Over the past decade, the practice of neurobiology has come to dominate hospital-based psychotherapy (1), and the teaching of psychotherapy has become marginalized in psychiatry residency programs across the country. As a result, psychotherapy supervisors must play an increasingly important role in maintaining the viability of this discipline. Psychotherapy supervisors now represent only the residual backbone of psychotherapy programs. The importance of what these supervisors teach and how they teach it has never been greater as the time devoted to teaching the art of psychotherapy diminishes, and the trainee has fewer settings in which to learn the principles of psychodynamic psychotherapy (2—4).
Among the greatest contributions by psychiatry to the practice of medicine has been the attention paid to the human being behind the illness. Rodenhauser (5) warns, "Not least among the reasons for revitalizing psychotherapy supervision is the observation that many of psychiatry's contributions to medical-student and house-officer education are by-products of skills in psychotherapy…[such as] fundamentals of the physician—patient relationship, maintaining concern for the whole patient, learning to interview patients, learning to manage difficult patients, and, for educators, various instructional skills. If the art and science of psychotherapy diminish further in importance might psychiatry's contribution to humanism in medicine be impoverished to the level of mere discussion of behaviors and neurotransmitters? (p86)"
Although the time and energy devoted to teaching psychotherapy has diminished, the time allotted to the teaching of psychotherapy supervision was small to begin with. In surveys of professionals, only 20%—33% have received any formal training in supervision (6,7). Informal surveys by Rodenhauser (5) of more than 300 psychotherapy supervisors participating in skill-development courses reveal that almost all cite their own supervision of residents as their only preparation for becoming a supervisor. Watkins (8) writes about the blind spot that allows programs to train residents in psychotherapy but offers no guidance in how to train supervisors of psychotherapy. "Something does not compute. We would never dream of turning [unsupervised] untrained therapists loose on needy patients, so why should we turn untrained supervisors loose on those untrained therapists who help those needy patients? Just as becoming a therapist is a labor-intensive endeavor for which training and supervision are needed, the same can be said about becoming a supervisor (p 97)."
The importance of educating supervisors is far-reaching. Without adequate preparation, supervisors run the risk of boundary violations (9,10), breaching ethical codes of conduct (11), destructive re-enactments through the phenomenon of parallel process (12,13), restrictive practice styles that limit the growth of their supervisees, inadequate coverage of the basic tenets of psychodynamic practice, and occupational "burn-out" from the isolation of doing work that is never seen or reviewed (14). Moreover, because the supervisory relationship is the main way that trainees develop their identity as psychotherapists, supervisors' development of knowledge and skill is critical to their role as mentor (15).
Rationale of Continuing Education for Supervisors
The need to revitalize the supervisory staff of our outpatient psychotherapy clinic arose after the virtual dismantling of this clinic due to a department-wide restructuring. A weekly psychodynamic supervisors' meeting was lost, and the absence of "coming together" as a group spawned an insidious decline in morale. Swiller and Davis (16) have documented the effectiveness of offering continuing education opportunities and ongoing psychotherapy conferences as a means of boosting morale and enhancing the quality and quantity of psychotherapy supervisors. As members of a psychotherapy task force convened by the residency training director to examine the entire outpatient psychotherapy division, the authors chaired the supervision subcommittee and surveyed the supervisory staff to learn what their needs were and how those needs could best be met.
We gleaned significant data about the supervision staff and their backgrounds. There was an 85% return rate on the survey that polled the 60 active psychodynamic supervisors on our faculty, a balanced mix of psychiatrists and psychologists. Demographic inquiry revealed that 70% of the respondents were women, 30% men. Half have been supervising for more than 15 years, about one-third 5—15 years, and another 16% have been supervising for less than 5 years. Two-thirds named "psychodynamic" as their primary theoretical orientation, with "eclectic" and "integrative" adding another 25% (t1). Supervision was ranked second, after patient care, as the professional activity in which most time was spent, with teaching, writing, research, and administration following in diminishing order.
Supervisors were asked, "What are the greatest challenges you face as a supervisor?" They ranked "isolation" first, followed by "feeling undervalued." Then they cited "lacking information about supervision," "lacking information about the training program" (new rotation offerings and core curriculum teachings), and "not knowing where to turn when facing a supervisory dilemma."
Supervisors were also asked, "What are the greatest joys you experience in supervising?" The most frequently endorsed response was "participating in the growth and development of young therapists" and "the opportunity to become a mentor." Other frequently chosen answers included having the opportunity to teach and being able to change set from delivering patient care. More than half pursued supervision for their own cases well beyond the requirements of training and licensure.
As predicted from surveys in other hospital settings, most of our supervisors had not received formal course work, workshops, or seminars on psychotherapy supervision. A full 53% of the faculty had had no formal training whatsoever, including highly respected senior supervisors who had been supervising for several decades. Those who had taken one course or workshop or as many as 2 years of formal training numbered 28%, and 6% reported 3 or more years of formal training (this included staff who had written dissertations on supervision).
When we looked at the findings as a whole, a pattern emerged. Most supervisors lack formal training in supervision but are inclined to pursue supervision as a professional activity. The role of supervisor was given high rankings among the many comprising a professional identity. It seems that the strength in the group of supervisors lies in experience, openness to new learning, the importance given to this work, and eagerness to share with others. Of the 85% who returned the questionnaire, 68% said they would be interested in attending evening continuing education opportunities for psychotherapy supervisors. Those interested included the most senior supervisors on staff as well as the most junior. The result was the formation of an ongoing faculty psychotherapy supervisors' evening symposium aimed at education and development of the supervisory staff. Of those who completed the questionnaire, 96% have attended at least one of the four evening dinner-symposia offered each of the past 2 years, with 60% attending regularly. Although we were pleased at the high turnout rate for attending at least one meeting, we wondered why a much smaller number of supervisors attended more regularly. Closer inspection of the data revealed no differences in level of seniority, satisfaction with the course, or previous training in supervision. However, gender was a significant factor. Despite a preponderance of women supervisors expressing interest in attending the symposia, it was the male supervisors who were overrepresented as regular attendees. This finding may reflect the conflicts that women continue to face in juggling their family and professional roles.
One of the recommendations of the Psychotherapy Task Force was to appoint a Director of Education and Development for psychotherapy supervisors. The first author was named, and together with the second author, developed the supervision curriculum that follows.
Our psychotherapy supervision faculty works predominantly part-time at the hospital, with private practices away from the hospital campus, making symposia offered during working hours very difficult for most to attend. Therefore, 2-hour evening meetings four times a year, with an added incentive of a catered buffet dinner were selected as the format most likely to be attended. In the second year, continuing-education credits were also made available, with risk-management credits offered for the symposia on legal and ethical issues in supervision. For the upcoming third year, the Harvard Medical School Department of Continuing Education has designated all the symposia in this series eligible for risk-management credits.
The topics for the seminars were chosen from input by our staff and from our reading in the field. We turned to our own faculty psychologists and psychiatrists with expertise on these subjects to prepare papers and discussions and developed a 2-year curriculum for our supervisors. The recruitment of the supervisory staff to speak at the symposia had the added benefit observed by Swiller and Davis that many part-time faculty do not make frequent presentations at scientific meetings, and these presentations offer an opportunity to advance their own professional growth by developing the skills necessary for scientific presentation (16). We were fortunate to have resident experts on most of the selected topics.
Although many psychiatry training programs across the country may not have the number and diversity of supervisors available at a large program such as the Massachusetts General Hospital (MGH)—McLean Psychiatry Residency Program, there are other options available to smaller programs. These may include renting videotapes from professional organizations, such as the one made by the American Psychiatric Association described in Symposium 8, creating a lending system among training programs so that lectures can be taped and shared, and inviting outside experts to give presentations.
Four talks were presented during each of the 2 years, covering eight topics. The titles of the talks in the curriculum and a brief description of each topic follow.
Four senior supervisors comprised a panel to discuss four vignettes illustrating real supervisory dilemmas (Boundary Lines in Supervision: How Is Supervision Different From Psychotherapy?). The first vignette was of a supervisee who comes chronically late to supervision, always with plausible reasons given. The discussants commented on the different meanings lateness might have for the beginning therapist who is new to notions of parallel process and the more experienced therapist who might expect that his lateness could have meaning relevant to his patient's treatment. The second vignette revealed a severely depressed supervisee, not currently in therapy, who implores his supervisor to maintain confidentiality even about his suicidality. The third vignette told of a trainee deeply committed to learning psychotherapy, engaged in her own psychoanalysis, but using supervision to make her own disclosures and associations to her patient's material so that the supervisor finds himself slipping into the role of therapist. In the last vignette, the supervisee comes to supervision without any notes and obtusely rejects the supervisor's suggestion to interpret transference. When the patient stops coming to therapy, the supervisee glibly states that her patient wasn't a good psychotherapy case.
These dilemmas provided a launching pad for supervisors to reflect on the ways that the practices of therapy and supervision differ. For example, the supervisor, unlike the therapist, holds a dual role—as a teacher of the supervisee and as an overseer of the patient's welfare. Self-disclosure and storytelling hold a much greater place in the repertoire of the supervisor than of the therapist. Also, supervision is not held to the same rules of confidentiality as therapy because trainees must be held accountable by their institution for their ethics, behavior, and mental health. When supervisors discover a serious block in a supervisee's learning, the other supervisors and the training director need to be notified, and a plan for continued training must be developed with the trainee.
The second topic in the series (Privacy vs. Secrecy in Supervision) focused on the many paradoxes inherent in the supervisory process, such as the dual awareness supervisees have of revealing a great deal about themselves while being evaluated. Because supervisees are often reluctant to reveal their mistakes for fear of being judged, conscious and unconscious processes occur that cause the reporting of sessions to be altered as a form of self-protection. Disclosure in supervision is further complicated by the fact that supervisors learn about their supervisees through case material rather than through taking a developmental history, as is done in the beginning of a psychotherapy treatment. The supervisor must experience the trainee's re-creation of the treatment to learn about the trainee's style and defenses. Supervisees' struggle with how much to disclose becomes a tool for understanding their learning process. Supervisors can welcome disclosure by modeling their own struggles and sharing their own mistakes. Co-construction of learning objectives and periodically addressing the progress together is a way of demystifying the supervisory process. Although privacy and secrecy are normative aspects of every supervision, there were differences voiced by supervisors about how much information to share with each other about a supervisee's work. Each training department must determine its own policy about privacy: should supervisors periodically assemble to discuss a supervisee's work, and should they do so with or without the supervisee present? It is important that training departments, with the input of their supervisors, determine their stance on privacy.
The third session (Evaluation in Psychotherapy Supervision: Necessary Evil or Teaching Opportunity?) addressed one of the chief concerns expressed by our supervision faculty in our initial survey: the duty to provide written evaluations of our trainees. Many supervisors felt there was an inherent contradiction in their roles as supportive teacher of psychotherapy and evaluator of a trainee's progress. In this symposium, we learned that providing good feedback is not only helpful, but ethically mandated. Trainees need to know how they can improve and be given time to demonstrate that improvement. Giving feedback stirs up anxiety in supervisors because it is the part of the role most unlike their more familiar role as psychotherapists. It is also the part of the supervisory role in which they get the least training. There should be no surprises at the time of a written evaluation. To ensure this, it is vital that the expectations of the supervisory relationship be stated, that a contract for learning be established, and that the existence of written evaluations be disclosed at the outset of the relationship. When feedback is given clearly and fairly, in language using behavioral descriptions of clinical work and with alternative proposals about how to change behaviors, feedback will be esteem-enhancing.
This presentation highlighted a significant difference in the evaluation process between our psychology and psychiatry departments and was responsible for a major procedural change in our residency evaluation process. The psychology department has always had two written evaluation periods per academic year, in November and May, whereas the psychiatry department has traditionally evaluated residents at the end of the academic year. This symposium stressed the necessity for providing an early benchmark to alert the trainee and the department to the strengths and weaknesses of each resident. In so doing, the resident has an opportunity to work on specific areas within the supervisory dyad. The psychiatry department now requires written evaluations that are discussed with each resident in the fall and the spring of each year.
The Department of Psychiatry at MGH has separate training divisions for psychology interns and psychiatry residents. In the fourth presentation (The Role of the Psychiatry Department in Psychotherapy Supervision Evaluation) the training directors for each division were asked to present evaluation procedures with the intent of formally introducing all supervisors to the procedures and opening discussion on the merits of each.
Psychology interns establish a verbal learning contract with each supervisor at the beginning of the academic year. Such contracts include time, place, length, and frequency of meetings, as well as specific learning goals and clarity about what form the supervision will take (i.e., live observation, audiotapes, videotapes, or process notes). With a clear contract in hand, little ambiguity exists if the trainee deviates from goals and expectations. Formal written evaluations with documentation of the learning objectives and performance are sent to the training director for review.
Supervisors of psychiatry residents are expected to discuss the frame of the supervisory process, expectations for attendance, and learning objectives at the beginning of the academic year. The residents each have an individual training supervisor, whose responsibility it is to oversee the training experience for that particular resident. Supervisors with concerns are expected to contact the training supervisor. The twice-yearly written evaluations are followed by a review from the training director at the end of the year unless serious problems are identified early on.
Training directors expect to be called under the following circumstances: 1) supervisees do not come to supervision; 2) supervisees do not perform the contracted method for discussing cases (i.e., process-notes or tape-recording); 3) the supervisory dyad seems to be a "bad match" of personality styles; 4) the learning process is not proceeding at an expectable rate; 5) unethical behavior exists. Neither division of training currently has a forum for discussing supervisory dilemmas, but this presentation highlighted the need for such an individual or board to be identified.
The fifth topic (The Beginning Phase of Psychotherapy) highlighted the delicate process of forming an alliance with a new supervisee. The phenomenon of "shame anxiety" was held up as the backdrop against which the drama of the emerging supervisory dyad is played out. A supervisor must be aware of the excitement for learning as well as the dread of being shamed that comes with a first supervisory experience. A supervisor must never forget how much the supervisee fears that the supervisor will discover a character flaw that might disqualify him or her from practicing. For this reason, normalizing these fears is of critical value to the supervisee. A good supervisor will convey that the amount of shame is a good barometer of how the supervision is going. If there is a lot of it, what would need to occur for the supervisory pair to be able to discuss the difficult subject? Usually some of the most important learning comes from students' ability to access their worst thoughts, feelings, or actions in their clinical work.
Obtaining some background information about the supervisee at the outset of supervision can help tailor the relationship to each supervisee's particular needs. Appropriate questions would include the following: educational background; the trainee's reasons for choosing this profession; clinical and theoretical courses completed; populations the student has worked with in volunteer and/or clinical experience; and level of preparation for managing a patient crisis. Learning about a supervisee's best and worst previous supervision experiences will give the supervisor insight into how to manage similar tensions in their work together. In addition to making a beginning contract (see Symposium 4), the limits of confidentiality must be outlined by identifying that the supervisory dyad is part of a triangle that includes the hospital administration. For safe and effective supervision to be conducted, each side of the triangle needs to be strong and dynamically involved.
The sixth topic (The Development of the Psychodynamic Psychotherapist in Supervision) offered a structure for the supervisor and trainee to refer to in an ongoing way for formal and informal evaluation. Nine areas of development were identified that can focus the supervisor on the strengths and weaknesses of the beginning therapist (17). The areas include 1) the ability to make observations of the patient's behavior, affect, and thought processes in order to build a multiaxial descriptive diagnosis; 2) a grasp of psychodynamic formulation; 3) an understanding of the course of therapy as having an identifiable beginning, middle, and end; 4) recognition of transference; 5) recognition of defense and resistance; 6) the capacity to identify and tolerate strong affect; 7) the ability to recognize countertransference; 8) the ability to use nuanced, affective, real language in talking with patients about powerful, sometimes unconscious feelings; 9) the mastery of theory and the development of the therapist's own unique style.
In the seventh symposium, a forensic psychiatrist and a hospital attorney discussed the legal responsibilities of the supervisor (Legal Aspects of Psychotherapy Supervision). The legal liability inherent in the role of psychotherapy supervisor is not made explicit to full-time faculty and part-time volunteer supervisors in the vast majority of training programs across the country (18). In the current era of heightened interest in medical liability and increased accountability demanded by insurers, supervisors must be made aware that they could be named in a lawsuit brought against their supervisee.
The duty to supervise includes educating supervisees in accord with national standards of practice, periodically evaluating their competency in light of these standards, and delegating responsibility commensurate with competency. Potential pitfalls include confidentiality issues, evolving national standards now shifting from psychodynamic to more psychobiological focus, shifts in reporting practices, and inadequate documentation.
This presentation invoked the need for our department to inform all supervisors of the direct and vicarious liabilities involved in their role, thus allowing them to supervise with full awareness of the risk involved. Offering continuing education on risk-minimizing strategies such as use of consultation, documentation of supervisee impairment, and supervision contracts can reduce anxiety associated with this information. Some comfort can be taken in the fact that, to date, no cases have been reported involving psychotherapy supervisors where there is a legal basis for litigation. In order for litigation of liability to occur in a claim of negligence against a supervisor, the situation must meet the following three criteria: there has been 1) dereliction of duty; 2) injury; and 3) proximate cause.
The eighth presentation (Ethical Issues in Psychotherapy Supervision) was focused on a videotape produced by the American Psychiatric Association (19) of a dozen role-plays illustrating a range of boundary violations. In one, a therapist reports to a colleague that he was swept away by feelings toward a patient and kissed her. He asks his colleague to consult with his patient and explain the situation to her. In another vignette, the therapist is in the process of asking his patient to have sex with him. After each vignette, the tape was paused so that the group could discuss their reactions and brainstorm about what actions could be taken.
With an estimated 6% of psychiatrists sued for sexual malpractice (20), it is critical that supervisors are knowledgeable about boundary violations and have strategies to understand and manage sexual feelings that frequently emerge between therapist and patient. In the discussion, the supervisors talked about the need to introduce into the beginning curriculum for trainees the notion that sexual feelings are common and expectable responses that should be talked about in supervision so they can be understood like other countertransference reactions. Other foci for group discussion included guidelines for reporting a serious boundary violation, the way that evidence of minor boundary violations on the part of a supervisee should alert the supervisor to the potential for more serious ones, and the difference between a therapist's having sexual feelings and acting on them.
A course evaluation was sent to all participating supervisors to evaluate the symposium thus far. The results of the evaluation of the program are as follows:
An attendance record showed that of our 60 psychotherapy supervisors, 96% attended at least one of the symposia, with 60% attending regularly. One hundred percent would like the series to continue, with 90% reporting that their knowledge of supervision has grown substantially. Prior to the symposia, the majority of supervisors in our psychotherapy division felt isolated and undervalued by the psychiatry department. The evaluation shows that 85% now feel less isolated, and about 60% feel more valued by the department. As a result of the series, more than half feel more connected to the department. The overall morale has greatly improved; 80% of supervisors stated their satisfaction with their role as supervisor had grown as a result of the series. For a comparison of responses based on senior or junior faculty status, see t2.
Supervisors suggested several areas needing more time in the future, such as breaking up into smaller groups to discuss specific therapeutic dilemmas and identifying a group of individuals in the department who will serve on an advisory board for serious supervisory problems.
Without a control group and objective measures, it is difficult to assess the effectiveness of the supervision course in adding substantively to the supervisors' knowledgebase and improving the quality of their supervision. However, by self-report, the course certainly seems to have boosted morale and provided a valuable forum for a disjointed group of faculty to come together in collegial learning. All of the participants reported that they wanted to see the supervision seminars continue. Almost unanimously, respondents rated the content of the seminars as being useful, reported that their knowledge of supervision had grown as a result of their participation, and asserted that their satisfaction with the role of supervisor had grown as a result of coming together as a group.
Although the true measure of the impact of our program would be to survey the residents before and after the symposia to determine whether there was a substantive change in the quality of their supervision, this survey remains to be done. Supervisors were asked to report how attending these symposia has changed their supervisions. Reports included the following: using a more formal contract at the beginning of supervision; having a new level of consciousness about what was being said; feeling less isolation as a supervisor; holding back from being the "star," and listening better to supervisees; and feeling more candid about one's own strengths and weaknesses. Many said they now discuss the evaluation process with their supervisees at the beginning of the relationship, rather than waiting until the evaluation period is upon them.
This group of supervisors is heterogeneous in terms of age, time spent at the hospital, professional discipline, previous participation in formal supervision coursework, and experience as a supervisor. We were particularly interested in the differential impact of this course on beginning supervisors as compared with more senior supervisors. When asked at the outset their reasons for supervising, the senior supervisors endorsed the wish to connect with the department and the opportunity to be a mentor far more often than did the junior supervisors. Conversely, the junior supervisors stated with greater frequency than their more-experienced counterparts that they chose to supervise in order to change set from doing therapy. Perhaps these supervisors, new to sitting with patients for long blocks of time and longing for the recent camaraderie of training, looked to supervision as a respite from the rigors and loneliness of psychotherapy. The similarities between the junior and senior supervisors, however, were far more striking than the differences. Although we had predicted that the senior supervisors might feel that their experience offset the need for formal education, this turned out not to be the case. We had also wondered whether the newer supervisors might have had more opportunities offered to them during training in supervision and, therefore, would not feel the need for seminars in supervision. Both groups of supervisors, however, reported a lack of training in supervision and a need for more knowledge.
Several factors account for the widespread interest in formal supervisory education among supervisors of different levels of experience. Whereas an informal, mentoring model of learning supervision may have sufficed in the past, more rigor is needed in the current climate. With the funding for psychotherapy training slashed, supervisors of therapy may want to hone their expertise and solidify their identity as supervisors by banding together. Furthermore, publications on the research and theory of supervision (5,8,10,21,22) have proliferated over the last decade, making this a field with much exciting knowledge to disseminate. Finally, as supervisors become aware of their legal vulnerability and accountability, many are motivated to protect themselves through education and risk-management.
The greatest benefits of the seminars were to invigorate a body of supervisors with few opportunities to come together and offer a forum for a lively exchange of ideas. These first 2 years offered a formal, fairly structured curriculum. Although this forum provided the safety necessary for coming together as a group, requests for a less structured format with more time for discussion came near the end of the first year. By the end of the second year, supervisors expressed the desire to meet in smaller groups to discuss actual supervisory dilemmas. Akin to the stages marking the developing therapist and psychotherapy supervisor (23), the continuing education group seems to be progressing through similar stages. Having established the safety of the group in the first year and group cohesion in the second, we look forward to the individuation phase where specific individual supervisory issues can be addressed. Our hope is that other psychiatry departments can benefit from adapting these learning opportunities for their supervisors.
The authors gratefully acknowledge all the speakers in our Continuing Education series for their expertise and willingness to share it with fellow supervisors. This series would not have been possible without their generous contribution of knowledge and time: (Symposium 1) Irene Briggin, M.D., Training and Supervising Psychoanalyst, Boston Psychoanalytic Society and Institute, Senior Psychiatrist, MGH, Assistant Clinical Professor, Harvard Medical School (HMS); Anne K. Fishel, Ph.D., Director, Couples Therapy Training, MGH, Instructor Psychology, HMS; Paul Hamburg, M.D., Assistant Director, Eating Disorders Unit, MGH, Assistant Professor, HMS; Edward Messner, M.D., Psychiatrist, MGH, Associate Clinical Professor, HMS; (Symposium 2) Anne Alonso, Ph.D., Director, Center for Psychoanalytic Studies, MGH, Professor of Psychology, The Fielding Institute, Clinical Professor of Psychology, HMS; (Symposium 3) Brenda Black, Ph.D., Supervision Educator and Consultant; (Symposium 4) John Herman, M.D., Residency Training Director, MGH, Assistant Professor of Psychiatry, HMS; Roberta Pressman, Ed.D., Member, Training Committee for Psychology Internship Program, MGH, Instructor in Psychology, HMS; Eva Schoenfeld, Ph.D., Member, Training Committee for Psychology Internship Program, MGH, Instructor in Psychology, HMS; (Symposium 5) Samuel James, Ed.D., Associate Director, Center for Group Psychotherapy, MGH, Clinical Instructor, HMS; Paula Rauch, M.D., Director of the Child Psychiatry Consultation Service, MGH, Assistant Professor of Psychiatry, HMS; James Groves, M.D., Psychiatrist, MGH, Associate Clinical Professor of Psychiatry, HMS; (Symposium 6) Jane Thorbeck, Ed.D., Faculty and Supervisor, Massachusetts Institute for Psychoanalysis, Supervisor, Center for Psychoanalytic Studies, MGH, Faculty, Advanced Training Program, Boston Psychoanalytic Society and Institute; (Symposium 7) Ronald Schouten, M.D., Director, Law and Psychiatry Service, MGH, Assistant Professor, HMS; Michael Broad, Esq., Legal Council, Partners Healthcare, MGH and Brigham and Womens Hospital; (Symposium 8) Dr. Anne Alonso; Carol Nadelson, M.D., Director, Partners' Office for Women's Careers, Brigham and Womens Hospital and MGH, Clinical Professor of Psychiatry, HMS.