COVID-19: What the Ethics Code says about reopening your practice now

As state and local governments relax stay-at-home orders, psychologists around the country are tasked with difficult decisions about if, when, and how to reopen their practices. The situation is fluid, testing psychologists’ ability to tolerate and navigate ambiguity while balancing their safety and well-being with the safety of their colleagues and patients.

Meanwhile, a parallel process is occurring across the world as leaders debate how to balance health risks for COVID-19 transmission with the continued risks of shutdown, such as an increase in deaths from alcohol and drug misuse and suicide; neglected non-COVID-19 medical issues; and increased domestic violence.

This is difficult, and there is no one-size-fits-all answer. APA’s Ethical Principles of Psychologists and Code of Conduct provides support for psychologists’ professional decision-making in such uncertain times. Here are some key considerations for psychologists grappling with the decision to resume in-person services.

Many practitioners have not been in the position of having to weigh the mental health vs. physical health risks of their patients. If a psychologist colleague approached you for consultation about the following clinical situation during COVID-19, what professional guidance would you offer?

My patient’s mother recently died. Now her depression symptoms are much worse, and her suicide risk is high. I was seeing her through telehealth every week, and we increased sessions to twice per week. Should I see her in person because she keeps getting worse?

Ethically, how do you balance the goals of doing good and avoiding harm (from Ethics Code Principle A) in this situation? Clinically, how do you weigh the need for an in-person session vs. possible COVID-19 transmission? Here are a few questions to consider:

• Using CDC guidelines, are the patient, psychologist, and close-contact family members at higher risk for COVID-19?
• Based on local conditions, has the psychologist prepared their practice to minimize risk of COVID-19 transmission?
• Suicide and COVID-19 have statistically higher death-rates for some populations and circumstances than others. How can the psychologist weigh (and document) the risks for this patient?
• Are there health equity or access issues (e.g., lack of reliable, low-risk transportation; no access to internet) to consider?
• How comfortable is the psychologist with depression/suicide risk assessment via telehealth? Is there reason to believe that an in-person assessment would be more reliable in this case?
• Is your clinical judgment that in-person therapy would be more/less effective than telehealth or phone therapy for your patient and their current situation?
• Is the psychologist trying to manage their own anxieties by holding an in-person session because using telehealth technology is new?
• Is the psychologist consulting with colleagues regarding these morally and ethically challenging issues? If so, document the consultation(s). Have they consulted with their liability insurance carrier?
• What is the psychologist doing for self-care?

This example is one of many highlighting complexities in clinical, ethical, and moral decision-making during the COVID-19 pandemic. It is important for psychologists to:

• Gather as much factual information as reasonable
• Be aware of recommendations from public health officials, professional societies, and regulators
• Consult with colleagues as needed
• Document all clinical and office policy decisions
• Practice intentional self-care

Some patients may request, or even insist, on seeing the psychologist in-person, but that alone does not professionally or ethically obligate the psychologist to do so.

Key code sections

Principle A, Beneficence & Nonmaleficence; Principle E: Respect for People's Rights and Dignity; Standards 3.04 Avoiding Harm, 3.12 Interruption of Psychological Services

Further reading

• When is it OK to resume in-person services?

The polarizing rhetoric of politics can amplify the stress associated with COVID-19. Determining whether to reopen your practice will require a balancing of risks and benefits for patients based on scientific information that is evolving and imperfect. Psychologists should look for scientific information from multiple, reputable, nonpolitical sources that clearly explain any underlying epidemiological assumptions and the source(s) of, and limitations in, the data.

There will not be a singular answer for all given differences in locations, patient populations and clinical needs. Consider both the physical health and mental health risks to your patients as well the possible impact of remaining exclusively available via telepsychology. For some patients, telepsychology is optimal. For others, it is more difficult. And another group of patients may be completely cut off from telepsychology due to their geographic location or physical abilities.

Also, be conscious of your own personal lens, and guard against confirmation bias. Consider that the life situations of your patients may differ from your own and whether your own personal circumstances could color your objectivity.

Key code sections

General Principles; Standard 2.04, Bases for Scientific and Professional Judgment; Standard 3.06, Conflict of Interest; 3.01, Informed Consent

Further reading

• COVID-19 information from individual State Health Departments

COVID-19-related inequities across racial, ethnic, and economic demographics have become more evident. Therefore, the initial perception of the public health crisis as a universal experience must be revised to acknowledge the varying rates of exposure and unique biopsychosocial risks of particular vulnerable populations.

Harm reduction principles, which avoid an all-or-nothing approach to disease prevention, acknowledge that individuals tolerate different levels of risk. Multiple domains of risk for each stakeholder must be considered, and the risks may be quite different for psychologists as compared to the risks for clinical and administrative staff members in the practice, trainees, and the individuals that we serve.

Moreover, when working with more than one individual (e.g., group therapy, staff meetings), psychologists must take into account how individual risk may impact the broader group. For example, how might you address some participants in ongoing group therapy wanting only in-person services while others desire continued virtual sessions?

As leaders in psychological science, psychologists bear responsibility to engage these individuals in conversations about their unique risks and circumstances to identify harm reduction principles that can respectfully and responsibly be applied to our work.

Key code sections

See General Principles; Standards 1.03 Conflicts Between Ethics and Organizational Demands, 2.02 Providing Services in Emergencies; 2.04 Bases for Scientific and Professional Judgments; 2.06 Personal Problems and Conflicts; 3.01 Unfair Discrimination; 3.04 Avoiding Harm; 3.11 Psychological Services Delivered to or Through Organizations

Further reading

• NAACP (2020). Ten equity considerations of the coronavirus COVID-19 outbreak in the U.S.: The imperative for civil rights advocacy, monitoring and enforcement (PDF, 780KB)

Minimizing liability is not the same as fulfilling ethical responsibility. Psychologists must be cautious of using ethical principles and standards to justify personal choices. Practitioners who are reopening practices bear responsibility for consideration and mitigation of risk to themselves, their employees, and their patients, as well as communicating all known risks to their staff and clients during an ongoing informed consent process.

First, assess risk for yourself and your own circumstances. Issues to consider include, but are not limited to, personal health risks, number of staff and staff characteristics, office setup, availability and necessity of personal protective equipment, access to telehealth, and even office ventilation.

Next, assess risk for each individual patient, which may include considering the patients’ families or communities.

Finally, take reasonable steps to mitigate risk where risk is apparent or anticipated. Keep in mind that ethical responsibilities may require more of a psychologist than merely reducing liability, and psychologists must uphold themselves to this higher standard.

Key code sections

See General Principles, Standards 1.02 Conflicts Between Ethics and Law, Regulations, or Other Governing Legal Authority, 3.04 Avoiding Harm, 3.06 Conflict of Interest, 3.08 Exploitative Relationships, 3.10 Informed Consent

Further reading

• The John Hopkins Operational Toolkit provides concrete resources for assessing and mitigating risk when considering reopening or expansion of services during COVID-19.

Life is easier when we are certain. Yet certainty is not possible during this public health emergency. Our plans for today may not work tomorrow, as new information emerges and new hotspots arise.

Psychologists must embrace ambiguity and change in order to ethically balance personal and professional responsibilities. But we cannot do this alone and must intentionally invest in building our competent community to support one another.

Take care of yourself. Take care of your colleagues. Working together, we can apply our expertise in tolerating ambiguity and distress to continue to provide quality services for the populations that so clearly need us.