Guidelines for RANZCP-Accredited Trainees who Experience Problems in Supervision

INTRODUCTION

The apprenticeship model has long been the cornerstone of Royal Australian and New Zealand College of Psychiatrists (RANZCP)-accredited clinical training. Supervision is the heart of that model. A number of efforts to define and operationalize supervision have been published.1–3 Generally, the process is regarded as one of demonstration, discussion and reflection in an atmosphere of mutual, open appraisal and feedback which is primarily focussed on the trainee's development of attitudes, skills and knowledge. Against this ideal, some of the problems encountered in the trainee-supervisor relationship have been described, including disinterested supervisors, lack of support in critical incidents and abusive behaviour by supervisors.[4], [5] However, there are no publications currently available that offer guidance to RANZCP-accredited trainees and/or supervisors who experience problems in their supervision and/or their supervisory relationship. This is the first in a series of two articles on behalf of the RANZCP Committee for Training, prompted by the recent publication of a similar article for British trainees.[6] This, the first article, is primarily for use by trainees; and the second will be primarily for supervisors.

BACKGROUND

RANZCP-accredited trainees usually encounter a new clinical supervisor twice each year for the first four years of training. In addition to these eight supervisors, most trainees have at least one psychotherapy supervisor and a principal supervisor for their dissertation year. If a trainee takes longer than the minimum time to complete their training (and most do) they will usually have had an average of 12 supervisors by the time they gain their Fellowship.

Clearly the quality of the trainee-supervisor relationship is important.

Trainees rarely make the decision about who will be their principal supervisor. They are therefore required to make significant adjustments each term, moving from one supervisor to the next. The likelihood that each trainee-supervisor relationship will be established smoothly, that each trainee will be well matched to his or her supervisor and that supervision will be swiftly beneficial to both is low.

Other factors also frequently supervene, including each party's previous subjective experience(s) of supervision, the prevailing attitude to supervision in the workplace, the pressures of service delivery, and the availability of an appropriate location for supervision. Furthermore, trainees most often embark on their training at a time when a number of significant life-events concur, including marriage and the advent of children, and both trainees and their supervisors may often need to take these factors into consideration when considering their supervision.

If problems arise in supervision, it is our experience that trainees often feel unsure about what to do; they may be confused about the nature and cause(s) of the perceived problem; and they are sometimes unclear about what assistance may be available to them. In addition, it is common for trainees to be reluctant to take up problematic issues related to supervision because of the fear that such action may, in the short term, make their working environment more difficult, or in the longer term, may jeopardise their career.[5]

With these issues in mind, we would like to highlight some of the common problems trainees encounter in supervision and suggest constructive guidelines on how these problems may be approached, and ultimately solved.

PROBLEMS IN SUPERVISION

Common problems in supervision include:

These problems may be usefully conceptualised in terms of:

PROBLEM-SOLVING IN AND OUT OF SUPERVISION

The initial response to any problem should be to think about it. While this may sound glib, there are often significant gains to be had in being able to clearly identify the problem, and to reflect on its causes. For example, marked anxiety before supervision may be the symptom, being caught up by an urgent phone call and then forgetting supervision may be the sign, and a chronically distracted or overly critical supervisor may be the cause. If the problem can be identified in these ways then it may be helpful to be able to think about the structural issues, content issues and interpersonal issues that have contributed to the development of a problem. In the example above, a structural issue may be that supervision is scheduled on a Monday morning when the emergency department needs to be cleared of patients admitted overnight after overdoses and there is always a tension between doing a thorough assessment and getting to supervision on time; a content issue may that supervision is not addressing a looming exam; or an interpersonal issue may be the trainee's feeling that their supervisor is not appreciative of the stress they are under from their clinical workload, increasing exam pressure, and having to move house.

If the issues can be identified and analysed in this way, it might then be possible to discuss and address them. To continue with the example above, it may be possible to reschedule supervision for later in the day (or the week), or it may be possible to shift the focus of supervision onto the upcoming exam, or it may be possible to raise the supervisor's awareness of the various stressors on the trainee and elicit a satisfactorily supportive response.

This, then, is the second phase of solving perceived problems: discussion with the supervisor. It is often the case that a supervisor is unaware of problems experienced by a trainee until the trainee raises the problem. It is equally common that once raised the problem may be successfully addressed. Unfortunately though, this is not always the case.

The next step is to seek advice outside the supervision.

Sometimes a more senior trainee will be able to discuss the problems arising in supervision and offer useful advice. For example, a senior trainee may be able to assist in identifying the problem and/or its symptoms and signs by being able to stand back from the trainee-supervisor relationship; or suggest the best way to raise the issues for discussion in supervision; or suggest strategies to explore with the supervisor to solve the problem.

On other occasions, another psychiatrist known to the trainee to be a respected supervisor may be useful. Often, hospitals/services have a local coordinator or director of training who takes responsibility for local training issues and is ideally placed to help resolve such problems. Equally, the Zone or Area Director of Training is a valuable person with whom to discuss the problem and seek advice. It is the responsibility of the Director of Training to ensure that all trainees within their program not only receive supervision in accordance with RANZCP requirements but also that the experience of supervision is as valuable as possible to the trainee.

Before or after pursuing other options the trainee may want to discuss the problem and seek advice from the Director of Training. If the trainee feels unable to approach the supervisor or that he/she has exhausted their own resources in dealing with the matter, the Director of Training can facilitate a meeting between the two parties or speak privately with the supervisor. If the problem remains intractable the Director of Training can then alter the supervisory arrangements

In some instances the trainee may wish to seek the advice of the local representative of the Association of Psychiatrists-in-Training (APT), as a support, as an advisor and/or as an advocate to the Director of Training and/or to the Branch Training Committee. There is no doubt that the APT representative can be a valuable resource to fellow trainees.

Sometimes the problems experienced by a trainee in supervision may be a reflection of much broader systems issues, which cannot be addressed by the Director of Training. In these circumstances the Branch Training Committee (BTC) may play a role in reviewing the identified problems and working through the Director of Training to address the issues for the trainee. Alternatively, where the problem is related to broader issues of accreditation and/or capacity to train, the bi-national Committee for Training (CFT) may become involved.

It is important that trainees are aware that they have both direct and indirect access to these individuals and Committees when problems arise. The Committee for Training and state/local committees rate improvement of supervision as a priority. Strategies to assist supervisors are discussed in a separate paper.

THE MOST DIFFICULT PROBLEMS

The most difficult problems arise in the area of interpersonal issues, and a dysfunctional supervisor may be a most confronting and distressing problem for the trainee. The dysfunction may be apparent in a number of ways:

It is unlikely that problems such as those identified above could be adequately addressed by careful thought and discussion with the supervisor, or simply by seeking the advice of a respected psychiatrist/supervisor or the Director of Training. Such measures are still worth trying in the first instance. However, these types of behaviours may well constitute occupational violence or harassment and should be reported to the employing agency, which has a responsibility to respond to such matters. In such instances, the Zone Director of Training should be involved as an advocate for the trainee[s] and assist in dealings with the supervisor and the employing agency, and should take responsibility to address the problem at a local level, through the BTC or through the bi-national CFT.

CONCLUSION

It is our belief that most problems in supervision can be resolved collaboratively by the trainee and their supervisor. When this is not the case though, clear lines of communication to colleagues must be available, utilised, responsive and effective. Whether the trainee chooses to utilise a more senior trainee, another psychiatrist or the Director of Training will be a choice they may make based on the nature and severity of the problem. And it must be clear at all levels that if the issues cannot be satisfactorily resolved, for whatever reasons, the trainee must be supported in taking the problem to the appropriate Committees of the College for consideration.

ACKNOWLEDGEMENT

The authors would like to thank Professor Pete Ellis who suggested the need for this paper.