Senior Resident as Junior Supervisor: Case Report of an Apprenticeship Model for Training Psychotherapy Supervisors

A postgraduate year (PGY)–2 resident (hereafter referred to as the junior resident) treating two patients with psychodynamic psychotherapy was offered the opportunity to participate in a pilot supervision project, in which the first case would be supervised by an experienced psychotherapist and the second case would be supervised by a PGY-4 resident (hereafter referred to as the senior resident) developing competence in psychotherapy and participating in a training program at a psychoanalytic institute. After the junior resident agreed to participate, the residency training director and the faculty director of psychotherapy education established parameters for an apprenticeship model between the senior resident and a supervising attending psychiatrist. These parameters required the attending psychiatrist and senior resident to have no prior formal relationship with the junior resident (although the attending psychiatrist had given several group lectures to the PGY-2 class); the senior resident to have an unrestricted medical license and to have received faculty feedback indicating advanced proficiency in psychodynamic psychotherapy skills for their level of training; the junior resident’s clinical documentation to clearly delineate the supervisory responsibility shared between the senior resident and the supervising attending psychiatrist; and the patient in the second case to be informed of the arrangement and consent to participate, with knowledge that more than one supervisor would have access to clinical material.

Potential patients were screened by an associate residency program director, and the patient who agreed to participate and was selected was determined to have an overall low safety risk, no history of problematic enactments interrupting treatment, and a generally positive orientation toward past therapists. The treatment for the selected patient focused on symptoms of depression, social anxiety, and distress in relationships thought to have been influenced by abuse during childhood.

The patient and junior resident met for 45 minutes weekly. The junior and senior residents met with each other for 1 hour every other week, and the senior resident and the supervising attending psychiatrist met for 1 hour monthly. The periodicity of these meetings was agreed on through consensus at the outset of the pilot project. The timing of the patient’s appointments and the junior resident’s supervision appointments took into account the patient’s treatment frequency and the junior resident’s availability. In alternating weeks, the junior resident was supervised by the senior resident and by a senior attending psychiatrist who was overseeing the junior resident’s treatment of a different patient. The monthly frequency of the senior resident’s meetings with the supervising attending psychiatrist was intended to connote the transitional nature of the senior resident’s role (i.e., the attending psychiatrist met with the senior resident about half as often as the senior resident met with the junior resident). Written communication between face-to-face sessions was encouraged and was used, as needed, during the treatment by all three participants. For example, the senior resident updated the supervising attending psychiatrist between scheduled meetings when the patient brought up a child safety concern with the junior resident. (This concern did not involve the patient or the patient’s children.)

Supervision sessions between the junior and senior residents consisted of reviewing case history and process notes, discussing aspects of the frame that were relevant to treatment, developing a shared formulation of the patient, advising on the junior resident’s legal and ethical questions as they arose, and processing the junior resident’s countertransference reactions during treatment. The sessions were not videotaped because of a technical limitation related to the COVID-19 pandemic, and the supervision sessions relied on process notes written by the junior resident. The senior resident worked with the junior resident to clarify themes related to the patient’s chief complaint and to outline strategies and techniques for helping the patient to explore these themes. Occasionally, the senior resident suggested and shared relevant readings. Role-playing was also used to demonstrate therapeutic interventions that the junior resident could use with the patient.

Supervision sessions between the senior resident and the attending psychiatrist consisted of a mixture of discussing direct clinical material shared by the junior resident, clarifying recurring themes in the patient’s material, and outlining general introductory principles of psychotherapy supervision by using the Riess and Herman study (6) and the McWilliams textbook (9) on psychoanalytic supervision as a theoretical framework. The senior resident was receiving and participating in personal psychoanalysis at the time of this project, and the attending psychiatrist highlighted instances of parallel processes among the treatment being discussed, the relationship between the attending psychiatrist and the senior resident, and selected elements of the senior resident’s psychoanalytic treatment.

We obtained written, unstructured, qualitative feedback from the four stakeholders: the junior resident, the senior resident, the supervising attending psychiatrist, and the residency program director. These four participants were asked to provide feedback on their overall experience with the supervision, including any information they felt would be instructive in evaluating and modifying the apprenticeship model for the next phases of development.

The junior resident reported that working with a near-peer supervisor facilitated openness and trust, particularly in sharing countertransference reactions and insecurities about their role as a developing psychotherapist. The senior resident’s skills in listening, observing, and processing helped the junior resident to better understand patient-therapist dynamics, generating avenues for further exploration. The junior resident also felt understood and supported in handling logistical issues arising during treatment, because the senior resident’s familiarity with the residency clinic exceeded that of most senior supervisors. Likewise, the proximity of the senior resident to the junior resident’s stage of learning facilitated a shared understanding of how structures inherent to the residency experience affected the junior resident’s progress as a psychotherapist. The junior resident also expressed appreciation for the structured near-peer relationship—the senior resident not only provided psychotherapy supervision but also advised the junior resident on curricular decisions and served as a model mentor to the junior resident. These interactions were particularly salient during the COVID-19 pandemic, when interclass relations were attenuated. One piece of constructive feedback from the junior resident was the suggestion that the attending psychiatrist, senior resident, and junior resident meet to discuss supervision dynamics in general as well as to hear the attending psychiatrist’s view of the case. The junior resident was also interested in processing the novel experience as a group and felt that meeting as a triad would lead to thoughtful discussion.

The senior resident found the apprenticeship model to be educational, supportive, and inspiring. They elected to continue serving as a psychotherapy supervisor after graduating and felt well prepared to serve in that role. The senior resident described benefiting from the supervising attending psychiatrist’s attention to parallel process, potential unconscious withholding by the junior resident, and vulnerabilities of each resident. About halfway through the academic year, the senior resident decided to revisit the McWilliams theoretical framework (9) for psychotherapeutic supervision, and parts of two meetings with the attending psychiatrist were used to guide the senior resident in outlining the textbook’s chapters, with attention given to ways in which key concepts had arisen during their supervision of the junior resident. As the academic year progressed, the senior resident became more confident in selecting areas of the junior resident’s therapeutic work to present to the supervising attending psychiatrist. First, the senior resident said that they became more comfortable presenting areas they wished to discuss and receive feedback on and less concerned that the attending psychiatrist might want or expect to discuss certain other topics. Second, the senior resident became better able to identify areas of the junior resident’s work that would benefit from attention in supervision, such as the patient’s and junior resident’s mutual avoidance of some aspects of the patient’s experience (e.g., aggression). In addition, the senior resident and attending psychiatrist together tried to achieve a balance between discussing the overall treatment of the patient and identifying more narrow issues in the supervision with which the senior resident sought particular assistance (e.g., how to advise the junior resident on establishing and maintaining the treatment frame). This model’s impact on the senior resident was evident in their growing confidence as an independent psychotherapist (choosing to see psychotherapy patients in clinical practice immediately after graduation) and their seeking of supervision of their own private psychotherapy practice. The senior resident indicated that they sought an experienced supervisor after residency, partly because of the insights gleaned from this pilot project, and they encouraged their graduating peers to do the same.

The supervising attending psychiatrist noted the interesting dynamics of hearing about a patient from the supervising (senior) resident and the complex task of teaching on two levels simultaneously. At one level, the attending psychiatrist helped the senior resident to understand the role of supervisor. At another level, the attending psychiatrist coached the senior resident in teaching the junior resident to listen for the patient’s underlying concerns and to develop techniques for addressing those concerns. The attending psychiatrist found that remaining alert for processes between the therapist (the junior resident) and junior supervisor (the senior resident) that paralleled processes occurring between the therapist and patient (e.g., defensiveness, withholding) was important. The supervising attending psychiatrist also listened for possible parallels between the processes occurring on these two levels and processes that emerged in the relationship between the senior resident and the supervising attending psychiatrist. An example of parallel process occurred in the junior resident’s initial inclination to focus on the patient’s relationships with others in relative isolation from the therapeutic relationship, which was mirrored by the senior resident’s initial focus on relaying content from the process material that was uncoupled from the senior resident’s experience of the new supervisory relationship. The senior resident was unaware of these parallel processes, and the supervising attending psychiatrist’s attention to them was impactful.

In general, the supervising attending psychiatrist found it helpful to alternate between a coaching role (i.e., giving concrete advice and instruction) and a more interpretive role (emphasizing the relational and process aspects of the supervision and treatment). The attending psychiatrist relied on the senior resident to assess whether lines of communication remained open and whether necessary information flowed freely among the junior resident, senior resident, and attending psychiatrist. The attending psychiatrist also relied on the senior resident to discern when attention needed to be paid to particular aspects of the treatment and to stay alert for safety issues. No problems with patient safety or inadequate communication among the triad arose. Overall, the supervising attending psychiatrist reported that the experience was rich and multilayered.

Feedback from the residency program director emphasized systematic benefits of this training project. Inviting PGY-4 residents to supervise psychotherapy conducted by junior residents may expand the pool of supervisors during residency and afterward, as occurred when the senior resident joined the faculty as a psychotherapy supervisor after graduating from residency. The residency program director also felt that this project might reduce anxiety among senior residents who were apprehensive about their readiness to supervise when they became junior faculty. The apprenticeship model served as a transitional experience, providing a theoretical and experiential framework the residents could use when providing independent supervision in the future. Finally, the residency program director opined that the experiential nature of the supervision afforded a more in-depth experience for PGY-4 residents desiring careers in academic psychiatry than participation in any didactic seminar could achieve, in line with other findings (10, 11) highlighting the benefit of experiential learning in psychiatry education.

We believe that the positive qualitative feedback obtained from the four stakeholders offers support for the value of this apprenticeship model in training PGY-4 residents in psychodynamic psychotherapy supervision. Whereas this article describes the early development of the model, further research and refinement could elucidate its effectiveness and help to establish guidelines for its implementation.

The feedback we received was mostly positive, which may have been related to the open-ended and nonanonymous data collection. In addition, the junior resident was eager to participate, and the senior resident was eager to learn supervision skills, which may have limited the generalizability of our findings to other residents. If this apprenticeship model is applied to a broader pool of residents, additional factors—such as having a suitable pool of appropriate patients, senior faculty members willing to participate, and room in PGY-4 residents’ schedules for two recurring supervision meetings—would need consideration and might affect educational outcomes.

Future phases of investigation would benefit from a formal needs assessment; a larger study population; and structured, systematic assessment of the intervention. Further research is warranted to evaluate whether PGY-4 residents participating in this apprenticeship model emerge with greater readiness to assume supervisory responsibilities after graduation, compared with junior faculty members without similar experiences, and whether PGY-2 residents supervised by PGY-4 residents have similar competencies in psychotherapy skill, compared with their peers supervised by faculty. Moreover, the results of this apprenticeship model could be compared with those of a didactic intervention, such as the supervision training proposed by Riess and Herman (6). Finally, additional investigation is warranted into the applicability of this model to other psychotherapy modalities, especially the other therapies required by the Accreditation Council for Graduate Medical Education as part of residency training (cognitive-behavioral therapy and supportive psychotherapy).

The academic frameworks we relied on do not represent the only scholarly work in this area, and future programs may benefit from considering the inclusion of multiple theoretical foundations. One prominent example is the competency-based approach to supervision by Falender and colleagues (12–14).

In our residency program, residents begin practicing psychodynamic psychotherapy as PGY-2 residents; therefore, the senior resident who supervised the junior resident was 2 academic years ahead, a separation that is common for near-peer teaching in our residency program. Programs beginning psychotherapy education in PGY-3 would have to evaluate the appropriateness of having a PGY-4 resident supervise a PGY-3 resident.

We were attuned to potential extrasupervisory interaction between the two residents involved. The senior resident did not supervise the junior resident in other rotations, and we intentionally avoided scheduling the two residents together for on-call shifts to preserve the circumscribed relationship. Although this scheduling required some forethought, it was not otherwise logistically challenging. Other programs interested in piloting this model may wish to follow the same scheduling practices—both residents commented that interacting in a work-related context outside the psychotherapy supervision might have presented additional challenges.

A promising future direction for this type of experience may involve the use of video-recorded psychotherapy sessions, which has become common in resident psychotherapy supervision (15–17). Recorded sessions may help prevent loss of information on the treatment in the supervisory cascade from junior resident to senior resident to attending psychiatrist. In addition, having the supervising attending psychiatrist’s feedback on recorded therapy sessions may benefit the senior resident. The triad could also consider recording supervision sessions between the junior and senior residents for review and input by the attending psychiatrist; this recording would offer the senior resident an opportunity to receive feedback from the attending psychiatrist that is based on direct observation of the supervision sessions. Viewing recordings of the supervision sessions between the junior and senior residents may also reinforce the parallels between learning to conduct psychotherapy and learning to supervise it, adding to the overall enrichment of the process by which residents become supervisors.

In this article, we describe a pilot apprenticeship model designed to offer a training experience for senior psychiatry residents learning to clinically supervise psychotherapy. We found this model mutually beneficial for the junior resident (the psychotherapist), the senior resident (the supervisor-in-training), and the residency program as a whole. See Box 1 for our recommendations for developing training in psychotherapy supervision. Our residency program elected to continue this educational offering in the subsequent academic year. We emphasized to the new participants that communication and trust among the triad of junior resident, senior resident, and supervising attending psychiatrist were essential to the success of the arrangement.