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Academic Psychiatry, 28:2, Summer 2004 151

Small-Group Videotape Training for PsychotherapySkills Development

Allan Abbass, M.D., F.R.C.P.C.

Objective: Psychotherapy instructors have used video technology to train residents forover 40 years. Though it has met with some controversy, many will argue that videotapereview is essential for self-directed learning and accurate psychotherapy supervision.Methods: The author describes a technique of small-group videotape training as providedin a psychiatry residency training program. Results: He reviews the merits and limita-tions of this format and suggests simple and inexpensive technical approaches to augmentthis training. Conclusion: The author concludes that small-group videotape training is anefficient psychotherapy training format that encourages self-monitoring and the exchange ofsupportive peer feedback. (Academic Psychiatry 2004; 28:151–155)

Dr. Abbass is Director of Education at the Dalhousie Uni-versity Department of Psychiatry, Halifax, Novia Scotia, Canada.Address correspondence to Dr. Abbass, Dalhousie UniversityDepartment of Psychiatry, 5909 Veteran’s Memorial Lane, Hali-fax, NS, Canada, B3H 2E2; allan.abbass@dal.ca (E-mail).

Copyright � 2004 Academic Psychiatry.

Videotape supervision has been an adjunct to psy-chotherapy training since the early 1960s (1).

Subsequently, videotape supervision has become cen-tral to some psychotherapy training and research pro-grams (2). Despite this acceptance, the use of video-tape supervision has historically been limited in anumber of residency training programs (3). Althoughthe problems (4–6), merits, and unique features (7–10) of this form of teaching have been described inthe literature, little has been written about providingvideotape training in a small-group format. Experi-ence with this method suggests small-group video-tape training is a specific and efficient trainingmethod. Moreover, this training sets a stage for life-long self- and peer-directed learning. In this review,the author describes the merits and potential prob-lems of small-group videotape training as well as atechnical approach to this method as it is used in apsychiatry residency training program.

Program Structure

The training process begins with recording the psy-chotherapy session. Trainees record their psychother-apy sessions on a weekly basis in rooms that are re-served for video-recording and tape review. These

suites are arranged so that the recording captures thepatient and the therapist face-on in a mirror that isplaced beside the patient. This allows a frontal viewof both the patient and the therapist. Other recordingapproaches include the use of a split screen or picture-in-picture device, with two cameras or the use of awide-angle lens to capture both participants side-on.Recording through a one-way mirror is an approachthat removes the camera equipment from the inter-view room. Optimal sound volume and clarity gen-erally require an amplified microphone.

Training groups typically consist of a supervisorand two to six trainees who meet for a 1 1/2 hour to3-hour supervisory block. Meetings are held weeklyin a room equipped with a videocassette recorder(VCR), a moderately large (� 20-inch) television, anda board to write on. The supervisor verifies howmany cases will be reviewed during the session inorder to apportion the time accordingly.

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Process of Small-Group VideotapeTraining Sessions

Supervisee Preparation

The trainees are expected to adequately preparefor the group training session. They should previewthe session videotape, note important segments of thetape, and attempt to self-supervise. Trainees are en-couraged to specifically note the state of therapeuticalliance, selection of focus, adherence to focus, natureof interventions, timing of interventions, and theemotional signals in the patient. Trainees should thenarrive prepared to present their material and, in someways, to function as a co-supervisor of the tape.

Tape Review

Supervision starts with the viewing of the veryfirst moment of contact. As trainees and supervisorshave often noted, the first few minutes frequently dic-tate how the whole session is likely to progress. Thepatient has presented “where they are” at that time,and the therapist’s job is to respond to this in accor-dance with the therapy model being used. One maycontinue playing the tape or fast-forward to a latersegment of the session. In general, 25 to 30 minutesinto the session will mark a peak of focus and emo-tional mobilization, thus a good place to observe andcomment on the process. The trainee may suggest aspecific segment to review. Two longer segments areusually adequate to form a reasonable impression ofthe session. Optimally, each trainee has at least 30minutes to show a videotape and discuss his or hercase.

Role of Supervisee While Showing Tape

At the end of each segment, the supervisor mayelicit comments from the trainee regarding thetrainee’s view of relevant theoretical and technical is-sues. This is an opportunity for the trainees to super-vise themselves in a supportive setting.

Overall, the supervisor’s task is to monitor thetherapy process and patient/therapist capacities towork within a given model. Feedback should firstaddress the therapist’s functioning within a partic-ular treatment model. Thereafter, feedback may in-

clude a brief review of a theoretical point such as acore principle of the specific psychotherapy modelbeing used.

Role of Other Trainees

Co-trainees are expected to observe both the pre-sented videotape and the supervisory process. Theymay offer comments or questions in a supportivemanner and at times in a constructively challengingway. Co-trainees are often seen encouraging their col-leagues to stay focused on the therapeutic task. Theywill often share one of their own parallel learningexperiences with the supervisee on the “hot seat.”

Adjunctive Procedures

Concurrent Seminars

This weekly training session may be comple-mented by a seminar on the psychotherapy model be-ing used. This is an opportunity for trainees to see thesupervisor’s videotapes and to learn relevant theo-retical aspects in an interactive fashion. The supervisorshould provide a broad range of videotapes that illus-trate various technical aspects of the therapy beingstudied. Additionally, the supervisor should be com-fortable showing and describing incidents in whichtherapist-related problems interrupted the treatmentrelationship (7). This seminar may be the most appro-priate setting for examining technical and theoreticalproblems experienced by the training group.

Large-Group Observation of Small-GroupVideotape Training

Trainees who are not yet treating patients mayobserve the supervision group, and thus may alsobenefit from this open supervisory model. Traineeswho are not yet comfortable recording their sessionscan use this process as an intermediate step to becom-ing an active participant.

Special Issues and Drawbacks Using Small-GroupVideotape Training

Video equipment and technical support are expensesthe training program must assume. In the 1960s when

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basic equipment could cost in excess of $20,000, videoequipment and playback equipment were significantrestrictives. With recent price reductions, the sametechnology, including a reasonable quality video cas-sette recorder (VCR), 20-inch monitor, and camcor-der, could be purchased for as little as $1,000 (Cana-dian dollars) today.

There is potential for patients to refuse treatmentthat involves video-recording. This would morelikely be the case for highly anxious patients (pa-tients with paranoid ideation or patients who arepublic figures). In practice, the rate of refusal is verylow, especially when one explains that the purposeis to directly and indirectly improve treatments pro-vided.

While anxiety is normal in the process of record-ing and showing one’s work, some trainees may ex-perience extreme anxiety. Introductory teaching,which includes showing the supervisor’s video-tapes, may desensitize and prepare trainees for re-cording and showing their own tapes. Experienceshows that persistence with recording and self-re-view generally results in improved tolerance of theprocess over the course of 6 to 12 months. For themore anxious trainee, the ability to self-review cou-pled with the support of a small group may makesmall-group videotape training a learning model ofchoice.

Extremely anxious patients may be unable to tol-erate being video-recorded. These patients usuallyhave such low anxiety tolerance that treatment tech-niques may need to be modified significantly in or-der to accommodate them. Recording a session maybe considered a relative contraindication in patientswith active psychosis, regardless of the treatmentprovided.

Video-recording, as with any other form ofmedical intervention, should be done in considera-tion of patient-physician confidentiality. Therapistsshould become knowledgeable of local or regionalpolicy regarding patients’ rights. A precise consentform written in layman’s terms should be devel-oped. This form should incorporate how confiden-tiality will be protected, where and how long tapeswill be stored, who will see the tapes, whether or notthe patient has access to the tapes, and who ownsthe tapes. In the form it should be clear that treat-ment will not be withheld if a patient is unwillingto be recorded at any time.

Benefits of Small-Group Videotape Training

Benefits of Video Recording

The benefits of small-group videotape trainingsubstantially outweigh the costs. These benefits in-clude the positive effects of video recording and theadvantages of a small group as a learning vehicle.

Video-recording eliminates the need to take notesduring the session, and it permits a full focus on thepatient. This focus may facilitate the initial rapportand ongoing working alliance. Complete notes maybe written during postsession tape review.

Therapist self-observation and self-awareness areenabled by having one’s own videotape to review.Seeing oneself on tape allows a more “objective” pe-riod of self-observation, free of any in-session pres-sure and distraction. This allows trainees to “self-supervise” while anticipating feedback from thesupervisor and the group. Thus, tape review allowsself-monitoring and self-supervision skills acquisi-tion that may facilitate ongoing professional growthand development.

Direct observation of the patient’s appearanceand behavior is possible with videotape of the ses-sion. As a specific example, the tape may indicate thedegree and manifestations of emotional states in thepatient. The trainee and supervisor may then focuson these specific patient cues to inform the therapist’sresponse.

Specific, observable therapist behaviors may like-wise be directly viewed. This allows a supervisoryfocus on therapist activities that, for example, includeselection of focus, maintenance of focus, efforts to en-gage the patient, efforts to maintain the therapeuticalliance, and adherence to a specific therapeutic tech-nique. Many psychotherapy schools have specifictreatment manuals with adherence guidelines. In-session videotape may reveal the degree to which thetherapist uses these specific interventions.

Videotapes are excellent means to assess treat-ment outcome. Specific changes may be observedwhen comparing pretherapy to posttherapy video-tape segments. Often, these changes are not reflectedin one’s notes or patient self-reports. This review isthe process by which therapeutic techniques may bedeveloped, researched, and fine-tuned by both ther-apists and researchers (2).

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Videotapes may also be used to evaluate trainees’acquisition of skills. With the use of standardized ad-herence criteria, tapes could be reviewed blindly todemonstrate change in therapist behaviors over thecourse of training. Hence, videotaping is a vehicle forresearch in psychotherapy education.

Benefits Related to Using a Group Format

Having several trainees in the same session ef-fectively multiplies the amount of teaching that maybe provided to each participant. This becomes criticalin our current climate of decreased resources to pro-vide supervision (11). For example, instead of super-visors meeting four residents for 1 hour each, theymay meet four residents for 2 hours total, therebydecreasing the amount of time taken by one-half anddoubling the amount of teaching for the residents.

In the group format, trainees are able to see andfollow the cases of other participants. This allows ex-posure to a broader range of patients than they oth-erwise could see. This is especially important in res-idency training programs where there is limited timeallotted for psychotherapy cases and supervision.

Although the focus of the training group is notgroup therapy, many of the benefits of a group pro-cess may provide an excellent learning and growthopportunity (12). Included among these “therapeuticelements” are cohesion, support, universality, realitytesting, modeling, and group learning.

Training programs are often criticized for notproviding education in how to teach and supervise.The group format allows a unique opportunity fortrainees to directly observe a supervisory process. Inconjunction with their own supervisory component,they may learn firsthand some of the basic elementsof psychotherapy supervision.

The group format also allows group members toprovide feedback to one another. As noted, this tendsto occur later in the supervision process. Experienceshows that this feedback is increasingly insightful astime goes on. Eventually, it also becomes suppor-tively challenging. Nonsupportive intervention by atrainee has rarely been observed in this format.

Small-group videotape training helps trainees be-come accustomed to openly discussing their work, asthey become comfortable giving and receiving feed-back in a respectful and supportive way. Hence, they

become at ease with peer-based learning as a vehiclefor lifelong personal and professional growth.

Program Evaluation

Trainee evaluations, results of pre- posttests, andother indirect measures suggest that the group formatis both valued and effective.

Trainees provide written feedback to the super-visor every 3 months. This training has been ratedhighly, averaging 4.9 out of a possible rating of 5 overthe past 5 years. Written comments frequently de-scribe the training as challenging but highly benefi-cial to learning. Three-quarters of the residents in theprogram seek this elective training experience in theirsenior years.

In the short-term dynamic psychotherapy train-ing group, trainees complete a 20-question multiplechoice questionnaire prior to and after 6-month train-ing blocks to assess knowledge acquisition. Thus far,(N�26) there is over 2 standard deviation (7.5 pointsout of 20) improvement before and after 6 months oftraining. The past 16 courses have been highly eval-uated by trainees, with an average global rating of 4.6out of 5.

Patient self-reported outcomes offer indirectmeasures of the program’s effectiveness. In the short-term dynamic psychotherapy training group, before-and after-therapy measures are currently used rou-tinely. With an N of 56 completed therapy courses,the mean global symptom score (13) improved fromthe abnormal to normal range, with a two-tailed t test,p�.001. The global interpersonal problem rating (14)improved nearly to the normal range with a nonsig-nificant p value of 0.10.

Another indirect measure of the success of thistraining method is the honorable recognition it hasreceived. Three of the past four Residents Association“Teachers of the Year” were teachers using this for-mat, and the 2001 Canadian Psychiatric AssociationChairs of Psychiatry Award for excellence in educa-tion was established as a result of the program.

CONCLUSION

The author has described an approach to psycho-therapy supervision in which a group of trainees rec-ord and show their actual interview materials on aweekly basis. Although the model poses some poten-

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tial drawbacks, they are far outweighed by the bene-fits. Recording allows the supervisor and groupmembers to provide input based on a direct view ofthe process and content of the session. Thus, the su-pervisee is more easily able to learn self-monitoringskills, and the supervisor’s time is used more effi-ciently, providing each resident with more trainingtime. The trainees are able to follow more cases thanthey could otherwise. Group members may learn anapproach to supervision through direct observation.The supervisor provides a model of self-reflectionand openness to peer input. Trainees are able to havea supervised experience of giving and receiving peerinput and support. Finally, trainees are facilitated toefficiently learn general and specific psychotherapyskills.

A multimodal evaluative component allowsmonitoring and remediation of small-group video-

tape training. Patient self-report outcomes allowquality assurance evaluation as well as indirect mea-surement of learning. The fact that small-group vid-eotape programs are sought after and highly ratedsuggests that they are not only palatable, but a train-ing approach of choice.

In conclusion, costs and anxieties should not dis-suade program directors from ensuring that thesmall-group videotape training approach is availablein postgraduate psychiatry training programs orother formal psychotherapy education. The authorstrongly encourages the provision of this supportiveand challenging opportunity for trainees.

The author thanks Jeff Hancock and Jennifer Haynesfor reviewing this manuscript, the Department of Psychi-atry, Dalhousie University, the Nova Scotia Departmentof Health, and Dr. K Roy MacKenzie for his mentorshipwith this and many other projects.

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