Checklist: Returning to the Therapy Office After COVID-19
Updated: 8/29/2023
“When can I, or should I, return back to my office to see clients in person?”
We never thought we would see the day when these recent conversations would be necessary — mask-wearing, office cleaning procedures, the implications of connection with hidden facial expressions, and more.
Let’s face it, these are truly challenging times that do not allow for a one-size-fits-all approach in response to the question of returning back to your office.
From what we can tell, each therapist is doing the best they can to decipher the right next steps. None of us want to cause harm to our clients, our families or ourselves. AND we’re weighing the risks of not being in the office for some of our clients.
Some clinicians have consulted attorneys, processed with clients, and chosen to be in their offices with clients. Others have chosen to not leave their homes for the past 6 weeks or more, having everything delivered.
Whatever you decide, it’s a hard decision to make. We’re considering so many factors.
Government:
Each city, county, state, and country has a different response to the pandemic with varied recommendations. You could do a quick Google search and easily find 10 recommendations that are conflicting with each other. For the purpose of your license, though, we recommend following your jurisdiction’s plans. For some, that means continuing virtual therapy indefinitely and for others, it means seeing clients six feet apart in the office with a mask.
Our Liability:
We’re going through a process of discernment where we’re weighing the risks and benefits of telehealth versus in-person sessions and trying to do what’s best for our clients inside of an imperfect situation AND not expose ourselves to possible complaints against our licenses or wrongful death suits. This is a whole new world.
Trust Insurance issued a “Statement on In-person Psychological Services During the COVID-19 Crisis” that really highlights this reality for many practitioners. Your decision to return to the office and how you do so could have a very different analysis and conclusion day-by-day and can look COMPLETELY different based on your local situation and local ordinances.
If you’re an employer, you have a lot of steps to take to limit your liability whether your employees remain at home, you take a hybrid approach to private practice, or you come back into the office. We highly recommend attending a training with an attorney who understands employment law in your state to see what steps you can take to avoid liability in this area.
Our Health:
Each clinician has different physical and health needs. Some of us have chronic health conditions that put us at a higher risk of infection while some of us live with people who have high-risk factors, and we cannot afford to chance infection.
Add to all of this the fatigue we feel personally and being on computers during the day. Some of us are thriving and others are struggling. It DOES NOT MEAN ANYTHING about who you are as a therapist if this transition has been hard. It’s hard. Some of us, our brains process the virtual sessions and don’t feel the dissonance. For others, it’s all utterly depleting, and many of you are wrestling with how much longer you can continue providing services in this way.
Our Clients:
The clients we work with also have different needs. Children, first responders, elderly, chronic illness conditions, serious anxiety, depression, and people with other struggles are all navigating this process with their therapists. Domestic violence clients are unable to leave their homes. Parents are struggling to help their kids with homeschooling and reduced contact with others, and they’re still navigating the issues that brought them to therapy.
Again, it’s a hard decision for many therapists, and judgement or criticism does not make the decision easier. We want to create a space to help you think through your next steps as you consider when and how to return to the office.
Here are some of the options for moving forward:
Case by case in-person sessions: You may choose to go back into the office depending on the client and their needs.
Full-time in-person sessions: You may weigh the risks and benefits and determine you’re ready to return to the office full-time.
Permanent virtual therapy: Some therapists have terminated their leases and decided to remain in virtual practice permanently for the next year — at the very least. You don’t have to go back to in-person sessions if you don’t want to. It may be a gift of the pandemic that you discover a new way of serving your community. We love this option if it works for you as a therapist and your clients because virtual work really can increase access for some people. It reduces commute time and makes scheduling easier. The focus for you moving forward would be announcing this to clients and updating your marketing for a virtual practice.
The Time for Documentation is NOW
Your process for returning to the office (whether that happens in a week, a month, or a year) is going to require a careful written analysis and documentation for your practice as a whole, and possibly on a client-by-client basis.
Trust Insurance recommends the following steps:
Consultation.
A thoughtful ethical and risk analysis process.
Careful articulation of their reasoning and conclusions for their chosen course of action.
A thorough informed consent process with patients/clients, with a special focus on the risks and benefits of in-person vs. remote care.
All these steps should be very carefully documented.
We highly recommend consulting their guidelines here for examples of what should be included in your risk analysis.
The question is, if you return to the office, what will be different?
Here’s a resource for U.S.-based businesses from OSHA on how to prepare a workplace.
We highly suggest you read it completely. It goes through a thorough review of things to consider and document moving forward for your business.
What’s the risk exposure per OSHA for therapists, counselors, or social workers in private practice?
According to OSHA standards, most therapists in a private practice setting would fall into a Medium Exposure Risk.
The OSHA standards read: "Medium exposure risk jobs include those that require frequent and/or close contact with (i.e., within 6 feet of) people who may be infected with SARS-CoV-2, but who are not known or suspected COVID-19 patients. In areas without ongoing community transmission, workers in this risk group may have frequent contact with travelers who may return from international locations with widespread COVID-19 transmission. In areas where there is ongoing community transmission, workers in this category may have contact with the general public (e.g., schools, high-population-density work environments, some high-volume retail settings).
While Low Exposure risk is seen as: " jobs are those that do not require contact with people known to be, or suspected of being, infected with SARS-CoV-2 nor frequent close contact with (i.e., within 6 feet of) the general public. Workers in this category have minimal occupational contact with the public and other coworkers.
We interpret low exposure risk to be people who are working alone or who have minimal contact with the public. Unfortunately, 50-minute (or longer) sessions inside of closed, private offices does seem to move therapists out of the lower exposure risk, even with low community transmission rates in your area.
Whatever you determine your risk level to be, be sure to document your decisionmaking. We'd recommend that you if you’re making an argument for being in the lower risk of transmission, that you seek consultation from an attorney and document that consultation to limit liability.
Rearrange furniture to allow for social distancing, if at all possible.
Wear a mask if recommended. OSHA recommends masks for Medium Exposure Risk workers.
Consider encouraging clients to wear a mask.
Some areas require a temperature check before entering into any building. You would need to purchase a thermoscan thermometer and sanitize after each use.
Consider closing your waiting areas, have clients wait in their cars, and text clients to come to your office when you’re ready.
Wipe down door handles and surfaces regularly. Create a checklist for you to follow each time you clean areas.
Schedule your appointments further apart to allow for time to disinfect the office.
Wash hands after every session and encourage clients to wash their hands before session.
Provide no-touch waste disposal options (trash cans with a foot lever).
Put a health policy in place that if a client has a fever or concern of exposure that a virtual session will be held in lieu of in-person sessions.
Provide single-use towels in bathrooms (paper towels, disposable items only).
Post your protocols in the office.
Install physical barriers, such as clear plastic sneeze guards.
Stay home if you’re sick or have known exposure.
Some therapists in private practice are considering additional safeguards for the higher exposure risks, including things like installing high-efficiency air filters and increasing ventilation rates in the work environment.
Your COVID Informed Consent
You’ll likely need an additional informed consent document as you return to the office that’s been reviewed by an attorney. It can be frustrating to realize that we’re held to a higher standard and are a greater target for lawsuits. We’re able to visit the grocery store or get our vehicles serviced without signing a special consent, but we’re held to a higher standard in a therapy context, and that standard can often be confusing to navigate.
We’re in a group practice with multiple offices… How is this going to work?
You can consider a rotating schedule to reduce the foot traffic.
Still have clients wait in their cars to reduce exposure in common areas.
As a team, you’ll want to meet to determine who will be returning to the office vs. continuing virtual sessions and for how long virtual sessions will be allowed to continue if they’re employees.
For the time being, training should be done virtual. Do not encourage travel for training until you have further direction from your country/state/jurisdiction.
Make sure everyone has masks provided if they’re employees. You’re responsible to provide the tools necessary to do their job.
Put disinfectant, wipes, tissues, and trash cans in all offices.
Be sure you have a clear understanding of the Families First Coronavirus Response Act.
We provide play therapy. Are there guidelines?
While you’ve likely had playroom best practices for many years, you’ve likely not considered them in light of a quarantine.
(Suggestions from the American Association for Play Therapy are no longer available but previously could be found here about how to mitigate risk in the playroom.)
Masks? Won’t that be weird?
Some therapists have chosen to stay virtual if at all possible, as they don’t like the limitation of reading expression with a mask. Others have found that the mask-wearing with clients has opened an opportunity to discuss what our clients are facing out of the office — a new world of mask-wearing and social distancing — and its impact on the therapeutic relationship.
Some people have been generous in sharing their innovation with creating masks with clear inserts to allow the client to see your face more fully.
Click here to download a clear mask-making tutorial.
You can provide this tutorial to your clients or their parents. While this tutorial was focused on increasing access for deaf and hard of hearing individuals, it just happens to also meet the needs of mental health providers who need to see face expressions to do our best work.
Where do I get PPE and disinfectants for our office?
Amazon is reserving PPE and disinfectants for first responders. And guess what? You’re a first responder! You can create a business account with them that allows you to order these supplies to some degree from Amazon.
Is it safe to return?
You have to decide if you feel comfortable returning to the office. If you lack clarity and confidence about how to keep yourself and others safe, that will come up in the therapeutic relationship. Imagine two people in a room both scared and unsure about the virus. That’s going to have therapeutic implications.
Am I going to be forced to go back to the office?
There’s some speculation about whether insurance companies can require in-office and lift their coverage of telehealth sessions. You run your own business and can decide for yourself what you want to do, but those contracts may need to be terminated if the ask by insurance companies is greater than what you can abide to.
This is a time to advocate, if at all possible, with insurance companies for the safety of yourself, your employees, and your clients. Both the clinician AND the client should have the freedom to determine whether they feel safe to do in-person sessions.
What about liability?
There are some unknowns about liability. If you’re a group practice owner and you require your staff to return to work, if they contract the virus, are you liable? If you have in-person sessions and the client comes in and says they contracted the virus, are you liable? Consult with your liability insurance provider.
What if I need to continue with telehealth sessions but hate / loathe / strongly dislike them?
There are things you can do to adjust. Just like if you started a new kind of service in the office and you realize it takes more energy, you plan around it. So, for telehealth, you may need to:
Take more breaks, and during your breaks, get away from screens. Your schedule and pacing may need to shift.
Get better tools for ease on your body and brain. Check into getting a bigger monitor or a comfier chair.
Recheck your financial plan based on your new caseload size for what you can handle. Maybe in the office you could see 18 clients, but virtually with taking breaks and all the other things happening in life, you can manage 12 clients. That’s going to affect planning.
How do I talk to my clients about this?
The key to good therapeutic outcomes, regardless of your decision, is to be clear with your decision and process with clients. When we think through each aspect of our process, it’s a way we contain the anxiety of our clients and let them know what we’re taking care of, so they don’t have to.
Once you’ve made a decision, we recommend writing a letter that you can give to the client during session, or via email if you’re still virtual. Give them dates or a timeframe for when you’ll update them again. Let them know if you’re returning to the office, the measures you’re taking, and why. Let them know what’s required of them as well in order to continue to support the safety of all involved.
Don’t forget to post your procedures in the office.