not-yet-known not-yet-known not-yet-known unknown Outcome and Prognosis Fast forward, Brian has now completed seven sessions with Jerimiah. I thought I would conclude here with a short vignette of DP and the SSM in action, from a couple of weeks after Jerimiah’s reporting S/I. What this vignette illustrates is that Jerimiah and Brian are just on cusp of getting underneath some of the sadness that exists under Jerimiah’s anger. In Brian’s supervision with me, DP and the SSM provide us with a set of exciting tools for the excavation of underlying feelings (Goldman, Vaz & Rousmaniere, 2021). By closely monitoring Jerimiah’s OQ scores Brain was able to “catch” his S/I in a timely way that allowed for a frank conversation about Jerimiah’s overwhelming distress. With video we were actually able to see the precise moment sadness emerges (Haggerty & Hilsenroth, 2011) and with the SSM I have a framework for direct feedback on what to do and what not to do with this delicate vulnerability and with DP Brian can practice the skill before he returns to his next session with Jermiah: [After watching for about five minutes, I pause and walk Brian through the SSM which is now front and center on the screen.] Jason: Okay, so here is what I think is happening. Notice how he is saying that he is completely inundated with life. What I think is happening here, and I think we both agree on this, is that he is not leaving any room for anything other than being reactive. He is constantly on the outer edge of reactivity, it’s like he is constantly being poked and has to react. He always has to stay on-guard because people are constantly encroaching on his space. In staying on-guard, hypervigilant, he never has time to look internally. When Jerimiah does this. You said [in your Supervision Preparation Form] that you see him looking sincere but not really going anywhere with that sincerity. I think he looks reflective, is starting to get sad and that he is starting to feel a feeling other than anger. This is good news. I think that he is recognizing, “wow, I’ve been so inflamed with the outside world that I never get to look inside and feel what is going on for me and I think that we can… Brian: [Interrupting me] So, I, in a way, missed that opportunity and we could have gone into what he was feeling right then. Jason: Exactly! It’s interesting to watch here… [I turn my screen back to the video of Jerimiah and Brian’s session and by narrating over the video I am able to show Brian, by pointing out Jerimiah’s facial features and body language as the sadness emerges and then turns back to anger.] Jason: If we watch him here he looks sad. He’s still sad here. His head is down and his eyes look a little watery. Now, he leans back in his chair, looks up and seems to go into his head. He seems to remember something to be pissed off about. Yep, he’s got something… Jerimiah: Yeah, that’s why when I was in school and people would ask me what I am doing with my time, it would be the same thing. It would piss me off. I’d ask, “Why are you worried about where I’m going?” Jason: See he’s angry again. He’s got another bone to chew on. We have to find a way [turning my screen back to the SSM] to practice helping him to know this sad and reflective state that is starting to show up in his therapy. That is the task, to help him out there. Brian: That’s so interesting how you pointed that out. He felt the feeling, leaned back, went into his head and grabbed something to be mad about. It’s like you narrated it. You could see it happening. That’s pretty cool. Jason: Yeah, it is cool. Let’s practice! [I stop sharing the video and just Brian and I are on the screen. I decide that this skill is going to be best rehearsed through roleplay because, by playing Jerimiah, I am going to be able to give Brian multiple opportunities to catch me in moments of sadness while the video only had one short moment.] This case illustration of the Sentio Supervision Model (SSM) shows, in our view, the supervisee’s development as a therapist and how the client is benefiting from his therapy. We see in the practice setting Brian’s growing ability to exert gentle pressure as a therapist and how it can act to encourage Jermiah to deepen his emotions past anger into places that bring up sadness and possibly loss. We believe that the nuance captured on video, the timely use of the outcome measure and the specific DP skill rehearsal provide Brian with a valuable learning experience that will help him to be a better therapist not only Jerimiah but across multiple clients. Jeremiah’s objective outcome scores over the course of his 9 sessions, assessed via the Outcome Questionnaire (OQ)-45.2 measure, are another reflection of how therapy and supervision provided a container to expand his tolerance of overwhelming feelings. The first time Jerimiah filled out the OQ at intake, he scored a 73 (“moderately high” distress level) but did not report any S/I. In his second session this score dropped to 62, which may be attributed to the relief of having talked to a therapist. It was in his third session that he reported S/I and his OQ score jumped back up to 73. Jeremiah and Brian talked about his S/I and, in the subsequent session, his OQ dropped all the way to 53 which we might attribute to the relief of having expressed his feelings in a safe place with Brian. Since then, Jeremiah’s baseline score has seemed to settle in at 65. Importantly, over the sessions the client has changed his self-report of S/I from “sometimes” to a steady “rarely”. This result suggests that targeted supervisory and skill building focused on the client’s suicidality may have had a positive impact in decreasing this particular client risk factor. We also chose this last vignette because it illustrates that DP and the SSM are not static models that require a cookie-cutter approach to being a supervisor (Levenson, 2024). Early on, I (Jason Brand) followed the SSM model as closely as possible because of all of the technological moving parts and specific instructions. As you can see above in my use of targeted roleplay and not video, I am getting more comfortable with the model and have (mostly) figured out the technology, I am increasingly discovering that outcome measures, video recording, the practicing of micro-skills, the SSM and DP are helpful containers for the spirit of a certain kind of learning. This learning is about paying close attention, not indulging in interesting distractions, facing hard challenges in an approachable and safe environment and ultimately a mentor/mentee relationship that furthers creativity through practice. With this in mind, I have been able to make the SSM and DP more my own and Brian has learned to provide better help to Jerimiah.