by Richard Metzner, M.D.
Time: The not so distant future. Place: The Semel Institute.
You are a UCLA psychiatric clinical faculty supervisor. The resident you supervise is presenting her latest video. The split-screen image shows her nodding blankly while the patient reports a litany of events with arms folded self-protectively. Because of the split-screen recording you are able to delve into issues that may never have come up had you not been able to see the unspoken subtext of their interaction.
While supervising another resident, you suggest a diagnostic possibility that he hasn't considered. He confesses that he has never seen a patient with that diagnosis. You refer him to the PCFA Online Digital Psychopathology Library (ODPaL). The next time you meet, he tells you that the ODPaL case evidenced many characteristics similar to his, and that he will revise his treatment strategy accordingly.
Thanks to Dr. David Coffey's posthumous gift, PCFA can now implement projects like these. The Split-Screen Pilot Project (SSPP) was launched in late 2013 with purchase of the required recording and playback equipment. After some initial technical problems, the first split-screen enabled supervisory sessions were successfully concluded. If you are interested in learning more about becoming an SSPP supervisor, please let me know (email@example.com ).
ODPaL was also launched at the same time with the placement of the first video ("Psychotic Patient with Grandiose Delusions") on the password-protected "Clinicians Only" part of this website's PCFA Journal. If you have a Semel Institute website username and password check it out . If you don't, ask Lela Degolia to help you obtain them (LDegolia@mednet.ucla.edu ). The extensive ODPaL source material was recorded in the 1970's, when Drs. Barnett Addis, Garrett O'Connor and I managed the departmental media centers at NPI and Brentwood VA Hospital. The videotapes have been preserved in excellent condition and are being digitized professionally. The first twenty VHS tapes now occupy 750 gigabytes on PCFA's new Mac Pro computer dedicated to the task. Using Final Cut Pro X editing software cases will be prepared for placement on the PCFA website over the next twelve months. The videos cover a wide range of categories. They include diagnostic interviews and therapeutic sessions conducted by faculty and trainees. All were recorded with signed patient consent for use in UCLA medical education. Residents who have seen clips from the collection have expressed great interest in having them as a resource. It is anticipated that faculty and trainees will use the library in a wide array of clinical teaching activities. One possibility is a series called "Then and Now" in which brave senior faculty members are shown watching and commenting on interviews they performed when they were residents.
David Coffey loved technology. It is with bittersweet emotion that we are seeing his gift bring forth a future that we wish we could be sharing with him.
David Coffey, M.D. (1959-2012)
Training for Psychotherapy Supervisors
Richard Tuch, M.D.
The Psychiatric Clinical Faculty Association has launched a pilot program to provide training to faculty members who supervise residents in psychiatry. We were pleased to invite Richard Tuch, M.D., an esteemed member of our faculty, to present at the UCLA Faculty Center on Wednesday January 29th, 2014.
In his presentation, Dr. Tuch challenged the audience with a controversial position that questioned what the supervisor can and cannot honestly offer the supervisee. Tuch asserted that while supervisors are often times better situated to be able to make sense of what’s going on between the resident and his patient, they are simultaneously poorly positioned to precisely know how to best utilize this knowledge— thus leaving it to the resident to decide what to do about what's been gleaned about the dynamics of the case. This idea runs counter to the typical assumption that it is the job of the supervisor to instruct the supervisee about how best to go about conducting the treatment under discussion. Tuch suggests that a first-‐hand experiencing of the patient generates knowledge that is often hard to put into words-‐-‐a gut level sense of the patient that is better attuned to when, whether and how to intervene (tact and timing) with a given patient.
Tuch observed that seeing clinical material from a distance permits the supervisor a broader vision of the panoramic process of the material, better positioning him to understand the meaning of the material unencumbered by the distraction of having to relate to the patient on a moment-‐to-‐moment basis. The supervisor retains his "presence of mind" that oftentimes is eroded when one is in the room with the patient experiencing the moment and one's own countertransference reactions. Tuch noted how he'd learned this to be the case when he'd gone to see his own supervisor, Dr. Norman Tabachnik-‐-‐who has just passed away-‐-‐while a psychiatric resident at UCLA. Tuch began presenting his process notes and was struck by the realization that he better understood the material now that he was no longer in the room with the patient. For this neophyte, the task of being "fully present in the room" interfered a bit with his other therapeutic responsibility-‐-‐to be thinking about the patient whilst sitting with him.
The implications of Tuch's position do not suggest that supervisors are not to instruct residents on matters of technique. Surely there is much a supervisor can offer with regards to the general issues of how one conducts treatment-‐-‐tricks of the trade, how to handle difficult situations that often arise, etc. He did note, however, that studies strongly suggest that supervisees rated technical advice about how best to handle a given case "least helpful" of all the input supervisors have to offer.
The dangers of a supervisor having too much to say about how a case should be conducted is illustrated by the too frequent situation where a resident introduces interpretations by the supervisor during the very next session with the patient, ignoring the fact the patient may have already moved on, meaning the patient may be more concerned with other matters. Introducing an "otherness" into the room in the form of an interpretation that was grafted on to the supervisee rather than issuing organically from him, introduces the shadow of the supervisor's presence that may well "spook" the patient. Accordingly it is wise to counsel residents to not make a habit of running backto the consulting room to try on for size suggested interpretations without regard for "where the patient is presently at.” This illustrates the saying: "You can't step in the same river twice."
Dr. Tuch’s presentation was very enlightening and was well received by all in attendance. We thank Dr. Tuch for participating in this program. Plans are in the works to invite other speakers in the future. We hope that you can attend.