Hi, everyone, welcome. Thank you for joining the third national conference on advanced and early psychosis care in the United States presented by SMI Advisor. My name is Dr. Olodunyi Olowoya, and I will be your moderator today and moderate in this session, which is titled Coordinated Specialty Care, Managing Teams Remotely During Times of Uncertainty and Change. I would like to introduce you to the faculty for today's session, Ms. Catherine Adams and Dr. Iruma Bello. Ms. Catherine Adams is a social worker who is based in Michigan and has over 30 years of experience as a clinician and a manager serving consumers with mental illness and their families. She has been a project director for multiple national research endeavors and is the co-owner and clinical director of ETEC, Early Treatment and Cognitive Health, which provides RAISE, Navigate Coordinated Specialty Care interventions and cognitive behavior therapy for psychosis. Dr. Iruma Bello received her doctorate in clinical psychology and she is a practicing clinical psychologist. She is based out of New York and is responsible for developing and implementing strategies to support the dissemination of the OnTrack New York treatment model for both in New York and across the United States. It is my pleasure to introduce both of these speakers for today's presentations, and none of these speakers report any relationships with commercial interests or conflicts of interest. And so I will now turn it over to Ms. Adams for her presentation to commence this session. Well, thank you very much for that introduction and welcome everyone to this topic. I did want to share before I leap into the learning objectives a couple of observations I've made attending sessions myself. And in particular, I've noticed that the chat is very lively. It's invigorated, it's passionate, it's affirming. And I found myself feeling very hardened by that because it seems to reflect to me an energy of transformation and healing. And you know, when I think about how many people are attending this conference, I think it's somewhere in the neighborhood of four to 5,000 people. That feels like a small compassionate army to me that I hope we're kind of arming ourselves with information and attunement personally and professionally. And hopefully we'll take that into a next step in terms of transforming things and healing. The other thing I've noticed is there's a lot of echoing between all of the topics. And what I've made of that is that I feel like we're at a time when we have been largely silent about some of these issues. We've been socialized, many of us, to find talking about race uncomfortable and to have a certain amount of anxiety about racial difference. And so I think hearing things in various ways from various perspectives with various voices is really an important part for me as a learner of an important part of unlearning and relearning and figuring out how to move forward. So I'm also enjoying kind of all of the different perspectives and the kind of review and reinforcement of the information we're all learning together over these two days. So for us today, our learning objectives are to describe changes in team functioning associating with the rapid pivot that we made to using technology, how we've had to come around managing the impacts of COVID, and how we've had to integrate either as a new practice or hopefully just expand an existing practice of explicit discussion on race and culture. We're also going to look at strategies that team leaders can employ to support their teams in trying to deliver coordinated specialty care in this new way, facilitate dialogue within the team around the impacts of COVID and trauma and cultural dynamics that we're all experiencing, and to oversee team members are utilizing principles of cultural humility when delivering those services. And last, we're going to spend some time looking at particular supervisory strategies that we hope can help with team building and team cohesion during times of uncertainty and stress and change. Next slide, please. So quick poll here, and I want to preface the poll by saying I know this is not an exhaustive list of the challenges that we're all experiencing trying to do this work and lead and manage during this difficult time. But these are a few things, team morale, your own morale, accountability, engagement, retention, and logistics. And I'm hoping we could just all take a minute to think about which one of these, if you had to choose one, which one rises to the top for you? And then Aruma and I can be thoughtful about making sure we emphasize some of that in our talk today. So if we could activate the poll, Chris, that would be great. And it'll be in your poll button, I believe. Yes. Well, okay. So yes, you click on show more in that button and that should allow you to make the choices there. We'll just give that a second. And then I think Chris is able to share the results with us. Very curious about what people are finding most challenging right now. Okay. Okay. So let's see, Chris, does it look like that's working and people are able to access that? If yes, could we show the results of that? Okay. Looks like, ooh, there's some neck and necks here. So team morale at 26%, your own morale, 21%, accountability, 13%. I'm sorry. Engagement, retention at 29%, and logistics at 11%. So three of them kind of very close, but engagement and retention proving to be especially challenging for people. And I'm looking forward to talking a little bit about that. We have found that to be the case too, especially now it wasn't originally the experience. It seemed like the novel approach of telehealth was attractive to some people once we problem solved, you know, barriers that might get in the way of that. But now we're noticing some, I think we're weary of it. And so certainly that is a factor for us as well. So thank you for participating in that poll, everyone. Next slide, please. Okay. So at the best of times, this is hard work. Susan Gingrich talked about that in her acceptance of the Larry Seidman award this morning. It's really can be incredibly hard work. For me, it's my end destination in my career. It's what I found to be the best fit for me. But it is challenging. And so right now, however, these are not the best of times even. So we're facing a global pandemic, financial crisis, personal crisis, and work crisis. So there's so much weighing down on our work lives and our personal lives right now. The shift to telehealth for most of us was rapid, and there was little time to prepare. Many of us, I'll speak for our sites, we did not have the infrastructure for it. And in Michigan, we went from one day being in the office to the next day being out of the office. So there was a lot of rapid adaptation that we had to take care of. And then we're all faced and exposed and aware of police brutality and racial injustice and justice being at the forefront of the national conversation. So these are all impacts that we're managing right now. Next slide, please. So challenges within team functioning, working from home and moving to that telehealth, I think continues to present challenges for people, even though most of us are past that initial pivot. Not sharing an office space is really difficult. Not having access to that informal interaction, that being able to trot down the hall, consult with somebody, debrief, de-stress, share a victory, something you're excited about, that is much harder to manufacture and create in this virtual world. I think for a lot of us, the lack of separation between work and home is proving a challenge. Many of us have our kids at home. Now we may be facilitating their homeschooling. Our partners may be working from home. Some families have brought home an older adult to get them out of harm's way where they were living. So there's a lot of shifting going on at home. And I think it can be hard to make the distinction of where one starts and stops. One of my staff had a clever idea where at the end of her workday, she drapes a beautiful cloth that she found along some world travels over her desk to really signal to herself that she's done and she needs to stop. Figuring out how to best use technology and support the team through technology can be a challenge. I think we all have varying proficiencies and comfort with technology. And it's important to know that about yourself and your staff. I'm working with one mom, a participant's mom, who in her workplace, it wasn't comfortable for her to come forward and say she really didn't get some of the technology and she felt ill-prepared. And so I think we need to create that safe space for people to let us know what's difficult about that in terms of the team functioning and to do what we can to support that. And then this is the biggie for me, and Aruma is going to spend a fair amount of time on this, managing and paying attention to collective grief and trauma. I think it might be a bold assumption, but I think that many of us came to this work because of something in our own story. And so that allowed us to be empathetic. It allowed us to be mindful, thoughtful, present with people, and yet kind of in their own journeys. But this feels different to me because this is a real-time shared collective experience. So oftentimes you might be screen to screen with somebody who's talking about a challenge that they're having, be it a team member in a supervision or somebody you're supporting in the program itself, and they're experiencing the same kind of difficulty that you're experiencing. So it feels very different to me to sort out how to navigate that and how to support our teams, how to understand it within ourselves, and kind of handle it in the clinical realm. Next slide, please. So in the context of team functioning, this is just a closer look of some of the dynamics and dilemmas. Staffing issues are proving to be challenging, not only with regard to turnover or staff changes and how do you manage training and retraining. For us, you know, training has always been a lively, robust, mutual kind of participatory experience. As you know, being on this this venue right now, that's a lot harder, that you can't have the exchange, you can't have the back and forth in the real-time collaboration and sharing of wisdom and all of that. So that's challenging. How to recruit for positions can be a little challenging, and how to kind of target to create a diverse market workforce. We just had a great presenter on that, so I came away with a bunch of ideas there. I think the next two bullets are about how do you support your team on managing what may be their own personal struggles as they figure out how to balance and work and home, and how to problem solve when they themselves may be feeling stressed and depleted, and how to help our participants and their families problem solve as, again, that collective experience of this moment in our lives. That disconnect from typical social networks because of social distancing, whether those be our work networks or our home networks, I'm a huge believer in the need across humanity of belonging, and I think it's much harder to have belonging in this version of life. It just really is, and the isolation and the apartness that we all feel has a widespread impact and a deep impact for us as we try to do our work. Another tricky thing has been developing competencies for certain positions, certain team members, certain roles on the team have shifted because of the economy and telehealth, and the ones that rise up for me are the supported employment and education role as well as the peer role. Those roles were often very active in the community. A lot of that work was delivered right out in the community or in participants' homes, and while some sites have gone back to some face contact outside with distance and PPE, for Michigan anyway, the weather's changing and we're not going to have that option, so we have to pivot again. We have to figure out how do we do these things, how do we job develop, how do we connect with employers, how do we support school and academic success and all these new versions of how that's happening for people. Another thing that I felt just recently so aware of was the challenge for prescribers to fully evaluate side effect burden or side effects using telehealth platform, and I think we've got this square of each other, and yes, you can ask somebody to do different things to get a better assessment, but I think it's challenging, and when someone was in for their meds this week, which we are still running obviously our face-to-face med clinic, I was struck by some side effects he's having that I don't think were visible just in this version of a telehealth appointment, so I think that's another area we need to pay attention to. And then participants' and families' needs have shifted particularly in communities of color. We've been learning a lot about those impacts, and we'll learn more from Aruma in a bit, but I think we have to make sure that our teams have access to that knowledge, that they have an awareness of how to move into that space and look into those kind of dynamics and be informed. This graphic just breaks it down a little more specifically to the impacts created by COVID, social distancing being one that we've talked about, PPE, obviously we're providing it to our teams, but do the people they might be working with have it? Can they afford it? How do they feel about using it? How does your team feel about using it? As Susan said, Susan Gingrich earlier, we all come from different perspectives and different viewpoints, so we have to kind of be thoughtful about that. Hospitalizations feel very different to me, and the best version of it, it's a traumatic experience. This is not the best version of it. This is frequently leaving a person at an ER without family able to go back with them. Once they're admitted inpatient, visitations were always clunky in my view and not available enough, and now it's even clunkier and people have to visit with their family member through a Zoom platform. They're not able to hug that person or offer support in the normal ways that they could previously, and I think that's a real devastation and heightens the trauma of that whole experience for families, but also for us and for the caregivers within the hospital. It's hard to watch people not have access to the people they love. That's a very hard rule and line to enforce. Death is certainly something that some people are facing. I have a few statistics about that in a second, but I think it's also loss and how to navigate losses in general. All the changes are a form of loss. Child care, what does that look like? Some of us don't have access to it anymore. It looks different. How do we support our team members and even participants and families in problem solving and figuring out how they can access child care during this time? Some team members on some teams actually had to redeploy to medical units, to spaces and environments that they never imagined they would be working. It wasn't what they signed up for. It wasn't what they thought their position would be looking like, so how do we support them and help them navigate the reactions they might be having to that? Then just again, an appreciation and awareness of what's going on in communities of color, activism and protests, disproportionate health and economic impacts, which are pervasive, and lack of resources and under-resourced opportunities. That was a lot, but I think it's reflective of all that's going on. I think for some of us, we've hit a pandemic groove. This is a good fit for some people. They like the telecommuting. They like the freedom. I think it works well because some people are working more in the evening than they would have otherwise, and it's accommodating for the people we're working with. There's certainly research that suggests that productivity is enhanced in some telehealth ways, and some departments at community mental health organizations, not so much clinical, but finance and other departments are actually shifting the whole departments to permanent telehealth, so obviously it can work. For some people, it's a bit of a groove. I think some of us have hit a pandemic wall. We feel depleted. We feel weary. We feel discouraged. The uncertainty is weighing us down, and I would put myself in that category at different times. Then, some of us are spiraling down, and I would attribute that to a couple things. One, I think when we're face-to-face with people, there's a feedback loop that happens that allows us to feel competent and like we're helping people or we're not helping people, and we need to adjust. I think this version of things, it's harder to get that loop, and it's harder to really develop the relational exchange and the development of ... I'm just making sure that nothing's going on because I'm hearing a little something. Okay. I think it's important because some people, and you guys endorsed it in the poll, the highest thing was retention and engagement, and I think when we're not retaining and engaging people, it causes some of us to call into question in our clinical prowess what we're not doing well enough, and I think it's important to understand where you and your staff are in these three bullets and also to understand that nobody hangs out permanently in one of these places. We probably drift around in these places, and it's helpful to zero in on where people are in terms of the impact of this experience. Next slide, please. Okay. Hopefully, this looks familiar to people. This is a tool and a graphic that we use a lot in our program to help families and young people understand some of the relationships between stressors and coping and when we're beyond our capacity, so knowing what your threshold is for stress and how do you, what can you manage, what's your buffer zone, and when have you exceeded the buffer zone, and right now, we've got a lot of faucets turned on at once, kind of filling our bucket, and I would say it overflows from time to time, and so it's helpful to understand what are the reactions to that, how are we coping in ways as teams, as organizations, as individuals that are not so helpful, and what can we do as teams, organizations, and individuals to have more adaptive, helpful coping? How can we support each other in that way? So I think this can be a useful exercise for teams and for individuals to kind of zero in on what are the contributors to stress right now, what faucets are turned on full blast, how do we turn those down, and how do we cope, how do we enhance our coping? It's also good practice because a lot of us, you know, we're facilitating this with young people and their families, an exercise like this, and it's good practice for that as well. Next slide, please. So these are just some ways that, and this is a place where I'm hoping people are really going to flood the chat with some of your own ideas because I think this is where imagination and reinvention comes into play. How do we stay connected in this time where the ways that we're attached to each other are very artificial and distant? I think some things we've done in our programs is I've sent out affirmations and self-care reminders in the mail. This is a picture one of my staff took after they received one of those. It was just a small note telling them that I was thinking about them, missing the face-to-face version of them, and sending them love and support, and it was also just a little aromatherapy thing. I heard from every person that day that received it appreciating that I had sent that, and what that told me was people are longing to feel connected again, that we don't like this detachment, it's not natural, it's not healthy for us, and I think getting something in the mail was a helpful thing, something unexpected, and it wasn't, it was low cost. We still are trying to virtually celebrate staff birthdays and participant milestones and birthdays. We do a thing in our team meeting called a peace sandwich where if we were together, we'd kind of layer our hands together with the person who was having the birthday. We would share affirmations about them, what do we appreciate about them, what do we cherish about them, what do they bring to the experience, to the people we're serving, to our teams, and I have to say those are usually tearjerkers on our team because people really like to feel connected in that way. We've also observed participant milestones, graduations, and things that have been happening in spite of COVID. And for those, we'll do handwritten cards. We had insomnia cookies delivered to people who had a milestone. And if any of you have insomnia cookies out your way, who wouldn't want those showing up on your porch? They're pretty good. We have virtual coffee hours, no agenda. The attendance is voluntary. Just come as you are, share what you need to. We've been fortunate to have team mindfulness coaching twice a month. We have an outside person come in and coach us on being mindful. And for me, that's just about slowing down, being still for a minute, turning off a lot of the frenetic thinking that's going on and the list making and other things that I'm doing and kind of just centering myself. And that, again, has been good training. And that is available to our participants and their families as well. That's been good training for us as we teach others how to have a mindfulness practice because there are such understood benefits from that. We also have mindfulness minute or three to five minutes actually to start our team meetings. Again, that rotates. It's helpful for people to practice that so they can share it with others. We try to find opportunities for humor that's sorely missing from these other platforms. We have a text chain that we use. We've done a game night using Jackbox, I think it's called. We hosted a book club. We read Glennon Doyle's Untamed. And now we have a twice every two weeks race and racism conversation. We're sharing articles, books, Martin Luther King's speech we watched. I would highly recommend a recent documentary called The Post-Racist Planet. And then talking about those very openly and hopefully bravely about those things. We were able to offer a really moderate technology stipend to support people in getting a printer at their house or other technology that would take out barriers to them working from home. People have taken their chairs home. Simple things like that just to have some accommodation at home so they have a comfortable ergonomic chair. And what I've learned in being type A, I always am learning it, is to be flexible, be flexible, be flexible. This is not a time when preserving the status quo or precedents are going to bear well or be helpful to people. So, next slide. Right here, I am delighted that we're going to have a few minutes to watch this video that was prepared by one of the teams at OnTrack New York. We've talked a lot about connection so far and how that's really challenging right now. And they created this video to share with their participants. And I'm already percolating my own version of it because I think it's such a great idea. So, have a look at this. Days are good, and that's the way it should be. You sprinkle stardust on my pillowcase. It's like a morning brush across my face. Nights are good, and that's the way it should be. You make me sing ooh, ooh, ooh, la, la, la. You make a girl go ooh, ooh, ooh, I'm in love, love. Did you see that shooting star tonight? Were you dazzled by the same constellation? Did you and Jupiter conspire to get me? I think you and the moon and Neptune got it right. Because now I'm shining bright, so bright, bright, so bright. And I see colors in a different way. You make what doesn't matter fade to gray. Life is good, and that's the way it should be. You make me sing ooh, ooh, ooh, la, la, la. You make a girl go ooh, ooh, ooh, I'm in love, love. Did you see that shooting star tonight? Were you dazzled by the same constellation? Did you and Jupiter conspire to get me? I think you and the moon and Neptune got it right. Because now I'm shining bright, so bright, and I get lost in your eyes. Did you see that shooting star tonight? Were you dazzled by the same constellation? Did you and Jupiter conspire to get me? I think you and the moon and Neptune got it right. I think you and the moon and Neptune got it right. I think you and the moon and Neptune got it right. Because now I'm shining bright, so bright, bright, so bright, bright, so bright, and I get lost in your eyes tonight. Okay, so thank you for that, Kathy, and I want to thank the Best Self team for letting us share that video with all of you guys. Somebody mentioned that in the chat where there's this idea around being creative and the more creative that we could get during this time, which is hard to do, I think the more that we can stay connected not only to our program participants and their families, but with each other. We know that a big part of coordinated specialty care and what makes us really effective in delivering these interventions is being able to work as a team and having that really strong team cohesion and team connection and conveying that. So this video is just one example of that. I'm going to continue now talking about some other strategies that could be helpful in supervising your team and helping with some of that team cohesion. So next slide, please. One of the things that we keep going back to and talking about is the use of technology, and it's been a steep learning curve, I would say, for all of us in trying to really move towards using technology with our participants and our families, but I think another piece that has become central and so important for our teams is using technology amongst ourselves in order to facilitate some of that natural interaction and some of that natural energy that gets created within coordinated specialty care. Some of the ways that some teams have recreated this and us at OnTrack have implemented some strategies to be able to stay connected in a less structured way are through the use of instant messaging, and sometimes it's through the Microsoft Teams app, for example, keeping that open. Some teams I know are able to use Slack so that you don't have to formally write an email or necessarily set time aside for a phone call but can quickly connect around things. The other thing that has become really important is using screen sharing features, using video, and being able to have multiple team members, the same way we would have done it in an office setting where you would maybe participants and families would meet with more than one team member at a time, or as Cathy was referring to, you would jump into someone's office to kind of discuss something. Having any kind of virtual sort of setting like this has been quite helpful with maintaining some of that teamness. I know that one of our teams specifically shared with us where they created something similar to a waiting room, but it's a virtual waiting room using Zoom, and I think it's breakout rooms, and people come in, they can connect with each other, but then also different team members can go into the breakout sessions and meet with people jointly. Other things that I think become really important, and a lot of CSE teams might have this already, but it's sort of becoming more robust, are the use of blogs, the use of Facebook groups. Some of our teams are doing gaming groups, and then doing that amongst your team, doing that as team activities to help boost morale and boost some of that, reduce some of the stress I think that we're all encountering nowadays, and the more that we are able to take care of ourselves, and the more available we are for our participants and our families. The other piece is that we want to leverage technology, we want to use video, but we also know that there's a lot of Zoom fatigue. When you're on video all day long, we're not used to that, we're used to interacting in person, so there has to be a balance of also taking breaks from video and using other strategies to connect as a team. Next slide please. So, the most important thing that I've noticed in working, our OnTrack network has 23 teams, so we've encountered a lot of different strategies that different people are doing and implementing in order to get this work done, and in order to stay connected. But I think one of the biggest challenges we're all facing is the learning curve for how to use technology, how to use different platforms without robust training, without robust sort of examples, and a lot of this just takes extra time. So, some of the things that we have seen work is when people practice using the different platforms, sometimes you'll have one platform that your agency allows you to use, sometimes you have to use multiple ones depending on what's available for others. So, as a team, putting time aside to practice these, understanding the different features that these offer so that you're just not using phone, so that you're just not connecting with each other, you know, without screen sharing. Some let you work on documents together, show graphics together. So, it becomes really important to spend time practicing how to use these because then I think that translates to being able to use them during your, when you're providing the coordinated specialty care treatment strategies. Using your meetings with your team, supervision meetings, team meetings, as opportunities to practice and getting creative around technology, I think, becomes super important because it allows you to prioritize the needs of your team, but then also allows you to model as a team leader some of the ways in which you expect your team to use this to deliver services. The other piece is to discuss barriers to technology and try to find workarounds or ways as best as possible to support people in their use of technology. Sometimes it has to do with software or hardware. Sometimes it's just not being sure how to click and how to make something happen. So, usually having someone who's designated to help with these things beyond the broader IT department, somebody within the team taking on a little bit of understanding and relaying some of this knowledge to the rest of the team members could become really, really important. I think to the extent that we feel comfortable with technology as providers, we'll be more likely to use it in our work day-to-day and moving forward with our participants. And the reality is, is that we've almost like opened up Pandora's box of technology in some ways, where I don't really foresee the use of technology and delivering care of services through telehealth going away 100%. So, I think it's in all of our best interests to get really familiar with it, but then also use it as a strategy for connecting with each other and for enhancing coordinated specialty care services. The other piece that could be really helpful is spending some time developing checklists for a workflow, developing how-to videos on how to use this technology and then adapt as needed, particularly with a lot of our on-track teams where we're seeing shifts in work where sometimes they're in the clinic, sometimes they're at home, sometimes only part of the staff is coming back to the clinic, part of the staff is able to do community work. So, there's all these continuous adaptations with COVID that are happening, and as the country opens up and shuts down in certain areas, we're always sort of recalibrating. And technology, I think, is our friend in being able to stay working as a team. Next slide. So, now I'm going to switch gears a little bit and talk about trauma and grief. And Cathy alluded to this, right? This whole idea that part of what's happening because of the state of things and with COVID-19 is that there's just collective trauma that we're all sort of faced with and just a sense of grief and uncertainty that I think permeates our entire culture at this point. Next slide, please. So, here's a quote that we found. Though no one's individual situation is the same, the COVID-19 pandemic has created a shared human experience of remarkable uncertainty, isolation, and hardship. It comes with fear, confusion, worry, despair, anger, and loss for us, for participants, and for families. So, that's sort of the backdrop of what we're encountering, what we're working under. We're all under a lot of stress, and it's something that needs to be sort of acknowledged and assessed within the team, not just towards or for participants and families. So, it's not something where we can separate ourselves. And then you compound on that the extensive trauma related to racism, oppression, health disparities, and how we're seeing certain communities of color getting impacted at disproportionate rates. And it just really blurs these lines between us versus them. A lot of these ideas of boundaries, of being empathic, as Cathy was saying earlier, it just becomes something that we're all grappling with very similar stressors compounded on top of the typical stressors of our lives. So, the idea that all of your team members are going through this, and it will impact their work, and it will impact the way that they're carrying out their competencies, and it will impact the way that they're relating to each other as colleagues. So, it becomes really important to pay attention to this. We see that searching for terms related to stress, anxiety, trauma, suicidality, et cetera, have risen sharply. And many of us are very concerned about COVID. And, you know, it's sort of the second track that's always going on as we hear personal experiences of people who we care about. And we love getting impacted by some of these things. And then, in addition to that, having to do your job, which is already a really hard job. So, as a team leader, or when you're trying to manage a team, and you're trying to support all of this, and doing it remotely, it becomes really helpful to have some kind of working models to help you navigate this. So, next slide, please. So, the idea is to be really mindful of the stress reaction. And you'll have these slides, so you can go into all the details. But stress reaction examples, you know, related to COVID-19 could impact people's confidence, increased anxiety, helplessness, depression, and grief. Next slide. It could impact levels of anger and levels of guilt. Next slide. And the idea is to be really mindful that your team might, on the one hand, be experiencing a ton of compassion fatigue, right? Burnout and secondary traumatic stress leads to exhaustion, feeling overwhelmed, a lot of sort of feelings of anger, frustration. And then, work-related secondary exposure to stressful events can lead to compassion fatigue, problems sleeping, having images pop in your mind. Your team members are struggling. And then, some of the value that we get from the work that we do can hopefully balance some of this out, right? Finding strategies for helping others through our work, feeling positive about our colleagues, and feeling like you're making a contribution to help balance that by increasing compassion satisfaction. But that requires being really, really clear that you're doing this and being really mindful of how to do this. Next slide. So, there's a model that shows the way that all of these things work together. And the idea is that as you're trying to keep in mind when you're supervising your staff members that there's all of these contributors and that they're not unidirectional, but rather the more that somebody develops some compassion fatigue, the more that then we need to bolster the compassion satisfaction piece of things. Next slide. And we can really draw from recovery, right? So, what are the things that help? Sense of safety, calming, connections, self-efficacy, and hope. And I think this is what Cathy was really drawing from when she describes all of these activities that she's been doing with her team, the way that the best self team, the on-track team that developed that video, like these are the things that I think people are tapping into in order to make sure that they have scaffolding and strategies for dealing with the stress and then being able to be in a more mindful, calm place to be able to do this really hard work. Next slide. And now I'll hand it back over to Cathy. Yeah, and I'm going to move pretty quickly through this. This is kind of just to sum up just reminders about self-care and what it's not. It's not beating yourself up when you're not doing it. It's not putting it on a list and having it have that kind of bearing in your life. It's understanding, and like Aruma said, across the whole dynamic, across our whole community, our teams, our participants, our families, that we're doing the best we can. We need to do a little bit of an inventory, I think, and let go of practices and habits and mindsets that aren't supporting us, align our lives with our values, and treat ourselves with self-compassion. I think recognizing that a lot of different selves are at your table. There can be an anxious and a worried self right now. There can be a frustrated self. There can be a depleted self. Be sure to leave a chair at your table for your compassionate self and learn to cultivate and care for that part of yourself and to encourage your teams and your participants to do so as well. Next slide. This is just a quick visual. I'm not going to go into depth. Again, as Aruma mentioned, these slides are available, but the quarantine question posted, some of you may have seen this. We've done this a couple times as a team, just a kind of a grounding exercise, a reminding exercise. I will just point out that there's been some research about gratitude and that the act of searching for gratitude in and of itself can release endorphins and serotonin. You don't even have to find gratitude. You can be having a crappy day, but the act of searching for it can be helpful. The self-care wheel, what I love about this is it covers a lot of self-care domains and it gives a lot of great ideas, things you or your teams or your participants may not have thought of. Take a closer look at that and consider bringing that into practice somehow. Next slide, please. All of this, we've talked about caring for your teams. I think it's important for supervisors. I think Aruma was on a recent meeting where she checked in with supervisors about their own self-care practice and most found that they had kind of let that go for themselves, so good reminders there to look inward and take care of yourself, but also how do we bring that into the realms for participants and families? How do we validate their experience of grief and trauma during a pandemic? How do we prepare them for the losses, perhaps even through death, you know, through anticipatory grief? Some of our team members might not feel real honed in responding to grief, so it's important to make sure they have that skill set and can invite and create an open path for people to have these explicit discussions about how this is affecting their lives. Next slide, please. So, cultural humility. We're going to spend the rest of our time kind of looking at this, you know, how do we facilitate, introduce, ignite, grow conversations around race and social justice? Next slide. Social determinants of mental health, this is definitely something that's getting echoed across all the presentations, so I'm not going to spend a ton of time on it. I think we're all aware that social and economic conditions can directly affect the prevalence and severity of mental health conditions, and those are circumstances like poverty, income inequality, interpersonal and collective violence, and forced migration, undersourced things, lack of affordable housing. All of these things disproportionately affect minority communities, and studies have indicated that that leads to an increased prevalence of mental health challenges there. These increases can be a consequence of discrimination, exclusion, cultural interpretation of symptoms or a combination of these factors or others, so it's really important that we inform ourselves about these social determinants, and I think then paths become clearer, things we can do. Next slide, please. So this graphic, you're definitely going to have to, I had to make a cheat sheet because the writing on it is small, but what I love about it, and I'll just sum it up real quickly, is that it really illustrates well how complex social determinants are and how multidimensional they are, and you'll see these different domains of it, so social determinant domains are demographics, economics, neighborhoods, environmental events, and social and cultural contributors, and then there are proximal factors, which are things like age, race, and ethnicity, safety and security, trauma, distress, individual social capital, social participation, and those, I would say that we do an okay job kind of touching those, I hope we do, in terms of our early kind of getting to know a person and our assessment process, but I would also say that most of us, we have a cultural competency training, we have prompts on our intakes around cultural consideration, hopefully a lot of us are using the cultural formulation interview, but most of those are client-facing things, and I think what we need to think about is those, are those distal factors, how to take what we do outside the walls of our treatment settings and into the one I'm going to spend a little time on in particular is neighborhoods. Next slide, please. So neighborhood-level socioeconomic deprivation is strongly associated with, in particular, psychotic disorders, but also depression and common mental health disorders in young people, and those are related, again, to life stressors that have been mentioned all throughout our couple of days together, exposure to violence, underemployment, under-resourced facilities leads to increased vulnerabilities, living in an urban environment has been reported to increase risk of developing schizophrenia, and racial segregation and community instability are associated with depression and psychotic disorders. So all of these things, these unequal effects of structural racism have a persistent influence, and these are through things like redlining, housing discrimination, underfunded schools, underfunded health care, lower wages. And so it's really important that we tackle some of these things and that we open our eyes to what's been going on for, as I said, centuries earlier. And I think one in four black Americans know someone who's hospitalized or died from COVID. Job losses, pay cuts, and hours cuts disproportionately affect minority groups, with 61 percent of Hispanics having dealt with that, blacks 44 percent, and white Americans 38 percent. Underfunded communities are less likely to have financial reserves, they're less likely to, they're likely to lose insurance and have no access to restoring it, and 54 percent of black Americans are employed in low-wage jobs with usually no benefits and in essential positions that are more likely to be exposed to COVID risk. In Detroit, we sadly lost a bus driver who was doing his job and making people's lives run smoothly and was exposed to COVID and died. So I think it's really important when we think about these racial issues and community instabilities that we're considering how COVID has taken a bad situation and magnified it in great measure and how can we use that awareness to make changes and be a vehicle to that kind of, to relief and to change in those policies and things that are impacting that. One little bright note is that a high density of particular ethnic group may have benefits for individuals of that ethnicity, has a protective quality that can reduce the risk of psychosis, depression, and anxiety, and that's related to social support, a sense of belonging, shared common language, and a positive self-evaluation. Next slide, please. So in particular, a lot of this will be reviewed for you, but I just want to touch on a couple things. Psychosis is a syndrome and a collection of symptoms, not a diagnosis, and I think since we have learned through the last day or so about the misdiagnosis and the overdiagnosis of schizophrenia in minority communities, especially black communities, we need to be really cautious about assigning a label. Five to 10% of adults, 15 to 18% of children and adolescents experience either auditory or visual hallucinations. I think that's an important statistic to normalize this experience and to know that it's important not to rush to pathologizing. In the U.S., approximately 100,000 young people a year with psychosis, three out of every 100. That equates to about 274, 275 people a day. Think about that across our 50 states. There's people out there in distress and suffering. We need to do better at creating pathways to care. And so in our neighborhoods, I think what we need to do is turn toward the neighborhoods and go beyond those kind of proximal factors and get out into neighborhood communities, we need to shed that kind of sense that we have authority or importance or knowledge to bring in. We need to understand that we have things to learn and we need to kind of enter those communities with humility and learn together and discover together what makes CSC service attractive, what makes it adverse, what are the repellents or the deterrents to getting care, and how do we adapt the care so that the pathway is easier to step upon. Peak onset occurring between 15 and 25 years of age, definitely derailing social, academic, and vocational developmental strides, and maybe putting someone on a path to accumulating disability. We certainly want to not only inform ourselves about ethnic and racial cultural considerations, but also about youth culture. So take a deep dive into youth culture, understand how to make your systems of care, your programs, your staff, that got mentioned on the last webinar as well, attractive to youth, youth centric, youth friendly. And one of the things that I think it was one of the speakers yesterday said is that it's important that we have knowledge, but it's important that we know thyself too. And so I think that's a really important part of this process is kind of that attunement to our own. I've learned some things have cropped up for me in this last day and a half that I need to further examine. So I think that's really important part of this process. Next slide, maybe Arumah. Yes. So I'm going to hand it over to Arumah. Thanks, guys. So as Cathy was saying, it becomes really important to understand individual culture. And what we mean by individual culture, all of those elements that contribute to each person's identity. And mental health is one piece, but there's a lot of other pieces, right? There's race and ethnicity, there's gender, age, SES status, religion, all of these things end up impacting. And we have a really good way of thinking about this for our participants and our families. We have tools to help us understand this. But there's an added layer where cultural competency, as we have come to embrace it and coordinate its specialty here, feels a little insufficient. Next slide, please. So that's where cultural humility comes in. And it's the ability to maintain an interpersonal stance that's other oriented in relation to aspects of culture. It's different from cultural competency, because as Cathy alluded to this, it's a co-learning. It's the idea that we're learning from each other what is important. And it really requires an awareness of historic realities, an awareness of structural racism, an awareness of systems of oppression, an awareness of just the historical context under which different groups have come to be in order to really understand what is in front of you in the moment. Next slide. And the idea is that this is not only true for the people that we serve. This is also very true for our team members, for ourselves. The culture of us as providers delivering the treatment can definitely influence the way it's delivered and how it's received. Culture includes each team member's social cultural background, their respective professional disciplines, the organizational culture of your agency or the system under which you're working. And it shapes the way in which providers interpret the views of the participants and families, their ability to accept explanations that are radically different from clinical ones, and their ability to effectively communicate with participants and families. So here we're really shifting and putting a spotlight not only into the idea that, yes, coordinated specialty care is the foundational pieces of this model is to be culturally competent, but to rather shift that focus to how are you and your team members developing an awareness of your cultural stance. Next slide. So here's some strategies. How do we do this on a very practical level? So clinicians can do some of their own work to understand their own biases and their worldview. We have to start from a premise that there are biases, that we all have bias, and that we all are have been formed under a system that has sort of a very Western centric way of understanding the way things should work. And this influences the way that we are trained professionally, the different identities that we take on. And it also shapes how we understand our place in the world. Therefore, when we're relating to other people, if we have a good grasp of where we're at, what our blind spots are, what our biases are, then we're better able to understand how we're relating and understanding the experiences of others and what we need to do to really connect and use cultural humility to provide better care. So the team members should engage in an ongoing process of self-reflection, which will help make explicit their perspectives and conceptualization about the psychotic experiences of their participants. So really it's connecting how do you think about the world and how is that influencing the way you're conceptualizing your work with the people that you're working with. And you should consider and engage in discussions to explore how your own culture, your own personal organizational professional culture shapes and informs this view. Next slide. So one way to do this, you might set aside intentional space and time, and some other speakers have definitely alluded to this, to identify what are the stereotypes that you hold on to? How do you manage new information? And how does this contribute to sort of reinforcing the biases that you bring to your work? And then how do you practice some self-reflection? Then individual team members could ask themselves questions. And here are some examples of some of these questions. What do I think is happening to this person? What do I think is most troubling? Why do I think that this is happening? What do I think is the help that she needs or he needs? How are my own professional experiences, personal experiences shaping my views? And having a discussion as a team about these things could really impact and shape the way in which you're relating to each other and help make you more culturally aware of the things that are influencing your work. And then as you're bringing this into your team discussions, it becomes part of how you're thinking about it. And slowly it helps to undo some of these racist beliefs and practices that are just part of the way that we think about the way the world works or the way that we think about disparities or don't think about disparities across different groups. Next slide. So some takeaway points from the whole presentation, we really tried to focus on how can you so support your team? What are the ways in which you can support your team that really require extra effort because of added stresses of COVID-19, added stressors of just all of the attention and energy that is getting sort of focused right now on social justice issues and that we need to really spend some time thinking about these things on top of everything else that we are thinking about in order to deliver really good care. And then we're all doing this in an environment where we're socially isolated, where we're disconnected and we're kind of just scared and uncertain about what's going to come next. So make sure that when you are thinking about supervision, when you're thinking about team functioning, when you're thinking about coordinated specialty care, you're adding on practices of self-care explicitly. You're encouraging and giving teams bandwidth and latitude to practice self-care. Finding fun and creative ways of connecting can pay off in dividends. Brainstorming and adapting strategies to meet the needs of your team members and service recipients. So this goes back to like the idea of being super flexible, being accommodating, thinking that there's a lot of different ways to get from point A to point B and we're going to be open to trying different ways. Create space and practice using technology because that's really difficult for most of us. It's a new world when it comes to technology and our young people can really benefit from services using telehealth. Create spaces for dialogue about grief and loss, create space for dialogue about race and culture and understand that you need to do your own work to understand your own positionality to be able to then help others with these issues of social justice. And then support your team in having these conversations with participants and families. The idea is that the team does their own work and then this gets conveyed to the people that we work with. Thank you, Ms. Adams and Dr. Bello for this wonderful presentation and we have about ten minutes to get in a couple of the questions from the audience and to have further discussion. So one of the questions was in relation to self-care and this is directed at both of you. How can parents really do self-care when kids are at home as well? I think there was discussion in the chat that was really talking about this integration of the home life and the work life and so can you talk a little bit more about potential strategies that we can use especially because the home and the work environment have kind of collided head-on. Well, Ruma has a two-year-old at home so I'm going to let her take that. Yes, I do. You know, it's tough as a parent, right, and it's tough when you're trying to really practice self-care. But I think that's where, and I apologize I see a little bit of a lag in my video, but I think that's where we have to be really creative. What does self-care mean? Does self-care really mean, as they were saying in the chat, taking a day off? And for some of us that we might be able to take time off and disconnect. I know that I'm rarely able to because of my two-year-old and I don't have a lot of family support where I live. My family lives in a different state. So for me, all of my free time is spent with my two-year-old. But other ways in which you can practice self-care is you need to identify for yourself what are those things that really help you calm down? What are those things that really help you disconnect? And sometimes that is separating yourself from others. But maybe for me, sometimes that's leaving my two-year-old doing something and even if I'm in the same room, I'm focusing on something else and keeping her distracted. I think parents have an extra challenge nowadays because of the whole uncertainty, fear of COVID, but also just the idea that kids aren't in school, typical systems of childcare are not in place, and there's no one in sight. So just getting creative, sometimes even having socially distant play dates where my toddler can run around and I can connect with another parent with a mask on has been a form of self-care. But it's really, really tough. I think another thing, just thinking of one of our participants who has two young children and a very kind of demanding life between her work life and her home life. I think for her, we've brainstormed with her like who's in her bubble, who's in her safety bubble in terms of people she would trust and feel comfortable with letting come in and give her an hour away. And she has identified a friend who she feels really good about that friend's safe practices and her brother. And so she has been able to carve out a little time by just really kind of taking an inventory of who's in her bubble and who is she comfortable kind of allowing into that space to support her own self-care. Thank you. Thank you. We have another question. I hear a bit of an echo, but another question was, one issue we face is working with clients by phone because they do not have access to video technology when the client might be struggling and yet they don't, we can't put their eyes on them. How can we get a better assessment in terms of working with technology? And I think a lot of what you both spoke about was the integration and the use of technology and how technology is not going to go fully away, especially with telehealth after we get past this time. And so how do we, what are some strategies in terms of engaging families and individuals and then how can we do best practices with using telehealth? Just one little quick thing I'll offer is that we had some consumers in that situation as well, didn't have the resource to access technology. Everything's on the phone, very hard to evaluate as that person mentioned, the distress that's going on or kind of do any kind of mental health support evaluation, but we were able to uncover in our region, some resources to help get people technology. There are some resources that are part of, might be the CARES grant or something coming down where we were able to get people access to smartphones, even a computer. Now getting sustained internet, a lot of these grants only offer like three months of internet and then the person has to be able to self-sustain after that. But I do think it's a real challenge to evaluate someone without the use of video. I think maybe it's, it could be important to touch base with family or somebody who maybe has worked with that person longer and might be able to pick up some of the nuances in their verbal way of putting things and what you can make of that in an assessment fashion and really drawing in. I think it's so important that we have collaborative relationships with families right now to fill in some of those gaps of the limits of the technology or people with not full access to the technology. And the other thing I didn't mention is the reason I'm in the office today is rural communities have sucky technology. I could not do this webinar from home because of the internet. So I think, and that's especially true in impoverished communities, rural communities. So I think kind of continuing to advocate along those lines for people. I think there was another part of that question, Aruma, did you pick it up? Wasn't there a second part of that? No. No. I think the only thing that I would add is, and it really just depends on your agency rules. What we've seen is a ton of variability where some agencies are letting their staff see people in person, some agencies aren't. So for those participants who can only be used via phone, if you have the ability to have at least one team member set eyes on the person, sometimes it's the nurse who's providing the injections. Sometimes there's somebody in the office that you can partner with and it's usually part of the medical team leveraging that resource. The other thing I've seen done for those agencies that allow it is seeing people socially distanced in the community. So they are not going back into the office, but they will have like a visit with someone at a park, taking a walk, wearing masks, socially distanced, at least lay eyes on people. But it's a huge challenge. No, thank you both for that. I think that it is a big challenge, especially when you start to think about the different communities and connectivity and access to a lot of resources that I think that we are all struggling with because everybody is on it. Even in this, like we see glitches with that. And so really jumping through those hurdles as providers using that technology and even facilitating that conversation with individuals and their family members to get them more comfortable with using different technology and finding alternative strategies is really important.

Coordinated Specialty Care

Remote work

COVID-19

Team support

Cultural humility

Self-care

Social determinants of mental health

Racism

Flexibility

Open dialogue