Online Clinical Training in the Virtual Remote Environment: Challenges, Opportunities, and Solutions

Mar 9, 2020 | Volume 10 - Issue 1

Szu-Yu Chen, Cristen Wathen, Megan Speciale

This article focuses on the clinical training aspects of a distance counselor education program and highlights what clinical courses look like in an online synchronized classroom. Using three courses as examples, including group counseling, child and adolescent counseling, and practicum and internship, the authors share unique challenges they have encountered and solutions they have adopted when training distance students on counseling skills. The authors further discuss pedagogy, teaching strategies, and assessments that have been utilized to engage diverse distance learners in synchronized class meetings in order to maintain equivalent quality and learning outcomes with traditional clinical training methods. Finally, the authors provide recommendations for future research to increase and solidify the reality of distance clinical training in counselor education programs.

Keywords: online clinical training, distance counselor education, virtual environment, synchronized classroom, pedagogy

The rapid development of technology over the past decade has caused significant changes in higher education (Swanger, 2018). According to Allen et al. (2016), in 2015 over 6 million students participated in distance learning courses. Following these national trends, distance learning opportunities in counselor education have grown (Snow et al., 2018), delivery modes for distance counselor education programs have been developed, and attention to distance learning pedagogy has become a critical focus. At the same time, counselor educators have held the belief that counselor education, especially clinical skills training, should be learned and taught in person because of the intricacies related to developing rapport and the complexity of the counselor–client relationship (Benshoff & Gibbons, 2011). As the helping relationship is key to effective counseling (Layne & Hohenshil, 2005), providing clinical training via distance education can be a concern in regard to students’ learning experience and growth, and ultimately their ability to connect and work with clients.

Despite this caution, the Council for Accreditation of Counseling and Related Educational Programs (CACREP) accredited program models have begun to shift the perspective in the counselor education field. Alongside numerous pedagogies specific to the online format, the Association for Counselor Education and Supervision (ACES) Technology Interest Network (2017) has published its own guidelines for online learning, showing its support of this method of counselor training. Additionally, to date, CACREP has accredited a number of fully online counselor education programs, supporting the provision of quality counselor training despite an absence of in-person contact between faculty and students. However, scholarly research around best practices and effectiveness of distance counselor education has not substantially increased. Barrio Minton (2019) reported in a thematic analysis of counselor education and supervision articles published in 2017 that only 4% pertained to distance counselor education.

A benefit of distance learning counselor training programs is that students worldwide have an opportunity to pursue an accredited advanced degree in counseling in the United States. When programs approach this type of training with a culturally competent perspective, qualified faculty, and intentional pedagogy specific to distance learners, they not only allow the profession of counseling to grow nationally and globally, they provide opportunities for individuals whose life circumstances have created a barrier to pursuing a counseling degree. With this responsibility, counselor educators recognize that it is crucial to continuously explore challenges and benefits of facilitating clinical training within the realm of technology. It also is vital for counselor educators to continue examining ways to create safe and student-centered learning communities, maintain meaningful teacher–student relationships, and model counseling relationships and clinical skills in a virtual environment. Thus, research and instruction around sound distance learning pedagogy is imperative (Perry, 2017).

This article focuses on the clinical training aspects of a counselor training program and highlights what clinical courses look like in a remote synchronized classroom. We will share unique challenges and solutions we have encountered when training distance students on counseling skills in group counseling, child and adolescent counseling, and practicum and internship. We discuss pedagogy and teaching strategies that we have utilized to engage diverse distance learners in synchronized class meetings in order to maintain equivalent quality and learning outcomes with traditional counseling programs. Finally, because of a dearth of research concerning distance training in counselor education, this article provides research recommendations to increase and solidify the reality of distance counselor education training programs. In order to ethically provide quality training, counselor educators must know what works and what best practices in distance learning produce quality counselors. In fact, Barrio Minton (2019) argued that “scholarly attention to methods for and effectiveness of distance teaching and supervision is the most neglected area within counselor education and supervision” (p. 12). With the number of online programs increasing, this should no longer be the case.

Review of Clinical Training in Distance Education

The 2016 CACREP Standards (2015) emphasize clinical training regarding general and program-specific knowledge, skills, and practice. Specifically, counselors must have knowledge, skills, and practice in conducting clinical interviewing; diagnostic assessments; case conceptualization; and individual, group, and career counseling. Students are expected to demonstrate ethically, developmentally, and culturally appropriate strategies and techniques for building and maintaining face-to-face (F2F) and technology-assisted therapeutic relationships, as well as prevention and interventions regardless of the context of the training medium (CACREP, 2015).

Although distance learning is not a new phenomenon, online counselor education has been slow to progress. Currently, CACREP (2015) defines an online counseling program as one having 50% or more of the counseling curriculum offered via distance technology. As of 2019, the CACREP database indicated 55 CACREP-accredited institutions offering 72 online master’s degree programs, compared to five CACREP-accredited online counselor education programs in 2012. As the number of CACREP-accredited online programs continues to grow, online clinical training has become a controversial topic given the nature of therapeutic relationship-focused and skills-based education. According to Perry (2017), some major concerns include whether distance students obtain as much knowledge and are able to develop comparable counseling skills as students who attend F2F training programs. To date, limited literature focuses on online clinical training and few researchers have examined the efficacy of teaching counseling practice skills through online courses (Barrio Minton, 2019). There are few studies comparing online and F2F programs’ learning outcomes in counselor education. We consider this a particularly important area to explore given that counselor supervisors and educators must conduct counselor education and clinical training programs in an ethical manner whether in traditional, hybrid, or online formats (American Counseling Association, 2014).

Online Clinical Skills Training

Concerns about the ability to translate clinical skills in an online environment are prevalent among educators (Barrio Minton, 2019; Perry, 2017). There is little research to facilitate changed attitudes around this common mindset. Researchers have examined the efficacy of distance students’ clinical skills development in the mental health professions. Murdock et al. (2012) assessed students’ skill development learning outcomes between online and in-person counseling skills courses based on Ivey and Ivey’s (1999) counseling skills training textbook. Participants included 19 students enrolled online and 18 students enrolled in person. Students were taught by the same instructor and the courses were facilitated similarly. A counselor served as an independent evaluator and 15 transcripts of counseling skills sessions were randomly selected. Results showed no significant difference in basic counseling skills based on the mode of course delivery. Similarly, Murdock et al. (2012) and Ouellette et al. (2006) found no significant differences between online and F2F sections of an interviewing skills course for undergraduate social work students.

Wilke et al. (2016) conducted a quantitative study to compare master’s social work students’ development of clinical assessment and clinical skills of crisis intervention between 74 students enrolled in an in-person class and 78 students in an asynchronous online class. All student participants were taught by the same instructor and were given the same assignments, including an assessment and treatment plan of a fictional case and a digital role-play. The role-play assignment was graded by a doctoral student who was blinded to the course delivery format. The results showed that there was no significant difference for students’ skill development between F2F and online classes. Wilke and colleagues concluded that clinical skills seem to be taught as effectively online as in a traditional classroom within the context of the same instructor.

Bender and Dykeman (2016) explored students’ perceptions of supervision in both online and F2F contexts. Counseling faculty and doctoral students provided supervision to 17 F2F students and 12 synchronous online students. Supervision took place for 90 minutes each week in a 10-week period. A posttest assessment, the Group Supervisor Impact Scale (Getzelman, 2003), was given to all participants to measure supervisee satisfaction, self-efficacy, and the supervisory relationship. The results showed no significant differences in the students’ perceived perspective of supervision effectiveness between the online or traditional supervision students. These articles stand out as starting a base of evidence for the effectiveness of online clinical training in counselor education; however, much more qualitative and quantitative research is necessary regarding a multitude of educational aspects connected to CACREP standards to sufficiently evidence the quality of online clinical training.

Assessment and Evaluation of Online Clinical Training

Reicherzer and colleagues (2012) pointed out challenges for online and hybrid programs in observing and assessing students’ counseling skills and practice because of the potential limits of a distance learning environment. Various counselor educators described similar challenges in providing experiential clinical training in a remote learning community. For example, Snow and colleagues (2018) surveyed 31 online counselor educators to investigate the features of current online counseling programs and educators’ online teaching experience, including the challenges they encountered and the strategies they used to ensure students’ success. The results indicated that some of the major challenges related to clinical training included providing experiential clinical training to distance students and supporting quality practicum and internship experiences for distance students.

Reicherzer and colleagues (2012) recommended that instructors develop program-specific standards and use technology to gather multiple artifacts that measure student learning outcomes associated with knowledge and skills. It is important for the program to determine what learning components must be taught in residencies (Reicherzer et al., 2012). Snow and colleagues (2018) further noted that asynchronous online teaching might not be an effective method for modeling, observing, and assessing students’ interpersonal and counseling skills. However, synchronous videoconferencing technologies may provide distance students and educators the same opportunity to conduct skills demonstration, provide immediate feedback, and practice experiential activities, such as role-plays (Snow et al., 2018). Furthermore, it is critical to include skills-based activities throughout the program and ensure students meet necessary learning outcomes before they advance to clinical field experiences (Reicherzer et al., 2012).

To address an increasing trend of distance counselor education, the ACES Teaching Initiative Taskforce (2016) provided suggestions for delivering a high-quality online educational experience for counseling students. It is proposed that instructors’ presence and engagement with students are key to students’ online learning experience. Thus, Hall et al. (2010) postulated a humanistic practice in distance education. Specifically, the authors proposed that instead of heavily relying on technology, instructors should make efforts to foster teacher–student relationships at the beginning of the class and intentionally maintain relationships throughout the course delivery by considering students’ personal, social, and cultural needs. It seems that with advances in technology, embracing humanistic educational foundations can help to ensure the integrity of the counseling profession.

Challenges and Opportunities of Online Clinical Training

Some educators might consider the integration of technology in the counseling training program as an opportunity for continued development in the counseling profession. Yet, others might question the capability and success of online modalities in meeting learning outcomes and standards (Snow et al., 2018) and view it as a threat given that the profession emphasizes therapeutic relationships as the core of effective counseling (e.g., Layne & Hohenshil, 2005). This argument is founded on the assumption that technology cannot provide students with a productive learning experience compared to F2F experiences (Layne & Hohenshil, 2005). Additionally, some online counselor educators identified changing their teaching style to fit an online classroom to be a major challenge (Snow et al., 2018). As a result, many educators are seeking ways to effectively maintain a focus on interpersonal relationships within a technologically oriented teaching format for some professions, including counseling, that are practiced through personal contact (Hall et al., 2010; Lundberg, 2000).

We have perceived and experienced various challenges and opportunities when providing clinical training in a virtual learning environment. Koehler et al. (2004) indicated that to effectively develop online courses, there are three components that must dynamically interact with each other: content, pedagogy, and technology. When the instructor has expertise in the subject, has skill in teaching effectively in an online environment, and understands and effectively utilizes technology in dynamic ways, students report having a better learning experience. Although there is an increasing focus on general online pedagogy in counselor education, concrete and practical strategies for online clinical training are rarely discussed. Accordingly, we aim to illustrate strategies that counselor educators can consider integrating into various skill-based courses to accommodate diverse learning styles, provide supports for students’ learning, and deliver quality clinical training.

Fostering an Effective Learning Environment for Clinical Skills Training

The element of classroom safety is an important consideration in fostering an effective virtual environment for clinical skills training. Because role-plays and mock counseling assignments often include information that is sensitive in nature, it is essential that students maintain confidentiality during and after class meetings (ACES Technology Interest Network, 2017). Although attending class in a private location is preferred, students in synchronous settings may join the class from a variety of locations in which privacy cannot be guaranteed (e.g., coffee shops, shared living spaces, and libraries), so it is important to establish classroom guidelines that address classroom confidentiality. Example guidelines that ensure a safe and respectful online environment may include: (a) using headphones in class to prevent the accidental sharing of classmates’ private information, (b) limiting background noise, (c) ensuring there is proper lighting so the student’s face is illuminated, (d) closing all other open windows on the computer to increase focus, and (e) avoiding side conversations with other students or outside persons during class.

Synchronous Tools for Clinical Skills Training

With the expansion of technology, instructors have been able to apply numerous synchronized technological tools to enhance students’ engagement and benefit students’ clinical skills development in the virtual space. One of the features of many videoconferencing software programs is breakout rooms, which function similar to small group breakouts in traditional classrooms. With breakout rooms, instructors can assign students to small groups in a virtual classroom where students can conduct case discussions and role-plays. Instructors can join each small group remotely to facilitate observations and assessment of students’ clinical skills, as well as provide feedback on students’ discussion and questions. This allows students to receive individual feedback immediately and to incorporate recommendations into their practice simultaneously.

Online counseling practice systems are another opportunity that can benefit students’ practice of counseling skills in the online realm. Instructors can incorporate this technology tool into the curriculum for students to practice specific counseling skills, such as paraphrasing, reflection of feeling, and question asking. These platforms usually provide a variety of short video clips of diverse mock clients with different presenting issues. Instructors can set up different modules and assign students to practice different skills every week. Students can watch video clips and record their therapeutic responses to mock clients as many times as they deem necessary. After students submit their responses, instructors evaluate their responses online and provide feedback by recording their skills demonstration. Additionally, instructors play mock client video clips during the synchronized class meeting and demonstrate effective therapeutic techniques. These online practice systems also serve as an additional opportunity for students to practice counseling skills in a technology-assisted counseling setting and help them understand the potential of online counseling settings.

Assessment of Clinical Skills

Although synchronous videoconferencing platforms allow counselor educators an opportunity to observe students’ verbal and facial/nonverbal communication, assessment of the full range of counseling microskills involved with facilitating a therapeutic environment is limited. Qualities such as eye contact, body positioning, proximity, and other subtle nonverbals are important markers of students’ therapeutic stance (Lambie et al., 2018); however, there are significant challenges to observing these behaviors over synchronous video. Because of the variations in the placement of student webcams and computer monitors, eye contact and body nonverbals cannot be measured consistently, so educators attempt to capture this behavior using real-time role-plays in class, as well as pre-recorded role-plays of the student performing mock counseling with an outside acquaintance (e.g., friend, family member, or other student). Using multiple points of observation, educators can gain deeper insight into the student’s nonverbal abilities and have multiple opportunities to provide feedback.

As both verbal and nonverbal communication are central to the assessment of students’ conveyance of empathy and non-judgment, limited access of students’ therapeutic presence in a synchronous format also poses challenges to the observation of cultural competency. In a residential classroom, group dialogue provides a critical opportunity for educators to assess student comfort in discussing cultural topics, such as discrimination, power, and privilege (Sue et al., 2009). During these conversations in a synchronous online format, it is difficult to observe the microbehavior associated with discomfort and reactivity, especially in classes with larger enrollment, and students that are struggling with the conversation can elect to remain muted or turn off their camera. As such, educators may find it beneficial to divide the class into smaller breakout groups to facilitate increased student engagement and bolster students’ sense of safety in smaller group settings. In this format, educators are better able to observe when and why students become disengaged or triggered by the dialogue and then intervene accordingly.

Examples of Online Clinical Skills Training in Counseling Courses

The delivery model of distance counselor education at our institution consists of synchronous class meetings via videoconference software and asynchronous learning via a learning management system. Students are required to participate in the synchronized virtual classroom meeting weekly for 1.5 hours. Instructors asynchronously assign weekly readings, facilitate additional discussion board activities, and post video lectures or other video resources.

Students enrolled in the online program are required to attend a one-week intensive basic counseling skills course residentially prior to taking other skills-focused courses online, such as group and child and adolescent counseling. We provide examples of facilitating advanced counseling techniques training in a synchronized format. Specifically, we illustrate how to structure and assess students’ clinical competencies and utilize creative and ethical solutions in group, child and adolescent, and practicum and internship courses in a virtual learning community.

Group Counseling Skills Training

Group counseling is identified by CACREP (2015) as one of the eight core content areas required for all graduates of accredited counseling and related educational programs. It is unique in that, in addition to knowledge and skill learning outcomes, there also is a requirement that educators provide “direct experiences in which students participate as group members in a small group activity, approved by the program, for a minimum of 10 clock hours over the course of one academic term” (CACREP, 2015, p. 12). This experiential component distinguishes the group counseling course as a premier opportunity for clinical skills training; however, to date, there is little research attesting to educational best practices in synchronous online learning environments about group counseling. Thus, in the development of this course, the instructors supplemented the limited existing research with consultation of group work specialists, group counseling instructors, and counselor educators specializing in synchronous online education. Through these dialogues, the following 11-week course structure was established, which is generally revised with each course offering by incorporating student feedback, continued consultation, and updated research.

Course Structure

     The required 10-week experiential component of group counseling in an 11-week online course can be achieved in a variety of ways. Common strategies include: (a) inviting external licensed group counselors (paid or volunteer) to facilitate a group counseling experience for students (without instructor observation), (b) implementing an instructor-led group counseling experience for students, (c) allowing students to serve as both group facilitators and group members in an alternating facilitation schedule (instructor-observed), and (d) requiring all students to locate and participate in an external group of their choosing (Merta et al., 1993; Shumaker et al., 2011). In consideration of the common challenges associated with an externally led and instructor-led group, including ethical concerns regarding potentially harmful dual relationships and problematic professional boundaries between students, as well as limitations imposed by the online training format, instructors chose to implement an alternating student-led structure for the experiential groups. A more thorough review of the benefits and limitations of each approach may be found in Shumaker et al. (2011).

At the beginning of the course, students are assigned to a small group ranging in membership from five to seven students each. Given the online setting, smaller groups may be more manageable for student facilitators and can give student members increased opportunities for engagement. Each group is responsible for determining a facilitation schedule for the 10 experiential groups in which students will choose the week(s) that they wish to lead the group. Students are directed to collaborate with group members to determine a specific focus of the group, falling within the realm of counseling professional development. The group meets in online breakout rooms for 60 minutes in each of the 10 weekly videoconferences. Periodically, instructors will incorporate a group reflecting team that will observe the group session live with their video and microphones off; record displayed group counseling skills, process, and content observations; and provide feedback for the group and group co-leaders based on the current lecture topics.

Ethical Considerations

Because of the potential for dual relationships, the in-class experiential group is not intended to be a therapy group. The group is described as a process group in which members will discuss issues related to professional development, and students are urged to exercise caution and intentionality regarding the nature of their personal disclosure. Students are reminded that the group experience is an assignment for the course in which participation in the group will be evaluated. Cautions regarding the limits of confidentiality and privacy are highlighted and an online practice screening session and example of a group informed consent is utilized.

Clinical Training and Assessment

The clinical skill outcomes determined for this course were developed in line with the 2016 CACREP Standards and the Association for Specialists in Group Work’s Professional Standards for the Training of Group Workers (2000). Group counseling clinical skills are assessed through the instructors’ online observation of: (a) each student leading a group, (b) course role-plays based on working with group roles that clients often take on, and (c) the ability to identify clinical skills when observing the group as a reflecting team member. Finally, the synchronous nature of the online group counseling course allows for dispositional assessment of students, as inappropriate behaviors are discussed throughout the class and are integrated into the group rules by the course instructor. In addition, the group instructor can intervene through synchronous technology when necessary, as they are able to do so in the F2F group counseling classroom.

Challenges, Strengths, and Solutions

     Challenges related to teaching group counseling online include facilitating a humanistic relationship between group members and instructors as well as among small group members in the online environment. Holmes and Kozlowski (2015) compared online counseling group courses with a small group component with a similar in-person group counseling course. The results showed that students assessed the in-person group counseling experience more positively than the online groups. This study signifies that there is more work to be done to improve the delivery of group counseling clinical training in online settings. A challenge that may contribute to this phenomenon is that students are often not trained on the nuances of noticing nonverbals in a videoconference setting. A second challenge is the variability in where students are located while doing group. Although students may be in a confidential setting, it might not be the most helpful setting to participate in a practice group session. For example, instructors have observed students in their cars, lying on their beds, sitting in a beauty salon, and having the television on while participating in group. Clear boundaries and expectations regarding the students’ background are vital, as contexts can be distracting for group members, group leaders, and for the individual. Technological difficulties also can impede the development of group rapport and trust as students’ screens can freeze during a discussion. Similarly, group leaders can have legitimate issues that make it difficult for them to be understood and communicate, and some students may be continuously logging on and off because of internet connection problems. Facilitating a discussion regarding thoughts and emotions around group technology issues is an effective way to normalize frustration and collaboratively brainstorm strategies to facilitate connection despite these realities.

There are, however, notable advantages to teaching group counseling online. These include the ability for the group supervisor to give immediate feedback to group leaders through online chat and video options. With consent, group sessions can be easily recorded for transcription assignments, supervision, real-time classroom discussion, and utilizing a reflecting team. Other supports and areas of importance include group rules about how students will utilize microphones. For instance, will they stay muted throughout the group until they want to share, or will everyone keep their microphones on so they feel freer to talk without having the extra step of turning on their microphone? Another consideration is whether to allow group members access to private chat abilities while in group. Instructors have experienced times when this has been distracting, as student group members may bring up unrelated topics while another person is sharing verbally. However, the chat function also can allow for increased support for individuals sharing, as group members can type in multiple responses. This can be a challenge for group co-leaders as they navigate both the group chat and group work occurring verbally.

Child and Adolescent Counseling Skills Training

Child and adolescent counseling is another clinical skill-focused course in which students are expected to understand and practice a variety of developmentally appropriate approaches to working with diverse youth. According to the 2016 CACREP Standards (2015), this course may assess students’ learning outcomes not only in areas of core content, but also in specialty areas, such as school counseling, clinical mental health counseling, and family counseling. Given the first author’s specialization in play therapy, she aims to provide opportunities for students to practice basic play therapy techniques and other age-appropriate modalities such as expressive arts activities. Therefore, this course is highly experiential.

When teaching play therapy skills in a virtual classroom, some unique challenges include students’ access to toys and art materials, space for play therapy demonstration and role-plays, and limited observations of nonverbal communication. Consequently, the following section focuses on how instructors adapt the virtual classroom environment to strive for maintaining quality clinical training and assessment in child and adolescent counseling competencies.

Course Structure

     To develop child and adolescent counseling competencies, students are expected to practice various play therapy techniques and take turns as counselors and mock clients during weekly synchronized meetings. Over the 11-week class, the instructor usually begins the class with a group discussion about assigned readings and clinical session videos. The instructor also highlights some important materials and demonstrates specific play therapy skills during this time. After the instructor’s modeling, students usually practice skills in small breakout rooms for 40 minutes. The instructor observes students’ role-plays and provides live feedback in the breakout rooms. At the end of the class, the instructor brings students back to the large group to provide overall feedback and allow students to process their role-play experience.

Clinical Training and Assessment

     The instructor utilizes multiple assessments to observe students’ development of child and adolescent counseling skills. Course assignments designed to measure clinical skills outcomes include: (a) in-class participation evaluations based on the student’s level of engagement in the role-plays and case discussions and (b) a recorded play or activity session with a child or adolescent with a session critique. One of the major clinical skills assignments is for students to facilitate a 30-minute play session with a child or an activity session with an adolescent depending on the student’s preferred working population. Students are recommended to find friends’ and relatives’ children for this role-play assignment. Students can also use their own children if they feel comfortable with this option. Students are expected to record the session and provide critiques and personal reflection for their session. This assignment allows students to practice their play therapy skills and language with an actual child or adolescent outside of the classroom and, most importantly, to experience the relationship-building process with a child or adolescent.

Students’ child and adolescent counseling clinical skills are assessed through the instructor’s observation of students’ ability to communicate with children or adolescents through developmentally and culturally appropriate interventions and therapeutic responses. The instructor also assesses students’ knowledge and competencies in areas of ethics, diagnosis, treatment planning, caregiver and teacher consultations, and advocacy. The weekly synchronized meeting also allows the instructor to conduct disposition assessments of students, including how students receive constructive feedback from the instructor and peers.

Challenges, Strengths, and Solutions

     Normally, online instructors are likely to sit in front of a web camera to facilitate the class activities or skills demonstration. However, when working with child clients in a playroom setting, counselors must move around to follow child clients’ play and attend to their play behavior and nonverbal communication. When facilitating creative arts activities with preadolescents or adolescents, counselors sometimes need more space for the activity and need to focus on the client’s process of creation, which involves critical observations of nonverbal communication.

In consideration of these challenges of toys and space, instructors can consider some creative strategies. For instance, when demonstrating skills, the instructor can set up a corner of the room with purposefully selected toys and ensure the camera captures a wide angle of the room so that students are able to observe the instructor’s verbal and nonverbal therapeutic skills. To have students personally experience the power of play and creative arts activities, instructors can facilitate activities involving basic art materials, such as colored pencils and markers, that students have easy access to in their settings. Instructors also encourage students to use any objects that are accessible to students and to be spontaneous when role-playing therapy skills so that students can experience children’s creativity. Students are encouraged to adjust their camera so that their peers can better observe their play behavior and body language during the role-plays.

Although instructors demonstrate various therapeutic responses, it is important to acknowledge the limits of demonstration and role-play experience because of the online environment. It is also imperative to consider ethical issues when assessing students’ clinical skills. For example, when students conduct a play or activity session assignment, instructors need to provide clear guidelines for the purpose of the assignment in that students are not providing therapy for children; instead, students are practicing therapeutic play skills and language. Instructors also want to provide informed consent information for the child’s guardians, including video and audio recording for this assignment and that only the instructor will review the session for the training purpose. Last, instructors want to ensure the privacy of all video materials; therefore, it is recommended that students record videos using HIPAA-compliant software programs and submit them using course platforms.

Online Clinical Skills Training in Practicum and Internship

A major portion of clinical training in a counseling program is group supervision of practicum and internship courses. Although students are most often working F2F with their clients and on-site supervisors, the group supervision experience for distance students takes place in a synchronous format, meeting HIPAA and confidentiality requirements legally and ethically. Jencius and Baltrinic (2016) highlighted the ethical imperative of online supervision competence when faculty are assigned to teach the practicum and internship courses. According to CACREP (2015), practicum and internship group supervision students must meet on average for 1.5 hours per week of group supervision at a 1:12 faculty to student ratio, and qualified supervisors with relevant experience, professional credentials, and counselor supervision training must be a part of the counseling faculty or a student under the supervision of a counseling faculty. While in these courses, counseling students accumulate at least 700 clinical hours, of which 280 must be direct client contact. Through these courses, CACREP standards are met, student learning outcomes assessed, and strengths and challenges are experienced. Following best practices in online learning and CACREP standards, the following online practicum and internship course was designed.

Course Structure

     The courses are designed to evaluate basic clinical skills, facilitate theory-based clinical insights, and advance students’ clinical skills through role-plays, case presentations, course discussions, readings, reflective assignments, and experiential activities. Online courses take place once a week for 1.5 hours during an 11-week quarter. In class, students review and present actual video or audio recordings (if allowed by the practicum and internship site) of clinical work, participate in giving feedback to other students in the course, participate in reflecting teams, and follow ethical and legal considerations for client confidentiality. Weekly, students present a client case presentation based on sessions from their practicum or internship site following a specific outline. If a site allows video presentations of clients, a 5–10-minute clip of a session is presented (with the client’s consent). Students receive feedback from their peers as well as the group supervisor. In the online practicum or internship course, consent is necessary from the site regarding how video and supervision are handled in the online format. It is imperative that a HIPAA-compliant mode of course delivery is utilized for the weekly class meeting and that students presenting videos and cases are instructed on specific expectations of recording, storing, and transferring their video clips and client information that protects their clients’ confidentiality. For example, it would not be appropriate for a student to record, store, and then upload a client session on their cellular phone without proper security compliance in place. At our institution, the ability to utilize the course delivery modality to record sessions is helpful as it provides a HIPAA-compliant way to record and store session clips.

Clinical Training and Assessment

     It is important to note that for practicum and internship courses, the structure, expectations, and assessment of students do not differ substantially from the traditional class. Students in practicum and internship meet the CACREP standards the program has identified for these courses through the Counseling Competencies Scale-Revised (Lambie et al., 2018), whereby instructors and students evaluate and discuss their ratings together through reflective assignments, role-plays, class discussion, and the client case presentation. Group supervisors also are able to monitor students on their dispositions as they participate in giving feedback to their peers, discuss ethical dilemmas and other issues that come up for students during the practicum experience, assess their case presentation and response to peer and supervisor feedback, and review reflective assignments such as journaling or self-care plans.

Challenges, Supports, and Solutions

     Challenges for teaching practicum and internship courses online include discussing informed consent with clients, practicum and internship sites’ buy-in and understanding of how the course works in an online format, the technology limitations of the instructors and students, and technology difficulties that might be encountered during discussions and class presentations. Also, as supervising instructors are rarely in the same location as students in a distance course, there are challenges in knowing and understanding the context of a variety of cultures, regions, and contexts. Legal issues, licensure requirements, and site requirements differ from state to state and can be challenging to navigate. The practicum and internship supervisor also can be in a different time zone from the site supervision, which can make coordinating meetings difficult. Finally, as group supervision is a type of group, there are many similarities with the challenges of teaching group clinical skills (e.g., making sure students are in a confidential location where no one else can see or hear video clips or class discussions regarding clients). Instructors must be clear about the seriousness of violating confidentiality and the expectations they have for the course. Additionally, it can be difficult to give and receive constructive feedback in a setting where nonverbals are more challenging to see and experience. Instructors must work to build rapport and trust and openly discuss with the class the strengths and weaknesses of technology regarding their supervision experience.

Strengths of online practicum and internship delivery include opportunities to develop cultural competency as students from different areas, regions, states, and even countries discuss client cases from their context. Instructors can utilize the chat options of the online format to ask questions while video clips are being shared or point out particulars without stopping the video. Potentially, client information does not have to be transferred as many places when students do not have to come to campus, versus students having client information go from their site, to their home, to their university setting, and back. Also, students are able to have more flexibility in choosing a site that is not region-bound. The availability of this format can be helpful to many sites and ultimately to clients who might not be located near a university with a counselor education program and who would benefit from having practicum and internship students working with them. It also provides opportunities for students that might not otherwise be able to complete a practicum or internship to enroll in a program and successfully complete it without needing to move and leave family or work obligations. With proper training of instructors, clear expectations for students, and legally and ethically appropriate technology, the practicum and internship course in an online format can be an effective modality for counseling students.

Discussion and Recommendations for Future Research

This article has overviewed the current literature regarding master’s-level online clinical training, provided a reference for challenges and opportunities regarding online pedagogy in counselor education courses, and described examples of online clinical course structures. When facilitating online clinical training, instructors must understand the unique nature of counseling and be intentional about maintaining student relationships within the realm of technology. This is especially critical for ensuring that the program strategically integrates the technology to advance the delivery of the program rather than the program heavily relying on the use of technology. In this article, we have identified humanistic approaches and specific strategies to ensure that meaningful teacher–student relationships and rigorous assessments remain the focus of instruction when technology is integrated. Facilitating personal and professional growth in distance counselor education presents many challenges to students and instructors. If instructors can intentionally and creatively use technology to promote distance students’ learning and training, a distance delivery format can reach students who would not have the opportunity to pursue counselor education.

Currently, the online delivery of counselor training skills is outpacing foundational research literature. For attitudes and pedagogy to change around the online academic environment, more research is needed. Future research could best focus on comparing the outcome of students’ counseling skills, including multicultural counseling competencies, between traditional and online courses. Skills needed for building rapport in the online environment may differ from F2F settings. Therefore, research regarding how the instructors’ and students’ use of language online impact the helping relationship and teacher–student relationship in virtual classrooms can be valuable. There also is a need to explore counselor educators’ understanding and experiences in conducting online clinical training, as well as students’ perspectives in receiving online clinical training and supervision. Future studies also might investigate different course structures and delivery methods for specific clinical skills courses so that the best methods for online clinical training could be applied by more counselor education programs.

Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.

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Szu-Yu Chen, PhD, NCC, LPC, RPT, is an assistant professor at Palo Alto University. Cristen Wathen, PhD, NCC, LCPC, is a core faculty member at Palo Alto University. Megan Speciale, PhD, NCC, LMHC, is an assistant professor at Palo Alto University. Correspondence can be addressed to Szu-Yu Chen, 1791 Arastradero Rd., Palo Alto, CA 94304, dchen@paloaltou.edu.