Psychotherapy Supervision: Conflicting Roles and Competing Tasks

“I would never find myself in that situation.” That’s the response one psychotherapy supervisor gave his supervisee when asked for advice about a clinical scenario. Another supervisor smoked cigarettes during meetings with a pregnant supervisee. Another occasionally fell asleep.

Some psychotherapy supervisors behave in ways that are demeaning, hostile, and rude. We all know what bad supervision looks like, but do we understand the skills and qualities that contribute to the best?

Psychotherapy supervision is considered essential to psychiatric education, key to helping trainees gain clinical acumen and forge professional identities. Yet the work of supervision is complex, with conflicting roles and competing tasks. How to focus can be a challenge.

The supervisor’s roles are varied. Supervisors have been described as “master” clinicians to “apprentice” trainees. A jack-of-all-trades, a supervisor is at different moments a teacher, clinician, confidante, mentor, medical ethicist, cheerleader, and judge.

Sometimes these roles can conflict. For example, when should a supervisor sit back and listen—and curb the impulse to instruct? When should a supervisor give critical feedback—in lieu of an understanding ear? Determining which hat to don, and when, can be challenging.

Supervision has three main tasks:

(1) to teach psychotherapy; (2) to ensure the patient receives responsible care; and (3) to help the resident develop a professional identity. Thoughtful consideration is necessary to determine which task should take precedence. For example, when do worries about a patient’s well-being override teaching of psychotherapeutic technique? When does supporting the resident’s developing a personal therapeutic style outweigh nonurgent clinical issues? Supervision requires artful attention to multiple simultaneous concerns.

The interweaving of competing tasks depends upon a positive supervisory alliance. This relationship is built on trust and mutual respect. Ideally, the supervisor cultivates space for honest reflection, often through the use of warmth, sensitivity, open-mindedness, and tact. The supervisor takes into account a resident’s level of training, cultural/racial/ethnic background, and specific learning strengths and weaknesses. Being reliable, available, engaged, and responsive also strengthens the containing quality of a supervisory space and helps the resident feel freer to self-disclose more fully.

The supervisor’s own self-awareness and openness about his or her aptitudes and intrinsic biases bolsters the alliance. Self-disclosure by the supervisor, especially about clinical mistakes, can foster greater honesty and collegiality in the supervisory relationship. When the supervisor is candid about her own missteps, this helps the supervisee be more open about his own uncertainties.

Clear boundaries must be maintained to ensure that the supervisory relationship does not mutate into a therapeutic encounter. For example, a supervisee mentioned how he found a patient’s maternally focused anger difficult to bear. His own mother had recently died. A discussion about the supervisee’s reactions to his mother’s death helped the supervisee sort out his responses to the patient. However, deeper exploration of the supervisee’s loss was not undertaken.

In addition, the supervisory alliance is understood as more than just a dyad: it is a triad that includes the patient. Bidirectional parallel processes connect the supervisor/trainee alliance with the trainee/patient alliance. When either alliance is threatened by conflict, stagnation, or negative affects—for example, annoyance or envy—operation of these parallel processes should be considered and discussed as potential factors.

Amid all this complexity, how does a supervisor decide what to focus on during a session? Since the most common format in psychotherapy supervision uses a case-based approach, a focus on the patient in the case might be the easy answer. However, a study by Shanfield and colleagues suggests this is not enough. Rather, the supervisee’s immediate concerns, especially his or her feelings and worries about the patient, should set the course for reflection and exploration in the supervisory session. The supervisor is advised to focus on the specifics of the supervisee’s narrative and use the data to help make sense of the patient’s words and behaviors. In addition, the data are used to help the supervisee better understand his or her own emotional responses to the patient and the role those reactions play in treatment.

For example, an unmarried supervisee described a feeling of turning away whenever her patient discussed her wedding plans. The supervisee attributed it to naivete about conventional marriage customs. Instead of launching into an explanation about the basics of wedding traditions, the supervisor chose to follow the supervisee’s feeling of turning away. Eventually, the supervisee identified an underlying anxiety about her own marriage prospects in the context of a recent breakup and history of parental divorce. Later, the supervisee reflected how she now felt better equipped to read her own reactions and listen to the patient.

The resident’s level of training also matters. Beginning trainees may need specific directions to build their basic clinical skills of listening, responding, and observing blind spots. In addition, the supervisor may provide more supportive remarks to build confidence and allay anxiety. Advanced residents with more developed clinical skills need freer rein to make their own therapeutic decisions. Accordingly, the supervisor may want to intervene less to encourage greater clinical autonomy, while helping advanced trainees expand their clinical repertoire and hone their personal therapeutic style.

One of the most difficult aspects of supervision is communicating constructive criticism. The supervisor is in the predicament of encouraging honest reporting while at the same time playing judge to the resident’s clinical decisions. If the critical feedback is not delivered in a tactful way, the supervisor runs the risk that the resident will feel unfairly attacked and may withdraw, distort material, or fail to progress.

In sum, psychotherapy supervision is a complicated endeavor with competing tasks and conflicting roles that require self-awareness and skill. A positive supervisory alliance as well as focus on the resident’s concerns can enhance the resident’s clinical skills and professional development and, it is hoped improve patient care. ■