Sharp HealthCare's APA-accredited doctoral internship in clinical psychology provides soon-to-be psychologists with a yearlong, in-depth training experience.

Each intern rotates through three of eight settings/programs. The training program on each rotation was designed by psychologists who either manage the specific program or provide service within that program. At Sharp, we have two child/adolescent rotations, two general adult rotations, two adult SUD rotations (one split with adult assessment) and two gero rotations.

At the beginning of each of the three rotations (R1, R2, R3), interns complete a self-assessment of competency in clinical psychology and review it with their primary rotation supervisors. This (and all) intern assessments are built around the nine profession-wide competency domains identified by the American Psychological Association’s Commission on Accreditation. A rotation-specific training plan (RTSP) is discussed at the outset of R1, R2 and R3, and modifications are made to reflect the intern's special interests and developmental needs. This personalized approach allows each intern the maximum benefit of training on any given rotation. Each intern receives a minimum of one hour per week of scheduled, face-to-face, individual supervision with their rotation supervisor. Daily contact and feedback is also the norm.

In addition, every intern meets weekly with the training director for one hour of individual supervision and one hour of group supervision. Psychodiagnostic and assessment supervision occurs both within the rotations and in weekly seminar/group supervision with the assessment supervisors. APA Competency Domains include:

• Research
• Ethical and legal standards
• Individual and cultural diversity
• Professional values, attitudes and behaviors
• Communication and interpersonal skills
• Assessment
• Intervention
• Supervision
• Consultations and inter-professional/interdisciplinary skills

Rotations and supervisors.*

• Child and adolescent (inpatient): Child and Adolescent Program (locked inpatient unit), supervised by Kelsey Bradshaw, PhD
• Adolescent (outpatient): Adolescent-IOP, supervised by Andrés Ruiz, PsyD, and Jennifer Wojciechowski, PhD
• Adult (inpatient): ICU and general psych (locked adult inpatient units), supervised by Garrett Work, PhD
• Adult (outpatient): Cog-IOP (Intensive Outpatient Program), supervised by Katie Spaventa-Vancil, PhD
• Adult/SUD (outpatient): Sharp McDonald Center Intensive Outpatient Program, supervised by Siri Hadland, PsyD, and Austin Slade, PhD
• Split Rotation: 50% Adult Assessment/50% Inpatient SUD, supervised by Mary Beth Bryan, PsyD, and Kelsey Bradshaw, PhD
• Gero (inpatient): Senior Behavioral Unit, supervised by Lynn Northrop, PhD, and Kimberly Mathis, PhD
• Gero (outpatient): Senior Intensive Outpatient Program, supervised by Kim Schulz-McGlenn, PsyD
• Psychological assessment: all interns perform assessment throughout the year across rotations; adult and geriatric assessments are supervised by Mary Beth Bryan, PsyD; child and adolescent assessment is supervised by Kelsey Bradshaw, PhD, Andres Ruiz, PhD, and Jennifer Wojciechowski, PhD

*Sharp is fortunate to employ highly qualified psychologists, many of whom are active contributors to our psychology training program. The supervisors listed here are current as of Oct. 19, 2021, but may or may not be those assigned to a given rotation at all times.

On all rotations, interns are in regular contact with their rotation supervisors and are mentored by these psychologists and other clinicians on the team. Several of our programs utilize a group co-therapy model. Interns work alongside staff psychologists and other professionals creating a rich and rewarding training experience. On each rotation, interns are part of a team of professionals working together to meet the needs of each patient. On the inpatient units, these teams are highly diverse, in terms of professional discipline. Interns have the opportunity to learn about/from/with colleagues in medicine, nutrition, social work, recreation therapy, music therapy, spiritual care, nursing and more. On the McDonald Center and Adult Cognitive IOP rotations, interns also have regular contact with postdoctoral fellows.

Rotations span the developmental age range and involve four main populations: child/adolescent, adult serious mental illness, substance abuse disorders and geropsychology. Each population has both inpatient and outpatient rotations.

Child and adolescent rotations.

Child and Adolescent Program (inpatient)

On the third floor of the Sharp Mesa Vista Hospital CAP Building, you will find the 23-bed Child and Adolescent inpatient unit (CAP3). CAP3 is divided into two patient treatment programs: an adolescent intensive care unit, treating acutely disturbed adolescents and dual-diagnosis youth, and a program for children ages 5 through 12. CAP3 treats youth who are experiencing impairment in their family, school or health functioning as a result of psychiatric illness. Typical presenting problems include depression/suicidality, runaway/conduct disorders, substance abuse/dependence, mood disturbance/behavioral disturbance/bipolar and/or the acute phase of a psychotic disorder.

The CAP3 rotation will familiarize interns with the developmental tasks and issues facing youngsters, and with how psychopathology becomes interwoven with such developmental issues. In the context of a shorter stay and the increasing severity of patients' disturbances, interns learn how to set appropriate acute-care treatment goals and disposition planning and learn how to use the program milieu to achieve these goals. Interns help facilitate a weekly family support group for parents and family members to learn about safety planning, communication and methods to support their child or adolescent in recovery. Work is fast paced, exciting and high demand. Interns on this rotation are expected to multitask and have balance.

Interns will gain didactic and clinical experiences in these clinical issues:

• Case management skills
• Chemical dependency treatment with dually diagnosed adolescents
• Cognitive-behavioral treatment with youth
• Crisis intervention with youth and families
• Developmental tasks of youth
• Group psychotherapy with adolescents and latency age children
• Inpatient management of acutely disturbed youth
• Multidisciplinary team approach
• Psychopathology of youth

CAP3 strongly emphasizes a team approach in which psychologists, psychiatrists, nursing staff, social workers, activity therapists, teachers, consulting staff, the patient and the patient's family work together on treatment goals. Interns become an integral part of the treatment team during the rotation. Interns serve as co-therapists in a variety of groups, serve as a liaison between staff and consulting psychologists and participate in treatment planning and treatment conferences, attend team meetings and in-service presentations and provide informal consultation to other staff.

Adolescent IOP (outpatient)

Child and Adolescent Outpatient Programs are housed on the first floor of the CAP building at Sharp Mesa Vista (aka CAP1). The Adolescent IOP intern’s primary post is in the Adolescent Cognitive Intensive Outpatient Program (IOP). The intern also has opportunity to gain experience in the Adolescent and Child Partial Hospitalization Programs and the Changes IOP (adolescent dual recovery), if it is in line with training goals.

The Adolescent Cognitive IOP provides treatment for mental health and chemical dependency issues. Patients receive evidence-based (CBT, DBT and ACT) group therapy, individualized psychoeducational skills (e.g., anger management, assertive communication, impulse control, self-esteem, body image, etc.), family therapy, multi-family group therapy and individualized case management. Family involvement is a crucial part of treatment and includes parent education and skills as well as mandatory weekly participation in multi-family group therapy and monthly family therapy meetings. The program provides a safe alternative to hospitalization and serves as a step-up from traditional outpatient therapy or a step-down from inpatient, RTC or PHP levels of care. Typical course of treatment is 3 hours per day, 3 days per week for approximately 2 months.

Outpatient CAP psychology interns participate in a wide variety of activities to learn about adolescent development, the nature of adolescent psychopathology and the interaction between the two. Interns conduct individual, group, family and multi-family therapy as well as intake evaluations, suicide risk assessment and safety planning. Group is often delivered using a co-therapy model (i.e., two therapists in the room), and there are opportunities to shadow supervisors and receive periodic live supervision in all clinical activities. Additionally, interns participate in department-wide measurement-based-care initiatives to evaluate IOP’s effectiveness for individuals and across patients and demographics. Findings allow for guidance and enhancements in IOP structure, curriculum and other program improvements efforts, which interns participate in alongside program staff.

Interns receive gain didactic training, supervision and direct experience with these clinical areas:

• CBT, DBT and ACT
• Suicide risk assessment
• Safety planning and means restriction
• Developmental tasks of adolescents
• Psychopathology of adolescents
• Chemical dependency treatment with dually diagnosed adolescents
• Family systems theory
• Family therapy
• Group psychotherapy with adolescents
• Multi-family group therapy
• Intake evaluations and triage
• Measurement-based care
• Program development
• Program evaluation and improvements
• Curriculum development

CAP Outpatient Intern hours are subject to change to best meet the needs of patients. The A-IOP is an afternoon/evening program. It is likely that at least two days per week, the CAP Outpatient intern will work from 11 am to 7:30 pm.

Adult serious mental illness rotations.

ICU and South Rotunda (inpatient adult)

The ICU and South Rotunda (SR) are two adult locked psychiatric units designed for individuals experiencing an acute phase of a psychiatric disorder. The ICU/SR  rotation provides clinical experience in the evidence-based treatment of patients across a broad spectrum of age and diagnoses, including psychiatric and substance abuse disorders. Working alongside the unit psychologist, interns provide evidence-based psychoeducation, group therapy, individual therapy and brief assessments.

This rotation will develop the intern's ability to effectively and quickly conceptualize and treat a challenging caseload of individuals who have multiple presenting problems. Interns will have the opportunity to conduct brief psychodiagnostic assessments to answer questions from the treatment team. These brief assessments are approached with a therapeutic assessment lens whenever possible, actively including the patient and the treatment team in better understanding and treating the individual. Additionally, interns will be actively engaged in program development, as ICU/SR psychology programming expands to meet the needs of this dynamic population.

Given short hospital length-of-stay, interns are faced with rapid patient assessments and formulate effective interventions to stabilize disequilibrium. By the end of the rotation, interns should be able to efficiently assess a patient with regard to differential diagnosis and with regard to particular strengths and weaknesses. Interns will learn to effectively communicate about these assessments with other interdisciplinary team members. Interdisciplinary collaboration is heavily emphasized in this rotation, and side-by-side work with social work, nursing, recreation therapy, psychiatry and peer support is encouraged and expected.

During the rotation, interns will be offered educational and clinical experiences in the following areas:

• Adult psychopathology assessment/diagnosis and treatment
• Brief, targeted assessment
• Behavior modification
• Brief crisis treatment of individuals, couples and/or families
• Electroconvulsive treatment (ECT)
• Group therapy process
• Program development
• Interdisciplinary treatment team approach
• Seclusion and restraint issues

Cognitive-Intensive Outpatient Program (outpatient)

Sharp Mesa Vista Hospital offers a Cognitive Intensive Outpatient Program (Cog-IOP) for high-functioning patients whose symptoms are not severe enough to require hospitalization, but who need more structured and intensive treatment than general outpatient therapy can provide. Patients may be admitted directly into Cog-IOP, or it can be used as a step-down program from inpatient care to facilitate the patient's transition back into the community. This program utilizes the principles of cognitive therapy in the treatment of depression, anxiety, panic and post-traumatic states and co-morbid personality disorders. All groups use a co-therapist model. Case conceptualization and intervention in this program is heavily influenced by the work of Aaron Beck and Jeffrey Young, among others. The team includes psychologists, psychiatrists, psychiatric nurses and social workers.

The goals of this rotation are to familiarize interns with the principles of cognitive therapy and to provide them with experience in applying these principles to a population with mood, anxiety, thought and (co-morbid) personality disorders. This is achieved through participation in group therapy, education groups, clinical team meetings and supervision. Interns may also be able to participate in couples or family sessions. Some interns participate in Cog-IOP's sister program - the Dialectical Behavioral Therapy-Intensive Outpatient Program (DBT-IOP) where there is also a postdoctoral fellow on the rotation. Upon completion of the Cog-IOP rotation, interns are expected to be able to conceptualize patients from a cognitive perspective, co-facilitate cognitive group therapy and clearly present educational material on a variety of topics related to cognitive therapy for depression and anxiety.

Interns will gain didactic and clinical experiences in these clinical issues:

• Assessment of suicide risk
• Cognitive group therapy
• Cognitive model of psychopathology
• Cognitive therapy for anxiety and panic
• Cognitive therapy for depression
• Cognitive therapy for personality disorders
• Interpersonal processes in cognitive therapy
• Multidisciplinary team approach
• Schema-focused therapy

Substance use disorder and assessment rotations.

Sharp McDonald Center — Substance Use Disorder — Medication Assisted Treatment Intensive Outpatient Program

Sharp McDonald Center provides comprehensive, evidence-based treatment to chemically dependent adults. It is San Diego's only freestanding, fully Joint Commission-accredited Chemical Dependency Recovery hospital. All programs operate out of two buildings and include three distinct settings that have areas of integration, including medical detoxification/residential, partial hospitalization and medication-assisted intensive outpatient programming. The Sharp McDonald Center is .7 miles from Mesa Vista. SMC interns attend group supervision and other meetings at Mesa Vista throughout the week and must have their own transportation available.

The treatments provided at the Sharp McDonald Center are evidence-based interventions for individuals with substance use disorder diagnoses. The therapeutic services serve those who are not so at risk that they require an acute medical or psychiatric hospital stay. The programs treat patients who are able to function in a subacute inpatient, partial-hospital or intensive outpatient setting.

Residential, partial hospital and intensive outpatient programs are abstinence-based and facilitate sober living skills, requiring these adults to take responsibility for self-maintenance and maintenance of their environment. Sharp McDonald Center provides daily therapeutic programming to provide continuity of care and to maximize clinical gains.

Sharp McDonald Center interns will receive training and experience with the following:

• Evidence-based behavioral
• CBT and ACT group and individual therapy
• Comprehensive psychosocial assessment and treatment planning
• Discharge planning
• Exposure to patient placement guidelines for the American Society of Addiction Medicine (ASAM) and Utilization Review
• Family therapy
• Program evaluation and development

Sharp McDonald Center interns work side by side with experienced professionals from several disciplines (e.g., psychologists, postdoctoral fellows in clinical psychology, licensed clinical social workers, marriage and family therapists, CADAC counselors, psychiatrists, chaplains). They provide group therapy and carry a caseload of three to five patients for individual therapy, comprehensive case management, utilization review, family therapy and couples sessions.

Split Rotation — Inpatient Special Projects and Assessment

For the assessment portion of this rotation, the intern will spend approximately 16.5 hours a week performing assessment-related activities. The intern will receive inpatient and outpatient testing referrals that may involve assessment of cognitive/intellectual functioning, neuropsychological functioning, daily living skills, psychological functioning and/or personality. The intern will learn and administer assessment measures, conduct clinical interviews, consult with treatment providers, obtain collateral information, score and interpret test results, chart on testing progress, write brief summaries and/or full integrated reports, and conduct feedback sessions. The intern may be asked to research certain topics related to their case to help inform aspects of their assessment — such as battery selection, differential diagnosis, and EBT recommendations.

The intern will be closely supervised and highly supported in this role, but also autonomous. If cases are low, the intern may be asked to assist with program development tasks (e.g., adding to the recommendations library, researching updated measures and norms, creating sample batteries for specific referral questions, monitoring inventory). Dr. Mary Beth Bryan will be the supervisor on this half of the split.

In the current training year, the “Inpatient Special Project” on which interns will focus relates to the identification and treatment of SUD across adult inpatient units at Sharp Mesa Vista. This rotation is new in the 2021-2022 training year, and is launching at a very exciting time. As a department and as a hospital we are venturing into a process of trying to better understand and better meet the needs of people who come to a psychiatric hospital with Substance Use Disorders. We have data to show that SUD are a part of the picture for many of our adult/gero inpatients. For some, the SUD is clearly “primary.” For most, it is heavily intertwined with other behaviors and other “disorders,” and the words “primary” and “secondary” bring to mind a chicken-and-egg kind of mystery. What is increasingly clear is that across all the inpatient units, we can do a better job conceptualizing and supporting the recovery of people for whom SUD is a part of the story. Historically, psychology has not been centrally involved in SUD treatment at Sharp Mesa Vista. We are investing resources (a half-time psychologist and half of an intern position) to change that. Interns on this rotation will work closely with Dr. Curci and Dr. Northrop and will be involved in both direct clinical service and systems-level activities (needs assessment, lit review, program development, outcomes evaluation, staff training). It is likely that this “special project” will be in play into the 2022-2023 training year. However, it may finish sooner than anticipated. What is certain is that the interns who are assigned to this rotation will be a part of the team identifying the next “special project.” Some we have considered include increasing the department’s ability to assessment outcomes in inpatient behavioral health (i.e., measurement-based care) and building out our ability to support all units in “positive behavioral support.”

Geropsychology rotations.

Sharp is proud to be one of only a few non-VA, APA-accredited doctoral psychology internships in the U.S. that offers multiple geropsychology rotations. Our clinical practice and training programs are in line with the philosophy and recommendations set forth in the APA Guidelines for Psychological Practice With Older Adults and the Pikes Peak Model.

Senior Behavioral Unit (SBU, inpatient)

At Sharp, we are committed to meeting the needs of the rapidly expanding senior population in San Diego County. The SBU is part of that commitment.

Psychology, social work, recreation therapy, nutrition, pharmacy, nursing and psychiatry are members of the core team, with physical therapy, music therapy, chaplaincy and internal medicine also involved. The SBU interdisciplinary team is skilled in working together to compassionately and effectively meet the bio-psycho-social needs of older adults with severe mental health problems.

The doctoral psychology intern is an integral member of the SBU interdisciplinary team, serving under the supervision of Dr. Lynn Northrop as the primary face of psychology on the unit. The intern plays a leadership role on the SBU psychology team, helping to oversee and support the work of advanced doctoral students. The intern leads or co-leads a process or coping skills group on the unit every day and carries an individual caseload of patients. Interns are routinely involved in leading interdisciplinary behavioral interventions, family education/support and psychological/neurocognitive screenings. Staff training and program development activities are an important part of the intern role. There is also time to spend in the milieu, and plenty of important clinical work occurs in these more informal interactions with patients and staff.

Many SBU patients are admitted from home and others come from board and care, assisted living or skilled nursing facilities. Patients typically are discharged to the same or higher level of care. Usual length of stay is one week to one month, though some patients stay much more than a month. Most patients are hospitalized voluntarily, but some are there on a legal hold and/or under conservatorship. Many patients receive follow-up care in our Senior Intensive Outpatient Program and there is some opportunity for interns to follow their individual therapy patients into the outpatient setting.

SBU interns can expect to develop knowledge and skill in:

• The Recovery Model and person-centered care
• Evidence-based, developmentally appropriate individual and group interventions (ACT, CBT, Behavioral Activation)
• Mood, anxiety, thought, neurocognitive, somatic, personality and substance use disorders in older adults
• 72-hour and 14-day holds, hearings and conservatorships
• Brief neuropsychological and psychological screening
• Caregiver support
• Community reintegration and other strategies to reduce relapse and readmission rates
• Electroconvulsive treatment (ECT)

Senior Intensive Outpatient Program

The Senior Intensive Outpatient Program (SIOP) is one of the fastest growing programs at Sharp Mesa Vista. It has quadrupled the number of actively enrolled patients in the last several years, and continues to expand. The SIOP staff are at the forefront of helping the hospital meet the needs of a rapidly growing senior population, collaborating with other programs and agencies throughout Sharp and in the San Diego community to ensure that patients continue to thrive, even after completing our programs.

The SIOP provides behavioral and cognitive behavioral group interventions, as well as case management, individual, couples and family sessions to support group work. Patients primarily present with severe mood disorders and/or anxiety disorders. Somatoform and Axis II disorders are also represented, as are thought disorders and mild cognitive impairment. Patients are triaged into the SIOP track that is the best fit for their presenting problems and level of functioning. Length of stay ranges from six weeks to six months or more. We begin "transition" or discharge planning with patients from their first day in the program.

The intern is an active, integral member of the interdisciplinary team. Under the supervision of the staff psychologist, the intern is involved in all aspects of the program.

The SIOP intern can expect to develop skills in:

• Adult development and aging
• Application of/adaptation of evidenced-based treatments for older adults (individual, group and family)
• Community outreach (building bridges with programs that serve/support older adults in the community)
• Community reintegration and Recovery Model
• Program development and evaluation

Psychological assessment (all interns, all year; not a separate rotation)

All interns participate in psychological assessment throughout the year. Depending on clinical rotation schedules, interns are assigned either one full day or two half days every week in “Assessment Clinic” to focus on assessment/assessment training. Depending on the mix of training goals in an intern class, individual interns could spend all year doing adult-gero assessment, all year doing child-adolescent assessment or have a combination of both.

Assessment supervisors provides a weekly psychodiagnostic seminar that meets throughout the year. This seminar focuses on the development of assessment techniques through didactics and group supervision for all doctoral interns as well as some advanced practicum students. Interns have the opportunity to mentor and supervise graduate students in assessment as well.

Psychodiagnostic and assessment skills are developed by responding to referrals for psychological assessment from all of the hospital's inpatient, outpatient and partial hospital programs. In addition to full psychodiagnostic assessments, brief assessments using self-report measures - Personality Assessment Inventory (PAI), Minnesota Multiphasic Personality Inventory-2-RF (MMPI-2-RF), Million Scales, etc. - round out psychodiagnostic activities. The range of assessments also includes detailed neuropsychological screening examinations (e.g., three-to-four hour batteries, not full-day batteries). This testing typically involves assessment of a premorbid IQ, intellectual assessment and broad evaluation of memory (e.g., CVLT-2, and selected Wechsler Memory Scales), language, frontal/executive (Trails, Stroop), motor and some form of personality assessment such as the PAI, Rorschach or MMPI-2-RF. Neuropsych screenings and brief neuropsych assessments are performed with patients of all ages throughout the hospital. This is not a specialty neuropsych rotation and interns seeking specialty training in neuropsychology should understand that our training program does not adhere to the Houston Guidelines.

Multiple levels of training in psychology and other disciplines.

In addition to the Doctoral Internship in Clinical Psychology, Sharp provides developmentally appropriate practicum training for graduate student who attend(ed) APA-accredited doctoral programs. Interns are involved in the training, supervision and mentorship of doctoral students. Sharp also provides supervised professional experience and training for individuals who have obtained their doctoral degree from an APA-accredited graduate program in psychology. Some of these individuals are in formal fellowship programs. Others are employed as behavioral health therapists (BHT) and are registered with the California Board of Psychology as psychological assistants. Interns may have the opportunity to work with and/or be supervised by fellows or BHTs.

Sharp Mesa Vista and Sharp McDonald Center are also training grounds for people working toward degrees and/or licensing in marriage and family therapy, social work, recreation therapy, pharmacy, chaplaincy, dietary, nursing and psychiatry. This commitment to training is in line with the value of Sharp and results in a rich environment for improving interdisciplinary team functioning. All of these disciplines are recognized as essential members of the interdisciplinary team.

Training in supervision.

Multiple levels of psychology training creates the opportunity for our interns to clinically supervise and mentor one or more junior colleagues throughout the year.

Training and supervision-in-supervision is a formal and integral part of doctoral intern training at Sharp. This is a rich and meaningful aspect of the training year for both interns and practicum students. And faculty report that training interns to supervise results in faculty members' growth as supervisors as well.

Intern stipend, benefits, cohesion, work-life balance and hours.

Interns are full-time, benefitted, temporary employees of Sharp HealthCare. The rate of pay is $22 per hour, with overtime awarded for hours over 8 in a day or over 80 in a two-week pay period. A shift differential is provided for if interns are scheduled to work evening shifts (e.g., CAP Outpatient). Assuming no overtime or shift differential, the annual pay is approximately $45,760.

Interns have paid time off (vacations and holidays), as well as sick leave. Paid time off amounts to 25 days per year, including 18 vacation days and seven paid holidays. In addition, interns accrue 2.15 hours of sick leave every two weeks. Interns are welcome to eat one meal per day in the hospital cafeteria, free of charge.

As psychologists, we understand the importance of social support and recreation in well-being. Interns are encouraged to form a cohesive unit during the training year. Some groups have formed book clubs and happy hours. In addition to spending time in clinical settings together, interns share office space. Department potlucks (also known as PIGS, or "psychologists in international gustatory studies") happen several times per year, and help to build cohesion among trainees and faculty. The department pays for an intern-only outing every year, such as a champagne brunch cruise on the bay, a day at Universal Studios or a day or picnicking and kayaking. A formal luncheon acknowledges the year's accomplishments and a "Hail and Farewell" picnic marks the transition from the old class to the new.

Interns work full time at the hospital, and the work is often intense. Outside employment is very strongly discouraged. The faculty places strong value on work-life balance and self-care, and every effort is made to keep average work hours in a comfortable range. However, interns should anticipate that assigned and elective reading, preparation for case presentations, spikes in assessment referrals and special or elective projects sometimes require interns (and faculty) to work more than a 40-hour week. Typical range is between 40 and 45 hours, including reading and other duties. Inpatient weekend shifts are required for every intern, regardless of rotation — typically not more than one per month. When working a weekend shift, interns take a weekday off to compensate. In addition to other staff working weekends, intern weekend shifts enable us to extend essential services to inpatients seven days per week. Weekend shifts also provide useful experience and training. For example an intern who opts for all outpatient rotations would have some inpatient exposure. And inpatient interns will get exposure to units they might not otherwise have seen.