Using Video Recordings of Psychotherapy Sessions in Supervision: Strategies to Reduce Learner Anxiety

Developing knowledge and skills in psychotherapy practice is an important component of competency-based psychiatry training in the USA [1]. The Psychiatry Milestones require learners demonstrate competency in using psychotherapy with patients [1]. Assessing this competency requires a mechanism to observe the learner’s skills and abilities in using psychotherapy. One method of assessment is by observing video recordings of psychotherapy sessions.

Review of video recordings allows supervisors to directly observe the learner’s psychotherapy sessions [2] and learner knowledge, skills, and abilities in conducting psychotherapy [3, 4]. As a result, supervisors are able to be more objective when assessing the learner’s skills, than what can be achieved through reading psychotherapy notes or through discussion in supervision [3, 4]. For example, by watching a video recording of a session, the supervisor is able to objectively observe the learner’s verbal and nonverbal behaviors. Using video recordings to identify these behaviors provides supervisors with data about the encounter and the learner’s ability to conduct psychotherapy [4].

For the learner, there are well-documented benefits of using video recordings. These benefits include increased self-observation, self-reflection, and self-awareness [5, 6]. With video recording, learners are more objective in assessing their technique and identifying areas for improvement [3, 5]. Learners can also better assess treatment outcomes and identify improvement in patient functioning as a result of therapy [5].

Despite identified benefits of using video recordings as part of psychotherapy supervision, actual use of video recordings is negatively impacted by a number of barriers, including learner anxiety regarding recording sessions and showing the recordings in supervision [5]. High learner anxiety is related to a decreased willingness to disclose aspects of the therapy session in supervision and to increased withholding of information from supervisors [7]. This anxiety may stem from the learner’s “unwillingness” to display insecurity to a supervisor and the learner’s “need” to portray professional competence at conducting therapy. This unwillingness may be due to the achievement orientation and competitive nature of an academic training program that may not allow for sufficient discussion of difficulties and vulnerabilities [8].

Other potential contributors to anxiety are fear of receiving a negative reaction from a supervisor, worry about a supervisor negatively evaluating a learner’s clinical skills, shame, and embarrassment [7]. These concerns may be especially pertinent when a supervisor will likely serve as a reference for applications for additional training and/or employment. A learner’s own personal and clinical issues with insecurity, self-doubt, and avoidance of feedback may also contribute [2, 7].

For these reasons, learners may delay, or avoid, using video recordings as part of supervision. Instead, learners may attribute the delay to a number of external factors, such as a patient’s reluctance to being video recorded, technical difficulties, forgetting the equipment, or other reasons.

This paper identifies strategies to reduce learner anxiety, increase use of video recordings in psychotherapy supervision, and ultimately improve the quality of psychotherapy supervision and training (Table 1).

Table 1.

Strategies to decrease learner anxiety when using video recordings as part of psychotherapy supervision

1. Build a positive, collaborative, trusting learner-supervisor relationship.

2. Establish a learning contract for supervision.

3. Expose learners to the video recording equipment and process early in training.

4. Discuss strategies to introduce video recording to patients.

5. Use learning theory and a developmentally appropriate supervisory framework.

6. Directly address anxiety related to using video recording with the learner.

7. Identify cognitive and behavioral strategies for learners to manage their anxiety (being careful not to engage in psychotherapy with the learner).

8. Show supervisors’ own video recordings conducting psychotherapy.

9. Explore the possibility of small group supervision.

Strategies to Reduce Learner Anxiety When Using Video Recordings

The first strategy supervisors can use to reduce learner anxiety is to build a positive, collaborative, trusting relationship with the learner. A strong, positive supervisor-learner relationship enhances trust, which allows the learner to address issues of competence with the supervisor. A strong relationship allows supervisors to reinforce the effective use of psychotherapeutic techniques, provide specific feedback of what went well and what can be improved, and brainstorm different therapeutic approaches, in a collaborative manner with the learner [9].

Supervisory relationships can benefit from the use of several strategies to enhance trust in the relationship. These strategies include openly discussing the power differential in the supervisor-learner relationship, the evaluative component of supervision, and feelings of inadequacy the learner may experience [7, 10]. Supervisors can continually discuss supervision-related issues throughout the course of supervision and make changes in the supervisory method when needed [7, 10]. Supervisors may also balance supporting and challenging learners in supervision sessions [7, 10].

A second strategy to decrease anxiety is for supervisors and learners to jointly establish a learning contract that includes video recording sessions. Establishing clear, measureable, and attainable learning goals, identifying methods to assess learning, and defining role responsibilities in supervision, is critical to learning [10, 11]. Elements of the learning contract may include (1) specific learning goals; (2) learner’s and supervisor’s responsibilities in supervision; (3) operational aspects of supervision, including frequency and length of meetings and number of patients; (4) the role of video recordings in supervision; and (5) the structure/agenda of the supervision session. The learning contract may also include the degree to which the supervisor will help the learner explore personal values and beliefs about conducting psychotherapy.

The learning contract can include a clear structure and agenda for the supervision meeting. This agenda may reduce learner anxiety and help the learner appropriately prepare for supervision [5]. An agenda for a supervision session may include the learner beginning supervision by presenting a “difficult” recorded segment from the therapy session; providing theoretical hypotheses about the nature of this segment and causes; identifying the learner’s own emotional experience of being in the session; discussing appropriate psychotherapeutic approaches; and summarizing the supervision discussion [12]. Learners may be hesitant to engage in the process of establishing a learning contract, especially when they are newer to training. These learners may benefit from increased guidance from supervisors on the development of a learning contract.

A third strategy to decrease learner anxiety is to expose learners to the video recording equipment and the recording process early in psychotherapy training. This exposure may help learners develop a neutral or positive association with the recording equipment [2]. Early and consistent use normalizes the process of showing video recordings of therapy sessions in supervision and desensitizes learners to the recording process [5]. Clear behavioral and technical instructions on how to use the video recorder, including identifying where the video-recording equipment is stored and the people to contact in the event of technical difficulties, need to be provided.

A fourth strategy to reduce anxiety is to have a detailed discussion with the learner about how video recording can be introduced to the patient [6]. Learners may initially have reservations about asking a patient to record therapy sessions. Following discussion with their supervisors, learners can focus on building a relationship with patients before asking them to record therapy sessions, be clear in their explanation of the educational value and purpose of the recording, and give the patient the option of having recordings erased after their intended use [13]. Video recordings can be viewed with patients to help patients see their own improvement [9]. Supervisors can also discuss alternate options to video recording, if the patient refuses. These options might include using audio tape, a one-way mirror, or live observation of the therapy session.

A fifth strategy to decrease learner anxiety is for supervisors to integrate developmentally based learning theory into their preparation for supervision [3, 8]. Before meeting with the learner, supervisors should consider the learner’s skill level in psychotherapy. The skill level may vary based on the patient’s demographics, mental state, therapeutic setting, and type of therapy used. The supervisor should adapt the approach to supervision accordingly. The Integrated Developmental Model of Supervision (IDM) incorporates learning theory into specific strategies supervisors can use when working with learners at different levels of training [3, 6, 14]. Specifically, the method and content of feedback given to the learner changes as the learner becomes more comfortable with the video recording equipment and conducting psychotherapy. The IDM model outlines three learning levels of psychotherapy skills [6].

In the beginner level (level 1) of IDM, learners have little experience using psychotherapy techniques or video recording sessions and may be the most anxious about discussing their own performance. To help learners gain confidence and skills, supervisors can role-play therapy sessions [6]. Supervisors can also video record these role plays to help learners gain familiarity with the recording equipment [6]. Supervisors may use these role plays to identify and highlight learner strengths, thus increasing a learner’s self-efficacy in conducting psychotherapy [7, 10]. Reviewing video recordings of these role plays helps learners become acclimated to the recording process in a “non-threatening” manner, identify feelings of anxiety associated with using the video recorder, and empathize with the patient’s reaction to being recorded.

When reviewing recordings of an actual therapy session in level 1, supervisors can focus their comments on observations of patient behavior and areas in which the learner performed well [6]. Specific behavioral examples can be identified during the supervision discussion. Questions can be used to seek clarification and elaboration on aspects of the session [6]. Supervisors can also provide specific and concrete feedback on what went well in the session and areas for improvement.

In level 1, learners can watch video recordings of therapy sessions prior to attending supervision. By previewing the recording prior to supervision, learners are desensitized to the process. This will allow learners to focus attention on learning psychotherapy and on the therapist-patient dyad, when reviewing recordings with their supervisor. Previewing also allows learners to pinpoint segments for further discussion in supervision and to self-assess their psychotherapy skills.

With more advanced, or level 2 learners, IDM recommends supervisors encourage learners to “re-experience” the session by focusing on the learner’s own cognitive and emotional experiences in the session [6]. Learners in this level should ideally understand the patient’s perspective and have greater self-efficacy in using psychotherapy. Learners can review recordings to observe how their clinical skills have changed over time, which may help them better appreciate the educational benefit of recording sessions. Learners can also view video recordings of other learners’ therapy sessions to gain perspective on other therapeutic styles. Supervisors may begin to self-disclose information to learners related to the supervisor’s own training experiences. For example, supervisors may share their own experiences and emotional reactions using video recordings as a trainee.

Advanced learners (level 3) function more autonomously and are less likely to be anxious about their clinical abilities [6]. Supervisors can encourage these learners to independently review their recordings, reflect on the therapeutic process, and identify areas for consultation. Learners drive supervision by selecting segments for review and discussion [3]. Supervisors at level 3 “inspire affective exploration, check out unstated agendas, or encourage cognitive evaluation” [15].

A sixth strategy to reduce anxiety is for supervisors to directly address the impact of anxiety on supervision [10]. Supervisors can “normalize” anxiety, identify it as prevalent among learners, and place a positive emphasis on the development of self-awareness and affective and emotional expression [8]. Supervisors can maintain an open attitude, give “verbal permission to fail,” and expect the learner to make mistakes.

Psychotherapy supervision can be an ideal opportunity to introduce learners to various therapeutic strategies to address the naturally occurring anxiety associated with using video recordings in psychotherapy supervision. Therefore, a seventh strategy to reduce anxiety is to identify how learners can use these therapeutic strategies to manage anxiety. Prior to engaging in this strategy, it is essential that therapy supervisors frame these strategies as tips for the learner to reduce anxiety, rather than a psychotherapy process, as to not be thought of as engaging in the psychotherapy process with the learner themselves. It is essential that supervisors maintain appropriate boundaries and do not engage in psychotherapy with the learner. If the supervisor believes that the learner would benefit from psychotherapy to cope with anxiety, this can be suggested to the learner following consultation with other supervisors and with training program leadership. Brenner (2014) identifies additional strategies for helping learners express and be comfortable with their own emotional reactions [16].

With this disclaimer about the role of the supervisor, there are a number of cognitive and behavioral strategies supervisors can suggest learners use to cope with anxiety about using recordings. Cognitive psychotherapy strategies can help learners identify negative automatic thoughts related to using and sharing video recordings, the distortions within these thoughts, and the development of statements to refute these distortions. Automatic thoughts learners may have about showing video recordings in supervision may include “I must show the supervisor how perfect I am at therapy.”; “I must make the right decision or something terrible will happen.”; “I must love doing therapy to be a good therapist.”; “The patient should do what I say.”; “I should be more competent.”; and “This patient is getting worse and I am failing” [12]. These thoughts may lead to heightened anxiety when reviewing recordings in supervision. Supervisors and more senior learners can help junior learners recognize and challenge these thoughts (e.g., “No one is perfect”), share automatic thoughts they had about using video recordings early in their training, and model for junior learners how to cope with these thoughts [10, 12]. Relaxation techniques, such as diaphragmatic breathing, imagery, progressive muscle relaxation, and meditation, can help learners manage anxiety when preparing to show video recordings in supervision sessions [10].

An eighth strategy to reduce anxiety is for supervisors to show their own video recordings conducting psychotherapy [3, 9], which can “dispel the myth” that supervisors are “infallible” [9, 15]. This strategy may help to increase learner self-awareness and emphasize the nonjudgmental nature of the supervisory relationship and of the training program as a whole. As a result, learners may be less anxious and more open and willing to share their recordings in supervision [15]. Through discussion of their own video recordings, supervisors model for learners appropriate self-disclosure about sessions [10], how to discuss their own recordings [5], and how to receive feedback from others. Observing a supervisor’s video recordings can also be used as a teaching method, as learners are able to directly observe how the supervisor uses certain psychotherapeutic skills in therapy sessions [9].

A ninth strategy to reduce anxiety is to explore the possibility of small group supervision where learners show and discuss video recordings of therapy sessions. A small group supervision approach may increase the positive and collaborative nature of the supervisor-learner relationship and allow for learners to provide support to one another, particularly via normalizing “blunders” and difficult situations in psychotherapy sessions [10]. Supervision groups can promote cohesion, support, universality, reality testing, modeling, and group learning and allow learners to provide feedback to one another [5]. While there are many potential benefits of small group supervision to help alleviate anxiety associated with video recording, care needs to be taken that the supervisors are well-versed in providing group supervision and the experience is developed in a manner that does not increase anxiety among learners.

In conclusion, there are numerous learning benefits to incorporating video recordings of psychotherapy sessions into psychotherapy supervision. Supervisors gain an objective view of the learner’s skills and abilities, which allows supervisors to give specific feedback to learners about their psychotherapy knowledge and skills. This feedback is essential, as training in psychotherapy is a required competency in the Psychiatry Milestones [1]. Moreover, many of the Milestones’ sub-competencies, such as the development of the therapeutic alliance, maintenance of professional boundaries, demonstration of compassion and respect for others, and conflict management [1], are best assessed via direct observation.

Although anxiety may initially serve as a barrier to using video recordings as part of psychotherapy supervision, there are several effective strategies that supervisors can use to decrease this level of anxiety. Ideally, using these strategies will increase the quality of the psychotherapy supervision, the learner’s training experience, and ultimately the clinical care provided. Further, the process of overcoming this anxiety and gaining additional mastery in conducting psychotherapy can be valuable to learners. The strategies identified in this paper can be integrated into the planning for psychotherapy training, and any changes in subsequent learning can be assessed.