Private Practices Adapt to a New World
By Sue Coyle, MSW
Social Work Today
Vol. 21. No. 2. P. 12

Throughout the pandemic, private practice clinicians have faced unique challenges as they attempted to meet the needs of their practice, their clients, and themselves.

There’s no question that COVID-19 has and will continue to have an impact on mental health. In fact, a survey completed by the Centers for Disease Control and Prevention (CDC) in June of 2020 found that 40.9% of respondents reported having an adverse mental or behavioral health condition. The CDC described this percentage as “considerably elevated” and “associated with COVID-19.”

The pandemic has continued on for more than nine months since then, furthering the opportunities for isolation, trauma, and other factors affecting mental health.

In a different vein, the pandemic has greatly affected small business owners. It is expected that a large percentage of small businesses will not reopen or be able to remain open once COVID-19 subsides. Restrictions and evolving requirements for in-person services have forced owners to continually assess and change how to maintain their business. Even if they remain afloat, it will have been a long and challenging journey.

These health and economic factors overlap in multiple ways, particularly when it comes to the operations of private practices. Clinicians running private practices have spent the past year determining not only how to best serve their clients with ongoing and new mental health concerns but also how to adapt their businesses for the new—or at least current—normal.

Office Logistics
When COVID-19 restrictions were first enacted (most took effect in March 2020), clinicians operating private practices had to determine where and how they would continue seeing clients. Some chose to keep their offices open for limited in-person appointments.

“I didn’t switch to telehealth probably until April, and I saw clients in person in conjunction with doing some telehealth work for a pretty long period of time,” says Cynthia S. Penwell, LCSW, a board-approved clinical supervisor and adjunct assistant professor at The University of Texas at Austin, who stopped seeing clients in person in the fall of 2020 when cases began rising again. “I had reasonable, cautious discussions with folks, and I moved my office around to make a six-foot distance. We closed down our lobby pretty quickly.”

Keeping the lobby open would have entailed wiping surfaces before and after every new client. “It was too much [for] two people in the office. We started going out and grabbing people, so we were the only people touching doorknobs,” Penwell says.

Penwell did not immediately mandate masks, noting that she put it off in part because of a mild hearing impairment and concern that she would miss important facial cues. However, she did eventually institute a mask policy and started keeping windows open for better ventilation as well.

Leah M. Niehaus, LCSW, a private practice psychotherapist, clinical supervisor, writer, and speaker, initially transitioned to full telehealth at the start of the pandemic. “Some of our clients, however, began requesting in-person appointments, and myself and the therapists in my practices felt that some children, adolescents, and young adult clients truly would benefit from in-person appointments,” Niehaus says.

Fortunately, safety and privacy concerns were assuaged by the setting. “We’ve been fortunate to have an outdoor balcony space where we’ve been able to see clients with relative privacy,” Niehaus says. “Our balcony has become so popular that we have a Google spreadsheet to rotate all of us in that outdoor space.”

 Niehaus has also met clients—individually and in groups—in the park and in an office courtyard. “I cannot guarantee privacy in these outdoor scenarios, but clients have seemed to feel comfortable and thankful for our flexibility in providing a way that they can be seen safely in person during a challenging time,” she says.

At-Home Logistics
Outside of the office—where most clinicians now are—careful thought had to be put into developing a space for telehealth appointments. Therapists had to find a way to ensure privacy for both themselves and their clients. While a toddler popping in unannounced or a partner passing by in the background might be amusing and welcomed in some online meetings, such a breach during a therapy session would not be acceptable.

David Wohlsifer, PhD, LCSW, a psychotherapist and clinical instructor at Florida Atlantic University, Phyllis and Harvey Sandler School of Social Work, whose husband is also a licensed clinical social worker, says that setting up an at-home office meant “accommodating our house in ways that we can’t hear each other, ways that give us space.”

During his sessions, Wohlsifer makes sure that the doors and windows are closed and his pets are not in the room. When those seemingly small details are taken into consideration, “the client has a sense of professionality,” he says.

Small steps such as those also allow clinicians to maintain their own privacy. After all, video calls offer windows into both the patient’s and the therapist’s home life and can be distracting.

Just as in traditional offices, therapists have gotten creative when setting up at-home work areas. Many, including Wohlsifer and Penwell, have converted spare bedrooms. Others also have taken advantage of outdoor space. “I do see people virtually outside. I have curtains up and a sound machine on,” Penwell notes.

Services
With physical logistics set, therapists had to determine how to deliver therapy. For many in private practice, telehealth was either a nonexistent or rare part of their services. Wohlsifer, for instance, saw some clients virtually prior to the pandemic, but they were few and far between—clients he had seen before moving from Pennsylvania to Florida seven years ago. Similarly, Penwell offered telehealth to her private-pay clients but says that it was a rarely used option.

Under these circumstances, when telehealth became the primary mode of delivery, therapists had to act quickly to set up a virtual practice. “I immediately secured telehealth platforms through SimplePractice and SecureVideo (to accommodate our online groups) so that we could continue to do our work with clients and to do supervision that was HIPAA secure. I had to come up with new consent forms for telehealth,” Niehaus says.

There also was the matter of becoming educated about the new mode of therapy. “I attended some continuing education courses and listened to some podcasts on how to do effective telehealth sessions for individuals and groups. The learning curve was quick and steep,” Niehaus says. “But my practice was quieter in March and April [2020], so I had time to adjust, learn, and prepare for the influx of new referrals and the return of existing clients.”

A part of this set-up included deciding what services may not translate well to telehealth. Penwell offers EMDR (Eye Movement Desensitization and Reprocessing) as an example. This was something that she continued to do in person for as long as possible and now does not offer (temporarily) while she remains fully virtual. “I worry about my folks who have been accustomed to some level of EMDR work. For some folks, we were in the middle of really difficult trauma work, so folks are on pause in a way,” she says.

Clients
Clinicians had to get their clients on board with the changes. “I reached out to every single one of them and had a conversation to process what it felt like to move online,” says Wohlsifer, who has created a telehealth consent form and offers free “practice runs” to clients if they are unsure of how the online platforms work.

The adjustment has been more difficult for some. Wohlsifer notes that a few of his elderly clients did not immediately continue on with services and, even now, several prefer to hold therapy over the phone rather than via video calls.

Young children also have had a difficult time making the switch. “The children between ages 4 to 12 years old do better in person vs. telehealth therapy,” says Remy Gordon, LCSW, MSW, BEd, founder of Seeking Shelter Inc. and a therapist at Remy Gordon Corp. “It is more difficult to keep their attention on a computer screen vs. in reality.”

However, even with these challenges, many in private practice have seen the opportunity to expand their clientele. For one, the need has increased and/or become more apparent. “There was a huge uptick in patients,” Gordon says. “Due to COVID-19, many people have been affected and are seeking therapy. I am seeing children who are feeling isolated, which presents in forms of depression and anxiety. I am seeing parents who are stressed and unable to cope with the responsibilities of work, essentially becoming a teacher at home while attempting to maintain a sense of normalcy for their children.”

Geography has become less of a barrier for therapists. Provided he is licensed in the client’s state of residence, Wohlsifer can welcome new clients from outside his area. Meanwhile, Niehaus has been able to remain with clients as they relocate. “I’ve been able to work with old clients who have moved away, and now we can still work together. I’ve been able to support young adults as they go off to college, if it’s been allowed across state lines,” she says.

Finances
However, that uptick in clients doesn’t necessarily apply to everyone. For example, Penwell saw a drop-off in private-pay clients at the start of the pandemic. She notes that many of her private-pay clients are small business owners. The cancellation of events, particularly Austin’s South by Southwest film festival, on top of the COVID-19 restrictions led to considerable financial concern for them. As a result, many chose to discontinue services.

Such a decline in clients had and has a significant financial impact on a private practice. Fortunately, insurance providers quickly expanded coverage for telehealth visits, often reimbursing providers in the same way they would have for in-person appointments. However, that development came with its own set of hurdles to clear. “The insurance companies provided zero information to clinicians and zero information to their clients,” Penwell says. “We were all sort of in the dark.”

Those in private practice had to navigate new questions about insurance largely on their own. The same was true when the CARES Act allowed businesses to apply for the Paycheck Protection Program (PPP), which “provides small businesses with funds to pay up to eight weeks of payroll costs including benefits. Funds can also be used to pay interest on mortgages, rent, and utilities,” according to the U.S. Department of the Treasury.

Private practice therapists had to find time in their schedule to apply, deal with errors in their application, and complete any additional follow-up paperwork. Throughout the process, Niehaus looked to colleagues for support.

“A group of colleagues and I conducted weekly Zoom consult groups to navigate all of the changes. This was a huge help, as we could all support each other through the PPP application process for small business, discuss our own self-care while parenting and working as therapists through this pandemic, and collaborate on tough cases,” she says.

Balance
In addition to the support described by Niehaus, maintaining a work-life balance is another component of private practice life in a pandemic that clinicians have had to be more in tune with. In some ways, it could be easy for a clinician to fill the hours previously consumed by commuting, socializing, and other prepandemic activities with more work, including accepting new clients. However, doing so isn’t wise.

“In the beginning, I had to really take a moment and take a few days off,” Wohlsifer recalls. “Being in quarantine, I had nothing else to do. It was very easy to work a lot more. I started filling all those hours with work. All my social plans were canceled, and my gym was closed.”

Niehaus, who has three children, found that she consciously had to create a separation between work and home. “I have tried to clump my working hours together so that when I am home and not working, I can be present for my family. Initially, the logistics of three children schooling from home and two adults working from home and trying to find quiet and privacy for my appointments was a challenge. As the months wore on, I began going into my office for my telehealth appointments, and that started to feel better and more manageable for me,” she says.

Looking Forward
While all of the changes that have occurred since March 2020 have become the new normal, it is expected that the pandemic will end in some way by the close of 2021. However, it is also expected that many of the adaptations made because of COVID-19 will remain in place. That’s true for private practices as well.

For example, all of the therapists interviewed for this article believe that telehealth will remain a prominent service delivery mode, noting that many of their clients prefer it. This alone could lead to more changes such as downsizing office space. For example, when Wohlsifer’s office lease expired, he chose not to renew it. Though his future plans are not finalized, he, his husband, and a colleague are considering an office share post pandemic in which they rotate days in the office.

Penwell, too, believes that when her lease ends, she will opt for a smaller space.

Beyond telehealth and office logistics, clinicians with private practices will walk away from the pandemic with new lessons learned about both their clients and themselves. “We have travelled a hard road over these past months together,” Niehaus says, “and we long to process this experience with other human beings, whether that’s with our friends, family, or in therapy with a trusted clinician.

“I have felt such gratitude for our clients—their amazing courage and vulnerability during this time and that they’ve trusted us to accompany them along this part of their journey. Though some days I feel weary, I always feel thankful that I’ve been called to this profession.”

— Sue Coyle, MSW, is a freelance writer and social worker in the Philadelphia suburbs.