key: cord-0059000-eoegeb8p authors: Cummins, Leslie title: Supervising Psychiatry Residents in a COVID-19-Only Hospital: A Hall of Mirrors date: 2020-09-29 journal: Shared Trauma, Shared Resilience During a Pandemic DOI: 10.1007/978-3-030-61442-3_5 sha: 749eeedfbbf809b65f69e8564a93c994d1133a46 doc_id: 59000 cord_uid: eoegeb8p Supervising psychiatry residents in an urban COVID-19-only hospital raised several challenges to what can be the tightrope of the supervisory relationship. The potentially thin boundary between supervision and treatment requires constant attention, but there may be times when supervisors are called upon to become a support and an advocate and perhaps more. There could be no time this would become more true than during an international pandemic. The line between supervision and treatment could be constantly and consistently tested, as similar dynamics and a common reality resounded through the various roles and relationships. Social work and psychoanalytic training were essential to walking this line in such extraordinary circumstances by adherence to the principles of both. As in treatment, shared trauma and the required modifications made to the delivery system (telemedicine and tele-supervision) could challenge the frame. Also, as in treatment, adherence to the frame, with enhanced attention to the supervisee’s and supervisor’s own experience, is essential. object; the roles can duplicate, repeat, and distort. The supervisee can overidentify with the patient, the patient with the supervisee, the supervisor with the supervisee and with the patient, the patient with the institution and their patients, and so on in a dizzying array of challenging possibilities. As Arlow (1963) writes, "[t]he phenomenon of transient identification with the patient… is also important in the supervisory experience" (p. 579). The supervisor empathizes with the student and their patient, but, as in ordinary times, the identification must be short-lived to avoid becoming unhelpful or even detrimental. The topic not only addresses the current pandemic but also touches upon what may occur when supervisor and supervisee share similar crises and experiences and highlights the importance of maintaining the supervisory relationship in the face of enormous stressors. However, a situation such as the current one tests all the boundaries. The supervisee needs support, as do the supervisor, the supervisor's patients, the supervisee's patients, and the institution; all as private relationships may be stressed by illness, absence, living situations, and/or relationships. The supervisor may be called upon for more support than usual, perhaps even advocacy, but the role of therapist is still best left to the supervisees' own process and peer groups or other institutional supports. However, the isolation posed by COVID-19 amplifies both the need for and obstacles to this assistance. The supervisor can also, of course, be caught between evaluator and educator status (Knight and Borders 2018; Scharff 2014a, b) , which can pose additional difficulties for both parties. The supervisor may act as confidant but also as reporter to the employing organization; the supervisee needs to discuss openly their difficulties with a case and to show the best work they can. These balances become even more delicate in such an environment. There exists no perfect analog to our current situation, neither is there a perfect blueprint for supervision or treatment. Other fields offer resemblances. Studies of combat trauma usually refer to post-traumatic stress disorder, by the DSM-5 definition requiring 1 month following the event to develop (as opposed to acute stress disorder, a diagnosis that can be made immediately). Disaster psychiatry often requires mental health workers to travel to the location of a circumscribed, discrete trauma. Our current situation has elements of these but doesn't fit neatly in either category. The pandemic is protracted; the enemy is protean, somewhat random, invisible, and inescapable -experienced literally by the entire world. The closest situation may be to mental health care in countries that have suffered years of war and random violence, such as Northern Ireland and Israel. Much of the recent research on trauma treatment comes out of those experiences as well as posthurricane and other disasters, including the World Trade Center incident on 9/11 (Ursano et al. 2007) . The past 20 years has seen a burgeoning literature on trauma studies, with an attendant growth of categories and nomenclature. Trauma, stated simply, is the overwhelming of the ego by a powerful event or experience (Herman 2015) . Largely growing out of disaster psychiatry, war-torn and refugee states, and terrorist attacks, various delineations have been made of trauma's effects on patients and providers. Burnout, compassion fatigue, vicarious trauma, and secondary traumatic stress are all terms that have been used to capture these effects. According to Halpern and Vermeulen (2017) , vicarious trauma is a trauma reaction by a therapist (or other helper) due to exposure to a client's traumatic experience. Its roots can lie in therapist empathy. This means the very quality required for good psychotherapy may predispose practitioners to a traumatic response themselves. These authors define secondary traumatic stress as more pervasive and pernicious, with a direct relationship to post-traumatic stress. In the current situation, there may exist few differences between stress reactions of direct and secondary exposure. For the purpose of this chapter, I will use the term vicarious trauma more broadly to include both definitions. More germane to the current situation is another concept: shared trauma. For Tosone et al. (2012) , the term adds to those listed above, to "describe the entirety of the clinician's experience when living and practicing in traumatogenic environments" (p. 231). Shared trauma refers to the therapist and patient experiencing the same overwhelming events simultaneously. It is important to delineate the differences in the current situation to those giving rise to most of the literature cited. This is not to increase or decrease the significance or magnitude of any of these experiences; it is merely to help further the discussion of similarities and differences in the various types in order to enrich the discussion of the challenges and needed supports in such a fluctuating situation. A brief word about the particularities of psychiatry training in regard to psychotherapy is in order. Psychiatry residents often do not begin outpatient work until their third year of study and therefore have had exposure to complex cases not always found with the beginning psychotherapist or even postgraduate training program candidate. By third year, most have been the audience to significant trauma histories, particularly those working in urban settings. They therefore may not need more "guidance and instruction" (Knight and Borders 2018, p. 25 ) when treating trauma. They usually do, however, have little exposure to dynamic therapy. In my experience, this can vary from one setting to another, but most dynamic exposure to this point has been through didactics and/or the supervisee's own psychotherapy. Even in hospitals that value insight-oriented therapy, the residency consists of students with varied interests and future plans. (In fact, one might take exception to the idea of "trauma-informed care" as an entire category, when psychoanalytic psychotherapy is founded upon treatment of all types of trauma.) The principal program in which I work offers dynamic supervision in an evening clinic that is utilized by both the academic community and the community at large. It is a well-utilized service that cares for people across the diagnostic spectrum. In addition, the psychiatry department began another hospital-wide volunteer service for more focused and short-term help to address the growing mental health needs of medical workers during the pandemic. The department provided its own faculty and students with increased meetings and support groups. At the end of March 2020, at the height of the pandemic, New York Governor Andrew Cuomo appointed the hospital as treating only COVID-19 patients. At the time, more than half (30,000 of 52,000) of the COVID-19 cases in New York state were in New York City. Also at the time, the medical education that could be conducted remotely was moved online. Residents in all specialties were being slated to be deployed to COVID-19 or other floors; psychiatry residents were required to shift their patients to remote treatment. Also occurring were travel bans, quarantine and isolation directives, confusion about signs and symptoms, and the consequent overburdening of all systems at all levels. Stressors were magnified at a residency program that includes many international medical graduates (IMGs). The preexisting potential for high stress of IMGs (loneliness, family concerns, immigration and visa status, language and cultural adjustments, and others) was now magnified exponentially by a pandemic and by a political situation that threatened to isolate them from their countries and families of origin even further (Kramer 2015) . Two physician couples faced the added strain of potentially isolating from their partners or, worse, isolating from and caring for ill partners. Anxiety levels about contracting the disease were high, particularly as the picture of the virus, possible treatments, and preventive measures were rapidly changing. By the end of April, two medicalworker suicides occurred in other New York City-area hospitals, further compounding anxieties among the student practitioners and faculty. Some examples will illustrate the complexity of supervising within the context of shared trauma. A young psychiatry resident has been working for a few months with a resident from another specialty, now transferred to a COVID-19 floor. The treatment had been going well. The resident is a conscientious and talented clinician. He prepares well for supervision, is attentive to the patient's presenting problem, and is attuned and warm, and, pre-pandemic, the patient's initial symptoms of anxiety have lessened and been reframed dynamically, that is, something to be understood, interpreted, and worked through. The resident is adept and interested in the dynamic approach and therefore interested in his own feelings as potentially meaningful about his patient. As can be imagined, the identification that the supervisee has with his patient, another resident sharing some attributes, is potentially complicated, offering opportunity for empathy but also for overidentification and disruptive countertransference. Due to the patient's deployment to a COVID setting, accommodations to his schedule were needed. This, of course, was consented to without consideration or further discussion. I think here we can see the easy slippage between potential overidentification with a patient, between the needed attention to external reality and internal conflict, and between supervision and therapy. Although minor, this became a pattern that soon had to be addressed. The patient requested many changes and additional sessions and grew irritated when they could not be granted, and this understandably resulted in feelings of resentment by the supervisee. To the student's credit, he did not seek the same of the supervisor. What did become obvious, however, were the feelings of inadequacy being induced in the therapist when he could not meet the demands, a reaction possibly sought by his perfectionistic and highly competitive patient. This example brings up two other issues: one is the nature of the helping professional, perhaps especially physicians, and the other is the tendency of the neophyte to underestimate pre-and unconscious pressure. To address the second point first, it was a common question of trainees to understand the necessity for and utility of addressing more long-standing and/or lessthan-conscious behaviors and symptoms of their patients. Often a dilemma for students who are new to dynamic therapy or who are more interested in biological and/or behavioral approaches, the question may have taken on added meaning for even those students who were psychoanalytically inclined: it became a place of rest and resistance. Learning a new approach, its underlying theory, and listening on several levels, in addition to the new stress of teletherapy and pandemic anxieties, became overwhelming. As with the students, I also found myself drawn to a more supportive stance with several of my own patients. (In fact, it was a patient's complaint that I seemed to be talking more than was quite helpful in this realization.) The third-year resident has not yet gained the conviction of the experienced practitioner of insight-oriented psychotherapy that helps maintain the stance of curiosity and exploration. But even the more seasoned clinician could find themselves leaning on supportive techniques to bolster one's own sense of security. The first point is also important and can be intertwined with the second -physicians often have what can become a debilitating Achilles' heel: their difficulty seeking treatment. In his book on physician suicide, Myers (2017) discusses these risk factors. As with other healthcare workers discussed previously, the positive attributes doctors need to be successful and professional, such as drive, high expectations, exacting standards, sensitivity, and altruism, can, under the wrong circumstances, tip into self-destruction. Myers also cites the medical culture of "the special club" and the marginalization of women and minorities as other possible contributors to distress and/or suicide. Perhaps more so than in other mental health disciplines, the stigma of becoming a patient and its perceived (or real) negative effects on records, career advancement, and liability may preclude seeking help. Additionally, the competitive and demanding nature of residency may dovetail negatively with the psychiatry resident's sacrificing, perhaps even masochistic, nature to be exploited by an overburdened system that may abet residents' "unconscious need for martyrdom" (Hashmonay 2020, p. 471) . As Figley (1995) observes, however, there may be a cost to caring, a cost that at times can be tragically high. As with my own patients and like other residents who were now seeking flexibility, I found myself wavering between yielding to the trainees' pressures and the need to maintain the structure and mission of supervision. Complementary to this, I remembered my own experience as a psychoanalytic trainee after 9/11: classes were held by my institute the same week, and I attended in disbelief and anger. At the time, reeling from a close family member's near-miss and my close exposure to the day's events, it seemed to me the epitome of classical psychoanalysis' failure to recognize reality. As with any trauma, it was easy to reexperience that feeling, and I was aware of wanting to demonstrate to the residents that I would not fail in the same way. However, I needed to refind my supervisory footing and remember all I had learned since -that there are many realities and privileging one may come at the expense of others. Some of the same personal difficulties plaguing the supervisee and his patient were experienced by me as well: worries about and separation from family, concerns about my and others' health, and concerns about my practice and my patients. Supervisees and patients did become ill, and I worried about my contact with them before transitioning to remote work. Several patients were medical professionals who were experiencing the same exposure as my supervisees and their patients; the call to support family, patients, and supervisees while experiencing the same anxieties could be daunting. Early on, I felt a fleeting sense of hopelessness and uselessness: what could I do for anyone in this situation so outside of our control? Aside from partially stale bromides, what did I have to offer? As Herman (2015) writes, "[p]sychological trauma is an affliction of the powerless" (p. 33). A regression to helplessness could be dangerously seductive. As carrying on business as usual was critical, there nonetheless needed to be an acknowledgment of a terrifying reality that required at times a more directly supportive stance, with all of whom I worked. Modifications had to be made, particularly with young trainees who not only were new to outpatient and psychodynamic work but also were being put into unknown situations professionally and personally, sometimes without clear guidelines or lines of support. Concurrently, I was working in a way I had previously used sporadically in temporary, sometimes transitional situations. Simultaneously, my practice was also moving online and to telephone, a practice previously held, and valued, in person. This was not only true of work with patients but also with supervisees as well. Walking the line between supervisor, advocate, and therapist threatened to become more complex. This resident's case took on more intense feelings of competition and potential belittlement. The patient, initially presenting with anxiety that was a thin veneer for disappointment with a family that focused on other family members' difficulties, found great solace in her new role as essential healthcare worker. The veiled charges of psychiatry as a lesser medical profession were rife, and my supervisee was sensitive to them. Simultaneously, as a licensed clinical social worker, my role could be seen as even lower on the hierarchy. My psychoanalytic training and supervision experience are the qualifications for my role, but being a clinical social worker in a medical setting could have the potential to fuel feelings of inadequacy in an increasingly dire situation. In another case, a young woman had begun treatment with a resident for intrusive thoughts and separation-individuation issues revolving around romantic and family relationships. Herself the child of a physician, the young woman was struggling against identifications with and the shadow of her parent, while choosing a specialty and training program. The treatment was proceeding well. The therapist and patient had made a good connection, the patient was beginning to see her "intrusive thoughts" as perhaps meaning something true about her relationship, and she began questioning her previously unexamined career choice that had been contributing to her anxiety. COVID hits. The patient's stable and strong physician-father struggled mightily; he was debilitated by a severe depression. As the patient's father, previously seen as an incorruptible model of success and fortitude, became further incapacitated, the patient became increasingly anxious and demanding of the supervisee. My earlier 9/11 memories of the debilitation and destabilization of loved ones resurfaced. The supervisee's world was similarly shaken, as he was put into new situations as was his physician-wife. The patient's situation potentially had too many similarities to those of the treating resident's not to pull on the trainee's insecurities and inexperience: they were of similar age, had comparable family backgrounds and constellations, faced stressors on their relationships, and were enlisted to help struggling family members. A significant difference for the supervisee was that he was now learning and treating in a completely remade landscape, with new demands on and by his partner and her patients. The similarities and difficulties among all involved demanded vigilance. With both these and other medical workers under my supervision, new demands for support and flexibility arose that had been more easily navigated prior to the pandemic. The few previous reschedulings, latenesses, and poor preparation threatened to become the norm. What could more easily be addressed as possible parallel processes, and in light of the supervisee's own educational level, were now overly tinged with reality factors that could blur the treatment and supervision processes. I, too, needed to shift things in my own schedule to accommodate patients' growing treatment needs. It became more difficult to know what accommodations actually needed to be made for residents and how much was coming from anxiety, resentment, overload, and/or true need. Never a martinet in my approach, I found myself bending more than usual; the stressors in my own life sometimes could make it easier to allow for cancellations and rescheduling, possibly threatening the supervisory frame. Further reverberations. Concurrently, I was volunteering to treat healthcare workers across New York state. As this progressed, I found myself further identified with my supervisees as I engaged with healthcare workers in my practice and others now deployed to COVID-19 settings across New York City. Listening to one physician and emergency responder after another recount overwhelming stories of illness, death, family management, frustration, and lack of guidance was overly close to supervisees' experiences at times, as the level of distress and uncertainty was unprecedented. Speaking to patients and supervisees could exacerbate the feelings of helplessness and futility, threatening my own equilibrium. One doctor whom I was seeing pro bono tapped into my own deepest fears when discussing deaths of several young people in his hospital. My own children were similarly aged and, as such, had been more casual and possibly more exposed. Attending to the details of horrifying experiences could become numbing, and I reminded myself more than once that these were not my children, nor were the elderly patients my parents. It was not only heartbreaking to attend to the stories of cellphones held up to a dying patient's ear, of efforts at FaceTime with families of those intubated, and of scrambling to find ways of communication for families with little or limited knowledge of English and/or technology, but it was also frightening. And counseling residents and patients who were now explaining potential death, life-threatening illness, and advanced directives was sad and, at times, angering. Young students, many of whom were not training in critical or emergency care, were struggling with anxieties that resembled my own. Moral injury, not a disorder but can cause negative thoughts about self, others, and institutions and may result in shame and guilt, was everywhere. A treasured colleague passed away, but, aside from peripheral acquaintances, I had not yet suffered the loss or illness of anyone close to me. But having worked at the hospital into the start of the pandemic, seeing several patients who had recently traveled overseas, frequent mass transit use, and other factors combined to increase the anxiety I was treating and supervising in others. There is a growing literature on what has come be known as "trauma-informed supervision." Berger and Quiros (2014) , for example, quoting Etherington (2009) , write that "trauma-informed supervision combines knowledge about trauma and supervision, and focuses on the characteristics of the interrelationship between the trauma, the practitioner, the helping relationship, and the context in which the work is offered." These writers discuss trauma-informed supervision as mitigating against vicarious trauma. They describe the essentials of effective supervision in these cases as bearing the same hallmarks of trauma-informed care: "safety, trustworthiness, choice, collaboration, and empowerment" (p. 298.). Historically, psychotherapy supervision has not been taught. Learning has been akin to that of a guild in which apprentices (trainees) are assumed or hoped to gain enough knowledge and proficiency to practice the skill themselves. Being a competent clinician has presumed competence as a supervisor. It has been argued by many (e.g., Cabaniss et al. 2014; Courtois 2018; Kolar 2020; Scharff 2014a, b) that there be formalized guidelines for training supervisors of psychodynamic psychotherapy. The competencies required of residents and candidates in other training programs should be required in teaching of supervision as well. I believe this may be an important change for several reasons: the efficacy and relevance of the method could be made more evident; the possible lack of structure reinforces ideas of lack of structure of psychodynamic therapy and social work; and it may improve learning outcomes and help with trainee confidence and conviction. The methods suggested by these and other writers are outside the interests of this chapter, but how we become supervisors is relevant in the current climate insomuch as a structured approach may provide important goalposts in an ever-shifting landscape. When a supervisee may be overwhelmed by a patient, particularly one with whom it may be difficult to empathize, I often point them toward the literature that may explain the genesis and possible meanings of the person's behavior. It might be helpful, when the ground is moving beneath everyone's feet, for the supervisor also to have guidelines and educational material to consult. Although of various magnitudes and specifics, we are all having a shared traumatic experience. Add in the varieties of experience, individuals, histories, personalities, identities, and the many permutations of how this pandemic may be experienced, the possible supervision complexities become clear. A young doctor comes to the resident service for symptoms of sleeplessness and irritability. This doctor may match the student's educational status and may be close in age, gender, and background. They are going through the same pandemic, which means they will also be socially distancing, if not quarantining. The supervisor is caring for similar patients, supervising the students, and in the same situation. This scenario can elicit strong feelings in all of us and present temptation to cross the boundary into familiarity, casualness, and over-involvement, if it does not affect us traumatically, as well. Group meetings with academic and professional colleagues were key to maintaining the conviction that even, perhaps especially, in an unknowable situation, I could be of help. Volunteering to offer counseling through various organizations and institutions was also beneficial. A large supportive family hedged against threatening despair. Maintaining as much stability for myself, patients, and supervisees was essential; and remaining as true as possible to the frames of these relationships was more important than ever. Training as a social worker and psychoanalyst, which could be seen as obstacles in postgraduate medical education, equipped me with balancing the roles as teacher, advocate, confidante, and support of the residents under my supervision. Flexibility and understanding were key as residents were deployed to medicine units or scheduling challenges arose. As I and supervisees faced the shift to remote treatment, we became students, together, of a method somewhat new to all of us. Listening actively, not only to the content being presented in supervision but also to the supervisee's experience, is vital. Social worker training is concerned not only with the patient but also with the supervisee within their environment. As some residents became ill or suspected they were, they became cut off from their families, either domestically or internationally, and were moved to units they had little or distant experience with, all the while attending to their psychiatric duties. This called up a strong maternal feeling for each of them. As with any reaction, I had to understand my responses as understanding something but also as a potential for inhibiting other responses, such as resentment or hostility. Further, I could not let external forces foster dependence or prevent the residents' own "theory of mind" from developing as an unfortunate and unforeseen consequence. Psychoanalytic training privileged the emerging affects and unconscious expression in the supervision. I held the belief that adherence to theoretical constructs steadied me, as I simultaneously had to consider its defensive aspect. Both taught me the importance of tending to the roles of provider/providee, which were consistently challenged, knotted, reflected, and refracted. Supervisor and the supervision need to mesh and complement each other during such a time. Prescriptions to one's patients need also to be made to oneself and one's students. These could include the usual recommendations such as meditation, mindfulness, journaling, and/or any of a host of customary behavioral interventions. However, some of the same suggestions could not be instituted -contact with loved ones could only be virtual (or not at all), helpful routines had to be abandoned, and formerly communal and spiritual activities could only be practiced alone. The effectiveness of cognitive restructuring appeared to have limitations in the face of the reality of the unknown and unknowable, when news could worsen from day to day. Scheduling, short-term projects, and virtual socialization were added to the arsenal of self-care. As a therapist and as a supervisor, however, one is obligated not to relinquish their roles nor their theoretical underpinnings. Perhaps regardless of theoretical approach, it is essential to adhere to the principles that one teaches at any time, to any trainee. Good psychotherapy supervision aids the resident in understanding the patient and the content presented; this requires theoretical grounding and a similar formulizing ear to the supervisee's material that models for them their way of listening to their own patients. The material the patient is presenting remains the focus of supervision, and students are helped in learning how to reframe and think of the patient, their difficulties, themes, conflicts, and other presenting material in terms of the theory and practice being taught (Shanfield et al. 1993 ). However, it may never be possible to steer clear completely of supervisees' personal dilemmas, perhaps impossible during a shared trauma. Indeed, I would argue it would not be indicated. According to some (e.g., Jacobs 2016; Scharff 2014a, b), the limitation may be neither simple nor in order. It is incumbent upon the supervisor to point out blind spots and consistent technical missteps to the supervisee: they owe it to the student and the patient. The current situation may call upon the supervisor to share their own experience in an effort at normalizing or empathizing with the trainee's experience. As with a patient, it is my experience that considering self-disclosure occurs proportionally to the gravity of the event or affect and, as such, should be weighed significantly before undertaking. And, as with a patient, self-disclosure in supervision should be done only toward a clinical end. Generally, I confine the definition of self-disclosure as being useful when it is of one's own reaction to the patient in an attempt to shed light on relational or defensive patterns and amplify the patient's sense of themselves and their inner and outer worlds. In supervising during the time of COVID-19, some sharing of the challenges to the role of the therapist has been in order with students. They have needed to see, while also being reassured and modeled for, that there is a recognition of our new reality. The supervisory situation is complex (Jacobs 2016) . It needs to move between roles within the relationship. As such, the supervisor must be aware of the special educational and sometimes personal needs of the student. There is an overlap here that cannot be avoided. In an organization, the supervisor may be a representative of the educational body, while also encouraging the student to grow through didactic processes, studied introspection, and self-knowledge. During a time of shared trauma, the supervisor also needs support, perhaps from the same body as the student, in addition to their own systems and loved ones. The containment function of supervision (Pisano 2014 ) may become even more pronounced, but it needs to be for the supervisee, not for the dyad nor the supervisor. As per Arlow (1963) , "in therapy, the patient oscillates between experiencing and reporting, while the therapist oscillates between identifying with the patient and observing him. During supervision, the therapist recapitulates this oscillation of roles" (p. 581). In the potentially disorientating oscillations of a global pandemic, technical and theoretical grounding is paramount to maintaining the stability of the supervisory situation. The supervisory situation Supervision for trauma-informed practice Using learning objectives for psychotherapy supervision Trauma-informed supervision and consultation: Personal reflections. 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