Residents Want to Learn Psychotherapy: Thoughts on Supervision

A 2014 survey by J.G. Kovach, M.D., and colleagues published in Academic Psychiatry revealed surprising news: “Psychiatry residents want more psychotherapy education than they are receiving.” Despite their hectic schedules, anticipated managed care roadblocks, and biologically focused research, psychiatry residents are hungry to learn psychotherapy.

What’s more, the survey found that supervision supersedes coursework, readings, and their personal psychotherapy as psychiatry residents’ favorite way to learn. Residents expressed interest in all types of psychotherapies, including psychodynamic, cognitive, behavioral, dialectical, supportive, family, and group. Given that residents highly value supervision, how can we optimize supervision and help busy residents?

Supervision requires a supportive environment in which residents can talk frankly and openly about their patients. In A Resident’s Guide to Surviving Psychiatric Training, a 2015 APA publication, residents are encouraged to “think of your most difficult patients, the ones you really don’t want to see” and “let your supervisor know everything, including your fantasies and fears, about this patient.”

For residents to report honestly how they feel about patients—and share exactly the words they spoke rather than the words they imagine we wanted them to speak—supervisors must cultivate a space of safe reflection where we, as supervisors, are patient, thoughtful, empathic, and nonjudgmental. Maintaining this stance will require effort at times. Try to observe your own feelings about the relationship with the resident; that may provide clues about the resident’s work with the patient. Supervisory moments may trigger memories of your own residency training. Keep in mind that what you say and how you behave may become the model a resident internalizes about how to engage with patients and colleagues.

In supervision, encourage your supervisees to consider every patient, especially their more complex ones, from a biopsychosocial perspective. Foster the idea that every patient encounter includes elements of therapy in terms of attention to the relationship between the patient and doctor; this concept is part of what psychiatry has to offer medicine in general. Too often, both supervisors and residents categorize patients as “medication management” or “psychotherapy” cases. Ask—and ask your supervisees to ask—more questions about patients. Encourage them to delve more deeply into their patients’ backgrounds, behaviors, and beliefs. Teach your supervisees to develop a broad, biopsychosocial understanding of each patient. This will help residents discover and make more thoughtful, informed, and effective clinical interventions.

Your theoretical perspective—psychodynamic, cognitive, behavioral, dialectical, supportive, family, or group—will frame how the supervision unfolds. To illustrate, consider a psychodynamic perspective. In psychodynamically focused supervision, first encourage residents to make meaning out of words and actions. Later, introduce psychodynamic concepts, like transference, countertransference, and resistance to help expand residents’ perceptions and open them up to new ways of listening. As residents begin to integrate a psychodynamic understanding of their patients into their work, often they will feel a sense of relief and increased self-efficacy. A “hopeless” case, where medication has been optimized but serious symptoms persist, can be transformed from frustrating to fascinating when psychodynamic understanding is present.

For example, after discussing her “psychotherapy” case, a supervisee mentioned struggling with her hostile feelings toward someone else she was treating—a chronically suicidal patient on a ketamine research unit. The resident understood her role on the unit as simply to monitor the patient’s response to ketamine. For the resident, assuming a “bystander” role in the treatment and considering ketamine the “active agent” created feelings of helplessness and boredom. As the resident presented the patient’s history and behavior on the unit, a vivid story of painful loss and familial turmoil emerged, rich with meaning. As her psychodynamic perspective of the patient deepened, the resident began to make informed interventions. When the patient’s response validated her predictions, the resident felt increasingly hopeful, self-confident, and interested in the patient.

Another resident initially regarded his role in a Medicaid clinic for young adults as the performance of “med checks.” With time, he began to bring a psychodynamic perspective to the clinical vignettes he presented in supervision and discovered that a psychodynamic framework “provided an additional lens through which difficult cases can be approached and understood.”

Psychotherapy supervision challenges us to create an oasis of calm and compassion in which patients’ lives can be thoughtfully examined. To paraphrase Donald Winnicott, M.D., “good enough” supervisors give their supervisees the freedom to securely explore the relationship with and psychology of each patient. Supporting residents with “good enough” supervision helps both residents and patients.

In a future article in Psychiatric News, the Group for the Advancement of Psychiatry Psychotherapy Committee will discuss challenges in meeting the needs for supervision in residency programs. ■