From Surviving to Thriving: Creating a Viable Virtual Model of Music Therapy Internship in Private Practice During a Global Pandemic

Though many music therapists pivoted to offer online clinical services during the COVID-19 pandemic, the methodology of music therapy internship sites that adapted to a virtual model of internship during this time is largely unknown. The private practice for whom the authors work, located in a large metropolitan area of the United States, has trained XI interns using a virtual model of music therapy supervision created during the pandemic. The practice’s five internship supervisors used Zoom, Google Drive, and Calendly as the basis for their virtual supervision program. Programming concepts for interns included online group supervision to discuss professional topics, intern social hours, intern study hall hours, and supplemental online resources for intern growth and reflection. Supervisor and intern feedback highlighted major challenges including clear communication, clinical skill development, and maintaining work-life balance during a virtual internship. The authors stress the need for vulnerable leadership and open communication in this model of internship. Advantages of a virtual model include decreased financial burden for interns, increased flexibility of programming, and increased accommodations available for interns. A partial or total online model of


Introduction
In the wake of the COVID-19 pandemic, many music therapists shifted their operations to include telehealth sessions, virtual music lessons, and pre-recorded video sessions (Gaddy et al., 2020). Though many individual music therapists have been able to adapt and continue serving clients during the pandemic, it appears that a significant number of university-affiliated and national roster internship sites are unable to provide enough internship placements to accommodate the number of students attempting to intern in the field. In the American Music Therapy Association's (AMTA) 2021 survey of music therapy faculty and clinical supervisors, 68% percent of respondents indicated that their students were having problems finding internship placements due to the COVID-19 pandemic (American Music Therapy Association [AMTA], 2021).
The need for distance supervision in music therapy has increased as a result of the expansion of educational programs and the field in general. Yet, there are a limited number of supervisors skilled in distance supervision due to the unique challenges of this supervision mode, including, but not limited to: technology; client and student confidentiality; safe relationship development between supervisor and supervisees; skillfully and intentionally maintaining an online presence; and maintaining a space for cultural humility in an online workspace (Forinash, 2019). Literature aimed to help clinicians develop virtual programming has been available since the 2000s and has increased in recent years, with resources providing models for various tiers of virtual music therapy services during COVID-19 (Baker & Krout, 2009;Knott & Block, 2020).
However, limited literature currently exists concerning a virtual model for the supervision of music therapy interns and practicum students. In this article, our supervision team will share key takeaways from developing a virtual model of intern supervision including 32 technology usage and considerations; programing concepts; remote competency development; supplemental materials for remote work; self-care and reflective practice tools; and implications for further developing an accessible model of virtual supervision that meets the needs of students seeking virtual and hybrid internship and practicum placements.

Background
The authors work for a home and community-based private practice in a large, metropolitan area of the United States that currently employs XI music therapists, five of whom are internship or practicum supervisors. Our practice established a universityaffiliated internship in 2012, became a national roster site in 2021, and to date has trained XI interns and XI practicum students since the start of the COVID-19 pandemic in March 2020. We provide an intern-centered approach within a competency-based internship and strive to support our interns not only in becoming competent music therapists, but in developing their own individual styles and techniques to achieve success on a personal and professional level.
Prior to the COVID-19 pandemic, our therapists had no experience with telehealth sessions and operated our clinical services and student supervision inperson. Clinical services were paused entirely in March 2020 when the pandemic first impacted the practice's metropolitan area. Due to the high risk for contagion in home and community-based settings, and the complex medical needs of our clients, our practice quickly adapted to a virtual model of services and supervision. In spring 2021, we moved to a hybrid model of supervision.

Self-Care and Reflective Practice
Self-care provides stress relief outside of an intern's caseload, it does not necessarily translate into awareness or control of internal and external stress reactions within a therapeutic setting. Sustainable careers in helping professions require high levels of self-awareness in relation to values and biases, which interns and new professionals must learn to navigate (Young, 2021). Maintaining longevity in helping professions personally and professionally requires a recognition of personal limits (Corey, 2011). Given the high levels of stress music therapy students reported prior to the pandemic, and the significant increase in stress from both the global pandemic and the challenges of completing a virtual internship, our supervision team felt it was imperative to assist our interns in developing reflective practice skills beyond selfcare (Moore & Wilhelm, 2019). Reflective practice involves critically assessing selfawareness of automatic reactions, decision making, and prejudices in a therapeutic setting by taking time to intentionally reflect through various methods such as journaling, peer mentorship, or expression through another creative medium (Young, 2021).
To help our interns develop reflective practice skills, they are assigned readings and recordings from various resources on burnout, compassion fatigue, self-care, and reflective practice for helping professionals. These resources are discussed, and interns are given the opportunity to reflect on what they did and did not relate to with their peers, during a weekly group supervision meeting. In follow up, they are given an application assignment to begin to develop a reflective practice routine that they can count within their internship hours, up to two hours per week. This includes meeting with a co-intern for 15 minutes per day to reflect, journaling, walking outside after work, or any activity that involves self-assessment of internal reactions and external decisions throughout the therapy day.
Interns also learned about polyvagal theory and its clinical applications by watching a counseling resource video which was later discussed in group supervision (Fay, 2018). Polyvagal theory describes the concept of neuroception, or pre-perceptive states that signal states of social safety (ventral vagal), anxiety (sympathetic), and shut down (dorsal vagal). When applied to clinical practice, therapeutic practitioners use polyvagal theory to identify which pre-perceptive states clients are in and how to safely move through these states (Porges & Dana, 2018). After group discussion, the interns created their own polyvagal maps as a reflective practice tool (Missimer, 2020).
Polyvagal theory is particularly relevant to developing reflective practice skills because it helps interns understand how their underlying stress could potentially impact their therapeutic relationship with clients based on their own polyvagal state. Our interns reported that this practice shifted their perception of reflective practice strategies from ideal to essential.
To reinforce reflective practice concepts, our team held a check-in during every group supervision meeting where each supervisor and intern shared a brief reflection on related topics such as self-care and compassion fatigue. All our interns who received virtual supervision reported in their site evaluations that the continual emphasis on these topics helped them feel better supported and connected in the virtual internship environment. Additionally, our team felt that modeling authenticity in our own reflections created a more nourishing, safe environment for interns to feel comfortable being genuine with us and each other.

Vulnerable Leadership
"Vulnerability is the birthplace of innovation, creativity, and change" (Brown, 2012, 5:49). Our private practice made a conscious choice to embrace vulnerable leadership prior to the pandemic, and this commitment made a marked difference in our ability to supervise effectively when COVID-19 hit. In her book Braving the Wilderness (2017), Brené Brown described vulnerability as more than just "openness," writing: The definition of vulnerability is uncertainty, risk, and emotional exposure. But vulnerability is not weakness; it's our most accurate measure of courage. When the barrier is our belief about vulnerability, the question becomes: "Are we willing to show up and be seen when we can't control the outcome?" When the barrier to vulnerability is about safety, the question becomes: "Are we willing to create courageous spaces so we can be fully seen?" (p. 154) Many interns reported a desire to model themselves after a mythical "can-do" music therapist who delivers services perfectly every time and bases their personal identity around their care for clients; however, researchers propose that music therapy students with a high capacity for empathy may be more likely to experience stress and burnout (Moore & Wilhelm, 2019). For this reason, our supervision team intentionally worked to break down the image of the ideal superhero therapist with our interns, and instead shared vulnerably and sincerely about our own struggles as clinicians and supervisors.
In this model, vulnerability is not a weakness, but is instead a catalyst to problem solve, give and receive feedback, and importantly for music therapists, to create.

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Vulnerable leadership requires supervisors to engage in ample self-reflection and self-assessment before it can be asked of students. It requires the "experts" (in this case, supervisors) to be willing to make mistakes, and, more importantly, take ownership of them. We developed our virtual model for supervision during a pandemic with no prior telehealth experience and made plenty of mistakes along the way. By vulnerably processing mistakes with our interns, we not only became better clinicians and supervisors, but modeled for our interns the process of recognizing mistakes and asking for help. Instead of looking at mistakes made by interns and supervisors as grievous errors or areas of personal inadequacy, we emphasized that mistakes happen to everyone regardless of how long we have been practicing, and that mistakes are steppingstones for growth.
This honesty between supervisors and interns extended to feeling "off" or inadequate as well. If we are pushing through and just getting by without reflecting on our feelings and asking for help, we are doing a disservice to ourselves and our clients. One of the biggest ways these feelings of being out of step or inadequate manifested during the pandemic was the mutual exhaustion and stress our entire practice felt. Factors like the month-to-month uncertainty of teletherapy extensions from funding sources, the uncertainty of vaccination access and spread of the Delta variant and feeling that there was no end in sight weighed heavily on our minds. We are extremely grateful for the privilege of working virtually, but we have all experienced screen fatigue and felt at risk for burnout at some point during the pandemic. It was extremely challenging to adapt to a fully virtual model of work, and the hours of sitting in front of a screen with limited in-person contact during the early peaks of the pandemic highlighted the absence of the meaningful connection and normalcy of delivering services in person. We learned that we can both love our work and be exhausted by it. Both supervisors and interns reported that it was a relief to have these thoughts and experiences validated by our co-workers. Even with a technologically savvy system and well-rounded programming in place, we feel that it was very unlikely for interns and supervisors alike to successfully complete a virtual internship by "toughing it out" and not allowing all parties to be honest with each other about the full range of emotions they may be experiencing.

HIPAA-Compliance and Client Privacy
Our supervisors have Zoom Pro accounts paid for by the private practice that are associated with our company's Business Associate Agreement (BAA), so the conducting and recording of teletherapy sessions is HIPAA-compliant so long as the sessions are hosted by the supervisors. For file storage and documentation, our practice utilizes Google Drive with a BAA for HIPAA-compliance. Interns are granted their own company emails and Google Drive accounts associated with this BAA and must use the company Drive account to access all client files and recordings. Many interns worked at home with their families, so we required sessions to be conducted in a private space away from the rest of the family and encouraged the use of headphones to protect client privacy.

Zoom Video Conferencing
Our supervisors find Zoom Pro to be the best fit for most of our virtual supervision needs given the capability for adjusting audio input for live music, remote control of screen, and automatic captioning, among other features. Our interns report using Zoom for most, if not all, of their online classes during their university coursework making it the most familiar and preferred option for interns. We use Zoom's recording option to create an archive of recorded sessions for interns to watch as observation opportunities. Clients sign a separate waiver consenting to sessions being recorded and viewed by interns, and we ask for verbal consent before recording meetings. In the case of illness, client cancellation, session rescheduling, or any number of circumstances that limit the number of live sessions an intern can participate in each week, they are able to use the recorded session archive to gain additional observations and hours.

Google Drive Documentation
Each client or group has their own folder in the company Google Drive where client data and documentation are all created and submitted. Interns learn to track data on shared Google Docs where interns and supervisors can comment, edit data, and ask questions in real time during sessions. When learning how to document, supervisors use the "Suggest Edits" feature in Google Docs which allows them to suggest changes to specific wording and formatting without the back-and-forth of separate files or pieces of paper. Supervisors use the commenting and assignment features within Google Docs to assign specific edits or tasks to individuals when multiple interns are working on the same assignment.

Google Classroom Assignments
In 2021, we set up a Google Classroom account for our internship in which the supervisors had roles as teachers and the interns had roles as students. Because we have overlapping interns, assignment due dates are assigned individually based on the intern's start date. Supervisors get an email notification when assignments are submitted, and interns receive an email notification when submissions are reviewed and graded. The Google Classrooms feature made it easier for our five supervisors to keep track of which interns submitted assignments and which assignments need to be graded when managing up to six interns at once. In addition, our interns report that the Classrooms system made it easy for them to keep track of what was due each month.

Supervision Scheduling
Supervisors are available to meet with interns on Zoom calls immediately before and after teletherapy sessions for individual supervision. In addition, interns can request additional supervision time with supervisors through Calendly, a free scheduling platform that syncs with digital calendars like iCal and Google Calendars. This has greatly reduced the number of back-and-forth emails between supervisors and interns when scheduling additional times to meet. It has also had the added benefit of modeling work and life boundaries for interns. If supervisors had a certain day or set of hours marked as unavailable, those times were unavailable for meetings, no questions asked.
Because of the high-stress environment created by the pandemic, and since music therapy students reported infrequently engaging in day-to-day boundaries between school and personal life prior to the pandemic, interns were encouraged to set similar unavailable times on their calendars and commit to not working on internship tasks or responding to supervisor communication during those times (Moore & Wilhelm, 2019).

Intern Onboarding Videos
Though more of our incoming interns have experience leading online sessions as the pandemic continues, we know that not every student has the same experience or access to technology prior to starting their internship. In addition to our intern orientation day, which is conducted online, supervisors created a series of training videos for interns to learn and review how to use our technology systems. Videos included instructions for leading sessions with Zoom, using Google Drive, completing and submitting paperwork and intern assignments, and using specific digital applications like OnSong.

Programming Concepts
Our interns and therapists have been scattered across the country throughout the pandemic and virtual platforms like Zoom Pro and Google Drive make it possible for us to coordinate and collaborate remotely in ways that are not possible in person.
Though we have up to six interns at a time so far in 2021, they are rarely in the same place at the same time; during most of 2020, they did not meet in person at all. We adapted our virtual training programming for our interns to meet their needs throughout various stages of the pandemic. This includes weekly group supervision to discuss professional development, biweekly intern social hours over Zoom, and weekly administrative hours where interns can log onto a Zoom call to see how we complete payroll and agency billing. Our most recent set of interns set up their own weekly accountability Zoom call where they worked on intern assignments, created visuals, or practiced interventions for upcoming sessions, like an online study hall.

Supervision Tools for Remote Development of Competencies
Assessing and helping interns remotely develop their professional competencies was one of the biggest challenges for our supervision team. Prior to the onset of the pandemic, our interns typically split their weeks between two primary supervisors.
Feedback was given individually from each supervisor to each intern through written and verbal formats. Scheduling changed dramatically during the pandemic, with virtual sessions often scheduled with two or three different supervisors in one day and often more than one intern participating in a session. We needed a uniform feedback delivery system to give the supervision team and Internship Director a better overall understanding of each intern's skill development. Utilizing Google Docs, we created feedback charts, and since Google features living documents, multiple supervisors could continually add feedback throughout the week, so the intern had all feedback and assigned preparatory work in one place (see Tables 1 and 2 Interns are given a sensory profile tool to use with clients based on a modified tool utilized in graduate study by the Internship Director (LaGasse, 2019). The sensory profile tool requires assessment of need levels in each sense, written descriptions of sensory seeking/avoidant behaviors, and recommended accommodations within teletherapy and in person settings. Interns also create their own sensory profiles as a reflective exercise. Feedback from our interns indicated that while they still did not feel as confident in facilitating sensory interventions in person, the sensory profile tools helped them think through more systematic and creative ways to address sensory needs via telehealth. Zoom as if they were client caregivers and then used that information to create appropriate goals and objectives and write an assessment report. Our interns reported that conducting a real assessment still felt intimidating, but the mock assessments helped them feel more confident and prepared. Prepare a task analysis for an emotion-based lyric analysis submitted to me in Drive by Aug 10 to lead on Aug 12.

Programming Supplemental Materials
As a result of being completely virtual most of 2020 and the first quarter of 2021, clinical hours were scarce. Therefore, it was important for us to have supplemental materials and resources for our students so they could still learn and grow while they 44 waited for therapist caseloads to pick back up. We have always included some supplemental materials as part of our internship, but the pandemic required us to build up and create additional resources that were both practical and informative.
We compiled lists of supervisor-approved podcasts and interviews, documentaries, and readings that students could engage with for no more than two to five hours a week along with a short reflection about what they learned, and how it might impact their current and future practice (See Appendix C). The goal was to provide new or additional perspectives, as many of the materials were not only musictherapy focused, but social justice and equity focused, which are vital to our practice.
Monthly roundtables are another addition to our supplemental repertory as a means for interns and clinicians alike to learn from professionals representing a variety of professional backgrounds. Initially conceived solely as a one-time resource, it was decided that roundtables would become a permanent monthly staple. Special guests are invited by our clinicians to give one-hour to 90-minute talks on topics related to music therapy, advocacy, and diversity, equity, and inclusion. Some of our guest speakers include a social work policy advocate at the capitol and a child life specialist as well as music therapists with specific expertise in areas like audio engineering, LGBTQ+ and Autistic identities, intentional inclusivity, mental health, neuroplasticity, and music therapy advocacy.
Many of the resources and roundtables cover several populations which can help provide clarity and insight for interns as to which populations they are most interested in or would like to learn more about. We continue to make changes as we find new or more comprehensive materials and encourage interns to give us suggestions for other resources we can add to our supplemental repertoire.

Challenges of Virtual Supervision
Moving the supervision process from in person to virtual format both exaggerated existing and created unexpected supervision challenges. Our supervision team found building rapport with interns, deciphering areas of need, assessing clinical competencies, and communicating consistently to all be more challenging in a virtual setting.
Striking a balance between work/home life balance was not a new area of focus for our practice interns, but when our practice moved to all teletherapy, it became a much more prevalent challenge in daily life. While most of our supervisors had the ability to create separate workspaces at home, our interns lived in family homes or small apartments where the best option was to create a teletherapy space in their own bedrooms. This made it particularly difficult to make the cognitive transition from working to resting. Our interns found that physical routines of setting up and tearing down workspaces aided this transition. Inconsistent internet was another inequitable challenge for interns living and working at home with many other family members.
Coordinating internet use schedules with their household was sometimes helpful for virtual interns, but not always possible.
Beginning in March of 2020, our supervisors and interns alike were in a constant state of grieving the changes that came with a global pandemic and shifting to a virtual model of practice and internship. With the addition of shared feelings of isolation, we 46 found that in order to shift into a therapeutic mindset, this grief could not be ignored.
Specifying time to process together and check in before and after therapy days was affirming for all. Check-in times also aided in building rapport and an open and consistent system of communication between interns and supervisors. Simply changing the question, "How are you?" to, "How are you physically and cognitively today?" added a specificity that helped interns develop self-awareness and assisted supervisors in offering feedback in preparation for sessions. Physical and mental check-in times at the start and conclusion of the therapy day could continue to be a helpful tool in virtual, hybrid, and in person internship experiences.

Advantages of Virtual Supervision
Though moving to a completely remote model of intern supervision was both unexpected and challenging, it was advantageous in many ways for both our interns and supervisors. Traditional in-person music therapy internships place a huge financial burden on interns who must often find a paying job to make ends meet during their internship, thus limiting the amount of time and mental energy they can dedicate to improving their clinical skills as music therapists during their internship, or worse, financial issues keep students from finishing internship and entering the professional world altogether. The completely remote internship was much more cost-effective for interns than a traditional in-person internship in which interns must pay for housing, gas, and car maintenance to commute to work. We are currently offering a hybrid model of internship in which some sessions and supervision meetings are online and some are in-person. We see great potential for this model of a total or partial online internship as one strategy that can be immediately implemented to reduce the financial burden placed on interns as our profession finds a long-term, structural fix for this barrier of entry that keeps good students from becoming great music therapists.
Both our interns and supervisors reported that completing a virtual internship allowed them to develop flexibility and creative problem-solving skills that they would not have otherwise developed. Instead of simply replicating interventions they had learned in university coursework, as many students do in the early stages of internship, our interns learned to tailor each intervention to the client's strengths, needs, and the resources available during telehealth sessions from the very start of their internship.
Access to instruments, caregiver support with technology, and high-speed internet performance varied between clients and even from day to day with the same clients, leading our interns to report that they felt well-prepared to handle unexpected situations as they entered the field.
Virtual supervision allowed for a high degree of programming flexibility for supervisors. Our private practice does not have a central clinic space; instead, our therapists traditionally travel around the metro area serving clients in their homes and facilities. Each intern is typically only able to work with one supervisor each day in our in-person model. With virtual supervision, interns can work with multiple supervisors each day and experience a greater variety of client populations. Supervisors can also place multiple interns in one virtual session that might be limited to one or no interns by in-person physical space or infection protocols. Because interns have increased access to more supervisors during the day, we are able to provide more in-depth supervision on a greater number of professional topics than we are in a solely in-person setting. Having at least some availability for virtual programming can allow for greater flexibility for internship sites, even if a fully virtual model is not feasible.
Perhaps one of the most significant benefits to this virtual model of supervision is increased accommodation for interns with work and family scheduling restrictions, illness, mental health, and disability. If our interns are not feeling well enough to participate in scheduled sessions, they are able to access the recorded session archives to observe sessions at their convenience to still get clinical experience. Interns who are symptomatic with illness but still feel well enough to participate can attend sessions without the risk of or spreading illness to clients. Interns who are unable to commute to sessions or spend entire days on the road due to personal scheduling or disability can lead sessions on a schedule that best accommodates their needs. Interns who require longer than the traditional six months to finish their internship can do so online without the added stress of securing additional months of housing.

Implications for Future Model Development and Research
With limited information and research on virtual supervision models available, further resource development and research is needed. More virtual supervision options are essential to provide safe, equitable, and financially viable clinical training options for all music therapy students. Further information sharing between universities, internship sites, and students will help develop accessible and beneficial virtual supervision models within the field of music therapy.

Conclusion
The process of developing a virtual model of intern supervision during a pandemic has been daunting and extremely rewarding. We see great potential in virtual 49 or partially virtual music therapy internships to increase the number and capacity of internship sites, to relieve the financial burden placed on interns, and to create a more equitable model of supervision for students better served by an alternative to the traditional in-person internship process. We hope that by sharing our methods and experiences, supervisors and potential supervisors can find encouragement, solidarity, and useful resources when developing vital virtual programming for their own internship sites.