At the time of this writing, May has begun, and it feels more like Corona-tide than Eastertide as I write this ethics piece. At 64 years of age, I am at the median of those whose births occurred between 1946 and 1964, the post war baby boom. In the middle of a pandemic that appears to kill those over 65 more frequently than others, I worry about toddlers and the elderly alike. I am anxious about the health and the livelihoods of many who are family, friends, and colleagues, one of whom died a few weeks ago from COVID-19. He was 68. I seek consultation in grief, I seek encouragement amidst fear, I seek to do the next right thing, healing and not harming.
I could not tell an X from a Y or a Z generationally when it comes to appellations used to reference people by birthdates. However, I can say definitively at the start, the AAMFT Code of Ethics (2015) clearly states per Standard 1.1 Non-Discrimination, that marriage and family therapists serve “without discrimination” when providing “professional assistance” with regard to “age” among many other particulars mentioned (p. 3). Further, under Aspirational Core Values, “The core values of AAMFT embody: 1. Acceptance, appreciation, and inclusion of a diverse membership” (p. 2). Being born in 1946 does not mean one is feeble or senile, any more than being born in 1996 means one is naïve or ignorant. As therapists, we do not discriminate against clients and address any countertransferences we have about age in supervision. No less as colleagues, respect is shown and diversity prized. If we are CEOs, clinical directors, and/or supervisors, then fair employment practices are to be honored and principles of equitable treatment upheld. My consultant’s age does not matter; empathy and competence do.
At this particular time, boomers and especially those over age 65 have reason to fear this pandemic given evidence of higher mortality rates. Researchers are seeking anti-virials and medications to help treat those afflicted by the pandemic. Artificial intelligence is aiding the hoped-for rapid development of vaccines by researchers. We are waiting on vaccine trials and controlled testing of medications to discover what will work and avoid what may harm.
In that context, I am reminded of the origins of our modern medical ethics. Waiting on research outcomes is founded on a fundamental rule of medicine, an ethic of Hippocrates “do good or do no harm” (Shmerling, 2015). Medicine that does not alleviate symptoms, and worse, harms the sufferer would be unethical. Safe guarding and promoting the well-being of humanity is the deontological imperative of medicine, and the art of healing. The AAMFT Code of Ethics Commitment to Service, Advocacy and Public Service states, “Marriage and family therapists are defined by an enduring dedication to professional and ethical excellence … Professional competence in these areas is essential to the character of the field, and to the well-being of clients and their communities” (AAMFT, 2015, p. 1). “Essential” and “the well-being of our clients and their communities” are deontological assumptions in our “ethical excellence,” seeking teleological fulfillment contextually in our tasks as marriage and family therapists. The dialectical tension in those ethical poles requires adaptation to specific contexts in which crisis and threat may emerge to well-being.
This pandemic presents us with the challenge of protecting our clients’ emotional and relational well-being while shielding them, others, and ourselves (boomer or not) from a potentially lethal virus. “Do good or do no harm” mandates adapting therapeutically to this pandemic. This imperative was underscored with fellow therapist and clinical director as we hastened toward social distance and technology assisted therapy at our clinic. What follows are my reflections on what we did and are doing and the related ethics codes that have guided us. I offer this with great respect for all my colleagues here to consider in their contexts as we learn from each other in the months that follow how to deal with this tragedy.
First, the commitment to Standard 1.11 seemed paramount as we were working against having the therapeutic relationship disrupted by an external threat. “Marriage and family therapists do not abandon or neglect clients in treatment without making reasonable arrangements for the continuation of treatment” (AAMFT, 2015, p. 3). The stay at home order was the rule for near term mitigation in the community. There were questions that needed a prompt answer at our clinic. A family therapy client tested positive for the virus after a session at the clinic, necessitating self-quarantine of our newest therapist who was also a mother with two young children.
How do we protect a 60-year-old client with congestive heart disease suffering depression who should not pause therapy? Teletherapy was negotiated as a solution for the near term to address depression and keep that client safe. What about the client struggling with a mood disorder, a deep depression with risk of harm to self? Assessing hygiene reliably and doing our utmost to protect well-being required seeing the client in person. Our oldest therapist, who is over 65, had a history of heart trouble—how does he mitigate risks and tend to clients?
This pandemic presents us with the challenge of protecting our clients’ emotional and relational well-being while shielding them, others, and ourselves (boomer or not) from a potentially lethal virus.
To prevent discontinuity that might cause harm during this trying time requires soliciting cooperation and agreement to go forward with teletherapy and/or in person meetings. We contract with the client on conditions for meeting safely in person, i.e., wearing masks, sitting a minimum of six feet apart. We sequester the client upon entry and exit to avoid contact with any others in the clinic at that time, keeping ancillary staff away from traffic flow areas. This means that all doors are touched only by the therapist escorting the client from entry to exit. Furthermore, appointments are staggered so disinfecting after sessions can be completed. For the oldest therapist, teletherapy replaced in person contact for the short term for a few of his clients. Some clients contracted to discontinue and return later to the therapist, while a few agreed to referrals. The therapist then decided to take FMLA for a couple months during which he could further assess his options.
Because the move to teletherapy was one that needed to be implemented quickly, our clinic chose a technology that was user friendly, HIPAA compliant, and was extremely easy to train for using. Billing and records continued on our existing EHR system. Code 6.1 Technology Assisted Services states the following with regard to teletherapy:
Prior to commencing therapy or supervision services through electronic means (including but not limited to phone and internet), marriage and family therapists ensure that they are compliant with all relevant laws for the delivery of such services. Additionally, marriage and family therapists must: a) determine that technologically-assisted services or supervision are appropriate for clients or supervisees, considering professional, intellectual, emotional, and physical needs; b) inform clients or supervisees of the potential risks and benefits associated with technologically-assisted services; c) ensure the security of their communication medium; and d) only commence electronic therapy or supervision after appropriate education, training, or supervised experience using the relevant technology (AAMFT, 2015, p. 9).
Code 6.3 Confidentiality and Professional Services states the following:
It is the therapist’s or supervisor’s responsibility to choose technological platforms that adhere to standards of best practices related to confidentiality and quality of services, and that meet applicable laws. Clients and supervisees are to be made aware in writing of the limitations and protections offered by the therapist’s or supervisor’s technology. (AAMFT, 2015, p. 8)
Consistent with Codes 6.1 and 6.3, two forms are reviewed, one explaining teletherapy, the other an informed consent to teletherapy that is signed. In addition, because a couple clients requested teletherapy immediately, their requests and agreements were documented in their files and notes. Landline-based telephonic therapy was conducted in clinic offices to maximize confidentiality. When the aforementioned forms were signed, online therapy could be conducted, and only then from the clinic offices by therapists.
As stated, boomers appear to be at increased risk of death from COVID-19; and more certain is that other health concerns will arise with aging. Entropy happens, health changes, and determining when to reduce work or retire is a question that occurs for those who live long enough. Careless mistakes, client notes that are incomplete or missing, information released without permission, or “forgetting” and “losing” present as signs of trouble. Cardiovascular events and cancer can strike anytime, but those 56-74 years of age are currently more at risk than those born after 1980 (Glick, 2020).
There are boomers who may want or need to work until they are 74 or older and do so competently. The Code of Ethics Standard 1.9 Relationship Beneficial to Client states, “Marriage and family therapists continue therapeutic relationships only so long as it is reasonably clear that clients are benefiting from the relationship”(AAMFT, 2015, p. 3). Standard 3.3 Seek Assistance states “Marriage and family therapists seek appropriate professional assistance for issues that may impair work performance or clinical judgment” (AAMFT, 2015, p. 5). Both Standards address two important concerns for boomers as they age, along with other colleagues facing health or interpersonal concerns that interfere with conducting therapy. One, the relationship exists to benefit the client, if my health or some other phase of life concern diminishes that, I must address it as the therapist. That was something I had to do about five years ago when I experienced hypothyroidism. Two, it was my responsibility to address the problem ethically. First, that meant seeking medical consultation and subsequent treatment. Second, I addressed it with my own supervisor analyst and determined how and when to approach clients. We discussed compensating or crediting clients when sessions were interrupted by fatigue in the course of my treatment. Therapy must benefit the client, and that means the therapist must be capable of engaging in therapy to make that possible.
On a final note, Seeking Consultation instructs, “Marriage and family therapists who are uncertain … are encouraged to seek out counsel from consultants, attorneys, supervisors, colleagues, or other appropriate authorities” (AAMFT, 2015, p. 1). Whether that pertains to concerns boomers face, concerns about boomers, or the challenges this pandemic presents us with, consultation is a good thing to seek, and AAMFT is a valuable resource to that end.
Whether we are boomers or not, in a pandemic or facing the next crisis, discerning and implementing that which heals and does no harm is work. Marriage and family therapists are encouraged by seeking consultation to cope with vicarious trauma, pain, fear, and depression that are brought to us. Consultations are how we avoid harming ourselves amidst a pandemic by any name, helping ourselves, helping our clients be well.
Jeffrey Romer, DMin, PCC, NCPsyA, is an AAMFT Clinical Fellow and Approved Supervisor. He is a member of the AAMFT’S Ethics Committee and serves as a Trustee on the American Board for Accreditation in Psychoanalysis. A retired pastor and assistant professor, he is clinical director at Personal Counseling Services, Inc., Indiana, an adjunct professor in psychoanalysis, and maintains a consulting practice in Metro Louisville.
REFERENCES
AAMFT. (2015). AAMFT code of ethics. Retrieved from www.aamft.org/Legal/Code of Ethics.
Glick, M. (2020, January). Health in 2020 and beyond: What do the numbers tell us? JADA The Journal of the American Dental Association, 151(1). Retrieved from https://jada.ada.org/article/S0002-8177(19)30833-5/fulltext
Shmerling, R. (2015, October 14). First, do no harm. Harvard Health blog. Retrieved from https://www.health.harvard.edu/blog/first-do-no-harm-201510138421
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