Delays, Delays, Delays

August 10, 2023 Medicaid Transformation in North Carolina, Part 2

Four years later….

Delays delays delays. 

Finally, with the launch of the standard plans in mid-2021. Patient Health Plan insurance programs.  The role of the Local Management Entities (LMEs) whose populations where to be enrolled in Tailored Plans (and now continue on “standard Medicaid.”)  The collapse of Cardinal Innovations LME.  NC DHHS at “full stop” – after four go-live dates, they no longer giving guidance for when they will activate the Tailored Plan.  The staggered role out of the Tailored Plan and the likely major mistake at the root of the Tailored Plan.   Implications for associate level clinicians finding their way in their careers.

“Capstone or perennial cycle: Supervision after two years of COVID”

I wrote “COVID and Supervision” two years ago.  It is time to revisit that article and add some other thoughts I’ve had.  Thoughts that derive – I say this humbly – from my own idiographic research (no control groups or other comparison groups, no A-B-A-B design) – simple observations.

I’ll say right off: it is still such a pleasure to contribute to the field, to see not only a new generation of clinicians, but to hear from former supervisees, many now well along in their careers, as they let me know of their successes, occasionally request formal consultation, and take advantage of my offer to discuss a crisis or ethical concern. 

I’ve learned a lot from this extended contact, and it has informed my understanding of what works in supervision.  Do you think I’ve learned about what is less workable?

First of all, my judgment about my practice of virtual supervision is, after two years of practice: Still not as good as live supervision.  Especially group supervision.  Comparing two groups live (who are masked, vaccinated, able to spread out in the room) vs two groups virtual, I know myself to be more at ease, more flexible, spontaneous.  Live, the group members are exchanging looks amongst themselves, they lean forward…I have my white board again.  There is more laughter.  My concentration and flow is not broken by scanning postage card (or stamp!) sized icons, sub-par acoustics, and neck pain (I’ve done my best ergonomically, I swear).

Individual supervision through virtual means also varies.  Sometimes there is no diminishment: an especially happy occasion for the supervisee and myself.  This can be described objectively: the supervisee who is prepared and attends supervision consistently helps our collaboration, keeps the Golden Thread of supervision secure.  Supervisees less prepared, in the virtual sphere, I work harder than when less prepared supervisees met with me live in my consultation room.  Past supervision notes must be consulted, more pre-planning is required, cue the Youtube videos, four clicks to get the screen share up and running, please remember to hit the record button.   

And, please recall, I am doing this “isomorphically” (as family therapists would say) as the supervisee is working with their clients virtually.  In psychodynamic terms (parallel process) “As above, so below,” which means, for the hyper-alert supervisor, my own effort must be consistent, even if frazzled.  Yes, for supervisees, early burnout is a recurring topic since 2020, and the need to provide three helpings of support for every challenge is present in my mind and practice. 

Meanwhile, I am training others to supervise and my personal goal is to graduate ten individuals with the North Carolina Addictions Specialist Practice Board’s Certified Clinical Supervisor credential over the next two years, by March 2024. (Score to date: 2 completions, 1 drop out, 5 in process).

Across North Carolina, across the nation, we are needed.

COVID and Supervision

COVID.   What have you been experiencing?

Thrust into delivering digital supervision, I experienced the most anxiety I had in years.

Anticipatory anxiety: I worried about technical details.  Which platform?  Or more than one?  What about on-line connectivity?

Performance anxiety: What should I wear?  How would I sound?  What would it be like watching myself (literally) perform, gazing at that thumbnail.   And the other people – their faceless avatars in Team – how they dress – untrammeled access to how they live.  Did I want to know any of this?

How would we do role plays, especially role plays that would be more active than sitting, being talking heads.  Or did that matter, since after all, the patients and the therapist had the same limits and I should just replicate those limits?  What about my white board!!!???  I’ll need to prepare notes ahead of time instead of surfing the conversation, adding detail to detail in real time; and if I don’t prepare notes, then what?

What about all the questions supervisee-therapists would ask me – about the ethics, the practice, the sheer new-ness of it all, questions that I didn’t have the answers to myself?

Three months later….

Did I mention those web platforms?  I am getting the hang of it, a few hours on Zoom, an hour or two on Doxy.me, two hours on Microsoft Teams.  Practice is making me – us – more skillful.

I think I’m ahead of some people – by no means all the people – clinically – because I had a year of telephone crisis counseling experience and some time working in front of and behind the one-way mirror.   I’ve attended to ‘set and setting.’  For setting – the ambience – I’ve carefully read articles on how to manage lighting, what to dress in (don’t wear white shirts), and selecting your background.  I’ve done my best to apply those learnings.

I’ve sent out more articles and I attend closely to following up from previous sessions’ material.  I’ve gotten into the habit of using legal pads to write notes – it’s simply easier to scrawl something down (rather than use my standard supervision progress note).

I still miss my whiteboard.

And most of all, I miss you.