Login  |  Register
Jooble
Advertise here
Advertise here

Online Supervision using Digital Health Technologies: the six-dimension model

15 July 2019    Pip Weitz

Introduction

“I hope to be able to inspire people to think differently; to not to be afraid to be who they are and not to take everything they were taught in the school or in the media or anywhere else just as a given. Actually to question what is being said and the validity of it and to do it in a way that is constructive and that leads to higher understanding and higher levels of creativity. I hope that my path and all this exploration I have done can inspire people.” (Haramein, 2016).

When I first heard Haramein (2016) make this statement, I stopped. I realised that this call to inspire people to think differently and to explore reflects the goal of all my teaching, supervision and therapy. When I think of all the years of supervision I have received being inspired is the one thing that made the difference, made me think, made me challenge myself and others, made me try new things, and made me the therapist and supervisor I am today.

This Haramein quote now features in the opening page of all our Academy for Online Counselling & Psychotherapy course handbooks as a guiding principle for all our online students. Any student with a “tick box” attitude will not survive with us, and in online supervision it’s the same.

Anything digital is evolutionary with rapid change, equally anything to do with online therapy and online supervision is going through equally rapid evolutionary changes – if we don’t keep up with these advances, supervisors, supervisees and most importantly our clients, lose out and get left behind. This includes therapists working in face to face practice (F2F) where inevitably digital technology now has a role in supporting that face to face clinical practice.

In other words, digital provides us with huge benefits as a mental health profession, but with it come the inevitable responsibilities to use it sensible and select only evidence-based ways of working. Just as working face to face has its downsides (e.g. travelling time) so too digital has its downsides. This article is not a mantra of “the only way is online”, I hope to demonstrate how Digital Health Technologies (DHT) also impact face to face supervision although that’s not the central aim of this article.

In this article I shall set out some definitions, the context, the theoretical bases, discuss the advantages and disadvantages, research around online supervision, discuss the methods of delivering online supervision including how creative this can be, the potential and exciting opportunities that Digital Health Technologies bring to online supervision, and some of the dangers and limitations.

My role in this article is to inspire you to be adventurous as a supervisor (whether face to face (F2F), blended or online), underpinned by sound theoretical underpinnings and solid knowledge and evidence-based methods of delivery.

Definitions

The current overarching term is Digital Heath Technologies, which are described by NICE as

“Apps, programmes and software used in the health and care system. They may be standalone or combined with other products such as medical devices or diagnostic tests.” (NICE, 2019).

NICE requires their effectiveness to be evidenced. NHS England confirms this is evidenced:

Digitally enabled therapy is psychological therapy that is provided online or through mobile applications, with the support of a therapist. There is evidence to show these therapies can achieve comparable outcomes to face-to-face therapy, when the same content is delivered in an online format which allows much of the learning to be achieved through patient self-study, reinforced and supported by a suitably trained therapist. Many people prefer to access therapy in this way. (NHS England, 2019).

The BACP Ethical Framework (2018), article 60 defines supervision as providing

“….. practitioners with regular and ongoing opportunities to reflect in depth about all aspects of their practice in order to work as effectively, safely and ethically as possible. Supervision also sustains the personal resourcefulness required to undertake the work” (BACP, 2018).

UKCP summarises supervision as being

“ …. conducted within a formal working relationship. But it can take different constructs such as in groups, on a one-to-one basis, by telephone, by internet, in writing or by video.” (UKCP, 2019)

And now to definitions around the format. Face to face (F2F) is generally used to mean where two (or more) people meet in person in a physical space. Online would be via any remote method using digital technology. For the purposes of this article I will include the following different sorts of digital supervision: email, video, audio, live chat (text based), virtual reality.  Artificial intelligence is just beginning to make its way into therapy arenas, so this will be covered in the discussion.

The Context

We talk about online supervision and supervision online as if they are the same thing. This is very confusing. So, what is the distinction between online supervision and supervision online?

Training is the short answer. The unifying factor is online. What varies is the “how?”.

I devised Figure 1 for my recent chapter on online supervision. (Weitz, 2018).  Of course, I immediately find fault with the chart as this only demonstrates polarities and doesn’t cover all the blended options and the reality is that many of us work across a spectrum for delivery or receipt of supervision. By the end of this article I will have explained why training is so important for an online supervisor and I would caution against any supervisor delivering supervision to an online therapist without online specialist training because of the dangers particularly for safeguarding risk and digital security. You don’t know what you don’t know.

In Figure 1, only those in Group B have done it the right way for supervising online and online supervision. All the other groups are only partially trained for working online and could be putting themselves at risk inadvertently. Group B online supervisors have trained to work online as therapists and have further trained to supervise online therapists in the online setting. They are likely to be on ACTO’s Online Therapists Register and on ACTO’s Online Supervisors’ register. ACTO is the Association for Counselling and Therapy Online – it is a unifying association drawing its members from all the F2F professional membership organisations including BACP, UKCP, BPS, BABCP. It holds a register of professional members who have trained to work online therapeutically, and a second register of supervisors trained to deliver supervision online. It also provides a list of ACTO Approved Online Training Providers https://acto-org.uk/training-providers/.

So, to clarify many supervisors deliver their supervision online to supervisees who are working F2F. This is often a pragmatic decision, and generally is safe enough.

An online supervisor will be trained first as an online therapist, and secondly with a specialist online supervision qualification. This is the recommendation, for example, of ACTO, The Association for Counselling & Therapy Online. The domain of online supervision is what I am going to focus on for the rest of this article, through email, video, audio, live chat (text based), virtual reality.

The reality is that many supervisors and supervisees are involved in online supervision without quite realising they’re doing this. The BACP Working Online Supplementary Guidance gives this advice about supervision and training:

“It is considered ethically desirable to receive at least some elements of regular supervision by the same method of communication that is used with clients, in order to gain direct experience of the strengths and limitations of the chosen way of working.

Changing the method of communication with clients introduces new challenges and opportunities that can be greatly assisted by appropriate training. Good practice requires that anyone making significant differences in their practice should give careful consideration to what will be involved and have taken adequate steps to be competent in the new ways of working before offering services to clients.” (BACP, 2015-2019, 12)

That’s a coded way of saying ensure your training in order to be sure you are working within your limits of competence, which is required within the BACP Ethical Framework in our Commitment to Clients, article 2. (BACP, 2018).

The theoretical bases for online supervision

There is only one key publication concerning online supervision, Online Supervision: A Handbook for Practitioners by Anne Stokes (2018). This is currently a world leader. I hope others will follow as there is a real paucity in this literature field.

Stokes has pioneered the training of online supervisors and Part 1 of this publication covers some new models for online supervision, based on the portfolios of graduating students – this provides inspirational reading for those wanting to think about delivering online supervision away from the face to face models, but all of these build on existing face to face models.

Models of online supervision put forward in this publication include:

- The CLEAR model of online supervision, by Maria O’Brien, drawn from the original ideas of Peter Hawkins in the 1980s. CLEAR stands for contract, listen, explore, action, review.
- The FORUM model of online supervision, by Suzie Mosson, drawn on the ideas of Petruska Clarkson’s (2012) five relationship model. FORUM stands for Foundation, Online Transference, Restorative, Uninhibited, Meaning.
- The CARER model of online supervision, by Liane Collins, drawn from the original ideas developing in teaching and nursing. CARER stands for contract, assess, relationship, explore/educate, review.
- The improvisation of possibility model of online supervision by Sally Evans. Evans produces a very simple but effective diagram that summarises her model, in Figure 2.

Evans summarises her chapter with the following quote which provides an excellent resumé of the models identified above and will provide an excellent start point for the development of my six-dimension model.

“See, my online supervisory model isn’t new! While the method of engaging with supervisees may have changed, our work as clinical supervisors hasn’t. The principles of ethical, effective clinical supervision remain. We simply need to think differently about the existing, creative theories we have already and to play around with them.” (Evans, 2018).

The six dimensions of online supervision – theory and practice united

The above summaries of models of online supervision show there are so many different ways of delivering online supervision and none of them are wrong.

I need a theoretical model that I could call to mind at all moments in the supervisory process. I find some other models just too complicated for me to call up at any given moment. And no doubt your choice of model will no doubt to some extent reflect your personality.

Like so many before me, I found Inskipp and Proctor’s (2001) Supervision Alliance Model very useful and this model provides an important central component to my six-dimension model.

Formative

The tasks of learning and facilitating learning

Normative

The tasks of monitoring, and self-monitoring, standards and ethics

Restorative

The tasks of refreshment

Figure 3 Inskipp & Proctor′s Framework for Tasks within the Supervision Alliance Model

However, this model was written before the advent of digital my own model for online supervision, based on on Inskipp & Proctor′s Supervision Alliance Model extends it further to allow for digital aspects.

Figure 4 summarises the six different dimensions involved in online supervision. I prefer the term dimension as it is broader and includes processes, tasks, functions.

 

Dimension 1: The Supervisory Alliance – the pivotal dimension

The sixth dimension, that of individual or group processes and dynamics, is actually the most important pivotal dimension in the model and integrates with each of the other five dimensions. Simpson (2014), Cook & Doyle (2004), Pihlaja, Stenberg, Joutsenniemi, Mehik, Ritola & Joffe (2018), Prado & Meyer (2004).  have all researched the online therapeutic alliance and found it to be as strong if not stronger than in face to face therapy. O’Mahoney (2018), quoting Bernard & Goodyear (2014) reminds us that

“A strong supervisory alliance is associated with supervisees feeling more confidence, more passionate about their work and more competent.” (O’Mahony. 2018).

Webber & Deroche (2016) equally have found that the supervisory alliance is the cornerstone of supervision.

Turning to research around the online supervisory alliance, whilst there is room for a great deal more research there are studies which have found the online supervisory alliance to be very positive. These include Coker, Jones, Harbach and Staples (2002); Reese, Aldarondo, Anderson, Lee, Miller and Burton (2009); Rousmaniere and Frederickson (2013) and Bussey (2015) who all found the online supervisory alliance to be effective. Although this is early days in this area of research we can conclude that the online supervisory alliance is effective and an essential ingredient in successful online supervision. In addition, within the UK context, that should be even more successful given that ACTO encourages online therapists and supervisors to be trained to work and supervise online and therefore they very used to the limitation that online might bright and have adapted their practice to take account of these.

When applied in the group context, the supervisory alliance concerns all members of the group. Hopper (2014) in his forward of Weinberg’s The Paradox of Internet Groups (2014) reminds us of the power of communication in virtual groups:

“I myself know how difficult it is to maintain a reasonable balance between involvement and detachment when caught up in the power of communication processes of virtual groups. I have found myself suddenly merging with the unconsciously imagined group, plunging into a role that is infused with projections.” (Hopper in Weinberg, 2014).

In both individual and group supervision, once the supervisory arrangements have been completed the online supervisor has an important role in managing all these dimensions… but just as important is the involvement and participation of the supervisee or supervisees for a group, and it does take time to develop the supervisory relationship.

The BACP 2018 Ethical Framework states in item 61 of the section on Supervision:

“Good supervision is much more than case management. It includes working in depth on the relationship between practitioner and client in order to work towards desired outcomes and positive effects. This requires adequate levels of privacy, safety and containment for the supervisee to undertake this work…..” (BACP, 2018).

This is as true for online supervision. I believe it is my role as an online supervisor to role model with supervisees …… and so I aim to deliver my online supervision in a reflective way inclusive of each of the dimensions. It’s such a strong method of learning.

I am going to discuss each of the other dimensions in the next sections.

Dimension 2: the Normative / Managerial Dimension

As with creating a safe space in F2F supervision, whether individual or groups, the supervisor has a very important role is setting the frame for supervision. This is even more important in the online context where things can more easily go wrong. I was taught when I trained to always assume goodwill. It has been one of the most valuable things I was taught on the course.

Creating a safe space for supervisees to enter into the six dimensions starts from the very first contact and the ensuing paper trail and contract to be signed. This is another thing that is different online – we onliners have been trained to use agreements, both for online therapy and online supervision. This is preceded by an information pack – very important as there is so much to think of in the online context that we take for granted in F2F work.

The Managerial / Normative dimension of online supervision provides the quality control function of the work with clients. It depends to some extend on the online supervisor’s managerial and ethical responsibilities to ensure the client’s welfare.  In an online supervision group this responsibility has some shared role, but it is very important in this dimension that the supervisee does not feel picked on by the group. This requires very careful handling by the online supervisor.

Within this dimension comes our requirement to think through the BACP Ethical Framework (2018) article 2 which requires us to make a commitment to our clients to work to professional standards by working within our competence, and keeping our skills and knowledge up to date.

Within this dimension we’ll be needing to discuss periodically the roles and responsibilities for individual supervisees caseloads, and ensure that the supervisee complies with the procedures & policies of any organisational setting, and works according to the code of practice and ethics of a professional body e.g. BABCP, UKCP, BACP or ACTO.

It is in this dimension that we have to think about safeguarding, risk and jurisdictional issues – something a supervisor working with F2F supervisees (i.e. those seeing clients F2F) would have no knowledge of. Of course, this ties in with Dimension 3, around the formative process, but is concerned with ensuring the supervisee stays on the right side of both the law and an ethical framework. Examples of this might be, as follows:

Example

Possible Actions to consider in online supervision

A woman client with two young children reports that her husband who is an IT consultant is being very abusive

 

Consider whether the husband has access to her computer and if so suggest and alternative ways of delivering the therapy perhaps away from the house or/and away from her computer or mobile phone

Consider the safety of the children and the client and whether you are required to involve Social Services (what if they were abroad?)

A young man requests online therapy who lives in Zimbabwe

This is where knowledge of local law is required – you may put this young man at risk by working with him online and discussing this as the conversation or live chat may be recorded / scanned by secret service robots.

Figure 5 Possible Actions to consider in online supervision

These are just two examples to demonstrate both how jurisdictional and digital issues could seriously interfere with the process of online therapy. An online therapist should know how to deal with these matters, this is the sort of issue covered within online therapy training curricula (or should be, if you are thinking of training please ensure that the course you are going to do includes jurisdictional and digital issues).

Dimension 3: the Formative/Educative Dimension

This dimension involves the tasks of learning and facilitating learning in online supervision.

As an online supervisor we are required to ensure that supervisees are fully informed of the latest technology and all the legal, technological, jurisdictional, relational, educational, practical and ethical aspects that could impact on the therapeutic relationship. A face to face supervisor would be out of their comfort zone very shortly when it comes to many of these items, hence the paramount need for training as an online supervisor.

Whilst client work is at the heart of the reflection on and exploration of the supervisee’s work with clients, this can also pan over into broader themes. For example, recently I was asked whether UKCP or BACP was better. This seemingly simple question engaged the online supervision group in a lively discussion about the benefits and disadvantages of both and raised issues that some of the group had never thought about. The group here were taking care of each other, informing each other and building a mutual understanding. In fact, I have now implemented within each of my groups a monthly consideration of one aspect of the BACP Ethical Framework, with special consideration of the online aspects. Each month a group member chooses the aspect of the Ethical Framework that they would like to present. This fulfils amply my commitment to the BACP Ethical Framework article 69:

“The application of this Ethical Framework to the work with clients will be discussed in supervision regularly and not less than once a year.” (BACP, 2018).

Another recent example that comes within this dimension is data security and GDPR. I am often surprised by how little therapists and supervisees understanding of the requirements in law regarding the management of data security.  Very quickly we see the overlap between the delegatory and legal requirements within the normative dimension and within the formative dimension. This is as true for F2F therapists and here Id say that those trained to work online have a much better grasp of the requirements of data security. Everyone worries about GCHQ levels of data security, though my experience is that most issues are far more basic – such as having client’s phone numbers and their names coming up on their mobile phone screens, and the same for messages. Through supervision we have a trickle-down effect … influencing good data security for therapists and clients.

The online supervision group through discussion and at times through group process itself encourages each of us to better understand our clients better. The richness of experience in the group means that each brings an individual contribution to the discussion, as demonstrated in this extract:

“The group gently begins to ask her [the co-supervisee] some questions and to reflect on these facts and events. We come as a group gradually to the view that somehow Jennie has taken on the counter-transference of her client and is doing the grieving that John should be doing. Jennie finds this very helpful and we can see her eyes flicker with recognition of an understanding of the process going on within her, quite physically regarding John…… We all share our concerns about both Jennie and John and I, as online group supervisor, can see that Jennie is looking cared for and supported by the group”

Through this online group exploration we each become more aware of our own reactions and responses to the client, we tease out the dynamics between the therapist and client …. sometimes as paralleled in the online group; we look at some of the possible interventions and their potential consequences.  What would have happened if Jennie had not become aware of the way she was carrying John’s bereavement? It was such a powerful session and in such a short time led to so much learning for the entire group. It’s one of the reasons I so like running online supervision groups, the group learning is so much more than the sum of the part.

Others in the online group may have other similar experiences to draw on which may help demonstrate the points being made. Equally, the different theoretical models practised by different members of the group provided a marvellous resource to the entire group.

The aim of this dimension in online supervision is to assist the supervisee’s learning and development.

Dimension 4: The Supportive/Restorative dimension

This dimension literally feeds the supervisee. It is amazing how one online supervision session can reinvigorate a supervisee, return them to remembering why they became a therapist, as the above example illustrated. We often talk about this dimension as a way of responding to supervisees who have become affected by the distress, pain and fragmentation of the client, but we can go further and act as a preventative layer, by taking care of the supervisee through supervision this person can feel held and we can avoid the crisis situations that sometimes arise where a supervisor may have to recommend that a supervisee stops working temporarily or permanently.

Spotting that a supervisee needs this support when working online in supervision can require some real reading between the lines. It may be easier for a supervisee to hide behind the camera, or email but the example above shows how the group dug out the supervisee through the use of counter-transference and helped her address the transference issues between her and her client.

This dimension may help the supervisee to reflect on over-identification with the client’s material (as was Jennie’s situation); working through transference and counter-transference processes, and watching for any re-stimulation of supervisee’s own experiences. This is an area where there is some cross-over between supervision and therapy, but there will be times when the online group’s role, or the supervisor in the case of individual supervision, is to encourage the supervisee to take an issue to their own therapy for further exploration. In many ways there is little difference between F2F and online work here, but the group will be looking out for the additional unseen, unheard aspects of the supervisee’s contribution.

In the example above we showed how the supervisory relationship was enhanced by offering support and a place where the supervisee can bring difficult issues and feel safe.  Emotional effects of working with clients can create intense feelings, especially if the client is in distress.  Additionally, the relationship with the supervisor and the combined effects of the supervisee’s work, training, home life, and own process will make an impact for the group. All this is true in F2F supervision, but because a supervisee can feel quite isolated when working online this good online supervisory alliance can really help an online supervisee not only get over the issue that was concerning but to develop within the online setting and use the support that online supervision supplies more fully.

Dimension 5: Digital Health Technologies Dimension

Norcross, Pfund & Prochaska (2013) in their seminal paper on forecasts for the future of psychotherapy in 2022 stated:

“For almost its entire history, psychotherapy has relied almost completely on two ancient technologies, namely, talking in the office and reading printed text for homework. Given how rapidly and widely digital interventions have spread in behaviour change for health promotion, wellness, disease prevention and management, it would seem like only a matter of time that such Innovation would be diffused as an integral part of mental health. (Norcross, Pfund & Prochaska, 2013, (p.369)

How right they were, and this is one of the biggest challenges to the counselling and psychotherapy professions at the moment …. and in turn creates quite a headache for supervisors as they struggle to keep up with the changes.

The Digital Health Technologies (DHT) Dimension incorporates the digital and cyberspace aspects of working online within the format of the supervisory relationship.

The UK’s National Institute for Health and Care Excellence (NICE) has as one of its priorities, the implementation of DHTs. But to be sure to get its money’s worth each DHT has to be evidenced and the summary of this is in the NICE document Evidence Standards Framework for Digital Health Technologies (NICE, 2019). Traditional private F2F psychotherapy would probably not engage much or at all with most of the aspects covered in the Figure 6.

 

Figure 6 DHTs classified by function and stratified into evidence tiers (NICE, 2019)

The NHS through its teams of psychologists and CBT therapists, together with some other counselling and psychotherapy traditions will be providing therapy within the framework set out above – this shows just how far the reach of DHTs is into therapeutic treatments, and as an online supervisor managing supervises working both within the NHS and private sectors for online work it’s my responsibility to be sure that I keep up to date. Most of the therapy we provide, and the supervision that I provide to those therapists, is within evidence tier 2, and I am showing in Figure 7 the NICE recommendations for DHTs. As an online therapist and supervisor, I find this both challenging and exciting as it bringing a whole new way of working to traditional psychotherapy, and rightly requires therapeutic tools to be evidenced.

 

Figure 7 DHTs in evidence tier 2 after being stratified by functional classification (NICE, 2019)

Under Inform, for example, amongst the tools that might be used is CORE-Net is a perfect example of collecting client data as an entirely an online tool. I have already mention ORCHA and apps, another tool.

Thinking about CORE-Net client feedback from the ACTO Pilot using CORE-Net confirms that the therapeutic alliance is a much more equal relationship, working together:

“On the effect of using CORE-Net on the therapeutic relationship, several therapists mentioned that they thought it gave the clients more ‘ownership’ of both the data and the process. Being able to discuss the data in the sessions seemed to make therapy more ‘transparent’, and so ‘empowered’ the clients, making the therapeutic alliance feel more ‘equal’.” (Klug, 2018).

Under Communicate, for example, would be included the choice of media, such as Zoom for video conferencing, or just for audio or live chat, Frama- mail for encrypted therapeutic emails.

Many of these items simply do not feature in F2F supervision and therefore a F2F supervisor would be quickly out of their comfort zone in any consideration of these areas. This is a particular area where all supervisors delivering supervision to either F2F or online supervisees need to focus on – DHTs is the future both within state funded and private therapeutic care. In addition, the use of DHTs help to assess and monitor safeguarding requirements. Tools such as CORE-Net will be invaluable for this and this field is changing all the time and very shortly CORE-Net will be joined by NORSE, which will give even great sensitivity and flexibility to the tools being used and be able to focus better on the evidence relating to the online therapeutic alliance.

The BACP is currently managing a working party looking at how DHTs impact in F2F therapy and are developing some resources to support practitioners. This will include the safe use of mobiles, emails, text-messaging, keeping notes. All the stuff that goes toward the management of a F2F practice. These items are as valid for online work but are overlaid by online administration and resources that are less used in F2F practice, for example the use of apps. For example ACTO has an online resources for both members and others visiting the site which provides information and guidance about apps that have been reviewed by ORCHA ensuring that only tried and tests apps are used by either therapists or clients – ORCHA is the world leader is mental health apps reviews and assessed apps for the NHS Choices Library.

Being aware of platforms that are suitable for therapy is critical. Being aware that therapeutic emails or emails that have client content within them should NEVER go on an open email. Being aware of whom might access a live chat text could be critical to the safety of a client. These are all the online supervisee’s responsibility to known and act upon, and for an online supervisor to advise on – you can see how this falls also into both ether formative and normative dimensions and is way outside the average knowledge of a face to face supervisor. This is not a criticism, it’s just a fact.

 

Figure 8 The Digital Health Technologies Dimension in online supervision

Figure 8 gives a summary of some of these digital aspects of psychotherapy but as things change so quickly this should not be considered an exhaustive list, and demonstrates why the BACP’s Ethical Framework article 2 asks us to commit to work to professional standards by keeping our skills and knowledge up to date. (BACP, 2018).

Dimension 6: the Relational Dimension

The relational aspects within the digital context are critical to success for this online relationship, and closely linked to the first dimension, that of the online therapeutic alliance. This is the case no matter what modality or training you may have. This is in some ways the most discrete area as it is often the unseen and unheard parts of the online relationship, and this is where training makes all the difference: in our Academy diploma courses a whole term is dedicated to this alone. This is the chunky area for consideration in online therapy and online supervision.  It’s a matter of using your powers of perception that you build up as an online therapist and supervisor, to consider the unsaid and unseen, and using the body as a barometer. In the example I used earlier, through the group’s gentle work Jennie became aware of the transference and countertransference within her relationship with her client John.

When working in an online supervision group the process which develops becomes such a supportive influence within the supervision and has influence and inspiration that goes well beyond the limits of the online supervision group. Trust is an important element of this and it is amazing how quickly this develops in an online context, and how group members hold each other and really care for each other.

Relational psychotherapy views the therapeutic relationship as central to psychotherapy and “relational therapists utilise the therapeutic relationship in order to become conscious of interpersonal dynamics between their clients and themselves to better enable the understanding of the client’s relational style.” (The Relational School, 2018). This relational psychotherapy adapts very well to the online context and is integral to my supervisory and therapeutic work. In online supervision it’s important for us to respect the tradition of each supervisee and their model for working therapeutically, as relational aspects will be more important in certain modalities. It’s the richness of each of these different modalities drawn together in the online supervision group that give such a richness to the supervisory process.

Dimensions Conclusion

The six dimensions, summarised in Figure 4 are interdependent with some element of cross-over. For example Digital Health Technologies might include technology needs, specific risk management and assessment; ensuring data protection compliance, or the jurisdictional issues that arise almost daily in the line of an online therapist and supervisor would fit usually within the formative and normative, whilst the relationship online including the unsaid and unseen (a different version of reading between the lines) underpins all these processes and without which, neither the normative, restorative nor formative could flourish. 

The advantages and disadvantages of online supervision

I am sick and tired of hearing “well we can do online until we can do face to face”, as if it were second best. Some of the evidence I have included in this article is even quite old by digital standards, 20 years, so working online either in supervision or therapy is not new, so I am puzzled why so many treat this as new or second best, despite the long-existing evidence.

Online supervision and online therapy are robust in their own right. Supervision delivered online is a winner for so many reasons. Here’s a few examples that demonstrate this:

- It cut down travelling time and costs – how many of your supervisees travel many hours to see you?
- It opens access to supervision for a whole group of therapists who could not otherwise access supervision easily (travel, carers with family commitments, those with physical illnesses, those with agoraphobia.
- It’s a new way of accessing people in their worlds, their psyche, and for many it’s an opportunity to do therapy and supervision in an entirely different and sometimes very creative new way.  As an example, just as Freud used free association on the couch, working via live chat (text-based therapy) can lead to a similar freeing, one of the wider aspects covered in the term disinhibition, which is explored fully by Suler (2016). This new way of accessing clients in their world is perhaps the most exciting of all these points.
- It’s more effective than face to face therapy. This is evidence based. I could quote pages of evidence, but here’s just a few to whet your appetite: Simpson, 2014; Wagner, Horn, & Maercker 2013; University of Zurich (2013).
- One of the things I enjoy most about online supervision is the joint building of the session notes – I deliver my supervision usually via Zoom video and we use the live chat facility to built the sessions notes together – everyone can add their bits, their ideas, their references and resources. By the end of an hour and a half we have such a useful resource for each of us to take away.

The benefits obviously are counterbalanced by some dangers that are inherent in online therapy. Any online supervisor needs to be fully aware and trained in the following aspects:

- The legal aspects of working online: safeguarding, different laws, informed consent, contracting, child protection, GDPR, Gillick competency and Fraser guidelines, our requirement to comply with the international sanctions list, the terrorism act, consumer contracts regulations
- The technological aspects of working online: being competent with the technology, managing time zones, understanding how technology impacts on the therapy and what’s safe to use as technology (eg. Why not Skype and why zoom?)
- Jurisdiction issues – how the laws of another country might impact on your therapeutic work
- The practical aspects of working online: developing a sense of screen presence, relational understanding of what is unseen unheard – for example the role of body language
- Therapists resistance to working online: how many times have I said in front of a group of therapists that I work online only to be told, that’s not possible. And that’s amongst the politer versions. I have received harassment and rudeness on open forums that I would never have expected from a profession that is invested in helping others to live and understand each other better. This resistance by therapists has been evidenced by Shore, Savin, Orton, Beals & Manson (2007); D’Arcy, Hanley, & Wolf (2012); Rees and Stone (2005). You’ll no doubt have noticed that some of this research is quite old, in other words, we’ve known this for some time!

We’ve already come across most of these within the Dimensions discussions. This is not an exhaustive list – it’s just to demonstrate that delivery therapy or supervision online without training is as dangerous as drink driving. One senior therapist said to me once “I only work a little bit on Skype” …. As if only drink drinking on Christmas Day when coming home from the pub is acceptable. Complacency and ignorance are preventing the psychotherapy profession from advancing in this world of DHTs which include the impact of social media, mobile phones etc within face to face (F2F) therapy space. In Chapter 5 of my book Psychotherapy 2.0, Alexandra Chalfont demonstrates graphically a couple inappropriately playing out their couple therapy within social media. (Chalfont, 2014).

In fact, working online without training is the short cut to a complaint as you can’t know what you don’t know. The same goes for online supervision, and as we’re nearing the end of this article, I hope you can see why.

Inspiration goes a long way. Being an inspirational online supervisor is all I aim to be. But that doesn’t happen on its own. It requires a great deal of study, experience, humility, openness, enthusiasm, looking at one’s own resistance, being open to challenge and to be challenged …. and above all vision. All this is seamlessly underpinned with theory.

Conclusion

As an online supervisor I am required to think on a number of levels all at the same time – about each of the six dimensions I have outlined, whilst also checking the group processes and ensuring fairness of the session.

The online and digital issues that have arisen would be challenging to someone without training to both work and supervise online.

As Norcross pointed out (Norcross, 2013) we are living in exciting times where technological disruption is the key driver in psychotherapy. This means that whilst it can be challenging for some, DHTs provides us with a completely new canvas to work on in online supervision which is daunting and exciting in equal measure.

I started my article by talking about the importance of inspiring supervisees and being open to be challenged and challenging. I end with an inspirational quote from Rogers (1972). Roger’s in his 1972 address to the American Psychological Association, entitled “Some New Challenges” finished with three small words: “Do we dare?” This is what I invite you to do: dare to train to work online and supervise online and embrace all the DHTs bring as tools for working a new and creative ways with supervisees and clients.

References

BACP. (2018). Ethical Framework for the Counselling Professions. Lutterworth: British Association for Counselling and Psychotherapy. 1st July 2018. https://www.bacp.co.uk/media/3103/bacp-ethical-framework-for-the-counselling-professions-2018.pdf [Last accessed 20/08/2018]

BACP. (2015-2019). Good Practice in Action 047 Fact Sheet: Woking Online in the Counselling Professions. Lutterworth: British Association for Counselling and Psychotherapy. March 2019. https://www.bacp.co.uk/media/2162/bacp-working-online-supplementary-guidance-gpia047.pdf [Last accessed 23/06/2019]

Bernard, J.M., & Goodyear, R.K. (2014). Fundamentals of Clinical Supervision. 4th edition. Boston: Pearson Education.

Bussey, L. E. (2015). The Supervisory Relationship: How Style and Working Alliance Relate to Satisfaction among Cyber and Face-to-Face Supervisees. PhD diss., University of Tennessee. Available online at: http://trace.tennessee.edu/utk_graddiss/3564.

Chalfont, A. (2014). Challenges and Dilemmas in the online consulting room: Same old, with new angles. In: Weitz, P. (Ed.). Psychotherapy 2.0: Where Psychotherapy and Technology Meet. (pp. 89-101) London: Karnac, 2014.

Clarkson, P. (2008). The Therapeutic Relationship (2nd edn). London: Whurr. http://web.archive.org/web/20061006235927/http://www.psych.lse.ac.uk/complexity/Seminars/1998
/clarkson98jan.htm
. [Last accessed 23/06/2019]

Coker, J. K., Jones, W. P., Harbach, R. L., & Staples, P. (2002). Cyber-supervision in the first practicum: Implications for research and practice. Guidance and Counselling. 18(1): 33–38.

Cook, J. E., & Doyle, C. (2004). Working Alliance in Online Therapy as Compared to Face-to-Face Therapy: Preliminary Results. CyberPsychology & Behavior. Vol. Volume: 5 Issue 2: July 5, 2004. https://doi.org/10.1089/109493102753770480. [Last accessed 24/06/2019]

D’Arcy, J.R., Hanley, T., & Wolf, W. (2012). Reaching out across the Virtual divide; An Empirical Review of Text-Based Therapeutic Online Relationships. In: Popoola & Adebowale (Eds). (2012). Online Guidance and Counseling: Towards Effectively Applying Technology. Hersey, PA: Information Science References, 2012.

Evans, S. (2018). Let’s play: the improvisation of possibility in online supervision. In: A. Stokes (Ed). Online Supervision. (pp.90 – 94). London: Routledge, 2018.

Haramein, N. (2016). The Connected Universe. 2016. http://getconnected.resonance.is/ [Last accessed 17/08/2018]

Hopper, E. (2014). New International Library of Group Analysis Forward. In: Weinberg, H. The Paradox of Internet Groups: Alone in the Presence of Others. London: Karnac, 2014.

Inskipp, F. and Proctor, B. (2001). Becoming a Supervisor. London: Cascade. Bubble 12.

Klugg, R. (2018). An Evaluation of Using CORE-Net with Online Therapy. ACTO. https://acto.org.uk/core-net/. [Last accessed 25/06/2019]

National Institute for Health and Care Excellence (NICE). (2019). Evidence Standards Framework for Digital Health Technologies. (March 2019).  https://www.nice.org.uk/Media/Default/About/what-we-do/our-programmes/evidence-standards-framework/digital-evidence-standards-framework.pdf [Last accessed 23/06/2019]

NHS England. (2019). Digital therapy selection. https://www.england.nhs.uk/mental-health/adults/iapt/digital-therapy-selection/. [Last accessed 25/06/2019).

Norcross. J.C., Pfund, R.A., Prochaska, J.O. (2013). Psychotherapy in 2022: A Delphi Poll on Its Future. Professional Psychology: Research and Practice. American Psychological Association. 2013, Vol. 44, No. 5, 363–370 0735-702.

O’Mahony, C. (2018). Learning from the past and looking to the future: research on online supervision. In: A. Stokes (Ed). Online Supervision. (pp.130 – 146). London: Routledge, 2018.

Pihlaja, S., Stenberg, J.-H., Joutsenniemi, J. Mehik, H., Ritola, V. Joffe, G. (2018). Therapeutic alliance in guided internet therapy programs for depression and anxiety disorders – A systematic review. In: Internet Interventions. Volume 11, March 2018, Pages 1-10. https://doi.org/10.1016/j.invent.2017.11.005. [Last accessed 24/06/2019]

Prado, S., & Meyer, S. B. (2004). Evaluation of the Working Alliance of an Asynchronous Therapy Via the Internet. MA dissertation. Sao Paulo: University of Sao Paulo.

Rees, C.S. & Stone, S. (2005). Therapeutic alliance in face-to-face versus video-conferenced psychotherapy. In: Professional Psychology, Research and Practice. 36, 649 – 653. http://psycnet.apa.org/record/2005-15843-010 [Last accessed 12/09/2018]

Reese, R. J., Aldarondo, F., Anderson, C. R., Lee, S.-J., Miller, T. W., & Burton, D. (2009). Telehealth in clinical supervision: A comparison of supervision formats. Journal of Telemedicine and Telecare, 15: 356–361.

Rogers, C. (1973), Some New Challenges. American Psychologist. American Psychological Association. May 1973: 379-287.

Rousmaniere, T., & Frederickson, J. (2013). Internet-based one-way-mirror supervision for advanced psychotherapy training. Clinical Supervisor, 32(1): 40–55.

Shore, J, Savin D., Orton H., Beals J., & Manson S. (2007). Diagnostic reliability of telepsychiatry in American Indian veterans. American Journal of Psychiatry. 2007; 164: 115–118. https://ajp.psychiatryonline.org/doi/10.1176/ajp.2007.164.1.115 [Last accessed 12/09/2018]

Simpson, S.G & Reid, C.L. (2014). Therapeutic alliance in videoconferencing psychotherapy: a review. Special Issues – Psychology in the Bush Original Research. The Australian Journal of Rural Health. Special Issues. 2014 22, 280-299.

Stokes, A. (2018). Online Supervision. London: Routledge.

Suler, J. (2016). Psychology of the Digital Age: Humans Become Electric. Cambridge: Cambridge University Press.

The Relational School. (2018). http://www.therelationalschool.co.uk/. [Last accessed 20/08/2018].

United Kingdom Council for Psychotherapy (UKCP). Supervision. https://www.psychotherapy.org.uk/about-psychotherapy/supervision/. [Last accessed 23/06/2019]

University of Zurich (2013). Psychotherapy via internet as good as if not better than face-to-face consultations. ScienceDaily. 2013, July 30. http://www.sciencedaily.com­/releases/2013/07/130730091255.htm [Last accessed 12/09/2018]

 

Wagner B, Horn, A.B., & Maercker. A. (2013). A. Internet-based versus face-to-face cognitive-behavioral intervention for depression: A randomized controlled non-inferiority trial. In: Journal of Affective Disorders. 2014 January 152-154. https://www.ncbi.nlm.nih.gov/pubmed/23886401

Webber, J. M., & Deroche, M. D. (2016). Technology and accessibility in clinical supervision: Challenges and solutions. In: T. Rousmaniere & E. Renfro-Michel, Using Technology to Enhance Clinical Supervision (pp. 67–86). Alexandria, VA: American Counselling Association.

Weinberg, H. (2014). The Paradox of Internet Groups: Alone in the Presence of Others. Londo

Weinberg, H. (2014). The Paradox of Internet Groups: Alone in the Presence of Others. London: Karnac.

Weitz, P. (Ed.). (2014). Psychotherapy 2.0: Where Psychotherapy and Technology Meet. London: Karnac.

Weitz, P. (2018). Supervision guidelines: online supervision and supervision online – what’s the difference? In: A. Stokes (Ed). Online Supervision. (pp.130 – 146). London: Routledge, 2018.

Biography

Pip weitz has special interests in counselling and psychotherapy online, especially in the success of the online therapeutic relationship, security, confidentiality and jurisdiction. She works internationally as an online therapist online supervisor and trainer.

Her current roles include:

  • Training Director for the ACADEMY FOR ONLINE COUNSELLING & PSYCHOTHERAPYwww.acadtherapy.online
  • Psychotherapy Director at Dr Julian the online psychotherapy platform. www.dr-julian.com
  • Advisor the Private Practice Hub’s Online Therapy section.
  • Vice Chair of ACTO - the Association for Counselling and Therapy Onlinewww.acto-org.uk
  • She is author/editor of Psychotherapy 2.0: Where Psychotherapy and Technology Meet(Karnac 2014) as well as series editor for the Karnac/ Routledge Psychotherapy 2.0 series including Online Supervision edited by Anne Stokes.

Pip weitz