Telehealth Best Practices: Christie Pearl On How To Best Care For Your Patients When They Are Not Physically In Front Of You
Give Verbal & Nonverbal Cues: Natural silences, looking away and other aspects of normal communication can come across as awkward or dismissive over telehealth. Giving verbal cues about what I am doing can help bridge the gap in communication with my client. For example, if I look down to write something, I tell my client that is what I’m doing. Or if I look away, I can say “Let me think about that for a second.” Nonverbal cues can also be valuable. For example, if a natural moment of silence occurs, gently nodding my head can indicate that I’m listening and gives a sense of motion on the screen to avoid a frozen visual effect.
One of the consequences of the pandemic is the dramatic growth of Telehealth and Telemedicine. But how can doctors and providers best care for their patients when they are not physically in front of them? What do doctors wish patients knew in order to make sure they are getting the best results even though they are not actually in the office? How can Telehealth approximate and even improve upon the healthcare that traditional doctors’ visits can provide?
In this interview series, called “Telehealth Best Practices; How To Best Care For Your Patients When They Are Not Physically In Front Of You” we are talking to successful Doctors, Dentists, Psychotherapists, Counselors, and other medical and wellness professionals who share lessons and stories from their experience about the best practices in Telehealth. As a part of this series, I had the pleasure of interviewing Christie Pearl, LMHC.
Christie Pearl is a Licensed Mental Health Counselor who uses the powerful benefits of EMDR therapy in her online private practice in Massachusetts and Virginia. She specializes in healing trauma, professional burnout and confidence issues. She is passionate about helping mission-driven women resolve emotional blocks so they can achieve their potential and fulfill their purpose.
Thank you so much for joining us in this interview series! Before we dive in, our readers would love to “get to know you” a bit better. Can you tell us a bit about your ‘backstory’ and how you got started?
Like many of my colleagues in the mental health profession, part of what drew me to becoming a therapist was my own painful life experiences and the empathy that comes with having done my own healing work. I like to think of myself as a fellow traveler on the journey, and I consider it an honor to accompany my clients on their own healing journeys. In late 2019, after working in the mental health field for over 15 years, I realized a longtime dream when I left a group practice and opened my own private practice. I rented an office, implemented my marketing plan, and quickly had a full caseload of clients. Little did I know that in a couple of months the dream was going to look very different! #COVID19. When it was clear that in-person sessions were no longer advisable due to the pandemic, I pivoted my practice to being fully online in a matter of days. Prior to March 2020, I had never done a telehealth session. At first, I was hesitant about doing online sessions because I wasn’t sure how it would feel for myself or my clients. But I have been pleasantly surprised at how this new format has worked and the results that my clients continue to achieve.
Can you share the most interesting story that happened to you since you began your career?
In spring of 2018, I had the honor of being cast in the Boston “This Is My Brave” show, where I performed an original essay about my personal experience with mental illness. This Is My Brave is an organization that works to end stigma about mental illness and spread hope through featuring stories from people who are living successfully with or are in recovery from mental illness. Being part of the production was a “coming out” of sorts for me, both personally and professionally. My goal in participating in the show was to share my own story so that it could encourage those who may be struggling, as well as to challenge myself to be more authentically myself. Because all of the shows are posted online, I knew that it was possible for clients to discover my performance if they search for me online. As a mental health professional, we are taught to hold strong boundaries around what we share with clients, and sharing my personal story in such a public way could potentially create complications in my therapeutic relationship with clients. I also felt vulnerable with the idea that clients could know about my most painful moments. Since the show aired, I have had a couple of clients tell me that they have watched it. Their responses were exactly what I would have hoped — they felt encouraged, and we were able to use their knowledge about me in a way that served their therapeutic growth.
Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?
One of my favorite quotes is “Not all those who wander are lost” (J.R.R. Tolkien). For many years of my early life, I wandered around feeling lost. I struggled to know who I was and what I was called to do. I envied people who seemed to have it all figured out from a young age, people who seemed to walk step by step along a straight path into their future. Eventually I realized I wasn’t lost at all, that I was being led along a different kind of path that was longer but purposeful. I learned that my contribution to others would come from my understanding of that other path.
None of us are able to achieve success without some help along the way. Is there a particular person who you are grateful towards who helped get you to where you are? Can you share a story about that?
One afternoon walking down the hall on my way to class in graduate school, my eye was drawn to two flyers hanging side by side on a bulletin board. One flyer was for a choral group on campus, and the other flyer was for the university gospel choir. As I stood there gazing back and forth from one to the other, my attention finally landed on the flyer for the gospel choir, UNITY. Still early in my relationship with my creativity, I was afraid to be “found out.” I had not sung in front of people since childhood, much less in a choir. I couldn’t sight read and didn’t even know what part I sang. The old voices in my head called me an imposter. Despite my reservations, I showed up at an open audition for the UNITY gospel choir not knowing what to expect and positioned myself in the back of the room. All of a sudden, a diminutive Black woman whose physical stature belied her commanding presence arrived and, without saying a word to anyone or even sitting down, skillfully and powerfully delivered a song from the piano. I was mesmerized. She organized us into sections and led us through simple songs with three-part harmonies. No one appeared to notice that I had no idea what I was doing, but I felt encouraged that I was able to follow the parts she taught. The music from the piano and all the voices ricocheted off the walls in the tiny room where we stood, enveloping me in a powerful swirl, and I felt like I was levitating. I had never felt like this before. This audition was the first of many nights I would spend with the UNITY gospel choir, both in rehearsals, concerts and other events in the area. Eventually, I was asked to lead songs and graduated from choir member to soloist.
One day a little before Easter, our choir director announced that if anyone didn’t have a place to go for Easter that they were welcome to attend her church. A church community was something I had longed for, but had not yet found the right fit. Feeling led to go, I got up early on Easter Sunday morning and made the trek across the city — two trains and a half-mile walk — to the church. As I walked up to the entrance, I heard music wafting out from the doors and, even before I actually saw her, recognized my choir director’s powerful command of the keyboard, a familiar refrain calling me inside. Although I felt comfortable being one of only a few White people in the room, I felt somewhat apprehensive about how my presence would impact the other churchgoers, whether it was OK if I was there. Once again, the familiar feeling of somehow being an imposter returned, only this time it was interrupted by a smiling woman walking toward me with her arms stretched out wide and love all over her face. “Welcome, sister!” she proclaimed, as she wrapped her arms around me in a motherly embrace. I immediately felt like I was at home. At the end of the service during the altar call, feeling as if I were being nudged toward the altar, I made my way forward and joined the church. Soon after I joined the Worship Team and was leading songs on Sunday mornings. That day was 17 years ago now, and the decision to become part of this community has opened doors to spiritual, relational, emotional, and musical growth that I could never have imagined. I would not be who I am today without my church family.
Ok wonderful. Let’s now shift to the main focus of our interview. The pandemic has changed so many things about the way we behave. One of them of course, is how doctors treat their patients. Many doctors have started treating their patients remotely. Telehealth can of course be very different than working with a patient that is in front of you. This provides great opportunity because it allows more people access to medical professionals, but it can also create unique challenges. To begin, can you articulate for our readers a few of the main benefits of having a patient in front of you?
Being in the same room with a client allows a deeper level of what therapists call “coregulation.” In other words, when we are physically together, our nervous systems can sense each other’s presence and adjust based on the actions or energy of the other person. When working with clients who have experienced trauma, often their nervous systems are in an activated or overwhelmed state, and part of the therapeutic process is first helping the client coregulate and then eventually they are able to regulate on their own. Part of creating an environment where the client can experience calming through coregulation is the physical environment. One benefit of seeing clients in the therapist’s office is that the therapist has control over the environment, and the client has a sense of transition from “outside life” into the containing environment that the therapist has created. Another benefit of meeting in person is the therapist’s ability to read facial and body cues more easily, as well as being able to limit distractions and interruptions to allow for greater focus and privacy.
On the flip side, can you articulate for our readers a few of the main challenges that arise when a patient is not in the same space as the doctor?
One of the main challenges when we aren’t meeting in the same space is using technology in a way that feels “human.” It takes a lot more energy to feel connected over a screen. Whether it’s from the strangeness of not being able to look directly into each other’s eyes, the urge to lean more forward or speak more loudly than you would in person, or simply the effects of blue light — telehealth is hard work. Also, we experience natural elements of communication differently when we’re online. Natural silences or physical stillness that occur during in-person sessions can feel anxiety-producing on telehealth out of concern that the connection is lost or frozen. Looking away, which we all do in normal conversation, can come across as indifference when on camera. Finally, technology isn’t perfect and sometimes there is a loss of connection, which interrupts the therapeutic process in a way that typically doesn’t occur with in person sessions. Staying mindful of these issues is important to maintaining the relational connection with clients when working via telehealth.
Other challenges include greater likelihood for clients to forget appointments because they are not building in travel time to an appointment and their sessions are falling more naturally into the fabric of their already heavily-scheduled day. With many people working from home and juggling competing demands, it can be easy for some to lose track of time.
Finally, some clients can struggle with boundaries and may allow family members or others to overhear their sessions or be distracted by others in the home or workplace.
Fantastic. Here is the main question of our interview. Based on your experience, what can one do to address or redress each of those challenges? What are your “5 Things You Need To Know To Best Care For Your Patients When They Are Not Physically In Front Of You? (Please share a story or example for each.)
- Appointment Reminders: Not the most exciting tip, but sending appointment reminders to clients both the day before and just prior to the appointment on the same day can really help keep things on track. Many electronic health records (EHR) systems have a built-in feature that allows you to set up automatic reminders which greatly reduces missed appointments. Include in the appointment reminder a prompt for the client to check their internet connection ahead of time. My EHR allows me to set up automatic email and text reminders so that every client can receive a 24-hour and 10-minute reminder, which has resulted in no-shows rarely occurring. And that’s exciting!
- Have a Backup Plan for Technology: Both therapist and client should check their internet connection ahead of time! Make sure you have a strong connection and, if you don’t, take steps to improve it such as closing other browsers, trying a different browser or consider upgrading your internet capacity. Therapist should have a backup plan such as an alternative HIPAA-compliant video platform or, if all else fails, conduct the session by phone (if permissible in your area). Most important for the therapist is staying calm and using your own regulation skills if you have technical difficulties so that you can maintain a sense of safety for the client in the conversation. This allows you to model for clients how to handle challenges. On several occasions when I have needed to use a backup method of communication, I have treated it as an opportunity to have a change of pace in the therapy and clients have experienced those sessions as a time for fresh perspective and new insights.
- Create Natural Beginnings and Endings: Whether in person or online, the first few minutes of a therapy session is typically transitioning into the therapy space, saying hello and preparing for the work to be done in session that day. Likewise at the end of a session, you are helping the client prepare to leave and transition into the rest of their day. When using telehealth, it is important to create that same sense of “entering” into the space by inviting the client to make the mental shift into your virtual office. I often give verbal cues about my physical space, such as commenting on what I’m looking at outside my window or connecting with something in the client’s physical space such as a plant or pet in the background. Being aware of each other’s environments helps build connection and mindful awareness of the present moment. I also sometimes start sessions with a few deep breaths together to help center us in the moment.
- Keep Healthy Boundaries: Boundaries help us feel safe in relationships, and that includes therapeutic relationships. It’s important to maintain the same boundaries in telehealth that you would in an office. Therapists vary in terms of their comfort levels with different locations that clients might choose for their sessions, and the privacy that they require. Sometimes clients struggle with boundaries, and doing sessions from home can highlight those issues. This can be helpful from a clinical perspective because it gives an in vivo experience for the client and therapist to work through together. I have had the opportunity to model good boundaries with a few clients when it was clear that others were walking into the room by saying, “Let’s wait until you’re alone to continue.” I have found that clients often begin to set their own boundaries after prompts like this. I have also found it helpful to outline my expectations for privacy in my Telehealth Consent Form.
- Give Verbal & Nonverbal Cues: Natural silences, looking away and other aspects of normal communication can come across as awkward or dismissive over telehealth. Giving verbal cues about what I am doing can help bridge the gap in communication with my client. For example, if I look down to write something, I tell my client that is what I’m doing. Or if I look away, I can say “Let me think about that for a second.” Nonverbal cues can also be valuable. For example, if a natural moment of silence occurs, gently nodding my head can indicate that I’m listening and gives a sense of motion on the screen to avoid a frozen visual effect.
Can you share a few ways that Telehealth can create opportunities or benefits that traditional in-office visits cannot provide? Can you please share a story or give an example?
The most obvious benefit of telehealth is the convenience. For many people, therapy is much more doable if they don’t have to factor in travel time and can fit it into their day in between other obligations. One group of people who have benefited from the convenience in particular is new moms. Telehealth allows mothers to stay home with their newborn, be comfortable in their own environment and still access the care that they need.
Telehealth also creates access for people who may be geographically distant from an available therapist. For example, since I transitioned my practice to telehealth, I now serve clients who never would have been able to work with me because they live far away from where my office was located. I practice a therapeutic modality that is very specialized, and now I can serve clients anywhere in the state, as opposed to being limited to my local area. This not only creates more access for clients, but it opens up greater opportunity from a business perspective as well.
Let’s zoom in a bit. Many tools have been developed to help facilitate Telehealth. In your personal experiences which tools have been most effective in helping to replicate the benefits of being together in the same space?
Screen sharing! I love sharing my screen with clients when I want to explain a concept through visual aids or teach a skill using words or drawing. I am famous for using my computer’s whiteboard so I can write or draw something out and sharing my screen so my clients can see it. It really helps build engagement and keep us in sync.
If you could design the perfect Telehealth feature or system to help your patients, what would it be?
I think it would be amazing to have a biofeedback mechanism built into the telehealth platform so that clients could be aware of their biometrics during session. The latest research in trauma and neurology tells us that we hold traumatic experience in our bodies as well as in our minds. As a Certified EMDR therapist, I routinely teach my clients to be aware of their physical reactions as we are working through issues, so having actual information about that would be amazing!
Are there things that you wish patients knew in order to make sure they are getting the best results even though they are not actually in the office?
The downside to the convenience of doing therapy in between other meetings is that sometimes clients don’t have much transition in between. I have thought about asking my clients to spend the 5–10 minutes prior to their session practicing their calming skills so that when we start the session they are in a more grounded state. This practice would simulate the “waiting room” time that used to exist when people came to the office and would give them more of a mental transition into the session.
I also wish clients remembered how sacred their time in therapy is even though it looks different now. With so much of life happening online for the past year, sometimes there is a natural tendency for therapy to blend in with everything else.
The technology is rapidly evolving and new tools like VR, AR, and Mixed Reality are being developed to help bring people together in a shared virtual space. Is there any technology coming down the pipeline that excites you?
I am very excited by the idea of virtual reality or any technology that simulates an in-person experience.
Is there a part of this future vision that concerns you? Can you explain?
I think advances in technology should excite us as well as concern us and that is a healthy way of looking at both the advantages and disadvantages of progress. As a mental health professional, I am always concerned about privacy because I want my clients to feel comfortable and protected when sharing personal information with me.
Ok wonderful. We are nearly done. Here is our last “meaty” question. You are a person of great influence. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger. :-)
I want to inspire a movement that educates the world about childhood trauma, its effects on people in adulthood and how to recover from those effects. I want the world to understand that “trauma” is more than the usual things that might come to mind when you hear that word, and that nearly all of us have experienced some form of it. I want people to know that healing is possible, but that there’s no checklist of what to do for that to happen — that there’s no shortcuts and you have to do the work. I want to help people heal from trauma so that future generations don’t have to carry the emotional pain of their ancestors.
How can our readers further follow your work online?
Thank you so much for the time you spent doing this interview. This was very inspirational, and we wish you continued success.