Remember taking chemistry in college? You would go to the lecture, learn about something, and then go to the lab to watch it happen before your eyes. Making a precipitate, smelling an ester, or catalyzing a reaction brought the concepts to life and helped you to understand them in a new way. Lab learning was also different because it was active—there were instructions, but you had to find your own way, make mistakes, and integrate the whole experience into a report. In the same way that the chemistry lab allows students to use their understanding of chemical principles to create reactions, conducting psychotherapy under supervision allows students to apply the concepts that they are learning in class to real situations. If the didactic and lab experiences are closely linked, the educational experience is consolidated in a way that enhances learning and facilitates integration of concepts. How can we do this for supervision?
Supervision of psychotherapy has its origins in psychoanalytic education. Originally combined with analysis, supervision was eventually split off from treatment and conducted by someone other than the clinician's analyst (1). Nevertheless, the style in which supervision was conducted continued to approximate the analytic model (2). Students reported on their work with patients while the supervisor listened and made some comments. "Listening with evenly hovering attention," the paradigm of good psychoanalytic listening first described by Freud in 1912 (3), was also the goal for supervisory listening. Supervisors tended to be reactive to the material presented, rather than inclined to teach certain concepts. In many ways, this style of supervision is useful. As in psychoanalysis, allowing material to float freely often enables the listener to hear things, such as transferences and countertransferences, that might have been less apparent to the clinician during the patient encounter. However, the learning that it produces may be less predictable. One student with one kind of patient might learn about one thing, while another student with another kind of patient might be learning something completely different. Similarly, supervisors have typically supervised in their own ways, emphasizing the concepts that they think are important, and, thus, two students with two different supervisors might learn completely different things.
This lack of standardization can result in uneven goals and objectives, inconsistent expectations for resident evaluation, and substantial variability in the supervisory experience (4). Despite its essential and historic role in residency training, supervision remains one of the least developed aspects of clinical education. In psychiatry, there are no specific standards for psychotherapy supervision set by the current Accreditation Council for Graduate Medical Education (ACGME) guidelines (5). Furthermore, the dynamic, interpersonal nature of supervision brings with it an inherent complexity that poses a challenge to research (6). As a result, there are few empirical studies on supervision in psychiatry.
The introduction of core competencies for psychotherapy training recognizes what has long been a seminal concept in education—that is, that all teaching enterprises need to be based on learning objectives (7). A learning objective is defined as what an educator wants a student to know after a learning experience (8). This experience could be a class, a supervisory hour, or a case conference; every learning experience can have defined learning objectives. Learning objectives, in the form of competencies written by the American Association of Directors of Residency Training (AADPRT) Task Force on Competency now exist for five psychotherapies, including psychodynamic and supportive psychotherapy (9). However, in order for the competencies to have their maximum impact on psychotherapy education and for the resident's educational experience to feel integrated, these objectives have to be intimately connected to both didactics and supervision.
Courses can be beautifully designed to capture the essence of the competencies, but if the supervisors are not on-board, the educational experience will feel disjointed. There is ample evidence that this is often the case. Several authors have demonstrated that, too often, residents do not know what they're supposed to be learning in supervision, and supervisors do not know what they're supposed to be teaching (10, 11). As an illustration, 50% of supervisors filling out an anonymous survey after a recent annual faculty-development workshop at our program reported that they were not sure exactly what they were supposed to be supervising before they attended the workshop. If supervision is not based on objectives, supervisors tend to focus on case-management and act as "outside observers of the therapy process," (12) despite the fact that, as reported by Kinsbury and Allsopp (13), residents want less time directed toward case-management and more time in supervision devoted to teaching and the discussion of theory (13). Also, effective supervisors are generally thought of as those who are particularly adept at linking theory and practice (14). Supervisors may also not be aware of the developmental trajectory for residents, or of what is being taught in class (15). All of these problems can make the teaching effort feel disconnected from—and sometimes even contradictory to—the teaching that is happening in the classroom. Thinking about supervision as a "lab course" is one way to address these problems.
How do we think of supervision as a lab? Going back to our chemistry analogy, the "lab of the week" corresponds to the "lecture of the week." Thus, if the students hear a lecture on enzymes, they troop up to the lab to catalyze reactions. This is easy for the lab instructors to orchestrate, since they design the protocols, provide the materials, and help the students with the experiments. "Not so easy with patients," you might say. Here, the materials are real patients who do not readily produce the kind of psychopathology and clinical situations that necessarily correspond to that week's seminar. Often, the variability and unpredictability of patients foils and frustrates supervisors, who are trying to teach one type of treatment or another. However, looked at another way, the problem is not with the patients—the problem is with the lack of faculty development for the supervisors. If supervisors know 1) what the students are learning in their classes; and 2) what they should emphasize in supervision, they can reinforce concepts to help their supervisees master a set of objectives (knowledge, skills, and attitudes) that are appropriate to that phase of their learning.
Course and Lab—in Practice
In order to connect supervision more closely to the residents' psychotherapy courses, we decided to formulate what we thought of as "meta"-learning objectives—or broad educational themes—for each year and to communicate them to our various supervisory cohorts (Table 1). We based these on the AADPRT Competencies for Psychodynamic Psychotherapy and Supportive Psychotherapy (9), which were written in response to the ACGME competency requirements (16). These competencies serve as standards for graduation, but, as Goldberg observes in his illuminating paper on phase-based learning in psychodynamic psychotherapy, do not give educators a sense of the developmental trajectory of the learning process (17).
TABLE 1.Phase-Based Meta-Objectives for Psychodynamic Psychotherapy
Although Goldberg's approach covers this process in detail, we intentionally tried to create broad categories to help our supervisors understand what we considered to be the major educational objectives for each year. Each of our meta-objectives is a condensation of many of the AADPRT competencies, and we have divided them by Postgraduate Year (PGY) in order to facilitate thinking of the way in which one learns psychodynamic psychotherapy as developmental. In arriving at these phase-based learning objectives, we were strongly influenced by the "Y-Model" of teaching psychotherapy (18), which emphasizes that the "stem" of the "Y" includes core concepts, such as setting the frame, setting goals, and establishing a therapeutic alliance, which are common to all psychotherapies, whereas the specific techniques of different psychotherapies branch off from this core. This model maps very well to a 4-year residency, with the PGY-I and -II years focused on "stem" issues—or core concepts—and the PGY-III and -IV years focused on the techniques of the specific psychotherapies. We used these objectives both to guide our curriculum development and to instruct our supervisors.
For the PGY-II year, we designed a course called "Core Concepts in Psychotherapy," which teaches the concepts that underlie many different types of psychotherapy. For the PGY-III students, we designed two specific technique courses: one that teaches "uncovering" techniques, and one that teaches "supporting" techniques. Once the didactics were in place, we turned our focus to helping the supervisors understand the major learning objectives for their year. Our major strategies involved 1) using faculty workshops; and 2) keeping the supervisors closely apprised of what we were teaching in class. We conducted separate, faculty development workshops for each cohort of supervisors. At each workshop, we reviewed the major learning objectives for that cohort of supervisees and discussed the importance of actively engaging supervisees in discussion of the major concepts; we used group exercises to model these for the supervisors. For example, in the workshop for PGY-II supervisors, we conducted an activity in which pairs of supervisors discussed short vignettes and then formulated an intervention designed to foster the therapeutic alliance. Similarly, in the workshop for the supportive-psychotherapy supervisors, we asked participants to write short scripts of a supportive-psychotherapy session. After these were "performed," the group had to name the interventions that the therapist used. These activities, modeled on activities conducted in the residents' classes, further connected the supervisors to the didactic curriculum by allowing the supervisors to experience some of our teaching methods first-hand. Also, at each workshop, we gave the supervisors all of the materials for the class that corresponded to their supervision. This included the schedule of classes and topics, syllabus materials, and reading lists. As the seminar proceeded, we sent periodic e-mails about what was being taught in class, what seemed difficult for the students to learn, and what the supervisors might emphasize. We also informed them about the writing (such as psychodynamic formulations) that the residents would be doing, and encouraged them to help the residents with these exercises in order to consolidate learning. Although the supervisors could not guarantee that the concepts learned in class will come up that week in supervision, they knew what concepts were key for each postgraduate year and could address them when they came up.
Our goal in using these meta-objectives is not to give supervisors an exhaustive list of what they need to teach their residents, but rather to orient them to the major learning milestones for that year in order to integrate the overall learning experience. We send these objectives to our residents as well, so that they are aware of the kinds of things that they will be expected to know and do by the end of any given postgraduate year. Thus, PGY-II residents and supervisors know that they need to work on assessment and "beginnings"—whereas the PGY-III residents and supervisors focus on learning specific techniques and formulations. Sharing our meta-objectives with both residents and faculty increases transparency of expectations and facilitates assessment. This also empowers residents to take a more active role in supervision (19).
Over the past year, we have had three annual faculty development workshops specifically based on this model (one for the PGY-II supervisors, one for the PGY-III long-term psychodynamic psychotherapy supervisors, and one for the PGY-III supportive psychotherapy supervisors). Of 51 supervisors, a total of 35 (69%) attended these workshops. After each workshop, participants were asked to rate the workshop on a 5-point Likert scale, indicating whether they agreed with specific statements regarding the value of the workshop (Table 2). Over 90% reported that they learned something new in the workshop and that they felt that the workshop would enhance their supervision of residents. Furthermore, 97% reported that having an annual meeting helped them to be more aware of what the residents were learning in their didactic courses on psychodynamic psychotherapy. Several individual supervisors spontaneously commented on this aspect of the program:
TABLE 2.Faculty Evaluation of Annual Workshops
Advantages of the Course and Lab Model
Certain advantages of this model are clear. Thinking of supervision as a "lab course" gives each type of supervision clear learning objectives that are understood by residents and supervisors. This guides the activity of the supervision and makes assessment both more standardized and more transparent. Connecting supervision to classroom seminars helps to integrate learning for residents, consolidating classroom learning in a hands-on way and diminishing the possibility of hearing contradictory messages. Although the above example is for the psychodynamic psychotherapy curriculum (which includes supportive psychotherapy), this model can be easily applied to any supervisory experience—including psychopharmacologic supervision.
The fact that our broadly outlined meta-objectives are concise provides another advantage. Rather than presenting supervisors with an extensive list of competencies, this outline offers each cohort of supervisors the three basic objectives that they should be focusing on for their given postgraduate year and keeps them oriented to the developmental-learning trajectory. This is helpful for assessment as well, in that it helps to focus the supervisors on what residents should be expected to do in each year of residency. This model has additional advantages for faculty development. Psychotherapy supervisors are often voluntary faculty, with a tenuous connection to the department (20). Thinking of supervisors as "lab instructors" of the course solidifies this connection, bringing the supervisors into the teaching faculty in an important way. New supervisors come into a ready-made educational matrix, become part of a group of colleagues, have materials to guide their supervision, and participate in faculty-development experiences to help them grow as educators. Supervisors report being relieved to know what they are supposed to teach, thus diminishing their anxiety that perhaps they are not emphasizing the "right" material. Unfortunately, most psychotherapy supervisors are not routinely taught how to supervise and subsequently draw exclusively from their own supervisory experiences as trainees (21, 22). Although there has been increasing awareness about the importance and necessity of providing training to clinician-educators and supervisors, in particular, there have been very few faculty-development programs for psychotherapy supervisors described in the literature (15, 20, 21, 23, 24). These programs have ranged from informal group meetings of supervisors discussing supervisory challenges (23) to formal didactic training programs focusing more directly on issues pertaining to the current knowledge and practice of psychotherapy (20) or on specific aspects of supervision, such as forming a supervisory alliance with the supervisee, understanding the legal and ethical standards of supervision, and learning core aspects of effective supervision, such as identifying educational goals (15, 21, 24). The approach presented here differs from these previously described faculty development programs by emphasizing phase-specific learning and facilitating an ongoing correlation with the didactic coursework.
Challenges and Potential Problems
Everyone is busy, so getting supervisors to attend faculty development meetings can be a challenge. As simple as it sounds, providing food at such meetings helps with attendance, as does careful planning. We organize workshops that are interactive and that offer tangible skills and resources. Supervising, like conducting psychotherapy, can be a somewhat lonely and isolating experience, and thus most supervisors are eager to come together to talk about their experiences. Similar to our findings, other groups have also demonstrated the importance of continuing-education programs on improving supervisor morale and sense of connection with the department (15, 20—22). Also, helping supervisors to learn about phase-appropriate learning offers them relief from the burden of feeling they have to "teach it all."
Encouraging active teaching based on learning objectives complements and enhances the ability of supervisors to listen in an "evenly hovering" manner. Every psychotherapist listens for certain types of material, for example, transference references or automatic thoughts. Similarly, if the objectives are carefully chosen, simple and phase-appropriate, and they make sense to the supervisors, they will become a natural part of the way in which the supervisor listens, guiding the supervisory listening process. A potential argument against the course-and-lab concept could be that it limits the variability in supervisory and therapy styles that a resident comes into contact with. We often think that it is an advantage for residents to learn from many educators in order to experience different clinical styles. Having objectives, however, need not preclude supervisors from imparting their own styles to their supervisees—it just helps the supervisors to cover certain topics that the group feels is essential to learning in that year. The use of broad-based meta-objectives could be viewed as reductionistic and lacking in adequate detail. However, we are not attempting to recreate learning-objectives that have already been established (9), but rather to provide a developmental context and framework for thinking about these objectives. Also, we provide all of the supervisors with detailed information about what we are teaching in each course so that they can stay apprised of what the students are learning from week to week.
Thinking of supervision as a lab course helps educators to organize, standardize, and assess the supervisory experience. It helps students know what they can expect to learn and helps supervisors know what they are supposed to teach. It brings supervision into the mainstream of the curriculum, makes supervisors part of the core teaching faculty, and helps to standardize our ability to monitor both teaching and learning as we train the psychiatrists of the future.