Telehealth Counseling: Best Practices and Ethical Considerations

The Rise of Telehealth Counseling

Telehealth counseling (also called teletherapy, telecounseling, or distance counseling) refers to the delivery of counseling services through technology-mediated communication, including video conferencing, telephone, text-based platforms, and asynchronous messaging. While telehealth existed before 2020, the COVID-19 pandemic catalyzed its widespread adoption, transforming it from an alternative modality to a mainstream service delivery method. Understanding telehealth competencies, ethical considerations, and best practices is now essential for all counselors.

Modalities of Telehealth Counseling

Synchronous Video Counseling

Real-time video sessions are the closest approximation to in-person counseling and allow for observation of nonverbal cues (facial expressions, posture, gestures). This is the most widely studied and supported telehealth modality for mental health services.

Telephone Counseling

Audio-only sessions remove visual cues but may be preferred by clients with limited internet access, technology anxiety, or concerns about privacy. Telephone counseling has demonstrated effectiveness for depression, anxiety, and other conditions.

Text-Based Platforms

Asynchronous messaging and chat-based counseling provide flexibility and accessibility but present challenges including limited nonverbal information, potential for miscommunication, and difficulty managing crises. These platforms may appeal to clients who are more comfortable expressing themselves in writing.

Evidence Base

Research consistently demonstrates that telehealth counseling is as effective as in-person counseling for many conditions and populations. Meta-analyses support equivalent outcomes for depression, anxiety, PTSD, substance use disorders, and eating disorders. The therapeutic alliance, a key predictor of treatment outcome, develops comparably in telehealth and in-person formats. Client satisfaction with telehealth is generally high, with many clients preferring the convenience and accessibility of remote sessions.

Ethical and Legal Considerations

Licensing and Jurisdiction

Counselors must be licensed in the state where the client is physically located at the time of the session, not just where the counselor is located. This creates complexity when clients travel or relocate. The ASWB Mobility Initiative and the Counseling Compact are efforts to facilitate cross-state practice, but counselors must verify current regulations in all relevant jurisdictions.

Informed Consent

Telehealth informed consent should address the specific modality being used, the technology platform and its privacy features, the risks and benefits of telehealth (including technology failures), emergency procedures (including the client's physical location for each session), alternative options (in-person referrals), confidentiality protections and their limitations in the digital environment, and the plan for technology failures.

Confidentiality and Privacy

HIPAA-compliant platforms must be used for video and messaging services. Counselors should educate clients about creating a private space for sessions, using secure internet connections, and understanding the limits of digital privacy. The counselor's own setting must also ensure privacy (no other individuals present, locked doors, sound masking).

Emergency Procedures

Counselors must obtain the client's physical address at the beginning of each session and have a plan for emergency situations including suicidal crisis, domestic violence, or medical emergency. Emergency contacts and local crisis resources for the client's location should be identified and documented.

Best Practices

• Test technology before sessions and have backup plans for technical failures
• Ensure adequate lighting, a professional background, and stable internet connection
• Make eye contact by looking at the camera, not the screen
• Adapt therapeutic techniques for the virtual format (shared screen for worksheets, digital whiteboards, mailing materials in advance)
• Be attentive to "Zoom fatigue" and consider shorter session formats when appropriate
• Assess client suitability for telehealth (technology access, private space, cognitive ability to engage with technology, severity of presenting issues)
• Maintain documentation that meets the same standards as in-person practice

Populations and Situations Where Telehealth Excels

• Rural and underserved communities with limited provider access
• Clients with mobility limitations or chronic illness
• Clients with transportation barriers
• Follow-up and maintenance sessions after intensive in-person treatment
• Clients who prefer the comfort and privacy of their home environment

Limitations and Contraindications

• Active suicidal crisis with no local support
• Severe cognitive impairment that prevents technology use
• Situations requiring immediate physical intervention
• Clients without adequate technology access or private space
• Some group and family therapy formats may be less effective remotely

Exam Tips

• Counselors must be licensed in the state where the CLIENT is located during the session
• HIPAA-compliant platforms are required for telehealth services
• Research supports equivalent outcomes for telehealth and in-person counseling for most conditions
• Emergency procedures must include obtaining the client's physical location each session
• Telehealth informed consent must address technology-specific risks and procedures
• The Counseling Compact is the legislative effort to facilitate cross-state telehealth practice