Commentary Supervision of Residents: Teaching Must Keep Pace With Knowledge carolyn B. Robinowitz, M.D.
Supervision is a significant component of residency education, and a major mechanism for teaching psychotherapy. The articles in this issue (1-3), while emphasizing different aspects of the process, address important facets of this educational tool. In particular, the article by Nestler (2) focuses on the divergent views of treatment of the same patient conveyed by two supervisors over a six-month period, as well as a third view provided by a case conference discussant. Nestler's methodology raises several questions including whether he is referring to psychotherapy supervision or psychiatric treatment supervision; the possible lack of consistency in his presentation of process notes (which by their nature are subject to editorializing and revision during their
Dr. Robinowitz is deputy medical director of the American Psychiatric Association, 1400 K Street, N.W., Washington, DC 2000S.
Copyright © 1990 Academic PsychiDtry.
I
f::
presentation); the weight given to clinical details and the context in which supervisors interpret such data; the supervisors' perception of their role and function (e.g., were they charged with patient care responsibility or did they understand their role as "consultants," meant to serve as an intellectual stimulus to the resident's development); as well as the absence of informed consent by the subject population (the supervisors). Although the patient described also poses many diagnostic and therapeutic questions not resolved by this brief presentation, Nestler's results must be carefully considered. This article raises three major concerns: the nature of modem psychiatric treatment planning and implementation; the role and function of supervision, supervisors, and supervisees; and the need for training and education in supervision. Modem psychiatry is developing a more rational and empirical approach to diagnosis and treatment planning. OSM-ill with its multiple axes has supported a more reliable and valid diagnostic nomenclature; the publication of Treatments of Psychiatric Disorders (4) has elucidated the process of treatment planning and begun the development of parameters or guidelines for care. The established modes of
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psychotherapy are becoming more codified, and thus replicable. Psychotherapeutic approaches taught to residents have expanded to include individual, family, and group; brief and long term; dynamiC and supportive; and psychodynamic, cognitive, or behavioral, to list but a few. Psychiatry is moving from treatment decision-making based on a therapist's interests and skills, with a near-religious adherence to values and beliefs, to treatment planning based on patient diagnoses, strengths, and needs. Further, the separation of treatment into psychotherapeutic or psychobiolOgical methods, while a correct reflection of history, is reductionistic. Current research supports a more integrated approach to therapy, choosing among and combining the available procedures as appropriate. This evolution has been no simple task. Many senior psychiatrists were trained at a time when fewer approaches and procedures were used. Supervisors may be more sensitive to or interpret data based on their own educational and clinical experiences. Few senior educators are skilled in all areas. Some centers have team teaching and supervision as a way to deal with individual strengths and limits, while in others, trainees themselves do the work of synthesizing and integrating different concepts. This blending and unifying is a major task for the field, but of special concern to those responsible for educating and training psychiatrists of the future. Exposure to divergent opinions can be enriching, but it also can be confusing or lead to therapeutic nihilism. We anticipate trainees will learn to tolerate some ambiguity in their search for more absolute approaches to care, since the art and science of medicine in general, not just psychiatry, has not yet reached the stage of certainty. We expect training programs to be sensitive to supervisors' varied backgrounds and trainees' needs as supervisory assignments are made. It is the responsibility of the educational administrators to consider the total supervisory experience of the resident, including the knowledge, interests, and strengths of supervisors, as well as more personal issues such as gender, age, and ethnic background. Additionally, the trainee should have opportunities to observe faculty as therapists and to consider clinical decision-making with them. Observed therapy can be augmented with discussion by still a third therapist/supervisor/educator. The goals of supervision have been the subject of much educational interest. In particular, the responsibility of the supervisor for the clinical care of the patient needs delineation. When faculty are charged with such responsibility, they may need to interact directly with the patient from time \l\I)I\llll'-,',llll\JI~)
';
to time to assure their full awareness of the clinical situation. Disengaged from that obligation, the supervisor may freely pursue topics suggested by the supervisory discussion that are less related to immediate clinical outcome. Videotapes and audiotapes of therapeutic sessions provide more ''hard'' data and information not only about the patient's functioning but also about the resident's technique. Process notes and descriptions of the therapist's thought processes, as well as interaction between supervisor and supervisee, encourage consideration of countertransference as well as transference issues. Discussion of countertransference leads to the second aspect of this issue: the difference between supervision as an educational endeavor and as psychotherapy of the supervisee. The report by Pate and Wolff (1) identifies core factors that lead to a resident's satisfaction with supervision: the supervisor's fund of knowledge and teaching ability and the rapport between the supervisor and trainee. Pate and Wolff s results suggest that the goal of supervision is the educational experience, not clinical management. While there is tacit agreement that therapy of the resident is not a goal of the supervisory process, the supervisor often is in the position to observe trainee behavior and characteristics that interfere with growth and clinical performance and that would benefit from personal examination and therapy. Goals and methods, therefore, must be addressed by the administration of the program and discussed with supervisors and supervisees. Finally, there is a need for more explicit supervisory education, or training the trainers. Reports of educational experiences for supervisors have been published elsewhere as well as in Academic Psychiatry (3~7), but supervision, much like psychotherapy, remains in many psychiatry residency programs an unobserved and sometimes idiosyncratic undertaking. Seminars for supervisors can clarify the goals and nature of I 1\
supervision and the lines of authority and responsibility for patient care and resident performance, and they can provide ways for supervisors to observe and evaluate others' performance as supervisors as well as actively hone their own skills. The videotaped program produced by H. James Lurie, M.D., for the American Psychiatric Association's Educational Development for Psychiatric Educators Project (8) serves as a clinical casebook addressing these topics, in addition to inviting more experiential participation and interaction. Academic programs increasingly rely on "clinical" faculty whose participation in departmental activities is limited. It is essential that these supervisors at a minimum be cognizant of the program's goals and objectives, as well as their role and responsibility to both patient and supervisee. Additionally, conferences should discuss approaches to patient care as well as the supervisory process, to set standards and identify problems. While supervisory training generally should take place without trainees' presence, interaction with and evaluation by supervisees adds information. The use of videotapes to view the performance of other supervisors and therapists provides an affective experience in addition to cognitive information, and promotes more active personal assessment and learning. The increasing complexity of psychiatric practice demands greater attention to all aspects of the resident's learning experience. Supervision is an important part of that educational experience. It is therefore vital that supervisors learn to supervise well and effectively. The old model of "see one, do one, teach one" must be replaced by a program of faculty development. Formal continuing medical education experiences for supervisors are well received by faculty and lead to. greater satisfaction with the program and the teaching experience, as well as better teaching of residents. That can only result in an increased quality of care for patients.
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References
1. Pate LA, Wolff TK: Supervision: the residents' perspective. Academic Psychiatry 1990; 14:122-128
2. Nestler EJ: The case of double supervision: a resident's perspective on common problems in psychotherapy supervision. Academic Psychiatry 1990; 14:129-136
3. Berger B, Simmons E, Gregory J, et al: The supervisors' conference. Academic Psychiatry 1990; 14:137-141
4. Karasu TB (ed): Treatments of Psychiatric Disorders. Washington, IX, American Psychiatric Press, 1989 5. Rodenhauser P, Painter AF, RudisillJR: Supervising
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supervisors: a series of workshops. Journal of Psychiatric Education 1985; 9:217-224 6. Kline F, Goin MK, Zimmerman W: You can be a better supervisor. Journal of Psychiatric Education 1977; 1:174-180
7. Goin MK, Kline F, Zimmerman W: The use of videotape in teaching supervision. Journal of Psychiatric Education 1978; 2:189-196 8. Lurie HJ: "Supervision." Videotape and Discussion Leader's Guide. Washington, IX, Educational Development for Psychiatric Educators Project, American Psychiatric Association, 1980
: I,
Supervision is a significant component of residency education, and a major mechanism for teaching psychotherapy. The articles in this issue (1-3), while emphasizing different aspects of the process, address important facets of this educational tool. In particular, the article by Nestler (2) focuses on the divergent views of treatment of the same patient conveyed by two supervisors over a six-month period, as well as a third view provided by a case conference discussant. Nestler's methodology raises several questions including whether he is referring to psychotherapy supervision or psychiatric treatment supervision; the possible lack of consistency in his presentation of process notes (which by their nature are subject to editorializing and revision during their
Dr. Robinowitz is deputy medical director of the American Psychiatric Association, 1400 K Street, N.W., Washington, DC 2000S.
Copyright © 1990 Academic PsychiDtry.
I
f::
presentation); the weight given to clinical details and the context in which supervisors interpret such data; the supervisors' perception of their role and function (e.g., were they charged with patient care responsibility or did they understand their role as "consultants," meant to serve as an intellectual stimulus to the resident's development); as well as the absence of informed consent by the subject population (the supervisors). Although the patient described also poses many diagnostic and therapeutic questions not resolved by this brief presentation, Nestler's results must be carefully considered. This article raises three major concerns: the nature of modem psychiatric treatment planning and implementation; the role and function of supervision, supervisors, and supervisees; and the need for training and education in supervision. Modem psychiatry is developing a more rational and empirical approach to diagnosis and treatment planning. OSM-ill with its multiple axes has supported a more reliable and valid diagnostic nomenclature; the publication of Treatments of Psychiatric Disorders (4) has elucidated the process of treatment planning and begun the development of parameters or guidelines for care. The established modes of
\ \ 'i
1 \ 11 I I • 'd \11\1 I, ' • I \ I I I "q( I
i~l )!~I
\,(
l\\
I!,'
psychotherapy are becoming more codified, and thus replicable. Psychotherapeutic approaches taught to residents have expanded to include individual, family, and group; brief and long term; dynamiC and supportive; and psychodynamic, cognitive, or behavioral, to list but a few. Psychiatry is moving from treatment decision-making based on a therapist's interests and skills, with a near-religious adherence to values and beliefs, to treatment planning based on patient diagnoses, strengths, and needs. Further, the separation of treatment into psychotherapeutic or psychobiolOgical methods, while a correct reflection of history, is reductionistic. Current research supports a more integrated approach to therapy, choosing among and combining the available procedures as appropriate. This evolution has been no simple task. Many senior psychiatrists were trained at a time when fewer approaches and procedures were used. Supervisors may be more sensitive to or interpret data based on their own educational and clinical experiences. Few senior educators are skilled in all areas. Some centers have team teaching and supervision as a way to deal with individual strengths and limits, while in others, trainees themselves do the work of synthesizing and integrating different concepts. This blending and unifying is a major task for the field, but of special concern to those responsible for educating and training psychiatrists of the future. Exposure to divergent opinions can be enriching, but it also can be confusing or lead to therapeutic nihilism. We anticipate trainees will learn to tolerate some ambiguity in their search for more absolute approaches to care, since the art and science of medicine in general, not just psychiatry, has not yet reached the stage of certainty. We expect training programs to be sensitive to supervisors' varied backgrounds and trainees' needs as supervisory assignments are made. It is the responsibility of the educational administrators to consider the total supervisory experience of the resident, including the knowledge, interests, and strengths of supervisors, as well as more personal issues such as gender, age, and ethnic background. Additionally, the trainee should have opportunities to observe faculty as therapists and to consider clinical decision-making with them. Observed therapy can be augmented with discussion by still a third therapist/supervisor/educator. The goals of supervision have been the subject of much educational interest. In particular, the responsibility of the supervisor for the clinical care of the patient needs delineation. When faculty are charged with such responsibility, they may need to interact directly with the patient from time \l\I)I\llll'-,',llll\JI~)
';
to time to assure their full awareness of the clinical situation. Disengaged from that obligation, the supervisor may freely pursue topics suggested by the supervisory discussion that are less related to immediate clinical outcome. Videotapes and audiotapes of therapeutic sessions provide more ''hard'' data and information not only about the patient's functioning but also about the resident's technique. Process notes and descriptions of the therapist's thought processes, as well as interaction between supervisor and supervisee, encourage consideration of countertransference as well as transference issues. Discussion of countertransference leads to the second aspect of this issue: the difference between supervision as an educational endeavor and as psychotherapy of the supervisee. The report by Pate and Wolff (1) identifies core factors that lead to a resident's satisfaction with supervision: the supervisor's fund of knowledge and teaching ability and the rapport between the supervisor and trainee. Pate and Wolff s results suggest that the goal of supervision is the educational experience, not clinical management. While there is tacit agreement that therapy of the resident is not a goal of the supervisory process, the supervisor often is in the position to observe trainee behavior and characteristics that interfere with growth and clinical performance and that would benefit from personal examination and therapy. Goals and methods, therefore, must be addressed by the administration of the program and discussed with supervisors and supervisees. Finally, there is a need for more explicit supervisory education, or training the trainers. Reports of educational experiences for supervisors have been published elsewhere as well as in Academic Psychiatry (3~7), but supervision, much like psychotherapy, remains in many psychiatry residency programs an unobserved and sometimes idiosyncratic undertaking. Seminars for supervisors can clarify the goals and nature of I 1\
supervision and the lines of authority and responsibility for patient care and resident performance, and they can provide ways for supervisors to observe and evaluate others' performance as supervisors as well as actively hone their own skills. The videotaped program produced by H. James Lurie, M.D., for the American Psychiatric Association's Educational Development for Psychiatric Educators Project (8) serves as a clinical casebook addressing these topics, in addition to inviting more experiential participation and interaction. Academic programs increasingly rely on "clinical" faculty whose participation in departmental activities is limited. It is essential that these supervisors at a minimum be cognizant of the program's goals and objectives, as well as their role and responsibility to both patient and supervisee. Additionally, conferences should discuss approaches to patient care as well as the supervisory process, to set standards and identify problems. While supervisory training generally should take place without trainees' presence, interaction with and evaluation by supervisees adds information. The use of videotapes to view the performance of other supervisors and therapists provides an affective experience in addition to cognitive information, and promotes more active personal assessment and learning. The increasing complexity of psychiatric practice demands greater attention to all aspects of the resident's learning experience. Supervision is an important part of that educational experience. It is therefore vital that supervisors learn to supervise well and effectively. The old model of "see one, do one, teach one" must be replaced by a program of faculty development. Formal continuing medical education experiences for supervisors are well received by faculty and lead to. greater satisfaction with the program and the teaching experience, as well as better teaching of residents. That can only result in an increased quality of care for patients.
\ 01 L \ If 14·" l \11\1 Ie; • I \ I I
J "'!II
I~ \
\I; I\.\ 1\\ I I /
References
1. Pate LA, Wolff TK: Supervision: the residents' perspective. Academic Psychiatry 1990; 14:122-128
2. Nestler EJ: The case of double supervision: a resident's perspective on common problems in psychotherapy supervision. Academic Psychiatry 1990; 14:129-136
3. Berger B, Simmons E, Gregory J, et al: The supervisors' conference. Academic Psychiatry 1990; 14:137-141
4. Karasu TB (ed): Treatments of Psychiatric Disorders. Washington, IX, American Psychiatric Press, 1989 5. Rodenhauser P, Painter AF, RudisillJR: Supervising
\l \[)I \11\ 1''-,\ l ! II \ fIn
supervisors: a series of workshops. Journal of Psychiatric Education 1985; 9:217-224 6. Kline F, Goin MK, Zimmerman W: You can be a better supervisor. Journal of Psychiatric Education 1977; 1:174-180
7. Goin MK, Kline F, Zimmerman W: The use of videotape in teaching supervision. Journal of Psychiatric Education 1978; 2:189-196 8. Lurie HJ: "Supervision." Videotape and Discussion Leader's Guide. Washington, IX, Educational Development for Psychiatric Educators Project, American Psychiatric Association, 1980
: I,
