Something Ventured, Something Gained: Ethics in Teletherapy

This guest post was written by Nancy Winfrey, Ph.D.

Nancy Winfrey, Ph.D.

Source: Nancy Winfrey, used with permission

Blogger’s Note: I’ve been thinking a lot and writing a little on the ethical issues of doing therapy via Zoom. But I am not a practicing therapist. That’s why I’ve asked Dr. Nancy Winfrey to share some thoughts from the virtual trenches.

Dr. Winfrey received her Ph.D. from the Child Clinical Psychology program at the University of Denver and did her internship at Stanford. She has a private practice working with children, teens, couples, and families and also supervises doctoral students at MotherWise in Denver.

Many of us have been doing therapy by Zoom since the pandemic started. What began as a quick pivot is now seen as pivotal to providing mental health treatment. What are some of the ethical considerations of working remotely with our clients?

In our informed consent process with clients, we talk a lot about privacy and confidentiality. In essence, we promise privacy—with certain exceptions. However, many clients simply do not have a private space to talk, especially given how stuck at home families are in the pandemic. A lack of privacy risks violating the ethical principle of confidentiality. This might make it harder for clients to trust us and disclose personal thoughts and feelings, which is an important path toward effective therapy.

At its worst, a lack of privacy could create a risk of physical harm for clients. In our work with victims of domestic violence, we have done things like set up a code word for a client to tell us if the perpetrator enters the room, have clients use the “chat” function to speak privately, or, if need be, end the session.

On the other hand, some clients seem quite cavalier about privacy and seem unruffled with others around. Therapy on a cell phone has made sessions portable and compounded the privacy problem. Recently, I realized a client I was working with was shopping in a superstore.

“No problem!” she said when I asked where she was. “It’s deserted!” she insisted. I reluctantly carried on until I realized she was “taking me” through the check-out line, sharing our session with the cashier.

Using cell phones or other devices for therapy runs the risk of blurring boundaries with our clients and creating a false impression of friendship—an unethical dual role. Clients now talk to us while lying in bed or in the kitchen when putting away their groceries. We see them in their home—and they see us in ours.

They might get the impression that we are available all the time. This has some advantages, to be sure; for example, we view more of their actual lives, instead of just hearing about them. Sometimes we “meet” family and pets (or, more precisely, pets and other family members!). But it can confuse people about what our role is.

Switching to remote mental health treatment has been more difficult, even impossible, for a lot of our child clients. I initially found teletherapy with children surprisingly doable, especially when I helped parents make it kid-friendly by providing things for their children to make or do while we met and by not requiring them to stay in the camera’s frame. However, I have found the shelf-life of Zoom limited for kids, especially for those already spending tons of time doing remote learning.

Despite the above concerns (and others; see Chenneville & Schwartz-Mette, 2020), teletherapy has made some things better. It has made therapy more accessible, especially to underserved clients with issues like transportation problems, medical conditions, or childcare worries—all heightened by the pandemic. It takes less time and hassle for clients to do therapy via Zoom. Doing family therapy with people distanced from one another has also become much easier.

By the way, I am loving supervising graduate students using Zoom. With informed consent from clients to record and share for training purposes, Zoom has made it possible for me to see both the therapist and client(s) simultaneously and to easily view sessions, both by myself and during supervision with trainees.

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Most importantly, doing teletherapy makes “being” with another person safe from COVID-19. Unlike some other professions that have been curtailed or halted, we have found a way to do no harm by meeting safely with those we serve. There are plenty of ethical issues to be aware of, but the bottom line is that teletherapy has been a lifesaver for many of our clients who otherwise would not be able to get mental health treatment.