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Nield. C, 2023, Technology and online CAT supervision, What a difference!, Reformulation 56, p.18-21
Introduction
This paper introduces the development of a tool to help self-supervision throughout online work with Cognitive Analytic Therapy (CAT) and may be used to facilitate supervision. The Specialist Interest Group Technology Assisted Supervision Training and Therapy [TASTT SIG] forms a part of the broader context. I intend to highlight the importance of considerations for online supervision and its application for CAT supervisors and supervisees in their clinical practice. The tool is available to trial by contacting me directly for a copy.
Existing Guidelines
After the peaks and troughs of the Covid-19 pandemic we can now reflect on the collective therapeutic shock that jolted therapists and clients towards online ‘remote’ working. Many therapists had to overcome personal resistance to working in this way and help their clients to work out how the online environment might or might not suit them. It has been an intense period of forced change and adaptation in terms of delivery of psychological services and therapies (UK Council for Psychotherapy (2021).
Within this new context, orientating ourselves towards the new order has been continuous with an expedient openness towards online therapy away from its previous silo practice. It has also contributed to a proliferation in research, building on the base already set by earlier pioneers of online work, (Simpson, S. et al 2020). Whilst more has been written about online therapy since the pandemic there has historically been very little written about online supervision, either of face to face or ‘in person’ therapy and less still of online therapy. A definition offered of distance supervision or tele-supervision refers to clinical supervision conducted by using technology such as telephone, email or videoconferencing (Brandoff, R and Lombardi, R. 2012). An extension of the definition might specify whether this pertains to face-to-face therapy or to ‘remote’ therapy via technology (Weitz 2018).
The UKCP (2018) made brief reference to online supervision in the suggestion that ‘supervision can take place in facilitated groups, peer groups, on a one- to-one basis, by telephone, online, in writing, verbally or by use of digital media. Appropriate modes of supervision will need to be determined by the circumstances; and using different methods (e.g. live observation, digital recordings, written and verbal reports’. In the more recent (UKCP 2021) guidance there is no mention of the impact of the pandemic on the provision of supervision.
Clinical supervision is however being considered as a distinct competency in need of professional training and systematic evaluation. Theoretical developments and experience-driven practice still seem to diverge, with online supervision being even more neglected than its more traditional counterpart. A systematic review of the status and quality of the current empirical literature on clinical supervision echoes gaps in the research, (Kühne, F. et al 2019).
Both the British Psychological Society (BPS) in their guidance document Digital Adaptations to Supervision and Observations (2020) and the British Association of Counselling and Psychotherapy (BACP) in their Supplementary Guidance for Online Work refer explicitly to online supervision and the need to pay attention to the technological medium (Bond,T. 2015).
The BPS emphasises the need for specialist knowledge and training in online working. Supervisors who are required to supervise online before they have had the opportunity to acquire specialist knowledge or training in online working are advised to engage in professional development, personal study and reading, webinars and/or receive supervision from a more experienced other in the field of online supervision. The BACP recommends that in working online with clients, at least some of the supervision should take place over the same medium as the therapy, for example if the therapy is conducted via videocall, then at least some supervision takes place via videocall too. Guidance also highlights the need for supervisors to be aware of the ethical and legal aspects of online supervision and the principle of working within one’s level of competence because of the additional considerations online supervision warrants. This may seem confusing when online therapeutic training has not been mandated by any of the regulatory bodies and there are few specifically extensively trained online supervisors.
The BPS refers to a key publication concerning online supervision, Online Supervision: A Handbook for Practitioners, Stokes, A. 2018. Chris O’Mahoney’s chapter on research highlights studies addressing the impact of technology on supervision practice. O’Mahoney cites early studies that investigated whether videoconference supervision affects the supervisory working alliance (e.g., Sørlie, Gammon, Bergvik, & Sexton, 1999), and whether the limited range of non-verbal communication in videoconferencing affects or limits supervision practice, especially the more subtle and complex aspects of supervision, such as countertransference or resistance in the supervisee or supervisor (Watkins 2014). O’Mahoney also points out that trainees may not only have different supervision needs but may find the ambiguity of online supervision more anxiety provoking, ‘heightening feelings of insecurity or uncertainty about their work’. O’Mahoney suggests that if early studies were to be replicated, results may differ due to advancements in technology and given our growing familiarity with working via technology.
Martin, Kumar and Lizarondo (2017) undertook a review of the literature and acknowledged the limited information on the quality and effectiveness of tele-supervision and outlined ten evidence informed practical tips to use technology effectively and more confidently. They emphasised practicalities whilst addressing some essential relational aspects of the online supervisory alliance, for example focusing on the supervisor-supervisee fit and paying attention to communication. These may seem obvious but there are some critical factors working via technology that may impinge negatively if neglected. They suggest basics, including that the supervisor and supervisee are both proficient in use of the technology (and if not then they access targeted training in the use of the equipment), and ensuring formulation of a plan to manage technical difficulties, the now ubiquitous contingency fall-back plan B.
Relevance for CAT supervision
How are supervisees held relationally at a distance and helped to manage the key aspects of CAT, for example working with the usual CAT tools including the psychotherapy file and working with ‘virtual’ mapping. As well as managing the relational aspects of the ‘online therapeutic alliance,’ including challenges to boundaries and the therapeutic frame, supervisees will also need to be aware of particular ethical and legal considerations of using technology, not least ensuring appropriate security for the storage and sharing of CAT therapy material. And where supervision takes place in group format supervisors will need to give additional considerations as to how this is managed in the on-screen environment.
In general terms we can be aware of guidance provided by our professional bodies, and make sure we keep abreast in this fast-paced environment. Good practice for online supervision would include providing supervisees with a clear induction to the context and expectations around offering telephone and video sessions, ensuring they are aware of policies regarding digital working, exploring their knowledge of technology, and processes for arranging digital sessions, responding to failures in technology, and for risk management issues when offering digital interventions.
As CAT supervisors we have responsibility to help the supervisee with their ‘online presence’ (described well by Geller 2020), and with establishing the framework for delivering an effective online therapy, the ‘online frame’. The BACP suggests that the format of supervision is at least in part the same as the format used for the therapy. Online supervision with the supervisee perhaps means parallel processes may also be more available when the format of supervision mirrors the format of therapy, but it also provides a window into how the supervisee presents and manages communication online, a glimpse into the supervisees skills around setting the frame, managing the technology and conveying their online presence. Can the supervisee manage and negotiate the online joining and connection? Is the supervisee confident with the tools of screen sharing? How does the supervisee present on video call? How do they arrange the background? Is only a head a shoulders portrait of the therapist visible, is it central to the screen, is there too much personal space visible in the background? Is their sound satisfactory?
These are relational matters that are important to attend to. Are these issues routinely explored and addressed in supervision? Supervisors can consider reflecting on these areas routinely to maintain the integrity of supervision even where it might feel unfamiliar or even uncomfortable to do so.
Online supervision in this way is also an opportunity to experience how the supervisee’s own characteristics and traits work with the features of video-therapy as Suler suggests potential interplay which may give rise to the online disinhibition effect (ODE), (Suler, J. 2005, 2016). Features of online communication (for example, physical distance, lack of eye contact and visual cues, a real or perceived sense of ‘invisibility’) may influence how able the supervisee feels bringing challenging clinical material. Without the physical presence or direct eye contact of the supervisor an illusion of liberation may be created. This could work for or against the process of supervision depending perhaps on the safe containment provided by the supervisor in this environment.
The BPS (2020) highlights that consideration may also need to be given to the potential for the ODE where supervisees working online might experience more frequent or earlier disclosure of abuse. The supervisor’s active curiosity about the pace of the supervision might reveal valuable information about the supervisee’s own awareness of the pace of the therapy, and of the potential need to regulate the session to ensure the client does not become overwhelmed or dissociated so that they can tolerate the disclosure. It raises a question about gauging the zone of proximal development – both in terms of the supervisor’s assessment of their supervisee in relation to working with the technology and also the supervisee’s ability to gauge that of their client. The CAT model might offer something specific to working online in this respect in terms of shifting the focus and regulating the session with mapping and being able to map dynamics that may be heightened by virtue of the online medium (Nield 2022).
Other specific ideas for exploration with the supervisee involve the impact of the online medium on the therapy, on the alliance, on risk, mapping, and on ending therapy.
Supervisors can help their supervisees to be curious about how patients work using technology, itself an active ingredient to draw out relational material. The supervisor helps by shared deliberation and thoughtfulness about this. For example, encouraging the supervisee to enquire and be curious about the impact of the patient seeing their own image may offer grounds for exploring meaning. An individual who reveals preoccupation or sensitivity with their own online image presents an opportunity to explore the reciprocal self to self relationship, the inner dialogue as well as their experience of the other. Without such direct enquiry it might be a missed opportunity.
Introducing an online CAT Supervision Tool
CAT’s curiosity about online digital technology and its impact on the supervisory and therapeutic alliance encourages supervisors to actively and routinely consider the format of the medium through which a therapy takes place. It offers an invitation to supervisors and supervisees to engage in dialogue about the experience of online supervision of online therapy.
Consideration of issues of competence, both on the part of the supervisor and supervisee are significant. In CAT we seek to recruit the supervisor’s and supervisee’s own observing eye. The ‘online lens’ has the potential to magnify and distort communication and psychological processes and requires competent navigation. The CAT supervision competencies may be helpful to refer to and consider through an online lens.
A CAT online supervision tool is currently being developed. It offers a structured framework and considers key domains for supervisors and supervisees working online to observe and to self-monitor as well as to aid self-supervision and assist with monitoring of the online therapy process.
As an interactive process the tool assists us in asking, what impact does the technology have on the alliance and the quality of supervision? How are difficulties in supervision experienced by the supervisor/supervisee?
Some initial key considerations are
- the skills and experience of the supervisor and supervisee
- the personal attributes of the supervisor and supervisee
- whether the format is individual or group supervision
- whether the supervision medium is via video or audio.
The draft tool is designed to aid in-depth self-reflection and self-supervision and serves as a prompt sheet to facilitate dialogue within CAT supervision, for both supervisee, and supervisor. With this in mind, there is a section for the supervisor with some suggested prompts. In a nutshell it suggests questions to pose when working online and working online in supervision. Ultimately it aims to improve the quality of the work of CAT therapists and supervisors and safeguard high standards of care.
The tool also offers a framework to structure thinking and experience so that the unique nature of online working with CAT is brought systematically into supervision. It is not designed as an evaluative tool. It may be useful in contributing towards planning for appraisal and professional development. Not all sections will be relevant for each session or for each supervision.
In sections, it covers eight domains. Some are modality specific. The domains are 1) generics of working with the technology, 2) the online supervisory alliance 3) the impact of features of online communication relationally, on both the supervisory and therapeutic relationship 4) working online with the stages of CAT, including the idea of online presence 5) use of CAT tools online in therapy/ supervision with particular attention to the supervisee/client’s online ZPD, 6) rupture resolution online, 7) risk online, and 8) diversity and inclusion and working culturally online.
We know that things do not fit neatly into boxes, so there is no need to feel restricted by the structure of this tool. Use it in any way that is helpful. If you would like to request a copy of the draft to trial in practice please contact me.
Cal Nield recently retired after many years in the NHS as a CAT psychotherapist and supervisor and continues to work within independent practice. Cal has a special interest in online working, curious enough to study a diploma in Counselling and Therapy Online, and leads the CAT-TASTT special interest group for ACAT members working digitally (Technology Assisted Supervision, Training and Therapy). Cal is also a member of ACAT’s Ethics Committee where she is particularly interested in thinking about the ethical implications of online practice.
Correspondence CATtherapy@protonmail.com
References
British Psychological Society (2020) Digital adaptations to supervision and observations. Available at: https://www.bps.org.uk/guideline/digital-adaptations-supervision-and-observations (Accessed: March 4, 2023).
British Psychological Society (2020) Digital Adaptations to Supervision and Observations. London. BPS.
Bond, T. (2015-2019). Working Online in the Counselling Professions. BACP Good Practice in Action 047. Lutterworth: British Association for Counselling and Psychotherapy.
Brandoff, R., Lombardi, R. (2012) ‘Miles apart: two art therapists' experience of distance supervision’. Art Therapy. 29 (2), pp. 93–96. Available at: https://doi.org/10.1080/07421656.2012.683729
Geller, S., (2020) ‘Cultivating online therapeutic presence: Strengthening therapeutic relationships in teletherapy sessions’, Counselling Psychology Quarterly, 34(3-4), pp. 687-703. Available at: https://doi.org/10.1080/09515070.2020.1787348
Kühne, F. et al, (2019) ‘Empirical research in clinical supervision: A systematic review and suggestions for future studies’. BMC Psychology, 7(1). Available at: https://doi.org/10.1186/s40359-019-0327-7
Martin. P., Kumar, S., Lizarondo, L., (2017) Effective use of technology in clinical supervision, Internet Interventions, 8, pp. 35-39. Available at https://doi.org/10.1016/j.invent.2017.03.001
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UK Council for Psychotherapy (2018) Practice Guidelines for Supervisors. London: UKCP
UK Council for Psychotherapy (2021) Psychotherapy and COVID-19: reflections on the pandemic. London: UKCP
Watkins C. E. (2014). ‘The supervisory alliance: A half century of theory, practice, and research in critical perspective’, American Journal of Psychotherapy, 68(1), pp. 19–55. Available at https://doi.org/10.1176/appi.psychotherapy.2014.68.1.19
Weitz, P. (2018). Supervision guidelines: online supervision and supervision online – what’s the difference? In: A. Stokes (ed). Online Supervision: A handbook for practitioners (Psychotherapy 2.0 Series). Abingdon, Oxon: Routledge, pp.130 – 146.