SUPERVISION OF PSYCHOTHERAPY WITH PSYCHIATRIC RESIDENTS One Model*
STANLEY
An incongruity has arisen in the field of psychiatric residency training. Because of the tremendous growth of knowledge in all areas with which psychiatrists must be conversant, most of the time spent in training is devoted to spheres other than the psychotherapeutic. And yet when residents complete their training, much of their work in the management of their patients is based upon psychotherapy skills. The incongruity is that so little time is spent in teaching psychiatric residents the work which will occupy most of their professional lives . There are various ways residents can become more knowledgeable and skilled in talking with their patients - some are casual, others are formal. One of the formal aspects of such training is the supervision of longer-term cases seen on a regular basis. It is not necessary for all residents to become psychotherapists, but it is impossible to be a competent general psychiatrist without a full feeling for all that is involved in more intensive psychotherapeutic experiences. The single most important teaching tool to give a feeling for this is the individual supervision of relatively intensive, long-term cases. This experience is important (even though the resident may not choose this form of practice) because without it the embryo psychiatrist will not understand the *Manscript received March 1975. 'Psychiatrist-in-Chief, Mount Sinai Hospital, Toronto, Ontario. Professor, Department of Psychiatry, University of Toronto. Can. Psychiatr. Assoc. J. Vol. 21 (1976)
141
E.
GREBEN,
M,D.!
emotional building blocks of his patient, nor will he adequately sense what is involved in the growth and change of people. A family practitioner may never have occasion to look under a microscope at the cellular structure of tissues: but if he has not had that experience under the supervision of a competent pathologist during his training he will be an inadequate family practitioner.
The Contract The supervisor and resident agree to meet once a week to discuss one or perhaps two patients whom the resident is seeing once or twice a week. These meetings should continue for at least a year. What the Resident Does: The Method of Reporting Some supervisors insist that the resident record and report his sessions with the patient, and many encourage a written record made at the time. Others say that writing interferes with therapy, and ask that the written record be made after the hour. Some suggest the use of tape or video recordings and others insist that no record be made, or at least that none be used in the reporting, since they feel this interferes with the spontaneity of the report. Of the various methods tried each has its shortcomings. As far as verbal content is concerned, the only way to have an exact record is to tape, but this consumes much
142
CANADIAN PSYCHIATRIC ASSOCIATION JOURNAL
too much time in the listening. Occasionally it can be useful in surprising a resident into a more accurate realization of how he 'comes across' to others, but as a regular method for all sessions it is an inefficient use of time. All written methods involve the loss of some material through forgetting or distortion, whether written at the time or in retrospect. When residents are allowed to choose the method they prefer, most elect to write an account after the therapeutic session; many others prefer to do so during the session, later reading from it in supervision. A few make very brief notes, and recall what they can from memory. Whatever method is used, material will be lost and distortion will occur. This is a serious matter only if one believes that the efficacy of psychotherapy hinges upon every word or phrase, as well as upon the exactness of the interpretation of each piece of material the patient brings. But equally or more important is the overall atmosphere of the meeting and that atmosphere can be sampled with a less than exact recording. The task of the resident is to try to convey what is happening in his sessions, and what it feels like to him. He must also raise his own questions for the supervisor to try to answer. This method of information exchange can occasionally be supplemented by having the resident arrange a meeting of all three patient, resident and supervisor. This is not routine as the privacy of the therapeutic arrangement is usually left uninterrupted. But sometimes it is difficult to understand what the patient is like; or else the resident may feel he cannot adequately convey his difficulty, and a three-way meeting may be very useful.
What the Supervisor Does: Various Types of Iutervention The principal intervention of the supervisor is to explain what' he thinks is going on. There is great variation from resident to resident as to how the supervisor contributes. A resident will often give the full report of a session before the supervisor makes any comment. In these instances I
Vol. 21, No.3
look for main themes running through the material, and when the reporting has been completed I elucidate these to the resident, showing him the threads which tie the session together. This includes both what the words and actions of the patient seem to be saying, as well as the currents in the relationship between patient and resident. The supervisor can then comment on the overall problems being expressed, and on the manner in which they have been taken up or avoided. Since the supervisory relationship extends over a number of months, it is possible to go back to earlier events in the treatment of this patient, and also to recall comparable or contrasting events in the treatment of other patients. Other residents may pause to ask questions during the reporting. In some instances a problem in the therapeutic session leads to a broader theoretical question, and this can become a jumping-off point to explore that topic more fully. The supervisor may then bring in clinical examples from his own experience, which residents find particularly helpful. Or he may refer to literature which deals with the problem at hand. To expand upon this didactic aspect of the supervisor's task: around the clinical examples which the supervisor presents there is a natural opportunity to encourage the resident to read relevant material. This will include papers on this type of clinical problem, but even more important it should include writings on the subject of psychotherapy. As supervisor, it is tempting to take the position that one knows what is best, and to dictate to the resident, but this will have poor results. As teacher, the best attitude is to discuss what one thinks it would be best to say. It should always be "I think I would have done this", rather than, "The right thing to have done would be this." To take the directing role is too arrogant in the face of the fact that we are trying to encourage growth of a new practitioner in an art which is at the most an applied science. The supervisor cannot give correct answers on technique to the student, but he can share his thinking after years of practice and
April, 1976
SUPERVISION OF PSYCHOTHERAPY
supervision, and allow the student to make what use he can of that material. A question which often arises when considering the supervisor's methods is, how are his interventions different from those of a therapist? They are different, and yet they may include quite personal material. The resident has not come for treatment, he has come to be taught. Therefore the main purpose is not to shed the fullest light upon his personality and his problems, but to refer to them only insofar as this is necessary and relevant within an educational context. The degree to which personality characteristics in the resident will be discussed will vary considerably according to the resident's interest and willingness to accept any opinions in that regard. Some residents will ask that the part they have played in a difficulty with the patient be commented upon. Others will be most resentful of any reference to countertransference aspects, and the supervisor must be guided in this by the student. He is wrong to make more personal comments than can be accepted. In general the rule is to stick to the relevance of such conflicts to the therapy being discussed. In some instances the resident's problems will be great enough that he will require therapy: if the relationship with the supervisor is a good enough one, the resident may choose to discuss this with his teacher, and even seek his guidance in the choice of a therapist or psychoanalyst.
General Characteristics of the Supervisor's Role The resident comes as a student, in order to learn. The supervisor is helpful in the following ways: • He provides another objective view of the resident's work with the patient; • To support his views he brings longstanding experience of treating patients; • He points out blocks in the resident's work, thus helping and encouraging him to persevere in the face of difficulties. This allows the resident, perhaps for the first time, to work with a patient long enough to see real change (i.e., growth);
143
• He is conversant with the views propounded by others with respect to psychotherapy and guides the resident towards a familiarity with and understanding of these views; • He becomes a model of how to function with another human being whom one is trying to help (his student). This will be important in the resident's identification with his teacher as a therapist, and in the development of the resident's professional identity. He experiences how he is treated by his teacher - if he is treated with respect and dignity he will be more likely to move in that direction himself in his work with patients.
The Ways in Which Such Supervision Can Help My observations of the change in the work of residents, discussions with them during and after the course of supervision, and recollections of my own experiences as a supervised resident have led me to the conclusion that what I have described can help promote growth in the resident as therapist. What are those changes and how are they related to the supervision experience? • The supervisor's objective view helps the resident develop a critical observing capacity for his work. Insofar as the supervisor is critical in a fair and friendly way, the resident's professional superego becomes critical but reasonable. The resident learns f'·om the supervisor's pulling the session together how to see the session as a unit with detectable themes running through it, and comes to visualize the process of therapy as a whole, with past and present themes, and future probable directions. • The supervisor who treats the resident with genuine respect induces the growing feeling that he is a colleague a professional person of some already developed competence rather than a rank beginner at the bottom of some new ladder. If the relationship has a friendly informality, it will include the use by the supervisor of experiences in his own training and professional life. This helps
144
•
•
•
•
CANADIAN PSYCHIATRIC ASSOCIATION JOURNAL
the resident see that the difficult problems he struggles with were also problems for his teacher, whom he now sees as a competent practitioner. The resident who is uncertain of his own competence first meets his supervisor with exaggerated feelings - on the one hand he sees him as potentially highly critical but on the other hand he idealizes him. However, real contact with the supervisor over many months, allows the emergence of a more realistic picture of the supervisor, both as a therapist and as a person. The resident needs to develop his own professional identity. A good supervisory experience will allow him to identify in part with his teacher. Ultimately, he will keep those attitudes and approaches which are consistent with his own values and capacities, and give up the rest. In this way a contribution is made to the development of his growing identity as a therapist. Consultation is an important tool in all medical specialties. In psychiatry (especially with respect to psychotherapy) it is probably used too seldom. A good supervisory experience will increase the likelihood that the resident, when he has qualified, will understand the importance of discussing his difficult problems with trusted colleagues. Psychiatric training, which often involves rotation from setting to setting, combined with hospital practices of discharging patients as quickly as possible, gives residents insufficient experience of the kinds of changes which can only take place after a number of months or even years of treatment. For this reason, when possible, some supervisory time should be offered beyond the year the resident is in formal supervision, and this would give him the experience of seeing true growth in his patient.
Conclusion A supervisory method is outlined which should lead to growth and development of
Vol. 21, No.3
residents as therapists. Such experience, whatever the subsequent mode of practice the resident chooses, will make him a more confident, insightful and effective psychiatrist. Summary Training of psychiatric residents should include supervised experience in psychotherapy, whatever the mode of practice the psychiatrist-to-be will later choose. Individual supervision of psychotherapy on patients seen at least once a week for a year offers the best opportunity for learning in this area. The supervisor has a teaching role which includes showing the resident how to look more objectively and insightfully at the materialrserving as a partial model of a professional identity, and giving direct didactic help regarding the subject of psychotherapy. Such an experience leads to growth and development of the resident in his professional role as psychotherapist.
Resume On devrait inclure dans la formation des residents en psychiatrie un experience supervisee en psychotherapie, quelque soit le genre de pratique que choisira le futur psychiatre. Une supervision individuelle d'une psychotherapie de patients vus au moins une fois la semaine pendant un an apporte les meilleures garanties d' ameliorer ses connaissances dans ce domaine. Le superviseur assume Ie role de professeur, car il doit enseigner au resident it voir d'une maniere plus objective et plus approfondieson malade, le superviseur devient un modele partial dans son identite professionnelle offre alors une aide didactique directe pour Ie malade en psychotherapie. Une telle experience favorise chez le resident, son perfectionnement dans son futur role professionnel de psychiatre.
STANLEY
An incongruity has arisen in the field of psychiatric residency training. Because of the tremendous growth of knowledge in all areas with which psychiatrists must be conversant, most of the time spent in training is devoted to spheres other than the psychotherapeutic. And yet when residents complete their training, much of their work in the management of their patients is based upon psychotherapy skills. The incongruity is that so little time is spent in teaching psychiatric residents the work which will occupy most of their professional lives . There are various ways residents can become more knowledgeable and skilled in talking with their patients - some are casual, others are formal. One of the formal aspects of such training is the supervision of longer-term cases seen on a regular basis. It is not necessary for all residents to become psychotherapists, but it is impossible to be a competent general psychiatrist without a full feeling for all that is involved in more intensive psychotherapeutic experiences. The single most important teaching tool to give a feeling for this is the individual supervision of relatively intensive, long-term cases. This experience is important (even though the resident may not choose this form of practice) because without it the embryo psychiatrist will not understand the *Manscript received March 1975. 'Psychiatrist-in-Chief, Mount Sinai Hospital, Toronto, Ontario. Professor, Department of Psychiatry, University of Toronto. Can. Psychiatr. Assoc. J. Vol. 21 (1976)
141
E.
GREBEN,
M,D.!
emotional building blocks of his patient, nor will he adequately sense what is involved in the growth and change of people. A family practitioner may never have occasion to look under a microscope at the cellular structure of tissues: but if he has not had that experience under the supervision of a competent pathologist during his training he will be an inadequate family practitioner.
The Contract The supervisor and resident agree to meet once a week to discuss one or perhaps two patients whom the resident is seeing once or twice a week. These meetings should continue for at least a year. What the Resident Does: The Method of Reporting Some supervisors insist that the resident record and report his sessions with the patient, and many encourage a written record made at the time. Others say that writing interferes with therapy, and ask that the written record be made after the hour. Some suggest the use of tape or video recordings and others insist that no record be made, or at least that none be used in the reporting, since they feel this interferes with the spontaneity of the report. Of the various methods tried each has its shortcomings. As far as verbal content is concerned, the only way to have an exact record is to tape, but this consumes much
142
CANADIAN PSYCHIATRIC ASSOCIATION JOURNAL
too much time in the listening. Occasionally it can be useful in surprising a resident into a more accurate realization of how he 'comes across' to others, but as a regular method for all sessions it is an inefficient use of time. All written methods involve the loss of some material through forgetting or distortion, whether written at the time or in retrospect. When residents are allowed to choose the method they prefer, most elect to write an account after the therapeutic session; many others prefer to do so during the session, later reading from it in supervision. A few make very brief notes, and recall what they can from memory. Whatever method is used, material will be lost and distortion will occur. This is a serious matter only if one believes that the efficacy of psychotherapy hinges upon every word or phrase, as well as upon the exactness of the interpretation of each piece of material the patient brings. But equally or more important is the overall atmosphere of the meeting and that atmosphere can be sampled with a less than exact recording. The task of the resident is to try to convey what is happening in his sessions, and what it feels like to him. He must also raise his own questions for the supervisor to try to answer. This method of information exchange can occasionally be supplemented by having the resident arrange a meeting of all three patient, resident and supervisor. This is not routine as the privacy of the therapeutic arrangement is usually left uninterrupted. But sometimes it is difficult to understand what the patient is like; or else the resident may feel he cannot adequately convey his difficulty, and a three-way meeting may be very useful.
What the Supervisor Does: Various Types of Iutervention The principal intervention of the supervisor is to explain what' he thinks is going on. There is great variation from resident to resident as to how the supervisor contributes. A resident will often give the full report of a session before the supervisor makes any comment. In these instances I
Vol. 21, No.3
look for main themes running through the material, and when the reporting has been completed I elucidate these to the resident, showing him the threads which tie the session together. This includes both what the words and actions of the patient seem to be saying, as well as the currents in the relationship between patient and resident. The supervisor can then comment on the overall problems being expressed, and on the manner in which they have been taken up or avoided. Since the supervisory relationship extends over a number of months, it is possible to go back to earlier events in the treatment of this patient, and also to recall comparable or contrasting events in the treatment of other patients. Other residents may pause to ask questions during the reporting. In some instances a problem in the therapeutic session leads to a broader theoretical question, and this can become a jumping-off point to explore that topic more fully. The supervisor may then bring in clinical examples from his own experience, which residents find particularly helpful. Or he may refer to literature which deals with the problem at hand. To expand upon this didactic aspect of the supervisor's task: around the clinical examples which the supervisor presents there is a natural opportunity to encourage the resident to read relevant material. This will include papers on this type of clinical problem, but even more important it should include writings on the subject of psychotherapy. As supervisor, it is tempting to take the position that one knows what is best, and to dictate to the resident, but this will have poor results. As teacher, the best attitude is to discuss what one thinks it would be best to say. It should always be "I think I would have done this", rather than, "The right thing to have done would be this." To take the directing role is too arrogant in the face of the fact that we are trying to encourage growth of a new practitioner in an art which is at the most an applied science. The supervisor cannot give correct answers on technique to the student, but he can share his thinking after years of practice and
April, 1976
SUPERVISION OF PSYCHOTHERAPY
supervision, and allow the student to make what use he can of that material. A question which often arises when considering the supervisor's methods is, how are his interventions different from those of a therapist? They are different, and yet they may include quite personal material. The resident has not come for treatment, he has come to be taught. Therefore the main purpose is not to shed the fullest light upon his personality and his problems, but to refer to them only insofar as this is necessary and relevant within an educational context. The degree to which personality characteristics in the resident will be discussed will vary considerably according to the resident's interest and willingness to accept any opinions in that regard. Some residents will ask that the part they have played in a difficulty with the patient be commented upon. Others will be most resentful of any reference to countertransference aspects, and the supervisor must be guided in this by the student. He is wrong to make more personal comments than can be accepted. In general the rule is to stick to the relevance of such conflicts to the therapy being discussed. In some instances the resident's problems will be great enough that he will require therapy: if the relationship with the supervisor is a good enough one, the resident may choose to discuss this with his teacher, and even seek his guidance in the choice of a therapist or psychoanalyst.
General Characteristics of the Supervisor's Role The resident comes as a student, in order to learn. The supervisor is helpful in the following ways: • He provides another objective view of the resident's work with the patient; • To support his views he brings longstanding experience of treating patients; • He points out blocks in the resident's work, thus helping and encouraging him to persevere in the face of difficulties. This allows the resident, perhaps for the first time, to work with a patient long enough to see real change (i.e., growth);
143
• He is conversant with the views propounded by others with respect to psychotherapy and guides the resident towards a familiarity with and understanding of these views; • He becomes a model of how to function with another human being whom one is trying to help (his student). This will be important in the resident's identification with his teacher as a therapist, and in the development of the resident's professional identity. He experiences how he is treated by his teacher - if he is treated with respect and dignity he will be more likely to move in that direction himself in his work with patients.
The Ways in Which Such Supervision Can Help My observations of the change in the work of residents, discussions with them during and after the course of supervision, and recollections of my own experiences as a supervised resident have led me to the conclusion that what I have described can help promote growth in the resident as therapist. What are those changes and how are they related to the supervision experience? • The supervisor's objective view helps the resident develop a critical observing capacity for his work. Insofar as the supervisor is critical in a fair and friendly way, the resident's professional superego becomes critical but reasonable. The resident learns f'·om the supervisor's pulling the session together how to see the session as a unit with detectable themes running through it, and comes to visualize the process of therapy as a whole, with past and present themes, and future probable directions. • The supervisor who treats the resident with genuine respect induces the growing feeling that he is a colleague a professional person of some already developed competence rather than a rank beginner at the bottom of some new ladder. If the relationship has a friendly informality, it will include the use by the supervisor of experiences in his own training and professional life. This helps
144
•
•
•
•
CANADIAN PSYCHIATRIC ASSOCIATION JOURNAL
the resident see that the difficult problems he struggles with were also problems for his teacher, whom he now sees as a competent practitioner. The resident who is uncertain of his own competence first meets his supervisor with exaggerated feelings - on the one hand he sees him as potentially highly critical but on the other hand he idealizes him. However, real contact with the supervisor over many months, allows the emergence of a more realistic picture of the supervisor, both as a therapist and as a person. The resident needs to develop his own professional identity. A good supervisory experience will allow him to identify in part with his teacher. Ultimately, he will keep those attitudes and approaches which are consistent with his own values and capacities, and give up the rest. In this way a contribution is made to the development of his growing identity as a therapist. Consultation is an important tool in all medical specialties. In psychiatry (especially with respect to psychotherapy) it is probably used too seldom. A good supervisory experience will increase the likelihood that the resident, when he has qualified, will understand the importance of discussing his difficult problems with trusted colleagues. Psychiatric training, which often involves rotation from setting to setting, combined with hospital practices of discharging patients as quickly as possible, gives residents insufficient experience of the kinds of changes which can only take place after a number of months or even years of treatment. For this reason, when possible, some supervisory time should be offered beyond the year the resident is in formal supervision, and this would give him the experience of seeing true growth in his patient.
Conclusion A supervisory method is outlined which should lead to growth and development of
Vol. 21, No.3
residents as therapists. Such experience, whatever the subsequent mode of practice the resident chooses, will make him a more confident, insightful and effective psychiatrist. Summary Training of psychiatric residents should include supervised experience in psychotherapy, whatever the mode of practice the psychiatrist-to-be will later choose. Individual supervision of psychotherapy on patients seen at least once a week for a year offers the best opportunity for learning in this area. The supervisor has a teaching role which includes showing the resident how to look more objectively and insightfully at the materialrserving as a partial model of a professional identity, and giving direct didactic help regarding the subject of psychotherapy. Such an experience leads to growth and development of the resident in his professional role as psychotherapist.
Resume On devrait inclure dans la formation des residents en psychiatrie un experience supervisee en psychotherapie, quelque soit le genre de pratique que choisira le futur psychiatre. Une supervision individuelle d'une psychotherapie de patients vus au moins une fois la semaine pendant un an apporte les meilleures garanties d' ameliorer ses connaissances dans ce domaine. Le superviseur assume Ie role de professeur, car il doit enseigner au resident it voir d'une maniere plus objective et plus approfondieson malade, le superviseur devient un modele partial dans son identite professionnelle offre alors une aide didactique directe pour Ie malade en psychotherapie. Une telle experience favorise chez le resident, son perfectionnement dans son futur role professionnel de psychiatre.
