Supervision of Art Psychotherapy

A Theoretical and Practical Handbook

Joy Schaverien, Caroline Case, Joy Schaverien, Caroline Case

• Publisher: Routledge
• Year: 2007
• ISBN:
  9781134130580
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

Supervision of Art Psychotherapy will be an inspiration for advanced practitioners and students in training. It is the first book to formulate a unique theoretical base to current practice in art psychotherapy supervision. A central theme is the nature of the image in supervision, defining its difference from other forms of supervision in the mental health professions. Clinical practice is brought to life through vivid vignettes from diverse settings with a variety of client groups.

• part I establishes a theoretical base, introducing innovations in practice and addressing complex clinical issues in child and adult work. Topics include the narrative of imagery in supervision, enchantment, ambivalence, a topographical approach, engagement in supervision, and working with the network in art psychotherapy with children
• part II focuses on supervision in groups addressing training, difference and peer group image consultation, as well as supervision of experienced practitioners
• part III explores theory related to purposes and challenges in supervision and research.

A vital contribution to the literature in the context of Continuing Professional Development, this volume establishes the image as central in the supervision of art psychotherapists. It brings the experience of the artist in the psychotherapist into the frame, provoking questions about the meaning of images and image making in supervision.

Chapter 1
Review of the literature on art therapy supervision

Caroline Case

There have been some significant articles published on supervision in art psychotherapy. As is well known, in the UK, artists practised in hospitals (as therapists) until the foundation of training programmes in the early 1970s. Art therapy then had to pioneer a place among the other clinical disciplines and gradually develop as a profession. Supervision was assimilated from social work practice, as well as psychology, and the emerging psychotherapies. There were two main reasons for this, firstly these were already available as models and, secondly, the pioneering status of the profession meant that students were supervised by many other disciplines on-site at their placements. Qualified art therapists simply were not in existence at the many varied placements that were becoming available. The richness of practice and the multitude of contexts in which art psychotherapists practice today would not have been possible without this pioneering generation who often had to explain art therapy to their supervisors and sometimes fit uncomfortably into the ways of thinking of other disciplines.

1970s and 1980s - placement supervision

The first articles regarding supervision emerged in the late 1970s and 1980s. The focus was on the student or trainee art therapist and their relationship with their placement supervisor. This is a very complex relationship as the student may work alongside the supervisor, observing or shadowing his or her practice. This was a relationship, that often progressed to that of colleagues. The supervisor was the interface between the student and the rest of the institution and was sometimes in the role of mentor, educator, co-therapist and assessor.

It is very difficult to address the uniqueness of the image in therapy when using a model of supervision from another discipline. Marion and Felix (1979) recognised this and illustrate their article with some vignettes of supervisor and student working alongside each other, noting how an intervention from the supervisor could be a practical one, or a verbal-emotional comprehension of a situation. They show how the student could be permitted to make mistakes and work towards their own solution. Sometimes supervisors may visit the student at another site to observe them working and this needs a sensitive presence, as it may be tempting for the supervisor to take over. It is a subtle dynamic to participate enough for all to feel relaxed with the supervisor's/assessor's presence.

Envy and professional jealousy

Because art therapists are sometimes seen as privileged to work with images, they may encounter professional jealousy from other members of a therapeutic multi-disciplinary team. The envy or competitiveness may manifest over the art therapist's insistence on confidentiality and their non-disclosure of confidential issues. These and other aspects of the art therapist's role in the team, as well as management problems, have to be dealt with at times. The supervisee's envy of the supervisor often manifests itself in the supervisor's sense that the therapist `knows it already'. This can produce feelings in the supervisor of having little or nothing to offer or being drawn into competition. It is helpful if the supervisor resists being drawn into competition and holds to the frame until the underlying anxiety of the supervisee can be expressed.

Marion and Felix (1979) begin to address this as well as the supervisor's awareness of their own envy of the student, who may be creative and innovative in one area, whilst needing a great deal of support in another. They suggest the need for a continuous dialogue with flexibility and cooperation, which may lead to mutual growth:

The mentors we remember-those whose styles, attitudes and techniques we incorporated into our own work-are those who somehow made us feel like colleagues while we honed our own rough skills on their experience.

(Marion and Felix 1979: 40)

Wilson, Riley and Wadeson (1984) explore the tasks for the supervision dyad at different phases of the placement. Wilson comments on the need for self-examination in the student, which must be separated from the selfexamination of personal issues in therapy. She acknowledges that they can become entwined in clinical work. Supervision groups at college, running parallel to individual supervision on-site, allow students not to feel alone with what are usually shared concerns. In student supervision an assessment is being made of the students' capacity to learn from mistakes. Wilson highlights two common difficulties-the desire to be active and the difficulty of `staying with', and the desire to know the meaning of a patient's artwork. This can lead to prescriptive interpretation rather than allowing the image to reveal its possible meanings through a slower reverie. Riley, discussing the middle phase of therapy, notes the parallel process between the student's casework and the supervisory relationship. Both student and the student's client may need to move out of a dependent position but may progress, stand still or regress at the same pace. The student needs to work with resistance and countertransference in therapy in order to grow and feel able to challenge the supervisor's interpretations:

The gift of supervision is the permission for the trainee to hypothesize, experiment, and fantasise creative moves both with the therapeutic plan and the art expression.

(Wilson, Riley and Wadeson 1984: 103)

The supervisory relationship often comes to an end when the placement ends and Wadeson explores this, pointing out how this therefore parallels the ending of client relationships. This is a testing time for the student and regression may take place as the re-working of old issues comes to the fore. The student may feel that no change has been made. There may have been a strong transference to the institution from both student and client. This phase of therapy needs much thought, preparation and holding in supervision. Wadeson comments on the huge emotional investment made by students in their training and how one's initial patients are `important, meaningful and memorable'. The supervisor needs to hold the focus on the ending and explore, as fully as possible, the loss and separations involved and the students' move towards being qualified and the anxieties that this may arouse.

A well-illustrated article followed an experiment by Durkin, Perach, Ramseyer and Sontag (1989). As previous writers, they recognised that a whole rich area of images and art making could be ignored in the supervisory process with supervisors from other disciplines. They set up an experiment using art `to understand further the dynamics of the supervisory relationship'. Wadeson (1984, 1987) had already suggested that images might be used to explore the transition to being qualified but, as far as is known, this is unique in exploring the supervisory relationship with art, rather than the therapist/client relationship. The paper traces two supervisory dyads that supplemented verbal supervision with two other modalities: journal writing and art making. Supervisor and supervisee therefore used artwork and journal writing to supplement verbal communication about their own relationship, exploring their thoughts and feelings about each other, as well as the whole placement experience. It was not prescribed as to how frequently the different modalities were used. The dyads proceeded slightly differently, however they had in common that both were in placement supervision and both dyads met formally once a week. They agreed to use journals and make artwork at home, as moved to do so, and after two months they incorporated all materials into supervision. They therefore discussed their developing relationship at the placement and the effect that they had on each other. This enabled them to explore conscious and previously unconscious dynamics, through the images that they made, or the feelings and impressions that they wrote down in journal form. Of note is that both supervisors were supervising for the first time. It is difficult to imagine someone with a supervisory practice being able to follow and respond to perhaps eight supervisees in this way.

The commentaries are interesting for highlighting the dynamics of a relationship, which in some ways is like therapy and in other ways very different. The supervisors explored feelings towards their own past supervisors: their wish to `get it right'; feelings of envy and sibling rivalry; the effect on other staff relationships of having a student; and the shifts in the relationship as the supervisee progressed through the training. The supervisees explored the countertransference with clients: the illusion that they were `fine'; envy of supervisors' qualities; the wishes that emerged around ending supervision and the relationship with the institution; fear of becoming a professional; dependence versus autonomy; and depression/ regression were also highlighted. The first dyad called the artwork `visual dialogues', which permitted

rich imagery for on-going conversations about the concepts of projection, transference and counter-transference, owning roles in conflicts and accepting individual limitations.

(Durkin et al. 1989: 40)

One gain was the setting up of a model for self-reflection and the facilitation of a non-judgemental atmosphere, in that both people were learning from each other. One feels that the newness of the participants to their respective roles helped this experiment to work. It was clearly very exposing at times and one supervisor found it useful to take material to her supervision group for supervisors. The article does not state whether any of the participants were in therapy, as one would expect these training relationships to be discussed in that context.

After reading this thought-provoking article I was left with reservations, particularly with regard to the exposing nature of some of the personal feelings in a supervisory context. I was left wondering who would sort them out when they became entangled with material that might be discussed in therapy. However it was an interesting experiment and does raise questions about journal keeping/artwork and how it might be used in training, as well as the relationship between therapy and supervision. In this book Brown, Meyerowitz-Katz and Ryde (2003, Chapter 10), Henley (Chapter 5), Robbins (Chapter 9) and Skaife (Chapter 8) all explore aspects of supervision in college and training.

1990s - therapy and supervision: the image and fantasy

Case and Dalley (1992, 2006 2nd edn) give a basic introduction to supervision issues, introducing them for the student and new practitioner and presenting a case for ongoing supervision as an ordinary part of the working week. They stress that new light can be thrown on the working practice of the very experienced through supervision, providing objective insights and new understandings. Expanding on their previous work, in this book Case (Chapter 6) explores the different states of mind and imagery that are helpful to the supervision process, illustrated by clinical work with children; and Dalley (Chapter 4) discusses the complex network around work with children and young people and the need for containment.

One of the only full length, in depth, discussions of supervision is by Dalley, Rifkind and Terry (1993). In Three Voices of Art Therapy they give a lavishly illustrated case study of art therapy from the respective viewpoints of client, therapist and, what they call, the supervisory voice. Although she was not the supervisor of the case Dalley observes the process, described by the other two, and offers a supervisory overview. This gives a very vivid discussion of the art process in art therapy. It also reveals the role of the supervisor as an objective person, reflecting on the pictures, as well as the process in which the therapist and client are engaged.

Malchiodi and Riley's (1996) Handbook of Supervision and Related Issues reflects their dual qualifications as a counsellor and a family therapist respectively. This informs much of the suggested practice in the book. They have an `aesthetic-pragmatic' approach to therapy:

The therapeutic encounter contains the creative elements of artistic and imaginative solutions to difficulties while simultaneously attending to the practical solutions that give support and comfort to the client.

(Malchiodi and Riley: 4)

The handbook focuses on art therapy students and placements, taking an educational approach rather than a psychotherapeutic one. They are critical of the emphasis on countertransference in the British literature of the time, citing ethical, legal, professional identity, documentation and welfare issues as also needing to be given attention. The emphasis on legal issues reflects the differing contexts of practice in the USA and UK and concerns about malpractice lawsuits. They cover thoughts about the development of professional identity in supervision, quoting Friedman and Kaslow (1986); working with the difficult supervisee, quoting Kadushin in Edwards (1993); and the possibility for integrating the art process in supervision. Some of these topics are expanded and developed in this book; the difficulties of engaging supervisees are discussed by Killick (Chapter 12), and the art process in supervision by Brown, Meyerowitz-Katz and Ryde (Chapter 10).

Malchiodi and Riley have a useful chapter on peer supervision that highlights the need for structure, inclusion of all members, maintenance of a common focus and the necessity for objective feedback, which they point out can be difficult if there are friendships in the group. Decisions need to be made as to whether the peer group is a leaderless group or there is a designated leader each week. (Exploration of the image in a peer group setting is discussed by Laine, Chapter 7, in this book.) This supervision handbook was pioneering in its day, having chapters on practical issues such as how to make notes on a session, the use of video and making a plan for a training course for supervisors, but has been largely superseded by developments in the profession, particularly in the last six years.

Keeping personal therapy and supervision separate

Keeping personal therapy and supervision separate is a topic that is addressed by several writers in this book. As a supervisor, it can be tempting, at times, to be drawn into the personal problems of the supervisee but it is very important to maintain a boundary in one's own mind about this. This tension, between therapy and supervision, is explored by Edwards (1993, 1997), who takes a historical perspective, exploring the psychoanalytic legacy on supervision today. Edwards (1997) refers to the early divide in psychoanalytic training as to whether supervision should be concerned with the teaching of technique and theory, or the exploration of emotional and unconscious responses to the client. These two approaches were taken up by the Viennese and Hungarian schools of psychoanalysis respectively, the former arguing for a separate analyst and supervisor, and the latter for the analyst to also be that analysand's supervisor.

One of the questions with which Edwards (1997) is concerned is the extent to which `supervision ought to be concerned with helping the therapist or trainee learn about their own feelings, as opposed to learning about therapeutic techniques and strategies' (p. 11). This could be re-framed as a question of whether supervision is primarily for the protection and wellbeing of the client or for the continuing development and support of the therapist. To some extent this is a false divide, as it is in the interests of both for the therapist to have a space set apart, within which to reflect on the work and relationship with their patients. A containing space for the therapist reduces anxiety and allows a new perspective on the work, which may lead to a new approach. Exploring the countertransference/transference dynamic will increase self-awareness and self-reflection. In supervision there is frequently an educative element, particularly during training, but also afterwards. It helps with reflecting on professional development and the gaining of insight in cases where the therapist feels stuck.

One of the complex dynamics in supervision, as we have seen, is the unequal nature of the relationship and that there are powerful transferences. This was made visible in the images made in the experiment described by Durkin, Perach, Ramseyer and Sontag (1989). In training, the supervisor may function as a door-keeper, guarding entry to the profession. After training the supervisor may be in several different roles to the therapist, including a managerial or administrative one. Even when this is not the case the therapist may see their supervisor as a role model or mentor and want them to think well of them. This could affect the decision as to what material to bring to supervision.

The model most commonly used in art psychotherapy training today is to have a separate analyst, psychotherapist or art psychotherapist as therapist, and a supervisor at each successive placement, as well as a college supervision group. The work of both therapist and supervisor is to aid the personal growth of the trainee. Michael and Enid Balint (1964) were influenced by the Hungarian approach to bring aspects of therapy and supervision to their group work with social workers to help them understand their clients. There is an aspect of this dual role present at times in every supervision: the supervisor will be faced with the intertwining of personal and professional issues in the presentation of case-material, or in the countertransference. The supervisee is sometimes aware that some of their own material has surfaced with a particular patient, but it may be unconscious and picked up by the supervisor, who then has to decide whether to discuss this in supervision or to suggest to the supervisee that it may be helpful to take it to therapy.

Edwards (1993) argues that supervision has `a vital role to play' in training, in bringing together the different forms of learning about self, client and the making of images, in the context of a psychotherapeutic relationship. He discusses the demands of training on students' emotional and intellectual resources and how `nervous anticipation and excitement' experienced by students at the beginning of training can be transformed into `waves of anxiety, confusion, uncertainty, vulnerability and helplessness' (p. 214).

He considers the in-college supervision group, the purpose of which is to `assist students with their learning while on placement'. This includes a focus on the students' relationship with their placement supervisor as well as `issues, feelings and images arising from the placement situation'. These first experiences of supervision are important in establishing a mode of support for the student's work as a therapist. Edwards warns of the dangers of newly qualified therapists finding defensive or destructive coping strategies, in order to survive difficult situations, and points out how they may be prey to fantasies of `not being good enough'. Establishing supervision as an ordinary part of the working week is essential for the protection of client and therapist. Edwards sees several tasks for the college based supervision group: reducing anxiety, improving the service to the client, playing with new ideas and approaches, examining prejudice and helping the student to develop a professional identity through increasingly independent thinking. It is necessary to create an atmosphere of `warmth, safety and trust' so that the students can articulate painful or exposing q...