Introduction

Increasingly, the families we meet, the therapists we train and the communities within which we work are engaging with real and digital worlds in a fluid manner. Our rituals for training, supervision and competence assessment which once relied on in-person interaction are now becoming influenced by the digital creativity which surrounds them. The digital disruption to practice brought by the COVID-19 pandemic offers opportunities for us to reflect on the dilemmas this brings for us as trainers and supervisors, as well as those aspiring to be the next generation of systemic practitioners and psychotherapists.

The aim of this paper is to consider how digital practices might reshape our systemic training, supervision and competence evaluation. What new digital competencies do we need to support in our students to equip them for current and future ways of digital working? How can we support them in the transition to homeworking and homelearning in order to enhance their learning and practice? Further, how can we harness the creative potential that digital methods of training might bring to develop and evaluate these competencies during systemic training programmes? We hope this paper is balanced, considering the dilemmas for both student and trainer, whilst also offering encouraging practical support for moving forward and considering new learning possibilities.¹

Our definition of digital systemic practice and systemic psychotherapy is broad and in line with that offered by Burbach and Pote in the editorial to this journal. Our training models therefore have to be diverse and also considerate of the multiple contextual shifts with which novice systemic practitioners are contending. The current context is complex for the student, supervisor and families alike. The shift to digital practice co-occurred with societal shifts brought about by COVID-19, such as increasing family isolation, lone therapist practice, rises in family stress, unemployment and mental health difficulties which affect everyone. For family therapists, more often working with more than one client, this requires the development of complex communication skills to engage their clients through digital methods. Ethical issues add an additional layer of complexity: are clients offered real choice about the move to digital practice? Is the choice equitable across individuals in a family? How does digital exclusion impact the families in most need? How is confidentiality ensured when working with multiple clients in household settings?

As trainers, we need to ensure we fully support novice practitioners as they embrace new rituals in digital practice and learning; define what is missing from our teaching delivery and assessments now in-room processes are absent, consider the needs of our online communities of students compared with our in-person cohorts in terms of support and group cohesion, and evaluate the fairness and reliability of our assessments as students move to online modalities. We also need to support more advanced practitioners to develop new competencies as they innovate and redefine their practice. It is important to encourage them to consider future possibilities for digital practice, across geographical boundaries, incorporating multiple cultural perspectives in ways which would not have been thought possible in a pre-COVID-19 era.

This paper will consider the issues for student, trainer and supervisor as they move to digital delivery of training, therapy and supervision. It will begin with definitions of digital systemic practice before considering adaptation and innovation in the delivery of systemic training. It will then discuss some specific considerations for the supervision of systemic practice digitally and conclude by detailing the competencies needed for digital practice, considering how these complement the existing systemic competencies (e.g. Roth and Pilling, 2008; AFT standards, 2015) and how we might evaluate them.

What is systemic digital practice?

Digital practice in mental health covers a whole range of digital data management tools and digital interventions to address mental health problems and promote wellbeing. These use different levels of automation and types of technology and may be client directed or therapist facilitated, or a blend of both (see Fairburn & Patel, 2017, for a review).

As evidenced online, psychologically informed interventions are being rolled out across NHS psychological services. However, these mainly have a psychoeducation and CBT focus and are a mix of guided self-help, text chat and blended therapy. Systemic-focussed online interventions are emerging, and examples are detailed in earlier papers in this special edition.

Since the advent of the COVID-19 pandemic, the majority of systemic family psychotherapists have begun to develop their digital practice competencies by adapting their usual therapy process for remote delivery by video-call. This is one important strand of the methods therapists might use in digital practice to enhance their work with families and will form the focus of this paper.

There is a gap between our clinical aspirations and our current practice and skills. At a policy level there is a top-down push for digital solutions to improve the delivery of mental healthcare and address unmet needs (NHS Long Term Plan, 2019). Policies cover both service organisation, digital interventions and informatics in this regard (Topol Review, 2019). It is important that, as a profession, we take the development of systemic digital practice skills seriously and explore the full implications for therapist training, competence evaluation and provision of supervision.

Training systemic therapists in digital competence

Digital learning and online education are not new. With its early origins in the development of correspondence courses in the 18^th century, online education has evolved alongside our relationship with technology. ‘Distance education’, defined as teaching where student and tutor are physically separated, in the form of correspondence courses, became increasingly popular in the early 1900s as interest in college and university education grew (Kentor, 2015). Educational broadcasting supported this process through the introduction of radio at this point, soon followed by the use of television broadcasts in the 1930s. By the 1960s, public radio and television broadcasting was gathering momentum, punctuated in the UK with the establishment of the Open University (OU) in 1969, which utilised television and radio to broadcast courses. Television programmes made for the OU were aired from 1971 until 2006, and the OU continues to deliver courses and training using a range of online platforms.

Prior to the creation of the internet and the World Wide Web, teaching took the form of asynchronous online learning, but it was the introduction of the internet and the possibility of online synchronous learning that really changed the landscape of distance education (Kentor, 2015). Since the 1990s, increasing numbers of universities and training centres have used online facilities, and in 2012 in the USA alone, one-third of higher education students were enrolled in online courses (Kentor, 2015). There was a growing recognition that online teaching and learning were here to stay, and academics and scholars alike recognised that ‘education has been, is being, and will continue to be cyberized’ (Sener, 2012, p. 157).

Fast forward to 2020 with the COVID-19 pandemic and the dramatic closure of most university campuses both in the UK and across the world, a large body of teaching shifted online with days’ and weeks’ notice. It is imperative at this juncture to distinguish between digital teaching pre-COVID-19 and the challenges associated with remote teaching during a pandemic. The impact of COVID-19 has had the most enormous and far-reaching effect on the delivery of teaching from primary school right up to post graduate level and clinical training. For many who are new to online teaching and learning, struggles with this digital format have become conflated with the anxiety and trauma of the pandemic; however, the biggest hindrance for this way of working remains the same in both instances – the potential loss of presence. Petriglieri reminds us ‘it is easier being in each other’s presence, or in each other’s absence, than in the constant presence of each other’s absence’ (2020), and the sense of disconnect and isolation for some has been heightened by remote learning.

Equally, for many, the opportunity to continue teaching and learning online has been invaluable, and the pace of change remarkable. ‘COVID-19 has prompted a vast expansion in telehealth practices and a considerable evolution in the methods and ethics for practice delivered through technology.’ (Lebow, 2020, p.310). The general benefits of online teaching include increased accessibility, flexibility, the potential increased levels of diversity in the student population, less travel and reduced cost as it is likely to be cheaper and easier to replicate and package. However, there are longer-term implications that may also be problematic, such as the potential dangers of erosion to existing teaching structures and intuitions, the lack of accessibility for some and the risk of increased sense of isolation for tutors and students alike.

We recognise that the internet is a social space (Lehman & Conceição, 2010), and the need to create a sense of presence is perhaps the biggest challenge and is imperative when teaching online. The area of online presence has been written about extensively by US academics who have been more familiar with digital formats for many years. We now have the challenge of understanding these processes through our systemic lens. Lehman and Conceição (2010) suggest that the importance of intentionally creating this sense of presence cannot be overestimated. They make distinctions between creating engagement online and creating a sense of community, both of which enhance social presence. There is evidence that learners who perceive high social presence online report that they have learnt more from others (Swan and Shih, 2005). However, Lehman and Conceição suggest that, for this to happen, learners must be introduced to the ‘notion of community building, knowledge construction’ and ‘the ways of being present during online discussions’ (2010, p.6). Tutors need to develop new ways of reading the group and recognise that previous ‘normal’ group behaviour may change once online. Students are more likely to feel inhibited and withdraw, or potentially become disinhibited and overshare or dominate the online space. Tutors need to give thought to the interplay between the feelings, thoughts and behaviours online, the physical world in which the student is situated and their private inner world of imagination and experience.

There are risks for the tutor in this setting too; tutors often report a sense of exhaustion, perhaps as a direct result of the amount of energy used to keep the teaching sessions going. The ordinary performative aspects of teaching here are challenged, and the potential lack of engagement and reciprocity in the teacher/learner relationship can be challenging. Thought needs to be given to the spaces around the teaching day as they are the liminal and transitory spaces in which the students ordinarily would check in with each other, make a hot drink and settle into the room. Without this orientation to the day, the shift from personal to professional life can be jarring. Tutors can mitigate against this disjuncture by giving time and thought to the beginning and endings of the day, providing a space for informal chatting and reflecting with the group about what would normally be taking place in this liminal space.

At this point in time, we can only guess at the long-term implications post pandemic. What is clear, however, is that online digital learning will become the ‘new normal’ far earlier that anyone could have predicted. As a step on this journey, we offer an outline of ideas for good practice in Table 1.

Offering supervision of systemic practice digitally

Supervisors working online bring their skills, expertise and perspectives on supervision from their previous experiences. However, as previously mentioned in regard to training, the context of moving to work online in March 2020 was, for most, unfamiliar and new. Complicated by the personal and professional worries and unfamiliarity of the COVID-19 pandemic, it was a time of feeling deskilled and yet wanting to continue to provide the best possible therapy resource to families and couples.

As a starting point, it is worth remembering that, as systemic therapists and practitioners, we are used to the concept of transitions in systems, and the move to working online is no different than other transitions in that the amount of change needed as part of this process, the newness, losses and gains, flexibility of the systems involved, all have an impact on how successful we, and the students and families we work with, find the experience. Sahebi (2020) points out that one reason for the slowness in family therapy to take up technology prior to the pandemic may be because of the centrality in many systemic models, of space and physical positioning, and the importance of emotional attunement and experiential therapy. Changes in delivery in the context of the pandemic has, for most, been a process of learning, from initial anxiety to increasing familiarity and confidence.

Contexts of supervision

The contexts of supervision that supervisors use in-person all continue to be possible online: retrospective (group and individual) and live supervision, each taking place within the boundaries of the policies and expectations of the agency context within which therapy is undertaken. Live supervision is the contemporaneous supervision of a therapist seeing a couple or family, either using a screen, video-link or being in the room with therapist and family. In-person this can be with qualified therapists or trainees working as singletons with supervisors or in teams, depending on the preferences of families and couples, training needs and technical resources available.

In offering the following practice guidelines for online supervision, we draw on the 2020 Family Process special edition on online working where Nadan et al. and Sahebi describe the challenges and opportunities of supervising online in Israeli and US clinical live supervision training contexts, as well as contributions from UK colleagues.

Retrospective supervision

• There needs to be discussion and review of the online working context and the supervisees’ comfort levels and learning needs in regard to this, both in their supervision and in their therapy.
• It is not just a case of moving families from in-person therapy to online from one session to the next as if you were just changing rooms; there needs to be a pause and re-contracting around consent and confidentiality issues.
• Additionally, there is the ability ‘to reflect in supervision on the client’s response to different digital modalities and the impact on the therapeutic relationship’ (www.digitalhealthskills.com/digitalcompetencies, accessed 8.11.20).
• There is the possibility with online working for retrospective supervision to more easily become live or shift into a consultation space, for example as a way of addressing impasse or stuckness.

Live supervision – New or established team working?

Supervisors describe experiencing gradations of novelty in the move to online working, such as taking an established team online and a new team beginning to work together there, along with the concomitant differences in the felt sense of security and safety of the team, supervisor and family.

• UK colleagues have described smooth transitions to online working where the team has already been working together and were known well by the family (similar to Nadan et al.’s findings). This, at the beginning of the pandemic, was enhanced by some families’ commitment to access a service when there was no other alternative.
• For any team new to online working there is a need for familiarisation with the technology, possibly utilising role play to increase confidence.
• With qualified therapists, one should not underestimate the de-skilling effect for some of the move to online supervision, although here the team’s understanding of their own therapeutic competence means the new learning may be quickly assimilated.
• Bringing together a new team online: the same joining exercises are possible as in-person supervision. Some supervisors felt this to be a slower process than in the room, with moving to personal exploration too early experienced as unsettling by students.
• It is important to consider the needs of supervisees with a disability and the management of this, for example clarifying confidentiality where an in-room helper is needed to access the technology.

Helping supervisees engage with families

Supervisors have noted the need for extra attention to beginnings and endings, with more effort needed by supervisees to engage new families.

• It is important to take time to explore a family/couple’s familiarity with online working, and the decisions made about how the family have accessed the therapy, such as on one device or separate, in different rooms or locations.
• There is the opportunity to meet additional family members who are housebound, busy or reluctant clinic attenders.
• Online sessions enable a continuity of engagement in therapy should people be away from home, or living in separate households.
• There needs to be careful attention to contracting – an extension of in-room conversations about confidentiality, recording, using shared screen to consider any forms needed.
• Negotiating the space and confidentiality goes both ways: introducing who is present but possibly not visible in the room (people and animals). This third space is not the same as clinic or in-home working, so explicit attention to privacy boundaries is important, for the therapist, supervisor and clients.
• In relation to the importance of an embodied presence in therapy and supervision (Bownas and Fredman, 2017) which is absent online, supervisees’ attentiveness and attunement to verbal and non-verbal communications, family interactions and emotional atmosphere are particularly important to actively develop and monitor. This can be a dilemma in the beginning stages of work where there are slower processes of relationship building yet more than usual attunement needed.
• Different rituals around endings also need to be considered: in the room saying goodbye often involves a physical connection, such as giving a handshake, hug, or card, and a physical leave-taking of the room. Online, this may mean more verbal signs of coming to a close, a formal wave to and from all, in a consideration of what fits for the family.

Negotiating the boundary of the screen

Screens are of course not new to family therapists, and teams sitting behind a mirrored screen experience affordances and constraints, for example the ability to observe family pattern and interactions but also an emotional distancing compared with being in the room. When working face to face, reflecting teams (Andersen, 1995) or in-room working may counter this in part. However the ‘gaze’ of a team online is very different from a team being with a family at the side of a room, and there are differing ideas about managing the online view for families. It is important to negotiate this in a transparent manner. Alternatives are:

• introducing, then muting team members who then turn off their cameras (turning on again for the reflecting team): this reduces the distraction of many faces for therapist and family which some clients experience as overwhelming.
• keeping cameras on can be seen as increasing the transparency of therapeutic process, but it is suggested families use speaker view so other participants are in small tiles, while the team keeps to gallery view.

Processes of online supervision: the supervisory alliance

Colleagues have talked about online live supervision as a tiring and intense experience and emphasised the need for supervisors to pace themselves. This intensity seems to come from the extra layers of complexity and working hard to stay attuned to group process, which is not as easy to perceive online. Sahebi (2020) also points out the additional attunement needed with supervisees at this time of pandemic fears, and anxieties about the technology – therefore the extra importance of the supervisory alliance. She points to the potential parallel processes of anxieties in the supervisor–supervisee relationship, and between the supervisee and the family, with a need for dialogue about these different levels. This can provide an opportunity to help students learn to sit with anxiety with families, and to work with the self of the therapist by linking individual responses to anxiety with family of origin issues. To explore opportunities and challenges, see Table 2.

Technical competencies for supervisors

Attending to the supervision processes raised above requires additional competencies on behalf of the supervisor and supervisee. For example:

• Confidence in the use of technology, agency policies and expectations for online working is important for the safety of clients. Holding student anxieties at the beginning of a training programme is a familiar process for supervisors, but if supervisors are also new to online working, it can be particularly challenging to contain one’s own as well as the supervisees’ anxiety and instil confidence in supervisees.
• Anticipating technical problems: there can be the potential for constant anticipation of technical problems to create a distracting low-level anxiety. It is important for supervisors to discuss with their supervisees their (and the family’s) access to technical resources and backup processes in terms of communication between the family and team.
• Digital recording: as with in-person recording, there is the need for family consent, agency agreement and clear understandings about where and how digital recordings can be stored. Agencies are also moving fast digitally and can be open to using secure cloud storage for recordings which can then be played back easily and quickly.
• Messaging between supervisors and therapist: use of text communication between supervisor and therapist may feel empowering and less disruptive to the therapist in training. However, for the rest of the team to be aware of the supervisor’s communication a group message needs to be used, or the supervisor to come in overtly and verbally on the phone or directly, or using the chat function to all, when the family will also directly read it.
• Messaging between supervisor and team: teaching points can be made pre- and post-session. This encourages the team to watch and listen carefully, and so become attuned to the online therapy process. Where supervisors wish to address teaching points with a team mid-session, this could again be done via group text. Nadan et al. (2020) noted this as a varied process in their training context, based on the personal preferences of the supervisor.
• Messaging about risk: Where there is an urgent need for the supervisor to talk directly to the therapist about mental health risk or potential adult or child safeguarding issues, the family can be asked to be moved back to the virtual waiting room, so that the supervisor can converse separately with the therapist and team. The supervisor becoming visible and audible can feel as big an intervention as knocking on the door or coming into the therapy room.

Competence frameworks and evaluation

For effective mental health service delivery, a trained and competent workforce is crucial, and whilst competencies have been defined for systemic practice over many years (e.g. Roth & Pilling, 2007; AFT Blue Book, 2015), frameworks for defining and assessing digital mental health competencies are only just emerging in the UK. Currently professional and regulatory bodies, such as the Association for Family Therapy and Systemic Practice and the Health and Care Professions Council in the UK, do not require the development of digital competencies as part of therapist pre-registration training. It is unclear, however, whether therapists working remotely using videocalls can offer clients the same level of competence in ‘working in a reflective manner’ and ‘facilitating communication across the system’.

Therapist competence is defined as ‘the extent to which a therapist has the knowledge and skills required to deliver a treatment to the standard needed for it to achieve its expected effects’ (Fairburn and Cooper, 2011). This section will consider how we assess competencies and what we assess within the world of digital systemic practice. There are three topics for consideration: firstly, the assessment of competencies using digital modalities, particularly in the current COVID-19 crisis; secondly, how our existing systemic competence frameworks stand up when considered through the lens of digital practice; and finally, what additional digital competencies we might need to integrate into our systemic training programmes and competence evaluations.

Assessment of competencies using digital modalities

The tasks of assessing students’ competencies through digital methods brings a number of challenges both logistical and relational. Logistically, students and their assessors/supervisors are coming to terms with the new digital modality as discussed and are together learning to share and monitor competencies in a way which is fair and sensitive enough to monitor change and encourage progress.

We are also uncertain how our current assessment methods, which are primarily based on observations of practice and observational ratings of competence schedules, will be as effective in a remote digital realm. The fact that for many years systemic practice and training has relied on digital methods might be to our advantage here. Trainees are used to video recording their practice and reviewing this with supervisors and families, so moving to live observations and assessment remotely may not be such a leap. Whether these remote methods will be sensitive enough to achieve successful assessment of overall competence is yet to be established. Formative and summative assessments of clinical competence also bring different challenges in a digital medium. For example, in summative assessments online, levels of student anxiety may be heightened when faced with a panel of assessors scrutinising them online, and issues of power and diversity may be magnified.

In addition, relational and emotional aspects of the assessment process are important. We are currently assessing trainees’ competencies at a time when they are taking many risks in their own learning, both as a result of COVID-19 and the rapid change to digital delivery of therapy. This will be the first cohort of students who are being assessed online, and this brings with it uncertainty and anxiety for trainer and trainee. We have to question whether this is a fair and optimal time to be assessing skills. As Sahebi (2020, p.992) points out, ‘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)’.

Applying a digital lens to existing systemic competencies frameworks

What we are assessing as therapists’ competencies also needs to shift. We need to reconsider our models of systemic competencies and integrate new digital competencies that our trainees need to possess now faced with a world where digital practice is a choice offered to most clients.

All aspects of systemic competencies will be shaped by the specific digital modality by which they are delivered. For example, skills in establishing a therapeutic alliance with multiple family members will need to be developed when using videocalls, in order to deal with online disinhibition (Suler, 2004). Observational skills related to the assessment of dyadic and systemic functioning will need to be enhanced to detect subtleties easily lost in digital translation. Treatment skills, such as offering reflecting teams, will need to draw on new ways to monitor the impact of reflections on family members. The most common tool for assessing systemic skills in training is the Systemic Practice Scale (SPS, Butler et al., 2020), which will also need to be extended to include digital practice.

Additional digital competencies we need to assess

Recent UK government reviews are clear that digital literacy needs to be built into clinical training programmes, career pathways and clinical placements to support the rollout of the digital delivery of healthcare (Topol Review, 2019). Health Education England (HEE) is establishing NHS Digital Education Programmes to oversee the implementation of a national digital education strategy across the whole health workforce.

‘Professional, Statutory and Regulatory Bodies (PSRBs) and practitioners need to identify the knowledge, skills, professional attributes and behaviours needed for healthcare graduates to work in a technologically enabled service, and then work with educators to redesign the curricula for this purpose.’ (Topol Review, 2019, p.17).

Within this context, a framework of digital competencies² has been initiated by the British Psychological Society, Division of Clinical Psychology and supported by IAPT London and HEE. It is the first comprehensive outline of the digital mental health knowledge and skills needed by all psychological practitioners in the UK. It draws on a range of national and international standards from Europe, the USA and Australia (e.g. British Association for Counselling and Psychotherapy, Telephone and e-Counselling Competences & Curricula, 2016; American Psychological Association Guideline for the Practice of Telepsychology, 2012).

The aim of the UK Framework of Digital Competencies for Psychological Professions is to enhance the skills of the mental health workforce by setting consistent standards for digital practice which inform training and curricula for pre-registration programmes. The framework may also be used by qualified practitioners, trainers and supervisors to monitor developing digital mental health competencies. The competencies have broad application across organisations, but they need to be considered by each profession and locally to ensure they fit practice models and specific clinical settings.

Rather than reinvent the wheel, it seems sensible to review whether this framework is applicable to systemic therapists. There appear to be some clear overarching areas we need to teach and assess across our systemic trainees in relation to their digital knowledge and skills. Some suggested competencies for systemic digital practice based on the existing digital competencies framework for psychological professions are detailed in Table 3. We offer these to encourage debate in the training community about the future of our curricula and assessments in relation to digital practice.

Conclusion

We need to work collaboratively towards naming and recognising competencies needed by trainers, supervisors and students as we all became more familiar with digital delivery of systemic practice. As the lack of an embodied presence online becomes a clearer constraint, it is particularly important to develop therapeutic competencies in attentiveness and attunement, and processes for trainers, supervisors and students that help enhance their online presence.

Moving forward, the reality of training and mental health provision is likely to be a blended offer, combining in-person and digital delivery, perhaps even in the same session with some members of the team or family online and some in the room, particularly in these socially distanced times. The monitoring of all aspects of behavioural and emotional interactions across two mediums presents challenges to trainers, students and supervisors. The ideas suggested in this paper for enhancing digital delivery of training, supervision and competence assessment highlight the importance of evaluating systemic practice and systemic psychotherapy within the digital realm. The rapidly changing context means that practice-based evidence, of which this paper is an example, will be critical in ensuring we continue to deliver an ethical and effective service to students and clients.