Online therapy or just therapy?

What’s the difference between online therapy and in-person therapy?

Nothing really. Online therapy is simply a modality. It’s not a distinct “thing.” We get inquiries almost every day from people who want to become an online therapist. The interesting thing is that some of these people aren’t mental health practitioners at all, yet there’s a pervasive myth that becoming an online therapist is somehow different than becoming a “regular” therapist. It’s not. Online modalities are just that: modalities. It just a method by which treatment is delivered.

There are some differences however between delivering a counseling session using the internet and delivering treatment in an office.

Drawbacks of distance therapy modalities

One of the key differences is perceptual. A practitioner in an online video session doesn’t generally have the ability to see the patient’s full body, thus fidgeting hands, restless legs or other potentially useful indicators aren’t visible. There’s also the lack of pre-session observation (how does the client walk into your office, how do they carry themselves, etc.) Finally, you can’t smell your clients over video. For some that could be a benefit, though smell can provide powerful clues into the mental state of certain types of patients. These drawbacks are even more pronounced with telephone or text message therapy as you have zero visual information.

Benefits of online therapy in mitigating avoidance factors

So while you lose some sensory input with distance modalities, you do gain other benefits. Avoidance factors common to the help-seeking process are often reduced or mitigated completely within a telemental heath context. David Vogel’s 2007 paper “Avoidance of Counseling: Psychological Factors That Inhibit Seeking Help,“; described 6 key factors the inhibit those needing help from seeking a professional:

  • Social Stigma
  • Treatment Fears
  • Fear of Emotion
  • Anticipated Utility and Risk
  • Social Norms
  • Self Disclosure

I recommend reading the paper linked above to get a more complete overview of each of those avoidance factors, some interesting points are summarized here. Vogel, when discussing the Anticipated Utility and Risk factor had this to say,

Another implication of this [Anticipated Utility and Risk] avoidance factor is that counselors may need to reach beyond traditional methods of providing services to access the individuals who are most reluctant to seek their services. If traditional methods are perceived as involving high risks, then nding alternative methods of treatment that are viewed as less threatening may be more useful to underserved populations. The literature suggests, for example, that men may resist counseling services to avoid feelings of inadequacy and dependence. Counselors seeking to reach a specific audience, therefore, may need to consider innovative methods to reach those individuals, perhaps by reaching out of their comfort zone and offering nontraditional services, in nontraditional ways.

Regarding the other avoidance factors, it’s clear that the online (or telephonic) treatment modalities can also mitigate many of the traditional reasons for avoiding therapy. There’s often reduced inhibition using distance modalities. The perceived power balance between practitioner and patient is more equal and thus with certain types of patients, that could be important to their willingness to seek or remain in treatment.

We’ve talked about the other benefits of teletherapy in prior posts, however as a refresher, here are some of the big benefits:

  • Missed appointment reduction
  • Improving treatment continuity
  • Expanding your practice reach
  • Lowering costs
  • Expanded availability

Online therapy augments but not necessarily replaces in-person sessions

There’s a time and a place for everything. While the advances in mental health practice management technology have been dramatic, the idea of online modalities replacing the in-person practice is nonsense. It’s much like the book industry. What happened wasn’t that physical bookstores completely disappeared — they simply evolved. Now when one visits a bookstore, it isn’t strictly to buy books, but to engage in a specific experience. So just as Amazon and physical bookstores can co-exist, as will online mental health treatment and in-person visits. However, that being said, the bookstores that have failed have done so because they refused to evolve.

The evolution of the private mental health practice

Recognizing that practitioners must evolve and adapt to new technologies, that begs the question: what does that evolution look like?

Make the entire therapy user experience more efficient

Adding things like online therapy appointment booking, eliminating the need for phone calls and going paperless are good starts. Anything that can decrease the “friction” of seeking treatment will be vital to the long-term sustainability of your private practice. When your competition makes life for clients easier, it means that you’ll potentially become one of the “failed” bookstores.

Use technology intelligently

This is a harder one to grasp. Just because you have access to a technology doesn’t mean that it’s the right tool for the job every time. For example, many patients aren’t comfortable with certain technologies (or can’t afford them.) That means that you still need to adapt to the needs of your clients.

Don’t force online booking on a client who’s only internet access is at the public library. However, don’t force telephone booking on clients who are more comfortable using their iPhone and other digital “toys.” Being able to respond to the different contexts of your clients is essential!

Also, be cautious of using technology just for technology’s sake. What that means is that every tool you use ought to solve an actual need you or your clients have. Just as a hypothetical, let’s pretend that clients can book appointments using Snapchat or Twitter. Does that mean that providing Snapchat-booking in your own practice actually solves any problem? Probably not. It’s clever and maybe fun, but a well designed online therapy appointment booking system ought to solve the need. That’s not to say that one day that method of appointment booking might become important, but just implementing that just because you can doesn’t mean that it’s really improving the user experience of your therapy practice. The point: curate your technology arsenal to provide the maximum utility for you and your clients. A great chef doesn’t use every ingredient — they use the right ingredients!

Online therapy is another tool in the toolbox — it isn’t the toolbox!

Online mental health treatment is a powerful option for most therapy practices, however it shouldn’t necessarily be your only option. The smart deployment of behavioral health practice management technology requires an understanding of how and when these tools are appropriate. You absolutely should have them ready for use, but your good judgement and professional experience should guide you on the best practices given a specific context.

What’s coming at iCouch..

Normally, this blog is dedicated to providing behavioral health practitioners with savvy (even if slightly irreverent from time to time) marketing, therapy practice management and other content created to help you run an amazing practice. We don’t often talk about iCouch the company and our products, but we do make exceptions from time to time — after all, this is the iCouch blog! Indulge us and keep reading.. we want to share some incredible stuff we have working and certainly we invite your feedback, suggestions and wish list items. (Be sure to leave a comment!) The entire purpose of iCouch, the company is to make therapy simple for you, the practitioner and your clients.

What does Therapy Simple actually mean?

The idea behind iCouch is that running a therapy practice is hard work — not just the actual providing of behavioral health services, but the process of running the business. How many hours does the average therapist spend on paperwork each week? In many cases, more hours than they spend in actual sessions! What are some of the pain points experienced by practitioners? A pain point is simply “Some area of work that is less efficient than it could be.” You could also define a pain point as “A problem in search of a solution.” Therapy Simple is the iCouch philosophy that drives us to make the therapy business simple. In an ideal world, you’d do nothing but conduct your sessions and check your bank account from time to time. We aren’t quite there (yet,) but iCouch is making that dream closer to reality than anyone ever thought possible just a few years ago. Therapy Simple — it’s our mission.

What’s happening to iCouch?

In a few weeks, we’re going to close new therapist sign ups to the existing iCouch platform. That means existing iCouch customers will continue to have full, unlimited access to the current iCouch therapy platform but new folks will sign up for our waiting list for a new iCouch that will quite simply, blow your mind. Anyone that’s an existing customer before we close to new sign ups will be given a huge discount if and when they switch to the new system. This is to reward our existing practitioners for sticking with us. If what you’re about to read makes you want to stand on your chair and cheer, then you might want to sign up for the existing iCouch if only to save your place in line (and earn a great discount) for when the new iCouch launches this summer. So what’s happening to iCouch? It’s getting better. Much, much better. So good that our competition is going to face an existential crisis.

It’s the therapy platform equivalent of the launch of the iPhone.

What’s special about the upcoming iCouch?

Everything. Since we started this company in 2010, we’ve been listening to our therapists and coaches who use the system. I’ve personally have had over 500 conversations with therapists to learn about how they work and what they want. We then assembled that information and with a team of User Experience designers, engineers as well as our Chief Clinical Officer, Jessica Dear we started with a single, blank sheet of paper. We sketched hundreds of pages of ideas. We did “paper tests” with our “paper application” to figure out how to make the entire therapy practice management process, including online therapy sessions, perfect. We’ve been going through this “paper development” process for the past 9 months. Some of you reading this were a part of that process — you know who you are and we thank you! In the coming posts, you’ll get to read about the new iCouch features coming in the new iCouch.

Be sure to leave us your email to join the early access list! Early access people will not only get invited to use the new iCouch first, they’ll also get a nice discount as well.

Try iCouch Free

Marketing for therapists, an Agile approach

If you’re a therapist entrepreneur (or a coach,) marketing is your lifeblood. When starting a private therapy practice, it’s easy to get caught up in office decorations, getting business cards printed and deciding on your office location.   Marketing is not exactly an afterthought, but it’s almost certain that many behavioral health professionals have spent more time browsing Pinterest for therapy office furniture ideas than they have spending time creating a marketing plan. The best business advice for therapists I have is simple: create an Agile marketing plan.

Before we jump into how to do this and why it’s important, it’s helpful to understand two common models for project management. Bear with me, the relevance will become clear when we get to the “how-to” section of this post!

A brief introduction to the Waterfall Method of project management

Traditionally, software development used a very inflexible model, called “Waterfall.” The Waterfall model is a sequential design process. It has 5 steps.

  • Requirements
  • Design
  • Implementation
  • Verification
  • Maintenance

The Waterfall Model

The Requirements step requires that stakeholders come up with a very exactly, fully comprehensive set required features for a particular software project. Once the requirements phase is done, it’s set in stone (more on this later.) These requirements are handed of to the next step.

Design involves the architecture of the infrastructure as well as the visual design of every single aspect of the project. After the Design phase is complete and signed off on by the stakeholders, it, like Requirements, are set in stone.

Then we move on to Implementation which is actually writing the software code. Finally we have Verification which is also known as Quality Control. This is where what was built is verified against the original requirements. Then, as with anything, there’s the Maintenance stage, which is typically ongoing.

What problems can you predict in this model of project management? One of the biggest issues is that the project depends on an absolute understanding of the problem domain. What happens if, six months after Requirements have been established, you discover that one of the requirements was wrong? It’s a very expensive way to make software because the finished product, while it might conform exactly to the requirements might not meet any new requirements that have arisen in the interim!

Agile to the rescue!

Agile is a method that depends on continuous feedback. There are some initial assumptions about the goals of a project and those form the basis of initial requirements. However unlike Requirements (with a capital R,) agile requirements are the absolute minimum requirements necessary to get started. The concept is that you start with some assumptions and then you build something simple based on those assumptions, you then try it out (or let users use it,) then you take what you’ve learned and feed it back into the process. You confirm or reject assumptions and you build more and more until you get to a point where the project is solving your needs. There’s always maintenance, but even more important than maintenance is constant learning and adaptation; the software evolves as life evolves rather than as a “finished” product.

By Planbox (Own work) [CC BY-SA 3.0 (], via Wikimedia Commons

The Agile Model

Therapists and coaches aren’t building software!

What does this all mean to you? You’re not building software right? That’s correct! You aren’t building software, however you are building a business. You are trying to sell a product. Your product might be online therapy, online counseling, coaching, in person therapy, couples counseling, children’s therapy — whatever it might be.. So while you aren’t building software, you are doing something conceptually similar; you’re trying to improve your therapy practice.

You’re (hopefully) interested in creating a marketing system that will go beyond a simple therapist website, business cards and an advertisement in the local Yellow Pages. You want a system of behavioral health marketing that will help you get more clients and improve your therapy practice. You do want that right? The median mental health counselor salary in 2013 was $40,580 per year. In 2015, it rose to just $40,957. You might be “lucky” and making more than that, but unless you’re happy with your income, keep reading! Even those at the top of the scale can earn more if they just know how to market their therapy practice.

Building a marketing system

As you may have noticed in the previous paragraph, I emphasized the word system several times. This is important. You aren’t just going to create a marketing plan, you’re creating a system. Kind of like software when you think about it.

The goal of software is to make doing something easier, to automate, to simplify. Imagine if I were to hand-write this blog post! However, many behavioral health professionals are doing the marketing equivalent of hand-writing their marketing. You need a system and now, with no further delay, I’m going to show you how to do it.

Agile Marketing for Therapists

Setting Goals

The first step in any endeavor is to decide what you want to accomplish. The goal setting process is something that almost every therapist or coach has discussed with a client at some point in their career. Now, it’s time for the physician to heal thyself.

What are some reasonable goals for your marketing? Of course, you want everyone that visits a find a therapist website to book an appointment with you right? You also want to “increase your client base” and perhaps “have a more regular income from your practice.” Those are terrible goals! Wait! Don’t stop reading! Before you leave this blog in disgust, let’s think about what a goal actually is.


  • are specific.
  • are measurable
  • are achievable.
  • have a deadline.

Doing something like “increasing your client base” is more of an aspiration than an actionable goal. However, let’s take that aspiration and turn it into an actual goal.

“I want to increase the number of my active clients by 5% by the end of the year.”

That’s a good goal! First, it’s very specific. You’ve said, “active clients.” This is very specific because it isn’t just about getting more numbers, it’s about getting more numbers based on a specific criteria. Let’s say you define active as having a session at least once per month. That is very specific.

Next, this goal is clearly measurable. At the end of the year, count your active clients. If that number is 5% higher, then you’ve won.

It’s certainly achievable. If you have a practice of 20 active clients, that’s just adding 5 more until the end of the year (unless of course, you’re making this goal on December 26!)

Finally, there’s a deadline. That’s important. You need to hold yourself accountable. Without accountability, you will not achieve your goals.

So, think to yourself, what do you want your marketing to achieve? Come up with a specific, measurable and achievable goal and establish a deadline. Write that goal down. Put it on your bathroom mirror. Write it with a Sharpie on your significant other’s arm. Carve it into your desk. It’s ok to have several goals, just be sure that you maintain focus. You can also create shorter term and longer term goals as well. Be sure the goals are complimentary.

Form assumptions

Now that you have the goals of what you want your therapist marketing system to help you achieve, now we need to brainstorm. At this point, we’re not brainstorming specific marketing ideas, but instead brainstorming about your assumptions about who you are trying to reach with your plan.

Know your audience and create personas

What would be your average demographic for your clients? What is their age, their sex, their typical condition? What is your ideal client? Create a “biography” of this archetypal client. Give him or her a name, an age, a background. Creating this “fake” client is important. Now do this with a few others. You should have perhaps 3-5 personas of the people you are trying to reach. Get to know these people. They’re going to be your best friends as you develop your therapist private practice marketing plan.

Make a list of questions your personas might have

Let’s assume these personas have never had a therapy session with you before. What do they want? What kinds of question might they have? Don’t think about just yourself, but think about them in general.

For example, let’s say Lydia, a 28 year-old single mother of two has periodic bouts with anxiety. She works as a paralegal and spends her spare time with her kids. She likes reality TV but she also reads the NY Times on her iPad when relaxing in the bathtub.

When her anxiety starts getting out of control, what do you think she might Google? What kinds of blogs might she read? What kinds of solutions might she try before booking a therapy session?

Lydia might read an article on WebMD or perhaps look on YouTube for some tips on how to cope with anxiety. She might even read the iCouch Waiting Room blog to find some tips on how to cope with anxiety. Perhaps she has tried to find how her diet could help her situation. Maybe she looks for some blogs or articles about beating stress for parents. She might have even looked for therapy appointment reviews on Yelp or some other online resource.

Now for our assumptions:


  • is reasonably educated.
  • is interested in new ways to beat anxiety.
  • is probably a stressed parent.
  • wants solutions but doesn’t necessarily think she has a problem needing medication.

Granted all of this stuff is just our imagination. However, by understanding your potential client, you can start to create a plan that will speak to Lydia. If you know the psychology of Lydia, you can understand how to provide her with content that will attract her into your sphere of influence.

The power of inbound marketing

I’m a huge believer of inbound marketing. If you’re reading this right now, then you’re experiencing the power of inbound marketing! I’ll let you in on a little secret: at iCouch, we love helping therapists and coaches however, we’re also a business. Our goal is to provide our audience with great, useful content, but at the same time expose you to our company.

We aren’t asking you to subscribe to our practice management software or use our system for video therapy, however the fact that you are reading this means that now you get a chance to find out more about iCouch if you so choose. You might not have ever have heard of us if not for this blog. And, what did it cost? Zero! We got our company in front of your eyes without spending a dime. How did we do that? By creating content that our personas want to consume.

This is definitely not a sales pitch — it’s a demonstration of the power of inbound marketing. If five out of every 100 therapists and coaches read this end up signing up, then that’s five more customers that we have that we wouldn’t have had without this content. Pretty powerful stuff right? You can do it too! The best part is that even if a therapist doesn’t sign up for iCouch, we’ve still (hopefully) provided some value to our readers. After all, we want therapists and coaches to be successful because it elevates the entire industry, benefiting all of us: practitioners, service providers like us and most importantly, the people that need help.

Start your plan

Now that you know something about Lydia, we can start creating your initial plan and, even more fun, start executing it!

1. Start a therapy blog

This is really important. Do this right away. We’ve written about this in the past, so please go check out “Why you should start a therapy blog and how to do it.”

The reason that starting a therapy blog should be done right away is because Google indexes what you write. The longer your content is on the internet, the higher it will go in the Google search results. As far as what to write about, just write to Lydia. Think about the kinds of things she might Google and then write posts based on what you think she’ll search for. For example, “5 ways to beat anxiety as a single parent.” Your posts don’t need to be long, just high quality. Write as if you were trying to help a friend. Try to write one post per week at a minimum. If you have 3 personas, then you should rotate “who” you’re writing to. Be sure that the bottom of each post has a “Call to Action.” For example, you can include a sentence like this:

“If you want to talk more about beating anxiety, contact me at” This gives the reader an opportunity to take the next step. You should also have the ability for readers to subscribe to your blog.

2. Create an email newsletter

Think about a newsletter that Lydia might want to read. In it, you can include excerpts from your blog (with links of course) as well as links and excerpts from other great content around the web. At the end of the newsletter, be sure to include a call to action! You can have a newsletter sign up form on your blog, but you can also have a pen and paper sign up form in your office. Your existing clients might love your newsletter and it’ll keep them engaged with you and your practice. Don’t use the newsletter as an advertising tool — provide great content! You should send out a newsletter monthly and consistently. If it’s good, people will forward it as well! Check out Mail Chimp. They’re a great company and it’s super easy to manage your mailing lists and create beautiful emails. You can also embed sign up forms on your Facebook page as well.

3. Tweet and Facebook!

Post links to your blog on Facebook and Twitter. However, try to make your Facebook and Twitter pages not all about you. Post interesting content from around the web that Lydia might want to read. Follow and retweet interesting content that you think might be something Lydia cares about. If you aren’t familiar with using Twitter, be sure to read our article about why therapists should use Twitter. You can also read more about responsible social media use by therapists in our post “How to use social media to market your therapy practice.

4. Get listed on online therapy sites.

Being able to offer online therapy and, more importantly, having an online profile for potential clients to visit is going to open up your potential client base to many more people than simply those that live near your office. You don’t have to become a full-time online therapist, but augmenting your existing practice makes it easier to get new clients. Read about how to add online counseling to your existing therapy practice for more information. This will help supplement your marketing because you’re making it easier for clients to potentially “buy” your services.

5. Talk to Lydia on YouTube

We recently wrote about YouTube for therapists and the basic idea is this: create a short video on a regular basis on a specific topic that Lydia might search for on YouTube. You don’t need fancy production, you just need to “talk” to your webcam or video camera providing some quickly digestible content. It could be as simple as a one minute explanation of how to do deep breathing exercises or a short chat about some new piece of anxiety research you’ve read about. Of course, at the end of the video, you should have a call to action such as “If you want to learn more about coping with anxiety, please visit my blog.” Don’t try to sell them. The goal is to get them to your blog so they can enjoy more content and then maybe they’ll consider a session with you. Don’t force it. Just invite your audience into your world.

6. Iterate

The most important part of this plan is that you do not fix anything in stone. If you notice that readers are responding to a particular type of content, create more of it! You should be constantly responding to feedback and data and adjusting course as necessary. Remember, our Lydia persona was based on assumptions. She isn’t set in stone. It’s critical that you refine as you go and be open to changing course (i.e. revising your personas) as you go. Don’t assume that all potential clients will respond to the same types of content, be sure to be constantly learning!


I know, this was a huge post and a lot of information. Hopefully, it provided some great ideas on how you should create a marketing plan, but more importantly, how you should be flexible, respond to change and avoid creating content that you care about, but that your audience cares about. All of this social-bloggy-persona “stuff” might seem like a therapist productivity killer, however the reality is that marketing has changed. The internet is pretty much the first stop people go to for information. Please read our article about inbound marketing for therapists if you want even more information about how all of this stuff works.

The Germanwings tragedy and the Disclosure Paradox

In the United States, some states, such as Illinois require mental health professionals to report conditions that present a “clear and present danger.” This reporting is part of the Firearms Owner Identification System. What this means that in Illinois (as well as some other states,) any patient that presents a danger must be reported and that report will be provided to the Illinois State Police. Keeping firearms out of the hands of the mentally impaired is a laudable goal, however, it would seem that the concern over firearms is rather short-sighted. Firearms are an obvious concern, but what happens if a taxi-driver, bus driver, school teacher, or, in the case of the horrible Germanwings tragedy, an airline pilot, presents a danger?

In China, where the private ownership of guns are almost non-existent, there were several high profile mass murders committed in schools by disturbed persons using knives. We’ve just witnessed the results of a mentally ill person at the controls of an airliner with the crash of the airliner over the French Alps. There are more than a few cases of criminally insane nurses killing patients. For example, this case in Texas was concerning a nurse who was killing newborn babies in their cribs! While many of these people never sought mental health treatment, if they did, would the Illinois requirements have been enough to prevent these tragedies? No. If it were an issue of access to firearms, perhaps the law and reporting requirements would have been effective, however the law falls well short of reporting airline pilots to the Federal Aviation Administration and their employer or nurses to the licensing boards and their places of employment. In fact, reporting a patient to their employer would be expressly prohibited by American (and presumably European) health privacy laws. Reporting to the government/police would be permitted, but only in a case of an imminent threat.

The question of when should a therapist contact authorities when they discover a potentially dangerous condition in one of their patients is a tough one. The laws generally allow such reporting in the event of an identifiable and imminent threat, but not for just generalized concern. This means that if your patient seems like they “might” snap at some point and they might have the potential to create a danger to the public, you can not report that. You can only report it (at least in Illinois,) when there is a specific threat or a “clear and present danger.” If your patient says that they want to kill themselves or they want to kill someone else, then you can report that. If they are less specific or even don’t say it at all but you have a suspicion that they might be thinking of causing harm, the guidelines are far less clear.

The Disclosure Paradox and mental health ethics

The problem with any sort of mandatory reporting law is that it creates a dangerous paradox. A patient won’t be forthcoming to their practitioner because they are protecting their career or in some cases, their freedom. With mandatory reporting laws, it’s possible that those in most need of care refuse to get it because they don’t want to jeopardize their professional ambitions. This is extremely common in the military; soldiers, while encouraged to seek care for post-combat issues, depression, etc, are highly unlikely to seek care until after they leave the military. Despite assurances to the contrary, many soldiers feel like seeking therapy will poison their potential for advancement in their military career. And, it just might. Therapy sessions are part of a soldier’s medical record and do have the potential (even if unofficially) to curtail certain future assignments.

Here’s a practical example:

Private First Class Jones just returned from a 9 month deployment with their Ranger unit in Afghanistan. He tells his commander that he needs to miss formation the next morning because of a medical appointment. The commander, by virtue of his responsibility to ensure unit readiness has a right to know the nature of the medical issue. For example, if it’s a sprained ankle, then that would mean that soldier would not be combat ready at that moment. In short, the commander must know the condition of all of his troops or else he would be unable to accurately assess their readiness for a mission. If a soldier were to hide the condition from the commander and the commander then orders the solider’s squad to conduct a parachute jump, then that solder could not only be seriously injured, but his teammates who were depending on him could be harmed by his lack of readiness.

If the solider tells his commander that it’s a mental health appointment, then that commander could (rightfully or wrongly) assume that the soldier isn’t mentally fit for combat. That commander may refuse to recommend the soldier for more challenging assignments that would then affect his promotability in the future. Regardless of the content of the solider’s therapy session, there is a perception that the solider may have a “problem.” It isn’t supposed to be like that and officially, it’s not, however a commander is human too with all of the bias that being human includes. For a very high stress, high performing unit like the Rangers, any doubt in the commanders mind will always be decided in favor of the unit and the mission and not the individual soldier.

Soldiers know this. As a result, they don’t seek care when they need it. It’s also a reason that many soldiers are turning to online therapy as an alternative to the military health system.

Applying this example to the Germanwings pilot Andreas Lubitz, if he knew that his doctors would report his condition directly to his supervisors, then he might not have ever sought care in the first place. Of course, the tragic outcome would indicate that the care he was receiving wasn’t enough to prevent the tragedy. The question is however, how many more Andreas Lubitzs are there driving our buses, flying our planes or teaching our children? If mandatory reporting laws were strengthened, would that potentially cause more tragedies because there would be fewer people getting successful treatment? The behavioral health ethics implications of this are profound.

Mental health privacy ethics is a very tough area. It’s likely that the Germanwings tragedy and mental health policy will be continually analyzed for years to come. The Disclosure Paradox as I’ve termed it, remains the biggest challenge in mental health reporting and public safety. If a patient knows you’ll report them, they won’t seek treatment. If they don’t seek treatment, tragedy could happen.

I wish I had the answers, but it’s an exceeding difficult ethics question. What do you think? How would you solve the Disclosure Paradox? Leave your thoughts in the comments below.

Getting Paid: a guide to therapy fees

Nobody likes asking for money! It’s one of the most uncomfortable conversations to have with current and potential clients. However, you can’t pay the bills with rainbows! This article should help get you the confidence to deal with getting paid for your hard work.

Ethics of therapy fees

All of the professional counseling and therapy organizations have ethical codes regarding fees. The Zur Institute is a great resource on the specific ethical codes for the various professional organizations. Be sure to check out their ethical codes page! For the sake of simplicity, I’ll quote from the American Counseling Association Code of Ethics and Standards of Practice, however most organizations have a similar idea.

Here are the major areas of the ACA ethical code regarding fees for service:

  • Self Referral
  • Unacceptable Business Practices
  • Establishing Fees
  • Nonpayment of Fees
  • Bartering
  • Receiving Gifts

Self Referral

The ACA ethical code prohibits referring clients to your private practice if you work for an institution unless the organization’s policies specifically allow for it. When you are allowed self-referrals, you should be very clear to the patient of other options available. Remember, when you are working for an organization, you should be a representative of that organization and not a sales representative for your own practice!

Unacceptable Business Practices

No kickbacks for referrals! No fee-splitting! A patient expects you to look out for their best interests — not your best financial interests. If there’s a financial incentive through fee-splitting, that leads to steering patients towards a particular practitioner because of your own self-interest and not the best interests of the client. The appearance of impropriety is enough to shatter the public trust in the behavioral health profession. Hold yourself to a high standard and financially you’ll end up doing better than if you compromise those standards for a quick payday.

Establishing Fees

Be conscious of the locale and the financial status of your clients. If you’re in Laramie, Wyoming and you’re charging $250 an hour, you’re probably not doing it right. If you’re in New York City charging $250 per hour, then that might be more acceptable. The key point — be aware of your market and don’t exploit them (but don’t be taken advantage of either!)

Nonpayment of Fees

Are you prepared to use a collection agency? If that’s the case, you must disclose this possibility within your informed consent documents. You should clearly spell out the consequences of non-payment before the therapeutic relationship begins. Certainly be flexible, but you definitely want to collect the fees you have earned.


While I personally don’t like the idea of bartering for therapy services, it is permissible only “if the bartering does not result in exploitation of harm.” The reason I don’t like bartering is that it’s often difficult to equate the value of a good and your services. What that means is that you’re adding some complexity to the arrangement. However, that being said, in many communities, bartering is an accepted practice. Just be clear on the exact terms of the barter and don’t allow it to be open ended. For example, if you’re bartering for web design services, establish what the price of those services would be if you were to pay cash, then “pay” for those services in an equivalent amount of your therapy services. Be clear, get it in writing.

Receiving gifts

In many cultures, small gifts are a token of respect and gratitude. However, it’s important to take into account the motivations for the gift, the monetary value and your motivation for accepting or declining the gift. Be culturally sensitive, but I would advise you to avoid large gifts. Use good judgment.

Your therapy fee structure and cancellation policy

Every client should have fees disclosed before they begin a relationship with you. If you chose to offer a sliding scale, be transparent about how that fee is determined. If you collect cancellation fees, make those crystal clear, including the cancellation policy. The upcoming iCouch, due out this summer, is going to make it really easy to both set a cancellation policy as well as enforce it. We know this is an uncomfortable subject for many therapists!

It’s highly recommended that you treat cancellation fees as non-negotiable and consistently apply them within the context of your policy. If your cancellation policy is clearly defined, unambiguous and fairly applied, your clients will respect it. However if you inconsistently apply the cancellation policy, you will lose money, but you’ll also be faced with the uncomfortable task of explaining how you can’t waive the fee “this time.”

Cancellation fees serve several purposes:

  • They compensate you for your lost time; you run a business and you have bills to pay (including your salary.)
  • They provide an incentive to not miss appointments (thus improving patient treatment outcomes.)
  • They establish the seriousness with which the patient should take their treatment.

If you devalue your services by not collecting the appropriate fees (including the cancellation fees,) the patient will devalue the importance of their treatment.

In later posts we’ll dive deeper into fees and therapy practice management, however hopefully now you have a bit more clarity as to how you should ethically approach your compensation as well as best practices on disclosing your fee schedule and cancellation policy.

How same-sex marriage could affect behavioral health licensing

Obergefell v. Hodges is a landmark case currently pending in front of the United State Supreme Court. It’s a case where a couple is suing to have their out-of-state same-sex marriage legally recognized by the state of Ohio.

The interesting and potentially groundbreaking implication to medical and behavioral health professionals is that this could open the door to states being forced to accept licenses from out-of-state.

The Sixth Circuit Court of Appeals, in a decision written by Judge Jeffrey Sutton, argued that the case of marriage recognition belonged in the hands of a state’s voters. Which interestingly has a parallel to the US Supreme Court case Dent v. West Virginia in 1889. The Dent case established that states can set reasonable license requirements to obtain a medical license. This isn’t much different than a state setting reasonable license requirements for marriage.

The potential impact of Obergefell on behavioral health licensing

The Obergefell case is going to break some interesting new ground if the plaintiffs win the case. If the plaintiffs win, that would be the Supreme Court saying that a state can’t refuse to accept another state’s licenses. While the intent of the case is “marriage” licensure, the precedent really has no barriers to affecting any sort of licensure, provided that the licensure was lawful in the originating state. We’ve already discussed the legal arguments about telehealth across state lines, however this potential situation would mean that a practitioner could physically practice within another state. Meaning, you could have an office in California but be licensed in Montana. That would send shock waves through the medical community!

We’d certainly welcome that because it would mean that practitioners could chose to live anywhere they wanted without artificial barriers to entering a new market. That would result in a more fluid supply of mental health professionals and could potentially help alleviate some of the profound shortages affecting the United States. The licensing boards will hate it because, it’s their passion to hate anything that even remotely infringes on their fiefdom.

Let me be clear an unambiguous: state licensing boards hate any thought of interstate online therapy, interstate medical practice, interstate anything. They exist supposedly to protect the public, but their real raison d’être is to protect the interests of their state’s practitioners. They have a vested interest in excluding out of state practitioners. It’s about power and money. If it was about patient safety then why wouldn’t they recognize the licensure of an out of state practitioner? Is there a medically significant difference between a doctor in Oregon and a doctor in Washington State?

It would be expected that states would attempt to use a public “safety” argument to defend against out of state practitioners, however the argument would be rather thin since physician board certifications are done at the national level and not at the state level. Thus, a board-certified psychiatrist in Montana has met the exact same certification standard as a New York psychiatrist.

Will this case actually change the health professions?

Not anytime soon. The reality of the Obergefell case is that this will likely not have an immediate effect on the health professions in the United States. Let’s face it, the reasoning is too clever to be obvious. However, in some years, when a case does hit the courts over out-of-state licensure, it is legally logical that the Obergefell case will have some bearing.

YouTube for therapists: improve your practice in 30 minutes per week

YouTube has made it simple to learn anything from anywhere and anyone. Interested in a complex cooking technique? YouTube can help. Want to test drive a Ferrari? YouTube can help! How about testing driving a therapy session? YouTube is a fantastic marketing tool that can seriously improve your therapy practice.

I love YouTube and you should too.

We’ve talked in previous posts about why therapists should use social media. It’s a given that a strong, professional and content-rich social media presence will result in more clients. The number one question I get almost every day is “How can I get more therapy clients.” This simple answer is that you need to provide potential people with a reason for wanting to book a session with you. You need to give them a test drive! You need to get in front of an audience. It’s a whole lot more than simply advertising or tweeting once a week. It’s the whole package. You need to give content away. You need to make yourself irresistable! The big question is how? Social media marketing for therapists IS marketing. Old-school advertising is becoming less and less effective. Most people find their therapists or coaches from a Google search. The smart therapist entrepreneur isn’t worried about right now; they’re working on building a sustainable body of content that is going to pay dividends for years to come. A blog post you publish today is going to be attracting potential customers for years as it slowly rises through the Google results. YouTube videos pay a similar dividend but are even more powerful because it’s a piece of content that “speaks” to your audience.

YouTube for Therapists

The key to any sort of content marketing (also known as “inbound marketing“) is consistency as well as providing useful information. So, for YouTube, that means that you should post a new video each week and that video should not be about you. It should be about solving a problem your viewers might have.

For example, if you’re a relationship specialist, perhaps record a one-minute “relationship tip of the week.” Start by writing out a short script. Here’s an example:

Do you want to be happy or right? How to achieve harmony in your relationship
Most of us love to win an argument. There’s nothing better than stating your case and winning an argument right? While winning the argument might be great if your a lawyer, in a relationship sometimes you have to ask yourself, if it’s worth it. You might know you’re right, your partner might know you’re right, but pride can often result in a small argument turning into something bigger. Ask youself, would you rather be right or happy? Sometimes, in fact many times, it can be better to just seek a peaceful resolution rather than an outright victory. Remember, you make a choice to argue with your partner. Be sure that when you do argue that it’s worth it. Ask yourself if either of you will even remember the subject of debate a month from now. It’s often better to just let things go. It’s ok to disagree, but pick your battles. Of course, if you’re finding that you’re disagreeing more than you’re agreeing, then it might be time to reevaluate your relationship or perhaps seeking help from a professional therapist or relationship coach. This is Dr. Awesome Therapist with your Relationship Minute! Do you have any tips for reducing arguments? Please leave a comment below!
Now that isn’t the best script ever written, however it only took me a few minutes. The next step is to practice it a few times. You don’t want to read it on camera. Just use it as a guide. Basically, you want to talk to the camera as if you were talking with a friend. It doesn’t have to be perfect! In fact, if it isn’t perfect, that can be even more authentic. For example, check out the following video from one of my great friends, designer James Victore. It does use a bit of rough language, but it’s a great example of how you can just talk to the camera. Don’t be too perfect. Just be yourself.
Just turn on the camera and talk. Be sure that you link from the video to either your iCouch profile, your website or your calendar. Promote your video on your social channels. Be sure to set up a YouTube channel so that users can subscribe. The whole “production process” should take you no more than 30 minutes per week. You really don’t even need to write a script. Just make a few notes, practice a few times, record and upload! Be sure to tag your video with appropriate keywords so that people can find your video.

Should a therapist use social media?

Yes! Every therapist entrepreneur should have a social media strategy YouTube is a critical part it.
Be sure you leave a link to your YouTube channel in the comments.. we’d love to see what you’ve come up with. Of course, we’ll also retweet your videos as well, just be sure to let us know when you’ve posted something at our twitter account @iCouchMe

The Paperless Therapy Office

As a therapist, you have a responsibility to protect the confidentiality of patient records. Whether you keep paper copies of documents pertaining to patients, you’ve upgraded to digital record-keeping, or you use both in your practice, it is essential to ensure that you’re in compliance with HIPAA requirements concerning patient privacy and the security of records. But in this day and age, with so many offices going paperless, the bigger concern may be understanding how you can meet your legal obligations as a practicing therapist while also being eco-friendly as well as saving yourself from a sea of paper. In other words, can you go completely paperless in your practice? And if so, how?

What paper is required?

The first thing you probably want to address is the issue of which documents you are required to have paper copies of. Although the legal system has slowly started to adopt a policy of accepting documents that have been digitally signed or scanned into digital format, it may still depend on the type of document and the legal situation in question.

Generally speaking, the only documents that you should store in hard copy are those containing signatures, unless you use some form of verified electronic signature. Signed agreements are legally binding and can be used in courtroom proceedings. As such, it’s always best to keep original copies of documents just in case. You may also opt to keep paper copies of medical records for easy referral, but this is merely a case of personal preference. If you’re quick with your computer system, you can just as easily call up digital files before, during, or after appointments.

Keep what you must, scan the rest

Pretty much everything else can be digitized. This isn’t to say that you won’t require hard copies down the line, but they can be printed out on an as-needed basis, saving you the hassle and clutter of dealing with a huge volume of paper related to your practice. However, you will need to be careful how you go about the process of creating a paperless office, especially since privacy and security concerns are so important to your practice and your clientele.

You need to first figure out how you’re going to convert your hard copies from years past to digital files. You could undertake this arduous process on your own, but you might also want to look into on-site mobile shredding services that will come to your place of business, convert your files for you, provide you with a disc, and then shred sensitive documents before removing them from the site. And you can easily find companies that meet HIPAA compliance standards, so you won’t have to worry about dumpster-diving thieves reassembling your shredded documents and stealing private information. If you have a small office, you can potentially do all of this yourself. But, be extremely vigilant in how you dispose of the shredded records!

Backups are vital!

Before you start converting and storing files, though, it’s probably best to set up a secure storage system for digital files. You can use iCouch to store digital files, but it’s also wise to have a secure, local backup (such as a dedicated hard drive and/or thumb drives that you would keep under lock and key.) No matter how much we love the cloud, having a backup is vital!

As a practicing therapist, you cannot afford to have client data compromised in any way. And losses can just as easily occur in the event of a power surge, an extended blackout, or even physical trauma to the system due to fire, flooding, earthquake, extreme heat, and so on. So having a backup in place is a necessary precaution. You just need to make sure that any location where files are stored offers the highest level of security to combat potential breaches, corruption, or loss. For local backups (meaning a backup that you have in your physical possession,) be sure to encypt the disk, contact me at or leave a comment if you want some free help in understanding how to do this. We’d love to help you (even if you aren’t an iCouch subscriber.) Why? Great data protection practices benefit our entire industry.

When in doubt, ask for help

There are certainly ramifications associated with transforming your therapy practice into a paperless operation. Be sure you ask us any questions if you have any doubts about the process. As I’ve said, we’d love to help even if you have no interest in online therapy, iCouch or any of our services. Ultimately, though, a paperless system could be to your benefit and that of your patients, as well. Digital files face fewer threats than paper files, especially if you exercise due diligence where security and back-ups are concerned. And you’ll help to clear the clutter in your office and do your part for the environment in the process. The paperless therapy office is within reach!

Have questions? Please leave a comment!

Feature sneak-peak: the iCouch therapist calendar

We are blown away by how many of you have signed up for the iCouch Early Access list. For those that don’t know the early access list is simply an email list of behavioral health professionals who are interested in being notified when the new iCouch is ready for release.

Try iCouch Free

We’re still on track for a late summer release, but in the meantime, I wanted to provide the occasional sneak peek into the great new stuff that is coming! Today, I’m going to share a little about the therapist appointment calendar.

Creating the perfect behavioral health calendar system

Here are some of the requirements that we at iCouch had for the therapist calendar system:

  • Must support a variety of appointment types, durations and prices
  • Must provide ways to easily track cancellations, no-shows and confirmation status
  • Must be flexible: a therapist should be able to enter availability easily as well as override default availability for specified days
  • Must make vacation and other periods of non-availability simple to set
  • Must have a user interface that’s familiar, yet purpose-built for the unique appointment needs of behavioral health professionals
  • Must have a powerful preferences section that allows for booking “rules” to be both easily set as well as automatically enforced.
  • It must be simple and beautiful. It shouldn’t look like circa 2007 Microsoft Outlook.
  • It must be simple and beautiful. (I mentioned that twice because it’s that important!)

Every design decision was informed by what is best for the therapist

Of course, beauty is in the eye of the beholder, however, our user experience decisions were based on over 6 years of experience with online counseling software engineering. We interviewed dozens of practitioners, not just online therapists, but also in-person therapists. We chatted with mental health veterans as well as students entering the field. Countless paper napkins were used for sketches before we employed our more serious design tools. The point is that while not everyone will cry tears of joy from the look and feel, every pixel of the calendar system has been scrutinized, field tested and subject to a spirited design process. What that means for you is that, if statistics are to be believed, you’ll love using this!

Please note, some of the following screen shots are subject to change. As we get closer to launch, details will be continually refined, but you can still get the overall idea!

The day view of the therapist calendar

iCouch therapy appointments calendar

When you select an appointment from the appointment listing, the basic details of the appointment appear in the right sidebar. There’s a familiar reminder system and, if it’s an online therapy session, a link to the video session. The light green sections of the day view are the therapist’s appointment availability that would be visible on their public-facing booking calendar.

On the top menu bar, you see a gear icon for your calendar/booking preferences, a selector for Day, Week or Month view and a button to quickly take you to “today.”

You’ll also notice in the top center, that you can select between your “Appointment” and “Availability” views. The Availability view, allows you to edit the ranges of times visible on your publicly-accessible booking calendar. The Appointment view of course, shows the appointments you have scheduled.

The top right of the calendar section allows you to edit your appointment types, durations, and prices as well as manually enter a new appointment.

Once we get closer to our release date, we’ll be providing more details on how all of this works. The first time you use iCouch, there’ll also be a contextual tutorial that will walk you through this stuff very clearly. I just wanted to provide a general introduction to what this is all going to look like!

The Week view of the therapy appointment calendar


Time zones are simple to change

You couldn’t see it in the Day view screen shot, but you can also change your time zone very easily, as shown in this screen shot.

Therapist calendars should be intuitive

The iCouch Calendar is very easy to navigate and after you spend a few seconds getting oriented, you should be able to get right to work! I’d bet that most of you can look at the screen shots above and immediately be right at home.

Therapy appointment confirmations, cancellations and no-shows

This feature isn’t obvious in the screen shots above, but clients can confirm and cancel their appointments via email or text messages (if you decide to use email or text message reminders.) The cool thing is that when they respond to an email or text reminder, it will automatically update your calendar. So each day before you get started, you can see your cancellations and confirmations right in the calendar view. You can also manually change the status of an appointment as well — you don’t have to use any of our automated reminder features.

One important feature is that you can set the status of an appointment to “no-show.” This is going to be really helpful when you look at your reports — you will be able to easily track no-shows and see the effect on your revenue.

More iCouch feature sneak previews to come!

I hope you enjoyed this very brief introduction to the iCouch therapist calendar system. In future posts, I’ll show you how the public-facing booking calendar works as well as setting booking preferences and adding appointment types, durations and prices.

Also, be sure to remember, although iCouch started as an online counseling company, the upcoming iCouch is designed for all behavioral health practitioners, regardless of the mode of therapy. So while iCouch has HIPAA compliant video conferencing, that’s just one feature of many in our therapy practice management system.

Be sure to check out our previous blog post answering some common questions about the upcoming iCouch (including pricing.) As always, feel free to leave a comment or contact us via Facebook or Twitter if you have questions!