COVID, Counseling, and Caution: Ethical and Relational Concerns By Cindy Silitsky, PhD on 11/24/20 - 3:38 PM

It was a typical session on a normal day in late September; as typical and normal practicing therapy can be during a global pandemic.

Jonny, a Black male in his mid-50’s who worked in law enforcement, was referred to me by a former client. He was skeptical of therapy and the process. He decided to attend after several years of being cut off from his adult son, after his long-time partner gave him an ultimatum about committing to their relationship, and after his co-worker’s convincing him that the process could be useful for him. On this day in late September, it was our fourth session together.

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I don’t recall anything especially memorable about that session. We explored his beliefs on parenting and delved into some of the history with his son. We paralleled this relationship to the one he had with his own father, discussed the type of relationship he wanted to have with his son and what was holding him back from doing so. Of course, we followed all the guidelines for COVID that we had previously agreed to. Jonny did not sneeze, cough, or exhibit any symptoms of illness during this session.

I have a small private practice in a community where the COVID positivity test rate had been under 3% for about 6 weeks, considered low community spread. The city has a population of 95,000, and the number of people in the city who tested positive had remained at 10-15 cases per day during this timeframe. Despite the low risk of encountering a client who was positive with COVID, all my clients were offered the choice of telehealth or in-person office sessions. Jonny would not have participated in therapy if the only option was telehealth, as he clearly explained to me, because he needed to be able to “read people.” For our office visits, we sat six feet apart and both wore face coverings. I have an air filter to ventilate the air, we keep the office door open for more air circulation, hand sanitizer is located in multiple sections of the office, and there are few other people in the office at any given time. Clients text me from their car when they arrive, and I text them back when it is safe to enter, so that they avoid mingling with anyone in the waiting room. I clean and sanitize the office between sessions, as well as have a weekly cleaning service. Clients and I both agree to inform the other if we are experiencing any symptoms, and they sign a separate COVID informed consent about the risks of conducting therapy in person during a pandemic. It was no different with Johnny.

About five days after that last session, I began to feel poorly. Although I did not experience the signs of COVID that we are generally taught to look out for, such as fever, cough, fatigue, and body aches, I did experience excessive nasal congestion, headaches and a sore throat. A few days after the onset of these symptoms, Jonny sent me a message to let me know that he had tested positive for COVID and was in the hospital receiving treatment. I made an appointment to get tested and learned 48 hours later that I was also positive. I experienced a mild case.

Ethical Dilemmas

The first ethical dilemma I encountered was that I needed to self -disclose my positive status to the clients who had potentially been exposed prior to learning of my status. I also needed to disclose to my other clients that any sessions while I was in quarantine would be done virtually. While therapists range in the amount of disclosure they do with their clients, I would rate my usual disclosure level at less than most therapists. I was fearful of disclosing to a few of them, as their anxiety about COVID had been high, prompting their seeking out services initially. How much information was necessary, and how much was too much? I prepared a basic speech with the facts and the importance of noticing symptoms and getting tested themselves. Some responded well; others less so. How to manage this anxiety? As clients check in with me about how I am doing, how much should I disclose? Will I feel differently towards clients who do not ask?

The second ethical dilemma I experienced occurred when the Health Department contacted me to gather basic information and begin the process of contact tracing. When they asked me to provide the name of the person whom I believed I had contracted the virus from, I was faced with the challenge of whether it was necessary to provide the client’s identifying information. Does this fall into the category of “harm to others,” one of the exceptions to maintaining client confidentiality? As my client was hospitalized, I felt confident that this information had already been sufficiently recorded, so I declined to provide identifying information and maintained his confidentiality. And yet, what if that had not been the case? When does public health outweigh the client’s right to confidentiality about receiving therapeutic services?

Relational Dilemmas and Further Questions

As of this writing, Jonny is still recovering, and I have not yet seen him again. I believe that he was unaware that he had been exposed and that he was in the asymptomatic stage of COVID prior to symptom onset. Due to this, I am not angry with him, I do not blame him for my exposure, and I am concerned about how he is feeling. And yet, what if I were less certain? Would I be able to continue working with him if I believed he suspected exposure or covered his symptoms and attended the session regardless? What if I viewed him as a “risk-taker” outside of our sessions, which prompted his exposure? If he experiences guilt over exposing me inadvertently, would that affect our relationship and work together?

Of the clients I contacted, only one family has tested positive, a 25-year-old daughter and 66-year-old mother who, ironically, were attending therapy because the daughter was concerned that her mother was engaging in too many risky behaviors regarding COVID and her health. Both are currently hospitalized. How will this experience affect our work together? Will they want to continue with me in therapy, assuming their health stabilizes? Although I have no way of knowing that I had been exposed at the time of their last session and was not exhibiting any symptoms, is there anything I could have/should have done differently?

Some of my colleagues believe that we should only be conducting telehealth sessions during this time, and many of them have not yet returned to live sessions. And yet, we are seven months into this pandemic, and the county is in Stage 3 of re-opening. At what point is it considered “safe enough” to resume? How many clients are not seeking services because telehealth fails to appeal to them? Black men as a group can be mistrustful of receiving therapeutic services, so what might be the ethics of refusing to offer these clients other format options? When do the benefits outweigh the risks?

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We are encountering many ethical challenges during this time. As essential mental health workers, we are also on the frontlines of this crisis and play an important role in helping people to get through this time of uncertainty. These situations prompt few answers, only generating more and more questions to ponder.  

File under: Law & Ethics, COVID-19 Blogs