Supervision

In my State of Washington, one of the requirements to become a qualified supervisor is 15 hours of supervision training. My wife, a clinical social worker with decades of experience took her training at an NASW-sponsored two-day session. Included in the session was the showing of a supervision video by the session trainers, who explained that they had lots of trouble finding a social work supervision video. Not hard to believe, because what they settled for should not have been a training video, it should have been a bloopers reel.

The video showed a social work student walking into a hospital ward, having a short and awkward initial session with a schizophrenic patient. Much of the encounter consisted of an obviously confused patient berating an obviously intimidated student social worker. The follow-up supervision session was like a re-enactment, except this time, with the supervisor berating the student. (There's nothing like a good tag team to shore up a student's confidence.) The student social worker responded to her supervisor as she was treated, as if she were a scolded child confessing her guilt.

In the discussion that followed, my wife suggested that the supervisor's role should be to put students in situations where the students would be successful. At the very least, the students should learn something that will help in future sessions, and as the saying goes, at least, do no harm. It was apparent that the supervisor did none of that. What she did was set her student up for failure and humiliation. The lesson learned by the student was you're on your own, and avoid mistakes at all costs, because you'll pay for them in embarrassment. It wasn't the student who should have been embarrassed, it was her supervisor. She had neither the student's nor the patient's best interests at heart. From all appearances, she was a bully hazing an intimidated student.

I expect that the supervisor my wife witnessed in the video would be a lousy supervisor for any intern.[1] Unfortunately, there are going to be some of those. And I am sure there are going to be supervisors who are good for some interns, and not for others. There are also those precious few supervisors who I believe would be good for any student therapist, and in my first-year internship, I was fortunate to have one. I'll discuss that below, but first I want to discuss my second-year supervision, which was useful in an unintended way.

Ich bin ein Berliner

For my second-year internship, I was placed in a clinic serving one of the wealthiest counties in the country. The internship program was run by a psychologist, Hildegarde Berliner, whose husband Bernard Berliner, a German-trained psychiatrist, helped pioneer psychoanalytic training on the west coast. Hildegarde Berliner, in turn, through sheer force of will, had turned this community mental health clinic into her personal psychoanalytic training institute. Though she was neither the agency nor clinical director, Ms. Berliner did not just run the intern meetings, she reigned over all clinical meetings.

The Berliners had fled their German homeland in the 30s to escape the Nazis. Prior to their move to America, Bernard Berliner had trained to become a psychoanalyst. Hildegarde Berliner (HB) once related an anecdote that shed light on the difficult relationship that developed between the two of us. In Germany, psychoanalysts-in-training attended classes that were called kinderseminars (children's seminars), because those in training were regarded as children by their training analysts.

Bernard Berliner, a World War I vet in his 40s, and already an experienced psychiatrist, was viewed as a child by his training analysts. Though HB was educated as a psychologist in America, her attitude towards interns was obviously influenced by her cultural background and her mentor husband.[2] In retrospect, I consider myself fortunate that she didn't warm a bottle of formula for me.

Along with her cultural attitudes, HB had a second source of personal authority — the prestige that psychoanalysis still held in the mental health system. Many years before evidenced-based therapy reared its head to compete with medications for managed-care insurance bucks, psychodynamic-based therapy was still on top of the hill. Humanistic-based therapies appealed mostly to college students and those in extended adolescence. Cognitive and behavioral were still just dating, or meeting in secret. And Big Pharma hadn't yet imposed its will on the mental health system. Most psychiatrists still practiced psychotherapy — either psychoanalysis or psychoanalytic-influenced (psychodynamic) therapy — and as ever, psychiatrists had the highest status in the mental health system.[3]

It was typical, then (in the 70s), that psychodynamic therapy was still dominant in community mental health agencies. What wasn't common was that no other approach was tolerated, even for discussion. Leaving behind the family therapy that I practiced in my previous internship seemed a step backward to me. At this fancy mental health clinic, both adults and children were always seen only in individual sessions. This was so, not just for interns, but for all the therapists in the agency.

Jumping into both the frying pan and the fire I, alone among the interns, had added to HB's authority over me by choosing her as my individual supervisor. She and I clashed regularly; she didn't trust my work. Rather than viewing her as support, I regarded her as someone who was in search of gotchas. At her insistence, I wrote post-session process notes, on which she marked mistakes with red pen.[4] As with the social work student described above, I felt I was being rebuked as if I were a child.

I may have given you the impression that the root of my quarrel with HB stemmed from her psychoanalytic allegiance, but I was not yet invested in any theoretical orientation. I had several approaches on my nay list — Gestalt, the Skinner brand of behaviorism, Roger's person-centered — and, beyond my admiration for Harry Stack Sullivan, little on my aye list. The root of my quarrel with HB was her that's how we think here attitude.[5]

Looking back, I have to admit that I was, indeed, the dummy. I wouldn't enter a Catholic church and argue with the priest that the Holy Trinity was but a point of view. Despite my belief that a community mental health agency should be secular, not the Church of Freud, it was what it was, and I was just an intern. More to the point, this agency had long served as one of the internship resources of my program. And despite my complaints, I profited from the experience, just for different reasons than a less headstrong intern might have.

My disagreements with HB became the initial catalyst for my thinking long and hard about approaches to psychotherapy, a habit that I have not shaken. In retrospect, I have accepted that I learned as much or more from a discordant experience as I would have from an additional harmonious one. I'm going to return to my first-year supervision and compare the long term effect as a contrast to my experience with HB.

I left my heart in San Francisco State University

“The cure for boredom is curiosity. There is no cure for curiosity.”
_Dorothy Parker

(From an interview with famous hypnotherapist, Milton Erickson, MD.)

Interviewer: Why did she tell you?

Erickson: Because I really wanted to know.

There's a clichéd belief among the general public, as well as clinicians themselves, that counselors (in general) have superior listening skills. Not so much, unless that means superior at listening to their inner dialogue. During sessions, counselors are often pre-occupied with where their clients fit into their (the counselor's) favored theory of personality, about transference issues, or which is the appropriate DSM code. While counseling programs explicitly teach listening skills, if a clinician isn't already curious about what makes people tick, no class will change that.

When I was in my early 20s, I was unhappy over a break-up with my (then) girlfriend and wondered about my part in the failed relationship. At the time, I was in a masters program in clinical psychology, and being curious what my friends saw in the theories of Carl Jung, I decided to quench two curiosities with one experience. After some time on a waiting list at the San Francisco C.J. Jung Institute, I got an appointment with an “advanced intern.”

The therapist, a middle-aged woman, introduced herself and led me to her office. After discussing my above-mentioned relationship, and telling her of my concerns, we came to a lull. She didn’t follow-up on my concerns, so we sat awhile in nervous silence. Finally, she asked if I had any hobbies. I explained that I was an avid photographer. She proceeded to describe my photographs to me, expressing enthusiasm over the beautiful colors in the highlights and shadows of my nature photographs. To the seeming relief for both of us, our time was up.

The session both disappointed and amused me. My therapist seemed uninterested in discussing my relationship concerns but perked up only when describing my photographs. I assume her intention was to segue to an interest in my creative side (a focus of Jungian analysis), but this resulted in the opposite effect. I did not take pictures, as she described, of natural settings in color; I took pictures of people in black and white. The photographs she enthused over existed in only her fantasy. From this first (and only) session, I concluded that the therapy would be about her interests and concerns rather than mine.

Unsurprisingly, many counselors become interested in psychology because of deep questions about themselves that stem from a difficult childhood or life crisis. An encounter with a helpful counselor may have been the catalyst for their career path. Nothing wrong with that; there would be far fewer counselors if that weren’t the case. Unfortunately, not all counselors make that transition from curiosity about self to curiosity about others.

Recently, I looked back on my masters paper, written 36 years ago, and realized that the young me might have some wisdom for the old me. My masters paper was on therapy supervision. During my first-year internship, I was placed in a child and family clinic in Daly City, just south of San Franciso. I had group supervision with eleven fellow masters students in the San Francisco State University clinical psychology program, and individual supervision with (the late) Professor Robert Suczek.

“What’s your concern?” That was Dr. Suczek’s primary verbal contribution to the supervision hour. He remained mostly silent while I talked. Occasionally, he’d ask a question. Now and then, I’d express my curiosity regarding his theoretical orientation, and he’d invariably reply: “My name is Robert Suczek. My only goal (as a therapist) is to understand.”

There were times, in these supervision sessions, when I’d worry aloud whether I should take on a certain client — especially those who expressed great anxiety that their counseling sessions (with me) would be their last chance (to make it). “Why should their last chance be entrusted to me, a fledgling counselor?” I would want to know. Dr. Suczek would reassure me that I’d do fine, that I’d figure it out. How would he know that? Where did his faith come from?

I believe that Dr. Suczek had an unshakable faith in both the resources of clients, and of student therapists.[6] His expectation, that I could and would muddle through to be of use to my clients, was as much or more of a signal of respect to clients as it was to me as a novice therapist.

Isomorphic Supervision

Sesame Street invented the game one of these things is not like the other. The concept of isomorphism is the opposite: it means that one process is the very model of the other. For example, family systems models were originally discussed primarily as isomorphisms of natural ecological and cybernetic systems. I believe that the most important aspect of early supervision is the isomorphism between therapy and supervision. The attitudes supervisors display towards interns are likely to get passed on as attitudes interns display towards clients. And these attitudes are likely to be persistent throughout a counselor's career.

If as a supervisor you focus on diagnoses, symptoms, resistance and other demeaning caricatures of client behavior, you'll pass that on to those you supervise. If you focus on the normality of interpersonal problems found within all human relationships and the resources that most clients have to make these problems diminish with a bit of effort, you'll pass that on to those you supervise. I believe that, early in our training, the attitudes we bring to practice with our clients are far more important than specific therapeutic approaches. While there are some approaches that embody respectful attitudes and expectations to a greater degree than do others, I think the differences are more within individual practitioners.

The Red and the Black

In the early days of personal computers, software games came with various sorts of pirating protection. One form of protection was a password printed on a square of cardboard using black type on a red background. Dark red and black cannot be distinguished by a copy machine, so you could not lend that password (and hence, the game) to a friend, easily. I believe that, as much as it felt like a root canal at the time, I benefited hugely from my time with Ms. Berliner.[7] As with black print on a red background, I might have failed to distinguish counseling approaches without the glaring contrast between that of Ms. Berliner's attitudes and mine. Comfort is... umm... comfortable... But sometimes a challenge is more useful. In retrospect, my experience with Ms. Berliner was an excellent complement to my comfortable first-year experience.

The supervision stages I went through were, first, supportive and modeling, second, challenging (more descriptively — mutually confrontational). There was no third stage of supervision for me, but if there was, it would have been assistance with learning a specific approach to counseling.

Shortly after receiving my masters, I developed a strong interest in systems theory and with the related therapeutic approaches. On my own I read incessantly, and lucky to live in the epicenter of the budding theory of systems-oriented therapy, I attended conferences and available workshops. At the time, there were no academic programs that supported a systemic approach to counseling and only a handful of books. I tried ideas in my practice and kept doing what worked and discarded what didn't. In short, my third supervisor — and the guide to a specific approach — was the bearded guy in the mirror.

I've laid out three stages of supervision: supportive, challenging, and specific (coaching). And I got them, primarily in stages, from three mostly distinct circumstances. I believe most counselors would suggest that all three of these stages can and should happen, simultaneously. Why can't a supervisor both support and challenge, while coaching a specific therapeutic approach? Is not mixing support with challenge a good model, a good isomorphic model? Probably. But there is something to be said for learning from conflict what you would not learn otherwise. [8] There's no ideal supervision, but over time if not simultaneously, I believe that it should include all the elements I've described: modeling, support, challenge, and coaching.

Notes


  1. I'm using the term, intern, very loosely, to mean anyone being supervised for licensing, or specific training (e.g., psychoanalysis, or cognitive-behavioral therapy) in counseling. Student implies still going to school. Supervisee isn't a real word, Supervised brings to mind a verb, not a person. Trainee sounds like a McDonalds hire. Protege sounds like the supervisor is trying to create a clone. Mentee and mentoree aren't real words and, ugh, anyway. You have a better term; send it along. ↩︎

  2. HB was 23 years BB's junior and started out as his secretary. ↩︎

  3. If you arrived at maturity in the 21st century (first of all, congratulations, many of us never matured), you may be under the impression that psychiatrists have always just done meds, that cognitive-behavioral therapy was always widely practiced, that systemic-based therapies has been, forever, taught in counseling programs, that Freud was just some old sexist pig who has nothing to do with how the great majority of psychotherapists still practice , and that Gutenberg invented the Kindle. (You got the last one right, he did.) ↩︎

  4. My dreams were filled with flashbacks of post-traumatic English class syndrome. ↩︎

  5. That is a quote. ↩︎

  6. An approach that I would, many years later, find intriguing in Solution Focused Based Therapy.  ↩︎

  7. Coincidently, both Ms. Berliner and I earned an MS from San Francisco State, but did not complete our doctorates. (I was told that she couldn't pass the required statistics class.) She was grandfathered into her psychology license. ↩︎

  8. Psychoanalysts might discuss the role of positive and negative transference here. My brother, among others, parental/adolescent separation. ↩︎