Category: Therapy & Technology

Videotaping Therapy

Posted on by Psychotherapy.net Team

Therapists have been using videotape to enhance psychotherapy training and supervision for decades. Recent technological advances have allowed for a range of creative new affordable ways to record “picture-in-picture”, so the video shows both the client and therapist. These setups do not require any video editing. Below is a list of instructions for picture-in-picture video setups, with links for more information. If you know of another recording setup, please email me, and I’ll add you to the list.  

(Updates to this list are available here:  http://istdpinstitute.com/resources/)

1. I use Wirecast software to combine two digital webcams, connected to my computer, into one picture-in-picture therapy video. Psychotherapy videos are stored on the computer and can be burned onto DVDs. No editing is required.

2. Nat Kuhn developed a system to video therapy sessions that uses two digital cameras, two DVD recorders and a Picture-in-picture (PIP) video mixer. Therapy videos are stored on DVDs and no computer editing is required. He provides very detailed equipment and setup instructions here: http://natkuhn.com/equipment/equipment.pdf.

3. Arno Goudsmit in the Netherlands has developed a psychotherapy recording tool for a 2-camera and computer setup (also adaptable for 1 camera), which gives a picture-in-picture effect on an mpg-file. He uses memory sticks which the patient can take home; and they keep a copy of the psychotherapy video for study purposes. (You could also burn the therapy video onto a DVD.) You can find his software at: http://www.edtmaastricht.nl/2cameras. His software is free and no video editing afterwards required.

4. Rick Savage is a producer in New York City who has experience helping setup therapy videotaping systems using Apple computers and digital cameras. He can be reached at 917-364-1866 and
www.savagetunes.com.

Also:  Jon Frederickson and I have been experimenting with the use of Skype for one-way-mirror supervision. Jon provided live, one-way-mirror supervision for me from Washington, DC, while I was working with clients in San Francisco. We have had very positive clinical and training outcomes with this new technology. If you would like setup instructions, email me.

Clinicians and supervisors may also find the following articles of interest:

1. Allan Abbass, a psychiatrist in Halifax, published “Small-Group Videotape Training for Psychotherapy Skills Development”, as well as “Web-Conference Supervision for Advanced Psychotherapy Training: A Practical Guide”

2. Peter Costello, a media ecologist and clinical psychologist at Adelphi University, wrote “The Influence of Videotaping on Theory and Technique in Psychotherapy: A Chapter in the Epistemology of Media”
 

Psychotherapy Training on Steroids: Remote Live Supervision

Posted on by Psychotherapy.net Team

Note to readers: This blog is dedicated to exploring new training tools and techniques to help us become better therapists.  May we all become “supershrinks!"

Learning a psychotherapy technique can be like a romantic tragedy.  You go to the workshop, fall in love with the technique (and occasionally the presenter), and go home with fantasies of all your therapy cases getting unstuck.  On Monday morning in your office, however, everything falls apart:  you can’t remember the techniques (despite the post-its), you can’t do them correctly, or, even worse, you do the interventions perfectly but the client responds totally differently than how the clients in the presenters’ videos responded.  Sometimes I want to yell, “No, you are supposed to cry when I say that line, and get angry when I say this line!”

Most training and supervision lacks the most important variable in therapy:  the client.  The best training occurs in an actual therapy session.  I want to know what techniques to use with my client, not the client in the case reports or videos.  But what if the expert I want to learn from lives across the country, or I don’t have a one-way mirror room?   Now, thanks to internet, I can bring him into my office.

I would like to share a new method of supervision that has been made possible by recent technological advances.  “Remote live supervision” allows a supervisor to observe a therapy session over the internet and give feedback to the therapist in real time.  The technology is inexpensive and easy to setup.  This new method has promise to greatly increase the accessibility of top-quality supervision and training across the field of psychotherapy, as therapists will no longer be limited by geographic distance. 

Specific instructions on how to set up the remote live supervision for both PCs and Macintosh computers, along with a discussion of technical issues, can be found here.

Combining the video of the therapy session with the transcript of the supervisor’s moment-to-moment comments makes for a powerful training tool, as trainees get to see the actual results of following (or not following) the supervisor’s interventions.  Another option for training is group video, where a team of trainees can observe a remote live supervision in real time.

I do remote live supervision with Jon Frederickson, MSW, to accelerate my learning of Intensive Short-Term Dynamic Psychotherapy (ISTDP), an affect-focused therapy effective for healing trauma, anxiety, anger, relationship problems and somatic symptoms.   One aspect of ISTDP that can be challenging for trainees to learn is how to identify and address the automatic, unconscious behaviors clients use to maintain an emotional distance between themselves and others (including the therapist), such as rationalizations, talking in hypothetical terms or being vague.   In a review of my work, I found that I was missing my clients’ distancing behaviors, and many sessions could go by without a significant emotional experience or change for the client.  

Of course, the client is not the only person in the therapeutic dyad who can unconsciously create emotional distance.   Colleagues in a consultation group helped me identify my own pattern of unconscious emotional distancing, especially when working with male clients who were emotional distant or angry.   However, I was unable to translate this insight into change in the therapy room.

Through remote live supervision I have been able to get immediate, moment-to-moment identification of distancing behaviors, by both the client and myself, in real therapy sessions.  Live supervision can be very challenging, especially when it addresses my own avoidance.  It is, however, extremely effective: Jon’s real-time feedback has resulted in multiple breakthroughs of sustained, heavy grief and character change in clients for whom therapy had previously been stuck.

If you have a new psychotherapy training technique you would like to share on this blog, please email me.

Ethical and Legal Issues in Telephone Therapy

Posted on by Psychotherapy.net Team

With today’s technology we are an ever mobile yet increasingly connected society. For example, a client who you have been treating in office and perhaps with a few phone sessions when he was stuck downtown at his office has now relocated out of state and wants to continue his therapy sessions. With telephone, Skype and e-mail, why not? Why not expand your practice and “see” patients across the country, especially if you have expertise in an area of treatment?

Over the past decade or so therapists have been warned of the pitfalls of telehealth. For example, bogus identities, unintended recipients, individuals lurking in group therapy sessions. There can also be misunderstanding or unavailability of the nuances of communication (verbal and nonverbal) through e-mail or the internet. In more recent years, various Codes of Ethics or statements from national organizations (ACA, APA, etc.) have provided guidelines about the need for informed consent, maintenance of privacy and confidentiality, and billing issues.

Most recently individual states have started to enact statutes regulating telehealth. While all 50 states have laws regarding general telehealth, only few have laws specific to psychologists and therapy. Few state licensing boards also have enacted formal regulations regarding telehealth practice. However, it seems to be only a matter of time until more states enact laws to protect their residents and to hold therapists accountable to their residents. The APA Practice Organization recently published an article about legal basics for psychologists and telehealth that has a concise review of the current legislative actions regarding this topic (APA Practice Organization. Telehealth: Legal Basics for Psychologists, Summer 2010)

Telehealth can be viewed in two broad categories: practice within state and practice across state lines. Within state, the therapist need only refer to the state specific statutes and good clinical practices. Providing therapy across state lines is a little trickier. The APA article noted that there is a strong legal argument that the therapist should be licensed in both the state in which the therapist resides and the state in which the client resides. Most states allow nonresident therapists to obtain a temporary license to practice for a prescribed number of days a year (often 30 days total). Although this may be cumbersome, it will decrease the probability of licensing board sanctions for practicing within another state without a license. Another alternative, for psychologists, is to obtain an interjurisdictional practice certificate to facilitate temporary practice in other states.

Framework for risk management: (1) Review the telehealth laws in your home state and the state of your client. (2) Contact the psychology board of your home state and the state of your client to identify specific telehealth policies. (3) Confirm with your insurance carrier the limitations , if any, to your policy for telehealth for in-state and between-state clients.