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Regular Article |
Received September 13, 1999; revised August 8, 2000; accepted August 24, 2000. From the Department of Psychiatry, University of Texas Health Science Center at San Antonio, Texas. Address correspondence to Dr. Shanfield, Department of Psychiatry, The University of Texas Health Science Center at San Antonio, Mail Code 7792, 7703 Floyd Curl Drive, San Antonio, TX 78229-3900. E-mail: shanfield{at}uthscsa.edu
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Abstract |
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Key Words: Psychotherapy Training and Supervision • Gender • Perceptions of Supervisors by Residents
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Introduction |
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METHODS |
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Experts rated the videotapes in earlier research. In that research, the authors and another member of the original research team, three men and a woman, rated supervisors on each videotaped session. They rated how helpful the supervisor was in dealing with the problems, dilemmas, countertransference difficulties, and concerns about the patient that the resident had brought to the videotaped session.2 This is a global variable on a seven-point scale ranging from little to none on one end (1) to an extreme amount on the other (7), and it is labeled "Excellence of the Supervisor as a Teacher."2,3 The research established a high interrater reliability of the Excellence variable. The intraclass correlation coefficient (ICC) was 0.62.2,9 Finn's Index, used to compensate for the ICC's sensitivity to skewness, was 0.79, which indicates considerable agreement among expert raters.2,10
Several years later, after viewing the videotape of their supervision session, former residents rated that tape. They were asked to rate the specific session, using the same format for rating excellence as experts.2 Former residents were blind to the scores of the research team. The mean time from videotaping to rating was 6.6 years (SD=2.6).
Former residents' ratings and experts' previous ratings of Excellence on the same tapes were analyzed by using Pearson's correlation coefficients. Correlation analysis tests the hypothesis that resident and expert ratings are independent; that is, that one class of ratings does not predict the other.9 Student's t-test was also used. This procedure tests the hypothesis that there are no differences between expert and resident mean ratings. The hypothesis is rejected if the t-test is statistically significant.9 In this instance, the groups would not be drawn from the same population. Additionally, Pearson correlation coefficients and paired t-tests were used to explore differences between experts' and male and female residents' scores. A rejection criterion of P<0.05 was used for both hypotheses.
A new variable was constructed to compare the differences in ratings on the Excellence variable between residents (male and female) and experts. This new variable, Criticality, measured how much residents were more or less critical of their supervisors than were the experts. The rating of an expert was subtracted from the rating of a resident for the same tape, so that there was a possible range of values from +6.0 to –6.0. A positive value means that the resident was less critical than the expert was (i.e., that the resident rated the Excellence variable higher than the expert). A negative value means that the resident was more critical than the expert was (i.e., that the resident rated the Excellence variable lower than the expert). A cutoff of one standard deviation above or below the mean was used to measure the frequency of male and female residents being more or less critical than experts of their supervisors.
A qualitative component was added to provide a deeper understanding of the residents' ratings of excellence.11–13 After former residents viewed and rated their videotape, the authors interviewed them for 45 to 90 minutes. In the interviews, residents were asked to explain the basis of their ratings. The interviews focused on the videotaped session, the overall experience with the resident's supervisor, other experiences of supervision, and the resident's development as a therapist. The Excellence and Criticality variables provided a guide to organizing themes from the interview data. A cutoff of one standard deviation was used to determine low, middle, and high ranges on these variables.
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RESULTS |
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On the Criticality variable, one standard deviation below the mean indicates that former residents rated their supervisors in the low range (rating range 1–3). One standard deviation above the mean indicates that former residents rated their supervisors in the high range (rating range 6–7). See Table 1 for means and standard deviations. Overall, as a group, women were more critical of their former supervisors than men were. On the Criticality variable, using a cutoff of one standard deviation above the mean, 5 women and no men rated their former supervisors lower than did the experts; 6 men and 2 women were less critical than experts and rated their supervisors higher.
Qualitative Results
The interviews revealed that former residents had a broader view than experts when evaluating the excellence of their supervisors. Moreover, their evaluations were seen through the prism of other supervisory experiences and their development as clinicians. For many, the interviews provided an opportunity to examine their overall learning experience with psychotherapy and assess their professional growth as therapists. The research process had the effect of revivifying their experience with the patient and the supervisor.
Former residents, at all levels of training at the time of videotaping, emphasized their novice status, noting a sense of deficiency of experience and skill in the conduct of psychotherapy and of feeling at a loss as to how to conduct themselves with their patients. These underlying concerns were not addressed directly in any videotaped session. Former residents focused on the accepting and nonjudgmental aspects of the relationship and appreciated supervisors who accepted their concerns and their work with the patients. A trusting relationship that allowed residents to present their problems in a nondefensive manner was a major reason for residents to rate supervisors high, and higher than the experts. A supervisor's attitude of calm acceptance helped residents tolerate the intensities stirred up, particularly by patients who were angry in or out of the session or who were potentially violent. Many viewed the supervisory relationship as one of the most important aspects of their training.
Supervisors who were rated at the highest levels were able to provide an accurate view of patients by using data provided by residents. This had the effect of affirming the residents' observational and reporting skills. Even what was not discussed was perceived as an affirmation that the residents' conduct with patients was adequate.
The highest praise was for supervisors who used the strategy of helping residents understand their own responses to their patients. This was particularly useful when a resident felt immobilized. This level of discussion caught "deeper levels of vulnerabilities" and encouraged residents to be more appropriately direct and active.
Highly rated supervisors often acknowledged the residents' worries about their personal experiences that might have an impact on the care of their patients. Women particularly wanted to discuss these concerns and were quite critical of their supervisors if their personal concerns were ignored. This was a major reason for residents, particularly women, rating supervisors higher (or lower, if these concerns were not discussed) than experts. On occasion, the concerns involved poignant and emotionally intense experiences, some of which were coincident with similar experiences in their patients' lives. These included the effect on treatment of their patient of their own depression, transition to chief residency, impending marriage, divorce, pregnancy, adoption of a child, or grief over the death of a loved one. Former residents remained thankful for such discussions even years after the supervisory experience and rated these supervisors as among the best of their residency.
For some, concerns that had been raised in the supervision still lingered. For instance, a former resident regretted that there was no discussion of how to deal with her patient who often drove a car while intoxicated. She mentioned that she still had difficulty with such patients. Another former resident talked of his innate shyness, a problem that he still struggled with, and his difficulty in appropriately confronting the patient discussed on the videotape. He appreciated learning to understand what it was he responded to in the patient.
Residents were particularly grateful for guidance about highly charged clinical dilemmas, which often involved concerns about safety for themselves or for their patients who were self-destructive, suicidal, angry, or violent. Supervisors who gave guidance in these areas were seen as quite accepting, and their instruction helped defuse the residents' sense of helplessness. This is illustrated by an example in which there was considerable disagreement on ratings between experts and the resident. On the videotaped session, the supervisor often ignored overt major affective cues raised by the resident. This was the main reason for a low rating by the experts. However, the former resident explained that at one time his patient had been chronically suicidal and uncooperative and had frequently called him from undisclosed sites to discuss her active suicidal plans. He appreciated the supervisor's instruction on management of this difficult patient and rated the supervisor high. This resident revealed that he picked this particular patient to present for supervision because he recognized the supervisor's strengths in clinical management.
Supervisors rated at middle levels of excellence were those who were not fully accurate in their assessment of the data provided by the resident. Residents were also critical because such supervisors did not discuss personal concerns or help them understand the issues to which they were responding.
Residents who were quite critical of their supervisors, including those who were more critical than experts, reaffirmed observations of those whose comments were positive. These residents saw their supervisors as without focus, superficial, and not using data provided by the resident. Feedback on residents' concerns was not provided, nor was the resident's view of the patient validated. Underlying issues were never explored, nor did their supervisors help them understand what they were responding to in their patients. Such supervisors left the residents without direction or insight into the care of the patient. As a result, residents felt discounted and devalued, and in a few cases subtly ridiculed. These residents were resentful that their supervisors were not in touch with their concerns.
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DISCUSSION |
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More data than can be included in one videotape are required to make a judgment about the quality of supervision. Former residents drew on data not available to experts and rated their overall experience with their supervisors rather than their specific supervision session. This difference likely accounts for the lack of correlation between experts' and former residents' ratings.
Comparative data from supervisors would be of value. Such data from supervisors would, for instance, clarify the extent of the discussion of the residents' personal concerns—whether they were mentioned in passing in the context of talking about their patients, or were discussed at length independent of concerns regarding the patient (likely the former).
Former residents' recollections were clearly reconstructions of past experiences. The research process provided them an opportunity to examine their development as psychotherapists and clinicians. Such a perspective would not be possible if they were debriefed at the time of taping. Nonetheless, studying responses at the time of taping would add to our understanding of the supervision process and provide a contrast to the present data.
The findings of the study suggest that the development of a mature therapeutic identity takes many years, well beyond the training period. An adult developmental perspective is useful for understanding this growth process.17 For residents, the domain of work and caring for patients is at the forefront of their lives. Usually one other domain, and perhaps two, are also operative in residents' lives. Other domains include intimate relationships, family, religion, and community. Activity in these domains allows for the expression and gratification of deep values and needs. An important element in the professionalizaton process involves integrating work and the other domains. The integration process explains residents' interest in discussing personal issues that affect their work. It can involve considerable emotional intensities that are easy to underestimate. This is a highly personal process that is nurtured in the context of the supervisory relationship.
As a group, men had a narrower range of responses than women or experts. Women were more able than men to acknowledge negative elements in their supervision, particularly regarding what they perceived to be empathic failures. This divergence suggests that the relationship between women and their supervisors may be different from that between men and their supervisors. Further study is merited.
What of the few supervisors who were rated low by experts and considerably higher by residents? Most often, residents provided data that revealed their supervisors to be quite supportive and accepting. However, in the instance of the supervisor who often ignored overt major affective cues raised by the supervisee, the research team thought this supervisor better suited for supervision of more structured clinical experiences. It is likely that residents choose what to present to different supervisors, sensing their strengths and weaknesses.
The study used a quantitative methodology in concert with a qualitative methodology. Indeed, one could not fully understand the process without using both. The qualitative component provided a deeper understanding of former residents' ratings of excellence. The quantitative data provided a template for organizing themes from the interview data.
The study does not include outcome measures as to how effective former residents are as psychotherapists. Rather, the study is of the process of supervision from the residents' perspective, independent of their skills as therapists. Also, this is a naturalistic study in which the patients were not preselected for study. As with any clinical population, some patients do better than others and some drop out, again, independent of the skills of the therapist.
This is an exploratory effort with a relatively small number of subjects. Further research with larger numbers is merited. The qualitative findings also merit validation with more systematic inquiry. In spite of these limitations, the data provide insight into the teaching/ learning experiences of developing professionals. These findings are likely mirrored in all clinical teaching settings.
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Acknowledgments |
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