Online therapy
by Seth Kleinman, LICSW
As social work has evolved in response to pandemic conditions, no more important matter has presented itself as ethical considerations. And as social workers have been navigating how to provide services, decisions with ethical components have been made in haste (often by necessity) and with the lens of these “unprecedented times.” That said, how much does it matter that these times are unprecedented? NASW revised its Code of Ethics just a few years ago, and almost all of these revisions reside in the interface with clients in the technological world. Thus, guidance developed with care and without the pressure of immediacy already exists. Further, ethical principles from the Code are generally translatable from one context to another.
Termination of services with clients has always been a consideration of social work ethics. After many social work service providers were recently placed in the position of abandoning face-to-face contact, termination considerations became more critical for some.
Many social workers have felt forced to close their brick and mortar offices and in-person service provision locations. In these cases, there are typically one of a few different paths ahead: stopping service provision altogether, switching permanently to only virtual service provision, switching temporarily to virtual service provision with plans to return to in-person service, or temporarily or permanently switching to a hybrid model—and with regard to the temporary options, the answer to the question about timelines of returning may be as-yet unknown.
The following represent some ethical considerations in termination planning under pandemic conditions.
Avoiding Termination If the Client Is Not Clinically Ready
If clients are not ready to terminate—meaning the client feels she needs to continue, or the social worker feels the client needs to continue and the client supports that—then termination should be avoided if at all possible.
Client aversion. In cases of pure client preference to avoid virtual contact—meaning the social worker is continuing services virtually and the client has the means for access—it is still beholden upon the social worker to consider creative solutions to allow the clinical work to continue. Perhaps there are forums that can be discovered through networking with which both social worker and client are comfortable, such as meeting in person but separated by a barrier of sorts, meeting outdoors at a safe distance, or more generally, meeting in person after agreement on detailed parameters for safety.
Further, a fuller exploration of the client’s aversion is warranted. What if the aversion is in fact a clinical issue that can be explored and resolved through the therapeutic process? (This could be a double-win: boring down to a meaningful clinical issue while simultaneously finding a way to continue the clinical relationship!) Or what if the aversion is rooted in a lack of technological awareness, which could be addressed with either the social worker or other natural supports providing tutorials? Or perhaps the client does not feel she has adequate privacy where she expects to be in contact with the social worker, and the solution lies in brainstorming alternative locations together. Tacit acceptance of a client’s aversion to virtual treatment at face value could easily be a disservice.
Advocacy. In other cases, the client would be fine to continue virtually, but she does not have the means—either the necessary hardware and/or internet access, or the financial flexibility to invest in those. In these cases, social workers need to embrace the role of advocate. All clients deserve equal access. Community grants, creative solutions, and political advocacy can all be successful solutions.
Social worker flexibility. In other cases, the client is willing and able to engage on a virtual platform, but the social worker is not. Although there is no mandate to continue treatment against a social worker’s will, the social worker still must consider fully any decision to stop a form of treatment, affecting current clients. Envision the obligation to serve clients in today’s world and be that change.
Taking Care When Termination Is Necessary
In other circumstances, a social worker might need to terminate, as a result of real physical risk to the client, the social worker, or someone to whom she is exposed.
Practicing paternalism fairly. The social worker does have a say in the continuation of treatment if she feels someone would be at risk. Further, it is important to not let the service pendulum swing too far, which can lead to the “hero syndrome” of continuing to serve clients after conditions have become unsafe. In these cases, it is incumbent upon the social worker to terminate with consistency—i.e., to have a set of uniform criteria to be applied to each client. In that regard, while the final plan may not be the same for each client, the applied criteria are. The social worker should be prepared to explain the application of these criteria, so that the client is fully informed and so as to avoid the client’s personalization of the termination.
Self-disclosure. When the reason for forced termination is the social worker’s safety or the safety of someone in her personal life, self-disclosure may need to be confronted. The disclosed information could range from personal medical information to cohabitation and relationship details. Of course, self-disclosure can never be approached lightly; in fact, many social workers resolve never to do so, pandemic conditions regardless.
Safety plans. Termination has the potential for serious negative effects on clients, leading to the need to err on the side of safety. This is especially true if full assessment capabilities are compromised by current conditions. Safety plans with high risk clients must be updated, agreed upon by client and social worker, and documented in communication with the client and in the social worker’s own records. Clients who are not assessed as high risk should still have a safety plan upon termination. Although this is always the case, it is more important now during higher-stress, lower assessment-capability circumstances.
Avoiding Abandonment: Not Leaving a Client in a Worse Condition
In terminating with a client for any reason, it is a social worker’s duty to do everything reasonable to ensure that she is not left in a worse condition than she was in prior to termination. However, this might look different in different circumstances.
Terminating without referral. Clients may decide that they no longer want to be engaged in treatment if it is with a different clinician or via a different modality. Of course, it is a client’s right to make this decision. In such cases, however, it is a social worker’s obligation to ensure client safety, and it is a social worker’s right to share professional opinions about decisions a client is making. Consider the difference between a client who was already on the doorstep of termination versus an actively suicidal client with high lability and impulsivity. Client self-determination is always relevant. However, the process of termination and the post-termination plans put in place would look quite different.
Terminating with referral to a similar form of support. Most of the time, this comes in the form of finding another clinician who does the same type of work, and transferring the ongoing work to the new clinician. This happens often and is sometimes successful. Following a positive and effective clinical relationship, it is common for the client to not follow through with the immediately subsequent clinician. The terminating social worker should ensure that the referral “sticks”—meaning, the client and receiving clinician do have a formal clinical interaction, completing the proverbial passing of the professional baton. If this does not occur, in most circumstances the terminating social worker should reengage the referral process to find a successful transfer with that or a different clinician.
Offering comparable care alternatives. At times, the client does not want to receive services from a clinician in a similar role, but still needs clinical support. In these cases, the client needs exposure to alternative options that offer comparable levels of care. This could mean a change in modality (switch from individual to group work), treatment framework (from long-term psychoanalysis to solution-focused brief treatment), another professional shift, or something more individual client-driven. Regardless, clients need to be presented with alternatives in some form in order to do everything possible to leave clients in the same or better condition than prior to termination.
Doing Your Best and Doing It Fairly
Aside from immediate safety concerns, care cannot be mandated in a voluntary clinical relationship. Clients can deny ongoing problems, disagree with professional assessments, decline referral options, and self-terminate in moments of perceived rejection and abandonment. Social workers still own the obligation to try, and more specifically, to try equally hard with all clients. Countertransference reactions must be managed in order to approach all clients with uniform criteria and uniform effort. Although this does not mean that the social worker draws the same conclusions about courses of action with all clients, it does mean that the social worker uses a fair decision-making process with all clients to inform approaches and decisions.
While societal circumstances may change, core ethical values generally remain the same. Current societal conditions have warranted a re-inspection of these values and how they might manifest now. Avoiding unwarranted termination, taking care when termination is necessary, leaving clients in the same or better condition, and safeguarding uniform criteria and effort are all tenets that social workers must practice. This has been true in the past and continues to hold true in the present day.
References
National Association of Social Workers. (2018). Code of Ethics of the National Association of Social Workers. https://www.socialworkers.org/About/Ethics/Code-of-Ethics/Code-of-Ethics-English
Seth Kleinman, LICSW, is an elementary school social worker outside of Boston, MA. He is an adjunct professor at Boston College and Simmons University, serves on both federal and local emergency response teams, and works extensively with NASW-MA, including as the chair of the Committee on Ethics.
Updated 5/5/21