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AN OVERVIEW OF SUPERVISION OF PSYCHOTHERAPY AS A COMMUNICATIVE RELATIONSHIP (Part 1 of 3)

The Supervisory Relationship in Psychotherapist Training

Below, I shall apply the foregoing theory to concrete examples to suggest specific ways to operationalize it. The examples are drawn from the literature of theory of supervision of psychotherapist training, and describe communication interactions between psychotherapy supervisors and supervisees. Thus it is needful first to get an overview of this interpersonal relationship and some of its communicative properties. I shall limit myself to certain aspects of selected kinds of supervision, and, as part of my description of this sub-space, I shall indicate what parts of the larger field I am leaving out.

An essential aspect of training to become a psychotherapist is for the aspirant to undertake treatment of clients under the guidance of an experienced practitioner. Supervision is the relationship into which the aspirant (a.k.a.: supervisee) enters with the experienced practitioner (a.k.a.: supervisor). The basic structure of this relationship is that the supervisee reports, and the supervisor listens and offers advice. The supervisee reports and otherwise discusses what is happening in therapy with his or her clients. The supervisor listens, and gives feedback to the supervisee, with the two primary objectives of (1) protecting the supervisee's clients from potential negative effects of the supervisee's inexperience, and (2) improving the supervisee's skill as a therapist.

When a person aspiring to become a therapist and an experienced therapist privately enter into a supervisory relationship, the foregoing may be the only important dimensions of their relationship. Often in reality, however, the supervisory couple operate under the condition that supervision is part of an institutionalized training program in which the person who aspires to become a therapist is enrolled as a student. Although a training program could leave the matter of supervision to the student to deal with according to his or her own initiative [I tried this, and my initiative was not appreciated...], in general, institutions which train psychotherapists become more involved in this aspect of their students' training. This generally results in addition of a third key dimension to the supervisory relationship: that the supervisor reports his or her evaluation of the supervisee's activities to the training institution, and this evaluation becomes an important determinant of the student's status in the program (leading, ultimately, to graduation or failure to graduate). In this case, the interaction between supervisor and supervisee takes on pragmatic import for the student (in terms of the student's aspiration to enter the profession) potentially in conflict with pedagogical and therapeutic goals.

Harold Searles has argued that the supervisory relationship in psychotherapist training is an exceptionally rich area for study:

...[L]et me emphasize that there would seem to be great value in studying exhaustively the interplay between the patient-therapist relationship and the therapist-supervisor relationship, since this total situation is without a parallel anywhere else among human relations, in that each relationship includes at least one expert in the study of intrapersonal and interpersonal processes. Thus this area offers unique possibilities for research. The results of such research might well be applicable not only to psychotherapy and to the supervision of psychotherapy, but to human relationships in general. (Searles, 1965, p. 176)

These are some of the reasons I have chosen to focus on this relationship in my dissertation. Reading, personal experience, and discussions with psychotherapists have all contributed to this orientation.

<a name="knowledge">Paul</a> Watzlawick points out that when persons become aware of a theory concerning their behavior, they are no longer bound by it but are free to disobey it (Watzlawick, Ed., 1984, p. 113). To develop this emancipatory potential of self-reflection, I will further elaborate Searles' remarks especially in one particular direction: the potential value of feeding research whose object is the supervisory situation back into supervisory interaction (and, of course, doing further research on the results and feeding that research back, ad infinitum...). Habermas spells out the theoretical foundation for this orientation:

The systematic sciences of social action, that is economics, sociology... have the goal, as do the empirical-analytic sciences, of producing nomological knowledge. A critical social science, however, will not remain satisfied with this. It is concerned... to determine when theoretical statements grasp invariant regularities of social action as such and when they express ideologically frozen relations of dependence that can in principle be transformed. To the extent that this is the case, the critique of ideology, as well, moreover, as psychoanalysis, take into account that information about lawlike connections sets off a process of reflection in the consciousness of those whom the laws are about. Thus the level of unreflected consciousness, which is one of the initial conditions of such laws, can be transformed. Of course, to this end a critically mediated knowledge of laws cannot through reflection alone render a law itself inoperative, but it can render it inapplicable. (Habermas, 1968/1971, p. 310)[fn.TBD]

Stated simply, by studying what they are doing, supervisors and supervisees may be able to transform what they do into something better than it "is."

Regarding this assertion, it is especially relevant to a consideration of supervision in psychotherapist training to note two points. First, supervision is a relation of dependence and in consequence is at least a prima facie candidate for harboring "ideologically frozen" patterns of interaction. Second, as Habermas himself argues earlier in the same book, the language Freud used in framing the theory of psychoanalysis (id, ego, superego, etc.) is too narrow to account for the language of the technique of psychoanalysis, which realizes self-reflection, whereas self-reflection has no place in Freud's metapsychological structure (p. 245). This criticism does not apply to all of psychodynamic psychotherapy, but it applies to much of it, even today, and especially to what students are taught [(or at least to what many of them learn)] in introductory, i.e., formative, courses. This criticism of the theory of therapy may be suggestive for uncovering similar problems in supervision of psychotherapy, i.e., dimensions of practice which are unaccounted for and therefore at best equivocally nurtured by theory.

Pursuant to Edmund Husserl's vision of humanity becoming pervasively self-responsible through self-reflection, I believe this process of rationally (i.e., conversationally) re-forming human existence needs to be done everywhere, from the boardroom to the bathroom. Pursuant to Searles' observation that in the supervisory relationship in psychotherapy training the participants already are experts in human relations who have entered into relation with each other for the purpose of studying human relations, it seems here the potential for elaborating this process is optimal.

To the extent, which I propose may be great, that this process leads into regions of experience where, to borrow the phrase from Startrek, "no persons have gone before," one practical desideratum in selecting supervision of psychotherapist training as my object of study is that it may prove a field in which new ground can be explored most expeditiously. Since arguably the "crisis" of contemporary humanity has further exacerbated since Husserl's time, there is, I believe, urgency to find out what's "out there," of which we might profitably avail ourselves in coping with our predicament. Unlikely as it may seem, psychotherapists may, at the present time, have potential for being, to borrow McLuhan's phrase, even better "antennae of the race" than McLuhan himself argued artists are (McLuhan, 1964, p. xi).

To try to describe all the possible nuances of the supervisory relationship is not necessary here. But at least one example is needed to help the reader appreciate the subtlety of the (to borrow a word from Susanne Langer:) "auras" around all the various aspects of the process of which I shall describe only selected salient features. Let us consider the fact, already mentioned, that supervision frequently takes place in the context of the supervisee being a student in a formal training program to which the supervisor reports evaluation(s) of the student which affect the student's status in the training program.

A likely dynamic here is that the student will filter his or her interaction with the supervisor to attempt to avoid unnecessary conflictual interactions, and perhaps the student will even go out of his or her way to please the supervisor, to try to elicit from the supervisor a commendatory and not merely satisfactory evaluation. This effort by the supervisee may take the form not only of not reporting certain material to the supervisor, but, more consequentially, of not doing certain things with clients to avoid having to evade reporting them. The potentials for turning communicative into strategic interaction, and for both intentionally deceptive and unwittingly mystified communication, not just between supervisee and supervisor but also between supervisee and client are both variegated and significant.[It should be noted that, often, the patient is unaware that what he or she says to the therapist, later gets repeated and picked apart (and perhaps even joked about...) by the therapist and the therapist's supervisor!]

Harry Stack Sullivan, in agreement with Searles, defines the psychiatrist [substitute: psychotherapist] as "an expert having expert knowledge of interpersonal relations, personality problems, and so on" (Sullivan, 1954, p. 12). Therefore, it is reasonable to expect that the supervisor will anticipate that the student may try to manage their interaction in various ways, including as indicated above. The supervisee/student may already be expert enough in human relations to be aware of this, and take it into account in his or her efforts to manage the interaction. The supervisee may try to make it look to the supervisor as if he or she was being ingenuously honest while withholding information or even fabricating information (a.k.a.: lying); the supervisee may present him or herself as less competent than he or she is, to gain room to maneuver and earn credit from the supervisor simply for correcting mistakes he or she doesn't in fact make; the supervisee may volunteer his or her worst mistakes and criticize them harshly to avert the criticism the supervisor might have made and to avoid having to deal with subtler issues which might be more threatening in the sense of subjecting the student's personal style more intensely to supervisory scrutiny. Of course, the supervisor can anticipate these maneuvers and try to undo their effects, either by confronting the supervisee, or by pretending he or she doesn't notice and stringing the supervisee along. Supervisor and/or supervisee may interpret the other's behavior in their interaction as strategically fabricated when in fact it is not fabricated but transparently sincere. Etc.

These equivocations can reach the extreme where, as Erving Goffman asks:

How many laminations can a strip of activity sustain? How far can things go? How complex can a frame structure be and still be effective in setting the terms for experience? (Goffman, 1974, p. 182)

While any human interaction is subject to such elaboration, it seems that the knowledge supervisor and supervisee, as experts on intrapersonal and interpersonal processes, are likely to have of these possibilities places the richness of their interaction for study in this regard in the same league with what may transpire (e.g.) in the world of espionage agencies, with the logistical advantage, however, that in the case of psychotherapy supervision, the material is more easily accessible to study due to relative absence of security measures.

Which leads us to another effect of the supervisor's reporting role vis-à-vis the student's training institute, or even if the supervisor is simply a member of the institute's faculty (and thereby subjected to temptations to gossip about the student). The student may have good reason to wonder whether what he or she tells the supervisor will stay "between the four walls," or whether the supervisor will either officially report or informally leak information. The supervisor, in turn, does well to consider carefully what he or she says to the supervisee, for fear of consequences to his or her own position on the faculty if the student passes it on (when a student is under pressure from some organ of the training institute to defend his or her conduct, a defense which will frequently get the student off the hook is: "My supervisor told me to do it.").

At a certain point, our hypothetical supervisor (whom, throughout this dissertation, we shall name: "S") tells our hypothetical supervisee (whom we shall name: "A," as in "Analyst") to do a certain intervention in A's interaction with A's hypothetical patient (whom we shall name: "P"). S and A may even appear to come to an agreement, conversationally, on this matter. This agreement may be real, or only apparent, for instance, in the sense that A says "Yes" despite reservations A withholds from S, or in the sense that A enthusiastically agrees with S, but doesn't deeply understand what he or she is agreeing to.

A goes off and performs the agreed upon intervention with P. P is puzzled and says to A that P doesn't understand, and that A's intervention even seems to miss the point of what is going on between them. This may well be true, because A is following orders with which A does not agree, or because A is blindly (i.e., without solid orientation to context) trying to do what A thinks he or she is supposed to be doing, etc. In practice, A will usually try to cover over this situation. If A disagrees with the supervisor and is trying to show how stupid the supervisor's instructions were, A may continue to do, in awareness, but without sharing this awareness with P, exactly what P has accused A of doing, so that A can take the results back to S (or perhaps to the institute's Supervision Committee) as evidence of S's fatuity. More commonly, A will try to blunt P's criticism, in hopes of postponing dealing with the problem until A can get further instructions from S (to avoid "digging him or herself in deeper"). (Unless A is an absolute neophyte, he or she will have learned broadly applicable, at least fairly effective techniques to "stall for time," such as asking P to elaborate on what P means by what[ever] P said.)

It is hard to see how any of this can be constructive for P, who may, in consequence, become even more unsure of him or herself (if that was already one of P's problems), even more distrustful of other persons' ability to help (if that was already one of P's problems), etc. One candidate suggests itself here as a way to put an end to P's iatrogenically induced reaction. A could say to P:

Yup. You got me. I was trying to do something I had agreed with

my supervisor to do, and now I find I didn't really understand how to pull it off [or: I really didn't want to do it anyway]. I'm sorry.

This response by A to P is in fact so implausible that I [BMcC] have not come across a single example of it in a book or in life in over three years of being a psychoanalytic trainee and researching theory of supervision for this dissertation. It is also a hint of recommendations I shall propose below, although more directly in the context of the supervisor-supervisee interaction, than, as here, in the supervisee-patient interaction (with an objective of helping keep the student from ever doing anything that would warrant such a confession).

Hopefully this example of the effect of the supervisor's role in providing evaluative reports to the student's training institute has been elaborated far enough already to give the reader some sense of the complexity of the communicative social interactions which can occur in the supervisory relationship. Since I initially said that this dimension of the supervisory relationship is, at least in principle, optional, i.e., that training institutes can, if they wish, make supervision a private matter between the student and a non-reporting supervisor who is not part of the training institution's faculty, it might seem that the solution to this problem would lie in precisely that direction. In fact, and for the reasons indicated, this sometimes is done, for instance, in some in-patient hospital settings where the results of the trainee's work come to the attention of other staff in the natural course of events "on the ward" (Dr. David Robbins, personal communication, 1993).

In out-patient settings, however, often there is no contact with the patient by anyone concerned with the student's training, beyond the student's interactions with the patient in the therapy sessions ("it's just A and P and the four walls"). In this situation, under "free market" conditions, i.e., where patients and therapists contracted as independent buyers and sellers of a particular service ("psychotherapy"), the non-reporting supervisor solution would also be helpful, by freeing supervisor and supervisee from having to deal with an unnecessary bureaucratic intrusion on their work. In practice, in general, however, training programs serve as credentialling and certification gatekeepers, and, albeit with some exceptions, a person cannot earn a living as a psychotherapist without being graduated from certain training programs (Master of Social Work; Ph.D. or Psy.D. in clinical psychology; M.D.). Without supervisors' evaluations, most of these programs would be hard pressed to come up with better ways of measuring students' performance.

The Lacanian school of psychoanalysts in France actually did come up with an alternative, in which a student's admission to the profession is determined by a procedure called "the pass":

In the "pass" procedure itself an analyst gives an account of his training analysis to three other members of the School, his "passers," all of whom are themselves currently in analysis. These passers then "pass" what they have heard to a committee of senior analysts, a committee that always includes Lacan. This committee would review the information gathered, not in a spirit of judging their fellow analyst's capacity to practice or train but in order to decide whether the analyst had reached the maturity needed to use his or her own analytic experience as research. (Turkle, 1992, pp. 193-4)

While this procedure clearly would take the pressure of concern about evaluation out of the supervisory interaction, it also seems it would tend to marginalize the supervisory process in general, since what happened there would have no direct effect on the candidate's objective of gaining admission to the profession (like all genuinely optional study in schools, which a student can do on a not-for-credit basis). The possibilities of the candidate employing strategic communication in attempting to gain a favorable response from his or her unknown and inaccessible evaluators (à la Kafka's Land-surveyor K. in his dealings with "the castle") may be even more byzantine here than in more traditional training situations.

Surely the ideal, again, to return to the "free market" model, is for the trainee's work as a therapist to be disjoint from anybody's evaluation except that of the trainee's clients who, if they don't feel he or she is providing the service they want, could leave and go elsewhere. An independently wealthy person such as the late Prince M. Masud R. Khan could practice this way. Guided only by his autochthonous commitment to do therapy according to the best of his ability, the Prince could "take what he liked and leave the rest" (to paraphrase a slogan of the ACOA self-help movement), subject only to the possibility of a lawsuit in the case of somebody claiming he had harmed a client, or contributed to a client harming some third party. And here we arrive at the end of this train of thought since, sometimes, psychotherapy clients, as part of their problems in life, act out the [unrealistic] belief that their therapists have harmed them (etc.), and then somebody has to decide how to adjudicate the indictment.

In practice, the main situation in which non-reporting supervision occurs is when a therapist who is already established in practice voluntarily seeks out a person to provide supervision because the would-be supervisee believes this person genuinely can facilitate growth in which the would-be supervisee is personally interested. I shall not consider this situation in this dissertation for several reasons: First, even though here the supervisor does not have "the power of the purse" over the supervisee, the intimacy of the supervisory relationship still leaves both parties vulnerable to many of the emotional issues of the reporting supervisory situation (including, of course, the possibilities of gossip).

Second and I think more important, however, in this situation the would-be supervisee's mode of being-in-the-world (and being-in-supervision) has already been shaped by extensive supervision of the other (evaluative) kind. Here Bateson's notions concerning deutero-learning and Mead's observations about the limits of imagination (etc.) forcefully apply. Any effects other than refining already acquired competencies and reinforcing already deeply embedded orientations will likely be the exception. If the changes I propose to supervisory practice were going to come into being through this path, they have had much opportunity but given little indication of happening.

I shall concern myself, herein, primarily with the early, formative supervisory experiences aspiring psychotherapists ordinarily encounter in their obligatory training. I have chosen this focus, not because I do not believe what I have to offer also applies to other [pragmatically derivative] situations, but because I believe the issues can more easily be seen and there is more motivation to try out my recommendations in trainees' early supervisory experiences, where the student has not yet adapted him or herself to the interactional norms. In addition, evaluative supervision of a student as part of a formal training program is by far the most widespread form of supervision (it is a "station" through which almost all therapists pass). I shall propose how this particular facticity can be turned to valuable pedagogical use when supervisor and supervisee become more self-reflective about their relationship.

Delimiting My Sub-area of Inquiry

The relationship between supervisor and supervisee consists almost entirely of talk about talk: supervisor and supervisee talk about the talk which goes on between the supervisee and his or her clients. Before we look at this relationship in more detail, I need first to further delimit my area of focus.

There are many different kinds of psychotherapy, among them: behavior-modification, paradoxical intervention, cathartic methods, etc. I shall here limit myself to insight-oriented forms of therapy derived from the pioneering work of Sigmund Freud and his psychoanalytic method. This kind of therapy is often called "psychodynamic."

There are wide variations even here. At one extreme are what might be called procrustean Freudians. These therapists try to reveal to the patient as little of themselves as possible in order to elicit the patient's repressed fantasies by forcing the patient to fill in the blank (these therapists describe their ideal self-presentation to the patient as being a "blank screen"). These therapists interpret their patient's problems of living in terms of supposedly universal individual unconscious mental structures and conflictual processes described by Freud. Among their polar opposites are interpersonalists who see functional problems of living as deriving primarily from pathogenic social situations to which the individual has been forced to adapt his or her orientation in life. These therapists strive to present themselves authentically to the patient. They emphasize development of a more honest real relationship between patient and therapist as the basis upon which the patient can discover distortions and constrictions of his or her orientation in life which resulted from those earlier pathogenic relations. In general, however, psychodynamic therapists see the individual's feelings and beliefs -- the individual's orientation in the world -- as motivating his or her social behavior and personal life through a complexly layered interaction of many factors (forces, etc.), and they believe the patient can improve his or her effectiveness and satisfaction in living via better insight into and consequent increase in capacity responsibly to deal with these factors.

I have stated the foregoing in very general terms. The point is that I am limiting myself to consideration of psychotherapy which is oriented straightforwardly toward helping patients gain insight into the dynamics of their form of living in order to become better able to assume responsibility for their form of living in future. Freud described this endeavor in many ways over the course of his long career, including the well known dicta of "making the unconscious conscious" and that "where id was there ego shall be."[ (this last assertion is better translated: "where unaccountable process was, there self-accountable action shall be.")] The basic model is that a person shapes his or her life based on what the person understands the available choices in life to be. As a result of developmental vicissitudes, the patient's awareness of important areas of life and his or her options vis-à-vis them are distorted or wholly blocked out of awareness. Therefore the patient chooses and acts based on impoverished and distorted information. The goal of therapy is for the patient to gain as clear as possible understanding of all important aspects of his or her life so that he or she can choose and act with maximal effectiveness, knowing both what he or she faces and the resources he or she has to face it with. As Freud wrote:

...[T]he pathogenic conflict in neurotics is not to be confused with a normal struggle between mental impulses both of which are on the same psychological footing. In the former case the dissension is between two powers, one of which has made its way to the stage of what is... conscious while the other has been held back at the stage of the unconscious. For that reason the conflict cannot be brought to an issue; the disputants can no more come to grips than, in a familiar simile, a polar bear and a whale. A true decision can only be reached when they both meet on the same ground. To make this possible is, I think, the sole task of therapy.

Moreover, I can assure you that you are misinformed if you suppose that advice and guidance in the affairs of life play an integral part in analytic influence. On the contrary, so far as possible we avoid the role of a mentor such as this, and there is nothing we would rather bring about than that the patient should make his decisions for himself. (1917/1963, p. 433)

I am limiting myself to supervision of psychotherapy whose objective is straightforwardly to bring about increased insight and autonomy in the patient. In other words, in supervision of this kind of therapy, supervisor and supervisee talk about how to foster the patient working over the patient's communicative matrix (the patient's representational image of the world) to make it more adequately and effectively represent his or her situation in life. An important consequence of this perhaps seemingly obvious point, for the purposes of this dissertation, is that because supervisor and supervisee are trying to foster communicative action between supervisee and patient, there is no intrinsic discrepancy between the kind of communication supervisor and supervisee may strive for in their own relation and that about which they talk therein.

On the other hand, in forms of therapy where, from a communicative perspective, in one way or another the patient is manipulated by the therapist, supervision can at best consist of communicative action between supervisor and supervisee which has as its content strategic action between supervisee and patient. In supervision of psychodynamic therapy, however, supervision can consist of communicative action (between supervisor and supervisee) which has as its content communicative action (between supervisee and patient). There is no a priori reason for this communicative interaction to have any admixture of mystified or distorted communication.

The second limitation on my area of focus concerns two major dimensions of the therapist's work which contrast especially strongly in such psychodynamic, insight-oriented therapy. As stated by Freud, above, one of the goals of dynamic therapy is to enable patients to make their own decisions in life and maximize their autonomy. I will call this kind of work psychodynamic therapy in a strict (or "narrow") sense, i.e., therapy which is directly focused on the vicissitudes of meanings which comprise the dynamics of the psyche (in contrast with pragmatic considerations); it alone is what I shall focus on herein. Ideally this kind of therapy consists solely of talk, with the patient being continually helped (as Freud often said) to remember his or her past and discuss it with the therapist, instead of the patient repeating the past in actions the meaning of which the patient is not aware. This is a "pure" field of conversation (and thus a "pure" field for studying conversation).

But much of a therapist's work deals with realities in patients' lives. I call this the "case management" aspect of therapy. A patient who is homeless, jobless (and lacking other financial resources), suffering from a physical ailment for which he or she is avoiding treatment, the object of ongoing abuse by other persons in his or her environment, etc. will likely need to have these issues handled before "talk therapy" can do much good. No talk therapy can be done with a patient who is dead or even "just scared to death." Sometimes, changes in environmental conditions may be all the help a person needs.

This pragmatic dimension of psychotherapy is very important, but I shall not concern myself with it in this dissertation. One reason is that case management is not necessarily part of every course of insight oriented therapy. There are patients whose current external conditions of life are "good enough" already. A woman who was a victim of childhood abuse and who is currently having difficulties relating to her husband who genuinely is and whom even she realizes is a kind and nurturing person, does not need a new husband but rather help in working through effects of her earlier experience which, with the best of intentions, are "too much" for the couple to handle without expert assistance.

Another issue is that, even where case management is an important part of therapy, frequently it is not enough, because even if all the external impediments to the patient's life are remedied, his or her patterns of relating to the world are such as to lead to the person generating new environmental entanglements and defeats. A person who has immense resentment concerning past abuse and neglect, if put in a nurturing social situation, may proceed to vent anger on these innocents with the effect of alienating them, thus putting him or herself back in the same situation as before ("See, people are all the same. Nobody helps me...."). Elias Canetti's novel, Auto-da-Fé (1935/1979), is a fictional example of this kind of self-defeating personality dynamic: A great scholar with otherwise very limited personality development gets involved in intrigues which he thinks will lead to a vast expansion of his scholarly library but actually lead to him losing everything he owns. His brother, who, ironically, is a psychiatrist, rescues the scholar from dilapidated homelessness and reinstalls him in his former life in all its details, but does nothing to deal with any personality issues. The brother leaves, thinking everything is well once again, and the scholar proceeds to commit suicide on a pyre of his books.

Freud described ideal circumstances for psychotherapy, and the constraints frequently placed on that ideal by reality:

In the years before [World War I], when arrivals from many foreign countries made me independent of the favour or disfavour of my own city, I followed a rule of not taking on a patient for treatment unless he was sui juris, not dependent on anyone else in the essential relations of his life. This is not possible, however, for every psycho-analyst. Perhaps you may conclude from my warnings against relatives that patients designed for psycho-analysis should be removed from their families and that this kind of treatment should accordingly be restricted to inmates of hospitals for nervous diseases. I could not, however, follow you in that. It is much more advantageous for patients (in so far as they are not in a phase of severe exhaustion) to remain during the treatment in the conditions in which they have to struggle with the tasks that face them. But the patients' relatives ought not to cancel out this advantage by their conduct and should not offer any hostile opposition to the doctor's efforts. But how do you propose to influence in that direction factors which are inaccessible to us? And you will guess, of course, how much the prospects of a treatment are determined by the patient's social milieu and the cultural level of his family. (1917/1923, pp. 460-1)

My main reason for restricting myself to supervision of dynamic psychotherapy in the narrow sense, ignoring the -- I repeat -- in practice often crucial issues of case management, is not that such work is not a key part of a therapist's professional endeavors, or that it is not important for the therapist to learn how to do it well. My primary reason is that supervision of this aspect of therapy is much less interesting from the standpoint of studying communication (incidentally, it may also, in part for this very reason, be easier to teach and learn).

Any time a learner's efforts are examined there is potential for anxiety. Where a technical skill is being acquired, however, the threat to the learner's self-esteem is relatively narrowly circumscribed. Nobody is expected to acquire dexterity in, e.g., surgery, without practice. A surgeon in training first develops his or her skills on animals and cadavers. Then the student is given gradually more demanding roles in real operations. Mistakes are expected and experienced practitioners are close at hand to help the learner get it right and to undo his or her mistakes before they cause significant harm. In learning a technical skill, only exceptionally inept students are likely to suffer serious damage to their self-esteem, and, even then, the failure does not cut so deep, since not everybody has the potentiality to do equally well every kind of skilled activity (the medical student who cannot master surgical technique might have a real knack for diagnostic, and become a fine internist...).

Supervision of the case management part of psychotherapy is this kind of communicative interaction between supervisor and supervisee. If a patient needs to be removed from an abusive home situation, there are social welfare and other resources to help deal with the situation. The student cannot be expected to know these without learning about them. To follow a supervisor's advice in handling such matters is for a psychotherapist like a surgery intern's following a surgeon's advice in suturing up an incision. There may be interpersonal "issues" here: a supervisor may tell the supervisee what to do in an unnecessarily authoritarian way which makes the student feel demeaned; the student may feel it is not part of his or her identity as a "psychoanalyst," albeit in training, to have to "get one's hands dirty" doing this kind of "social worker" work. But these problems can usually be smoothed over with reasonable sympathetic encouragement from the supervisor (or else, the student may soon enough find out he or she really doesn't like the work).

In supervision of the core communicational aspects of therapy (what I have called "psychotherapy in the narrow sense"), the potential threat to the student's self-esteem is massively greater. Logistically, there is far less opportunity to introduce the student to the complexities of the work in a graduated way. Even when training cases are carefully selected, so that training institute faculty believe the student has been provided with a client whose problems are within the student's ability to handle with the help of the student's supervisor (and possibly other support resources), from his or her very first therapy session, the student generally walks into a room with the patient and shuts the door, and, for the next "hour" (even if it is only 45 minutes) is "on his or her own" -- somewhat as if a surgery intern's introduction to the operating room was a patient anesthetized on the table and the nurses standing by to follow the intern's orders, but nobody available to give him or her any advice. And since psychological "diagnoses" are far more uncertain than pre-surgical medical evaluations, it is always possible that the patient will do "anything." The pressure on the student psychotherapist's performance is immense.

Even more anxiety producing, in doing psychodynamic therapy, no matter how much their training program may tell students that they are learning a "skill," the underlying situation is always the communicative relationship between therapist and patient. I believe that students are often confused about this -- by which I do not mean just that they lack orientation due to inexperience, but more lamentably that their training [iatrogenically] makes them confused by teaching them all sorts of theory and technique and not emphasizing the basic communicative nature of their work. I contend that the two fundamental pedagogical objectives on which psychotherapist training should focus are: (1) developing interpersonal communication -- especially conversational -- competence, sensitivity and confidence, and (2) learning case management skills. Without this foundation firmly in place, "personality theory," "psychopathology," "therapeutic technique," etc. -- the content matter which occupies center stage in training programs -- is all, at best, ineffectual and even frequently deleterious (student-therapists will often interact with patients in insensitive ways because their training has taught them it is "good technique").

When the therapist in training makes a "mistake," it is generally not analogous to a faulty suture on an anesthetized surgical patient, which the overseeing surgeon can rectify without the patient even (or ever) noticing it. The psychotherapist's patient feels the "mistake." Since patients often have sought therapy in part because they are sensitive to being hurt, the impact of the student's mistake on a patient may be magnified (A to S: "I don't know what I did. I just said to P something like: 'You talk about these bookish things because this helps you to overcome your anxiety,'[1] and P just blew up."). --The underlying threat to students' self-esteem here is that no matter how much their training may tell them that therapy is a technical skill or a "science," so long as a thoroughly objectivating attitude is not adopted toward the patient, the students' interactions with patients are conversation, and a student's [technical] "mistake" is also a failure of simply-human empathy with a fellow person.

The communicative interaction of supervision of psychotherapy (as I have limited my focus above!) has as an intrinsic part of its content the supervisee's personal character and overall sense of "who he or she is." An essential part of what is examined in supervision is "who the supervisee really is," as revealed in his or her work with clients, as well as in his or her interaction with the supervisor concerning this highly sensitive material. The nuances of this communicative relationship (and I am far from having covered "everything") promise to be rich material for study.

As a further restriction of this dissertation, I note that I am going to focus on one-on-one supervisory interaction. There are a variety of alternatives in which a group of students meets with a single supervisor ("group supervision"), which would also be interesting to study, especially in regard to how group dynamics affect the supervisory process differentially from the intimacy of a one-on-one situation. Some writers argue that the group situation reduces the supervisor's potential to intimidate the student, and the student's potential to overidentify with the supervisor (etc.), by introducing the multiple points of view and mutual support of the several students vis-à-vis the supervisor (technically, this is called "diluting the transference") (see, e.g., Caligor, 1981, p. 4). I have concern, on the other hand, that the group situation can, instead, foster conformity, since it may be harder for an individual to assert him or herself vis-à-vis a group's "consensual reality" than against the position of another individual who, even if more experienced, socially powerful, etc., is nonetheless ontologically the person's equal (see, e.g., Wolstein, 1984, pp. 136-7; Gaoni & Neumann, 1974, p. 113). The possibilities are surely interesting, but will not be explored here.

Briefly to review my delineation of the object of study in this dissertation: I am going to examine one-on-one supervision of the narrowly psychodynamic component of insight oriented psychotherapy. I am going to examine such supervision under further restrictions: Wherever it makes a difference, I will bias my considerations toward the situation of students who are at the beginning of their training, and whose supervisors have responsibility to provide evaluative report to the student's training institution.

I repeat that many of the things I am excluding are important (esp. case management). I feel that they are in various ways theoretically peripheral to my focus on "conversation as the true home of persons" and my objective of exploring one seemingly exceptionally promising scenario (again, I do not claim there are not other candidates) how to operationalize this. Pursuant to this orientation, another aspect of supervision which I shall not consider is supervisory traumata, inquisitions and holocausts. They happen (I personally have been the object of one). Jeffrey Masson's book, Final Analysis (1990) is a public record of the extreme degree of intimidation to which a student can be subjected by his or her putative mentors in this field. But, again, this is not an essential aspect of supervision, and its potential contribution for study to learn about the constructive potentialities of conversation is poor.

There is, however, a reason I have included the evaluatory aspect of supervision in my considerations, in a general way (as opposed to its [more egregious] potentials for abuse). This connects with a point in a preceding quote from Freud, where he said that it was best for patients to remain during treatment in the social situation in which they will continue to be after treatment is over. I personally strongly endorse all efforts to ameliorate patient's real-life circumstances. "The clinical picture of a person who has been reduced to elemental concerns of survival is still frequently mistaken for a portrait of the victim's underlying character" (Herman, 1992, p. 117). And the man whose name is eponymic for "'the survival of the fittest'... is of particular interest to dynamic psychiatry[, since] few men had been less fit for a life of harsh competition than Darwin himself... [who] would not have been able to carry out his work had it not been for his personal fortune and the care of a devoted wife" (Ellenberger, 1970, pp. 235-6).

Nonetheless, there are limits, often seriously, frustratingly, tragically constricting limits, to what can be done to ameliorate a person's real life situation. We find ourselves embedded in social matrices which often are less than "good enough." In this dissertation, I shall propose some practical measures persons can take to significantly improve their lives without depending on institutional or other changes outside their immediate sphere of effective action. Most patients find themselves in situations where they have to make compromises with "reality." That an aspiring psychotherapist has to deal with the issues of supervisory evaluation as part of his or her supervisory experience is not desirable. But it is an often inescapable fact from which some [pedagogical] utility may be salvaged.

If, as Ruesch and Bateson proposed, insofar as biologically unnecessary but socially unevadable asymmetrical social relations continue beyond the requirements of infantile dependence, disturbances of communication and consequent mental ill health are likely to ensue (Ruesch & Bateson, 1951, p. 38), then the supervisory situation provides as good a laboratory as anyone is likely to find for figuring out how to minimize the disturbances when their cause cannot be removed. In general, in the supervisory interaction, the level of expertise in interpersonal relations the participants can bring to bear is higher and the real-life "stakes" lower than in most other asymmetrical communication situations (e.g., boss and worker, parent and child, doctor and patient, etc.). With reasonable good will on the supervisor's part, the evaluatory dimension of supervision can be turned to good account in helping the student more effectively come to terms with this aspect of life which is and likely will continue to be a leitmotiv of his [(or her)] own and his [(or her)] patients' lives.


 
 
 
 

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Footnotes

  1. I have borrowed this sentence, with some shift of context, from my primary example: Example 1.


BMcC signature seal stamp. Modelled on 18th century messenger's letter box in collection of Suntory Museum, Tokyo. Japanese write poems and prayers on slips of paper which they tie into knots like this shape although with longer legs. Prayers are often tied to branches of trees which can look like they are covered with snow. "Symbol of a symbol, image of an image, emerging from the destiny that is sinking into darkness...." (H. Broch, "The Sleepwalkers", p.648) Always remember. Add value. (This image created not later than 21 May 2003)Invenit et fecit


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