The changing face of telesupervision and digital training in response to COVID‐19

Abstract

Supervision is a core foundation within the field of marriage and family therapy (MFT)/couple and family therapy (CFT) because it guides the personal and professional development of therapists‐in‐training. Traditionally, case supervision and self‐of‐the‐therapist work has been engaged through in‐person individual or group supervision on a campus or at a placement site. A review of training programmes, accredited within the United States by the Commission on Accreditation for Marriage and Family Therapy Education (COAMFTE), reveals that the majority of programmes are still campus based, with a small percentage of programmes now offered online or in a hybrid format (COAMFTE, 2021). Family therapists have lagged behind other mental health professions in their utilisation of teletherapy and telesupervision (Pickens et al., 2020; Sahebi, 2020; Watters & Northey Jr, 2020). However, for most in‐person masters and doctoral CFT programmes, the coronavirus disease 2019 (COVID‐19) pandemic necessitated a shift from both in‐person therapy and supervision to teletherapy and telesupervision in response to social distancing and shelter‐in‐place orders. Specifically, the shelter‐in‐place order in the United States required that, unless deemed essential personnel, citizens were to remain at home and leave only to complete tasks outside of their residence necessary to sustain life and health. This rapid pivot was important to maintain continuity for both clients and supervisees alike during COVID‐19 (Simms et al., 2021; Tarlow et al., 2020). It is likely that many CFT programme faculty had difficulty transitioning to these modalities owing to a lack of experience with virtual formats. Managing issues of informed consent, confidentiality, documentation, supervisory alliance, technology, professionalism and all other related procedures requires significant modifications in operating processes when providing virtual therapy and supervision. While the pandemic will eventually diminish, it is presumed that the use of teletherapy and telesupervision will only increase moving forward. This will allow clinical training programmes to reach clients who may not have otherwise been able to access their services, which may be particularly important for disadvantaged and/or low‐resourced communities (Augusterfer et al., 2020). It will also expand opportunities for clinical supervisors to provide telesupervision to clinicians working in remote and/or potentially international settings. Goodyear and Rousmaniere (2019) asserted that it will not be long before clinical supervision in various settings is influenced by technology in some form. Consequently, it is important to discuss the benefits, challenges, ethics, repercussions for self‐of‐the‐therapist work and implications for how telesupervision is conducted.

TELESUPERVISION

The onset of the pandemic caused universities across the world to shut down and pivot to online education quickly. Digital knowledge and skill sets varied widely among faculty and students, creating a sizeable learning curve for many and increased anxiety in the ability to adequately teach and/or learn effectively in this new modality (Sherbersky et al., 2021). Additionally, university programmes with mental health training ceased in‐person therapy and shifted to teletherapy and telesupervision.

Accredited programmes require a certain number of supervision hours to be based on raw data. Raw data, defined as audio, video or live supervision, is an important part of enhancing CFT supervisee competence. One of the advantages of raw data is that supervisors can provide feedback and suggestions based on observable therapist–client interactions. Raw data collected through asynchronous formats such as video or audio review allow one to watch and re‐watch sections of a session, providing the supervisee increased opportunity for self‐observation and self‐reflection (Topor et al., 2017) while allowing the supervisor to attend to particular behaviours, skills and interactions that occurred during a session. Synchronous formats would include video conferencing programmes (e.g., Zoom) where supervisors and supervisees are interacting in real time (Montalvo, 1973; Nadan et al., 2020). Live supervision is an integral intervention for supervisee development because they get immediate feedback and can implement interventions in real time. Traditionally, feedback in live supervision takes place through a knock on the door, midsession break or a phone call to the therapist in the room, whereas now, live telesupervision occurs via videoconferencing technology.

Nadan et al. (2020) described live supervision of teletherapy sessions with the therapist and the clients being visible and audible to one another, while the supervisor and any other supervisees watching are muted with no video but are able to hear and see the therapist working with a client. They suggested there are three primary ways in which supervisors can intervene during live videoconferencing supervision. First, the supervisor is able to talk or text the supervisee during the session to provide interventions and feedback to the therapist. Second, they can ‘enter’ the therapy room by activating their camera and microphone, enabling them to talk directly to the therapist as well as the client(s). Third, the supervisor may choose to have the camera and microphone on during the entirety of the session (Nadan et al., 2020). Most videoconferencing platforms also provide a feature called ‘breakout rooms’ where the therapist, supervisor and other supervisees can sequester themselves away from the client to deliberate about the case. A breakout room is analogous to a knock on the door or a midsession break in traditional live supervision formats. Generally, live supervision sessions have individual or group discussion prior to the session regarding case conceptualisation, any pertinent self‐of‐the‐therapist (Aponte & Kissil, 2014; Simon, 2006) concerns (which are defined and discussed in a later section), identification of what the supervisee needs from the supervision group and conversations regarding interventions. Following a live supervision session, there is a debriefing time where the supervisee and supervisor review the session and discuss the case moving forward. Telesupervision offers a different way to go about this process, but the process in and of itself remains unchanged (Nadan et al., 2020; Sahebi, 2020).

Telesupervision assumes technological competence on the part of the therapist, client and supervisor, and lack of competence can create anxiety in teletherapy and telesupervision. Additionally, internet connections issues due to low bandwidth or bad weather, limitations to internet access or lack of knowledge about or openness to telesupervision can make telesupervision more challenging (Augusterfer et al., 2020). Regarding live supervision specifically, other members of the supervision team are unable to engage in ‘sideways talk’, where they can whisper to one another during the session (Nadan et al., 2020). Although having a group text chain (e.g., WhatsApp) can mitigate some of this, trainees will likely be more selective on what they discuss in the text chain, not to mention that there is a delayed response and it is much more cumbersome to type ideas compared with talking with someone else. Additionally, it can be difficult to assess group dynamics within the supervision team (Nadan et al., 2020).

Although telesupervision has been available for over a decade, many training clinic supervisors resisted this format prior to the COVID‐19 pandemic (Sahebi, 2020; Watters & Northey Jr, 2020). One reason for hesitance to use telesupervision in training programmes is the potential impact on the supervisory alliance and self‐of‐the‐therapist work.

SUPERVISORY WORKING ALLIANCE

Supervisory working alliances, as defined by Bordin (1983), are relationships built on mutual understanding with goals, tasks and strong emotional bonds between supervisors and their supervisees. Relational therapists typically value in‐person supervisory processes, which are an extension of their own clinical training, to achieve this alliance and question if supervisors and supervisees can effectively connect when not in physical proximity with one other (Watters & Northey Jr, 2020). Indeed, a study by Hertlein et al. (2014) found that the majority of relational therapists are reluctant to providing online therapy owing to impact on the therapeutic alliance, a similar construct to the supervisory alliance. Additionally, many supervisors may be digital immigrants born before the widespread use of technology and are less digitally fluent than digital natives, possibly contributing to some of the resistance (Watters & Northey Jr, 2020).

Digital immigrant or not, supervisors are tasked with understanding the process of teletherapy as well as telesupervision. Supervisors must understand policies and procedures for online services as well as be prepared to manage technological issues that arise. However, since telesupervision is relatively new, digital competencies are only recently beginning to emerge, but the focus is on clinical practice rather than supervision (Pote et al., n.d.). While the British Psychological Society has published guidance for clinical supervisors to adapt to digital services (2020), as Sherbersky et al. (2021) note, there are no clear guidelines identifying what digital competencies are needed by supervisors to provide appropriate training of students to work in teletherapy. They further suggest competency guidelines are particularly salient for relational therapists, who must develop complex communication skills to effectively work with multiple clients in the room. This is also true for supervisors working with multiple supervisees in the room. The supervisor's knowledge and confidence in this area will influence the supervisory alliance, as he or she is able to instil confidence in their supervisees (Sherbersky et al., 2021).

Nadan et al. (2020) reported their experiences utilising Zoom for telesupervision at their training clinic in Israel. Owing to the social distancing guidelines implemented in Israel, all supervision and clinical sessions were moved to a virtual format for fourteen supervisors working with twenty‐eight supervisees and their clients. Supervisors reported their perception that the supervisory relationship was unchanged by the pivot to telesupervision. Supervisees reported that the safety they felt in supervision remained intact through the transition, and some noted that they felt more secure and less vulnerable receiving supervision online as opposed to being seated face to face with their supervisor. The authors noted that group supervision was also used successfully via Zoom, and supervisors and supervisees alike reported feeling safe and that the new format actually enhanced the group discussions (Nadan et al., 2020). Tarlow et al. (2020) transitioned three doctoral students from in‐person supervision to telesupervision and found no differences in supervision satisfaction or supervisory alliance. In a content analysis on the effectiveness of telesupervision, Inman et al. (2019a) found three consistent variables: the effectiveness of supervision, therapist development and the supervisory relationship. Analysis of these studies suggests that telesupervision is at least as effective as in‐person supervision and that supervisors and supervisees are able to establish a strong working alliance (Inman et al., 2019a). However, almost all studies utilised a hybrid model where supervisors and supervisees met in‐person at some point in the supervisory process. In fact, most authors recommended that supervisors and supervisees meet in‐person prior to videoconferencing.

ETHICAL CONSIDERATIONS OF TELESUPERVISION

Regardless of method of delivery, clinical supervision is a multi‐layered endeavour owing to the supervisor's responsibility for the quality, professionalism and ethics of both their supervision and their supervisees' therapy (AAMFT Code of Ethics, 2015; Vaccaro & Lambie, 2007). Telesupervision, with its reliance on technology, adds yet another layer to supervisory ethical concerns that include confidentiality (Hames et al., 2020; Orr, 2010; Wood et al., 2005), informed consent (Abbass et al., 2011; Barnett, 2011; Vaccaro & Lambie, 2007), competency (Barnett, 2011; Barnett & Johnson, 2008; Inman et al., 2019a), regulatory issues (Hames et al., 2020; Orr, 2010; Wood et al., 2005), documentation and record‐keeping (Falender & Shafranske, 2004; Orr, 2010) and self‐care (Bernard & Goodyear, 2014; Hames et al., 2020). A common belief before the COVID‐19 pandemic was that supervisors who were proficient at providing face‐to‐face supervision were also competent to provide telesupervision; however, it is now clear that the competencies required in face‐to‐face supervision do not always transfer directly to telesupervision formats (Watters & Northey Jr, 2020). The following discussion explores the ethical challenges of telesupervision that unfold differently than face‐to‐face supervision.

Supervisors are responsible for maintaining the confidentiality of their supervisees and their supervisees' clients (AAMFT Code of Ethics, 2015). Telesupervision takes place in cyberspace where there are no 100% guarantes of privacy, and therefore, the threat of unauthorised access to confidential material is increased (Inman et al., 2019a; McAdams & Wyatt, 2010; Vaccaro & Lambie, 2007; Wood et al., 2005). However, as in therapy, video‐conferencing platforms are vulnerable to unauthorised access unless they are equipped with appropriate security protocols (Abbass et al., 2011; Inman et al., 2019a, 2019b). Unlike providing therapy services, though, supervisors often supervise by viewing recorded therapy sessions. Although a very useful mode of supervision, it could constitute a potential threat to confidentiality unless the videos are stored, maintained and viewed in secure physical and electronic settings (Abbass et al., 2011; Hames et al., 2020). In addition, when telesupervision entails the transmission of documentation or other materials for review, there exists a potential risk of breaching client confidentiality (Abbass et al., 2011; Wood et al., 2005). Even with the use of encryption software, there is still the risk that a person other than the supervisor might retrieve the communication and documents (Orr, 2010). The use of HIPPA (Health Insurance Portability and Accountability Act of 1996; USA)‐compliant websites or cloud storage sites that allow documents to be securely accessed by authorised individuals could be a better choice for the sharing of supervision materials. Other recommendations for addressing email confidentiality include disclaimers on emails stating that it is of a confidential nature (Morissette et al., 2012), clear and documented agreements between supervisor and supervisee about how these issues will be handled and development of a standard operating procedure (Inman et al., 2019a; Orr, 2010). Additional suggested protocols for maintaining confidentiality while engaging in telesupervision include ensuring that supervisor and supervisee's physical space is private, with reduced potential for interruptions or being overheard (Hames et al., 2020), and refraining from the use of identifying client information when discussing cases online or engaging in electronic communication (Abbass et al., 2011; Wood et al., 2005).

The utilisation of telesupervision also has ethical implications for the supervisors' informed consent or supervision contract (Barnett & Molzon, 2014), as well as the supervisee's informed consent for therapy (Wood et al., 2005). Recommendations for supervisors' contracts include an agreement of how to maintain privacy while online; policies for confidentiality, security and encryption for the period of the contract and an agreement of whether sessions are audio or videotaped, how they will be stored securely, how long they will be kept and what they will be used for (Orr, 2010). The supervisee must also inform their clients that they are engaging in telesupervision and of the risk to confidentiality that may entail (Barnett, 2011; Vaccaro & Lambie, 2007; Wood et al., 2005). Furthermore, the client should be informed that their information may be transmitted electronically to the supervisor (Vaccaro & Lambie, 2007), and if therapy recordings are being utilised, clients must be informed of the video conference process in plain language (Abbass et al., 2011).

Supervisors are expected to oversee supervisees' competence and professionalism (AAMFT Code of Ethics, 2015). They are also expected to possess competence in the clinical areas to be supervised and in the practice of clinical supervision (Barnett, 2011; Barnett & Johnson, 2008; Sahebi, 2020). Therefore, supervisors must be competent in the technology, practice and ethics associated with providing clinical services online in order to supervise ethically, particularly if they are also supervising therapists engaged in providing teletherapy services (Barnett, 2011). Suggestions for helping supervisors ensure that they are practicing telesupervision ethically include reviewing the code of ethics (Morissette et al., 2012), training in technology for both supervisor and supervisee (Tarlow et al., 2020; Vaccaro & Lambie, 2007), developing protocols and back‐up plans in case of technological failure (Hames et al., 2020; Vaccaro & Lambie, 2007), routinely reviewing guidelines and updates from software providers (Abbass et al., 2011) and regularly updating virus scan programmes (Wood et al., 2005). An upside of telesupervision is the increased availability of and access to supervisors with specific therapeutic expertise, which has the potential to enhance supervisee training and competence (Watters & Northey Jr, 2020).

Another telesupervision ethical challenge is that of jurisdiction (Inman et al., 2019b; Vaccaro & Lambie, 2007; Wood et al., 2005). Supervisors may be required to have a licence in the supervisee's state (Inman et al., 2019a; McAdams & Wyatt, 2010; Wood et al., 2005), or it may be that supervision hours acquired through telesupervision may not be approved to count towards a supervisee's required supervision hours for licensure (Inman et al., 2019a; Tarlow et al., 2020; Wood et al., 2005). In addition, the supervisor should verify that, if the supervisee is providing teletherapy, they are licensed in the jurisdiction in which they are providing services (Orr, 2010). If the supervisor is working within a training setting, recommendations are that they should also check their regulatory codes and accreditation bodies to ensure there are no special restrictions on supervisees' practicum supervision experiences (Hames et al., 2020). Although jurisdictional issues must be properly attended, the possibilities for providing supervision to clinicians located in underserved and unreached communities around the world through telesupervision is exciting. Duan et al. (2018) discussed their experiences of supervisors in the United States providing supervision to Chinese clinicians, providing much‐needed mental health services in China. Although many challenges were encountered, the authors noted the success and wonderful multicultural learning experiences that this setup presented for the supervisors and supervisees involved.

Family therapists and therapists‐in‐training are generally relational people who value contact with others. This contact is experienced differently in online settings. Nadan et al. (2020) noted the challenges of the extended, focused screen time associated with telesupervision. For supervisors providing live supervision, intense divided attention was necessary to stay attentive to the session being supervised, communicating with the supervisees as needed, engaging with an observing supervision group and collaborating with any co‐supervisors. Supervisors noted the high level of fatigue that came from orchestrating all of these activities via a computer screen. Supervisors need to be aware of the potential for this fatigue and provide necessary breaks to help keep themselves and their trainees engaged in the supervision process in order to provide the best learning environment possible (Nadan et al., 2020).

Finally, ethical supervision is supervision that monitors psychological wellness, self‐care, distress and burnout, as well as concerns around professional competence of supervisees, regardless of the mode of delivery (Bernard & Goodyear, 2014). Supervisees, by definition, have a relative lack of clinical experience, and Tarlow et al. (2020) suggest that, paired with clinical responsibilities, this makes them more vulnerable to secondary traumatic stress and burnout. In addition, researchers are predicting a rise in mental health issues, including anxiety and depression, substance use, loneliness and domestic violence, in the general population as a result of the fear and social isolation surrounding the COVID‐19 pandemic (Galea et al., 2020). These factors taken in conjunction may indicate an increased need currently for supervisory focus and monitoring of clinician self‐care. Simms et al. (2021) reported the need for supervisors to always show compassion for their supervisees' distress over pandemic‐related and transition‐to‐telesupervision‐related distress, regardless of the supervisor's own perception of that distress. Galea and colleagues also suggest that digital technologies have the potential to bridge social distance, particularly when the contact involves voice and/or video. Telesupervision entailing video conferencing and incorporating an intentional focus on self‐awareness and understanding may be an important component in reducing social isolation and positively impacting supervisees' self‐care.

CONCLUSIONS

There are numerous benefits to telesupervision including increased scheduling flexibility, reaching trainees where supervision would not be otherwise possible and supervisee self‐of‐the‐therapist work, and these benefits can benefit both masters and doctoral CFT programmes. There are, however, some downfalls to telesupervision, including issues related to identifying group dynamics and establishing safety to engage in self‐of‐the‐therapist, possible environmental influences (e.g., distractions such as children, partners, surfing the internet) and confidentiality issues. Given the strengths and limitations of telesupervision, training programmes should be intentional in determining whether to implement as an alternative to in‐person supervision or an adjunctive form, particularly programmes that place a strong emphasis on self‐of‐the‐therapist. Furthermore, the discipline should develop technical competency guidelines for telesupervision (Sherbersky et al., 2021). Should programmes want to implement telesupervision and also focus on self‐of‐the‐therapist, then we recommend having in‐person supervision first to establish rapport and familiarity and then shifting to telesupervision.

AUTHOR CONTRIBUTIONS

H.G., C.H., P.R., M.J. and M.F. each wrote a section of the manuscript. H.G. and P.S. were in charge of manuscript revisions and submitting the manuscript. P.S. assisted with each of the manuscript sections. C.H., P.R. and M.F. assisted with some of the revisions.

CONFLICT OF INTEREST

The authors declare that there are no conflicts of interest.

ETHICS STATEMENT

The authors followed university and ethical guidelines in the preparation of this manuscript. Furthermore, as far as all authors are aware, no part of this manuscript infringes in any way on the copyright of other manuscripts.

Notes

Grames, H. , Sims, P. , Holden, C. , Rollins, P. , Jeanfreau, M. & Fitzgerald, M. (2022) The changing face of telesupervision and digital training in response to COVID‐19. Journal of Family Therapy, 00, 1–12. Available from: 10.1111/1467-6427.12415 [CrossRef] [Google Scholar]

REFERENCES