Telepsychiatry

1. Introduction

Version followed: APA/ATA Best Practices in Synchronous Videoconferencing-Based Telemental Health (American Psychiatric Association and American Telemedicine Association, March 2022) as the core procedure; the American Psychological Association's Guidelines for the Practice of Telepsychology (eleven guidelines, approved by the APA Council of Representatives in August 2024) for psychologists; UKCP Guidelines for Working Online/Remotely (2021), BACP's Online and Phone Therapy competence framework (2021, updated August 2026) and the BPS Division of Clinical Psychology Digital Healthcare Sub-Committee's Effective therapy via video: top tips (interim, undated) for UK practice. Regulatory and licensure status is dated as of October 2026.

Telepsychiatry (and its wider family, telemental health, telepsychology and online therapy) is not a therapy or school; it is a mode of delivering assessment, psychotherapy and psychiatric care at a distance, mainly by live video, also by telephone, and in hybrid combinations with in-person care. The therapy itself (CBT, psychodynamic, family therapy etc.) stays the same; what changes is the frame around it: the law that applies (the client's physical location), the security of the channel, the consent conversation, knowing where the client is and who is with them each session, and how you would get help to them in an emergency when you are not in the room. The working assumption of the guidelines is that care by video must meet the same standard as in-person care, and that procedures are adapted, not lowered, to reach that standard. [source: APA/ATA 2022; APA 2024, Guideline 7; UKCP 2021]

Who does what: psychotherapists, psychologists and counsellors deliver psychotherapy by video within their own licence and scope. Psychiatrists and other prescribers additionally prescribe by telemedicine under separate drug-control rules (US: the Ryan Haight Act and DEA telemedicine flexibilities; see 4.25). This guide is written for the psychotherapist; prescribing material is descriptive and for collaboration only. [source: APA/ATA 2022]

2. Framework

Telemental health has no fixed session count; it runs for the length of whatever therapy you deliver. The guidelines imply a sequence of set-up and per-session tasks, arranged here as six stages [synthesis, built from APA/ATA 2022, UKCP 2021, DCP top tips].

Stage A. Practice set-up (before any client). Goals: lawful, insured and secure practice. Tasks: confirm licensure for every jurisdiction where clients will be physically located (4.1); choose a secure platform and sign any required agreements (4.2); write policies for emergencies, disruptions, recording, communication and records (4.7, 4.10, 4.15, 4.21); confirm indemnity insurance covers online work in all relevant jurisdictions (UKCP 2021); make sure your supervisor is competent in online work (UKCP 2021). Move on when: licence, platform, insurance and written emergency procedure are in place.

Stage B. Intake, suitability and consent (first contacts). Goals: decide whether remote care is safe and suitable for this client, and obtain informed consent. Tasks: suitability and risk screening (4.3); a non-clinical technology test or "pre-session" (4.4); telehealth consent and contract (4.5); collect emergency contacts and the local emergency resources for the client's usual location(s), and a patient support person where appropriate (4.7). Format: often one short test call plus a first assessment session. Move on when: consent is documented, the emergency plan is on file, and remote care is judged clinically appropriate; otherwise offer in-person or hybrid care or refer on (APA/ATA 2022; UKCP 2021).

Stage C. Session-opening routine (every session). Goals: confirm identity, location and privacy before clinical work. Tasks: identify everyone present at both ends, confirm the client's physical location and a callback number, check privacy, and remind the client of the disconnection plan (4.6). Takes 1–3 minutes once routine [synthesis on timing].

Stage D. Ongoing therapy with video adaptations. Goals: deliver the chosen therapy at in-person standard. Tasks: telepresence and relationship work (4.13), frame and boundaries (4.12), adapted materials and homework sharing, ongoing risk review (4.8), periodic review of consent and of whether remote care still suits the client (4.5, 4.16).

Stage E. Contingencies (as needed). Disconnection (4.10), emergencies (4.9), privacy breaches or third parties entering (4.11), and data breaches (4.2).

Stage F. Transitions and ending. Moving between video, telephone and in-person (4.16); referral or discontinuation if the client cannot be managed safely at a distance (APA/ATA 2022 says consent should explain that services may be discontinued in that case); ordinary ending work, plus closing down remote channels and records (4.21). Criteria for switching to in-person or ending remote care: the client repeatedly cannot secure privacy or a stable connection, cannot cooperate with safety procedures, needs a physical examination that cannot be arranged, or risk rises beyond what can be managed remotely (APA/ATA 2022).

3. Guiding principles

Same standard of care. Remote care is judged against in-person care; adapt procedures rather than skip them. [source: APA/ATA 2022; APA 2024, Guideline 7]
The client's physical location governs. You need authority to practise where the client is sitting during the session, not only where you are. Practical meaning: ask and document location every session. [source: APA/ATA 2022]
Both ends are a consulting room. Treat your space and the client's as clinical rooms for privacy, safety and professionalism. Practical meaning: you check the client's setting, and you keep your own private and uncluttered. [source: APA/ATA 2022]
Follow the stricter rule. Where federal, state or national privacy laws conflict, follow the more stringent; when working across borders, comply with both your own and the client's jurisdiction. [source: APA/ATA 2022; UKCP 2021]
Competence is specific. Video work needs its own technical and clinical skills, kept current and reviewed in supervision; beware "unconscious incompetence". [source: UKCP 2021; APA 2024, Guideline 1]
Consent is layered and repeated. Consent covers both the treatment and the technology, and is revisited when platforms, terms of service or circumstances change. [source: APA 2024, Guidelines 2 and 3]
Plan the emergency before it happens. Each client has a written plan for the extreme case, presented as routine. Practical meaning: emergency contacts, local services and a support person are collected at intake, not mid-crisis. [source: APA/ATA 2022; UKCP 2021]
Stay connected in a crisis. Do not ask a client in crisis to hang up and dial emergency services; you coordinate with services and stay on the line until help arrives. [source: APA/ATA 2022]
Patient choice plus clinical need. Choice between video, telephone, in-person and hybrid care is guided by the client's preference and clinical need; allowing switches often improves attendance. [source: APA/ATA 2022]
Document the remote frame. Record modality, platform, location, who was present, identity checks and technical problems. [source: APA/ATA 2022; APA 2024, Guideline 5]
Cultural competence and access. Assess comfort and experience with technology, language and disability needs, and reassess over time. [source: APA/ATA 2022]
The frame shifts online. Online work can change the power balance, raise disinhibition and alter how challenge lands; attend to it actively and in supervision. [source: UKCP 2021]
Prescribing is the prescriber's. Psychotherapists coordinate and pass on observations; decisions about medicines stay with the prescriber. [synthesis]

4. Intervention inventory

The "interventions" of telemental health are the procedures that make remote therapy safe and effective. Your therapeutic techniques themselves come from your own modality's guide.

4.1 Jurisdiction and licensure check

Purpose / when: before accepting any remote client, and again whenever a client travels or moves. US guidance requires an active licence in the state where the client is physically located during the session, plus malpractice cover; federal systems (VA, DoD, IHS) follow their own rules; interstate compacts or state telemedicine licences may be used if all their requirements are met. [source: APA/ATA 2022]
Steps:
1. Record the client's usual location(s) at intake and ask about planned travel.
2. Check each location against your licence(s) directly with that state or national board; do not rely on platform or employer assurances.
3. Psychologists (PSYPACT): for telepsychology into other participating states you need, from a participating home state, an Authority to Practice Interjurisdictional Telepsychology (APIT, issued by the PSYPACT Commission) and an ASPPB E.Passport; temporary in-person practice uses a Temporary Authorization to Practice plus an Interjurisdictional Practice Certificate, limited to 30 days per calendar year per state. Eligibility is limited to doctoral-level licensed psychologists. The count of participating states differs between sources (one 2023 page, modified 2026, gives 40 including one not yet active); check the live list with the PSYPACT Commission [uncertain: not verified]. [source: Barton Associates PSYPACT overview]
4. Counsellors (Counseling Compact): as of October 2026 per counselingcompact.gov, ten states are live for privileges (Arizona, Arkansas, Georgia, Indiana, Louisiana, Minnesota, Ohio, Oklahoma, Tennessee, Wyoming; Oklahoma's go-live date given as 1 October 2026), with 29 further states and DC working towards participation; ACA reported in April 2026 that 38 states and DC had enacted compact legislation. Eligibility: a counsellor licensed for independent practice in, and residing in, a member state; pre-licensure graduates are not eligible; a privilege expires with the home licence and must be renewed separately; the Commission advises privilege holders to review the applicable law in each state and to check with employers, platforms and insurers. [source: counselingcompact.gov; ACA 2026]
5. Other professions (e.g. social work, marriage and family therapy) have separate compacts or none; check your own board [uncertain].
6. UK and international: comply with the laws of both your location and the client's; check whether registration is needed in the client's country; confirm insurance covers each jurisdiction; state in your contract which ethical code, complaints route and governing law apply; check sanctions lists; note time zones. [source: UKCP 2021] BACP's framework lists working across borders as a core difference of online practice. [source: University of Wolverhampton blog on the BACP OPT framework]
Example language (illustrative): "Because the law that applies is the law where you're sitting, I'll ask where you are at the start of each session. If you're planning to be away, let me know beforehand so I can check whether I can still see you there."
Watch for: clients joining from holiday, work trips, a partner's home in another state, or abroad without telling you; a licence or privilege lapsing on a different date from the home licence. Working: location is logged every session and you have pre-checked every location used.

4.2 Platform selection, security and data protection

Purpose / when: at practice set-up and whenever you change tools.
Steps:
1. Choose a platform with appropriate verification, confidentiality and security features, adequate bandwidth and audio/video resolution for the service, and a telephone fallback. [source: APA/ATA 2022]
2. US (HIPAA): OCR's COVID-19 enforcement discretion for telehealth ended on 11 May 2023, with a transition period to 9 August 2023 during which OCR expected providers to choose and implement HIPAA-compliant technology; after that, telehealth must fully comply with HIPAA. [source: McGuireWoods alert, April 2023] Establish business associate agreements with technology partners and a written breach-response plan; follow secure data-disposal practice. [source: APA 2024, Guidelines 3 and 4; breach-response plan per telehealth.org summary of APA 2024] Recognise heightened protection for mental health and substance use records, including specific consent before releasing substance use information; follow state privacy and duty-to-warn law and, where laws conflict, the stricter one. [source: APA/ATA 2022]
3. UK (UK GDPR): private practitioners should be registered with the Information Commissioner's Office; update the privacy notice to cover online work (what data, why, retention, sharing, which law and jurisdiction apply); store all forms of data (emails, texts, audio/video, phone and financial records, notes) securely and only as long as needed; consider a separate work device; free platforms tend to be less secure; team-collaboration tools may not suit individual therapy. [source: UKCP 2021] GDPR is one of the areas BACP's framework treats as specific to online work. [source: Wolverhampton blog on BACP OPT]
4. Establish policies for physical security of devices and electronic security of data, and for storing and retrieving remote-care records. [source: APA/ATA 2022]
5. Email: keep content minimal, separate administrative from clinical content, consider end-to-end encryption and password-protect sensitive documents. Phone: confirm you are speaking to the right person before identifying yourself. [source: UKCP 2021]
Example language (illustrative): "The video service I use is set up for healthcare and has a confidentiality agreement with me. No method is completely risk-free; the main risks are someone at your end overhearing, or a device being shared. Let's go through how to reduce those."
Watch for: links sent over unencrypted or public channels, consumer apps without a healthcare agreement, shared family devices, auto-saved chat logs, and platform terms of service changing. Working: written agreements on file, breach plan exists, client knows the residual risks.

4.3 Suitability assessment and patient selection

Purpose / when: at intake, and whenever circumstances or risk change.
Steps: consider cognitive capacity, history of cooperation with treatment, substance use, history of violence or self-injury, distance to the nearest emergency facility, strength of the support system, current medical status, preferences, goals and likelihood of attending; decide whether an in-person physical examination is needed and, if it cannot be done remotely, document it and arrange one. [source: APA/ATA 2022] Confirm the client can set up the system, keep it working, secure a private space and cooperate with safety management. [source: APA/ATA 2022] Refer on clients unlikely to benefit, at added risk online, or beyond your competence; remember substance use is harder to observe on video. [source: UKCP 2021] Developmental, emotional or financial circumstances do not automatically rule out video, but weigh risks and benefits. [source: DCP top tips]
Example language (illustrative): "Video works well for many people. Before we decide, I'd like to understand a few practical things: where you'd be joining from, who else is around, how far you are from the nearest emergency department, and who you could call if things got very hard."
Watch for: recent serious self-harm with no local support, intoxication at sessions, no private space at all, coercive or controlling household members, cognitive difficulties that make the technology a barrier. These call for hybrid or in-person care or extra safeguards, not automatic exclusion [synthesis].

4.4 Pre-session technology test

Purpose / when: before the first clinical session.
Steps: offer a short non-clinical "pre-session" to test bandwidth, set-up and use of the technology [source: APA/ATA 2022]; agree in a prior phone call how the client will join (computer, laptop or phone) [source: DCP top tips]; test your camera, microphone and speakers and check the right audio device is selected; use wired internet where possible, or close unneeded programmes; practise with a colleague first [source: DCP top tips]. For groups, label the test run as not a formal session [source: CDP group telehealth tip sheet].
Example language (illustrative): "This ten-minute call is just to check the technology, not a therapy session. Can you hear me clearly? Let's try the backup: I'll call your mobile now so we know it works."
Watch for: echo, lag, a camera angle that hides the face, the client joining from a car or public space. Working: by the first session, sound and picture are reliable and the backup number has been tested.

4.5 Telehealth informed consent and contracting

Purpose / when: before treatment starts; revisit when the platform, the client's setting or the modality changes.
Steps:
1. Follow local, state and national rules on verbal versus written consent; electronic signatures where legal; implied consent only where the law allows (e.g. emergencies). Document consent in the record. [source: APA/ATA 2022]
2. Cover two layers: consent to the treatment and consent to the telepsychology modality. The APA guideline lists what to discuss: the nature of remote services and the channels used (video, phone, chat, portals, apps); risks, benefits and limits of the service; privacy and security measures, including what data are stored and how; where the client will be during sessions, emergency procedures and what happens if the technology fails mid-session; limits of confidentiality, including for minors; boundaries and out-of-session contact, including when you will respond; the client's part in keeping a private, quiet setting and handling technical problems; fees, including charges for interruptions and cancellations; and your licensure and the jurisdictions where you are authorised to practise. Use plain language adapted to the client's language, disability and culture, obtain assent plus parental consent for minors, and treat consent as an ongoing conversation. [source: APA 2024, Guideline 2]
3. Include: limits of confidentiality on video; the emergency plan and your contact rules between sessions; the disconnection plan; that services may be discontinued if the client cannot be safely managed remotely; all potential charges before services begin; recording policy; changes for hybrid care. [source: APA/ATA 2022; DCP top tips]
4. UK: put terms, fees, methods, complaints, referral and termination in a written contract (recommended, not mandatory); decide whether electronic signature is enough; obtain consent to electronic contact such as appointment texts; consumer rules may allow cancellation within 14 days with refund less sessions held. [source: UKCP 2021]
5. Present remote therapy as an option, not a requirement, and document the client's choice. [source: DCP top tips]
Example language (illustrative): "There are two parts to agreeing to this. One is the therapy itself. The other is the technology: what it can and can't protect, what we'll do if the call drops, and how I'd get help to you in an emergency. Let's go through both, and you can ask about anything."
Watch for: consent signed without being discussed; clients unaware that a family member could overhear; consent not updated after switching platform or adding telephone sessions. Working: the client can say back the disconnection and emergency plans.

4.6 Session-opening routine: identity, location, people present

Purpose / when: at the start of every session.
Steps: identify everyone present at both sites; verify and document your name and credentials, the client's name, and the client's physical location; record immediate contact details for both parties and relevant supports; clarify expectations about identity checks and others being present. [source: APA/ATA 2022] Verify identity (and age where relevant), using documents such as a passport or driving licence where appropriate, especially at first contact. [source: UKCP 2021] Confirm the location at the start of every group session too. [source: CDP group telehealth tip sheet]
Example language (illustrative): "Before we start: are you at home today, at the same address? Is anyone else in the room or able to hear? And is your mobile still the best number if we get cut off?"
Watch for: a new or vague location ("in the car", "at a friend's"), someone off-camera, the client lowering their voice or typing answers. Working: the check takes under a minute and the client starts offering the information unprompted.

4.7 Emergency plan with local contacts

Purpose / when: set up at intake; update when location or supports change.
Steps:
1. Keep your own competence in emergency management; know local civil-commitment rules, hand-off requirements and duty-to-warn or duty-to-protect law for each area served; build working relationships with local resources. [source: APA/ATA 2022]
2. For clients at home or other unsupervised settings: know the client's location each session and document local police, emergency departments and crisis teams for each location. [source: APA/ATA 2022]
3. Agree with the client at the start how risk will be assessed and responded to; collect emergency contacts and GP, family or friend details early; and recognise the limits of what you can do when you are not physically present. [source: BACP OPT framework 2026] Plan for emergencies at the client's location, and confirm and document that location, since it decides which law applies and where emergency services would be sent. [source: APA 2024, Guidelines 6 and 9]
4. Consider a Patient Support Person (PSP), chosen by the client, to help in an emergency, with the client's agreement; involve household members only at clinical discretion and with agreement. [source: APA/ATA 2022] UKCP calls this a trusted "safety contact" who knows the client is in therapy. [source: UKCP 2021]
5. Agree before therapy when secondary contact methods will be used, and ask the client to keep a phone on during sessions. [source: UKCP 2021]
6. Ask whether the client has out-of-hours and crisis information; if you email crisis details, confirm they were received. [source: DCP top tips] For overseas clients, record full name, phone number and date of birth for emergencies. [source: UKCP 2021]
7. In supervised settings (clinic, school), agree written protocols with clear roles, after-hours cover and criteria for calling other staff; train staff and review every emergency afterwards. [source: APA/ATA 2022]
Example language (illustrative): "I ask everyone for the same things, so this isn't about you in particular: the address you usually join from, the local crisis line and nearest emergency department, and someone you trust whom I could contact if I were seriously worried about your safety and couldn't reach you."
Watch for: reluctance to name a support person (explore it; it can signal isolation or a controlling relationship), outdated numbers, clients who use several addresses. Working: the plan is complete, on file and checked at least when anything changes.

4.8 Remote risk assessment and safety planning

Purpose / when: at intake and whenever risk indicators appear; risk assessment is carried out as in person, with the same actions available (e.g. contacting the GP). [source: DCP top tips; UKCP 2021]
Steps:
1. Use your usual structured risk assessment; ask directly about suicidal thoughts, intent, plans and preparation, and about risk to others [synthesis, standard practice].
2. Compensate for the narrower view: ask what you cannot see (substances, the room, who is nearby), and attend closely to voice, pauses and camera behaviour [synthesis; UKCP 2021 notes substance use is harder to observe].
3. Ask about access to lethal means and discuss securing items of concern. [source: CDP group telehealth tip sheet] Keep lethal-means counselling to safe storage, removal and involving a support person [synthesis].
4. Build a written safety plan the client keeps at home, including the local crisis contacts already on file [synthesis].
5. Plan in advance what you will do if the client ends a session abruptly, especially after disclosing plans to harm self or others. [source: DCP top tips]
6. If risk is high, consider keeping the client online after the session with a trusted person present, with their permission. [source: CDP group telehealth tip sheet] Plan follow-up for clients who leave a session in a strong emotional or behavioural state. [source: APA/ATA 2022]
Example language (illustrative): "On video I can't see everything around you, so I'll ask more directly than I might in person. Are there any medicines, weapons or other things nearby you've thought about using? What would help make them harder to reach tonight, and who could help with that?"
Watch for: the client moving out of frame, muting, a sudden flat or calm tone after distress, logging off. Working: the client can name their next steps and contacts, and you know exactly where they are.

4.9 In-session emergency response

Purpose / when: imminent risk to the client or others during a remote session.
Steps:
1. Stay connected; do not ask the client or PSP to hang up and call emergency services. [source: APA/ATA 2022]
2. Coordinate directly with emergency services for the client's location (using a second phone line), giving standardised hand-off information verbally and in writing, and your own contact details; remain connected until responders arrive. [source: APA/ATA 2022]
3. If the client or PSP will not cooperate, be prepared to work with local emergency personnel. [source: APA/ATA 2022]
4. Afterwards: document, debrief, review the emergency with your team or supervisor, and update the plan. [source: APA/ATA 2022]
Example language (illustrative): "I'm going to stay right here with you. I'm also going to call for some help to come to where you are, on my other phone. You don't need to hang up. Can you tell me if the front door is unlocked?"
Watch for: your own urge to end the call to make phone calls (use a second device or a colleague); the client leaving the room; arriving responders needing a safe, calm description. Working: help reaches the stated address and you have stayed in contact throughout.

4.10 Managing disruptions and technology failure

Purpose / when: agreed at intake; used whenever the connection fails.
Steps: have a backup plan for interrupted sessions, such as switching to telephone, and check technology is ready before each session [source: APA/ATA 2022]; agree with the client in advance what to do (reconnect, or continue by phone) and have a service procedure for re-offering interrupted sessions [source: DCP top tips]; put the plan in writing [source: UKCP 2021]; remind group members of the alternate number at the start of each session [source: CDP group telehealth tip sheet]. A practical default: if the link drops, the clinician tries to reconnect once, then phones the agreed number within a set few minutes; the client stays near their phone [synthesis].
Example language (illustrative): "If we get cut off, stay where you are. I'll try the video link once, and if that doesn't work I'll ring your mobile within two minutes. If I can't reach you and we'd been talking about your safety, I'll follow the emergency plan we agreed."
Watch for: drops that coincide with painful material (explore gently whether they are technical or avoidant); a drop just after a risk disclosure (treat as a possible emergency per 4.8–4.9). Working: interruptions cost minutes, not sessions.

4.11 Privacy and the home environment (client and clinician)

Purpose / when: at set-up and every session.
Steps (client side): help the client find a private, comfortable space where they cannot be overheard; agree what to do if someone interrupts; suggest headphones or earbuds [source: DCP top tips]; discuss who is nearby, pets, caring duties such as a child in another room, shared or public computers, and whether any third party might want to intercept communications [source: UKCP 2021]. The client's location should be safe and appropriate as a healthcare setting. [source: APA/ATA 2022]
Steps (clinician side): make sure you cannot be overheard; camera at eye level, face visible and well lit, no window behind you; a background free of confidential material and distractions [source: APA/ATA 2022; DCP top tips]; if working from home, identify your location and the privacy and safety standards you follow, and keep professional standards regardless of location [source: APA/ATA 2022]; consider what your space communicates to the client [source: UKCP 2021].
Example language (illustrative): "Where in the house works best for you to talk freely? Some people use a parked car, a bedroom with music on outside the door, or headphones. Shall we agree a word you can say if someone walks in, so I know to switch topic?"
Watch for: guarded answers, glancing off-screen, background voices, a partner who "just happens" to be present. Possible domestic abuse or coercion needs a safety-focused plan and, where possible, an in-person or otherwise safe channel [synthesis]. Working: the client speaks freely and privacy problems are raised rather than hidden.

4.12 Frame, boundaries and between-session contact

Purpose / when: set at contracting; maintained throughout.
Steps: agree who initiates each session (who sends the link or calls whom) [source: UKCP 2021]; encourage a small transition ritual into and out of the session in place of the journey [source: UKCP 2021]; define communication policies: acceptable channels, response times, content limits and which channels may be used in emergencies [source: APA/ATA 2022]; keep administrative and therapeutic messages separate [source: UKCP 2021]; with young clients especially, avoid non-emergency contact outside hours, unplanned session extensions and personal disclosure [source: APA/ATA 2022]. Note that online work may shift the power balance towards equality, and that some clients disclose more, faster (disinhibition): pace disclosure actively, and watch for hostile disinhibition such as threats or trolling [source: UKCP 2021].
Example language (illustrative): "Let's make the start and end of our sessions feel like arriving and leaving. Maybe a cup of tea before, and a short walk or a few minutes on your own afterwards, rather than going straight back to the family or your inbox."
Watch for: sessions from bed or while multitasking, messages sent late at night expecting reply, fast deep disclosure followed by shame or no-shows. Working: a stable, predictable frame the client can describe.

4.13 Telepresence and the therapeutic relationship

Purpose / when: all sessions; especially early and with clients new to video.
Steps: talk slowly at first while gauging the connection, and take time to put the client at ease [source: DCP top tips]; use a headset to improve voice quality, which supports "telepresence" [source: DCP top tips]; use more frequent verbal encouragers on the phone so the client knows you are listening; agree that neither party has to look at the screen all the time; check how challenge lands, since it may feel different at a distance [source: UKCP 2021]; screen-share or email materials if you usually draw or write in session [source: DCP top tips]; review the effect of the online medium on the relationship in supervision [source: DCP top tips]. BACP's framework considers translating theoretical models to online media a specific competence [source: Wolverhampton blog on BACP OPT].
Example language (illustrative): "On video I can miss some of the small signals I'd catch in a room, so I'll check in a bit more often. If something I say lands badly, please tell me, even if it feels minor."
Watch for: the client looking only at their own image, lag causing talking over each other, fatigue on both sides. Working: the client reports feeling understood; alliance measures, if you use them, are steady.

4.14 Text, email and asynchronous communication

Purpose / when: whenever any written contact is used.
Steps: obtain permission before sending any text, including reminders, and include it in the contract; balance warmth with professionalism and follow each medium's norms; be alert to delays and misunderstandings; treat changes in writing style or gaps between messages as possibly meaningful; watch for transference and fantasy about the therapist. [source: UKCP 2021]
Example language (illustrative): "I use text only for appointment times. If something important comes up between sessions, bring it to the next session; if it's urgent, use the crisis numbers we agreed, because I may not see messages straight away."
Watch for: clinical content creeping into reminders, crisis disclosures by text out of hours. Working: written channels stay administrative unless deliberately agreed otherwise.

4.15 Recording policy

Purpose / when: set at contracting.
Steps: say whether the platform can record and whether you will; record only with explicit, informed consent; state where recordings are stored (they form part of the clinical record; NHS services would not normally record without written consent); make clear that clients must not record or share sessions without discussion; prohibit recording of group sessions. [source: DCP top tips; UKCP 2021; CDP group telehealth tip sheet]
Example language (illustrative): "I don't record our sessions. I'd ask the same of you, and if you'd ever like a recording, for example of a relaxation exercise, let's talk about it first."
Watch for: recordings used in disputes or shared online; clients recording to replay you compulsively. Working: no recordings exist that nobody agreed to.

4.16 Hybrid care and changes of modality

Purpose / when: when choosing or changing between video, telephone and in-person.
Steps: let client choice and clinical need guide modality; allow switching, which often improves attendance; set procedures for transitions; communicate directly when you recommend or make a change; adjust scheduling and consent for hybrid care. [source: APA/ATA 2022]
Example language (illustrative): "Things have been more risky lately, so I'd like to see you in person for the next few weeks. That's not a step back; once things settle we can go back to video if you'd like."
Watch for: clients choosing video to avoid being seen (e.g. weight changes in eating disorders, signs of self-harm); a switch to telephone that becomes permanent without review [synthesis]. Working: modality is a deliberate, reviewed choice.

4.17 Group telehealth

Purpose / when: running therapy or psychoeducation groups by video. APA/ATA 2022 does not cover groups directly; the guidance below comes from a provider tip sheet and UK multi-person guidance, with [synthesis] where marked.
Steps:
1. Screen each member for remote suitability (telehealth only or mixed), suicide risk, technology and support. [source: CDP group telehealth tip sheet]
2. Orient individually: how the video group differs from in-person, why this format, and a test run labelled as not a session. Obtain individual telehealth consent, including that you are not physically present. [source: CDP group telehealth tip sheet]
3. Send links through an encrypted channel or with a password; prohibit recording; confirm each member's location at the start of every session; hold each member's local emergency resources and a phone number; remind members of the backup number. [source: CDP group telehealth tip sheet]
4. Agree group rules: private space, headphones, no one off-camera, cameras on, how to use chat and raise hand, what happens if someone drops out [synthesis].
5. With a co-facilitator, assign roles: one leads, one monitors chat, connection problems and members in distress, and can move a member to a private breakout room or phone call [synthesis].
6. If a member reports suicide risk, consider keeping them online after the group, with a trusted person present if they agree. [source: CDP group telehealth tip sheet]
7. In couples or family sessions, decide in advance how each participant will appear on screen. [source: UKCP 2021]
Example language (illustrative): "Each of us is in a different place, so our privacy depends on all of us. Please use headphones, let us know if anyone comes into your room, and don't record or screenshot. If your connection drops, I'll ring you."
Watch for: members whose screens show housemates, side-chat, a member going silent with camera off, distress in one member while the group continues. Working: members participate across the screen and confidentiality concerns are raised openly.

4.18 Children and adolescents

Purpose / when: any remote work with minors.
Steps:
1. Apply the adult guidance with developmental modifications (motor skills, language, relatedness). [source: APA/ATA 2022]
2. Set up the room with enough space, furniture and age-appropriate materials for the child to engage with parent and clinician. [source: APA/ATA 2022]
3. Include parents or other relevant adults as you would in person, adapted for video; if a "presenter" (e.g. school staff) assists, consider the effect on confidentiality. In schools, work with staff on safety, privacy and accommodations. [source: APA/ATA 2022]
4. Assess the young person's safety, the availability and mental health of supportive adults and the site's ability to respond to emergencies. [source: APA/ATA 2022]
5. Maintain firm boundaries: clear roles, no personal disclosure, no non-emergency contact outside hours, no unplanned extensions, explicit communication rules. [source: APA/ATA 2022]
6. UK: consider the child's capacity to consent; where a child uses a parent's phone or account, obtain and record the parent's consent to therapy and to that use; liaise with carers and organisations about platform risks; keep heightened safeguarding awareness because children may disclose less from home; get consent from all relevant parties before any recording; international work with children needs careful research and supervision. [source: UKCP 2021]
7. AACAP lists a Clinical Update: Telepsychiatry with Children and Adolescents (October 2017) and a joint AACAP/APA telepsychiatry toolkit; it notes that home-based care gives an ecologically valid view of the child's environment. The Clinical Update's detailed recommendations are not summarised here [uncertain]. [source: AACAP Telepsych Home]
8. Obtain the young person's assent and the parent's or guardian's consent, explain the limits of confidentiality for minors, and take reasonable steps to confirm the client's legal age and identity, because legal and ethical rules differ for children. [source: APA 2024, Guideline 2; BACP OPT framework 2026]
Example language (illustrative): (to a parent) "For part of each session I'll talk with Sam on their own. Could you be in another room where you can't hear, but close enough to come if I call you?" (to the young person) "If someone walks in and you'd rather not talk, just say 'pause' and we'll change the subject."
Watch for: a parent hovering off-screen, the child unable to speak freely, younger children wandering off camera, safeguarding cues in the home background. Working: the young person has a private space and both child and parent know the safety plan.

4.19 Cultural, language and accessibility adaptations

Purpose / when: at intake and throughout.
Steps: assess comfort and prior experience with video and reassess over time; learn about the communities served (site visits or cultural facilitators may help); address language barriers and funding for technology; recognise how group identity affects attitudes to care; use sign language interpreting only with reliable connections at both ends, and make captioning available; confirm understanding frequently with visually impaired clients; adapt cognitive testing for video. APA/ATA 2022 also gives population-specific notes (older adults, military and veterans, rural, forensic and correctional, inpatient and residential, primary care, and several cultural, sexual and gender minority, Deaf, visually impaired and developmentally disabled groups). [source: APA/ATA 2022] BACP's framework treats accessibility as a core online-practice issue. [source: Wolverhampton blog on BACP OPT]
Example language (illustrative): "How do you usually find video calls? Some people prefer captions on, or the camera off for part of the time. Let's set it up the way that works for you."
Watch for: digital poverty (data limits, one shared phone), mistrust of surveillance in some communities, interpreter lag. Working: attendance and engagement match in-person peers.

4.20 Competence, supervision and training

Purpose / when: before starting and continuously.
Steps: judge whether your skills suit online work, train where needed and review this with your supervisor; confirm your supervisor is competent in online work or find additional supervision; consider more frequent supervision because of safeguarding risk; set supervision time aside for culture, inclusion and access to technology. [source: UKCP 2021] Stay aware of the evolving competences telepsychology requires, informed by current research and literature. [source: APA 2024, Guideline 1] If you supervise or train others in telepsychology, including remotely, be competent in both the services and the technology involved. [source: APA 2024, Guideline 10] BACP's online and phone therapy (OPT) competence framework (updated August 2026) asks practitioners to find a supervisor with OPT knowledge and experience, to match supervision to the modality (including blended work) and to use it to reflect on how remote work affects both client and practitioner; it also covers the practitioner's own self-care (ergonomics, screen strain, regular breaks). [source: BACP OPT framework 2026]
Example language (illustrative): (in supervision) "I'd like to look at how the video format is affecting my work with this client: I think I'm missing early signs of dissociation."
Watch for: fatigue from long screen days, drifting standards when working from home, unexamined assumptions that video is "lighter" work [synthesis]. Working: online-specific issues appear regularly on the supervision agenda.

4.21 Documentation and records

Purpose / when: every session and at closure.
Steps: document consent, client location, emergency and PSP information; note that the service was delivered remotely (also for billing and coding); record cases where a physical examination was needed but not possible and what was arranged; track emergencies; set up processes for storing and retrieving remote-care records. [source: APA/ATA 2022] Record platforms used, identity-verification steps and technical problems. [source: APA 2024, Guideline 5; detail per telehealth.org summary of APA 2024] Note in the record whether the consultation was by telephone or video. [source: DCP top tips] Keep data only as long as needed and dispose of it securely. [source: UKCP 2021; APA 2024, Guideline 4]
Example language (illustrative): (note) "Video session, [platform]. Client at home address on file, alone, verified. Backup number confirmed. 4-minute disconnection at 20 min, resumed by video."
Watch for: location left blank, notes saved on personal devices, chat logs not captured or not deleted per policy. Working: an auditor could reconstruct where, how and with whom each session happened.

4.22 Emerging technologies and AI in remote care

Purpose / when: when you, your platform or the client use AI tools (e.g. transcription, note-writing, chatbots) or extended reality.
Steps: apply the same ethical, legal and empirical rigour to any new technology as to established practice; the APA guideline names AI, virtual and augmented reality, wearables and mental-health monitoring among such tools. For tools with automated or AI-facilitated features, have a business associate agreement with the vendor (US), confirm that tools which store data are HIPAA compliant, and review the vendor's data-management and retention policies before use and periodically afterwards, because terms of service change. [source: APA 2024, Guidelines 3 and 11] Check whether any AI feature of your video platform (auto-transcripts, summaries) processes session content, and cover it in consent and your privacy notice [synthesis]. Never present an AI chatbot as a replacement for therapy [synthesis]. Ask clients whether they use general-purpose AI for emotional support, and explore it non-judgementally [synthesis].
Example language (illustrative): "Some platforms now offer automatic transcripts. I've switched that off, so nothing we say is written up by software. If you've been talking things through with an AI app between sessions, I'd be interested to hear how that's been."
Watch for: AI note-takers enabled by default, clients relying on chatbots in crisis. Working: no undisclosed processing of session content.

4.23 Collaborative care with a telepsychiatrist or prescriber

Purpose / when: when a client also sees a psychiatrist or prescriber, in person or remotely.
Steps: coordinate care with other professionals with the client's consent and within privacy rules [source: APA/ATA 2022]; agree who holds the emergency plan, how risk information is shared, and how quickly [synthesis]; suggest a medical review when you notice new or worsening symptoms, possible side effects, physical health concerns or a need for physical examination, which the guidelines say must be arranged on site if it cannot be done remotely [source: APA/ATA 2022]; support informed consent and shared decision-making by helping the client prepare questions for the prescriber [synthesis].
Example language (illustrative): "That sounds like something your psychiatrist needs to know about. Would you be OK with me letting her know, or would you rather raise it at your appointment? Shall we write down the questions you want to ask?"
Watch for: fragmented care across platforms, each clinician assuming the other holds the safety plan. Working: one shared, current emergency plan.

4.24 Conversations about medication, adherence and warning signs

Purpose / when: whenever a client in remote care raises medication.
Steps: listen to ambivalence, worries and side effects without advising any start, stop or change; route all medication questions to the prescriber; pass on (with consent, or as risk requires) reported side effects and warning signs; if the client describes symptoms that could be a medical emergency, follow your emergency plan for their location (4.9). [synthesis, consistent with the prescriber holding prescribing decisions]
Example language (illustrative): "It sounds like you're unsure whether the tablets are worth the side effects. That's a really important conversation to have with your prescriber before changing anything. What would you want them to understand?"
Watch for: clients stopping medication abruptly because they feel better or worse; remote prescribing that has lapsed because of rule changes (4.25). Working: medication concerns reach the prescriber quickly and the client feels heard rather than instructed.

4.25 Telepsychiatry prescribing rules (for prescribers; descriptive)

Purpose / when: relevant to prescribers and to psychotherapists working with them; psychotherapists do not prescribe.
Status: US prescribers must follow federal and state rules on controlled-substance prescribing, including the Ryan Haight Online Pharmacy Consumer Protection Act of 2008, based on setting, care model, scope of practice and the patient's location, and should anticipate regulatory change. [source: APA/ATA 2022] DEA and HHS (SAMHSA) issued a fourth temporary extension of the COVID-19 telemedicine flexibilities (Federal Register document 2025-24123, published 31 December 2025), running 1 January 2026 to 31 December 2026: DEA-registered practitioners may continue to prescribe Schedule II–V controlled medicines via audio-video telemedicine without a prior in-person visit, in line with DEA rules and state and federal law, provided the prescription meets the conditions set in the rule (legitimate medical purpose in the usual course of practice, an interactive telecommunications system, and a drug class covered by the practitioner's DEA registration); a separate final rule on telemedicine buprenorphine treatment for opioid use disorder took effect on 31 December 2025. DEA continues to work on a permanent framework, including a proposed special registration published in January 2025; the temporary rule does not finalise it, and arrangements after 31 December 2026 are [uncertain]. [source: Federal Register 2025-24123; telehealth.org] AACAP's page also flags that some Medicare telehealth flexibilities were due to expire on 1 October 2025 without Congressional action; current status [uncertain]. [source: AACAP Telepsych Home] UK: RCPsych urged in March 2020 that assessments be moved to video and audio during the pandemic; its current detailed remote-consultation guidance [uncertain]. [source: RCPsych news, 25 March 2020]
Psychotherapist's role: know that a client's access to a remotely prescribed medicine can depend on these dates and on their location; if a client says remote prescribing may stop or they are crossing state lines, encourage them to contact the prescriber early and include it in planning [synthesis].
Steps [synthesis]: (1) Note in the shared-care record who prescribes, from where, and whether by telemedicine. (2) If the client moves, travels or crosses state or national borders, prompt early contact with the prescriber. (3) Before a known regulatory date (in the US, the end of the current extension on 31 December 2026, per Federal Register temporary rule 2025-24123), invite the client to ask the prescriber about continuity. (4) Never advise on obtaining, changing or stopping a medicine; route every such question to the prescriber or pharmacist.
Example language (illustrative): "You mentioned your online psychiatrist said the rules might change at the end of the year. It might be worth asking them now what that would mean for you, so it doesn't catch you out."
Watch for: gaps in supply, clients obtaining medicines from unregulated online sources. Working: the client has a plan with the prescriber for continuity.

5. Handling problems

Sources address disconnection, emergencies, privacy and suitability; most other responses below are [synthesis] from general psychotherapy practice adapted to the remote frame.

Client refuses to give location or an emergency contact. Explain that it is a routine safety and legal requirement applied to everyone (APA/ATA 2022 ties emergency planning to knowing the location every session). Explore the reason (privacy fears, an abusive household, shame). If they still refuse, offer in-person sessions or explain that you cannot safely provide remote care without it, and help them find an alternative. [synthesis on the response; requirement from APA/ATA 2022]
- Example (illustrative): "I'm not asking to check up on you. If something happened and we got cut off, I'd need to know where to send help. What makes it hard to share?"
- Watch for: an address that later turns out to be wrong; consider asking again at each session.
Client logs off abruptly after a risk disclosure. Treat as a possible emergency: try to reconnect, phone the agreed number, then the support person, then local emergency services for the documented location, per your plan; document each step. [source: DCP top tips advise planning for this in advance; APA/ATA 2022 on coordinating with local services; sequence is synthesis]
Repeated disconnections. Check bandwidth and device; switch to telephone for the rest of the session; offer audio-only if video is unstable; if it persists, consider in-person or hybrid care. Explore whether drops follow difficult material. [source: APA/ATA 2022, DCP top tips on backup plans; exploration is synthesis]
Lack of privacy at home (shared flats, children, controlling partner). Problem-solve: time of day, headphones, a parked car, a walk with earbuds, a code word for interruptions, chat-only moments. If coercion is suspected, avoid questions that could be overheard, use closed yes/no questions, and arrange a safer channel or in-person contact. [source: UKCP 2021 and DCP top tips on interruptions and third parties; tactics are synthesis]
- Example (illustrative): "Just answer yes or no: is it OK to talk right now?"
Stuck clients and "flat" sessions on video. Check telepresence basics (camera, lighting, sound, self-view off); add more explicit process checks; use screen-sharing or shared documents for formulation work; review whether some sessions should be in person. [source: DCP top tips on lighting, sound and resources; rest synthesis]
Resistance or avoidance expressed through the medium (camera off, multitasking, joining late from the car). Name it gently as part of the work rather than only as a technical rule; agree minimum conditions (camera on for most of the session, stationary, private) in the contract. [synthesis]
- Example (illustrative): "I notice the camera's been off a lot recently. I wonder if it's easier not to be seen at the moment. Could we talk about that?"
Overwhelm and disinhibition (rapid, deep disclosure early on). Slow the pace, check the client's state, use grounding, and agree how the client will look after themselves when the screen goes off, since there is no journey home to settle. [source: UKCP 2021 on pacing disinhibition and transition rituals; grounding is synthesis]
Non-adherence (homework, attendance). Use the platform's practical advantages: share materials by secure link, review homework on screen; for missed sessions, check whether the format itself is the barrier and offer a switch of modality. [source: APA/ATA 2022 notes modality choice often improves attendance; rest synthesis]
Ruptures. They can be harder to see on video: lag, a misheard phrase or a challenge that lands differently at a distance. Ask directly after interventions that might sting, invite feedback, and repair explicitly; take patterns to supervision. [source: UKCP 2021 on challenge at a distance; DCP top tips on reviewing the relationship in supervision; repair steps synthesis]
Client travels to another state or country mid-treatment. Check your authority to practise there before the session (4.1); if you are not authorised, pause sessions, arrange interim local support or crisis information, or a short in-person or compact-authorised arrangement where lawful. Do not hold a clinical session just because the client is distressed and the link is open, unless it is an emergency response [synthesis; licensure principle from APA/ATA 2022].
Third party appears on screen or overhears. Stop clinical content, check with the client, and resume only when privacy is restored; in groups, ask the member to fix privacy or step out and rejoin. [synthesis; agreements for interruptions per DCP top tips]
Unauthorised recording discovered. Raise it directly, refer to the agreement, and discuss what happens to the recording; seek advice from your professional body or insurer if it is shared. [source: UKCP 2021 on clients not recording without discussion; response synthesis]
Data breach or platform compromise. Follow your written breach-response plan, inform affected clients and the relevant authority as the law requires (e.g. HIPAA breach notification in the US, the ICO in the UK) [source: telehealth.org summary of APA 2024 on breach plans; notification duties synthesis, check current rules].
Group-specific difficulties (one member in crisis, members chatting privately, a member off-camera). Use the co-facilitator to move the member to a private call while the group continues; restate group agreements; follow up individually after the group. [source: CDP group telehealth tip sheet on keeping a member online after the group; rest synthesis]
Child or adolescent who cannot speak freely at home. Offer school-based or in-person sessions, schedule when parents are out (with consent arrangements in place), and stay alert to safeguarding signs, since children may disclose less from home. [source: UKCP 2021 on safeguarding; scheduling synthesis]
Clinician fatigue and home-working drift. Limit back-to-back video sessions, build in breaks away from the screen, keep a dedicated private workspace, and use supervision. [synthesis; DCP top tips advise seeking support for the different feel of remote work]
Prescribing access uncertain because rules change. Encourage the client to raise continuity early with the prescriber; never suggest alternative sources or changes to medication (4.24, 4.25). [synthesis]

Sources

Primary and secondary sources:

Named only: AACAP, Clinical Update: Telepsychiatry with Children and Adolescents (October 2017), as listed on the AACAP telepsychiatry page; its contents are not summarised in this guide [uncertain].

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