THE BRITISH ASSOCIATION FOR
PSYCHOANALYTIC AND
PSYCHODYNAMIC
SUPERVISION
July 2007
Foreword
Chris Driver (Chair)
What an
exciting Newsletter this is. Four
thought provoking and dynamic papers on supervising work with addiction and some
fascinating reflections on the work within BAPPS. What this Newsletter, and those over the past
few years, reveals is the range and depth of experience of BAPPS members and
the knowledge and understanding that is brought to clinical work and clinical supervision.
In this
Newsletter Dr. Mary Addenbrooke, Bill Reading, Jenny Gower, and Dr Dale Mathers
give detailed and informative reflections on working in the field of
addiction. Dr. Mary Addenbrooke explores
the importance of Knowledge, Understanding and Open-mindedness; Bill Reading
looks at the ‘addictional bond’ and an approach derived from attachment theory
and Jenny Gower considers culture, addiction and unconscious processes in
relation to addiction. The final paper
by Dr. Dale Mathers considers how addicts are ‘often considered as difficult
and as Shadow patients’ and he considers both the complexities of the work as
well as the importance of the role of intuition and hope. It is clear from all of these papers that
working with addicts and the impact of addiction is a difficult and complex
task. The papers are a rich resource for
all clinicians and supervisors and I am very grateful that the four authors
have shared with us their insights and understanding.
Another rich
resource within BAPPS is the conferences.
I would like to thank the conference committee for putting together a
fascinating conference on ‘Countertransference, Enchantment and the Erotic
Transference in Supervision’. This was a
fascinating day with thought provoking input and a lively discussion of the
kind that so often occurs when BAPPS members meet. For those of you who were unable to attend
Ruth Barnett has written a reflection on the day in this Newsletter.
You will also
find in this Newsletter details of the Autumn Conference. At the last AGM it was agreed to have a
half-day conference followed by the AGM in the Autumn so as to enable an
earlier finishing time. Please put the
date of November 10th in your diary for a morning conference with
Gill Bannister on ‘What shall we do with
the narcissistic supervisee’? This
will be followed by the AGM and I look forward to seeing you there so that we
can consider, discuss and decide important issues in relation to BAPPS.
Following on from the Spring conference the next Newsletter will focus on the Erotic Counter transference. If you would like to write something on this theme please let the Publications Committee know. Even if you only have a germ of an idea we would be pleased to hear from you and discuss it.
Finally I
would like to thank all BAPPS members for their work and commitment. The Newsletter and conference reflect a
growing development of ideas and practice.
In addition BAPPS membership is growing and we look forward to meeting
new members during the course of the year and would welcome your contribution
to the work of BAPPS.
Wishing you
all a restful & rejuvenating summer.
With all good wishes. Chris
Driver (Chair)
Knowledge,
Understanding & Open-mindedness
in Supervising Work
with Substance Misusers
Dr. Mary
Addenbrooke
Supervising the work of a colleague treating clients with
substance misuse problems poses many challenges. There is the prevailing negative or
ambivalent attitude to substance misuse in general, and a preconceived idea
that substance misusing clients are resistant to therapy or lacking in
openness. Such ideas may colour the
perception of therapists. In addition,
there are a variety of competing ‘therapies’ available to clients.
Therapists and their supervisors can feel alarmed at the
anxiety aroused by clients who misuse chemical substances (prescribed drugs,
alcohol or ‘illicit’ drugs). As a
psychoanalytic supervisor one may be asked to supervise therapists engaged in
this work in various different contexts.
Some supervisees may be working in drug and alcohol treatment agencies,
while others may encounter a substance misusing client in their private
practice or in an agency not specifically set up to treat substance
misusers. While the context of the
therapy in itself has implications, there are certain principles which apply
across the board, and my aim is to highlight some common anxieties and propose
three useful antidotes: knowledge, understanding and open-mindedness.
Knowledge
Knowledge
about the Substance: Supervisor and supervisee can each get
caught by the fear that they have insufficient knowledge about the
substance. The starting point for the
supervisee is not so much the drug itself, but the client’s view of it, and as
this may well be a partial or even erroneous view, it is important for both
supervisee and supervisor to have access to reliable sources of
information. In particular they both
need to be aware of harm that can come to the client through misusing the
substance. This involves learning about the harmful effects, both short and
long term, both psychological, social, and physical, both hidden and
overt. Only in this way can the
supervisee develop an informed opinion concerning the many myths and
exaggerations that abound, and become aware of the true risks involved in the
specific substance misuse. Some clients
are genuinely unaware of the risks they are running, while others deny or
minimise the risks, and yet others may carry on regardless. There are two reputable organisations,
Alcohol Concern and Drugscope, both of which have websites which provide
information and list further sources (alcoholconcern.org.uk and
drugscope.org.uk). I have also listed a
couple of extremely readable handbooks for supervisors to have on their shelves
(Edwards, 2000 and Tyler, 1995).
Knowledge
about addiction: A situation where a supervisee’s knowledge of
patterns in the escalation of substance misuse is invaluable is at the initial
assessment of a client who presents overtly with past or present drug or
alcohol problems. Yet, whereas some clients openly acknowledge their own unease about
their substance use, others only disclose the full extent of their use once
they develop some trust in their therapist. Each class of intoxicating substance has its
natural history. For example, the
pattern of drinking binges separated by
varying periods of social drinking is rarely seen with any other substance.
Another tricky area is the use of a substitute substance, either illicit or
prescribed, when the drug of choice is hard to come by. Every therapist should be aware, too, that a lapse from abstinence by a client who is
struggling to stay off drugs or alcohol need not escalate into a full-blown relapse, and may need their supervisor’s
advice and support with this particular challenge. Clients often suffer from a crippling sense
of guilt and inadequacy at this point.
Knowledge about other interventions: The supervisee may see a client who is having, or
has experienced, other types of psychological intervention. As supervisors, we may be asked about
these. While, as ever, the client’s own
views are of paramount importance, it may be useful for a supervisor to know
about the most frequently encountered of these, so I have added references to
motivation interviewing (Miller and Rollnick, 2002), the model of change
(Prochaska and Di Climente, 1983), relapse prevention (Marlatt and Gordon,
1985) and, last but not least, Alcoholics Anonymous and Narcotics Anonymous.
Understanding
Understanding
the magic of drugs and alcohol:
Sometimes the supervisee gets so caught up in fears about the harm the
substance is causing their client that they need reminding that the substance
has brought rewards too. Substance use
and misuse is not all gloom and doom!
There is a need to explore the psychological effect of the initial
experience with the drug. This
experience leaves an indelible mark which the user recurrently tries to
recapture. Apart from sheer euphoria,
there is the defensive action of intoxication, and of the lifestyle of addiction,
which can put all attempts at sorting out life’s difficulties on hold, as well
as adding to them. To be able to change
one’s state of mind at will – this is not to be underestimated. Supervisees may need reminding that every
individual has his or her own take on the benefits the substance can bring
them. They can be encouraged to
appreciate this and explore its significance for their client from a
psychodynamic point of view, just as they would want to learn more about their
client’s investment in any love object.
Throughout the therapy the supervisor can usefully keep in mind the
question, ‘What does the use of the drugs or alcohol mean to this client?’ This may sound obvious, but I am surprised by
how often I find myself asking supervisees if they are continuing to consider
it at every stage, along with other aspects of the therapy as it develops.
Understanding
transference onto the substance:
It falls to the supervisor to elicit what effect the patient’s substance
misuse is having on the supervisee. What
emotions are being aroused? One
difficulty is that the supervisee may have to withstand the loneliness of being
overlooked in favour of the drug. How
much more tempting it may sometimes be for a drinker to go out for an evening
session in the pub rather than attend a therapy session. As people become more dependent physically
and/or psychologically on their drug of choice, so they become less open to a
transference on their therapist (Smaldino, 1991). Their transference affect is
focused on the drug.
Understanding
addiction: It is desirable in supervision to encourage
exploration and a growing understanding of the complex interaction between the
individual, his or her environment and the substance. For example, if the prevalent attitude in a
family is that there is a ‘pill for every ill’, it is hard for a member of that
family to draw back from using their preferred substance. Enormous pressure is put on us all by
advertising and the media, and peer pressure exerts an equally powerful influence. If a supervisor keeps these matters in mind,
the supervisee can develop a philosophy of addiction on which to base his or
her approach. As with all our
understanding of theory, this forms the perspective from which we enter the
therapeutic or the supervisory relationship.
It comes into play as we listen to our clients or our supervisees.
Understanding
our supervisee’s fears and anxieties:
A supervisee may have to bear the fear that the patient will come to
harm through drug use. Accidents and
financial problems, including the inability or unwillingness to pay for
sessions, are overt, whereas the insidious harm being caused to the self by
long term heavy drinking or drug using habits is covert. It is all too easy for the client to deny
these through feelings of shame. In
other words, the more the supervisor can carry anxiety, and, by his or her very
being demonstrate trust in the supervisee, the more the supervisee can reflect
this, and can develop the skill of gauging what needs to be voiced at a
particular time. The behaviour of
substance misusers can seem perverse – the drug dependent may express the wish
and the intention to change their ways, but find themselves unable to do so at
first. We need to remind supervisees
that this is because of the strong transference on to the drug. Failures can be instructive too. Sometimes,
as Alcoholics Anonymous says, it takes a while for a drug user to come to the
point of being ready to stop, and often this involves some sort of ‘Rock
Bottom’ – an accident or an existential crisis.
Understanding
and tolerating co-working:
Supervisees may find themselves in the position of co-workers. If a
supervisee’s client receives additional treatment from a local statutory or
voluntary treatment agency, staff are often happy to co-operate with the
pre-existing treatment arrangement. Even seeming opposition from the ‘rival’ group
or therapist can often be diffused, so long as the psychodynamic therapist is
prepared to stay within his or her own domain –
the psychodynamic approach itself. Then any conflict or confusion
described by the client becomes like any other communication, that is,
something to be explored as ‘material’.
We may have to stand by and watch while the client goes out of our
supervisee’s orbit, into a rehabilitation centre for example. Temporarily we
may have to endure being out of the picture.
Understanding
the dangers: Any behaviour which is potentially risky to the
individual, if not actively self destructive, constitutes a source of anxiety
for the therapist. One of the
temptations is to get drawn into a strictly social work mode of thinking, and a
desire for control. But the control over
the use of the substance and over the substance itself is precisely what the
patient may be desperately seeking, -
and then projecting into the therapist.
As the first of the Twelve Steps of
AA says, ‘we recognised that we were powerless over alcohol.’ We are not in a social work relationship with
this client. Our task is rather to try to analyse what is going on between us
and in the client’s world.
How often I
have longed to thump the table, metaphorically, and say to a supervisee, ‘This
is what you should do.’ I doubt whether
it would ever work. The reason for my desire to control is most probably a
reflection of the client’s diminished sense of control over the drug use,
refracted through the lense of my supervisee’s anxiety. I tell myself then that
we can all fall prey to acting out - but must resist the urge!
Occasionally
we may have to face a disaster – an overdose or an accident from which a client
does not recover. It is much harder for the therapist working in an individual
setting to grieve the death of a client, than for a member of a treatment team.
The loneliness, depression, guilt and anger can be extreme – and it is then
that the supervisor may be the only person in whom the supervisee can confide.
Open-mindedness.
On
the first occasion I attended a relapse prevention group as a potential future
facilitator, I was engulfed by an incapacitating sense of drowsiness. Yet the
group was large, strident and busy at its work. I believe that the longing for
sleep descended on me because my mind resisted what I was hearing. This experience taught me that as supervisors
it is wise to be quiet and watchful while our supervisees struggle to contain
their feelings about substance misusing clients. Beneath the behaviour their clients are
recounting or exhibiting lies hidden the truth of their lives, just as with any
other client. Only trust, patience and empathy can elicit it.
There is the
question of what the therapist does if a patient turns up for a session
intoxicated, and even worse, if they have driven to the session in that
state. It is relatively easy for
cognitive behaviour therapists to establish rules with clients at the very
beginning. As psychoanalytic therapists,
we balk at laying down the law, yet we can still work toward mutually accepted
rules about sessions. Think how effective we can be over session times and
breaks. We may be non-confrontational in
manner, yet we are self-assertive in many covert respects. These matters are the material of discussion
in supervision, and in particular highlight the need to avoid generalising. Each client will bring a different
challenge. We listen and learn from each
one, and in supervision the material can be reflected upon and distilled. As always, we need to be open-minded about
the outcome of therapy. George Vaillant,
tracking the progress of alcoholics over many years discovered that they
increasingly tend to achieve sobriety as they age. Time is on our side.
Our task
Our task is to
help and encourage our supervisees to keep to the task of trying to understand
the meaning of what their substance misusing patients do and say, and to help
them towards freedom from relying on intoxicating substances so that they can
move towards growth and individuation.
In this we can help our supervisees avoid the mental trap of ‘nothing
but’ thinking. It can take a long time
for the links between present and past to be made fruitfully, just as the
meaning of the substance using and misusing will unfold between patient and
therapist only gradually. The reason
someone drinks today may be very different from the reason he or she liked to
drink at the age of seventeen. Both are
important. It is very revealing to
discover what drinking meant at the start of a person’s drinking career. What pleasures did it bring? Does drinking bring them these same
satisfactions now, in spite of the down side?
Or has this changed? Once we can
encourage this sort of dialogue to become part of the repertoire of our
supervisees, the conundrum of whether the person or the problem is the focus of
the therapy is transformed into a journey of exploration which can set the scene
for change.
References
Alcoholics Anonymous www.alcoholics-anonymous.org.uk
Alcohol Concern www.alcoholconcern.org.uk
Drugscope www.drugscope.org.uk
Edwards, G. (2000)
Alcohol: The Ambiguous Molecule.
Marlatt, G.A. and Gordon, J.R. (1985)
Relapse Prevention: Maintenance
Strategies in
the
Treatment of Addictive Behaviours.
Miller, W.R. and Rollnick, S. (2002) Motivational Interviewing: Preparing People
for Change in Addictive Behaviours.
Narcotics Anonymous www.ukna.org
Prochaska, J. O. and DiClemente, C.C. (1983)
Transtheoretical Therapy: towards a more
integrative model of change.
Psychotherapy: Theory, Research and Practice, 19: 276-288.
Smaldino, A. (1991) Psychoanalytic Approaches to Addiction.
Dr. Mary Addenbrooke is a Jungian Analyst
practising in
Working with the
‘addictional bond’;
thoughts on the
supervision of therapists working with addicted clients
Bill Reading - Psychoanalytic therapist and
supervisor, Canterbury,
Over the many
years during which I have worked as a psychotherapist and supervisor in both
general and addiction-specific domains, I have been aware of the vast ranges of
theories and techniques which are available and of which I have had personal
experience. I have tried here to
summarise some of the main features of my approach to supervision within addiction-based
therapy. I think it would be helpful for me to make a few general observations
as to my own, psychodynamic approach before offering views on more particular
aspects.
My central
approach is one derived from Attachment Theory (AT) & has been reinforced
by more recent clinical & empirical studies which seem both to further
underpin and to refine Bowlby’s assertions. Much of this model’s relevance for
me spans both generic & addiction-oriented psychotherapy but a few
particular assumptions on the latter seem appropriate.
Firstly, I try
to understand addictive problems (and their intra-personal correlates) most
prominently in their interpersonal context. More recent emphasis on the
regulation/co-regulation of affect states within AT makes it an especially
helpful paradigm for framing the relationships existing between client/drug,
client/therapist and therapist/supervisor. I tend to view problems of addiction
in their relational context with regard
to the establishment, persistence and therapeutic remedy of such problems.
Secondly, I
find that the notion of the ‘inter-subjective field’ provides a compelling and
less reductionistic platform for exploration of
transference/countertransference phenomena or perhaps, more succinctly, the
‘co-transference’. Supervisees may be
sometimes disconcerted by this apparent challenge to their separateness but
generally come to value its liberating potential as they become more able to
‘be in the treatment’.
Thirdly, AT
seems to provide sound and highly useful principles of relatedness which traverse
the many particular theories and ideologies which abound in the world of
‘addictionology’. As well as typifying
my own approach to the supervisee, I find that many have responded well to
greater familiarity with these ideas in their applied form although they may
operate from diverse rtheoretical or ideological positions.
Finally, AT
has been the best way in which I have been able to understand and manage the
observation that it is the ‘non-specific relationship variables’ (rather than
particular technical models) which most powerfully predict the success of both
generic and addiction-specific psychotherapies.
In both therapeutic and supervisory situations, the provision of secure
base conditions (especially the facilitation of ‘interactional co-regulation of
affect states’) provides a safe field within which, client, therapist and
supervisor are enabled to prosper in their respective roles. Whilst the supervisory experience may often
require confrontation with that which is painful, it is neither necessary nor
sensible for it to be persecutory in its approach. Just as the client must find
his/her own way of resolving the presenting difficulties, facilitated by the
presence of the therapist I assume a parallel process whereby my presence aims
to assist the supervisee in becoming freed to function as fully as possible in
giving service to the client.
Whilst there
are undoubtedly more and less-skilled therapists, I think increasingly that it
is the therapist’s ability to desist from making errors which counts for more
than displays of skill. Whilst the field
of addictions psychotherapy is one in which the primitive, appetitive,
regressed, borderline and similar tonal qualities of material which emerges is
often considered to be associated with particularly intense
countertransferences, I am keen to consider routine aspects of the therapy such
as the adequacy of the therapeutic setting, the therapeutic contract and other
factors which enable the therapist to feel ‘role-secure’ and thus, to express
‘therapeutic commitment’. I include here
the matter of both therapist and client being free from the effects of
intoxication or drug withdrawal symptoms in order to maximise the prospects for
effective therapeutic relating and thus, improved outcome.
I consider it
essential to try to understand the idiosyncratic (e.g. ‘being in personal
recovery’), ideological (e.g. “addicts are in the paranoid-schizoid position”),
cultural (e.g. “addicts must abstain”) and other dispositions which the
supervisee brings to the work and how such states transform and are transformed
by, the therapeutic encounter. Perhaps
one of the most commonly occurring tensions which arises in this respect is
observed as the therapist balances respect for the uniqueness and autonomy of
the client with the desire to assist the client in behaving differently. In this respect, I do not consider
addiction-based psychotherapy to differ from analytic therapy with other
categories of client. Whilst addicted
clients may often provoke higher levels of morally inclined responses than some
others, the therapeutic requirement to maintain an ethical posture must
prevail. The supervisee’s task is to
assist clients in making the changes which they wish to make, rather than those
preferred by the supervisee or others.
Research
concerning the effectiveness of psychotherapy in the addictions is unequivocal
in supporting a supportive (rather than catalytic/expressive) approach,
particularly in the early stages of therapy.
I encourage supervisees to be mindful of the hypotheses which they
develop as they enter the client’s world more deeply but try to balance this
with a need for caution in applying such hypotheses prematurely. In a zone of
therapeutic endeavour where clients will typically allude to non-conscious
elements to their behaviours (e.g. “I know I should take less cocaine but…”, “I
don’t know why I do this…” etc.), it may be tempting to proffer suggestions as
to what may be happening ‘in the unconscious’ (e.g. ‘omnipotence’, ‘masochism’,
‘archaic object dependence’, ‘pre-oedipal meta-eroticism’ etc., etc.) and to
overlook the possibility that such quasi-dynamic phenomena may be better
explained as artefacts deriving from recent drug use which will abate and even
remit entirely once drug use is reduced or stops. Even where overt behaviour and subjective
experience seems legitimately to point to some, as yet, unconscious
determinant, I am powerfully persuaded of the dramatic relief in symptoms (and
apparent psychopathology) which clients often undergo with minimal explicit
therapeutic intervention as they emerge fro the internal and interpersonal haze
which drug use has occasioned. The therapist’s ability to function as a
temporary attachment figure can be seen as enabling the client to free
him-/her-self incrementally from the addictional bond to the drug. It is at this point where it becomes possible
to distinguish those dynamics which require psychotherapeutic attention and
those which do not. Supporting the supervisee in valuing the importance of the
holding relationship during such times is vital.
I hope that
what I have had to say has communicated something of my personal approach to
such supervision – essentially, one in which addiction based psychotherapy and
supervision has more in common with other forms of therapy than it has
differences and where its effectiveness and rewards are of a similar nature.
References
Cassidy, J.
& Shaver, P.
(1999) Handbook of attachment; theory, research and clinical applications. NY,
Holmes, J. (1993) John
Bowlby and attachment theory.
Reading, B.
& Jacobs, M. (2002)
Addiction; questions and answers for counsellors and therapists.
Schore, A. (2003) Affect regulation and the repair of the self.
Schore, A. (2003) Affect dysregulation and disorders of the
self.
Bill Reading started working in the field of addiction in 1979
and is Head of the
Supervision
of Counsellors in an Addiction Treatment Centre – Culture & Unconscious
Processes
Jenny Gower
I supervised a group in an addiction treatment centre from 2003 to
2006. It was not a residential setting
but the clients attended the Centre seven days a week and were also expected to
attend a twelve step meeting at least twice a week. The Counsellors worked with
every kind of addiction from drugs, alcohol, food, gambling, sex etc. They worked with the twelve-step programme,
which meant that the clients were totally abstinent from their ‘drug’ of
choice. The clients were assessed as
soon as they arrived at the centre and then put on a detoxification programme.
They were aged between 17 and 65, referred by statutory organisations,
self-referral, private companies and charitable organisations. Often the clients were in poor health due to
their addictions and may have been sleeping rough. There were more male clients than females and
a large majority of the group could have been black African-Caribbean from a
specific referral agency.
The counsellors’ roles were multi faceted in that they counselled the
clients and also worked with them in their groups. They also had to maintain discipline. Confidentiality was held within the centre to
guard against splitting and secrets.
There could be
up to twelve counsellors working in the centre & there were times when
there were only half this number. The
counsellors had a range of experience & qualification mostly using the
Integrative Model of counselling. A few of the Counsellors were completing a
degree in Addiction Counselling, some had a Diploma in Counselling & there
were always three or four Students who were on placement for a counselling
course. The majority of the Counsellors
were recovered addicts.
Supervision was one and a half hours fortnightly on the same day and
time of the week, which took some negotiating but became a strong learning
curve on boundaries. My task as a supervisor became clear in that I acted as a
container of the chaos and helped the counsellors make sense of it. Bion refers
to psychic states and feelings that have to be contained to become manageable
and meaningful. To encourage the supervisees to understand unconscious
processes, especially countertransference issues, was often difficult, as they
had never been taught this in a way that they could understand. They often
became defensive as they thought it was all to do with their own ‘baggage’.
However, there were times when the counsellors were traumatised by a client’s
presentation or when a client had relapsed. At these times they needed to
understand what they were holding.
There was one particular presentation when the supervisees were very
agitated and declared that the whole group of clients were very angry and felt
out of control. They described the mood
as black and had brought it to supervision to try to make some sense of it. (As
you will see this was a good unconscious description that I missed!) In the one
to one counselling sessions the process seemed to be working well and the
clients were all writing their journals and working enthusiastically in their
activities. There were no signs of any
of the group relapsing but when they came together in the personal development
group they were antagonistic towards the counsellors. There were often different group counsellors
and this was a normal occurrence in this setting.
In supervision the supervisees were talking about what had happened in
the group and what issues were discussed but the underlying feeling was of hostility
and the counsellors were feeling angry.
We discussed the fact they were holding the anger of these clients and a
few were able to admit that they had great difficulty with anger and this was
stirring up their own unresolved feelings. As we discussed each individual
client we could also understand that they each had unresolved anger from their
past. However, it was felt by the
supervisees that this was only part of the issue and there was something else. I wondered with them about how they felt towards
me as I was finding it difficult unravel this.
This was dismissed as not being part of the equation! Then I realised
that I was unaware of the culture of this group of clients as there had been
quite a change since the previous supervision.
They felt this was irrelevant as they were all here for a common cause,
to beat their addiction. However, one of
the supervisees told me that it was an all male African-Caribbean group. (I had
missed the unconscious communication earlier when the supervisees had described
the ‘black mood’ of the group.) At this
time all but one of the supervisees were white British, including myself. The group dismissed this again saying that
they did not feel this had anything to do with the anger. I encouraged them to think about how they
could address the cultural differences between them and the power that the
supervisees were holding both in their roles and their culture. However there was great reluctance to look at
this and the supervisees were very uncomfortable with the word power. I wondered about the anger the clients were
experiencing and the power this was exercising over the counsellors. They accepted this more readily and I thought
about linking this to my power as a supervisor but decided against this. I wondered whether this was my resistance or
the countertransference from the group’s resistance to look at power. The supervision ended there and I went away
feeling quite demoralised and powerless which was how both the supervisees and
the clients were feeling.
In Lago and Thompsons paper ‘The Triangle with Curved Sides’ they refer
to the way that a communication between a client and a counsellor of different
cultures can become a ‘curved communication’. That each person forms a ‘proxy
self’ to over compensate for the cultural differences and there is a circular
route of communication instead of a direct route. I felt that the clients were trying to get a
direct route to the counsellors through their anger and I had also failed to do
this with the supervisees.
In
the next supervision group the chaos had subsided & the group felt
comfortable & at ease. I waited to
see who was going to present & if they were going to comment on the last
supervision. Nothing was said & so I
focussed on the calmness in the group & I wondered if this was a reflection
of their clients. I was told that it was
‘very odd’ but when they went into the group the next day they were challenged
by the clients that their cultural differences had not been discussed or
explored in the group. The group
counsellors felt that this should be discussed further &immediately picked
it up. They had a very lively and good
discussion and the clients said that they felt it was the first time that they
had been heard. I reflected on the parallel
process that I was unsure whether they had heard what I had offered at the last
supervision but that there was now direct communication between the clients and
counsellors. I encouraged them to think
about and explore their own attitudes towards other cultures and power. This was met with some defence but they did
agree that these issues needed to be discussed further. D’Ardenne & Matani
write, ‘cultural knowledge of any kind
is of little value if counsellors, whether black or white, cannot critically
examine their own attitudes and expectations.’ (Transcultural Counselling in
Action). At the end of that supervision session I was left with the sense that
there was more of an understanding of issues of culture & power and maybe,
of unconscious processes.
References
D’Ardenne & Matani, Transcultural Counselling in
Action: Sage
Bion WR (1961) Experiences in Groups and
other papers.
C Lago The
Triangle with Curved Sides
M Weegman & R Cohen (2006) The Psychodynamics of Addiction.
Jenny Gower is the Chief Executive Officer for
Southampton Counselling (WPF Affiliate) & a Senior BACP Accredited
Counsellor. She has been teaching on the WPF Certificate in Supervision at
Supervision,
Addiction & Intuition
Dr Dale Mathers, MRCPsych.
I’ll use addiction in an
‘old fashioned sense’ meaning to hard drugs or alcohol, rather than the wide
range of behaviours which benefit from ‘Twelve Steps’ programs. In Chambers
dictionary it is defined as ‘being a slave to a habit or a vice’, ‘given up to,
dependent on’, or, ‘a habit impossible to break’. These definitions help
clairfy the dilemmas addicts live with, transfer to their therapists and, by
parallel process, create in supervision. Addicts are often seen as ‘difficult’,
as ‘Shadow’ patients. They leave us feeling as hopeless as they feel
themselves. Indeed, some practicioners insist on sobriety first and therapy
afterwards. To my mind, this is like telling a kid with a broken leg they can
only have it set once they’ve healed the fracture themselves. It’s cruel:
mirroring the mindless cruelty which so often lies behind chronic dependence.
The system {drug / patient
/ therapist / supervisor} is a sticky sado-masochistic dynamic, in which
tensions as between master and slave flick to and fro. Reflecting an addicts’
life-position, it may feel ‘giving up’ is the only option, for addiction is a form
of chronic suicide. For young heroin users, five-year follow up studies show
about one third die, one third ‘get clean’ and one third are still using. For alcoholics,
the same. Alcohol is far the more dangerous drug, yet, in our culture at this
time, socially accepted; perhaps as it comes in bottles - reminding us
addiction is a regressive experience, an attempt to fill an inner emptiness; a
continuation of comfort-seeking from a ‘bad breast’, in object-relations
language. I made this interpretation once in a group of chronic young heroin
users, by sucking my thumb. The boy I made it to drew his flick knife. I’d
become ‘difficult’. He didn’t know what else to do. Fortunately the ‘Higher
Power’ of the group did. Intuitively, his mates disarmed him with a smile . . .
sucking their thumbs too.
Take it as given that
‘addiction’ is the name for a final common pathway for people with early
experiences of deprivation, abuse and neglect
- much as ‘rheumatism’ is the name for the final common pathway of
degenerative joint diseases. Suppose ‘difficult’ is an intuition about
personality rather than a signal to give up hope. Suppose in addiction
parenting archetypes have been inadequately humanised, then everything goes to
fill a chronic inner emptiness. To paraphrase Jung (whose advice to ‘Dr. Bill’
led to the founding of Alcoholics Anonymous), ‘spirits’ have taken the place of
‘Spirit’. Personality development, a Spiritual journey, has frozen. Being in
the presence of a frozen object can, often does, freeze a therapist’s capacity
for intution, for future perspective, (Charlton 1997) which, in a Spiritual
sense, is called Hope.
A primary function of
supervision is to keep Hope alive. This makes the difference between whether a
patient ends up dead or alive. But intuition is not a wish-fulfilment. It is a
predictive psychic function mediated by its Shadow, the known. The Shadow, as
an Archetype, can be defined as ‘the thing a person has no wish to be’
(Jung, CW 16, para. 470). It does not mean ‘bad’, or (as in George Lucas’s
‘Star Wars’ films) ‘touched by the Dark Side of the Force’; simply, ‘what we
have no wish to be’ . . . If we’ve no wish to be a policeman, then our
‘policeman like’ qualities -
judgement - may be part of our Shadow.
If we are a child who feels unloveable, then our Shadow is ‘to be loved’. How
can we have no wish to be loved? To be loved would be to give up attachment to
a bad object, which, as Fairbairn said, is the hardest attachment to end (1952
p 68). Being loved is a ‘not-known’ for most addicts. In supervision, this
appears as compassion, &a non-judgemental attitude.
Intuition means being with
not-knowing. Working with addicts, ‘difficult patients’ who produce ‘difficult supervisees’, requires
tolerating uncertainty, the Shadow of knowing. In each ‘supervisory fix’ we
say ‘this could be right, equally, this
could be completely wrong’. So, a sense of Shadow might be defined as a sense
of the Opposite of Self: with chronic dependence, the supervisors attitude is
both to be as innocent as a child, and as cunning as a serpent.
‘Self’ here is a Verb
(not a noun) - that is, it names the capacity to show ‘. . .The four
invariants of self - coherence, continuity, agency and affective relational
patterns’ . . which . . ‘shape a particular ego-complex to
function more or less in maintaining the unity of the subject over time.’
(Young - Eisendrath, 2005 p 208). Coherence means being able to narrate
a personal history, continuity is a personal sense of evolution and
development, agency is an ability to make autonomous choice, and affective
relating means sharing feelings with empathy. When difficulties with some of
these appear in the system {drug,
patient, therapist, supervisor}, the system loses it’s ability for
Self-determination. The situation becomes problematic. When all four invariants
are lost, it’s ‘difficult’. We find ourselves reacting, rather than acting. We
become concerned with results (outcome) rather than attending to the a priori
environment, the Unconscious process. We start feeling we must do something.
Always a bad sign.
Maintaining hope within the
system relies on paradox - don’t do anything, just be. The
developmental delay or arrest which lies behind addictive behaviour usually has
origin in failures to let a child be themselves. It results from doing
(of which active neglect is the worst form) by parents who use a child as a
narcissistic object - a little version of themselves who will live their
unlived life. Supervisors need awareness of this dynamic, to note how it will
inevitably repeat in the work. What is not needed is a ‘sitting next to Nelly’
approach, ‘do it like me, then it will be alright.’ That is another form of the
same thing. Rather, don’t know what you are doing, then you, the
therapist and the patient have some chance of sharing the same head-space. If
this sounds risky, that’s because it is. Work with severely addicted people is
risky - but then, so is surgery. For example:
Adam is a mixed-race young
professional footballer, a striker. He came to therapy actively suicidal,
heavily addicted to cocaine, and self-harming with a flick knife. He’d be late,
early or come at the wrong time, fight about the bill, rage ’you’re not
helping’ and, once, slashed his wrists in his therapists toilet. My supervisee,
David, was concerned for his own safety, as Adam would play with this knife in
sessions. David felt murderous at this threat. I suggested he felt pressured to
make Adam better, but might try using paradox, suggesting he ’do it more’.
David suddenly found himself suggesting Adam ’murder’ one of the cuddly toys
they’d used to symbolise the warring parts of his fragmented psyche. Adam
stabbed the black teddy to death. It represented his heroin-using Jamaican
mother. He felt she failed to protect him from the ’White Fathers’ in the Irish
children’s home he’d been left in after his alcoholic father died of cirrhosis,
at thirty. The first stabs were violent. Then Adam dropped the knife, sobbed
and, for the first time, trusted David enough to tell him about brutalising
physical and sexual abuse by a Priest. Up till then, we’d intuited this had
happened. After this ’murder’, we knew.
Survival depended on wisdom
and compassion in the system {patient, therapist, supervisor}. As I trusted
David’s wisdom, and he trusted his Unconscious, he could trust Adam, even in
extremity. None of us planned the teddy bear’s murder. For Adam, who hadn’t
developed much ability to symbolise, this ‘enactment’ in the room allowed that
to begin. With addicts, something of this kind - though not always so graphic -
seems essential to allow them to contact
their own ‘Higher Power’ (Spiritual sense, or transcendent function). This
holds them to the Collective Unconscious, as a real social network (friends).
‘Difficult people’ vandalise their social networks. Adam’s career was on the
line after too many fights in matches, too many red cards and too much time on
the bench. He fought referees, team mates and any rules, having been beaten too
often as a child for breaking rules he didn’t understand. Next, David and I
used a semiotic trick: suggesting a new meta-language to Adam, based on the
difference between a rule and a recommendation.
We helped him replace a
language of cruelty with a language of morality, which David taught him by
firm, consistent and clear boundary keeping, as modelled in supervision. Adam
began to see his (Irish) team manager as separate from ‘Irish fathers’. He
began to tell a coherent story to himself about his own life. With coherence
came continuity, agency and affective relating. He stopped getting red
cards and started having friends. He cut through, instead of cutting lines of
coke.
The symbol of the knife is
a key one in this paper. My best ‘learning from the patients’ about addiction
came at knife-point. The group taught me there has to be a ‘cutting through’,
which, like surgery, requires appropriate and clean conditions - as well as a
Team. And that humour is the best knife of all. The first thing to cut through
is therapeutic nihilism. Under all addiction, there is a terrified child,
willing to respond generously if given space in which to just be, and be
heard. Therapist’s terror of such patients is an appropriate syntonic
counter-transferential response. There are no special techniques needed, apart
from Hope. There are no wise interpretations apart from the symbol of ‘thumb
sucking’. When I left the group, the kids kindly gave me a Swiss Army knife. I
still use it.
"This
clinical example is fictionalised with the assistance and consent of both
supervisee and patient."
References
Charlton, Randy (1997) ‘Fictions of the Internal Object’, Journal of Analytical
Psychology 42,1: 81 - 99.
Fairbairn, Ronald (1952) Psychoanalytic studies
of the personality,
Jung, C. G. (1953 – 77) Collected Works
of C. G. Jung, 20 vol. (ed. Herbert Read, Michael Fordham and Gerhard
Adler; trans. R. F. C. Hull).
Young - Eisendrath, Polly (2005) Subject to change,
Dr Dale Mathers, MRCPsych.
Member of the International Association of Analytical Psychologists
(IAAP). Trained in psychiatry at
BAPPS’ SPRING
CONFERENCE
“Countertransference,
Enchantment & the Erotic Transference in Supervision”
Ruth Barnett
The final
conclusion I came away with from this BAPPS Spring Conference was that not
enough attention is generally paid, in training and practice let alone in
supervision, to the powerful unconscious erotic processes that are almost
inevitably there, but so often unacknowledged, when client- therapist or
therapist-supervisor pairs meet for intensive work together. It is almost as if
clients, like the ‘innocence’ of childhood before Freud, are not supposed to
have unconscious erotic fantasy lives, and, as professionals, we keep that
aspect of ourselves out of the encounter. As with money, we tend to avoid
getting into exploring the symbolic depths of gender, sexuality and sexual
orientation. We don’t like the reality that we offer our psyche to our clients
for money. A sort of prostitution? Can we be comfortable including the psychic
‘private parts’, the sexual/erotic parts of our psyche in what we offer our
clients in an encounter for which the client pays us money? Without erotic
involvement are we deluding ourselves that we are keeping the client ‘safe’?
Joy Schavarein
treated us to a foretaste of her recently published book on this topic. She
emphasised supervision as an important outer frame that holds and contains the
setting within which contracted boundaries provide a frame for the client’s
narrative to unfold. She invited us to apply an analogy of the Theatre, the
‘home of enchantment’, to therapy. The audience has a real role of buying a
ticket and coming to partake within certain ‘houserules’ of times and limits on
behaviour. The theatregoer also enters into the ‘as if’ of the drama presented
on the stage through entering a state of ‘willing suspension of disbelief’. The
drama may be affected, even stopped, if a theatregoer is unable to hold this
tension between make-believe and reality. An example cited was of a man who
jumped on stage when an actor was about to stab another actor, wrestled him to
the ground and took the knife away to ‘save’ the other actor. For this
theatregoer, the drama was no longer ‘as if’ but had become concretely real.
In therapy the
therapist is the audience observing the drama that the client presents through
her narrative and behaviour. The erotic transference can create such a powerful
tension in the Countertransference that the therapist may become confused
between the symbolic and real and is consequently unable to keep her ‘as if’
stance. She is then ‘enchanted’ or ‘under the spell’ of the drama and feels it
to be concretely real. It then falls to the supervisor, who is outside the
consulting room drama and able to observe more objectively, to break the spell
and release the supervisee from being ‘in thrall’. Schavarein told us an
interesting case of a supervisee, Daisy (a composite not an actual supervisee),
who was unusually powerfully attracted to a particular male client without
knowing exactly why. She told this to her supervisor who appeared not to
notice. Daisy didn’t bring this client again until she had a new supervisor.
Daisy’s second supervisor disapproved and advised Daisy to end the therapy as
soon as she could. Daisy actually did end the therapy quickly. But she was left
feeling uneasy and guilty until she brought this to a third supervisor,
Schavarein, who helped her to understand the symbolic meaning of this erotic
countertransference that the first supervisor simply avoided and the second
supervisor had confused with reality.
In supervision,
both the supervisor and the supervisee are observing the consulting room drama
together to reflect on and understand it. This makes less likely but does not
necessarily preclude erotic transference taking hold in supervision, perhaps
through parallel process. The task is similarly to dissolve the concreteness
through focusing on the symbolic meaning. Here Schavarein referred to an
important difference in the supervision session. Interpretation is largely to
be avoided to keep a boundary between supervision and personal therapy. If
concretised erotic transference develops into thrall between supervisee and
supervisor there is the possibility of supervision of supervision to
disentangle the symbolic and real and enable supervision of the supervisee to
continue.
A lively
discussion ensued both before and after lunch in the plenary and also during
lunch in small groups. Not only was the plenary small enough (39 including the
speaker) to be in two concentric circles but, with so many colleagues who had known
each other for many years, it was a safe group in which to explore in depth
issues around erotic responses that might not feel safe to open up in other
groups. Scharavein’s presentation had fascinated us and enabled us to enter
more deeply into discussion of erotic responses without fear of getting
confused between the symbolic and real. Some of the ideas embraced were the
differences generated by different gender and sexual orientation
client-therapist and supervisor-supervisee pairs, the disadvantages that may be
caused by ‘rigid gender-certainty’, the vicissitudes of trust, the symbolic
role of money when some colleagues are working voluntarily and others are paid
and the dynamics that can get set up when a client or therapist (or
supervisor?) is pregnant. It was certainly a fertile and fecund meeting.
Something To Think About
Conference Committee
We had a great
conference this year! bapps now has a membership of around
250, and about one sixth came to our main annual Conference. It was great to
see so many of you there – and it would be wonderful to see even more!
The conference
committee are committed to enhancing the public perception and reputation of bapps, enabling those interested in the
field of supervision to be engaged at the forefront of academic thinking. We believe the conferences provide an ideal
forum for debate, as evidenced by the very rich and stimulating discussions we
enjoy there! The most recent conference,
led by Joy Schaverien - supervising the erotic transference and countertransference
- was so fascinating that there was little small-talk over lunch; colleagues
were so ‘enthralled’(qv)
by the topic that they seemed reluctant to drop it, and continued to develop
their thoughts informally over the lunch break.
Following on from this we are delighted that the Autumn newsletter will
publish short pieces which were stimulated by the speaker and subsequent
discussions.
It is one of
our ambitions to encourage even more of the membership to prioritise BAPPS
conferences in what we appreciate are already busy schedules. In addition we
want to attract a wider audience; other clinicians who may not as yet be BAPPS
members but are interested in the psychoanalytic approach to Supervision,
whether as a qualified supervisor, or a committed supervisee.
All BAPPS
members have already made a significant commitment to train as
Supervisors. We hope and trust you will
continue to develop this interest in Supervision by supporting and
participating in workshops and conferences. These can help challenge and enrich
understandings as well as keep us up-to-date with current thinking. Ultimately
this investment benefits not only us, but also our supervisees, and the work
with clients. The Conference committee
act on your behalf to facilitate your cpd
– and we really need and value your active support. .
Our next morning-only Seminar is on Saturday 10th
November (the day of the agm),
and will be led by Gill Bannister, on supervising the withholding supervisee,
in ‘What shall we do with the narcissistic
supervisee?’ Lunch will be provided
before the agm.
Hope to see
you there!
Your Conference Committee
Carolyn Couchman
Janet Hughes
Deirdre Schueppert
