What we Talk about when we Talk about Supervision

Background of Supervision in the Psychoanalytic Tradition

In psychoanalytic supervision, one of the three components of analytic training, candidates meet with a supervisor, usually weekly, to discuss their “control cases.” The trainee presents information through process notes or recollections of a patient encounter, including disclosure of associations and interventions. The supervisor explores the trainee’s thinking regarding the case and the session’s interventions, suggests alternative ways of listening to and speaking with the analysand, refers the trainee to pertinent literature, and helps the trainee understand countertransferences in the case (Akhtar 2009). Differentiating supervision from treatment, Salmon Akhtar (2009) writes: “the supervisor is not the analyst of the supervisee’s character, only of the supervisee’s analytic ego as it is engaged in the clinical supervision under scrutiny” (p. 21). Although this process is now well established and widely familiar to the analytic community, formal supervision initially had little role in psychoanalytic training. Freud wrote little about supervision and described it as something one “can” get rather than “should” get. He did, however, meet regularly meet with students to discuss clinical cases (Leader 2010). It was not until the 1920s that supervision became a mandatory component of training (Leader 2010). With psychoanalysis coming to play a prominent role in American academic psychiatry, the relationship of training and supervising analyst to analytic candidate came to closely resemble that of “attending” psychiatrist to intern/resident. Unfortunately, as psychoanalysis has faded from prominence in academic psychiatric settings, the richness and explicit understanding of what makes for high-quality supervision has been lost, along with any awareness of the history of supervision, leaving many interns and residents puzzled about the nature of supervision.

General ACGME Guidelines for Supervision

Supervision has long been an integral part of general medical education. Over the past twenty years, the Accreditation Council for Graduate Medical Education (ACGME) has attempted to codify what constitutes ideal supervision. These policies have arisen in response to (1) poor treatment outcomes in cases with undersupervised trainees (e.g., the case of Libby Zion, whose psychiatric medication regimen and care played a role in her highly publicized death) and (2) several studies regarding effective educational practice that argue for increased levels of supervision (see, e.g., Lerner 2009; Whalen and Wendell 2011). ACGME’s goals for supervision include ensuring that residents provide safe, effective care for patients, have the tools necessary to progress to unsupervised practice, and are helped to “establish a foundation for continued professional growth”; treatment of patients with supervision is called “the essential learning activity” for residents (Program Guide in Psychiatry, July 1, 2014). Common Program Requirements for all medical specialties, developed in 2003 and 2011, specify different levels of supervision (direct observation of clinical interviews, discussion of a case with a supervisor who is not present, oversight feedback after care delivery), outline duty hour requirements, and mandate institutions to identify individuals responsible for overseeing supervisory activities (Whalen and Wendell 2011). However, beyond the Common Program Requirements, ACGME provides little guidance on the structure or practicalities of supervision.

ACGME Guidelines for Supervision in Psychiatry

Interestingly, psychiatry-specific ACGME requirements are unique in medicine for stipulating minimum amounts of supervision. For example, the ACGME Internal Medicine guidelines (revised July 1, 2013) specify that residents must have “longitudinal relationships” with faculty, but no other specifications are given regarding duration or frequency of supervision.⁹ While not explicitly stated in the guidelines, this disparity suggests that deeper reflection, along the lines of psychoanalytic supervision and its goals, is a component of psychiatry residency supervision.

Within psychiatry, several milestones (educational goals of increasing levels of complexity to meet core competencies) include supervision (Psychiatry Milestone Project, July 2013). For example, level 3, “Seeking and providing psychotherapy supervision,” specifies that the resident “balances autonomy with needs for consultation and supervision.” However, the loose framework of the milestones does not distinguish the modality of psychotherapy a trainee might practice, the theoretical stance of the supervisor, or the scope or content of the supervisory relationship. Despite increasing efforts by educational organizations to define supervision and its requirements more precisely, ambiguity remains. Like analytic trainees, psychiatry residents often work with different supervisors during the same time period, sometimes without a clear understanding of working with one supervisor on a particular case. Instead, residents might have two supervisors covering one case or one supervisor officially covering several cases but having limited time with the supervisee. This confusion about what may or may not be adequate in terms of supervision prompted us to look at residents in our program to ascertain their feelings about supervision.

The Trainee Experience

To better understand what our trainees think of the supervision process, we surveyed our program’s General Adult Psychiatry residents and Child and Adolescent Psychiatry fellows regarding general impressions and definitions of supervision, supervision models they are exposed to, usefulness of supervision in different contexts, and incorporation of didactic teaching in supervisory interactions. Some residents found supervision a meaningful experience, describing it as a “chance to talk through patient cases with someone who is more experienced and through this interaction learning how to reflect on and shape future patient care in a way that meets patients’ needs/goals and fits in with our identity and values as providers.” Others were dismissive of the process, stating, for example, that “basically, it’s someone in psychiatry who has done psychiatry longer than you who has opinions on how to do things. It’s as inconsistent as are the guidelines for psychiatric practice.”

We drew two main conclusions from our survey: (1) trainees each have their own description of what supervision entails, with no clear point of reference; (2) closer levels of supervision were felt to be more useful for early levels of training and indirect supervision more appropriate as training progresses. Some of our findings are graphically presented in Figure 1.

OPEN IN VIEWER Figure 1

Discussion and Future Directions

We suspect the varying perspectives of our residents and the diversity of their supervisory experiences are shared by psychiatry trainees in other programs. There are many practical and ethical issues involving supervision that warrant further discussion in the residency training community, including patient confidentiality / obtaining informed consent for supervision, legal liability of trainees and supervisors, and how trainees can feel safe revealing their psychological vulnerabilities in an asymmetrical evaluative relationship. A formalized curriculum should be considered that helps residents (1) identify goals for supervisory experiences and conducive characteristics of supervisees and supervisors; (2) understand parallel processes that may occur between supervisor and trainee and trainee and patient; (3) avail themselves of mechanisms for timely feedback; and (4) formulate a supervision contract. We liken the idea of a supervision contract to developing a treatment frame between analyst and analysand and suggest this would be a highly beneficial process for trainees and supervisors alike. As in the psychoanalytic tradition, the frame is a structure that allows both parties to identify discourse goals, particular challenges to focus on, and how the supervisee-supervisor relationship can shed light on the supervisee’s interactions outside the supervisory space. As nonanalysts we submit the poster, in part, to elicit the psychoanalytic community’s thoughts on supervision. It is from the analytic community we received this gift—how might we best use it?