Therapy conducted from 11 000 kilometres away
Refilwe S. is a clinical psychologist registered with the HPCSA who has practised in Johannesburg for eight years. She moves to Perth, Australia, for eighteen months to care for her mother. She keeps her HPCSA registration and her South African practice number, does not tell the Registrar that her address has changed, and continues seeing 20 South African patients by video - mostly on a free consumer video platform whose default setting records calls to the cloud. She has never met six of these patients in person. One evening a patient in Kimberley discloses active suicidal ideation with a specific plan and a stockpiled supply of tablets; the connection drops and Refilwe has no emergency contact number, no local colleague and no hospital contact in Kimberley. Her medical scheme claims continue to be submitted under her Johannesburg rooms address. She also opens a TikTok account giving mental health advice, which reaches 60 000 followers, and accepts two Australian clients who ask her to bill Medicare.
1. What is Refilwe's regulatory position in continuing to treat South African patients from Australia, and what must she do about it?
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She remains within the HPCSA's jurisdiction for services she renders to patients in South Africa. Registration is what authorises her to practise; it must stay current, and the Council's guidance on telemedicine and telepsychology requires the same standard of care, the same record keeping, and the same competence as face-to-face work. Registration alone, however, is not a complete answer - she must also be able to practise lawfully from where she is and to reach her patients safely.
Notify the Registrar. A change of address and practice details must be reported. Continuing to claim under a Johannesburg rooms address creates a false picture of where the service is rendered.
Australian law. Providing psychological services from Australia to clients in Australia is regulated there through the Psychology Board of Australia/AHPRA. She needs to establish what her status permits before accepting Australian clients; her HPCSA registration does not authorise practice in Australia.
Indemnity. Many policies are location-specific and require disclosure of changed circumstances. She must notify her insurer or she may find she is uninsured for exactly the case that goes wrong.
Continuing obligations. If she cannot meet the practical requirements - a reachable emergency contact, a local clinician or hospital for each patient, reliable connectivity, time-zone-appropriate cover - she should not continue, and should transfer care formally rather than drift into abandonment. There is no rule against practising from abroad, but there is a rule against practising without the infrastructure that makes the care safe.
2. Set out the minimum telepsychology standard Refilwe failed to meet, using the Kimberley incident as the test case.
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Informed consent specific to the modality. Written consent covering the technology, its risks, what happens if the call fails, alternatives, fees, and how emergencies will be handled. A generic consent-to-treatment form does not do this work.
Suitability screening. Not every patient is appropriate for remote care. Risk level, diagnosis, support available at the patient's end and the availability of local services are all part of the decision - and six patients never seen in person is a pattern that needs justifying, not a detail.
A written emergency protocol. For each patient: physical address, at least one emergency contact, the nearest emergency department, and a named local practitioner willing to be contacted. Refilwe had none of these for a patient in Kimberley, which is the most serious failing in the case.
Secure platform. A free consumer service that records to the cloud by default is not an appropriate place for clinical material. The Protection of Personal Information Act 4 of 2013 governs her handling of patient information, including storage and any cross-border transfer of data.
The incident itself. She must act - attempt contact on every number, ring emergency services for the patient's address, document each attempt and each time. Afterwards she must review the case, record what failed, and not simply resume.
Records. Same standard as in-person, including a note that the session was remote and any technical failure.
Competence and scope. Unchanged by distance. If a patient's needs exceed what she can safely provide remotely, the answer is referral, not adaptation.
3. How should the TikTok account and the two Australian clients be handled?
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TikTok - the problem is format, not platform. General psycho-education is permissible. What the ethical rules and the Council's social media guidance prohibit is advertising and canvassing, testimonials, creating false expectations of cure, disclosing patient information, and giving individualised advice that amounts to unassessed treatment. A 60 000-follower account giving mental health advice invites all of these. A commenter describing symptoms will start receiving what looks like advice, and a practitioner–patient relationship may be created without consent, contract, records or boundaries. The corrective is concrete: general information only, no individual responses, no case material, no identifiable patients, a clear disclaimer, a statement of registration, and moderation or disabling of direct messages.
The Australian clients. She cannot bill Medicare: a Medicare rebate requires recognised provider status under the Australian system, which her HPCSA registration does not confer. If she is providing psychological services to clients located in Australia, she needs to establish whether she must be registered with AHPRA - and if she is not, she should decline and refer rather than risk practising without registration in that jurisdiction.
The South African claims. Billing an SA medical scheme for a South African patient is not inherently wrong, but the billing must reflect the service truthfully. Claims lodged under a Johannesburg rooms address while she sits in Perth misstate where the service is rendered and will need to be corrected; scheme rules and the practice number conditions must be checked before further claims go in.
The advice to give her. Shrink the footprint to what she can do lawfully and safely from Perth. Correct the address and billing. Refer the Australian enquiries. Rebuild the TikTok presence as education with boundaries. Then tell her insurer what she has done.