Abstract
‘Supervision is central to the development of skills in psychiatry’ [1].
This belief, widespread amongst trainees, supervisors, and fellows of the Royal Australian and New Zealand College of Psychiatrists (RANZCP), is treated as fact in discussions of psychiatric training in Australia and New Zealand. Successive revisions of the RANZCP by-laws have been increasingly prescriptive and detailed about supervision [2–5]. It is frequently stated that supervision is based on the apprenticeship model. There is, however, no clear definition of the meaning of this term in the context of psychiatric training. The New Oxford English dictionary defines an apprentice as ‘a person who is paid to learn a trade from a skilled employer’ [6]. Maddison, one of the founding fathers of the RANZCP, stated that ‘in the acquisition and development of those skills and attitudes which are the psychiatrist's crowning glory there is no substitute for the sensitive, empathic relationship between trainee and supervisor’ [7]. He clearly envisaged supervision as more than just a teaching/ learning relationship, and also a supportive one.
In the psychiatric setting the term ‘supervision’ implies that the trainee and supervisor work closely together, in terms of both physical proximity and clinical time spent together. The practice of psychiatry, however, has changed significantly in the last three decades, as a consequence of deinstutionalization and the focus on the ‘productivity’ of all clinical staff.
Currently, it is not uncommon for the supervisor and trainee to spend much of their working time on separate sites, meeting only for the supervision hour [Ellis PM, pers. comm., 2000]. This Australasian experience is mirrored in Europe and the UK where 150 psychiatric trainees informally surveyed at a conference reported that one-third of them had never seen a psychiatrist interviewing and one-half had never been observed interviewing [8]. While the advent of the First Year Assessment in Australasia has ensured that trainees are observed interviewing at least once (and usually more frequently) during their first year of training, informal discussions with trainees and supervisors suggest that joint interviewing occurs rarely after the first year.
The College is currently undertaking the most significant revision of its by-laws for training and examinations since the inception of the College. The changes include significant enhancements of the roles of supervisors, who will have a formal role in evaluating trainees. Given the terms ‘supervision’ and ‘apprenticeship’ are often used interchangeably (although they may be different), and given the changes in psychiatric practice in the 30 years since the founding of the College, it is essential to clarify the current meaning of the term ‘supervision’ as the new by-laws are finalized and implemented. In an attempt to answer the question ‘how is supervision understood in the RANZCP and how is it practised?’, the author is conducting a qualitative research project. This has involved an extensive review of the literature on psychiatric supervision, some of which is presented as a stimulus to discussion of these issues.
Method
This search included the use of both Medline and Psychlit electronic search facilities as well as manual searches of relevant journals, retrieving references in the English language and from the bibliographies of articles identified by that search. Keywords included psychiatric training, supervision, residency, education and combinations thereof. In excess of 200 articles were reviewed. The review was wide-ranging, addressing, among other issues, underlying theories and models of supervision, awareness of contextual issues and their influence on supervision, processes of supervision, training of supervisors, and techniques of supervision. The extensive work that dealt purely with supervision of psychotherapy or counselling was largely excluded. This was for two key reasons. First, the separation of psychotherapy supervision from general clinical supervision in the RANZCP training programme implies that these are considered to be different and separate activities. Second, supervision of counselling or psychotherapy is focused largely on that one aspect of a patient's management generally within a particular theoretical model, whereas general clinical supervision (which reflects the workload of most general psychiatrists in Australasia) must integrate the biological and sociocultural with the psychological, often utilizing a variety of theoretical models. Some work pertaining to psychotherapy supervision has been included (and identified as such) when this was considered to have had significant influence on conceptualizations of general clinical supervision. The selection of literature presented here focuses on the meaning of the term ‘supervision’, and the models of supervision which have influenced current conceptions. In keeping with the qualitative nature of the author's study, it is representational rather than exhaustive.
Results
The material published about psychiatric supervision was found largely in British and American writing, with a smaller amount in the Canadian and Australasian literature. Much of this was written in America in the 1960s and 1970s. As such, it reflects the psychoanalytic tradition and sociocultural climate of that country at that time. Training literature was largely written by white men, and provided by and for white men [9, 10]. Supervision in the context of general psychiatric training was mentioned infrequently, often as a coincidental topic. Most work on supervision focused on the supervision of the psychotherapeutic work of the trainees. It must be noted, however, that the concepts from this setting were often transferred directly into the setting of general clinical supervision as if the two situations were identical. Similarly there was considerable writing which focused on training and models of training. Some of this has been included as these models inform and influence the supervisory relationships. These earlier articles (from the 1960s and 1970s) fell largely into two groups: (i) those that were prescriptive of the programmes or descriptive of the programmes and the demographic characteristics of the trainees; and (ii) those (predominantly from the USA) that offered models of the training process.
The more recent articles, in contrast, were more often written by trainees, and/or focused on the shortcomings of supervision and training and more often emanated from Great Britain and Australasia.
Earlier writing
Prescriptive and descriptive studies
In the UK in the 1970s Brook published a series of studies that consisted of questionnaire surveys of recently appointed consultants [11–17]. These investigated their perceptions of the adequacy of their training and supervision to equip them for their roles as psychiatrists in a number of areas and subspecialties. The surveys were notable for the high response rates (79–90%) and the high level of dissatisfaction (30–70%) with the supervision or training. There are, however, difficulties in the interpretation of these data, in that the wording of the questions made it impossible to distinguish between dissatisfaction with the amount of experience and dissatisfaction with the amount of supervision of that experience. It also focused purely on quantity, not quality or content of supervision. Thus while Brook's extensive work suggested that new consultants were dissatisfied with the supervision they had received, the methodological difficulties limit its interpretation and do not enhance understanding of the meaning of supervision. In a description of a regional training programme in Britain, while supervision was noted as ‘of the utmost importance’ in the training of junior medical staff, this was only explained as meaning the involvement of the trainees with the management of patients ‘under supervision’ [18]. Supervision, other than of psychotherapy, was not even mentioned as part of the prescription for a suitable training programme in the Royal Medico–Psychological Association's memorandum on educational programmes for trainees in psychiatry in Britain published in 1971 [19].
In the USA, similarly, supervision was not mentioned in a survey of psychiatric residents’ training needs [20], nor in a survey of residents’ attitudes to controversies in psychiatric education [21], nor in a description of ‘characteristics of psychiatric residency programmes’ across the country [22]. The recommendations regarding the criteria on which psychiatric training programmes were to be judged in the USA made minor mention of supervision, advising that evaluators consider the balance of individual to group supervision [23].
Models of training
While the focus of these writers was not on supervision per se, such models, many of which continue to underpin concepts of training, have influenced the nature of supervision and the role of the supervisor. Three main models of training can be discerned:
as a developmental process, as a pathological process, and as role acquisition.
Training as a developmental process: Psychiatric training was conceptualized as a developmental process with trainees being likened to children who would grow to become adult psychiatrists under the influence of their supervisors.
Holt referred to ‘the learning of a profession like psychiatry as a generally maturing experience’ [24]. He described at length his view of the maturing process that occurred during training. Similarly, from the perspective of psychotherapy supervision, parallels were drawn between psychiatric training and adolescence [25, 26]. When Drucker et al. [26] found the ratings of supervision given by second year trainees were more critical than those of first or third year trainees, the trainees’ dissatisfactions were not explored, but explained by recourse to the supposed ‘adolescent struggle’ of second year. While this is a possible explanation, there are others, for example, that those in second year were more assertive than those in first year and further from exams and job-seeking than those in the third year, enabling them to be more openly critical. The model of the ‘adolescent struggle’, however, absolved the authors from further exploration.
In contrast is Brent's conceptualization of training in terms of adult development informed by the work of Levinson et al. [28]. Brent suggested that psychiatric training was a ‘special form of occupational development’, and looked at the commonalities between psychiatric trainees and their contemporaries at the same life stage [27]. He highlighted that the adaptations necessary for trainees to become psychiatrists were shared with others of their age who were adapting to career roles.
Training as a pathological process: This work was often anecdotal, based on the authors’ experiences as psychiatrists, supervisors and/or directors-of-training [29]. It was assumed these experiences were universal for trainees and consisted of predictable patterns of response to psychiatric training, regardless of the nature of the programme, personality of the trainee or any other contextual factors.
A number of writers conceptualized the process of psychiatric training as pathological, variously referring to it as ‘the quest for omnipotence’ [30], ‘that most difficult year’ [31], ‘the beginning psychiatry training syndrome’ [32], ‘the crisis of psychiatric residency’ [33], and ‘regression in the service of residency education’ [34]. The ‘beginning psychiatry training syndrome’ was first defined by Gregory Zilboorg in a seminar for psychiatric residents in 1949 (cited in [32]). Merklin and Little elaborated on this phenomenon based on their observations of training, discussion with colleagues and reading of the literature [32]. They defined it as ‘a psychological response occurring in the first year of psychiatric training characterized by transitory neurotic symptoms, psychosomatic disturbances and symptomatic behaviour’, consisting of three phases, ‘a prodrome, reaction and resolution’. It was viewed as a response to the patients seen and the personal challenges of psychiatry as a growth experience ‘essential to the making of a psychotherapist’ (sic). The role of the supervisor was not mentioned per se, but ‘instructors and those in authority’ were exhorted to ‘help the resident gain insight… rather than responding with hostility’. This ‘syndrome’ was seen as the explanation for disagreements that occurred between the trainee and their supervisor or for expressions of dissatisfaction by the trainee [34]. Shershow noted that it was possible that such complaints were based on ‘reality’ (whose ‘reality’ was not defined), but seemed to regard this as unlikely, instead suggesting that the role of the supervisor in this situation was ‘limit-setting’, bringing the ‘regression’ of the trainee to her/his attention and providing limits for behaviour, as a consequence of which the regression could become developmentally useful to the trainee [34].
Training as role acquisition: These writers addressed the role of supervision in facilitating the acquisition of the role of psychiatrist. Most shared the view that there were two goals of supervision viz the acquisition of knowledge, and the bringing about of ‘a change in the way the resident thinks, feels, and conducts his or her life’ [35]. To achieve the latter, supervision should not only ‘oversee the acquisition of knowledge and skill’, but also ‘monitor the evolution of competence and confidence and seek evidence of personal growth of the resident’. Much of the writing in this area assumed, as did Maddison [7] that the relationship between the trainee and supervisor was the key to successful supervision. In the American writing on psychotherapy supervision, which informed current concepts of general clinical supervision, the relationship was conceptualized in psychoanalytic terms, with reference to transference and counter transference, Oedipal issues, narcissistic needs, and inner conflicts of the participants [36, 37].
Others focused on identification and role modelling (referring to psychotherapy supervision), stating that the ‘psychiatric attitude can be acquired by identification of the student with his teacher’ [38] or that the professional and personal life experience of the supervisor was ‘the guiding force throughout the training experience’ [35]. The importance of ‘corrective learning’ (the supervisor asking questions and helping the trainee to arrive at the answers) and ‘creative learning’ (the supervisor asking questions which in turn teaches the trainee the questions to ask of the patient) were stressed along with identification [39], again with reference to psychotherapy supervision.
This model was supported by de Rosis [40] who described in detail how the method of questioning used by the supervisor in session with the trainee should model the method to be used by the trainee in interviewing the patient. It should be noted that again these models equate the role of the trainee with that of the patient. Many of these writers described modelling as critical, with other elements (reflection, observation) appended and with little attention to the content of supervision.
In contrast Ornstein cautioned against identification, noting ‘the dangers of relying upon identification… lie in the fact that neither the therapist nor the teacher has any control over what the patient or trainee will actually identify with’ [41]. In his view the responsibility of the teacher (and presumably supervisor) was to ‘create an emotional climate’ which would enable the trainee to learn from the patient. The nature of the training in psychiatry was seen in educational terms, with the ‘pedagogic task’ as being ‘to broaden, deepen and shape’ the basic skills the trainees bring to training from their own life experiences.
The technique of the supervisor directly observing the trainee interviewing was described in sporadic studies, but focused on the difference in the outcome of the assessment for the patient [42, 43] or described the practice of observing trainees interviewing and the perceived advantages and challenges of the method without any evaluation of the technique [44, 45]. Yager delineated a number of techniques of supervision and encouraged direct observation of the supervisor by the trainee [46]. He highlighted the need for the supervisor to be prepared to discuss her/his own thinking and reasoning in order to avoid the trainee blindly emulating the supervisor and also advocated that the supervisor question him/herself openly in supervision as well as questioning the trainee, use role play, use multiple supervisors for the same patient and advise on reading.
One of the few British works to address this area did not mention supervision per se, but referred to clinical learning, which was seen as a ‘stimulus-response model’ [47]. This was explained as the patient providing the stimulus to learning and the consultant, by providing immediate feedback based on his (sic) experience, providing reinforcement and thus speeding the learning of the trainee. This was in keeping with the primarily behavioural approach of British psychiatry at that time. In addition the formation of the ‘correct attitudes’ was considered to depend on ‘professionally led discussion groups’ and the influence of the consultant at ward rounds.
Recent contributions
More recent literature, which is predominantly from Britain and Australasia, has had a somewhat different focus, identifying problems with supervision.
Calls-to-arms
These papers, written almost exclusively in the last decade, shared the theme of lamenting the current state of training and/or supervision and making recommendations for improvement [e.g. see 48–54] It was suggested there should be ‘greater academic interest to promote critical thinking about scientific, ethical, and relational aspects of clinical supervision’ [49]. More specific recommendations included the need for training of supervisors, teaching trainees what to expect from supervision, evaluating supervision, and developing a curriculum [50]. Cottrell, based on his experience as a Sub-Dean of the Royal College of Psychiatrists (RCP), listed common concerns of consultants who are supervisors. These included ‘finding time, uncertainties about boundaries, giving effective feedback; and the balancing of: direction versus facilitation, line management versus trainee autonomy, service needs versus training needs, trust versus monitoring’ [51].
Trainees’ perceptions
A trainees’ charter, which would define the trainee's rights to supervision, feedback, support, decent working conditions and respect, was suggested [55]. Cunningham and Carmelo challenged the utility of the RCP's audit panels, on the grounds that trainees feared being ‘singled out as troublemakers’ if they expressed frank opinions about supervision [56]. They conducted their own audit, which found that supervision was generally thought to be unsatisfactory. Unfortunately more detailed results were not published.
A comprehensive study of psychiatric training in New South Wales (Australia) with 233 participants who were current or recent trainees, and a response rate of 78%, reported that trainees rated competence of the consultant as a clinician as the most helpful characteristic in training, followed by availability, breadth of psychiatric knowledge, and the ability to accept responsibility. Fifty-eight per cent of these trainees felt that they had suffered from ‘educational neglect’ by their supervisor, and 50% from ‘emotional neglect’, the latter referring to lack of empathy, lack of interest, and lack of support [57].
Discussion
This review highlights the paucity of research on supervision and the lack of replication of that research. There are scattered examples of specific supervision techniques that are rarely evaluated, replicated or further developed. In addition, given that this writing about supervision has informed and influenced our current understanding of supervision, it is important to examine and challenge its current relevance.
Much of the writing emanated from the USA 30 to 40 years ago where the medical and postgraduate training was quite different from that of Australasia today. The patients seen were either in large institutions or in psychoanalytic psychotherapy in private clinics. The trainees and supervisors were largely white, middle-class men. Issues of culture, religion and gender were not addressed. This raises serious concerns about the transferability of concepts arising from that writing to Australasia in the third millennium.
The lack of definition of supervision is one of the few areas of consistency in this writing. It is often assumed that the meaning is apparent, subsumed under the general rubric of training or defined rather imprecisely as ‘preparation for a consultant post’ [13]. This lack of clear definition fosters the multiplicity of undefined roles which the supervisor is expected to assume. Given the high priority that the RANZCP places on supervision and the time devoted to it, at the least a clear definition should be agreed upon.
Most of the writing in this area was by supervisors until recently. While clearly they have one view of supervision, it is important to recognize that their view will be different from that of trainees. Some of the writing by trainees outlined the reasons why they may feel intimidated and reluctant to complain openly about their training and showed the different result obtained when an audit was conducted by trainees, rather than by the RCP [56]. This would imply that if the College wishes to know the realities of supervision from the trainees’ perspective it must find safe, anonymous means for them to give information without fear of the consequences. While site visits are valuable and important, they may not be as safe for the trainees as is hoped.
The supervisor is portrayed as having many roles: mentor, role model, Oedipal transference figure, limitsetter, parent, and treater of the ‘syndromes’ of training. To those could be added, although rarely mentioned, teacher and evaluator. There are difficulties with some of these roles and with the situation of a number of roles in one person. Conceptualizing trainees as regressed adolescents is potentially damaging. It discounts that which as doctors and adults (and often as parents and spouses) they already know, and fosters uncertainty and insecurity. In models that conceptualize training, or trainees, as pathological, this insecurity can in turn be pathologised as regression, unresolved Oedipal issues, or dependency. The supervision task then becomes one of ‘treating’ this pathology – a task for which psychiatrists are trained. A further danger of this conceptualization is that it can allow supervisors and directors-of-training to discount dissatisfaction expressed by trainees, dismissing it as a sign of adolescent regression [26].
While people invariably occupy many different roles in their lives, it is not common to be occupying multiple roles in relation to the same person at the same time in a work setting. The risk of doing so lies in the different responsibilities, rights and privileges that are inherent in the different roles. There is the potential for a significant mismatch of expectations with resultant disappointment/ dissatisfaction with each other's respective performances when the two partners in the supervisory relationship have different concepts of their roles with respect to each other. This is particularly important in light of the increasing emphasis on the supervisor as evaluator as proposed in the new by-laws. The paradox of expecting the trainee to reveal her/his worst fears, mistakes and interactions to the same person who will evaluate her/him should be acknowledged and addressed.
The importance of role modelling is one of the areas on which most writers agree, although the caution regarding the inability to control what is modelled should be noted. After the first year, however, trainees often spend minimal time practising psychiatry with their supervisors; therefore there are significantly fewer opportunities for role modelling than 30 years ago. This increases the importance of the individual supervision hour and the need for clarity of roles during that time. Psychiatrists would wish to be modelling clear boundaries; thorough assessment before formulation and treatment; acknowledgement of the power imbalance inherent in patient/doctor and trainee/supervisor relationships; open communication; and respect for individual differences. It must be asked, however, what psychiatrists are modelling by confusing the roles between therapy and supervision; ‘diagnosing’ transference problems or ‘training syndromes’ without a full assessment and formulation; assuming that the training experience is the same for all trainees regardless of their social context and life experiences; assuming that trainees can give open and honest feedback despite their inherently vulnerable positions.
Finally it is apparent that there has been little incorporation of the knowledge from the field of pedagogy. The proposed new by-laws have a strong emphasis on adult learning during the years of advanced training. The medical education literature abounds with information about adult learning, yet this knowledge is rarely incorporated into thinking and writing about supervision.
One of the key questions must be why, despite repeated exhortations for change from trainees, RANZCP authorities and supervisors, so little change is apparent. There are a number of possible answers to this, all of which require further research validation, and none of which is mutually exclusive:
There are an increasing number of competing pressures on the time of psychiatrists, which in turn mitigate against change. Most psychiatrists are expected to supervise, whether they want to or have the skills. Psychiatrists are not taught to supervise or to teach – they are taught to treat and give therapy. The calls for change, while laudable, are infrequently accompanied by practical advice on how to implement this or acquire the new skills and knowledge needed. In some circumstances there may be institutional disincentives for supervision or for change in how it is practised. There is a lack of clear alternative paradigms. There is a lack of research evidence on outcomes. There may be simple inertia (supervisors may see no benefit from, or need to, change their supervision).
The proposed revisions to the by-laws provide an opportunity to move on from the lack of clarity and problems identified. The training committee should define what it means by supervision in the RANZCP for the next decade. The multiple roles which have been subsumed by the term ‘supervisor’ should be acknowledged and consideration given to whether it is appropriate and desirable for these to be vested in one person. The principles of adult learning are implicit in the new by-laws. Therefore training of supervisors needs to incorporate these principles and to teach supervisors how to teach as well as how to be psychiatrists. It is important to acknowledge that not all psychiatrists have these skills or wish to acquire them. The College will therefore need to move from the current practice of expecting that all psychiatrists will supervise to recognizing only those with specific skills and training as supervisors.
Conclusion
This review of the literature demonstrates the paucity of the knowledge base that underlies the linchpin of training in the RANZCP. The majority of the work is outdated and irrelevant to psychiatry in Australia and New Zealand in the third millennium. Despite repeated calls for change from trainees and supervisors in the last decade, there has, to date, been little change. The proposed new by-laws offer a significant opportunity to implement change. They will highlight the needs for training of supervisors, and potentially provide the opportunity to address some of the other issues such as defining supervision, evaluating it and giving effective feedback. There is an urgent need for both quantitative and qualitative research on supervision as the changes are made in order to clarify the meaning of supervision in the College and ensure that new models are appropriate and achieving their goal.
Footnotes
Acknowledgements
I wish to acknowledge the invaluable assistance of Professor Peter Ellis and Dr Anne Opie in the preparation of this manuscript, and the very thought-provoking, helpful comments of the Journal's referees.