Three heads are better than one: Psychiatry trainees’ experiences of a psychotherapy written case supervision group with three co-supervisors

Methods

A retrospective survey was conducted using SurveyMonkey®. The survey was sent out via email to trainees who had completed their PWC supervision. Demographics were not collected to protect the identity of trainees.

Survey questions addressed several domains and were based on the Evaluation of Group Supervision Scale developed by one of the current supervisors (Ryan T, unpubl. data, 2011). Slider scale questions were used to assess how the respondents felt with regards to how focused the sessions were, the cohesion of the group, how understood participants felt, how helpful supervision was, participants’ preference for individual versus group supervision, the group being a safe space and having adequate time to discuss their case. The points chosen on the slider scale was converted to a number between 0 (negating statement) and 100 (supporting statement) when responses were evaluated. The mean, median and standard deviation were calculated for the data.

Participants were also asked a yes/no question as to whether the supervision group met their training needs and asked to provide comments on their experience of the group, three co-supervisors and the PWC.

Endorsement as a non-research project was obtained from the Townsville Hospital and Health Service Human Research Ethics Committee (LNR/QTHS/62,495).

Results

Eight of 10 eligible trainees completed the survey. All eight trainees stated ‘yes’ to the question of whether the supervision group met their training needs. The mean rating (out of 100) for how focused the trainees felt sessions were was 71.63 (minimum 29) with large variation among the trainees (Table 1). The mean rating of how the group worked together was 87.38 (minimum 77). The mean rating of having adequate time to discuss the case was 89.71(minimum 79). There was a wide degree of variation for preference for individual versus group supervision (mean 64.88, minimum 30). The relational experiences of the trainees in terms of feeling understood by the supervisors and each other rated positively, particularly the individual experience of feeling understood by supervisors (mean 91, minimum rating 61) (Table 1).

OPEN IN VIEWER

Table 1.

Descriptive statistics for sliding scale questions.

	Mean	Median	SD.	Min	Max
Approach
The sessions were not (0) - were focused (100)	71.63	79	27.13	29	100
Cohesion
The supervision was not a safe space (0) - was a safe space (100)	86.75	86	11.72	66	100
The group did not work well (0) - worked well together (100)	87.38	87.5	9.32	77	100
Relationship
The group did not understand (0) - understood each other (100)	84.38	82	13.80	67	100
The supervisors did not understand (0) - understood the group members (100)	83.25	86.5	17.30	50	100
The supervisors did not understand (0) - understood me (100)	91	99	13.95	61	100
Meeting needs
Group supervision was not helpful (0) - was helpful to me (100)	86.13	88	15.45	56	100
I did not have enough time (0) - had enough time to discuss my own case (100)*	89.71	94	9.69	79	100
Supervision preference
Individual (0) versus group supervision (100)	64.88	70.5	23.06	30	100

Written feedback about changes trainees would like to see in the group suggested that trainees would like the opportunity to have individual supervision alongside the group supervision. ‘I really like the group format but I think there is some advantage/benefit to having some or occasional individual feedback’. ‘Make it explicit that trainees can check in with a supervisor, not necessarily in only the group format, at intervals where they might be stuck’. ‘I think being able to approach whoever you are most comfortable with supervisor wise and discuss discomfort/direction more informally was something I wish I had done’. One trainee commented that they would have liked more focus on a suitable psychotherapeutic framework from the outset to help inform the case and write-up. One trainee preferred smaller group size (maximum three trainees).

A strong theme emerged of appreciation of the variety of experience the supervisors brought. ‘Good for different perspectives and enthusiastic advice’. ‘I think the three supervisors generally complement each other in that they have contrasting experiences and approaches which can demonstrate that there is more than one way of doing things/different theoretical frameworks can be used for the same case’. ‘Multiple Supervisors was helpful in getting a more varied range of styles and approaches’.

Trainee comments on the overall experience of the PWC supervision group included the following statements: ‘A wonderful experience. So much so I am continuing with another case’. ‘Enjoyable, safe and an excellent, containing learning experience’. ‘It was a valuable experience which is hard to be gained outside the training’. ‘It has been an overwhelmingly positive experience that I have greatly appreciated’. ‘I enjoyed the meeting of minds, and it reawakened a lot of interests for me, especially writing’.

Undertaking the psychotherapy case itself was described as an ‘invaluable experience’, ‘very interesting’ and training experience which ‘motivates deeper learning through reading and thinking’. The process of writing up the case provoked a comments about being ‘tedious’ and ‘very much like ticking boxes’.

Discussion

The co-supervisors intuited that the group was working well and sought to objectively measure this. The trainees provided very positive written feedback about their overall experience of the supervision group. The breadth of experience provided by the different supervisors was commended. This is in keeping with literature suggesting that group supervision has the advantage of different angles of approach and perspectives. ⁴ The experience of being in the group also enhances knowledge about interpersonal relationships and decreases individual vulnerability.

Having more than one supervisor introduces a possibility of varying and conflicting views and lack of focus which can be confusing. This has emphasised the importance that the supervisors use pre-supervision weekly meetings to focus on having a streamlined and uniform approach to the group as well as the group process. Organisational issues and demands can impinge on the experience of the group.^2,4,5 The supervision group tries to keep a boundary around this by giving trainees a protected weekly supervision space. Supervisors have on occasion found they need to advocate at a service level for trainees to attend. There is a need every 6 months or so to reassert this training requirement.

In a group setting, supervisors can model respectful and productive discussion around theoretical approaches and psychotherapy methods. We recognise that apprehensive entrants often want more direction as to method of approach than is warranted in commencing therapy with a new patient. This modelling in the group and consensus around the acceptability of initial uncertainty is reassuring. The use of the co-supervisory model also provided a training experience for the Psychiatrist undertaking the Certificate of Advanced Training.

Acknowledging that avoidance might be compounded in a group setting, the co-supervisors also regularly reminded trainees where necessary of expectations of their participation as part of training requirements. There was a wide degree of variation in the trainees’ preference for individual versus group supervision. Although individual supervision was offered, the group supervisors need to be alert to reminding trainees about this and proactively facilitating this where desired or needed. Our survey result is in keeping with research findings that suggests individual supervision should complement group supervision. ²

Cohen and Hatcher ⁶ identified a category of the ‘daunting/revered’ supervisor in trainee experiences of the PWC. The more junior Psychiatrist supervisor in the group was often approached first by trainees wanting individual support. Using this group format concentrates supervisory talent and enables the supervisors to reflect on and improve their supervision.

Limitations of this evaluation survey include the potential bias in responses. Although the survey was anonymous and did not collect demographic information which could identify respondents, trainees were still aware that the co-supervisors were undertaking the survey. Ögren, Apelman and Klawitter ⁴ note how traumatic it can be for supervisors to receive criticism. It would have been difficult for trainees to provide negative feedback without fear of disappointing or wounding the supervisor/s. Using a metric tool to assess a supervision experience also has drawbacks, balanced by providing several opportunities to provide written feedback in the survey.

Another limitation of the survey was the reliance on trainee self-report without concomitant evaluation of case progression, quality of case write-ups and pass rates. The authors note that written case quality is generally good, but there is a near universal problem in a long delay once trainees have completed the case (this seems to be a ubiquitous problem and not specific to the group supervision model however); likewise, trainees for whom English is a second language found the write-up challenging. At time of writing, of the original 10 trainees invited to participate in the survey, eight have submitted their case. Four passed the write-up on first attempt, three on the second attempt and one has moved services so the outcome is not known. This is consistent with RANZCP trainee results bi-nationally.

Conclusions

This evaluation survey supports the use of three co-supervisors as a novel model of group supervision for the PWC. Supervision is not only meeting the trainees’ needs, but is offering a deep learning experience. Group co-supervisors need to be vigilant to the need for complementary individual supervision alongside group supervision and keeping sessions focused whilst continuing to provide a breadth of perspectives to the trainees. Our group supervision model may be of use in other settings, particularly regional centres in Australia where there is limited capacity to provide psychotherapy supervision.