Online therapy guidelines
Updated September 2022
There are many reasons why individuals seek out online or telephone therapy. The recent public health crisis played a large part in opening people’s awareness to this type of provision and this has had the benefit of creating a network of therapists working remotely who are now able to offer services to a far greater range of individuals. This includes to people who live in remote places with no nearby therapists; those who have mobility problems and so are unable to leave their home very easily; those who live or work in a country where their native language is not spoken – or those who simply have a preference for working in this way, or for working with a particular therapist not based in their geographical location.
The client’s needs should always be considered before undertaking any type of therapy. When working out a client’s best possible therapeutic pathway we must look at the ethical considerations as to whether face-to-face or online/telephone work is the best fit. There are many considerations to be balanced here, and these must take into account the client’s preferences, the particular circumstances and presentation, and, of course, the therapist’s level of expertise and experience. This may mean, in some cases, referring a client on to someone who can deliver face-to-face therapy – for a rewind for instance – because this is felt to be more appropriate for the client.
Additional considerations for trainee HG therapists
Because of the increased risks of delivering therapy online, all newly qualified therapists and GHGI Members (Trainee HG therapists) are required to attend the Online and phone therapy training course if they would like to deliver online therapy. They must also inform their supervisor that they wish to do work online.
A written agreement between the supervisor and trainee (GHGI Member) must then be prepared. This agreement needs to include that the trainee understands the limitations of delivering therapy online and will desist from using guided imagery and the rewind technique with online clients. For more detailed guidance on what level of online therapeutic work is suitable for HG Trainees, please see the latest HG College Working Towards Part 3 document.
Principles of working online
The following guidelines outline the important considerations before starting to deliver therapy online.
1) Data protection and informed consent
As with face-to-face therapy, practitioners in the UK providing online treatment have a legal duty to comply with the Data Protection Act of 2018 and the General Data Protection Regulation (GDPR) as well as with ethical responsibility to prevent unauthorised disclosure of information. Practitioners working outside the UK have, with regard to this, the duty to follow the similar regulations applicable in the county where they are practicing. Therefore:
Clients should be informed that the legal basis for processing this personal data is: “Legitimate business interests and legal duty of [insert name] as the data controller” and that processing is required for the performance of a contract with the data subject or to move towards entering into a contract.
Clients should understand when confidentiality might be overridden by other considerations e.g. safeguarding.
Clients also need to be informed that no online platform can ensure 100% confidentiality.
2) Privacy Notice
A privacy notice sets out the rights and obligations of the client and practitioner in relation to personal information before and during psychotherapy. You should already have a privacy notice for any face-to-face work that you undertake but it may need to be updated in order to cover the kinds of data you will be processing if undertaking work online.
These might include:
- case notes
- phone records
- text messages
- audio/ video messages
- digital recordings
- financial records
An example of a template for a privacy notice can be found on the Information Commissioners Office (ICO) website: https://ico.org.uk/for-organisations/sme-web-hub/make-your-own-privacy-notice/
3) Recording sessions
Clients should be made aware that you will not record and will not allow recording of sessions without prior discussion and consent in place.
4) Client safety
- Therapists should obtain exactly the same contact details – name, address, contact phone number, next of kin, GP and/or other healthcare practitioner etc. – as in face-to-face therapy.
- It is important for the client to have access, if any level of risk is identified, to support local to where they receive online therapy in the event of an emergency. Therapists should take reasonable steps to support clients in making arrangements for such support as appropriate to the situation from a family member, friend, GP, etc, if the need arises during or following online therapy – especially when working with techniques such as rewind. This might entail having a family member / supporter present in another room while the work is being undertaken, or having prearranged that a trusted other will be available on the phone if needed.
- Therapists should take reasonable steps to ensure that clients are in a safe environment whilst undertaking online work and that they are informed about the safe use of technologies. This includes the need for adequate security measures to protect sensitive information held electronically and that it is highly inadvisable to place confidential data on publicly accessible sites such as Facebook and other social media platforms. Note: Therapists cannot be held responsible if clients do not follow advice.
5) Legal considerations
Providing therapy online is subject to both the legal requirements of your current location as a therapist AND to the local laws and to local regulatory bodies where the client is receiving therapy.
Practitioners need to take account of the law prevailing in a prospective client’s country. Different geographical regions are subject to legislation concerning delivery of therapy – such as the USA, where individual practitioners need to be licensed to practise therapy. Holding a license means that a practitioner has completed a level of training specified by a licensing board. In the US licensing is regulated at the state level and it is illegal to offer services while physically within that state unless licensed by that state. The same applies to online therapy. Similar regulations apply in some provinces of Canada.
If you are considering providing online therapy to someone living in another country you should check with your insurer as to the limits of your cover and take advice from them as to whether to proceed.
In many EU countries psychotherapists are required to hold a degree in Psychology, in addition to their psychotherapeutic training. Laws vary from country to country. It is the practitioner’s responsibility to check if they can lawfully use ‘Psychotherapist’ as their title in the event of practising with clients based outside the UK, or when providing psychotherapy from an overseas location.
The HGI advises individuals to check this, as unfortunately they can only advise for the regulations of working within the UK, they cannot advise for other countries. On some occasions the practice may be illegal.
Where practicable, overseas residents can be referred to an HG practitioner based in their country of residence – see the HGI online register or enquire at the HG office.
It is vital you check your policy or contact your insurer to confirm that your cover extends to working online.
N.B. If you are proposing working online with individuals living in a country other than the one in which you reside you should contact your insurer to confirm that they cover you to deliver online therapy in that country.
7) Recommended teleconferencing platforms
The ICO recommend that all practitioners ensure their clients give their informed consent about the use of online therapy and the associated risks, particularly with respect to confidentiality – as no platform is 100% secure. Some of the most popular platforms are Zoom, FaceTime, Skype and Microsoft Teams.
To conduct a satisfactory therapy session online you will need to ensure you can deliver a high quality audio and visual connection. You may need to upgrade your computer webcam and microphone, as well as checking you have a stable and fast internet connection.
Online therapy checklist
- If you are a trainee, have you discussed online work with your supervisor and set up an agreement?
- Does your insurance provider cover for online therapy?
- Have you considered the country in which clients are receiving online therapy from you? See 'Legal Considerations' above.
- Is the client online therapy agreement in place including all the necessary information – address, next of kin or professional contact in the event of safeguarding issues etc.?
- Are you using a recognisable, security-aware platform and ensuring you have good quality internet connection?
- Have you discussed with the client at the beginning of the first session what you will do if the technology breaks down during a session? If the internet connection is poor at the beginning of the session, then you should finish the call and restart. If there is no difference you should postpone the session or switch platforms (e.g. Skype to Zoom) or switch to telephone. See further guidance below if carrying out a rewind.
- Have you checked the client is somewhere where they will not be interrupted?
- Suggest to the client that their device is placed or propped up on a firm surface and not held in their hand – to ensure you have a good quality image of client’s face, especially during any use of guided visualisation.
- Check that the client is alone (unless it has been agreed beforehand that a third part will be attend) – the presence of a third person may be distracting and/or breach confidentiality.
- Follow advice for use of the rewind technique.
Online application of the rewind technique
- A rewind should never be a client's first experience of receiving HG therapy online. Do not rush into a rewind. Spend plenty of time building rapport.
- As with face-to-face work, there are clients with whom guided imagery should not be used – such as in the absence of rapport or where a client is actively psychotic or has previously experienced psychosis.
- You should never attempt a rewind if it is evident at the beginning of the session that the internet connection is unstable.
- Never record a rewind and send to the client.
PLEASE NOTE: HGI guidance states that practitioners should have delivered the rewind technique at least 30 times face-to-face (with clients) before undertaking such work online. It goes without saying that rewind work should not be carried out over the telephone.
The HGI recommends that practitioners use the rewind technique (and/or use an affect bridge, or carry out work with molar memories) and other forms of guided imagery when clients are physically present, so that any abreaction can be managed sensitively and swiftly. Wherever possible clients who need trauma treatment should be encouraged to travel to a therapist’s premises. Only when a therapist is very experienced should they be using the rewind technique, or carrying out work involving affect bridge/molar memories, online.
Where rewind is being undertaken online, treatment should be carried out under the following conditions:
- The therapist is experienced in the use of the rewind technique – meaning, as above, that you have delivered the rewind technique with clients (i.e. not as part of your training) on at least 30 occasions and have attended the appropriate HG College training.
- The client has arranged for a trusted relative or friend to be available, ideally in an adjoining room, to provide support if necessary. An instruction along the following lines can cover this requirement without planting undue anxiety about abreactions, which are in any event rare occurrences:
“Please make sure that a trusted friend or family member is with you where you are receiving the online therapy – but not in the same room – in case you need someone with you at any point.”
In the event of an abreaction, simple walking up and down combined with a reassuring approach can help calm and ‘ground’ the client. It may, on occasion, be appropriate or necessary to complete a rewind without your client having a trusted person in the vicinity due to the unique circumstances of your case. In such an event you need to judge whether the client is suitable for such work and if so carefully assess any risk.
- Always use guided visualisation with a client in a separate session before any use of rewind – to test their reaction to being deeply relaxed. Never use a rewind during an online client’s first experience of guided visualisation.
- Ensure that an agreement has been made regarding the resumption of communication in advance of providing therapy. You might agree, for example, that in the event of the technology breaking down therapy will continue via telephone.
- If in any doubt regarding the client’s suitability for online work, test the rewind process with the client with an event that has been a negative experience but not deeply traumatic, e.g. going for an interview and not getting a job; failing a driving test. Trying out the rewind process in this way enables the therapist to judge how the client might respond to rewind when used to address more serious traumatic experiences.
- Never go ahead with a rewind unless the client responds well to guided visualisation and the test rewind/s.
- Inform the client that you will need to see their face clearly on the screen throughout the process and that, if needed, the therapist may prompt the client to face the screen. This is important if the client begins to slump as they become more deeply relaxed, and their face can no longer be seen.
- During the rewind process take it slowly and be prepared to ease off into relaxing imagery if there are undue signs of discomfort in the client.
- Aftercare: As with face-to-face therapy it is helpful to ask a client to make contact (by telephone / email or other agreed medium such as text message) if they feel unduly uncomfortable or distressed following an online therapy session. Clients at risk should always be provided with contact details for crisis support, as individual therapists are rarely able to offer 24/7 emergency support or response.
HGI Ethics and Complaints Procedures
The HGI’s Ethics and Professional Policy and complaints procedure apply no less to remote working.
Payment for Services Delivered Remotely
For your own and your client’s protection, it is advisable to have secure arrangements in place for the transfer of money, for example, PayPal, Sage Pay, Direct Bank Transfer, etc.
Education and training
Since these guidelines do no more than cover the basics of online working the HGI recommends that its members undertake further education and training before delivering online therapy by attending HG College’s live online course: Online and phone therapy training – this course is mandatory for Trainee HG Therapists wishing to work online, but not for those only working face-to-face.
Additional training is also available elsewhere:
- The Specialist Certificate in Cyberculture: Online Therapy provided by the Online Therapy Institute. For further details, click here
- Related courses run in association with the BACP which are open to Non-BACP members.
Continue to: Whistleblower Policy (Appendix 2)
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