Residency Supervision Workshop Finds Educators on Shaky Ground

Presenters at a workshop of APA’s Commission on Psychotherapy by Psychiatrists (COPP) were so determined to improve resident training in psychotherapy that even a major earthquake did not stop them.

The February meeting, which bore the theme “Psychotherapy Supervision in Psychiatric Residency Training,” was interrupted by the first major quake to hit Seattle in 50 years.

The rumbling sent some residency training directors scurrying under their tables to take cover, while others ran for the outdoors, where the sidewalk was moving back and forth like those at a funhouse.

“It was fascinating,” observed David Goldberg, M.D., executive director of the American Association of Directors of Psychiatric Residency Training. Goldberg, who was delivering his presentation when the earthquake struck, said, “It was a serious quake, yet we reconvened, and that was the last we heard about it. We were all in this group denial of what happened, yet we are psychiatrists.”

And so it went. Once the shaking stopped and Seattle’s Renaissance Madison Hotel was deemed safe to reenter, residency training directors from all over the country reunited to share nervous laughter, a few earthquake jokes, and ideas about how to best teach psychotherapy to tomorrow’s psychiatrists.

“In light of the new psychotherapy competencies,” said Jerald Kay, M.D., chair of COPP, “we wanted to teach residency training directors how to be proficient in supervision and also how to run a better supervised psychotherapy curriculum for their trainees.”

The Accreditation Council on Graduate Medical Education (ACGME) now requires all psychiatry residents to demonstrate they are competent in the practice of brief therapy, cognitive-behavioral therapy, combined psychotherapy and psychopharmacology, psychodynamic therapy, and supportive psychotherapy. Many of the COPP workshop presentations were related either directly or indirectly to the new competencies. The new requirement went into effect in January (Psychiatric News, April 5).

The morning portion of the workshop featured presenters such as Marcia Goin, M.D., David Bienenfeld, M.D., and Goldberg, who answered questions on such issues as these: What qualities make one psychiatry residency supervisor rise above the rest? How can I assess psychotherapy competency among residents? How can psychiatry programs develop and retain excellent supervisors in the face of decreased funding for psychotherapy education?

Goin mentioned a study she conducted with colleague Frank Kline, M.D., in the mid-1970s. They videotaped and interviewed 24 residency training directors and second-year psychiatry residents at the adult psychiatric outpatient clinic at the University of Southern California Medical Center.

Goin pinpointed the qualities of the most successful training directors—they were empathic and pushed the residents to the limits of their capacity, for instance. Goin is a clinical professor of psychiatry at the University of Southern California School of Medicine.

“Those training directors who received the most praise from residents helped [the residents] to understand their own responses to the patients when conducting psychotherapy,” said Goin, who is also an APA vice president. The most successful supervisors communicated clearly and were sensitive to the residents’ problems, she said.

Bienenfeld is a professor and vice chair of the department of psychiatry, and director of the psychiatry residency training program at Wright State University in Dayton, Ohio. In 1998 the Residency Training Committee in the department of psychiatry at Wright State embarked on a plan to measure its residents’ skills in psychiatry and psychotherapy (Psychiatric News, July 7, 2000).

“The residents in the program were involved from the very beginning in the creation of the competencies,” said Bienenfeld.

In the practice of psychotherapy, psychiatry residents must demonstrate general and specific skills. General skills might include being able to establish initial rapport and maintain the therapeutic alliance with a patient or setting appropriate treatment goals.

Specific skills are required for psychodynamic psychotherapy, cognitive therapy, and supportive psychotherapy. For instance, a resident practicing psychodynamic psychotherapy must be able to recognize and describe a patient’s defenses and resistances.

“For the most part,” said Bienenfeld, “the residents have seen [competency criteria] as advantageous because they receive immediate feedback on where they stand in regard to ultimate training goals.”

Goldberg, who is also director of residency training at California Pacific Medical Center in San Francisco, spoke about how to nurture and develop a cadre of well-trained resident supervisors in psychotherapy. Goldberg noted that in the recent past, there have been serious inconsistencies in the ways that supervisors teach residents about psychotherapy. “Now we need to reconvene with the supervisors in a mutual task of defining what we want to teach in psychotherapy,” he said. In addition to developing knowledge and skills that are fundamental for all psychiatrists in psychotherapy, Goldberg stressed the importance of reintegrating psychotherapy into psychiatry, both of which are sometimes seen as separate entities, according to Goldberg.

“We must show the supervisors how important they are to the future of psychiatric education and make them feel valued,” Goldberg said.

He also recommended that directors of psychotherapy education hold meetings to discuss academics, meet other training directors, and promote academic mentorships.

During the afternoon sessions, Lisa Mellman, M.D., and John Markowitz, M.D., discussed different methods of psychotherapy supervision.

Mellman, who is vice chair of APA’s Task Force on Core Competencies and a clinical professor of psychiatry at Columbia University, discussed the pros and cons of using process notes in psychotherapy supervision.

Mellman said she believes that handwritten notes from a resident-patient encounter are invaluable for training directors and offer them a window into patient sessions. She acknowledged, however, that there are certain problems with the use of such notes.

“It is hard to listen attentively to the patient when taking notes,” she observed. “Also, process notes encourage focus on one particular session, but not on the flow from session to session.”

Markowitz, who is an associate professor of psychiatry at Weill Medical College at Cornell University and director of the psychotherapy clinic at Payne Whitney Clinic in New York City, led a discussion about the advantages and disadvantages of group versus individual supervision of residents practicing psychotherapy. While neither panelists nor attendees reached a consensus about which method was more effective, important points were raised about each.

Markowitz commented that in group supervision, residents have the opportunity to see how their peers respond to patients in certain situations and how they deal with certain problems that arise in the psychotherapeutic session.

He acknowledged that individual supervision allows the training director to give each resident more attention and permits more thorough discussion about in-depth issues such as countertransference.

The COPP workshop was held in conjunction with the annual meeting of the American Association of Directors of Psychiatry Residency Training. ▪