Psychotherapy Bulletin

Psychotherapy Bulletin

Clinical Impact Statement: The manuscript provides important information to trainee psychotherapists about how best to approach and utilise supervision. It also provides information to supervisors about the challenges their supervisees face and how they can aid their growth.

Introduction

To be in supervision for beginner therapists is a nerve-racking experience, which has the capacity to change the life of the trainee. Hyde (2015) describes beginner therapists as intelligent, gifted, and successful individuals who in supervision face scrutiny, which threatens their self-esteem and stirs up anxieties and defenses. She says, “In supervision, we feel all our core selves are exposed, leaving us not so much concerned about our patient’s or client’s capacity to flourish or flounder, but our own” (p. 14).

In this paper I describe three experiences in supervision that trace my personal journey as a trainee psychotherapist. To undertake this experiential process, a framework of the context of my training seems imperative. When I joined the National Institute of Mental Health and Neurosciences (NIMHANS) Bangalore in Southern India, I had a master’s degree in psychology and the experience of working with adults and children, both in internships mandated by my graduate program as well as in a job as a psychologist at an inclusive school. I felt myself adept in theoretical concepts and counseling skills. I assumed that this new undertaking would allow for me to gain mastery in dealing with cases with complex psychopathologies, and I was prepared to read and understand all I could to be a better therapist. I had taken on, as I thought then, an intellectual challenge. I understand now that the challenge was an emotional one. The training entailed large caseloads, time-intensive attempts at therapy, and diverse supervisors with different therapeutic frames. It meant managing time to complete coursework, psychodiagnostic assessments, and to attend outpatient clinics and departmental programs, in addition to seeing clients in therapy. The training program has been discussed elsewhere at length (Grover, 2015; Rao, 2001). In attending to my anxieties about performing well and dealing with a depowered position in the institution, the struggle was often about getting the job done and not about my personal growth as a therapist. Supervision was a way for me to attain direction in proceeding with case management and, perhaps, reinforcement for my work.

Underlying the three experiences discussed below is my changing notion of supervision. In the first experience, I thought of supervision as a vehicle of intellectual learning and positive reinforcement, aimed at bolstering the confidence of the trainee. In the second experience I realized that it was an emotional medium to enhance trainees’ reflective skills. In the third experience, which happened much later after the completion of my clinical psychology course and during my doctoral work, I accepted supervision to be for my own professional and personal growth. My perception of what entailed my growth as a therapist, too, may have changed over time as proposed by Kumaria, Bhola, and Orlinsky (2017).

Beginning Steps and Narcissistic Anxieties

The first of the three experiences was in supervision for a female client who had been raped and suffered from posttraumatic stress disorder. I went into supervision with a detailed history and a psychological formulation of the case. The supervisor reinforced my efforts and my understanding of the case, and asked me to initiate supportive psychotherapy. She was confident in my abilities and allowed for me to take autonomous decisions. I felt reassured and ready to take on what was a complex case of psychological trauma.

Early on in therapy itself, I remember feeling that the client related to me on a superficial level and did not emotionally engage with me, but I dismissed this feeling as arising out of the client’s emotional numbing. I did not talk about these feelings in supervision and instead would update my supervisor on tasks completed in therapy. We discussed how best to make the client functional and engage in meaningful activities that could keep negative emotions at bay. The supervisor displayed trust in my work and, in an attempt to remain a “good student,” I did not discuss my worries. As the therapy progressed, I continued to feel that I was not truly understanding the client’s gruesome experiences and not allowing for the trauma to be emotionally processed.

When I think about the case now, I can see that my relationship with the client and with the supervisor had many similarities. Both relationships were positive and cordial but superficial. In neither relationship were real emotions being discussed. Also, the client was not telling me that I was not discussing her feelings in depth, and I was not telling my supervisor that we were not engaging in deep emotional conversations about therapy. I had begun to judge the supervisor as being incompetent in handling complex cases; perhaps the client had similar feelings about me. The parallel process that had emerged here went unnoticed and unaddressed. The parallel process is a phenomenon in supervision that was first discussed in psychodynamic literature. Here the supervisee brings into supervision therapy material to which the supervisor responds as a therapist and the supervisee takes the role of the client. In skillful supervision, parallel processes are discussed and supervisors attempt to respond differently so as to model for the therapist ways to break patterns in the therapist-client relationship (Tracey, Bludworth, & Glidden-Tracey, 2012).

This example highlights three challenges in supervision. The first is the question of autonomy. While allowing self–direction and autonomy in supervision has been recognized as a positive supervisor quality (Ladany, Mori, & Mehr, 2013), it may be important to consider how much autonomy is adequate, especially for beginner therapists. I felt that the trust and autonomy I received, over-estimated my capabilities and compelled me to handle too much on my own. There is merit in over-schooling beginner therapists as discussed in an Indian study wherein supervisees mentioned the importance of metaphorical hand-holding and providing direction in supervision (Bhola, Raguram, Dugyala, & Ravishankar, 2017). Ladany and colleagues (2013) advise against offering unbridled optimism about supervisees and instead create a positive supervisory space wherein supervisee may take on challenges. A balance between providing direction and autonomy needs to be struck, with the emphasis shifted to the former for beginner therapists.

The second issue is that of nondisclosure in supervision. Despite needing greater direction and feeling incompetent to handle the case, I did not discuss this with the supervisor as I felt that it would rob me of the positive regard I was receiving and bring to the fore my deficiencies. Feelings of shame have been related to nondisclosure in supervision in literature wherein feelings of inadequacy and an over-evaluation of the self may lead to disturbances in communication in supervision (Yourman, 2003). Hyde (2015) describes this as follows,

When suffused with shame, trainees bring little to supervision, or, in an attempt to avoid this most uncomfortable feeling, repeatedly tell tales of how well they are doing, focusing on and amplifying their successes; it’s all about them, not the patient. At these times, for the supervisor, supervision feels empty and boring as the trainee skates across the surface of issues, not revealing what is truly happening, not describing sessions or the patient sufficiently for the supervisor to get a sense of the process, all with a brittleness and brightness that betrays their underlying vulnerability. They use the supervisor to mirror their great successes. (p.16)

I also felt at the time that disclosing my difficulties with supervision would mean that I was questioning the supervisor’s methods. I was afraid that this would be perceived as being disrespectful and arrogant of me, and flouting the implicit hierarchy. Bhola and her colleagues discuss that in India, the supervisory relationship tends to be more formal than in the West, due to the cultural notions of deference towards authority figures in collectivistic societies. The authors found that Indian psychotherapy trainees may tend to refrain from questioning their supervisors and advised that supervisors need to address the power hierarchy explicitly early on in the relationship so that supervisees can express their opinions and feelings freely (Bhola et al., 2017).

The third issue was that of the perceived competence of the supervisor. Supervisors’ ability to demonstrate their clinical skills and disclose clinical information to aid the discussions has been considered an important aspect of effective supervision (Ladany et al., 2013). Good supervision has been understood as bridging the gap between scholastic knowledge and clinical practice (Jacobsen & Tanggaard, 2009). I felt that my supervisor provided minimal clinical or theoretical input and rather relied on my understanding of the case. The supervisor, who is assumed to be more competent that the supervisee, bears the responsibility to ensure that skilled and competent psychotherapy is provided. It is the supervisor’s job to ascertain when the trainee is ready to be trusted with this responsibility (Falender & Shafranske, 2007), and this my supervisor was certainly not able to do.

Scaffoldings and Self-reflections

Another important experience in supervision was in my second year of training. I sought supervision for therapy with a client who seemed quite burnt out in the context of her son’s autism, her marital discord, and her poor social support. I felt that a supportive stance in therapy would be useful in helping her vent about her caregiving burden and the difficulties with her marriage. My supervisor, however, believed that I was underestimating the client’s emotions and her ability to accept more intense forms of therapy. My supervisor’s style was a bit uncomfortable, and without her saying anything too incriminating, I would become defensive about therapy. I learned over time that instead of defending myself, I needed to reflect on what made me uncomfortable and unsure about the work I was doing. Supervision became an experiential space for me. The supervisor encouraged me to first allow myself to feel with the client and focus on what the client evoked in me, rather than hide behind cognitive techniques. For this patient, processing decades of anger was understood as being much more pertinent than learning to cope with her day-to-day crises and negative thoughts. The supervisor posed what has been called in literature as a constructive challenge. This has been understood as an important characteristic of effective supervisors and can help scaffold the trainee to a higher level of skill (Ladany et al., 2013). Some supervisees work better if they are knocked off their pedestal and pushed to attain new insights (Jacobsen & Tanggaard, 2009). Feedback and provision of alternative methods of management from supervisors has been considered to enable learning of the supervisee and has been shown to be valued by them. Effective supervisors tend to discuss explanations of therapists’ feelings in therapy, provide meta-perspectives and allow reflection (Wilson, Davies, & Weatherhead, 2016). My supervisor not only challenged my theoretical orientation but also my emotional one. In supervision, we would speak about various levels of processes in therapy such as immediate skills, the purpose of therapy in the life of the client, and the purpose of this client in my life. The supervisor also provided instances in her own journey as a therapist where she had only touched the surface of what had turned out to be an ocean of emotional strife. Self-disclosure in supervision has been advised in literature to be used judiciously and in the service of the supervisee (Ladany et al., 2013). There is evidence that supervisors’ self–disclosure is perceived positively by trainee therapists, as it helps normalize supervisees’ experiences and encourages them to share their own feelings (Wilson et al., 2016). In my experience, the self-disclosure served as an opening to discuss my own feelings about the therapy.

The supervisor’s clinical skill resulted in the lowering of my own defenses and an emotional awakening. Resolution of my discomfort in supervision helped resolve several instances of my discomfort in therapy. Supervision is meant to provide a safe space to process feelings and allow for the development of an internal supervisor (Wilson et al., 2016). I was truly connecting to clients’ emotional difficulties perhaps for the first time since I had joined the training. I felt less inclined to excel academically and more enthused to have emotionally meaningful experiences. Looking back I realize that, unlike a majority of my supervisors, this one did not evaluate me purely on my theoretical knowledge and verbal fluency, but on my reflective capacities and therapeutic skill. I have since become more comfortable with discussing my frailties and mistakes in therapy, and have become a more authentic therapist.

The Real Relationship

The third experience was the supervision of my doctoral work. My study population was comprised of women who had substance use issues, emotional difficulties, histories of trauma, and difficult relationships. The process of recruitment, assessment, therapy, and follow up seemed unending and exhausting. My doctoral guide supervised the cases that I recruited and even though by this time I felt much more competent in handling complex cases, I needed my supervisor to contain the enormous anxieties that arose in the process of the doctoral study, which I am certain is the case for most doctoral students.

I realize now how I had evolved as a person through my training. When I started out, I was self-assured, almost conceited about my capabilities. Through the years I learned about my many shortcomings, and by the time I started my doctoral work, I believed that I was not actually as skilled and efficient as people assumed. This phenomena has been explained as disillusionment with the self of a trainee therapist (Hyde, 2015). It would emerge often in my doctoral reports, wherein I would portray the work I had done as much lesser than it had really been. My supervisor had the ability to tell me that I was selling myself too short in an encouraging and insightful manner, making me reflect upon why I was doing this and how my sense of self had changed.

For a majority of my colleagues the doctoral supervisor, with whom they spent the largest amount of time in their training, was also the person toward whom strong ambivalent feelings and avoidance developed. The supervisor’s role was not only to supervise therapy but also to oversee the research at large, and so this dual relationship would often become strained. In my supervisory experience, any potential strain or avoidance on my part would be discussed by my supervisor, often with humor and always centered on my personal growth. In one such experience, the clinical team had planned an outing and a few of us decided to have tea at my residence. We decided to not disclose the location to my supervisor and keep it a surprise. When the location became known, my supervisor refused to accompany us, stating that it would be a violation of professional boundaries. I had prepared the meal and was extremely disappointed—even angry—that my supervisor could not let go of professional ideals. My supervisor perceived that this impersonal move could potentially alter the positive working relationship we enjoyed and discussed the issue with me at length. She explained about the “slippery slope” that seemingly innocuous boundary crossings could create. I understood the notion of “supervisors serving as fiduciaries” and that they are ethically and legally bound to model appropriate professional conduct in the best interest of supervisees (Barnett, Cornish, Goodyear, & Lichtenberg, 2007; Gottlieb, Robinson, & Younggren, 2007). This instance helped me understand my own feelings of attachment towards my supervisor and served as an excellent example of resolving ethical dilemmas in supervisory relationships.

In an institutional context where my experiences with other supervisors were short lasting, often limited to single cases, my experience with my doctoral guide was the longest supervisory relationship I had had. I view this relationship as consisting of all the ingredients of a real relationship. There existed mutual genuine regard for the person behind the professional role and I feel that my authenticity and nondistortion arose from the implicit and the unshaking support that my supervisor provided. The real relationship has been understood in psychotherapy and supervision to encompass realism and genuineness, and has been understood to enhance professional connectedness, social relatedness, and attachment. It contributes to building the identity of the therapist (Watkins, 2011; Watkins, Jr., 2017). In my relationship with my supervisor, I learned better to thrive in my organizational system and manage my professional anxieties better.

My Developmental Journey in Summation

In this developmental journey from a therapist-in-training to a trained therapist and a doctoral student, my needs changed. In the first experience, I had needed structure and skill-based inputs from my supervisor. I also needed to learn how to talk about difficulties in therapy and supervision, and how to access supervision better. Having eventually developed these capacities, by the second experience I needed to loosen up in my process of therapy, allowing myself to stay with emotions and not try to “fix” problems automatically. In the third experience, I enjoyed much greater autonomy in psychotherapy, and needed supervision to help manage multiple roles and anxieties. My experiences trace Loganbill, Hardy, and Delworth’s (1982) stages of counselor development: stagnation (naïve unawareness), confusion, and integration. The authors added that in becoming master counselors, eight critical issues need to be resolved: competence, emotional awareness, autonomy, theoretical identity, respect for individual differences, purpose and direction, personal motivation, and professional ethics. In tracing my journey, several of these issues have been touched upon and highlight that experiences of supervision in India do not differ qualitatively from those described in Western literature. These experiences highlight the pivotal role of the supervisor in transitioning through the stages of development, and call upon the need for competent supervision in therapist training.

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Cite This Article

Hargun, A. (2019). A work-in-progress: A supervisee’s reflections. Psychotherapy Bulletin, 54(1) 56-62.

References

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