By Rob Weatherill
As is common in most psychotherapy training, individual supervision of case work is an essential part of the training process, alongside a theoretical training and a training analysis. The present minimum requirement, in terms of supervision, for full membership of the Irish Forum for Psychoanalytic Psychotherapy (IFPP), is 120 hours (2 cases spread over 3 years, plus 2 years post-training experience). This paper will look at some of the issues that confront the trainee in supervision.
Modern psychoanalytic psychotherapy training imposes burdens on trainees that supervisors need to be aware of. For instance, trainees are exposed to a vast literature in psychoanalytic theory, some of it very academic, which, at first may seem strange and inappropriate to the clinical setting. Most trainees will have to continue full-time work while doing their training. They must also embark on a training analysis, as well as the more modest demands of supervision of their patients, whom they will be expected to take on.
These are not inconsiderable demands and pressures. Supervision is crucial in the formation and later professional style of the therapist. Apart from the central concern of clinical work, the supervisor might also be available to advise on essays and the reading of relevant material for their particular cases. Often it is important to direct the trainee to write her course essays on clinical topics, indeed around those issues that have been discussed in the supervisory sessions themselves. This makes the essays relevant, interesting and useful, rather than perfunctory, academic pieces to fulfil the requirements of the course.
Relevant or Not
Ordinarily, what is required from the trainee in supervision is that, after the session with a patient, the trainee must write down as closely as possible (preferably verbatim) what has occurred in the session. This means specifically, what was said by the patient and the therapist, comments on entering and leaving, the feeling evoked in the trainee before, during and after the session, and anything else that springs to mind, whether it seems relevant or not. The therapist is required to be objective about the session, as Freud required of his patients, without censorship or critical evaluation. This enables the supervisor to understand the session from the therapist’s and the patient’s point of view.
From there, the crucial task of the psychoanalytic supervisor is to teach the trainee how to recognise and listen for the unconscious. Just as Jesuits in formation, I believe, are told to search for God in the elements of everyday experience, so the psychoanalytic psychotherapist in the session is attempting to tune herself to the manifestations of the unconscious, through dreams, slips of the tongue, bungled actions (parapraxes), phantasies, jokes and so on. The supervisor’s job is to aid in this process of detection; essentially to point out where the unconscious appears.
And then the question arises – which unconscious? Is it the Jungian unconscious? I will not attempt to enlarge on this sense of the unconscious, which extends all the way from the personal to the collective. I will confine myself to the personal unconscious. Even then, is it the classical unconscious of forbidden wishes to be interpreted at the appropriate time? Or is it the Lacanian unconscious of abandoned signifiers?
Or is it the Kleinian unconscious of extreme affectivity? Or is it, for instance, the Winnicottian unconscious which has among other things, to do with playfulness, aliveness and spontaneity? All these different formulations are useful, and ideally the student needs to become familiar with each before developing a personal preference and idiom, later in their professional life. Some would say this leads to an uncommitted eclecticism! Is it best to concentrate on just one approach, the Lacanian or the classical, for instance?
My own intuition and training inclines me to be a committed eclectic, recognising, at least in principle, the value of each different approach. To adhere to just one school is just too restrictive. Here I would agree with Bollas (1989 p.99), when he says; “… my view of what constitutes the analytic is not a classical or a Kleinian position. I think that each of the (psychoanalytic) schools in some respects polemicises a single feature of analytic life. Each Freudian should be a potential Kohutian, Kleinian, Winnicottian, Lacanian and Bionian, as each of these schools only reflects a certain limited analytic perspective”.
However, in the reality of the therapeutic situation, such differences may not be so important. We have found in case conferences, experienced therapists of differing psychoanalytic backgrounds often arrive at broad agreement on how to proceed in particular cases being presented.
Another question is how far analytic technique should be emphasised (of whatever persuasion), or should the trainee simply be there, in mind and body, without too much technical preparation? Some courses go so far as to role-play situations with difficult patients. However, there may be a danger in this, as any patient worth her salt, senses and distrusts technique per se. An important problem remains. A trainee going to a Lacanian supervisor, will have a radically different supervisory experience than one going to a supervisor of the independent tradition.
The former privileges the patient’s signifiers while the latter pays attention not only to what the patient says and how he says it, but also emphasises the countertransference, the analyst’s private free association, the working alliance, non-verbal clues, and so on (Rayner 1992). Yet both are doing psychoanalytic psychotherapy. And if, as Michael Fitzgerald has stressed in an unpublished paper, the supervisor is the largest influence on the professional development of the therapist, these must be important issues.
Another problem that is not sufficiently recognised is that many therapists may be required to take on patients too early in their training, or they may take on patients that are not suitable for psychoanalytic psychotherapy.
In either or both instances intense countertransference problems can develop rapidly. Lack of awareness of the Kleinian paranoid-schizoid experience in one’s own personal therapy, for instance, is likely to provoke strong resistances in the trainee confronted with such problems. Patients who fail to improve become persecutors and mirror the therapist’s own severe internal objects (Racker 1968).
The therapist can feel hopeless, leading to further deterioration in the therapeutic relationship. Here the supervisor must step in and attempt to analyse the total situation and restore the therapist’s confidence. The supervisor has to oversee not only the trainee but also the patient’s well-being. The supervisor’s ultimate responsibility is to the patient the trainee is treating. If the patient indicates, for instance, that she is passively suicidal and the therapist proceeds without taking this seriously enough, the supervisor must alert her to this possible resistance in herself and the patient.
Another problem is that trainees coming from the health professions have often had earlier training in the cognitive/behavioural area and are therefore prone to emphasise the more rational, reality based, ego-ego functioning and to revert to this when under stress from patients whom they may now be trying to treat more analytically.
This is more likely to be the case in health service settings. Trainees will not immediately see how the unconscious, and its interpretation can be relevant in pressured public clinics. Winnicott (1971) was exemplary here. The supervisor’s task is to make it clear that the analytic position may (not always) hold good whatever one’s actual clinical environment. It is the particular stance that the therapist/analyst takes which is ultimately determinative. During training the trainee will learn the various psychoanalytic models and theories, and ideally these will come to inform her new work.
I always tell trainees to draw on their previous experience, and bring the new analytic understanding gradually to bear on and deepen their therapeutic work. This does not mean that one abruptly changes to become a psychoanalytic psychotherapist. The analytic position means being open to being surprised by the unconscious. The unconscious is always surprising. It is always about some hidden truth, which is in the third position vis-a-vis the therapist and the patient.
The supervisor’s job is to help the trainee to see where she is being placed in the transference and to maintain this third position (which has to do with Oedipus) rather than being drawn into the patient’s demands. Understanding this transference positioning can help the trainee maintain the analytic position without retaliation.
The hysterical patient, for instance, will try to disrupt the session and here the supervisor will have to assist the trainee to be firm. If the trainee is afraid of his own aggression he will not be able to confront the patient when necessary.
If the trainee doesn’t value himself, his self-esteem is low, then he will either over value or devalue the therapy he is practising. The supervisor needs to point out this subtle countertransference. The very resistant patient causes problems and may lead the therapist to become a superego figure, repeating instead of analysing the patient’s past. What about patients who grossly act out or need to be hospitalised? The supervisor needs to be able to act quickly and decisively here.
All the time, the supervisor needs to be aware how the trainee might act out their own problems with their patients. For instance, trainees who have been mother dominated may have particular difficulties with women patients and/or they may collude with their patients’ hostility toward their own mothers, rather than analysing the hostility. Similarly, trainee men or women imbued with a feminist perspective may not be inclined to analyse hostilities towards husbands, fathers, brothers and so on. This will be particularly difficult if their feminism is founded upon unconsciously denied hostility towards mothers. Of course none of us is ideologically neutral, but, in order to maintain this analytic third position, we need to be able to move between and recognise ideological frames in the clinical setting, and analyse them, rather than be caught within them.
If the supervision is going well, the trainee will provide the supervisor with a real sense of the patient. If this is not apparent, the supervisor must ask herself if this lack of representation of the patient is due to the patient’s pathology or the trainee’s pathology and/or lack of skill. The trainee’s attention must be drawn to this lack. Is the trainee listening and attending to the patient fully?
A Full Picture
Or is the patient’s lack of representation, his incapacity to speak for himself, precisely indicative of his failure to establish what Lacan calls ‘affective density’? The trainee must be encouraged to obtain (over the course of many sessions perhaps) a full picture of the patient in three main areas: The transference, the patient’s current life, the patient’s childhood. The patient should become interesting.
Does the trainee become too preoccupied with the supervisor, too worried about what the supervisor will think of her case reports? This can have an anti-therapeutic effect on the trainee’s clinical work. The transference to the supervisor is often an idealised and somewhat fearful one, especially in view of the real contact and power the supervisor may have with the training organisation.
The trainee, after all, is trying to enter the parental bedroom of the analytic institute and Janet Malcolm (1982) has identified just what a castrating process this can be. The supervisor may use her power to gather a clique of ideologically pure trainees around her, and indeed, to exclude others. Equally the trainee may make the supervisor feel inadequate, reduplicating something of the supervisor’s past. Unanalysed, the supervisor’s feeling of inferiority may lead to undue criticism and undermining of the trainee’s efforts.
Finally, we might conclude, when things go well, supervisors have a valuable opportunity to help trainee therapists. This makes for good training for both participants. The supervisor is also in a unique position to learn, from her special vantage point on the therapeutic process (Langs 1979). The trainee-supervisor relationship is best fostered in an atmosphere that is free from training institutes. In Ireland there is as yet relatively little interference, but here we are only starting.
Bollas, C, Forces of Destiny: Psychoanalysis and the Human Idiom. 1989, Free Association Books
Langs, R., The Supervisory Experience. 1979, Wiley.
Malcolm, J., Psychoanalysis, the Impossible Profession. 1982, Picador
Racker, H., Transference and Countertransference. 1968 Marlsfield
Rayner, E., The Independent Mind in British Psychoanalysis. 1990, Free Association Books
Winnicott, D., Therapeutic Consultation in Child Psychiatry. 1971 Hogarth
Rob Weatherill is a psychoanalytic psychotherapist and teaches psychoanalysis on many courses in Dublin. He is the author of ‘Cultural Collapse’ (Free Association Books, 1994)