Therapeutic Supervision


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Authored on :
24/01/2020by :
Jenny Sprince

Containing Groups

This is the text of a talk given by Susan Maciver

There has been a quiet revolution in supervision over the past fifteen to twenty years. I suspect that many supervisors have been providing therapeutic supervision without necessarily pausing to name it and others have not shouted about it from the rooftops because they a slightly shame faced about it. Like some other innovations it started with child psychotherapists, many of whom supervised workers who were dealing with very disturbed and disturbing children in their roles as family case workers, foster parents, residential care workers etc. I am talking about children who project a great deal as a primitive and unconscious way of communicating and who can leave the worker feeling very stirred up, confused, upset and at times angry. It would have been ridiculous to suggest to these low paid front liners that they go and have an analysis or time in therapy and so instead CPs encouraged them to talk about the impact of the children on them. This led to an interest in the workers’ backgrounds, family experiences, and sensitivities, unconscious as well as more conscious etc which could be talked about and held in a safe setting .It meant that the supervisees did not resort so much, unconsciously for the most part, to reacting in a defensive way and could remain available to contain and think about the children with whom they worked. My friend and colleague Jenny Sprince has written about providing such opportunities for the staff of a therapeutic community for children.

Of course, it is not only children who pack a powerful punch emotionally speaking and so therapeutic supervision is coming of age. Writing in The International Journal of Psychoanalysis Brenman claims that whatever personal information or experience enters the supervision can enrich it and can deepen the understanding of the countertransference. 

This is rather contentious, and we may want to discuss it later. Where we may all agree is acknowledging that it is the countertransference that is the grist to the mill of the therapist’s thinking and of their capacity to contain their client.

But I must nail my colours to his mast and indeed am part of an organisation, APPCIOS that has just set up an online course about Therapeutic Supervision. My own learning about this has been from experience and from my supervisors. The formal training in supervision taught me other things.

A great opportunity came my way a few years ago when a large national charity dealing with children and families in the direst of circumstances asked me to provide monthly spaces in which individual workers could think about the impact of the work on them: in other words, therapeutic supervision. The request from their staff was for a safe space where they could process upsetting experiences. Some had their own children to go home to and that was difficult in view of what they’d had to deal with in the course of their working days. I’d like to demonstrate TS in action by reference to my own experience as a supervisee.

The week before last I fell flat on my face, hurting my knee and my chest. This was on the Sunday and I was very shaken up. On Tuesday I had to drive for two hours there and back to take part in an away day of an organisation with whom I work, dashing back to see a demanding and difficult client who turned out to be at his most borderline best. The session exhausted and frustrated me. While intellectually I knew that his behaviour was of course connected with our ending in December, nevertheless I was drained. The next day there was a provocative piece of acting out in the shape of an email containing a bit of a bombshell. While intellectually I thought I could understand what was going on: I was being given the experience of feeling taken by surprise and excluded, on an emotional level I was incandescent with rage! Later that day I had my Skype supervision session with my supervisor with whom I’ve worked for about 4 years. That was sheer good luck!

He asked as he always does how I was and I found myself telling him about my fall, how old and vulnerable it left me feeling. He listened with concern. I then started to talk, not for the first time about ending my clinical work. I think there was a connection between the emotional experience of ending work and falling. What is important is that he didn’t leap in with an interpretation but allowed the facilitating environment to enable me to understand a bit more about where I was in all this. I wondered out loud what I was going to do when my working days ended for good: sit around and crochet (metaphorically) and wait for death. He agreed it was a bleak prospect and after a while reminded me I’d still be doing supervision and consultancy for some time. 

I moved on to talk about the ending I’d had the week before with a very long term client, of how appreciative he had been of our work together and of how  touched I’d felt when he said he hoped my retirement would give me more time with my family and to enjoy the beautiful environment in which I live. My supervisor spoke of the importance of accepting and acknowledging the loving feelings of the client, of how the expression of genuine gratitude is an indicator of how far people have come.

I then turned to my borderline client, well known to my supervisor through our sessions together. I told him how furious I felt. I understood that in the transference I was feeling his intense anger with me for retiring. He suggested that he was also very afraid; scared of retaliation from me for his awful behaviour. Like goosy goosy gander he expected me to take him by the left leg and fling him down the stairs. We also talked about how petrified the client was at having to manage on his own.

Without this timely supervision session in which I was able to say how I felt I think I too would have acted out, in a subtle therapist kind of a way. I might have questioned my client about the acting out in a remote voice, tinged with coldness, instead of being more open to his fears. This doesn’t mean the acting out couldn’t be brought up but the crucial thing is how it was brought up. My capacity to be thoughtfully and compassionately curious about his state of mind was not only restored but enhanced.

What is also interesting is that in starting our session by talking of my fall and death I was also conveying the main themes of the recent session with my borderline client who felt my retirement as a death or falling from a great height.

Something transformative took place which brings to mind Michael Parson’s wise words.

Whatever the analyst’s orientation, it is the essential humanity of the psychoanalytic process that helps the human being ... to think it might be possible to change. 

Just as we are very influenced by our therapists in the way we are therapists, so too we are very influenced by our supervisors. In thinking about this I find the concepts of projective identification and internalisation very helpful. For me one aspect of PI denotes an incorporation of the other, an unconscious trying them on like trying on a suit of clothes, false self comes to mind, which at worst produces a kind of parody. Years and years ago a group of fellow students and I used to giggle at reports of a supervisor who always began a session by asking “Where is he or she in relation to the breast”. We giggled because it didn’t feel like a genuinely curious question but something formulaic that didn’t really belong to him. Who was he in identification with? Melanie Klein perhaps?

In contrast internalisation has the connotation of something that becomes part and parcel of who the other person is, a strengthening of an internal object and a capacity to be more fully one’s self. As Twyman says, “The basic aim of the supervisor is to help her supervisee to do his best for his patients: one of the supervisor’s tasks is to support her supervisee to become the practitioner s/he is capable of becoming, not to become a therapist like his supervisor.”

It may be that for the new counsellor or supervisor PI is a stop on the way to a more integrated internalisation.

 I had some difficulty with one of my supervisors from whom I also learned a lot because she would always tell me what she would say, what she would do or what she’d heard about what the great and the good did in similar circumstances to the ones I was describing. This was sometimes helpful and interesting but didn’t take account of what I was anxious about so that I would leave the session with questions unanswered, worries not attended to. One day I burst out with, “But you are not me! I have to be me in my consulting room”

What is interesting is that during that time with her I became aware that I was talking far too much when I was supervising someone and that I needed to shut up and listen more closely. It came to mind when I heard my supervisees saying what I rather plaintively said to her, “I was coming to that.”

 

I think of Winnicott who writes of patients but the same applies to supervisees

“If only we can wait, the patient arrives at understanding creatively and with immense joy, and I now enjoy this joy more than I used to enjoy the sense of having been clever.”

This brings to mind the subtitle in an excellent chapter on supervision by Mani Vastardis and Gail Phillips   which I commend to you, “Avoiding Omniscience, and Encouraging Play.”

Before I get too hard on supervisors, including myself, it is worth reminding ourselves that projective processes play their part in encouraging omniscience. I think of my much younger self, convinced that my supervisor knew exactly what to say and do and that if I sat at his feet for long enough I would also know- by a process akin to osmosis. This immature dependency is often part of being new to the work, anxious and afraid of criticism, projecting a rather cruel superego into the supervisor who meanwhile may be struggling with frustration at working with someone afraid to share their thoughts and feelings. It is important as supervisors we try to remember our younger selves just starting out, of the struggles we had, the mistakes we made.

Of course it takes time to trust someone and without some trust play is impossible.

Let’s turn to Winnicott again.

Where he mentions psychotherapy, please add on supervision

“Play takes part in the overlap of two areas of playing, that of the patient and that of the therapist. Psychotherapy has to do with two people playing together. The corollary of this is that where playing is not possible then the work done by the therapist is directed towards bringing the patient from a state of not being able to play into a state of being able to play.”

New and not so new supervisees may lack confidence in their intuition, may be reluctant to accept just how important they are in the inner world of their patient and may fear being on the receiving end of negative transference. It is the supervisor’s job to help with all this, to bring the supervisee to the point where s/he can be creatively curious and playful.

Play can only occur in what Winnicott calls potential space, originally the space between baby and mother. Space is a key idea. In bringing material to supervision the supervisee lets the light of day shine on it. Sometimes realisation will come in this space without a word from the supervisor because like the baby alone in the presence of the mother, the supervisee is alone in the presence of the supervisor. Alone but not lonely. This space has much in common with what Ron Britton wrote about the third position: i.e. the position that a child needs to occupy for his development where he accepts being a witness and not a participant. It seems to me that part of what we need to do as supervisors is help our supervisees be witnesses as well as participants in the relationship with their clients, something which is inimical to some clients and therefore difficult for the therapists. In practice this might be a narrative in which the supervisee comes across as very much on the client’s side, seeing things through their eyes but leaving me, as supervisor, with a curiosity of how the other participants in the drama would see it. 

Coming to develop binocular vision, seeing the hatred as well as the love, is something with which supervisors need to help supervisees: for example realising that recurrent lateness has a meaning beyond the dog ate my homework kind of excuses and to face that there could be ambivalence towards the therapist or even that it is an aggressive act. Where the supervisee can be honest in their recounting of a session, open and descriptive of their associative thoughts an atmosphere of learning for both supervisor and supervisee can develop.

A supervisee has given me permission to illustrate what I mean from something that happened in one of our sessions.

 He is a talented and recently qualified psychodynamic counsellor brought who brought a dilemma. He had been advised by the agency manager to offer 12 sessions to a client which was different from the normal practice of providing open ended sessions. He was annoyed and told me that the client, on session 8, was anxious about ending, and had asked for further sessions which he probably could get away with providing. We had to work at setting aside his feelings about being directed in a rather peremptory way by the stressed manager before we could examine what he really thought was in the client’s interests. In the course of our discussion he heard himself say “piece of work”. He stopped and asked me in a rather shocked tone of voice, “Do you hear how I just referred to the client?” Now I had heard him refer to” this piece of work” but he knew that internally he was also talking about her, saying “she is a piece of work.”

 He was taken aback at his disparaging tone and remark but was freed up to recognise and talk about the frustrations of working with her, of how he really didn’t know how far she and he could go and of whether she needed support rather than therapy. The decision was his, but in arriving at it he was greatly helped by this exploration of his less conscious feelings about her, brought to his attention by what he heard himself say.

By way of a final thought, I had mulled over for some time my feeling that if I couldn’t imagine the client about whom I was being told, then something needed to be attended to. Then I read some of Ogden’s ideas about the reciprocity between supervisor and supervisee.

The analyst does not bring the analysand to the supervisory session: rather (with the help of the supervisor) the analyst dreams up the patient in the supervisory session... dreaming up the patient ...represents the combined effort of the analyst and supervisor to bring to life in the supervisions what is true to the analyst’s experience of what is occurring at a conscious, preconscious and unconscious level in the analytic relationship.

 

Maybe I’ll stop here, mindful of the patience and kindness of my supervisors and with the aspiration to be like that for my supervisees. Good supervision sessions are highly creative; ideas emerge in the space between supervisor and supervisee and both learn a lot.


Comments

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Fiona Henderson

29/06/2020

I really enjoyed this piece Susan; full of honest musings and insights and I appreciated your links into other thinkers. I too think about the need to stay quieter as a supervisor, even if one is full of ideas, and instead to work on promoting a creative space in which thoughts (as yet unknown) might emerge. 

Thank you for this personal and generous account of your work.

Susan Maciver

30/06/2020

Thank you so much, Fiona.