Doing right when things aren’t right: Ethical perspectives on face-to-face counselling and psychotherapy practice during a pandemic  by Mike Hackett MIACP & Niall Bulfin MIAHIP  

Never, never be afraid to do what’s right, especially if the well-being of a person or animal is at stake. Society’s punishments are small compared to the wounds we inflict on our soul when we look the other way – Anon.

Doing the right thing is difficult. Personal values, morals, societal norms, professional standards and cultural imperatives shape each and every endeavour we undertake as we go about our work as therapists. Being a therapist is challenging. Often, we must balance our personal motivations (earning a living, doing meaningful work, self-care) with the needs of clients (urgency of care, holding suffering, being emotionally available), professional body guidelines (ethical compliance, maintaining standards, gatekeepers of the profession) and the professional context in which we operate (landlords and rent demands, placements and the curricula of training institutions). This is challenging enough under ‘normal’ circumstances, but what happens when faced with an extraordinary global event such as the ongoing Covid-19 global pandemic? How do we manage all of the above factors when we, our clients, our profession and indeed our society are gravely impacted due to a profound existential threat? How do we figure out what the right thing is when normality has to be profoundly readjusted? How do we do the right thing when our livelihoods are impacted? How do we know what is the right thing when such a situation is unprecedented and we cannot rely on answers from wise elders like supervisors and our professional bodies – because they too are faced with profound uncertainty and the same threat as ourselves. As every therapist in the country grapples with the question of how to provide therapy during a pandemic, this reflective piece explores these themes with a view to providing therapists with reflective anchors from which they can formulate responses to the challenges the pandemic presents and hopefully, be better equipped to ‘do the right thing’.

Is there a ‘right thing’?

We feel it important at this point to comment on our term - ‘right thing’. Here, we are not implying that there is an objective truth, a certainty of knowing or an absolutely quantifiable outcome, rather to acknowledge the ambiguity and uncertainty inherent in ethical discernment. By ‘right thing’, we ultimately mean, that which we are willing to live with, faithful in the knowledge that life is risk and that noble intent is no guarantee of good outcome.

What is the ‘right thing’?

Perhaps the most difficult question of all is the question ‘What is the right thing to do?’ as it inevitably creates a myriad of further questions, ambiguity and uncertainty. Many additional questions arise beneath such an apparently simple question. The right thing for whom? Is doing nothing right? How do I measure the impact of the action? How do I identify the best choice when presented with a range of ‘right’ options? What ‘sacred cows’ of our professional values may need to be sacrificed in order to do the right thing? Are we willing to change? What are the limits to our willingness to ‘do the right thing’ when faced with a collapse of our practice, pressure from clients to work face-to-face, requirements of training courses and compliance with legal and public health guidance?

This difficult prospect was, as Ireland began its first national lockdown on 29^th March 2020, echoed in the minds of many in Irish society and perhaps in particular, in the minds of those who have a duty of care to others. Counselling and psychotherapy are action-oriented endeavours and as with any action, they have circumstances, contexts, consequences and outcomes.

Circumstances, contexts, consequences and outcomes

As the impact of Covid-19 began to sweep the globe with infection rates increasing, many therapists and clients were faced with the prospect of moving from traditional face-to-face settings to an online therapeutic space. This resulted in a necessary journey to chart a course through an online world of technology and therapy platforms which contain video, payment, scheduling and records management in a single service. In a few short months, the circumstances of counselling changed. Therapists and clients struggled with isolation due to the stay-at-home order, fear of infection, the impact of news and social media on wellbeing and the presenting problems of clients being amplified by the pandemic. The contexts changed. Therapists had to encroach on a boundary of home/work by creating a space and navigating with family/partners also working from home, they had to suddenly upskill technology competencies, and for many this seemed like a task well beyond their ordinary skilfulness and expertise. Many resisted the potential altogether, citing a range of challenges, some preferential (I don’t want to work online), some practical (I don’t have training/ equipment/broadband), some professional (the way I work doesn’t suit online) etc. This likely reflected the inevitable shock and variety of responses which accompany a global pandemic as therapists and clients alike struggled with the existential, emotional and self-care challenges such a situation represents.

Further consequences ensued. During the pandemic, student therapists lost placements and access to clients, many clients lost their therapists, many wise elders retired or withdrew from working and yet more struggled from loss of income and their self-employed status, leaving them vulnerable to financial hardship. If all of this were not enough, the outcomes changed.  For those therapists and clients, who due to the great leveller a pandemic represents, became ill or died, pre-pandemic focus of therapy shifted to themes of shock, tragedy, grief and the impact of the failed rituals of mourning as funerals were severely curtailed. The stories of all those affected, lay or professional, were often reduced to private narratives of profound existential suffering.

In light of these circumstances, contexts, consequences and outcomes, many assumptions about the way we previously operated as therapists needed to be revisited, with numerous changes to the therapeutic contract requiring explicit revision. Specifically, therapy being a mostly face-to-face endeavour meant that therapists used to have control over the therapeutic environment (seating, light, heat, minimising distractions etc.),  providing a confidential physical space and in-person emotional containment, features all critical to maximising the conditions for process. In the new online context, sessions in beds and bedrooms, at kitchen tables, in garden sheds, in cars and in some cases while walking on beaches or in woodlands all required sensitive management and careful negotiation. Broadband drop-outs, network contention issues, physical interruptions (deliveries, pets, children, etc.), client disinhibition, eating, smoking, consumption of beverages during session and a host of previously accepted norms of in-session behaviour required careful, sensitive re-negotiation. It would appear that perhaps for many therapists the ethical concern of ‘informed consent’ became singular focus in the attempt to maintain therapeutic continuity in very difficult shared circumstances.

Further, our attention to ethics came into even sharper focus after the first lockdown when restrictions began to ease in May of 2020, when another crucial evaluation was required: the decision as to whether to return to face-to-face work in the context of an active pandemic.

From lockdown to the resumption of face-to-face therapy

Following lobbying by a number of Irish counselling and psychotherapy representative bodies, counselling and psychotherapy was identified as an essential service under the umbrella banner of Social Care. However, the announcement explicitly states that the designation of counselling/ psychotherapy “which is an essential service” was limited by the inclusion of the words “(for essential cases)” (IACP, 2020; IAHIP, 2020; emphasis added). Further, RTE news reported on 29^th March 2020, that, as part of its classification of Human Health and Social Work activities included “paramedical and essential therapy activities” [emphasis added]. However, the guidelines for therapists to apply when considering a return to face-to-face work completely omit the requirement for a resumption to be for “essential cases”, emphasising instead public health and safety measures rather than protocols for assessing whether or not therapy cases were actually essential. The second and third lockdowns have not altered this position as therapists and clients are caught up in cycles of face-to-face, online, face-to-face, online and for some, with a focus on health and safety measures (cleaning, ventilating, social distancing, screening and mask-wearing), an otherwise resumption of therapy as normal. This, in the face of viral mutation and increased transmissibility (the UK strain is estimated to be 70% more transmissible than that circulating in March 2020).

It might then be reasonable to consider that in the absence of explicit guidance, the ultimate determinant of good practice is to revert to ethical principles. In particular, for counselling and psychotherapy, these might include the principles of non-malfeasance, beneficence, autonomy, justice and self-care.

Ethical principles in action

So, how do we apply the ethical principles which guide our work under ‘normal’ circumstance at an extraordinary time such as a global pandemic? Perhaps it is worth reflecting on each in order to build a foundation for ethical decision-making or ‘doing the right thing’.

Non-malfeasance: the principle of doing no harm. Typically this is extended to doing no harm to the client but in the context of a pandemic, reciprocally, to the therapist who themselves remains as vulnerable as the client.

Beneficence: the principle of actively contributing to client wellbeing. Doing no harm is insufficient in this principle, as therapists are called to consider how to enhance the wellbeing of clients. In this case, therapists too should be included as the potential transmission from in-session contact not only has an immediate impact on them, but every one of their close contacts and the close contacts of their clients.

Autonomy: respecting the right of client self-determination in the expression of their life choices. During a pandemic we are moved to consider the difference between a client expressing a preference for face-to-face therapy and our professional role to assess whether or not face-to-face therapy is essential in line with public health guidance and the law.

Justice: treating clients with honesty and fairness. Here, we must weigh individual choice with the consequences of those choices more broadly. Can we honestly say that therapy is a safe space with a virulent and pervasive virus in our communities? Should we become ill with Covid-19 following a week of face-to-face client work, our obligation to inform clients of our positive Covid-19 test result may shatter the safety of the therapeutic space. Is it societally acceptable just to consider only the client’s preference (or our own) for face-to-face work when we are advised to reduce our contacts with others, and not in fact increase them?

And finally, the principle of self-care; our obligation to protect and monitor our own wellbeing sufficient to working effectively with our clients. How do we reconcile the need to safeguard our financial wellbeing with the risk of clients disengaging from therapy should online work be rejected by them as a therapeutic option?

These reflective anchors provide an initial orientation to some of the questions which require serious and diligent consideration. By casting a reflective light into the shadow of face-to-face work during a pandemic we can satisfy ourselves that we have carefully, considerately and ethically reaffirmed our obligations to ourselves, our clients, our profession and our society. We can stand proud over our decisions congruently and compassionately, balancing our own wellbeing and livelihoods. With this in mind, we offer the following reflective model to support you in navigating a resumption of face-toface therapy.

Image copyright William Pattengill 2021

Working through the dilemma, ethics in action

Therapists work to ‘do the right thing’ all the time. Our intentions are noble, considerate and fundamentally client-centred, sometimes even to the detriment of our own wellbeing! That’s how far we are willing to go for others. We do our best, employing compassion, empathy and kindness, and mobilise all of that to enhance client wellbeing. Our work is difficult, dealing with abuse, neglect, trauma, depression, anxiety, loss, grief, typically all the things others avoid. Our work often goes unnoticed and underappreciated, silent heroes battling the myriad causes of human suffering. Despite all of this, at extraordinary times like these, our noble intentions are no guarantee of successful outcomes, especially when it comes with the threat of serious illness or death posed by Covid-19.

Therefore, we believe that the decision to work face-to-face is not simply one of observing public health guidance, but constitutes an important ethical dilemma. Historically, we as a profession have never faced an ethical dilemma in which the therapist could infect the client with a virulent and highly transmissible disease despite reasonable precautions taken, especially when we have received no training in these preventative measures.

Perhaps the most familiar ethical decision making model is that of Michael Carroll’s and Elizabeth Shaw’s six stage model of ethical maturity. A short summary is provided here:

1.        Ethical sensitivity: an awareness of our own values, our professional standards, public health guidance, of the potential for harm in these contexts, the consequences of that harm and the impact of both our behaviour and our initial intentions.

2.        Ethical discernment: diligent reflection balancing emotional awareness, problem solving and arriving at potential ethical decisions.

3.        Ethical implementation: understanding what might block me from acting, what might support me, and thinking through how to implement my decisions.

4.        Ethical conversation: thinking about how I might defend my decision, how I present my decisions to my clients, my peers, my supervisor, my profession and to wider society – I connect these to the prior principles.

5.        Ethical peace: I can live with the decision I’ve made and actions I’ve taken in exercising my free will and accountability, using my support networks, watching for changes to base assumptions, managing the limits of my decisions, learning from the process and letting go of that which I cannot control.

6.        Ethical growth: using my reflective ability to further enhance my self-knowledge (my values, my morals etc.) and to become more ethically sensitive and attuned.

With that in mind then, how might we thoroughly reflect on the dilemma at hand? To do this, we might apply the model above in the case of two therapists. As you consider these two therapists, we invite you to consider – which do you consider most compelling and why?

Ethical Component	Therapist A	Therapist B
Ethical sensitivity	Clients need therapy. Therapists need clients. Clients have preferences for engaging with therapy, therapists have preferences for providing therapy. Preferences are not the same as needs. Some preferences are needs. Not all needs are preferences. How do I know the difference when my decision may represent serious harm to my client, myself, our respective families and wider society? How do I balance my needs with those of my clients especially if rejecting client preferences costs me my practice? Do I want to adapt to a safe alternative (e.g. working online)? Is a safe alternative appropriate for some clients (e.g. clients with no guarantee to privacy)? What level of risk am I willing to accept? What level of risk is my client willing to accept? In either of us accepting risk, we may be transferring risk to others (e.g. a client takes a bus to therapy thereby coming into contact with others).	Clients need therapy. My livelihood is to provide therapy. My clients prefer face-toface therapy. I prefer face-to-face therapy. I think I can take adequate precautions and rely on clients’ agreements to not come to therapy when feeling ill or having been notified of being a close contact of someone who is ill. I don’t have the technical knowledge or skill to adapt online work. My way of working is not compatible with working online. If I am willing to take the risk, and if my client, aware of risks, chooses to work face-to-face, I believe that is in the spirit of respecting autonomy. My work has been deemed an ‘essential service’. I therefore have permission to work face-toface. I am not responsible for the choices my client makes outside of therapy.
Ethical discernment	I value reducing risk to as close to zero as possible, especially the risk of physical harm. I place this above my financial wellbeing, above the survival of my practice. I value the ‘safe space’ therapy represents by accepting the trade-off between potential interruptions/privacy for clients and the risk to physical health or death. Can my client and I explore solutions to create ‘virtual safe spaces’ and adapt to interruptions, limitations, constraints imposed by going online? I choose the anxiety of navigating the world of therapy online over the anxiety of Coronavirus in the therapy room. I want to honour the spirit of public health guidelines by limiting close contacts over my ability to work face-to-face due to my designation as an ‘essential worker’.	If I put in place adequate steps, compliant with public health and health and safety guidelines, I see no reason not to offer faceto-face sessions. For some of my clients, face-to-face therapy is essential as they have no space at home which is private/ confidential. I am in the office anyway for those essential clients so it makes sense to extend face-to-face to clients before and after that essential session. Online therapy isn’t as good/effective as face-to-face therapy. I don’t have the technical skills to provide an alternative to face-to-face therapy. I don’t have access to technology/ broadband sufficient to provide a good online experience.

Ethical decision	As a result of weighing the above, understanding my values, considering alternatives and having balanced the various risks involved, I have decided to offer my clients therapy via phone/online only. This reduces our physical risk of harm to zero. We can both build from here and negotiate ways to address technical and space issues which might be a barrier to us working online (e.g. sessions from their car, after children have gone to bed, use of headphones, etc.). I accept the risk of the impact to my practice if clients refuse the offer of online therapy thereby honouring their autonomy and will seek ways to advertise my online practice. I will resume face-to-face therapy when three conditions are met: a) Covid is not circulating in the community (or when herd immunity is achieved), b) a viable, effective and safe vaccine has been administered to myself and each of my clients and c) there is a safe and effective treatment for Covid which renders Covid as a serious but non-fatal disease.	Having looked at the variables above, I conclude that providing face-to-face therapy, though not zero risk, is sufficiently mitigated by my enforcing the following: a) myself and my clients are temperature checked on arrival to my practice, b) I do a close-contact screening before each session, c) the chairs in the room are more than 2m away, d) I do not handle cash, e) we both wear masks, f) windows are open and g) there is a Perspex screen between the client and me. I deem these precautions adequate as they are in line with best practice guidance from public health officials.
Ethical conversation	I have taken steps to discuss my thinking and my feelings with my partner, two peers, my supervisor and a friend who trains student therapists. I encouraged each to engage critically with my decision so that I could uncover any biases or values unconscious to my current thinking.	I spoke to my supervisor in our last face-toface session and took a full hour to discuss my thinking. My supervisor felt that my protocol was similar to his and seemed to meet current guidance. He did recommend that I review the situation in three months.
Ethical peace	I feel that I have done the best I can to respect ethical principles of beneficence and nonmalfeasance, respecting autonomy and the potential impact on my clients who chose not to move online (removing themselves from therapeutic support) and myself (the impact to my practice).	I have followed all the guidance, kept my practice going, provided a safe space for my clients and have put significant effort and investment into reducing risk as much as possible.
Ethical growth	Since my decision, news that a new strain of the virus is 70% more transmissible and potentially 30% more severe has affirmed my prior decision. Though a vaccine is becoming available, I will need to carefully consider in collaboration with my clients about resuming face-to-face work when the other conditions are sufficiently met to justify the non-zero risk to physical harm.	We have been working well face-to-face for the last four months so my decision to remain stands. There is no evidence that the news of a new, more transmissible strain would constitute additional risk to the protocols I have in place. I will however respect clients’ decisions and monitor closely as we move from lockdown to lockdown.

A practical framework for working face-to-face during Covid-19

Whilst recognising that ‘doing the right thing’ is a complex endeavour and one which can lead to feelings of ambiguity and uncertainty, our obligation is to act ethically. For many therapists (and indeed perhaps for many clients) and for a myriad of reasons, face-to-face therapy will be the outcome of ethical discernment. Considering the real and not the ideal then, we offer further anchors of reflection in order to help professionals address the greater than zero risk of working this way. For this, we propose the following framework;

Step	Task	Example or consideration
1. Identify a narrow and well-defined list of candidate ‘essential therapy’ categories	Assess each client individually against these categories	•     Clients who are experiencing domestic abuse in the home •     Clients with high suicidal ideation •       Etc.
Validate clinical judgement with your supervisor / peers
Ensure you collaborate with clients on the outcomes of assessment as to whether therapy will be online or in-person
Document the assessment, validation and ultimate decision in your case notes
2. Engage your risk reduction protocols	Health & Safety protocols	Sanitising, masking, distancing, airflow, Perspex barriers, cashless, no waiting room, breaks between sessions, temperature checks, risk assessment etc.
Therapy protocols	•     Check that your insurance provider is covering you for face-to-face work during the pandemic •     Consider how you will manage confidentiality should you or your client become ill and need to participate in contact tracing or be identified as a close contact •     Consider how you will handle withdrawing from practice should you become ill •     Consider the boundaries of access to personal bank details or other ePayment methods when not handling cash •     Ensure adequate before and after session time to effect health and safety protocols •     Ensure your Professional Will is up to date •     Re-evaluate the assumptions which led to face-to-face work as more information is available from public health and professional bodies
3. Accept those risks which cannot be mitigated	Ensure clients are informed about the risks when choosing face-to-face work - update your contract and your notes
Validate accepted risks with your supervisor
Review each client situation on an ongoing basis to evaluate if face-to-face is still ‘essential therapy’ using ethical models rather than on the basis of permissibility or habit

Conclusion

Being on guard for ethical issues can be challenging in the best of circumstances. Working ethically during a global event like a pandemic brings many new challenges which require diligent and thoughtful reflection. In a very real sense, our ordinary outward obligations (towards clients) are amplified by an equally powerful need to consider inward obligations (towards ourselves) and indeed careful consideration of the wider familial and societal impact of our decisions. Discerning the difference between preferences and needs offers a first step toward ethical decision making. Having access to a well-established method for ethical practice, coupled with new protocols in light of present circumstances, may offer therapists confidence in their professional practice, personal conscience, client care and societal obligations as good citizens. We hope that this reflective piece in some small way offers fellow professionals practical support, professional inflection points and reflective anchors which assist them in entering bravely into the territory of ‘doing the right thing’ when things just aren’t right.

Mike Hackett is an accredited therapist and supervisor in private practice, is senior faculty with PCI College and is the founder of Introspect Counselling.

Niall Bulfin is an accredited therapist in private practice with Introspect Counselling.

References    

Carroll, M., & Shaw, E. (2013). Ethical maturity in the helping professions: Making difficult life and work decisions (Kindle Ed.). Jessica Kingsley Publishers.

Irish Association for Counselling and Psychotherapy. (2020, October 20). Level 5 Restrictions Update for IACP Members.https://iacp.ie/level5-restrictions 

Irish Association for Humanistic and Integrative Psychotherapy. (2020, May 22). IAHIP UPDATE 22nd MAY 2020 | IAHIP. https://iahip.org/news/iahip-update-22nd-may-2020

(C) IAHIP 2021 - INSIDE OUT 94 - SUMMER 2021