Risk Management | Private Practice from the Inside Out

Skype-Assisted Therapy – How Secure Is It?

Jan
17
2012

Security Concerns about Skype

Back in October, Dr. Arthur S. Trotzky, a member of the Georgia Therapists Network, brought up on the online discussion list his concerns about the security of using Skype for online counseling. He specifically cited Fast Company’s post, Skype’s Huge, New Security Headaches.

Frank Pratt, III, LCSW responded on the GTN list by offering the following explanation. While I do not use Skype or provide online counseling at this time, I thought that many of you would, like me, find his explanation useful in understanding how and what potential risks might be. I contacted Frank and he graciously agreed to allow me to print his email below.

How the Internet Works

I have a good working knowledge of this kind of thing, so I’ll take a stab at it.

The point of this [Fast Company] article is that hackers have been able to determine IP addresses of Skype users. Without going into too many details, you could easily determine the general location of an IP address, though in most cases, it would be far more difficult to pinpoint the exact location of the computer.

It is usually very easy to get an IP address, because this address is always sent when you send data to another computer on the internet. This email [from Frank to the GTN discussion list] is being sent from the following address: 68.213.17.7. We have a DSL line and BellSouth assigns this IP address to our [unique] modem, which is connected to the BellSouth system. All the computers on our network use this IP address.

Every time you send an email address or send data to a remote server (e.g. you post a message on an online forum,) there is a good chance that the remote server keeps a log of your IP address. I looked up this address on several search engines. My research indicates I am in Atlanta. Georgia. Look at my e-mail signature below, and you will see that the search engines are off by 50-60 miles.

Note that this quick and dirty search did not reveal the name on the DSL account. Just a rather inaccurate geographical location.The search engines show me to be in Atlanta, because our modem connects to a server in Atlanta, via. a phone line (much the same way as my fax machine would be connected to a fax machine in Atlanta if I sent a fax to a business in Atlanta). I would guess that hundreds, if not thousands, of a DSL modem in Atlanta and the surrounding area connect this very same computer in Atlanta. So, I am connecting to the internet from Rome? Lawrenceville? Atlanta? Athens? Snellville? Conyers? one of the Suburbs? Good question!

If a skilled hacker were so inclined, he/she could possibly hack into BellSouth’s servers to get the name on the account, which is the name of our company. This would require extensive expertise, and a possible risk of felony prosecution for the hacker. Even if a hacker decided to do it anyway, they would only get the name of our company, since that is the name on the account.

That narrows it down to 6 computers and just as many staff members. If you get the IP address for a computer at an academic institution, or a large company, you might be able to easily determine which school or company the message was sent from, or perhaps even which campus building the message originated from. However, this might only narrow it down to hundreds or thousands of individual users. Again, the servers at that institution might have logs that could tell you which user was assigned a given IP address at a given time, but a hacker would need to hack into a server to get this data. Bypassing security measures, and possible civil/criminal prosecution continue to be problems.

So, can you get the name of the person who is using an IP address for a Skype call? The practical answer is probably “no”, in most cases. The far more important question is whether or not the actual content of the conversation can be intercepted. Could a hacker listen in on a session that was conducted via Skype?

When it comes to hacking, anything is theoretically possible. However, given the encryption that Skype uses (see “Does Skype Use Encryption?”), it would be extremely difficult to do so. Breaking a 256 bit AES encryption key would probably require a considerable expertise from a hacker, and a very powerful computer (or computers).

It would probably be far easier to tap a normal phone line. Keep in mind that we all use phone lines to convey privileged information on a daily basis (along with every hospital, physician’s office, etc.) Also keep in mind that caller ID and “reverse lookup” search engines make it quite possible to pinpoint the street address of a caller, perhaps far more accurately that an IP address. After spending 30 seconds on a site such as WhitePages.com, you could very easily (and legally) use my phone number to figure out the street address of my office. I am not an attorney, but I would argue that if a phone line is secure enough to convey protected health information under HIPPA guidelines, then Skype is as well.”

Thanks, Frank! I so appreciate your explanation of how / where mental health professionals might be vulnerable online.

Other Skype-Related Resources

One of my primary resources for online / distance therapy is the Online Therapy Institute. As you are making your own decisions about if and how to conduct online therapy, you may also want to check out OTI’s post, Videoconferencing – Secure, Encrypted, HIPAA-Compliant.

And, if you know of other resources related to conducting therapy online in real time, I hope you’ll share them with us below!

[Frank Pratt, III, LCSW notes that since I writing his response above, his office has
switched from traditional phone service to using a Voice Over IP (“VOIP”) service for
all of voice and fax lines.]

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Filed under: Risk Management, Technology, Tools and Resources Tagged with Distance Therapy, Online Therapy, Skype, Video Conferencing

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The Difference Between Clinical Supervision And Consultation

Dec
6
2011

by Tamara Suttle

Cultural Differences

I have a friend that I’ve only met online who is a Board Certified Music Therapist. She is also a professional singer, songwriter, musician, and blogger. Her name is Roia Rafayen and here is a comment she left recently in response to a previous post I had written about clinical supervision .

Tamara, thanks for your post. As always, you boil everything down very nicely and clearly. I do have a few questions, though regarding clinical supervision for counselors (since I’m not one). First, I presume it’s required. Second, is it only required if one is working toward licensure? Because then I can see that there would be an evaluation component to it.

Is it different when it’s simply professional clinical supervision for ongoing growth and insight as a counselor? Just trying to figure out how it all differs from music therapy. I know we’ve had various “conversations” about this before, but there are still elements that seem to be very different in our professions. Maybe that’s why you folks have had an easier time of getting licensure.”

Roia is picking up on the differences in the way that some of the mental health disciplines use the term “supervision” so this seems like a good day to address this issue.

First of all, I’m chuckling at having “an easier time of getting licensed.” Roia, you just might have a few counselors here taking you to task, of course, because we don’t think it’s so easy at all. But, you are right in picking up on the difference in the way that some mental health disciplines use the term “supervision.” I think of these as cultural differences.

State by State, Discipline by Discipline

As far as I know, all licensed mental health professionals in the United States of America are required to go through a period of clinical (as opposed to administrative) supervision in order to satisfy conditions for licensure. Each state determines what the specific requirements for licensure are for each discipline and they may vary considerably from state to state and discipline to discipline. For example, although licensed social workers and professional counselors require at least a Master’s Degree in a specific discipline, licensed psychologists require a Doctoral Degree. Individual states also dictate which graduate schools provide sufficient training (typically based on the type of accreditation a university has) to satisfy licensing requirements.

Additionally, to become a licensed professional counselor / licensed clinical social worker / licensed psychologist / etc. , each state also requires face-to-face clinical experience and clinical supervision. For example, to become licensed as a professional counselor, the State of Colorado requires 2000 hours of clinical counseling and 100 hours of clinical supervision; the State of Texas requires 3000 hours of experience with at least 1/2 of that being direct contact with clients while under supervision. (It’s worth noting that in a society as mobile as that in the USA, these differences in requirements can play havoc with a mental health professional-in-training trying to get licensed.)

Clinical Supervision

Clinical supervision for these disciplines implies a hierarchical relationship with one of the components being evaluative. In other words, while under clinical supervision, the supervisee is legally and ethically required to comply with the supervisor’s directives. And, the supervisor is legally and ethically responsible for everything that takes place between the counselor-in-training and the client. It is a significant responsibility, commitment of time, and potential liability for any supervisor.

The evaluative component is included because the purpose of clinical supervision is to both support the counselor-in-training’s professional development and also to protect the public from incompetence. At the end of supervision, the supervisor must attest to the competence of the counselor-in-training. That same supervisor is obligated to note whether this individual is actually ready to function independently as a professional counselor. The same is true for licensed social workers, licensed psychologists, and licensed addictions professionals.

Professional Consultation

Once a professional license is obtained, the standards of clinical practice, professional codes of ethics, and / or best practices in risk management dictate that professional counselors, social workers, and psychologists are to engage in peer or professional consultation on a regular basis (rather than clinical supervision.) Like clinical supervision, the purpose of professional consultation is to continue professional growth and development as well as provide access to collegial input on specific cases. However, while the difference between clinical supervision and professional consultation may appear at first glance to be simply one of semantics, those within these disciplines recognize “consultation” to indicate a collegial relationship with no evaluative component and no obligation to comply.

That’s the difference – It’s a difference in connotation that is unique to some of the mental health disciplines. And, until I met you, Roia, and we started our dialogue about this topic, I, too, made certain assumptions about those terms based on the culture of professional counseling. I assumed that one was under supervision, s/he was either in training or under the scrutiny of a licensing board for some type of corrective action!

Thanks to you, I’ve done a bit more research and have reigned in some of my assumptions. And, I’m hoping that some of you reading this post can join the conversation and expand the discussion.

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Filed under: Clinical Supervision | Consultation, Risk Management Tagged with Ask Tamara

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Oh, Yes, You ARE! On Call 24 / 7

Nov
9
2011

by Tamara Suttle

My colleague, Bonnie Goetz, MA, LPC, NCC wrote in on the Denver Therapists Network online discussion list asking for help . Having just had this conversation earlier this year in my Peer Consultation and Supervision Group, I asked her if I might address it here on my blog so that others can join the discussion.

Here’s what Bonnie wrote . . . .

I am wondering if anyone out there . . . has found a good way to offer the mandated 24/7 coverage other than being constantly strapped to a cell phone? I know some people use answering services, but from what I understand the service would call the therapist directly in case of emergency anyways.

I would really like to be able to turn off my cell phone at the end of the day, but have not been able to figure out a way to do this and still be in compliance with my [insurance] contracts. Generally I handle this by not taking clients who have high needs between sessions, but I still get the occasional call from people on the weekends or evenings, and I hate checking my phone all the time!

Any thoughts or suggestions would be greatly appreciated!”

Yep, I have a few thoughts and suggestions, Bonnie. Acts of omission, such as not returning phone calls in a timely manner, are definitely grounds for a malpractice suit. I’ve heard attorney Bart Bernstein, J.D., LMSW refer to this particular situation many times in his workshops on ethics and counseling. The example he gives is this . . . . If a client calls you and gets your answering service or, worse yet, gets an unanswered phone . . . and you as his therapist are the only person the client feels like he can talk to about a particular issue / crisis . . . and you fail to return the phone call in a timely manner i.e. within 24 hours . . . , you have, in effect, abandoned your client.

That’s why your question, Bonnie, is such an important one. Some therapists believe in error that being available 24 / 7 is stipulated by a particular managed care company. And, while that may be true, the bigger picture is that your professional associations, your licensing board, and your state laws are also likely to be requiring the same thing – that licensed mental health professionals must respond and be available to clients in a timely manner.

For those reasons, here’s a few of the ways that you can responsibly, ethically, and legally take care of your clients’ needs while also taking care of your own needs, too.

Trade off with another trusted colleague.
Use a professional answering service.
Hire a virtual assistant or office manager to manage the initial contact with your callers.
Consider using a paging system.
Forward calls to another licensed mental health professional.
Create a call group of licensed mental health professionals.
Provide a code word for clients to use when they call in case of a crisis.

Or, you can choose to cover your own phone calls 24 / 7. Just remember that you are ultimately responsible for that coverage. If you have someone else covering for you, make sure that s/he is competent and trustworthy. Your clients’ lives, your own reputation, and your own licenses are on the line.

If you have found other ways to meet your clients’ needs 24 / 7, I hope you will take a moment to share with us here!

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Filed under: Risk Management, Time, To-Do's Tagged with Acts of Omission, Answering Service, Coverage, Telephone

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8 Reasons To Work In A Community Agency BEFORE You Go Into Private Practice – Part 2

Nov
2
2011

by Tamara Suttle

This is the 2nd part of a 3 -part series.
To see the previous post in this series, click here.

The Clinical Experience Will Be Invaluable

By working in a community mental health agency, nonprofit organization, or psychiatric hospital after graduation, new mental health professionals can learn to work with a wide variety of clients and issues. This strengthens your clinical and diagnostic skills. Oftentimes, the clients you see in these settings will have fewer resources and a greater number of social and clinical challenges. That’s an experience that is unique to these community settings and will help prepare you to competently work with a variety of presenting issues.

Professional Development is Usually FREE

Every mental health professional is ethically obligated to continue their professional development throughout their careers. Even Colorado has finally stepped up to this standard! One of the best things about working in community settings is that continuing education is typically provided for employees on the job at no additional expense. Consider that the typical workshop or conference that I attend may cost me at least $15-20 per hour without counting transportation and lodging. That’s a a great deal and a huge incentive for the new professional! Think about it – If your state requires that you attend 24 hours / 2 year cycle like Texas does, that equates to $480 / 2 year cycle plus transportation and lodging. If that training does not come as a perk from your employers, then it’s coming out of your paycheck!

Peer Consultation is Right Down the Hall

Most mental health professionals in private practice are sole proprietors who work in offices isolated from their peers. The number one complaint I hear from them is “It’s lonely in private practice!” By working in a community setting, you have an opportunity to work with and learn from your colleagues right down the hall from you. When you have a clinical or administrative question, you will have peers an arms’ length away to staff a case or help you find resources. Once you are out on your own, that immediate availability is likely to be much more difficult to find.

Shared Liability Reduces Your Risk

When you work as a therapist in a community mental health agency, it’s likely that you will make your share of mistakes just like the rest of us humans do while we are learning new skills. The benefit of making them there is that should you encounter a disgruntled client that decides to sue for malpractice, your entire agency can rally to your defense. Once you are in private practice, you are all on your own!

Administrative Supervision is Free and Abundant, Too

OK, so I’ll admit it . . . . I rarely appreciated administrative supervision when I had it. Mostly, it seemed like a lot of red tape i.e. a pain in the butt. Nevertheless, after 30 years of working in the field of mental health, now I get it. I get how critical it really is to learn early on how to write a strong progress note and treatment plan, how to deal with money matters and cancellations, and how to set an appointment, and how to be a team player in an organization. And, equally important, I get why someone needs to make sure that an agency continues to meet their own goals just to survive. Administrative supervision is critical – to the agency, yes, but also to you as a new professional. Administrative supervision teaches you to put foundational habits and practices in place that will support you in the field of mental health for decades to come.

Clinical Supervision at No Additional Cost

No one told me when I entered graduate school that I would need clinical supervision post-graduation in order to get licensed and practice ethically and competently. And, when the topic eventually came up . . . in my Practicum class, no one bothered to spell out that in all likelihood it would be ME paying for every minute of that supervision unless I had an employer or tooth fairy that was willing to provide it to me at their own expense!

If you were as clueless as me, let me clue you in now . . . . The customary fee for clinical supervision post graduation can easily cost you an additional $30,000. Here are some more thoughts about fees for clinical supervision. However, for now, let me just say that if that’s coming out of your wallet right out of graduate school, it’s going to hurt! Many employers will provide individual and / or group clinical supervision at no additional cost to you.

Community Resources Abound in Agency Settings

One of the challenges to any new mental health professional is a general lack of knowledge about the community resources. Yes, many communities have a “Blue Book” of community resources but that is not sufficient to support your clients and minimize your liability in private practice. By spending time in an agency, you will have time and experiences that allow you to develop a knowledge and understanding of specific agencies’ strengths and challenges. For example, if you were in private practice today, would you know

How to support and keep safe a suicidal client who has phoned you? (Check out ASIST through LivingWorks.)
Where to send a client who is struggling with staying sober? (Inpatient treatment if detox is needed; Alcoholics Anonymous for ongoing peer support.)
Who provides group therapy to court-ordered domestic violence offenders? (Here in Colorado, providers must be approved through the Domestic Violence Offender Management Board.)
Who to call first when you’ve been threatened with a lawsuit? (Yes, call a mental health attorney.)
Where to turn when your client needs resources to help her adult son who is soon to be homeless? (For me, it’s the Douglas County Youth Initiative’s resource guide.)

Of course, those questions are just a fraction of the resources that you will need to know in private practice. And, working in an agency for a few years will build up your knowledge of community resources faster than anything else!

Opportunity Foster Community Relationships Will Pay Dividends Down the Road

And, while you are building up that knowledge of community resources, you will also be building up your address book as you continue to meet and problems solve with other agencies and professionals in your community. You may see this initially as simply “doing your job.” But, the truth is, you are planting seeds! Once you leave the agency and move into private practice, you will see that you have fostered many relationships with individuals and organizations. If you’ve done this right, you will know many who can and will be eager to send clients to you for counseling and support!

Here, in Colorado, many new therapists eschew agency work and opt to immediately hang out their shingles only to find that they struggle. I can’t say that I’m really surprised. If you haven’t planted the seeds to help clients find their way to you, it’s not likely that you will have great success in private practice. There are many paths to building a successful and vibrant practice, but working in an agency is definitely one that can pay off in dividends if you have the wisdom to pursue it!

Have you worked in a non-profit or agency of some type? What has been the benefits for you? Are you now in private practice and didn’t take this route? I hope regardless of your path, you’ll take a moment to drop in here to chat and let us learn from your journey, too! I look forward to chatting with you!

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Filed under: Clinical Supervision | Consultation, Money Matters, Professional Development, Risk Management Tagged with Agency, Community Organizations, Community Resources, Hospitals

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8 Reasons To Work In A Community Agency BEFORE You Go Into Private Practice – Part 1

Oct
31
2011

by Tamara Suttle

This is the 1st part of a 3 -part series.

Dorlee M, in New York blogs on Social Work Career Development. Earlier this year, she wrote in asking why I have have repeatedly stated that working in a community agency (nonprofit, hospital, or organization) is the smartest thing a new graduate can do.

Here’s 8 reasons why I believe new mental health professionals (and coaches) should spend at least 3-5 years gaining their clinical sea legs before stepping out into private practice.

The clinical experience will be rich.
Professional development is usually free in a community agency.
Peer consultation is right down the hall.
Shared liability in an agency reduces your risks.
Administrative supervision is free and abundant in a community agency.
Clinical supervision at no additional cost will position you for greater success with your clients.
Community resources abound in agency settings.
Opportunity to foster community relationships will pay dividends down the road.

Not sure what I’m talking about? Check in on Wednesday for Part 2 of this post as I explain. And, if I’ve left off other benefits to working in a community agency, feel free to add them below!

27 Comments

Filed under: Clinical Supervision | Consultation, Networking, Professional Development, Referrals, Risk Management, Time, To-Do's, Tools and Resources Tagged with Agency, Community Resources, Consultation, Continuous Learning

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Skype-Assisted Therapy – How Secure Is It?