Author: Janessa Brown, M.S.
As the era of COVID-19 is accurately conceptualized as an “unprecedented time,” many well-traveled avenues, which typically serve as a roadmap for practicing psychologists, are suddenly traversable only in-part. Many providers have pivoted to a hybrid model of in-person and telehealth services as COVID-19 vaccines have become more widely available. However, many vulnerable populations continue to require distanced services. In said cases, unique considerations must continue to be made. Particularly relevant is the manner in which mental health providers must strike balance between continued social distance measures and the ethical delivery of care. Given a clinical psychologist’s obstructed ability to be in-room with a subset of vulnerable patients, one must call upon the American Psychological Association’s Ethical Principles of Psychologists and Code of Conduct (American Psychological Association [APA], 2016) and the Guidelines for the Practice of Telepsychology (Task Force, 2013) to inform the most ethical and highest quality of mental health services during this tumultuous time.
Early in the document, the Code of Conduct specifies the requirement of psychologists to practice within their boundaries of competence, both with regard to multifaceted patient populations in standard 2.01.b and the implementation of new technologies in standard 2.01.c (APA, 2016, p.5). As telehealth only recently became a ubiquitous medium for service delivery, many psychologists may lack the proficiency necessary to render the best possible care. To address this concern, psychologists should gain training in said technologies, consult their professional networks, and apply the findings of telehealth research literature (Task Force, 2013). Where standard 2.02 specifies that clinicians may practice outside their competence in emergency situations, standard 2.03 of maintaining competence is now superseding due to the prolonged nature and indiscernible end of COVID-19 (APA, 2016, p.5). As such, adequate training and the resumption of fully competent practice is an ethical imperative and works to uphold the aspirational principle of “Beneficence and Nonmaleficence” (APA, 2016, p.3).
Nearly a year-and-a-half into the current pandemic, psychologists should fully comprehend the risks and benefits of implementing virtual services and be sensitive to the manner in which technology may differentially impact various patient populations. Standard 2.01.b alludes to the vital nature of multicultural competency, an issue at the crux of ethical considerations during virtual care delivery (APA, 2016, p.5). The historical access issue of specialty mental health now also encompasses the task of facilitating technology interfacing to all demographics. As lower socioeconomic status (SES) and older adult populations are disproportionately impacted by COVID-19, often contracting the illness at steeper rates and enduring greater psychosocial impact (Chenneville & Schwartz-Mette, 2020; Kikuchi et al., 2021), delivery of mental health services is vital. Regrettably, these same individuals are often equipped with less technological access and expertise, thereby requiring astute problem-solving on the part of a mental health practitioner (Weber et al., 2020). To abide by standard 2.01.b, uphold the APA principle of “Justice”, and follow telepsychology guidelines, psychologists may work to connect patients to social service programs and provide pro bono care (APA, 2016, p.3, p.5; Task Force, 2013).
As the engagement with telehealth services is accompanied by a partial relinquishing of confidentiality control, the upholding of standard 4.01 of maintaining confidentiality and standard 4.02 of discussing limits of confidentiality is of the utmost importance (APA, 2016, p.7). During COVID, clinicians and clients alike are positioned to engage in highly sensitive psychological services often from the suboptimal locations of their respective homes. With this arrangement comes the potential risk of outside parties, such as household members, gaining access to confidential therapeutic information. Similarly, unintended breaches of confidentiality can occur through blindspots inherent in cybersecurity and electronic record keeping, thus drawing attention to ethical standard 6.02.a (APA, 2013, p.9). Psychologists should therefore secure files through encryption and password protection, deliver services from a private and soundproof room, and discuss with clients their role in maintaining confidentiality within their own home (Chenneville & Schwartz-Mette, 2020). Regarding privacy, it is also a legal stipulation that clinicians abide by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). To protect a client’s confidentiality amid a virtual landscape serves to safeguard the public’s confidence in the mental health field while also upholding the APA principles of “Beneficence and Nonmaleficence” and “Fidelity and responsibility” (APA, 2016, p. 3).
Ensuring the safety and well-being of clients and others is amid the greatest responsibilities of a practicing psychologist. Yet, pre-pandemic protocol for protecting clients from suicidal or homicidal intentions was largely predicated on physical proximity. As such, ensuring safety and upholding APA ethical standard 4.05.b, which states that a psychologist will disclose confidential information to protect others from harm, becomes all the more complex while services are rendered virtually (APA, 2016, p.8). Because the duty to protect is also legally incumbent upon mental health providers (Appelbaum, 1985), it is imperative that practitioners act creatively and proactively to thwart risk and maintain safety. Luxton et al. (2014) suggest obtaining the exact location of a client at the beginning of each session, continuously engaging in thorough assessment, and providing exhaustive safety planning if risk arises. A release of information for a contact safety support person able to respond in emergency situations should also be obtained. Extensive risk prevention training that accounts for telehealth nuances is also of the utmost importance. Applying said recommendations to this at-risk population diligently upholds the APA ethical principle of “Beneficence and Nonmaleficence” (APA, 2016, p. 3).
Considering the aforementioned ethical concerns regarding the virtual delivery of care, specific and targeted informed consent is a fixed expectation for practicing psychologists. APA ethical standard 3.10.a mandates obtaining informed consent for any individual engaging in psychological assessment or treatment, dictating a necessary adjustment for the consent of electronic communication (APA, 2016, p.7). As such, clients should be made aware of limits to confidentiality, per standard 4.02, as well as potential discrepancies in the empirical support of virtually delivered treatment, per standard 10.01.b (APA, 2016, p.7, p.14). Given disparate procedures for assessment delivery that may otherwise be standardized or normed for in-person samples, discussions of potential altered validity and reliability when delivered virtually is critical. Risks and benefits of virtually administered assessments should be deliberated, consented to, and noted as a limitation in psychological reports given standards 9.02.b and 9.03.a (APA, 2016, p.13). The ongoing consenting process with respect to practice differences necessitated by COVID-19 social distance procedures works to uphold perhaps each of the APA’s aspirational principles. The practice of proper consent is to strive to benefit clients and prevent harm, garner trust and uphold professional responsibilities, promote an accurate depiction of the treatment landscape, provide accurate information to all clients, and to respect a client’s right to make informed treatment decisions (APA, 2016, p.3).
As plainly evidenced, mental health providers have much to balance while practicing in a hybrid fashion and maintaining professional ethics. To sum a paradigm perhaps most helpful to one’s clinical approach during these times: “Aspirational ethics is good risk management” (Knapp et al., 2017). If psychologists remain steadfast in their approach to quality client care, the aforementioned considerations should intuitively fall in line.
References
American Psychological Association. (2016). Revision of Ethical Standard 3.04 of the “Ethical Principles of Psychologists and Code of Conduct” (2002, as amended 2010).. American Psychologist, 71(9), 900–900. https://doi.org/10.1037/amp0000102
Appelbaum, P. (1985). Tarasoff and the clinician: Problems in fulfilling the duty to protect. American Journal of Psychiatry, 142(4), 425–429. https://doi.org/10.1176/ajp.142.4.425
Chenneville, T., & Schwartz-Mette, R. (2020). Ethical considerations for psychologists in the time of COVID-19. American Psychologist, 75(5). https://doi.org/10.1037/amp0000661
Joint Task Force for the Development of Telepsychology Guidelines for Psychologists. (2013). Guidelines for the practice of telepsychology. American Psychologist, 68(9), 791–800. https://doi.org/10.1037/a0035001
Kikuchi, H., Machida, M., Nakamura, I., Saito, R., Odagiri, Y., Kojima, T., Watanabe, H., & Inoue, S. (2021). Development of severe psychological distress among low-income individuals during the COVID-19 pandemic: Longitudinal study. BJPsych Open, 7(2). https://doi.org/10.1192/bjo.2021.5
Knapp, S., VandeCreek, L., & Fingerhut, R. (2017). Practical ethics for psychologists: A positive approach. Washington, DC: American Psychological Association.
Luxton, D. D., O’Brien, K., Pruitt, L. D., Johnson, K., & Kramer, G. (2014). Suicide risk management during clinical telepractice. The International Journal of Psychiatry in Medicine, 48(1), 19–31. https://doi.org/10.2190/pm.48.1.c
Weber, E., Miller, S. J., Astha, V., Janevic, T., & Benn, E. (2020). Characteristics of telehealth users in NYC for covid-related care during the coronavirus pandemic. Journal of the American Medical Informatics Association, 12. https://doi.org/10.1093/jamia/ocaa216