I am glad you are seeing this as a learning opportunity. That is part of the purpose of feedback - to help you grow and develop. If you were already fantastic at everything you wouldn't need to do a residency at all. My programs seems to be accepting more autistic residents these days so I often have to instruct my residents about this. The best way to learn about this is through directly observed supervision and feedback and case discussion. I hope your senior actually gave you specific examples in the moment of the things you were missing rather than making a sweeping statement. In addition, during your psychotherapy training you will learn to listen to patients. Listening to patients is really the key of what we do and that means getting the subtext, noting the large amounts of non-verbal communication and whether they align with what the patient is telling you, a focus on form rather than content, and also picking up what the patient is telling you.
I will give you some examples to think about here:
1. A young man with a history of psychotic illness is hospitalized following a suicide attempt. you see him and offer him different medications to treat his depression and psychosis, as well as other treatment options, all of which he rebuffs. he is agreeable to hospitalization even though he adamantly refuses medications and appears to have capacity to refuse. he notes nothing has ever worked for him. he says he enjoys hearing voices. you continue to explore potential treatment options and instill hope, to no avail.
You are missing that this patient is telling you he is unhelpable, he enjoys being sick, he wants to be taken cared for, and is frightened of recovering and being confronted with the responsibilities of life and the possibility of failure. continuing to offer treatments and hope is to miss the point.
2. A middle aged homeless woman with a history of depression, fibromyalgia, and cocaine addiction presents to the ER following a reported overdose as a suicide attempt. She appears calm, cheerful and comfortable in the emergency department with no objective symptoms of depression but ongoing suicidal ideation and intent. she complains of a wide range of physical symptoms that she attributes to her "fibro." You consider that she might be malingering or feigning suicidality for shelter given incongruence of her presentation.
You are missing that this patient's calm and somatization indicates a deeply disturbed personality structure, and a high risk of suicidality, despite the lack of classic depressive symptoms. Further assessment would likely reveal a history of trauma, insecure attachment, and alexithymia.
3. You evaluate a woman who presents to establish psychiatric care. She begins by reporting that she was sexually abused as a child and goes into graphic detail about the nature of this abuse and feel unable to cut her off given the content of what she is describing and the level of intensity. by the end of the evaluation you know very little about her other than that she is a survivor of childhood sexual abuse and wonder about PTSD +/- borderline personality disorder.
You are missing that this patient has not told you anything about her current circumstances. She is using her past to avoid talking about the present which is much more painful if more mundane. Her ability to talk in great deal coherently about this makes PTSD related to childhood sexual abuse highly unlikely. She wants to shock you, provoke you, and silence you. she needs to cling on to seeing herself as a survivor , and thinks you will only be interest in her if she titillates you in this way.
These are more nuanced examples I would expect most students not to get. It's also possible you are having trouble grasping with the basics and not acknowledging more obvious things patients are saying or providing empathic validation, paraphrasing, summarizing, clarification, confrontation, identifying and naming emotions etc. Some students (and residents) focus so much on gathering the history and asking about SI/HI/AVH that they miss the patient in front of them and their story.
