On March 11^th, 2020 the World Health Organization (WHO) declared the COVID-19 outbreak a pandemic (American Journal of Managed Care Staff, 2021). During this time, like many states across this country, Governor Kate Brown also issued Executive Order 20-12, which was a mandatory stay-at-home order, challenging mental health care providers to continue care for their clients (State of Oregon, 2020). In response, mental health care providers quickly integrated varying degrees of teletherapy (also referred to as telemental health, telepsychology, telemedicine, telehealth, or telepsychiatry) into their practices. Over the last year, the rise in teletherapy served as a catalyst for organizations such as the American Psychological Association (APA), Board Certified-teleMental Health Provider, and Zur Institute Certificate Program in teleMental Health & Digital Ethics to emerge and provide guidelines, training, and certification for the practice of teletherapy (Burgoyne & Cohn, 2020).

With progress slowly being made in regards to the COVID-19 pandemic, mental health care providers now need to prepare for the transition back to in-person therapeutic services. Many factors need to be considered for each provider, clinic, and organization during this transition. While factors related to clinical issues or public health matters are beyond the scope of this article, we will an ethical decision-making model to address the ethical dilemmas that mental health care providers may face during this transition period.

Several provisions in the American Psychological Association’s (APA) Ethical Principles of Psychologists and Code of Conduct (2017; hereafter referred to as the APA Ethics Code) are relevant to this discussion.  First, the General Principles of the APA Ethics Code “guide and inspire psychologists towards the very highest ethical ideals of the profession.” Specifically, Principle A (Beneficence and Nonmaleficence) states that a psychologist has the duty to “benefit those with whom they work and take care to do no harm.” Principle E (Respect for People’s Rights and Dignity) asks that psychologists “respect the dignity and worth of all people.”  Finally, Principle D (Justice) states that all persons have “access to and benefit from the contributions of psychology.”  Additionally, practitioners should be aware of relevant standards in the APA Ethics Code regarding the resolution of conflicts between the Ethics Code and governing bodies (Standard 1.02: Conflicts Between Ethics and Law, Regulations, or other Governing Legal Authority) and organizations (Standard 1.03: Conflicts Between Ethics and Organizational Demands).  It is with these aspirations and standards in mind that we explore the ethical-decision-making model.

The first step within an ethical decision-making model is to identify the problem and which principle(s) and standard(s) may be potentially violated. For example, a potential dilemma for clients who are house-bound, live in remote communities, or have disabilities, is the change in accessibility to care when considering in-person psychotherapy as compared to teletherapy. In this situation, Standard 3.12: Interruption of Psychological Services states that psychologists should “make reasonable efforts to plan for facilitating services in the event that psychological services are interrupted.” The APA Guidelines for the Practice of Telepsychology (2013) state that psychologists “carefully examine the unique benefits of delivering telepsychology services” (Standard 2: Standards of Care in the Delivery of Telepsychology Services), which include considerations pertaining to access of care based on geographic location, convenience for the client, and accommodations for client needs.

The second step of the ethical decision-making model is to develop alternatives and hypothesize solutions for the identified dilemma(s). Collaboration and consultation with mental health professionals may be useful in this process. The APA Ethics Code explicitly encourages psychologists to cooperate with other professionals “in order to serve their clients/patients” in an effective and appropriate manner (3.09: Cooperation with Other Professionals), reach out to local or state psychological groups such as an ethics committee (1.06: Cooperating with Ethics Committees), or reach out to colleagues for consultation (4.06: Consultations) to aid and support in the identification of ethical dilemmas and seek ways to respond and serve client needs. For clients with a change in accessibility, collaboration and consultation may allow psychologists to discuss referral sources that are geographically closer to the client.

After all potential solutions have been generated, the third step is to evaluate and analyze all identified options. In this step, psychologists are encouraged to incorporate the solutions that provide the most benefits and advantages while minimizing disadvantages. When prioritizing, solutions that honor the guiding principles to do the most good and least harm, particularly in regard to the client (3.04: Avoiding Harm) should be considered most ideal. In addition, solutions should remain within the competency of the psychologist providing services based on “their education, training, supervised experience, consultation, study or professional experience” (2.01: Boundaries of Competence). This can be particularly important for psychologists who have recently entered the field or for psychologists in training who have not yet had the opportunity or training to work with clients in a face-to-face modality. Identified referral sources should be accessible for the client, and the psychologist should be knowledgeable in the current treatment modality the client is receiving or wishes to receive.

The fourth step in the ethical decision-making model is to implement a course of action. For example, implementing a course of action may include informing the client “as early as is feasible in the therapeutic relationship about the nature and anticipated course of therapy” (10.01: Informed Consent to Therapy). During this informed consent session or any other session, a psychologist should provide “sufficient opportunity for the client/patient to ask questions and receive answers” as it pertains to the transition to in-person services. As with most work of a psychologist, documentation of the selected course of action should be created and appropriately stored (6.01: Documentation of Professional and Scientific Work and Maintenance of Records). If termination is the selected course of action, the psychologist should “provide pretermination counseling and suggest alternative service providers as appropriate” (10.10 Terminating Therapy). As part of that counseling meeting, plans for confidential transfer of client records should be collaboratively identified (6.02 Maintenance, Dissemination, and Disposal of Confidential Records of Professional and Scientific Work). If applicable, a meeting with the new psychologist in the client’s area may be held in order to provide an opportunity for a warm hand-off. The current psychologist, the transfer psychologist, and the client can all meet to allow the client to become comfortable with the transfer psychologist and the transfer process.

The final step in the decision-making model is to evaluate the effectiveness of the solution that was identified and implemented. One needs to consider whether the ethical dilemma has fully and appropriately been resolved. If the dilemma continues, such as limited or no mental health professionals in the client’s area, an alternative approach may be warranted .  To identify this alternative approach, the psychologist may need to work through the decision-making model again, identifying additional options and weighing pros and cons of each option.       In conclusion, as the practice of psychology continues to evolve in Oregon during this pandemic, mental health care providers are encouraged to utilize the APA Code of Ethics as a guide to assist them during the transition to in-person services.

References

American Journal of Managed Care Staff. (2021). A timeline of COVID-19 developments in 2020.
https://www.ajmc.com/view/a-timeline-of-covid19-developments-in-2020 

American Psychological Association. (2013). Guidelines for the practice of telepsychology.
https://www.apa.org/practice/guidelines/telepsychology 

American Psychological Association. (2017). Ethical principles of psychologists and code of conduct
          (2001, amended effective June 1, 2010 and January 1, 2017). https://www.apa.org/ethics/code 

Burgoyne, N., & Cohn, A. S. (2020). Lessons from the transition to relational teletherapy during COVID-19.
          Family Process, 59(3), 974-988. https://doi.org/10.1111/famp.12589 

State of Oregon. (2020). Executive order No. 20-12.
https://www.oregon.gov/gov/admin/Pages/eo_20-12.aspx