Videoconference for Psychotherapy Training and Supervision: Two Case Examples

Introduction

Psychotherapy supervision and training are now widely available online. A Google search for “psychotherapy Skype supervision” reveals expert training via internet-based videoconference in virtually all major psychotherapeutic modalities, including acceptance and commitment therapy, cognitive-behavioral therapy, dialectical-behavioral therapy, emotion-focused therapy, eye-movement desensitization and reprocessing, intensive short-term dynamic psychotherapy, and psychoanalysis among others. An eclectic range of new technologies are being integrated into supervision and training, including webcams, tablet computers (e.g., the iPad), the internet “cloud,” web-based software for tracking clinical outcomes, and supervision “apps” such as www.iSupeLive.com. As the implementation of new technologies spreads, research on their effectiveness is likewise quickly ramping up: over 25 clinical research studies on technology-assisted supervision and training (TAST) have been conducted since 2000 in training sites around the world, including Australia, Canada, England, Norway, and the United States (Rousmaniere, 2014). Among the potential benefits of TAST are greatly increased flexibility, reduced travel costs, and the opportunity to increase the limited availability of clinical training in rural, remote, and underserved areas (e.g., Abbass et al., 2011).

However, for supervisors who are not technologically savvy, these new developments may seem abstract or be perplexing. Many supervisors may still wonder how supervision on the internet actually works, and ask what it actually looks like. Furthermore, questions have been raised about the impact of these new technologies on supervision practice. For example, does videoconference supervision affect the supervisory working alliance (e.g., Sørlie, Gammon, Bergvik, & Sexton, 1999)? Does the limited range of non-verbal communication in videoconference affect or limit supervision practice (e.g., Vaccaro & Lambie, 2007); especially the more subtle and complex aspects of supervision, such as countertransference or resistance in the supervisee or supervisor (Watkins, 2010a, 2010b)?

The goal of this article is to address these questions. First, an overview of videoconference technology will be presented, including a brief review of the applicable research. Then, case examples of internet videoconference-based psychodynamic training programs will be described. Transcripts from two cases will be presented, to provide clear examples of how internet-based supervision actually happens. Last, the impact of videoconference on supervision practice and effectiveness will be discussed, based on research data, case examples, and clinical theory.

Videoconference Technology

The most widely used new technology for internet-based supervision is videoconference, which permits simultaneous (“synchronous”) audio and video communication via the internet. Videoconference is currently being used to provide supervision and training in practically all major therapeutic modalities, for both prelicensure trainees and postlicensure clinicians (Rousmaniere, 2014). Originally, videoconference was largely used to provide individual supervision to trainees in rural or remote areas (e.g., Sørlie et al., 1999). However, videoconference is increasingly being used by urban clinicians who seek training in particular specializations from geographically distant experts (e.g., Rousmaniere & Frederickson, 2013). Recent advances in videoconference software permit group-videoconference from multiple locations, and the option for videotapes to be shown within the videoconference software, permitting supervisors to provide videotape-based group psychotherapy training for an international pool of trainees (e.g., Abbass, 2011).

Required Hardware and Software

The rapid decrease in computer costs and the rise in internet connectivity speeds have made the accessibility of videoconference technology practically ubiquitous, at least in developed areas. In the first quarter of 2012, the average global internet speed was 2.6 Mbps (Akamai, 2012; technologically developed countries had substantially higher average speeds), which is five times greater than the speed recommended for good quality videoconferencing. Readers can test their local internet speed at the website www.speedtest.net. Many large technology companies provide free software for individual and group videoconferencing (e.g., Google, Skype). Virtually all new personal computers, smart phones, and tablet computers come with videoconference software pre-installed.

Research on Videoconference Supervision and Training

While the field is still in its infancy, preliminary empirical research suggests that videoconference may be effective for individual supervision, group supervision, and didactic teaching (e.g., Reese et al., 2009; Xavier, Shepherd, & Goldstein, 2007). Research also suggests that videoconference supervision has the potential to increase self-disclosure and reduce disinhibition in supervisees (e.g., Cummings, 2002), and may not impair the supervisory working alliance (e.g., Reese et al., 2009; Sørlie et. al., 1999). Anecdotal experience and case reports suggest videoconferences can be effective for international and cross-cultural supervision (e.g., Panos, Panos, Cox, Roby, and Matheson, 2002; Powell, 2011). Concerns that have been raised about videoconference supervision include: (a) the risk that cultural misunderstandings may be increased by geographic distance between supervisor and supervisee (e.g., Powell, 2011), (b) challenges in understanding nonverbal communication could be heightened by electronic communication (e.g., Vaccaro & Lambie, 2007), (c) anxiety, which may be heightened in some supervisees (e.g., Sørlie et al., 1999), (d) unfamiliarity with local laws and regulations, and supervisors’ inability to provide help from a distance (e.g., Abbass, 2011), and (e) the possibility of reduced effectiveness when compared to in-person training (Scholomskas et al., 2005). Some trainees have reported preferring in-person supervision to videoconference supervision (e.g., Coker, Jones, Staples, & Harback, 2002). Given these concerns and challenges, supervisors using videoconference are recommended to emphasize a collaborative approach to supervision, especially in light of recent data that highlights the importance of collaboration in maintaining a positive supervisory working alliance (Rousmaniere & Ellis, 2013).

Reliability

Anecdotal experience and case reports suggest that the reliability of videoconference software and internet connections are mixed, so users should expect occasional problems with dropped calls or poor connectivity (e.g., Powell, 2011). In the first author’s experience using a range of different videoconference software weekly for over three years at both a University Counseling Center and private practice, about 20% of calls had minor to major connectivity problems. Group videoconference often has worse reliability. Unfortunately, most of the reliability issues with videoconference are due to connectivity problems in the international internet network, which is outside the control of users. These network problems affect all videoconference software companies, so no videoconference software has yet been demonstrated to be more reliable than any others. For these reasons, videoconference should only be used if both the supervisor and supervisee are comfortable with the realistic reliability limits. Likewise, backup methods for supervision should be designated (e.g., phone). The best way to improve reliability is to get the fastest internet connection available in your area. Other ways to improve reliability are to close internet-intensive programs running in the background while using videoconference (e.g., internet-based file-sharing software), limit the use of “screen sharing” features, or turn off the video camera when internet connectivity is poor.

Security and Confidentiality

Videoconference supervision usually involves the transmission of patient protected health information (PHI), and thus may fall under the regulations of the Health Insurance Portability and Accountability Act (HIPAA), which set minimum standards requiring the protection of the confidentiality of all electronic health information. The American Recovery and Reinvestment Act of 2009 included The Health Information Technology for Economic and Clinical Health Act (HITECH), which modified HIPAA. Videoconferencing software that permits compliance with HIPPA is also now available at affordable pricing (e.g., www.nefsis.com, www.wecounsel.com). However, most videoconference software runs through a central server, and thus is not considered “secure” by the standards of HIPAA. One risk is that an employee of the videoconference company could listen in on a session. For this reason, it is important to fully inform supervisees about the limits of confidentiality, and patient consent should be obtained if Protected Health Information (PHI) is going to be transmitted over videoconference. However, it is worth noting that this risk is no greater than the risk of a telephone company employee listening in on a supervision or psychotherapy session done via telephone. Clinicians who use videoconference or any other electronic communication of PHI are recommended to consult with the HIPAA compliance officer in their institution’s Information Technology department or local professional association (Rousmaniere, 2014). For a thorough discussion of videoconference security, confidentiality, and HIPAA, see http://www.zurinstitute.com/skype_telehealth.html#debate. The website www.personcenteredtech.com also contains a host of information on this topic.

Three of the simplest and most effective ways to enhance online security are: (a) use “strong” passwords (do not use birthdays, names, or words in the dictionary; use at least eight characters; and use a combination of numbers, special characters, and upper/lower-case letters); (b) do not use the same passwords for multiple accounts, and change your passwords regularly; (c) be extremely careful when downloading attachments in emails or clicking on links in emails—this is one of the most common ways to get a virus and have your email account hacked.

Videoconference for Supervision of Unlicensed Psychotherapists

Although it is possible videoconference could be used effectively for supervision of unlicensed psychotherapists, a host of regulatory questions must first be answered. For example, in their comprehensive survey of 46 state counseling regulatory boards in the United States, McAdams and Wyatt (2010) found that regulations for internet-based supervision were in place in six states, in development or discussion in 18 states, and prohibited in 19 states. Sixty percent of boards limited the hours of internet-based supervision that could be applied to licensure, with the limits ranging from 10% to 50% of total hours (McAdams & Wyatt, 2010). Supervisors wishing to supervise pre-licensure trainees via the internet should consider questions such as:

(Kanz, 2001; McAdams & Wyatt, 2010; Rousmaniere, 2014; Vacarro & Lambie, 2007).

Software Options

There is a wide range of videoconference software options available. An up-to-date listing of videoconference options can be found at www.telementalhealthcomparisons.com For video-based supervision, users have three options. Videos can be shared via the mail, which is technologically simple but slow and expensive. The second option is sharing videos via online file-sharing programs, which are fast and inexpensive but technologically more complicated. Online file-sharing programs have significant security vulnerabilities (Devereaxu, 2012) that can be addressed via encryption programs (e.g., www.BoxCryptor.com). The third option is using videoconference software that permits users to show session videos within the videoconference (“screen sharing”), which is the logistically simplest method of sharing videos, but this can reduce the quality of the video.

The technological options available for videoconference supervision are growing rapidly, and clearly outpacing the clinical research. Software and hardware options change frequently, and internet businesses open and close on a monthly basis. The advantage of this rapid growth is that new features are regularly becoming available (e.g., enhanced security options, more reliable internet connections). The challenge for supervisors is that we can never rest on our laurels and assume that a program we use today will work the same tomorrow. Thus, supervisors who want to provide services via videoconference are recommended to regularly explore the new range of videoconference technologies, as they enter the market. This can be done simply by searching for “new videoconference technology” or “secure videoconference” in Google. The best software and video-sharing options will depend upon each supervisory dyad’s unique needs and level of technological comfort.

Videoconference Supervision: Two Case Examples

Following are two case examples of videoconference supervision. In both cases, the supervisees are licensed psychotherapists who sought advanced psychotherapy training in intensive short-term dynamic psychotherapy from geographically distant experts. The use of videoconference for supervision greatly reduced the financial and time burden that would have been incurred by travel.

Case Example #1: International Video-Based Group Supervision

One of the authors runs international supervision groups for postlicensure clinicians studying Intensive Short-Term Dynamic Psychotherapy (Abbass et al., 2011). Groups meet weekly or biweekly for an hour or two via group videoconference. The supervision is based on psychotherapy session videos that are shared amongst the group via an online encrypted file-transfer program. Students take turns presenting session videos in half-hour to one hour blocks. As the group watches the video, the supervisor comments on the session via the videoconference chat window. Generally, groups contain four to five members. About 75 clinicians have participated, including members from Australia, Canada, Italy, Denmark, Norway, Sweden, the United Kingdom, and the United States.

The benefits of this supervision format are similar to traditional inperson group supervision: the opportunity to learn from a supervisor and one’s peers simultaneously (Bernard & Goodyear, 2014). Members benefit from group cohesion, peer support, universality, modeling, and group learning (Abbass, 2004). The group-format of supervision is also economical, because the trainees share the cost of supervision. One student describes his experience in a group as, “learning by viewing others’ work and the feedback they received … I find [the group] very supportive and normalizes my struggles with using this approach” (J. Cooper, personal communication, June 27, 2013). The use of session videos in psychodynamic supervision has been well established as effective for addressing the problems of absent-mindedness, misattribution, and unconscious bias that affect supervision based on process notes (Haggerty & Hilsenroth, 2011). Session videos also serve a reality-testing function that can address idealization or devaluation: group members see that their and others’ videos are rarely as excellent, or as awful, as they had imagined.

Challenges for this distance-format of group supervision generally have to do with group membership and cohesion. If a supervisor isn’t careful, a group can end up with members whose skills vary too greatly. This can make supervision boring for some while going over-the-head of others. Likewise, if a group is formed without having met in-person, there is a greater risk of mismatches between group member personalities, trainee and supervisor interests, clinical foci, or training goals. For these reasons, it is recommended that supervisors take time to get to know group members and their learning needs or goals. Likewise, it can be helpful for the group to meet in person periodically.

The limited range of vision in online group supervision can also pose challenges. In the best conditions, the supervisor can only see the trainees’ faces; even those may be obscured while watching a video. The limited field of vision mutes group members’ emotional responses and can encourage projection or false assumptions, especially in moments of silence. For these reasons, it is recommended that supervisors use clear and ample communication via voice or text throughout the supervision process. Hence, trainees need openness and some degree of confidence to participate in this supervision format.

There are also technological challenges for the online group supervision format. Group members must be proficient and comfortable with simultaneously using videoconference and file-transfer software. For this reason, it is recommended that new members assess their technological competence, or practice with the technology, before starting a group. Another challenge can be scheduling, especially if group members are in different time zones.

Below is a partial transcript from a videoconference group supervision. There were five supervisees in this group, each in a different location in the United States. The supervision group met weekly for one hour, during which two supervisees would each present a half hour of session video. In this supervision, the supervisee presented a case in which progress had stalled, and the supervisor attempted to bring understanding as to why that might be so.

In this excerpt, the supervisor identified that the supervisee had used challenge prematurely with the client, causing misalliance. This supervision helped identify countertransference material that was previously unconscious in the supervisee. The supervisor effectively made use of session videotape to help the supervisee identify how his words and voice tone came across as critical of the client. As Haggerty and Hilsenroth (2011) have so aptly indicated, “It is not uncommon for psychopsychotherapists to practice without ever having their work directly observed by another colleague. It is also not uncommon, in many training programmes, for a student to spend an entire training year (i.e. externship, internship, postdoctoral) without ever having their work directly observed by a supervisor” (p. 193). The opportunity to accurately assess voice pitch and tone is but one example of how using videotape can prove of enormous benefit in psychotherapy supervision, as this would not have been possible with session process notes. Another benefit is that the supervisor has direct observation of the client, allowing for more accurate psychodiagnosis, treatment planning, and outcome assessment. Additionally, supervisees gain an empirical perspective of their own work, which can help counter the tendency towards self-glorification or devaluation that may occur when learning challenging psychotherapy techniques. While these opportunities for advanced training were previously limited by geographic restrictions, videoconference now offers the unique ability to provide these benefits across international borders, at very low cost.

Case Example #2: Videoconference for Live One-Way-Mirror Supervision

The second case is an example of Remote Live Supervision (RLS): A promising new use of videoconference technology is to provide live one-way-mirror supervision at any geographic distance (Rousmaniere & Frederickson, 2013). In RLS a supervisor watches a live psychotherapy session via the internet, and gives guidance to the psychotherapist in real-time. RLS removes the geographic restrictions of traditional in-person live supervision, allowing “live” training in any location with a good internet connection. The model of RLS presented here is appropriate for advanced training of licensed psychotherapists.

Physical Setup for Remote Live Supervision

The client and supervisee sit across from each other, as in a traditional therapy room. A webcam transmits live video of the client during the therapy session to the supervisor in another location. In visual-format RLS, the supervisor types text interventions into a chat window in videoconference software. A laptop computer sitting next to the client displays the supervisor’s interventions in large type, like a teleprompter for the supervisee. The supervisor’s interventions are not in the client’s field of vision during the session, but the text can be shared with the client after the supervision if this is clinically warranted (indeed, sharing the supervision text can help reinforce the supervisor’s interventions). Alternately, in audio-format RLS, the supervisor speaks interventions into their computer’s microphone, which are heard by the supervisee via an earpiece. The supervisee decides which interventions to integrate into therapy.

Asynchronous forms of supervision (e.g., process notes, videotape review) are aimed at building cognitive awareness of psychotherapy processes and models. In contrast, live supervision is synchronous, so the supervisee can learn from the supervisor’s ability to make moment-to-moment clinical assessments and interventions in real-time. Live supervision is experiential learning aimed at building procedural psychotherapy skills, and permits state-dependent learning, as the supervisee receives the supervisor’s guidance at the exact moment it is needed. Live supervision is also an opportunity to “walk in the supervisor’s shoes,” and see the psychotherapy model come to life. However, live supervision is a challenging method of training. The supervisee must simultaneously track the client and the supervisor’s comments. There may be a risk of beginning clinicians feeling confused or lost during the session, or going passive and blindly following the supervisor’s comments (Bernard & Goodyear, 2014). While research has suggested that in-person live supervision can be effective for beginning trainees (Bartle-Haring, Silverthorn, Meyer, & Toviessi, 2009), the distance component of RLS may heighten the potential challenges or risks inherent in live supervision. For example, if beginning clinicians do not have the skill (technical or interpersonal) to apply the supervisor’s interventions, a clinical problem could be created that the supervisee is unable to correct later, when they do not have the supervisor nearby. Thus, RLS may be not suitable for pre-licensure trainees located in a distant location or different jurisdiction from the supervisor (Rousmaniere & Frederickson, 2013).

RLS and Transference

While the supervisor and client have no direct contact in RLS, the supervisor may still unintentionally elicit transference and projection as if he or she were in the room (in this sense, the supervisor is a “blank slate”). For example, a perfectionistic client may project their self-judgment onto the supervisor, and imagine that the supervisor is thinking critical thoughts about the client. If handled carefully, this can facilitate corrective emotional experiences that are also learning experiences for the trainee. For example, if a client becomes angry at the supervisor, the psychotherapist could encourage the client to express those feelings. Meanwhile, the psychotherapist could address any defenses that arise in response to that rise of feeling. In other words, the presence of the supervisor and the patient’s reactions become “grist for the mill,” subject to the same working-through process we would bring to any psychological phenomenon in therapy.

RLS and Countertransference

When more advanced trainees become stuck, the problem is often countertransference (Jacobs et al. 1996). With countertransference, the supervisor faces a dilemma: Do we teach or treat? (Ekstein & Wallerstein, 1972) Trainees’ clinical blind spots are often emotional, based on the trainee’s past. The most effective supervision addresses trainees’ blind spots and simultaneously has an emotionally transformative effect on the trainee. Remote Live Supervision offers a new way to address countertransference because the supervisor can offer an intervention at the very moment that the trainee becomes “stuck.” All of the supervisor’s comments are, in effect, interventions for both the client and trainee. This can facilitate experiential insight for the trainee and resolve countertransference difficulties. As the trainee tries the new interventions, the supervisor provides emotional support to go where she has never gone before; as the client changes, the trainee changes simultaneously.

RLS and the Supervisor

The supervision literature has highlighted the power imbalance inherent in supervision, and the “games people play” within that dynamic (Kadushin, 1968). Watkins (2010b) highlighted the risk of new supervisors overpowering or harming supervisees due to their own insecurity in their role-identity. Remote Live Supervision is a particular intimate form of supervision; since the supervisor is on-line, she cannot hide. In live supervision, it is immediately obvious whether the supervision is helping the supervisee and/or client. Thus, RLS could feel threatening for novice or insecure supervisors. However, if the supervisor is sufficiently secure in their role-identity, RLS can serve to even the playing field, providing a useful corrective to the power imbalances inherent in supervision.

RLS Case Example

The following are two excerpts from a transcript of one remote live supervision session. The client was a 20-year-old woman who had been sexually abused as a child. She presented with daily cutting and high anxiety, including panic attacks. Although therapy had progressed well initially in reducing the client’s cutting and anxiety, it had recently become stuck in regards to the client’s inability to enjoy sexual intimacy. The psychotherapist offered remote live supervision to the client as a chance to get therapy unstuck, and the client agreed to “try it out.” At the conclusion of the session, the client expressed very high satisfaction with the session.

In the first excerpt, the client is discussing the negative self-talk she experiences about sex and other issues, which she labels as the “policeman.” The supervisor helps the psychotherapist make a more clear cognitive separation between her healthy ego and pathological superego introject.

[Note: the supervisor comments in this transcript appeared on a laptop screen sitting next to the client, in view of the psychotherapist.]

The second excerpt takes place 47 minutes into the 75 minute session. The client had expressed rage at her mother for not protecting her from being abused 14 years previously and had visualized chopping up her mother. In this example, the supervisor uses the supervisory session to give focus to that rage and its possible meaning.

As can be seen in this excerpt, the supervisor helps the supervisee make dynamic connections regarding how the client’s self-abusive behavior (cutting) was displaced rage at her mother. Intensive short-term dynamic psychotherapy theory states that to get the most complete symptom relief and character change, it is important for clients to accept not just their rage, but also the full range of their complex feelings towards their attachment figures, including guilt for their rage, sadness, and love (Davanloo, 1994; Frederickson, 2013). In this excerpt, the supervisor helps the supervisee target the client’s warded off complex feelings towards her mother.

In this transcript we can see one of the benefits of RLS in action: It allows the supervisee to take a step beyond a cognitive understanding of the psychotherapy model, and instead have the actual experience of successfully applying the model with a challenging case. Although the guidance is from the supervisor, the supervisee is in control of the session, and may use his own words to interpret the supervisor’s interventions, thus showing that he is assimilating and internalizing the supervision as it is occurring. Additionally, the supervisor’s moment-to-moment guidance helps the supervisee become aware of his own countertransference (avoidance of complex feelings from his history)—an awareness that had not been achievable in traditional delay-report supervision. Previous to videoconference, the availability of live supervision was limited to the geographic location of the supervisor. Now, via videoconference, supervisors can provide this advanced training opportunity to supervisees across the globe.

Bringing it All Together: A Description of a Videoconference-Based International Psychotherapy Training Program

As the use of videoconference for clinical supervision spreads, it is moving beyond the individual and group level and starting to become the basis for entire psychotherapy training programs. One example of the use of videoconference at the programmatic-level is the China American Psychoanalytic Alliance (CAPA), which runs a program that provides psychodynamic psychotherapy training to 160 students across eighteen Chinese cities (Fishkin, Fishkin, Leli, Katz, & Snyder, 2011). Started in 2008, the psychodynamic training program uses a hybrid model that provides combined in-person and internet-based training and psychotherapy by CAPA’s 400 Western members. Students have one individual supervision session per week for two to four years. Elective courses include infant observation and supervision. Additionally, CAPA analysts and analytic psychotherapists make regular visits to China for in-person lectures, supervision, and treatment (E. Snyder, personal communication, June 27, 2013). China American Psychoanalytic Alliance courses are taught in English via online videoconference, and the readings are provided online in PDF format.

Cathy Siebold, the CAPA Chair of Supervision, reports that videoconference supervision usually “seems to go like any other supervision with both student and supervisor learning something from each other” (C. Siebold, personal communication, June 28, 2013). However, she also reports that the limited field-of-view in videoconference may reduce supervisee comfort, and logistical challenges, such as missed calls due to time-zone changes, have the potential to threaten the supervisory alliance. The effectiveness of videoconference supervision may depend upon each individual’s level of comfort with the technology, “Like the transference, the process on [videoconference] can seem real [or] not real to some clinicians and students” (C. Siebold, personal communication, June 28, 2013).

Taubner and Henning (2013) studied the CAPA training program using quantitative measures of supervision process and qualitative interviews of trainees. Overall, preliminary data analysis suggested that the videoconference supervision component was effective for clinical training and creating meaningful supervisory relationships. However, the videoconference format was found to be significantly different from the inperson format. One difference is that the limited visual range in the videoconference format made it harder for the dyad to “read” each other, and thus enabled a wider range of transference reactions (for better or worse.) The limited range of nonverbal communication and occasional internet connectivity problems interfered with the natural flow of emotions and made some trainees feel less held, close, or connected to their supervisors. Theoretically, these challenges could exacerbate skills deficits or unconscious resistance in the supervisor (e.g., Watkins, 2010a). Notably, all of the CAPA trainees interviewed reported that they preferred the in-person format for supervision (Taubner & Henning, 2013). However, trainees also reported that the more anonymous nature of Skype supervision encouraged greater openness; this was similar to findings of other studies (e.g., Sørlie et al., 1999).

Questions have been raised about whether cultural differences may be exacerbated by videoconference supervision (e.g., Panos, et al., 2002; Powell & Migdole, 2012). David Powell, who provides videoconference supervision to trainees in Turkey, Singapore, Vietnam, China, has anecdotal evidence suggesting that videoconference can be effective for cross-cultural supervision in substance abuse treatment, but he recommended that supervisors stay alert for cultural cues or miscommunications (Powell & Migdole, 2012). Likewise, data from Taubner and Henning (2013) suggested that the cultural and language differences between the Chinese trainees and American supervisors had an impact on training and could be problematic. Notable cultural differences reported by trainees included the Chinese focus on the group instead of the individual, increasing the speed of life rather than trying to slow it down, and orienting towards the outward rather than inner-life. The data suggest that these differences may have contributed to increased self-doubt, stress, and less healing involvement (Taubner & Henning, 2013). More research on the impact of cross-cultural videoconference supervision is clearly needed. Panos et al. (2002) proposed the “triad model,” where supervisees have two supervisors: one on-site who is well versed in local culture, and one on-line. Related information about the supervision use of a blended in-person and videoconference training model can also be found in Sorlie et al. (1999) and Siebold (2013).

China American Psychoanalytic Alliance’s training program is relatively new, so it is too early to assess the overall effectiveness of the program. However, even in the preliminary stages, the program already has served a very important role for the field of psychotherapy by demonstrating that international, cross-cultural clinical supervision is now possible, via video-conference. Given that videoconference technology is nearly ubiquitous throughout the technologically advanced world, and rapidly spreading in developing nations, this new method of supervision offers to greatly extend the educational reach of psychotherapy training programs across international borders, and exponentially escalate the opportunities for clinical training at the programmatic level. It is likely that CAPA is just the first in a coming wave of international, cross-border psychotherapy training programs.

Conclusion

The goal for this article was to provide three examples of how videoconference is currently being used to provide clinical supervision and training. These case examples show how technology is greatly enlarging the availability of psychotherapy training throughout the world. Also discussed were questions about the effects of videoconference technology on supervision process variables, like the supervisory working alliance. While the research on technology-assisted supervision and training (TAST) is still in the preliminary stages, there is a rapidly growing body of encouraging data to suggest that TAST can be effective and safe, if used conscientiously, in the context of the limits posed by the technology.

The authors would like to conclude with a note on perspective. The majority of the research and writing on the use of new technology in supervision and training began from the perspective: “Are these new technologies as effective and safe as the traditional methods?” This perspective is understandable, given that the first rule of the helping professions is to “do no harm.” However, there is a risk of adopting a fear-based perspective on new technologies which may blind us to new opportunities, or alienate a new generation of supervisors. Let us remember that the traditional methods of psychotherapy supervision and training are widely accepted largely by tradition rather than research data; indeed, empirical research has yet to truly demonstrate their effectiveness at improving patient outcomes (e.g., Ellis & Ladany, 1997; Watkins, 2011). Rather than solely viewing new training formats in comparison to the past, we recommend supervisors conceptualize themselves as inventors, and dream of new possibilities. By clinical necessity, all supervisors are familiar with uncertainty and accustomed to creative problem-solving through experimentation. We propose that those same traits can make supervisors superbly qualified to be explorers in the new technological frontier. Google regularly challenges its employees to “think big:” to open their minds to the endless ways that the internet can serve the world (Levy, 2013). The time may have come for clinical supervisors to “think big” as well; to grow beyond the geographic limits we have traditional lived within, and instead consider how our services can serve the wider world.