Abstract
Supervision is a cornerstone of psychiatric training in Australia and New Zealand [1], and the problems that have arisen in the psychiatrist-trainee relationship in New South Wales (NSW) in recent years have been clearly identified [2,3].
The Royal Australian and New Zealand College of Psychiatrists (RANZCP) NSW Branch Training Committee (BTC) decided in February 1998 to address a number of problems in the psychotherapy supervision experience of pre-Section I trainees in NSW.
It was apparent that the supervision of pre-Section I psychiatry trainees in the psychotherapies was inequitable and of variable standard. At some sites trainees were unable to obtain psychotherapy supervision; whereas at others the psychotherapy supervisors were not experienced in psychotherapy supervision. In some cases only one model of psychotherapy was supervised and in others the theoretical underpinning of the supervision were particularly narrow. On occasions psychotherapy supervision was disrupted due to service needs and at some sites the administrators required that psychotherapy supervision occur outside usual working hours.
These problems were accentuated by some trainees being provided with on-site supervision in the psychotherapies as part of their employment conditions, whilst others had to travel away from their workplace, in their own time and pay for their supervision.
The problems identified applied to the supervision of pre-Section I trainees in all the psychotherapies including psychodynamic psychotherapy, cognitive behavioural therapy, strategic/systems (group and family) therapy, and the brief psychological therapies.
The RANZCP NSW BTC convened a consensus sub-committee to develop guidelines for pre-Section I psychotherapy supervision for trainees in NSW, which met first in June 1998. The sub-committee was made up of representatives from the RANZCP NSW BTC, the NSW Institute of Psychiatry, the RANZCP (NSW) Section of Psychotherapy, and the (NSW) Association of Psychiatrists-in-Training. Members of the subcommittee were selected to ensure that the major schools of psychotherapy identified in the training requirements of the RANZCP [4] were represented.
The sub-committee met on four occasions over a twelve-month period to develop consensus guidelines for the use of supervisors and trainees for pre-Section I psychotherapy supervision. The guidelines are commensurate with the RANZCP Fellowships Curriculum [5], the RANZCP Code of Ethics [6] and the RANZCP Fellowships Board Training and Examination By-laws [4]. These guidelines are presented below.
NSW BRANCH TRAINING COMMITTEE CONSENSUS SUB-COMMITTEE FOR (PRE-SECTION I) REGISTRAR TRAINING IN THE PSYCHOTHERAPIES
SUPERVISION GUIDELINES AIMS
The guidelines are designed to facilitate the recognition of the integral role of the psychotherapies in all aspects of registrar training and in the registrars' future practice of psychiatry. The guidelines are designed to assist supervisors and trainees, to ensure that all trainees have access to and receive the best attainable, standardised, clinical supervision in the psychotherapies. The guidelines are designed to foster the development of particular attitudes, skills and knowledge. These are:
3.3 (Attitudes)
3.3.1 Respect for the knowledge and skills of colleagues involved in practising and teaching the psychotherapies. 3.3.2 Respect for the role of particular psychotherapies in the treatment of particular disorders. 3.4 (Skills) 3.4.1 Competence in the assessment of individuals in the context of their personality, developmental stage, adverse life events, strengths and coping mechanisms. 3.4.2 Competence in the psychotherapies in terms of their clinical principles and practice, under appropriate supervision. 3.4.3 Competence in the appropriate selection and use of a psychotherapy as a component of biopsychosocial management. 3.3 (Knowledge) 3.3.1 Understanding of the psychotherapies in terms of their historical development, theoretical underpinning, research base and outcomes.
COMPONENTS OF SUPERVISION
Supervision is a formal collaborative process that monitors, develops and supports trainees in their clinical role and is a priority in the training requirements of the RANZCP. Supervision in the psychotherapies should be supplemented by a broad-based theoretical program and a skills-based workshop program covering a range of theoretical approaches. Trainees should be supervised with attention to the principles and/or practice of:
normal human development across the lifespan the infant-carer relationship developmental psychopathology attachment theory the psychoanalytic theories the assessment of personality functioning psychodynamic formulation cognitive behavioural theory and treatment planning brief psychological therapies systems theory – group/family models at appropriate times in their training and as relevant to their clinical experience at the time. Supervision of clinical work should focus on the general principles of the psychological therapy utilised, and facilitate understanding of the underlying theoretical model, therapeutic techniques and the role of the therapist. Trainees and supervisors should be aware of the local requirements in relation to the keeping of records.
STRUCTURE
Supervision in the psychotherapies should take place as early as possible in training, and should be conducted regularly (and optimally) once weekly, and this time should be respected and facilitated within the workplace.
It should be understood by the employing authority that the trainee is relieved of usual duties during the period of supervision.
Supervision will usually be conducted in small groups of three or four trainees. This system is helpful in that there can be learning by example in the case of the less experienced. It also permits trainees to have the advantage of understanding the dynamics of a variety of different problems in a number of cases.
Supervision should last for at least 90 minutes where there are small groups.
Supervision may take place individually and would then usually last for 60 minutes.
THE SUPERVISION AGREEMENT
The psychotherapies should be supervised by experienced and recognized supervisors who are accredited with the RANZCP NSW Branch Training Committee.
Supervisors have a responsibility to their trainees to model and promote awareness and adherence to the principles in these guidelines.
Supervisors and trainees should establish an informed supervisory contract which covers all aspects of the setting and which differentiates supervision from personal therapy.
In cases where the trainee has two supervisors (a clinical supervisor and a supervisor in one of the psychotherapies), the psychotherapy supervisor would be responsible for supervising cases on a teaching basis, but the clinical supervisor should retain clinical responsibility unless an alternative is agreed to by all parties.
Trainees should keep a logbook of patients seen and supervised in the psychotherapies to ensure they have a sufficient breadth in their training experience and to assist in completing the By-law requirements for RANZCP training in the psychotherapies.
THE CONTENT OF SUPERVISION
Trainees should acquire appropriate knowledge of and skills in:
formulating an individual's psychological issues in terms of basic developmental principles describing an individual's personality functioning, relationship (attachment) style and adaptive, and coping behaviours the importance of early attachment experiences in the presentation of current difficulties the consideration of an individual's history of attachment relationships and the social/family context of their current attachment difficulties recognising the transgenerational transmission of relationship difficulties and psychological problems selecting an appropriate psychological therapy integrating the psychological therapies with biological and social therapies, appropriately understanding of and working in a psychotherapeutic framework transference and counter-transference issues considering the clinical material from the viewpoint of several models with appropriate references from the literature
Trainees should be supervised with appropriate attention to gender issues and sexuality, ethnic background and the sociocultural context of the patient.
Trainees should be supervised with appropriate attention to the issue of patient education relevant to the particular therapy utilised.
Trainees should acquire a range of specific cognitive behavioural skills including:
assessing cognitive distortions and maladaptive patterns of behaviours and how to present these to a patient in a sensitive and appropriate manner
the use of relaxation techniques and hyperventilation control
the use of symptom hierarchies in the treatment process
graded exposure and response prevention
the use of appropriate self-monitoring techniques for the patient to use in a variety of clinical problems
the use of a variety of patient- and clinician-administered rating scales
Supervision should encourage a focus on the changes in the patient's cognition and behaviour, and gains made between treatment sessions through homework exercises. Reasons for lack of progress need to be clearly delineated and worked through.
THE METHODS OF SUPERVISION
Supervision methods may include live interviews, audio and video tapes, process notes, or case notes.
Supervision using telephone or video linking techniques may be considered in certain circumstances.
A mechanism for the trainees to feedback their experience of supervision should be provided by the local coordinator of training.
PATIENT SELECTION
The patients who are to be treated and presented for supervision should be discussed with the psychotherapy supervisor or at least the clinical supervisor to ensure their suitability to the psychotherapy of choice.
All patients presented in supervision should have been informed on the treatment approach with the pros and cons of alternative treatments discussed. It should be clear that prior to the treatment process staring the patient has given informed consent.
The initial assessment process is important to establish whether there are issues which need urgent attention. For example, if the patient is depressed, suicidal intent must be assessed; if someone is complaining of difficulties in managing children, the possibility of physical abuse must be explored.
The patient needs to feel safe to disclose important and often distressing information. This will be facilitated if there is a warm and trusting atmosphere, no risk of censure, and if the therapist is empathic and clearly committed to helping the patient overcome current difficulties.
ETHICAL ISSUES
The supervisor is responsible for maintaining the professional boundaries of the supervisory relationship. Supervisors shall not exploit trainees sexually, financially or otherwise.
Supervisors shall treat trainees with appropriate respect and remember that supervision is not a place for interpreting the unconscious motivations of the trainee.
Supervisors shall not engage their trainees in personal therapy.
Given the primary purpose of supervision is to ensure that the trainee is addressing the needs of the patient:
Trainees are responsible for presenting and exploring the therapy as honestly as possible with the supervisor
Supervisors are responsible for encouraging and facilitating trainees to develop professionally, with appropriate respect and support, as well as for reflecting constructively upon the work presented
Supervisors have a responsibility not to collude with unprofessional practice by the trainee
Supervisors have a responsibility to respect the boundaries of the trainee's therapeutic relationship
The principles of confidentiality cover all aspects of the supervisory relationship. Contact with third parties should only occur with the knowledge and the consent of the trainee.
The supervisor and the members of the supervision group must treat the material with respect and confidentiality. Supervisors and trainees have a responsibility to ensure that the privacy of the patient is respected: e.g. where possible case material shall be effectively de-identified.
CONCLUSION
The Consensus Committee has agreed on these guidelines as a template to be used by pre-Section I trainees and their supervisors to maximise the benefits of the experience of supervision as part of training in the psychotherapies.
The guidelines should be used as a template for supervision in psychodynamic psychotherapy, cognitive-behavioural therapy, interpersonal therapy, brief psychotherapy, family therapy, marital therapy, and group therapy.
The Committee would appreciate feedback from all parties involved in utilising these guidelines.
Consensus Guidelines Drafted December 1998 Approved May 1999 (RANZCP NSW BTC Consensus Sub-Committee)
DISCUSSION
A number of issues require continuing attention in relation to access, equity and quality of supervision in the psychotherapies for pre-Section I trainees in NSW.
The first of these is the implementation of these guidelines. The preferred model of the Consensus Sub-Committee is for supervision to be delivered in the workplace during working hours by psychiatrists trained in psychotherapy and accredited by the NSW BTC specifically for supervision of pre-Section I trainees in the psychotherapies. Supervisors may participate in a service on a staff specialist or sessional basis. In the case of the latter, it is recommended that a session be made up of three hours of trainee supervision (e.g. two groups of four trainees) and one hour of other relevant activity within the service.
The second issue is related to funding. The Consensus Sub-Committee was of the opinion that the benefits of ensuring equal access to and quality of supervision are significant. For example, it is likely that the trainees' experience of training and morale amongst trainees in the workplace will be enhanced by the provision of on-site supervision and this may lead to improvements in recruitment and retention.
The third issue concerns evaluation and monitoring. In terms of process, there will need to be feedback mechanisms in place for trainees and supervisors, whereby problems can be identified early to ensure prompt attention and confidence that the quality of the process is maintained as far as possible. Such mechanisms may include trainee and supervisor reports, and peer review for accredited supervisors. In terms of outcome, the anticipated benefits (above) are potentially measurable by qualitative and quantitative means [7].
High quality supervision in the psychotherapies is an essential part of basic training, and it is our hope that these guidelines may be useful to trainees and supervisors in Australia and New Zealand to ensure its delivery.
Acknowledgements
The authors would like to thank Richard White, Joan Haliburn, Carolyn Quadrio, Chris Wever, Howard Johnson, Mohan Gilhotra, Ron Spielman, Charles Enfield, Isla Lonie, Eng-Kong Tan, Carolyn Delohery and the NSW Institute of Psychotherapy for their contributions to developing these guidelines.