Clay Cokrell: Hello and welcome to the Online Counseling Podcast, the show where online therapists come to learn. This is episode 38, and we have now reached over 15,000 downloads. I can’t believe it. And I have to thank all of you online therapists for all of your support. It’s been an incredible year and I’ve learned so much. Hopefully you have too, which of course is the whole point. It’s the goal of this podcast to educate and inspire therapists who want to take their practices online and reach a larger audience through telemental health. And just look at our two most recent episodes with Maelisa Hall. We learned all about documentation and the needs of a good informed consent when doing online therapy. And most recently, we got to learn about online therapy in Australia and how Nicole Hind created a 100% online practice in a really short amount of time with clients all over the world. So I hope you are getting both value and inspiration.
CC: For those of you following along, I’m still in Miami, loving February in Miami. But I think a part of the fun of being in Florida for the winter is watching CNN and seeing how my home in New York is freezing and covered in snow. Well, not this year. I’m talking with my clients back home and they’re saying, “Yeah, 70 plus degrees, sunshine, not sure why you left, it’s great out.” Oh well, I’m sure as soon as I get home we will have a March snowstorm. And we will be heading home this weekend. I’ll be making the two-day drive up the coast, putting on layers the farther up I go. That’ll be fun. But it’s been great, and I’m so grateful for the online practice that I’ve built that allows us some extended travel.
CC: Okay. A quick update on the directory. Wow! So in the last episode, we made a huge announcement about the price discount for yearly members, which drops the monthly price to only $12.47 a month, which is, I think, kind of a bargain. Well, I think we have hit the sweet spot. You guys really responded, and we have all sorts of new therapists from all around the world who have signed up. It’s so much fun learning about these people who are coming into the family at the Online Therapy Directory. So we are going to keep this going for a little while, not sure how long. So if you were thinking of listing your practice, now is the time. Just go over to onlinecounseling.com and click on List my Practice.
CC: Now, on to today’s interview with Kenneth Fields of Open Mind Counseling in Hawaii. He’s a new member to the directory, and I wanted to have him on the show because he has been doing online counseling almost from the beginning; started back in 2006. And he has particular experience with what can be termed online clinics. Now, some of you have probably seen them out there. There’s several. There’s, Talkspace, Breakthrough, BetterHelp, etcetera. Many of them match the client with you after asking a lot of information from the client. We at the Online Therapy Directory decided to do things a little differently, allowing the client the freedom to learn about different online therapists and choose their own. But I think the online clinics have a place too; they’re just a little different. And as you know, we have guests on here that you may or may not agree with, and who may challenge your concept of just what psychotherapy is. But I found Ken to be very thoughtful in his approach, and he has a long and extensive experience with these online clinics, watching them change over the years and improve, and he’s just… There’s really no one I could think of who could be better at taking us through that world.
CC: And again, I want to stress, you can have an online practice that does not include these companies. Just a couple of weeks ago, Nicole Hind talked about building her practice and she hasn’t used them. I haven’t used them, and true, I’ve heard objections from some of you on how they do business or how they match clients to online therapists or how they take a percentage of the fee. But Ken makes a really good point that they really aren’t that different than some brick and mortar agencies that we’ve all worked for, and I do believe that there is a place for them, and they are allowing therapists to meet the client where they are at, and at the level they feel comfortable entering the process. Just take a listen to Ken. He surely has found a way to make it work.
CC: Hello and welcome. I am so excited to have one of our newest members on the Online Therapy Directory join us today to talk about counseling, Ken Fields of Open Mind Counseling in Hawaii. Ken, thank you so much for coming on the show.
Kenneth Fields: You’re welcome, and thank you for having me.
CC: And just because I know a lot of people are gonna ask, How are things in Hawaii?
KF: Things are very pleasant in Hawaii. As they say on The Weather Report, we have the best weather in the planet. I’m not entirely sure that’s correct all the time. We do have storms. We have hurricanes that come through during hurricane season, and that’s always anxiety-producing. [chuckle] A lot of preparations and they don’t happen.
CC: Absolutely, absolutely. Well, I’m fascinated by your practice. Tell me a little bit about you and what brought you to the world of counseling in general.
KF: What brought me to counseling in general was I was doing some middle school teaching right after college. I got my degree in secondary education. Found a position at a local middle school and did that for about a year, but wasn’t quite happy with it, and discovered a Master of Arts in Counseling Psychology program in the area and enrolled and completed that. It kinda fit. Even during the teaching, I was leaning more towards counseling the kids than offering instruction. I kinda have a pet peeve around modern educational curriculum these days. So the counseling fit more with my style. I went through the program, got my Master’s and then began doing counseling in agencies for a couple of years. And then kind of dropped out a little bit and did some traveling, and consider myself an incognito counselor because you’d meet people and you just talk story. And a lot of counseling is just talking story, and maybe if you’re inclined towards the counseling approach, you’re listening a lot more, and you’re maybe providing a little feedback, a little insight into what the other person is saying. So I like doing that. I like hearing people’s story, I like providing feedback from what I’m hearing, to what I’m hearing, and maybe presenting some questions about the validity of what I’m hearing. And a lot of therapy is based on that kind of interaction.
CC: Yeah.
KF: Then in ’96, I moved to Hawaii. After a couple of years here I got a job at a human service agency. Was there for about six years and then laid off, because I rose through the ranks and became the administrator of the agency, and didn’t quite like being an administrator, so that ended. And right about that time, which was around 2006, online counseling was becoming a little more viable. Online stuff had been happening. You were getting into online shopping, of course, online banking, and online counseling was kind of catching my eye. So I put together a website and started to market it a bit, but also discovered what I call online therapy clinics. These are large sites that have a collection of online therapists, and they do the advertising and the marketing and the billing. And so, I got involved with a few of those as well, and over the years, it’s just been kind of rolling on.
CC: Not to interrupt, I’m fascinated with your experience with online clinics, but before we jump to that, are you saying that your journey to private practice, it started with online work, or did you have a face-to-face practice that then eventually became online as part of a private practice?
KF: I did not have a private practice at the time. I was working at the Human Service Agency as kind of a direct service provider, and then a program director. We would contract out with other agencies to provide the direct service, and I really didn’t have a private practice at the time. It was when I was laid off that I began to think about private practice, and then I went towards the online platform as a way of, “I’m gonna develop my private practice online.”
CC: I see. Okay. So now, so what was it like for you starting a business and a private practice? Did you find it pretty easy or were there some bumps in the road?
KF: There’s a lot of bumps in the road in terms of marketing online. There’s just such a wealth of information online, and you really have to get out there. It’s like hanging your shingle on the door, but there’s 100 other doors with shingles on it. So how do you get noticed? And you get into search engine optimization, and the whole marketing online kind of approach, which it’s not my forte, I learned a lot, but I did hire some people now and then. And the private practice, my own website got some business, but not nearly as much as the online therapy clinics were providing. So I found myself spending more time with the online clinics, and became a part of three or four of them. Some of them rose and then fell away. Some new ones came on. Some didn’t fit very well. But I found my niche there and seems to have been working pretty well.
CC: So, and this is what fascinates me, because in our initial conversation, you’ve been doing this kind of since the beginning, and your experience with these different clinics and how they’ve been bought out by other people and changed names. Can you take us through a little bit of some of them that your experience with them and what the good, bad and the ugly, I suppose?
KF: Yeah. So the first one that I discovered, was at the time, and this is around 2006, 2007, was called Casamba. And it was primarily a psychiatric network. And online psychiatrists were very popular, probably still are, but Casamba had also introduced a counseling section, and so I joined there, and actually was doing quite well. And then after several years, Casamba was sold to LivePerson. LivePerson was a big company, United States company, that worked with customer support services in providing a live chat, basically, for customers. And they upped, ramped it up a bit. They provided live chat, email-based counseling sessions and telephone, and that went on quite well for several years. It was fairly productive and lucrative. Then they changed their name to PrestoExperts, and kind of focused on education, tutors if you will, although there’s a fair amount of controversy about is it tutoring or is it cheating? And the counseling, they stopped advertising the counseling and so that one went kinda down.
KF: Around that time, there were some new sites coming on. One was, and this goes back to 2007 as well, Ingenio, which is a platform, a clinic, if you will, also psychics, but also education, also shopping, also tech support, all kinds of stuff and counseling. That was primarily telephone-based and that was pretty good. That fluctuated more. There were months that were really good and months that were really slow. But that’s okay, because it was just one of a few of, if you will, income streams. And I’m still on Ingenio and I’m still on PrestoExperts, although not as active. BetterHelp came on, Breakthrough came on. The most recent one is called Talkspace, and I’ve been with them for about a year and a half now, and they’ve kind of taken online counseling up to a higher level because there are people. Many of these other clinics are somewhat automated. With Talkspace, a client comes on and they talk with a real person and they’re getting a sense of what’s going on, and then they’re matched with a therapist by a real person. There’s a lot of support, a lot of clinical guidance. It’s a very viable, a very active platform for online counseling. And they offer email-based or live-chat or online therapy sessions. And video has become increasingly popular as an option. However, what I find is most people still like the, and this is one of the hallmarks of online counseling, is the anonymity of it.
KF: In many cases, a client will have a user name. It’s not their real name. If you’re dealing with live chat you’re not seeing them, you’re not hearing them, and there’s a value there. People are very willing to open up and share things they may not share in person, at least not right away. Telephone has the voice element, but not the visual element. And then you have the video, which is the visual and the audio element. It’s the closest to real-time, in-person sessions. And they’re not as popular, again, because you lose a lot of the anonymity. You gain the intimacy, if you will, but you’re lose the anonymity, and anonymity is an important feature of online counseling.
CC: It’s fascinating to me that talking with you from your perspective, and I talked with the Irish Online Psychotherapy Service, and they talked about how there is sometimes a progression of a client will just be text-based, and then they’ll grow into maybe email, and then they grow into telephone or just the audio of the audiovisual connection. And it’s like they increase in their intimacy level.
KF: Right.
CC: And so that’s interesting progression. With some of these different, and again, I think that you’ve tried most of them out there, the different online clinics, I did not realize that Talkspace had essentially an intake coordinator…
KF: Right.
CC: That will get to know that person. And then I’m assuming they know the different providers out there to make that match.
KF: Correct. They have several intake coordinators. And what happened maybe five months ago now, is Talkspace went to state matching, so that the therapist in state A must be matched with client in state A. That has to do with licensure issues. It’s a hot topic about national licensure portability and so forth. Talkspace started not doing the state matching, so it was a little more of a free-for-all. Now with the state matching, it’s a little more restrictive in some ways. I think there’s only three online therapists on Talkspace here in Hawaii. So any client would not have the choice available they would in say, California or New York, or if there was not state matching. It’s often based on the state licensure laws. For example, California has some very strict licensure laws around working with clients outside of the state. Hawaii, to date, has no restrictions whatsoever. So from a licensure point of view, I’m free to work with clients in any state.
CC: I see. Okay. So with the Talkspace, what’s the business model? Are you working for them? Or do you set your own fees? Is it by the minute?
KF: We are considered independent contractors. Talkspace has plans, subscription plans, and they set the fee, and we as a provider get a percentage, about 50%. There’s a lot of oversight. They do expect the provider to check in with the client once a day, sometimes twice a day, five days a week, and they monitor that. There’s a lot of background information on the client. It is primarily asynchronous text base. It’s not live chat, it’s not immediate, although that can be arranged. And you do build up a pretty a good relationship with people. It’s one of the more, what’s the word? Monitored, if you will, or managed, if you will. The antithesis to Talkspace would be BetterHelp which is entirely automated. I mean, there’s no intake coordinator. There’s no oversight or supervision, per se. There’s forums and there’s ways of emailing the client or the therapist saying, “Can we meet?” And so forth. But very automated. And they have a whole different payment schedule based on word count.
KF: And another program I’m on called Ether, which is a third party platform for connecting via telephone. They don’t do any advertising. They just give you an 800 number and a pin code, and people can call you through that, and then Ether takes their very minimal percentage for the hook up and the billing. There is lots of different platforms out there for what you want. I suspect new ones will be coming along every year as the demands for online therapy increase.
CC: Absolutely, and I’ve been aware of BetterHelp and Breakthrough and Talkspace. With BetterHelp, they match, again, it’s not where the client says, “Hey, I’d like to go see Ken Fields.” They fill out all this information, and then they would be matched with someone through this automated algorithm. Right?
KF: Correct. Correct.
CC: And then you are paid by the… This is again, asynchronous text/email-based therapy.
KF: Correct.
CC: Okay.
KF: They do have… BetterHelp does have an option for telephone and for video online therapy. Needs to be set up with the client; you schedule a time for it. And then they have kind of a different pay rate for that, but it’s still based on word count. They have come up with some kind of algorithm that, like 30 minutes equals so many words.
CC: Wow, okay. And is this something where you have to say, “I’m going to be online every day from noon to three,” almost like a hotline or a crisis center to put your time in on these? Because I get a sense that this is in the moment. Somebody wants to talk with somebody right now, not, “I meet you at Tuesdays at 3.00 o’clock.”
KF: Well, that’s an interesting point. LivePerson, now PrestoExperts, has a live chat feature, and if you’re online and available, someone can drop in and connect with you right then and there; if you are online. If they want to schedule something with you they can email you through the platform and say, “I’d like to set up a schedule.” But one of the real attractions of the Presto site is this drop-in feature. So I’m online, and I’m around my computer, and all of a sudden I hear a ring. Well, someone’s wanting to live chat, “Okay, well I’m here and I’m available and, hi, how are you? And here we are.” And it starts going, and then it’s billed by the minute, and I do set the fee that I want to charge, taking into account the percentage that Presto would take.
CC: Right. Okay. So with these platforms, are any of them of where it is an ongoing relationship versus…
KF: Yeah most of them.
CC: Okay, okay. You’re actually building a relationship with the client.
KF: Yes, often. So with Presto, with the drop-in situation, you may get someone coming in once, and then you have a session for an hour, sometimes it can go two or half an hour, and that’s all they wanted. They just wanted to get something off their chest. They want some advice, feedback. They wanted to talk about some specific point, done, and may not hear from them again. Others check in and off we go, and they could check in or call in several times a week, maybe weeks will go by and you don’t hear from them, then you hear from them again. Several years ago I had a client who was fairly regular, two or three times a week for well over a year, close to two years. I have some clients who I hear from once or twice a month, maybe going once, that’s every three months, but it’s been over well over a couple of years. So we have a good relationship. And they have the opportunity to check in whenever they feel the need without an appointment if I’m online, or they can email me and say, “Can we talk?” And I’ll say, “Sure.” That’s with Presto.
KF: With Talkspace, I check in in the morning and there’s maybe six or seven clients that have written messages, and I get back to them. I usually check in to Talkspace twice a day, and I’ll reply to those clients that have written to me.
CC: I see. Okay. And what about Breakthrough? You haven’t mentioned much about Breakthrough. Is that similar to Talkspace or is that more of a directory?
KF: No, well, it’s both. But they do provide direct service, primarily video, and they do state matching. So, for me in Hawaii where there’s a fewer clientele base and it’s entirely video, it wasn’t really worthwhile of my time. Because again, most people still don’t like the video as much as they do the telephone or the live chat or email. So it just didn’t work for me as well, so I kinda let that one slide.
CC: I see. Okay. So your experience here, I would imagine that there’s a lot to keep track of on different platforms, and sometimes it’s a scheduled thing, sometimes it’s a moment thing, kind of contracts to stay in touch with people, sometimes once a day. What’s that like?
KF: Yeah, it can be, and I do kinda make sure that I don’t have too many plates spinning, and I’m a fairly organized kind of guy. So in the morning I get on the computer and check and see who needs online therapy, and within a couple of hours that’s usually all taken care of. Check in in the afternoon, and again, check who, what’s going on and attend to that. So for me it’s been okay. There have been times when it’s been overwhelming, but that happens very infrequently. So far it’s been manageable.
CC: Okay. Okay. Now if someone were to contact you through your website and say, “I would like to have a regular session,” and then what platforms have you used? What do you use currently that you would connect with them if they met you independently?
KF: As an online therapist, I offer the live chat, email, telephone and video. And again, most people have opted for the live chat or email, then telephone, and then video. I do have video clients, it’s just percentage-wise, there are fewer than the live chat or the email. For me, a lot of this kind of counseling is educational, and in some respects, remedial education. The whole field of cognitive behavior therapy lends itself very well to online counseling because it’s information that needs to be presented, and then applied. Once the information is presented, which can be done well in e-mail or live chat, as well as telephone and video, but then when you get into telephone and video, it’s more about, okay, you have the information, let’s now apply it to very specific situations in your life, and that’s where telephone and video work better, because there’s a lot of back and forth discussion, a lot of interaction around the situation and around how to apply some of these cognitive behavioral principles and methods.
CC: I see. And I guess what technology then do you… Is it Doxy.me or Zoom?
KF: Yeah, Zoom is an option. There’s a new one called RingWell, which is an option. These are HIPAA compliant platforms. Interestingly though, Skype seems to be the most popular because people are familiar with Skype. They don’t seem to care about HIPAA, and I give them the choice. I say, “We can do this or that. These are HIPAA compliant, secure. Skype is available; however, it is not secure.” And inevitably, they’re gonna say, “Let’s do Skype.”
CC: Okay. And I guess I’m just still struck, because it’s just been the opposite, my experience, that all my clients have been video. And to hear from you that that’s just really not what the majority of the population is drawn to. They want the anonymity of text-based counseling.
KF: Yes, that’s been my experience. It may be shifting more. I know video calling is very popular in terms of cellphones and people, friends. But when it comes to online counseling, meeting a stranger, if you will, for the first time, there is some degree of safety and distance and anonymity, and like you noted, that it can progress more towards the visual video platform once they’re comfortable, and I’m fine with that. There have been some clients that start off video, then that’s great. I remember as a kid in the 1960s being at Disneyland, and they in Tomorrowland, they were demonstrating video phone capabilities. This was in the ’60s. So we were talking and seeing somebody in New York from Disneyland, and it never really took off. Even today you don’t see, well, before cell phones, let’s say, you would have people with their telephones in their home, but they were the standard phones. There was no video capability. And even now today with cell phones, people still have landlines, but there’s no video connected to it. Phone companies didn’t jump on the idea of video calling. It’s very feasible. We can all do it, but it never really took off, because you get a call in the morning and you don’t wanna be seen sitting there and your robe and not yet ready for the world.
[chuckle]
CC: Okay, that’s a good point. And I wanna move to this other idea, because you kinda brought up this idea of the 1960s. You and I are both, let’s say over 40, and there are a lot of listeners that are looking to retirement and want to be able to work or maybe retire to Arizona or Florida, and continue to work and have maybe a small part-time income, but are intimidated by the technology. What was it like for you to learn this, to grow with it? What’s your experience been?
KF: I’ve kind of always enjoyed computers; writing programs, basically, and then when the web started to really come on board, and websites, and I was right there with it, designed my own websites and so forth. Have since shifted over to WordPress, which is a lot easier. But for me, it was a smooth transition. It was fun and exciting. For those who are technologically challenged it can be a fairly steep learning curve. It’s not that difficult to set up a website. You can go to places like I think TherapySites, it’s like a pre-packaged website for you. They do all the back-end stuff. You just plug in the information, and there you are. So for someone who is somewhat technologically challenged, there are options to make it very easy to get online and provide a service.
CC: And do these online clinics, BetterHelp, Talkspace, etcetera, are they pretty easy to get around and use and…
KF: Yeah, yeah, they’re fairly easy. It takes a little bit of getting in there and looking through all the options, and what you need to do and so forth. Unlike all of the other online clinics, Talkspace actually has a training you need to go through to become credentialed with them.
CC: Okay.
KF: Which is a good idea, but once you, again, go through the training, you have your mentor, you know who to ask questions to, and you get in and start doing it, you pick it up soon enough.
CC: Mm-hmm. Mm-hmm. Okay. So anything in particular… I find it fascinating that you’re in Hawaii. I think a lot of listeners romanticize the state. You mentioned that there aren’t any current regulations for telemental health in Hawaii. But do you think that the Hawaiians are drawn perhaps to this? I know there are several islands. Perhaps this is a convenience to them? Can you speak a little bit about counseling and your state, things that maybe we may not think of?
KF: I think online therapy is convenient for anybody in any state. I do have several clients in Hawaii. I’m also licensed in Oregon and have several clients in Oregon. I started Talkspace when they did not do the state matching, so I have quite a lot of clients throughout the country, and I’ve had clients throughout Europe and Asia and the Middle East. Online counseling is global.
CC: Yeah.
KF: It’s not necessarily United States or state-based. But I think the convenience of it is another one of these real, positive attractions. You don’t have to set a schedule, go to an office, take time out from work, find a place to park, pay for parking, go to the office and then come back. And you can take for a 50-minute to an hour session with an online therapist, it could take you at least two hours.
CC: Sure.
KF: ‘Cause of driving there and parking. Plus interestingly enough, online counseling is a lot more confidential and private than would it be going to an office, because you go into an office, people see you going into the office, they see you coming out of the office. And whereas with online counseling, you’re in your own home or in your car or at a coffee, wherever you wanna be, and you don’t have to go to an office, you don’t have to take the time away from work. Many online therapists work in the evening, as do I. I also schedule time on weekend mornings. So convenience is a big feature of online.
CC: And from your experience through the years working with these different clinics, I’m assuming that it has been lucrative?
KF: Yes. It’s been lucrative enough. I’m not making a ton of money, but I’m covering my expenses with a little bit to spare, and that’s okay.
[chuckle]
CC: And so, just to kind of wrap things up. Do you have advice for therapists who are looking to begin an online practice? Anything that maybe we need to stay clear of, or an entry point into the market when you begin looking at online clinics?
KF: I think any one of them is probably a good entry point, just to begin to get a sense, a flavor of how they work, what kind of clientele they tend to serve, and one or two or three is okay, is doable. And you may find which one you align with more and find yourself putting more time into that one. The advantage, one of the advantages of the online clinic is that they do the marketing, the advertising. If you’re going out on your own with your own website, the marketing and the advertising is a big piece of it. And like many artists who are not good at selling their art, therapists aren’t necessarily that good at marketing their service.
CC: Yeah.
KF: And so having someone else do that is a plus.
CC: Yeah, absolutely. But with these clinics, it almost seems like that they are bringing clients to your door.
KF: Yes.
CC: And then also facilitating the connection. They take a percentage of that, but they are facilitating the connection.
KF: Correct. Correct. And it’s not unlike in-person, brick-and-mortar clinic, where you’re just there and it’s the clinic that has the doors open and the sign out and brings people. And I think the trend is going to be increasingly towards online services across the board. So if a therapist is thinking about online counseling, providing online counseling, yeah, go for it, because it’s only going to become increasingly popular, increasingly available.
CC: And do you see across the age ranges? Because I’ve heard that millennials are very… It’s easy for them to use a computer to connect. Are you seeing that this is across all age populations, that people are beginning to use more and more technology to connect with their therapist?
KF: Correct. Lots of millennials for sure. But middle-aged, elders as well. I work with couples. Family therapy is difficult because you’re dealing with the husband and wife and the kids. That would work on video counseling perhaps, but doesn’t really work well with live chat or even telephone. But couples, fine. Individuals, fine.
CC: Okay. Alright. Well, again, this is fascinating to learn from your experience. I’ve never come across someone that has had this length and depth of the different clinics that are out there. Any final thoughts that maybe we haven’t covered you wanted to make sure that our listeners heard?
KF: Yeah, just that with the convenience of online counseling, and the anonymity of it, it makes it so much more viable to connect with a therapist. And you can shop around now. You go to any one clinic and there’s lots of therapists to choose from you. You don’t like one or jive with one, you can choose another. And the rapport, the relationship you have with a therapist is very important. I think some research indicates that 80% of the effectiveness of online therapy is based on the relationship itself, aside from any techniques or methods or approaches. And there’s something really of value to have a, if you will, a consigliere, a counselor, a consultant, someone with whom you can talk to who is neutral, who is not biased, who is not emotionally attached, who can give you straight feedback, not worried about being your friend or not. It’s nice to have friends to talk with, but friends are biased. They’re not gonna necessarily be that objective.
KF: And therapists are generally trained to listen to what you’re saying, to be objective, to provide some feedback, some insight and some information around mental health and mental well-being, and largely in terms of the cognitive behavioral approach. Our thinking is important. How we think influences how we feel about ourselves, about others, about the world. Cognitive Behavior Therapy is now considered the most effective treatment for anxiety and depression. It’s becoming more popular in the treatment of trauma. And it’s information that needs to be presented, and what a great way to get it.
CC: Yeah. Well, Ken, I thank you. I can’t thank you enough for coming on the show. Welcome to the Online Therapy Directory. I’m really pleased to have our first therapist from Hawaii, and I wish you all the best. Thanks again.
KF: Thank you very much.