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Contents lists available at ScienceDirect

The Arts in Psychotherapy

istance supervision: Research, findings, and considerations for art therapy

enelope P. Orr, Ph.D., ATR-BCdinboro University, 215 Meadville Street, Edinboro, PA 16444, United States

r t i c l e i n f o

eywords:rt therapyupervisionistance supervisionechnology

a b s t r a c t

Art therapy internships are arguably one of the most important aspects in the training of future profes-sionals in the field. Many counselors and educators have written about the need for greater links betweenuniversities and fieldwork placements (Howey, 1996; Imig & Switzer, 1996; Ishler, Edens, & Berry, 1996;Khamis, 2000; Perraton, 2000; Rahman et al., 2006). Most of the current research on providing distancesupervision has been written in education and general counseling journals and usually are examininginternational uses of supervision (Rahman et al., 2006; Roland et al., 2006). In both education and coun-seling fields, as in art therapy, the use of the Internet to provide supervision has the similar issues of

confidentiality of the clients or students, the ability to observe and provide feedback, and the need tosee the student or beginning professional conducting sessions, and the sharing of the session/class prod-ucts for assessment and review (Burrak, 2008; Simpson, 2006; Szeftel et al., 2008). In the art therapyfield, there have been presentations at national conferences on techniques for distance supervision, butthere has yet to be a written research study on the topic. Therefore, this paper will investigate what hasbeen researched and written about in the general counseling and education fields in order to provide a

ing t

framework of understand

ntroduction

Upon graduating from an American Art Therapy approved pro-ram in 1991, my plan was to return to my home state of Southarolina, start an art therapy in the public schools program, andork on attaining my Art Therapy credentials. However, when I

rrived in my home state I ran into a few hurdles. The most criti-al hurdle was that I was not able to find a registered art therapistithin my area. The closest registered art therapist who could pro-

ide me with supervision was 3 h away and mostly worked in aedical setting with adults. I found that upon graduation, I did

ot have easy access to supervision and in particular did not haveccess to a supervisor who had actually worked with the clientelewas interested, or in the setting in which my population existed. Iolved my problem by getting a job as an art therapist in a hos-ital and putting off my work in the school system for severalears.

Since the early 1990s when I was starting out, art therapy hasrown substantially, making the task of finding a qualified art

herapy supervisor a little easier; however, gaining access to appro-riate and quality supervision is still an issue in the following cases.irst, each year art therapy programs around the United States grad-ate a number of international students who may wish to return to

E-mail address: porr@edinboro.edu.

197-4556/$ – see front matter © 2010 Elsevier Inc. All rights reserved.oi:10.1016/j.aip.2010.02.002

o work within.© 2010 Elsevier Inc. All rights reserved.

their home countries upon graduation where art therapists are inshort supply. These students may need continued support, supervi-sion, and coaching when returning to their home countries. Second,the increased breadth of the possibilities for art therapy place-ments, populations, or procedures also has created sub-specialtiesin art therapy. There are art therapists who are well known for theiruse of phototherapy, work with veterans, trauma, crisis interven-tion and many other areas. Access to supervision with a personwho has specialized knowledge of a particular population, mediaor placement may be needed and would provide more appropriatesupervision. Third, Feinber (1993, p. 109) made the point that “thequality of clinical supervision varies tremendously in the field ofart therapy, yet it is difficult to overstate the importance of goodsupervision in the development of skilled art therapists.” Goodsupervision is dependent on the quality of the skills of the super-visor, and should not be dependent upon simple proximity to thesupervisee. And finally, as members of a helping profession, it isour obligation to make sure that we provide access to our services,including supervision, in a safe and ethical manner, but also in amanner that includes all persons and reduces unintentional bar-riers. We need to find solutions to address the barriers to qualitysupervision that exist today.

As a person who specializes in the use of technology in art ther-apy, it seemed logical to me that current advances in online meetingcapabilities would make it possible for art therapy supervision tooccur at a distance in a simple, barrier-free way. However, as a per-son who looks at using technology in a confidential manner in a

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reative field, I was unsure about how this would work and whatssues were involved. As a result, I started to research the litera-ure on what has already been accomplished in art therapy andelated fields so that I could develop a protocol of best practicesor developing an initial trial distance supervision with some of myrt education students, to be followed later by a trial with recentlyraduated art therapists.

This paper will investigate what has been researched and writ-en about in the general counseling and education fields in order torovide a framework for understanding potential distance super-ision issues and benefits for the field of art therapy. Technologicalpplications are rapidly evolving as a near-normative vehicle for aariety of medical and psychological interventions. These applica-ions are gaining acceptance through more widespread usage, rules,egulations, and reimbursement mechanisms. We are beginningo acknowledge and incorporate telehealth and distance appli-ations into policy and procedure. As an example, changes ineimbursement codes, e.g., CPT code 0074T, by the American Med-cal Association (Kraus, Zack, & Stricker, 2004) in the U.S. nowllow for billing of certain online consultations. Ethical and profes-ional issues when using the Internet in counseling are addressedy regulatory bodies such NBCC (2009) and ACA (2005) and theTCB (2009), which shows the viability of distance communicationshere confidentiality is necessary and people are working across

raditional borders. Also the Center for Credentialing and Educa-ion, the newest credentialing arm of the NBCC, has establishedDistanced Credentialed Counselor certification (CCE, 2009). This

redential was developed to ensure standardization of online andistance counseling practices as well as to assure the public thatounselors who use distance technologies adhere to a specializedet of ethical and practice codes. As solutions to the issues sur-ounding the transmission of information via the Internet (whethern counseling or as a part of supervision) is refined, the potentialnd need for distance supervision of internships and practica willrow in importance.

Art therapy internships are arguably one of the most impor-ant aspects in the training of future professionals in the field.

any counselors and educators have written about the needor greater links between supervisors and fieldwork placementsHowey, 1996; Imig & Switzer, 1996; Ishler et al., 1996; Khamis,000; Perraton, 2000; Rahman et al., 2006). During art therapyeldwork, students and new professionals begin to combine theheory and content knowledge that they have learned in their artherapy classes with hands-on practice working with clients. Stu-ents need feedback on counseling techniques and interventions,rocessing of sessions and artwork, and evaluation of assessmentechniques and results.

Research has shown that supervision has the strongest instruc-ional impact when it occurs early and often during the fieldworkxperience (Zahorik, 1988). However, supervisors are often lim-ted in the timing and frequency of in-person supervision becausef distance and scheduling issues, which reduces the impact of thatupervision (Casey, 1994) as well as the above-mentioned list ofotential barriers.

Most of the current research on providing distance supervi-ion has been written in education and general counseling journalsRahim et al., 2006; Roland, Jones, & Birmingham, 2006). In bothhe education and counseling fields, the use of the Internet to pro-ide supervision imposes similar problems of confidentiality of thelients or students, the ability to observe and provide feedback, theeed to see the student or beginning professional conducting ses-

ions, and the sharing of the session/class products for assessmentnd review (Burrak, 2008; Simpson, 2006; Szeftel et al., 2008). Inhe art therapy field, there have been presentations at national con-erences on techniques for distance supervision, but there has yeto be a written research study on the topic.

rapy 37 (2010) 106–111 107

Literature review

Distance supervision in education

In the education field, supervision is used to help train pre-service teachers. The goal of this type of supervision is to helpstudents gain an understanding of their strengths and weaknessesby providing feedback of observations of students in the teach-ing environment. It is also to help students gain an understandingof their interaction style with their own students, review lessonplans for compliance with education standards for the location inwhich each student is working, and to help them make connectionsbetween theory and practice. Supervision in this field allows stu-dents and supervisors the opportunity to review taught classes, todiscuss what worked well and what didn’t, and to help with plan-ning the next class. Each supervisor is also given the opportunity toassess the competence of each student prior to graduation to makesure that no one who may possibly cause harm gets a teachingcertificate.

Ideally, a student teacher will have two supervisors. One super-visor will be a field teacher who works at the site where the studentis completing his or her student teaching, and one supervisor worksfor the university or other body that is granting the teaching cre-dential. The university supervisor visits the site where the studentteacher is working several times during the period they are placedthere to observe and meet with the student and the field teachersupervisor. However, there are many instances in which this idealset-up for the student teaching experience and supervision is notpossible due to circumstance, environment, resources, and dis-tance. As a result, distance supervision of student teachers has beenhappening for many years, and the education field is grappling withthe same issues as the counseling fields on how to provide qualitydistance supervision ethically and professionally.

Simpson (2006) compiled a review of attempts by universi-ties internationally to meet the challenges of training teachersin environments that were not conducive to a campus or cen-tral training environment. She focused primarily on the difficultiesof conducting and supervising the field experiences of studentteachers.

“Field experience is a core element in an initial or pre-serviceteacher education programme. It allows students to enact andreflect on their developing philosophies of teaching and is the“testing ground” for theory/practice links. Educational theo-rists and programme planners in distance delivered teachereducation programmes acknowledge the centrality of fieldexperience. Yet for distance education students, that experienceis often minimalized because of administrative costs and a rangeof supervision factors.” (Simpson, 2006, p. 241)

Simpson acknowledged that at the time of her review, the infor-mation on distance education for the field experience aspect ofteacher training was sparse. She was able to identify and review12 programs in New Zealand, Australia, Zimbabwe, North America,and England whose creators had written about providing supervi-sion for distant field experiences. In these instances, supervisionwas handled through training in-field teachers to complete thesupervision, placing student teachers at one school to providesupervision to each other in addition to the teachers at that site, orusing online chat environments to provide three-way discussionsamong the university supervisor, the student teacher, and the fieldteacher.

Her findings from this review were that distance supervision forstudent teachers is needed throughout the world; that universitieshave developed micro- and macrosolutions to meet this need; andthat these practices are still developing. She stressed that whendeveloping such programs, educators need to remember to blend

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he best practices from traditional student teacher supervision withewer technologies and ideas about supervision. And she encour-ged educators to define solutions for student teaching distanceupervision in terms of the needs of students and the teaching pro-ession, and not on the mode of delivery. She stressed that the

odes will change over time, but the quality of the supervisioneeds to remain intact.

Burrak (2008) also addressed the issue of distance supervisionor teachers, but he conducted his own study comprised of two pilottudies and then a larger cohort of student teachers. In his stud-es, Burrak used two-way communication in the form of laptops

ith sound and video. A laptop was given to the student teachernd the university supervisor. Observations were carried out overlatforms like SKYPE and then the student teacher and the univer-ity supervisor would have an iChat discussion later in the eveningbout what happened in the classroom.

In this study, Burrak found that online distance supervisionncreased the ease of scheduling and observing and allowed forater processing of observations in cases where the student teacherad another class following the observation time. However, thereere technical problems that prevented the use of this technology

n half of the study cases. Burrak was in agreement with Cosgrove1998) in that he found the biggest challenge in using the technol-gy in the teacher preparation program was accessing compatibleechnologies between sites.

The technical issues that prevented online supervision includedack of Ethernet or wireless access at the school, school firewallshat did not permit needed programs, or low bandwidth at thechool.

Burrak found that not only was scheduling easier when usingistance supervision, but also the number of actual observationsor each student increased, and observations could be sched-led as needed when problem issues arose. An outcome thatas not planned as part of this study was that student teach-

rs began to use their laptops to record and reflect on theireaching. These findings showed increased opportunity for feed-ack from the university supervisor, as well as increased studentelf-reflection.

In the education field literature on distance supervision, it wasound that there is a need for distance supervision; people areonducting and experimenting with different forms of distanceupervision; and that there are some benefits and drawbacks toroviding supervision at a distance.

istance supervision in counseling

In the counseling fields, supervision is used to help train pre-ervice counselors in areas such as child psychiatry, social work,nd general counseling, among others. Similar to the educationeld, the goals of this type of supervision are to help the coun-eling student gain an understanding of his or her strengths andeaknesses by providing feedback of observations of the stu-ent in the counseling environment. Unique to counseling is theeed to address interaction style, transference issues, treatmentlanning, and ethical and professional compliance for the loca-ion in which the student is working through the supervisionrocess.

As in the education field, a student counselor will usually havewo supervisors. One supervisor will be a field therapist who workst the site placement, and one supervisor works for the university or

ody that is granting the counseling degree. The need for distanceupervision during practica and post-graduation while working onhe credentialing process has been a need in areas where few artherapists practice and continues to be a need as international artherapy opportunities grow.

rapy 37 (2010) 106–111

Rahman et al. (2006) developed a pilot study looking at trainingand supervision in child psychiatry using the Internet. In this study,participants in the Internet supervision reported that their diagnos-tic and management skills had improved; that they felt they werewell supported; and that they felt they were better able to sup-port other trainees. Feedback from patients whose counselors wereparticipating in distance supervision indicated that they valued theexpert opinions and consultations provided during distance super-vision interactions with experts in the field. The overall profile ofthe service at the local site was raised as a result of these distanceconsultations.

This study determined that distance supervision providedadvantages such as focus on increased training for participantswithout substantial increase in clinical work for the supervisor,increased access to resource materials for supervisors during super-vision, and a reduction of conflict of interest for the universitysupervisor, since he or she was not physically on-site with studentsand could remain more objective about the cases presented. One ofthe most important findings was that a high level of quality health-care supervision and consultation by experts in the field could beprovided to remote and low-income areas that previously had beenunderserved. However, because this was a pilot study, the majorityof evidence collected was anecdotal, and a more in-depth study isplanned.

Hurley and Hadden (2009) conducted a similar study involv-ing distance supervision of student counselors within the contextof the telehealth environment. Hurly and Hadden reviewed workby Stamm (1998) and Miller and Partin (2003) which suggestedthat online supervision is a valued and valuable training method-ology. This particular case study on distance video supervisionwas based upon a mutual desire of the first and second authorto extend the traditional supervisory relationship beyond theface-to-face supervision mode and experiment first-hand witha reasonably available medium-tech distance video supervisoryformat.

Hurley and Hadden found that they had to address several issuesin order to make distance video supervision a viable option. Theyfound that they had to allow time to experiment with and workout technical problems before the actual supervision could begin.They also were concerned with and had to adjust their practices toaddress security limits to hardware applications, software appli-cations, and environmental conditions used in supervision (Litz,Bryant, Williams, Wang & Engel, 2004).

They found that video supervision had some distinct bene-fits over traditional supervision. Use of video supervision actuallyoffered some convenience of record keeping not normally presentin face-to-face supervision. The chat function of Net meetingallowed for the input of process comments by the supervisor thatwould then show up on the supervisee’s computer screen along-side the video image. These types of text comments often helpedframe future directions/actions for clinical work, research designand/or teaching. These notes were also a documentation of thesupervision sessions that could be saved on both the supervisor’sand supervisee’s individual computers.

Discussion

Issues in distance supervision

The above studies on providing distance supervision in edu-cation and the counseling fields have similar themes. Each study

indicated that there are several issues to be overcome in order toprovide distance supervision, and several issues for which there areno definitive answers at this time. The studies also indicated thatthere were some unique benefits to conducting distance supervi-sion.

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rossing bordersMore research and testing has been done in telehealth and

upervision over distance in areas outside the U.S. because reg-lations may already be in place to allow cross-border services,r such practice is not regulated. In the U.S., counseling psychol-gists, supervisors, and educators must be licensed in each stater province in which they provide services or perform activitieshat fall within the “scope of practice” of that jurisdiction’s psy-hology licensure or practice act (Mallen, Vogel, & Rochlen, 2005).ost commonly, counselors and educators are licensed to prac-

ice within their states of residence; however, it is possible forherapists and educators to connect with clients or students fromnywhere in the world. This presents a significant question regard-ng what state’s or country’s regulations (i.e., the student/client’s orhe supervisor/therapist’s) should take precedence if there is anyype of dispute related to the delivery of service. Similarly, malprac-ice insurance is typically valid only if the counselor or educatorrovides services within the scope of his or her license, which isommonly bound by state regulations.

However, if an art therapist is working on gaining supervisionours for the Registered Art Therapist (ATR) alone, then the cross-tate border issue may not be applicable. This credential offeredy the ATCB is a national credential and can also be obtained by

nternational art therapists after a course-by-course review of theirducation is conducted.

Reciprocity of licensure is based on participating states orrovinces conforming their licensure requirements to the agree-ent’s standards and accepting each other’s licenses. Reciprocity ispossible solution to these issues and is common, though ungainly,

n education fields. However, this idea is still gaining strength in theounseling fields, so only a few states at this time have regulationsor reciprocity currently in place.

For now the issue of providing inter-state, inter-province andnter-country supervision in the fields of counseling, education andn particular art therapy is still murky at best, but progress is being

ade towards clarity.The benefit to being able to cross borders in supervision, is that

upervision may be provided to counselors and students who liven isolated areas or countries where qualified supervisors may note present. This expands the reach of supervisors with expertise

n specific areas and allows students to provide services in areashere it has traditionally been lacking.

onfidentialityAnother problematic ethical issue addressed in each of the

eviewed studies is related to confidentiality (APA Ethics Code.01). For instance, to conduct online sessions through synchronoushat or asynchronous e-mail, a counseling psychologist must taketeps to limit the risk of a third party’s receiving or stealing thenformation shared during an online session. The most commonecurity step is to use encryption to safeguard the data transferhen communicating to a client. When using video, it is common

o use platforms such as SKYPE, which includes encryption as partf the process. However, as with traditional face-to-face supervi-ion, confidentiality can only be maintained if the supervisor andupervisee are aware and are diligent in addressing the issue.

Another issue surrounding confidentiality during distanceupervision is the ease with which one can save what transpiresuring a therapy session. Either the supervisor or student couldave transcripts from synchronous-chat sessions, or asynchronous-mails, or could record video feed to have an accurate log of what

ranspired. This has both potential benefits and negative outcomes.t could be beneficial for a supervisor to have an accurate accountf what occurred with a supervisee to refer to when developinguture goals and to help the student with planning. There are alsoeveral risks associated with saving transcripts/video. Most impor-

rapy 37 (2010) 106–111 109

tant, if the student or the supervisor decides to save the messages,then another person might be able to retrieve them. However, theserisks are present during traditional supervision when student ses-sions are taped and must be addressed in a similar ethical manner.The main difference between tapes of traditional supervision andrecordings of distance supervision is that copies may be kept oncomputers unknowingly or without consent. The ethics surround-ing this issue need to be clearly discussed between the supervisorand supervisee and a standard operating procedure developed forsessions prior to distance supervision commencement.

Another issue of confidentiality that was not addressed in thereviewed literature that is an important component of distancesupervision is the transmission of documents. Distance super-vision requires documents to be sent back and forth throughe-mail, postal mail, or document sharing; supervisors must signtrainees’ case notes and share client artwork and treatmentplans, and this constant flow of documents can become con-fusing and cumbersome. Clients will need to be made aware ofthe nature of the distance supervision and will need to sign aconsent form agreeing to the practice. As technology advancesthis issue is being addressed through platforms such as GoogleDocuments, because many businesses have similar documenttransmission and confidentiality issues. However, supervisors andsupervisees need to agree upon ethical handling of and trans-mission of confidential information prior to beginning distancesupervision.

Relationship buildingNone of the studies reviewed mentioned the issue of the build-

ing of trust within the supervisor and supervisee relationship asan issue for distance supervision. However, it is possible that ifthe supervisor and supervisee had never met outside of the dis-tance supervision relationship, that this relationship formationcould require more time to develop than in traditional supervi-sion. Supervisors will need to be more overt about the process oftheir relationship with the trainee. Issues such as trainee resistancemay be difficult to detect, and these and other complications couldhamper the supervision process. Trepal, Haberstroh, Duffey, andEvans (2007) have discussed the need during the training of stu-dents who will be conducting online counseling that in traditionalcounselor preparation programs, students are taught not only tofocus on verbal messages in sessions, but also to monitor nonver-bal behaviors (Ivey & Ivey, 2007; Young, 2005). They felt that theabsence of nonverbal information online may create some anxietyfor students because they perceive that they are unable to read theirclients’ body language or to see how a message is being received.Thus, online counseling involves a unique set of skills and tolerancefor ambiguity when interacting in an environment that is devoidof nonverbal information. This same set of skills will be necessaryfor any successful supervisor who is working at a distance withsupervisees.

Conclusions and gaps in the literature

As the above literature review suggests, many unansweredquestions regarding distance supervision remain; however, thereview does provide supervisors and supervisees with a basis ofknowledge. The literature related to process variables in distancesupervision is sparse, but the findings of studies evaluating theoutcomes of distance supervision have been mostly positive. The

literature on distance supervision for art therapy is essentially non-existent at this point and definitely needs to be addressed to keepthis field on par with related counseling and education fields. Fromthe literature reviewed a listing of best practices was developed(see Fig. 1).

110 P.P. Orr / The Arts in Psychotherapy 37 (2010) 106–111

Fig. 1. Best practices in distance supervision.

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for teaching online counseling skills: Establishing relationships in Cyberspace.Counselor Education & Supervision, 46, 266–279.

Young, M. E. (2005). Learning the art of helping: Building blocks and techniques. Upper

P.P. Orr / The Arts in Psyc

The results in the reviewed literature provide preliminaryvidence that distance supervision can be an effective form ofupervision in counseling and education fields if all the ethical andechnical issues are rigorously addressed. Research has also offeredreliminary support to the notion that distance supervision may beseful for increasing services to populations that underutilize clin-

cal services, such as disabled or rural individuals. In the literatureeviewed, each study indicated that participants thought distanceupervision was a needed alternative to traditional supervision.articipants also indicated that they found distance supervision toe helpful and beneficial for the student, the supervisor, and thelient. Distance supervision is beneficial where other options areimited, and the drawbacks it faces are currently being addressedhrough advances in technology and governing policy. Distanceupervision is likely to continue to become more prevalent as onlineducation grows and art therapy spreads throughout the world.esearch on this practice within the fields of education, art ther-py, and other counseling fields is strongly needed to help guide itsuture ethical and quality development.

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