An approach to supervision in health care settings

This article describes a flexible approach to supervision which allows for the fact that integration may mean different things to different people under different circumstances. In the health contexts described the clinical mix which was found most helpful in the supervisory work combined psychodynamic, Jungian and humanistic perspectives. The application of this particular mix of clinical techniques is demonstrated with reference to the work with two supervisees. It is felt that the methods employed are consistent with the current notions of difference in counselling and psychotherapy.     

Trainee therapists’ views on the alliance in psychotherapy and supervision: a longitudinal study

The shape of alliance in psychotherapy and supervision using growth curve modeling was examined for clinically inexperienced trainee therapists, who were engaged in long-term cognitive behavioral - or psychodynamic individual psychotherapy at a Psychology Clinic in Sweden. Trainee therapists rated their view of the alliance with their clients and their supervisors on the Working Alliance Inventory at five time points. The alliance to the client show a consistent, positive development throughout the therapy. The alliance to the supervisors show initially a decrease, followed by an increase, and then again, the rate of increase in the supervisory alliance ratings slowed down indicating a more complex view of the supervisory alliance compared to the view of the alliance in psychotherapy.     

Supervisory reactions: an important aspect of supervision

Anne Alonso was passionate about the practice of supervision. An excellent supervisor herself, she sought to identify and teach the ingredients of effective supervision throughout her career. Her first book, The Quiet Profession (1985), was about the supervisory relationship and the various influences on it from within and without the relationship, and she insisted that the Center for Psychoanalytic Studies training program that she directed for many years include a required course on supervision. While the usual focus in supervision is on the supervisee and the clinical material presented, supervisors often experience powerful emotional reactions. Sometimes this is parallel process, in which the dynamics of the psychotherapy are replayed in the supervisory relationship. However, many other sources can contribute to supervisory affect, including the personality, background, and developmental stage of the supervisor, the impact of the clinical material, and the setting in which the supervision takes place. Supervisory reactions can be informative about the psychotherapy being supervised, about the supervisory relationship, or about the supervisor. Supervisors need self-awareness in order to identify their own contribution to their affective responses in supervision. The use of a supervisor decision tree of 1) awareness of reaction, 2) identification of its source, 3) relevance to current supervision, and 4) appropriate use of the reaction in the current supervision is recommended.     

Gegenübertragung im stationären Therapie-Setting

Background

Countertransference is seen as an instrument of research into a patient’s unconscious and is therapeutically useful in furthering psychodynamic work. For inpatient psychodynamic psychotherapy, where patients are treated by a team of psychotherapists, countertransference is much more complex and makes consideration and integration of different countertransference feelings necessary. Using the first German translation of the countertransference questionnaire (CTQ, Zittel Conclin and Westen, the countertransference questionnaire, 2005) an attempt was made to identify differences in countertransference phenomena in a team of psychotherapists and to show the impact countertransference has on therapy outcome.

Materials and methods

A total of t multiprofessional teams of psychotherapists (15 physicians, 5 psychologists and 9 body and art therapy psychotherapists) took part in the study and completed the CTQ for 137 patients (100 female, 37 male) at the beginning and at the end of inpatient psychotherapy. In addition, the patients completed two questionnaires, the Symptom Check List Revised 90-R (SCL-90) for the severity of symptoms and the Assessment of DSM-IV Personality Disorders Questionnaire (ADP-IV) for personality disorders.

Results

Body and art therapy psychotherapists expressed more positive, protective and involved countertransference feelings whereas psychotherapists for single and group therapy expressed more aggressive and hopeless feelings. Countertransference has an impact on therapy outcome and feelings of a lack of interest, aggression and resignation at the beginning of therapy can point to a poor outcome. Patients with personality disorders activate more negative countertransference reactions than patients without personality disorders but at the same time they may also evoke parent-like feelings of protection.

Conclusions

Using the CTQ it is possible to differentiate countertransference phenomena in a team of psychotherapists treating inpatients with psychodynamic psychotherapy. The timely perception and integration of countertransference feelings has a positive influence on the therapeutic process and therapy outcome.     

The peer supervisory group for psychoanalytic therapists

The recent interest in peer supervisory groups for psychoanalytic therapists raises important questions regarding both psychoanalytic training and group process. The present paper explores these issues and suggests that there exists a continuum from case-centered peer supervisory groups to process-centered peer supervisory groups. Transference and countertransference and the recognition of parallel processes in psychotherapy supervision are examined in their relation to the supervisory group experience. The authors suggest that the model a therapist employs regarding the role of countertransference will most likely influence the kind of peer supervisory group that s/he will choose. Further, there are specific techniques, as well as experiences, which may foster alteration of the group's psychic organization. Illustrative case examples are provided throughout.     

Assessing personality change in psychotherapy with the SWAP-200: a case study

Many studies document the efficacy of psychotherapy for acute syndromes such as depression, but less is known about personality change in patients treated for personality pathology. The Shedler-Westen Assessment Procedure (SWAP-200; Westen & Shedler, 1999a, 1999b) is an assessment tool that measures a broad spectrum of personality constructs and is designed to bridge the gap between the clinical and empirical traditions in personality assessment. In this article, we demonstrate the use of the SWAP-200 as a measure of change in a case study of a patient diagnosed with borderline personality disorder. We collected assessment data at the start of treatment and after 2 years of psychotherapy. The findings illustrate the personality processes targeted in intensive psychotherapy for borderline personality.     

How honest do counsellors dare to be in the supervisory relationship?: An exploratory study

A study was conducted to investigate the extent to which psychodynamic counsellors feel able to disclose sensitive issues in supervision. Ninety-six counsellors in supervision responded to a questionnaire that asked about supervision arrangements, the supervisory working alliance, and the likelihood of disclosing issues such as erotic feelings towards clients and discomfort with the supervisor. Results showed that supervisees were likely to disclose more in individual rather than in collective supervision, when their supervisor was someone whom they themselves had chosen rather than had allocated to them, and when they were supervised independently of the setting in which they counselled rather than in-house. There was a positive correlation between the quality of the supervisory working alliance as experienced by the supervisee and the extent of his or her disclosure. Implications of counsellors feeling inhibited from disclosing particular issues in supervision, and the impact on the quality of their work with clients, are discussed.     

Creative Group Living in a Children's Institution Edited by Susanne Schulze

Psychoanalytic psychotherapy is not well developed in Japan (Kotani, 1996). Until recently, group psychotherapy in particular has not been well received by patients or clinicians. Cultural difficulties in using group psychotherapy with Japanese patients have now been overcome and a theory of systematic intervention techniques has been developed. The basic dynamic factors of group psychotherapy such as culturally embedded aspects of social and personality structure are analyzed in this article. Culture-bound psychodynamic characteristics of Japanese patients as activated and worked through in the group process are first described with case illustrations. A systemic hypothesis linking cultural and psychodynamic structure is then delineated and the focal points of interventions are explained in terms of the field dynamics of social structure and boundary dynamics of personality structure.     

Parallel process in supervision

This paper addresses the concept of parallel process and its application in clinical supervision. Parallels between therapy and supervision are examined as well as some of the key issues surrounding the use of parallel process as a supervisory intervention. Although there is a need for more investigation to explain and support this concept further, the authors would argue that parallel process interventions in supervision can enhance the supervisory process and the task of teaching and learning for both the supervisee and supervisor. A case example is provided to demonstrate the parallel process in supervision and its potential as a facilitative intervention.     

The supervisory alliance and the training of psychodynamic group psychotherapists

This article focuses on the role of the supervisory relationship in the training of psychodynamic group therapists. The supervisor's teaching responsibilities include identifying what the novice leader needs to learn about running a group, and designing and implementing supervisory strategies in a safe, collaborative, and creative setting. Of particular importance to psychodynamic supervision is the recognition of emerging impediments to learning and discerning their significance for understanding the underlying dynamics of the supervisees' treatment groups. Examples of two supervision groups are provided, one in which a misalliance had developed, and another in which a more promising supervisory relationship was forming.     

Are psychodynamic and psychoanalytic therapies effective?: A review of empirical data

There is a need for empirical outcome research in psychodynamic and psychoanalytic therapy. However, both the approach of empirically supported therapies (EST) and the procedures of evidence‐based medicine (EBM) have severe limitations making randomised controlled trials (RCTs) an absolute standard. After a critical discussion of this approach, the author reviews the empirical evidence for the efficacy of psychodynamic psychotherapy in specific psychiatric disorders. The review aims to identify for which psychiatric disorders RCTs of specific models of psychodynamic psychotherapy are available and for which they are lacking, thus providing a basis for planning further research. In addition, results of process research of psychodynamic psychotherapy are presented. As the methodology of RCTs is not appropriate for psychoanalytic therapy, effectiveness studies of psychoanalytic therapy are reviewed as well. Studies of psychodynamic psychotherapy published between 1960 and 2004 were identifed by a computerised search using Medline, PsycINFO and Current Contents. In addition, textbooks and journal articles were used. Twenty‐two RCTs were identifed of which 64% had not been included in the 1998 report by Chambless and Hollon. According to the results, for the following psychiatric disorders at least one RCT providing evidence for the efficacy of psychodynamic psychotherapy was identifed: depressive disorders (4 RCTs), anxiety disorders (1 RCT), post‐traumatic stress disorder (1 RCT), somatoform disorder (4 RCTs), bulimia nervosa (3 RCTs), anorexia nervosa (2 RCTs), borderline personality disorder (2 RCTs), Cluster C personality disorder (1 RCT), and substance‐related disorders (4 RCTs). According to results of process research, outcome in psychodynamic psychotherapy is related to the competent delivery of therapeutic techniques and to the development of a therapeutic alliance. With regard to psychoanalytic therapy, controlled quasi‐experimental effectiveness studies provide evidence that psychoanalytic therapy is (1) more effective than no treatment or treatment as usual, and (2) more effective than shorter forms of psychodynamic therapy. Conclusions are drawn for future research.     

Refusing to be excluded: finding ways of integrating psychotherapeutic modalities to the emerging needs of a Pupil Referral Unit

This paper describes the application of child psychotherapy, its theory and practice, in a Pupil Referral Unit (PRU). It examines the importance of a flexible approach to outreach work and the implementation of interventions that take into consideration both the internal and the external world of the adolescent. Furthermore, the process of development of a psychodynamic group with PRU students is described and illustrated. Additionally, it explores the importance of developing psychodynamic models of working with allied professionals in supervision and collaborative efforts in general. The paper explores the usefulness of the concept of mentalisation when working in the context of schools as well as the need to develop an accessible psychodynamic language that enables multidisciplinary collaboration. Overall, this paper reflects on the importance of holding in mind the challenge of balancing the needs of the external and the internal world, which becomes very evident in the process of outreach work.     

Integrating Individual and Family Systems Psychotherapy to Treat Borderline Personality Disorder

This paper focuses on two areas. The first is the framework for psychotherapy integration used by Unified Therapy, a psychotherapy approach that is an integration of psychodynamic, cognitive–behavioral, and family systems therapy. The second is the use of this treatment paradigm in the psychotherapy of adults with borderline personality disorder. The theory posits that continuing and recurrent interpersonal behavior patterns within the patient's family of origin serve as behavioral triggers to typical acting-out behaviors. Therapy is geared toward planning strategies to alter these destructive patterns. A case example is presented to demonstrate the use of the therapy's theories and techniques.     

Indikation zu Psychoanalyse und analytischer Psychotherapie

Based on the diagnostic process in the initial interview, which is an intersubjective encounter, the various developmental steps for establishment of the indications for psychoanalysis are presented. Freud and his followers, who were initially oriented to the psychiatric diagnosis, were later oriented to the criteria of approachability, analysability and in particular on the aptitude for psychoanalysis. The criterion of aptitude was not only elaborated from the perspective of Ego psychology but was also relevant for all high frequency non-terminated psychoanalyses which followed the basic psychoanalytical principles of “afocality”. This has so far characterized the standard procedure of all psychoanalytic schools. Due to the experiences of psychoanalysts with early disturbed, structurally Ego-disturbed neuroses and personality disorders, the extent of lability of the mental structure and by turning to countertransference analysis, the person of the psychoanalyst become more important for the assessment of the indications. In Germany the integration of psychotherapy, which is financially supported by healthcare insurance, ultimately leads to differential indication assessments between high frequency psychoanalysis or analytical psychotherapy, modified psychoanalytical psychotherapy and less frequent psychodynamic procedures.     

The counsellor and the GP: The gulf and the isthmus - or the dilemmas of difference

Research supervision in the field of counselling and psychotherapy is a fruitful area for investigation in view of the fact that the research supervisory relationship is powerful and highly charged, whether consciously acknowledged or not. Researchers trained as counsellors and psychotherapists possess the skills to facilitate the emergence of, and work creatively with, impasses and crises, both in the research itself and the supervisory relationship, as a result of their training and experience in dealing with crisis and catharsis in clinical work. This paper will demonstrate these points using a case vignette from my work as a supervisor of research dissertations undertaken by students on a Masters in Therapeutic Counselling course. Drawing on narrative analysis, clinical supervision theory and discursive analysis it will look at the strengths and weaknesses of a ‘psychotherapeutic’ approach to research supervision.     

The Supervisory Alliance as Quintessential Integrative Variable

The concept of alliance in psychotherapy supervision is now a half century old. But over the course of its first 50 years, how has the supervisory alliance come to generally be viewed by supervision scholars and practitioners? and What is its specific place now within different visions of supervision? In this paper, I would like to consider those two questions by: (a) describing the two enduring perspectives on the supervisory alliance that have dominated and continue to dominate the supervisory scene; and (b) examining the ways in which the alliance appears to currently be conceptualized and implemented across several distinct views of supervision. Each view of supervision is also presented as containing and actuating its own message and meaning about the role of alliance in supervision, and those messages and meanings are accordingly identified. The supervisory alliance appears to now be widely regarded as being a transtheoretical common factor that binds by means of: (a) bond/rapport; (b) supervision goals; and (c) supervision tasks. Much like the therapeutic alliance in psychotherapy, the supervisory alliance has increasingly come to be seen as the very heart and soul of supervision itself and may indeed be the quintessential integrative variable in psychotherapy supervision.     

A tale of two visions: can a new view of personality help integrate psychology?

Personality psychology studies how psychological systems work together. Consequently, the field can act as a unifying resource for the broader discipline of psychology. Yet personality's current fieldwide organization promotes a fragmented view of the person, seen through such competing theories as the psychodynamic, trait, and humanistic. There exists an alternative--a systems framework for personality--that focuses on 4 topics: identifying personality, personality's parts, its organization, and its development. This new framework and its view of personality are described. The framework is applied to such issues as personality measurement, psychotherapy outcome research, and education. The new framework may better organize the field of personality and help with its mission of addressing how major psychological systems interrelate.     

Eine Therapiestunde mit einem Mörder

Although psychodynamic concepts may be helpful in identifying the complex interpersonal and manipulative processes that occur between inmates and therapists and to transform them into the therapeutic process they are hardly ever applied in a correctional setting. The author provides an insight into the psychotherapeutic work conducted in prison. The first part of the paper outlines the special conditions in which psychodynamic psychotherapy occurs in a social therapeutic intervention institution within the German prison service. Characteristic transference and countertransference constellations are described. Based on a verbatim report an account is provided of a therapy session with a serious violent offender. In his reflections on the session the author focuses on the effects on the transference process of, in the offender’s eyes, being both therapist and assessor at the same time.     

An experiential group model for psychotherapy supervision

This article presents an experiential group model of supervision constructed for both group and individual therapy presentations, emphasizing concepts from object relations theory and group-as-a-whole dynamics. It focuses on intrapsychic, interpersonal, and systems processes, and stresses the group aspect of the supervisory process. Its central thesis is that material presented in a group supervisory setting stimulates conscious and unconscious parallel processes in group members. Through here-and-now responses, associations, and interactions among the supervisory members, countertransference issues that have eluded the presenter can make themselves known and be worked through on emotional as well as cognitive levels. Selected excerpts from supervisory sessions demonstrate various attributes and strengths of the model.