A Teachable Moment for Counselor Education

By Ryan Rominger, Associate Research Chair

When I was earning my Masters of Science in Clinical Mental Health Counseling we were admonished to see clients only in the face-to-face format while earning our hours. While our program was primarily online, with two residencies and numerous videoconferences, our education was focused on in-person face-to-face interventions, our practicum was in-person face-to-face sessions only, and our internship was in-person face-to-face only. During our courses, we were exposed to articles on teletherapy and telemedicine, but it was not a part of our formal, regular curriculum.

Regarding regulations, counseling programs are regulated by the Council for Accreditation of Counseling and Related Educational Programs, also known as CACREP. While I was a student it was never clear whether CACREP approved of teletherapy for educational programs for counselors. The focus was always in-person, face-to-face services, and this led to an assumption that teletherapy was second-rate at best. Fortunately, the current crisis has allowed CACREP to more prominently clarify its stance. On their website (https://www.cacrep.org/for-programs/updates-on-covid-19/#march63) CACREP clearly outlines the flexible stance this organization has taken. Regarding CACREP standards 3.G and 3.K discussing clock hours for practicum and internship within a program, CACREP clearly states “CACREP does not have any prohibitions against telemental health or distance supervision.”

While CACREP regulates educational programs, licensure, however, is regulated at the state level. Within the state of Montana, where I reside, most indices point toward support for telehealth. A lack of clarity comes, however, when discerning the definition of ‘face-to-face’ supervision. Montana Rule 24.219.604 #2 clearly indicates that supervision must occur ‘face-to-face’ (http://mtrules.org/gateway/ruleno.asp?RN=24.219.604). Client hours are defined as direct or indirect (with direct client hours including sessions, and indirect hours including trainings, writing of therapy notes, and the like). However, for supervision hours must be face-to-face. The question arises, does face-to-face include videoconference technology as found within telehealth? Or, is the presumption that face-to-face automatically includes ‘in-person’ interactions as opposed to ‘at-a-distance’ interactions? Thus, a three-fold opportunity arises.

1. First, students and post-graduate therapists completing hours for full licensure should clarify their state requirements regarding in-person and at-a-distance, or telehealth, supervision.

2. Second, programs attempting to adhere to state regulations should also clarify with their states if practicum, internship, and post-graduates seeking full licensure may engage in videoconference telehealth supervision.

3. Third, state legislatures have the opportunity to align state requirements with CACREP policies, including recent statements regarding flexibility and lack of prohibition against telemental health or distance supervision.

The current crisis has made us aware that telemental health and teletherapy are unique aspects within the counseling paradigm. They are far more critical than we had once thought. In a very short period of time, we found counselors scrambling to move their practices online and move away from in-person, face-to-face therapy towards teletherapy. Counseling organizations and online CE organizations quickly put out guidelines, certifications, and best practices pieces regarding teletherapy for the counselors who are already engaged in the practice. And we as counselors at the height of our own anxiety, to meet our clients’ needs, continue to eat it up. These ongoing CE trainings and best practices pieces have made us aware that our own education around teletherapy was sorely lacking. It seems that we now have an opportunity to grow counselor education to include issues around practicing teletherapy including learning how to integrate teletherapy into our practicum and internship experiences. I can only imagine how different counselor responses would have been had we been trained prior to this crisis how to integrate teletherapy for use with multiple client populations. For example, how can teletherapy best be used with children between the ages of five and ten years old struggling with behavior problems, or with seniors struggling with depression and anxiety? I believe the exploding practical use of teletherapy opens up a ripe opportunity for research, training, and education within teletherapy on how teletherapy can best be used with certain mental health disorders and with certain populations. In a sense, the current period of the Covid-19 crisis is a call to action for CACREP and all counselor or therapist professional organizations to integrate teletherapy and telemedicine into formal educational programs.

So, what might a teletherapy or telemedicine program element look like? It would ideally include discussion of issues related to ethics, use of hardware and software, and use of teletherapy for particular disorders and with particular populations. It would include research that has been done on best practices and on how teletherapy should and should not be used. Also, we would learn about how teletherapy may be used with specific clients, individuals, couples, and groups as well as within different institutions such as community mental health centers and substance abuse treatment centers. We would learn the different social, economic, cultural, and cross-cultural implications of using teletherapy and telemedicine, as well as how a therapist might conduct mental health assessments in a culturally competent manner (and while aware of issues related to social-economic status including access to resources such as computer technology) during teletherapy. There are many elements that may be explored, and I imagine that the field of counseling will be inundated with auto-ethnographic and case-study articles on many of the topics above as we continue the advancement of our knowledge regarding the utility of teletherapy during times of crisis or otherwise.

Originally published at https://research.phoenix.edu.

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