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This post was co-written with Mitch Handelsman, who also writes the "Ethical Professor" blog.
We received a comment and the following request on our blog titled "What do you see: Red Flag or Green Flag?"
"Can you please blog on the ethics (yes, it's perfectly legal if the therapist makes the proper referrals, but is it right?) of a therapist ending a long-standing (2 years) and positive for the patient therapeutic relationship when a patient moves away in-state (NO licensure questions) rather than continue to work with that patient who wants to try to work by Skype teleconference?
What a good question! You have identified a true ethical dilemma where there are good arguments for both keeping the therapeutic relationship and ending it. Of course, as readers you probably already know that the ultimate answer we will give here is, "It depends." We can list some issues that psychotherapists need to consider, but we can't even speculate about how any particular therapist would weigh each issue. In addition, we do not know: (a) the training, experience, comfort level with technology, and other factors about the therapist; (b) the issues, procedures, and goals for therapy; (c) information about the client; (d) how close to the end of therapy both parties feel they are.
Although we can't give a "yes" or "no" to the question, we can share some of our thoughts and a process to consider-this ethical choice making process which is based on James Rest's work and is discussed in our book, Ethics For Psychotherapists and Counselors.
Good (ethical) therapists will draw upon their ethical sensitivity. They take stock of different possibilities and the outcomes of each. They do some perspective taking: "If I were the client what would I hope my therapist is taking into consideration?" They notice and reflect on their initial or automatic response to the client's request. Rest calls this ethical motivation, or a commitment to acting ethically.
With any ethical dilemma there will be personal motivations and professional motivations based on ethical principles that compete for the final outcome. Therapists might really enjoy the client as a person and want to continue only for that reason. On the other hand, the work in therapy might really be over and deciding to end therapy is reasonable. On the other hand, therapist motivations might include a simple dislike for technology. Or they may be incompetent with such technology. Self reflection is important to assess the sources of our motivations. Consultation with some trusted colleagues would be a good idea.
Another step in the process is formulating an ethical plan by assessing the facts of the case along with the ethical principles of the psychotherapy profession. One of the facts of the case is whether the therapy goals have been accomplished. If yes, then it would make sense to suggest that the therapy is over. If no, therapists may consider ways to be a supportive and maintain some level of contact until the client can get connected with a new therapist in the new locale.
Of course, the plan needs to include guidance from codes of ethics, policy statements from professional groups, government agencies, and others. In our book we outline ten "Ethical Foundations for Psychotherapists," which is a list of ten principles that underlie ethics codes from various groups of psychotherapists (psychologists, counselors, and social workers). At least five of these statements are relevant for this question about teleconferencing with a client:
• Do good for clients .... (This is also called beneficence.)
• Avoid doing harm or exploiting clients. (This is also called nonmaleficence.)
• Treat clients with respect. (This is also called respect for autonomy.)
• Become and remain competent.
• Preserve confidentiality.
• Inform client of important information.
Additional guidance comes from a statement of the American Psychological Association on "Services by Telephone, Teleconference, and Internet," which says, in part: "Psychologists considering such services must review the characteristics of the services, the service delivery method, and the provisions for confidentiality. Psychologists must then consider the relevant ethical standards and other requirements, such as licensure board rules." The California Board of Psychology has some excellent advice on its web page, as does the APA Division of Psychotherapy.
One primary issue would be one of competence: It is possible that therapeutic effectiveness would be hampered because teleconferencing is so different from face-to-face therapy. Although the client may feel very comfortable with teleconferencing, the therapist may not have the same comfort level. (Just because a client feels comfortable with something doesn't make it ethical!)
Therapists may be showing respect for the client by encouraging the client toward more autonomy and less dependence by terminating the relationship.
Another consideration is confidentiality: Therapists are obligated to maintain the privacy of therapeutic communications-and to inform clients of potential threats to that privacy, which includes electronic transmission of information.
With ethical sources of guidance in mind, ethical sensitivity heightened, and ethical motivation checked, the next step is ethical follow through. Whatever their decision, therapists would need to (a) discuss their concerns with the client and listen well to theirs; (b) inform the client not only of threats to confidentiality but of other potential risks of the Skype format; (c) revisit the informed consent process to see if issues like insurance coverage, emergency situations, payments for missed sessions, etc., have been discussed; (d) set a time for reevaluation for this type of session; (e) make good referrals if necessary; and (f) document their decisions and the reasons for them.
Thank you to the person who submitted the question. Having worked this situation, it left us wondering what experiences people have had with long-distance therapy, changes from face-to-face to internet therapy, or other technology-enhanced therapy experiences. We encourage you to share your thoughts and stories.
