Online therapy guidelines
Last updated April 2020
In recognition of the fact that therapy is increasingly being delivered remotely by means of technology, the HGI has prepared the following guidelines, which relate to safe and ethical online working.
Inexperienced Therapists and Online Therapy
The HGI normally stipulates that therapists who are beginning their therapeutic career should gain substantial experience of face-to-face therapy before undertaking remote working.
However, for the duration the Covid-19 restrictions relating to face-to-face work, trainee therapists may deliver online therapy as long as they have had a conversation with their supervisor beforehand. Following on from this conversation, there is to be a written agreement between the supervisor and supervisee. The agreement will state that the trainee understands the limitations of delivering therapy online and agrees to desist from using guided imagery or rewind and that this has been discussed with their supervisor.
Trainees can do a lot of good work delivering psycho education and using stories, reframes etc., but absolutely no guided imagery.
Clearly, supervisors need to be familiar with the guidelines set out in this document, with regard to delivery of online therapy, the technical side as well as the clinical side.
Advantages and Disadvantages of Online Therapy
- Enables people in remote areas, and those who are disabled or housebound to access services.
- It is usually fairly affordable and convenient.
- There are concerns around confidentiality, privacy and unreliable technology.
- Therapists are not in a position to respond directly to crisis situations.
- The scope of the help provided can be limited. (See ‘Content of Online Therapy’ below.)
- Some insurance policies may not cover online therapy.
As is the case with face-to-face therapy, practitioners providing treatment via technology have a legal duty to comply with the Data Protection Act 2018 and the General Data Protection Regulation (GDPR), and an ethical responsibility to safeguard clients from unauthorised disclosure of information.
The duties of practitioners in relation to data protection legislation are highlighted in the ‘Essential Information’ section of the HGI website.
Again, as in face-to-face contact, clients must be informed about the nature of the service being offered. Therapists should also make clear the circumstances in which confidentiality can be broken, i.e. if it becomes apparent that there is a risk of harm to the client or others or where there is a legal duty of disclosure. 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.
Safety of Clients
Practitioners should take reasonable steps to ensure that clients are in a safe physical environment and are informed about the safe use of technologies, e.g. that adequate security measures are needed 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 web-based fora. Note: Practitioners cannot be held responsible if their clients do not follow the advice given.
At the outset of therapy, practitioner and client should agree how to proceed if a technology breakdown occurs, arranging, for example, to try to reconnect in five or 10 minutes. In case reconnection isn’t possible, there should be an arrangement to phone or e-mail with a view to rescheduling the session.
It is important for the client to have access to local support in the event of an emergency. In this regard, the client should have an arrangement to receive support from a family member, friend, GP, etc, if the need arises. As with face-to-face therapy, the therapist should obtain the contact details of the client’s GP and/or another responsible individual.
Practitioners need to take account of the specific laws of a prospective client’s geographical location. In this regard, different geographical regions are subject to legislation that affects the delivery of therapy. A case in point is the USA, where individual practitioners are required by law to be licensed in order to practise counselling or psychotherapy. Holding a license means that a practitioner has completed a level of training specified by the 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. In the US, online therapy is also subject to state by state licensing rules. Similar regulation applies in some provinces of Canada.
If a US or Canadian resident requests online therapy, you should explain 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, adding that they understand and accept that the work is being carried out in accordance with the laws of your own country and that any disputes will be subject to the jurisdiction of your country. *If you are unsure about the terms of your insurance policy in this regard, it is vital that you check with your insurer.
Also bear in mind, that in the case of US residents, you can refer them to an HG practitioner based in the US – see the online HGI Register or enquire at the HG office.
If you are planning to deliver therapy online, it is important that you check your policy or contact your insurer to confirm that your cover extends to working online.
N.B. If you are offering Online Therapy to individuals in a country other than the one in which you reside please contact your insurer to confirm that they cover you to deliver online therapy in that country.
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.
HGI Ethics and Complaints Procedures
The HGI’s Ethics and Professional Policy and its Complaints Procedure apply to remote working.
In June 2015, the HGI advised therapists not to use Skype for online therapy. This advice was based on concerns regarding the security of Skype. At the time, the Information Commissioner’s Office (ICO) informed the HGI that it was considering the suitability of Skype as a platform for online therapy with a view to issuing a statement later in the year.
Subsequently, the ICO advised the HGI that Skype can be used for online therapy provided clients give their consent, having been informed by their therapist that its use adds an element of insecurity in relation to the confidentiality of information that is beyond the control of both therapist and client.
- An email message from the client indicating that they give their informed consent should be sufficient in this regard;
- As a further safeguard, both client and therapist are advised to avoid sending sensitive information in written form via the Skype messaging facility.
- Both parties clearly need to take steps to ensure that the conversation can't be overheard by unauthorised third parties in the same building. To this end, the use of headphones by both client and therapist is advised.
This is the full ICO statement:
“The ICO’s official position on this is that the Data Protection Act 1998 (DPA) would not prevent the use of Skype for online Counselling. The DPA requires the data controller to consider the security implications with such use and then implement measures to ensure the information is appropriately secure.
“In addition to this we would expect you to ensure that the individuals who could potentially use this service is made fully aware of how you will use the service i.e. what is likely to be discussed, what if anything will be held as a result of use along with any security implications. If the individual consents to the use of Skype for the purpose of online counselling after being given the relevant fair processing you would be able to go ahead with such use.”
Other teleconferencing platforms
There are alternative, reputedly more secure, teleconferencing platforms such as VSee, WebEx and FaceTime (see below for further details). However, since there can be no guarantee that any platform will remain fully secure over time in a fast-changing ‘digital world’, therapists are advised always to ensure that clients give their informed consent, having been made aware of the risks. (See the advice in relation to Skype above.)
- VSee claims to be a secure platform. For general information on VSee, go to https://vsee.com/. Details of VSee security can be viewed at http://vsee.com/blog/tag/vsee-review. The basic VSee package is free – see https://vsee.com/pricing.
- WebEx, offers a free trail, after which a monthly fee of £15 is payable for the basic package. See http://www.webex.co.uk/
- FaceTime, which is produced by Apple for Mac users. This platform appears to be sufficiently secure for online therapy.
- Zoom https://zoom.us/
Note: Please click here for tips on how to increase the security of Zoom calls
Further observations on the above
Use of video communications platforms such as VSee, WebEx, FaceTime or Skype (see above) makes good sense since they enable appraisal of facial expression as well as tone of voice. Therapy by telephone is also an option. Whilst the above platforms can usefully be supplemented by e-mail, texting, instant messaging, etc, the supplementary media described must not be used to transmit sensitive data where the data subject(s) can be identified.
Content of Online Therapy
Human givens therapists already engaged in remote working report successful delivery of the following:
- Guided visualisation
- 7/11 breathing
However, there are some specific concerns about the use of guided visualisation without being physically present. An assessment of clients’ suitability for guided visualisation is essential in such circumstances. Whilst it may be quite safe and helpful in most cases, experience suggests that it will not always be, so caution is needed. (See the section entitled Safety of Clients above.)
Online application of the rewind technique
The HGI generally recommends that practitioners use the rewind technique and other forms of deep trance work only where clients are physically present, so that they are in a position to deal effectively with any abreaction. Wherever possible, clients in need of de-traumatisation should be encouraged to travel to therapists’ premises. A number of HG therapists report that clients have visited them from overseas for treatment.
However, since it would be unethical to withhold treatment where an individual is in urgent need of detraumatisation and is unable to travel, and where there is no possibility of referral to another source of effective treatment, rewind via remote means may be the only alternative. Such treatment should be carried out only under certain conditions, as described here:
- The therapist is suitably experienced. Note: The HGI recommends 150 therapy contact hours, with a minimum of 30 different clients from a range of backgrounds.
- There is a pre-arranged agreement as to how to resume communication if a technology breakdown occurs, for example by telephone.
- 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 quite rare occurrences: “Please make sure that a trusted friend or family member is in the house (but not in the same room) during your session, just in case you need someone with you at any point.”
- In the event of an abreaction, simple walking up and down, together with a reassuring approach can help calm and ‘ground’ the individual;
- A possible way to pre-handle the possibility of a client feeling upset or destabilised in the days and nights immediately following a rewind, as can sometimes happen, is to simply say, “If you have any questions you want to ask me before our next appointment, just get in touch”.
Further important safeguards:
- Rewind must not be carried out where symptoms of psychosis and schizophrenia are in evidence. Such symptoms would include hearing voices or other hallucinations, and where clients are unable to feel parts of their bodies.
- It is important to establish whether clients are comfortable with relaxation and guided imagery before proceeding to rewind.
- Do not undertake online rewind if you have any reason to think the client has drunk alcohol. Note: It is not unknown for clients to feel it is acceptable to have an alcoholic drink while they talk online since this is something they do while chatting with friends via Skype or using social media.
- It is essential always to conduct a follow-up session with a view to checking progress and dealing with any concerns that might have arisen.
- Wherever possible, therapists should discuss each case with their supervisor before undertaking the online rewind treatment.
Education and Training
Since these guidelines by their nature can deal with the basics of online working only, the HGI recommends that its members undertake relevant education and training before delivering therapy by remote means. Members may wish to investigate the following:
The Specialist Certificate in Cyberculture: Online Therapy run by the Online Therapy Institute. For further details, click here
Related courses run in association with the BACP (Note: Non-BACP members can participate)
The following book by Kate Anthony and DeeAnna Merz Nagel is also recommended:
- Therapy Online: A Practical Guide (2010) Sage Publications
Continue to: Whistleblower Policy (Appendix 2)
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