As we move towards standardisation of practice in psychotherapy, the need for on-going in-depth supervision throughout one’s practice is one subject where there is divergent opinion. In this piece Ger Murphy presents one view.
The question of supervision within the field of psychotherapy often meets with ambivalent and contradictory attitudes on the part of the practitioner. While it is universally approved of as an essential ingredient in all training programmes there is often a “them but not us” stance taken by the qualified practitioner. Supervisory requirements in practice can be either eliminated or at least reduced to brainstorming alternative strategies to help in dealing with particular clients. In this article I wish to point to the continuing need for practitioner supervision, of a quality which reaches far beyond that of a sharing of alternative technical strategies of intervention to explore the dynamics of the practitioner-client contact.
The use of supervision as an ongoing tool in therapeutic practice is firmly based on the belief that the practitioner needs to continue to develop. On qualification as a psychotherapist we can easily succumb to the temptation to see ourselves as fully trained, with the new pressure of having to be seen to know what we are doing at all times. In this sense I see supervision as just as essential for the seasoned practitioner as it is for the student who at least has the license to be in a learner position by definition.
The practitioner’s continuing need is indicated by the trend to use consultation instead. This can have an implicit assumption that as an experienced worker we should be able to have a clarity on the issues arising in our practice and therefore not get enmeshed with our clients, or stuck in our own unresolved issues as they are triggered by the interaction with the client.
The different approaches to psychotherapy may indeed reach this particular blind spot from a variety of angles. The behaviourist may come to it by the definition of the therapeutic as primarily to impart technical information and strategies to the client. The analytical therapist may come upon it from the assumption of the training analysis being a once and for all event, thus the concept of a “full analysis”. To either, the continued existence of personal blind spots emerging during contact with clients can be seen as a personal failing. Finally, the humanistic practitioner, through belief in equality within the therapeutic relationship, and emphasis on the primary role as that of facilitator of the client’s therapeutic process, may shy away from exploring their own impact on the client in the relationship.
In attempting to define what I mean by supervision, I see the analogy used by Shohet and Hawkins in “Supervision in the Helping Professions” to be a valuable one. They draw a parallel with Winnicott’s concept of the “good enough mother”; whereby the mother can hold the child, accepting the child’s communication as a communication of its needs and not as a personal attack or criticism even when the child is rejecting or raging.
Winnicott points out that mothers also need to be held by another person who will support her in this function, thus developing a “nursing triad”. The supervisor I see as acting in this manner so as to support and, where appropriate, to challenge the therapist. While I appreciate the value in the supervisory relationship for exploring alternative strategies and offering an environment for reviewing the developmental needs of the client, this holding of the therapist in the intense relationship with the client is paramount. I regard the prime value to be in exploring the transference of the therapist as well as that of the client. It is in this area that the value of the outsider is, I believe, especially relevant as the dynamics involved can be, and often are, outside of the awareness of the therapist. This need not imply a defect in the therapist’s ability or competence. It should be seen as a simple fact of the therapist and client developing over time a system which involves them both in a deeply personal relationship. To quote Neville Symington: “Together they form what we might call a corporate personality”. The therapist cannot be external to this system, and it is this system which benefits from exploration with a supervisor.
Patrick Casement in “On Learning From The Patient” (reviewed in Vol. 1 Issue 2 of Inside Out) states: “Towards the end of training, I believe that the process of supervision should develop into a dialogue between the external supervisor and the internal supervisor*. It is through this that therapists develop the more autonomous functioning that is expected of them on qualification”. While he cautions against expecting the process of internalising the supervisor to provide a finished product, I consider it inherently contradictory to expect a therapist at any stage to establish adequate distance to unravel fully the meanings of the transference in which he himself is involved. I do believe that it may be possible with the growth of the internal supervisory process to view the client’s transference relatively clearly.** However, the therapist also brings an emotional world and emotional relations which are activated in the therapeutic process in a way which goes far beyond the simple reactions of the therapist to the transference of the client.
The therapist’s own unmet needs and shadow side are equally likely to emerge, and it is these that the supervisor needs to be alert to, given the unequal relationship entailed in psychotherapy. Furthermore, I believe that far from seeing the transference and counter-transference as neurotic phenomena to be analysed an d worked through, they can be in effect a primary means of creating a bond between the client and therapist. This is especially true when the work with a client is of a pre- Oedipal nature, (i.e. where the issue to be dealt with involves helping the client to have a separate personal boundary rather than working on an Oedipal level where issues of power, control and interpersonal relations are focused on). In these situations it is often impossible for clients to describe how they are feeling as such a description presumes their awareness of themselves as separate beings. Rather their means of communicating their state is often only through how they make the therapist feel.
Stanley Keleman in “Bonding” outlines four types of transferential connection or, as he calls it, four levels of bonding, which he symbolically represents as Embryo to Uterus, Mouth to Breast, Child to Parent, and finally Adult to Adult. He then explores how the therapist can meet the needs expressed by the client in developing each form of connection as well as encouraging the client’s movement through each developmental stage. Should such attempts at bonding be resisted by the therapist or merely interpreted by them, it will result in the frustration of the client’s attempt at contact in what may be the only way open to him/her. Thus in Keleman’s model the kind of contact between therapist and client may vary widely from actual physical contact to dialogue.
To enable such a range of contacts to take place safely, the therapists themselves need to be firmly held by the supervisory relationship. Without such holding the therapist may err on the side of safety and opt for a sterile distance which can strongly affect the transformative power of the therapeutic relationship, if we acknowledge, like Keleman, that clients may need to make contact with the therapist at a variety of levels so as to reintegrate their lost self or “hidden self (Guntrip), we can also find agreement with Balint that where the essential issue to be dealt with is in the area of what he calls the “basic fault”, i.e. the split in the person from his essential self then the demands on the therapist are to allow the regression to pre-Oedipal levels where words “cease to be reliable communication” – Balint.
Whether or not we choose to use the actual contact with the therapist or contact with the therapeutic situation to become the primary object for contact in replacing words and other techniques to which the client can connect while regaining contact with themselves, we can clearly see that the pressures on the therapist in either situation and the potential rising of his/her own unresolved issues are great. For example, the ability to tolerate silence, raging attacks etc., are often severely tested in such circumstances and in this context there lies great potential for the surfacing of the therapists own internal monsters, such as fears of his/her own worth, his/her own sadism etc. I believe that these issues clearly argue for the necessity for an on-going and in-depth supervisory holding, so as to allow the client to really develop as they may need to as well as to protect the mental health of the therapist.*Note: Patrick Casement in “On Learning From The Patient” describes and “internal supervisor”. * *Note: In this we are seeing transference as the phenomenon spoken of by Sigmund Freud where patients ”develop towards their physician emotional relations which are not based upon actual situations but are derived from their relations towards their parents.”
Ger Murphy works as a psychotherapist and trainer at the Creative Counselling Centre.