Good morning all I Think we'll we'll wait one more minute till 801 and see if anyone else meanders in We we were just discussing and assuming that almost everyone here is probably from the East Coast And it feels like lunchtime to you, but let's see if a couple people drift in Yeah, we wrote two papers while we were sitting here waiting All right, well it is 801 and so welcome in to our small but mighty band and our goal today here in this Particular workshop is to is to really work experientially to discuss Challenges that occur in supervision and my name is Donna Sudak. I'm the program director at Tower Health Phoenixville, and I'm also a professor of psychiatry at Drexel and I'm joined by my colleagues Amber Frank Who is an assistant professor at Harvard? and a senior advisor to the training program at Cambridge Health Alliance Amy Mary who is assistant professor and assistant director of the CAP Fellowship at the University of Minnesota and Ann Ruble who's director of psychotherapy training and associate training director and assistant professor at Johns Hopkins We also want to thank David Topar who does this workshop with us? And has worked we've all worked together on things surrounding supervision for quite some time, but he couldn't be with us today So our plan is to give you a general overview of some core principles about supervision But then to look at some challenges that occur for us and for others in supervision and Think creatively about how we might navigate those challenges And hopefully you'll feel free to chime in ask questions We're going to work participant in a sort of a participant model here so that we can all learn and grow together So the first question is how do you define supervision? What what thoughts do people have about what supervision is? Apprenticeship and meaning Meaning So it's modeling it's Having someone with more experience discuss particular problems that one has What else happens for you in supervision? It's teaching and modeling self-reflection And I I think of that as really a core principle because in fact over time you want to make yourself obsolete right and and one way to make yourself obsolete is to Teach the supervisee to to reflect and apply Sort of an outlook of how could I improve this process better right? other things that without endangering patients because of their lack of knowledge. So it's a safety valve as well. It is a safety valve as well. So there are a number of different roles that we play as supervisor. Sometimes, at least in my experience, we're trainers. We get supervisees who come to us without core skills, and so there's training, there's case management, there's evaluation and gatekeeping, there's role modeling. So you're wearing a lot of different hats. The problem with supervision is that, and this was asked 30 years ago, we still have less than optimal answers to this. There are few supervisors who are trained as educators. If you're a good clinician, you're generally a supervisor. My role in supervision happened at the turn of a calendar page. June the 30th, I was a fourth-year resident. July the 1st, I was a supervisor and really didn't have very much in the way of instruction. So that one thing that we might think about is how do we improve conditions for supervisors to make them better equipped to navigate the dyad. And we've made a lot of assumptions about supervision that only recently have started to be tested. We do know now that supervision improves people's outcomes. In fact, it might be the most important influence at maintaining skills and confidence in therapy. And we know a number of things about dissemination. So if you don't know anything about Fixin, if you Google Fixin, you will get a monograph. Fixin is an implementation scientist. And he looked at the question, why is it that it takes 17 years for people to implement a new kind of treatment for someone when we could do it in months? And part of the reason is that they don't have supervision. Many of you might have had the experience of going to a conference and learning a new kind of therapy for two days, and then you'd say, well, that was kind of interesting, but you don't implement it at all. And the way to get people to implement new things is through supervision. The best study right at the bottom is Bambling's study, where they actually had a training for the supervisors, and they looked at patient outcomes over time, both in terms of alliance and in terms of skill ratings for the supervisees, and found that supervisees who had trained supervisors had patients who did much better. And really that's where the tire meets the road, right? We want people to have better outcomes. What we also know about supervision is that supervisors spend less than a quarter of their time, if you listen to what they're doing, doing the things that in supervision make the most difference, and that is reviewing actual sessions with segments of recordings, rehearsing and practising new behaviours with their supervisees, assigning their supervisees things to do between supervision, you know, extending learning in a way that allows for focused practice, and also modelling new behaviours. So we might want to think about implementing this a bit more. We also know that we need to teach our supervisees how to practise things outside of therapy sessions that will make their patients do better, most specifically reviewing their own therapy recordings, reflecting about those, doing things that will potentially monitor the progress of their patients over time. And controlled for experience in caseloads, therapists who do this have much, much better patient outcomes. One thing that I like to think about is the model for supervision as a lab. This was an article by Deb Cabaniss and Melissa Arbuckle, and if you think of... All of us have chemistry classes, right? And you go to the chemistry lecture and you listen to something and then you go into a laboratory and you pour things into flasks and things explode and it's very exciting and you learn by doing. And so if we are supervising someone who's in a training programme, one of the things that we could do that would amplify our supervision would be to know the didactic series that's happening for our supervisees so that we can highlight what they're learning in their classrooms with what we're doing in supervision. So I'm a CBT person, so, for example, when I know that they're working on agenda setting in class, I'm going to highlight that in supervision and make this like the lab. My comment is the last one that wasn't in the article. I think what we want to do is to inculcate our supervisees with the idea that they need to become experts, that being competent when you graduate is not good enough. I don't want a competent surgeon, I want a Jedi master surgeon, and we have to teach our supervisees how to make that happen. And supervision at the lab means that we are, as supervisors, listening with the mind of a therapist and speaking with the mouth of a teacher. So we have to translate what we would think about as a therapist to a learning process for the supervisee. So we're identifying learning goals and monitoring the progress of our supervisees. What we need to do when we're supervising is to ask ourselves these questions. What does the supervisee know? What do they need to know? And do they need to know how to do something or do they need to know facts about something? Both are critical for clinicians. Supervision is also a lot like therapy in that it's learning something new in the context of the relationship. And the relationship is what is going to help the supervisee be empowered to do things that are difficult. So we have to facilitate that by looking at bonds, tasks, and goals, just the same things that we know about that work in therapy are particularly workable in the context of supervision. In fact, there is a supervisor working alliance inventory that you can ask your supervisee to do to see what your alliance is like. And our goals in supervision, as we mentioned, can be training, case management, career development, gatekeeper. All of these are critical functions that we have. And the last is a source of tremendous anxiety for supervisees. So we have to be transparent and clear about the way that we present the evaluation methods and metrics to our supervisees and give them the opportunity to work with us to be able to help them to self-evaluate at the same time. One piece that I think is really important is that we know that nondisclosure in supervision is significantly problematic. Supervisees don't often tell us what is a problem, and sometimes they don't know what is a problem, so that we need to at some point be able to actually observe their work. And we can do that in several different ways. We can role-play, but we can also listen to recordings or watch behind a one-way mirror if that's possible. I also happen to love written case formulations. I think when people write, they think a lot more clearly, and we can know something about their knowledge base that way. And we need to inculcate the notion that they should be getting outcomes from their patients, both about the patient's problem as well as the therapeutic alliance. So with that backdrop of sort of facts about supervision, now we're going to talk about troubles in supervision. And I'm going to let Amber present what we're going to be doing next. Thanks, Donna. So I'm Amber Frank, for those of you who joined more recently. And as Donna introduced and warned you earlier, we're going to have this be a fairly interactive workshop. So if that's a little bit nerve wracking this early in the morning, you can start thinking about that now. It's coming in the next few minutes. And by way of my own background, I was a training director for multiple years and had the great experience of working with these fine folks in educational settings and conferences. And I also now work as a chief psychiatrist for tachyatry. So while we're presenting a lot of this with the training frame in mind, I would say as we work through the scenarios, also think about what your frame is. You may be a training director. You might be a vice chair or a chief or a clinic medical director. Whether you're working with trainees or junior faculty or nurse practitioners, we picked some common themes that can come up in a variety of different venues. So think both about the scenario that's presented and also how it might particularly relate to your situation that you work in. So I'm going to walk you through our first scenario, which we fondly refer to as the oil and water supervisor or supervisee pair. And I am just going to read this to you. I know it may be a little small for those in the back of the room. Pretend you are a training program director of a small training program. A second-year resident approaches you and reports to you that she feels many of her interactions with her supervisor have been negative. She feels that her supervisor is, quote, out to get her. She feels that her supervisor is dismissive of her clinical impressions of patients and is not able to deliver helpful feedback in an appropriate manner. The resident has received positive reviews by other faculty she has worked with. Later that day, the supervisor, a longtime faculty member with positive reviews by past residents, calls you to speak about the resident. She says that the resident is, quote, touchy when receiving feedback, dismisses any concerns that the supervisor notes about the treatment plan the resident has developed, and believes the resident, quote, feels she does not need supervision. She's asking you for what to do next and also if she's the best person to provide supervision. So we have some guiding questions for us to talk about as a group. So I'll walk you through each of these. And we'd like to just discuss as a large group. We don't have a big audience this morning, so we can discuss through each one. What are some ideas you all have about what might be some next steps, very concretely in this kind of situation, where the supervisor and the supervisee are seeming to be in this oil and water kind of situation? Can I ask a question? Yeah. Is this the first time that this resident has been in supervision? No, they've had supervision with other supervisors before, we're assuming. So only the supervisors had many? Yep, so they both, it's not the first ball game for either one of them. One of the questions, have we heard about the supervisee's track record or the supervisee's track record? So the supervisor also has had positive reviews by past residents. So you're probably a little bit surprised that this is coming to you. I'll gently suggest that they talk to each other about their relationship. Great idea. So promoting some of the self-reflection that came up earlier, and suggesting that they might actually talk about this a little bit and reflect about it together. Any other thoughts? Great, absolutely. So the themes I'm hearing are true to psychiatrist form, recognizing we don't actually have enough information yet. We need to dig a little bit deeper. And that might be promoting some self-reflection on the part of both the trainee and the supervisor, perhaps meeting with each of them, asking more questions so that you understand it better. And as Marshall said, assessing, can this fit be made or not? How about number two? What interventions, if any specific ones, do you think could be used to really assess, again, this question of, can this relationship be repaired? Or are we beyond repair? Or did we never have that basis for a good supervisory relationship to begin with? How would you assess that? So you bring up the point on both ends, right? Is the supervisor perhaps overconfident and perhaps a little stuck in their ways? And similarly, is the supervisee, are they receptive? Are they overconfident? And this goes with the third question as well, is on the flip side, how and when do you decide that a supervisor or supervisee pairing isn't a good fit and does need to be changed? So any other comments about either question two or question three, other ideas about this one? Could get along somehow. So it's a great point, right? We all have different resources and different, broader environments that we're working with within the snapshot of a scenario. And I think Dan's comments about, you want to think too about, is this more from one side or the other? And if so, how do we think about where someone is in their career progression? What do they need to learn even about a supervisory dyad and working with someone else? And also, I don't know if I misread this subtext into your comment, Dan, but also assuming that if the supervisor is the issue, that may be remediable. Or as Marshall alluded to a little bit too, sometimes if it's been 30 years and someone's been doing it the same way, there might be a little bit less room, although you can certainly try. And yeah, you may not have another pool to dig from for other alternative supervisors. And so that might mean that it's even more pressing to try to make it work. I think building off that point too, reflecting on the fact that we all come into, whether it's treatment relationships or supervision relationships, with our own stuff that we bring in. And supervisees and supervisors aren't always as primed as they might be in a patient relationship to think about that and think about, why is the supervisor ticking me off? Or why does the supervisee seem completely incorrigible to me? But it also might be things that people are bringing in individually to that relationship. Let me move on to the fourth question. How would you approach the situation differently if the supervisee and supervisor were of the same versus different cultural backgrounds, gender, et cetera? How about if the supervisor was a new attending or a nurse practitioner rather than a resident? How do you think some of those different dynamics might affect? I don't know if you had an image in your mind of what the identities were of the supervisor and supervisee. But if it was something different from what you internally imagined, how might that affect how you'd approach the situation? Describing it in a nutshell, I think you brought up a number of things. It sounds like you were attuned to the fact that there were factors at play that needed particular attention beyond just generic supervisor supervisee, and that special education was needed for the supervisor. And that also it had the potential to impact the supervisee's ability to learn and be in an appropriate learning environment differently than a more run of the mill kind of supervisor-supervisee difference. What other thoughts? I went to a workshop yesterday, I feel like last week. And one of the concepts that came out was that there's an enormous problem of suicide in black youth, and the problem solution is not finding black people to work with black people and Latinos to work with Latinos, because it's not possible. You need to do what's called a racial or ethnic match. And so the question is, what do people need to learn about talking about this mismatch or the difference in gender, race, whatever? And we don't create an environment. So I remember one day you're a medical student, the next day you're an intern with a beeper on a cardiac care unit. And nobody is prepared for that. One day you're a resident, the next day, as Donna said, you're attending who's been assigned to a few supervisors. The learning of how to be what you're supposed to be is absent, except for what I'm trying to do in our program. I've tried for 15 years. To train this force, the PGY force, to actually become supervisors as force of junior residents to learn the process of becoming a supervisor. And then I run a seminar where they come in and talk about their supervision. Amber can talk more about this probably wiser than I can. And what came out of my discussion yesterday and then my experience of this is that you can't really solve a problem until you have a context that's safe. We know as psychiatrists we have to attend to defensive mechanisms. And as we get older, we get more fixed in our ways. I can attest to that as an actual older person. And I think as a younger person, we get defensive that we're supposed to know more than we do. So creating an environment about learning, knowledge, and difference in culture, race, ethnicity, gender, whatever, sexual orientation. We have to really have a conscious process in our system to make that as valuable as knowing what the newest antidepressants that you prescribed for patients. Absolutely. I don't have an answer to that, but we know some of what we need to do. And the question is how do we use supervision as an opportunity to try some of these things out? Yep, and I think your comment harkens to an earlier point, which is part of the process is learning how to talk about the difficult stuff. And we know that in work with patients, right? And that can be true in the supervisory diet as well, acknowledging not just the conflict, but in this case, maybe there's some identity pieces to it as well. And how does that play in? Dan, were you gonna add something? It just makes me think of the tension between the notion that as a psychiatrist and therapist that we, the fact that these differences ultimately ideally shouldn't matter, right? Versus now the notions of focal competency and as a patient or a supervisor or a consumer, this idea that we can sort of dial up that this therapist that's going to understand me, supervisor is going to understand us because of some greater awareness, some similarity. And I think it's hard to reconcile those two ideas. Yeah, I see one more comment and then we'll move on to the last question and some wrapping thoughts. My thought is around the supervisee, supervisor. I mean, on the one hand, supervision of the case, but when you say supervisee, supervisor, it's supervision of the trainee. And I wonder how to embrace both of those two, that you're supervising the case as sort of treatment is delivered by the trainee, you should call it supervisee, supervisor for the most part. And I think there's that clear connection. I think oftentimes connection is sort of assumed to be around sameness. And yet, how can you honor difference and connect? And then just to throw in there, too, that the law degree does reflect the patient and the case as manifesting in some parallel process. Yeah, absolutely. And so it's not just, like, neutrality and investigation are kind of part of that. I think both of the last two comments really bring up the importance of the cultural humility perspective and supervisory humility perspective, right, the being comfortable with not knowing, because, of course, the likelihood as a supervisor that we are going to be perfectly matched to a supervisee or our supervisors that we supervise will be perfectly matched is pretty unlikely, right, even if on the surface people appear well-matched, which leads me to the last question. How do you match supervisors and supervisees? We'll just take a couple comments on this one and then some key points, and then we have two more scenarios. Anyone have a method that you've found magically works so that you never have this scenario? No comments on this one. Is this because you're shy to share or because perhaps you haven't put as much thought into it or resources are limited? They don't actually work very well. They might like each other. I think also then sometimes, too, there's the downside of there's an idealized idea of who the supervisor is going to be, and no one can ever match up to that idea, too. So great points. You know, you may assess what do you know of the supervisor and the supervisee? What are the supervisee's goals? How does that match with the supervisor's? You know, perhaps there's preferences. And also, for anyone who is staying quiet, because your resources may be limited, maybe your resources are limited, right? Maybe you don't have the luxury of thinking about these things. However, if that's the case, also, we can think about how do we prep our supervisors and supervisees to go into the relationship and make the most of it. So you all brought up some excellent points. And these are some of the key points that we just want to highlight before we move on to the next scenario. So big picture, 30,000-foot view, hearkening back to our first question. When you run into a situation like this, first of all, we need more information. Let's gather additional data from both parties. You, in this time-intensive way, as a supervisor of supervisors, may want to consider meeting with both parties together or offering another third party to do so. I think the long, complicated example with some cultural elements to it is a great example where some additional help may be needed. You can plan programming for trainees or supervisees and supervisors on ways to address issues with match in the future, proactively thinking about these before the supervisory relationships start, whether that's annual trainings for supervisors or introduction to supervisees of here's how we do supervision at our institution, and so on. And in educational literature, the alliance between psychotherapy supervisors and trainees is one of the most influential factors in trainee satisfaction, and we can imagine that would extrapolate to lots of different supervision situations. Other training regarding skills and building alliance can be helpful, and also in other related factors like how do you give feedback, and as a supervisor, how do you receive feedback? How do you solicit it, and how do you respond in a non-defensive way if maybe you as a supervisor are pretty used to doing things the way you're doing? So with that, let me hand things over to Ann Rubel for our next scenario. Hi, everyone. Good morning. I appreciate everyone's participation so far. It's been really great. So I wanted to comment that like Amber, I supervise in a lot of different settings, so I have psychiatry residents I supervise, but I also supervise psychiatric nurse practitioners, licensed clinical social workers, and the nurses in our substance use program as well. So I think there's lots of situations in which these questions can apply. So I'm just going to review Scenario 2 for us, and it's a diversity, equity, and inclusion focused scenario, because as we commented in the earlier scenario, this is a circumstance which can come up a lot during supervision. And like Daniel mentioned, it can be very fraught and challenging to think about how to work through. So this scenario involves a newer supervisor as well as a senior trainee. So a PGY-4, 28-year-old, cisgender, white male resident comes to speak with you about a concern with his supervisor who's a junior faculty member, just a few years his senior. He's concerned as he has two outpatient cases that he's been discussing with this supervisor. One is a 20-year-old cisgender, white, female college student on the undergraduate campus who was diagnosed with depression in high school. She describes periods of feeling overly energized, not needing to sleep, spending much more money than normal online shopping, and going on multiple Tinder dates, which often end in sexual activity. She had also described smoking marijuana on weekends and sometimes at night. Part two is that the resident's other patient is a 22-year-old cisgender African-American female patient care technician employed by a local community hospital who is also in school for nursing. She initially presented with a depressive episode and was smoking marijuana at night to try to fall asleep after her shift at work and sometimes on weekends with friends. She then reported escalating energy over several weeks, spending more time out at night with her friends instead of studying for her classes, which is atypical for her. And these evenings out would often end in sexual activity with friends or others that she met while she was out. Part three. The resident believes the diagnosis of both patients as bipolar disorder and that they need mood stabilizers, but he's noticed that the supervisor's approach to these cases seems to be quite different. He's amenable to mood stabilizers and has recommended supportive psychotherapy for the white patient. But he told the resident that the African-American patient needs a drug treatment program and to focus on motivational interviewing so that she will agree to this program. The trainee also feels that his supervisor implies they have the same understanding of the two cases based on a shared cultural experience and background. And the trainee is not sure how to dissuade the supervisor of this idea. So we have some prompts as well on this case. So how would you engage the supervisor as a discussion around his differing approaches if you were the faculty member's supervisor? Yeah, I mean, I think it's very possible that the supervisee feels a certain way but the supervisor has no idea that the sort of shared beliefs about the way they're envisioning the case and the discussion of the patient's presentations is any different. So you know, to, and that of course is the assumption of the supervisee. So I think getting the idea, maybe the supervisor has noticed that there's a problem or that there is some kind of tension. So I think that that's a really good point, kind of finding out whether this is a shared belief that they have or different. Yeah, I think that's important. Well, and I think also just the point a lot of people have been making where, you know, we don't know what kind of training that this person has had to be a supervisor. So I think part of it is that, you know, sometimes when you haven't had specific training about what it might mean to be a supervisor, it's just like, well, we come in and we talk about cases. And I think we're talking about cases together is going just fine, you know, kind of like running the list essentially, more so than actual supervision. So it might be a good opportunity also to do some faculty development with that young faculty member about what supervision is for and how it might be important to learn some skills in terms of that. Sure. And I think also the question that comes up in our program definitely sometimes about, well, this is a small enough program that if my supervisor figures out that it's been me that said this, is there going to be some kind of discomfort between us moving forward and how to navigate that kind of discomfort in that situation? For sure. I think that that's, you know, I think that thinking about, you know, what is the culture of my institution and what is my institution doing at a faculty development level and an institutional level to make these conversations, you know, part of our treatment and part of our culture and part of psychotherapy in general. And so I think it's really important in terms of having those conversations be an accepted part of supervision so that the trainees can feel more comfortable. Something that we've done in our program and also in conjunction with Donna's program is that we are teaching broaching skills as part of our psychotherapy curriculum so that it actually brings it into supervision in a way that the residents can easily say, oh, we're learning this in our broaching curriculum and can we discuss how this might apply to this particular case. So in a way that it's a lot more comfortable instead of saying, you know, I have concerns about, you know, things that I'm worried that are coming from you might be racism, right? That's a much different conversation than I'm learning this new skill set and can we apply it to these two cases and see how it might apply. And part of broaching is that you really are supposed to broach with every patient even if they appear to be of your same background so that, you know, you can really think about even though I might assume we have shared cultural differences, that might not actually be the case. So I think that might be a nice way also to bring it into supervision. So I think as we integrate these ideas, it makes it easier. Sure, Daniel. Do you share some of the resources or broaching skills that that can be very valuable? Absolutely. We're working on it. And we're trying to actually make a curriculum that's widely available, so through AdPerts. So we are working on that as part of our committee and we're happy to do that. So let's move on to number two, which is do you see any potential pitfalls in this conversation and have any ideas for troubleshooting? Can you see how these conversations might go wrong? Which conversation are you talking about? I'm sorry. Yeah, no, I know we talked about several things. So what I had envisioned when we were talking about the scenario was essentially the conversation of the resident has concerns about, you know, how you're providing supervision for this particular case. And this could apply to many scenarios as well, but any situation where the resident might have concerns about how the supervision is going. Yeah. Yeah. So I think, you know, a couple things to consider. One is that, you know, we always need to consider the history of our field and where we've come from and where we're going in terms of when we think about individual patients and their diagnoses. And also at the same time be thinking, well, we need to have open conversation and it's possible that this trainee just hasn't asked the supervisor for enough clarification as to why they're formulating the person's illness in this particular way. And so I think that, I agree, it's hand in hand, those things you have to think about both of them. You can't just make assumptions and then you'll get into trouble in these types of situations. So just a couple key points to wrap up. One of them I think we've talked about really nicely here, which is to be curious and to ask the trainee and the supervisor to provide their feedback about the case and their individual experiences including whether or not they're on the same page and also why the ideas they might have about the diagnosis. Consider any patterns, which I think we covered in the last scenario as well, which is have there been any concerns regarding the supervisor in other circumstances or in other pairings? And considering opportunities for faculty development, therefore we don't have to put the burden on the trainees, right? Maintain awareness of any disruption of the supervisor-supervisee dyad following this conversation. You know, something that we will have sometimes when there's kind of a little bit of a problem is that all of a sudden the trainee will be like, well, I don't have time for supervision at this point. So I'm very, very busy. So you have to kind of watch out for that one a little bit. And then recognize that the conversation may generate discomfort and help the trainee or supervisor or both process the scenario and essentially encourage these kinds of conversations even though they're difficult, they're beneficial. And then due to the power differential in this scenario, the program director might need to initiate a conversation about implicit bias and microaggressions if you determine that indeed that occurred. So thank you so much. And with that, I will pass over to Amy Murray. All right, so we're going to switch gears. And for this particular one, we're going to talk about telesupervision, which has some unique aspects to it. If you haven't done it, a lot of you probably have, either as a supervisee, as a supervisor. I think this will probably continue to be around. I know there might be some changes and requirements around supervision here soon, but I think it will stay around, especially if we have a shortage of supervisors in our field and might have to reach out to different places to get it. So in this particular scenario, we have a junior clinician who's interested in more in-depth training in psychotherapy and has sought supervision from a senior clinician As part of your clinic's review process, 360-degree feedback is done. While going over a peer review for the junior clinician, you notice that she has multiple critical remarks from her therapy supervisor whom she sees for telesupervision using Zoom. The supervisor notes that the junior clinician does not come to supervision prepared. The supervisor also reports that the supervisee seems to multitask during supervision as she doesn't make eye contact and can sometimes be heard typing. »» Okay. Memories coming up. When you meet with the junior clinician to discuss this further, she reports that she thinks the supervisor is out of touch and offensive. She tells you that the supervisor started their supervision hour while still buttoning up his shirt. She thinks it is completely unfair that he is joining supervision from his vacation home in the woods while she has to be near the hospital for continued on-call duties. She also notes that the supervisor's video freezes frequently and he does not seem to understand how to use the technology. For example, he will refer to a resource and will just try to walk her through it instead of sharing it on screen. She reports that the supervision is nearly useless to her. So she tries to work on other tasks on her to-do list during tele-supervision. All right. So some of that might have resonated with some folks out there, some of those different scenarios. But to get to the first question, what are some of the challenges in tele-supervision that this scenario illustrates? I like this idea of the proactive aspect of getting ahead of it and being mindful about this will probably happen, right? That we will have conflict at some point and how are we going to handle it? And if we do that proactively, then more than likely we can, first of all, that will build rapport in the beginning because we have this discussion about how we're going to go about it. But also if it does come up, we have something in place that it feels safer then because we know these are the steps we take for the conflict. Yeah. I know we're going to... So just real quickly, the last question is kind of shifting and thinking about if this wasn't collegial and that it would be more a resident or a nurse practitioner, something a little bit different than what you might have originally been thinking about in the dyad. Would there be any changes in that? For the sake of time, I think I'm going to move on, but I'll let that be a thought question for you. So some key points in this particular scenario. I don't know that this is as much of a point now, but I still think with upgrades in every technology we have ongoing, like whenever an upgrade happens, I'm like, I hope I still know how to use this, is that there's an acknowledgment of a steep learning curve and that changes happen constantly in technology and how we connect to the internet in different places and knowing all this stuff can be hard and maybe having a conversation about things come up and how we're going to handle it and how we're going to manage it. If you know something that I don't know, please tell me. Being humble about the approach would be important too. If it's possible, provide training in telesupervision and the technology. There are unique aspects of telesupervision that people might not even be aware of. Like telepresence is a concept that is out there and how do you create telepresence? Telepresence isn't something we necessarily learn as we're going through training, but now it's happening quite frequently and so this is the idea of how do you bring somebody into your space when it's in a virtual platform? A lot of people would say like describing your space, what I'm doing. When I look here, I'm actually looking at you and this is what my eyes look like. If I look at a document up here, this is what my eyes look like. So bringing them into the space and explaining. So having people understand these concepts and how we interact with people through the technology and then basic netiquette, right? Can we agree to shut our email down, put our phone somewhere else? How are we going to create the frame and set the expectations of how we're going to interact as if we were sitting in our office together, right? Can we set some of those things up ahead of time? Address the possible avoidance, like there seems like passive aggressive or some sort of avoidance where they're not talking to each other. Has there been a discussion, trying to figure out what's happening there? There's something going on there that seems a little bit unusual, especially in our field I think. And then the last thing, and this came up a few times, is the ability to raise conflicts in supervision is actually a supervision competency. This is something that if we're going to supervise, we need to know how to do, right? We need to know how to model it, how to describe it, talk about it, because as our learners, our supervisees are going into and talking to their patients, they're going to have conflicts and how are they going to learn how to manage that if we're not modeling it and talking about it in supervision? So that's the last point on that. Amber, are you next? Yes. Amber. We're in our final 15 minutes, so you've gotten through the most mentally taxing early morning part of the workshop. What we want to do is wrap up with a little time for individual reflection and thinking about your unique practice environment and your role, whatever it may be. And what we'd like to encourage you to do is just take a moment to yourself and think about what are the most, one to two most important things you learned from this workshop? If your experience at conferences is anything like mine, there's a wealth of things that I want to take home with me and then I often do not take all of them home with me because the rest of life happens and so on. So what are one or two most important points for you and building off of that, what is one new idea you might think about implementing at your home institution? So there might be a measure of actionability that changes from question one to question two, but I'd be curious if anyone is willing to share. And if you're someone who hasn't volunteered anything yet, please feel welcome to start now because there's zero wrong answers to this. So there's a few key points I just want to pull out of that, one of course being the value of actually getting people together. And we talked, you know, like a one-on-one observation, but that just having your supervisors get together to not just talk about cases, but their own supervision is really valuable. To build skills and also to build support too, of course, because it's not necessarily an easy task. And with the question of how do we ensure that this can actually happen knowing that it is not a reimbursable hour of meeting, I would also draw attention back to some of Donna's earliest comments as she was beginning with we do have some evidence that regular and good supervision is tied to improved patient outcomes. And so that's one thing perhaps to draw attention back to if you're in a situation where you're trying to advocate for time for your supervisors to be with each other, be with you as a supervisor of supervisors. Any other comments about important points for you, an idea about implementing something in your home institution, or other ideas about how to support supervisors? I hope that for those of you who didn't want to share that you still have something in your head that you're hoping to take back. So we're going to wrap up, and we talked about a broad introduction to supervision and its importance and the fact that we need to actually structure supervision and education on supervision. And we ran through three scenarios, and there were lots of really great discussion points that came out of each step of the way. And so we just wanted to zoom back and think about big picture overarching across all of these. What are some key takeaways and things that are common among them? So first, supervision is, in fact, a distinct educational activity. It requires planning, it requires learning goals, it requires alliance. Supervisors can benefit from regular meetings to talk about norms and values. And also, we didn't touch on this as much, but also to become familiar with the big picture, other components and expectations of your department or of your training program. Setting expectations is a critical component of successful supervision. Setting the frame. This came up multiple times, whether it's telesupervision or in-person supervision. What are the learning goals? This goes back to the very first one, first scenario, but it came up multiple times in the scenarios. Encouraging self-reflection in both our supervisors and supervisees, knowing that difficulties can come from both sides and often do. Supervision communication and mutual respect are key to successful supervision. That sounds like a no-brainer, but sometimes we really do need to go back to these basics in order to solve some of these stickier issues. And then one final mnemonic that I particularly like, ABC, always be curious. Solving supervisory challenges often involves digging deeper, using a nonjudgmental stance to move forward. So that brings us to the end of our formal programming. And the only thing we have left is questions, comments, any last things that people might want to ask or share. Thank you all. Thank you for your attendance and participation.

psychiatry supervision

supervisory skills

cultural humility

conflict resolution

telesupervision

reflective approach

training competencies

patient outcomes