Key Takeaways

  • From exposure to trauma to living with a serious mental illness, there are all sorts of reasons a client may experience increased risk. 
  • Many people benefit from the increased flexibility, convenience, and privacy that teletherapy provides. But some providers have safety concerns about managing risk in a virtual setting. 
  • While some extra precautions must be taken to manage risk in a teletherapy context, therapists can provide excellent virtual care using the same general safety planning and crisis response protocols used in an in-person care setting.
There’s lots to consider when helping your clients navigate an increase in risk. And some therapists are understandably hesitant about managing risk in a virtual setting. They may wonder about safety planning, monitoring, and how to maintain a strong therapeutic alliance across a digital connection. The good news is that managing risk requires the same general protocol whether in an in-person or digital setting. While responding to risk in teletherapy does require some extra considerations, you can use the clinical skills you already possess to create an effective, affirming virtual treatment environment for clients facing an increase in risk.

What counts as an increase in risk?

When it comes to mental health, increased risk can take many forms. Some individuals may experience an uptick in symptoms in the aftermath of a major life event, exposure to trauma, or other significant change. In addition, people living with a serious mental illness may experience episodes of increased acuity. This population may face a greater risk of self-harm, suicidal ideation, and suicide attempts throughout their lives. In addition, people living with an active substance use disorder are also at risk for self-injurious behavior or a relapse that could compromise their safety.  If you’re unsure whether or not your client is facing an increase in risk, you can use an assessment like the GAD7, PHQ9, CSSRS, or AUDIT to better understand their experience. These assessments can help you monitor changes in the severity of their symptoms so that you can create safety and treatment plans that reflect your client’s needs. 

Tips for managing risk via telehealth through the therapeutic journey 

1. Gather extra context during intake and the start of each session

Many therapists worry about managing an active crisis virtually. So during your intake process, be sure to ask the client for their location as well as a local emergency contact number. As you discuss informed consent and the limits of confidentiality, be transparent about how and when you might need to use that information. As you continue to work together, ask your client for their physical location at the start of every session. This is important in case a crisis arises and emergency support needs to be called.

2. Determine a client’s risk level and monitor for changes

One of the most important steps in successfully managing risk in a teletherapy environment is to monitor the level of risk over time. You can do this by using one of the assessment tools mentioned above (the GAD7, PHQ9, CSSRS, or AUDIT) along with exploring a client’s risk and protective factors. Then, regularly assess for changes using whatever questionnaires are most relevant for your client. Clients expressing suicidality should, at a minimum, complete the CSSRS at every session.

3. Co-create a safety plan 

Use an industry best-practice risk management tool like the Stanley-Brown to co-create a personalized safety plan for clients whose history indicates they may experience an increase in risk. As part of this conversation, ask your client, if appropriate, whether they would prefer you to reach out to their emergency contact or their local emergency services in the event of a crisis. Document the plan and share a digital copy with your client (by email, for example). Throughout your client’s journey, make updates to the plan whenever necessary. You can find more tips on how to create a safety plan in a teletherapy setting here.

4. If needed, perform standard crisis intervention protocols 

If a client is in high-risk distress, or there is an active suicidal ideation or imminent danger occurring, therapists should perform their standard crisis intervention protocols and refer to their client’s safety plan. Virtually, this would involve keeping the client on the call while you contact the appropriate agency or individual. If a client in crisis suddenly hangs up or leaves the call, then it is appropriate to contact the client’s local authorities or the client’s emergency contact. Keep in mind that all HIPAA regulations still apply in these situations. Provide any outside party (emergency contact, police, etc.) with the most minimally required information possible to keep your client safe. 

5. Hold firm on professional boundaries, even if a client is in crisis 

In moving beyond the limitations of a traditional, in-person practice, teletherapy allows us to be more accessible to our clients. But sometimes this can lead virtual therapists to feel compelled to be “on-call” or available more than they would if they were in an office. This dynamic requires therapists to hold firm to their professional boundaries, even when clients are in crisis. So talk to your clients about what steps to take if they require after-hours support and provide crisis resources (like the 988 Suicide and Crisis Lifeline) from the very first appointment and consistently thereafter. 

How Rula supports therapists when risk is present

At Rula, we know that all therapists benefit from having a connection with their professional peers. So we built our platform to provide virtual therapists with opportunities to come together for peer support and clinical consultation when risk is present, and beyond. With Rula, you can choose to work with clients at the acuity level you’re comfortable with and our care coordination team will be there to help with higher level of care (HLOC) referrals whenever necessary.  To learn more about how the Rula community can help you build a thriving private practice, visit our website

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