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Supervision: Integrating Self and Skill

Welch, L., 1994. Supervision: Integrating Self and Skill. Reformulation, ACAT News Spring, p.x.

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Supervision: Integrating Self and Skill

Lawrence Welch

An old Japanese story tells of a peasant farmer who accidentally insulted a samurai, Being sensitive to sleights to his honour, the samurai swordsman immediately challenged him to a duel and a date was set for two weeks later, The farmer, in fear and trembling at his own ignorance of the sword compared with the samurai’s renowned proficiency, sought out a sword master to gain instruction in what to do. The sword master, sighed at the futility of training the farmer and advised him to prepare himself for death. To help him meet the challenge with a display of dignity, the master demonstrated the most basic defensive position with the sword and how to make one attacking cut. On the day of the challenge the farmer said a final goodbye to his family and friends, The samurai, expecting an easy victory, swaggered to the appointed place. However, with one look at the farmer, he fled. Anticipating death whilst determined to demonstrate at least one hard learnt cut, the fatter gave no opening to the samurai, By centring himself, the farmer was able to face the skills of the lethal samurai.

The story illustrates in stark form the importance of both self and skill in the training in a life and death art, While the drama of life and death issues in psychotherapy are found only in the relatively infrequent suicidal client, the process of change often confronts clients with the death of a stifling but familiar self. Training therapists in skills alone will prove insufficient to meet the challenge that each new client brings. At the same time developing the capacity to face a particular client’s painful feelings might suffice for one or two powerful encounters but will soon prove exhausting without a solid background of skill to base it on, The superior skills of the samurai would have overwhelmed the farmer had the samurai been equally prepared to face death.

Skills are consciously acquired procedures of specifically linked thoughts, feelings and activities which constitute the transmitted practice of a profession. For example, empathy is a skill which can be consciously learnt by putting oneself in someone else’s shoes. It requires directing one’s thoughts and feelings towards another person and then translating this activity into words which convey to the patient that s/he is understood, As the skill becomes established and integrated with other skills, it no longer requires conscious attention. In the highly skilled practitioner the distinction between skills and self can become blurred: the self is the highest order most general, organising point of activity, serving to integrate the diverse skills.

Most of the theorising about the self focusses on the personal self, but I think the key to understanding the role of the self at work is to construct a concept of a ‘professional’ self. The professional self emerges as the personal self transforms part of itself into a conscious and consistent centre of activity through the learning of skills. A relationship is established between these two distinct but permeable professional and personal selves, a relationship which is most evident at the boundaries between work and personal life perhaps in the Monday morning blues as the personal self faces the transition into the working week.

The relationship between the personal self and the professional self is perhaps at its tautest in psychotherapy, In other caring professions, the tension can be somewhat more easily resolved by creating a distance between the painful feelings of a client and one’s personal feelings. The professional can seek refuge in feeling that he or she possesses skills that will address a specific problem. For example, nursing can often (though by no means always) translate into a series of practical actions providing real practical physical comfort for both patient and nurse but can also transform the self into an object to be treated rather than a person to be related to, In contrast1 for the psychotherapist, awareness of personal feelings of boredom, excitement, irritation, anxiety cannot be treated simply as a peripheral commentary, irrelevant to the main task. These feelings and a playful, light, intelligent awareness of these feelings, is essential to the process of appraising and evaluating the communication from the client, This places the personal self in much closer relationship to the professional self and. brings with it the dangers of the loss of the professional self as in overstepping sexual boundaries or the freezing of the professional self where skills become a defence against the painful feelings engendered by the client.

CAT is at a critical stage in its development as a training organisation as it moves from an informal arrangement where the relative security of the professional selves of the supervisors could be relied on to ensure the effective transmission of CAT skills to trainees who were considered to be capable of building humane and empathic relationships with their clients. Both with the expansion of CAT into a larger, formal organisation and with, the external demands of the UKCP, CAT can no longer take for granted the development of a professional self appropriate to the skills of the therapy; The aim and role of supervision and training in developing that professional self needs to be debated. With its time boundaries and focussed work, CAT runs the danger of creating therapists who ray demonstrate discrete skills, but who lack a robust enough relationship between their personal and professional selves. With the development of necessary standards in order to Judge what is and what is not CAT, we are at risk of creating a punitive superego, hardening into applying rigid techniques and fearful that our creativity or our mistakes will suddenly cast us outside the pale.

While I believe that the relationship between the personal and professional selves and the role of skills in the development of the latter is particularly acute in CAT at this time, it clearly exists within other much more established frameworks. I came across this conflict very vividly recently in two artides in a book on psychoanalytic supervision, raising both useful issues in themselves but also, I hope, illustrating my theme. The first article by Joseph Newirth outlines an approach to developing a professional self, while the second article by Jerome Singer, in part a commentary on the first, describes a more skill based approach, Newirth’s article caught my attention as it was intriguingly entitled “The mastery of countertransferential anxiety: an object relations view of the supervisory process,” His Object Relations account outlined three countertransferential anxieties he argued that supervisees have to master in the process of training as therapists. He states “The supervisory process includes many - different educational and emotional experiences; the most important involves the development of the therapist’s ability to use his or her self as the major emotional force or fulcrum in the treatment situation” (p157). Thus, “Two primary concerns of the supervisory experience are to assist the developing therapist in his or her ability to be available to the patient and to overcome the anxiety that develops in the psychotherapeutic situation” (p159). Following traditional Kleinian thought, he calls the first the Schizoid anxiety of abandonment. In this the therapist is faced with the fear of abandonment by the supervisor, and is confronted alone by the patient. An expression of this is “an intense need to know what to do to help the patient’ (p159), in the Paranoid state, the therapist deals with a loss of boundaries as he empathises with the patient and becomes identified with her/him. The often unspoken fear is that of madness or a feeling of being in the wrong occupation. The Depressive anxiety is characterised by the struggle to tolerate hatred and guilt towards the patient.

While I, in CAT fashion, took issue with Newirth’s terminology and felt unconvinced by the notion that supervisees have to go through stages as he outlined, I felt there was much value in identifying and being sensitive to fears that often remain hidden from sight in supervision. One can sense that a supervisee is uncomfortable with something but it can be difficult to tease out the transference from the countertransference within the space of a pressurised 20 minute slot of supervision. One supervisee struggled with a client’s denial of the significance of ending and the discussion of the work could only move forward as the supervisee spoke of her own difficulties in acknowledging that she had an important and powerful role in the client’s life. It was not a question of finding the right set of words to communicate to the client, but rather addressing wider issues to do with how. to accommodate a legitimate sense of power into her professional self.

What intrigued me about the second article by another analyst whose credentials included supervision by Erich Fromm - and also 35 years of giving supervision, was how profoundly he. took issue with Newirth. In outlining three responsibilities of the supervisor he shifts away from Newirth’s focus on the Supervisee’s internal world to: ensuring the patient receives a good service; providing the students with support; evaluating the student. Reflecting on his experience, Singer goes on to dismiss Newirth by saying “It was a rare student indeed … who seemed to feel abandoned, terrorized or deeply in despair during work with patients… While a few were certainly somewhat immature socially or inept interpersonally, the vast majority of trainees I worked with in five different settings were not only intelligent and autonomous but also socially relatively effective. They were more like colleagues than terrorized children, They were generally curious and eager to understand and help their patients, but they only rarely lost their sense of boundaries” (p 169). Singer sums up his own approach to supervision by arguing that ‘Perhaps the best thing we can offer students as supervisors is to model for them an attitude of deep curiosity, empathy for the patients’ dilemmas and excitement about the process of trying to understand and to help troubled clients” (p172). His concentration is on alleviating the therapist’s sense of ‘being out there ‘alone’ on the front lines’ by communicating an attitude of “we’re in this together” (p 112). He takes for granted the professional self, focussing largely on the skills that are essential in the task of learning how to be an effective therapist.

No doubt Singer’s rejection of the object relations framework accounts for much of his dismissal of what Newirth had to say, but I feel it also reflects profound splits in the understanding of the purpose of supervision. I felt it was valuable to illustrate this split within the Analytic camp because it demonstrates that it occurs within a framework as well as between competing theories. The split in this instance was between an emphasis on the development of the therapist’s sense of professional self, and one where the patient was centre stage and the task of supervision was to promote the therapist’s skills and cognitive ability to cope. Where Singer places great emphasis on the development of skills and competence in trainees, Newirth deals with the anxieties which can undermine the capacity to develop skills.

I suspect that in practice the two approaches combine a subtle mix of both elements, What varies is what the supervisor places in the foreground. For example, Newirth takes for granted a safe and supportive atmosphere in supervision whereas Singer puts support of the trainee in the foreground. Both tackle the issue of therapeutic omnipotence, the feeling that the therapist ought to be able to provide, a cure for whoever comes along. But while for Newirth this is a central anxiety which must be worked through with every trainee, Singer approaches the issue through offering common sense advice as the need arises.

While CAT is equally subject to the tension between skill and self, it is also well placed to develop a coherent model. In theory, at least, CAT is able to make explicit the relationship between the professional self and the development of skills, The richest and most complex area for exploration lies in the idea of Reciprocal Role Relationships. Technical skill is needed to generalise from relatively little information to the higher order concepts of RRPs. While RRPs are often glaringly obvious when pointed out by another, and can seem obvious and clear when described in case presentations, one is usually presented with a product rather than a detailed account of how that product is created. Trainee therapists struggle particularly when they conceive of these as narrowly intellectual concepts. The capacity to describe accurate RRPs requires many different skills: awareness of transference and countertransference; the capacity to identify critical acts by the client embodying these relationships; a developed sense of how historical information can inform the current predicament; a sensitivity to how the client orders his/her thoughts, feelings and actions; awareness of abstract patterns of relationships providing templates against which to appraise information. The list of available skills would probably vary from therapist to therapist.

The value of the concept of RRPs is demonstrated every time that a therapist is able to go from supervision with a particular set in mind and identify them effectively and with confidence within the therapy. However, what distinguishes the moments of clarity from the moments of confusion and uncertainty? The ability to identify RRPs also requires the development of a relatively secure sense of self, a capacity to think, a good observing “I”, a space inside in which to skim through the facts presented by the supervisee or patient, the ability to translate those facts into specific, meaningful, provisional concepts, the ability to communicate those concepts effectively. Of course practice, the disciplined repetition of therapy with many different clients within, a theoretical framework provides the bedrock of this developing sense of self and skill. However, supervision needs to ensure that the trainee therapist realises that it is only with a full engagement of self that the skills of CAT will become active enough to effect change in the client.

A vital part of therapy is for the therapist to be able to both. identify RRPs and discover ways of responding creatively to the client’s invitation to play out one side of a Reciprocal Role. It is in this engagement that the tension between the personal self and the professional self is at its sharpest. Therapists are facing roles the client has had a lifetime perfecting. The power of the reciprocal role is often such that the therapist can find herself enacting one side of this role in supervision — in one supervision group the therapist who was working with a particularly frustrating client, banged down her papers in irritation at a remark I made. The skill of supervision is attempting to use these situations so that the therapist’s sense of professional self is strengthened and not undermined.

To conclude: we need to develop a supervisory framework in which the trainee therapist develops both skill and a sense of self. Like the sword master of the Japanese story, we need to be able to ensure that the trainee therapist has skills to use but at the same time that they go into their encounter with the client alive to the possibility of defeat rather than placing complete trust in skills still insecurely held. In this way, hopefully the client will not depart with the speed of the samurai but will rather be enjoined in a lively and fruitful struggle.

References

Lane, R,C, (ed) (1990) Current Issues in Psychoanalytic Practice, Monographs of the Society for Psychoanalytic Training No,2: Psychoanalytic Approaches to Supervision Brunner/Hazal mc,

Newirth, I, ‘The Mastery of Countertransferential Anxiety: An Object Relations View of the Supervisory Process’

Singer,J, ‘The Supervision of Graduate Students who are conducting Psychodynamic Psychotherapy’

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Welch, L., 1994. Supervision: Integrating Self and Skill. Reformulation, ACAT News Spring, p.x.

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