Telehealth and Social Work Ethics

Image Credit: Dejan Krsmanovic. Flickr.

While telehealth (especially teletherapy) has been part of the healthcare conversation for quite some time, it has been brought to the forefront by the crisis of the COVID-19 pandemic as social workers are suddenly forced to adapt by switching to remote work at a fly-by-night pace and preventing disruption of client care. However, as my clinical supervisor says, we’re one of the lucky and privileged ones who can still work during this uncertain time.

The resistance to teletherapy makes sense. Social work, and especially clinical social work (one of the psychotherapy disciplines), is about providing presence in a world where it’s difficult to sit with any degree of “evenly suspended, curious, and open attention to the other” as the psychoanalysts of yore would say (or at the very least, without a phone on the table during dinner). Therapy is supposed to provide the psychological “jar” or container where the accountability lies in completely unplugging as much stimuli as possible so that all feelings and thoughts can surface up, unencumbered by the nearest stimuli fix. Wouldn’t teletherapy, then, negate the ethos of the profession? Or at the very least, the frame that makes it possible?

Yes and no. I am of the opinion that nothing will replace in-person work (or in-person anything for that matter). That said, I have also witnessed therapeutic experiences for clients of equal quality in online as much as in-person forms. As with all kinds of therapy, I have been amazed by people’s willingness to share the deepest parts of their stories and their self-directed transformation—in many cases, even without having met me at all. My experiences with telehealth began with Talkspace and Betterhelp in 2016, where my first contact with a client would often start from the safety of written messages (perhaps a modern version of the couch and free-association?) long before “meeting” for a live video session. It seems like with teletherapy, part of the therapeutic intimacy is lost, and yet another part seems gained because of an added glimpse of a different part of someone’s life (one of my personal favorites: meeting people’s pets).

From a social work student’s vantage point (especially those of you studying for the social work exams), what are some of the ethics around telehealth that you should keep in mind?

  • State licensure: This one is crucial. At the time of writing, you must be licensed in the state where your client resides. Some states allow for exceptions for temporary client travel.

    You can be licensed in more than one state (and even Canadian provinces—because tbh, you never know if you need to book it up to Ontario based on certain election results—thanks for sending over those scores, ASWB!).

  • Risk Assessment: Online therapy is generally not an appropriate modality for crisis situations since it can complicate locating someone or even getting to the right emergency dispatcher if someone is at risk. Teletherapy can also be criticized for making it more difficult to assess in general (since other nonverbal cues are lost in interactions).
  • Training: Scope of practice and competency are two mandates in the NASW Code of Ethics, and teletherapy is no exception. It’s not just important to be trained on the technology (Skyping from your phone while doing dishes and scolding the dog for barking is probably not going to be HIPAA-compliant) but also on the ethics and special logistical/legal/clinical considerations when practicing in this way. One of the principal ones is the use of systems—informed consent, use of an encrypted HIPAA-compliant platform, electronic record-keeping, being aware of insurance regulations, and appropriate equipment.
Note: This is not a HIPAA-compliant call. Image Credit: Kars Alfrink. Flickr.

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