Clinical Supervision of Psychoanalytic Psychotherapy

Jill Savege Scharff

• Publisher: Routledge
• Year: 2018
• Print ISBN:
  9780367103057
• eBook ISBN:
  9780429912009
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

In Clinical Supervision of Psychoanalytic Psychotherapy, psychotherapy supervisors from the fields of psychology, psychiatry, social work, and dance movement therapy deal with the ambiguity and complexity of the supervisory role. They attend to the need to establish open, respectful verbal and non-verbal communication, a trusting relationship, a shared language, and a commitment to examining unconscious conflict in the supervisory encounter as well as the patient-therapist dynamics. The contributors show how the supervisor makes room for the supervisee to express her anxieties without becoming her therapist, thereby providing a model for empathic listening but within appropriate boundaries. They also describe the many ways in which the therapist's issues reflect or are triggered by those of the patient, are further reflected in the dynamics of the supervisory pair, and in the institution where supervisee and supervisor work.

Chapter One
Theory of psychoanalytic psychotherapy supervision

Jill Savege Scharff

I became interested in the theory and practice of supervision when I noticed that mental health professionals were emerging from graduate school with inadequate preparation for psychoanalytic psychotherapy Psychology programs emphasize diagnostic assessment and cognitive behavioral approaches; social work programs teach evidence-based treatment methods that are short-term and easily reimbursed by insurance companies; psychiatry trainees emerge with strong knowledge of pharmacological approaches to patient complaints, and so they are most likely to offer pharmacology consultation and medication review rather than arduous analytic psychotherapy which takes longer, feels emotionally demanding, and is less profitable. Those who find it more interesting to relate in depth to their patients quickly come up against their own limitations and need to seek continuing education. Theory and technique courses are important, but the most important thing is to get in to the room with the patient and do the work over time. To do that well the trainee psychotherapist requires clinical supervision.

Basic preparation for supervisors

What of the supervisors? What do they require? To be effective, they also need supervision. They need preparatory courses in the theory and technique of supervision; and they need a trusted group setting in which to develop their skills by listening to and discussing supervision experiences and challenges. Once a new supervisor is assigned a supervisee, she can present the challenges of that supervision in the group setting and learn how to be a good supervisor.

Just because a therapist has excellent clinical skills does not mean that she will be a good supervisor. Clinical skill is a prerequisite, and some of that skill and sensitivity is definitely useful in supervision. Certainly there is overlap in manner of listening, but supervision is quite distinct from therapy in aim. The task of supervision is facilitation and education, not healing. The task is also evaluative and prescriptive. Supervisors need to be aware of the complications arising from the duality of the facilitating and evaluative aspects of the supervisory role, each being essential to the learning process. When the evaluation process is organized as a two-way process with freely flowing input from the trainee, the supervisor can learn how best to meet the trainee’s learning style.

Much of what I will describe of the role of the supervisor applies whether the supervision occurs in a private setting or in an institution. But the setting for supervision does introduce specific variables that need to be taken into account. In the institutional context the role of supervisor is complicated by other institutional positions held. For instance, a supervisee may feel privileged to be assigned to a supervisor who is the director of his training program, but, cowed by the weight of that authority, may inhibit his evaluative feedback for fear of retaliation that could affect his progress, graduation, or promotion within the institution. Keeping this transference aspect and possible conflict of interest in mind, the supervisor needs to give careful attention to role and boundary. In the private setting, supervision may be a choice not a requirement. It may take the form of consultation rather than supervision. This feels much more collegial. But the supervisor must bear in mind that she still shares legal responsibility for the care of the patient, and so there is always an evaluative aspect even when it is not as obvious as when a report of progress must be made to a training authority. Whether in privately arranged or programmatically required supervision, the relationship between supervisor and supervisee will reflect the relationship between the supervisee and his patient. There is some disagreement as to how to work with this inevitable resonance, as I will discuss later in this chapter.

The aim of clinical supervision is to teach psychotherapy. How do we do that? We establish a secure setting with a reliable frame within which we teach first and foremost a language for communicating experience. Within the frame, supervisee and supervisor engage in an emotional human interaction with a fine balance of support and confrontation, as supervisee and patient do during therapy. As we listen to clinical material we connect it to concepts of theory and technique. We help the supervisee to develop a way of working with the patient under discussion, and this practical knowledge transfers as a way of thinking about clinical situations in general.

The frame and focus of supervision

Supervision occurs within a frame, just as therapy does, and we maintain that frame as a secure, well-bounded environment within which to work. The frame has been described by Szecsödy (1997) as having stationary, mobile, and focused aspects.

The stationary aspect of the frame refers to the contract to meet at a certain regular time and place at a particular fee to be paid by a certain date, to discuss one individual, couple or family in depth, and to use an agreed method of reporting. Supervisors vary in how they accept clinical material. Some like to listen to the supervisee’s narrative, some ask for discussions of problems encountered, others require full process notes. I prefer full process notes of at least one session, and if the supervision has to be on the telephone or Skype, I ask for written notes so that I can follow more easily. This is especially important if the remote supervisee is not fluent in English. The added value of process notes in giving access to the detail of the session, the back and forth between supervisor and supervisee, makes the extra effort worthwhile for the supervisee. Some supervisors work with audiotapes of sessions for more accurate recall, and that has its uses, especially in research, but that would not be my choice. I do not want tape-recording of sessions, because I want to work with not what actually happened but with what is filtered through the mind and memory of the therapist in training.

The mobile aspect of the frame refers to supervisor and supervisee maintaining a continuous reflection on their way of working in supervision. Some supervisors do include the supervisee’s style as a subject for inquiry, or more accurately they focus on her characterological problems shown in relating to the supervisory task. They notice if she is passive or aggressive, intellectualizing or too empathic with her patients, submissive or omniscient in relation to the supervisor. They focus on tendencies to have poor boundaries, to be poorly prepared, or to present the material in a confusing way, so as to help the supervisee mature as a supervisee, with the expectation that this corrective will carry-over into her way of managing therapy and communicating with her patient.

The focus aspect of the frame refers to attention being given to the interaction of patient and therapist and the interaction of the supervisor and supervisee. We can distinguish three types of focus in supervision: Some supervisors use a didactic, patient-centered approach, that is to say, they focus solely on the patient/therapist dyad and do not address the supervisee/supervisor relationship (Tarachov, 1963). These supervisors emphasize the instructional aspect of supervision and steer well clear of any slippage into therapy territory. They teach the theory of the therapeutic relationship. They regard transference to the supervisor as a problem split off from the transference to the analyst, and they see countertransference as evidence of unanalyzed neurotic conflict. They do not address these manifestations but refer them back to the supervisees’ personal or training analysis.

Other supervisors use an object relations approach. They focus less on the content of the clinical case presentation and more on the process of object relations found in the patient/therapist/supervisor relationship triangle and in the complex network of transferences and countertransferences occurring there. Through attending to these realities, the supervisor hopes to facilitate a transformation in the supervisee’s self-awareness and clinical acumen. The focus here is not on what the supervisee should do, but on what he did do and how it was received by his patient in therapy and by the supervisor in supervision, and on how he receives the supervisor’s comments. The supervisor attends closely to the supervisor/supervisee interaction, exploring slips and silences, as together they review the impact of the interventions. The aim is to express a psychoanalytic orientation towards the conduct and process of supervision, without psychoanalyzing the supervisee.

In summary, the supervisor may focus on one person, either the patient or the supervisee. She may focus on two people in interaction, the patient/therapist or the supervisee/supervisor. She may focus on multiple person interaction, patient or supervisee, patient/therapist, supervisee/supervisor. In my view, the multiple interactional focus is preferable, and will include attention to institutional influences and constraints on the therapist’s work and on the supervisory process.

Whichever focus supervisors espouse, they face a loyalty conflict over their concern for the patient’s needs or for the supervisee’s growth. They may want to focus on the supervisee’s learning difficulties but instead find themselves becoming preoccupied with the patient’s dynamics, or the supervisee’s unanalyzed conflicts. They may be so sensitive to the supervisees’ unconsciously determined affects, perceptions, and behaviors that they feel pulled in to offer interpretation as if they were analysts, not supervisors. If a supervisor comes to believe that her supervisee’s analyst is ineffectual she may attempt to rescue the situation by making a recommendation for a new analyst. Better to invite the supervisees to explore their blind spots further in their own analysis.

Facing role conflict

Supervisors also face conflict with their supervisees. Because the supervisor often also has an evaluative role, and at the very least brings with her the authority of years of clinical experience, there is a power differential that can bring out resistances and problems with authority. The unscrupulous or inadequately prepared supervisor may abuse that power by lording it over the supervisee, judging his competence against unrealistic standards, reporting harshly on progress, and giving in to prejudice and discrimination against him. The supervisee may be reactively argumentative or unduly compliant. The good supervisor considers this, not as evidence of neurotic conflict or pathology (which it may partly be) but as a sign of difficulty learning within this supervisory context. Monitoring the relationship, maintaining an open dialogue, prevents unfairness to the supervisee and provides a vehicle for reparation when problems have occurred.

Transference and countertransference come into focus in the supervisee’s clinical interaction with her patient but they also color the supervisor’s feelings about the supervisee and vice versa, as transferences to figures in early life are stimulated in therapeutic and supervisory relationships, both of which are characterized by a power differential like that in the parent/child relationship. In addition, the supervisor has feelings about the supervisee in reaction to both the supervisee’s defenses against learning and the supervisor’s anxieties about being an effective teacher.

Learning difficulties in the supervisee occur because of a fear of being exposed and then being found insufficient. The supervisee is afraid of feeling small, being embarrassed by the clinical material, or ashamed of her work with it. She does not want to feel anxious about her work and is terrified of seeming insane as she grapples with her patient’s primitive anxieties. Teaching difficulties occur when the supervisor is afraid of losing authority because of not knowing enough. Then she pretends to know when she does not, and defends against this by becoming competitive with her supervisee, or using jargon to give a false sense of confidence and an air of belonging to the analytic world. Instead of saying such things as, “Tell me more. How did you feel? Did any fantasy cross your mind at that moment?” The insecure supervisor ties up her anxiety in a technical comment full of jargon that closes the space for thinking and splits off the necessary recall of whichever emotion had accompanied the clinical moments being presented. The supervisor may lack awareness of having her own weak, blind and dumb spots. She may be too dependent on the approval of the supervisee. She may mince her words because of being afraid that speaking directly will hurt her super-visee or make her angry. Then she may fear being displaced when the supervisee who is not satisfied asks to transfer to another supervisor.

Tasks of supervision

The first task of the supervisor is to create a secure base for learning. He comes well prepared from his own years of clinical experience, seminars in supervisory technique, and supervision of his supervision when he was beginning his appointment as a supervisor. He provides clear boundaries, a clear focus, and an egalitarian, friendly and safe holding environment for the supervisee and thereby for the patient/therapist couple. Having created the context, he and the supervisee are ready to interact with challenging clinical material. He absorbs anxieties and metabolizes them, giving them back to the supervisee in thinkable, manageable form. With an enquiring attitude, and no need of jargon and no jumping to premature conclusions, he opens a transitional space in which meaning can emerge from experience and reflection. He faces gaps in his knowledge without shame. He tolerates criticism and learns from it. He remains open to learning and self-examination, and so provides a model for identification as an ethical analyst in a state of lifelong learning.

The supervisor is responsible for imparting an ethical stance. He ensures that the supervisee understands that her ethical duty is to her patient, to her profession, and to society. He speaks of the need to ensure informed consent for the proposed treatment to be supervised and to inform the patient of the background presence of the supervisor. It is the supervisor’s duty to ensure the supervisee’s competence and commitment to observe confidentiality of the patient’s identity, clinical material, and records, and to fight to maintain the privilege in any court proceedings. In light of this, the supervisor asks the supervisee to disguise the identity of her patient when presenting to him or to a case conference and when writing up the case for a journal. The supervisor raises objection to any hint of exploitation of the patient that occurs to gratify the therapist’s sexual, social, or financial desires, and similarly does not engage himself with the supervisee in exploitative ways.

Features of good and bad supervision

The qualities that make for a good supervisor have been studied by De la Torre and Applebaum (1974). They found that the good supervisor has tact, sensitive timing of interventions, empathy for the patient and the supervisee, and intuitive ability. She shows respect for her supervisee’s work, courage in taking on challenges, and frankness in confronting difficulties (her own as well as those of her supervisee). She works with an attitude of inquiry and reflectiveness, open-ness to personal associations, adaptability, and mutuality. In role as a teacher, she is nevertheless a learner alongside her supervisee. In a study of psychotherapy supervision, Thomas (2004) found that clinical social work trainees most valued a good working alliance and an attitude of mutuality and respect (and see Chapter Seven). They were against any exploitation of the power differential. They preferred a supervisor of integrity, one who attends to the supervisee’s concerns and treats her in a personal, optimally responsive manner, and whose perceptions they could trust. They wanted to be sure of supervisors’ interest in their experience. According to the clinical social workers interviewed for the study, the good supervisor inquires deeply into the clinical material and the supervisee’s experience of it, encourages a rich description, and evokes a sense of being with the patient. She provides a holding, containing, transformative experience. She is empathic, stays attuned, focuses on the therapist’s narrative, and tracks affectively charged concerns. She engages willingly in an open analysis of what may have gone wrong between therapist and patient, and between supervisee and supervisor. The interviewees added that they prefer a supervisor who does not charge for missed sessions! I myself do not charge for missed sessions because I am not the analyst and do not have the authority to investigate the unconscious meaning of the lapse, nor do I want that to become a focus. By not holding the supervisee personally accountable I feel free to investigate how the cancellation relates to the patient–therapist or supervisee–supervisor dynamics in relation to the patient’s dynamics.

Thomas’s interviewees also identified aspects of bad supervision. They pointed to supervisors who engaged in power struggles and dual relationships on the one hand and a lack of collegiality on the other. The bad supervisor does not inspire trust and inhibits learning by being intimidating and pouncing on the supervisee. They did not appreciate supervisors who were too neutral and abstinent and who charged for missed sessions as if the supervisee were in analysis. They described bad supervisors whom they experienced variously as critical, judgmental, disparaging, condescending, controlling, and frustrating of the supervisee and disrespectful of the client. Some bad supervisors were unreliable and procrastinating. The worst of the lot were indiscreet, unethical, and careless of boundaries.

Similarities and differences in supervision and analysis

When the supervisor brings analytic sensibility to the supervision, boundaries are essential to ensure that supervision stays on task and does not get conflated with psychoanalysis. Supervision is not analysis. Analysis is open-ended without goals. Supervision is goal oriented and time limited. The analyst listens with suspended attention, dealing with the patient’s unconscious fantasy and the historical roots of conflict. The sup...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• ACKNOWLEDGEMENTS
• ABOUT THE EDITOR AND CONTRIBUTORS
• INTRODUCTION
• INTRODUCTORY ESSAY Supervision as a mutual learning experience
• CHAPTER ONE Theory of psychoanalytic psychotherapy supervision
• CHAPTER TWO Boundaries in supervision
• CHAPTER THREE Supervision as a model of containment for a turbulent patient
• CHAPTER FOUR Supervision or thera-vision? Working with unconscious motives in the supervisory encounter
• CHAPTER FIVE The supervision process in training
• CHAPTER SIX Supervision of art psychotherapy: transference and countertransference
• CHAPTER SEVEN Social workers' experience of conflict in psychotherapy supervision
• CHAPTER EIGHT The group supervision model
• CHAPTER NINE "Can you hear me?" Cross-cultural supervision by videochat
• CHAPTER TEN Supervision of the therapist's resonance with her patient
• CHAPTER ELEVEN Supervision in the learning matrix
• INDEX