Eighteen months in, the pandemic we once believed would be over in a few weeks or months at the most, continues to impact our daily work and personal lives. And, with the rise of the Delta variant, there is no clear end in sight.
What does this mean for the therapist who would like to return to in-person sessions or for those who have already made the decision to see patients in the office? Is it appropriate to ask about vaccination status? Can a therapist require masks during sessions? Can a therapist refuse to do in-person sessions with someone who is not vaccinated?
Like with everything during the Covid-19 pandemic, there are many unknown, and constantly changing, factors to take into account.
Firstly, to be clear, the CDC does still recommend that everyone wear masks in healthcare settings, no matter the vaccine status.
Secondly, each state, and even some towns or cities, may have different laws or regulations that could affect in-office practice. It is the therapist’s obligation to understand and follow all applicable laws.
Within the laws or guidelines, there may still be some wiggle room when it comes to making decisions around in-person practice. This area is where the therapist needs to use his own best judgment.
“I think these are ethical questions,” said Mark Spellman, Ph.D., a clinical psychologist in New Fairfield, Connecticut, and treasurer and legislative and executive committees’ member for the Connecticut Psychological Association, “and the first guiding principle for all ethical questions is the patient’s best interest. The second guiding principle is the therapist’s emotional and physical well-being.”
Looking at the issue from the patient’s best interest, he added, you need to take into account the fact that it is not just the person in front of you whose health is at risk.
“If you are going to have people back in the office,” he said, “you must acknowledge that you are also protecting the next patient who is coming in after them.”
With this in mind, he explained, the therapist has both a right and an obligation to insist that patients who want to be seen in person, indoors, must be vaccinated.
“If someone asks ‘why can’t you see me, you’re vaccinated,’ you can explain that it is because of the next patient. If we have 55 percent possibility of asymptomatic transmission with the Delta variant, you have every right to insist that everyone who comes to see you is vaccinated,” Spellman said. “You are not obligated to work with people who are not complying with safety regulations.”
Of course, the other option is to continue to see some clients virtually, via telehealth. In fact, many clients may choose to continue virtual sessions aside from Covid-related safety measures.
“There was a big Pennsylvania study that showed that 70 percent of people surveyed wanted to continue online treatment even after it was possible to go back in,” Spellman added. “So clearly, the patient considerations would be to keep online always on the table.”
In May, the American Psychological Association published an article suggesting that therapists look at several factors when deciding to re-open an in-person practice.
Firstly, determine if in-person therapy is necessary.
Secondly, review the risks both physically and mentally around in-person versus telehealth for that client.
Thirdly, establish new rules around safety measures like mask wearing and social distancing and hand sanitizing.
Fourthly, look at ways to make your office healthier with re-arranging seating, opening windows or purchasing high quality air filtration systems.
Lastly, it is important to implement policies that are clear to everyone for the protection of both clients and employees. That can include re-writing your patient informed consent form, providing specific wording for a receptionist to read to any new clients who call the office or adding language to a website that explains in-office Covid policy.
“It is important to avoid surprises,” said Jeff Zimmerman, Ph.D., a licensed psychologist in Connecticut and New York and founding partner of The Practice Institute, a consulting service that works with psychologists to build ethically responsible practices.
“Surprises are not a good thing in this context. It is important to make your policies obvious and clear on your website and on first contact with the patient, not just on the first visit.”
When working with current clients, there may be special considerations for making changes before coming back into the office, he added. A change like this could lead to ethical situations.
“If I didn’t require something, like a mask mandate or proof of vaccination, and now I do, I need to tell clients explicitly,” Zimmerman said. “If someone drops out or I end up discontinuing treatment, I run the risk of inadvertently abandoning the patient. We need to make sure that all transfer of care is done appropriately.”
Therapists need to be aware of the ethical and legal ramifications of requiring vaccines or masks or other practical changes done for health reasons. For instance, could restrictions on who you would see in person be seen as discrimination?
“I don’t think we could imagine discriminating against a patient because they have cancer or some other health condition,” said Zimmerman. “Although one might argue that cancer is not contagious as we know it, the idea that we might even inadvertently discriminate against a patient by refusing to treat them due to fear of illness is important to be aware of.”
It may be a stretch to consider an accusation of discrimination over vaccine status but it is a legal area that has not been fully explored yet, either.
“Case law in your state may not have been determined yet,” said Zimmerman, “But do you want to be that test case? It is important to know the laws and regulations in your state and look to CDC guidelines for input.”
When making the call to go back to in-person, you cannot rule out personal comfort in the equation. If a therapist feels anxious about putting herself or her clients, employees, or family in jeopardy, will that affect the therapy itself?
“We need to ask ourselves, ‘Am I distracted from providing the best care or am I resenting the patient because of the situation?'” said Zimmerman. “APA Ethics code speaks to our responsibility to refuse to treat if we are biased in some way or have an emotional reaction to that patient that would impair clinical judgment. We need to ask, ‘Do I have a conflict of interest because my objectivity or my effectiveness is impaired?'”
In some cases, dealing with children or doing assessments, it may be necessary to be in-person. This judgment needs to be balanced with the risk factors. As Spellman put it, it is about maximizing safety points and minimizing risk.
“How can I pick up more safety points if I need to be in the office?” he said. “For those who want to come in, you need to justify that it is worth it clinically. And you can make that choice but you are picking up risk points and you need to counter balance that with safety points.”
For himself, Spellman has chosen to see clients completely outdoors, in parkas during the winter months, because he has the space to do that. He is currently investing in an addition to his home office that will include two “screened” walls, a large stone fireplace, and good ventilation. It is an option that not every therapist would be able to create.
“In the meantime, I have viable outdoor space options so I can hold out until it is ready,” he said. “I really see no way to treat people safely indoors. That doesn’t mean you can’t justify it on clinical grounds, though, as long as you work to minimize the risk. That is ethical.”