ACA Graduate Student Ethics Award for Master’s Degree Students

By Mercedez Ruiz, Felipe Alexandre, Jay Sontag and Carl Bain of New Jersey City University

Madigan, Racine, Cooke, and Korczak (2020) stated that COVID-19 required an urgent change to the implementation of mental healthcare. With stay-at-home mandates and business lockdowns occurring in the interest of public safety, clinicians needed to adapt in order to provide much-needed services to their clientele while ensuring medical safety for all parties. Telemental health services allowed for a continuation of care while adhering to the safety protocols put in place. Benefits to telemental health include a reduction in certain barriers to treatment (transportation, access in rural & urban settings, reduced cost; Madigan, Racine, Cooke, & Korcak, 2020). However, there are also significant limitations to telemental health such as magnifying social inequalities (lack of adequate or no internet connection, lack of devices that can connect to the internet, lack of internet literacy; Madigan, Racine, Cooke, & Korcak, 2020). There is also the question of a clinician’s comfort and competence level to provide telemental health services. All of these benefits and limitations combined create a very unique situation that many clinicians and students may be facing when navigating telemental health services. This brings us to Shannon’s dilemma as a practicum student whose clinical field experience changed drastically due to the pandemic.

Decision Making Model: Identification of Problem, Application of Code of Ethics, and Nature of Dilemma

Shannon’s site has allowed for distance counseling but has not ensured that supervisees are able to offer knowledgeable or competent client care. In addition to lacking telehealth training, Shannon does not possess the right technological resources and cannot offer an appropriate setting to deliver confidential, ethical, or effective counseling remotely. Because supervision is overseen virtually, Shannon is finding it difficult to maintain a healthy working relationship with her supervisor (B.3.c. Confidential Settings; American Counseling Association, 2014). Shannon’s lack of training and resources, and the current management style of her supervisor, may be contributing to her feelings of discomfort towards distance counseling. Shannon is certainly faced with unique challenges caused by a global pandemic but attempting to overcome these issues would be consistent with the foundations that the counseling profession is built on.

While their recent attempts to meet have been unsuccessful, Shannon must work quickly to improve the relationship with her supervisor and address her personal concerns (F.8.d. Addressing Personal Concerns; American Counseling Association, 2014). By working closely with her supervisor, Shannon will have the best chance of achieving her main objectives — delivering confidential, knowledgeable and competent client care during practicum.

Shannon must ensure that she is skilled enough to provide distance counseling, so she must ask her supervisor to direct her towards the best telehealth training module. When discussing options, Shannon should be ready to suggest some of the online courses that she has found, especially if her supervisor is unfamiliar with telehealth training. By working with her supervisor to identify optimal telehealth training resources, Shannon may be able to obtain the right levels of knowledge and competency (H.1.a. Knowledge and Competency; American Counseling Association, 2014).

Next, Shannon must identify the best way of delivering private and confidential care to clients. Because she lives with two roommates, it may be unrealistic for Shannon to expect privacy for herself or her clients. Furthermore, internet providers in her area do not offer reliable service, which will likely lead to continued frustration for Shannon and her clients. While Shannon can inform clients of the benefits and limitations of digital counseling, the level of care that she can offer under current conditions could potentially do more client harm than good.

Shannon’s community mental health agency is limiting in-person activities; however, mental health providers do qualify as essential under current guidelines. Once she is knowledgeable in digital counseling, it may be prudent of Shannon to explore the possibility of offering distance counseling to clients from the mental health agency rather than her apartment. The agency site will presumably have the technological resources that Shannon needs for distance counseling. It is also very likely that the site can offer a private setting for Shannon to conduct digital counseling alone and undisturbed. Shannon is uncomfortable offering counseling under her current circumstances; however, it is possible that her feelings may change once she is able to offer counseling under better conditions.

Despite the global pandemic, in-person mental health services are still the only way that some individuals can obtain treatment. Fortunately, the Community Mental Health Centers Act of 1963 mandates that these community centers provide a wide range of federally and state- funded outpatient services to the underprivileged and low-income community (National Council for Behavioral Health, 2021). As such, it is possible that Shannon’s site will continue offering in- person counseling to some capacity. During conversations with her supervisor, Shannon should also explore the possibility of offering in-person counseling services at the agency. By doing so, she may be able to serve the disadvantaged members of her community, while at the same time, provide therapy in a way that is more consistent with her previous training. While providing in- person therapy may be a good option, Shannon must carefully discuss the various safeguards and protocols that are in place at the agency in order to make the best decision for herself and her clients.

Potential Course of Action

We have determined the following as possible courses of action for Shannon to take. We concede that each option has some undesirable consequences and/or risks associated with them. They are: A) to continue working from home by problem-solving individual issues; B) to explore the option of returning to the site or her university; or C) to discontinue practicum. Problem-solve current work-from-home situation (Option A)

Step 1. Consider getting supplemental training in telemental health. Telehealth training courses can be found online and are usually completed in under eleven hours (Center for Credentialing & Education, 2021). Shannon should seek out other professional development resources such as the ACA to receive additional training (there are digital resources available on the counseling.org website).

Step 2. Documenting site supervisor. We are not of the opinion that this supervisor needs to be reported, given the current unusual circumstances regarding COVID-19. We do, however, believe that Shannon’s supervisor may be behaving unethically and in a way that is unjust both to Shannon and, more importantly, to the clients she is serving. Shannon should keep a regular and accurate record of the number of meetings missed by the supervisor as well as detailed notes regarding anything that has led her to believe that the supervisor is “distant.” This way Shannon has a log of the things that have been done outside of her control that may be affecting her current growth and practice as a counselor, as well as her mental health as a pupil.

Step 3. Work out a strict schedule with roommates. The efficacy of this plan is seriously limited by what kind of space Shannon has, but the reality is that she cannot continue to work in her current environment if there is any risk to the clients’ privacy.

Step 4. Work closely with her graduate program supervisor. One step which needs to be taken before any other action or plan is put in place is that she must get in contact with a program supervisor regarding the difficulties experienced with the site supervisor. While her weekly group meeting might not be the optimal time for her to voice her concerns, she still must make the time and space to reach out if she is to proceed ethically.

Desirable Outcomes

Shannon will be able to continue practicum. Naturally, Shannon is eager to complete her hours and graduate in a timely manner. Trying her best to adapt to and persevere in the current global situation would be important for Shannon’s livelihood and may even be necessary depending on her current economic standing. Additionally, clients will be able to continue service with the same counselor they are used to and with whom they have formed a rapport. It is important to remember that especially during times of national and worldwide crisis, clients who have underlying emotional challenges are made more susceptible to negative thoughts and feelings. Shannon should try very hard to continue seeing her usual clients, but only if she can provide care competently and with integrity.

Undesirable Outcomes

Shannon still has difficulty with her internet. Since this is a problem with her region as a whole, this is not a resolvable issue, and Shannon would have to continue seeing clients with the understanding that calls or sessions may be dropped. A significant risk of this ethically is that if Shannon is seeing a client who is contemplating hurting himself or others, she is at even more of a disadvantage than the normal (suboptimal) remote session would allow, since she may not be able to get back into contact with the client. Likewise, a client may forget her circumstances and misinterpret a dropped call, triggering feelings of rejection or abandonment.

Even with a schedule resolved and use of headphones, it may be unavoidable that the roommate could overhear information regarding a client. For the roommates to even know the name of Shannon’s clients is a breach of the clients’ privacy, and so the specifics and nuances of the living situation really could provide an insurmountable block for Shannon’s practice. In addition, during quarantine the roommates may not have another location to go and may be uncomfortable with leaving home or even susceptible to the COVID-19 virus. Given these circumstances, it would be important for Shannon to consider how much space she and her roommates have and if there is a way to ensure maximum possible privacy.

Return-To-Site or Find Secure Alternative Location (Option B)

Step 1. Consider getting supplemental training in telemental health.

Step 2. Seek more and better support from the site supervisor. This may require Shannon to go to her program’s faculty with her documentation or she could simply go to the supervisor and be direct about her discomfort. We would advocate the latter as a show of professionalism and respect, but if Shannon is struggling emotionally and mentally then having additional support may be necessary.

Step 3. Inquire about the potential for Shannon to be counseling clients remotely, from the site. This option has the highest potential for positive outcomes out of our three solutions.

Desirable Outcomes

As stated above, we believe that the clients should whenever possible have continuous service from the same individual to whom they have grown accustomed. Rather than seeing clients face-to-face, the risks of catching or transmitting COVID-19 are made lower by continuing to have remote therapy. Shannon’s internet service will be better at the site than in her home. Client privacy is guaranteed if Shannon is able to practice in a space similar to her previous onsite area of practice. The security and integrity of Shannon’s practice will be improved significantly if she is able to be onsite and interact with her direct site supervisor or other mental health practitioners at the community health center. Shannon can still attempt to gain feedback and consult with other professionals, rather than being isolated in her home during her practicum. Finally, Shannon can still gain her hours and experience, graduating from her program on time.

Undesirable Outcomes

It is still possible that the site may not allow for Shannon to return by herself or may not view her services as “essential.” Shannon may still have unresolved issues with telemental health even if she receives supplemental training and has a more efficient environment. Shannon may also be uncomfortable with elements related to COVID-19, particularly if she relies on public transportation for her commute or if she is in an especially vulnerable group for contraction of the virus. If Shannon is able to drive directly or walk to her site, and if the center is open and has regular sanitation maintenance, then her risk is reasonably low.

Discontinue Practicum (Option C)

Step 1. Admit Incompetency. If Shannon cannot remedy her current situation greatly using options A or B, then it is not ethical for her to continue practicing and seeing clients in this way. If she is not able to guarantee safety, privacy, and quality care to her clients, then unfortunately Shannon should show respect to the profession and her clients by stepping down temporarily and resuming her program when circumstances are better for her.

Desirable Outcomes

While we sympathize with Shannon and think that this option is to be pursued only if no other alternatives remain, it is the better option ethically. In her current state, Shannon is doing a great deal of unintentional harm. She is damaging her clients, and herself, emotionally. Shannon is not comfortable with her current level of care, which indicates that she is not in the correct place emotionally or mentally to be taking on the difficulties of others. During an unprecedented time when many people are undergoing loss, trauma, financial difficulty and instability on such a wide scale, mental health practitioners are needed and needed at their best. She is also violating her clients’ right to privacy. Shannon cannot currently guarantee their privacy by continuing to practice in an open space where her roommates may hear information or recognize faces. Currently, Shannon is also not receiving sufficient supervision to learn from or grow from her experience, meaning that even if she completes the hours necessary that does not mean her education will have been of sufficient quality to begin practicing or obtain a license.

Undesirable Outcomes

Shannon’s clients will face the difficulty of transferring counselors, and given the pandemic, it is possible that there is a shortage of working mental health practitioners to fill her spot. As stated above, we are of the opinion that it is very undesirable for clients to be taken from the counselors they have relationships with, especially during this time of general upheaval and instability. This will also have unfortunate consequences for Shannon. She may have to put her career on pause, may face financial instability, and may even experience a worsening of her currently suboptimal mental state. Our advice to Shannon if she absolutely had to follow this option would be to prioritize her own mental health and try to decompress from the stressful situation and painful decision.

Review of Options and Conclusion of Best Course

Our conclusion on reviewing these options and the positive and negative consequences of each, is that Shannon should first attempt to implement option B. If she is able to go to the site with her laptop and mask and can deliver care safely (and perhaps even receive improved site supervision and further training in telemental health) then we believe this imposes the fewest ethical violations and risks. If this option is made impossible by the site or another factor relating to Shannon’s health and comfort, we would urge her to follow the steps outlined in option A and to seek guidance on how to proceed ethically from her program’s faculty. We are unanimous that Shannon should not pursue option C unless absolutely all other factors are unimprovable. Just as a counselor would encourage their clients not to give up and to problem-solve their issues, we would hope Shannon does not cave under pressure but rather gathers herself and tries again.

Evaluation of Selected Course of Action

After reaching a conclusion regarding the best choice of action, we administered three self-tests to evaluate our choice. The first was the test of justice, asking ourselves if we would treat others in a similar situation the same (Remley & Herlihy, 2016). The second test was the test of universality, asking ourselves if we would recommend our course of action to others in a similar situation (Remley & Herlihy, 2016). If other counseling students or clinicians found themselves in a similar situation, we felt confident and comfortable that we would provide them with similar recommendations. Offering a menu of options such as receiving additional training, problem-solving privacy/internet issues at home, and seeking support from supervisors/colleagues provide the individual with an array of options that are culturally sensitive. In regard to Shannon’s situation, and those who are in similar situations, it is difficult to provide a one-size-fits-all solution to this. While for some working out a schedule with a roommate is an easy fix, others may find this very difficult. Keeping in mind that every counseling student does not have identical home environments, access to high-speed internet, and access to private office space, we feel that the course of action listed in option B is culturally considerate and promotes justice and universality. The final test was the test of publicity, asking ourselves if we were willing to have our actions be known to others (Remley & Herlihy, 2016). We felt willing to have our course of action be known and felt hopeful that having others know of our actions could provide guidance to those in similar situations.

Conclusion

In summary, we understand that as a graduate student and aspiring mental health counselor maintaining the competence of a consummate professional is not just an ideal but is paramount and attainable. We believe in order for Shannon to proceed ethically and with the most professional standard of care, these are the optimal options to ensure that both the clients receive adequate counseling and Shannon eschews continuing to do her clients a disservice, which could lead to irreparable harm. We also believe that these are the requisite steps to ensure her clients receive counseling that is conducive to a healthy and appropriate environment while also giving Shannon the space where she feels comfortable, competent, and supported by a present and active supervisor.