Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Sunday, September 29, 2013


I consider psychotherapy supervision to be part of lifelong learning. I now supervise residents and interns in psychodynamic psychotherapy, but I also continue to work with a supervisor, myself.

The supervision I get is different from the supervision I provide. I call my supervisor every once in a while and say, "Hey, I'm a little stuck with a patient, can I come in and talk over the case with you." Sometimes I present process material, other times I just give an overview. It's a pretty relaxed thing, and it's now up to me to be honest with myself and recognize when I need some outside help.

I've had all kinds of supervisors, and I've learned things from all of them, even the ones I thought were idiots (like, what not to do). I've had brilliant supervisors and stupid supervisors. Warm supervisors and awkward supervisors. Helpful supervisors and confusing supervisors.

As a PGY-3, I had a child medication supervisor who never showed up (well, he showed up once). I had an adult medication supervisor who made me realize it's possible to do nothing but outpatient med management and still get to know your patients in a meaningful and caring way.

I had a kind, warm supervisor who inspired me to pursue analytic training. When I asked him if it was worth all the effort, he said, "It's right for the way you think." And he was right. He died just before I started my training. I still miss him.

I had a supervisor who would start drinking his mug of tea at the beginning of the session, and then fall asleep. He still managed to understand more about the patient than I could have seen myself. It wasn't my boring presentation style. He used to fall asleep in class, too. Eventually, I found his dozing off comforting.

I had a supervisor who made me think of Edvard Munch's The Scream every time I walked into his office. He's one of the reasons I don't do any CBT.

An interesting part of supervision, for me, was getting to see different offices. One supervisor had an office on Gramercy Park. He had this amazing mid-century furniture, with the most beautiful desk I've ever seen. The wood glowed. And there was never anything on it, except for a small, Inuit sculpture.

Another supervisor has a paper towel dispenser in the bathroom-I don't know where she even finds the towels to fill it. It's very thin, and the paper is so smooth and thick you could use it for wedding invitations.

The same supervisor, who is a child and adolescent psychiatrist and psychoanalyst, had two books by Bowlby on her shelf, Attachment, and Separation. She had them right next to each other, and I was always distracted by the thought, "Should they be together like that, or apart, at opposite ends of the shelf?"

The worst experience I had in supervision didn't have to do with the supervisor. I was sitting there, holding my notebook and reading my process notes, when I noticed the back of my hand start to itch. I turned it over to scratch it, and there was this huge spider crawling up my arm. To this day, I'm proud of the fact that I didn't scream. I did have spider dreams for some time afterwards.

So what makes a good supervisor? I think a lot of if is about style and personal preference. For me, there needs to be an environment where I feel safe enough to admit to my mistakes.

I had a well-meaning supervisor once who I found very unclear. I couldn't understand what he wanted me to do, even though I would ask him to clarify. I would try to implement what I thought he had suggested, but when I read my notes to him, he invariably told me I'd done it wrong. Eventually, I started making things up. And I was nervous when I was with the patient. I couldn't stop thinking, am I doing this right? What's he going to criticize if I say that? That patient quit treatment.

It's also important for a supervisor to know when the supervisee can go it alone. I had one supervisor who was great early on, when I needed a lot of specific direction. But down the road, she had trouble recognizing that I knew what to do without her help.

There are supervisors with whom I haven't felt all that safe, but from whom I still learned a lot. Some of the pearls:

When you're not sure where to go, get more history.

Don't worry that you're going to spook the patient by saying something prematurely. If you've thought through it, just say it.

Sometimes, telling the patient you've been thinking about what they said in the last session can have a powerful effect.

What have you learned from supervisors, and what kind of supervision do you find most helpful?


  1. Great pearls. The best one I have is: "If you are concerned about the patient's safety let them know about it." The particular case had nothing to do with suicide or homicide but a situation where the patient was taking risks. When you are a rookie sometimes supervisors just give you permission to use common sense at a time when psychotherapy seems more mysterious than that.

    I also found it useful to request supervisors who I had seen in action before but did not have a lot of personal experience with from a variety of backgrounds. I had the very fortunate experience of not being disappointed and also being socialized by some into arguing points and disagreeing in a way that seemed alien to the Midwest culture. I have been argumentative (in a good way) ever since.

  2. Here in NYC, I think we have to make an effort not to be too argumentative. It's like a sport.
    As a resident, I probably got a more eclectic mix of supervisors than as an analytic candidate, but that's just an artifact of training in an analytic institute with one (main) theoretical perspective (If arguing is a sport, "The Institute" is its arena). The upside is that , unlike in residency, I did get to chose my supervisors, and I had the privilege of working with some amazing people.