Preserving a Sense of Wonder: The Integration of an Ego-Supportive Psychodynamic Approach to Supervision in an AIDS Psychiatry Fellowship

The challenges of working with medically and mentally ill persons with a paucity of resources, inadequate networks of social support, and multiple stresses and losses may be daunting to even the most seasoned of caregivers. A psychiatric trainee may be overwhelmed by the despair, sorrow, and desperation encountered in the day-to-day care of the complex severely ill patient with lethalmedical and lethal psychiatric diagnoses. Individuals who are infected with HIV and hepatitis C, who are polysubstance users, and who are benzodiazepine dependent present with inordinate demands for prescribed substances to use or to sell in the street. The trainee needs to become comfortable with both limit-setting and harm reduction in order to keep the patient engaged in both lifesaving medical and psychiatric care. Nurturing and supportive supervision enables the trainee to integrate skills and work toward an understanding of countertransferences. An ego-supportive psychodynamic approach to supervision in an AIDS psychiatry fellowship facilitates conflict resolution and improves the care of patients with complex and severe medical illness.