Stages of supervision in psychoanalytic psychotherapies

In this contribution, I attempt to categorize the supervisory process based on the phase of professional development of the supervisee.

I believe more advanced supervisory techniques are best introduced as the therapist moves from neophyte to master therapist, though there are exceptions.

Supervision of Neophyte Therapists

Therapists new to analytic approaches often first need help in assessing which patients can be treated with dynamic therapy. Also, the supervisor should advise the therapist about what material is germane, and the best order in which to present it to the supervisor.

The supervisor should find out from the therapist if the patient has ever trusted anybody. Additionally, emotional distancing may show up when the therapist goes to schedule a follow-up appointment, and the patient suddenly becomes too busy. The supervisor should also alert the supervisee to the danger of what I call the dynamic fallacy. I.e., it is mistaken to believe that simply formulating defences, affects, and conflicts is sufficient to determine if a patient can be treated psychodynamically. Ego defects, object relations deficits, and excess primary process in consciousness (Hoch & Polatin, 1949; Kernberg, 1975) portend a more guarded outcome with insight-directed approaches.

The supervisor can prevent supervisee burnout. If analytically untreatable cases are begun, the treatment failures cause the supervisee to become demoralized about the type of treatment. The supervisor should reiterate the importance of assessing abstraction ability – needed for mentalization (Bateman & Fonagy, 2016); reality testing – needed for separating fantasy from reality (regarding transference); and integration – needed for re-thinking and changing thought processes/actions after previously unconscious conflicts are understood. For treatable patients, the supervisor is in a good position to suggest how to handle initial unconscious resistances (Gray, 1994). The supervisor teaches about the alliance, since resistance often becomes visible when the patient breaks or attempts to break the frame of the therapy setup – including the “frame” (Langs, 1988), the “working alliance” (Greenson, 1965), and the “therapeutic alliance” (Zetzel, 1959).

Supervision Journeyman level Therapists

When the supervisee understands that psychoanalytic treatability rests on ego functions, object relations (and self), ego strengths, & superego, and can conceptualize intrapsychic conflict, the focus shifts to formulating technique.

Therapists are required to be able to formulate “on the fly” – to borrow a term from computer programming (Wang & Cook, 2002). To help the supervisee develop this ability, the supervisor may interrupt the supervisee’s presentation periodically, modeling “fast thinking” (Kahneman, 2013). When the supervisor stops the therapist’s presentation to ask questions, both can “get to” important material the therapist may have missed – often because the patient’s defences have not been addressed. By highlighting what the therapist is missing, the many simultaneous defences used by people in treatment gets clearer. In favourable supervisory situations, the supervisee will respond with new material about the patient, clarifying compromise formations of structural and object relations conflicts (Dorpat, 1976).

Intermediate therapists are at a position to learn to handle episodes of transference resistance. The supervisor can illustrate how the patient’s dreams, fantasies and acting-in (Paniagua, 1998), as well as behaviour that breaks the frame, indicate transference toward the therapist. In 101 Defenses, I attempt to summarize and add to the analytic interventions first adumbrated by Compton (1975) and later Volkan (2011): exploration, clarification, confrontation, linking interpretation, dynamic interpretation, genetic interpretation, dream interpretation, resistance interpretation, transference interpretations, interpretation of acting out and acting in, and reconstruction of the past and of the present (Kanzer, 1953).

The supervisor also explains how to alternate between interpretive and supportive techniques (Blackman, 2013, 2016) including 1) expression of understanding, 2) containing (Bion, 1962), 3) advising, 4) arguing, 5) self-disclosure, or 6) praise. Intersubjective techniques (Stolorow, 2013), relational techniques (Mitchell, 2001), and counter-projection (Havens, 1980) can be discussed for patients whose abstraction ability, reality testing, or affect regulation are impaired.

After interpreting defensive threads, new defences may not be adaptive – so the therapist must wonder, “what am I treating now?” (Volkan, 2011). Supervisees should now learn not to ask too many questions (Dorpat, 2000). They should ask themselves, “What defences is my patient using?” (Blackman, 2003, 2011).

Supervision of Master Therapists

In this stratum, the supervisor can be more relaxed. I sometimes have referred to this type of work as “fancy supervision.” All sorts of wonderful things happen.

Therapists can now undertake to make interventions that utilize the principle of multiple appeal (Hartmann, 1951). Supervisor and supervisee devise pithy interventions that will touch on the patient’s entire compromise formation. Reinterpretation (Schlesinger, 1995) when the patient returns to “square one,” is discussed, as well as novel ways of communicating about transferences.

“Curbside consultation” – style interactions at times can be used by the supervisor. Here, the supervisor uses inductive reasoning, resulting in quick, intense interactions with the supervisee. Supervisor and supervisee associate to each other’s thoughts about the case, leading to a more in-depth conceptualization regarding the patient.

As supervisees enlarge their knowledge base and skill, relational elements appear between supervisor and supervisee. In parallel, judicious relational elements in the supervisees’ therapeutic work with their own patients should cause their technique to become more effective (though less manualizable or statistically measurable).

Other parallel process elements enter the supervision; now they can be identified “with the cards up” (Renik, 1999).

Therapist and supervisor allow a certain degree of free association, including material from their own personal and professional lives.

At this level, the therapist and the supervisor can also associate to the supervisee’s patient’s material. This freedom leads to a creative understanding that would not have otherwise been possible. The supervisee’s countertransferences to the patient (Marcus, 1980) now can be discussed with some detail (Blackman, 2003a).

Much education and mastery are needed before delving into countertransference matters, in my opinion. In advanced supervision, the supervisor’s countertransferences to the supervisee and the supervisee’s countertransferences to the supervisor may be quite illuminating.

Finally, the advanced supervisee must tackle matters of ending the patient’s treatment – after the successful resolution of the presenting problems and any other problems that cropped up during the treatment. Discussion of recrudescence of some types of material during termination is always fascinating, as are cases which finish without too much fanfare, and those where new symptomatology causes a prolongation of the treatment.

Jerome S Blackman, MD is professor of Clinical Psychiatry, Eastern Virginia Medical School, Norfolk, Virginia Distinguished Professor of Mental Health, Shanxi Medical University, Taiyuan, ChinaSupervising & Training Analyst, Contemporary Freudian Society, Washington, DC