How to launch a practice that is 100% online

Therese Mascardo, PsyD, used to spend four hours a day commuting between her Los Angeles home and the Orange County office of her practice Exploring Therapy. While the COVID-19 pandemic has her holed up in her current European home base of Lisbon, Portugal, she typically travels full-time, seeing patients via videoconferencing just two days a week. “I knew there had to be a better way to use my time and still serve my clients,” says Mascardo, who spends much of her down time exploring the city and working on such projects as an e-course on how other psychologists can start a virtual practice of their own.

For Monica Lyn Thompson, PsyD, not having a “brick and mortar” presence for her Atlanta practice Therapy for Queer People of Color was “a no-brainer.” “I wanted to keep my overhead costs as low as possible as I built my practice,” she says. Plus, she adds, a virtual practice can help increase access for many patients, reducing their worries about finding transportation and childcare, or other logistical concerns.

Mascardo and Thompson represent a growing number of psychologists who had exclusively virtual practices even before the pandemic forced other practitioners into telehealth. A survey of APA members found that 76% of the practitioners who stopped seeing patients in person because of COVID-19 have been treating all their patients remotely.

If you’d like to launch a 100% virtual practice, Thompson and other experts offer these tips.

Telehealth isn’t a good fit for every patient, such as individuals with cognitive issues, hearing problems, or attention deficit-hyperactivity disorder. And some patients just aren’t comfortable with technology or convinced that teletherapy works, despite an ever-increasing body of evidence and research.

To help assuage concerns, Thompson has stopped doing initial consultations over the phone and now uses videoconferencing as a way for would-be patients to try it out for themselves. “It’s a great way to reduce people’s fears,” she says. Check out APA’s informed consent checklist for more information on how to ensure patients understand the potential benefits and risks.

Once you take someone on as a patient, make sure you verify they are who they say they are by asking them to hold up a driver’s license or other picture ID, says Deborah Baker, JD, director of legal and regulatory policy at APA. “Medical identity theft is a serious concern,” she points out.

Although technology allows you to conduct a virtual practice anywhere, your psychology license does not necessarily allow you to practice anywhere, especially if the patient is in a location outside of the state where you are licensed, emphasizes Baker. Psychologists can only practice beyond the state where they’re licensed if the other state has a temporary practice provision or via an interstate agreement like PSYPACT. Make sure you find out where patients are during each session, too, especially if you notice their environment looks different than it has in previous sessions.

Also be sure you have researched emergency resources where patients are, adds Jeffrey Zimmerman, PhD, ABPP, a partner in The Practice Institute. “If you’re working in a very large or rural state, you may not be aware of what’s happening elsewhere,” he points out. “If a client calls you and needs a higher level of care on a fairly urgent basis, you may not have knowledge about available resources if you haven’t researched them.”

Because would-be patients from around the country and even the world can easily find you, it’s important to note your geographic limitations on your website. Thompson also offers a directory of other therapists around the country who offer the same kind of highly specialized services she does.

“When your practice is 100% virtual, you need a virtual footprint,” emphasizes Thompson. A simple, user-friendly website is key, along with using whatever social media platforms your target population uses.

Mascardo uses her Instagram account for marketing her practice, for instance, sharing not just mental health tips with her 18,000 followers but glimpses into her life. “In my doctoral program, we were taught to be a blank slate,” says Mascardo, who earned her degree in 2008. “But people want to see who their therapists are, and Instagram provides an opportunity for that to happen.”

Just because you’re working from home doesn’t mean you can “do therapy in your pajamas on your couch,” says Thompson, whose home office projects professionalism and gives her a physical boundary between work and private life.

Spend some money to make the online experience better for patients, she and Mascardo suggest. Headphones add clarity and privacy, for example, while a white noise machine can filter out background noise on your end. A ring light can eliminate shadows and help clients see your face more clearly. There are also clamps that hold your phone or tablet up so you can maintain good eye contact with patients. For more information on how to set yourself up, see APA’s office and technology checklist.

Of course, you’ll also need a Health Insurance Portability and Accountability Act-compliant platform—and a signed business associate agreement—for holding video sessions with patients. An all-in-one electronic health record system that includes videoconferencing, secure messaging and scheduling, billing and other administrative features is more convenient than “piecemealing things together,” says Thompson, who uses SimplePractice.

Check in during sessions to make sure patients can see and hear you. And have back-ups in case of tech glitches, such as the ability to use your cellphone as a hotspot or plug directly into your router in case your Wi-Fi goes out.

When Mascardo became a “digital nomad” psychologist in 2018, “it felt like the wild West,” she remembers, noting that very few psychologists had online-only practices. When launching their practices, both she and Thompson relied on online peers to help answer questions via the Facebook groups Location Independent Therapists and the Online Therapists Group, which cater primarily to mental health professionals who have chosen 100% virtual business models by choice.

In addition, APA and APA Services, Inc., offer guides and resources that can help psychologists forced into virtual services by the public health emergency navigate the transition to the digital world.

For Thompson, the fact that the pandemic is forcing other psychologists to shift to telehealth, if only temporarily, is exciting. “I’m glad more people are seeing the utility,” she says. “I definitely think it’s the wave of the future when it comes to mental health treatment.”

To hear more about what it’s like to be a telehealth-only psychologist, check out Mascardo’s blog post.