Supervision in Psychoanalysis and Psychotherapy

A Case Study and Clinical Guide

Diana Shmukler

• Publisher: Routledge
• Year: 2016
• ISBN:
  9781317330011
• Edition: 1
• Topic: Psicología
• Subtopic: Psicoanálisis

Supervision in Psychoanalysis and Psychotherapy demonstrates why supervision is an essential component of any psychoanalytic or therapeutic work. Drawing on Winnicott and rich clinical material, and featuring work with Patrick Casement, this book provides new guidance on psychodynamic supervision and explores how its skilful use can have a significant effect on the outcome of such work, enabling the practitioner to rethink their theoretical approach, and thereby view issues differently in the clinical setting.

Built around the case study of a challenging but successful long term individual therapy, Supervision in Psychoanalysis and Psychotherapy examines how clinicians can become 'stuck' in their work with certain patients, struggling to find a way to get through to them. Diana Shmukler brings together a fascinating combination of various perspectives, detailing the patient's own words, the therapists' views and reflections and the effect of a brief introduction to Art Therapy, whilst underlining the power and impact, both theoretically and practically, of using a different approach in supervision. Shmukler superbly integrates theory and practice, underlining the validity of a two-person psychology and the therapeutic relationship, whilst also illustrating the centrality of both participant's commitment to, and belief in, the process of therapy. Importantly, the book provides a clinical example in which the subjectivities of all the participants are shown to be clearly central to the work. Shmukler underlines the significance of supervision to complex cases, even that of a highly experienced therapist.

Supervision in Psychoanalysis and Psychotherapy will appeal to psychoanalysts and psychotherapists, students and trainees in integrative psychotherapy, counsellors and psychiatrists, as well as patients seeking help for deep seated issues.

Chapter 1

A search for a safe pair of hands

This chapter will introduce the story of the therapy, the central features in the patient/therapist dyad and the theoretical frame within which the work was embedded.

Setting the scene

This is the story of a breakdown and recovery. It is also the story of a therapy conducted over a period of seven years. It is described from a number of different perspectives with an interplay of internal and outer worlds and the space between them.

The patient’s story

My version of the story of the therapy

It is a rare privilege to work with such a gifted patient as the person to be described in this book. She is gifted in her ability to use therapy, her commitment to the work, and her ability to capture her internal experience in words.

There have been numerous challenges in this work. In the first place, doing the therapy was challenging. At the completion of this therapy, however, I was faced with the challenge of describing the work. What makes the description so complex are the many parts to the story and the challenge of presenting them in a coherent and sequential fashion. Furthermore, in doing justice to the experience, there were other considerations such as the patient’s wish that the emotional quality be preserved in some way. Thus I have included her words, where possible, as they particularly convey and capture something of the quality and flavour of the work. I have her words available to me in several ways: from an interview we recorded some time after the therapy had ended; from various e-mails before, during and after; and some verbatim statements captured from the sessions; and, centrally, from the letters that were written to me throughout the entire duration of the work.

Including Jane in this way seems only appropriate and right in the spirit of our co-created work. It has been her consistent wish that, if there is value to others that can arise from this work, it be used as such. In that spirit I proceed, while at the same time being aware of the possibility of this interfering in some way with the anonymity, and confidentiality of the work.

As author, this presentation as a whole rests upon my own subjectivity, apart from the occasions when I can quote the patient verbatim. Even here my subjectivity is reflected in my choice of quotes. Thus there are numerous aspects to be thought about, including my story, the story of the work, the patient’s story, the perspective from supervision and finally, but equally important to me, the theoretical implications that can be drawn from a rich and complex piece of work such as this. I have woven these elements together in order to create a coherent picture of the complex and multi-dimensional process that intense, individual, relationally oriented therapy can generate.

Jane’s thoughts in this regard are:

As far as protecting myself is concerned, obviously I would not want my name used. That would be more to protect me with people who don’t already know because there are obviously those who lived with me through that time….

In another communication she added:

I have also been thinking about the possible book. I want to have parts of the letters as part of that – and because of that I want a pseudonym – a bit like the letters themselves this allows a freedom which I could not allow – partly for my own protection. I am not interested in any kudos of co-authoring; more important to have the freedom to be real – particularly as I think this is one of the things which may help.

She continued with:

In a way it’s not about me anymore. It doesn’t feel as if it is about me, rather about a period in my life. It was an incredibly important, life-changing event but I’m not defined by it in the way I probably was at one time. I don’t need to be attached to it and I don’t need to be recognised for it. I am interested in letting people know. I think it gives hope and encouragement. I was helped by various accounts of successful work while I was going through my own therapy.

This work is positioned within a relational frame. It is clearly an example of therapy that is integrative and developmental. It is also inter-subjective and a story of co-creation. It is my own need to wrap theory around it. However I will leave the theoretical reflections till later and get on with the story.

The aim in this chapter is to tell the story – describe the work – and to conceptualise it within a frame that makes sense.

I will begin at the beginning and I will be calling my patient Jane.

The story begins where the work ends, because this account starts with a taped meeting that my patient and I had, some two years after the therapy had ended, and we had then not met with each other at all for some time. Jane’s words that are quoted in this part come largely from the transcribed tapes of our retrospective reflections, which culminated in some discussion concerning a possible book about her journey through therapy.

The story of Jane’s therapy

The initial meeting before the work had clearly started

My first meeting with Jane was in a workshop that I ran as a visiting trainer. At the time I was still living in South Africa although I had begun the process of moving to the UK.

I saw Jane as a tall, thin, pale woman. What I noticed immediately were the deep black rings around her eyes. There was an intensity about her and she was noticeable in the quality of contact she made as well as what seemed, even then, to be the depth of her despair.

In her words, retrospectively, she said:

I think I just knew that if I was going to have a life this was my opportunity to find a life because I really think that life can bring a chance. I have lived such a tortured inner world. I mean I knew I could not go on … and meeting you seemed like an opportunity that I had been waiting for.

At the end of the third and final day, Jane enquired very nervously if she could ask me something. It was the last thing in my mind when she asked if she could come into therapy with me, despite the fact that I was not yet living in the UK at the time. It seemed to me that she was determined to get my agreement about therapy and would not take ‘No’ for an answer. Thus, in spite of the fact that I was still travelling backwards and forwards, I agreed that, on my coming to settle in England, I would be happy to work with her as a patient in a long-term therapy.

There was a precedent to this arrangement in the TA community, in the sense that some visiting trainers had contracts and therapy clients overseas. It was a practice I was already both critical of, somewhat skeptical, and worried about. However, Jane persisted and insisted saying that she would wait for me to come back to the UK. Further, she wanted to see me whenever I was in the country, which at that time was every few months.

Jane had added:

I don’t know what would have happened if for some reason you could not see me. I guess I would have survived and got myself together, but at the time it felt like life and death.

The next year and the start of the regular weekly therapy

The way in which the work began inevitably shaped and coloured the therapy. Here the work formally began after a long period of waiting and anticipation, filled with hope and dread for her. Many years later she wrote to me about how she had been led to believe that healing would come if only she could find the right person and be a ‘good enough’ client. She had been labelled ‘avoidant’ by some of her previous therapists and trainers. So we began the work with a sense of herself that the healing she was seeking was just out of her reach, but I seemed to embody the solution. I appeared to her to be part of the dominant culture and it looked as if I could offer the good experience that held the key to her cure.

Jane was participating in a workshop run by another visiting trainer and I attended the workshop, largely as an observer. I had worked previously with this trainer in a variety of ways over the years. At this stage, however, I was simply intending to observe and think about the work.

I didn’t know that I had been cast in the role of ‘saviour’ by Jane. Neither was I clear about what role the internationally well-known trainer saw me in, in that workshop (whether as assistant, colleague, commentator?).

On the first morning however the trainer literally threw the patient into my arms, saying something about her longing and waiting for me to arrive. I imagined he had intuitively picked up something about her waiting for me and her desperation to begin the work.

A retrospective comment that Jane made was:

Our work started before you were in the country so I had probably had a year or more of longing before you arrived which also contributed to my breaking down.

So began a long and challenging journey together, full of intense emotions and remarkable moments. A journey that was going to be life-changing for Jane and which would give me the opportunity to learn, understand, and grow in my capacity as a therapist as well, of course, as a person. In fact this work transformed my own understanding and practice as a therapist, supervisor and teacher of psychotherapy.

Jane spent the next five days, almost wordless, deeply regressed and very physically close to me in the workshop. At the time we didn’t talk much about that experience between us or how this had shaped and contributed to the subsequent work.

In her words Jane acknowledged how important it was to the powerful early transference that she developed in relation to me.

And yet that was all part of my connection to you and part of what helped me to tolerate how awful it had all become.…

During the five-day workshop, Jane created an opportunity to access some of her hidden aggression and violence, in order to show me and I think to warn me, by requesting time and space to work with both the visiting trainer and her previous therapist as co-therapists.

The group usually identifies with the client/patient in these scenarios and the therapist or therapists work with the presenting issue(s). These scenes are often highly charged and emotional as they invite the client to regress and experience from the therapist a different form of response than the one they might have got from parents. It certainly evokes a cathartic reaction and, in the immediacy of this experience, provides relief and often new insights into the childhood situation as, needless to say, regressed clients access their early experiences. However from my point of view, as observer in this case, it seemed somewhat artificial and it didn’t make much sense. So it took me a long time in the therapy to connect this display of inner violence to the good compliant and scared patient that I saw in my consulting room.

Jane chose to travel quite a long way to London to see me. She knew that she needed a regular time and a space that should be as safe as possible, somewhat removed from her familiar environment.

From the beginning Jane was clear about what she felt she needed, and I trusted her sense of this by going along with it whenever I could. For example a regular 50-minute session felt too short and we always worked for a double session.

At the time I was working in a flexible way as I hadn’t fully settled in London, or adjusted to my new working life, and I had not established a regular working schedule. However, I made sure to see Jane at the same time and same day each week. Thus, as the work proceeded it was contained within a regular weekly therapy session.

As I reflect on this unorthodox and somewhat shaky start, and wonder about its impact with the hindsight and understanding that I now feel I have, it seems to be related to how I thought about the work then. In this sense it carries the influence of working for years in the relatively disorganised and somewhat chaotic situation at the time in the South African context.

Here is an example of how today I might never have agreed to work in this fashion.

Jane retrospectively echoed my sentiments, saying:

It’s not the way I work here. It’s not the way I work at all. And I can feel sniffy about people who do. I sometimes catch myself because I am feeling quite sniffy about people who work in this way. Maybe it’s partly my experience of breaking down and what it means. I don’t think I could have made the transformation without breaking down, but whether it had to be so painful for so long I don’t know either.

Jane and I were also commenting on how we had become increasingly critical of, and had strong reservations about, the practice of swooping into a group, making powerful interventions and then departing again having often generated therapeutic crises, and leaving much of the necessary sustained hard work of the therapeutic containment to others.

So, despite these reservations, there was clearly something powerful and valuable in engaging in a process that felt possible, and working it out from there. She was a patient looking for a therapist and I was a therapist available to work with a patient.

By the time we began working Jane was by no means a naïve patient, having already had much therapy and also having completed several trainings in psychotherapy. She was already practising as a therapist, engaged in supervision, and was well regarded by colleagues and supervisors. This background will become evident, as we see how she was able to reflect upon, comment on and contribute greatly to, this body of work through her insight, capacity for self-reflection and knowledge of the field, and her general level of skill. At the same time all who met her professionally, in whatever capacity, could recognise her distress.

At the beginning of the work I was equally not a naïve therapist. However, I took Jane’s initial presentation at face value and was completely unprepared for the regression and collapse that followed, as we began to engage more regularly. Nevertheless, throughout the strenuous process of the therapy, Jane continued to function, held down a job, looked after her children and home, and even managed from time to time to lighten up and have a bit of fun. Generally though, I would have described her at the time as being anxious and deeply depressed, on the edge of a psychotic depression for a number of years before and during the early to middle stages of the work.

Jane said of this:

On one level I could do that, I could act appropriately but it had no bearing on what I was experiencing on the inside. I mean I could be completely regressed and talk forever as, in a way, I’d done that all my life. I also knew I had to take the fear somewhere and I thought, when I watched you in that workshop, that my hope was you would have the understanding of what the chaos was about. You would not simply want me to put a lid on it. Maybe that’s what I had always been told: ‘Put a lid on it, you have a choice to put a lid on.’ That was abusive but not intentionally so.

In the early stages of the work, I was doing what I was used to doing as a therapist. By this time I had been working as a therapist for some fifteen years and, prior to my formal training in South Africa, as a psychotherapist engaged in various ‘people related’ work such as counselling, crisis work, interviewing, and teaching psychology at a university.

My frame for understanding the work at that stage was primarily a humanistic one, based on an integration of Transactional Analysis with Gestalt Therapy, a TA/Gestalt approach that was influenced by Developmental Psychology, which I taught as an academic discipline, and some superficial understanding of Self Psychology and Object Relations theory gained largely from reading.

At the time I was impressed by the value and the power of what could be described as negotiated regression. I had seen how feelings from the past could be accessed therapeutically, by those active approaches to therapy, and integrated into the present adult functioni...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Acknowledgement
• Foreword by Patrick Casement
• Introduction
• 1. A search for a safe pair of hands
• 2. Little girl and better mother
• 3. The impact of the art therapy
• 4. The changing transference from idealisation to the failing mother
• 5. Supervision: finding the missing ingredient
• 6. The letters and their role in the therapy
• 7. Finishing the work: The final crisis and ending
• 8. Some of the theoretical ideas that supported the therapy
• Afterword
• Bibliography
• Index