Reflections of a Psychology Intern in Participant-Supervision

Transcription

1 124 Psychotherapy and the Ultra-Orthodox Community Reflections of a Psychology Intern in Participant-Supervision Sivan Shragay, M. A. Seymour Hoffman, Ph. D Participant supervision refers to supervision which takes place during cotherapy by a student, intern, trainee and a senior supervisor. (Yerushalmi and Kron, 2001).This form of live supervision provides an excellent opportunity for the training of a less experienced therapist by a more experienced therapist by working together in treating individuals, couples, families and groups. (Bernard, et. al., 1980; Roller & Nelson, 1991; Hoffman and Laub, 2004). In a research study by Nelson (1978), one of the findings reported was that trainees from clinical psychology, counseling psychology, psychiatry and social work, among the teaching methods Ss preferred was observation of the supervisor conducting therapy. The participant supervision model provides patients with the direct interventions of a seasoned clinician while at the same time preserving the in vivo experience which all new therapists must have. For the trainee, the most important benefit is the direct modeling, which provides a different and more vivid kind of teaching than is usual in clinical supervision. In supervisor-trainee cotherapy, trainees observe supervisors at work while experiencing the affective pulls and swirls of the treatment process first- hand. Seeing the supervisor deal with particular situations, especially when supplemented by subsequent discussions about the rationale for particular interventions can be extremely useful for the professional-in-training. (Bernard, et. al., 1980). For the supervisor, the first important benefit in this model is the increased opportunity to exert quality control over the care of patients for whom the supervisor has ultimate responsibility. In this situation, the supervisor can scrutinize the therapeutic process as it evolves and view counterproductive aspects of the treatment (eg., counter-transference, etc.) which may not be raised (intentionally or unintentionally) by the trainee in the traditional supervisory model.

2 Reflections of a Psychology Intern in Participant-Supervision 125 The area of counter-transference response to the patient is both difficult and important to address in the training of therapists, and the cotherapy training model is especially well suited for this as the supervisor is witness to what is going on and can interrupt/modify this negative process and/or wait until the post-therapy discussion to raise the issue. Finally, the shared responsibility which is inherent in the cotherapy model diminishes the loneliness of responsibility which characterizes most clinical work, reduces the overwhelming anxiety experienced by beginning therapists and enables them to experience positive/successful treatment experiences, which will have a positive effect on their self-image and confidence. It is our impression that participant supervision maximizes trainee learning and enhances patient care. Below are the personal reflections, insights and observations of a young clinical psychology intern in treating individuals, families and groups in a day hospital treatment program who was exposed to non-traditional supervisory experiences in her first year clinical internship. Reflections I was assigned to a day hospital treatment ward in a mental health clinic under haredi auspices where the staff comprised haredi and dati professionals and the patients were overwhelmingly from the haredi and dati communities. The majority of patients suffered from severe pathology but did not require in-patient treatment. The patients, who included those suffering from schizophrenia, bi-polar disorders, borderline personality disorders and severe depression, spent five days a week, five hours a day participating in individual, group therapy, and occupational therapy, ward meetings and other activities. Family and couple therapy sessions were also arranged depending on the treatment needs of the patient. Therefore, I was exposed to a variety of psychopathologies and treatment formats during my first year of clinical internship after completing a practicum in a psychiatric hospital.

3 126 Psychotherapy and the Ultra-Orthodox Community Understandably, I was full of anxiety at the onset of the internship before meeting my supervisor. At the first meeting, the supervisor shared with me his views on psychological treatment in general and mentioned the possibility of working together as cotherapists in working in different formats in treating patients which would also serve as supervision. On the one hand I was excited about the possibility since it would provide me with a rich opportunity to see an experienced therapist in action. On the other hand, I was hesitant about accepting his proposal since I would be under intense scrutiny which would possibly limit my spontaneity and effective functioning. The supervisor suggested that we start by co-leading a group to which I readily agreed. The supervisor emphasized the importance of meeting before and after each meeting in order to exchange ideas, reactions, feedback, and to plan strategies. He explained to me that the group and patients that we see together were mine and that he would be joining me in the treatment processes of select patients, at times briefly and at times for an extended period of time. He suggested that in all the sessions together, I take the initiative in the beginning of the meetings. In the group therapy meetings, I asked the participants to introduce themselves and afterward I explained the rules, expectations and purpose of the group, in order to facilitate my entrance and involvement in the group. This I felt was helpful and reassuring. Throughout the year I was also supervised in the traditional manner, where I would present the patient s history, what transpired during the session and any difficulties or questions I had regarding the treatment and the supervisor would relate to it. On several occasions when I felt stuck, unsure of the diagnosis, unsure how to proceed or bogged down by counter-transference issues, the supervisor suggested that I invite him as a consultant after I obtained the patient s permission. I found these brief interventions helpful and educational as the supervisor was able to freely deal with sensitive issues, confront the patient and at times be provocative and challenging, and make comments, remarks, observations and say things that I wanted to say but refrained from doing so because of my concern of the

4 Reflections of a Psychology Intern in Participant-Supervision 127 negative impact it might have on the therapeutic relationship. What I learned from these brief experiences was not to view all patients as weak and brittle and to direct one s attention and therapeutic efforts to the healthy aspects of the patient. In the conventional supervisory sessions, the supervisor at times pointed out that the treatment format should be modified in order to accommodate the possibility of seeing the patient together with his/ her spouse or family. This possibility never entered my mind since I had no experience doing couple or family therapy. The supervisor pointed out that at times, in certain situations, it can be very beneficial to see the spouse or family one or two times with the patient since these meetings can provide much important data and facilitate greater understanding of the patient and his situation and environment. I happily agreed to his offer to see select spouses and families together which encouraged me to be more flexible in modifying treatment formats when necessary in the future. The participant supervision situation reminded me of a similar situation when I began taking driving lessons. I recalled being fearful and concerned that I had so much power in my hands and feared that I would be responsible for causing and doing irreparable damage. However, the presence of the driving instructor, who was sitting besides me and observing me, reassured me that if I should press the gas or brake pedal too forcefully, steer the car in the wrong direction, or place the gear in the wrong position, he would bring it to my immediate attention or intervene directly, to remedy the situation. What I also felt helpful then was the short discussions held before and after, the driving sessions. As a result of receiving traditional supervision on the majority of my cases and non-traditional supervision on a minority of cases, what stood out dramatically was the counter-transference problems in therapy and the absence of its awareness in the neophyte therapist. If the trainee is not aware of its presence, then he will not raise it as an issue in the supervisory session. In cotherapy, the supervisor can bring it immediately to the trainees attention or grab the steering wheel, in order to avert possible damage.

5 128 Psychotherapy and the Ultra-Orthodox Community In the therapeutic encounter, the opportunity to see and learn from a live model was very significant for me. When complex issues and difficult moments arose, I felt I was not alone and I was more receptive and free to learn from the therapy session. During the meetings that followed the cotherapy session, the supervisor freely shared his views and observations with me which at times were counter to mine. This enabled me to do likewise which strengthened my self-confidence and professional standing. In the group therapy meetings, there were quite a few uncomfortable and awkward moments that I found difficult to handle, as for example when a patient asked me personal questions or dominated the conversation in the meeting. I felt relieved when my cotherapist stepped in and handled the anxiety provoking situations and within a short period of time, I acquired the confidence and skills to cope with these and other challenging treatment situations. One of the important lessons that I learned in working together with an experienced therapist/supervisor, was that one can at times be challenging and confronting with patients and not only supportive and empathic. As my experience increased so did my self-confidence, daring, creativity, flexibility, competence and independent functioning. In summary I would say that the participant supervision experience was for me a very eye-opening, educational, enriching, and enlightening one. As a result of this experience, I was able to increase and broaden my clinical skills and knowledge, and also, self- awareness, and self-confidence. I would strongly recommend that every therapist trainee experience this form of supervision.

6 Reflections of a Psychology Intern in Participant-Supervision 129 References Bernard, H. S., Banineau, R. and Schwartz, R. (1980). Supervisiontrainee cotherapy as a model for individual psychotherapy training. Psychiatry, 43, Hoffman, S. and Laub, B. (2004). Dialectical cotherapy. Israel Journal of Psychiatry and Related Sciences, 41, 3, Nelson, G. L. (1978). Psychotherapy supervision from the trainee s point of view. A survey of preferences, 9 (4), 1978, Roller, B. and Nelson, V. (I991). The art of cotherapy: How cotherapists work together. New York: Guilford. Yerushalmi, H. and Kron, T. (2001). Participant supervision in cotherapy. Israel Journal of Psychiatry and Related Sciences, 38, Source: International Journal of Psychotherapy, 19, 2, 2015