Clinical supervision is an integral part of working and developing as a psychotherapist or counsellor.
- Supervision is built around the task of understanding more about another person, in this case, a client or patient.
- In clinical supervision, a representation of the client is created through the communications and experience of the person being supervised, the supervisee.
- Clinical supervision provides a theoretical framework through which the psychotherapist can gain insight and perspective on the work.
- These conversations and models help the psychotherapist to make sense of all aspects of communication, both conscious and unconscious.
- As clinical supervision progresses, as increased understanding is gained, the supervisee starts to develop an observing ego in themselves which helps them to think, process and work clinically.
Clinical supervision is a complex working relationship involving awareness of sophisticated themes
It requires that the supervisor learns how to accommodate and adapt. Supervision requires that the supervisor be able to consider, contain and understand the different dynamics and perspectives that are part of the two-person psychotherapist/client relationship, as well the three-person supervisor/psychotherapist /client relationship.
A further set of processes and complexities are introduced when the supervision is taking place in a group, sometimes a supervision group in an agency setting.
Clinical supervision in an agency setting
There is a lot of anxiety in a counselling agency. The clients bring anxiety, the agency holds its own anxiety about how it functions. Most agency counsellors are at some point in their training. For some, these are the first clients they see.
In an agency, we look to provide counsellors with an opportunity to develop their experience, working identities, confidence etc.
In supervising I base my focus around 3 points;
- the frame
- the development of therapeutic relationship within that frame
- development of supervisory attitude within supervisors
When counsellors join a supervision group the first focus is on trying to develop a working group.
In the clinical supervision group, I am looking to foster the sense and experience of a larger group mind. It is important to remember that the problems, challenges and successes we as individuals face, are just part of the ongoing experience of work. At some point, we will all face these things.
We all learn from each others struggles and successes
In a psychotherapy relationship, we never know how things are going to develop.
In some cases, a client will present with high anxiety, be difficult to adapt to the frame, will miss sessions, come late, pay late, but then over time we see this change.
In clinical supervision we work to foster and develop an atmosphere that is conducive to reflecting and thinking about experience. One of my personal satisfactions is seeing this develop over the course of a year.
A clinical supervision group has a lot of work to do
- Typically a supervision group has 4 supervisees, each of which can build up a caseload of 4 clients. The group will meet weekly for 90-minute sessions.
- Counsellors take in turns to present bi-weekly and ideally have 45 minutes.
- It isn’t possible to hear all of a counsellor’s work.
- We try to make sure that any pressing concerns are raised and following that, listen to a particular presentation.
- It is hard work in that there is no slack in it.
- There is little formal time to be social, there is work to be done. So a professional atmosphere.
In clinical supervision we try to develop:
- an analytic attitude; a containing, holding group, processing,
- trying to develop a questioning attitude and observing ego within supervisee.
Clinical supervision – The clinical rhombus
Ekstein and Wallerstein introduced the concept of the clinical rhombus (1958)
The clinical rhombus is an invaluable model
It is an elegant model that describes the 4 points that need to be kept in mind when working as a clinical supervisor in an agency setting.
It can be tempting, particularly within the hurly-burly of very busy clinical supervision to lose sight of the different relationships that need to be kept in mind if an agency is to function healthily.
Because the task of clinical supervision can be so demanding it can lead the supervisor to treat their group as though they are a private supervision group and nothing to do with the agency. This is unhelpful.
- The more we can remember the need to relate to the central administration parts of the agency the healthier things remain.
When there are problems in an agency, problems around different groups not communicating well with other groups, people, and functions, it is worth referring to the clinical rhombus. Try not to forget the importance of the administrators. The more the individual counsellors and the supervision group keeps the administrator in mind the better the thinking, creativity and ongoing experience of support tends to be.
Clinical supervision and learning to work
In clinical supervision, particularly with new counsellors, we try to nurture an approach to work that sees therapy as a conversation. Albeit an idiosyncratic conversation. We don’t know how silence will be received, to many people it can quickly become unhelpful.
There are two points:
- to meet the need of the unhappy person that has presented themselves or been referred to the agency
- to help the counsellor think about how they respond to their clients’
Listen to the need, get a feel for it, note the internal object world that is being communicated and conveyed, note the transference and the countertransference, but do it all within a conversation. The more you practice the habit of these conversations, the more you do so with each client, the more the client learns to trust you, the relationship and the space.
When we forget the clinical rhombus we can start to see problems as located within one individual, rather than remembering that they are part of a system.
An exploration of the dynamics of the clinical rhombus (Ekstein and Wallerstein, 1980) becomes fore-closed which means that particular insights become inaccessible to the group.
A strong pull to split the group into polarized positions of ‘the group’ versus ‘the supervisor’ or versus ‘the agency’ emerges. Keeping the clinical rhombus in mind helps us all to remember our interrelatedness.
I have been supervising individuals, and groups for many years. I find clinical supervision rewarding and satisfying.
- I trained as a supervisor with the Society of Analytical Psychology in 2008/9.
- I am a member of the British Association of Psychoanalytic and Psychodynamic Supervisors
- As well as being an individual supervisor, I am currently a group supervisor at South Bucks Counselling
- Previously I have run supervision groups at Riverside Counselling Agency in Henley, Manor House Centre for Psychotherapy and Counselling, the Association of Independent Psychotherapists. I have presented on supervision to the Guild of Psychotherapists supervision course.
Please contact me if you would like to discuss any aspect of clinical supervision.