Chapter 1. Introduction: Am I Qualified to Supervise?

A third-year psychiatry resident working the emergency department has just evaluated a patient who was brought in after an overdose, her third in the past 2 years. Later in the day, he and his psychotherapy supervisor discuss this patient’s case.

Throughout most of the last century, psychotherapy was at the core of what it meant to be a psychiatrist. Psychiatry training and practice was steeped in psychodynamic principles. A psychodynamic understanding of patients contributed to all phases of psychiatrist–patient interactions as it permitted a comprehensive perspective of our patients and their lives. With our growing appreciation of epigenetic modification, we could even connect those factors to neurobiological changes (Kay 2017; Ravitz 2017). Abundant evidence existed for the efficacy of psychodynamic psychotherapy in a broad array of common and complex mental disorders, including personality disorders (Abbass et al. 2017; Fonagy 2015; Leichsenring and Rabung 2008, 2011; Ravitz 2017). Psychodynamic psychotherapy informed our understanding of the mind and formed the basis for effective psychiatric treatment. Learning how to provide psychotherapy was viewed as an essential element in training to be a psychiatrist.

Today, this is no longer the case. Beginning in the late twentieth century, a decline in provision of psychotherapy by psychiatrists began to occur. In the 1980s, approximately half of all psychiatric appointments involved psychotherapy (Dorwart et al. 1992). By 2004, the percentage of psychiatric visits involving psychotherapy had decreased to only 29% (Mojtabai and Olfson 2008). Many factors contributed to this drop, including the introduction of novel psychotropic medications, the emergence of managed care, and shifting payment schemes for psychiatric care that discouraged reimbursement for psychotherapy. Additionally, an increase in educational debt has led many early-career psychiatrists to seek more lucrative practices within organizations that discourage the provision of psychotherapy by psychiatrists (Clemens et al. 2014; Kay 2017). A vicious cycle was set in motion: as early-career psychiatrists observed fewer psychiatric attending physicians practicing psychotherapy, the assumption that “psychotherapy is not something that psychiatrists do” became more widespread.

Despite these gloomy trends, hope continues for reviving the practice of psychotherapy by psychiatrists. In a survey study of Canadian psychiatrists (N = 423), nearly 81% reported practicing psychotherapy, with the most common theoretical orientation being psychodynamic psychotherapy (Hadjipavlou et al. 2015). Percentages of psychiatrists practicing psychotherapy were highest (> 85%) among more experienced psychiatrists (> 20 years of experience) and early-career psychiatrists (< 5 years of experience) (Hadjipavlou et al. 2015). The American Academy of Psychoanalysis and Dynamic Psychiatry reported that the preferred type of psychotherapy among its members was weekly individual therapy and that nearly 95% of members reported psychotherapy session durations of 45–60 minutes (Alfonso and Olarte 2011). In an online survey of applicants to a Canadian psychiatry residency program, 55% of medical students endorsed “emphasis on psychotherapy” as a motivator for them to enter psychiatry; this was the second-highest motivator behind “favorable job market for psychiatry” (Wiesenfeld et al. 2014). Finally, in another online survey examining psychiatry residents’ perceptions of and experiences in training, residents expressed a desire for more training in psychotherapy and more hours of psychotherapy practice, and they described supervision as being the most important training modality for psychotherapy (Kovach et al. 2015).

Psychotherapy training continues to be an essential part of psychiatric residencies. The Accreditation Council for Graduate Medical Education (ACGME), which governs the standards for psychiatry residency training, still requires that all graduating residents demonstrate competence in “managing and treating patients using both brief and long-term supportive, psychodynamic, and cognitive-behavioral psychotherapies” (Accreditation Council for Graduate Medical Education 2020, p. 21). Supervision is considered a central component of the psychotherapy education process. Learning to deal with the complex situations and emotional challenges engendered during psychotherapy cannot be done by reading articles and attending lectures alone. Supervision offers the safe space that residents need to express themselves more freely (Kennedy 2016).

We believe that psychotherapy remains a critical skill for all psychiatrists. A psychodynamic understanding allows us to comprehend the combination of genetic vulnerabilities, social/cultural realities, early-childhood experiences, unique circumstances, and personal decisions that contribute to how our patients experience their lives and engage in the world. Gaining competence as a psychotherapist requires a knowledge of theory mixed with experience in clinical work and thoughtful clinical supervision. Psychotherapy supervisors play a critical role in forming the next generation of psychiatric psychotherapists.

With this renewed interest, there is a growing call for more psychotherapy supervision and an expanding need for additional psychotherapy supervisors. Unfortunately, the events of the past 30 years have left the field of psychiatry with a profound shortage of psychotherapy supervisors. Waving the proverbial wand will not make a fresh crop of psychotherapy supervisors magically appear. Becoming a psychotherapy supervisor is a developmental process. Many psychiatry training programs lack the personnel and other key resources required to train new psychotherapy supervisors, despite the ongoing need for a steady supply of new supervisors to replace those who are retiring. Some early- and mid-career psychiatrists are hesitant to take on the mantle of psychotherapy supervisor. They may feel daunted either by memories of their esteemed supervisors or by a lack of any role models at all. This book addresses issues raised when a psychiatrist or psychotherapist wonders “Am I qualified to be a psychotherapy supervisor?”

Although the evidence base is still evolving, psychotherapy supervision is a skill that can be developed, just like any other skill. We put this book together to help. The main prerequisites for becoming a psychotherapy supervisor are a basic understanding of psychotherapeutic principles, a sincere desire to become a “good enough” psychotherapy supervisor, and an opportunity to supervise someone. But prospective supervisors may have a range of other concerns, such as the following:

Trainees do not need supervisors who are perfect. They need supervisors who are engaged, knowledgeable, and humble, and who provide supervision in a deliberate and thoughtful manner. Mistakes will be made, but as is the case in parenting, making a consistent effort, being willing to acknowledge and correct mistakes, and sincerely desiring to do the right thing will more than make up for a variety of innocent errors. Our goal in compiling this book was to help encourage the growth of the “good enough” supervisor. Just as Winnicott described the “good enough” mother as one who adapts to her child’s needs and supports their growth and eventual autonomy (Winnicott 1953/1971), it is our hope that you will recognize that the process of becoming a supervisor is a lifelong journey, that every supervisor will make missteps, and that there is always, always, more to learn.

Although we hope that you will read this book from cover to cover, we realize that many will pick those chapters that seem most immediately relevant to their situation. That is fine. Do what works best for you. To help your efforts, we next explain the organization of the book.

As a last recommendation, we would suggest that you not read this book alone. If you are supervising trainees, get together with other psychotherapy supervisors and discuss the topics in this book and other pertinent supervision topics. Peer support can be extremely important, as psychotherapy supervision can sometimes feel like a lonely endeavor. Based on our experiences, though, it can also be one of the most rewarding aspects of your career.

“Am I qualified to be a ‘good enough’ psychotherapy supervisor?”

It is our hope that after you read this book, your answer will be a resounding “Yes!”