the shift from "ordinary" to "extraordinary" experience in psychodynaimc...

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The Shift from “Ordinary” to “Extraordinary” Experience in Psychodynamic Supervision

James Tobin, Ph.D.

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James Tobin, Ph.D.

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James Tobin, Ph.D. Private Practice, Newport Beach, CA

Assistant Professor of Clinical Psychology Argosy University, Orange County, CA

phone: 949-338-4388web: www.jamestobinphd.comemail: [email protected]

http://www.jamestobinphd.com/

mailto:[email protected]

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Introduction

In this presentation, I will present an approach to psychodynamic supervision inspired by my work with one particular student.

Her use of the word “extraordinary” in a discussion helped me to conceptualize an important process in dynamic supervision: the shift from “ordinary” to “extraordinary” experience; this has become a central organizing metaphor in my work and I will attempt to describe its heuristic value in this talk.

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Introduction

If we agree, as Ablon and Jones (2005, p. 564-565) observed in their empirical work on the analytic process, that “psychological knowledge of the self can develop only in the context of a relationship within which the psychotherapist endeavors to understand the mind of the patient through the medium of their interaction”, then I hope this presentation will provide a pragmatic framework for how to support supervisees in creating this medium through the metaphor of the “extraordinary.”

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Psychotherapy Training: A Fairly Bleak Picture

Numerous researchers and writers have portrayed a fairly bleak picture of the efficacy of psychotherapy training at all levels of professional development, including the training of psychoanalytic candidates.

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Psychotherapy Training Issues

Major problems with current training approaches are well documented in a comprehensive review by Fauth et al. (2007) and include:

• Too narrow of a focus on therapeutic micro-skills;

• Emphasis on technical adherence to theoretical orientations at the expense of more global capacities;

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Psychotherapy Training Issues

• Strict adherence to manual-guided techniques;

• The failure to foster durable improvements in overall therapeutic effectiveness.

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Binder’s Critique

In two important papers in which he evaluated the empirical and theoretical literature re: psychotherapy training, Binder (1993, 2002) concluded that we lack a research-informed pedagogy for formal psychotherapy education and training at the graduate level, and that the effectiveness of our academic programs is assumed largely on faith.

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Binder’s Critique

He observed that clinical psychology programs customarily teach specific procedures and skills in a progression from simple to more complex performances, with an emphasis on micro-skills in which discrete teaching modules expose students to particular facets of the clinical situation and interventions (e.g., active listening, open-ended questions, etc.).

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Binder’s Critique

He stated, “It appears, however, that while these ‘micro’ components of interviewing can be effectively taught, the components do not easily gel into the more complex performance skills actually used in clinical interviewing” (Binder, 2002, p. 4).

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Binder’s Critique

Curricula expose students to theories and procedures linked with various treatment models followed by “an abrupt transition to ‘practicing’ with real patients” (Binder, 2002, p. 5).

Conceptual knowledge is not readily useable to guide a practical understanding and skillful performance in the real world; there is little information available to students about how a treatment is actually conducted.

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Binder’s Critique

Binder (1993) suggested that it is likely supervision is being conducted incompetently by many supervisors.

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Negative Perceptions of Supervision

Many supervisees view supervision to be an unhelpful and, at times, a highly negative experience (Fauth et al., 2007; Ramos-Sanchez et al., 2002).

Galante (1998), for example, found that 47% of trainees had experienced at least one ineffective supervisory relationship.

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Lack of Training/Not a Distinct Professional Activity

Little formal training is offered for supervisors (Russell & Petrie, 1994) and supervision itself is not typically perceived as a distinct professional activity with its own unique processes and goals.

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Stylistic Preferences and Rigidity of Roles

The personality of the supervisor tends to correspond to broad supervisory styles (task-oriented, interpersonally-focused, etc.) (Freidlander & Ward, 1984; Shanfield & Gil, 1985) that unwittingly shape and determine the supervision experience.

Many supervisors approach supervision in a vague, undetermined way (Milne & James, 2002), often resulting in their being primarily didactic or adopting a largely supportive or collegial role.

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Perpetuation of Poor Supervisory Models

Supervisors also tend to repeat the mistakes made by their own supervisors (Worthington, 1987).

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Ladany’s “Litmus Test”

Ladany (2007) observed that we have not done a good job in determining graduate school admission criteria that reliably predict psychotherapy competence.

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Ladany’s “Litmus Test”

He (2007) wrote, “It should not surprise us, then, that a decent percentage of students graduate who are not well equipped to be reasonably good therapists. A good litmus test for this supposition is to ask ourselves whether we would refer a family member (that we liked!) to a therapist whom we are graduating. I would venture a guess that about a third of the time the answer would be no” (p. 395).

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But the Good News Is We Are Making Forward Progress

Despite these training problems and the corresponding lack of a consensual model for conceptualizing and implementing supervision, we are making significant strides!

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Expansion of the Supervisory Function

The supervisor’s task is no longer viewed as solely didactic or focused on merely imparting technical or theoretical knowledge; instead, the supervisory function consists of numerous interrelated roles that include supportive, technical and modeling components directed toward the cultivation of a therapeutic identity (Milne and James, 2002).

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Developmental Stage Models

Developmental stage models (e.g., Heppner & Roehlke, 1984; Stoltenberg & Delworth, 1987, 1988) have helped to define approaches to supervisory intervention based on the supervisee’s level of competence and experience.

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Relational Emphasis

The supervisory relationship (Ekstein & Wallerstein, 1972; Hedges, in press; Watkins, 1997, 2011; Worthen & McNeil, 1996) has also been emphasized as a primary framework for understanding how complex, co-creative interpersonal patterns of interaction and enactment between supervisor and supervisee may correspond to the trainee’s relationships with her patients.

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Relational Emphasis

This emphasis reflects the notable empirical finding (which has transtheoretical implications) that, more than any other factor, the quality of the psychotherapeutic relationship remains the strongest predictor of treatment outcome (Hedges, in press; Norcross, 2002; Orlinsky et al., 1994).

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The Educational Pyramid

A triadic model (Bernstein, 1982; Seidman & Rappaport, 1974) in which the inter-relationships of the three figures of psychotherapy training (client, trainee, and supervisor) has contributed to the design of empirical research programs and a supervisory focus on clearly connecting theoretical and didactic learning with interventions and outcomes.

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Moving from Micro-Skills to Super-ordinate Goals

Micro-skills continue to be addressed in supervision yet are so within a broader set of therapeutic competencies and super-ordinate goals that more realistically reflect the professional role of therapist.

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Moving from Micro-Skills to Super-ordinate Goals

For example, Binder (2002) defined 4 super-ordinate goals for the student in supervision: (1) to conceptualize clinical material; (2) to select and apply therapeutic interventions; (3) to develop professional beliefs and values; and (4) to behave ethically.

For Binder, the best supervisors find ways to link these 4 goals into a cohesive learning experience for the trainee.

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Self-Awareness as a Therapeutic Competency

Beyond knowledge- and skill-based approaches to supervision intervention, there has been increasing interest in encouraging the supervisee’s self-awareness and ability to understand and use the self in the clinical situation (Ladany, 2007).

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Tuckett’s Three Frames

In an attempt to conceptualize the competence of psychoanalytic candidates, Tuckett (2005) theorized that advanced skill level is characterized by the capacity to sustain three linked lenses or frames: (1) participant-observational, (2)conceptual and (3) interventional.

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Tuckett’s Three Frames

As described by Sarnat (2010, p. 21), Tuckett (2005) defined the participant-observational frame as “ ‘the way the analyst is with the patient’ (p. 37), and emphasized the analyst’s capacity to bear and process, rather than act, on the emotional states that the patient evokes within her or him.”

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Self-awareness/Use of the Self: The Lack of a Clear Pedagogic Method

Self-awareness and the use of the self in the clinical situation are contextually valid and fundamental components of therapeutic work, especially evident in highly-skilled experienced therapists.

But the capacity to identify and use self-experience is highly difficult to cultivate and refine in trainees and often is not even approached by supervisors (due, in my opinion, to the lack of a clear pedagogic method for how to do so).

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A Major But Under-emphasized Issue: “Sterile” Supervision

In my reading of the literature, and upon reflection on my own work and the work of my colleagues, I have often wondered if the lack of a clear pedagogic method for promoting the supervisee’s use of self-experience causes “sterile” supervision.

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Sterile Supervision

Sterile supervision is characterized by content and process factors which dilute the authentic experience of the supervisee (and of the supervisor as well), attenuating the interaction significantly and restricting the range of interpersonal experience and psychological inquiry to safe comfortable zones.

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Sterile Supervision

Sterile supervision, in my opinion, arises from pressures (within the supervisee, the supervisor, and/or within the institution in which treatment and supervision are occurring) toward standard forms of social etiquette and decorum that tend to predominate the supervisory interaction.

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Sterile Supervision

We have all heard about or even experienced supervisory sessions that seem no different in tone or content from formal business transactions, classroom experiences or dinner parties!

Although these modes of interaction are, at times, reasonable and appropriate for the supervisory relationship, I think the patterned and consistent dilution of the supervision experience represents a more insidious problem.

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Evidence of Sterile Supervision

For years, anecdotal evidence and empirical research have suggested that the supervisory interaction is frequently inauthentic, falsified, and/or censored.

Gabbard (2010) notes that supervisees’ presentation of clinical material is commonly filtered or distorted.

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Compliance and Social Desirability

Many supervisees, of course, experience a conflict between presenting what makes them “look good” to their supervisor vs. sharing their struggles and difficulties “which may maximize the learning process but could result in a less glowing evaluation” (Gabbard, 2010, p. 193).

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Compliance and Social Desirability

In my own discussions with students and practicing professionals, some quite sophisticated, many indicate that they still feel as if they have “to be” a certain way clinically in order to appeal to the overt and covert preferences of their supervisors or peers in consultation groups.

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Empirical Evidence of Compliance in Supervision

Further, there is a growing body of research that indicates strong bidirectional processes of control, compliance/submission and social desirability in clinical supervision.

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Using an intensive case study method to evaluate speech acts throughout one semester of supervision, Martin et al. (1987) found that the supervisor being evaluated frequently acted in a more controlling and assertive manner as compared to the more compliant supervisee.

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Alpher (1991), in a study of short-term psychodynamic treatment, found that the interpersonal process between supervisor and trainee frequently consisted of control behaviors on the part of the supervisor and submitting behaviors on the part of the trainee. Interestingly, these observations corresponded with additional data showing that, at times, the patient viewed the trainee-therapist to be controlling as well.

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Empirical Evidence of Compliance Supervision

Alpher (1991) also noted that as the supervisor’s controlling acts evoked a greater degree of submission on the part of the trainee, the supervision gradually became narrowed in scope, with content condensing to the trainee’s requests for specific instructions from the supervisor and submission to the supervisor’s insights.

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Alpher concluded that control and submission appear to be dominant interactive evocations in supervision, and that such evocations provide evidence of parallel process in which “interdependent transactions occur in a coherent manner across the dyads” of supervisee-supervisor and supervisee-patient (Alpher, 1991, p. 228).

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Alpher’s (1991) data and inferences are particularly relevant for my concerns because they imply that sterile supervision likely corresponds to sterile therapy (more on this later!).

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The Supervisor’s Social Desirability

Also contributing to sterile supervision is the need on the part of supervisors to be seen favorably by their supervisees, particularly in settings in which trainees’ ratings are perceived by administrators as indicative of supervisor competence.

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The Supervisor’s Social Desirability

Supervisors face a conflict between what they personally value as meaningful for teaching and supervision and the prevailing rules, norms, and policies of the organization in which the therapy and supervision are taking place (Fauth et al., 2007).

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Supervisors’ Desire to Protect, Shield and Prevent Narcissistic Injury

I also believe there is a tendency among many supervisors who, conscious of the trainee’s fears, naiveté, demoralization and low professional self-esteem, over-compensate by attempting to shield the supervisee from common realistic challenges of the therapy situation and self-experience (e.g., narcissistic injury) often associated with the growing pains of learning the complex task of psychotherapy.

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Supervisors’ Desire to Protect, Shield and Prevent Narcissistic Injury

I once heard a story of a supervisor who, when the potential to add family therapy as a treatment modality in his training clinic was being discussed, vehemently argued against the idea.

He felt trainees were having enough difficulty with individual therapy and anticipated that the complexity of family therapy would be overwhelming.

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An Implicit Rule: “We have a very nice relationship …”

An additional factor contributing to sterile supervision is the mutual avoidance of conflict or dissonance in the supervisory relationship.

Recihelt and Skjerva (2002, p. 770) claim that an implicit rule is often embedded in the supervisory process and mutually reinforced by both supervisor and trainee: “We have a very nice relationship, and do not want to say or do anything that may make it less pleasant” (as cited by Binder, 2002, p. 18).

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The Avoidance of “Touchy Issues”

Similarly, Lizzio et al. (2009, p. 129) noted about the supervisor’s role: “However, it is not only important to provide support, but also to do so at an appropriate level. While a perceived lack of supervisor support can have negative consequences for supervision, too much support, in the absence of other important supervisory relating behaviours, can also inhibit the effectiveness of supervision. For example, if a supervisor is

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The Avoidance of “Touchy Issues”

overly concerned with ‘being supportive’ they may become too permissive and not address ‘touchy issues’ such as supervisee competence or performance. This can result in a ‘phoney’ supervision relationship where the needs of the client are relegated behind the supervisor’s need for acceptance and approval or their avoidance of conflict ...”

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Toward a Definition of “Ordinary” Experience

The many factors contributing to sterile supervision suggest a patterned interpersonal dynamic between supervisee and supervisor restricted to conventional relatedness in which discomfort, tensions and anxieties are suppressed or avoided via numerous conscious and unconscious activities falling within a profile of affirmation, decorum, censorship, politeness, rapport, compliance and social desirability (i.e., the “ordinary”).

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Toward a Definition of “Ordinary” Experience

Phony or sterile supervision is supported by the collusion of supervisor and trainee to reside within a sanctioned safe zone relegated to fundamentally ordinary ways of being with each other to which both parties are well-accustomed.

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The Press Toward the Ordinary

Unfortunately, many of our training institutions embody a culture of ordinary experience that fails our students and supervisees in numerous ways, including not socializing trainees to the potential power of a true therapeutic environment unencumbered by social mores.

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Relegation to the ordinary in sterile supervision does not engage the trainee in an “interpersonal atmosphere for generating an appreciation of the power of the professional relationship itself” (Hedges, in press), especially components of self-experience that may be controversial or viewed as inappropriate when conceived of in the context of usual social discourse.

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Consequently, stimulating and refining the trainee’s self-awareness/use of self in the clinical situation is not really possible; self-experience is censored because it is categorically associated with conventional social discourse.

In this way, a venue for the trainee is not provided that adheres to the distinct social discourse characterizing a psychoanalytic/psychodynamic model.

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I think the press toward the ordinary may be due, at least in part, to a misguided, exaggerated use of the conclusions drawn from the large body of work on the relational paradigm (e.g., Bordin, 1983; Frawley-O’Dea & Sarnat, 2008; Gill, 2001; Hedges, in press; Ladany, 2004; Watkins, 2011).

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Emphasis on the alliance often becomes reduced conceptually and interactively (both by supervisor and supervisee) to an exaggerated focus on rapport-building and the avoidance of discomfort, conflict and distress -- at the expense of other vital elements of the therapeutic process.

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Many supervisors also seem to fundamentally misconstrue what will ultimately promote the supervisee’s self-assuredness, confidence and deeper learning (Lizzio et al., 2005; Ronnesttad & Skovholy, 1993); standard forms of assurance and corrective feedback seem less productive in this regard than exploring and legitimizing the supervisee’s experience of learning to be a therapist.

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My Central Critique

My main point thus far is that due to benign and protective motives on the part of many supervisors, as well as more insidious processes of control, submission and compliance, the supervisee’s subjective experience as therapist,learner and person is ordinarily

thwarted.

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My Central Critique

Overly-protecting, supporting or instructing the supervisee may, in fact, have the unintended consequence of ultimately invalidating her self-experience, the accessing of which and using is a crucial therapy competence and serves as both an anchor and compass for negotiating the challenges of actual clinical work.

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The Supervisee’s Self-Experience

In my view, it is the supervisor’s primary task to explore extensively the supervisee’s self-experience with relative abstinence in order to preserve its validity and model for the supervisee a mode of “being with” another’s experience.

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Being “Supported Away”

Many of the supervisees I encounter are discouraged or demoralized because their own views have apparently never been inquired about or allowed to stand as valid sentiments (e.g., a supervisee once told me she felt like all of her concerns as a therapist-in-training were “supported away”).

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A Common Realization of Trainees

What is most difficult for many trainees is their newly-emerging realization that they cannot combat or overcome the severity and refractory nature of the dilemmas and characterological problems in patients who present for treatment.

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Drama of the Gifted Child

This realization is especially unbearable for some students who are encountering, perhaps for the first time, the limitations of their long-held proclivity to heal, a proclivity born in their own personal histories and that evolved a way of being in the world which inspired their very entry into the mental health profession (e.g., Alice Miller’s Drama of the Gifted Child); feelings related to this cannot and should not be supported away!

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Supervision as “Metaphoric Experience”

The traditional notion that personal therapy is the best way to gain self-awareness and one of the best ways to learn how to actually do psychotherapy (Ladany, 2007, p. 393) is a bit misguided, from my standpoint.

Instead, I believe the supervisory experience can provide a “metaphoric experience” of the psychodynamic therapy situation, which, at its core, revolves around one mind attempting to make contact with and understand deeply the mind of another.

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Supervision as “Metaphoric Experience”

This sentiment is reflected in Sarnat’s writings: “Although the supervisory and clinical tasks are different, the supervisor demonstrates competencies in supervising that are closely related to those she is striving to develop in her supervisee” (Sarnat, 2010, p. 26).

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Emulation of the Ordinary

Exposure to sterile supervision leaves the supervisee with a constricted perspective of therapeutic relatedness experienced vis-a-vis the supervisor.

A natural consequence is the supervisee’s proclivity to emulate the “ordinary” with her own psychotherapy patients, manifested in similar or identical forms of tension reduction, avoidance and conformity/control/submission dynamics experienced in supervision.

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My Approach: The Shift to Extraordinary Experience

The pedagogic principle I am proposing is that psychodynamic supervision should facilitate in the supervisee a transition from common forms of social discourse and convention including conflict avoidance, compliance and social desirability (“ordinary” experience) to an alternative form of relatedness that inherently values an ambience of inquiry, uncensored subjectivity and acceptance (“extraordinary” experience).

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The supervisee is approached not as a narcissistically vulnerable figure who needs consistent support and cheerleading, but as a maturing professional whose therapeutic identity will be promoted primarily by a close inspection and understanding

of her particular experience.

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As in psychotherapy, this approach assumes that due to a variety of interpersonal and intrapsychic factors there will be resistance to the expression, examination and tolerance of the supervisee’s uniquely personal experience.

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Therefore, I see my primary task as one of coaxing into expression the supervisee’s self-experience; my sense is that if the supervisor's self-experience cannot be engaged and validated, then meta-cognitive competencies underlying psychodynamic psychotherapy including the use of the self, intuition, pattern recognition, spontaneity and self-assuredness will not be promoted.

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Supervision Vignette

• A supervisee, in her first practicum placement in a university psychology clinic, discusses her patient who has recently no-showed for a session; the supervisee begins to reflect on what it has been like for her to work with this particular patient; in one supervision session, she says, “I find myself oscillating between being my self and being a professional self, and this makes me feel anxious, not in balance.

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• When I am too much the professional me, I become blocked in my thoughts, in my perceptions and in my freedom during sessions. Often, I get this way with her. With other clients, I am more natural and there seems to be a balance of the real me and the professional me. I find myself and I find a professional identity almost at the same time.

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• But with her, I get kind of defensive; I don’t think I really am all that defensive in actuality, I just feel it. At those times, I become too much of a therapy-me. Again, it’s the issue of feeling too much of one vs. too much of the other. But sometimes with her I get too reactive and I become too much me. It’s strange. I am unable to integrate this all into one me. Wow! That’s cool. (I inquire about what’s cool.)

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• I didn’t realize this all before. Just describing it really helps. It’s not really anxiety, now that I reflect on it, it’s just that with her I sometimes get uncomfortable ... Yeah, this is cool. (Cool?) Just the fact that I am seeing how I am with her, naming the way I feel when I am with her. I have not been able to describe it before or even identity it. So you’re helping me capture it now.

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• Sometimes I’ll be more spontaneous, the natural me, but I feel like it’s too much me with her … Yeah, I’ve read about stuff like this, I’ve had courses where it’s been talked about, but to actually experience it is exciting, it’s extraordinary, really. I’m actually experiencing it, I am in it, rather than just reading about it. I am seeing myself as I am with her.

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• I am blurting this all out to you now, without really thinking about it or organizing it …. I guess I allow myself to be spontaneous with you, ironically as I am talking about not being able to be that way with her. That’s funny, really. With her, when I allow myself to be spontaneous I feel like it bleeds into being impulsive, and when that happens, I get really restrictive and rigid again.

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• I then become my professional self, and I think that makes me withdraw from her. I feel a distance between her and me and I can’t connect with her, it’s a kind of psychological distance. When I am more me-me, I feel like her buddy, I feel closer to her and comfortable with her, the way I’d be with someone I know and am close to. I seem to be one way or the other with her.

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• And I guess this all isn’t really a bad thing, I’m just putting it into words. This is really exciting. (It’s exciting because?) It’s exciting because the person who did the original assessment on her described her as borderline. I am not sure about that view of her, but I obviously feel a certain split and maybe it has to do with something in the patient or with something in me in being with her. I don’t know. I just don’t know.

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• At some point in my last session with her, I couldn't bring myself to tell her what I really wanted to say. I was fighting back the natural me and I don’t know why; maybe it was because I have some fear of expressing the natural me. That if I did, I would be in trouble somehow. I would easily say what I was thinking to a friend, but with her I didn’t sense she could tolerate or use what I wanted to say, so I just held onto my ideas.

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• So there’s this professional me and a natural me, and I am realizing as I talk to you that this is all a part of me getting to know her. Just thinking about it is really helpful. This is all a bit of a roller coaster ride. (Roller coaster?) Extreme, intense. But it’s nice to just be able to ramble on about it all. Talking about it and verbalizing my thoughts is really good. And you seem to be able to prod me along.”

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Evidence of the Supervisee’s Growth: Reduced Self-Criticality

This supervisee began work with me with a heightened degree of self-consciousness and self-criticality, along with a constant worry that she wasn’t “doing it” right.

For a long time, she would not even directly expose me to her work (via listening to audiotaped recordings of sessions) and I often felt that our sessions were overly cordial and inauthentic. This clearly has changed!

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Evidence of the Supervisee’s Growth: Reduced Self-Criticality

She now approaches her own reflections without judgment, although fears of “doing something wrong” when with her patient still remain; she observes that her ideas and feelings, and the troubling dynamics with her patient, are not necessarily “bad,” just a part of how she is getting to know and understand her patient.

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Evidence of the Supervisee’s Growth: Disinhibition

The clinical process previously made her extremely anxious, clearly not excited, and she certainly didn’t view it with any wonder or awe as she does now.

Now, she is remarkably spontaneous with me, free to blurt out things whereas previously the degree of censorship and inhibition she exhibited was palpable.

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Evidence of the Supervisee’s Growth: Autonomy and Fewer Preoccupations

Before, she seemed to rely heavily on me and other prior supervisors for direction.

Now, she is relatively autonomous in most of her work, and she seems content to use supervision primarily as a space for her to identify her self-experience without being preoccupied with the need to determine meaning or formulate interventions.

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Evidence of the Supervisee’s Growth: Recognition of the Patient’s Character Structure and Relational Dynamics

While the supervisee previously seemed to objectify her patients (she tended to “fit” the patient to a theoretical idea or intervention), she is now beginning to appreciate the complexity of her patient’s character structure and how it impacts their relational connection.

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Evidence of the Supervisee’s Growth: Recognition of the Patient’s Character Structure and Relational Dynamics Stemming from It

This development reflects Sarnat’s (2010, p. 20) view:“Effective psychodynamic intervention is derived from what the psychotherapist has experienced, processed, and conceptualized about the relationship with the client and about the client’s internal object world.”

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Evidence of the Supervisee’s Growth: Emergence of a Therapeutic Identity

Formerly, the supervisee seemed to lack a professional-therapeutic identity; her interventions were frequently impulsive and largely devoid of her own humanity.

Now, her progression is striking: she clearly has a therapeutic identity (manifested in her naming of it) and is devoting attention to issues and drawbacks re: integrating her personal and therapeutic identities.

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Evidence of the Supervisee’s Growth: A Shift Out of the Ordinary

Overall, as the supervisee’s therapeutic identity begins to emerge, she recognizes she cannot merely be a “me-me” in her work with patients, which represents one element of a shift out of the ordinary.

She now appears invested in creating an ambience with patients and within herself that is fundamentally different from how she typically is in her “real life.”

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Moreover, she is newly cautious about introducing her own personhood into the clinical situation in ways that may not be helpful for her client or that herclient may not be able to use.

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At the same time, she also is attending to reasons why the best of her spontaneity with friends (her “natural me”) does not yet carry over into her relationship with her patient – potentially suggesting the need in ongoing supervision to understand lingering reservations and fears of deeper, more intimate contact with patients unencumbered by social convention.

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Techniques and Guiding Principles

In conclusion, I would like to propose 6 supervisory techniques and guiding principles emerging from my work with this student and other supervisees like her who have informed my approach.

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Techniques and Guiding Principles: (1.) Limit Convention and Compliance/Social Desirability

Fundamentally, I attempt to create an atmosphere in supervision relatively devoid of social convention that obstructs the supervisee’s exposure to an alternative form of relatedness.

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For example, I directly observe to the supervisee “ordinary” social phenomena as it occurs (both in relation to me and between the trainee and her client), and I invite an exploration of its purpose and utility within the clinical situation as well as within supervision.

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Head nodding in standard social discourse is an easily recognizable example of the many forms of social convention to which I attempt to sensitize the supervisee.

Therapists-in-training often cue their patients (and their supervisors) with head nods.

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I work hard to sensitize the supervisee to this social convention and how it, like many other conventional behaviors, generally promotes an inauthentic (“ordinary”) relational experience that restricts the more expansive, wide-ranging and uncensored quality of the distinctive therapeutic experience.

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Techniques and Guiding Principles:(1.) Limit Convention and Compliance/Social Desirability

Many supervisees have reported to me how striking and productive it is when they begin to practice not returning the head nods of their patients (or not do offer a head nod themselves!) -- which often promotes in supervision important discussions of traditional analytic notions of abstinence and neutrality and their continued relevance.

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Techniques and Guiding Principles:(1.) Limit Convention and Compliance/Social Desirability

As supervision proceeds, I hope to continue to engender the supervisee’s relinquishing an “ordinary persona” characterized by social convention and, in turn, cultivating an alternative therapeutic persona.

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Similarly, I try to sensitize the supervisee to a host of dynamics and events between themselves and their clients (including violations of the frame, hypervigilance re: the other’s discomfort, fears of not being liked or viewed as good/helpful, avoidance tactics, a rigid unconditional positive regard) that represent adherence to social convention and a loyalty to the ordinary persona within the trainee as well as her patient.

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Techniques and Guiding Principles:(2.) “Don’t just do something, sit there!”

As a central supervisory technique, my listening approach is primarily neutral/abstinent, embodying the spirit of “Don’t just do something, sit there!” (Alonso & Rutan, 1996).

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As I listen, I hope to model a “self-reflective capacity” (Sarnat, 2010, p. 24) in which I demonstrate a highly attuned experiencing of the supervisee and what she is telling me.

I am also attempting to expose the supervisee to the fact that this capacity is not concerned with reactivity or action “of an automatic, habitual pattern” (i.e., that often constitutes “ordinary” experience).

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Occasionally I will offer questions and educative instruction, and will self-disclose, but I generally maintain a stance of listening, experiencing and reflecting.

I also attempt to limit discussions of highly abstract theoretical concepts and a “Q and A” rhythm to supervisory sessions, which more often than not reinforces the supervisee’s dependency and impedes self-agency.

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Techniques and Guiding Principles: (3.) Promote Mindfulness Via the Extraordinary

In listening to and experiencing the supervisee, I attempt to model a residence in the “extraordinary” promoted by the meta-cognitive skill known as “mindfulness” (i.e., the moment-to-moment awareness of one’s experience) (e.g., Binder, 2002, 2004; Fauth et al., 2007; Germer, 2005; Safran & Muran, 2000, 2001).

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“... psychotherapist mindfulness represents ... sustained attention toward the immediate experience of the session, accompanied by an attitude of acceptance and compassion, as opposed to judgment, toward all that arises” (Fauth et al., 2007, pp. 386-387).

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Bishop et al. (2004, p. 235) indicated that “in a state of mindfulness, thoughts and feelings are observed as events in the mind, without over identifying with them and without reacting to them in an automatic, habitual pattern of reactivity” (as cited by Fauth et al., 2007, p. 387).

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As I listen mindfully to the supervisee, I hope to provide a metaphoric experience in which the supervisee feels closely attended to, not judged or acted upon – and begins to experience the moment-to-moment process of supervision as a process in and of itself worthy of investigation and inquiry (rather than it merely being a mandatory appointment in which therapy sessions are reviewed and the supervisee is evaluated).

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Techniques and Guiding Principles:(4.) Attend to Shame

The experience of shame in therapists, particularly those early in their careers, is ubiquitous (i.e., the therapist wants to help or cure the patient and fails). Yet, to my knowledge, shame in not extensively addressed in the supervision literature.

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Shame is a universal human experience that has been conceptualized in numerous ways (e.g., Alonso & Rutan, 1988; Gans & Weber, 2000; Nathanson, 1987).

With regard to supervision, the perspective on shame I am most aligned with is the affective experience arising from the failure to achieve a desired response from an important object (Alonso & Rutan, 1988); for the trainee, this important object is her patient.

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Inevitably, though, the trainee begins to realize she will not be able to achieve what she wants from her client including a preferred form of relatedness (Winnicott’s [1969, 1975] distinction between “object usage” and “object relatedness” is relevant here) which, in my terminology, is essentially “ordinary” experience.

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Processing shame reactions is thus a major component of my work with supervisees; I help the supervisee contend with the fact that patients, more often than not, will manifest “object usage” (as opposed to object relatedness) in treatment – often to the disappointment of the trainee who has little experience with being related to in ways that deviate from her preference (i.e., generally, social mores).

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Shame is often the main affective response as the supervisee begins to acknowledge this emerging dilemma and becomes more aware of her reluctance and corresponding attitudinal and behavioral responses to being used, not related to, by the patient.

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Techniques and Guiding Principles:(5.) Dispel Expectations of Progress and Social Comparison

I try to dispel the trainee’s expectations about where she thinks she “should be” in terms of development and skill level, especially when comparisons with peers are routinely made.

Similarly, I try to directly challenge the supervisee’s vision of her patients – these often reflect curative fantasies and a narcissistic desire to heal.

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My attempt here is to socialize the supervisee into a view of herself and her training and development as unique and acceptable, just as therapy is a forum for the patient to define and contend with his/her individuality.

Comparisons with others, then, represent another form of conventionality and “ordinary” experience I am attempting to free the supervisee from.

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In a similar vein, I make ongoing attempts to disengage the trainee from my own value system and clinical approach; e.g., supervisees often ask me, “Is that what you would do?,” and I respond, “It doesn’t matter what I would do – you and I are different.”

More often than not, this drives home the point that all interventions are motivated by some element of our unique personhoods which simultaneously may limit and expand our potential with particular clients.

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Techniques and Guiding Principles:(6.) Promote Acceptance of Unconscious Relational Forces

I attempt to downplay standard views of, rules about and conventional opinions on therapeutic course and action; instead, I emphasize an acceptance of what is occurring in the supervisee’s clinical process, especially its thorny and unclear nature, and the ongoing evaluation of its many potential meanings.

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To expand on this idea, I attempt to move the supervisee away from “inert clinical knowledge” (Binder, 2002, p. 11) and, instead, encourage her to become her own repository of clinical experience, including all failures and achievements, intentions and outcomes;

This hopefully marks the transition from Am I doing it right? or Do you agree with what I did? to This is what happened between us at that moment.

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To this end, in supervision I often claim that “there are no mistakes in therapy” to encourage supervisees to move past a right/ wrong approach to their work and begin to appreciate the mutually co-constructed unconscious dynamics between client and therapist that profoundly impact how each thinks, feels and acts upon the other.

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For example, trainees are often terrified as they begin to see clearly, from the perch of supervision, how they have “acted out” with their patients countertransferentially.

Acknowledging the strength and complexity of unconscious relational forces is initially startling for many trainees, but gradually these forces become viewed more benignly as constituents of psychoanalytically-informed treatment.

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Techniques and Guiding Principles:(6.) Pursue “Professional Me”/“Natural Me” Tensions

Finally, I actively conceptualize the learning process for trainees as contending with the emerging tensions of disparity and integration vis-a-vis the presence of the “professional me” and the “natural me” in clinical work.

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Pragmatically, this often translates into encouraging inhibited supervisees to bring into sessions more of their “natural me,” and encouraging disinhibited supervisees to develop a greater degree of caution.

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At a deeper level, it fosters an exploration of how the supervisee may be unwittingly exposed to herself, her patient (Aaron, 1991; Hoffman, 1983) and her supervisor in the course of psychotherapy and training, how to tolerate these exposures, and how to make use of them clinically.

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Summary

Given the unchartered territory of psychotherapy, supervisees typically rely on what has worked for them so far in their personal and professional lives (i.e., conventional attitudes and relational tendencies), many of which are non-transferrable and often disadvantageous for psychoanalytically-informed psychotherapy.

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Summary

In this presentation, I have outlined an approach to supervision that seeks to engender in the supervisee an attitudinal and behavioral shift from “ordinary” (i.e., social convention) to “extraordinary” experience in which the patient's subjectivity, and that of the therapist-in-training as well, is authentically expressed, acknowledged and understood.

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Summary

For numerous reasons I have described, both the supervisee and supervisor may collude in a press for the ordinary which detracts from exposing the supervisee to an alternative mode of self- and self-other relatedness akin to the psychoanalytic model.

Consequently, qualities of sterile supervision are often emulated and transferred into the trainee’s work with her own patients.

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Summary

My supervisory approach emphasizes that an invaluable function of the supervisor is to model a way of being that transcends standard forms of social etiquette.

In this way, internal representations not only of the supervisor as role model (Gabbard, 2010; Gitterman, 1972), but of the relational experience the supervisor enacted with the trainee, support the supervisee's therapeutic potential.

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Discussion and Evaluation


James Tobin, Ph.D.

Private Practice, Newport Beach, CA Assistant Professor of Clinical Psychology, Argosy

University, Orange County, CAphone: 949-338-4388

web: www.jamestobinphd.comemail: [email protected]

http://www.jamestobinphd.com/

mailto:[email protected]

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Alpher, V.S. (1991). Interdependence and parallel processes: A case study of structural analysis of social behavior in supervision and short-term dynamic psychotherapy. Psychotherapy, 28, 218-231.

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Biography: James Tobin, Ph.D., Licensed Psychologist PSY 22074

Dr. Tobin is a licensed psychologist in private practice in Newport Beach, CA, and is Assistant Professor of Clinical Psychology at Argosy University/The American School of Professional Psychology in Orange, CA, where he currently supervises graduate students at the Argosy University Therapeutic Assessment and Psychotherapy Service (AUTAPS). He also participates in an ongoing supervision group at the Newport Psychoanalytic Institute with Lawrence Hedges, Ph.D., the institute’s founder.

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Biography: James Tobin, Ph.D., Licensed Psychologist PSY 22074

Dr. Tobin is a former advanced candidate in psychoanalysis at the Psychoanalytic Institute of New England, East and former staff psychologist in the Department of Psychiatry at the Massachusetts General Hospital and Clinical Instructor, Harvard Medical School. Dr. Tobin received an A.B. magna cum laude in Psychology and Social Relations from Harvard University, and a Ph.D. in Clinical Psychology from The Catholic University of America in Washington, D.C.

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