Telehealth Best Practices: Dr Dominique Morisano On How to Best Care For Your Patients When They Are Not Physically In Front Of You

There is something different, and more energizing, about connecting with another human in a physical space vs on a screen or on a phone-call.

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 Dr. Dominique Morisano.

Dr. Dominique Morisano, CPsych, is a clinical psychologist, adjunct professor, and researcher living in Toronto, Canada. After returning to school for a Certificate in Psychedelic-Assisted Therapies and Research at the California Institute of Integral Studies in 2020, she joined Field Trip Health, a psychedelic-assisted therapy company, as their Chief Psychologist. She holds academic appointments at the Centre for Addiction and Mental Health (Collaborator Scientist), University of Toronto (Adjunct Professor), and Erasmus University Rotterdam (Visiting Scholar), where she conducts research on personal goal-setting. She also runs a private practice in Toronto and New York (drmorisano.com) focusing on trauma and addiction.

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?

My path to becoming a therapist and Chief Psychologist of Field Trip Health, a psychedelics-assisted therapy company, has been somewhat unconventional. Sometimes I feel like Homer Simpson in how seemingly random life events have interacted to drop me into my current position. But three clear notes infuse my “backstory”…I tend to say “yes!” to most opportunities that appear in front of me. In addition, I am an optimist. And finally, I thrive on social connection. I always take time to get to know the people I meet along my life journey, and form solid relationships. This has manifested in an amazing network of colleagues and friends around the world, many of whom work with me now. In general, however, my backstory is non-linear. There were many times where I felt unclear about next steps. I got “knocked down” frequently, both literally and figuratively, and learned that I was responsible for picking myself back up. While my parents were both psychologists, and I’m sure that influenced me, I never wanted to be a psychologist…in university, I was more interested in becoming an anesthesiologist, joining Doctors without Borders, and playing jazz clarinet. Then, after a series of unexpected events, I found myself a recent college grad on 9/11, making $1.50/hr as a server in downtown NYC, completely overwhelmed by the state of the times. My student loans were piling up, restaurants were shutting down left and right, I was supporting myself, and I had to make a quick decision. I took two weeks, applied to a bunch of grad schools in psychology, because I always liked psychology..and decided to venture to Canada, on my own. From there, a string of events ensued across a number of cities that included getting heavily involved in the music scene, completing a PhD, starting a first-episode psychosis clinic, taking an implementation scientist position, opening a private practice, becoming an assistant professor, creating a goal-setting chatbot, and moving a couple of times to Europe. I was lucky that a career in Psychology allowed me to pursue all of my passions. I was very interested in understanding all the ways in which humans are affected by both acute and complex trauma, and what to do about it. In summary, with regards to my story, I would say that I have devoted the bulk of my life to figuring out how best to help people work through difficult experiences. A couple of years ago, I went back to school to study psychedelic-assisted therapies — a radical yet extremely promising route for addressing trauma, working through depression, and clarifying one’s ikigai, or life purpose…since then, everything has shifted for me.

Can you share the most interesting story that happened to you since you began your career?

The most interesting thing that’s happened in my career (that I can share here) is finding out that five years after I finished my PhD, a Dutch university was applying my research findings on the impacts of personal goal-setting to their entire student body to improve academic achievement and mood…and having success! All one can hope for as a grad student is that someday, somewhere, someone will read your work, so this discovery was beyond my wildest dreams. Ultimately, it led me to a long-term research collaboration with the Rotterdam School of Management, which has been extremely rewarding.

Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?

This is a tie between “This too shall pass” (Persian adage) and “When I accept myself just as I am, then I change” (Carl Rogers). The first has allowed me not only to get through dark days, but also to be fully present to sunny days. Everything in life is fleeting, a year can pass in a day, and we cannot hold on to anything. But that doesn’t mean we can’t appreciate the shifting tides or the experiences and visions that we have in the moment…or look back at the tough times and appreciate the lessons we have gained. The second has been key to my work with clients — my work is highly informed by Bill Miller’s Motivational Interviewing. As long as we feel unacceptable to ourselves and others, it is easy to feel stuck, and to give up. But when we see that our sense of worth (both in our own and others’ eyes) does not depend on us changing, it paradoxically allows us the freedom to explore other ways of being. I believe that all humans ultimately want to be better and to feel better, and I want to help them do just that.

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?

I am lucky to have had multiple mentors along my journey…people who would go out of their way to give me a step up whenever I got knocked down. My parents never failed to challenge me and teach me that I had to work hard…and as well, to let me fall often and pick myself back up…all the while offering me steady love. But additionally, I was incredibly fortunate to have an academic mentor, Dr Tom Babor, whom I have now been working with for 20+ years…he gave me my first job as an intern volunteer research assistant studying substance use disorders and making photocopies when I was 15. We have worked together on many books, workshops, presentations, and papers, and now we are co-organizing an international research conference on psychedelic-assisted therapies and medicines. He has always been there to lend an ear, crack a joke, give me advice, and keep me firmly grounded in ethical work.

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. Can you articulate for our readers a few of the main benefits of having a patient in front of you?

Some of the benefits of having a patient in front of you is that you are both able to experience the “little things” re: in person contact. I can get a sense of how they arrive into a session (punctuality, level of calm), how they get around town (transit, car, walking/biking), their overall appearance, the energy they are carrying, any smells (e.g., cigarettes, alcohol, cannabis, hygiene)…how they interact with the front desk, other clients in the waitroom…whether they are able to wait in the waiting room or come right to my door…I do miss seeing my clients in person. There is something different, and more energizing, about connecting with another human in a physical space vs on a screen or on a phone-call. I was an early adopter of Telehealth, and started doing “virtual” or video psychotherapy in 2011 for some of my clients…but it’s only been for the past year that I have been practicing entirely virtually. I think Telehealth is incredible, and offers a number of benefits over in-person, but I can’t say that it’s entirely the same.

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?

The challenges can be multifold:

1. There is something ineffable and almost energetic about the experience of being in close proximity to another human. Our brains are wonderfully complex, and pick up all kinds of information that would be difficult to ascertain on a screen (size, smell, overall appearance, body language, comfort in a space that is not home, interactions with the front desk and other visitors to the clinic, ability to wait to be let in, etc). If I come into the office and see that someone is two hours early for their appointment, that tells me something about them and what is going on in their life at that time. I can’t get that kind of information on video.
2. If someone discloses a serious desire to hurt themselves or someone else, I have less control over what happens next. I can call 911, but I cannot escort them myself to the emergency room or call someone to help me make sure they stay safe in my space. There is a lot of trust needed in a telehealth relationship.
3. We can miss some of the special components about being in a physical space with another human. For instance, if I am saying goodbye to a client I have seen for several months or several years, sometimes they appreciate the opportunity to be able to give me a hug. I have said farewell to many clients during this pandemic whom I care about deeply, on a screen. That has been tough, both for my clients and for me (though less tough for the clients whom I also started with on a screen!)

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.)

I think many of these challenges can be best addressed by first understanding that there are pros to virtual care, and that these serve to balance out what can feel “missing” from the video experience. But it’s also true that virtual care will not work well for everyone. I think that is:

Thing #1: For many clients, virtual care works as well as in-person care. For some, it works better than in-person care. And for others, it does not work as well as in-person care (and that’s ok). When I work with children, for instance, or even young teenagers, I find that even though the care I am providing virtually is better than no care…it is often not ideal. And for clients with specific phobias, it can be difficult (though not impossible!) to do physical stimuli exposure exercises over the internet. For some people, we are providing ideal care right now. And for others, we are providing stabilization, support, and harm reduction. As we work through this global pandemic, we are in an unprecedented time for mental health care, and in many ways, we are doing the best that we can.

Thing #2: To address potential emergencies, it is important that you always know where your client is located when you are meeting with them (i.e., address); furthermore, it is key to have an updated emergency contact on file for your clients. It can be good to have a backup way to contact someone in case internet cuts out, as well — this might mean making sure there is a phone that you can contact the client at, if need be, and as well, giving the client a phone number that you can be reached on during the session.

Thing #3: Consider taking advantage of the additional information you might gain from a client virtually, to offset the information you might normally observe from meeting a client in person. For example, pay attention to the space they are calling you from. And if they suggest it, remain open to meeting the other people (and animals) who live in their space. Yesterday a client offered to introduce me to their new baby, and it was an absolutely lovely interaction. I was able to observe my client as an active parent, and I would not have had this opportunity in the office.

Thing #4: Consider enacting a “virtual hug” at the end of final sessions, if they express the desire for an in-person goodbye hug (this happens frequently), and it feels appropriate for the client. For some of my clients who have been seeing me for a long-time virtually, I do often offer them an in-person session as their final session. During these pandemic times, I have made an agreement with some clients I have closed with that when it is safe to do so, we can meet again, for an in-person goodbye session, if that is something they still want at the time.

Thing #5: Get a good set of headphones, and suggest the same for your clients. Headphones can really help with privacy concerns, and influence the quality of the conversation (e.g., reducing feedback, improving sound clarity). In addition, test your internet speed (fast.com or speedtest.net are helpful sites) before you start doing virtual care and consider upgrading if you have lower than a 30mbps download speed or 5mbps upload speed. And ask your clients to do the same. For clients who cannot afford faster internet or who live in rural areas, sometimes it can be helpful to put the video call on mute and use your phones as a backup voice connection (or to just drop the video altogether).

When all is said and done, privacy matters, internet speed matters, headphones help, you can show care and compassion through a screen, and you can truly help people online.

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?

One thing that I love about Telehealth is that I can see a client in their home environment. That means I can see how they are living outside of my office, “meet” their pets (one of my favorite parts of virtual therapy), meet their kids, siblings, parents, and partners quite easily, and get a better sense of the context from which they are embarking into therapy. As well, my clients that used to be late for appointments due to public transit delays or traffic are now on time and making the most of their session hour. We can look things up together online (e.g., courses, job opportunities, community resources and opportunities), and even action items that might normally be “homework” — this can be a good exposure exercise for clients with anxiety. For instance, if someone has been wanting to exercise, or get out in the sun, but has been unmotivated to follow through, we can use our time together to do just that — I can encourage my client to take me “on the road” and go out for a walk, or jump on their stationary bike while we talk on the phone. I can also quickly send clients links, as well as a copy of the goals they set in the session, to action before we meet again…vs them having to take notes themselves. For clients who have trouble leaving the house, virtual care makes the process of managing mental health much more friendly. Finally, and I think we talk about this one less…sometimes the feeling of distance created by the virtual visit can facilitate a comfort in client disclosure of difficult experiences, especially for clients with attachment issues. Though I’m sure many therapists can appreciate the potential safe “container” that an in-person visit provides, I have also found that some clients have felt more comfortable sharing information about traumatic events from their past to me on the phone, or on video, than they would in person. I think this is the same reason that therapeutic “chatbots” have become popular in recent years…sometimes there is a safety in distance. And we can work with that.

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?

I have to be honest that I have kept my own Telehealth practice pretty simple. I generally like to focus on the therapy itself vs. all of the bells and whistles. I think it is difficult to replicate the in-person experience, and I think it’s ok for Telehealth to offer a different experience with its own unique benefits. For my private practice, I use a simple privacy-compliant video software program, take notes on my computer, use a double-encrypted email tool, and that’s about it! I do work with clients in integrating a fair number of “apps” in our work together, depending on the presenting concern (e.g., meditation apps, habit loggers, sleep trackers). But I use apps regardless of whether I see clients in person or on video. In the future, I think there are a lot of potential applications of VR for Telehealth. We just aren’t there yet, at least in the mainstream. And I will also say that at Field Trip, we include multiple tools in our psychotherapy treatment program that are designed to help improve the virtual experience. For instance, we give clients access to a “portal” tool through which therapists can send them information about their treatment, videos, and meditations, where they can co-create various goal and activity plans, and where the clients can communicate with the care team. Tools like this can be helpful in facilitating connection and rapport in the therapeutic relationship.

If you could design the perfect Telehealth feature or system to help your patients, what would it be?

I think that privacy at home is one of the toughest things my clients have to deal with — how to find a space where they can feel free to talk openly, and freely, without fear that their roommates/partners/parents/kids/etc can hear through the walls or enter the room. “Headphone problems” and “bluetooth problems” are also an issue in pandemic-era Telehealth. Having headphones on during a session definitely ups the privacy…but often comes with its own set of technical caveats. General ambiance of the space can also be an issue. And when we only see the upper half of someone, body language can be missed. If I could design a feature to solve these problems, well, I think I would know that I was living in the future. Maybe down the road, if this Telehealth trend continues, we could set up soundproof pods with telehealth connected screens in cities and communities where clients could go for private conversations with their healthcare providers…perhaps virtual reality could also play a role in setting up a “virtual office” and allow us to both be “physically present” in full (wider screens? Video capture of the whole space?). The possibilities are endless, and someone somewhere has likely already thought of a solution for all of these issues!

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?

I think it’s important for clients to know that whatever the setting for therapy, the work they put in will be correlated with the outcomes they see. If they show up with their fullest selves, aim for an authentic and vulnerable relationship with their therapist, and set feasible goals that they can commit to seeing through…they should see results. I always tell people that even if I see them 1 hour weekly…that leaves 167 other hours to grapple with…so following through on intentions in between sessions is paramount to success.

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?

An old friend of mine was plugging VR to me as a tool for psychotherapy about 6 years ago…and at the time I saw the potential, but couldn’t ascertain a clear need. Presently, with stakes rising in population mental health, we are at a crossroads. In 2021 people are suffering, and our need for virtual wellness options is growing exponentially. I think that VR represents an incredibly exciting well of potential. There is something “missing” in the 2D. I know that virtual therapy works, and works well, but I would love to design all the features of my “virtual office” and have offerings within it that I could use to both resource and creatively challenge my clients. I can’t wait to see what happens as the field of VR wellness grows.

Is there a part of this future vision that concerns you? Can you explain?

Great question. This has come up as a thought exercise for me even in my decision to reduce my hours at the office space I lease in downtown Toronto…if Telehealth is so convenient, are the benefits of in person care enough to make us return? And what does this mean for psychological care in general? New therapists are graduating and never having the experience of working in an office space in person with clients. My younger brother graduated from therapy school last year and went straight to working online. I hope that what Telehealth does for us is simply expand our options, instead of limiting us to one form of practice.

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. :-)

While I won’t admit to being a person of great influence, I will say that through my clinical and academic work, I have been able to influence a moderate number of people to go after their goals, chase their dreams, and infuse their lives with as much joy and compassion as possible. As I see it, there are no real rules in life. We are here for a relatively short time, we all got here around the same time, and we are all just figuring it out in unison, as best we can. I hope that as a collective presence on this planet, humans can work together, with other species, and enact principles of social justice to help each other live the best lives possible, with the least harm possible, and the most compassion possible. I hope that we can help each other to heal from our collective suffering and live with as much joy as we can muster.

How can our readers further follow your work online?

I don’t have a big online presence, as most of my time is spent seeing clients, working at Field Trip, doing research, or teaching. But if you do want to see what I am up to, you can keep an eye out on my website drmorisano.com, which I try to update now and then, or my fledgling Twitter account (@drmorisano). As well, you can follow progress on the international psychedelics research conference I am organizing next year at fromresearchtoreality.com (website in development)…it’s a volunteer project, but a labor of love!

Thank you so much for the time you spent doing this interview!

It was my absolute pleasure!