Ask The Ethicist: Phone Therapy
January 7, 2010 by Jeffrey Barnett
Filed under Ask the Ethicist, Latest from the Division of Psychotherapy
Question by Dr. Betty Scott Noble.
I have a female client I have seen for several years (abusive marriage then divorce and a very recent re-marriage). She has moved with her new husband about two hours away and does all her work by computer, so she doesn’t come to Atlanta anymore. She asked if I could do “phone therapy” with her. I am guessing probably every other week (at the most) and once a month (at the least). She doesn’t use insurance. I would prefer that she just come down to Atlanta once a month, but she has two kids and a full time job, so it’s not so easy to do. I am guessing this “phone therapy” wouldn’t be for much longer, maybe just two to three times, but I’m not sure. Thanks for your input on this matter.
Response by Dr. Barnett.
Hi Betty. Good questions. There are a few relevant issues. If this is just for a few sessions to tide her over until she can find a new psychologist in her local area or to help her with the transition to her new situation, and thus is time limited, it is much more appropriate. If this is to be the primary form of treatment over an extended period of time it raises several concerns. Can telephone contacts replace in-person
psychotherapy? A lot of that depends on the client’s treatment issues and needs. For some clients this may actually appropriately meet their clinical needs. For others it may prove insufficient. Doing a careful assessment is important and documenting all options considered and relevant factors, pros and cons, the rationale of your decision, and the actual decision. Then, you will want to be sure to fully address these issues in the informed consent process (an ongoing process where you address any significant changes to the treatment contract). It is also important to familiarize yourself with resources in the clients local area so you can access them or
refer her to them should she experience an emergency. Since she’s two hours away and not 12 hours away for example, this may be less pressing an issue, but still important to address proactively. Also, since the client is still in the same state you don’t need to consider licensure issues; you’re not providing services across state lines. That could be problematic. But, even with that, two phone calls when a client is on vacation or on a business trip is very different than providing ongoing treatment via telephone (telehealth/e-therapy) across state lines.
I suggest discussing with the client her needs and her reasons for wanting this type of continued contact with you. If a call once or twice per month for a couple of months is all that is needed it should be less an issue than if this is ongoing treatment. But, any agreement struck with your client should also include what will happen if her treatment needs change. Initial agreements that sound reasonable at times need to change due to changing circumstances for the client. If she needs more intensive treatment will you provide her weekly telephone sessions for an extended period of time or will the agreement stipulate that she will then accept one of the referrals for in-person treatment in her local area that you provide to her?
These are some issues to consider. As always with ethical dilemmas there is no one right answer, but rather, several issues, factors, and options to consider. Also, closely monitoring the situation and having needed agreements in place are all important. I hope this is of help. If you have additional questions or reactions to this response please let me know.
Thanks and best wishes – Jeff
Hi Marguerite. I agree that this is a challenging situation. There are a number of issues to consider. First, will the client be relocating to a location in your state or in another state? If it is in another state you would likely need to be licensed in that state as well as in your own to provide her with ongoing treatment provided through technology (e.g., the telephone, Skype, e-mail, etc.). Most state licensing boards don’t make an issue of phone sessions and the like for short periods of time such as when a client goes on vacation. But, ongoing treatment is likely to be seen differently. Also, there’s a big difference between using technology to augment ongoing in-person treatment, providing treatment solely through technology when treatment was previously provided in-person, and providing treatment solely through technology with no past in-person contact.
With regard to the concerns you raise, why are you uncomfortable? Is this due to the client’s treatment needs and your concern about them effectively being met through ‘Skype therapy’? Is it because of your discomfort with the technology or even the thought of providing treatment in this way (with any client)? Or, is it for some other reason? Clarifying this for yourself seems important to do.
If the client was going to be away for a short time this situation might be addressed differently, but two years is a significant period of time. Why is your client uncomfortable seeking treatment from a new psychotherapist? There may be some important clinical issues there to address. Also, I don’t see any abandonment issues here. Abandonment occurs when you fail to meet a client’s treatment needs. That doesn’t necessarily mean that you have to personally provide the treatment. If you have a legitimate reason for not continuing to provide the client with treatment you obligations are to 1) discuss this with the client in advance, 2) share a plan for how you suggest the client can have these ongoing treatment needs addressed, 3) make appropriate referrals, 4) offer to assist the client with the referral process, 5) with the client’s permission share relevant treatment information and treatment records to help facilitate the transition to the new clinician. Doing these things ensures that no abandonment is taking place. While the client may not be happy with your decision (again, a potential clinical issue to address) you are under no obligation to provide treatment you are not comfortable providing. You are, however, obligated to make a good faith, reasonable effort to ensure that the client’s ongoing treatment needs are met as I have described above. But, that’s different than you having to provide the ongoing treatment regardless of the situation or circumstances.
I hope this is of help. If you have other questions or would like to discuss it further just let me know. Best wishes – Jeff
You write…
“A lot of that depends on the client’s treatment issues and needs. For some clients this may actually appropriately meet their clinical needs.”
What happens in this situation: I’ve seen a patient for almost two years, once a week. That patient is relocating far away for work and family purposes for about two years, and then will return to the area, she says. She is relocating too far to come to my office. This patient has had a productive therapeutic relationship with me and has basically begged me to continue with her either by phone or by Skype, even though I am not comfortable working that way, in my gut. The patient says that may be true, that I might be uncomfortable, but there’s no way of telling whether the phone/Skype thing will work in her interests in actuality — or my interest, for that matter! — unless we try it for a few sessions and then evaluate. She seems to think that while phone/Skype will understandably not be as productive as coming to my office, it could well be more than productive enough, and in her opinion would be far more productive than finding a new therapist and then switching back to me when she moves back to the area in a couple of years. In her opinion, phone/Skype will meet her clinical needs, and my failure to work with her this way would create a clinical problem for her. In my opinion, I don’t know if it would meet her clinical needs, but it would not meet my needs. She says that if after a few sessions of phone/Skype I professed ongoing difficulty, she would demur and terminate, at least until she returns to the area.
I find it hard to argue with her logic, which makes me very uncomfortable, because my emotional feeling is still not to pursue phone/Skype with her. Is my unwillingness to work this way tantamount to abandoning her? I kind of think not, since I’m not the one moving away, and she is. Yet my discomfort persists.
I look forward to your thoughts.