Online therapy guidelines

Updated April 2024

APPENDIX 1

There are many reasons why individuals seek out online or telephone therapy.  The covid-19 pandemic 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.

Ethical considerations

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 because this is felt to be more appropriate for the client. 

Training to work online

This is mandatory for all therapists qualified since September 2022 and all trainee therapists wishing to work online.

Because of the increased risks of delivering therapy online, especially therapy involving work carried out in trance, all therapists who have completed their Part 3 since September 2022, when these guidelines were last updated, are required to undertake 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 and we highly recommend that if a therapist is working online, their supervisor should also have experience of delivering therapy in this way.

Although not mandatory for therapists who qualified before September 2022, all human givens practitioners beginning online work are strongly encouraged to attend the above course, in order to ensure that they are practising ethically and safely when using this new medium.

Trainee therapists – Part 2 to Part 3 of the Diploma course

It is expected that the vast majority of trainee therapists will carry out all their supervised practice hours face-to-face with clients. This is to ensure the safety of their clients and themselves and to give trainee therapists the opportunity to best develop the requisite skill sets that will be assessed on Part 3.

In the rare cases where a hybrid approach is needed (perhaps due to distance from a client where an initial session might be conducted online, followed by face-to-face sessions for any work in trance), there must be a clear understanding that trainee therapists should not deliver any work in guided imagery online and the intention to do any work at all online must be discussed with their supervisor beforehand.

A written agreement between the supervisor and trainee therapist 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. 

In exceptional circumstances (such as a trainee already practising as an online therapist, with experience in delivering work in trance before undertaking the HG diploma) case-by-case variations may be made – but only with prior agreement from their supervisor, after discussion with the Clinical Governance Group (CGG).

When a trainee has successfully completed Part 3 and is a fully qualified HG therapist, they may begin delivering work online (including guided imagery) only on completion of the Online and phone therapy training course and with the knowledge and agreement of their supervisor. As detailed in the specific guidance relating to rewind (see below) 30 face-to-face rewinds must have been carried out before any HG practitioner can begin delivering rewind work online.

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 practising.  Therefore:

• The practitioner should have a privacy policy (see below for link). This should be available for clients through a link in an initial contact email / on the website and should be made explicitly available to the client before they enter into a contract with you.

• 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:

• emails
• 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 licence 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.

6) Insurance

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

1. If you are a trainee, have you discussed online work with your supervisor and set up an agreement? 
2. Does your insurance provider cover for online therapy?
3. Have you considered the country in which clients are receiving online therapy from you? See 'Legal Considerations' above.
4. 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.?
5. Are you using a recognisable, security-aware platform and ensuring you have good quality internet connection?
6. 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.
7. Have you checked the client is somewhere where they will not be interrupted?
8. 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.
9. 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.
10. 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 undertaking work in trance online.  Do not rush into a rewind.  Spend plenty of time building rapport and ensuring your client has a good guided imagery skillset.
• 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. If a client has a history of psychotic episodes, but has not experienced symptoms for some time, then an experienced practitioner should judge on a case-by-case basis, in collaboration with their supervisor if necessary, whether guided imagery is appropriate in this instance and, if so, ensure that adequate support measures are put in place.
• 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 it to the client.

PLEASE NOTE: HGI guidance states that qualified practitioners should have delivered the rewind technique at least 30 times face-to-face – with clients – before undertaking such work online. This can include rewind work undertaken during supervised training hours in preparation for Part 3. It goes without saying that rewind work should never be carried out over the telephone.

Where rewind is being undertaken online, you should carry the work out in line with the following conditions:

1. You are experienced in the use of the rewind technique – meaning, as above, that you have delivered the rewind technique with clients in person on at least 30 occasions. 

2. 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. Never go ahead with a rewind unless the client responds well to guided visualisation and the test rewind/s.

3. 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 contact will be made via telephone – although this would not, as previously outlined, include continuing any work in trance.

4. Inform the client that they will need to be in a position where you can see them clearly on the screen throughout the process. This is important if the client begins to slump as they become more deeply relaxed.

5. If deemed necessary, and certainly when newly beginning to deliver rewind online, you should request that the client arranges 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.”  

   It may, on occasion, be appropriate or necessary to complete a rewind without your client having a trusted person in the vicinity. In such an event you need to judge whether the client is suitable for such work and if so carefully assess any risk.

6. If you are in any doubt regarding a client’s suitability for online rewind work, test the process with the client with an event that has been a negative experience but not deeply traumatic for that individual – for example, 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.
7. 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.
8. 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 Conduct Policy and its complaints procedure also both apply to remote working.

• View the HGI Ethics and Conduct Policy here
• View the HGI Complaints Procedure here

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 strongly 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.

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Continue to:  Whistleblower Policy (Appendix 2)