Online Therapy

Ethical Parallels Between Teletherapy and Remote Education

Has COVID-19 infected our ethics?

Posted Jan 28, 2021

I’ve been reading quite a bit about ethical issues in teletherapy: psychotherapy via phone, internet, etc. The prevailing wisdom is that the same ethical principles apply to both face-to-face and remote therapy, but that teletherapy presents some unique challenges to implementing those principles. Mental health professionals have been doing teletherapy for a number of years, but the coronavirus pandemic has accelerated the pace of change—therapists adopted remote formats almost overnight. The situation for college instructors was very similar—some have been teaching online for a while, but many of us packed up a few boxes on a Friday in mid-March and started teaching remotely the next Monday. 

In both psychotherapy and education, shifts from face-to-face to remote formats predated the current pandemic and were slow to develop. People were skeptical that “it” could be done ethically, but a few pioneers starting trying it—often as an adjunct to face-to-face interactions. As remote options reached the tipping point of inevitability, people started talking seriously about how to do it ethically and excellently—rather than whether it should be done. Then the pandemic forced even the skeptics to make the transition. Now, serious people are questioning the extent to which we will, or should, ever go back to the old systems.

Let’s look at the parallels between remote versions of psychotherapy and education in regard to three basic ethical issues. This is not an exhaustive list, or a comprehensive treatment of each issue. But it’s a start.

Beneficence/Nonmaleficence

Provide benefit—do not harm. Pretty basic stuff, right? But in practice, these two principles raise lots of complex questions. There is some empirical evidence that remote psychotherapy can work just as well as face-to-face. It even has some advantages, such as reaching underserved populations and those who cannot make it to an office (e.g., Anthony et al., 2010). These same benefits accrue to distance education, and researchers are busy exploring other potential benefits—and risks—of remote learning.

Regarding psychotherapy, Martin (2013) wrote: “Most experts agree that telemental health sessions are not for every patient” (p. 77). As we deliberate the ethics of both enterprises, we need more evidence about many aspects of our work. We are moving beyond the basic questions like, “Does therapy (or teaching/learning) over the internet work?” We now are asking questions like, “What type of modalities provide what kinds of benefits/risks for what kind of people with what kinds of goals at what points in their lives?”

Competence

Going remote doesn’t mean you just do what you do in front of a camera instead of other people. It’s not like watching a baseball game on TV rather than at the stadium. It’s more like playing baseball over the TV rather than in person. With the onset of the pandemic, lots of psychotherapists and educators find themselves thrust into positions with limited competence in various aspects of their new situations. These areas of limited competence raise the probabilities of harm, or at least limited benefits.

Professors are fond of complaining of our students’ short attention span and the likelihood of them being distracted—whereas if they were in class they’d be riveted to our every word, right? Wallwork (2013) brings up a parallel point about teletherapy: It’s not only clients who can lose concentration while on the phone or Skype. “Colleagues have acknowledged getting away with texting, checking their investments online, skimming through magazines, adding to a grocery list, making to-do lists, and preparing bills, while listening with half an ear.” (p. 93) Thus, even good lecturers may lose their place when their phones buzz to let them know their latest Prime package is on the doorstep.

Part of becoming and staying competent means navigating the unique aspects of our new environments. It also means coming to know both the drawbacks and affordances the remote modalities offer, and communicating them to students. That brings us to our next principle.

Informed Consent

I made the connection between the syllabus and the clinical doctrine of informed consent to therapy many years ago (Handelsman et al., 1987). More recently—last week—I made the point that professors need to be very explicit with their students about the benefits and risks of remote courses. In regard to therapy, Wallwork (2013) talks about one of his patients: “The fact that I was only an unseen voice in his ear meant that the therapeutic relationship lacked the grounding in reality that might have strengthened his new … adaptations (p. 86). Likewise, there are aspects of the professor-student relationship that might be diminished—as well as some that might be enhanced. Perhaps we need to address some of these issues in our syllabi, or at least at the beginning of our courses.

A robust informed consent process is part of the evolution of psychotherapy (and other professions, like medicine) from a paternalistic enterprise, in which therapists made the decisions about what was best to do in therapy, to a more collaborative effort. Our shifts to remote modalities may be facilitating this evolution. Wallwork again: “Teletherapy has tended to push the concept of mutual construction of the setting even further, because so many unique features of this kind of work require full discussion and mutual agreement.” (p. 92). Likewise, I find myself much more likely to ask students about how Zoom is working (or how to work Zoom!) than I used to ask them about how to arrange chairs, write on the blackboard, or hand out handouts in our classroom. As our new “classrooms” expand, so does the need for collaboration and good information.

(Tentative) Conclusion

The bad news is that over this past year, my students and I all found ourselves in situations we did not bargain for, that dashed at least some of our expectations, and challenged the mastery we believed we had for this academic enterprise. We need to be much more mindful of our ethical responsibilities and more explicit about how we meet them. The good news is that such mindfulness and communication will serve us well no matter what our teaching and learning look like in whatever comes next.

References

Anthony, K., Nagel, D. M. & Gross, S. (Eds.) (2010). The Use of Technology in Mental Health: Applications, Ethics and Practice. Springfield, IL: Charles C. Thomas.

Handelsman, M. M., Rosen, J., & Arguello, A. (1987). Informed consent of students: How much information is enough? Teaching of Psychology, 14, 107-109.

Martin, A. C. (2013). Legal, clinical, and ethical issues in teletherapy. In J. S. Scharff (Ed.), Psychoanalysis online: Mental health, teletherapy and training (pp 75-84). London: Karnac.

Wallwork, E. (2013). Ethical aspects of teletherapy.  In J. S. Scharff (Ed.), Psychoanalysis online: Mental health, teletherapy and training (pp 85-94). London: Karnac.