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Regular Article | September 01, 2001

Psychotherapy Supervisor Training: Differences Between Psychiatry and Other Mental Health Disciplines

Sarah M. Whitman, M.D.; Bernadette Ryan, M.S.S., A.C.S.W.; David F. Rubenstein, Psy.D., M.S.W.

Academic Psychiatry 2001;25:156-161. 10.1176/appi.ap.25.3.156

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Supervisory ApproachesPsychiatry vs. Psychology

Dr. Whitman is Assistant Professor, Ms. Ryan is Adjunct Instructor, and Dr. Rubenstein is Clinical Assistant Professor, in the Department of Psychiatry, Medical College of Pennsylvania and Hahnemann School of Medicine, Medical College of Pennsylvania and Hahnemann University, Philadelphia, PA. Address correspondence and reprint requests to Dr. Sarah Whitman, Hahnemann University Hospital, 1427 Vine Street, 8th floor, Philadelphia, PA 19102. e-mail: sw32@drexel.edu

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Abstract

Supervisors and residents spend a significant amount of time and effort in psychotherapy supervision, yet receive little or no training in how to supervise. No specific requirements for supervision training exist in psychiatry or social work programs. Accredited graduate programs in professional psychology are required to expose students to supervision. The field of psychoanalysis has some requirements for being a supervisor, but not any specific training for supervisors. In contrast, the American Association of Marital and Family Therapy (AAMFT) requires extensive training for its supervisors, which is described. The authors explore the reasons for the absence of requirements in psychiatry. Regardless of the number of requirements, all disciplines show a striking paucity of empirically-based research in supervision training. Authors discuss the deleterious consequences of the lack of both research and supervisory training requirements and propose critical elements for supervision training and research.

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For some time, a "persistent paradox" of supervision (1) has continued. Psychotherapy supervision is one of the most important avenues through which residents learn psychotherapy, yet the teaching of the art and skill of supervision remains minimal (1—6). Informal surveys in psychiatry reveal that most current supervisors have not had any formal training in how to supervise (6). In psychology, licensure is generally necessary to engage in formal supervision. In clinical social work, supervisors are required by the National Association of Social Work (NASW) to have 3 years of post-master's degree experience in the field to be able to supervise. Schools of social work do encourage supervisors to participate in seminars and courses about supervision, which many of these schools provide (7). Over the last two decades, this widespread lack of training in such an important area has received regular attention. Yet, to date, there are still no specific requirements for training for supervisors to ensure supervisory proficiency in psychiatry, APA-accredited psychology doctoral and internship programs, or graduate social work programs.

Likewise, residency programs rarely teach their residents how to supervise, despite the fact that many will have supervisory responsibilities in the course of their careers (6). Accredited graduate programs in professional psychology are required to expose students to supervision experience. However, there are no specific requirements for students in any of these disciplines to learn supervision skills (8).

Psychoanalysis is one field that does have requirements for being a supervisor, known as a training and supervising analyst. This designation allows one to be a psychoanalytic candidate's personal analyst and supervise a candidate's cases. The goal of the American Psychoanalytic Association's requirements is to identify analysts who have "a demonstrated commitment to education, with extensive clinical experience and skill, with a high level of personal and professional ethicality, and whose work has been subjected to extensive peer review" (9). The requirements include, among others, being a certified analyst; "clinical immersion" in the practice of psychoanalysis, with a specific and varied number of cases required over at least 5 years; teaching and administrative experience as a member of an Institute's faculty; and "demonstration through adequate review, of superior quality clinical work, teaching, supervising, and in administration." Supervision experience is not a requirement, but it is "strongly recommended that the potential training analyst have significant experience in supervisory work that is also evaluated by the Institute."

Review of a potential supervisor's clinical work is done by presentations of his or her own analytic cases at an institute. However, review of supervision work is rarely done. Some review of ongoing supervision work may occur. After being accepted as a training and supervising analyst, a beginning supervisor is at times matched with a senior supervisor for consultation. At regular institute meetings of training and supervising analysts, supervision issues are sometimes discussed, but this is informal, rather than formal or regular. It is noted in the guidelines that the American Psychoanalytic Association "provides opportunities to discuss matters related to personal analysis and supervision by participating in workshops" at national meetings. There are no ongoing study groups solely for supervision. When the American Psychoanalytic Association Committee on Institutes visits sites for the purpose of evaluation, some supervisors are observed, and feedback occurs, in addition to other evaluation of the institute. There are no specific, objective guidelines for how these supervision sessions are evaluated; the evaluation is based on the reviewer's clinical judgment. Although helpful, this occurs for only one supervision session and only once every few years (private communication; J. Solomon, R. Benson, May 2000).

CURRENT OPTIONS FOR LEARNING SUPERVISION SKILLS

Abstract | CURRENT OPTIONS FOR LEARNING SUPERVISION SKILLS | RECOMMENDATIONS | CONCLUSION | References

How then do supervisors learn to supervise? According to Loganbill and Hardy (10), supervisors usually draw on their own experiences in supervision ("reciprocal role experience") and on their clinical therapy skills, ("transfer of therapy training"). Such roles as "teacher, researcher, colleague, and consultant" may also provide new clinical supervisors with skills and experience to rely on when supervising (2).

A number of models of supervisor development have been proposed, and a limited number of empirical studies have been conducted to test these models (11,12). These models assume that supervisors develop in their role and that this growth is in stages from less to more developed. Each stage has various developmental issues and concerns associated with it. Our understanding of these models of supervisor development is at a beginning level; we need further clarification and empirical studies in areas such as how supervisors behave at different developmental levels and how supervisors move from one stage to the next (11).

Although they are few, there are some programs for both supervisors and students to learn supervision skills. They vary widely in terms of length, format, content, who teaches the program, and for whom the program is designed. Some examples that have been described in the literature include a preparatory two-semester seminar taught to third-year graduate students in professional psychology (13), a formal supervisory course offered to first-time field instructors in social work (14), and the use of a clinical supervision manual to assist in the development of supervisory proficiency (15). Other vehicles through which supervisory skills are taught include workshops led by faculty members (16), a brief in-service training program (17), and informal conferences and study groups (18,19). Of note, the first supervision course was offered in 1911 by an agency headed by Mary Richmond, a pioneer in the social work movement (7).

The American Association of Marital and Family Therapy: a Contrast

The American Association of Marital and Family Therapy (AAMFT) is a professional organization for family therapy that, in part, provides guidelines for family therapy training for therapists and supervisors. Clinical membership is available to therapists after completing 2 years of clinical experience under the supervision of an "approved supervisor," in addition to completing other family therapy training requirements.

In contrast to the lack of training for supervisors in psychiatry, the AAMFT requires that candidates complete the following in order to be designated an "Approved Supervisor" (20):

Of the 23,000 clinical members of the AAMFT, approximately 10% are "Approved Supervisors" (21).

These requirements are stringent and in sharp contrast to the paucity of requirements in psychiatry. There are several reasons for the AAMFT's requirements. First, there is an emphasis in family therapy on supervisors being active participants in the treatment, including using such supervision modalities as live supervision. It was felt that this increased level of involvement of the supervisor may heighten the need for training in supervision, as well as a more objective review of a supervisor's work through supervision of supervision and the use of videotaped supervision sessions, rather than relying on process recordings and case reporting. Second, a parallel exists with the training of family therapy students. There is the belief that students are active participants in the therapy and need to be aware of their own family-of-origin issues. In supervision, then, there is the need to raise pertinent family issues of therapists, but without engaging in therapy with trainees. The ethical need to maintain clear boundaries in supervision necessitated again an increased attention to the training and supervision of supervisors. A third rationale for the requirements was the desire of the AAMFT to increase the legitimacy and prestige of both the organization and the field. The AAMFT has felt that its significant requirements for supervisors' training will support its claim of providing a unique, high-level training experience to family therapists (22).

Given the comprehensiveness of the AAMFT's requirements for "Approved Supervisor" status, one would expect practitioners to be well prepared to supervise. Surprisingly however, there are no data yet to support or refute the position that meeting these requirements improves either supervision or the clinical care provided.

Reasons for and Implications of the Lack of Requirements

The reason for the lack of requirements regarding supervision training in psychiatry is probably multifactorial. First, the quality of supervision may be viewed as adequate, although no documentation exists to support this. There is some evidence to the contrary that identifies the existence of poor supervision, including sexual harassment, sexual acting out between student and supervisor, therapy done by the supervisor instead of supervisee, other boundary violations, and learning environments that are overly critical (23). There is also some evidence that supervision skills do not improve over time as supervisors gain experience (5). A second reason for the lack of requirements may be that at a time when it may be harder to recruit supervisors, especially volunteer faculty, for financial or legal reasons, residency training programs may not want to add additional educational, credentialing, or licensing hurdles for potential supervisors to cross. Another reason for this resistance may be that, because of a traditional but jaded sentiment in medicine of "see one, do one, teach one," the need for training in supervision may be viewed as a weakness or may not even be considered. Evaluating supervisors can also be problematic, both logistically and qualitatively, so that identifying supervisors in need of remedial education may be difficult (24). Supervisors may also be reluctant to have their work evaluated because of universal feelings of fear of exposure and criticism, and so may be hesitant to push for requirements.

The existing programs that teach supervision skills could provide a foundation on which to build our understanding of training in supervision. However, there are several limitations in the literature to date about such programs. No comparisons between programs exist, nor is there a sense that one program has built upon the foundation of any other. Unfortunately, this prevents the identification, replication, and development of effective components from different programs. A second concern is that few evaluations of supervision programs are described in the literature (15,16,18). Although participants' responses to some of the programs have been positive, there is a lack of scientific evaluation of improvements in supervisory skills. Last, different programs may reach different goals, but these are not demonstrated. Are some programs better for beginning supervisors and some for more experienced supervisors? Is there a minimal program that can be successfully implemented or are only comprehensive programs beneficial?

This lack of basic, empirical research both in programs to develop supervisory proficiency and the efficacy of such training is striking. The ramifications of this paucity of research are far-reaching. The first is the lack of development and progress in the field of supervision. With both new and experienced supervisors relying predominantly on their clinical skills as well as their experiences as supervisees, the provision of supervision is based on anecdotal experience rather than facts or data that have been empirically validated. When there has been little research to determine what is effective—followed by dissemination of this information—there can be no widespread and uniform improvement in supervision.

Second is the need to define what the areas of expertise are for psychiatry. If we fail to define and study supervision, it may be an important and enjoyable area of work that will be done instead by those disciplines that have "supervision expertise." In clinical practice, especially in interdisciplinary settings, psychiatrists are asked more and more to practice only pharmacotherapy and do initial evaluations and to supervise those in other disciplines. If we do not train residents and psychiatrists in the skills of supervising well, other disciplines may not tolerate being supervised by us, and we may be left with an even more limited repertoire of practice. We have already experienced such a decrease in the scope of practice in the provision and teaching of psychotherapy (6).

Third, managed care pushes for definition of appropriate standards of quality for clinical care. It may be in our interest to include supervision requirements as part of these standards of care because of both their training and financial implications. In our experience, managed care often hesitates or even refuses to allow or to pay for care provided by residents. In our effort to modify this situation, we may have more success if we have defined and researched how the supervision of clinical care is best done. This can serve as a quality-assurance method; it may improve our ability to train residents; and it may directly affect our fiscal health. To propose supervision requirements, however, we first need to empirically define, operationalize, and study the key elements of supervision.

RECOMMENDATIONS

Abstract | CURRENT OPTIONS FOR LEARNING SUPERVISION SKILLS | RECOMMENDATIONS | CONCLUSION | References

Given that empirically supported key elements necessary to develop supervisory proficiency have not been identified, we would propose that all supervision training programs include the following components. Components 1—3 are chosen to help establish a research base in supervision. Components 4—5 seem intuitively beneficial, though their ongoing inclusion would need to be supported by research. Evaluation of improvement in supervisory skills could include supervisor self-assessment, supervisee feedback, and, potentially, some correlation with patient clinical outcome:

The implementation of a supervision training program for supervisors within a psychiatric residency training program would be ideal. Given the five recommendations identified above, the following description outlines how such a program might operate. Measurable and objective goals for the supervision training program would be identified by a residency or faculty committee. Each supervisor would complete a supervisory skills assessment of his or her strengths and weaknesses. If available, previous evaluations of the supervisor by supervisees could add to this assessment. This process would establish formalized and individualized supervisory proficiency training goals. The didactic portion of the training program would have review and discussion of material about supervision, meeting for regular class sessions perhaps twice a month. Audio- and videotaped supervision sessions of each participant would be used as teaching tools in the training program, both in class sessions and for individual supervision of supervision. Assessment of an individual supervisor's progress in meeting his or her goals could be done by written evaluation, review of supervision sessions, and student evaluations. On the basis of the performance of participants, the committee could then complete a program assessment and evaluation.

With regard to developing and evaluating such a program as identified above, "research is only as good as the measurement tools and procedures that are used for assessment and evaluation" (24; p 94). Watkins notes numerous areas of supervision research to which careful attention must be given. Some of these areas include research design and experimental control, the need for psychometrically sound assessment and evaluation procedures, further evaluation of the relationship between supervision and therapy outcome, and a need for an increase in the number and types of raters used to measure supervision.

CONCLUSION

Abstract | CURRENT OPTIONS FOR LEARNING SUPERVISION SKILLS | RECOMMENDATIONS | CONCLUSION | References

Despite its importance to training and practice, psychotherapy supervision has not received the attention it merits. The AAMFT has extensive requirements for its supervisors that are unique in their extent and content, in particular, supervision of supervision. These requirements have not been empirically evaluated, however. Popular wisdom has it that supervisors learn by doing and can simply use their therapy skills and supervisee experience to provide this service. This notion has been disputed. The paucity of research on supervisory training affects psychotherapy and supervision training, clinical practice, and funding for services. We propose the adoption of certain components by supervisory training programs as a step toward expanding our understanding of this field, and we outline a potential program. Adequate attention to this area of training is long overdue.

References

Abstract | CURRENT OPTIONS FOR LEARNING SUPERVISION SKILLS | RECOMMENDATIONS | CONCLUSION | References

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