Clinical Supervision of Couple and Family Therapy during COVID‐19

Abstract

This paper addresses the need for a swift transition from in‐person clinical supervision to telesupervision during the time of the COVID‐19 global pandemic. Five specific areas will be discussed in the effort to enhance the quality of clinical supervision provided to couple and family therapists in training at this time including the following: (1) COVID‐19 and the structural changes and technological adaptation of supervision; (2) culturally and contextually sensitive guidelines for clinical supervision during COVID‐19; (3) the supervisee’s competence and the clinical supervisory process; (4) the new set of boundaries and the supervisory role; (5) and the supervisory alliance and supervisees’ vulnerabilities in the face of COVID‐19.

Clinical supervision has been defined as a mentoring relationship between an experienced psychotherapist and a trainee who performs the task of psychotherapy (Mead, 1990). Mead (1990) defines the purpose of the clinical supervisory relationships as a way to preserve the safety of the clients and guide training therapists in ways that enhances their practice of psychotherapy and influences their personal and professional development (Liddle, 1988).

During the COVID‐19 global pandemic, outpatient clinical practice has almost exclusively become a telehealth practice in order to ensure the safety of clinicians and clients. As such, clinical supervision, both individual and group supervision, practices of psychotherapists in training also followed the same telehealth model. The telehealth platform has provided the same variety of options as in‐person supervision, which includes case consultation, case notes and session video review, and live supervision.

Although the platform in which clinical supervision was conducted has changed during the COVID‐19 pandemic, the essence of what is important in a clinical supervision session has not been altered. Yet, providing clinical supervision for couple and family therapists in training during the time of the COVID‐19 pandemic may be experienced as a challenging task due to both contextual factors and logistical changes in accommodations. Nevertheless, supervision during this period can present a unique opportunity to ensure trainees’ awareness of and sensitivity to the macrosystemic factors presented by couples and families who seek therapy. Fundamentally, the critical task of socializing couple and family therapy trainees (Todd, & Storm, 2002), with limited or no previous psychotherapy experience, remains a crucial developmental task. This task is no less important during a pandemic. The supervisory relationship can play a major role in developing the trainees’ sense of self‐efficacy and competence (Bischoff, Barton, Thober, & Hawley, 2002) while working under some of the most adverse times in global history.

COVID‐19 and The Structural Changes and Technological Adaptation of Supervision

The onset of COVID‐19 has led to the need for many adaptations in addressing the health and safety of clients, clinical trainees, and supervisors. A swift overnight shift needed to take place in transporting the in‐person traditional healthcare and training systems to telebehavioral health (TBH) systems (Hilty et al., 2004). The utilization of TBH platforms includes the use of technology and the Internet to provide behavioral health assessment and mental health services, including treatment of couples and families. TBH has several benefits including improved explanation of provider options and resources, as well as flexibility of time and location of services. With TBH also comes many challenges including access to care for the underserved clients who may not have the technological resources, as well as others who do not have the familiarity or capacity to learn this type of new platform as a means to connect. While the use of TBH platforms has been widely established and utilized for over a decade (Bacigalupe, Camara, & Buffardi, 2014; Cabieses, Faba, Espinoza, & Santorelli, 2013), couple and family therapeutic services specifically, and couple and family mental health services in general, have continued to lag in utilization of teletherapeutic services. This problem has been exacerbated by many of the mainstream approaches for working with family systems and subsystems having in focus such transformative foci as the use of space and physical positions (Haley, 1991; Minuchin & Fishman, 1981), the process of physiological and emotional attunement (Greenberg, 2002; Greenberg & Watson, 2006; Shapiro, 2001), and experiential foci for challenging homeostatic problem sequences (Satir et al., 1991; Whitaker & Bumberry, 1988).

Supervision of couple and family therapists in training has radically changed during the pandemic, with clinical supervision evolving in some of the parallel processes to those being experienced in clinical service. COVID‐19 and the swift change to TBH platforms have forced revisiting traditional means for both conducting psychotherapy and supervision. In both supervision and clinical practice, on HIPAA compliant videoconferencing platforms, we must revisit ways in which such aspects as creating a therapeutic alliance, assessment of dyadic and systemic functioning, treatment strategies, and the use of self can be both conducted and taught.

Clients, supervisors, and trainees have adapted and adjusted to the TBH platform during the time of the pandemic in creative ways. One important way in which the given tasks of clinical supervision are now accomplished centers on extending the flexibility and time required for the needs of the supervisees. Another has been remaining vigilant to any presented self‐of‐the‐therapist supervisees’ factors that emerge within the context of the larger systemic context of the pandemic and providing the space for the supervisee to explore the connections. Assisting trainees in their developing of a sense of themselves as a therapist, without actually being in a room with them, requires additional adaptations by the clinical supervisor and supervisees to remain focused. The supervisor needs to be specially attuned to the supervisee’s reflections, their fears, their learning curve both within their client work, and issues with technology. Sharing appropriate parallel disclosures with examples is also helpful. Furthermore, clinical supervisors must also be mindful of things that they may not have thought about in the same way prior to telehealth supervision including camera’s focus, distance from camera, background, eye contact through the camera, and lighting and sound quality, which all have a great impact on how the trainees experience the alliance within supervision sessions. Seeing supervisees in their homes is also much different than in the office.

Differences also apply in both conducting and evaluating “live” supervision of clinical practice. Now, instead of conducting supervision behind a one‐way mirror during an in‐person live supervision session, the clinical supervisor and the consulting team are made available in a teletherapy session and can provide live private chats with the psychotherapist in training who is in session. There is also the option of utilizing breakout rooms for consultation with the supervising team during the live session just as if the trainee would leave a therapy room to seek consult behind the mirror wall with the team during an in‐person life session.

Review of video sessions is also an integral part of individual and group clinical supervision sessions where the clinical supervisor is made to be the cohost of the shared material and can pause and discuss different parts of a session with the clinical trainees. With brief training for the supervisors, the utilization of all that technology platforms for TBH have to offer can provide trainees with a rich and beneficial learning experience that includes aspects that were not available prior to the pandemic’s impact on distance learning practices.

Of course, ultimately research will be required to measure and compare the efficacy of the efforts and the transformative process of the student therapists throughout their clinical training. There are unique advantages in telesupervision even as that format is missing the in‐person contact available previously. This balance also may be different between those who already are well anchored in a supervisory relationship before the pandemic and those who now might only begin in such a supervisory relationship.

Culturally and Contextually Sensitive Guidelines for Clinical Supervision During COVID‐19

Informed systemic clinical supervisors have been encouraged to attune to the supervisees’ points of discussion (Rajaei & Jensen, 2020) with a foci on: (1) the relational processes within cultures; (2) consideration and discussion of power; (3) awareness of sociocontextual factors; (4) awareness of intersectionality; and (5) practice of cultural humility. These supervisory practices remain even more relevant during the COVID‐19 global pandemic. It is typical for supervisors to have greater comfort to the extent they experience similarities to the lives of their supervisees; differences enhance the possibilities for blind spots outside of awareness (Todd & Rastogi, 2014). In the context of COVID‐19, the universalists’ position that “we are all in this global pandemic crisis together” may greatly reduce the supervisors’ vigilance about issues of similarities and differences in supervisory relationships (Todd & Rastogi, 2014), as well as the exploration of the supervisees’ multidimensional foci (Falicov, 1995) on their clients’ direct and indirect systems. Beyond the many other differences that may be obscured, it is critical for clinical supervisors to remain mindful of the great disparities that exist between individuals and groups during the global pandemic.

Utilization and integration of a culturally informed supervision model can assist clinical supervisors in their efforts to help their students move from a universalist position on life during COVID‐19, to a more multidimensional outlook on the experiences of trainees and of the couples and families they treat. The supervisor can provide specific guidelines as to how to encourage awareness of multisystemic attitudes about the global pandemic by highlighting the reality of related differences and similarities. Such a vantage point can help increase the supervisees’ awareness of how such differences and similarities impact work with their clients’ systems (Campbell, 2000). Such efforts to promote self‐awareness enhance supervisees’ ability, through personal exploration, to understand their own position and perhaps polarized biases, resulting from their personal socialization, about the COVID‐19 global pandemic.

The process model of multicultural supervision (PMMS; Ladany et al., 1999) can also serve as an effective supervisory tool to identify obvious and covert markers and address the supervisees’ awareness on the multidimensional and macrosystemic nature of their clients’ presented issues within the zeitgeist of COVID‐19. Such markers may include insensitivities to the experiences of their client systems, lack of connection due to limited supervisee experience, and a universality mentality. PMMS allows the supervisor to introduce a task environment that creates a safe space for supervisees to work through the interactional sequences and constraints that may be involved (Ladany et al., 1999). Similarly, including spaces for supervisees to explore their own related feelings and focus on their awareness of the complexities within the zeitgeist is an important element of growth. Exploring these interactional sequences can also provide opportunities to focus on and enhance the supervisory alliance that assesses supervisees multicultural and contextual knowledge, awareness, and skills.

The Supervisee’s Competence and The Clinical Supervisory Process

In addition to logistical factors and shifts in ways that psychotherapy and clinical supervision has been conducted during the COVID‐19 global pandemic, clinical supervisors also experience a number of challenges in terms of assessing supervisees’ level of competence. The contributing complexities and associated factors related to assessment of competency include the ability to meet with supervisees in the ways that are most familiar, the ability of supervisors to guide and train supervisees within a novel uncharted territory, the experiences of loss and grief that is intermingled with the work at numerous levels, and macrosystemic shifts contributing to uncertainties about the future, as well as the radical changes in the formats of supervision and training. The anxiety associated with COVID‐19 and its direct and indirect impact can readily become manifested in a parallel process within the supervisory relationship. Just as self‐awareness is a prerequisite for multicultural competence, so is self‐awareness about the supervisee’s own level of anxiety associated with the pandemic; this is a critical exploration that requires dialogue within the context of clinical supervision.

When supervisees are invited to explore their own anxieties about the zeitgeist and integrate this newly founded self‐awareness within their clinical roles, they are more likely to feel at ease with inviting members of a family system to explore difficult similar conversations with one another. Such self‐exploration helps trainees develop complex perspectives on the multidimensional influences in their role as clinicians and to more effectively hypothesize and converse with their clients. Not only does this help in assessing client strengths and problems, but also in learning to recognize the importance of and impact of factors such as cultural membership and socialization (Inman, 2006) in experiencing the global pandemic and the many social changes that have come with it. The complex and highly emotional task of working with clients during the pandemic can feel overwhelming, leading to the student experiencing decreased competence (Inman, 2006) and self‐efficacy (Bischoff et al., 2002). Individual or group supervision can provide supervisees with a sense of multidirectional partiality, much as that given to each member of a family within the context of therapy, as well as the safety and space to explore their own experiences of the COVID‐19 pandemic. That exploration now has become a critical aspect of nurturing the supervisees’ growth of self of the therapist.

The New Set of Boundaries and The Supervisory Role

The COVID‐19 global pandemic has created a number of unique and almost universally experienced challenges for many supervisors and their trainees including expanding the use of technology for therapy and supervision, the sense of anxiety about the ongoing related uncertainties and isolation, the need for social distancing, the redundancy of repetitive tasks within a working day, and limited accessibility and flexibility in being able to virtually connect with colleagues and clients while working from home. Some of these challenges, such as the use of technology, have led to some degree of role reversal in supervision as young trainees often have greater ease and agility in navigating new technology than their seasoned clinical supervisors. Similarly, younger trainees may be more comfortable and easily situated in a world of digital connection. To the extent this is the case (and even sometimes when the skill gap is not so great), the skillfulness and sense of competence of supervisors has at times been reduced in the swift shift in the transition to TBH platforms. This also has sometimes led to overcompensation on the part of the supervisor and checking in too frequently about how to support their supervisees’ needs.

In this time of the pandemic, clinical supervisors must keep in focus the supervisory goals of helping trainees build their newly relevant and much needed skillsets for forming an alliance with their clients while not being in the same room. For example, conversations in supervision must now much more than earlier focus on who will be present in each session and how to set guidelines and strategies to control who enters and exits the clients’ space during the sessions (e.g., presence of children in the room during a couple therapy session). Another crucial skillset focuses on how supervisees can manage conflict among families and couples at a distance, especially in those who become highly dysregulated during sessions. New special supervisory conversations are also needed regarding ongoing assessment and evaluation of the clients’ needs and session environments as new challenges emerge (e.g., the change of seasons making things difficult for sessions that could only be possible in the client’s car or an outdoor space).

Supervisors who are not able to see recordings of their supervisees’ therapy sessions now learn to have their supervisees report regularly about a series of logistical items as part of their case presentation and consultation for case. Such logistical reporting may include but are not limited to how and where each session was conducted (i.e., where was each member of the family during the session), ways in which TBH experienced constraints during their last session (i.e., poor connection, low video, or audio quality), and issues related to safety and security of the session (i.e., what part of the indirect therapy system may have been present during the session). The logistical items about a session inform the context of the client’s experience and are a new addition to the TBH experience of remote clinical supervision.

Research highlights that supportive mentorship leads to increased well‐being and retention for students (Thomsen & Gustafson, 1997; Tillman, 2000). Such mentorship is even more critical in times of emotional distress and uncertainty. The question becomes how to maximize such a supportive mentorship during this critical time of the pandemic. Much has changed about clinical supervision since the TBH platform has been utilized for the task, the most obvious being the blurring of boundaries around where and how supervision has traditionally been conducted. Given the novel experience of using a different technology‐based platform for supervision needs, it is clearly beneficial for clinical supervisors to share their own level of training and comfort of using the platform with their trainees and collaborate with their supervisees about how to maximize their learning.

For many trainees, there may be an increased level of anxiety about their clinical competence in this novel environment. Almost no one today begins with experience of teletherapy. In this environment, where almost everyone is new to the experience, many trainees find themselves with a decreased level of confidence about not only themselves, but also the quality of training. This readily can potentiate their angst regarding matters such as isolation and excessive worry of the uncertainties about their future. Consequently, it is not surprising that clinical supervisors experience a greater degree of need for connection from their supervisees at this time. In a positive way, this may result in greater connection and additional mentorship and guidance from their clinical supervisors. However, there is a need to monitor such processes. For example, supervisors may show more willingness to become available outside of the dedicated supervision time through other means such as availability through text messages and phone calls outside of the supervision hour, which may lead to burnout (Rosenberg & Pace, 2006). This, of course, is well intended and often very useful. However, supervisors also need to attend to the possibility that their greater accessibility might also hinder their growth as therapists in training. One developmental challenge for therapists in training lies in their ability to sit with their client‐related anxieties and become more curious in the expansion of their case conceptualization. To ameliorate this potential problem, it is helpful for supervisees and supervisors to revisit contractual guidelines for this time and for other times in the future when trainees transition from in person to TBH platforms.

The Supervisory Alliance and Supervisees’ Vulnerabilities in the Face of COVID‐19

For many, the turbulence and angst resulting from the multifactorial nature of the global pandemic have also led to a degree of mistrust of systems in place to that have historically been viewed as intended to protect the public. While anxiety and uncertainty run high, the sense of questioning one’s view in relation to the larger system, intended to protect and provide safety, may also become generalized in any number of smaller systems and subsystems including educational and vocational institutions and relationships within them. This has often been the case in supervision during the pandemic; a time when macrosystemic issues are intrinsically interwoven into mentorship experiences.

In response to such forces, this is a time during which there is a great need for strengthening and reassurance of the reliability of trusted networks. The supervisory relationship is perhaps the most essential foundation of clinical training. As such, supervisors should pay even more attention to enhancing the supervisory alliance than in other times (Storm, Todd, Sprenkle, & Morgan, 2001). It is even more essential than in other times to provide warmth, support when requested, empathy about the challenges supervisees may be facing, genuineness including relevant and thoughtful self‐disclosure, humor when appropriate, and optimism about the learning opportunities that have emerged from training as systemic therapists in the midst of a global pandemic. When differences emerge in perspectives between supervisor and supervisee, this also is a crucial time to emphasize balance; communicating the facts and keeping in mind appropriate and inappropriate uses of supervisory power (Murphy & Wright, 2005; Todd & Rastogi, 2014). The goal remains to create and maintain a collaborative and supportive climate necessary to facilitate growth for trainees (Storm et al., 2001). This is also a time in which it is natural for students to question authority. Leaders have failed the society, and young people are the outstanding voices in this time for social movements. Supervisors’ skillfulness in major part lies in supporting supervisee voices and perspectives, while also working to maintain the positive traditions of supervisor–supervisee relationships.

It is not a surprise that supervisees are challenged more in this time of the COVID‐19 global pandemic than others. Supervisees also often feel more anxious. They may have more anxieties at work in their own personal lives. There is also the greater polarization within couple and family systems they treat; potentiated by their own now frequently more visible emotional triggers. Beyond helping trainees manage these vulnerabilities, this is a time to be sure to use the full range of supervision tools with supervisees. Having an effective clinical toolkit is one way of reducing therapist anxiety.

Another is work focused on self of the therapist. One‐time honored effective way to guide couple and family therapists in training lies in assisting them to gain insight about how some of their current experiences are influenced and maintained through multisystemic patterns beginning with their own family of origin through a genogram. Although this may feel like a risk in exploring their vulnerabilities (Mason, 2005) during a heightened state of emotions, it may be a needed risk to take in order to help them remove the constraints related to their emotional triggers. Such exploration can also help supervisees learn how to ask better exploratory circular questions (Patterson, Williams, Edwards, Chamow, & Grauf‐Grounds, 2009). Therapist‐in‐training self‐reflective exploration also can highlight how supervisees might differently explore constraints to progress and conceptualize their reaction to presenting problems in terms of recursive family processes (Celano, Smith, & Kaslow, 2010). Such exploratory efforts in understanding their own family of origin helps psychotherapists exponentially develop their needed competencies, gain great insight into their own reactivities, better understand cultural context (Celano et al., 2010), and differentiate their anxieties from those of their clients (Hill, 2009; Inman, 2006; Mason, 2005).

Conclusion

The process of supervision is complex and challenging due to the number of direct and indirect systemic influences and relationships that involve the trainee, the supervisor, and the clients (Whiting, 2007). The complexity of this task has been heightened due to the anxieties and turbulence of working together within the context of the COVID‐19 global pandemic and the multitude of related factors that impact each system. Consequently, special attention, care, and time need to be given to ensure that clinical supervision during the COVID‐19 global pandemic adapts to these times. Goals needs to focus on training couple and family therapists who are sufficiently differentiated and skillful in providing systemic treatment, and able to gain competence in their ability to work within a changing and often virtual environment with agility and clinical proficiency. At the foundation, what matters in supervision now are the same underlying principles, skills, and concerns as ever, but the remarkable differences in form of the supervision, in what is being supervised, and in the world must be recognized and incorporated to adapt these methods to these times.