What do excellent psychotherapy supervisors do?

OBJECTIVE: The author's goal was to discover strategies used by psychotherapy supervisors judged to be excellent teachers. METHOD: In an earlier study, experienced teachers of psychotherapy rated the level of excellence of 34 different supervisors in 53 videotaped supervision sessions. In this study, the authors examined the transcripts of the nine videotapes assigned the highest ratings as well as three videotapes assigned mid-level ratings and three videotapes assigned low ratings in the previous study. In analyzing these transcripts, the authors drew from their experience with the complete set of videotapes. RESULTS: Supervisors with high ratings allowed the resident's story about the encounter with the patient to develop. They consistently tracked the most immediate aspects of the resident's affectively charged concerns. Most of their comments were directed toward helping the resident further understand the patient and were specific to the material presented in the session. The resident was invited to speculate about the material, and technical words were used sparsely. Discussions about the relationships between resident and patient and between supervisor and resident were in the context of the resident's concerns. Supervisors with mid-level ratings were less disciplined in tracking the resident's concerns and inhibited the development of the resident's story. Supervisors with low ratings paid little or no attention to the resident's issues. CONCLUSIONS: The ability to track residents' concerns is at the center of supervisory activities rated as excellent. The resident provides data about what occurred, and new knowledge is constructed in the supervisory interaction. These findings provide an empirical basis for orienting supervisors to supervision.

A reliability assessment of the Psychotherapy Supervisory Inventory.

The authors investigated the reliability of the Psychotherapy Supervisory Inventory scales, which rate behaviors of supervisors on the basis of observation of supervision sessions. The scales assess focus on the therapist and the patient, intellectual and experimental orientation, number of clarifying and interpretive comments, intensity of confrontation, depth of exploration, verbal activity level of the supervisor, dominance of the supervisor and the therapist, comfort and tension levels, and empathy of the supervisor. Intraclass correlation coefficients were significant for all scales, indicating that trained observers can agree in distinguishing supervisory behaviors. These scales can be used in further research and for feedback to supervisors.

Parents' reactions to the death of an adult child from cancer.

Twenty-four parents whose adult children had died of cancer completed a bereavement questionnaire and the Brief Symptom Inventory an average of 2 years after the death of their children. The parents had experienced growth in a number of areas, and although they had residual levels of grief, few had more psychiatric symptoms than would be found in a normative population. Factors that shaped the response to the loss included the prolonged and debilitating nature of the illness, the sex of the parents and children, and aspects of the parent-child relationship.

Quantitative assessment of the behavior of psychotherapy supervisors.

OBJECTIVE: The aim of this study was to explore the behavior of psychotherapy supervisors by using the Psychotherapy Supervision Inventory. METHOD: The authors used the Psychotherapy Supervision Inventory to rate 53 videotaped supervision sessions of 34 different supervisors. They also used the variable of the rater's perception of the excellence of the supervisor as a teacher. The data were subjected to a cluster analysis and a K-means analysis. Discriminant function analyses were applied to the comparison of the behavior of 19 supervisors with two different residents and the behavior of all 34 supervisors with residents in three different years of training. The relationship between rater-perceived excellence and Psychotherapy Supervision Inventory scores was analyzed by using stepwise multiple regression. RESULTS: There was a high level of agreement among the four raters' judgments of supervisors' excellence. Empathy accounted for 72% of the variance in rater-perceived excellence and focus on the therapist accounted for an additional 5%. When empathy was dropped from the equation, experiential orientation accounted for 60% of the variance in ratings of excellence, clarification and interpretation accounted for an additional 16%, and depth accounted for another 3%. CONCLUSIONS: In the context of established relationships, supervisors have stable behavior patterns. Rater-perceived excellence is related to the supervisor's focusing on the resident's immediate experiences and making many synthesizing comments in depth. The Psychotherapy Supervision Inventory can be used to orient supervisors to supervision and provide feedback about their behavior.

Using quality improvement teams to improve documentation in records at a community mental health center.

OBJECTIVE: A community mental health center sought a system for qualitative review of patients' records to improve the quality of documentation through the engagement of clinical staff in the review process. METHODS: The center developed a quality improvement system in which treatment team clinicians use a scored 30-item protocol to measure the quality of record documentation by peers. Questions address whether the record documents the full range of the psychiatric treatment process, including assessment and diagnosis, treatment planning, and provision of clinical services. Other questions address specific contractual or regulatory requirements, such as whether procedure codes are correct, and evaluate the physician's record of medication management. Each treatment team at the mental health center's six clinics has a quality improvement work group, composed of the team psychiatrist and at least one other team clinician. Each month the work group meets to review two randomly selected medical records from another treatment team at the same clinic and arrive at a consensus score. An administrative oversight team meets regularly with clinician-reviewers to foster uniform scoring of the protocol throughout the center. RESULTS: An analysis of the trend in protocol scores over a 21-month period suggests that the procedure improves the quality of the documentation in patients' records. CONCLUSIONS: A team-based quality review process appears to have a positive impact on the quality of medical record documentation. Improved documentation may improve continuity of care and improve the accuracy of record information used for other quality measurement systems.

Return to work after an acute myocardial infarction: a review.

The rate of return to work after an acute myocardial infarction (AMI) is decreased among previously working women, blue-collar workers particularly with physically strenuous jobs, and persons with emotional problems. Although more severe AMIs decrease return to work rates, psychosocial factors appear to be more prominent in their effects on the rates. Supportive psychotherapy as well as specific advice to return to work for patients with uncomplicated AMIs shortens length of convalescence. Little evidence exists, however, that current interventions largely geared to improving cardiac status have any impact on ultimate return to work. Specific interventions tailored to individuals at risk of not working may increase rates of return to work.

Some observations of a psychiatric consultant to a hospice.

The experience of a psychiatric consultant to the inpatient and bereavement components of a hospice is reported. The bulk of the consultation is to the hospice staff. Activities of the consultant include attendance at a weekly patient care meeting and patient and staff groups, consultation with the bereavement team and the administrative leadership, and the evaluation of patients. Clarification of the inevitable psychologic problems that arise in dealing with the mostly elderly very ill patients with end-stage cancer as well as with their families is a major function. Many of the problems special to the hospice relate to loss, mourning, and death. Psychiatric diagnostic input has been helpful in the treatment of organic and functional psychiatric disorders including the treatment of the emotional components of pain and disordered grief which is manifest as depression. Consultation is provided to individuals at risk of problems in the bereavement period. The psychiatric consultant to a hospice is helpful in establishing and maintaining a sensitive therapeutic system of care for the patient and family. He provides an important presence and a forum for the discussion of psychologic issues for the staff. In addition, he has an important role in clarifying the psychodynamic issues involved with death, loss, and mourning for the patient, family, and staff. He provides input around the treatment of functional and organic psychiatric problems seen in the patient and family. Such activities require the continuing membership and leadership of a psychiatrist on the hospice team. The hospice is a laboratory for the understanding of death, loss, and mourning. Although they have been the subject of much inquiry, these issues can be studied fruitfully at the hospice because of the accessibility to dying patients and the bereaved, both before and after the death of their loved one (Kubler-Ross, 1970; Parkes, 1972; Schoenberg, Carr, Kutscher, Peretz, and Goldberg, 1974; Jacobs and Ostfeld, 1977; Kastenbaum and Costa, 1977; Greenblatt, 1978). Much remains to be learned about the processes and outcomes of mourning, as well as dying styles and character styles and family variables as they relate to death. Psychologic principles around the care of the dying and their families that have application to other settings (Shanfield, 1978; Shanfield, 1982) need to be clarified in the hospice setting.

Myocardial infarction and patients' wives.

When a patient has a myocardial infarction (MI), all aspects of marital function are affected. Soon after the MI, patients' wives experience psychological distress that decreases with time. Illness behaviors among the MI patients' wives increase, and aggressive and sexual impulses are often inhibited. Many families experience changes in members' work status after the husband has an MI, and wives are faced with increased chores. Marital interaction also changes. Dysfunctional marital relationships are associated with a poor psychosocial outcome. Additionally, spousal factors such as dependency are also likely to affect patients. Intervention strategies are best directed to wives at risk for problems.

The mourning of the health care professional: an important element in education about death and loss.

This article explores the centrality of the mourning process in the education of developing health care professionals who are the survivors of complex and manifold losses. This was discussed in an elective seminar for senior medical students and graduate nurses. Learning about clinical responsibility often occurred in the context of loss and mourning. The outcome of mourning included for some a greater sensitivity to the impact of clinical interventions and a more accurate empathy for losses incurred by patients as a result of illness. Old and unresolved loss and mourning experiences were reawakened as a result of the seminar, which led to a sorting and mastering of these experiences. This is felt to be a common result of discussions about encounters with death and loss. Courses on death and dying for the health care professional, although important, are not sufficient by themselves for mastery of these topics. Clinical teachers must be aware of the student's response to loss and provide an atmosphere that legitimizes learning about these issues. The principles of awareness and open acknowledgement of loss and mourning are applicable to all health care settings.

Death of adult children in traffic accidents.

The loss of adult children after traffic accidents is relatively common. Bereavement under these circumstances, however, has been little studied. Forty predominantly midlife parents (20 men and 20 women) of predominantly young adult children (27 men and 13 women) who died in traffic accidents were studied 25.6 months after the death. The parents completed the Symptom Checklist 90, the Beck Depression Inventory, and a Bereavement Questionnaire which sought information about the parent, the child, the rest of the family, and the relationship between them. It was found that the parents continued to grieve intensely and had higher than expected levels of psychiatric symptoms as well as increased health complaints. Some parents were more at risk for problems in the bereavement period. Those with unstable families who had ambivalent relationships with their children and whose children were perceived to have had problems at the time of the accident, had more guilt and increased psychiatric symptoms. Parents who had prior bereavement experiences seem to have been protected from higher levels of distress. Additionally, being a mother, losing a daughter, losing children who live at home, losing children born earlier in the birth order, and losing children in single car, single driver accidents seems to portend a more difficult bereavement. This is an important area for further study.

Excellent supervision: the residents' perspective.

Former residents rated their videotaped psychotherapy supervision sessions on how helpful their supervisors were as teachers during the session. Residents' and experts' ratings of the same videotape were compared and found to have no significant correlation. However, male residents were less critical than either female residents or experts. Former residents were also interviewed. Supervisors were rated as excellent when they were accepting and also when they provided guidance about highly charged clinical dilemmas. Discussion of the impact of the residents' personal experiences on the clinical encounter was also rated high and is best understood from an adult developmental perspective. The findings reveal the lasting value of sympathetic supervisors acknowledging personal concerns and are likely mirrored in all clinical settings.

Using narratives to evaluate psychiatry residents' competence.

The authors propose a new way to assess the clinical competence of psychiatric residents. Faculty eualuators would be trained by using narrative descriptions of appropriate and inappropriate practice in various clinical settings. The training has the potential to provide more realistic data about the clinical abilities of residents than current methods.