The journey from beginning resident to competent psychiatrist is challenging. One of the most important factors in determining the quality of a resident's educational path is his/her psychotherapy supervision. A resident who begins his/her professional journey without knowing how to use supervision is like a person setting out on a trip to an unfamiliar place without knowing how to use a map. A session on how to get the most out of supervision can serve as a welcome travel guide for trainees, who can benefit from discussions both of the literature and of others' experiences in supervision.
We found, in the literature, only one article on helping supervisees prepare for supervision (
+1). However, it did not provide a structure for translating the information into a specific session or course, or for any evaluation from participants. This lack of training for supervisees parallels the lack of training in how to supervise for current and future supervisors in both psychiatry and other disciplines. Residency programs rarely teach their residents how to supervise, despite the fact that many will have supervisory responsibilities during their careers. Informal surveys in psychiatry reveal that most current supervisors have not had any formal training in how to supervise (
+2).
Described here is a one-session, 90-minute, interactive program given to third-year residents as they begin their outpatient year. Because our Outpatient Service is multidisciplinary, the trainees also included clinical psychology interns and practicum students and clinical social work trainees. An evaluation by the trainees was done at the end of the session.
+
One-Session Program Description
The program topics are listed below and then described in further detail.
+
1. Participants' past supervision experiences.
Types of supervision are covered; that is, individual, group, and peer. Trainees discuss their previous supervision experiences, focusing on what contributed to either a positive or negative outcome. Factors that make supervision challenging for trainees are briefly discussed, including revealing weaknesses, revealing mistakes, and the evaluative component (
+3—
+5).
This section introduces different options for supervision that trainees might not have considered. It also encourages reflection on what makes supervision experiences optimal and makes trainees' ambivalence about supervision more conscious, so their concerns can be addressed more directly.
+
2. Characteristics of good supervisees.
Supervisee characteristics that contribute to learning are presented. These include psychological-mindedness and openness, interest, initiative, interpersonal curiosity, flexibility (personal, theoretical, clinical), intellectual openness, and minimal defensiveness. Different characteristics contribute to a positive outcome in different areas; for example, having "interest/desire" is identified as a "facilitator of relationships with supervisors," whereas "interpersonal curiosity" and "empathy" are identified as "facilitators of relationships with patients" (
+3).
This section helps to reduce beginning trainees' anxiety by showing that they are not expected to be master therapists or expert psychopharmacologists. Rather, it shows trainees that an openness to learn is most important, and a willingness to share mistakes, problems, and feelings, as well as clinical progress, is a strong asset.
+
3. Characteristics of good supervisors.
The characteristics of both good and poor supervisors are presented, building on participants' observations from their own experiences from Section 1. Good supervision includes time set aside exclusively for supervision, direct feedback, mistakes being welcomed as learning experiences, and discussions of issues of concern to the resident (
+6—
+9). Poor supervision includes experiences such as "students competed for [the] supervisor's attention," "sexual advances were made by [the] supervisor" (
+7), and little or no attention being paid to the resident's issues (
+6).
This section is used to discuss what good supervision entails, and helps trainees identify supervision that needs improvement. Also, residents are empowered by hearing that good supervision should be the standard, not the hope, and is also a resident's educational right.
+
4. A supervision agreement.
A supervision agreement, a verbal or written contract between supervisor and supervisee that outlines the parameters for supervision (
+10), is a foundation for supervision. A discussion of the training goals and objectives for supervision is central to creating an agreement. These goals can then inform decisions both about concrete matters, such as the frequency of meetings, and learning issues, such as how the resident will report on therapy sessions in terms of content and process. For example, if the resident wants to learn psychopharmacology but sees only a few patients suitable for this modality, the frequency of supervision sessions could be less than the typical one time per week. Alternatively, group supervision could be used, so that more cases could be reviewed and learning experiences shared between residents. If the resident wants to explore countertransference issues, videotaped sessions may be used, as this modality may provide more examples of countertransference manifestations than brief summaries of sessions. A discussion including the resident's previous positive and negative supervision experiences, how the resident thinks he or she learns best, what he or she perceives his/her strengths and weaknesses to be, and any pertinent current personal issues may also help the pair tailor supervision to increase the likelihood of a positive experience.
In this section, residents are encouraged to set goals for supervision and consider how best to meet them. A discussion of various options for supervision, for example, weekly or less often, process notes, videotapes, and so forth, introduces new ideas to trainees as they consider how to meet their goals. This section again empowers residents by setting parameters for good supervision, for example, regular, full-length, uninterrupted supervision sessions, and supervision individualized to the learning style of the resident. Residents are also encouraged to be proactive and take responsibility for their own learning. They are encouraged to initiate a conversation about these supervision-agreement issues if the supervisor does not bring them up. Residents also need to consider and then communicate information about themselves, for example, how they learn best or what personal issues may affect their work in psychotherapy. A secondary benefit of a supervision agreement is that the process parallels a therapy agreement, and therefore may help the resident in psychotherapy work.
+
5. Addressing supervision problems.
Problems that arise in supervision are described, with examples drawn from the participants' previous experiences shared in Section 1 of the session; the examples of poor supervision, in Section 3; and my own experiences as a supervisor, supervisee, and a coordinator for supervision assignments for the residency program. One study of graduate clinical psychology students reported that 39% had experienced a "major conflict with a supervisor that made it difficult to learn from supervision." The three major types of conflicts were "theoretical orientation or therapeutic approach, style of supervision, [and] personality issues" (
+11).
The focus in addressing problems is on the importance of early, direct, constructive communication with the supervisor and continued work to try to fix problems that negatively affect the resident's learning. A specific administrative path for addressing problems is outlined, (Supervision Coordinator, then Residency Director), so it is clear with whom residents should discuss problems. We emphasize that, because of the importance of supervision in their professional education, students should address all significant problems.
Parallel process, a behavior or interaction in the supervision that repeats a behavior or interaction in the therapy, is explained (
+10,
+12—
+15). This process can also start in the supervision and move to the therapy. Thus, a supervisor is involved in the process of supervision as a participant, not an observer; supervision is a triad, not a dyad. Parallel process may be especially important to consider when a problem arises in supervision or therapy, as the problem may reside within anyone in the triad or between any participants (
+12). By being made aware of this possibility, residents can look for this phenomenon, discuss it when present, and use it as an avenue to learning.
+
7. Professional vs. personal issues in supervision.
In this section, the similarities and differences between therapy and supervision are explored. At issue are both therapists' questions as to how much to reveal about themselves in supervision and the problem of therapy occurring in the supervision setting. Personal exploration occurs in supervision, for example, learning to use one's self in therapy, understanding and using elements of countertransference, and learning when one's personal issues may or do affect therapy. However, the surfacing of a therapist's own issues in supervision is addressed in such a manner as to improve clinical skills or professional competence, not explored for therapeutic reasons (
+4,
+10).
+
8. Learning to supervise.
In this final section, supervision is framed as a vital career-long professional activity of continued learning. Developing the ability to self-supervise is presented as a goal of training, while, at the same time, continued post-training supervision, either paid or peer, is encouraged. The ability to self-supervise includes having a self-reflective stance. Trainees are also encouraged to develop their own problem-solving abilities while in supervision, rather than focusing on being given the "right" answer by a supervisor. This problem-solving skill will develop during their training, with more direction usually provided by supervisors initially, and less as trainees gain experience and confidence. Because many of the trainees will also become supervisors in their careers, supervision is presented as a challenging and rewarding teaching activity.
A 10-item questionnaire was given to the trainees at the conclusion of the one-session program. The questionnaire included five fill-in-the-blank questions designed to gather professional discipline and year-of-training information and information about their previous supervision experiences and supervision education, one Likert-scale question to assess general helpfulness of the session, and four open-ended questions to assess the value and impact of the in-service program. The questionnaire was anonymous, was turned in to an independent collector, and was reviewed by the author (the presenter). Data were gathered from two sessions, in 1998 and 1999, and are aggregated. The program, presenter, and questionnaire were identical for the 2 years.
A total of 17 trainees attended the in-service program; 17 questionnaires were completed and reviewed. Four participants (24%) were psychiatry residents, 7 (41%) were clinical psychology trainees, and 6 (35%) were clinical social work interns. The psychiatry residents were all PGY-IIIs. The psychology students were in their third, fourth, or fifth and final year of training, (n=2, 3, and 2, respectively). The social work trainees were all in their second and final internship year.
Trainees had had an average of three previous psychotherapy supervisors, with a range of 1 to 8 supervisors. In 29% of these previous supervision experiences, a verbal or written supervision agreement (or something similar) had been discussed. For the subset of residents, the average was 3.3 previous supervisors, with a range of 2 to 5. In only 15% of residents' experiences was a supervision agreement discussed. For the subset of clinical psychology trainees, the average was 3.7 previous supervisors, with a range of 2 to 8. In 23% of their experiences, a supervision agreement was discussed. For the subset of clinical social work interns, the average was 1.8 previous supervisors, with a range of 1 to 4. In 64% of their experiences, a supervision agreement was discussed.
Only four of the trainees (24%; three in social work and one in psychology), and no residents, had ever received any other education on supervision, "formal or informal, provided to you, or self-study." Of the trainees who reported some supervision education, three had received in-service training, and one cited "an informal discussion in another class."
Regarding evaluation of the one-session program, it received a mean score of 4.6 out of 5 on "how helpful the session was to you as a supervisee," (Likert scale: 1=not helpful at all; 3=somewhat helpful; and 5=extremely helpful). If a trainee did find the session helpful, he or she was then asked in an open-ended question which particular issues were the most helpful. The three most helpful issues were delineating the characteristics of good supervisors, how to address problems in supervision, and the supervision contract/agreement. When asked in another open-ended question if and how the in-service training would change their approach to supervision, the trainees' three most common responses were "felt more comfortable about supervision," with 7/17 (41%) reporting this benefit; "will be more open in reporting problems and feelings in supervision," cited by 6/17 (35%); and "will try audiotaping psychotherapy sessions for supervision," cited by 3/17 (18%). One interesting, unanticipated comment made by two trainees was that simply having such an in-service program demonstrated the Outpatient Service's commitment to learning and training. A suggestion made by several participants was to have supervisors attend the same presentation.
This article presents a one-session program to teach residents how to use supervision most effectively. Residents reported no previous education in supervision, as was true for most of the psychology trainees. In contrast, 3/6 (50%) of the social work trainees had received some previous introduction. These data support previous findings showing a lack of training within psychiatry in this important teaching modality.
A supervision agreement was used in only a small percentage of residents' previous supervision experiences (15%), as was true for the psychology students. However, an agreement was discussed in 64% of the social work trainees' experiences. In the author's experience, an agreement is a crucial step in beginning supervision with residents. An agreement helps to set joint goals for supervision and allows the supervisor to learn about the resident both within the learning context of the residency program and personally. How this process occurs without an agreement was not explored. This raises the possibility of a lack of joint goal-setting in supervision, which may undermine the course of professional development during the year. Psychotherapy supervisors receive little, if any, training in how to supervise, and they may not consider discussing training goals and how to meet them. This in-service program is currently being expanded to include supervisors, in an effort to expose them to a program that trainees have found helpful, and to learn from their experiences. More empirical data are needed on the use and value of supervisory agreements/contracts, as well as supervisors' responses to the program.
Of the topics covered, trainees reported that one of the most helpful was the delineation of characteristics of good supervisors. This section seemed to help trainees determine the reasonable expectations of supervisors. For example, trainees wanted to know if regularly scheduled and conducted supervision, without multiple interruptions by phone and beeper, was a reasonable expectation. Another section trainees found to be most helpful was how to address problems in supervision. After expectations were clarified, trainees then seemed ready to hear the discussion on how to improve problematic supervision. Currently, a second questionnaire is being administered later in the training year to assess whether the in-service program remains helpful as supervision progresses during the year, whether trainees feel that the same topics or other topics are the most helpful, and whether there are other areas that should be covered in the in-service program.
The trainees reported a positive effect on their comfort and willingness to share problems and feelings in supervision as a result of the program. Also, they reported an increased willingness to try audiotaping, an often anxiety-producing modality. Further study could be done to measure whether these attitudinal changes persist, or whether behavioral changes such as trying new modalities actually occur.
There are several limitations to the study. The small sample size limits the generalizability of the findings. The heterogeneous population revealed interesting contrasts between disciplines, but limits the generalizability of the findings to other psychiatry residents alone.
Because the program was well received and resulted in positive change, we recommend that such an in-service program be tried in other residency curricula. Psychotherapy supervision is a crucial element in residents' education; this program can help open the door to this avenue of learning.
The author thanks David Rubenstein, Psy.D., for his helpful suggestions on this article.