Episode 3: Inclusion and Exclusion Criteria for Your Online Therapy Practice
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Welcome to the online income for therapists podcast!
what this episode is all about
Do you worry about who to bring in or who to refer out in your online therapy practice? In this episode we discuss who you are allowed to see in your online practice, inclusion and exclusion criteria, treatment differences in an online practice, and documentation regarding your decisions.
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Introduction: (00:13)
Hey there, friends. Welcome. You are listening to the online income for therapists’ podcast. I'm your host, Amber Lyda, and we spend time here to talk about how you can build more freedom, flexibility, and flow into your work life and your personal life. We do it by harnessing the power of the internet. We take all of those big ideas you have, the passions that you hold and all of the hard-won experience and expertise you already have. We put them all together and we form them into a business online or maybe two or three businesses. Totally up to you. I help people learn how to build an online therapy practice or use their helping skills in other ways like build online courses or membership sites, eBooks, online coaching, whether it be life coaching or business coaching. If you're thinking about moving your business online, you want to stay tuned to this podcast. All right, let's go ahead and get started.
Who Am I Allowed To See In My Online Practice?: (01:31)
Hey, I'm so glad that you're listening in. One of the biggest questions that I get from therapists who are wanting to build an online practice is who am I allowed to see in my online practice? So today we're going to be tackling that topic together. I want you to first think about who you would want to see in your face to face practice. So, let's imagine for a moment that the online piece of this isn't even on the table and I want you to think about it as a solo practitioner. So, it's just you, you own your own private practice. I want you to think about the gate and who you would allow into your private practice and who would you not. So, I'll give you some examples. If I'm a solo practitioner, I want to make sure that the people that I see aren't going to need services beyond what I'm able to offer. As a solo practitioner, I can't answer emergency phone calls during the workday because I'm going to be in with other clients. So, if I'm screening someone to come into my solo practice, one of the things I'm thinking about is, is this a person who is likely to need emergency services during the workday? If so, I want to refer them to a practice that can manage that. Oftentimes group practices have the ability to manage that because they have multiple therapists on-site, so if there's an emergency, perhaps they have something built into their plan so that another therapist can kind of step in and cover them when the primary therapist isn't available. I'm also going to think about the fact that even outside of business hours, I'm not going to want to answer emergency calls. I've worked all day, I have to recuperate at night, and so I want to think about, okay, is this somebody who is likely to need frequent or recurrent after-hours crisis intervention and if so, they're going to need more care or at least a different kind of care, then I'm able to provide in my practice as a solo practitioner. I also think about the fact that while I might do a great job screening people in the beginning, so that if they need frequent or recurrent crisis services, I get them connected to somebody who can provide it. We can't always predict what might change in someone's life after they've gotten started with therapy. So, I think about making sure that I'm really clear about how their state or country regulations work to know if I can adequately respond to crises, should they come up. I make sure that I understand how emergency services work in their county and that they're aligned with how I work in my practice and I know how to get them help, should they need it. So I sort of think about, all right, I want to make sure that I screen people out who need crisis services recurrently or frequently so that they can get exactly the type of therapist and practice they need, and I want to make sure that in case something changes for this client while they're in therapy with me, that I am able to respond to their needs. So if they happened to live in a country where I can't make sure that we can get some crisis services to them because it's online, my practices online, then I'm going to have to refer them to someone who can help them in person or perhaps somebody who works online in that country and has more access to resources.
Inclusion and Exclusion Criteria: (05:06)
Okay, so we've been pretty focused on crisis management and emergency services, but let's switch gears now. I want you to make two lists on the left-hand side, inclusion criteria, on the right, hand side, exclusion criteria. So on the right-hand side for me as a solo practice owner, anyone who's going to need a recurrent or frequent crisis service or emergency responding. Let's think about what else you may want to put in your inclusion and exclusion criteria. I limit my practice to those folks that I am very, very competent to treat. Under inclusion criteria, I would have people who had symptoms of anxiety or depression, a recurrent depression, but maybe not so much a dysthymic depression. I would have complex trauma. So those are conditions that I know I'm really well trained to treat. So, take a look at your paper right now and just start to jot down those sorts of clients or symptoms or personality types that you know you are particularly competent at helping. Now, I hope you guys paused and did that. Now as you go back to that list, you might start to think again about those early exclusion criteria that I talked about for my own solo practice. And when I think about treating people with complex trauma, let's say, I have to think about the fact that often early in treatment, clients with complex trauma may be particularly emotionally dysregulated. They may be prone to need more crisis services than I'm able to offer in my solo practice. So, I have to go back and I have to kind of tease out, all right, so even though I'm very competent to treat people with complex trauma, is my practice set up to be able to really help them, to be able to support them. And so where I have landed with that is that if somebody has been through the foundational work for complex trauma, particularly if I've treated them in the past and a community mental health or university center, then yeah, I'll bring them into my practice because they're emotionally regulated and the likelihood that they would need crisis or emergency services is pretty low. But if it's somebody very new to me and I don't feel like they have the foundation already in place, then I'm going to refer them likely to a group practice who have more emergency and crisis resources available to support the client. So go back to your inclusion list and look at those folks that you feel really well equipped to treat from a training and expertise point of view and evaluate whether or not they fit for exclusion criteria you may have around kind of the scope of your service, what's you're able to offer if you're a solo practitioner.
Online Practice and Treatment Differences: (08:30)
Now let's switch gears a little and talk about the fact that your practice is online, right? So, it's not just a solo brick and mortar practice, but it's an online practice. And let's think about that list of people you're super competent to treat and think about how that treatment may look different online. And the sorts of situations that most often come up here are where you would need cues that might not be available to you in an online-only situation. For example, if your specialty is in treating folks who have a restricting style eating disorder that might present as a change in, body size or might present with other physical cues, you may be a little more reticent to treat that person online. So you might need to think about, okay, so what are the cues that I wouldn't be able to have and are there any workarounds? So, for example, I do know clinicians who specialize in treating restricting or other types of eating disorders that would present with some physical cues. And the way that they work around them is that they have a registered dietician that they work with who sees the client in person regularly and they work as a team. So, they're still able to get the data that they need and they're able to offer the service online. Another clinical example that often comes up is if somebody has a substance abuse or use disorder that you might be able to pick up cues in an in-person session, for example, alcohol on the breath or on the skin that you wouldn't be able to pick up in person. But if that's your jam and you know that those are the folks at your best or amazing at treating, you can consider if there might be some workarounds for you, if there might be some ways to utilize somebody who's on the ground is what I say, who's on the ground to support your treatment with that person. Or perhaps they're in an IOP, but you are the individual therapy provider and the other services are provided on the ground or in-person. So, there are lots of workarounds. We just have to be really conscientious to make sure that we're doing the right thing by our clients. So, we've talked about number one, thinking through what's appropriate for a solo practice, whether it's in person or online. And when I think about that, I'm also thinking about what's appropriate, not just by somebody else's recommendations of a solo practice, but the way that I want to live outside of my solo practice. I don't want to be on call. It's not good for me and I don't think that it makes me a great provider during normal business hours. So that's number one. What do you think is appropriate for you and what do you think is appropriate for his solo practice? I guess that's one and two. And then number three, if we're going by that count, given what you are really kick ass at doing. So, writing your list of these are the folks I'm super competent to treat. Are there any issues that I might miss by providing the service online instead of in person? And are there any workarounds? So again, my workaround is that for complex trauma, it's somebody who has been through a substantial amount of treatment already. They have the skills to stay emotionally regulated and they're unlikely to need crisis and emergency services. Another workaround with that might be, that they have an in-person maintenance DBT, a DBT group, DBT support. There are lots and lots of ways that we can provide excellent clinical care, but we have to keep that at the forefront of our minds as we're making clinical decisions about who to bring into our practice.
Documenting Decisions: (12:35)
I also want to point out another piece that might enter your head as you're deciding who to bring in and who not to. When we think about who would be looking at our practice and our choices if we were to ever get in some sort of trouble. So if a client were to ever bring, I was going to say a lawsuit, but if our client were to ever bring charges against you or go to your board with a complaint, you need to make sure that the decisions that you have made are either A. completely in line with what most other therapists would do or B. that you have thought through and documented carefully. A decision that you have made that may not on its face be what other clinicians would do in your situation. In our step-by-step course, I have a document that I share that is exactly that documentation. It walks you through the process of making difficult decisions in your online therapy practice and also kind of gives you the prompts that you need to make sure that you're thinking those decisions through and that you have documentation about what you have done to make sure you're making a great clinical decision and how you landed at that decision. It includes things like checking your professional ethics and guidance statements, checking your state or country law, checking in with your liability insurance, consulting with a well-informed clinical colleague, and then landing at your own decision and documenting that process as well as documenting a check-in date to revisit the decision, particularly if it's an ongoing one, like I'm bringing this person into my care as a clinician. I want to check in with my decision making every six months or so and document that as well. If you want that play by play, it's part of a lot of documents that I give you if you're in the course. But hopefully, I've outlined it well enough here that you're able to use that even if you don't end up in the course. I do think that it's that last part that scares most clinicians, the idea that if another clinician or a group of clinicians were to look at what I was doing, would they make the same decision? And here's where I think that we really we’re really at a disadvantage as online clinicians because when I asked my colleagues who practice offline, they practice in person what they would do in a clinical situation online, the sort of pat response I often get is don't take high-risk clients into your online practice or don't take complex or acute clients into your online practice. And when I really pin them down and say, okay, so let's talk through a particular case and we do that and then I say, and exactly what would you and I do differently? So, let's take, for example, somebody who is actively suicidal. They become actively suicidal during the course of our treatment and I find that out as an online clinician and I find that out as an in-person clinician and the person is in session with me and they say I'm out of here and they walk out of session, whether it's in person or online and I know that they are actively suicidal and there's imminent risk of them acting on those thoughts. In an in-person practice, what am I going to do? Am I going to tackle them and be like, no, you cannot leave? No, of course, I'm not going to do that. In an online practice, what am I going to do? It's the exact same thing. I'm going to call the police. I'm going to tell them I have a patient I'm really worried about and this is the last thing that they said. I think they're imminently at risk for self-harm. Please go do a safety check and they're going to say, where are they? And in either case, I am not going to know. I'm not going to know if they're in person. I'm not going to know if they're online. So, I give them the address of the last place that I've seen them. And that's either my office if I'm in person or it's the address that I keep on file for them if they're online. Right? What is the difference in how I would handle that? And if I've created a kick-ass crisis management plan, which of course we will have done right for our online clients and should also do for our in-person clients, then I'm going to activate that plan to make sure that they get the care and the protection that they need. So when you come to one of those places where you're thinking about, I don't know what I should do here, I want you to next ask yourself, what would I do if this were an in-office client and is there anything different that I am capable of doing or not doing online? Most times the answer is no. There is no difference at all. And this is why I think that it's really unfortunate for online clinicians because I do think that if you were to ask a random clinician standard of care, they would say something like, yeah, you don't see high-risk clients online. And then if I asked them, okay, so what is it that you're doing differently in person than I would be doing online in a high-risk situation? They're not going to have an answer to that question.
Cover Your Ass Document: (18:01)
This is why I came up with that document. I do call it the Cover Your Ass Thought Doc because I felt like, you know, I need to know for myself that I have moved through all of the steps I can think of to make sure that my thinking is clear and I'm making the most informed clinical decision and not just a sort of off the cuff yeah, just don't do it. Because that's not helpful for our clients. That's a fear-based decision. I want to make a decision that's clinically indicated, well thought out and really well documented. Also, I have a really bad memory. So being able to have that document, if anything were to go wrong one day, I can look back at it and be like, no, Amber, you really did think this all the way through and I can present that document to back myself up if I need to. So let's do a little recap, shall we? When you're thinking about inclusion and exclusion criteria, you're gonna jot down those two columns and in the inclusion criteria you're going to have all of the things that you know, you're great at treating. In the exclusion criteria, you're going to have all of the things that you know you can't support if you're in a solo practice. So if maybe for you, maybe for you that risk stuff, maybe for you that is any sort of disorder or symptom cluster that would be really difficult to treat online, missing some of the subtle cues that you might get in person. On the inclusion side, all of the people and, and personality traits and symptoms and presentations that you really kicked butt at treating, exclusion side anything that just as a private practice owner you feel like is really going to be outside of your ability to fully support a person. For me that's, that's crisis and emergency services. Now go back to your inclusion criteria and look at all those presentations that you wrote down and consider is there anything that I would be missing online that I would otherwise be able to pick up in person? And then ask yourself, is there a workaround? If yes, document that. Now in our course we create an entire scope of practice, so it's kind of a document, it's not kind of, it is a document of what are your inclusion and exclusion criteria for your practice, which is really nice way to protect yourself and also to continue to make good decisions even after it's been a few months since you've taken the course or listened to this podcast. So, this is kind of what we're outlining here, your scope of practice, your scope of service. So then go back to your exclusion criteria, right? And look and see is there anything in this inclusion side that I would not be able to do as good of a job online as I would in person. And is there a workaround, if not, I would put them in the exclusion side, in the exclusion side. Okay.
Other Reasons to Exclude Someone (21:14)
Now let's talk about any other reasons to exclude someone. If they don't have really good internet, exclusion criteria for me, because I do video-based counseling only unless somebody's video is broken for the day and then we'll do phone. But in general, I would prefer to do video. If someone is really uncomfortable with technology that's not gonna suit them. Right? Anytime there's any sort of tech hiccup, it's going to make them more anxious and that doesn't facilitate great care. So if they're technophobic, then that's going to go over there and the other side. If they don't have access to a private place to be able to do therapy that goes to the other side. Makes sense. Right? So I hope this is helping you to really think about that. It's not that difficult to figure out who to bring in and who not to bring in. And then when it comes down to it, a lot of this is more about being in a solo practice all by yourself as opposed to say a group practice. Then it really is about being online. At least it is for me. There are some situations that I really have to think through about bringing someone online. But my ideal clients, the people that I know I'm most qualified to work with, usually don't present with those things that would be a little bit easier in person than online. If yours do, don't let that scare you from at least deeply thinking through the options. I know many eating disorder specialists who work with clients who have active eating disorders, but they just partner with somebody on the ground, a physician, a registered dietician so that they can provide the best care possible. And the fact is that they would be providing this more holistic care anyway. They would be working with the team anyway. The same is true of my colleagues who are working with people with active substance use issues. They would be working in a team approach anyway, so when they really think it through, there's not very much difference in what they would be doing. In fact, they might even do more collaboration of care, which better serves their client.
Formal Document For Exclusion and Inclusion Criteria: (23:31)
Okay. So, I know that it would be nice if there was just a very clear document out there somewhere that had exclusion and inclusion criteria. There is not a formal document available. There are some journal articles that have been with some suggestions, which I would encourage you to look at. But I would more encourage you to do your own deep thinking, be well informed. You know, you've listened to this podcast, you can check out Google Scholar and see if there are any documents about your profession specifically an inclusion, exclusion criteria for telehealth. But let that inform you and use your own really great brain to make the decision for your practice. Consult, consult, consult with other colleagues providing online care and then document that. I really encourage all of you to have a written scope of service where you include as one piece of that your inclusion and exclusion criteria for your practice and the reasons why. A word of caution on that document, what we don't do is discriminate based on diagnosis. What we do is think very clearly about who we're great at serving and include those people. There are tons of therapists out there and so there are lots of therapists for clients to choose from to find the ideal match. To me, I would be underserving a client if I brought them into my practice when I knew there was someone who specialized in what they needed, and I didn't. That's okay, that's not discriminating. That's being a really good and thoughtful clinician. If there are particular symptoms that are outside your scope of competence, again that's not discriminating, that's being a good therapist and if there are certain presentations that are especially acute or emotionally dysregulated and they need services beyond what you offer in your private practice, you guys get to decide what services you offer, then it is only kindness to refer them to someone who does. Right?
Wrap Up (25:54)
Okay. I hope that was really helpful. You may have been hearing some thunder and lightning and rainstorm in the background. I hope it was soothing and not annoying, but I really wanted to get this podcast out to you. I hope that you have a really lovely day. I hope that this inspired some tranquility and not any anxiety, but you can always feel free to ask any additional questions in the Online Therapist Group. This podcast is brought to you by Step-by-Step and all the things guide to starting up your online therapy practice. It's an eight-week course where I walk you through everything you need to know to build your practice with confidence and competence. And yes, we do cover marketing. I know that's the big question. We cover all things, legal issues, ethical issues, but most importantly, we cover online practice building so that you can open up those waiting room doors on your virtual office feeling confident and competent.
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