Articles: My patient may be placing others at risk of contracting COVID-19: What should I do? &
Retailers could help shape future of mental health treatment {Below}

My patient may be placing others at risk of contracting COVID-19: What should I do?

By Samuel Knapp, Ed.D., ABPP, Michael Gottlieb, Ph.D., ABPP and Mitchell Handelsman, Ph.D.
August 2, 2021

We have been asked to respond to the following scenario:

A nurse-client told me that her kid just informed her that she can no longer taste or smell. The nurse knows the drill and said that she is going to quarantine her child for two weeks from school. I asked about her, and what she was planning on doing herself. She replied, “I’m going to work; I need to.” She works in a health care facility. My question ethically is: What do we do about a client who is a health care provider who may well be infected, but insists on going to work and tells you so?

Psychologists have an obligation to protect patient confidentiality unless the patient gives authorization or permission, the disclosure is permitted or required by law, or a court orders the release of the information. A major question becomes whether the laws of the state require or permit disclosures.

The psychologist should look to the “duty to warn” or “duty to protect” statutes of the state — and get legal consultation. However, these statutes usually require intent to create a danger of harm against an identifiable victim and in most if not all states, that standard would not apply in this situation. The actual risk to her patients may be minimized — although not eliminated — if the health care facility tests all its employees periodically or takes their temperature before every shift.

Because public welfare (the ethical principle of general beneficence) is involved, psychologists have a responsibility to make every effort to persuade patients to act more responsibly if they believe that their interventions have a likelihood of success.

Generally, psychologists should be able to talk to most patients about COVID-19 related behavior. Efforts to persuade this patient to act more responsibly can vary according to the motives of the patient, her life circumstances and the degree of risk she poses given the nature of her work.

The psychologist should listen carefully to the nurse to understand her motives. Is she a COVID-19 minimizer — a person who believes that its health risks have been exaggerated

for political purposes? Or does the nurse appreciate the health risks but is under

tremendous financial pressure? Or does the nurse have sociopathic tendencies

and simply has little concern for the impact of her actions on others? The answers

to these questions can help guide the practitioner’s response.

If the patient identifies with a group that minimizes the health impact of COVID-19, the psychologist can appeal to the patient’s sense of public responsibility to others and note that public safety protections from COVID-19 are normative even among many political conservatives. She should avoid the trap of trying to debunk falsehoods or arguing with the patient as this may just prompt counterarguments and defensiveness.

If the patient is reluctantly going to work because of pressing financial issues, then the psychologist can help the nurse think through the financial issues, seek to identify alternative sources of income or ways to cut expenses, ask the patient to reconsider the relative weight she is giving to her financial issues compared to her responsibility as a nurse, and/or explore other steps to minimize risk, such as asking the nurse about the possibility of minimizing contact with others while she is at work.

Finally, if the nurse has sociopathic tendencies it may be worthwhile to emphasize the repercussions to her if she became sick and it was revealed that she had been exposed to COVID-19 and failed to notify her employer as required by agency policy and state guidelines.

Although there are some exceptions based on patient need, psychologists usually should not accept the nurse’s decision to return to work without a discussion of the issues and an effort to get the nurse to reconsider her decision. Legal consultation about the state duty to protect or duty to warn laws may be indicated and psychologists should document their actions and rationales.

Samuel Knapp, Ed.D., ABPP, is the director of professional affairs for the Pennsylvania Psychological Association and has written extensively on ethics, ethical decision-making and suicide prevention. He may be reached at Samuelknapp52@yahoo.com.

Michael C. Gottlieb, Ph.D., ABPP, is a forensic and family psychologist in independent practice in Dallas, Texas, and a clinical professor at the University of Texas Southwestern Medical Center in Dallas. His interests include ethical decision-making and the psychology-law interface.

Mitchell M. Handelsman, Ph.D., is a professor of psychology and a CU Presidents Teaching Scholar at the University of Colorado Denver. He has published widely in the areas of teaching and professional ethics.

Retailers could help shape future of mental health treatment

By Chuck Nelson, Associate Editor
August 4, 2021 - Last updated: August 2, 2021

Is the future of mental health therapy right around the corner? Say, at your local CVS or Walmart?

That’s the concept some national retailers are growing through pilot programs at select locations. It’s one that could help improve access to mental health care in general – especially in underserved populations – while also providing a role for psychologists.

“What we know is that we have an access gap problem in this country that existed prior to the pandemic, where we have more people who needed services than we had a workforce to provide,” said Vaile Wright, Ph.D., APA senior director for healthcare innovation.

“That’s only been exacerbated by the pandemic. So, we need to think of innovative ways to address this access-to-care issue.

“And if one of those is bringing services to where the people are versus just expecting the sort of traditional model of individuals who need help seeking out providers, I think that can be one step in the right direction.”

That’s with the caveats that services are provided safely and effectively, that the providers are licensed, trained and appropriately supervised, and there’s some way to measure the outcomes to make sure the model achieves its goals, she said.

“In reality, it’s not that much different than what we’re seeing with integrated primary care, where you have a behavioral health provider that’s part of the primary care office, which we do know is effective” she said.

Currently, four national chains are offering mental health services, primarily through telehealth, The New York Times reports.

CVS has added licensed clinical social workers to 13 locations in Houston, Philadelphia and Tampa, Fla., offering mental health assessments, referrals and counseling in person or through telehealth. The company plans to expand to 34 locations in the same cities.

Rite Aid is offering a teletherapy model in 13 locations in Idaho, New Hampshire, Pennsylvania and Virginia.

Walgreens is providing therapy appointments through its web platform, Walgreens Find Care is linking customers to providers like BetterHelp. It also offers free online screenings through a partnership with Mental Health America.

And Walmart announced plans in May to acquire MeMD, which offers medical and mental health visits.

The shift to retailers follows the same changing healthcare dynamics of walk-in medical clinics and urgent care centers in consumer shopping zones, notes Advisory Board, which studies the challenges healthcare leaders are facing. Healthcare systems, which traditionally focused on inpatient revenue, shifted their thinking to make outpatient revenue part of their strategic plans, the site noted.

“To the extent that it can improve access as it relates to convenience, maybe reducing the

stigma because people are more comfortable approaching their pharmacy, I think that can

help,” Wright said. “I also think it has the potential to alert people to their mental health needs.

Maybe they notice a sign that says, ‘free depression screenings,’ which maybe isn’t something

they ever thought of doing before.”

CVS uses that approach on its program’s website: “Stressed? Feeling a little down? We want to help.”

“Someone could come in, be screened, receive some psychoeducation and some reading material and that might be sufficient,” Wright said. “Somebody may benefit from a 20-minute intensive behavioral session for something like smoking cessation.”

But not everybody needs the same care, she said, noting that these models could provide a more tiered approach to levels of service.

“Ideally, the model would be that you would have a robust referral source, so that if somebody needed more traditional, weekly 45- to 60-minute therapy sessions, you could ensure that you could consistently provide those,” Wright said.

Wright notes that providers in most of the retail settings are master’s level or licensed clinical social workers.

“So, depending on the state, the role of the psychologist could be twofold,” she said. “One could be providing some of the supervision services that might be required based on the scope of license of the practice. I think another could be psychologists learning more about what their local pharmacies are doing and then serving as a referral source for when somebody is identified for needing more traditional or intensive kinds of psychotherapy services.”

The models differ between companies, all of which will need to navigate licensing requirements on a state-by-state basis to determine who can interact with patients and what level of training would be required.

“We also still know that the No. 1 barrier is cost and I haven’t necessarily seen any discussions about how affordable these options are,” Wright said.

CVS – which has owned Aetna since 2018 – is covering the cost of sessions for Aetna insured-patients and negotiating for similar terms with other insurers, RetailWire.com notes.

“But again, there are multiple barriers to access and if this addresses even a few, from a population health approach, it could help solve the mental health crisis that we fear we are approaching,” Wright said.