The challenge of assessing resident competency in all areas of psychiatry and medicine is in the national spotlight as all residency programs are charged with this overarching mandate. To ensure competence, it follows logically that residents’ teachers must be qualified to teach and supervise the psychiatrists of tomorrow. Supervisors play a major role in the development of psychiatry residents but there are currently no standard training programs for this role (1, 2).
As the hours for learning psychotherapy become scarce, it is increasingly important that supervisory skills be defined and taught to faculty supervisors (3) but surveys show that most supervisors across the country receive little or no training (4). In a survey at Massachusetts General Hospital we found that more than 75% of supervisors had no training in supervision and 20% had attended only one seminar (5). Because they do not receive formal training, supervisors use their own experience of being supervised as the foundation for their role, but there are critical topics in supervision that should be learned systematically. Without adequate training, supervisors risk committing boundary violations, breaching ethical codes of conduct, participating in harmful reenactments through parallel process, having practice styles that limit growth of their trainees, and providing inadequate coverage of the basic principles of psychodynamic practice (6).
Psychodynamic psychotherapy is the subject of continuous research and support because its effectiveness has been well documented (7–13). The theoretical basis for psychodynamic psychotherapy supervision has a long tradition embedded in the supervision literature (14–18). This article describes a course specifically for psychodynamic supervisors although many principles can be applied to other forms of supervision.
This course was designed because psychodynamic psychotherapy requires specific skills in maintaining psychological boundaries with trainees as well as other core legal and ethical concepts. Because reading about supervision alone is insufficient to grasp the nuance and subtlety embedded within supervision, class participation and discussion of case examples were key components of the learning process. The breadth of the material and the need for discussion precluded the use of a single lecture or slide presentation. The course outline with reading list is available from the authors.
This article describes the eight sessions of the course (Table 1
) that were developed by the first author from literature reviewed at a two-year, weekly journal club on psychodynamic psychotherapy supervision, and a seminar series offered to faculty supervisors at Massachusetts General (5). Subsequently, the course “Becoming a Psychodynamic Psychotherapy Supervisor” was offered to senior residents and faculty. Class size was typically 6−10 people, combining faculty and residents in the same class. There were two main reasons that participants enrolled in the course: they felt they had inadequate knowledge to begin their role as a supervisor, or they felt they had not had enough training to feel comfortable in their current supervisory role.
The course goals included establishing a frame, forming an alliance, and identifying learning goals; learning the legal and ethical standards of supervision; learning what excellent supervisors do and use of parallel process.
Session 1: Introduction, History of Supervision, and Key Issues in Supervision
The instructor presented the course goals and the history of psychotherapy supervision. The history begins with Freud’s earliest supervision, which resembled a master-apprentice model. Decades of debate between the Berlin, Germany, and Budapest, Hungary, Institutes evolved about how best to supervise beginning analysts. The first analytic supervisors were also the analysts of the trainees. Ultimately, the consensus was that ethical supervision required a separation of analytic and educational activities (19). Current pedagogy focuses on teaching a fund of knowledge and modes of thinking to residents (14). This educational focus does not detract from the premise that personal therapy can help trainees distinguish between their own dynamics and their patients’ as well as support residents in their work.
Talking about the supervisory relationship can ease anxiety and serve as a role model for psychodynamic work. Key issues, discussed in depth later in the course, are raised to encourage thinking about the relationship. These included the role of shame anxiety that comes with trainees being asked to reveal a great deal about themselves while also being evaluated (20); the unequal nature of the relationship because of the inherent differences in status, experience, and power of the dyad (14); and questions of how personal supervision should be. Participants were invited to discuss how these issues have been managed in the past and ideas for optimizing such discussion were solicited.
Session 2: Opening Phase of Supervision
There are seven crucial steps for an effective and ethical opening phase in supervision.
1. Form an alliance. This is the main task that will set the stage for the relationship and decrease the trainee’s anxiety. The supervisor should not focus too quickly on patient material, but take time to become acquainted with the trainee.
2. Establish a frame. The frame is a contract for meeting and identifying specific learning goals (21). The frame creates agreements for the relationship, including when and where they meet, how many patients will be supervised, the expected method of case presentation, advance notice for absences, and how the supervisor can be reached in a clinical crisis.
3. Discuss the evaluation process. It is ethically mandated that a trainee know the criteria prior to being evaluated. Showing the evaluation form to the resident at the beginning of supervision, discussing it, and having the resident sign it at the mid-year review will ensure a dialog takes place and that there is time for the resident to work on problems areas before the end of the year.
4. Give mutual feedback. This is essential for building confidence in a trainee’s strengths and redirecting the work when necessary so that the learning goals can be met before the evaluation period.
5. Discuss limits of confidentiality. Supervision, unlike psychotherapy, is not a confidential relationship. The supervisor works in a psychiatry residency training program and concerns about the resident must be brought to the attention of the training director.
6. Teach the importance of self-reflection. This must be taught from the beginning so that countertransference reactions can be identified and used in the service of the therapy.
7. Teach the importance of self-knowledge in psychotherapy so that the resident learns to distinguish his own personal dynamics from the patient’s. The opening phase is the best time for all trainees to learn that their own personal therapy can enhance their self-knowledge and reactions to patients.
Session 3: Assessments of Learning in Psychotherapy
There are five thought processes requiring assessment in becoming a competent psychotherapist. The first four were proposed by Jacobs et al. (14).
1. Inductive reasoning: an inferential process that expands knowledge in the face of uncertainty
2. Associative thinking: the joining together of one thought with another without an immediate conscious goal
3. Creative thinking: the flexibility and originality of thought and ability to synthesize different points of information
4. Self-reflection: using the mind to observe its own workings
5. Pattern recognition (22): organizing the patient’s narrative and looking for patterns in a way that this knowledge can be used to break destructive repetitions.
Session 4: Boundary Lines in Supervision: How Supervision is Different from Psychotherapy
Weekly 50-minute sessions can foster assumptions that supervision and psychotherapy are alike, but there are important differences. Because the supervisor works for a training institution the supervisory relationship is not confidential and there are specific times when the training director needs to be involved. These include absenteeism, inadequate progress, lack of case material, concerns about the trainee’s physical or mental health, and unethical behavior. Behaviors such as lateness and missed sessions in supervision are not managed the same as way as patient resistance. Rather than interpreting these behaviors, supervisors must consider other reasons embedded in the system or in the resident-patient-supervisor-triad. Another major difference is the fact that supervisors, in their role as therapists, do not evaluate their patients, so the role of evaluator is one with which most supervisors are least familiar. Supervisors need to be educated in performing this important task.
Session 5: The Evaluation Process
Supervisors need training in arriving at meaningful evaluations and discussing them with their residents. Establishing explicit learning goals at the outset of supervision makes clear what will be evaluated so there will be no surprises, as described in detail by Goldberg (21). Ende (23) describes feedback as presenting information about behavior, both positive and negative continuously, while an evaluation is a summation of the trainee’s work (23).
Session 6: Legal and Ethical Issues in Supervision
Few supervisors or trainees are aware that supervisors are legally responsible for their trainees’ actions (24). Supervisors may not only be directly liable, but are subject to vicarious liability for the negligence of their residents (25). The actual degree of involvement of the supervisor in the psychotherapy case is not relevant in the legal setting. This applies whether the supervisor is an employee of the hospital or not (26, 27). Actual litigation of psychiatrists most often involves a tangible injury, the most frequent being sexual misconduct and suicide (28, 29). The supervisor must ensure that proper record keeping is maintained by the resident. Documentation of the supervision process itself is necessary if residents do not follow recommendations that impact on patient safety or do not disclose all the information needed for the supervisor to make informed recommendations. Providing coverage while the supervisor is away and limiting the number of cases being supervised will also increase protection for all.
Sherry (30) notes that supervision is vulnerable to ethical misconduct for three reasons: the power differential of the participants; the “therapy-like” quality of the relationship; and the conflicting roles of the supervisor as educator, overseeing patient welfare, and evaluating the trainee. Morgan (31) raises the important issue that ethical supervision also implies awareness of the impact of gender, race, background, and ethnicity issues on the supervisory pair. Finally, ethical supervision requires that supervisors be evaluated by their trainees.
Session 7: Supervising Intense Affects In Psychotherapy
The ability to recognize and describe affects is a task of the first-year resident. Supervisors help residents to tolerate direct expressions of hostility, affection, sexuality, and other powerful emotions and to use their own affective responses appropriately with patients.
With an estimated 6% of psychiatrists sued for sexual malpractice, much attention is needed in learning how to manage intense feelings. Bridges (6) warns that the supervisor must initiate and set the tone for these conversations because of the degree of shame surrounding these feelings.
Among the most important reasons for managing intense affects is to avoid mishandling and abandoning patients in ways that ultimately hurt the patient, the relationship, and the clinician. Supervision is also vulnerable to sexual exploitation. Sexual boundary violations occur in resident-educator relationships in the United States at an alarming rate of 4.9% (32). Kay and Roman (33) believe that sexual boundary violations with patients are more likely to occur if they have occurred in resident-educator relationships.
Session 8: What Excellent Supervisors Do and Notes on Parallel Process
Supervisors judged to be excellent were active, empathic, and oriented to the immediate experience of the material presented by residents (34), and videotapes showed that supervisors with high ratings allowed the resident’s story about the therapy session to develop and consistently tracked the resident’s most immediate concerns. Kline et al. (35) have shown that analysis of videotapes of supervision revealed that excellent supervisors, far from being “blank screens,” were willing to clearly express unambiguous opinions about the patient, the student therapist, and the transference. They encouraged residents to formulate their thoughts and pushed residents to the limits of their capacity. Excellent supervisors also made judicious use of sharing their own clinical experiences and sparsely used technical terms (3). Another hallmark of excellent supervision is the use of the parallel process between issues in the resident’s relationship with his patient and his interactions with his supervisor. Parallel process, first associated with the supervisory situation by Arlow (36), is an indication of conflict in the patient-therapist dyad that is displaced onto the supervisory relationship (1).
The question of whether or not to make parallel process explicit merits judicious decisions as a supervisor, as encroaching on the dynamics of the resident is off limits. Certain reenactments in supervision provide rich teaching moments that should not be squandered. Using shame avoidance as a guide will help most supervisors decide whether or not to make their observations explicit, as the following example illustrates.
A male resident had worked with a fragile female patient for 2 years. A few weeks before the treatment terminated the patient brought a wrapped present to the session. They did not talk about the present, and at the end of the hour she left the room with it. During the next supervision the resident brought his supervisor a cup of coffee for the first time. She noted to herself that this was unusual, but thanked him. He then spoke of his great discomfort about the patient’s gift, saying he felt he did not know what to do since the patient had not given it to him directly. He feared that if it were not intended for him she would be embarrassed, and if it were, he would not “know what to do.” At that moment the supervisor held up the coffee cup and they both laughed at the same moment. He understood from her motion that she had accepted his “gift” and his laugh signaled that he saw the parallel and they were then able to draw on the analogy with his patient. A nonverbal attunement to the situation made it clear that it would not be shameful to discuss it. The supervision facilitated his broaching the topic with his patient before they parted, and the termination was mutually satisfactory for therapist and patient once she could talk about her strong feelings for him.
Results from Course Evaluation
Thirty-four participants have taken this course and rated it for content and presentation (Table 3
). Participants added comments on the evaluation form that indicated a strong needs assessment for supervisor training: 100% of trainees wrote that they felt much better prepared to become supervisors because of the course, and 82% of supervisors spontaneously reported that they wished they had received this training prior to beginning to supervise.
Training programs that can enhance knowledge and effectiveness of teachers will optimize competent practices in our graduating residents. This article describes a course where supervisory “best practices” are taught and could be used by any training program. Future directions include using videotapes of effective and ineffective supervision for demonstration purposes and offering video feedback to supervisors who request or require it based on evaluation of their own performance. Wider use of peer supervision for new and experienced supervisors would continue to hone supervisory skills.
The challenge in medical education is to balance the fundamental responsibilities of “first do no harm,” with its mission: the graduated and incremental assumption of responsibility toward the end goal of independent and collaborative practice. Psychotherapy skills involve behaviors and attitudes that are inherently hard to capture on pencil and paper tests. The act of supervisors teaching and modeling skills and entering into ethical relationships with residents is critical to the development of competent psychotherapists. Supervision and learning are lifelong processes. Indeed, the supervisors need training and supervision, and failure to recognize this jeopardizes the safety of us all.