Holding and the Dilemma of Inadequacy: Reflections on Group Supervision of Practicum Students

By:  Rachel Saks, Psy.D., Licensed Psychologist, Assistant Professor of Psychology, Chestnut Hill College.

The following are comments made via an online discussion assignment for my graduate level supervision group:

A student writes to the group:

“I don’t know if I did this correctly, but I am constantly second-guessing myself when it comes to treating clients. I have worked with children for several years but I feel so overwhelmed. I don’t know whether I will be offensive or be able to establish the therapeutic alliance the way that is needed. I have been directed to make sure that the treatment plan and crisis plan are done the first few sessions, so how do I begin to build alliance if I am focused on record-keeping and diagnosis?  I have been told that I’m on the right track but I’m constantly second-guessing myself. I don’t want to make mistakes or lose clients. I know that when I tried therapy I didn’t continue after three sessions because I felt that there wasn’t a connection but just a focus on technique. I also feel that because I took Techniques I so long ago I don’t know if I will remember how to approach clients? What is my theoretical orientation and does it really matter?  Help.”

Here is a response from another student:

 “Thank you for your complete transparency here. I felt the same way during my first few weeks when I was doing all new intakes and building my case load. And I still feel that way with certain clients when I have room for new intakes in my book… Use the first few sessions to allow some of your personality to shine through and stay on the same pace with the client within reason. Sometimes I have to assist people to focus a bit because they might be nervous and talkative, but even then, being present and listening IS therapeutic.

I completely hear what you’re saying. We’re all new therapists and it’s easy to second-guess ourselves and get in our heads. Thanks for sharing so openly and allowing me the space to respond and share my experience with you.”

I am struck here, not only by the honesty of the first student’s post, but also the supportive and helpful tone of the response.  The student has the courage to not only tolerate, but also to share, to communicate about her feelings of inadequacy. The student respondent not only reassures her, but normalizes the feelings and joins with her.

Reading these posts, I found myself reflecting back on my own experiences of group supervision in a psychoanalytically-oriented doctoral program.  While I learned a great deal, I do not recall experiencing the same kind of support, and I suspect I was not nearly so honest about my own sense of not knowing what to do or how to be as I assumed the role of therapist for the first time.

I know that for me this self-conscious cautiousness began long before graduate school.  As the child of two therapists – my father was a psychiatrist/training analyst and my mother practiced as an analytically oriented clinical social worker — I was steeped in the language and perspective of dynamic psychology from a young age.  My parents’ work was a mystery to me in many ways, and the patients that my parents cherished so intently were strangers to me.  These patients were tended to by my parents in an intense and focused way that captivated and preoccupied them.  Though I yearned for the kind of nurturance and care that I imagined they gave to their patients, I was naturally protective of my own wants and needs.  I hesitated to seek out that care directly.  My father, a Holocaust survivor, was loving but remote.  Though he dedicated his professional life to working long term with difficult and demanding traumatized patients, I sensed that it was important to him that I be okay.  He worried at a distance, and I could see how much worry pained him.  I worked to portray myself as well, even if I did not always feel that way.  Under such circumstances, it is no wonder that I developed and made use of what Winnicott (1960) terms a “false self.”  So much of how I presented myself to others was motivated by an internalized pressure to sense what others want, and deliver it, rather than express my own feelings and ideas in a less guarded, more authentic way.

In significant ways, this tendency of mine was activated by aspects of my graduate training experience.  Participation in analytically oriented training can be an exquisitely vulnerable experience, one which brings up any number of conflicts, wishes and fears for students, each with his or her own history and associated transferences.  For many, the supervisor becomes a parental figure, poised to validate or disapprove of the emerging therapeutic identity of the student. Students wonder if the professor will approve of and feel pride in their clinical accomplishments. They might worry about being rejected by the supervisor, or long for some special connection to develop. In similar fashion, peers become siblings who alternately provide comfort and protection or compete for attention and approval.

In my graduate training, group supervision was an ongoing course experience and central feature of the curriculum.  Students met weekly to present and explore case material from their practicum and internship placements. This model continues to be a standard feature of graduate psychology programs.  The expectation is that students share their work as novice therapists with professors and fellow students.  They are asked to present their clinical material and explore associated feelings about the experience of treating clients and to solicit guidance from the supervisor and their peers about how to go about this work.

I clearly recall the anxiety associated with presenting cases in these classes as I strove to deduce just what the professor expected of me and to deliver that in the presence of other students.  I worried that my flaws and weaknesses would be revealed to my supervisor and peers, much to my shame. I felt quite constrained by not only the wish to please my professor, but also the various ways that the other students might respond.  Would they feel dismissive, competitive and disdainful or supportive and empathic?

This, thankfully, got better over time, and was certainly influenced by the role of the professor acting as group supervisor.  When a professor was attuned, accepting and nurturing, I felt more secure.  Security allowed me to be more spontaneous and authentic and creative.  A different professor, more opaque, neutral and academic in style evoked a more stilted and careful response from me.  I suspect that the tenor of my supervision experience spilled over into my performance as a therapist.  When I felt more self-conscious about how I would discuss a case in group supervision, perhaps I was more stiff and remote with that patient.   Conversely, if I felt that the group would be supportive and collaborative about a case, I suspect I was more authentic and present with that client.

In one of life’s many ironies, after many years I now find myself in the opposite role.  As a professor at Chestnut Hill College, tasked with leading group supervision, I am keenly aware of the vulnerable position in which my students find themselves.  They do not yet know just what they are doing, yet they are asked to share their experiences and performance as therapists with both me and their fellow students.  To them I am a support and source of expertise, but I also function as an evaluator. I know that they cannot truly learn to counsel others in a meaningful way without attending to their own vulnerabilities and emotional responses to their clients. Yet, I am also aware that they risk shame if they present their true selves to the group and do not feel accepted.

I recall one of the more interesting discussions I recently had during a supervision class.  A student shared that she was struggling to engage a particular patient and feared that she had alienated him and failed to form an alliance.  She suspected that she had come off as stiff and overly professional, and that he had found her distant and hard to relate to.  Other students chimed in, humorously imitating the uptight “therapist selves,” that they felt they sometimes turned into when they became anxious about “messing up.”  We reflected together about the difficulty negotiating between developing a professional identity and maintaining appropriate boundaries while still genuinely being in the room with their patients.

There is, of course, a parallel process occurring in group supervision.  If I, the supervisor, do not bring my true self into the room, then how can my students feel safe enough from shame to be authentic about their needs?   Returning to Winnicott for a moment, the false self emerges through the process of introjection, of internalizing one’s experience of others. If spontaneous expressions are met with disapproval, then the child becomes overly motivated to please others. The conditions that allow the true self to emerge and become integrated are responsiveness, reassurance and attunement (Winnicott, 1960). My task, as I see it, is to provide a good-enough holding environment for my students to tolerate their own vulnerability.  The supervisory room must become a transitional space, where they can play with their ideas about how to meet the needs of their patients.  It is through supervision that they can begin to integrate the need for a sense of competence and control over the process with humility about what they can accomplish as clinicians.

Winnicott (1971) states, “It is in playing, and only in playing that the individual child or adult is able to be creative and to use the whole personality, and it is only in being creative that the individual discovers the self.”  He goes on to assert, “Psychotherapy takes place in the overlap of two areas of playing, that of the patient and that of the therapist.  Psychotherapy has to do with two people playing together.” (p. 54) Cannot the same thing be said of supervision?  And if so, what conditions must be met for this playing to occur, and for my students to discover their creative, therapist selves?  Winnicott (1971) speaks of an intermediate area, between the subjective and objective, where fantasy and reality meet to create a shared experience.  For such a transitional space to be created, the relationship must be one of reliability and trust.  As the “good-enough” supervisor, it is my responsibility to create and maintain this relationship, not only between myself and my students, but also between the students and their peers.

Providing this environment has been a challenge for me in that it involves some interpersonal risk.  I must present myself as capable of containing their anxiety.  At the same time I hope to help them internalize acceptance of vulnerability and inadequacy.  So, I cannot just play the role of “supervisor” or “professor.”  I have to involve my true self in the process.  I struggle to show them that I can play and be vulnerable, and also be capable and safe.  I often give examples of mistakes that I made as an intern and later as a therapist, and then encourage them to support and supervise each other.  If a student becomes too vulnerable and begins to share more with the group than they may be able to tolerate, I work to contain them without making them feel embarrassed.  My hope is that they internalize my “mothering” in a way that encourages them to become a part of the holding environment.  If they can accept and support vulnerability in their peers, then they can risk shame themselves and reach out for help when they find the work challenging.

Winnicott asserts that if adults can manage to “enjoy the personal intermediate area” of play, “without making claims,” that they can develop a shared culture of common experience. (1971, p. 100) He links the development of a safe transitional space, a play space, with the development of shared values, ideas and beliefs. In my approach to the working graduate students I am attempting to facilitate the development of a supportive culture in the space of the supervision group. Within a supportive culture, graduate students can risk vulnerability and explore their own inadequacy while creatively developing their therapeutic selves.

I would like to conclude by sharing another student’s response to my supervisee’s post, which I hope illustrates the shared culture I am working to create in group supervision:

“I feel a lot of the same feelings sometimes and I think that is normal for someone in your (our) position. You’re just finding your feet and your own style and that will take time and practice for sure! I know it’s hard not to worry about making mistakes and doing well in a session (I know I do) but for me personally, the more I worry about it, the more I get stuck in my own head and make more ‘mistakes’. I find that if you put all your attention into what the client is saying rather than trying to focus on your style or whether or not you’ve messed up or what question you should ask next the session flows much more smoothly and with a natural progression! Easier said than done for sure (still working on it!), but my teachers in the past who have practiced clinically have said that even after years of practicing there are still things they wish they could do differently in sessions. I found this particularly comforting because it speaks to the idea that while everyone wants to live up to their own idea of ‘the perfect therapist’ you’ll probably always have things that you wanted to change, but as long as you are your genuine self and do your best to be what the client needs you to be, someone to listen to them, you’ll be successful!”

References

Winnicott, D. W. (1960). Ego distortion in terms of true and false self. In: The maturational

 processes and the facilitating environment. Madison, CT: International Universities

Press, 1987, pp. 140-152.

Winnicott, D. W. (1971). Playing and reality. New York: Basic Books.

Rachel Saks may be contacted at: SaksR@chc.edu

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