I am delighted to welcome you guys this early on a Sunday morning to our workshop, Becoming a Good Enough Psychotherapy Supervisor. And I'm speaking into the mic now so that I can introduce myself. And I'm actually Dr. Kiki Kennedy. I'm on the clinical faculty at Yale, where I also supervise. And I'm joined here by my colleagues, who are going to introduce themselves, Dr. Frank Yeomans, who is at Columbia and Cornell. Yeah, in the opposite order, more at Cornell than at Columbia, but that's all right. I've been at Columbia, Cornell, since I was a resident there. So a lot of what we put in the book made me think about my days as a resident getting supervision. I might use an anecdote from that. But I am a clinical associate professor at the Weill Cornell Medical College and adjunct at Columbia. And I'm Randy Welton. I am the chair of psychiatry at Northeast Ohio Medical University. And you're incoming president of ADPERT. Current, actually, technically, for two months. I am the current president of ADPERT, which is the American Association of Directors of Psychiatry Residency Training, which is a great acronym, but a really difficult name. So it's the Training Directors Group. Hello. And I'm Maya Prabhu. I'm an associate professor at Yale in the Law and Psychiatry Division, which is the forensics division. And I have an appointment at the Yale Law School, too. And I appreciate your nostalgic comment there about thinking about where you've been. I have to admit that writing this chapter and preparing for this made me think about all the supervisors who'd been so gracious and kind to me. So I will thank you all, both for coming here at 8 in the morning when there's so many choices, and also for your commitment to supervision, as I imagine you are. Otherwise, you would not be here. And maybe I'll do a little shout out to actually one of my own supervisors, who's sitting there in the third row, Andy Morgan. Thank you, Andy. Great. All right. So these are the learner's objectives that hopefully motivated you guys to come here. We're really going to talk about some of the fundamental basics of the supervisory relationship and how to approach working with supervisees, try to understand from you what some of the barriers you find to engaging in supervision or practicing it, and then think about, just as always, a caveat, some of the legal considerations. And as many of us have said, thank you so much for joining us. There is the San Francisco beta breakers race going on right now, so we're happy that you're here with us, although it might be more fun to watch people running naked through San Francisco. But anyway, thank you so much. And so, as you know, the title of this talk and the book, the subtitle references the good enough mother. And actually, right before we started, Dr. Elna Jarr mentioned to Dr. Prabhu that that was part of the reason she came here. And Dr. Elna Jarr, you had told me that you wouldn't mind explaining why the good enough concept of DW-Winnicott was helpful to you when you were in residency. First, say your name properly and where you're from. You said it really perfect. Thank you. I'm Elna Jarr. I'm a child psychiatrist at Bradley Hospital, Brown University. I graduated fellowship about a year and a half ago from Montefiore. I've been in training for about like 11 years because I did combined neural and psych residency in Egypt. Then I came here. I did it again, but I did child fellowship after. So I'm just taking off the supervisee key, like code, and trying to become a supervisor. So when I started residency, I have two kids. One of them, Judy, was one and a half year, and Jasmine was four years old. I think it was really hard to actually have the two identities without feeling guilt about like being a lousy mom. I don't have a lot of support here, just me and my husband. We both were in training, so I had a nanny. Coming from a cultural background with the mother identity is very important to be sometimes prior your doctor identity. I always had that guilt of like the good enough mom. I told myself on one of the late calls in the ER, there was like a situation at home, and I don't know who's going to be at home when I come back. And so I said, you know what? I'm just going to be okay to be a shitty mom today. So excuse my language, and it's not going to be just for today. There's some situations where it's going to happen, and I'm going to be a good enough mom. Like fast forward, go to child fellowship, seems to be like there is a concept with attachment. And I just internalized that since then, and it's helped so much to be a better mom. So I just wanted to share that. Thank you so much, Dr. Al-Najjar. That was really helpful, and I think it really illustrates what the importance of this concept is, not just for being a good enough mother, but for being a good enough whatever. And so that's why we decided to apply this term to becoming a good enough supervisor, because it is a developmental process. It is one where you're challenged by lots of different issues. And also, one aspect that wasn't mentioned is that it's actually better for the child to allow them to separate from the mother, to have these small frustrations, and to be able to move out of their hallucinatory, illusory world into a world of reality. And while that might not be something that we're going to apply to supervisees, it is something where we do need to nudge them to become more independent, to be able to operate as psychotherapists and maybe psychotherapy supervisors at some point. And so I would just be really interested, for those of you who are here, I don't want to assume that you are psychotherapy supervisors. I'm wondering, who are psychotherapy supervisors here? Do you identify as one? Or are you—actually, how many people are actually engaging in psychotherapy supervision now? Great. So, probably, maybe two-thirds of the group. How many are psychotherapy supervisor wannabes? Great, great. So I think—and I guess for those of you who didn't raise your hand, we're going to be having some discussion later, or actually, maybe shortly, about why not? Why are you here? What is getting in the way of maybe imagining yourself doing that? So actually, we're here right now. So maybe for those of you who feel comfortable—again, we are having this recorded, so if you feel comfortable, we'll take a few people coming up to the mic, if possible—it'd be really helpful to know, what are the barriers, or were the barriers practical, emotional, to you becoming a psychotherapy supervisor? Any brave takers want to go up to the microphone? Hi there, good morning. I'm Bob Kurtzner, and I do psychotherapy supervision at Columbia. This is a very particular question that I have in my mind, and it has to do with the evaluation of supervisees, and the predicament of—I work with very talented supervisees, but I feel an obligation to try to find something to constructively criticize them about. And I'm aware of the power differential, so I don't just think this is a question of sensitivity about how a supervisee may be affected by my comments, but it's sometimes really hard to parse out what seems to be an important criticism to share with them. And likewise, I want to encourage them to tell me how I can do a better job, and sometimes that's difficult, too. So any suggestions about how to facilitate an honest back-and-forth between supervisor and supervisee would be very helpful. That's great. We're not going to answer—we don't have the answers, first of all. We may try to discover some of the answers, but I think you bring up such an important point about the power dynamic, and creating trust, while at the same time needing to give constructive feedback. And so thank you for sharing that. I didn't raise my hand. I'm Andy Morgan. Oh, no, no. No one—just go up to the microphone. No, I didn't raise my hand because I'm mainly focused in doing forensic psychiatry right now, and I think one of the barriers is many of the cases that I'm on seal the information. And I think one principle that I learned from my supervisors that I would love to—I'd like to continue doing with supervisees is I like sharing that information and working through the problem set and the different kinds of questions. And so I think in the last few years, that's limited some of the supervision I've been able to do on some cases, but I'm going to explore that with my—in our department and see how to do that. Because for some cases, I'm not even allowed to include a resident on the case, otherwise they become a potential witness. So that's what curtailed it mainly, whereas when I was running the clinic, supervision was easy and fun, I mean, in that way. But that's one of the barriers right now that I'm experiencing. Right, and so administrative barriers. And I've heard from colleagues, not necessarily in forensic departments, but at universities and other places where there are very practical barriers to psychiatrists supervising psychotherapy where, for whatever reason, the departments want non-psychiatrists to be supervising psychiatry trainees, which is a really interesting kind of concept. So I think there's probably a lot of different administrative barriers. Any—before we move on, anybody else want to share the barriers? Yes, please. So I'm a training director, so I'm a program director for a smaller program of about six per year. I think one of our biggest barriers to becoming psychotherapy supervisors that I hear from psychiatrists is, I don't practice therapy very much anymore. And because we work in a community model, most of my psychotherapy supervisors are LCSWs who are, one, somewhat uncomfortable supervising psychotherapy, and I think a lot of programs do use therapists now for supervision just because of time and availability. But also, like, their training in therapy did not include much heavy focus on psychodynamics, so they have some trouble, and so I have to, like, teach them what—how much they actually already know. I'm like, you use all these terms, you just don't know they're psychodynamic. And so those are some of my barriers, is that they have a different training set in becoming a psychotherapy supervisor. So I have to supervise psychotherapy supervisors and be a psychotherapy supervisor myself. So those are kind of my barriers. That is wonderful. I mean, that's honestly a lot of the reason that we—shamelessly, promotion—wrote the book, because there is, you know, as some of the more kind of—well, a lot of us have these ideas of these, you know, older-seasoned psychotherapy supervisors that we can't possibly emulate. And so a lot of people also, as you're saying, don't understand the skills that they already have if they're not practicing it. So thank you very much. Does anybody want to comment about that, or? The last or anyone? Go ahead. All right. Any, all? Any, all? All right, Andy. I look forward to more conversations about the challenges, particularly in forensic supervision. But can I just comment on the very first question about creating expectations, about giving feedback, and so on? And so I will say more in my talk about supervisory contracts. They don't need to be formal and written, but it's useful to set expectations, and including the expectation that you will give feedback. And there's a couple of ways you can do it. If you do it at set times and let them know that you're going to do it at a certain time, you can do it at a certain time. If you do it at a specific time, you can do it at a specific time. If you do it at a specific time, you can do it at a specific time. And if they know that they have the chance to give you some feedback, that can lessen any bite there. And I started doing, creating expectations around frequency meetings, including feedback, even the limits of what they can disclose, and my own reporting obligations. And when I started doing that, I was worried that it would limit the rapport, inhibit the trainee, and they've never flinched. And in fact, I found that it's been, they entirely expect it now, and it has not, I can promise you, based on the conversations I've had with my supervisees since, impaired the relationship in terms of the warmth and the rapport. So I think just setting the expectations early on, and maybe having the frequency of feedback so they know it's coming, can be a useful tool. And coming from the residency training world, as I do, the concern you brought up is a very real one. The big recent study, right, only 22% of visits with the psychiatrist code for psychotherapy as part of it. 53% of psychiatrists said they don't do psychotherapy at all. How are they going to become psychotherapy supervisors when they're not practicing it or not practicing it very much? And one of the driving ideas behind this talk, and again, behind the book, was that some of this is a skill set that can be taught. There was this idea out there that you just have to be born a brilliant supervisor. My supervisor just seemed to do it effortlessly. They were all different, and they all had their individual styles, and I can try to copy them, but I'm not them, and I'm never going to be able to do it. But what we're trying to do, and we'll show some of that here in the next hour or so, is that some of this is a skill set that you can break down, that you can operationalize, that you can teach, you can practice, you can get better at it. And even that person who is an early career psychiatrist, even that person who didn't come from a psychodynamically dense kind of training background, they can still become really good, useful supervisors, because often, just as you said, they know more than they think they know. Great. Thank you. So we are going to keep moving ahead. These are some common barriers that we've come up with, and some of you already touched on this, challenging to switch from a biomedical approach, lack of role models, experience, know-how, administrative barriers. A lot of, especially early career psychiatrists, talk about lack of time and lack of support and so on. And so I'm sure there's other barriers as well, as have been discussed today. I just want to mention that for a lot of people, it's important to recognize that becoming a psychotherapy supervisor is a process, that it takes time, that it's developmental, and that at the very different stages, whether you're early, mid, or a bit more seasoned, you're going to be growing and learning. As Randy said, it's a series of skills that you can continually work on and improve. And in fact, it's ideal, and I think we're going to be doing this later today, to think about what is a specific skill set that you really want to focus on and work on that in order to grow and develop as a psychotherapy supervisor. So I'm just going to mention a few foundational ideas before I turn the mic over to Randy. And this may be more for early career psychotherapy supervisors. It's important to understand that if you're a trainee, really what you just need, the basics are a safe space, trust, an opportunity to reflect on issues, receive feedback, discuss challenges. And with the goal in mind, and we're going to be talking about goals, of how to develop certain skills and techniques, how to integrate theoretical knowledge that they may have learned in the classroom into their clinical care. And then how to move from a more biomedical way of formulating and kind of doing that a lot of people have learned in medical school and in their PGY1 or 2, but to develop kind of a more open, questioning, reflective attitude of a psychotherapist. And again, just to mention, it takes like any skill. It's helpful to have specific goals, to practice, and to be open to change. So I'm going to turn this over now to Randy to talk a bit about this complicated relationship between psychotherapy, supervisee, and supervisor. Thank you. Thank you. And thank you all, again, for being here. I'm Randy Welton, the chair out at Northeast Ohio Medical University, also currently the president of Antpert, and got the great privilege of working with Frank and Kiki on this book. And again, thank you for being here. One of the things, for those who are early career, one of the misconceptions I had is that to write something, you had to already be an expert in it before you could write it. But sometimes, writing it causes you to learn about something that's really helpful. And that's what we're going to be talking about, is this idea of supervisory relationships, and how I learned about that in the process of writing some stuff about it. And when we talk about relationships, it's plural, but I'm not talking about you working with several different supervisees. It's the different relationships that occur within a single supervisor-supervisee dyad. So much like you can do in therapy, we're going to break it down into three. There are three components. They're all present. You may not be attending to them. You may not be thinking about them, but they're all there, and it's best if you are aware of them. So there's the real relationship, what we're going to call the supervisory alliance, and then the unconscious relationship. So the real relationship comes from the fact that there are two people sitting in a room who come from different backgrounds with different styles, and they're trying to communicate, and they're trying to develop trust in a hierarchical situation. That's a difficult thing to do because everyone's busy. If there's anyone in here who's not busy, please raise your hand because I have some stuff I can give you to do for me. We're all busy. We all have schedules. Our trainees do. Our supervisees do. Our supervisors do. We're having to meet on the fly sometimes. There's real differences in power and authority that already came up. It's a hierarchical kind of arrangement from the very beginning. There's potential differences in engagement and communication styles. There are some who are warm and outgoing and gregarious, and others who are quiet and indirect, and some who are bold and direct, and that can be both supervisees and supervisors. And sometimes you have to struggle because your communication styles are just very, very different. There's potential differences in gender, race, age, ethnicity, cultures. All of that can play a part. And there's also the fact that you don't always have a choice who you're being partnered with. Now, if you are in private practice and you sign a supervisory agreement with someone, yeah, you got to pick that person out. But if you're a resident, you may or may not have had much say in who your supervisor is, and yet you're going to be working with them maybe weekly for the next year. How do you manage that? It's like an arranged marriage. Sometimes it works out really, really well. Sometimes it's a bit of work. Actually, unarranged marriages are, too. But anyway, so it works there. And it... Part of the challenge is assumptions. Assumptions that the supervisor makes about the supervisee. It's assumptions that the supervisee makes about the supervisor. It can be based on differences in gender or sexual orientation, race, ethnicity, religion, accent, age, stage of training, appearance, what they look like, what they're dressed like. You know, I was trained a long time ago. My residents that I work with now, they don't look the same as I did, or the expectation of dress isn't the same as when I went through training. And how do I adapt to that? How do I come to realize that that resident who's showing up in cargo shorts and, you know, a little like golfing shirt, is just as professional as I was when I showed up in my tie and my suit. You know, that it's a different day, and it's a different time, and I shouldn't automatically assume that they're a slacker who doesn't care. That's not true. But you can make those kinds of assumptions based on your past experiences, based on implicit biases, based on just upbringing your cohort, right? So you have to be able to be aware of that. You have to negotiate through that. And the way you do that is through conversations. And you as the supervisor, you're the one who has the power. You're the one who has the authority. You need to be able to lead those conversations. And you lead them in an open, curious, and humble manner, and often by sharing something about yourself, right? There are some things I think you need to know about me. As we get started our work here, let me tell you about who I am and how I got here. And be able to share a little bit about your social identity. Again, you're not going on for hours about every detail of your life, but a little bit about your path, your track, your beliefs, your experiences as a supervisor. Let them know that, and then ask them politely to engage in that conversation. They don't have to. You don't want to force them. You don't want to pressure them. But, you know, a simple question like, is there something about you that I should know as we start to work together? Something about you that might impact our supervision. Something about you that might impact the therapy that you provide. Something about who you are as a person that you think is very foundational and important. Let's talk about that. And again, you start the conversation. It just leads to identifying similarities and differences, and you get it out on the table. It does two things. One, it helps the supervision go better, but you will hear this throughout my little portion. You're also modeling for them how to do this with patients. How to have these kind of conversations. How to ask questions in a tactful way. How to bring this up. There's a parallelism through everything that I'm going to be talking about today. So, we also have the supervisory alliance. This is obviously based on the work of Borden with the Therapeutic Alliance. It has the same three components. You want to have a positive emotional bond. You want to be working toward predetermined goals that are collaborative and agreed upon. You want to have mutually agreed upon tasks and roles. So, and be aware of that because you are doing something more than just taking your car to a garage, right? If I take the car to the garage, I have a real relationship with my mechanic. But, this is more than that in supervision. You're training them. You're teaching them. You're helping to mentor them. You're helping them to grow. So, you need to pay attention to the supervisory alliance as well. You need to work at developing that positive emotional bond showing that you value supervision. That you prioritize supervision. There's nothing worse for a resident than to show up to supervision and their supervisor is characteristically 10-15 minutes late because they're doing something else. Or the supervisor who takes texts or answers emails or interrupts the supervision because they have to do something else. What you're conveying to that supervisee, you're not really that important to me. All these other things are more important than supervision and it's hard to have a positive emotional bond when someone knows that they're not important to you. Show up on time. Remain focused on the task. Be reliable. Be trustworthy. You develop that positive emotional bond and then all the things we hope that the therapists are doing as well, right? Displays of empathy. All of us were beginning therapists at one point, right? We do know what they're going through. Some of what they're going through. We can imagine it. We can put ourselves in their position. We can be accepting and understanding when they make a mistake. Oh, I can't believe I did this. I can't believe I said it. It's alright. You learn from that. You grow from that. You will bounce back from that. Here's how we're going to do it next time. You show that you're understanding. That you're accepting them. That you have respect for their efforts and respect for where they are in the learning process. That they are growing. You validate their efforts. And again, remember that as you work on this supervisory alliance and creating this positive emotional bond, it relies on you, the supervisor, to do it because you're the person who has the authority. You're the person who has the power. Now, I'm not going to talk much about collaborative goals because Frank is going to dive deeply into that right after I'm done. But just realize that this is an important part. And this is something that I hadn't thought about when I was a beginning supervisor. Because as far as I know, none of my supervisors actually did this. We all just kind of came in and talked. And you were talking about assessment before. How do you assess? Well, if you don't know where you're going, it's hard to know if you're actually getting there, right? So without goals, it was hard to frame it. It was hard to assess progress. And so we'll talk some more about goals here in a minute. Mutually acceptable tasks and roles. This is basically the frame of supervision, right? When and where do you meet? Now, characteristically, in the training world, we think of it's weekly. You know, at the same time, in the same day of the week, and all that kind of stuff. But for a resident, that may not be possible. They have different rotations. They may be on a different service, and they can't get away. And you have to have some flexibility. And that's something you need to have talked about beforehand. How many cases do you discuss? I've had residents who like to discuss every patient every week. Well, what that means is you get depth on nobody. You get a, you know, a 10-minute briefing on five different folks. You're not able to do much work there. Or do you take one person? Well, if you're only taking one patient a week, that means you're ignoring several of their patients. Which patient is it? Do you randomly rotate through? Do you focus on the one that's having problems, on the one that they're most interested in? Well, then you run the risk of ignoring a patient for three or four weeks in a row. So how do you do that? Again, I don't know that there's a right answer here. But this is a conversation to have with your supervisee. How do you want to do this? What do you think would be most effective? How available are you between sessions? You know, do they have a supervision hour, and that's when you're available, or can they call you at any time? Can they call you here, you know, while you're at the APA? Is it all right for them to give you a call or a text, because there's a crisis back home, and they're not sure what to do? Again, there might be differences in expectation there. You need to have those conversations. Do they record the sessions, the audio-visual recordings? If so, how do you use those? I used to work at Wright State, and we recorded all of the therapy sessions for the patients. But you had some supervisors who would watch every single hour of tape sessions, because they do it on their free time. Others who never looked at tape sessions. You know, what's the balance? Is it, should we watch 10 minutes of tape every week? Should we watch 40 minutes of tape? Should we only watch tape when we need to? How do we determine that? Again, all of these are great questions. There's no simple single answer, but all of them are conversations you have. How much theory versus direct clinical content? That early trainee, they're wondering, what do I say? How do I answer? What do I do, and they don't show up late? It's all very, very specific and related to that patient. But you get a more advanced trainee, and suddenly you're starting to talk about kind of psychodynamic theory and how that applies. What do you think's going on here? Let's talk a little bit more about theory, and the same thing with reading assignments. Is this something you expect? Is this something they expect? I had supervisors who would give me, not only were we talking about our patients, but we also had a book chapter every week that we talked about. Only one. It wasn't real popular with me at the time, but I learned an awful lot by doing that. Can you give reading assignments? Can you give kind of homework to them outside of the session? Again, no right simple answer to that, but it's something that you need to consider. And the last one, and one that probably we think about least of all, is that unconscious relationship. Now, you know, in therapy, it's transference and countertransference. This is analogous. I don't know if we can use those words. So we just refer to it as the unconscious relationship. But you have one, because you have a lifetime of interactions with people, a lifetime of relationships, so does your supervisee, and you bring those into the session. Those expectations, those demands, those considerations, those past experiences, all of that is going to show up in the interaction between you, and especially in a relationship that is hierarchical. How do they respond to authority figures? That's going to show up. That might be conscious, but it's likely going to be an unconscious thing. How do you respond to people who are dependent on you? How do you respond to people who question you, when people challenge you, when people, an example I had, I had a resident, and we were early resident. We were talking about something, and I'd point something out, and this was a great resident, and they were a great resident because they flattered me a lot, right? So that's the definition of a good resident is to say wonderful things about me. You know, oh, that's so bright. Oh, I never thought of that. That's amazing how you thought of that. I'm going to certainly take that approach, and they never did, right? And this would happen time after time. Oh, that's great. I'm going to absolutely use that, and then I'd check a week later. Oh, no, I didn't do that. And so we had some unconscious stuff going on here, right? They wanted to please me. They wanted me to be happy, but they had no intention of following through with what I was suggesting, right? So that's something we needed to discuss, something that we needed to consider, because those unconscious expectations and the unconscious expectations of both the supervisee and supervisor are going to sometimes be gratified, and they're going to sometimes be frustrated, and that's going to affect supervision. And if you're not looking out for it as a supervisor, you can pretty much guarantee it's never going to be addressed. So you need to monitor that. What are the emotions going on in this room? What are their unconscious attitudes toward me? What are my unconscious? What are my reactions toward them? What does that say about my unconscious response to them? Identify those processes when it came up, like this resident who seemed to always want to please me, but never actually followed through, and be able to ask about that, to be able to point that out. Gee, I've noticed that. Maybe we should think, what do you think is going on here? Maybe I didn't say it in a way that you really understood. Maybe it was something you didn't agree with, but you were afraid to tell me. What do you think is going on? And again, not only are you helping out the actual supervision, but you're modeling for them an approach that they can use in therapy. So just remember, and you as the supervisor, you have the obligation to look at both perspectives. It's not only your understanding of the resident or of the trainee, but you also have to be thinking of how is the trainee relating to you? How are they thinking about you? What is their part of the relationship? And with that, I will turn it over to Frank to talk about setting goals in the supervisory relationship. Forward, back. Okay, good. Well, following up on what Randy said, I'm going to try to unpack this complex process a little bit more. And to start, we thought it might be good if you all think of a specific person that you're currently supervising, and then ask yourself, what topics and issues are you working on right now? Because the whole point of this book and of this meeting with you is to try to get everybody to appreciate how many pieces of the puzzle there are. It's interesting. I don't think we use that metaphor, but if you write a book with the APA, they choose a cover for you. So it's kind of interesting they chose a puzzle. It just fits with what we're trying to communicate. There are so many pieces to this puzzle, it's important to think about which ones you're working on and turn them into goals. So just to start and to simplify a little bit, I would say there are two basic components when you're supervising somebody. One, and the most important one, is you want to help the person provide good treatment. So it's about clinical care. But at the same time, you're educating somebody, and those obviously overlap, but sometimes one might seem a little more important than the other, and hopefully the clinical part is the priority part. It also differs a little bit whether you're training somebody, whether you're supervising somebody who's in their professional training, and that's part of a system, and they're going to get evaluated for it. Or if you're supervising somebody who's already in practice, they're seeking supervision to perfect the work that they do. And that's a little bit of a different context. It has a little bit of a different feel. And one thing I would argue from my own experience and that of my own group, I've worked with a group at Cornell for about 40 years now, and we've had a weekly supervision group that just never ends. So part of our position, and this is true of all groups who specialize in treating people with serious personality disorders, whether it's TFP, which I do, or DBT or MBT, you have to have help from your peers. Too much gets stirred up to do it all on your own. So, moving forward. Now, you have to know something, as Randy has said, about the person you're supervising. What have they been taught and what do they know? As this slide points out, those can be two different things. And then you have to try to get this mix I was talking about between didactics and good practice. So we talk about the lecture and lab approach. The lecture is the more didactic part, theory, what are the ideas that should be kept in mind as one is listening to the patient. And the lab part is the application of all of that. And I think it's very important to think about how we engender and teach the application of techniques. One of my great frustrations as a teacher and as a supervisor is that we often teach our students to come up with really brilliant formulations. But you can't tell your patient the formulation. You know, you figured out there's a projective identification going on. And somehow you're filled with an odd kind of anger or rage or hatred. You don't say to the patient, you know, I just think you must be feeling some rage you're not letting yourself get in touch with because I'm feeling it. And that's really not the part. So, no, I'm serious. My favorite question when I'm supervising these days is to say to the trainee, I get the idea. What would you say to the patient now? Because the real task in applying our formulations is to find words, phrases, a way of communicating that doesn't just impose an idea, but kind of sneaks a little bit behind the patient's defensive system and gets them to look at what they're doing in a way they can be curious about it. So, where is that thing? All right. So, getting a little more into the weeds here. We want to talk about what the trainee expects from supervision. We also want to know what they need because their idea of what they want might be different from our observation of what we think they need because of what they might be lacking in. And we want to know what particular areas they want to work on. Interventions, as I just mentioned. Understanding different approaches. Acting on a way to conceptualize cases. But I would add to this, and I think it's something in training we don't do quite enough of, I think we have to help our students develop better diagnostic skills. I think people are too quick to rush in. The patient's depressed. So, oh, I'm going to treat the person for depression. But what is the underlying kind of source of their depression. Is it a characterological depression? Is it an affective illness? So I think we have to slow down and make sure the person has good diagnostic skills, and then there has to be adequate framing of the treatment because not all therapies are alike. This is one of the great frustrations. We had a meeting of the psychotherapy caucus yesterday, and one of the problems in the delivery of psychotherapy is that the term is so vague, and a lot of people think it just means two people sitting down, being nice to each other, and trying to understand things better, and we have a lot more specific to offer than that, and that's one of the things we want our trainees to understand. Now the next slide I'm gonna go over very quickly. We wanna do this in a way that follows this acronym SMART. We want our goals to be specific, measurable, achievable, relevant, and time-limited. Why is that? We want to avoid what often happens, which is that psychotherapy supervision sort of just falls into an unstructured experience that two people sit down and have a vague notion that more can be understood about what's going on, but without a particular approach, without a particular frame, and that, of course, is a parallel process with a lot of what happens in therapy. There isn't a specific frame. There isn't a specific approach. It becomes vague, and I think that's one of the reasons the insurance companies so successfully criticize therapy, because if it's not structured, if it doesn't follow a particular model, it can be vague and endless. Now I'm gonna, and how much time do I have, Kiki? Few more minutes, okay. Now here's where we get really into the weeds, and it is helpful to think about different stages of supervision, so we're gonna talk about early stage, intermediate stage, and advanced stage, and I'll try to do this a little bit quickly, but very important, upper, in the first column here, assessing the patient's suitability for therapy. Don't assume, because the patient's been referred to therapy that they're a good candidate for therapy. You have to help your supervisee do an assessment to determine if therapy is the appropriate treatment for this patient. Maybe it's not, or if it is the appropriate treatment, is the patient willing to accept proper conditions of treatment? I think when I was supervising at Bellevue, the big city hospital in New York, and I taught about this part of the process, the trainee said, oh, you mean I don't have to see this guy who comes to every session drunk in twice a week intensive psychotherapy? And I said, no, if he's coming in a state that doesn't allow you to do your work, of course not. So you have to get the suitability of the patient, both in terms of their diagnosis and in terms of their willingness to participate. Then you have to look at helping your trainee develop an alliance, and this is something I think is really important, because one of the most solid findings in psychotherapy research is that a good alliance is associated with a good outcome, but the therapeutic alliance is not so simple. Unfortunately, the rating instruments for therapeutic alliance, one of them being the CALPASS, which is the California something, but I just want to honor California for having invented the CALPASS, and the problem with it is it's all about very simplistic notions of an alliance. To the patient, did you feel better after the session? Did you feel better when you walked in than when you walked out? That isn't always what a good alliance is. A good alliance, as some of these other points is going to emphasize, is about containing affect. Does the patient feel comfortable with you, the trainee, to let you know everything they're experiencing and know it's safe for that to happen? So I think the best simple definition of a therapeutic alliance is can your patient leave the session telling you go to hell, you're an asshole, and know that you're welcome back in the next session? That's a good alliance. It's not saying I just feel rosy at the end of the session. So then it's a little bit more complex than I can go into in this talk, but we have to help them identify defenses. That's interesting because we all love defenses and we all can name defenses, projection, denial, intellectualization, rationalization, humor, and so on and so forth. I'm actually gonna skip to the next slide because I just wanna go over a little bit of the mid-phase. So when we get to the mid-phase, we're talking now about the process being in place and we're looking for resistance. We're looking for transference. We're looking for counter-transference and helping the trainee identify those. This is interesting because I think we go from those easily nameable defenses to what we call character defenses, the way the patient is with the therapist, the way they just interact very spontaneously. Do they treat you like you're a buddy? Do they look at you very fearfully? Are they hesitant to talk and speak freely? So this gets a little bit more into depth. And then corresponding to that is we wanna help the therapist get a comprehensive formulation. How can you begin to put together what you're seeing into an overall way of understanding the patient? Putting it in terms of psychodynamic work, how do you understand their basic conflicts? Are they afraid of intimacy? Does that keep them isolated and kind of in a schizoid position? Are they afraid about aggression within themselves that might pop out? Is it some combination of the two? So we help people have a formulation. Then when we get to the more advanced phases, we begin, and this is where the didactic part comes in. And actually, in terms of this part of our writing, I'm a little ambivalent about this because when we say you help the trainee compare and contrast specific psychodynamic theories and approaches, one could argue that that might come at the beginning because then you'd kinda wanna understand right from the get-go which way to formulate and what model to apply to your patient. But actually, it's in the doing. When you get to know the patient in enough depth, you can say how would this be understood from an ego psychology point of view? How would this be understood from a self psychology point of view? How would this be understood from an object relations point of view? And once again, the challenge here is helping people go from a formulation to interventions that help the person really think beyond the way they are. So, just to wrap up, we're getting to a little bit of a concrete, oh, hold on a second, yeah. You have to always ask yourself, I think it's good, I always say to my trainees, as a therapist, it's always good at some point in the session just to have in the back of your mind why is the patient telling me, choosing to use his or her time at this point to tell me what he's telling me right now among all the different things that he could be telling me. Same thing about supervision. Why is the supervisor telling me this? What are they not telling me that might be relevant? What aspect of being a therapist seems to be the most difficult you wanna know from your trainee? And what seems to be holding back progress? And finally, to go again to something a little bit concrete, we wanna make sure we don't get lost in a murkiness and a vagueness. So, when you and your trainee begin, you put down a finite number of goals, you track them, periodically you take a time out and say, do you feel better about your diagnostic skills? Do you feel better about how you can frame the treatment? Do you feel better about how you can turn your sort of intellectual and theoretical formulation into phrases that might teach, help the patient understand themselves better? And then you move on. So, I'll just end there because we have a lot more else to tell you. Thank you. Hello, everyone. And again, thank you for coming. Can you hear me OK? So, just a comment about thinking about the legal issues and risk management issues inherent to supervision. There is a literature that comments on sometimes the fact that psychotherapy supervisors can have a slightly jaundiced opinion or perspective on having to think explicitly about some of the legal and risk management issues. That for some individuals, it can feel like antithetical to the core, what is often seen as the core value of a psychotherapy supervisory role, which is to sort of help mentor, develop and educate. I'm going to use the word trainees and residents interchangeably, although I realise some of you may be doing supervision with people who are in independent practice already. And I think I wanted to say that I don't see that thinking about having to think about the legal and risk management issues as antithetical to sort of the core, humanistic core that I feel is at the heart of the supervisory relationship. And that, in fact, by being able to model that you can have a legal and risk sensitivity and that you don't need to practise just in a defensive way and at the same time be able to formulate compassionate, empathic ideas about a patient to be able to model that is incredibly valuable in the practice of modern psychiatry. And also I think shows, obviously has a protective role for you, the patient and the trainee. So I wanted to sort of, I can comment more on that, but I just sort of wanted to acknowledge that sometimes thinking about those forensic and legal issues can be seen as a little challenging for individuals, but I do think that they can be really well integrated. Unfortunately, undoubtedly, as psychotherapy supervisors, you will have some exposure to, and you can be drawn to a lawsuit and you can have some legal and risk management exposure. And part of the reason why you've been named as part of a lawsuit is because you may have deeper financial pockets, you have more financial assets available, and your insurance, frankly, might cover acts that the program's insurance doesn't cover or the actual trainee's insurance may cover, which raises the point, do not assume that if you're engaged in a psychotherapy that the program or the department's insurance is going to cover your potential liability. So you will want to inquire in advance with your own insurance company about what it covers, and you want to be aware of, or at least inquire with program directors or whoever is organizing the supervisory psychotherapy program for trainees, what their insurance will cover for you. And there are multiple ways in which you may be drawn into, you as a supervisor, maybe have some legal exposure. One is sort of under the theory of what's called negligent administration. There may be expectations about what you may need to do as a supervisor. That may be decided by the program. There also might be state differences and obligations about what needs to go into a supervisory role. And some of that may be related to, say, frequency of your contact with the supervisee, systematic review of their notes. It may involve whether you're, in fact, listening to or audiotaping or videotaping supervisory sessions. So before you begin a supervisory relationship or enter into an arrangement with a program, ask if there is a manual. See what the expectations are. Feel free to share that with your supervisee. Sounds obvious, but many supervisees, particularly at the earlier stages of their training, may not be aware that you may have some liability as a result of their practice or their interactions with you. And there's not a lot of information always about how, of course, there's gonna be great variability amongst programs about what sorts of expectations there are for supervisors. Some programs that are small may not even have a program manual. It might be worth helping develop one around what the supervisor's expectations are. And so going back to the earlier question about how do you give feedback in such a manual, and this is where getting to the idea of a collaborative relationship, which includes setting expectations or being aware of mutually understood expectations about what feedback are, being able to establish that you maybe will look at their notes or that you will expect to meet with them at such and such a frequency, and being aware of what kinds of coverage you may provide or when you might not be available are all things that you really do want to work out in advance. So you may be liable under negligent administration. You may also have some legal exposure on sort of direct liability, recommendation that you make or acts of omission. So, for example, making a particular recommendation, say, around a medication or a line of inquiry or failing to make inquiries about things that can become problematic. Obviously, one of the areas in which, including residents, may be vulnerable are sexual contacts or sexual misconduct with patients, failing to make inquiries about such dual roles. I mean, we'll talk later, but I was unfortunately in a conversation with trainees recently, and none of them had supervisors who actually proactively asked about dual roles or sexual countertransference or sexual relationships with their patients. So there are many ways in which you can be, have some legal exposure by both failing to ask and also sort of positive acts or affirmative acts that you may undertake. There are also no standard national standards for what expectations are for supervision. So I also encourage you to take a look at your state licensing board. There may be different expectations for physicians, psychiatrists, and therapists, because some states and some licensing boards do have some guidelines about what you're expected to do. So I've talked about legal liability. Just to comment on process notes. So certainly this was a big piece of my own supervisory sort of history, and you may be asking your supervisees to take process notes. I encourage you to look up the HIPAA statute, the HIPAA legislation, which defines psychotherapy notes as process notes, as any form of documentation that sort of reflects on the contents or analyzes the nature of the relationship between you and the patient. You may need to advise your supervisees that process notes are different from clinical notes, that process notes should not include information, for example, around treatment plans, diagnoses, and medication changes. Often, supervisees are unaware of this. Sometimes even supervisors are unaware of this. Process notes need to be kept separate from clinical notes, and sometimes supervisees are unaware that process notes may still be discoverable in certain states, and that not all states, so they can be specifically asked for by patients or under a court order or in a lawsuit. And so whatever your practice is for keeping process notes, often when there is an error or something goes wrong, a panicked trainee may destroy the process notes. Always remind them that process notes, like general clinical notes, should be protected and preserved in the same way that you would with other aspects of the patient chart. Remedial supervision. So perhaps I bring this up because, as a forensic psychiatrist, we're often drawn into cases where there's already been some complicating aspects in the trainee's education. Just to comment that, particularly when there may have been already an issue around the trainee's education, you want to be aware of what that is. What problems have already arisen? What problems is the department aware about? What are the expectations for you as a supervisor to report back to the program about the trainee's performance? So again, to go back to that first question, being very clear with your supervisee about what the expectations that are on you to report back and to think about metrics for performance. Younger trainees or less experienced trainees may sometimes have difficulties in distinguishing between therapy and supervision. They need and deserve a safe space, but that does not mean that it can be a space where you do not have your own reporting obligations and you don't have expectations from the program about being able to give feedback on their performance. The issue of trainee non-disclosure, so them not telling you things that have gone wrong, is a very big issue. There's a literature that shows that large numbers of trainees, even in trainees who aren't in a remedial situation, don't disclose everything, and for perfectly understandable reasons. So we've talked about the power dynamics. Trainees are concerned, of course, about looking foolish, about being seen to make a mistake. Sometimes they may not even realize that there's something to report to a supervisor. So if you are gonna think about a sort of a supervisory contract with your trainee, it can be helpful sometimes to very clearly delineate what it is that they must report to you affirmatively. Things like an open conflict with a patient, threats of suicidality or homicidality, any accusations of misdoing, a threat of a lawsuit, I'm gonna file a complaint against you, against whomever they think they can file a complaint against. I would affirmatively ask about countertransference, sexual countertransference, romantic countertransference, and the development of relationships or contacts with the patient outside of that clinical role. Again, it may seem obvious to people who have been experienced and have been in practice for some time, not always so clear for the younger supervisee. And also errors. If the supervisee has a specific concern that they've done something wrong, encourage them to bring it up in supervision. I always tell my supervisees, it is much easier to fix a mistake early on. I would much rather know we can fix this together, again, reinforcing the collaborative piece of it. And I think most trainees sort of fundamentally respond well to that and understand that. And often there's huge relief that they do not need to manage things alone. One of my favorite lines with supervisees is, do not worry alone. Never worry alone. And that, again, can be sort of helpful, or at least supervisees tell me that it's sort of helpful. Oh, OK. Just a comment about tele-supervision. Obviously, during COVID, during licensing rules about having to be in the same state or geographic mandates have been loosened up. They are now tightening up. So make sure that you inquire with your own licensing board about what the expectations are or what allowances you might have to be in another state. If you are engaging in remote supervision, also check with your program. And also, do not assume that your insurance coverage is going to cover you if you engage in remote supervision. And last, just a comment on DEI and culture issues. And we'll talk more about it, I'm sure, in the workshop, obviously, dramatically changing landscape and culture around language, around talking about identity issues. There's no doubt that recent cohorts of trainees experience, want to discuss, and choose to discuss identity issues very differently than older cohorts, and may have very different perceptions around how adept you are as a supervisor in talking about issues around gender, ethnicity, language, culture, and background. So do keep up with your training programs, DEI trainings, and also be aware that there are grievance processes under Title IX, which you may be included in, unfortunately. But I will talk more about this in the workshop, and I'm happy to answer questions about your exposure on DEI and culture issues, too. Thank you for coming. All right. Thank you, Maya. All right. So now we are coming to the workshop portion, and we are going to ask you to form groups of two, maybe three, just turn to your neighbors, and we are going to pose a couple of examples for you guys to spend a few minutes just discussing amongst yourselves, and then we're going to be able to talk more about this. And I want to let you know that in our book, there is a chapter, I actually see some of the people who contributed here in the room, where we solicited supervisees' comments, observations, reflections, experiences in supervision, and compiled a number of the ones that we thought really were important and resonated with us, and they're collected here. So I've picked a few of these scenarios to share with you, kind of bits and pieces, and then ask you to discuss the questions that we raise, or any other ideas or feelings that you have after reading this. So I'm going to read this to you. Maybe you guys can figure out who you want to talk to, but this is a little bit of a brief part from the supervisee, and my experience, the ground traversed within psychotherapy is often murky, subtle, and seemingly ineffable for both the patient as well as the therapist. Intuitions, affects, and somatic sensations carry deep meaning, but can pass by quickly and faintly within sessions. Supervision has given me the satisfying opportunity to more deeply explore these experiences, articulating and reifying what was initially confusing and invisible. So with that as kind of a jumping off point, please turn to your neighbor and we'll give you maybe three or four minutes just to discuss, you know, how do you help your supervisees understand that emotional responses experienced in both the psychotherapy sessions and the supervisory sessions can be as important as the ideas, formulations, and so on that are discussed. So I'm going to time you guys, and then we'll move on. All right, we're going to stop you and move to one more scenario. This is so awesome. We're going to give you one more scenario, you're still going to be able to talk. We're going to take a couple of comments about this experience, then we're going to do one more scenario, and then we're going to have some open questions. Anyone want to share anything that came up? And because this is being recorded, we do ask you to go to the mic. So thank you very much for the wonderful workshop. I have to say I bought the book a couple of weeks ago because I am from Israel and I am responsible for supervising and teaching the psychodynamic part of the psychiatric training in a large psychiatric hospital in the centre of the state of Israel. We cater for a very ethnically diverse population, as is usually the case in Israel. So trying to reflect upon the question, I have the residents commencing the psychotherapy with a very medical outlook. So they come to describe the symptoms, sort of DSM-like, and with a sort of problem-solving approach, telling me how much the patient may or may not have improved between the sessions. And I need to start from the very basics, that emotional responses and paying attention and empathising with the subjective experience of the patient is something legitimate and is something that is part of the psychiatric training because it's not sort of understood. And there is a constant reference in the trainees, they are saying, am I thinking with the – there is an expression in Hebrew, putting my psychotherapy hat or my psychiatry hat, which hat I am using now. So I just will stop here. Thank you very much. I'm glad to know the book will be internationally welcomed. I just wanted to comment on that because I think that's an extremely common, especially in those early therapists, that they'll give you the checklist. Well, how does the patient seem? Well, they reported that they had sadness and they're not sleeping – no, no, no. But how do they – and I had one person, and we were videotaping at the time, and I said, okay, I'm going to turn off the sound, I want you to watch the video of this person, and you tell me, does that person look sad? Oh, no, they don't look sad at all. Well, you just told me they're really, really terribly depressed. What's the difference? Yeah. They get so invested in the checklist and the DSM criteria that they miss what's in the room. Thank you. Anybody else want to comment on this? We're going to do one more scenario. Yes, please. Hello. My name is Francisco Aranillo. I'm from El Salvador, Central America. And we discuss about the importance to know about all the things in the psychotherapy that are unconscious things, and the view of a psychodynamic perspective to understand things like the transference, contact transference, and that is important to know to the trainees, to the people who we will supervise, to know about that feelings, unconscious, that that will be make conscious in a process, in a process. I work with the Department of Psychiatry of, we in El Salvador only have two psychiatric hospitals. I work in the Department of Psychiatry of one of them. And we supervise the trainees. Me especially, the part of the emergency, that this another kind of medical relation because he's in the short term, but very important because it's the first time that the patient see the therapist. There are several of us who are a very similar idea. I think we're referring to it as creating psychodynamic psychiatrists. And the idea, we use those specific words to say wherever you're doing psychiatry, psychodynamic understanding is important. If you're in the emergency department, if you're doing consult liaison, even if you're in a busy outpatient medication management clinic, understanding the unconscious components of how the patient's presenting, the unconscious components of the relationship. David Mintz, who is here, wrote a book on the unconscious components of prescribing medications. That that's an important part of what you should be doing as a psychiatrist. Yes, we're referring here more to specifically psychodynamic psychotherapy formally, but really in every aspect of psychiatry, we should be getting that psychodynamic understanding back into our repertoire. Yeah, great. Okay, thank you. So we're going to do one more scenario. So this again is from the book, from the supervisee. He sat back slowly in his chair, turning his head toward the sun-filled window. He rested his head against a half-closed hand and shifted his gaze gently upward, as if searching for an answer from above. For a moment, he looked like a statue, but as his eyes continued to welcome the beaming light rays, it began to appear that the much-anticipated answer was imminent. I don't know, he said. He shifted in his seat and faced us directly, his lips curled softly with hints of a subtle smile, now looking armed with a more confident answer. Again, but now with a more curious tone, he said, I don't know. The vignette described above with my psychotherapy supervisor was an important and impactful event during my psychotherapy training. He illustrated that uncertainty is not to be shunned, but rather to be embraced, particularly in a psychotherapeutic context. So, in your small groups, discuss. Do you feel okay saying you don't know? If not, what do you think keeps you from feeling okay with that, with saying I don't know? All right, five more minutes, and then we'll have questions. Okay, so we are going to move on. Before we open it up for discussion, we're going to shift things a little bit before we have you reflect about this experience. But what we really want to make sure that you do is you take something home from this workshop. So, we want you to take one minute by yourself just to think about what is going to be your next step that you're going to do, whether you're an early psychotherapy supervisor or mid or more seasoned. What do you want to work on after this? So, take one minute, think about it, and then we're going to open everything up for discussion. Now, it's open for questions, discussion, what you'd be interested in knowing what your two-person, three-person dialogue was about, what your own, maybe if you felt comfortable sharing what your own takeaways are, whatever, whatever questions you have for us. Again, this is being recorded, so go to the mic. But we are now open until 930 for all of that. Hi, I'm Lynn Spiller. I work in Austin, Texas, and I've been supervising residents at the medical schools for probably 10 plus years. But I've run into a very peculiar thing in the last year. My current resident has not seen her therapy patients in person. And so, I'm wondering, you know, even the reflection about all the sort of the nuance of what happens with the electrical exchange, the seeing the whole person, not just a snapshot. How do you guys, what are you thinking about or finding, and I'm sure everybody's in a similar circumstance of some form or another, that we have a whole generation of people becoming therapists who've never seen a patient in person. And that's, what is this going to, I just don't know how to even think about it sometimes. So, I'm curious what other people's thoughts might be. Can I just ask, is that because her program, because the patient refuses to come in or the program allows patients to be seen only remotely? I'm a little surprised that. Well, it started out in the pandemic when everything was shut down and nobody was able to see anything. And then the next year was a spacing issue because they leased part of the therapy clinic space to another program because it was more profitable. So, there's multiplicity of things that are happening. And then now it's become, for my particular resident, that several of her patients are very comfortable working online. Why should I have to come in? She's invited one of her particular therapy case patients in and now she realizes the benefit of coming in and that's a good thing. And that's what I find how it goes. And so, it started out with, you know, it's changed. But now I think patients, I'm finding, are more comfortable to not come in. It's a great challenge. It's a great dilemma. There is no easy answer. So, the literature in general says that teletherapy is just as effective. The limited literature that's out there says it's just as effective. I got all that. So, I did a very unscientific poll at my local APA chapter up in Northeast Ohio. And so, we kind of presented that. All the literature says that it's fine. And I asked this, you know, room full of 12, you know, psychiatrists, how many of you actually believe that's true? And no one did. But I said, so, you've all returned to in-person practice then? And they said, no, because it's just so convenient. And so, yeah, I don't – the evidence is saying it's just as effective. People will rely on that. It is convenient. Patients like it. I mean, the therapists like it. They don't have to wear pants. I'm sorry. You know, they can do therapy. I'm sorry. Very casually and casually dressed. I'm sorry. I make Kiki nervous. Please don't be inappropriate, Randy. Every time I talk, she gets nervous. But it's just convenient. It's comfortable. And convincing them that it's not the best and you miss out on something by not being a person has been really hard to do. Thank you. Hi. Hi. I'm Denise. I'm from the Netherlands. And I have a question. Because I never really set goals, let alone smart goals, in supervision. So I'm just wondering, you know, how do you formulate goals anyway? Just move on with it or so? I don't know. First of all, you're not alone. I think the large majority of supervisors have a very simplistic view that you just sit down and somehow understanding will happen. So that's one of the reasons we decided to focus on this in the book. It's new for most supervisors. And it has to do with breaking the therapy process down into the many component parts. Like I was saying, diagnosis, setting the frame, understanding the different levels of intervening, trying to sort of distinguish in one's mind as a supervisor how are they doing with empathic listening. patient. So this is relatively new I think so you shouldn't feel bad. I've often found that it's helpful to ask them what they think their weakest area is and what they would like to work on and promise them that we'll check in on that topic at various points over the year. One, it allows for vulnerability but framed in the way of being constructive. We all have areas that we need to work on what's the thing you find most difficult. Second, it gives me a little hint about what their weaknesses or challenges might be and I often frame it in terms of look you are now in training you get more supervision more support this is the place to address your the things that you find hard before you go off into independent practice and I tend to work with fellows and senior residents and so they're very keenly aware that they have resources available so I frame it in terms of while you have the resources intensely available to you what are the things you find hardest. And I'd like to say this is this is where why we asked you to set this ask this question to yourself kind of to set your own goal. I know we've been constrained by being recorded so I'd like to just ask right now forget about the recording does anybody want to raise their hand and share like what some of their goals or next steps are that they reflected upon or that they are thinking about doing? Great. And there's really two sections to that. One is training residents to do teletherapy, but there's a whole nother skill set of doing supervision by tele because we have, we the supervisors, have just as much problem paying attention and it's hard not to click on your emails while the residents droning on about something that's not really interesting, you know. How do you, sorry that never happens to me. I do tend to discourage tele, audio telephone supervision only and I always try to encourage, right, because you need to see the affect and so on, but I also strongly encourage supervisees to try to have at least one in-person moment, session with the, with the person that they're evaluating or treating. Right, because you write, there's so much information you gather. I find it's much easier, you can have a productive video relationship, but that, that some experience with the, with the patient in person can, can really be transformative. The people that I see, they've known people for years. They've never met in person. They have friends. They've only known through Instagram and Facebook. Well, I would question that, though, because just a little n of 1 experiment. There was one particular patient I'd seen some before the pandemic. Then I didn't see him in person for two years. And then the first time I saw him in person again, I thought when he walked into the room that I had taken some kind of drug because I was so overwhelmed with how much I was taking in that had been missing during those two years of seeing him on the screen. And if your trainees have had their friendships and other relationships online, they're missing a lot. They might not know what they're missing, but they're missing. Oh, yeah. I don't disagree with that. I'm just saying they seem quite comfortable. But we've got to teach them. We've got to teach them to have more in-depth object relations. So we have two more minutes. And I really would just love to hear some people's personal goals. So yes. Great, thank you anybody else share what you're gonna work on in your own is your own in your own supervisory role Yes Anybody else? One more minute. All right, I'm going to sneak in here. Ask them about social media contacts with their patients and cell and texting. Again, I appreciate the question about we're dealing with a different cohort of trainees. And they will Facebook, Friend, Instagram, share text in a very different way with their patients in a way that probably most of us would. That's a great observation. Thank you so much. All right, well, we are at time. I think all of us can stick around if anybody wants to ask us questions or just come up and let us know what ideas you're going to take away. Because if we do this again, we'd love to know what worked and what didn't work. So please feel free to come up to us. We really are grateful for your time. Thank you so much. And I should have had a slide with all of our contact information. I think you can find it in the website. But we're also happy. I'm katherine.kennedy at yale.edu. And anyway, if you want our contact information, we can share it with you. I don't think it's on the slide. Anyway, thank you so much. Thank you.

psychotherapy supervision

emotional responses

teletherapy constraints

trust in supervision

clinical care support

diagnostic skill refinement

supervisory relationships

legal risk management

dual relationships

countertransference

telehealth challenges

psychotherapeutic education