Provider Resources

Ensuring Safety in Telehealth: A Guide to High-Risk Mental Health Cases

Explore the challenges of working with high-risk clients via telehealth, and delve into the strategies that work best for specific client populations.

Written by
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Dr. Amy Marschall
Spring Health Provider
Clinically reviewed by
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Doctor showing a telehealth patient how to check vitals

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    In recent years, telehealth expansion has significantly improved the accessibility of mental health services for many clients. 

    For those obstructed by location, transportation challenges, or disability, in-person sessions are often inaccessible. Additionally, many individuals prefer the privacy and convenience of attending sessions from the comfort of their homes.

    Research consistently supports the efficacy of telehealth, showing comparable treatment outcomes to in-person sessions across various diagnoses. While the American Psychological Association (APA) doesn’t rule out telehealth for specific symptoms or demographics, it’s crucial to recognize that some clients may prefer in-person care, due to personal choice or specific risk factors.

    At the same time, it’s possible to address specific risks ethically with telehealth clients. By exercising careful consideration, therapists can provide competent care to high-risk clients via telehealth in many situations.


    Cutting, burning, and other self-harm behaviors are concerning to therapists. Even if a client isn’t suicidal, these behaviors pose serious risks, including injury, infection, and other complications. 

    Some therapists are wary of providing telehealth services to such clients due to the difficulty of monitoring behavior severity through video or audio sessions. But it’s important to note that clients can hide self-harm even during in-person sessions. 

    Research indicates that modalities to address self-harm behavior, such as Dialectical Behavioral Therapy, are beneficial in a telehealth setting. Ensure you continue to get appropriate education on telehealth and supporting clients through their treatment method, and communicate non-judgmentally about any safety concerns related to their behavior.

    Utilizing motivational interviewing and harm reduction strategies can assist clients in minimizing risks associated with behaviors they struggle to control. These approaches can help clients develop healthier coping mechanisms while working toward behavior alternatives. 

    Suicidal ideation

    One in four psychologists lose a client to suicide at least once in their career, according to a survey shared by APA. Other research shows similar rates for counselors, with 24% losing at least one client to suicide in their career. As therapists, we value our client’s safety and well-being, which is why addressing this issue is paramount.

    With telehealth, providers often worry about their ability to maintain client safety and implement appropriate safety measures. It’s worth noting that research highlights the positive impact of telehealth, reducing suicidal crises and emergency room visits, especially for clients in rural areas. This underscores the importance of conducting regular risk assessments for suicidal ideation throughout the treatment process.

    Additionally, it’s crucial to establish the client’s physical location at the beginning of each session for emergency purposes. Intake paperwork should include details about who the therapist can contact in case of an emergency, and therapists should always be well-informed about local crisis resources and emergency response protocols in the jurisdictions where they provide telehealth services. 

    If a client expresses suicidal thoughts without an immediate danger to themselves, assist them in developing a safety plan for potential crises. This plan can incorporate coping skills, reliable support contacts, and specific steps to take if they become a danger to themselves.

    It’s unlikely for a client to express active suicidal ideation and abruptly disconnect from a session, just as it’s unlikely for them to express such thoughts and immediately leave an in-person session. Ensure their commitment to the safety plan or connect them with an appropriate crisis resource before concluding the session.

    Impulsive and reckless behavior

    Therapists occasionally encounter clients who, while not actively intending self-harm, make choices that could jeopardize their safety. During telehealth sessions, therapists have limited control over the client’s physical environment, making it vital to address such behaviors proactively:

    • Is the session conducted in a secure location?
    • What activities are they engaging in during our conversation? 

    Establish clear guidelines and expectations for sessions, outlining specific policies if a client participates from an unsafe location. Collaborate closely with the client to create a safety plan, ensuring their active involvement and agreement with the plan. 

    This proactive approach fosters a safe and supportive therapeutic environment, even in the context of telehealth sessions.


    Clients experiencing psychosis often find it challenging to participate in telehealth sessions because of delusional beliefs affecting technology use and hallucinations hindering communication. On the other hand, psychotic symptoms can also create barriers to leaving the house, making telehealth a valuable and accessible option for care.

    Engage in a candid conversation with your client about their treatment options and their openness to telehealth. Extensive research shows that clients with psychotic disorders can benefit from telehealth if they are engaged and open to this method of treatment

    As with all client populations, therapists must remain dedicated to continuing education, ensuring they can provide effective interventions through telehealth services.


    While no diagnosis automatically excludes a client from telehealth, dissociative symptoms can challenge engagement in this setting. Given therapists’ limited control over the client’s environment during sessions, clients might struggle to prevent environmental triggers for dissociation. Additionally, re-engaging the client without physical presence can be more challenging.

    To address this, collaborate with your client to establish a safe and calming environment for their sessions, aiming to minimize triggers. Develop protocols for handling sessions if dissociative symptoms interfere, allowing the client to identify a nearby trusted person who the therapist can call for physical support if needed.

    Disordered eating

    Eating disorders have the highest mortality rate of any mental health diagnosis, surpassing suicide and complications from disordered eating. Clients with eating disorders require close monitoring of vital signs and physical health, and this can be difficult to monitor via telehealth.

    Therapists specializing in eating disorders must undergo specific training to provide comprehensive care. Clients must receive integrated medical and mental health treatment, ensuring a holistic approach to their diagnosis. Certain aspects of their care, especially medical treatment and vital signs monitoring, may require in-person sessions with the appropriate healthcare provider.


    Victims of abuse often find solace in telehealth, offering them mental support within the safety of their homes. However, in-home telehealth carries risks for this vulnerable population.

    Clients lacking privacy must find a secure location away from potential eavesdropping from their abuser. Collaborate with them to identify safe, private alternatives, ensuring their location is known for safety purposes.

    Whenever possible, schedule sessions when the abuser isn’t present, granting the client privacy. Regular risk assessments are crucial, enabling the creation and implementation of safety plans, similar to other clients facing danger.

    Clients can discreetly signal distress during sessions, using gestures like clenching their fingers around their thumb. Establish protocols for responding to these signals, as asking the client directly might jeopardize their safety. Develop codes for different situations, ensuring effective communication without compromising safety. 

    As always, comply with all relevant laws concerning mandated reporting for children, elderly adults, and vulnerable populations.

    Tailoring telehealth for high-risk clients

    While it’s crucial to recommend in-person sessions for those unable to engage in telehealth safely, many high-risk clients derive significant mental health benefits from telehealth services. 

    By proactively mitigating risks, telehealth can enhance accessibility to care for these individuals, ensuring they receive the support they need. This balanced approach enables therapists to cater to diverse client needs, promoting safety and accessibility in mental health services. 

    Discover how building a strong therapeutic alliance creates the foundation to assist clients in reaching mutually defined treatment goals.

    About the Author
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    Dr. Amy Marschall
    Spring Health Provider

    Dr. Amy Marschall is a clinical psychologist licensed in South Dakota, Montana, New York, North Dakota, and Florida. She got her doctorate from the University of Hartford in 2015 and completed her internship at the Psychology Training Consortium, Central Region. She has a full-time clinical private practice, Resiliency Mental Health, where she provides therapy and psychological assessments. She is also a speaker, educator, and author.

    About the clinical reviewer
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