Online therapy guidelines
Last updated May 2022
In recognition of the extensive amount of online therapy provided by HGI members, revisions to the Institute’s online therapy guidelines are suggested as follows.
Face-to-face therapy is often preferable to online, but not always possible. This is not just because of the current public health crisis but because people who need help may live in remote places with no nearby therapists or they may have mobility problems and so are unable to leave their home very easily. Some people living and working in a country where their native language is not spoken may want to access an online therapist who speaks their native language. Hence there are many reasons why remote therapy becomes the realistic option for some people seeking therapy.
Ethical consideration - It is an ethical consideration when working out a client’s best possible therapeutic pathway. This may mean referring them on to someone who can deliver face-to-face therapy for instance for a rewind because this is felt to be more appropriate for the client. The client’s needs should always be considered before undertaking any type of therapy.
The following guidelines outline the important considerations before starting to deliver therapy online.
Considerations for trainee HG therapists
A written agreement (view a sample here - in members area) between supervisor and trainee must then be prepared. The 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.
Principles of working 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:
- Informed consent is required just as with face-to-face therapy. Customisable documents to support this process can be downloaded from the ‘Essential Information’ page of the HGI website. The HGI strongly recommends that practitioners make use of these.
- Clients also need to be informed that no online platform can ensure 100% confidentiality.
- Clients should understand when confidentiality might be overridden by other considerations e.g. safeguarding
2) 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 to support local to where they receive online therapy in the event of an emergency. Clients should make arrangements for support from a family member, friend, GP, etc, if the need arises during or following online therapy.
- Therapists should take reasonable steps to ensure that clients are in a safe environment and 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.
3) Legal considerations
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 a US or Canadian resident requests online therapy, it should be explained that you are not licensed to do so in their particular locality. If you know that your professional indemnity insurance covers you to deliver online therapy in the locality concerned* and if the prospective client is happy to proceed you should ask them to provide their written consent to therapy on the basis that you are not licensed. It should also be stated that the client understands and accepts that the work is being carried out in accordance with the laws of the therapist’s country and that any disputes will be subject to the jurisdiction of that country.
US residents can be referred to an HG practitioner based in the US – 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.
5) 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 web cam 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 on-line 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.? This might mean in extremis – particularly during lockdowns – that the client sits in their car (although this is not ideal).
- Suggest to the client their device is not handheld – to ensure a good quality image of client’s face especially during any use of guided visualisation.
- Check that the client is alone – 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 the first experience of a client 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.
The HGI recommends that practitioners use the rewind technique and other forms of guided imagery primarily where 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. Where this is not possible, treatment should be carried out under the following conditions:
- The therapist is experienced in the use of the rewind technique – meaning that you have delivered the rewind technique with clients (i.e. not as part of your training) on at least 30 occasions.
- The client has arranged for a trusted relative or friend to be present 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. Very occasionally it may be 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 cases you need to judge whether more harm is done by not doing a rewind than taking the risk of the client receiving therapy whilst alone.
- Always use guided visualisation with a client before any use of rewind – to test their reaction to being deeply relaxed. Never use a rewind during a 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.
- 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 phone if they feel unduly uncomfortable or distressed following an online therapy session. Clients should be advised that in the event of the phone being unanswered that contact will be made as soon as possible.
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, 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.
Members are recommended to undertake one or both of the following further training courses:
- 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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