Technology-based Clinical Supervision: Extending the Reach of Clinical Supervisors

[Trainer’s name][Date], 201X

Technology-Based Supervision:Extending the Reach of Clinical

Supervisors

AGENDA

8:00 – 8:30 Check-in

8:30 – 9:00 Introduction

9:00 – 9:30 The Big Picture

9:30 – 10:00 The Problem

10:00 – 10:15 Break

10:15 – 11:45 The Solution

11:45 – 1:00 Lunch

1:00 – 3:00 The Action Plan

3:00 – 3:15 Break

3:15 – 4:15 Problem Solving

4:15 – 4:30 Wrap up & Evaluation

Familiarize Clinical Supervisors with technology-based clinical supervision (TBCS) research, demonstrate its utility, and provide

opportunities to observe and practice delivery of clinical supervision services using different

types of technology.

1. The Big Picture

2. The Problem

3. The Solution

4. The Action Plan

5. Problem-Solving

By the end of the training you will be able to:

1. Define substance use disorders health disparities

2. Explain three barriers to accessing quality clinical supervision

3. Discuss six key benefits of using technology to extend the reach of clinical supervision

4. Identify three key ingredients needed to do effective technology-based supervision

5. Demonstrate how to use at least one type of technology for clinical supervision

6. Develop strategies to overcome at least two barriers to technology-based supervision

Neither the NFAR ATTC nor the trainers presenting today endorse or promote the use of any specific

technology application mentioned in this training. All technology applications are discussed as examples of

available resources only. The NFAR ATTC does not guarantee that any technology application discussed

is compliant with HIPAA, HITECH, or any other federal, state, or local confidentiality regulation. Please

consult with an attorney, your institution’s HIPAA compliance officer, and/or your local licensing agency before utilizing any technology for clinical purposes.

2ND

This course is designed for individuals with training and

experience as a Clinical Supervisor and should not be used as a

foundational clinical supervision training course.

Three Key Questions

1. Why is access to supervision a problem for the SUD workforce?

2. How can technology-based supervision alleviate that problem?

3. What tools are needed to make it work?

• Your profession and agency

• Years of experience in the SUD field

• Years of experience as a Clinical Supervisor

• Challenge(s) to delivering clinical supervision

Have you ever …• Booked travel arrangements online

• Purchased an item costing more than $100 online

• Checked bank account information or moved money between accounts online

• Applied for a credit card online

• Signed up for insurance online

• Signed up for telephone, cable services, or utilities online

• Paid a bill online

• Owned a Kindle or iPad

• Owned access to an electronic book to read on your computer

• Purchased audio files (e.g., music, books) online

• Purchased/rented video media (e.g., movies, TV shows) online

• Owned a cell phone with a digital camera or smart phone with Internet access

• Owned a robotic cleaning device (e.g., Roomba)

• Filed your taxes online

• Used a bank that was online only (i.e., one with no physical structure)

• Owned or interested in owning a vehicle with voice activation technology for cell phone use and/or interfacing with stereo or comfort control systems

“Be Sincere,Be Brief,

Be Seated”

Franklin Delano Roosevelt

The Big Picture

Values =

health care equity, quality, and accessibility for the entire population.

Every community is affected by drug abuse and addiction.

• inequalities in health status• adversely affect groups who have experienced

greater obstacles to healthcare access based on ‒ Race & Ethnicity‒ Religion‒ Socioeconomic status‒ Gender‒ Age‒ Mental health or disability‒ Sexual or gender orientation‒ Geographic location‒ Other characteristics tied to discrimination or

exclusion

Health Disparities

(Office of Minority Health, 2011)

Substance use disorders are widespread

3.3%

19.3 million people needed but did not receive treatment for illicit drug or alcohol use

Did not feel they needed

treatment

(NSDUH, 2011)

In 2011, 20.6 million people aged 12 or older met the criteria for substance use disorders

Felt they needed treatment – Did not

make an effort

Felt they needed treatment – Did make an effort

Do substance use problems affect certain groups in

disproportionate ways?

SUD Health Disparities Among Rural Populations

Over half of the country’s land mass is designated as frontier or rural

(NRHA, 2008; USDA, 2000)

Approximately one quarter of the U.S. population (62 million people) lives in

frontier/rural areas

16-20% of those individuals experience substance dependence, mental illness, or

co-morbid conditions(NRHA, 2008)

Individuals residing in remote areas have

- higher mortality rates,

- higher suicide rates, and

- more severe alcohol/drug problems.

(Baca et al., 2007; Goldsmith et al., 2002)

The availability of behavioral health services is limited in rural and frontier communities.

Adults in rural areas were more likely than urban adults to rate their mental health status as fair or poor.

Studies show that those residing in rural areas use substance abuse treatment less often than those in urban areas because of individual, structural, and

geographic barriers, as well as the stigma associated with receiving treatment.

(Finfgeld-Connett & Madsen, 2008; Oser et al., 2012)

There are many complex and overlapping reasons why those who live

in rural areas may have more severe drug and alcohol problems.

Causes of Rural Health Disparities

• Lack of providers and services

• Geography: isolation and distance

• Lack of confidentiality

• Stigma

• Poverty

• Rural location exacerbates other SUD health disparities

• Fragmented system of care(Rawson et al., 2002; Simons et al., 2005; NRHA, 2010; Gray, 2011; NIH, 2009; NRHA, 2008)

Today’s training is based on the evidence that better clinical supervision leads to better SUD

treatment, and better health outcomes.

Using technology for clinical supervision is an important step toward ensuring the best possible health outcomes for everyone.

The Problem

The SUD specialty treatment workforce is

characterized by …

Over 20% Turnover Rate

(NRHA, 2008; Knudsen et al., 2008; DHHS, 2006)

Aging

(Ryan, et al., 2012)

Difficulty recruiting new counselors

Limited training/CE opportunities

ACA is changing workforce demands

• With expanded health insurance coverage, increasingly more individuals will have access to SUD treatment services.

• There are not enough providers to meet this demand.

• The need to train and retain a workforce who can provide SUD services in a variety of settings is critical.

Supervision is the fields’ “critical teaching

method”, and YET …

(Holloway, 1992)

We know that there is a lot of work to be done to improve access to

and quality of supervision …

In a study published in 2013, the

authors found that 93% of

counselors were receiving

inadequate supervision and 35%were receiving harmful supervision.

(Ellis et al., 2013, p.436)

Inadequate supervision…

supervision on the fly

"The deleterious effects of harmful supervision on supervisees may parallel the detrimental

effects of harmful therapy to clients.”(Ellis et al., 2013, p.436)

• There aren’t enough SUD counselors.

• Those that are working aren’t getting enough professional support.

• Opportunities for collaboration and support between therapists is limited.

• Burnout and turnover result from feeling overwhelmed.

• Low job satisfaction leads to lower quality services.

• Supervision takes time and money, and leaving less time to provide services.

Summary of the Problem

(Kanz, 2001; Reese et al., 2009)

“As a supervisor that provides oversight to many different offices in rural areas, it is impossible to be everywhere you are needed all the time in person. Some of our providers are in extremely remote areas and perhaps are one man/ woman shows. This contributes to isolation and inability to use a team approach for clinical staffing. In addition, when experiencing problems with a consumer there are few resources to reach out to and gain perspective or insight on how to handle the situations. As a supervisor it is difficult to feel like you are really connected to the staff person. Which results in supervision meetings not occurring frequently enough because to get to them in person would mean you, as the supervisor, have to mark out a whole day to provide the meeting time because travel might take up half of it.”

-Kathy Hoppe, VP of Treatment Services, Preferred Family Healthcare

Turn Disparity Into Equity

Ensure equitable, quality, accessible substance use disorder treatment services

to everyone who needs them.

... but how do you do this without well-trained and supported clinicians?

The Solution

Quality Clinical Supervision

What is Clinical Supervision?

Bernard and Goodyear (2014):

“[The] relationship is evaluative and hierarchical, extends over time, and has the simultaneous

purposes of enhancing the professional functioning of the junior person(s), monitoring the quality of professional services offered to the clients …and

serving as a gatekeeper for the particular profession the supervisee seeks to enter.”

Supervisors serve as gatekeepers(Harrar et al., 1990)

Further Defined…

Perry (2012):

“…transmits the field’s values, body of knowledge, professional roles, and skills to the new clinician. Training and supervision are also primary vehicles through which a field evolves.

They prepare future generations to be the representatives and developers of the field’s viewpoint, with the hope that they will move

beyond their mentors in conceptual, therapeutic, and professional development.”

Supervisors prepare future generations to represent the field

(Perry, 2012)

Why Clinical Supervision?

“Clinical supervision in the behavioral health care field goes beyond supervisory support as measured in most other occupational studies. It is a more complex relationship than generic

job supervision. And understanding the impacts of clinical supervision on counselor

retention and well-being can lead to the design and delivery of workplace interventions

targeted at enhancing the quality and quantity of supervision in these settings.”

(Knudsen et al., 2008, p. 388)

Clinical Supervision

(Knudsen et al., 2008)

plays a protective role in counselor well-being

High-quality supervision is important for trainees to develop into competent professionals

Quality Clinical Supervision…

• increases– Counselor morale

– Counselor skills

– Connectivity to others in the field

• improves client outcomes

(Ryan et al., 2012)

Support from Clinical Supervisors is the best predictor of job satisfaction

in a rural setting.(DeStefano, Clark, Gavin & Potter, 2006)

Another study found increases in job satisfaction and rural retention rates for

mental health physicians are linked to access to technology which allowed them to

connect with other health professionals outside of their geographic area.

(Meyer, 2006)

Clinical supervision in remote areas

(Mitchell et al., 2009)

increases retention rates

by alleviating burnout

It works - even when delivered remotely - and is critical to building a more capable workforce

Let’s ask ourselves -

How many counselors are working without quality supervision?

How could technology improve access to supervision?

“Most of the research and theorizing on technological developments in supervision and training have focused on evaluating

whether the new technologies can approximate the experience of “traditional”

in-person supervision and training.”

(Rousmaniere et al., 2014)

Can technology approximate the experience of in-person supervision and training?

“The traditional methods of supervision are in wide use because they were the only methods

available, not because research determined them to be the most effective. Making the assumption

that the “old methods are best” may do the field a disservice by blinding us to new opportunities and

alienating a younger generation of supervisees who identify with technology being integrated

into every part of their lives.”

Reframe the Conversation

(Rousmaniere et al., 2014)

Rather than questioning whether TBCS is “as good” as traditional supervision …

What is now possible and how can it serve my supervisees and their clients?

ASK

(Rousmaniere et al., 2014)

“Supervisors serve multifaceted roles. In addition to their gatekeeper role, supervisors, by

necessity, must also be clinical explorers and inventors.”

(Rousmaniere et al., 2014)

• supervision delivered to counselors via media, such as

– telephone

– email

– video-conferencing

– web chats

– apps

– combination of the above

– technology + face-to-face supervision

Technology-Based Clinical Supervision

Technology Fear

Factor

“Good supervision is dependent on the quality of the skills of the supervisor and should not be dependent

upon simple proximity to the supervisee.”

(Orr, 2010)

“The practical limitations of the physical world introduce a variety of obstacles that are

eliminated in the virtual world.”(Dillon, 2014)

Literature Supports TBCS• Effective for individual supervision, group

supervision, and didactic teaching

• Ability to provide feedback in a timely manner improves counselor development

• Hybrid model is positively related to attitudes toward technology in counselor education, future professional practice, and the overall supervisory experience

• Quality of e-supervision is equal to or better than traditional supervision

(Byrne & Hartley, 2010; Conn et al., 2009; Dudding & Justice, 2004; Rousmaniere et al., 2014; Panos, 2005; Reese et al., 2009)

61. Increases access to quality supervision

2. Enhances cultural competency

3. Strengthens professional identity

4. Supports program integration

5. Shepherds in a new era of technology

6. Promotes fidelity to evidence-based practices

Key Benefits to Technology-Based Clinical Supervision

Benefit #1Increases Access to Quality Supervision

Provides better use of resources,is cost-effective, and reduces travel time

Technology greatly expands the available pool of supervisors

• Increases supervision in areas where qualified supervisors may not be available

• Allows access to supervisors with a specific population expertise

• Allows access to supervisors with specific therapeutic technique expertise

Technology allows greater access to supervisors

Technology increases access to training

• Inadequate training may be a primary workforce recruitment challenge

– According to a recent ATTC Workforce Report, Clinical Directors said many counselors lack

experience in SUD treatment (50%) and

insufficient training/education (49%)

• Access to training and development ensures better trained clinicians

(Ryan et al., 2012)

Benefit #2Enhances Cultural Competency

Using technology allows for direct observation of clinicians in the communities

in which they work, which has positive implications for building cultural competency.

(Byrne & Hartley, 2010)

(Byrne & Hartley, 2010)

“Recording in the community has the benefit of capturing real-life settings, and

supervisors can evaluate whether the student considers environmental cues when

assessing the client’s functioning.”

Supervisors should strive to improve cultural competence at several levels

• Supervisor’s response to counselors

• Counselor’s response to clients

• Program’s response to cultural needs of the community being served

Technology increases access to supervision for those in rural areas, which also means that urban-based

supervisors may be providing supervision to counselors with rural

practices. Supervisors must learn about rural culture, and the specific needs and resources of rural clients.

• one onsite who is well versed in local culture, and• one online who possesses the needed competence

in clinical supervision.

(Rousmaniere, 2014b, p. 1083)

Panos et al. (2002) proposed the “triad model” of supervision, in which

supervisees have two supervisors:

Benefit #3Strengthens Professional Identity

“the task of supervision is co-authoring with the trainee a story of professional

identity development” (Perry, 2012)

Professional identity is constructed through relationships with peers and supervisors/ instructors, and doing professional things (e.g., actually doing therapy with clients).

(Perry, 2012)

Professional identity comes from being witnessed in a professional role, and

receiving encouragement and feedback.

(Perry, 2012)

Professional identity is what makes people

strive to improve their work, to develop new

and better skills.

It is the driving force behind competence

and mastery.

(Perry, 2012)

Technology ParadoxLimitations imposed by technology improve the focus and quality of conversations, decrease inhibitions, and equalize contributions in group settings.

(Reese et al., 2009; Gamon et al., 1998)

Strong professional identity = ethical practice

“The supervisory relationship is the crucible in which ethical practice is

established and reinforced.”(SAMHSA, TIP 52)

“The need for clinical supervision is pressing. I believe one of the main reasons that clinicians engage in unethical behaviors is due to the lack of proper supervision. It is too easy to lose perspective or not to recognize ethical dilemmas if we are not processing and getting feedback on practice on a regular basis. I don’t think that clinicians want to act unethically, but without proper supervision, it can happen. Too often in rural settings we may feel secluded and not have the opportunities to get consult and supervision that is very much needed.”

–Christina MacFarlane, Hope and Wellness Resources

The Clinical Supervisor

• Models sound ethical and legal practices

• Translates ethical concepts into practice

• Helps the clinician develop ethical decision-making tools

Benefit #4Supports Program Integration

Program integration is coming and technology-based supervision will

serve clinicians working in integrated settings.

Models of Integration

• Technology-based clinical supervision in urban settings to expand supervisory access

• Oversight of transfer of care from one provider to another

• Workforce training

(Rousmaniere et al., 2014a; Carey et al., 2013)

• SUDs are common in primary care patients. In one study, 23% of primary care patients had an SUD

• SUDs can cause or exacerbate other health conditions

• SUD interventions are best when carried out with fidelity

• Supervision can improve comfort with behavioral health interventions

• Physicians will play a larger role in SUD treatment (services are reimbursable and MAT is expanding)

• On-site services are better than referrals

Why Clinical Supervision should involve Primary Care

• Many insurance companies, including Medicare, will only reimburse for services provided by a licensed clinical social worker.

• Professional licensing standards for counselors to reach this level of licensure include supervised clinical experiences.

• TBCS will expand the field of licensed clinicians, since many clinicians working in remote areas may not have access to local supervisors to meet the requirement for credentialing.

Technology enables highly trained counselors to receive reimbursement

Clinical supervision is a major requirement for someone to obtain their LSCSW. By utilizing supervision via televideo, this has allowed more clinicians to obtain the supervision that they need to obtain their clinical license and be able to provide much needed services to a region. Currently, I am providing clinical supervision for a LMSW who is seeking her LSCSW in Kansas. We meet 2 hours a month in person at one setting. The other weekly supervision times are completed using televideo. The Kansas Behavioral Services Regulatory Board has approved this plan due to this clinician not having anyone in a 100 mile radius to provide this type of supervision for her. Part of the supervision time must be face to face, but another percentage may be done through televideo. This has opened up a lot of doors for practitioners in rural and frontier areas to obtain degrees in order to provided much needed services in rural and frontier regions.

-Christina MacFarlane, Hope and Wellness Resources

Benefit #5Shepherds in a New Era of Technology

57.8%

55.5%

44.1%

43.1%

35.5%

31.3%

30.3%

26.1%

19.9%

4.3%

Two-way video/webcam

Image sharing technology

Email

Patient portal

Video conferencing (group)

Medication management technology

Scheduling tool

Remote patient monitoring

Smart phone (picture, text, app)

Other

HIMSS Survey 2014: Most Widely Used Telemedicine Technologies

(HIMSS, 2014)

TBCS increases comfort with technology, which is important as

service delivery becomes more and more infused with technology.

(Wood et al., 2005, p. 176)

Technology Transfer for Clinical Supervisors

Suggested actions for Clinical Supervisors:

• Share your experience using new practices with other Clinical Supervisors

• Contribute to and foster the “evidence-based culture” within the organization

• Relate compatibility of practice with regulations and standards (federal, state, accreditation, etc.)

Benefit #6Promotes Fidelity to EBPs

• The literature indicates that fidelity to an evidence-based practice is often directly related to the amount of supervision.

• It’s not enough for counselors to go to a training on EBTs. They need ongoing, interactive support, feedback on skills, and coaching.

(Dorsey et al., 2013; Smith et al., 2012; Anderson et al., 2012)

Technology-based supervision is an effective way to build EBP skills

• Extends training into broad range of community-based programs

• One study using telephone-based direct observation and feedback following MI training demonstrated improved therapist MI skills proficiency

(Smith et al., 2007)

Overall: Better Client Outcomes

Improved infusion of evidence-based practicesleads to better client outcomes

EBPClient

Values

Professional

Expertise

Best

Research

Evidence

“In substance abuse treatment, clinical supervision is the primary means of

determining the quality of care provided.”

(SAMHSA-TIP 52, pg. 5)

Therefore, TBCS will extend the reach of Clinical Supervisors and help promote the

quality of SUD treatment services.

“Technology has assisted to fill the gap where needed. In the past a phone call was used to fill the gap but here at Preferred Family Healthcare we have integrated virtual services and teleconferencing into our service provision and have found that using those same tools in supervision meetings is extremely beneficial. We have used our virtual platforms to conduct staff and team meetings. We have also used teleconferencing tools to be able to meet individually and as groups for supervision. Both of these technologies have benefited me as a supervisor and I believe the supervisee to be able to feel more connected in the meeting, and those meetings are more productive. And supervision occurs on a more frequent basis because it does not interfere with our schedules as attempting to meet in person did. I believe this makes it easier for staff also as I am sure that in the past they dreaded the days I was coming to visit. On those days I would try to cover everything that needed to be addressed and that was going to need to be addressed all at one time to reduce my travel time. Not only did that overload my supervisees it also took a great deal of their time out of service provision in one day and since we addressed so many things the retention of information was low. Now we are able to address things face to face or virtually in a timely manner and at the appropriate times rather than jam

everything in one meeting.”

-Kathy Hoppe, VP of Treatment Services, Preferred Family Healthcare

“The use of televideo options has opened the door to provide quality

supervision on a regular basis without the added costs of lost

work time and travel. By utilizing supervision via televideo, this has allowed more clinicians to obtain the supervision that they need to obtain their clinical license and be

able to provide much needed services to a region.”

–Christina MacFarlane, Hope and Wellness Resources

I want us to ask ourselves every day,

how are we using technology to make a real difference in

people’s lives?

(President Obama, Opening Session of the Forum on Modernizing Government, 2010)

The Action Plan

Three Steps for Technology-Based Clinical Supervision

1. Provide quality clinical supervision

2. Choose the best technology

3. Use the technology to extend the reach of quality supervision

Step 1: Provide Quality Supervision

Basic structure of supervision

• One hour per 20-40 hours clinical practice (preferred one hour per week)

• Direct observation

• Group supervision

Above all else, Clinical Supervisors using technologies to deliver clinical supervision services should be well-

trained in clinical supervision.

SAMHSA’s Clinical Supervision Competencies

TAP 21-A

TIP 52

Essential Elements of Supervision• Goal is to protect the welfare of the client and

ensure integrity of clinical services

• Supervision is all about the relationship

• The supervisor is an advocate for the client, counselor, and agency

• The supervisor uses current scientific and evidence-based practices

• Guidance provided during supervision is operational and practical

• Supervision is outcome oriented to improve counselor competence

(Roche, Todd, & O-Connor, 2007)

The Four A’s

• Available– Open; Receptive; Trusting; Non-threatening

• Accessible– Easy to approach and speak freely to

• Able– Having real knowledge and skills to transmit

• Affable

– Pleasant; Friendly; Reassuring(Roche et al., 2007)

• Unbalanced

• Developmentally inappropriate

• Intolerant of differences

• Poor model of professional/personal attributes

• Untrained

• Professionally apathetic(Magnuson et al., 2000, p.193-197)

Six Overarching Principles of Lousy Supervision

Importance of Clarifying the Supervisory Role

• Consultant

• Evaluator

• Coach/mentor

How will technology enhance your role as a supervisor?

Step 2: Choose the Best Technology

Technology for Use in Supervision

• Telephone

• Videoconference

• Digital video and audio recordings

• Email

• Text/Chat/Instant Messaging

• Apps for smartphones and tablets

• Avatars

Overall Best Practices • Never discuss protected health information (PHI)

unless technology is secure, password-protected, and vetted by legal expert

• Be aware of tone and style: check in to make sure your meaning is understood

• Develop a communication structure that includes systematic check-ins and summarization

• Engagement is the key to success

Prepare and Practice!

Telephone

Use for direct observation, individual or group supervisory sessions, crisis intervention,

time-sensitive and/or confidential matters

Benefits:

• Easy to maintain confidentiality

• User-friendly

• Inexpensive

• Versatile

• HIPAA Compliant

Telephone or Polycom

Telephone Best Practice Tips• Practice listening skills and be on the alert for

non-verbal cues

• Develop a technique to manage group conversations, such as systematic check in

• Use head-set, as needed, to improve sound quality

• Conduct calls only in a private and closed office

• Avoid using public or unsecured WIFI for calls on a mobile phone

• Never record calls

• Meet face-to-face at times, if possible

“It takes practice for a counselor to learn to trust their ‘inner ear’ and rely

only on what they are hearing.”

(Rosenfield, 2003)

Activity: Telephone

Videoconferencing

Benefits:• Audio and visual cues• Free and low-cost options available• Promotes alliance

Use for direct observation, individual and group supervision, screen sharing

video, and didactic teaching

Videoconferencing Best Practice Tips

• Have a back-up means of communication planned in case of lost connection.

• Attend to non-verbal nuance and signs of anxiety.

• Plan ahead: check that everyone has access to the technology, email an agenda in advance, and practice facilitation skills.

• Do not record videoconferences or disclose PHI.

Physical Environment

• Aim to provide comparable professional specifications of a standard office

Ensure privacy

Limit distractions

Announce presence of other people

Be aware of what others see

Activity: Group Supervision Via Videoconference

Videoconference for Live Supervision

• Heightened awareness of privacy and confidentiality is required whenever a client is observed.

• Client consent must be obtained.

• Best practice is to focus the camera on the therapist rather than the client, to preserve anonymity. Supervisor may not be able to see visual cues.

Principles for Direct Observation

• Accomplished through live observation (in-person, via phone or video feed) or recorded audio or video

• Consider effect on client-counselor interaction

• Choose a variety of contexts, challenges, clients to observe

• Should be constructive, not critical

Tips for Providing Feedback During Live Observation

• Offer direct or structuring interventions

• Promote self-sufficiency in therapist

• Interrupt for client benefit primarily

• Use affirmations and validation

• Provide concrete instruction

• Learn about the client and supervisee’s level of experience before beginning

(Champe and Kleist, 2003)

Is Live Supervision Disruptive?

Live Supervision

• Research has shown that supervisory interruptions do not cause significant disruptions to counseling sessions

• Live supervision enhances professional development

• Increases skills and confidence

• Learning opportunity for both supervisor and supervisee

• Increases safety and attention on client(Champe and Kleist, 2003)

Supervisors must manage their need

to make a lot of comments

Activity: Live Supervision Chat

Digital Videos or Audio Recordings

Use to record counseling sessions for review by supervisor. The supervisor can record

sessions for teaching therapeutic techniques or demonstrating role-plays.

Benefits:• Enables direct observation of client-

counselor interactions

• Inexpensive

• Flexible means of sharing

Digital Video or Audio Recording

Video/Audio Best Practice Tips

• Recordings should never be made, stored, or transferred to a computer without complete security protocols in place.

• To better protect client privacy, focus the camera on the counselor only.

• To capture both the client and counselor, a mirror can be positioned beside the client, who faces the counselor and camera.

Some software programs can create transcripts to improve practice.

(Nagel et al., 2009)

Options for Sharing Files

• Mail - Snail mail

• Screen Sharing - Supervisees play video on their own computer and use share screen option in videoconferencing software: technologically simple, but requires excellent internet connectivity and may reduce video quality

• Online file transfer - Use HIPAA-compliant service and encryptor: fast and economical, technologically more complex

(Rousmaniere et al., 2014b)

How will the audio or video file be stored and deleted to protect client privacy?

Cloud-Based Software

Use for storing and transferring files from one device to another, such as for sharing

video or audio recordings of sessions.

Benefits:• Cheap or free• Easy to use• Increasingly common

(Devereaux & Gottlieb, 2012; Rousmaniere et al., 2014b)

File Sharing Best Practice Tips

• Never use cloud-based storage without first thoroughly vetting the program for HIPAA compatibility and ensuring that sending and receiving devices are compliant with privacy and confidentiality standards.

• Use encryption software to protect confidential data.

• Always use passwords and ensure proper privacy settings by all users.

Benefits:• Easy to use• Allows for thoughtful exchange without

time constraints; prompts reflection• Lowers inhibitions• Allows for record-keeping

EmailUse for providing feedback or answering non-urgent

questions that do not include confidential information.

Email Best Practice Tips

• Never exchange PHI via email, and delete any message that contains sensitive information from the reply

• Avoid use in crisis situations, given the asynchronous nature of email

• Plan with supervisee for which situations warrant alternate method of communication

• Practice careful monitoring of tone

• Plan for time to write emails—rushed messages often lead to miscommunication

Security of Email

• Emails are stored at multiple locations: the sender's computer; your Internet Service Provider's (ISP) server; & the receiver's computer.

• Deleting an email from your inbox doesn't mean there aren't multiple other copies still out there.

• Emails are vastly easier for employers and law enforcement to access than phone records.

• Finally, due to their digital nature they can be stored for very long periods of time.

“Email is not like mailing a sealed letter or package. It’s more like sending a postcard –people are not supposed to read it while in transit, but it passes through many hands, and one

can never be sure that someone is not reading it illegally.”

(AMA, 2013)

Ms. Wendy Woods

National Frontier & Rural ATTC

Reno, NV 89557

USA

Case Study: Email

Text/Chat/Instant Messaging (IM)

Use for quick, non-confidential conversations and for providing prompts

during live direct observation.

Benefits:

• Synchronous and immediate

• Secure applications are available

• Easy to use

• Allows for discreet feedback in direct observation

Text/IM Best Practice Tips

• Never exchange PHI via text or chat, unless using a HIPAA-compliant program.

• Clarify with supervisee when text and chat are appropriate means of communication.

• Use for simple exchanges; choose another means of communication for complex conversations or communications between a group.

• Carefully monitor the tone of messages.

• When using chat tools for providing prompts during live supervision, practice for clarity, brevity, and how to communicate praise and critique.

Apps for Smartphones and Tablets

Use for chat and video-conferencing to provide rapid feedback during live supervision

Benefits:

• Accessible on many devices

• Portable

• Cutting edge technology

Smartphone/Tablet Best Practice Tips

• Never exchange PHI without confirming that an application and all sending and receiving devices are HIPAA-complaint.

• Make sure all users are comfortable with the technology’s privacy settings.

• Password-protect all devices and enable remote wiping of data if stolen.

• Never use apps on public/unsecured WIFI.

• Monitor use of new apps.

AvatarsUse for individual or group supervision and for live supervision of counselors who use

avatar platforms with clients

Benefits:• Adds an element of realism• Allows for anonymous interaction• Imaginative

(Dillon, 2014)

Avatar Best Practice Tips

• Plan for time to practice to feel comfortable with the technology.

• Use in-world presentation devices such as whiteboards, presentation screens, video streaming tools, etc.

• Choose the appropriate communications level (text chat vs. audio) depending on the current circumstances.

• Use the private chat feature to communicate with supervisees for therapeutic, training, or general group management purposes.

• Have a plan for handling emergency situations that might arise during a virtual counseling session.

(Dillon, 2014)

Combinations and ComparisonsIt may be helpful to switch up modalities.

What works well for one person/group may not be ideal for another.

Extensive details about various programs, includingcomparisons of capabilities and security features:http://www.telementalhealthcomparisons.com/

All-Inclusive Platforms

• Online platforms are available that deliver many of the technology options from a single source.

• Can be used with clients for counseling

and with therapists for supervision.

Do Not Use …• Facebook or other social networking sites

• Public WIFI to access any confidential files or websites

• Email, Chat, or Text Message to exchange protected health information unless its through a secure, password-protected program

• Advice from others about using a program without consulting your own HIPAA compliance resource expert

• Any technology without client consent

Step 3: Use the Technology to Extend Quality Supervision

What is the Goal?

Effective telecommunication applications for clinical supervision should aim to reduce the isolation of health

care providers in rural communities through the expansion and enhancement of the virtual network, which provides educational and Clinical Supervisory services. They should increase access to clinical consultative services and health

education programs for rural supervisees and provide supervision expertise that would not otherwise be

available in rural settings. Furthermore, the implementation of telecommunication technology should

provide a feasible and sustainable system of supervisor consultation capable of accommodating multidisciplinary

and specialty supervision. (Wood et al., 2005)

Questions to Answer Before Doing TBCS

• How are supervisees currently receiving supervision?

• Are you supporting students, new, or long-time counselors?

• What training is your staff in need of?• What is your comfort and skill with technology?• How can the technology enhance program

integration?• How can the technology eliminate barriers for

clients?• How will this process improve outcomes for

clients?

Problem Solving

TBCS Concerns

• Developing competence with technology

• Establishing alliance

• Behaving ethically

• Ensuring informed consent, with regard to how media is handled, shared, and deleted

• Using caution to maintain confidentiality

(Kanz, 2001)

Many online counseling regulations also require that counselors demonstrate not only

their competence in counseling but competency with the technology and

equipment. This would also be true for Clinical Supervisors using TBCS.

Competency with all equipment

Proficiency

• Typing skills

• Computer technology

• Security settings

• Email programs

• Chat and text messaging

• Uploading, sending, and receiving encrypted files

• Use of new technology: apps and avatars

(Rummel & Joyce, 2010; Midkaff & Wyatt, 2008)

• Learn how to use the technology and have a back-up plan in case it fails

• Create written policies that include use of technology, including storage and disposal of records

• Access ongoing training

• Be aware of new dilemmas

• Prepare and practice!

How to Overcome Technology Barriers

(Nagel et al., 2009; Vaccaro & Lambie, 2007; Lannin & Scott, 2013; Kanz, 2001)

Many seasoned Clinical Supervisors may be lessfamiliar with technology, yet have supervisees who

are using technology with clients. This can negatively impact the supervisory relationship

SUPERVISORY ALLIANCE

• Provide clear and consistent guidelines and expectations around how to communicate

• Take extra time to plan for supervisory sessions

• Develop a written contract with supervisees, with clear rules about use of technology

• Let the supervisee know how work will be evaluated

• Try to meet in person once before using technology for supervision

How to Build Supervisory Alliance

• Be very deliberate in tone and meaning (nuance may be lost)

• Check in to make sure meaning is received as intended

• Practice how to mine for misunderstandings

• Use technology to enhance communication (emoticons, write out tone [sarcasm], ellipses… allow for pauses)

How to Improve Communication

Strategies for Typed Communication• Emoticons like the smiley :-), winky ;-), and

frown :-( capture subtle nuances of meaning and emotion.

• Parenthetical expressions that convey body language or "sub-vocal" thoughts and feelings (sigh, feeling unsure here).

• Voice accentuation via the use of caps, asterisks, and other keyboard characters in order to place vocal *EMPHASIS* on a particular word or phrase.

(Suler, 2004)

“Technology will continue toevolve, but the ethical principles

remain constant.”

(Koocher & Keith-Speigel, 2008, p 212)

Research Ethical Standards for TBCS

• Increasingly, professional boards are establishing ethical guidelines specific to TBCS.

• Clinical Supervisor is responsible to determining which guidelines apply to their work.

• When in doubt, apply existing face-to-face supervisory standards to any work done via technology.

Examples of TBCS Ethical Standards

• Include all electronic communications exchanged with clients and supervisees as a part of the record, even when strictly related to clerical issues such as change of contact information or scheduling appointments.

• All electronic therapeutic communication methods shall use encryption and password security.

National Board for Certified Counselors

• Adhere to state regulations especially if supervision is related to licensure

• Apply standards relating to face-to-face clinical supervision

• Be competent in the technologies used

• Supervisor shares responsibilities for the services provided by the supervisee

(NASW, 2005)

National Association of Social Workers

• Determine which technology serves supervisee best

• Discuss the risk associated with TBCS

• Use secure methods for transmission

• Ensure supervisees are trained to use technology

• Receive informed consent

• Practice within jurisdictions

• Ensure privacy and security

American Association of Marriage & Family Therapists (proposed 2015 ethical standards)

Other Ethical Codes

• American Psychiatric Association 2014 Policy/ Guidelines for Supervision: Try to include in-person supervision sessions along with TBCS

• Association for Addiction Professionals (NAADAC) Ethical Code: No mention of TBCS

• International Certification & Reciprocity Consortium (IC&RC): Does not create or maintain a Code of Ethics

• Links to other professions’ ethical codes: http://www.zurinstitute.com/ethics_of_supervision.html

What does your state certification/licensing boards say about TBCS?

Questions to Ask• Are there limits on # of hours of online supervision

that count toward licensure, CEUs, etc.?

• What jurisdiction has legal accountability for supervision that crosses state lines?

• Are there specific informed-consent requirements?

• Are there regulations about reimbursement specific to internet-based supervision?

• Do professional liability insurance policies cover internet-based supervision, or supervision in multiple legal jurisdictions?

(Rousmaniere et al., 2014a,b; Kanz, 2001; Nagel et al., 2009; West & Hamm, 2012)

INFORMED CONSENT“meeting of the minds”

Informed Consent Guidelines for Clinical Supervision

• Obtain from supervisees and clients

• Include the following:

– How information will be kept confidential

– What happens if there is a technical failure

– The benefits & risks of using technology

– The emergency plan for client crisis

Privacy, Security, and Confidentiality

• Do not use names or identifying information

• Periodically delete electronic messages (e.g., Internet chat postings)

• Develop security protocols and passwords for access to group supervision information

• Use encryption whenever information is sent from one computer to another

• Discuss sensitive information off-line

(Olson et al., 2010, p.211)

1. Use “strong” passwords: do not use birthdays, names, or dictionary words; use at least eight characters and a combination of numbers, special characters (*&@), and upper/lower-case letters.

2. Do not use the same password on multiple accounts.

3. Use two-factor identification on your accounts.

4. Be extremely careful when downloading attachments or clicking on links in emails.

5. Use antivirus and antispyware software, and keep it updated.

5 Steps to Enhance Online Security

(Rousmaniere et al, 2014b)

Privacy Rules Overview

• Three main federal regulations apply:– HIPAA– HITECH– 42 CFR part 2

• Assume these apply to you –the penalties for breach are stiff

HIPAA Compliance

• HIPAA establishes national standards for the privacy of personal information and the security of electronic PHI.

• In order to be HIPAA compliant, there needs to be a Business Associate Agreement with the technology company if any PHI is recorded or stored.

• Documents (authorization forms, privacy notices, business associate agreements) should be reviewed by legal counsel.

HITECH Compliance

• HITECH mainly provides incentives to accelerate use of electronic health records but also expanded the scope of protected information to include IP addresses and zip codes

• Increases enforcement and penalties

• Skype is not compliant

42 CFR Part 2 Compliance

• Developed to prevent stigma and fear of prosecution from deterring people from seeking SUD treatment

• Applies to most SUD treatment programs

• Restricts disclosure of any information that would identify someone as having sought SUD treatment

• Requires written patient consent for disclosure of any PHI

BEFORE delivering services

and purchasing equipment

Issue to Avoid… having your digital recording

of clinical supervision session posted on…

Conclusion

Technology-based clinical supervision can open the door for expanded and improved services

by clinicians who have had limited access to supervision.

Objectives Review: How Did We Do?

1. Define substance use disorders health disparities

2. Explain three barriers to accessing quality clinical supervision

3. Discuss six key benefits of using technology to extend the reach of clinical supervision

4. Identify three key ingredients needed to do effective technology-based supervision

5. Demonstrate how to use at least one type of technology for clinical supervision

6. Develop strategies to overcome at least two barriers to technology-based supervision

Better services for clients = Equity, Quality, Accessibility

of substance abuse treatment.

“As members of a helping profession, it is our obligation to make sure that we provide access to our services, including supervision,

in a safe and ethical manner, but also in a manner that includes all persons and

reduces unintentional barriers.”

(Orr, 2010, p.106)

Imagine the Future of Rural Practice with TBCS

Without Supervision• Few clinicians• High burn-out• Limited use of EBTs• Isolation• Stress• Clients who can’t

get care

With Supervision• Expanded provider base• Improved professional

identity• Innovation and EBT• Connectedness• Improved work conditions• Access to care

The future of clinical supervision?

Questions

www.nfarattc.org