, Jeffrey R. Strawn2 and Ernest V. Pedapati3
(1)
Division of Psychiatry and Child Psychiatry, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
(2)
Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, Cincinnati, OH, USA
(3)
Division of Psychiatry and Child Psychiatry Division of Child Neurology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
The meeting of two personalities is like the contact of two chemical substances: if there is any reaction, both are transformed.
—Carl Jung
In contemporary psychiatric practice and training, “supervision ” consists of regular meetings between a supervisor —typically a psychiatrist with experience in the subject—and a supervisee , often a trainee. The meetings between supervisor and supervisee typically involve matters regarding patient care. To this, they may choose to review relevant scientific literature, discuss pharmacological approaches, or use clinical material to formulate diagnostic interventions about a psychotherapy process. In regard to the psychotherapy process, the supervisor attends to what has transpired between the supervisee and his or her patient, with the goal of providing guidance for how best to proceed in terms of moving along the patient’s psychotherapeutic treatment. However, the process of psychotherapy supervision has evolved considerably over the last 50 years due to the introduction of the concepts from two-person relational psychology and based on the findings from neurobiology and developmental psychology as discussed in Chap. 3. Thus far, these concepts have been studied and disseminated mainly by psychologists and social workers; it is our hope that with this book, we can bring the concepts of relational two-person psychology, including psychotherapy supervision, to the attention of young child and adolescent psychiatrists and psychotherapists.
In this chapter, we begin our discussion of the supervisory process with a brief review of the traditional one-person model as it relates to supervision, followed by a review of the supervisor’s use of a relational two-person psychology model and the supervisee’s experience. Accordingly, we hope to provide an in-depth understanding of the different ways in which contemporary theoretical concepts can influence the process for both the supervisor and the supervisee. To create a “good supervisor–supervisee fit,” it is important for supervisors to be well versed in the supervisory model and to tailor their teaching styles to the learning style of the supervisee and not vice versa (Carol 2010). Finally, this chapter provides a guide for the supervisee on what to expect from supervisors who utilize a contemporary relational approach.
It is our hope that child and adolescent psychiatrists or clinicians who have trained in an academic institution where psychodynamic and relational concepts are part and parcel of the understanding and treatment of their young patients will make use of this book as they begin their journey toward becoming a well-versed supervisor.
14.1 Historical Background of Psychotherapy and Core Psychotherapy Competencies
The Accreditation Council for Graduate Medical Education (ACGME) has developed a series of core competencies that need to be acquired by child and adolescent psychiatry trainees. These include six general competencies (patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice) (Andrews and Burruss 2004). In 2001, the Residency Review Committee (RRC) officially mandated psychotherapy training for psychiatry trainees, which included competency in five core modalities of psychotherapy: (1) supportive psychotherapy , (2) psychodynamic psychotherapy , (3) cognitive behavioral therapy (CBT), (4) brief psychotherapies, and (5) combined medication management and psychotherapy. Additionally, exposure to family therapy, couples therapy, group therapy, and other evidence-based psychotherapies was also introduced as a requirement (Tucker et al. 2009). Nonetheless, it was recognized that finding trained faculty to teach all five psychotherapy competencies was difficult. By 2007, it was clear that interest in psychotherapy had declined and the RRC made updates to the core psychotherapy competencies, which included reducing their required training to only three areas: psychodynamic therapy, CBT, and supportive therapy. Meanwhile, the training in family and group psychotherapy remained in the form of exposure only (Tucker et al. 2009) which is unfortunate in many ways. Of note, it limits the number of newly minted child and adolescent psychiatrists who are well versed in family and group therapies, which is an important, complex, and daunting task when working with children and adolescents, which benefits from training. In addition, it requires trainees to devote more time to pharmacological interventions, and it encourages referrals for psychotherapy to psychologists and social workers who have limited collaboration with the busy trainee due to the time constraints of training.
Of interest, the American Psychiatric Association (APA) committee on psychotherapy developed the Y model for the use in teaching the three competencies required by the RRC (Plakun et al. 2009, see Fig. 14.1). The model is efficient, integrated, and evidence based, and it avoids pitting one form of psychotherapy against another. According to Plakun, “The place where psychotherapy education begins in residency is conceived of as composed of the shared elements of psychotherapy across schools. Located among the shared elements are the current brief, supportive, and combined medication and psychotherapy competencies” (Plakun 2006). In the Y model, the stem consists of the core processes that are identified as being common to all forms of psychotherapy: empathic listening; identifying dysfunctional patterns; developing a formulation; and attending to issues of boundaries, confidentiality, crisis management, and involvement of significant others. The Y model assumes that psychotherapy unfolds within the context of a therapeutic alliance (Plakun et al. 2009). The two branches of the Y model involve teaching specific aspects of CBT and psychodynamic therapy. Unfortunately, there are experienced cognitive and behavioral psychotherapists that openly reject psychodynamic psychotherapy for not being evidence based, which leads trainees to have confusing and unsettling experiences about the benefits in all forms of psychotherapy.
Psychotherapy Supervision as a Core Competency
The American Board of Psychiatry and Neurology (ABPN)—in association with the Accreditation Council for Graduate Medical Education (ACGME) and the American Academy of Child and Adolescent Psychiatry (AACAP)—recognizes psychotherapy supervision as a core competency in the treatment of children and adolescents. This provides the acquiring of clinical skills in major treatment modalities, which include brief and long-term individual therapy, family therapy, group therapy, crisis intervention, supportive therapy, psychodynamic psychotherapy, cognitive behavioral therapy, and pharmacotherapy. As Mellman and Beresin (2003) state, “[Psychotherapy supervision’s] eminence in psychotherapy education seems well established and well assured.” Watkins and Scaturo (2013) add, “Psychotherapy supervision has long been and remains a critical means by which the culture of psychotherapy is taught and perpetuated.” However, as Cardoso Zoppe et al. (2009) state, “There is still tension between biological and psychosocial tendencies,” and they go on to highlight that current teaching methods for trainees routinely lack integration regarding the many elements of what is helpful to patients, due to the fact that the supervisors are influenced by the setting in which the patient is seen, and their school of thought. Every trainee and every supervisor have a theory of cure that guides his or her approach. It is important for the supervisor and supervisee to understand what theory the supervisor is working from in order to be able to talk openly about its role in the current state of psychotherapy. Therefore, it is important to support and educate our supervisees about the value of an integrated approach in a world of Diagnostic and Statistical Manual of Mental Disorders, 5th Edition ( DSM–5 , APA 2013). Most supervisees are eager to learn about psychodynamic and relational theories if we demonstrate excitement in applying and teaching these dynamic concepts throughout their training. As Reiss and Fishel (2000) state, “Psychotherapy supervisors now represent only the residual backbone of psychotherapy programs. The importance of what these supervisors teach and how they teach it has never been greater as the time devoted to teaching the art of psychotherapy diminishes, and the trainee has fewer settings in which to learn the principles of psychodynamic psychotherapy.”
Although the process of supervision continues to be embraced by many, it is also important to note that many outstanding psychiatrists and other clinicians have declined to supervise trainees in psychotherapy. In this regard, many have limited their supervision to pharmacological aspects of treatment. This trend parallels a larger trend over the past decade in which psychiatrists have reduced the time spent practicing psychotherapy (Mojtabai and Olfson 2008). We hope that our efforts serve to contribute to the enthusiasm of teaching the art of psychotherapy and supervision.
14.2 Becoming a Supervisor
The process of becoming a psychotherapy supervisor is an important developmental step for child and adolescent psychiatrists and psychotherapists. Moreover, this process is seen as an integral part in shaping future clinicians. As Berger and colleagues (1990) note, “The supervisory relationship is the main way that trainees develop their identity as psychotherapists.” A supervisors’ development of knowledge and skill is critical to their role as a mentor (Angus and Kagan 2007). Following the completion of his or her training, a newly minted child and adolescent psychiatrist may be asked to become a supervisor in psychopharmacology, consultation liaison, or psychotherapy. Some training programs may require recent graduates to take a course on supervision before they begin to supervise, while others may utilize ongoing supervisor conferences, and still others have no prerequisites. Needless to say, this important process in the formation of our future clinicians has not been standardized.
In a recent discussion by the lead author with medical students and child and adolescent psychiatry trainees, they noted that they had little exposure to psychodynamic psychotherapy and that they were not aware of child psychiatrists who continued to practice such a form of treatment.
Supervision: From a Traditional One-Person to a Relational Two-Person Model
The process of psychodynamic supervision has evolved considerably, from a foundation rooted in Freud’s structural and drive theories and Klein’s object relations theories to a more contemporary understanding informed by temperament, attachment, developmental psychology, neuroscience, and relational theories.
Supervision in a Traditional One-Person Model
Any discussion of psychotherapy supervision , particularly with regard to traditional psychodynamic tenets, requires a brief foray into the role of psychodynamic thinking within training programs. Traditional one-person psychodynamic psychotherapy has been taught in psychiatry training programs since the 1940s and is based on five fundamental assumptions: (1) a central importance of the unconscious in mental functioning, (2) the symbolic meaning of behaviors, (3) the existence of internalized unconscious conflicts, (4) the idea that symptoms have meaning, and (5) the belief that transference-based thoughts and behaviors are critical to understand and help the patient change by overcoming the developmental interference on the emotional growth process (Delgado et al. 2012). The traditional one-person supervisor runs the risk of being seen as an omniscient observer whose function is to enlighten the supervisee (Yerushalmi 1999).
Critiques of the Traditional One-Person Approach to Supervision
As discussed in Chap. 6, we have colleagues who continue to supervise trainees using the traditional one-person model. They perpetuate the archaeological inquiry of a child or adolescent patient’s unconscious inner life through the use of play, transference issues, and the interpretation of dreams. This form of inquiry allows the clinician to clairvoyantly know the patient better than the patient himself. Also, traditional one-person model supervisors give importance to oedipal conflicts in elementary school age children and the loosening of the regressive parental ties in adolescents. Orange et al. (1997) state that this view represents a rather Cartesian approach in the understanding of our patients. This does not take into account the many important aspects of the patient’s and their family’s temperament and innate working models of attachment—nature—nor the important contribution from their environment, nurture, in forming their personality.
It is unfortunate that supervisees learning about psychodynamic psychotherapy are generally not exposed to a relational two-person model, and if so, it is usually in the form of a minimal amount of lectures with the implication that it is not relevant or important for the child and adolescent psychiatry trainee to learn. It has become a problem in which those who adhere to the traditional one-person model often criticize the relational two-person model without a thorough understanding of it. Further adding to this problem is that in some training programs, trainees are expected to complete the Psychodynamic Psychotherapy Competency Test (PPCT), a 2-hour multiple-choice exam that is administered once a year during their training and is based on traditional one-person model concepts (Mullen et al. 2004). In doing so, training programs imply what is correct and thus limit the trainee’s ability to learn about the importance of developmental research in regard to psychotherapy and have the freedom in deciding which model is best for their patients.
14.3 The Two-Person Relational Model and Its Relevance to Supervision
Over the last 30 years, with the emergence of a two-person relational psychology, there has been a significant shift in the understanding and treatment of a person’s psychological problems—from intrapsychic and object relations conflicts to problems of internal working models of attachment, affective attunement, and implicit relational knowing. This shift has led to treatment interventions that focus on the bidirectional here-and-now subjectivities continually modified by the reality of both persons, known as intersubjectivity. Supervision in psychotherapy is inherently bidirectional; the supervisor must be open to teach the supervisee as well as learn from the supervisee. In a relational two-person model of psychotherapy, the terms “cocreate” and “intersubjectivity ” are sine qua non to the theory and technique. They reflect the active participation by both patient and psychotherapist in the encounter, with continuous and novel changes created from each other’s nonconscious subjective experiences (Fig. 14.2). We offer Kierkegaard ’s quote as a reminder of our task in two-person relational psychotherapy supervision: “Instruction begins when you, the teacher, learn from the learner, put yourself in his place so that you may understand what he understands and in the way he understands it” (Kierkegaard 1998).
Fig. 14.2
Schematic representation of the intersubjectivity during a supervisor and supervisee encounter. Learning occurs in the intersubjective field (IF), the overlap of subjective experiences. Bold arrows in the IF represent here-and-now moments of meeting
Undoubtedly, the notion of a two-person, relationally based psychodynamic model of psychotherapy was not well received by supervisors of the traditional one-person psychoanalytic model, as it challenged the legitimacy of its tenets.
As stated by Friedman (2010), “Many classically trained psychoanalysts may in their actual practice incorporate changes that have been advanced by relational psychoanalysis, [although] their basic stance remains unchanged.” As Frawley-O’Dea (2003) aptly states, “The relational supervisor holds that it is crucial to live out mindfully with the supervisee and eventually to make explicit with him relational patterns set in play within their relationship.” The relational two-person model has gradually become a concept that most psychodynamic psychotherapists must contend with, as it has served as an umbrella for several forms of psychotherapies that endorse implicit or explicitly well-timed self-disclosures and enactments (e.g., mindfulness, dialectic, cognitive, patient centered).
However, training programs have struggled with a lack of experienced faculty who are qualified and able to teach the complex and specialized courses needed to learn, embrace, and apply the relational two-person model. As such, for a trainee to begin to master relational psychodynamic psychotherapy, the two-person model must be incorporated early in adult psychiatry training and continued in child and adolescent psychiatric training, and the trainee must be continually open to observation and discussion about the applicability of the theories to practical day-to-day patient care, whether it be on the inpatient unit, in the outpatient clinic, or on the consultation service. Additionally, regarding the art of two-person relational psychodynamic psychotherapy, the abilities to observe and share details about patients—to follow ongoing “threads” of subjectivities and make inferences of implicit relational patterns—are often passed down by experienced faculty orally and subjectively through their work. The importance of this form of teaching cannot be emphasized enough; it is not only teaching the “art” but also providing the mentorship needed for the next generation of colleagues.
Reiss and Fishel (2000), in reviewing the literature on supervision, observe that “without adequate preparation, supervisors run the risk of boundary violations, breaching ethical codes of conduct, destructive reenactments, restrictive practice styles that limit the growth of their supervisees, inadequate coverage of the basic tenets of psychodynamic practice, and occupational ‘burnout.’” In this regard, we have known colleagues who were not well versed in relational psychodynamic tenets and declined to help the supervisee further learn these concepts. They often would state: “Relational is just a new word for what we already have a theory for. It is not that complicated; you just need to be empathic with your patient.” This could not be further from the truth. Supervision in a two-person relational model is not only gratifying, it can also be difficult in helping supervisees overcome their anxieties when asked to become active and present in the psychotherapeutic process. The complexities of supervising psychodynamic psychotherapy are eloquently described by a colleague in a clinical case presentation on supervision:
In the beginning of a supervision, I try not to give any directions as to what the supervisee should or should not do—bring notes or not, stick with presenting one patient or not. I am curious about how the supervisee will organize him or herself in relation to the task of learning. Once I’ve understood the ways in which they do this, for better or for worse, I may suggest modifications. For the obsessional supervisee hiding behind her notes, I may suggest she not bring them, explaining that I would like to hear how she filters the information from her patient through her own psyche rather than rely on a per verbatim report. For a vaguer and more loosely organized supervisee, I may suggest he bring notes to better understand the interactions.
14.4 The Two-Person Relational Supervisor
At the outset of supervision, the supervisor should show his or her vitality and curiosity about the supervisee ’s previous educational and supervisory experiences: How does the trainee feel that his or her training is going? What have been their previous supervisory experiences (including the good and bad)? What does the supervisee consider his or her strengths and weaknesses as a psychotherapist? What would he or she most like to learn from the supervision? The answers to these questions will orient the supervisor with regard to his or her approach to the supervisee.
The foundation of any good supervision, from a relational perspective, will include a review of the patient’s biological, psychological, and social history—as well as consideration of the internal working models of attachment used when relating to the psychotherapist—and a determination whether the supervision is for crisis intervention, relational psychotherapy, family process work, cognitive behavioral therapy, etc. Moreover, flexibility and the ability to allow intersubjectivity to influence the supervisory dyad are of paramount importance, as described by Kernberg (2010): “I have found it very helpful to vary the intensity and rhythm of my contributions to the supervisory process, ranging from periods in which I might very actively try to convey information and influence the therapeutic process, to those in which I might sit back and position myself on the receiving end as I listen to what is going on with the patient, and to what new contributions the therapist may make.”
Goals for the Relational Supervisor
The supervisor should be well versed in the theories that he or she is asked to supervise.
The supervisor must openly disclose his or her goals and objectives and should also disclose areas of limitation.
The supervisor should encourage the supervisee to share his or her expectations of the supervision process.
The supervisor should carefully ascertain the level the trainee is at with regard to his or her development as a psychotherapist.
The supervisor must establish an atmosphere of safety for the supervisee to feel comfortable to present case material, as well as raise issues that he or she would like to further learn.
The supervisor—if at all possible—should openly encourage the use of video and audio recordings by the supervisee.
The supervisor should review theories that fit the patient’s needs and should be willing to explain differences between relational models (self-disclosure and enactments) and traditional models (boundaries) and cognitive therapies.Related posts:
Two-Person Relational Psychotherapy: Infants and Preschool Age Children
Two-Person Relational Psychotherapy: High School Age Adolescents
Two-Person Relational Psychotherapy: Middle School Age Youth
Setting the Frame
Putting It All Together: The Four Pillars of the Contemporary Diagnostic Interview
Deconstruction of Traditional One-Person Psychology Concepts
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