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Articles: Therapy in the time of COVID-19: A look at one ethical issue &
Psychologists pivot to teletherapy as pandemic takes hold 

Therapy covid 19

Therapy in the time of COVID-19: A look at one ethical issue

By Samuel Knapp, Ed.D., ABPPP Michael Gottlieb, Ph.D., APBB and

Mitchell M. Handelsman, Ph.D
July 28, 2020

Consider this scenario: During a therapy session, a patient stated that the media was hyping the threat of coronavirus, that it was no worse than the regular flu, and that he was still going out with friends for non-essential social activities.

At a time when much of the United States is under “shelter in place” orders to thwart the spread of the coronavirus, we still hear reports of individuals who dismiss concerns about COVID-19 and circumvent public-health instructions on distancing themselves from others. Some of these attitudes may be fueled by disinformation websites or blogs, leading one researcher to refer to an infodemic on coronavirus (Vlessides, 2020).

Of course, the risk falls along a continuum and conscientious citizens need to balance the risk of exposure with the welfare of others. One can appreciate the dilemma of patients who must decide whether to go to work and risk exposure, or how to care for an elderly parent who needs their assistance. However, the worrisome situation discussed in this article is exemplified in the opening vignette and concerns patients who egregiously and unnecessarily expose parents, children, neighbors, or other members of the public to infection.

Every psychologist needs to check the laws in their own state, but let us assume the situation described in the scenario we presented above would not qualify under “duty to warn or protect” standards because the patient has not made an immediate threat of imminent physical harm to an identifiable third party. Consequently, psychologists must rely on their ethical judgment to guide their interventions. We offer a decision-making model that can guide psychologists based on principle-based ethics.

According to Ross (1930/1988), moral agents, including psychologists and trainees, can evaluate the morality of their behavior based on several overarching ethical principles. Beauchamp and Childress (2019) opined that the moral principles of beneficence, nonmaleficence, respect for patient autonomy, and justice were especially salient for health care professionals. Later, Kitchener (1984) added fidelity and Knapp and VandeCreek (2004) identified general beneficence (obligations to the general public) as also being salient for psychologists.

Ross anticipated that moral principles will sometimes collide and suggested a methodology to follow when these conflicts occur.

When I am in a situation in which more than one of these prima facie duties is incumbent on me, what I have to do is to study the situation as fully as I can until I form the considered opinion (it is never more) than in the circumstances one of them is more incumbent than any other. (1930/1998, p. 268)

Beauchamp and Childress (2019) expanded on this methodology and presented several steps to follow when one moral principle temporarily outweighs another. The most salient steps are to: determine if there are better reasons for acting on behalf of one overarching ethical principle than the other; determine if the intervention is likely to succeed; and minimize the level of infringement to the offended principle.

When a patient expresses an intent to circumvent public-health measures and place the well-being of others at risk, a conflict arises between respecting the autonomy of patients to do as they please (ignore or grossly minimize the risks to the public, such as by needlessly violating public-safety measures) and protecting the public by attempting to alter the behavior of patients. We also could note that attempting to alter the behavior might also harm beneficence or nonmaleficence (to the extent that it harms the quality of the psychologist-patient relationship, or the life of the patient). Let us consider the three steps in addressing this autonomy/general beneficence dilemma.

Is there a reason to prioritize one principle over the other? Ross only stated that one

principle should override another based on “a considered opinion” that one “is more

incumbent” than the other. We assume that in a pandemic, general beneficence takes

precedence over respecting patient autonomy, beneficence or nonmaleficence.

Is an intervention likely to succeed? Psychologists need to consider whether they would be likely to convince the patient to adopt more socially responsible behavior. There may be unique clinical features that make the intervention likely to fail. Perhaps the patient has paranoia or, at least, overvalued ideas. The patients’ thinking could make challenges to their assumptions or behaviors unlikely to succeed and damaging to the therapeutic relationship.

Can the intervention minimize harm to patient autonomy? Ideally, psychologists would be able to persuade patients to alter their behavior without harming, or causing only minimal harm to, the psychologist-patient relationship. It might be best to start with an inquisitive approach and ask patients to explain the reasons behind their actions. Then, psychologists can assess further the specific social or psychological factors that maintain the harmful behavior.

Psychologists should not discount the possibility that some patients are still acting out of lack of information (pure ignorance) and that an educational approach may be enough.

Other patients may passively acknowledge the benefits of social distancing and other precautions but have not yet translated those ideas into actions.

Psychologists can remind these patients that individuals, as a rule, consistently overrate their personal vulnerability to illnesses (Dunning, Heath, & Suls, 2004). They can discuss the ways that confirmation bias (“My friends haven’t gotten sick yet.”) may influence their patients’ behavior. Finally, they can appeal to their patient’s prosocial motives. For example, among healthcare professionals, handwashing interventions that focused on the well-being of patients tended to get a better response than interventions that focused on personal well-being (Grant & Hoffman, 2011). Perhaps the finding that focusing on public well-being improves healthcare behaviors could also apply to patients of psychologists as well.

Psychologists can help patients think through concrete steps on how to be responsible to their family, friends, and community while, at the same time, meeting their social or personal goals. They can discuss pragmatics about how to get groceries, keep relationships going, minimize unsafe interactions with others, and/or reduce risk in other ways.

Other patients may be acting out of misinformation, or out of more complex motives. Misinformation may come for many reasons, including reliance on non-credible sources, or a perception that some have overemphasized the dangers primarily to discredit President Trump. Such patients may present a greater challenge because nobody likes to be told that what they believe is wrong.

Psychologists need to frame their comments in a manner that, for example, would minimize politicizing the discussion or appearing to attack the intelligence or good intentions of patients.

References available from author

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

Working at Home

Psychologists pivot to teletherapy as pandemic takes hold

By Kathy Lynn Gray, Associate Editor
July 28, 2020

For clinical psychologist Alison McGrath Howard, Psy.D., the decision to stop practicing face-to-face and begin using teletherapy to counsel patients was a no-brainer. On March 13 – the Friday of the week that COVID-19 turned America upside down — she woke up with a fever and a cough and felt “horrific.”

The week before, she’d traveled from her Washington, D.C., home to a conference in New York City. On her return, she learned some participants had tested positive for coronavirus. When she became symptomatic, she had herself tested.

She had COVID-19.

“I was in a panic,” said Howard, 54, a psychologist for 19 years. “I saw 50 people that week and I didn’t know I was sick.”

To her knowledge, none of her patients got sick. Howard wasn’t hospitalized, but by late May she still hadn’t fully recovered.

Despite her illness, she continued to practice, and despite never having used teletherapy, she was seeing patients within a week after what she calls “a steep learning curve” as she switched to online counseling exclusively, first from her home and eventually from her office.

Across the country, psychologists interviewed by The National Psychologist in late May told similar stories about their abrupt pivot to teletherapy and shared insights in the hopes that other psychologists would benefit.

Early-career psychologist Teresa Young, Ph.D., had some experience with teletherapy but mostly saw patients face to face in her private practice in Columbus, Ohio. That made it easier for her to switch to teletherapy but not necessarily easier for her patients, particularly those in their 70s and 80s. She’s been doing telephone sessions with some patients, hoping she’ll be reimbursed.

“I think, to some extent, we might have to eat some of these costs,” said Young, 33, who’s been practicing for three years. “It’s kind of the cost of doing business during a pandemic.”

Sheldon Kramer, Ph.D., had an entirely face-to-face private psychology practice in Encinitas, Calif., just north of San Diego, when he had to close his office on March 17 and begin teletherapy at home.

In the past, he had taken classes with friend Marlene M. Maheu, Ph.D., who founded the Telebehavioral Health Institute, so he found the switch to online therapy fairly easy.

Like all the psychologists interviewed, Kramer, 69, misses seeing his clients in person.

“Online can’t duplicate the human energetic exchange between a psychologist and their patient,” he said. But he’s found multiple advantages to teletherapy, so much so that he’s considering ditching his rented office space and using his home full time, possibly with a mix of in-person and online therapy.

Kramer has found that his patients are more relaxed talking to him from their homes, leading to more intimate conversations as well as the bonding experience of showing each other their homes. He’s been able to lead meditation and incorporate music into his sessions and feels he has closer contact with patients in some ways because he’s looking at them intently on the screen.

New York City psychologist Yasmine Saad, Ph.D., also has found her therapy has deepened because her patients are talking to her from their homes.

“It’s much more personal, more like talking with a friend,” she said. “There’s an ease about it because you don’t have to commute. I had one of my most productive sessions with one patient because she felt so safe when she was talking to me from her bed.”

Saad, 44, who has a group practice with more than 10 other psychologists, has managed to

keep seeing patients, despite having COVID-19 in mid-March and watching her 6-year-old

daughter during work hours. She had occasionally used teletherapy before the pandemic for

clients who were traveling, but many of her patients had never tried it. Some initially balked

but finally gave it a try when it became clear that in-person sessions weren’t a possibility anytime

soon, Saad said.

As of late May, she had no plans to return to in-person sessions anytime soon. New York City has been hit hard by the virus and many people continue to work from home. To travel to her office, most would have to take public transportation and face possible exposure to COVID-19. And Saad doesn’t believe she could effectively counsel clients wearing masks, a hurdle she doesn’t face with teletherapy.

Psychologist Jim Broyles, Ph.D., director of professional affairs for the Ohio Psychological Association (OPA), said his private practice was all face-to-face before COVID-19. Since then he’s transitioned to a mixture of in-person and online therapy, all from his office in Grove City, Ohio, just south of Columbus. Patients coming to the office wait in the parking lot until it’s time for their session, have the option of wearing a mask and socially distance themselves during sessions, Broyles said.

Through his job with OPA, Broyles has heard from many psychologists about the chaotic switch to teletherapy.

“It wound up not being as challenging as they thought, but the biggest hurdles were working through all the laws and rules and insurance company policies so that we were in compliance with all the regulations we had to follow,” he said.

Also, in early March, Medicare switched its policy on teletherapy so patients could use it from their homes. Previously, psychologists couldn’t get paid for a teletherapy session unless the patient accessed it from a designated area, such as a doctor’s office. Broyles said he’s heard about “surprisingly few” psychologists having problems being reimbursed for teletherapy.

Mary Alvord, Ph.D., who heads a large group practice with offices in Rockville and Chevy Chase, Md., had to switch individuals to teletherapy in March and the resilience-building group therapy sessions she runs for children and adolescents. Between 10 to 15 percent of her practice already was online and she’d used video meetings to link her two offices since 2005.

Privacy for patients can be a problem, as well as technology glitches, she said. But the advantages are many, including reduced barriers to treatment such as travel time, bad weather and mobility issues.

Alvord has no plans to reopen her offices for in-person appointments anytime this summer. She and her colleagues continue to discuss that option but have reached no conclusions about overcoming issues such as having enough personal protection equipment and keeping surfaces clean.

“I’d rather err on the side of continuing telehealth rather than take chances,” she said.

Marlene Maheu of the Telebehavioral Health Institute in California said her company sold more training and consultation during the first two months of the pandemic than in all of 2019.

“We’ve had a constant flow of individuals and now, larger institutions that want training,” she said, including universities and community health centers. Maheu also is in heavy demand to do webinars for associations and other organizations, including the American Psychological Association.

As for Howard, the Washington, D.C., psychologist who’s still recovering from COVID-19, she’s back to a full schedule of therapy, all online, and is leery of face-to-face sessions anytime soon. Her office is in a busy apartment building with people coming and going constantly.

“I know it’s really unlikely someone would get COVID from coming into my office, but until I can know that with 100 percent certainty, I don’t want to do it,” she said. “Until I have a lot of assurance that I can’t get sick again and my patients can’t get sick again, I don’t think it’s ethically OK.”

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