Jencius and Baltrinic (2016) described this as at least a two-step process beginning with (a) knowing how to use the technology and (b) applying it in clinical and supervisory practice. The authors explored the various ways in which counselor educators and supervisors use technology, including technologies such as bug-in-the-ear, bug-in-the-eye, audio and video recording, and synchronous videoconferencing, both as a means of connecting and also as a method of instruction. Jencius and Baltrinic further described synchronous videoconferencing as “using a new technology to provide an old supervision format instead of considering the unique opportunities that technology can provide” (p. 254). Nelson et al. (2010) noted that ethical practices are “fundamental to all clinical supervision regardless of supervision delivery modality” (p. 4).
As for pregraduation clinical experiences for counselors-in-training, Council for Accreditation of Counseling and Related Educational Programs standards do not specifically address the differences in how the standards should be applied to distance supervision versus face-to-face supervision. Students in distance supervision are held to the same standards as those in face-to-face scenarios, including weekly, real-time communication with a clinical faculty supervisor; evaluation of recorded sessions or live on-site supervision; and evaluation of counseling performance. These are often accomplished through a combination of video, audio, and text-based chat (Carlisle et al., 2017).
Supervisors should have some form of written informed consent in the supervisory relationship that includes the risks and responsibilities of using technology in online supervision. This is in addition to the information that would be included for face-to-face supervision (AMFTRB, 2016). This can be included in supervisory contracts, supervisor professional disclosure statements, or course syllabi. The informed consent should include discussion of the following:
The distance counseling and supervisory credentials of the instructor,
The risks and benefits of using computer-mediated communication in supervision,
What to do in case of technology failure,
Anticipated response time,
Emergency procedures,
Cultural differences,
Time zone differences, and
Potential denial of benefits for this service. (Jencius & Baltrinic, 2016, pp. 264–265)
In addition, Standard F.4.a. of the ACA Code of Ethics (ACA, 2014) stresses that supervisors identify the policies and procedures to which they adhere and the due process involved in appealing individual supervisor actions. Issues unique to the use of distance supervision should be included in the supervisor’s informed consent document.
Scenarios for Discussion
The Case of Joe
Betty has a small private practice in a midsize town that is surrounded by small rural communities in the Midwest. Her client Joe is elderly and has several health conditions. Recently, his health has declined, and he has not shown up for several sessions, always with good reasons. He has been placed on medication that makes it unsafe for him to drive, and he does not have close family or neighbors to help him drive. He suffers from depression, and his depression is exacerbated by isolation. His wife passed away 18 months ago after 47 years of marriage.
The Case of Rico
Rico works for a large agency that has recently obtained a contract to work with veterans who are serving in isolated regions. His newest client is a retired veteran with three small children. She struggles with alcoholism and has been mandated to counseling by the court for a recent DUI. She self-isolates and she does not enjoy contact with people. She consumes up to 10 drinks per day. Her children are in school until the early afternoon, and then they are alone with her until their father arrives home from work in the early evening. Rico’s client has active combat experience, but she refuses to talk about her service or any symptoms related to it. The closest face-to-face counseling option is 2 hours away, and she no longer has a driver’s license.
The Case of Boa
Boa is attempting to finish her clinical internship for her master’s degree in counseling. Because of health concerns, her agency has changed from 100% in-person services to behavioral telehealth services. She is struggling to decide whether she is comfortable offering services in this manner. She usually uses public Wi-Fi, and she often video chats with friends using FaceTime and other similar programs. She does not have strong coursework in this area, and she is concerned that she will not be capable of providing this service well; however, she realizes that her clients will suffer if they do not have continued services. Many of her clients are from poor backgrounds or are children. Others are caregivers who are struggling with working at home and having children at home. Boa is attempting to process this with her university supervisor as well as her site supervisor. She wants to do what is best for her clients.
Questions to Explore
What must be included in your informed consent (according to state law)?
What must be included in the client record or supervisory record?
Are there any specifications regarding electronic records?
What legal provisions must be made in the event of provider death or incapacity?
Does your state law allow for the use of technology in counseling? Does it specify the type of technology that is allowed (synchronous vs. asynchronous)?
Does your state law allow for the use of technology in supervision? Does the law specify that a certain number of hours must be completed in a face-to-face setting?
How does your state define residence?
What requirements does your state licensure board have around the use of technology? For counseling sessions? For supervision?
Does your liability insurance cover distance counseling or behavioral telehealth?
Conclusion
Telebehavioral health is a useful therapeutic tool that helps connect counselors and clients, especially when physical proximity is not possible or preferred. It is imperative to recognize that all ethical and legal guidelines guiding treatment for in-person therapy apply to telebehavioral health, as do additional guidelines for the use of technology. It is critical that counselors remain aware of geographic limitations outlined in relevant laws as well as specific guidelines outlined by federal and state governing entities. Counselors must ensure that they have appropriate licensure, training credentials, and liability insurance as they engage in these practices. It is important that the informed consent contain appropriate standard information as well as specific instructions for the use of technology.
References
1 Alexander, P. (2018, October 23). The psychiatrist who tried to save Sylvia Plath: Paul Alexander on the real “Doctor Nolan.” Literary Hub. https://lithub.com/the-psychiatrist-who-tried-to-save-sylvia-plath/
2 American
