On Being Skilled and Deskilled as a Psychotherapy Supervisor

Anne Alonso, Ph.D.

Accepted September 30, 1999. From the Department of Psychiatry, Harvard Medical School, Cambridge, MA. Address correspondence to Dr. Alonso, 17 Lakeview Avenue, Cambridge, MA 02138.

Key Words: Psychotherapy Supervision Grand Rounds Those of us who take pride in supervising psychotherapy have a huge investment in keeping the flame of our profession alive and in successfully mentoring new generations of clinicians. To the extent that we succeed, we meet our professional ego ideals. We teach, cajole, inspire, and shape our students toward our own standard of professional excellence. If we are really lucky, we learn new things and grow in the process. By the same token, when we fail, the cut is deep and the challenge to our sense of competence is profound. The goal of this Grand Rounds is to explore the clinical process in supervision and to offer examples of clinical supervision that illustrate successful and failed instances in that process. Emerging ideas about intersubjectivity lead us to a renewed awareness of the influence the two parties have on one another. So if I as a supervisor am skilled, that depends to some extent on my student's participation in making me skillful and on my own part in increasing his or her level of clinical competence. By the same token, if I am deskilled (meaning that my skills are not proving adequate to this particular supervision), I suspect we are both participating in that sorry state, to our mutual detriment, to say nothing of the patient whose well-being ideally remains central to our concern. If measuring a successful therapy is an elusive goal, measuring a successful supervision is even more elusive. More poignantly, we remain in the dark about how the work can go awry so quickly when it doesor, for that matter, how to fix it. My own definition of an optimal psychotherapy supervision is one in which the supervisor is focused primarily on the clinical and professional development of the supervisee. Thus, the supervisor is always perched on the border between teaching the student and therapeutically addressing the implicit developmental impediments to the student's learning. The supervisor, in effect, must listen with a clinician's ear and speak with a teacher's mouth. To do less is to avoid the power in the supervisory situation. Although my context in writing this is the supervision of psychoanalytic psychotherapy, I believe that many of the same principles apply across the range of theories. Currently, we may be guided to some extent by new developments in intersubjective theory,13 which insist that all parties to the field are influencing and influenced by any processes and changes that occur in the clinical situation. From this perspective, the more overly interested I become in guiding the patient's therapy without appearing to do so, the less effective I become as a supervisor, and the more I have to note a potential resistance to the process either in the student or in myself. At the other extreme, the more I find myself

feeling like an analyst of the student rather than like a supervisor, the more attention I must focus on the shared transference and countertransference between my student and myself rather than on the student's clinical work. After all, the goal of all this is to provide optimal clinical care to the patient, whose best interest is easily subordinated in the supervisory confusion. When supervision goes well, the experience is valued highly by both parties to the interaction. A supervision at impasse, however, is painful and anxiety-laden, and there are few guidelines for clearly setting forth a curative path. I am aware that my use of the words "cure" and "healing" in this context may make some of my colleagues uncomfortable, since those words imply a more clinical and less educative function. But this is just my point that the clinical and the didactic are inextricably linked in the supervisory encounter. At the point of impasse, supervisors usually feel disabled. The tools available to use in the hour with a patient are not necessarily appropriate or helpful in the supervisory hour. From the point of view of the supervisee, it is difficult to imagine emerging from a serious impasse with a supervisor without feeling doubts and shame about one's work and, for that matter, without questioning one's competence and identity as a clinician.

IMPASSE AND RESISTANCE IN SUPERVISION

No impasse develops quickly, although this wisdom is usually only available in hindsight. At a conscious level, the work may appear to be proceeding very well indeed, and it feels as if the impasse has come from out of nowhere. In retrospect, though, it is usually possible to notice unattended instances where trouble was brewing. The resistances that can be involved are myriad and complex. The following discussion is an exploration of supervisory resistance gleaned from supervisory experience over several decades. The way one defines resistance speaks volumes about one's theoretical and clinical positions. Resistance here is defined as a moment of conflict in either the trainee or the supervisor that emerges in the course of the work as "static in the field" that threatens to create a problem in the supervision. In the course of any dialogue between two people, there will arise moments of pause, when one or the other averts the eyes, changes the subject abruptly, moves to a more superficial level of exchange. One way to understand these instances is to define them as anxietymanaging maneuvers, designed to maintain the contact with the other at the expense of some authenticity. The supervisory hour, laden as it is with the emotions and impulses of the patient, the therapist, and the supervisor, is fertile ground for resistance to emerge and to flourish. The following are common sources of supervisory resistance: 1. Because there is so little agreement in the field about the definition of supervision, the supervisor may be unclear about the border between teaching and

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psychotherapy. The border problem is illustrated in the cases that I will describe later in this article. Minimal training in the art and science of supervision tends to throw supervisors back on their psychotherapeutic skills and habits. This throwback leads to major problems in the supervision when a problem arises. The tendency is either to diagnose the student and cross educational boundaries inappropriately, or else to skim over the problem or otherwise avoid the supervisory role and obligation. Unconscious oedipal anxiety adds to the confusion. The competitive spirit inherent in all parent-youngster dyads is also present in the supervisory situation. If the supervisor is insecure or the student especially challenging, and if the patient is especially adept at generating struggles among the helpers, things can get quite heated in the supervisory hour. Shame in the student generates parallel shame in the supervisor concerning exposure of all parties to the transaction. Exposing mistakes is always embarrassing, and the student in a good supervision is encouraged to do just that. If the student is too shame-prone, or if the supervisor is harsh and humiliating, the pain to both parties is great.4 Real or fantasied legal and ethical liability adds to the mix of confounding variables. Just how responsible is the supervisor for his or her student's blunders? Can the student really learn without making serious blunders? So long as these blunders do not endanger anybody's life, I try to encourage my students at the beginning of the year to make all the mistakes they know how to make while we have the chance to work together. I have always done so, but I must confess that in these increasingly litigious times, I do so with a twinge of internal anxiety.

CLINICAL EXAMPLES
The first example represents a successful and skillful resolution of teachingpsychotherapy tension in the supervisory encounter. For an experienced supervisor, it is not always easy to be sensitive to the narcissistic problems inherent in the role of trainee. This is especially true in the case of a student who is culturally different, or of someone who sought training later in life after success in a related field. It is always difficult to present one's intimate work to the critical eyes of a supervisor or a therapist. The patient has the protection of a safe regression guarded by the laws of confidentiality. The supervisee, on the other hand, is expected to expose areas of vulnerability to a supervisor who is charged not only with helping the clinician, but also with maintaining standards of training and with writing evaluations about the work of the student to the administration. In addition, the supervisor is also going to be evaluated either formally or informally by the student and the system. Therefore it should not surprise anyone if the stage is set for possible difficulties with hearing critical feedback, or any feedback at all. If, in addition, either party to the supervision is anxious, easily wounded, or quick to anger, an attitude of defensiveness can emerge that compromises the learning.

Dr. A. was a resident trained in a foreign country who had recently immigrated to the United States. He arrived at our first supervisory session and began by introducing himself as an experienced doctor in his country of origin, which in fact he was. He also told me that he did not believe in the unconscious and furthermore that in his country, women did not tell men what to do. I imagined that our relationship would be a very brief one, lasting approximately 15 minutes. Perhaps this was my hope, as well, since I could anticipate a difficult situation at best. Nonetheless, I was intrigued by this man, who, in fact, acted in a courteous and warm manner that belied the message contained in his words. I repeated to him the process of supervisory selection and pointed out that he had all manner of other choices available to him, should he wish to avail himself of them. He told me that he understood the process very well and had indeed gone to great lengths to secure this hour with me for himself. Now I began to experience the ambivalent attachments that were to characterize many of his learning dilemmas with me and also his work with his patients. I decided to experiment with a model that I hoped would reduce his shame around the student role. I suggested that we split the hour in half, and that for the first half I would present a case to him and he could discuss it from his perspective, reversing the process for the second half. To my delight, we worked productively in this way for about two months, whereupon he suggested that we stop this "silly arrangement" because he really needed my help for the whole hour. I continued to supervise this gentleman's work for several years and have followed his professional growth through the literature with pleasure since then. I notice that I use the word "gentleman" in referring to Dr. A., and I think this exemplifies the extreme care and tact with which I felt I needed to approach him, lest I insult his rather fragile sense of dignity. At the same time, his approach to me was courtly and polite, which both underscored that our collaboration was formal and potentially curtailed the depth of our work. I believe the supervision with Dr. A. is one in which the boundary between teaching and treatment was negotiated by focusing carefully on the teaching and learning of clinical theory and its application in the cases we presented to each other. But this emphasis originated from a need to heal the psychological tensions of the student and to deal, however indirectly, with the challenges to his narcissistic equilibrium. Was this teaching or was it therapy? Obviously the dichotomy is a false one. Nonetheless, the burden is on the supervisor to find a way to meet the student where he begins, and to adhere to the boundaries of the supervisory privilege. In my work with Dr. A., we avoided all discussion of his family of origin, except in a general discussion of cultural assumptions about development. We did not say a thing about the difficulties of being a beginner after being an expert, but we did talk about the patient's pain in beginning treatment. I'm certain that none of this was lost on Dr. A. and that he would be more or less conscious of these conflicts as he proceeded in the work.

What I am saying is that the supervisor has to listen with a clinician's ear and speak with a supervisor's mouth. Thus, we discussed the patient's dilemmas, but I was always aware that we were also indirectly speaking to Dr. A.'s own pain. We used the patient as a "displacement" and relied on the parallel process to heal both patient and doctor. Although I began with a much more supportive supervisory stance by leveling the power dynamics between us, it was not long before Dr. A. let me know that we could now move on to a more intensely psychodynamic focus on the patient. It was never entirely clear to me what allowed the work to deepen to a much more serious level of exploration; I believe that the gradual building of trust between Dr. A. and me finally lent him the courage to abandon pathological certainty and be really curious about the patient's life. This time, the supervisory process worked. The judgment call about the effectiveness of the supervision always depends on the nonspecific aspects of the supervisory work, just as in the therapist's work with his patients. By nonspecific aspects I mean the common basic assumptions of psychotherapy, such as the climate of attentive listening and persistent exploration of the relationship. One of the major reasons that this case worked out so well is that Dr. A.'s eagerness to learn was profound and his integrity beyond question. However, I do not want to give the impression that this supervision was a seamless process with no obstacles along the way. There were times when Dr. A. would try to engage me in highly theoretical conversations relevant to his prior experience, and I would find myself impatient and angry with him over these regressions. To the extent that I could step back from enacting this anger and instead explore his frustrations with our work, we were able to progress beyond these sticking points. My openness to learning from him was authentic, and we both enjoyed new ideas and options. This made for an attitude of respect that allowed a potentially disastrous supervisory relationship to flourish and deepen. It is not always so, alas. Next I will offer two cases where the supervision foundered. Many years ago, Ekstein and Wallerstein5 described six potential sources of impasses in supervision: 1. 2. 3. 4. 5. 6. Dumb spots. Blind spots. Reactions to the patients' transference. True countertransference emerging from the clinician's personal life. A mismatch in learning and teaching styles. Frank personality conflict between supervisor and supervisee.

To their list, I would add these other factors that may bring the work to a standstill: 1. 2. 3. 4. Unrecognized and poorly managed shame. Anxiety centered on power and competition. Unconscious replication of the supervisor's own difficult experiences as a student. Fear of disappointing one or both parties.

5. Either party's feeling devalued by the institution and by the prevailing clinical climate. The forms that supervisory resistance can take are myriad. It can involve problems such as avoiding conflict to preserve the relationship, neglecting to adhere to the clean boundaries usually valued in the psychotherapy hour, and blaming the patient, among others. The following two cases are examples of supervisory impasse that proved more or less disastrous to the work of clinical training. In the first example, clues were present early in the form of inadequate attention to the frame of the supervision hour. Even clinicians who impeccably maintain the frame in the therapy hour rarely adhere to and examine for ruptures the parameters of the supervisory hour. Cancellations, late arrivals, or interruptions for answering beepers are easy to write off as inevitable inconveniences of a busy practice. Although this is often true, the failure to examine these breaks in the frame is a lost opportunity to understand more deeply the resistance of any or all of the three parties to the supervision. We supervisors are accustomed to insisting on hearing the details of our patients' lives, but we are not as attuned to hearing the supervisee's material with the same attention to detail as to what is included and, especially, what is omitted. The supervision of Dr. B. nearly foundered on the shoals of this supervisory carelessness. This was a supervision conducted by a colleague who sought my consultation when she felt worried about her student's progress. Dr. B. was a warm, charming resident, hard-working and apparently eager to learn. However, he persistently avoided bringing process notes to his supervisor. When pressed to do so he devoutly promised to provide them for the next hour, but seldom did. The supervisor colluded in this omission, and the two had long and fascinating discussions about the "kind" of patient Dr. B.'s patient represented. However, the patient started missing her therapy hours, and Dr. B. began arriving later and later to supervision. Finally he had nothing to report and wished to move on to another case. The supervisor, having become increasingly concerned, insisted on a verbatim account of what had occurred during the last hour with the patient. Dr. B. reported that the patient had handed him a gift on the way to his office, while blushing and stammering her "Happy Holiday" wishes. Dr. B., caught in the patient's embarrassment and not wanting to add to it, simply accepted the gift. On further inquiry, he admitted that in fact, this was not the first gift. The patient often brought little gifts, such as a cookie or coffee, to the office to share with her therapist, all of which he uncomfortably accepted with no comment. Dr. B. knew his supervisor's strict adherence to the boundaries between patient and doctor and was fully aware of her disapproval of gift exchange. In truth, he was correct here; it would have been very hard for the supervisor to be neutral about this matter. He kept this "secret" from her for many weeks, since he valued her opinion of him and feared her criticism. However, his anxiety skyrocketed when he opened the last patient gift, which turned out to be a valuable piece of jewelry. He returned this to the patient with alarm and

some barely veiled anger. His disapproval was not lost on the patient, who dropped out of treatment in an agony of shame and rage. The supervisor was sensitive to the resident's loss of face as well. She recounted a similar memory from her training days, confessing that she too had hidden from her supervisor that she had frequently exceeded the 50-minute time limit with a patient, only to find that this very difficult patient in fact did well in treatment despite her supervisor's dire warnings about the destructiveness of ever violating the frame. She was too fearful to ever confess to her supervisor that she knew better in this case. They shared a laugh at the dogmatism of the long-departed supervisor, who had remained mercifully ignorant, and they began to address the problems in their supervision of this case. Upon further discussion, this resident became extremely anxious and burst into tears. He proceeded for the next several weeks to talk mostly about his family's tensions about gift-giving and the overall sense of poverty in what in fact was an upper-middle-class family of comfortable means. He also pressed the supervisor to explain and justify more persuasively why her position was more legitimate than that of his own former therapist, who had accepted gifts from him at various points in the treatment. Dr. B. and his supervisor moved on to a discussion of the meanings of the gift to the patient in light of her family history, and then to the theory that informed the management of boundaries such as gift-giving. They explored the patient's impulse to give gifts, to examine its underlying meanings, and to illuminate the potential ambivalence in the giftgiver. These discussions evoked powerful resistance and much shame on the part of the student. Dr. B. finally said his main fear was that he would lose the patient if he were to examine the gift-giving in any way. In turn, then, he would lose face with the supervisor for "failing" in the work with this patient. She urged the student to work in his personal therapy on his personal responses to the situation, leaving the two of them freer to concentrate on the work of supervision. The challenge for the supervisor was to bring the work back, time and again, to the best interest of the patient. Indeed, the patient did drop out of treatment. The supervision continued for the rest of the year as a postmortem exploration of the case, but the gains were marginal after this point. Two weeks after the supervisory termination, an elaborate gift was delivered to the supervisor's office from the resident, with a thank-you note. The supervisor asked if they could meet and if she could return the gift, but the resident refused. The supervisor found herself disappointed and quite dismayed at the clinician's persistent inability to contain the impulse to act out the seduction with her. Supervision is an ambiguous business; it contains aspects of so many roles that the situation lends itself to confusion and anxiety. Add to this the discomfort of a treatment that is not going particularly well, and the dyad may find themselves visiting, chatting, missing meetings, going out for a drink, or otherwise resisting the discipline of the supervision. The following example describes another time when I was called to consult on a supervision at impasse.

A colleague called me to ask for help with a student whose work was stalled. More important, the colleague found that he could hardly stay awake during the hour, and in fact had found himself double-booking the hour more than once. He had finally resorted to meeting the student for lunch, and, even then, they tended to chat about movies or some new article in a professional journal. My colleague enjoys the reputation of a fine supervisor, and deservedly so, yet increasingly he found himself appalled at the level of nonprofessionalism in which he colluded in his work with Dr. C. He struggled to understand why, since on the face of it, Dr. C. was an exemplary student. She arrived promptly each week, with full process notes that were duplicated so that each could have a copy. The references to the relevant literature were even included in the margins, and Dr. C. always had questions about the case to ask of her supervisor. These invariably concerned areas such as theory of technique or outcome studies. Dr. C.'s supervisor could find nothing to fault in the externals of the supervision, but he could not penetrate the boredom. His work with his student had an antiseptic quality that he assumed represented the mood of the clinical hour as well. When he asked Dr. C. about the patient's feelings or inquired about the therapist's feelings toward the patient, Dr. C. offered the most superficial level of understanding and showed little curiosity about deeper meanings or inferences. She remained focused on the pragmatics of the case, and expressed pity for the poor patient. When the supervisor attempted to suggest some overidentification with the patient, Dr. C. simply redoubled her efforts to relieve the patient's suffering in practical ways that remained unexamined. At the same time, the supervisor found himself admiring Dr. C.'s patience and determination to help her patient, who was indeed a very sick woman. He was loath to make her feel bad about the work. Indeed, the patient seemed to be making some progress with the management of her life, to Dr. C.'s great pride and satisfaction. He decided that the problems stemmed from his own ignorance of the learning paradigms from Dr. C.'s training as a pastoral counselor. He decided that if he got to know Dr. C. better, he could help her to relax and be more in touch with her feelings toward her patient and toward the feelings the patient aroused in her. Thus the decision to meet over lunch in a less formal setting. He did not express to Dr. C. his wish that she enter treatment herself, since he was strongly opposed to what he felt was a common intrusion on the part of supervisors toward their students. It was at this point that the supervisor called on me to consult on the supervision. I recommended that the frame of the supervision be tightened to the usual time and place and that my colleague and his student use their avoidance of the work of supervision as an opportunity to wonder what was being avoided in the therapy. They agreed to do so. Unfortunately, 3 weeks later Dr. C.'s patient made a drastic suicide attempt resulting in serious and permanent brain damage. Dr. C. and the supervisor were blindsided by this. Both felt horror for the patient and guilt at not having perceived the risk to this patient's

life. His guilt overrode all of the supervisor's efforts to help Dr. C. understand what went wrong or to learn from it. It was all more than this vulnerable student could absorb, and she left the field for another subspecialty.

SAFEGUARDS IN SUPERVISION
Our training programs are still sadly lacking in opportunities for learning how to supervise. Mostly one becomes a supervisor just by aging. In those happy instances where there is formal training, we still lack continuity. I know of no requirement for continuing education in supervision; for that matter, I know of no formal criteria for adequate supervision. We are still much more casual than is safe or creative. More formal training in an agreed-upon set of expectations would help us avoid some of the pitfalls I have described. So, what could these supervisors have done differently? An ounce of prevention would have been worth a pound of cure. Training institutions would do well to put in place some potentially helpful safeguards. For example:
1. A Supervisory Contract:

Close, early attention to the supervisory contract helps supervisors assess the learning situation and perhaps predict areas of future difficulty. I have learned to be as specific as possible about how I work and to develop a learning contract at the beginning of each supervisory relationship. (I also recommend relevant literature5 and ask the student to describe his or her preferred learning style.) The contract includes time, place, and expectations about a variety of matters such as process notes and cancellations. For example, I meet with my students one hour a week, every week. Exploring supervisory cancellations and lateness is as important as exploring cancellations and lateness in the therapy hour. I clarify as best I can the difference between teaching and treatment, and I pronounce my avowed bias that trainees need to be in their own therapy at the same time that they are in supervision with me. Of course this is not something that can be mandated, but should the work underline this need further, they can expect to hear me repeat this recommendation. Expectations about process notes should be made clear. There is a wide variety of opinion and practice as to how supervisees should present data to their supervisors. Some supervisors prefer process notes; some prefer literal transcriptions of audiotapes or videotapes of the hour; and others rely on the student's recall and recounting of the hour with the patient. Each of these methods has its advantages. The material on tape will certainly be more accurate as to content, whereas the verbatim from memory will illuminate blind spots better. I myself prefer that the student record the specific interactions between the patient and the therapist after the hour. This allows me to work with my student about omissions, parapraxes, and distractions that come up both in the treatment and supervisory hours. No method, however, is immune to supervisory resistance. How many blank tapes have you tried to listen to? How many memory gaps and lost process notes have our students reported with embarrassment and chagrin? Although some of this is natural and

inevitable, the persistent absence of concrete and verbatim material is ultimately a source of serious trouble if not addressed.
2. Timely Outside Consultation:

Supervisors might seek outside consultation sooner. In the case of Dr. C. and her patient, earlier consultation might have helped all parties to address the perceived impasse earlier on and to help reestablish the supervisory alliance6,7 in a more useful direction. In cases of irresolvable impasse, one might usefully refer the student to another supervisor. We do not do this often enough, perhaps because we remain confused about whether this is teaching or therapy. We may tend to forget that the student may learn much better from a colleague than from us and does not need to resolve the relationship with us in the same way that we would wish for our patients. So we fail to help them switch with dignity, leaving them little option but to fail or to hide from us. Fortunately for all of us, we have the wise and compassionate words of Donald Winnicott,8 who reminded us that a "good-enough mother" was indeed good enough. There is hope that the same value obtains for supervisors as well and that we can arrive at a good-enough state for our students and for the future of our profession as well. In the final analysis, it is in the realm of "good enough" that creativity and passion flourish and enrich us and our students.

Footnotes
Dr. Alonso is Professor of Psychology in the Department of Psychiatry, Harvard Medical School. She is the Director of the Center for Psychoanalytic Studies, Massachusetts General Hospital. This article is based on a Grand Rounds presentation at the Cambridge Hospital, Harvard Medical School, Spring 1999.

References
1. Benjamin J: Like Subjects, Like Objects. New Haven, CT, Yale University Press, 1995 1. Stolorow R, Brandchaft B, Atwood G: Psychoanalytic Treatment: An Intersubjective Approach. Hillsdale, NJ, Analytic Press, 1987 1. Gans JS, Alonso A: Difficult patients: their construction in group therapy. Int J Group Psychother 1998; 48:311326[Medline] 1. Alonso A, Rutan JS: Shame and guilt in supervision. Psychotherapy: Theory, Research, Practice and Training 1988; 25:576581 1. Ekstein R, Wallerstein RS: The Teaching and Learning of Psychotherapy. New York, Basic Books, 1963 1. Alonso A: The Quiet Profession: Supervisors of Psychotherapy. New York, Macmillan, 1985 1. Kleinberg JL: The supervisory alliance and the training of psychodynamic group psychotherapists. Int J Group Psychother 1999; 49:159179[Medline] 1. Winnicott DW: Collected Papers: Through Paediatrics to Psychoanalysis. New York, Basic Books, 1958