Telehealth Therapy: What Changes When You Work Online
By Kristen McClure, MSW, LCSW | TherapistWorksheet.com
Telehealth is not simply therapy conducted on a screen. The medium changes the clinical relationship, introduces unique technical and ethical considerations, and requires deliberate adaptation of practice. This guide covers what actually changes in telehealth and how to adjust.
What the Research Says
The evidence base for telehealth therapy has grown substantially since 2020. For most presentations — depression, anxiety, mild to moderate PTSD, adjustment concerns — telehealth produces outcomes comparable to in-person therapy. Exceptions and nuances: severe psychiatric presentations, clients requiring close safety monitoring, and populations who need the containment of an office environment may be better served in person. Clinical judgment about modality matters.
What Changes in Telehealth
The physical space
You cannot control the client’s environment the way you can control your office. Clients may be in their car, a closet, a bathroom, a shared apartment. Privacy, interruptions, and physical safety become relevant in new ways. Assess the client’s environment early: “I want to make sure we have a setup where you can speak freely. Where do you plan to have our sessions? Will you have privacy?”
Nonverbal communication
Telehealth flattens the information available from body language, posture, movement, and subtle affect cues. You see a face and a torso. Therapists who rely heavily on full-body observation need to adapt. Compensate by checking in more explicitly: “I want to make sure I’m reading you correctly — what’s happening for you right now?”
The frame and boundaries
The physical boundaries of the office — the door, the waiting room, the fixed location — help create a contained therapeutic space. Online, these cues are absent. Some clients have more difficulty transitioning into “therapy mode” from their home environment. You may need to build a verbal ritual that signals the beginning and end of session.
Safety planning
Safety planning changes in telehealth. You need: the client’s physical address at every session (in case emergency services are needed), a local emergency contact, and a clear crisis protocol. Do not rely on the client knowing to call 911 if they are in crisis — have a plan.
The technology
Technical difficulties are inevitable. Have a backup plan: “If our connection drops and we can’t reconnect in two minutes, I’ll call you at [number]. Here’s my number in case you need to reach me.” Normalize technical problems without letting them derail sessions.
Legal and Ethical Considerations
Licensure across state lines
You can generally only practice telehealth in states where you are licensed. The PSYPACT and Counseling Compact allow multi-state practice for some licenses. Know your state’s specific requirements and those of any state where your clients are located.
HIPAA-compliant platforms
Standard Zoom, FaceTime, and Skype are not HIPAA-compliant for therapy. Use platforms that will provide a Business Associate Agreement: SimplePractice, Telehealth by SimplePractice, Doxy.me, TherapyNotes’ telehealth feature, or Zoom for Healthcare.
Telehealth-specific informed consent
Your standard consent form is not sufficient for telehealth. Add: technology risks, what to do in a technology failure, privacy limitations in the client’s home environment, emergency protocols across distance, and limitations of the medium.
Client Selection for Telehealth
Not every client is an appropriate candidate for telehealth. Clients who may need in-person care:
- Active suicidal ideation with insufficient safety support at home
- Severe dissociation that requires physical grounding
- Active psychosis
- Clients who cannot maintain a private space for sessions
- Clients who find the medium itself deregulating or distancing
Frequently Asked Questions
Is telehealth appropriate for trauma treatment?
For many clients, yes — with adaptations. Eye contact and proximity cues that matter in in-person trauma work require explicit attention online. Somatic and grounding work is more limited (you cannot hand the client a weighted blanket or a glass of cold water). Some clients actually feel safer doing trauma work at home. Clinical judgment case by case.
How do I handle it when a client is in a different state than where I am licensed?
You cannot provide clinical services to someone in a state where you are not licensed. If a client moves, travels frequently, or was only available in another state, you need to address the licensing issue. Check multi-state compact options for your credential.
What do I do if a client discloses suicidal ideation during a telehealth session?
Confirm their physical location (have this at the start of every session). Assess risk using your standard protocol. If hospitalization is needed and the client is refusing, emergency services can be called to their physical location — which is why you always need the current address, not just a home address.
Should I have a camera policy?
Yes. State your expectations about video clearly. Most telehealth therapists require the client to have video on for clinical reasons (your ability to assess presentation). Address exceptions directly — some clients have sensory or privacy reasons for camera-off requests, and these deserve clinical conversation.
Kristen McClure, MSW, LCSW is a licensed therapist who creates practical clinical tools to help therapists navigate the hardest moments in their work.