"Unsafe" Psychotherapy Supervision

Psychotherapy supervision is essential to conveying knowledge and protecting patients and is critical to the development of psychiatric trainees. Both supervisors and supervisees generally find it rewarding. The authors describe and discuss two surprising parallel instances in which psychiatric residents at different programs abruptly terminated psychotherapy supervision, declaring it psychologically "unsafe." Psychological safety in supervision requires a supervisory alliance, which when disrupted may lead residents to feel unsafe, impede their ability to learn, and impair outcomes for their patients. Psychotherapy and supervisory encounters require a tolerance of strong affect that not all individuals possess. The authors review these supervisions, discuss the inherent rigors of psychotherapy and supervision, address ways to identify and repair ruptures in the supervisory alliance, and consider the gatekeeping role of the supervisor. They also speculate on secular changes that might be altering residency education.