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Abstract
Alleviation
of Anxiety
Creation
of a Potential Space
Difficulties
in the supervisory relationship
Group
supervision
Ending
of the Relationship
Conclusion
References
|
Abstract
Since the early 1990’s clinical supervision has been on the nursing agenda
(Faugier & Butterworth, 1994). Other professions
such as Psychologists, Psychotherapists and Social Workers have a well-established
tradition of clinical supervision (Morcom & Hughes,
1996). The nurse's understanding of supervision may be coloured by
misinterpretations of the term, and it is often used interchangeably with
managerial supervision (Platt-Koch, 1986). There
are various models of supervision (Hawkins, 1989)
and it is important that an explicit model is followed.
Clinical supervision in Psychodynamic Psychotherapy is well documented.
This paper will outline psychodynamic concepts, which can be applied to
the supervisory relationship to enable both supervisor and supervisee to
gain some insight to the dynamics of what is occurring within the relationship.
This insight of the here-and –now in supervision can be a useful vehicle
for skill development, which is one of the main aims of supervision. Through
gaining an understanding of dynamics in the somewhat cosseted setting of
clinical supervision, it can be translated into the real world of the psychiatric
ward and community environments.
A consideration will be given to transference, creation of a potential
space, identification, difficulties in supervision, group supervision and
ending the supervisory relationship. While psychoanalytic concepts may
seem to be difficult and not always accessible, the applicability of these
ideas will be demonstrated, and the insights that they can give to supervision
will be highlighted.
Alleviation
of Anxiety
Within nursing, both general and psychiatric it is well documented that
situations in which nurses find themselves give rise to anxiety, dynamics
of dealing with patients which give rise to strong feelings and anxieties
in nurses. Nurses must find strategies to deal with these anxieties. Menzies
(1959) outlines the strong institutional defences, which can be a means
of coping with anxieties in nurses.
Similarly in the supervisory relationship the supervisor can encounter
material, which may give rise to strong feelings in him or herself. Stein
(1985) has written about the response the physician has to the material
presented by the patient, he argues that unconscious processes can determine
the physicians’ response. Main (1989) describes in
some detail ways in which unconscious processes can be influential in day-to-day
interactions.
In the supervisory relationship the supervisor has to deal with the projections
of the supervisee as well as dealing with his or her own response. McMahon
(1996) emphasises the importance of the management of the transference
and suggested that psychodynamic insights can be extremely helpful in preventing
the relationship from becoming destructive. This paper will explore some
psychodynamic concepts which will allow insights into the relationship
which will prevent it from becoming destructive and enhance the capacity
to alleviate anxieties, enable the nurses to develop positive coping strategies.
Creation
of a Potential Space
The process of clinical supervision has many parallels with psychotherapy.
It is not therapy in the strict sense but some ideas from psychotherapy
are helpful in understanding what is happening in the relationship. Winnicott
(1951) introduced the idea of potential space within a relationship,
his idea is based on the way in which the infant explores the world and
develops a sense of “me” and those aspects that are not part of him or
her. The infant creates a potential space between him or herself and the
mother. This is the area of play and is an important part of the development
of the self.
Similarly in the supervisory relationship this sense of space or play area
needs to be developed. Casement (1990) emphasises
the value of “playing” with clinical material and allowing creative ideas
to emerge in clinical supervision, this sense of playing must be allowed.
This is not to minimise the importance or serious nature of the material,
but rather it allows the development of the ability to stand outside situations
and creatively think and explore ways of dealing with issues, which arise
in everyday work.
An example of how this may work is taken from a colleague who described
a patient:
“He makes me doubt
my suitability to nursing as a career. He is usually involved in a discussion
group but he is very overbearing and always takes over the conversation.
He picks up on small things that people say and criticises them. He has
an insinuating voice, insists on having his own way and is basically very
petty.
“I think he annoys me because
he is the very opposite of me. I am not interested
in the small things
of life, and it irritates me when people over react to small unimportant
things.
“When he is around I try
to be patient and communicate with him without showing my dislike of him.
I feel inadequate as a nurse. When such a situation arises my patience
becomes frayed, but I cannot ignore my personal feelings and I think it’s
better to own up and understand them than pretend they are not important.”
While at one level this response
represents an acceptable response in that the only way she can deal with
the patient has been in a passive acceptance. However, it could be argued
that the nurse has experienced an intrusion in her capacity to think that
is paralysing, and her helplessness mirrors the patient. Exploration of
the relationship in supervision and in particular in this “Potential Space”
being actualised, allows a degree of objectifying which is essential in
understanding the dynamics of the situation and important insights to develop.
Through such a relationship
the nurse explored her reaction to the patient and realised that the patient
was conveying a helplessness, which she was unable to respond, but could
only mirror. She was able to explore alternative strategies and ways of
dealing with this situation.
While it is useful to compare the supervisory relationship to a therapeutic
relationship, it must also be acknowledged that, as the therapeutic relationship
is fraught with difficulties as is the supervisory relationship. Psychodynamic
insights can do much to illuminate many of these difficulties.
The Kleinian view of the incorporation of knowledge is that it is a similar
process to infant feeding. The infant has to feel secure with the mother
to take in that which the mother has to offer. Similarly in the supervisory
relationship the supervisee must feel secure within the relationship for
learning and development to occur. One can deduce that attachments and
identification are two pre-requisites for successful supervision.
Acknowledgement of the importance of attachment and identification is important.
The supervisor should be seen as someone with something of value to offer.
Clinical credibility necessary to allow identification and be sufficiently
in touch with clinical practice to create credibility.
This argument makes it extremely important that clinical supervision should
not be compared with management supervision (Platt-Koch,
1986) but should be apart and overrides the immediate situation. This
is particularly important as discontinuity can promote identification,
that is a separation of the supervisor and supervisee through time and
space. Ideally the supervisor should be someone outside the organisation
and the supervisor should be sufficiently in touch with clinical practice
to allow identification.
Difficulties
in the supervisory relationship
As in the therapeutic relationship difficulties can occur which can be
viewed as, in many ways a necessary part of the process and are in which
much can be learned. The Kleinian concepts of envy and splitting can be
useful in highlighting processes, which occur between the supervisor and
supervisee.
Envy, while a concept in everyday life, can in psychodynamic terms be described
as; the process in which good attributes of another are spoiled in an attempt
to diminish the pain of not possessing the attributes. As has been stated
there should be a positive identification in the supervisory relationship
and envy is almost inevitable in that those positive attributes that promote
identification can also give rise to strong feelings of envy. Envy ensures
that the skills of the supervisor are seen as desirable yet unobtainable;
because of this these skills may be denigrated or denied as being unimportant.
In the context of a learning relationship, envy can be destructive (Salzberger-Wittenberg,
Henry & Osbourne, 1983). It is important therefore that envy is
acknowledged and explored.
John was a Community Psychiatric Nurse fairly early in his career and he
was involved in clinical supervision with a highly experienced colleague
from another area. A particular difficulty he encountered in his work was
dealing with patients who had personality problems and who tended to be
manipulative. In supervision this was explored at length and various strategies
were determined. John continually degraded the patient group and privately
thought that his supervisor was conned into thinking that they were worthwhile
and was a victim of manipulation. An impasse was reached, and as his supervisor
identified what was happening within the relationship, the situation was
satisfactorily worked through.
Splitting, is another Kleinian concept, which can explain what is happening
within a therapeutic relationship. Splitting is described as primitive
in that it relates to an early stage of development, in which the infant
experiences the carer as alternately good and bad. When this stage is worked
through the infant realises that good and bad feelings may co-exist within
the same relationship. Again, this may occur within the supervisory relationship,
where the supervisor becomes split into a good and bad person and the supervisee
is unable to accept that all the responses are from the same person. When
this occurs any criticism (no matter how constructive) is seen as a personal
attack (Wilkin, Bowers & Monk,1997).
Mary was involved with clinical supervision from a highly experienced Clinical
Psychologist, she had a particular difficulty with a patient and she explored
issues arising from the relationship at considerable length with her supervisor.
She became very angry on one occasion, when her supervisor examined a situation
that Mary did not handle particularly well. Mary angrily said that she
felt her supervisor did not understand what was going on, and felt very
strongly that her supervisor was against nurses and did not understand
nursing. Mary felt very confused as she could see many positive attributes
of the supervisor, yet she also felt very strongly that her supervisor
did not really understand what nurses did and had no right even to comment.
She thought about changing her supervisor. These feelings were worked through
in supervision and Mary began to value her supervisors’ opinions and suggestions.
She also accepted that her supervisor was not always right but was attempting
to provide alternative ways of examining a situation that Mary may find
helpful.
While many of the difficulties can be attributed to negative feelings,
the identification, which is a pre-requisite of successful supervision,
can also lead to problems. The supervisee can idealise the supervisor and
over accommodate the supervisors’ suggestions. Mary in the previous example
realised that her supervisor made suggestions that were often helpful but
sometimes were not particularly helpful. This over-identification
can be destructive within a relationship in that it does not allow a genuine
exploration of ideas and suggestions but rather a blind allegiance.
Psychodynamic concepts while highlighting issues and processes of daily
life are not always accessible to the uninitiated. It is also highly impractical
to suggest that supervision can be likened to a psychoanalytic psychotherapy,
yet psychodynamic concepts can explain much of the process of supervision,
their insights can turn a negative situation into something beneficial,
in which much can be learned through an examination of the here and now
and feelings arising from the supervisory relationship. Psychodynamic concepts
are one way of identifying issues arising in the relationship and determining
reasons for feelings evoked. This can also be helpful in creating the capacity
for the identification of feelings within the supervisees’ relationship
with his or her patients, which can lead to insights and improve treatment.
Group
Supervision
Supervision commonly involves groups of individuals engaging in group supervision
with a single supervisor, dynamics are equally important in this setting.
A useful analogy is to think of group supervision rather like a web or
network, which contains a group of people each with a common purpose. Therefore
the personalities, backgrounds and theoretical stances of the participants
will shape the nature of the group and the reflective processes occurring
within the group setting.
Similar issues can occur as in individual supervision, and the particular
manifestations of group dynamics are well documented. In the context of
group clinical supervision interesting phenomena in the enmeshment of the
group can act as a form of defence. To use the analogy of a mirror, the
reflective function of the group can act as a concave mirror reflecting
only the operations of the group. This means in practice the group supervision
sessions become a forum adept at avoiding any sense of criticism, and the
group becomes a forum for self congratulation (Faugier
& Butterworth, 1994). Alternatively the reflective function
could be distorting. Faugier and Butterworth (1994)
noted that group supervision sessions can turn into situations characterised
by complaint against others outside of the group situation.
In a group supervision setting lead by one of the authors the group was
characterised by continual complaints against the management and organisational
changes being made. The supervisor noted a great deal of energy was expended
on situations which the participants could do nothing about and which were
in fact the result of government policy, rather than the management being
deliberately awkward. While this ‘letting off steam’ is an essential and
necessary part of supervision, the process seemed to be holding the group
up. They became more and more unhappy and dissatisfied and failed to address
issues that they could address and change. The supervisor saw his role
and moving the group on and getting them to the realisation that there
are things that they have to accept and learn to live with.
Ending
of the Relationship
At the end of he supervisory relationship issues around mourning and separation
must be acknowledged. The recurrent theme of this paper is the usefulness
of psychodynamic concepts as applied to supervision. It is important that
these concepts continue to be acknowledged and applied as supervision is
completed.
It has been argued that supervision is the creation of space where issues
can be explored in a similar manner to the child discovering and developing
through play (Winnicott, 1951). As the child moves
on and matures so does the nurse. Different types, different approaches
to supervision may be important at different stages of the individual’s
professional life. To continue with the analogy of play, like the child
discarding play, different approaches to supervision can enrich and empower
the nurse. As Lund (1990, pg. 353) points out: “The
strong tendency of therapists is to teach as they were taught, just as
children parent as they were parented.” It is, therefore, important
that at the end of a supervisory relationship these points are made articulate
and the supervision ends on a positive and conscious note.
Conclusion
The interpersonal and intrapersonal
dynamic of supervision cannot be overlooked within the supervisory process.
While supervision has several functions (Proctor, 1986;
Faugier
& Butterworth, 1994) one important function is that of skill acquisition
and development. Concepts from psychodynamic psychotherapy, when
applied to the dynamics of the supervisory relationship, can lead to insight,
which contribute to the development of clinical practice skill.
While
it is not advocated that supervisors receive psychodynamic training, they
should be encouraged to attend to what is happening within the supervisory
relationship. Having a bsic knowledge of the concepts reviewed here can
be of assistance in this process. On the other side of the equation, a
supervisee can gain valuable insight from an understanding of concepts
from psychoanalysis and can, in turn, integrate these approaches into his
or her clinical practice.
References
Casement,
P. (1990). Further Learning from the Patient,The Analytic Space and Process
London: Tavistock Pub.
Faugier,
J. & Butterworth T. (1994). Clinical Supervision: A Position Paper
School of Nursing Studies. University of Manchester.
Hawkins,
S. & Shobet, R. (1989). Supervision in the Helping Professions. Open
University Press.
Lund,
C. (1990). Training in Psychotherapy. Current Opinion in Psychiatry 3,
351-354.
Main,
T. (1989). The Ailment. In:The Ailment and other Psychoanalytic Essays.
London: Free Association Books.
McMahon,
N. (1996). Understanding the Interpersonal Dynamic in Teaching. Mental
Health Nursing, 16(6), 7-10.
Menzies,
I. (1959). The Functioning of Social Systems as a Defence against Anxiety.
Human Relations 13, 117-124
Morcom,
C. & Hughes, R. (1996). How can clinical supervision become a real
vision for the future? Journal of Psychiatric and Mental Health Nursing,
3, 117-124.
Platt-Koch,
L. M. (1986) Clinical Supervision for Psychiatric nurses. Journal of Psychosocial
Nursing, 26, 11, 7-15.
Proctor,
B. (1986). Supervision: A Co-operative Exercise in Accountability. In:
Marker & Payne (eds.), Enabling and Ensuring. Leicester National Youth
Bureau and Council for Education and Training in Youth and Community Work.
Salzberger-Wittenberg,
I., Henry, G. & Osbourne, E. (1983). The Emotional Experience of Learning
and Teaching. London: Routledge.
Stein,
H (1985) The Psychodynamics of Medical Practice. Berkeley:The University
of California Press.
Wilkin,
P., Bowers, l., & Monk, J. (1997). Clinical supervision: managing the
resistance. Nursing Times,19, February 19.
Winnicott,
D. (1951). Transitional Objects and Transitional Phenomena. In: Through
Paediatrics to Psychoanalysis. London: Hogarth Press. |
Books
on this topic:
Pre-order:
Fundamental
Themes in Clinical Supervision
by John R. Cutcliffe (Editor),
Tony Butterworth (Editor), & Brigid Proctor
(June, 2001)
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