Glen Jennings, Ed.D.
This study shows a procedure for supervision of marital therapy on the Internet. The study began with a supervisory agreement specifying the relationship between the supervisor and supervisee. The hierarchy between the supervisor and the supervisee on the Internet depended primarily on the supervisor's experience rather than on the socially ascribed status. Online therapy and supervision occurred at a much faster pace than in conventional modalities without losing the quality of supervision. Based on these findings, online supervision may be considered for inclusion into the academic curricula for training of marriage and family therapists and of counselors who may desire to practice on the Internet.
SUPERVISING MARITAL THERAPY
ON THE INTERNET
The use of the Internet for counseling individuals and couples grew rapidly in the 1990s (Cabaniss, 2002). For example, in June of 2002 Yahoo lists 3378 web sites promoting counseling clinics and individual practices. Out of this number 104 web sites were listed as “online therapy.” Yet at this time it is unlikely that any of these “online therapists” have had supervised training to prepare them for practice in this new medium (Cabaniss, 2002; Jedlicka & Jennings, 2001; Powell, 1998). Until supervisory processes are monitored to assure ethical expectations (DeTrude, 2001), the ethics of online counseling and therapy may remain controversial (Cabaniss, 2002; , 1999; & Herlihy, 2001).
This study explores a supervisory process based
on the participant observations of supervised, online, marital therapy. One
participant observer in this study was a marital therapist holding a temporary
license in the state of
According to the ethical standards of the American Association for Marriage and Family Therapy (AAMFT) (2001) “marriage and family therapists practice in specialty areas new to them only after appropriate education, training, or supervised experience” (3.7). Practicing on the Internet seems to be enough of a departure from the conventional modalities to justify specialized supervision and training. In the absence of some supervised training, ethics and efficacy of the therapy on the Internet appear questionable. To remove some of that doubt, this study suggests a supervision process that can be monitored, evaluated, and considered for inclusion in academic programs.
The Initial Supervisory Arrangements
Before the study began, the supervisor and the supervisee entered into what may be the first supervisory agreement for marital therapy on the Internet. Without a precedent for stipulating the criteria for evaluation of the supervisee on the Internet, this supervisory agreement was based on the AAMFT’s (2001) ethical and pedagogical standards, while remaining adaptable to unforeseen contingencies. The object was to discern how a supervisor may benefit the clients and at the same time evaluate the performance of an online therapist. In other words, how does a supervisor observe the maturation process of a supervisee without the aid of videotapes?
The resulting supervisory agreement encompassed some basic logistic requirements, while remaining more flexible than the experts recommend (Fox, 1983; Storm, 1997a). The agreement took into account that this was an experiment and not a conventional trainee-supervisor relationship. The agreement included five stipulations as worded below:
1. We agree that supervision will go forward to the best of our abilities, and that we will make ourselves available to each other at mutually convenient times at a place of supervision selected by the supervisor.
2. The records on each online client will be kept in accordance to the ethical standards of the AAMFT and the record keeping practices established at the Family Therapy Clinic at the Texas Woman's University.
3. The supervision will consist of case presentations based on presented problems and researchers’ responses. A record is to be maintained for supervisory purposes of all communication between the online clients and the researcher.
4. This agreement will become binding upon approval of the research by the Human Subjects Investigation Committee or an Internal Review Board on the Use of Human Subjects.
5. This agreement will inure for the duration of research project.
Before announcing the study on the Internet, the
Human Subjects Investigation Committee at The University of Texas at
Recruitment of Clients and Online Procedures
The study was posted on the Yahoo's search engine as a web site entitled "Online Couple Counseling Study." The key search words listed were "marital therapy," “couples," "counseling," and "couple counseling." In six months, eleven couples qualified for and agreed to participate in the study. The recruitment lasted six months while online therapy continued until the last couple terminated the treatment. The shortest time online spent with a couple was four days. The longest exchange lasted 14 weeks. The average duration of online therapy was six weeks.
The eleven participating couples were screened using a series of "yes" or "no" questions. These questions revealed that each couple currently experienced marital problems requiring therapy, but none were in counseling or therapy at the time they volunteered for the study. They also indicated that neither spouse was physically abusing the other, that no children were at risk of sexual or physical abuse, and that neither spouse was inclined toward violence or suicide. After the screening, each couple was directed to the informed consent agreement.
The consent statement informed the clients of the research procedure in which they were to participate, of their rights as clients, and of the limitations to protect their confidentiality on the Internet. They were also informed that their counselor was working under supervision and that their information would be shared with the supervisor. To participate in the study, both spouses were required to sign and mail a consent form.
The therapy began when the therapist sent an email to the couple asking them to explain their situation and to indicate what they expected from therapy online. This initial message, their responses to it, and all subsequent communications became a part of their record. The record was kept in the manner practiced at the Texas Woman's University Family Clinic at that time, meaning that the supervisee maintained a manila folder with the chronological record of each exchange between client and therapist.
On the left-hand side of the folder was a form on which the superevisee recorded the date of each interaction with the couple. The right side of the folder included a complete chronological file of all the email sent to and received from the clients. In the study, all interactions, other than the informed consent form, consisted of email messages. Each time an email was sent or received the time and the date were recorded on a line of that form. The first item on the line was always the date the informed consent was received in the mail. The second item included the date the counselor first contacted the couple. After that, each contact by clients or the therapist was recorded until the last closing email from the therapist to the client.
The Initial Supervisory Procedures
These folders were used during the weekly, face-to-face supervision sessions. During these sessions, the supervisee would summarize each case orally. The folder served as verbatim evidence of the weekly communications with each client. The supervisor perused the written communication and the supervisee read selected passages. Sometimes the supervisor kept the folders to study before the next supervisory session.
Even though the supervision involved only two or three cases per week, it was clear from the start that the traditional method of supervision was too slow for online counseling. On the Internet, the clients expected a response from their therapist the next day. The interaction between the clients and the counselor appeared equal to two or three week’s worth of accomplishment in face-to-face, office-based sessions. At that pace of interaction, the weekly supervision lagged behind the pace of the online therapy. Clearly, the weekly supervision was too slow, too little, and too late for the clients and for the supervisee.
After the first month, the Internet became a medium of supervision. This change confirmed the view of those who argue that supervision in general is isomorphic to the process and the structure of therapy itself (Liddle & Saba, 1983; 1985). That is, supervision was conducted in the manner that the supervisee conducted the therapy.
Online Supervisory Procedures
After introducing the online supervision, copies of email messages in manila folders became less important during the weekly scheduled face-to-face supervision. Instead of waiting for the folder, the supervisor requested the supervisee to forward certain email messages before sending them to the clients. In the messages to the supervisor the supervisee could ask the supervisor for advice, and the supervisor could request a plan of treatment immediately after the client presented the problem. This flexibility resembled live supervision. The supervisor could intervene at times when it was most appropriate without making the client wait. The Internet supervision had an element of live supervision behind a mirror: supervisors "can help supervisees who are stuck or signaling for help by suggesting alternatives otherwise not considered by supervisees" (Storm, 1997b, p. 284). Considering the disadvantages of scheduling and planning conventional live supervision, supervision on the Internet may become accepted even in academic settings.
The weekly face-to-face sessions continued in addition to the online supervision. Between these sessions, the supervisor could suggest interventions, attach reading materials to the email, and critique supervisee's email before it reached clients. The communication between the supervisor and the supervisee became a part of the permanent record that accumulated chronologically as the therapy unfolded. In retrospect, that record reveals a change in the content of the messages exchanged.
Initially most of the comments and suggestions related to the immediate need of particular clients. Toward the end of the study, the supervisor used email more often to promote the maturation process of the supervisee. The maturation process was evaluated on the supervisee’s ability to carry on increasingly longer periods of interactions with the client without the supervisor detecting a need to intervene. Unlike face-to-face supervision in which the supervisee is assessed subjectively in conversations, on the Internet the evaluation of the supervisee has a quantitative component to it. The supervisor can measure the time between requests for help as the supervisee learns self-critique and self-supervision.
To illustrate the progression from particular, client-specific supervision, to universal, general and abstract issues that deal with the supervisee's maturation, below are some excerpts from selected email sent to the supervisee by the supervisor. In the beginning stages of the supervision, the messages tended to focus on the particular case and the immediate need:
Hang in there and keep working on her differentiation. She may have bought too many love songs--can she hear the fusion and emptiness in many of the songs?
The easiest person to love is the one that doesn't need someone else to fill him up. She should make herself easier to love if she wants Tom to love her more. People find loving an empty person very, very tiring--there is no relief. Can she self-validate, self-calm, self-soothe? She should be more appreciative of herself--she is very talented.
I suspect that he grew up on tons of other validated intimacy and developed a huge emptiness/appetite. It is time for him to begin becoming his own father and mother (self-actualized). Check Roberta Gilbert, Extra Ordinary Relationships.
Yes, for this couple keep weaving together family of origin and solution--family of origin is a theory from nature and the triune brain, and solution is about change and the language of change.
Quite often shopping is a poor way to have togetherness--spend, spend, spend. Money problems are greater and more reoccurring than sex problems. Attached for your reading is "Money and Differentiation."
As time progressed, the supervisee contacted the supervisor less frequently, and the supervisor felt less compelled to intervene without a request. When the online communication did occur, it tended to be oriented toward the issues relating to the maturation of the supervisee. Here are some excerpts that the supervisee found of lasting value:
Our differentiation goes with us everywhere--on the internet, restroom, work, play, in faculty evaluations, it even rides with us down the highway and by-ways; it even creeps into bed with us and rears its undifferentiated head during sex. If we try to deny it, it becomes more visible--so the only hope is to take ourselves on to grow a more basic self.
It does not bother me that you share our supervision with clients. I would rather that you own what you say to them. I think it would be better if you kept to the differentiation model and look at how people set up paradoxes in their individual lives and in their relationships. There are usually paradoxes around differentiation issues and/or it may appear as they want their cake and eat it too--that is the paradox is built around two things that cannot co-exist in their life, e.g., intimacy with mate and an affair. It matters little whether the affair is sexual or not, e.g. partner intimacy and alcohol, partner intimacy and workoholism, partner intimacy and footballism, etc.
The difficulty with what I share with you is that the client may interpret it to mean that you do not know what you are doing. But because you are bright, and I have more experience, we can put together something that will help the clients. Keep up the good work.
I encourage you to read every day about differentiation, triangles, cutoffs, fusion, losses and other Bowenian Natural Systems materials. As always, I appreciate your stimulation and enjoy our communication.
Such exchanges were regular, but not scheduled. Usually, they foreshadowed the content of the weekly face-to-face supervisory session. Toward the end of the experiment, the supervision adapted to the medium in which therapy took place. The change of content from primarily particular to universal confirmed the viability of online supervision. Because an earlier study verified that online therapy can improve marital relations of some couples who were not likely to seek office-based therapy (Jedlicka & Jennings, 2001), online supervision may be worth considering as a component for training of counselors and marital therapists in academic settings.
Discussion and Conclusion
One finding in this study shows how the medium of supervision, in this case the Internet, can influence the nature of the hierarchy between the supervisor and the supervisee. As the supervisee and the supervisor adapted to the new medium, the situational and symbolic hierarchy found in office settings was less important than the hierarchy based on the supervisor's experience. On the Internet, a supervisee in a dilemma about how to react to a client defers to the supervisor who then responds to the supervisee, just as the supervisee is expected to respond to the client. In this modality the supervisor loses non-verbal projection of authority, must communicate in a neutral medium, and is subjected to the verbatim recording and scrutiny on the same level of hierarchy as the clients and the supervisee. When the hierarchy between the supervisor and the supervisee develops in this system, it is based on the demonstrable advantage of the supervisor's greater experience. In short, it is difficult to conceal incompetent supervision on the Internet.
It has been said that we cannot know the nature of an object until we discover its opposite. The opposite of the office-based, face-to-face, weekly supervision could be supervision on the Internet via email. The office-based supervision was too slow for the pace of online therapy and the extent of disclosure. Some clients disclosed more in one email message than would usually be disclosed within two or three sessions in office-based visits. For example, clients disclosed their sexual problems after two or three exchanges of email within the first week of therapy. The Internet, it seems, reduces their inhibitions, increases the likelihood of intimate disclosures early in the therapy, and therefore, demands equally swift and responsive supervision. This experiment shows that supervision online can be swift and highly responsive while also complying with the ethical and professional standards proposed by the AAMFT (2001).
Marital therapy on the Internet--or as some call it "web therapy" or “cybercounseling”--is a specialized skill. One way to gain this skill requires supervised, online training not yet provided in traditional academic programs (Powell, 1998). Because a large numbers of counselors and marital therapists already practice online, it seems the ethics would dictate that the academic programs supplement their training by including a supervised training for counselors and marital therapists who intend to use the Internet in their practices. Online supervision is suggested here as a supplement for office-based supervision for those who wish to conduct a part or all of their practice on the Internet.
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Address correspondence to:
Davor Jedlicka, Ph.D.
Department of Social Sciences