The COVID-19 global pandemic has generated innovative adjustments related to how mental health services are accessed. Telehealth has become a convenient, safe, and necessary avenue for people to receive mental health care, such as therapy. With benefits like increased reach and accessibility, and decreased cost and travel (Madigan et al., in press), it is an appropriate treatment modality for a lot of people. Yet on the other hand, there are also disadvantages that emerge with telehealth such as threats to confidentiality (Madigan et al., in press).

Rates of interpersonal violence and domestic violence (DV) have been a concern during the pandemic. On April 30, 2020, the United Nations Population Fund (UNFPA) suggested that if lockdown and shelter-in-place orders continued for six months, there would be an estimated 31 million new DV cases globally (Impelli, 2020). The UNFPA also stated if lockdown orders continued for nine months, there would be an estimated 45 million new DV cases globally (Impelli, 2020). Telehealth services may be limiting for victims who are trying to receive or continue mental health services. The present article will discuss ethical and safety concerns for clients who are engaging in telehealth therapy related to domestic violence.

Domestic Violence & the COVID-19 Pandemic

The COVID-19 pandemic has altered the way that domestic violence is perpetuated in people’s lives. The pandemic presents numerous stressors, such as home-schooling children (Kaukinen, 2020), limited access to friends and family, financial instability (Jarnecke & Flanagan, 2020), and the intense amount of uncertainty that comes with such an unprecedented and widespread event. In addition, stay-at-home orders are keeping partners in close proximity and making it more difficult for people to leave or receive help (Kofman & Garfin, 2020). Shelters may not be accepting new people for fear of the virus spreading to existing occupants (Jarnecke & Flanagan, 2020), and others may not be willing to accommodate someone sleeping on their couch due to the same fear. According to Tolan (2020), there has been an increase in domestic violence calls in nine out of twenty major cities. The stress of the pandemic or the barriers to leaving are enough to cause concern for people experiencing domestic violence in their intimate relationship. Adding at-home telehealth therapy to the existing tension is risky.

For clients engaging in therapy related to domestic violence, there are concerns regarding the use of telehealth and the threat to confidentiality that this treatment modality imposes. For clients who are living with their partner, confidentiality is not just a professional standard, but it is critically important for their safety. Participating in at-home telehealth therapy decreases clients’ privacy and confidentiality and produces opportunities for further power and control behaviors in the home (Kaukinen, 2020). Whether someone else is overhearing the therapy session accidentally or intentionally, without the privacy of a traditional therapy office, the client’s confidentiality is at stake and can make a client less inclined to disclose information.

Clinically, therapy via telehealth may not be the best option for clients across contexts. Koocher (2007) found that ratings of the therapeutic alliance, an important factor for successful therapy, was lower in telehealth than in-person therapy. In addition, researchers have indicated telehealth is also not the best option for clients who are wanting to focus on relationship-based problems in therapy (Brenes et al., 2011). For individuals experiencing intimate partner violence, relationship-based problems may be a main treatment goal. Conducting therapy sessions via telehealth eliminates the ability for the therapist to monitor their client (Madigan et al., in press). Monitoring is critical for a therapist to gather nonverbal information and assess a client’s physical environment when participating in services remotely. Telehealth platforms might limit the ability to know where the client is located, assess whether anyone else is nearby and listening, or examine if the client is in a safe environment to talk freely. While a therapist can ask a client these questions in an attempt to understand the situation, if the client is not truly granted privacy, their answers may be restricted.

Ethical Considerations

As clinicians are making clinical decisions regarding telehealth during the pandemic, it is important to examine whether it is ethical to allow clients who are experiencing domestic violence to engage in telehealth from home. The American Psychological Association (APA) 2017 Ethical Principles of Psychologists and Code of Conduct (Code of Ethics) 3.04 Avoiding Harm notes that psychologists will avoid and minimize harm that could come to their clients (APA, 2017). In the case where a therapist is aware of domestic violence within a client’s relationship, allowing the client to engage in therapy from home where their partner could be overhearing or monitoring may be putting their client in harm’s way. Typically, these therapy appointments could be scheduled when their partner is at work or otherwise not in the home. However, stay-at-home orders limit these options for many victims. Therapists can minimize any foreseeable harm from telehealth treatment by utilizing safe words and safety plans with clients that live with their partner.

Further, 4.01 Maintaining Confidentiality states that “psychologists have a primary obligation and take reasonable precautions to protect confidential information” (APA, 2017). Confidentiality and privacy are a common ethical concern when using technology (Van Allen & Roberts, 2011). Confidentiality is essential to any therapy but is especially important for clients participating in therapy related to domestic violence. Allowing a client to participate in telehealth therapy from home may not be giving them the best opportunity for confidential treatment. In-person therapy, following all recommended Centers for Disease Control and Prevention (CDC) or jurisdictional COVID-19 guidelines, should remain an option for the clients who do not have opportunities to engage in private and confidential therapy via telehealth due to stay-at-home orders, partners working from home, or even children schooling from home (Madigan et al., in press).

Lastly, while the APA ethical principles are intended as a guide rather than an obligation, the guidelines serve as an important reminder of the values a psychologist should strive to uphold. For instance, Principle A of the APA ethical code states that psychologists “take care to do no harm” and “seek to safeguard the welfare” of their clients (APA, 2017). Clinical discretion is an important tool in ethical decision-making, and continuous assessment of the risk for potential harm that could come to a client remains a necessary part of the therapeutic process. 

Recommendations & Conclusion

Therapists should take extra precautions when working with clients via telehealth to ensure that the treatment modality is clinically appropriate, safe, and ethically sound. Can your client make progress toward their treatment goals over telehealth? Does your client have a private and isolated location to participate in treatment? Is there any foreseeable harm that may come to your client due to compromised confidentiality? The intake should include extra questions such as these before treatment continues. For clients engaging in therapy related to domestic violence, safety is a major concern. Determining whether telehealth therapy is appropriate will need to be examined on a case-by-case basis. Therapists should take the necessary steps to minimize any potential harm that may come from a breach in confidentiality. For example, determine a safe word at the start of therapy to make certain the client is able to send a signal to the therapist. In addition, encourage ending the phone or video call if necessary during their intake, with the understanding that there are absolutely no consequences to doing so. Informing clients that there will be no consequences to a shortened or missed session is especially relevant for clients who are court-ordered to receive treatment related to domestic violence. The pressure to attend and adhere to court mandates should not put them at risk for harm. Therapists that work with court-ordered clients know the unique vulnerability of this population. Advocating on behalf of clients and collaborating with probation officers or other court officials is crucial. Lastly, if engaging in telehealth treatment from home does not appear to be safe for a client, do not allow it. Clients have individualized treatment needs and telehealth may not be appropriate for everyone (Barnett & Kolmes, 2016), even in a pandemic.

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Lori Ahuja, B.S.

Lori Ahuja is a second-year graduate student in the master’s in forensic psychology at the University of Denver and a counselor intern at Creative Treatment Options. Previously, she has interned with the Denver Office of the Medical Examiner, the Minnesota Department of Human Services, and To Write Love on Her Arms.