when you’re not physically in the room with the client.

Online therapy doesn’t help all people equally well. For example, studies show that CBT therapy is just as effective online as in person, but other types of treatment, like eye movement desensitisation and reprocessing (EMDR), do not support an online method of service delivery at this time.

However, real life-changing connection can and does happen effectively online. If it happened in the days when people would send handwritten love letters via snail mail, it’s not much of a surprise that real connection can also happen through a computer screen.

In fact, many of my teen and young adult clients prefer online therapy. Clients who initially hold reservations about online therapy tend quickly to warm to the idea. In my years of practice, I think I’ve only had one or two clients say they didn’t want to do their sessions online after trying it out. The bottom line is, most people become accustomed to the idea of online therapy and many end up loving it for the convenience factor. While online therapy doesn’t feel exactly the same as in-person therapy, it seems effective at doing what is arguably it’s most important job – helping therapists and clients to feel connected.

How therapists exist online is quickly evolving

2018–19 saw an explosion of mental health professionals and mental health content on social media platforms, especially on Instagram. Mental health and wellness accounts bring support, inspiration, and practical tools and tips to the Instagram community, increasing access to valuable mental health resources. There have been more outspoken voices for mental health online. Famous people from Lady Gaga to Lizzo to Prince Harry are vocal advocates for mental health and will often take to their social media accounts to share their own struggles vulnerably.

One of my favourite trends has been the uptick in mental health memes across social media platforms. Memes are often imbued with lots of humour while simultaneously breaking down mental health stigma. The hashtag #therapymemes, for example, has nearly 30,000 posts as of today.

There has also been a recent spike in therapists living and working as ‘digital nomads’. While providing therapy online, these therapists choose to travel the world, with stays ranging from a few days to several months. Living as a digital nomad for over a year (spending time in places like London, Berlin, Tokyo, Paris and Lisbon, to name a few) has broadened my worldview, exposed me to ways of practising wellness around the globe, and increased my quality of life significantly. I no longer have to limit my travels to a measly two weeks. (One of the things I’ve learned is that Americans have a pitiful number of vacation days a year compared with the rest of the world.)

When I see people travelling to exciting destinations, feelings of sadness that I’d never be able to travel there myself have been replaced with excitement. No destination is out of reach when you can continue to earn a living while you travel. Living as a digital nomad has completely redefined the concept of what it looks like to operate a private practice, and many colleagues in the mental health field are keen on the idea. A Facebook group I participate in, called ‘Location Independent Therapists’, has over 500 members, up several hundred from when I joined a year ago. Every week new therapists join the group, eager to learn how they can create a practice that allows them to travel and work at the same time.

It’s easier than you think

If you’re considering an online practice, it may be easier than you think. A life beyond the office, with potentially limitless travel, doesn’t have to be just a fantasy. The first step is to research the regulations within your state or country. At the time of writing this article, most US mental health professionals are limited to practising with clients who are physically located within their state(s) of licensure. PsyPACT is an agreement between several US states allowing clinicians to practise across jurisdictional lines.

If you’re panelled with insurance, you’ll want to confirm that telehealth is an allowable type of treatment.

It’s not necessary for you to be a technological genius, but you will need to have at least some basic internet skills when it comes to setting up your practice for success, so you can help your clients troubleshoot if and when technical difficulties arise. It’s also absolutely essential that if you are practising in the US you utilise a HIPAA (or equivalent if you practise elsewhere) compliant telehealth platform.

What does a successful online practice consist of?

The key to a successful online practice is the same as for an in-person one. Just being a good therapist doesn’t cut it. An effective marketing strategy that can connect you to potential clients is paramount. There are many ways to market yourself effectively, but my favourite way to connect with potential clients has been via Instagram. With 500 million daily active users, Instagram probably has more marketing power than any other social media platform in this day and age.

Unlike Facebook, people on Instagram are interested in purchasing goods and services as they scroll. I started my Instagram account back in April of 2018, and I receive an average of three to five inquiries a week from people interested in therapy. Because of Instagram, I’ve also received opportunities to collaborate with therapists and organisations whom I admire very much. I don’t think any of these opportunities would be possible if I didn’t make efforts to increase my Instagram presence.

Technology has afforded our field more options than ever before to have a successful private practice. With so many possibilities to live and work, one thing is for certain: the best way to build your practice is the way that is most life-giving to you.

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About Author

Therese Mascardo

Dr Therese Mascardo, Psy.D., is an online therapist and travels full time as a digital nomad. She founded Exploring Therapy, a wellness community to help people build a life they don’t need a vacation from. She teaches courses to other mental health professionals on how to start their online practice. You can find her on Instagram, @exploring.therapy

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