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Supervision and its Vicissitudes

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A collection of papers dealing with supervision. 192 pages.

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CHAPTER ONE. On transference and countertransference and the technique of supervision

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León Grinberg

Introduction

Among the many definitions that have been given to describe the process of supervision, I would like to underline the following ones: “It is a learning experience, in which an analyst is sharing with a colleague the fruits of clinical knowledge” (Arlow, 1963). Or, otherwise, “a complex process that takes place on behalf of an experienced analyst whose goal is to enable another analyst of lesser experience to be as efficient as possible in his task of helping the patient” (Horn, 1957). Supervision is a process that allows for personal and professional growth in the supervisee, and one of its objectives is to make it possible for the analytic situation to develop in a way that allows the supervisee to experience the phenomenon of psychoanalysis, to learn to conceptualize the experience he is living, and to reach and have insight in the experiences lived by the patient (Schlesinger, 1981).

John Keats (1817) referred to Negative Capability as that “when a man is capable of being in uncertainties, mystery, doubts, without any irritable reaching after facts and reason”. I agree with Blomfield (1985) when he says that analyst and supervisor should apply the principle of “negative capability” in psychoanalytic work. Our contact with early phantasies and primitive mental mechanisms, our accumulated knowledge, the application in therapy, in teaching, and in those theoretical branches all derive from the disciplined use of “negative capability”.

 

CHAPTER TWO. Psychoanalytic supervision of untrained therapists

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Victor Sedlak

Introduction

In this chapter I describe aspects of the supervision of therapists who have not had a formal, comprehensive training, part of which would have included psychoanalysis for themselves. I argue that the supervisory process with such people throws light upon several important aspects of all psychoanalytic supervision. Principally, I wish to show that a therapist’s work will deteriorate at the moment at which he is unable to deal with the countertransference in a professional, psychoanalytic manner. More specifically, it is when a negative countertransference is being experienced and cannot be managed that problems most frequently arise. This can be a greater handicap to the therapist and pose a greater risk to the therapeutic endeavour than the therapist’s lack of knowledge of the finer points of the theory of psychoanalysis.

The unavailability of personal therapy or analysis and of a good training experience does not stop people in the caring professions working in what they consider to be an analytic or dynamic way. Senior practitioners can of course choose to have little to do with this possible diminution of standards; alternatively they can explore in what ways they can help, while maintaining their professional integrity. I have chosen the latter course.

 

CHAPTER THREE. On the process of supervision in psychoanalytic psychotherapy

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Montserrat Martinez del Pozo

Introduction

This chapter is based on the ideas of Freud, Klein, and other post-Kleinian authors—especially Leon Grinberg—and also originates from my personal experience of receiving and giving supervision. The supervisions have been carried out with psychotherapists in four-year training programmes in both the public and the private sectors (the Clinical Psychology Service of the Fundacion Puigvert, Hospital de la Santa Cruz y San Pablo, Universidad Autonoma de Barcelona, and the School of Psychoanalytic Psychotherapy of the ACPP-AEPP). The clinical material comes from children, adolescents, and adults undergoing individual or group psychoanalytic therapeutic processes.

The relationship between the “learning position” and the different psychic positions in the supervision process and in the interaction between the various participants in the supervision unit

When a supervision process develops favourably, we become aware that we are submerged in a rich, complex, and shared process of evolution in which each of its components—the patient, the supervisee, the supervisor, the staff, and at times the institution— all experience a beneficial transformation. (In the 1970s, through a teaching programme, “Psychoanalytic Psychotherapy in the Public Institution”, members of the Spanish Psychoanalytic Society— Bassols, Bea, Campo, Corominas, Eskelinen, Esteve, Feduchi, Folch, and Hernandez—made it possible for systematic supervision to be inserted in the public-health network, contributing to a considerable transformation in the quality of service provision in mental health institutions.) We can then affirm, without a doubt, that skilled supervision is one of the most important channels for understanding the patient, as well as for transmitting and integrating theoretical, technical, nosographic, and developmental knowledge. Through a supervision we transmit knowledge to a therapist and a specific patient in a very live, personalized, sensitive, and thoughtful way, as well as know-how and a psychotherapeutic attitude actively based upon the emotional experience undergone in clinical practice. Also, supervision through a psychoanalytic psychotherapy framework allows a much broader view of emotional problems and illnesses, far beyond those of only the therapist-patient relationship.

 

CHAPTER FOUR. Supervision in mental health teams and institutions

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Ulrich Streeck

Introduction

Psychic and social factors exercise a lasting influence on the manifestation, progress, and treatment of mental diseases. In addition to pharmacological and social therapeutic treatment, psychotherapeutic means can positively influence psychotic disorders. Furthermore, the relationship to the patient of the therapists involved in the treatment, the relationship of the members of the therapeutic team to one another, and the institutional conditions in general, all play an important role in the progress of the disease and its treatment. Experience of this has led to an awareness of the importance of recognizing and understanding these psychosocial conditions, with their diverse and complex relationships in psychiatric institutions, in order to create the requirements necessary to influence them therapeutically. Supervision is designed to achieve this goal.

Attitudes towards supervision

Attitudes towards supervision in psychiatric institutions have long been conflicting, and one still occasionally meets with reservations and ambivalence. The majority of therapeutic co-workers regard supervision as indispensable, but sometimes one also encounters the viewpoint that supervision in psychiatry—particularly psy-chodynamically and psychoanalytically oriented supervision—is superfluous or even harmful. Unrealistically high expectations are occasionally attached to supervision, but supervision is also at times regarded as a luxury that is contrary to the essence of psychiatry. Sometimes the prospect of supervision awakens anxiety because it is associated with control and surveillance. Such fears are especially strong in institutions that operate, as do many psychiatric hospitals, in the force field between therapy and state control—though again, false hopes may be attached to supervision as a means of liberation and self-government. With the prospect of supervision also arise fears of a subversive element that could endanger the familiar security and routine of day-to-day psychiatry, while, on the other hand, supervision may become the focus of illusory hopes for relief from untenable situations.

 

CHAPTER FIVE. Supervision in a hospice for AIDS patients

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Peter-Christian Miest

The setting

The care of terminally ill patients confronts caregivers with a set of specific stresses and requires effective institutional support such as regular supervision of the staff. As Vachon has recently pointed out in her comprehensive review (Vachon, 1995), this necessity has received much attention by the modern hospice movement. This chapter reflects some of my experiences over the past five years of supervising carers in a nursing home for AIDS patients. Prior to the supervision there had been an alarmingly high turnover of personnel; it was hoped that, through supervision as a form of caring for the caregivers, this turnover could be reduced.

The supervised institution is a twelve-bed hospice with about thirty-five, mostly part-time, staff members chosen from diverse occupational fields. The hospice admits patients who, because of their AIDS illness, have in some way come to need additional care. They therefore exhibit all kinds of features of terminal bodily breakdown. It can be that a patient, because of a psycho-organic brain condition, needs not so much physical care but rather a cognitively and socially supportive environment; or that a patient, who until now was cared for by relatives, takes advantage of the infrastructure of the hospice and moves in—even with his relatives. In exceptional cases, and when there are beds available, patients who suffer from a terminal illness not caused by AIDS will also be admitted. Not all patients who come into the hospice die there. After all, it is typical with AIDS that totally unanticipated deterioration or improvement in the condition occurs. This sometimes leads to patients being able to return to their previous surroundings after a phase of intensive care. Frequently, they are readmitted after a few months, when their condition again worsens. The composition of the group of a maximum of twelve patients changes rapidly and randomly, depending on which patients were just admitted and which have already left or died. The mean length of stay of a patient in the hospice is forty-five days. From the nature of HIV infection it will be readily understood that intravenously injecting addicts and homosexual men are the most frequent patients.

 

CHAPTER SIX. From action to thought: supervising mental health workers with forensic patients

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Dorothy Lloyd-Owen

Introduction

The Portman Clinic is a national resource, an out-patient clinic within the public sector, offering psychoanalytic psychotherapy to children, adolescents, and adults, who come with problems of sexual perversion, violence, or delinquency. It is a small clinic, staffed entirely by psychoanalysts and psychoanalytic psychotherapists, some of whom are psychiatrists, others having backgrounds in psychology, social work, or related disciplines. Our understanding of our patient group is based firmly in clinical practice and developed through research and training.

Consultation and supervision are offered to colleagues in primary forensic settings, such as special hospitals, prisons, regional secure units, and the probation service. The vast majority have no psychoanalytic background, and their approach is, broadly speaking, behavioural and cognitive. Ostensibly, these colleagues come to the Portman Clinic because they want to learn and think more about the psychodynamic approach to understanding their patients/clients and their task. However, in my experience they actually come because they feel themselves to be impoverished or frozen, and they find that their one-dimensional techniques leave them ill-equipped to deal with forensic patients who are highly disturbed. Such a sense of impotence means that they often come for supervision with the expectation (and hope!) of being offered a magical solution.

 

CHAPTER SEVEN. (How) Is learning possible in supervision?

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Imre Szecsody

Having been engaged in the training and supervision of psychoanalysts and psychotherapists, and also in the training of supervisors, for many years, I have become increasingly more interested in how learning takes place in supervision. This interest stimulated me to start a study of the supervisory process. My point of departure was that psychoanalysis and dynamically oriented expressive psychotherapy are applications of the same basic science. The aims of both psychoanalysis and psychotherapy are to enable and facilitate change, growth, and emancipation for the troubled individual. The common task is to establish a specific relationship within a specific frame in which the patient can gain insight into his consciously and unconsciously enacted experiences, expectations, wishes, and fears. Appelbaum (1978) notes that insight presupposes accommodative learning, which goes beyond the assimilative type of learning (defined later in this chapter) and can lead to change, which is further facilitated by what many call a corrective emotional and ideational experience. Within the boundaries of the analytic situation the individual’s history is re-experienced, restructured, and, above all, narrated; it acquires new meaning and regains old meanings that were lost. Uniting seemingly separate events into meaningful sequences establishes a coherence, a new order, by way of understanding: “It is a final act of self-appropriation, the appropriation by oneself of one’s own history” (Marcus, 1985). (I use the terms psychoanalysis/psychoanalyst and psychoanalytic psychotherapy/psychoanalytic psychotherapist without necessarily distinguishing between the two activities and roles for the purposes of this chapter because my supervision technique and my research investigations were the same in both.)

 

CHAPTER EIGHT. The framework of supervision in psychoanalytic psychotherapy

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Robert Langs

All human interactions take place within a framework or context—a setting, an array of rules, and well or poorly defined physical and interpersonal boundaries. Such frames constitute a vital factor in determining the nature and meanings of the interactions that occur within their confines. Thus, transactions involving frames and boundary conditions are, per se, critical events for the individuals involved. These principles, which apply throughout nature, pertain to both psychotherapy and its supervision. (For purposes of focus, I confine my comments here to the supervisory experience; the application of these principles to the treatment situation can be found in Langs, 1992,1993,1997.) On both conscious and unconscious levels, ground-rule interventions and behaviours are a major influence on both parties to a supervisory experience. Nevertheless, because of an almost exclusive concentration in supervision on the contents of presented sessions, the many powerful effects of ground-rule-related actions and especially a supervisor’s management of the framework of supervision have been largely neglected.

 

CHAPTER NINE. An advanced training in the supervision and teaching of psychotherapy

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Kurt Gordan

The training of psychotherapists can never be better than the competence of its supervisors. In 1976, this realization influenced those of us working at the Erica Foundation to plan and put into action the first two-year systematic supervisor training programme for psychotherapists in Sweden. [The Erica Foundation in Stockholm, Sweden, is an independent institute providing at university level: (1) a professional training for child and adolescent psychotherapists; (2) a psychotherapy service for children and adolescents; and (3) research. Both the training programmes and the psychotherapy service are based on psycho-dynamic approaches. The institute is largely funded by central government and the county council.]

During the twenty years that have passed since then, this training has naturally changed and improved. However, the overall plans and content have, for the most part, proved to be practicable in reaching the goals that we set out to achieve. Our model for the training of supervisors and teachers of psychotherapy has also formed the basis for the majority of training courses for supervisors that have now been arranged elsewhere in Scandinavia. Considering the great interest that our training for supervisors has aroused outside Scandinavia, it is appropriate to describe here the essence of the Erica Foundation training for supervisors and teachers of psychotherapy.

 

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