With Supervision - Virginia Summer Institute for Addiction Studies

Transcription

Using Technology for Online
Distance Counseling &
Supervision
Rawson Carlin
Licensed Professional Counselor in NC and Wyoming
Licensed Clinical Addictions Specialist in NC
Certified Clinical Supervisor in NC
Licensed Addictions Therapist in Wyoming
Master Addiction Counselor
National Certified Counselor
Distance Credentialed Counselor
President of E Care Counseling, PLLC (Private counseling practice and
approved education provider for NAADAC & NBCC)
Website: ecarecounseling.com
Email: [email protected]
Teletherapy Essentials © 2014 Behavioral Health Innovation, Jay Ostrowski, MA, LPC-S, NCC, DCC, ACS
Overview
What is Teletherapy/Distance Counseling?
History & Growth of online therapy
What modalities (types) are used?
Is there a need?
Effectiveness of online therapy
Who supports telemental health?
Pros/benefits & Cons/risks
Legal & Professional requirements
Is it reimbursed?
Training and certification
Technology-based Clinical Supervision
What is Teletherapy
2015
The provision of mental health services through technological
means, usually over the internet.
Teletherapy has been defined as ““the application of
telecommunications technology to delivery of professional services
at a distance by linking clinician to client, or clinician to clinician, for
assessment, intervention, and/or consultation.” In a nut shell, it’s
online therapy.
According to National Board of Certified Counselors online counseling
defined as “technology assisted distance counseling for individuals,
couples, and groups involves the use of the telephone or the computer to
enable counselors and clients to communicate at a distance when
circumstances make this approach necessary or convenient”.
Frequently used terms for online counseling
Cyber counseling
Web based counseling
Online support
Web therapy
E counseling
E therapy
Telephone counseling
Technology use has invaded our lives
Technology use has invaded our lives- Cont.
87% of Americans use the Internet (Fox & Rainie, Pew Report, 2014)
90% of American adults have cell phones
58% have smart phones (Pew Report, 2014)
More people own cell phones than use the Internet (Fox, 2013)
HIMSS Survey 2014: Most Widely Used
Telemedicine Technologies
Health Information and Management System Society
Video-Based Online Mental Health Services
“Telemental health is one of the most active telemedicine
applications rendered in the United States. Telemental health is an
intentionally broad term referring to the provision of mental health
and substance abuse services from a distance. Mental health is
particularly suited to the use of advanced communication
technologies and the internet for delivery of care. By using
advanced communication technologies, mental health professionals
are able to widen their reach to patients in a cost-effective manner,
ameliorating the mal-distribution of specialty care. “
Practice Guidelines for Video-Based Online Mental Health Services
May 2013 by American Telemedicine Association
Use of the internet technology is growing
There are new professions that are utilizing the internet
for conducting business everyday.
The idea of receiving therapy from a counselor remotely
is not necessarily a new idea.
There have been counseling hotlines for quite a long
time helping people for different problems they might
encounter. (Suicide and pregnancy hotlines are examples.)
Counseling has jumped on the bandwagon of utilizing the
internet as well for delivery of therapy to clients.
Today the internet can connect a licensed therapist with a
client/patient remotely.
Use of the internet technology is growing-Cont.
Technology has become vital in everyone’s lives and people are
turning to it for reasons such
Meeting new people and developing relationships
Learning new skills
Pursuing education
Accessing support
Accessing finance
Shopping online
Digital Therapy
2015
History & Growth of online therapy
Digital Therapy
2014
1950s - First recorded Telemedicine events (1959)
2014 Psychotherapy Networker
Conference: Therapy’s Digital Future - © 2014 Jay Ostrowski, MA, LPC-S, NCC, DCC, ACS
http://telehealth.gcatt.gatech.edu/HTML/Nebraska1.html
Growth of Online Therapy
Slow start
1950s - First recorded Telemedicine events
1973 - American Journal of Psychiatry - Dr. Thomas Dwyer - practiced video
& telephonic counseling for 5 years.
1980s - All states had at least one program.
- State and grant funded, few were self-sustaining, research focused
1997 The Balanced Budget Act (BBA)
-Mandated Medicare reimbursement for telehealth care
-Funded telehealth demonstration projects 2000 Benefits Improvement and
Protection Act (BIPA)
-Expands rural access and guidelines for rural health access
2001 Consolidated Appropriations Act (CCA)
-Telehealth policies (H.R. 5661, Section 223)
2008 Medicare Improvement to Patients and Providers Act (MIPPA)
-added more originating telehealth sites and SNF
Growth of Telemental Health
Momentum from Federal Mandates and Funding
2009 American Recovery and Reinvestment Act (ARRA)
- Significant investments in health technology
-Broadband, Health IT, Telehealth and e-health technology
2009 Department of Defense (DoD) Appropriations
for Fiscal Year (p. 405)] H.R. 2638
"…the Department is directed to establish and use a web-based Clinical Mental
Health Services Program as a way to deliver critical clinical mental health services to
service members and their families in rural areas.”
2010 Affordable Care Act (Obamacare)
- Strong Telehealth Mandate and funding
ACA, Section 3022: Creates a "shared savings program" that will encourage
investment in the infrastructure and redesign of care processes. "An ACO is required to,
among many things ... coordinate care through the use of telehealth and other
enabling technologies."
Teletherapy
2015
What Modalities (types) are used?
Main Types of Online Therapy
Asynchronous (Store and Forward)
Not reimbursable by
Medicaid or insurances
Text-based therapy
Examples:
Email, texting, chat
9
Asynchronous Technology
Companies That Stated HIPAA Compliant & BAA*
Examples
Encrypted Email
7 of 107 surveyed
Encrypted Live chat
11 of 105 surveyed
*Companies that state they are HIPAA compliant & will sign a Business Associate Agreement (BAA).
Asynchronous
Technology (cont)
Chat
Asynchronous Example
Avatar Therapy
Computer-Simulated & Synchronous Avatar Therapy
DOD’s Self-Help for PTSD
www.t2.health.mil/vwproj/docs/video/VW-PTSD_EXP.mp4
www.t2.health.mil/vwproj/index.html 3:15
https://t2health.org/vwproj/index.html
Avatar Therapy
Avatar Therapy
Online Therapy Institute’s Avatar Therapy Session Room
http://bit.ly/158wKvN
Synchronous Technology
Synchronous (Real-time) Video
Secure Video
Encrypted connection
HIPAA compliant
VA held over 280,000 clinical mental health sessions in 2013
VA is Currently Piloting in home care with different telehealth providers
http://www.stonephillipsreports.com/2012/04/veterans-health-telemental-health/
ONCE A CARTOON….
NOW REALITY!
Zoom Video
Technology Companies
180
Volume of Online Therapy
Technology
190
Total Companies
Private Practice
Networks
Enterprise
Consumer
135
175
90
108
45
93
83
43
Enterprise
Networks
0
All
Private Practice
Consumer
Oriented
From www.telementalhealthcomparisons.com
Each company may have more than one focus.
As of 9/20/14
Technology Overview
Survey of Technologies (cont).
As of 12/1/13
Companies that stated HIPAA
compliant & BAA*
Synchronous
Examples
Encrypted
Video
14 of 111
surveyed
*Companies that state they are HIPAA compliant & will sign a Business Associate Agreement (BAA).
Main Types of Online Therapy (cont)
Apps - Online Therapy In Your Pocket
mHealth
As of 3/1/14
450+ Apps
For Therapists
For Therapy
Therapy Students
FDA beginning to regulate Apps as medical devices.
For now, only focusing on a few medically related.
www.telementalhealthcomparisons.com/apps
Main Types of Online Therapy (cont)
Apps - Online Therapy In Your Pocket
Examples of DOD Apps
Considerations When
Using Apps
Make sure…
• You use the App yourself before prescribing it.
• It doesn’t get in the way of the therapy objective.
• The client CAN use it and WANTS to use it.
• The app is secure, if obtaining client PHI.
• The use is time limited to achieve compliance.
Have you ever …Rate your comfort with technology 0 - 16
• 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
The Need
67M
34M
Get no care
24M
Americans
have a mental
illness
Get
inadequate
care
9M
Get adequate
care
Two-thirds of PCPs struggle to refer to mental health providers
~ Commonwealth Fund
Includes adults (htt://1.usa.gov/MPYzPQ , http://1.usa.gov/N5kwH4) and children (http://1.usa.gov/N5kDma, http://1.usa.gov/LDRbU6, http://bit.ly/RwQkaW
Shortage of Mental Health Providers
Effectiveness
(cont.)
Research on Online Therapy
Studies Show
150
Positive Outcomes
No Difference
between face-to-face
& online therapy
High Patient
Satisfaction
100
Moderate to High
Clinical Satisfaction
75
120
Meta-analysis of 92
Studies of online therapy
Meta-analysis of 148 peer-reviewed studies on
the use of video therapy online
Journal of Technology in Human Services, Vol. 26, No. 2, Clinical Psychology: Science and Practice, Vol. 16, No. 3
Effectiveness
Does Online Therapy Work?
2012 study of 98,609 veterans
who chose live video care
http://1.usa.gov/KZd4LT
25% fewer
hospitalizations
25% shorter
hospitalizations
2009 study of 37 drug addicts
randomized to live video group or
in-person care
2007 study of 495 patients
randomly assigned to live video
or in-person care
http://1.usa.gov/LDJqNT
http://bit.ly/Ncumcy
Equal rates of recovery
Equal rates of recovery
Patients preferred online
care
Online care cost 10%
less
Great Outcomes
Dr. Linda Godleski presentation slides from the American Telemedicine Association Conference 2014
Resources
Mid Atlantic Telehealth Resource Center - Consulting and training
http://www.matrc.org/
Technology comparisons and resources
www.telementalhealthcomparisons.com
Jay Ostrowski, MA, LPC/S, NCC, DCC, ACS
www.behavioralhealthinnovation.com
[email protected]
Jay Ostrowski is the Director of Product and Business Development with the National Board
for Certified Counselors and Affiliates. He also serves as a technical editor for The
Professional Counselor journal and a consultant on telemental health to state license
boards.
As the president of Behavioral Health Innovation (BHI), he servers as a telemental health
consultant and develops technology and services for online mental health programs and
niche applications. BHI maintains a comprehensive database on telemental health
applications, networks, programs, and relevant laws in all fifty states for all major mental
health professions.
Distance Counseling: A Comparison of State Licensure Laws 2014. Jay Ostrowski, National Board for Certified Counselors
VA-High Volume
Dr. Linda Godleski presentation slides at the American
Telemedicine Association Conference 2014
Great Outcomes
Growth Projections in Telehealth
Telehealth is…Everywhere
14 Federal agencies are focused on supporting telehealth
• Financial support -grants
• logistical support
25+ Medical Schools actively
developing telehealth programs
Clients Choosing
Online Therapy
150K
15%
VA Sessions
Per Year
Video-Chat
w/Provider
Psychologist
Video-Chat
Soldiers
Clients
Therapists
Physicians
The VA is
performing
secure video
conference
sessions at a
rapidly growing
rate.
Independent
research shows
15% of clients
want to video-chat
with their
providers.
A growing number
of psychologists
report that they are
providing services
through video-chat
like venues.
http://bit.ly/PnVgAx
Accenture
http://bit.ly/Nxt3EL
American Psychological
Association
Doctors are treating
patients through
video. Use of
electronic medical
records will likely
make doctors more
comfortable with
this medium.
http://bit.ly/18QsXFK
Department of Defense
10%
7%
Physicians
Video-Chat
http://bit.ly/NcKA1o
Manhattan Research
No data has been reported on counselors use of video conferencing with clients.
Who supports Telemental Health?
White House
NIH
HHS
SAMHSA
HRSA
CMS
AMA
APA
NASW
ACA
NBCC
AAMFT
Teletherapy
2014
Cons/Risks of online counseling
Counselors need training in computer technology related
to distance counseling.
Some counselors/clients are not comfortable using
technology or are reluctance toward learning about
technology
Possible technical problems (internet connection,
computer crash, etc.)
Counselors and clients need to become savvy to potential
distance counseling problems.
Possible breach of confidentiality/privacy if proper
precautions not taken
Counselors must ensure that clients are intellectually,
emotionally, and physically capable of using on-line
counseling services, and of understanding the potential
risks and/or limitations of such services
Pros/Benefits of online counseling
Flexible to those who have time constraints (work or home schedules)
Accessibility to those who live in remote areas (transportation issues)
Physically disabled or home bound clients are able to utilize counseling
services at their own convenience
Reduces social stigma of receiving counseling (won’t be seen going into
a counseling office)
Greater selection of therapists to choose from.
Affordability
Technological advances provide means for secure online scheduling,
payments, completing & signing forms with electronically, and HIPAA
and privacy/confidentiality compliance.
Legal & Professional Requirements
Each state has counselor legislation and practice acts that
determine the scope and activities of professional counselors.
(Online therapy laws vary)
There is considerable variation among state counseling boards with
respect to the legal practice of online counseling (Haberstroh,
2009).
Once the legality of online counseling is verified, ethics require
counselors screen potential online clients for appropriateness
related to their technical, emotional, and cognitive capacities for
online counseling (ACA, 2005)
Online Therapy Laws By Profession
All Boards Have Policy
Social Work Board Only
Counseling Board Only
Two Boards Have Polices
Psychology Board Only
No Official Policy
Results By State & Profession
Mental health license board policies on telemental health Spring 2014
1
22
21
22
Psychologists
Counselors
Social Workers
Marriage and Family Therapy Board
Types of Requirements (cont.)
Informed Consent-Risks
See Face-to-Face First
Require Special License
ID Client Location
Electronic Privacy
ID Client Age
Training Required
30
See Face-to-Face
First
23
27
Special License
Required
ID Client
Location
22
15
8
0
3
6
5
2
States
Mental Health License Boards
1
Total Boards
State Boards That Have Policies
States In Which All 3 Boards Have A Policy
State Boards Have No Policy
Boards That Provided Conflicting Gudiance
State Mental Health
License Boards
140
Gave
Conflicting
Guidance
All Boards
Have Policy
105
127
No Boards
Have Policy
Total
70Boards
35
0
66 *
Have
Policy
15
States
12
16
* Kentucky Marriage and Family Therapy Board has a separate policy
What laws are emerging related to telemental health?
Core Concept/Definition (Best ethical/professional practices)
Implementation
Abide by association or credentialing body ethics
One time- set up protocol
Jurisdiction-Verify location
Each time- Location
Training in telemental health
One time and annually updated CEs
Display Verifiable Credentials
At all times on promotional spaces
Assess client suitability
1st time and throughout treatment
Professional services - Informed consent
1st time
Verify the client identity & age
1st time
Verify the clients location at the time of services
Each session
Verity psychological safety-no one else in client’s room/private space Each session
Identify access to emergency services for that client (person or
agency to contact in case of emergency)
Provide viable referrals
1st time, each time different location
Privacy protection
Each time
Data Security-ensure data protected at login, in route and at rest
Each time
Provide Alternate communication means
1st time
Do no harm
Always
Telesupervision
Last time
Per credentialing body policy
Documentation Best Practices
As with office based services
DURING THE FIRST SESSION
•
•
•
•
•
Assess client suitability for TMH
Emergency Services & an emergency contact
Obtain informed consent
Verify identity including age
Establish alternative communication method
Introduction to Telemental Health © 2015 Center for Credentialing & Education
Documentation Best Practices
•
•
•
•
•
•
As with office based services
PLUS++
DURING EACH SESSION
The client location at the time of service
Confirm alternate communication plan
Psychological safety & private space
Access to emergency services
Privacy protections & informed consent
Security of Data at login, in route & at rest
LAST SESSION
Provide viable referrals
Introduction to Telemental Health © 2015 Center for Credentialing & Education
Reimbursement Rising
Third Party Health Insurers
As of 10/1/13
21 States and DC Mandate Private Insurance
Reimburse for Telehealth
Arizona (2013)
California (1996)
Colorado (2001)
Georgia (2006)
Hawaii (1999)
Kentucky (2000)
Louisiana (1995)
Maine (2006)
Maryland (2012)
Michigan (2012)
Mississippi (2013)
Missouri (2013)
Montana (2013)
New Hampshire (2009)
New Mexico (2013)
Oklahoma (1997)
Oregon (2009)
Texas (1997)
Vermont (2012)
Virginia (2010)
District of Columbia
In 2013, bills have already been introduced in Arizona (ENACTED)**, Connecticut, Florida,
Illinois, Massachusetts, Mississippi (ENACTED), Missouri (ENACTED), Montana
(ENACTED), New Mexico (ENACTED), New York, Pennsylvania, South Carolina, Tennessee,
Washington and the District of Columbia (ENACTED). (9 in process)
Reimbursement Rising
Third Party Health Insurers-Continued
In general, the state laws say-- A health benefit plan may not deny
coverage on the basis that the coverage is provided through
telemedicine if the health care service would be covered were it
provided in-person. Coverage for health care services provided
through telemedicine must be determined in a manner consistent
with coverage for health care services provided in-person.
Training and Certifications
Online Therapy Institute
Certificate
STAR Telehealth
Board Certification in Telemental Health*
Telemental Health Institute
Certificate
Zur Institute
Certificate
Behavioral Health Innovation
Certificate, tailored training
Higher Education:
Currently, very little is mentioned in clinical training.
Usually covered nominally in ethics courses.
*Other criteria apply, see ww.cce-gloabal.org/bcth for details.
Virginia Telehealth Network
February 26, 2015 Special Pre-Summit Workshop: Telemental
Health Training for Counselors, Psychologists and Other
Behavioral Health & Substance Abuse Service Providers
This “How To” session covers the key aspects of online therapy
including choosing HIPAA-compliant technology, billing insurance,
ethics, laws and practice etiquette. Get your questions answered by
industry experts and network with a community of potential
telehealth referral sources. $50 fee. Participants who successfully
complete this workshop may elect to receive the following types of
continuing education credits: American Psychological Association (3
credits), National Board of Certified Counselors (3 hours), Maryland
Board of Social Work Examiners (3 credits) and West Virginia Board
of Social Work Examiners (3 hours). For more information and to
register: http://matrc.org/summit/agenda.html
Virginia Telehealth Network-Cont.
The mission of the Virginia Telehealth Network (VTN) is to advance
the adoption, implementation, and integration of telehealth and
related technologies into models of healthcare to support the
delivery of quality care and improve access to care for all Virginians.
****************************************************
The Southside Telehealth Training Academy and Resource Center
(STAR) has developed a training program for health care providers
seeking to use advanced telemedicine and telehealth systems to
improve access to quality healthcare for rural and medicallyunderserved populations. Students in health care programs may
participate also.
Technology-based Clinical Supervision

Extending the Reach of Clinical
Supervisors
How about a shortage of Clinical
Supervisors?
RATE your knowledge on Technology-based
Clinical Supervision
Knowledge of Technology-based Clinical Supervision
1
Never
heard
of it
2
Does it
include
video
games
3
4
5
I have We have
We just
heard
had added new
other
several
TBCS
boards requests
statutes/
accept for TBCS regulations
it
Summary of the Problem: Substance Use
Disorder Workforce Issues
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 (over 20%) result from feeling overwhelmed.
Low job satisfaction leads to lower quality services.
Supervision takes time and money, and leaving less time to provide
services.
Difficulty recruiting new counselors
In
93% of
counselors were receiving inadequate supervision and 35%
a study published in 2013, the authors found that
were receiving harmful supervision.
The Solution
Quality online 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. ”
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.”
www.nfarattc.org
Purpose of the ATTCs
- develop and strengthen the workforce that provides addictions
treatment and recovery support services to those in need
Technology-Based supervision: Extending the Reach of Clinical
Supervisors
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.
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?
SSubstance Abuse Disorders are withspread
disorders are widespread
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)
There is 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.
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 …
Inadequate supervision…
supervision on the fly
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?
Supervisors prepare future generations to
represent the field
(Perry, 2012)
High-quality supervision is important for trainees to
develop into competent professionals
Support from Clinical Supervisors is the best
predictor of job satisfaction in a rural setting.
(DeStefano, Clark, Gavin & Potter,
2006)
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?
Reframe the Conversation
“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.”
Rather than questioning whether
TBCS is “as good” as traditional
supervision …
ASK
What is now possible and how can it
serve my supervisees and their
clients?
Technology-Based Clinical Supervision
 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
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 Effectiveness of 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)
Key Benefits to TechnologyBased Clinical Supervision
1. 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
Benefit #1
Increases Access to Quality Supervision
Provides better use of resources,
is cost-effective, and reduces travel
time
Technology greatly expands the available pool of
supervisors
Technology allows greater
access
to 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 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.,
Benefit #2
Enhances 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,
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.
Benefit #3
Strengthens Professional Identity
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)
“The supervisory relationship is the
crucible in which ethical practice is
established and reinforced.”
(SAMHSA, TIP 52)
The Clinical Supervisor
Models sound ethical and legal practices
Translates ethical concepts into practice
Helps the clinician develop ethical decision-
making tools
Benefit #4
Supports Program Integration
Program integration is
coming and technologybased 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.,
Benefit #5
Shepherds in a New Era of Technology
Cyber supervision’s time has come
Quotes from David J. Powell, PhD
“Clearly, the substance abuse field cannot ignore the influence of webbased technology and how best to use the Internet to enhance
education, training and supervision. The key will be how to use the tools
offered through technology without giving up quality.”
“Cyber supervision is here to stay, and supervisors need to learn to use
computer-assisted supervision effectively. It is efficient, economical and
convenient to both supervisee and supervisor. “
“Generally, cyber supervisees see this delivery medium as convenient
and comfortable. Although there may be generational/age differences
in one’s comfort level with technology (if I want to know anything about
my computer, I ask my daughters), these issues can be overcome with
training. Besides, the next generation of counselors who we are training
and supervising today are far more comfortable with this medium than
us “old folk.” Supervisees generally feel that accessing counseling
sessions through the Internet is problem-free and easy to hear and
understand.”
TBCS increases comfort with
technology, which is important as
service delivery becomes more and
more infused with technology.
(Wood et al., 2005, p. 176)
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
Benefit #6
Promotes 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
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
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!
Overall: Better Client Outcomes
Improved infusion of evidence-based practices
leads to better client outcomes
Best
Research
Evidence
EBP
Professional
Expertise
Client
Values
“In substance abuse treatment, clinical
supervision is the primary means of
determining the quality of care provided.”
Therefore, TBCS will extend the reach of Clinical
Supervisors and help promote the quality of SUD
treatment services.
(SAMHSA-TIP 52, pg. 5
“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
Three Steps for Technology-Based Clinical
Supervision
1.
Provide quality clinical supervision
2.
3.
Choose the best technology
Use the technology to extend the
reach of quality supervision
Above all else, Clinical Supervisors using
technologies to deliver clinical supervision services
should be well-trained in clinical supervision.
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
Telephone or Polycom
Use for direct observation, individual or group
supervisory sessions, crisis intervention, timesensitive and/or confidential matters
Benefits:
Easy to maintain confidentiality
User-friendly
Inexpensive
Versatile
HIPAA Compliant
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
Videoconferencing
Use for direct observation,
individual and group supervision,
screen sharing video, and didactic
teaching
Benefits:
 Audio and visual cues
 Free and low-cost options available
 Promotes alliance
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
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,
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
Live Supervision Chat
Digital Video or Audio Recording
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
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.
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.,
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.,
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.
Email
Use for providing feedback or
answering non-urgent questions that
do not include confidential
information.
Benefits:
•
•
Easy to use
Allows for thoughtful exchange without time
constraints; prompts reflection
• Lowers inhibitions
• Allows for record-keeping
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.
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.
Avatars
Use 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 Comparisons
It 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, including
comparisons 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
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?
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, 20
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.
How to Overcome Technology Barriers
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!
(Nagel et al., 2009; Vaccaro & Lambie, 2007; Lannin & Scott, 2013;
Many seasoned Clinical Supervisors may be less
familiar with technology, yet have supervisees
who are using technology with clients. This can
negatively impact the supervisory relationship
How to Build 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
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 to
evolve, but the ethical principles
remain constant.”
(Koocher & Keith-Speigel, 2008, p
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
National Board for Certified Counselors
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 Association of Social Workers
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)
American Association of Marriage &
Family Therapists (proposed 2015
ethical standards)
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
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 &
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)
5 Steps to Enhance Online Security
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.
(Rousmaniere et al, 2
Privacy Rules Overview
Three main federal regulations apply:
HIPAA
HITECH (The Health Information Technology for Economic and Clinical Health Act)
42 CFR part 2
 Assume these apply to you –
penalties for breach are stiff
the
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.
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.10
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?
Resources
Jay Ostrowski Contact Information:
[email protected]
www.telementalhealthcomparisons.com/about-bhi/resources
Technology comparisons and resources
https://www.telementalhealthcomparisons.com
https://www.adaptivetelehealth.com/ free trial & support
Mid Atlantic Telehealth Resource Center - Consulting and training
http://www.matrc.org/
http://www.matrc.org/how-can-we-help/request-technicalassistance

References
Landau, E. (2009). Therapy online: Good as face to face? Retrieved
from
http://www.cnn.com/2009/HEALTH/08/31/online.internet.therapy.cbt/i
ndex.html.
National Board for Certified Counselors, Inc. & Center for Credentialing
and Education, Inc. (n.d.). The practice of internet counseling. Retrieved
from
http://www.nbcc.org/assetmanagerfiles/ethics/internetcounseling.pdf.
Sutton, D (2010). What is internet counseling? Retrieved from
http://counseling.suite101.com/article.cfm/internet-counseling.
McAdams III, C. R., & Wyatt, K. (2010). The regulation of technologyassisted distance counseling and supervision in the United States: An
analysis of current extent, trends, and implications. Counselor Education
& Supervision, 49(3), 179-192. Retrieved from EBSCOhost.
Stretch, L.S., Nagel, D.M. & Anthony, K. (2012). Ethical Framework for
the Use of Technology in Supervision. Therapeutic Innovations in Light
of Technology. Vol. 3 (2). 37-45.

With Supervision - Virginia Summer Institute for Addiction Studies

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