Psychotherapy Supervision and Consultation in Clinical
Practice
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Psychotherapy
Supervision and
Consultation in
Clinical Practice
Edited by
Judith H. Gold
jASON ARONSON
Lanham • Boulder • New York • Toronto • Oxford
Published in the United States of America
by jason Aronson
An imprint of Rowman & Littlefield Publishers, Inc.
A wholly owned subsidiary of
The Rowman & Littlefield Publishing Group, Inc.
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Copyright © 2006 by Rowman & Littlefield Publishers, Inc.
All rights reserved. No part of this publication may be reproduced,
stored in a retrieval system, or transmitted in any form or by any
means, electronic, mechanical, photocopying, recording, or otherwise,
without the prior permission of the publisher.
British Library Cataloguing in Publication Information Available
Library of Congress Cataloging-in-Publication Data
Psychotherapy supervision and consultation in clinical practice I edited by
Judith H. Gold.
p. em.
ISBN-13: 978-0-7657-0399-6 (cloth: alk. paper)
ISBN-10: 0-7657-0399-8 (cloth: alk. paper)
1. Psychotherapists-Supervision of. 2. Psychotherapy-Study and
teaching. I. Gold, judith H., 1941-
RC459.P76 2006
616.89'14-dc22 2005037366
Printed in the United States of America
@ ™The paper used in this publication meets the minimum requirements of
American National Standard for Information Sciences-Permanence of Paper for
Printed Library Materials, ANSI/NISO 239.48-1992.
Contents
Part 1: Introduction
Introduction 3
Robert Michels
1 Why Psychotherapy Supervision Is Essential for Mental Health
Professionals 7
judith H. Gold
2 Supervision: Models, Tools, and Supervisory Experiences 21
judith H. Gold
Part II: Issues in Supervision and Consultation in
Psychodynamic Psychotherapy
3 Supervising Psychodynamic Psychotherapy 35
Norman A. Clemens
4 Discussing the Undiscussable: The Limits of Supervision 59
Francis T. Varghese
5 Improving Supervisory Skills: An Exercise in Lifelong Learning 73
Marcia Kraft Gain
6 Supervision of Boundary Issues 83
Gail E rlick Robinson
Part III: So Now I'm Grown Up-Do I Need Supervision?
7 The Supervision of a Psychiatrist-Manager 109
]acima Powell
v
Vl Contents
8 A Hospital-Based Clinician's Experiences of Psychotherapy
Supervision 125
Mee Ling Khoo
9 Supervision in Private Practice 135
judy Somerville
Index 145
About the Editor and Contributors 149
I
INTRODUCTION
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Introduction
Robert Michels
Caring for psychiatric patients is difficult and challenging, and those who do
so face complicated and unusual tasks.
First and foremost, they work with people who, by definition, are hard to
understand and not always collaborative. They must employ a wide variety
of methods-biologic, psychologic, and social. Although there is a growing
body of empirical evidence concerning the effectiveness of these methods,
the evidence rarely prescribes what a given therapist should do with a given
patient at a given point in time. There are a seemingly infinite number of
intervening variables: patient variables, such as comorbidities, life situations,
life histories, and fantasies about illness and treatment; therapist variables,
such as knowledge, experience, career trajectories, and theoretical and per-
sonal biases; and situational variables, such as the social and economic con-
text of the treatment, its anticipated intensity, and the time frame. As a
result, there is rarely a single right way to treat a patient, although there are
often many wrong ways, and therapists do not learn "right ways" as much
as learn how to proceed to plan and conduct the treatment in the face of
ambiguity and uncertainty.
How do they learn this? Like the conduct of therapy itself, they do so in
every possible way. A professional who plans to work with the mentally ill
has a responsibility to know what is known and to learn what can be learned
through didactic instruction, books, lectures, and journals. Case conferences
are valuable, providing accounts of how others see problems and how they
go about trying to solve them. Many who conduct psychotherapy find their
own personal psychotherapy to be helpful. Learning about transference or
resistance is like learning about swimming or dancing; there is a limit to what
3
4 Robert Michels
didactic instruction can achieve. One has to experience it directly in order to
understand what it is about. When all goes well, these several methods, com-
bined with clinical experience, lead to a therapist who is prepared to work
with patients. Paradoxically, clinical experience can be valuable even if it is
experience of failure. One can learn from mistakes if one is able to examine
and reflect on them. In psychiatry, as in the rest of medicine, the usual prin-
ciples of training have the novice work as an apprentice for a relatively long
period of time so that the first time he is alone in a clinical situation, he has
already had the experience of having done it many times in the past.
And then there is supervision, the subject of this book. Most experienced
psychotherapists would agree with everything that I have said but would also
agree that in spite of this, the most important component of their psycho-
therapeutic education has been supervision. Furthermore, as this book
uniquely discusses, supervision is the experience that is likely to continue
after formal training has been completed and to influence and shape profes-
sional development throughout the therapist's career.
Supervision involves talking about one's work with another. It occurs in
every conceivable permutation and is as varied as psychotherapy itself. The
other may be an individual or a group, a senior mentor, or a peer, someone
who is simultaneously administering or evaluating one's work or is seen in a
totally private and protected relationship. It may occur as a single event or a
regular periodic meeting. It can focus on the patient, the therapist, or the
therapeutic process and may shift among these domains. The goals of super-
vision also vary. It can provide quality assurance (including the maintenance
of appropriate boundaries) for the patient, support and reassurance for the
therapist, or an opportunity for professional learning and growth for the
therapist (and, probably most often, a mix of these with the proportions
shifting from time to time). It may include didactic teaching (defining a con-
cept or suggesting a reading), but that should not be its central theme. It is
usually differentiated from administration (supervision requires an atmo-
sphere of tolerance and safety, with support for self-disclosure, while even
the gentlest of administrative relationships may lead to some wariness on the
part of the therapist). There has been particular concern to differentiate
supervision from personal psychotherapy-supervision has a goal, a focus,
and boundaries that are quite different from those of psychotherapy, and the
skilled supervisor respects and maintains these in spite of temptations to blur
them.
This book explores psychotherapy supervision from a variety of perspec-
tives. We hear from both supervisors and supervisees, from early-career cli-
nicians, and from senior members of the profession. The role of supervision
in the therapist's professional development, particularly after formal training
has been completed, is emphasized throughout. Difficult and special issues
are faced, such as management of the patient's response to the particulars of
Introduction 5
the therapist, especially those that might be stigmatizing, or the supervision
of boundary crossing and even of potential boundary violation.
The supervisory autobiographies of several supervisees trace their experi-
ences as they complete their training and pursue their careers. Particularly
interesting is the extension of supervision, which began as a tool in the teach-
ing of psychodynamic psychotherapies to its use in other types of psycho-
therapy, case management, and clinical administration.
Supervision does not transform a poor therapist into a good one, but it
can help any therapist become a better one. It is a method that is peculiarly
suited to its subject matter-highly individual, a mixture of art and science,
centered on an intense personal relationship, and based on a mixture of
understanding and insight, emotional learning, and the transforming poten-
tial of human relationships. We are indebted to Dr. Gold and her colleagues
for providing views of what happens in a variety of types of supervision and
enhancing our understanding of the difference it can make and how it does
so.
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1
Why Psychotherapy Supervision Is
Essential for Mental Health
Professionals
judith H. Gold
Susan Smith is a staff psychiatrist in a busy urban general hospital. She has
held this position since passing her examinations three years ago. The psy-
chiatry department is understaffed, and she has been placed in a senior posi-
tion overseeing an acute care ward where she is the psychiatrist in charge and
is also responsible for teaching residents and other mental health staff. Susan
works long hours and also has family responsibilities. Lately, she is fre-
quently angry with some of her patients and worrying about others. She
feels tired and overwhelmed by her responsibilities. A colleague suggests
that Susan seek supervision immediately.
John Smith is a caseworker in a government family services department.
Trained as a social worker, he now has between eighty and one hundred
active files and tries to oversee the welfare of all the involved children. Con-
scious also of recent legal action regarding the responsibility of care by social
workers for these children, he feels increasingly pressured to follow all his
cases closely. He often fears for his safety, having been threatened by angry
parents and visiting families on his own because of a lack of staffing. In addi-
tion, he provides psychotherapy for many of the children placed in foster
care and for some of the parents. Recently, one parent died by suicide after
John had removed his children from his care. John is considering resigning
and finding another career.
Jane Smith is an occupational therapist working in a community mental
7
8 Judith H Gold
health clinic. With a policy of team care for patients, she finds herself provid-
ing long-term psychotherapy or case management for patients with a variety
of mental health disorders. Often she feels that her cases are complex and tax
her expertise. She frequently asks the psychiatrists who provide psychophar-
macological management and oversight for advice but feels increasingly
overwhelmed.
These are a few examples of people working in an increasingly complex
and demanding mental health system. Understaffed usually, frustrated by
demands placed on them, and conscientiously trying to service their clien-
tele, mental health professionals often feel inadequately trained to manage
the psychological health of their patients. Whether in private practice or in
public service, many face an underfunded and understaffed system with
growing scrutiny of their professional behavior. In other settings, clinicians
are asked to treat patients in collaboration with another mental health pro-
fessional and must then find ways, together with the other clinician, to work
optimally with the patient, frequently without adequate training in the com-
plexities of split treatment. Further, with the cutbacks in funding for long-
term psychotherapies by many insurers, many clinicians find themselves in
conflict between their recognition of the treatment best for the patient and
the treatment that is fundable. In some areas, and in some countries, the
shortage of trained mental health clinicians leads to pressure on the clinician
to treat more patients more quickly, to work long hours, and to accept
responsibilities beyond their training or experience.
While demands for evidence-based treatment protocols are growing, clini-
cally it is known that all interactions between clinicians and patients have an
interpersonal psychotherapeutic basis. Research has demonstrated that suc-
cessful treatment requires a therapeutic alliance and that compliance with
treatments is enhanced by such an alliance. 1• 2 Even very brief encounters
engender some type of interpersonal reaction for both patient and clinician.
Understanding and managing these interactions is an essential skill for every
mental health professional and clinical team. When the factors influencing
these interpersonal relationships are not appreciated or are overlooked,
ignored, or mismanaged, treatment failures can ensue, as can boundary vio-
lations.
Requesting consultation with a senior colleague in specific incidents or
arranging supervision on an ongoing basis can assist clinicians in all settings
and circumstances. This book seeks to demonstrate the usefulness of consul-
tation and supervision as well as to discuss the barriers perceived to exist in
making such requests for assistance in increasing competency. We describe
how both clinician and patient benefit. The idea for the book arose from
reflection about the role of psychotherapy supervision in the work life of
busy mental health professionals. This was precipitated by a discussion with
some of the authors of the following chapters about the dissipation of a tra-
Why Psychotherapy Supervision Is Essential for Mental Health Professionals 9
clition of supervision and consultation among clinicians as therapeutic inter-
ventions centered more and more on psychopharmacology and case
management rather than on psychodynamics and interpersonal interactions.
Books and papers on supervision tend to focus on trainees or on psycho-
analytic case supervision. Little attention seems to have been paid to the need
for psychotherapy supervision-or for consultation-for those clinicians in
practice in the community. Clinical oversight and consultation is often avail-
able in hospital settings to assist in case management but appears to be rarely
available for psychodynamic interactions and treatments. An extensive litera-
ture search conducted through Medline revealed few publications in the past
two decades. Nevertheless, many professional organizations recommend
ongoing supervision and consultation to their members. Emphasis on the
importance of such activities is found in discussions of the avoidance of
boundary violations and in practice guidelines such as the American Psychi-
atric Association's "Practice Guideline for the Treatment of Patients with
Borderline Personality Disorder." 3• 4• 5
Expertise as a psychotherapist continues to develop throughout one's
career and does not culminate with graduation from a training program. Just
as clinicians must constantly update their knowledge of psychopharmacol-
ogy, the practice of any of the psychotherapies requires continuing attention
to new theories, to new research data, and to the maintenance and improve-
ment of therapeutic skills. While some of this can be acquired through read-
ing and didactic courses, clinical interaction with others well versed in
psychodynamic techniques and familiar with current theories and research
is as useful for practitioners as for trainees.'·
Furthermore, many mental health professionals, including psychiatrists,
will find that their training has not prepared them for the complexities of
practice. Courses during training provide a practical knowledge of psycho-
therapy sufficient to meet training and examination requirements. Many dis-
cover that this experience is insufficient and that they will benefit from
learning more advanced techniques; some find that other skills are needed,
especially when dealing with complex patients such as those with personality
disorders. While professional associations are beginning to require compe-
tency in a number of psychotherapies, it is not uncommon for a professional
working in a mental health clinic or practice to have expertise in only one
modality, such as cognitive-behavioral therapy, interpersonal therapy, or
dialectical behavior therapy. The difficult patient, the person with intractable
depression, the poorly compliant person, and the person with complex psy-
chosocial problems will strain the skills of these clinicians. In addition, many
treatment settings will demand a broad range of psychotherapeutic skills
from each clinician, especially in these times of restricted budgets and under-
staffing. A mental health professional in practice in a small or underserviced
area may also discover that his or her training is inadequate to meet the
10 judith H Gold
therapeutic needs of clients. Additionally, some patients may arouse feelings
in the clinician that can lead to a variety of boundary violations, from inap-
propriate treatment settings to overt sexual activity.
In all these instances, the clinician will benefit from supervision with their
cases or, at least, from consultation with someone more expert. Finally,
understanding the psychological functioning of an individual will assist in
the development of a therapeutic alliance. The chapters that follow in this
book discuss and illustrate all these points in detail.
Mental health professionals should be encouraged to seek supervision
both to increase their understanding of underlying psychodynamics and to
broaden their psychotherapeutic skills. 7 Organizations that maintain profes-
sional standards could offer credits for continuing education and mainte-
nance of competency to both supervisee and supervisor, much as some now
credit peer study groups.
Professionals with expertise in psychodynamic psychotherapy will also
benefit from supervision to help maintain and extend their skills. Supervi-
sion also provides a forum for addressing ethical concerns and boundary
issues as well as transference and countertransference. It can also help those
who work in multidisciplinary teams develop an understanding of complex
team dynamics that may be affecting patients' treatment. Supervision can
also assist the professional in becoming aware of the underlying dynamics in
patients who have seemingly intractable symptoms or who are noncompli-
ant. When the clinician is experiencing personal difficulties, supervision can
be essential for effective clinical practice. H
THE SUPERVISORY PROCESS
The role of the supervisor is multifaceted but does not include providing
treatment for that person. If the supervisee would benefit from psychiatric
or psychological treatment, that must be obtained elsewhere. The supervisor
is also not a cotherapist and does not actively participate in the treatment of
the patient/client under discussion during the supervision. The supervisor
must also be aware of his or her motivation in agreeing to supervise and be
sensitive to the supervisee's level of self-esteem as well as transference issues. 9
A discussion of training for supervisors can be found in chapter 5.
Psychotherapy supervision of both trainees and clinicians demands the
sensitivity of a good teacher and the intuitive skills of a psychotherapist.
Supervisees should feel accepted and respected while being assisted to
develop their therapeutic expertise. In all instances, the process involves con-
fidentiality, both for the supervisee and for content related to the patient(s).
The supervisor does not permit boundary violations to occur between them.
