THE NEUROBIOLOGICAL PERSPECTIVE, AS YET UNEXPLORED, may have much to offer in terms of understanding the supervisory process. Supervision offers an important means by which practitioners may explore the clinical process and the changing nature of the therapeutic alliance as it develops with any given patient. It also provides an added protection for a vulnerable patient population. It seems essential to me that a practice that is valued so highly by our profession should look to exploring its grounding in the neurobiology of emotion. I have chosen to return to the processing of mirroring and empathy (see Chapter 3) but with a particular emphasis on the relevance of these aspects of the neuro-biology of emotion in relation to the countertransference aspects of the supervisory process. Watt (2005) describes empathy as “one of our most critical social abilities, and essential to the mitigation of suffering” (p. 187). He suggests that this extension of mammalian nurturing behavior that humans are capable of allows for an “increasing appreciation of the internal spaces of others,” and of the “development of a theory of mind and perspective taking” (p.189). He identifies
• “native empathy,” which he designates genotypic
• phenotypic empathy, developed through good early attachment experience
• empathy evoked by the specifics of the sufferer, noting that “we are far more empathically mobilized by the suffering of a small helpless creature with a rounded face and big eyes than by the suffering of a dominant, aggressive and powerful alpha male” (p. 198)
• empathy which is made possible by the current affective state of the empathizer, noting that “affect-regulation must be relatively intact in the empathizer, as must self-other differentiation” (p. 201)
• the automatic “primitive emotional contagion” aspects of empathy whereby unconscious, continuous automatic processing means that the individual instantly resonates to the emotion of the other (p. 202)
• the more complex cognitive aspects of empathy that give rise to emotion identification and theory of mind
Watt concludes that the brain’s “early (short time-scale) receptive functioning prioritizes contagion responses while later responses may prioritize more cognitive processing” (p. 204). The success of the supervisory process will depend on the level of capacity for each aspect of empathy in the individual supervisor and also in the supervisee. Such an understanding of empathy implies that both therapeutic and supervisory skills cannot actually be taught but perhaps can be finetuned.
Schore and Schore (2008) note that “a neuropsychoanalytic right-brain perspective of the treatment process [and, I would suggest, of supervision] allows for a deeper understanding of the critical factors that operate at implicit levels of the therapeutic alliance, beneath the exchanges of language and explicit cognitions” (p. 18).
But how do implicit knowings impact on the therapeutic alliance and the supervisory process?
The Neuroscience of Mirroring, Resonance, and Empathy
Let us first explore the neural processes underpinning the mirroring that occurs in supervision. Gallese (2007) asserts that during our social exchanges, we “seldom engage in explicit interpretative acts”; rather, he describes our understanding of the other as “immediate, automatic and almost reflex-like” (p. 659). He argues that, although we are capable of thinking explicitly about another’s mind in a complex and sophisticated manner, we actually have “a much more direct access to the inner world of others” (p. 659). Lyons-Ruth (1998) notes that “implicit knowings governing intimate interactions are not language-based and are not routinely translated into semantic form” (p. 285). The dominance of the implicit level in interactions must inevitably affect the supervisory process, which has sometimes been seen as dependent on verbal communications concerning the analytic hour. In supervision as in therapy, the right-hemisphere to right-hemisphere resonance that arises from the nonverbal aspects of communication, such as tone of voice, gesture, and posture, as well as the fast-acting communications that often occur below levels of conscious awareness will underpin the work. Words give rise to left-hemisphere to left-hemisphere resonance and enable the ability to think about the session and to develop of a coherent narrative concerning the patient (see Chapter 7). Detailed consideration of the process of developing such a narrative is as important for the therapist as for the patient. Empathy has both a cognitive component that can be communicated in words and an affective component—and both influence the development of a shared understanding.
What is the nature of this more direct access that we have to the other and how does it affect the process of supervision? Watt (2005), in a discussion of the meaning of empathy, suggests that all attempts to describe it “outline a common ground of a positively balanced supportive response to the distress of another creature” but adds that to define this core process is critical for neuroscience (p. 187, emphasis in original). Research has confirmed that empathy allows the sharing of experiences across individuals (Carr et al., 2003) by means of a mirroring process. Carr et al. (2003) make clear that we understand what others feel by a mechanism of action representation that enables empathy and our emotional responses. Exploring responses to a range of emotional facial expressions, these researchers demonstrated a fundamental role for the insula because of its capacity to relay action representation information to the limbic areas that process emotional content. Their data also show lateralized activation of the amygdala during imitation of facial, emotional expression. They conclude that the empathic resonance that is brought about by imitation does not require explicit representational content such as would involve the left amygdala. Rather empathy is grounded in a form of mirroring that occurs via an experiential mechanism involving activation of the amygdala in the right hemisphere. It may be that we should understand the left hemisphere’s cognitive capacity as giving rise to cognitive empathy, whereas the right orbitofrontal cortex orchestrates a response that speedily involves the right hemisphere at every level. We might think of this as the fast route to affective empathy. Watt (2005) poses what appears to be a crucial question and ponders the implications of an answer in the affirmative:
Does a “categorical” and “preconscious” [precognitive?] recognition of the prototype states of separation distress, anger, fear, play, etc., emerge from the same basal forebrain, diencephalic and paralimbic regions necessary for the core affective states? If so, then cortical receptive processing and recognition of emotion (organized largely in the right hemisphere) may be a cortical–cognitive “extension” of a more primitive receptive processing possibly invisibly embedded in the distributed subcortical emotion architectures. (p. 204, emphasis in original)
Schore (1994, 2003a, 2003b) suggests that the nonverbal transfer-ence–countertransference interactions take place at preconscious– unconscious levels and represent right-hemisphere to right-hemisphere communications of fast-acting, automatic regulated and dysregulated emotional states between patient and therapist. Such communications appear to develop out of the “embodied simulations” (Gallese, 2007) that arise from the earliest experience of right-hemispheric bodily, facial, and gestural communication between mother and child, out of which the capacity to relate and the development of communicative language gradually emerge. It seems that supervision exemplifies this process in a particular way: Observation of another such as that which takes place in the consulting room, and again in supervision, is initially an implicit, automatic process, occurring at levels below conscious awareness, which may then gradually emerge into awareness and become possible to discuss.
Harrison et al. (2006) used fMRI scanning to explore the existence of emotion-specific autonomic signaling in affective communication. Their study provides the first evidence to support a role for the autonomic nervous system in perception–action models of empathy, as exemplified in the emotion of sadness. Their research has shown that “observed pupil size…influences the perceived intensity and valence of expressions of sadness” and that the “interaction between pupil size and (facial, muscular) expression induces contagious corresponding pupil responses in the viewer.” Their findings provide “evidence that perception–action mechanisms extend to non-volitional operations of the autonomic nervous system” (p. 5). Using their fMRI results, they were able to demonstrate that these effects were “associated with neural activity changes in regions that process salient social cues, including the amygdala and superior temporal sulcus” (p. 274). They conclude that “effective communication of emotional feelings engages visceral autonomic reactions underlying feeling states” (p. 726, emphasis added).
Decety and Chaminade (2003) emphasize that “perception of emotion activates the neural mechanisms responsible for the generation of emotions” (pp. 583–584). They conclude that an understanding of another (in this case, supervisee and patient, and supervisor and supervisee) takes place as one represents the mental activities and processes of the other by generating in one’s own mind (and body) “unconscious processes that might almost be described as unconscious imagination, that is, a generating of neural experiencing at an unconscious level of similar activities and processes in oneself” (p. 582, emphasis added).
From this material let us outline certain key aspects of functioning that the effective supervisor is able to utilize:
• The ability to receive communications concerning underlying feeling states, via what might well be described as the “gut reaction,” which may be one aspect of an empathic response to distress in the patient.
• The ability to capture fleeting emotions in others
• A capacity for unconscious imagination, that is, an experiencing at an unconscious level in oneself the feelings experienced by the other.
Empathic understanding through unconscious imagination, such as is manifest in countertransference phenomena, is therefore key not only to the successful therapeutic process but also to its supervision. Cozolino (2006) defines such resonance behaviors as automatic responses triggered by mirror systems that are reflexive, implicit, and obligatory. Cozolino stresses the part played by both the insula cortex and the anterior cingu-late in activating empathy both in our bodies and our minds. He cites the work of Phan et al. (2002), who found that both became activated during emotional recall as well as during tasks involving imagery. Cozolino (2006) explains: “In its role as an integration cortex the insula bridges and coordinates limbic and cortical processing as well as somatic and visceral experience” (p. 208). He argues that mirror and resonance circuits are required to “combine with visual–spatial, cognitive and abstract networks” to fully enable an empathic understanding of the other (p. 203). This process also describes adequate functioning within the supervisory process. As we have seen, Watt (2005) emphasizes not only perception, conscious imitation, and theory of mind but also the need to appreciate the centrality of affective activation within the empathizer. He advocates a complex and affectively sophisticated theory of mind that also includes primitive resonance induction mechanisms. Thus Watt offers a cognitive and affective foundation for empathy. If these dual bases for empathy are indeed the case, they would explain very clearly the extensive unconscious processes that are at work in supervision alongside the higher cortical, conscious processing that also takes place.
Some supervisors favor an approach to a supervisory session that is similar to Bion’s approach to an analytic hour—that is, to be without memory or desire, to be in a seemingly restful state out of which a creative engagement with the material presented occurs. Although such a notion can only be speculative, it might be that in this unique resting state, the default network—that is, the system in the brain which appears to be active when the brain is seemingly at rest (see Chapter 4) is activated along with its connections to the hippocampus, which allow the creative connections between past and present to emerge and to be thought about in the supervision. Certainly the supervisory process requires the supervisor to think, to process and integrate both right- and left-brain functioning, including the affective and cognitive components of empathy, both of which must be engaged if therapy or supervision is to be effective.
A Psychoanalytic Perspective
A psychoanalytic perspective on the neuroscience understanding of empathy has been presented in a cutting-edge paper by Zanocco et al. (2006), “Sensory Empathy and Enactment.” Here sensory empathy is defined as “that process which is based precisely on the ability to assimilate, through imitative identification, what another person is feeling” (Zanocco et al., 2006, p. 148). The paper explores the interaction in the analytic dyad and also sheds light on the unconscious aspects of the supervisory process. The paper opens by stressing the unconscious—what might be termed the “bottom up”—nature of sensory empathy which the authors link to Freud’s concept of primary process. Zanocco et al. describe the analyst’s dawning awareness of unspoken communications from the patient as “empathic intuition” (p. 148). No doubt a similar process occurs between supervisor and supervisee and underpins successful supervision.
Zanocco et al. (2006) value Gallese’s (2007) work on mirror neurons and the understanding of observation of another as predominantly an implicit, automatic process that is grasped by another person by means of a mirror mechanism analogous to the reading of actions. It is just such an understanding that enables an empathic response. They see in this functioning confirmation of “the concept of intersubjectivity at the most primitive levels of communication” (Zanocco et al., 2006, p. 153).
Empathy achieved through the mirroring process is, by its very nature, not always comfortable. Let us imagine that a supervisee arrives, saying that she feels very low, her self-esteem is low, she is uncertain of her ability as a therapist. Almost as she speaks I might find myself uneasily drawn to thoughts about my own inadequacies. As I bring my mind back to the room, I find that my supervisee is describing an extremely difficult encounter with a new and rather disturbed patient, currently referred with problems of anger and depression. As she tells of the course of the session, it becomes clear that she has dealt sensitively with her patient’s pain and unacknowledged anger. My supervisee reports feelings of low self-esteem that had attacked her in this very difficult session as she experienced her patient’s very low, rather deadened, state of mind. Toward the end of the session her patient had been able to say a little about the severe trauma and neglect that had characterized his childhood.
As I continue silently pondering my experience at the beginning of the session, my supervisee gradually begins to recognize that her own acute experience of low self-esteem actually relates to her patient’s inner world, which was so painful for him to acknowledge. A supervisor engaged in this process may be more or less active in regard to both intervention and disclosure of his or her own inner experience, according to the individual supervisee’s needs. What the supervisor has experienced is the empathic mirroring of the supervisee’s uncomfortable feelings as she, in turn, mirrored her patient’s (until then) unacknowledged inner trauma and distress. Working at the edge of either extreme avoidance or unbearable encounters with pain requires great skill on the part of the therapist, and the enabling and supportive role of a skilled supervisor should not be underestimated. Such work requires supervision of timing concerning the stage in therapy at which it is safe to explore the client’s inner world in this way as well as the timing within an individual session that will leave sufficient space to do such work but also for the client to recover before it is time to leave.
Meares (2005) points out that both therapist and patient are influenced by subliminal signals that potentiate change in the patient’s state without, or in addition to, the use of words. The supervisor may need to differentiate between a thoughtful, empathic approach in a supervisee that enables understanding of the other and a supervisee’s false assumption that his or her resonance experiences exactly match the inner world of the other, inevitably resulting in unhelpful consequences. In these situations identification or fusion may be being mistaken for empathy. Here it seems to me to be clear that what is required from the supervisor, as much as from the therapist, is a relational approach consisting of empathic responses that are also informed by clear thinking. The supervisor needs to help the therapist to be empathic while remaining separate enough to be able to think. Schaverien (2003) uses a metaphor to illustrate this point:
Analysis is a drama that takes place between two people, the patient and the analyst (or in group work the group and the analyst). As if from the privileged position of the audience, the supervisor witnesses the drama, sometimes moved by what is observed. There is an attempt to help one of the actors de-role and to join the supervisor/spectator in observing the action from a critical distance. In order to do this the actor/analyst makes a psychological split that permits her simultaneously to stand beside the supervisor, as a spectator of this drama, and to play a part in it. (p. 170, emphasis added)
Although the notion of observing the action from a critical distance while sometimes being moved by what is observed perhaps privileges cognitive empathy over affective empathy, this description nevertheless does appreciate the value of both. What I would add is that great drama pulls audience members in so that they feel the action on the stage as if within themselves. The concept of a drama that involves the audience as much as the actors and in which emotional experiencing is key does allow for the more primitive automatic affective empathic response that is at the heart of countertransference experience in supervision. Effective supervision inevitably requires an empathic response of both kinds from the supervisor to both therapist and patient. Schaverien’s (2003) analysis of the “psychological split” acknowledges the affective empathic response of the therapist as he or she plays a part in the drama, and the cognitive empathic response as he or she is the spectator. Schore and Schore (2008) suggest that it is the affective that conveys the personality of the therapist (and we may infer, the supervisor’s as well) more so than conscious communications. The supervisor will experience the nature and quality of the work being presented through his or her countertransference at least as much, if not more, as through the words that are spoken.
Empathic experience in the supervisory session may give rise to moments of unease in the supervisor’s countertransference. How do we deal such moments? Ultimately, of course, we hope that the supervisee will be able to explore the unconscious emotion (e.g., fear, anxiety, anger, or shame), that underlies the difficulty and gives rise to the affective empathic response of unease in the supervisor. Sometimes a pause, a moment before we respond, may be sufficient for this to happen. Sometimes it may be desirable to wonder out loud. What do I mean? I will demonstrate briefly.
Case Example of Supervision
A supervisee might describe a patient who, in several sessions, had suddenly become frightened, saying in a very young voice on each occasion, “Don’t let Mummy come in here. Please, don’t let Mummy come in here.” Such encounters allow “clinicians to use their emotional reactions to better understand their patient’s world” (Fonagy & Target, 1998, p. 110). Each time the supervisee might have replied, “It’s all right, there’s just us here.” However, there are several responses one might make to this plea. My concern here would be to begin to help the supervisee figure out how to help the patient recognize and feel the fear that seems to be dissociated and to explore it without allowing the patient to become unbearably frightened. This therapeutic exploration of fear becomes possible because the feelings are experienced, contained, and voiced by the therapist. As a supervisor, I might feel a great pressure to remain detached and silent in an unconscious identification with the dissociated part of the patient. Alternatively, I might let the reassurance pass out of an unconscious identification with that part of both patient and supervisee that wanted reassurance. Or I might wonder out loud: “I wonder what would have happened if you had said something like ‘We’ll do what has to be done.’” Together we might come to the conclusion that such a statement might be experienced as quite persecutory, and the therapist might be in danger of being perceived as all-powerful and abusive. We might together reflect on the importance of timing and tone of voice as well as what might be said. Panksepp and Bernatzky (2002) and Andrade (2005) stress the importance of tone, lilt, and rhythm of the therapist’s voice, which, they say, mirrors or modifies a patient’s earliest experience of the mother’s voice (held forever so close to those centers of the brain–mind that give rise to a sense of self). If the therapist were to wonder out loud, then the tone of voice would be crucial for this patient who is clearly both fragile and hypervigilant.
My supervisee and I might continue to muse together that whatever was said and how it was said would need to “hold” the patient and impart a sense of safety while still exploring how very frightening the original situation was, and how frightening the undoing of it is. The supervisee might say, “I guess I could have said, ‘It sounds as if it was very frightening if Mummy came into the room.’” I might comment, “Well, yes, that sounds as if it might help to begin to allow the dissociated contents into mind.” Countertransferentially, I may find it difficult to make such a comment and to encourage this development in the supervisee’s work because of the patient’s dissociative defense against pain. If I was able to realize this, I might add, “Sometimes it may be helpful to say something like ‘That was then, not now” toward the end of the session, once some of the difficult work has been done.” In this situation the then and now need to be clearly differentiated to enable the patient to leave with a feeling of being contained securely in the present, ready to deal with life as it is now rather than still drowning in past experience.
Supervision of a Supervision Group
Using my applications of neuroscience to clinical work, Bhurruth (2007) makes the following acute and relevant observations concerning therapy conducted in a group:
Through the process of resonance, neural pathways in the listener are activated through hearing of experiences from another, as if they had the experience themselves. This does raise questions about group composition. It would seem that a group member with a history of trauma would respond well to exposure to how other non traumatised group members make sense of the here and now interpersonal experience and the expression of modulated associated affects, thereby integrating left and right brain functioning. However there is an implication that a group composition of a number of traumatised group members may kindle in each other a fear response through the process of neural resonance that cannot easily be quenched without psychological casualty. (p. 421)
Here Bhurruth underlines the importance of my extension of the concept of resonance to analytic work with patient groups. The role of the supervisor in exploring these issues with the conductor of the group will be key.
Much supervision takes place within a small group setting. In these circumstances Schaverien’s (2003) metaphor needs to be developed to include a number of plays, some with deeply disturbing content wherein primitive states of mind predominate, with a group of spectators who together listen to one member’s account of excerpts from a particular play in an emotionally engaged way, each bringing his or her own unconscious empathic response into the dynamic of the group, each allowing an unconscious psychological split within that will permit, through the process of unconscious imagination, the generation of the mental ideas and feelings of another to be born inside his or her mind. Complex neural activity patterns and interactions provide the elements by which meaning is made. The right hemisphere plays a significant role in the processing of the forward-looking, imaginative relational exchanges. The key focus will be the spectators’ inner bodily and emotional imaginings, their cognitive response to their inner experience, and their attempts to help the supervisee who is presenting his or her work with both aspects of experiencing through the process of de-roling and making the psychological split that Schaverien describes as simultaneously standing beside the supervisor as a spectator of the drama as well as playing a part in it.
Over 1 year in one such group of say, four members may well bring with them material from 10 supervisees, who may have presented, as together, work with 20 patients. The processes of reflection, mirroring, and empathic intuition within such a supervisory work group are immensely complex because of the numbers of people whose conscious and unconscious processes hover in the room, particularly in the form of transferences and countertransferences. If this were to be represented visually, it might be as an ever-changing kaleidoscope, made up of the colors and their mixes that appear in Figure 9.1
Such a group will be concerned with conscious and unconscious communications and transferential and countertransferential experiences at every level. The group will experience the interplay of both personal and cultural complexes. Most supervisees may be working with individuals for supervision, but one may see his or her supervisees in a group. Most of the therapists may do individual work, but one may have seen a couple. While one may have been working in a setting where the work is strictly time-limited and short-term, others may be engaged in longer work. Moreover, those therapists supervised in a workplace group will also have to contend with organizational complexes. The members of any such group will bring various levels of experience and competence to the process. The empathic capacity of the supervisor enables these conscious and unconscious aspects of relating to be held safely and in such a way that they can be discussed.
I want to offer a possible illustration of work within such a group. I have chosen to present an imaginary extract from supervision of a supervision group because, although complex, the processes of neuronal mirroring, resonance, and empathy are writ large when another layer of experiencing of the patient’s material is added to the original supervisory process. One might say that the original encounter with the patient is sometimes literally reenacted, first of all in the experience of the supervisor, whom I will call Dee, and her supervisee as they work together, and then again in the experience within the group as the work is discussed. When the group is finally able to recognize just what is happening, it provides a powerful learning experience; it also provides an opportunity for the detoxifying of toxic contents. Driver (2002) comments: “Unconscious identifications by supervisees with the client’s material and the subsequent reflection process and parallel process can open up the client’s unconscious issues and aspects of the transference” (p. 95).
Case Example of Supervisory Group
In this imaginary account, the experiences of a patient whose dissociative defense system means that she is often in quite numbed and “switched-off” states of mind are mirrored in the experiences that occur in a supervisory group. Generally the therapist experiences the dissociative quality of the patient as a struggle to consciously keep the material and the patient in mind, and in supervision to present the material with clarity. For the supervisor there may also be a difficulty in following the material and in making the links that are so shunned by the patient. A nurse practitioner whom I call Eleanor was supervised by Dee, who in her turn received supervision in a group supervision. Eleanor began a psychodynamic psychotherapy training fairly recently. Dee had been practicing as a psychoanalytic psychotherapist for several years but had only recently taken on supervision. I explore here only the initial sessions of the supervisory group’s encounter with Dee’s work.
Dee came to her first presentation with thoroughly prepared notes and copies for each member of the group. Dee described how she quickly had found herself confused as she sought to supervise this young health professional who had been allocated an adolescent as one of her training cases. As Eleanor described some of the early sessions in her work with Kay, the patient, it became clear that on the first occasion Kay’s mother had remained in the room, had done a lot of speaking for her daughter, and had described the reason for the therapy as “school refusal,” that is, staying out of school because Kay was being bullied by other girls. As the group began to explore the material brought by Dee, we realized that Eleanor was faced with a 15-year-old patient who was struggling with the vicissitudes of florid adolescence. Kay, the patient, sometimes seemed to be fragmenting as she struggled in the grip of a recurring Oedipal experience in the context of current, extremely difficult, primitive, and rather dissociated states of mind. It became more and more apparent that she had never negotiated earlier developmental stages successfully. It seemed that Kay oscillated between overarousal and rather manic teenage acting-out with her friends and underaroused, switched-off, dissociated states of mind in therapy. This state of low arousal was mirrored very powerfully in the experience of the group.
Kay had come to therapy ostensibly because bullying at school had led to attendance problems; some of the hazy, indeed foggy, states of mind that the group experienced all so pervasively at the beginning of this supervision gradually lifted as we became more aware of the complexity of the relationships within the family. The father had left the family 2 years earlier; this behavior replayed an earlier occasion when he had left the family for some months when Kay was about 18 months old. This time after he left, he joined a fundamentalist sect and lived in a cult community with a new partner. For long periods of time Kay heard nothing from her father; she longed for even just a card on her birthday, but there was nothing. The sect did not observe birthdays, she later discovered. Even if she tried to visit him, she was not always allowed to see him. The sect had very particular requirements as to the clothing to be worn by women and also concerning the subjugation of women. Kay felt that she must conform when there, but in so doing she felt completely lost; her sense of self, tenuous at best, would vanish almost completely. Kay felt that she had lost her father, indeed that he had been taken away by another woman and another passion, the passion that he felt for “the cause.” She found it difficult to be sure that she could hold onto her mother and swung from clingy to rejecting modes of attachment with her sister, her boyfriend, and others who mattered to her, including her therapist. It seemed that she must often feel as if she herself, as well as her life, was fragmenting and falling apart.
Affective empathy can feel uncomfortable in different ways; the particular feeling tone or bodily experience carried in the countertrans-ference will relate closely to the unconscious affect that patients are not yet able to experience for themselves. The key to the work in the supervisory group lay in developing the capacity of the group to engage with and to think about their affective empathic experiencing of Kay’s primitive dissociated states of traumatized mind. Probably it was what she was experiencing as an adolescent that first Eleanor, then Dee, and the group also went on to experience through the empathic mirroring process. It is likely that this experiencing actually arose out of much earlier states of overwhelming distress resulting in defensive hypoarousal that Kay must have experienced as a toddler when her daddy left. It seems she had experienced her own loss and her mother’s uncontainable distress as overwhelming and had resorted to a defensive protective state of hypoarousal. In effect, her early experience of loss of her father was replicated as she entered adolescence. At a time, when as a girl, she would so need him to be there for her, he was once again absent. In reaction she was now reex-periencing an implosion of the implicit self.
The whole area of memory—what should be explored, what should be preserved and in what form, what may be thrown away or forgotten, what hazards might either remembering or forgetting hold for the patient—is a complex issue with no simple answer; rather, many questions arise that both supervisor and supervisee will need to explore together. Working with such traumatic memory brings its own complexities and hazards for therapist and supervisor as well as high degrees of pain and uncertainty for patients.
As Dee presented her supervisory material for the first time, I almost instantaneously began to feel fragmented and unable to think. As I listened to and read the description of this work, it felt as if my mind was dissolving, indeed was being wiped out. Dee spoke of her own confusion and the difficulty she had experienced as she sought to engage with Eleanor. She found it difficult to get hold of the quality of relating between Eleanor and her patient. As Dee spoke rather hesitantly and quietly about the difficult feelings of inadequacy that she was experiencing in the work, so I too felt hesitant, confused, and inadequate as the seminar leader, as I struggled just to be clear who was who in the material that I was experiencing. I was aware of a certain numbness somehow pervading my being in quite a physical way that I had not experienced before. Others in the group began to ask clarifying questions that indicated that they were also experiencing similar difficulties.
The next time Dee came to present, she had organized her notes for the group in a different way to try to aid clarity. Yet once again the group immediately began to struggle with who was who, in what I can only describe as a fragmented sort of way. I became more aware of the under-aroused, somewhat dissociated quality of the mood that prevailed in the group. Dee once again described her own confusion and uncertainty, commenting hesitantly that she felt particularly fragmented and unable to think as she struggled to help her supervisee with the work. She felt that Eleanor seemed to maintain a rather distant, matter-of-fact attitude and at one point seemed to medicalize her patient’s material. In the group we were able to explore, through the subdued affect we were experiencing, our unconscious imaginative experience of Kay’s hypoaroused defensive state of being, which had become mirrored in our combined experience within the group. Adequate exploration of our feeling states enabled us gradually to work also from a cognitive empathic stance. Through the combined experience of affective and cognitive empathy, Dee gradually became able to realize how helpless, overwhelmed, and fragmented Eleanor felt. Slowly she understood that the rather distant and matter-of-fact attitude maintained by Eleanor was an old dissociative defense against emotional pain adopted by the supervisee in her years as a nurse.
Particularly significant for us as a group were the reenactments that we experienced over the initial weeks as we struggled to comprehend what was happening. An understanding of the intensity of projections that may emanate from these patients at these times and that are received by the therapist is central to adequate supervision of what one might term the inner workings of the therapeutic alliance in these circumstances. The way in which the supervision group may also get pulled into an enactment is particularly relevant here. All of these dynamics need support, exploration, and clarification within supervision. Stewart (2002) notes that “the supervisor can provide a cathartic holding experience, a space to think, or in Schore’s terminology the opportunity to co-regulate or recover to a more mature mode of functioning” (p. 76).
At this time we struggled with states of underarousal that sought to deaden the group. Each member later described feeling confused, dissociated, unable to distinguish who was who in the presentation, and unable to hold on to the thread. We found it hard to know who was who in the narrative, whether Dee was referring to herself, her supervisee, even the patient or the patient’s mother. There was no feeling of a central character with a central, lively core. The fragmented and fragmenting inner world of this adolescent got inside each one of us. Her confusion, dulled state of mind, depressed feel, and “switched-offness” often filled the room and the individual experience of each of us. As a group we gradually became able to explore the experiences of fragmentation and deadening switched-offness that overcame us in relation to the material; a similar fragmentation to that experienced by Kay, the patient, and in turn by Eleanor, as she sought to work with her patient, was also occurring in our experience of the material. We became aware of this as we each struggled with our own inability to think and make links in the material that was being presented to us.
For several weeks Eleanor struggled to establish the frame with this acting-out adolescent. The initial struggle had centered around whether Kay would come at all (which matched Eleanor’s own anxieties around her ability to hold onto her patient), which—as Eleanor gradually became aware—mirrored Kay’s own, much greater, anxieties about being able to hold onto and be contained by the therapy. There was also a struggle over just who would come to a session. If Kay did come, would her mother come with her, or her sister, or her boyfriend, or a friend? Eleanor struggled with just how she would manage to establish a twosome, as a third seemed ever-present. At first it was just as simple and as difficult as establishing that the session was just for the two of them. This acting-out we gradually understood represented Kay’s experience of her family, at this particular stage in her development, which was dominated by her reexperiencing of Oedipal conflicts. Who was Dad? Did she have a birthday, an existence, an identity? If she tried to see her dad, who would he be with? Would she get to see him? What sort of adjustments would she have to make in order to retain even the most tenuous of relationships with him?
The overall experience for the therapist and those involved in the supervisory process of this particular patient was of a consistent affective empathic experience of very primitive, defensively underaroused states of mind. Such an understanding of what occurs in the supervisory process gives a sound foundation for our understanding of transference and countertransference as emanating from the realm of the implicit and arising from the very earliest experiences of life. I understand the therapist’s, and in turn the supervisor’s, dawning awareness of unspoken communications from the patient as “empathic intuition” (Zanocco et al., 2006, p. 148).
Such awareness concerns primitive elements of experience that have not yet come into mind and become nameable for the patient. In my illustration the empathic power of these affects can be seen reaching out through the therapist to the supervisor and into the experience of the supervisory group as the group members encounter these primitive elements in the experience of the supervisor and in their experience as the material is being presented. Often awareness of these elements came through the bodily experiences of the group members, through tone of voice and conscious and unconscious modes of interchange, as they discussed the material that was being presented. Mathew (1998) comments that the body may be understood as the instrument of physical processes, an instrument that can hear, see, touch, and smell the world around us and that can tune into the psyche and search into its darkness for meaning.
It becomes clear from these imaginary extracts that the group found it difficult to get hold of even the simplest dynamics of Kay’s relationships, and that this experience reflected Kay’s limited capacity for mentalization. Zanocco et al. (2006) describe such experience, in turn, as “a part of the ego [that] has retained a primitive way of functioning” (p. 150). It was just such functioning that Kay was bringing to her session, that was then being experienced by the individual members of the group and the group as a whole as a struggle for any sort of coherent understanding that could be felt and then thought about.
Hidden Hazards of the Supervisory Relationship
Material that arises in the work, especially in work concerned with early relational trauma, may be sufficient to unsettle the internal world of either member of the supervisory dyad, especially if either is unduly stressed by trauma in his or her current circumstances. For example, a supervisor or supervisee whose early attachment style happened to be avoidant, and who is suddenly overtaken by severe emotional distress arising from a close personal relationship, may be thrown back from the acquired stance of learned security into the earlier mode of being and will seek to ignore and avoid the needy baby part of the patient that actually needs to be held and contained through the supervisory process.
An important boundary for the supervisor to be able to hold internally is the most fundamental one: It is the supervisee’s patient, and the supervisee is the one who is doing the work. To stay in a “hands-off,” enabling way of being may become most difficult when one begins to feel anxiety, envy, or anger. These feelings may be felt because the supervisor’s own psyche is the problem, and unconscious emotion needs to be processed. Knight (2003) raises the issue of the supervisor’s unconscious transferences to the supervisee and cites Stimmel’s view that parallel processes in supervision provide opportunity for the enactment of, and resistance to, the awareness of such transferences (as cited in Knight, 2003). On the other hand, it may be a case of the supervisor’s counter-transference giving clues, for example, about the anxiety of either patient or supervisee.
There are several related boundary dangers to which the unwary would-be supervisor may succumb. Issues concerning boundaries will always form an integral part of supervision of work with patients whose boundaries have not been respected, and in the case of earliest relational trauma may not have been established adequately. The first is what I tend to think of as red-pen supervision. A colleague once described an experience in which he had felt that his supervisor was like a teacher who underlined every mistake and told him exactly what should have been said or not said. The supervisee eventually felt able to say, “Well, no doubt that is what would have happened if X was in therapy with you, and indeed she might do better, but she is actually in therapy with me.” The supervisor looked startled, something shifted, and haltingly they found their way to a more fruitful experience. Of course, not every supervisee is able to be so clear about the boundary issue, and not all such situations will have the good outcome that occurred in this example.
Another danger takes the form of what Fiscalini has termed “analysis by ventriloquism” (as cited in Astor, 2003, p. 52). Astor suggests that in these instances the supervisor may be privileging the patient’s unconscious over the supervisee’s understanding, a hazard that arises out of the automatic mirroring and resonance processes that occur in the supervisory dyad’s shared experience. This may well be the case or it may be that the supervisee, under the stress of such supervision, is functioning out of an adaptive false self, rather than working creatively from within. Such a way of being in the supervisee will have been learned in the earliest relationship to a parent who is predominantly self-aware and who is unable to fully allow the child the chance to find him- or herself. This dynamic may be more likely to emerge in supervision if the supervisor temporarily loses sight of the real person actually in the room with him or her. This response, of course, inevitably mirrors the abusive experience of the trauma patient who has not be seen and valued as a person but rather abused and shamed.
A further difficulty is highlighted by Mander (2002), who explores the concept of cloning, arguing that the supervisor must take care to avoid the danger of cloning that may occur “particularly when working with an impressionable, perhaps idealising supervisee” (p. 43). She comments:
There is a fine line between influence and control and it is easily crossed, when the furor didacticus possesses the supervisor, perhaps in response to something in the clinical material which exerts a particular fascination and invites expansive analysing in the context of theory…. Equally difficult is the curbing of expectations, whether positive or negative, which, as with parents and children, can do much harm when the recipient is in a dependent relationship and then resorts to pleasing. (p. 43)
The Ethical Attitude in Supervision
Using supervision appropriately has long been seen as one aspect of adopting an ethical attitude concerning clinical work. Solomon (2007) has explored at length the origins of the ethical attitude from a developmental and attachment perspective. She understands the ethical function as a relational function involving the assessment of subjective and inter-subjective states involved in self–other relationships. I am reminded of De Laurentis’ (1966) view that individual subjectivity consists of the “patterns by which experiential and emotional contexts, feelings, images and memories are organized to form one’s self-image, one’s sense of self and others” (p. 5). The arrival at such a capacity, as Solomon (2007) understands the ethical function to be, involves a developmental achievement that is fostered by the initial empathic response of the mother to her baby and then develops through the quality of relationships that comprises the world of the healthy toddler.
The Neurobiological Substrates of the Ethical Attitude
Panksepp (1998) affirms that emotions are learned states which develop out of our earliest experience of relationship. Narvaez (2008) concludes that “the emotional circuitry established early in life relates to the brain’s architecture for morality and later ethical expression” (p. 97). She posits three distinctive moral systems which are based on three brain areas. The first and most primitive is security, which she relates to primitive survival strategies arising from activity in the oldest brain structures described as the reptilian brain. Engagement is the second, which she understands as arising from the limbic or emotional or intuitive brain, and which enables the intuitive aspects of empathy, rooted in “the mammalian systems that drive us towards intimacy, such as play, panic and care” (p. 100, emphasis in the original).
Schore (1994) points out that, around 18 months, the parasympa-thetic nervous system begins to provide the decrease in arousal and excitement that makes socialization possible and that enables the development of “the neural substrate of shame.” He argues that this is achieved through “socialization stress-induced, experience-dependent, structural transformation (rewiring) of the orbitofrontal cortex” and suggests that this enables the development of the “braking mechanism of shame” (p. 343). It may be argued that just as experience in the second year of life leads the child from a dyadic way of relating into triadic experiences, so the empathic third who is the supervisor helps to counterbalance the intensity of the experience within the therapeutic dyad and enables the development of greater insight and understanding. A capacity for separation and autonomy lays the groundwork for a capacity to behave ethically in relation to another. Many of the ethical problems that arise in therapy develop when some part of a person is not able to function in the “separate but aware of the other” way of being that characterizes the development of full agency.
The regulatory aspects of the parasympathetic nervous system arise from the regulation brought about through our earliest attachments. Narvaez (2008) notes that this occurs “in part via the regulation of the cardiac vagal tone, upon which emotional, behavioral and motor regulation are dependent” and explains that “the parasympathetic nervous system regulates cardio output through vagal tone under environmental stress” and that “responsive parenting with co-regulated communication patters leads to good vagal tone whereas nonresponsive parenting leads to poor vagal tone” (p.102). She adds that good early experience also leads to the development of healthy neuroendocrine functioning which inhibits defensive behaviors and enables “positive social interactions and the development of social bonds” (p. 102).
The last aspect of the ethical attitude that Narvaez proposes is that of imagination. She understands the capacity for this as arising from the neomammalian brain, stressing the importance of the frontal lobes, especially the prefrontal cortex. By imagination she means the capacity for free choice in ambiguous situations, the capacity for original and creative thought in relation to moral dilemmas, the capacity for fairness-related behaviors which she attributes to the dorsal lateral prefrontal cortex. She notes that damage to the prefrontal cortex “leads to poor impulse control, dysregulation of emotion and an inability to foresee consequences” (p.104). Although much of our ethical response is unconscious and intuitive, the prefrontal cortex, with its capacity for reasoned judgment may override the instinctual and the intuitive but may also listen to the needs for security and engagement as well. In supervising a therapist who is working with profoundly dysregulated patients such qualities are vital in the supervisor if he or she is to hold and contain the anxieties that may arise in the therapist in relation to the patient and in relation to those who may have responsibility for assessing his or her work, especially when the supervisee is working towards qualification with a training institution. The supervisory encounter itself is often appropriately opened to others—for example, in response to training institutions’ or employers’ requirements for reporting for the purposes of assessment and appraisal, or in the case of a supervision group, for assessment of the individual group members. Left-brain-dominated assessment and appraisal seems to increase in a world that moves inexorably toward the performative society. Ball (2001) warns that “performativity is a technology, a culture and a mode of regulation…that employs judgements, comparisons and displays as means of control, attrition and change” (p. 210). He argues that seeming transparency may actually lead to resistance and opacity and that continuous exposure to assessment can become a recipe for ontological insecurity. He highlights ethical dangers that lie in wait and cautions that “there is a real possibility that authentic social relations are replaced by judgemental relations” and “concern for patient need and professional judgement [are replaced] with commercial decision-making” (pp. 214, 223).
An ethical attitude toward our supervisee constitutes a form of boundary holding and enables the provision of a safe and reliable container that will facilitate, in turn, the supervisee’s provision of just such a safe container for the patient. Martin (2002) discusses the question of theft in supervision; “Possibly the most insidious form of supervisory theft is the theft of the safe container” (p. 122), which often occurs when supervision is taken less seriously than therapy. He gives examples of failure to keep proper boundaries with regard to time, telephone-call answering, and many other infringements of normal analytic practice. In another paper he comments:
If supervisors are tempted to offer “strawberries and cream” symbolically or literally (coffee and biscuits and the chance to gossip), or alternatively, “sour cream” (changes of room, time, a different fee structure, the establishment of a relationship that is more than a working alliance) then…they may be warning signals that ethical boundaries are in danger of being breached. (Martin, 2003, p. 150)
An ethical stance is sought for all aspects of therapy. After all, we guarantee to provide regular sessions that begin and end on time, to provide continuity of time, space, and environment. We seek to provide a room that is not overstimulating, that is containing and protected from intrusion. Within the analytic frame we respect confidentiality and aim to work in a way that facilitates trust. We seek to behave in an absolutely predictable way around management of breaks, holidays, and fees. The supervisee may learn a great deal about the patient’s transference to him or her at any given moment in the therapy from any and all of these. In short, we regard boundaries as having an essential part to play in the therapy itself and as one of the ways in which the ethical qualities of the analytic relationship can be maintained.
Temperley (1984) notes the difference in her experience of working at the Tavistock Institute in London, where a colleague would have hesitated to knock on a door with an engaged sign even if it were to announce that the building was on fire, with her experience of working in a general practice surgery, where the receptionist walked in to access notes that were in the room, who couldn’t understand why the two, who were “only talking” while the patient was fully dressed, should not be interrupted. From this experience of a senior colleague, we can easily imagine how difficult it can be for the inexperienced counselor or therapist to maintain the analytic frame. For example, a patient being seen in a voluntary center confronted the therapist on every aspect of the frame, from who answered the door onward. This supervisee struggled but was able to hold this very borderline patient in therapy with the containment provided by regular supervision. She was particularly fortunate in that she was able to increase the number of sessions for the patient and, through the greater frequency of meetings, the patient gradually became able to gain and hold down a job and to make use of the therapy in a way that enhanced her quality of life.
Conclusion
It is clear that supervision requires multitasking of extreme complexity, yet when done well it is often characterized by a simple sense of being at ease in a holding relationship while being deeply engaged in a meaningful task together. Schore and Schore’s (2008) words concerning clinical effectiveness in therapy are equally apposite concerning supervision:
Clinical efficacy is more than explicit left hemispheric technical skill in interpretation. Rather, increasing levels of clinical effectiveness…involves more complex learning of a number of nonconscious functions of the therapist’s right brain…the ability to receive and express nonverbal affective communications; clinical sensitivity; use of subjectivity/intersubjectivity; empathy; and affect regulation. (p. 16)