Psychodynamic Supervision of Psychotherapy
by Paul A. Dewald, MD
Achieving skill in conducting dynamic psychotherapy is a never-ending developmental process that continues throughout the professional life of each therapist. Theoretical discussion and reading can provide a scaffold, but genuine learning requires direct personal clinical experience with a variety of patients. While some therapists resort to self-teaching and a “trial and error” approach, these methods tend to be limited in effectiveness. Nor is it necessary for each individual to “reinvent the wheel”. Psychotherapy supervision offers a situation that allows the supervisee to use the skills, experience, and understanding of a senior therapist as a guide to enhance the educational process of a developing therapist.
Several models of supervision offer both advantages and limitations. Individual supervision allows for intensive and sustained focus and may allow freer and more open discussion of transference-countertransference experiences, but it limits exposure to only the supervisee’s own work and cases. Group supervision offers exposure to a wider variety of cases and therapeutic styles but dilutes the supervisee’s opportunity to present his/her own work, and issues of confidentiality become more complex. Sustained focus on one or two cases allows a deeper and more detailed study of the therapeutic process as it evolves over time. Brief and intermittent discussion of multiple cases, on the other hand, offers a broader comparison of clinical material and therapeutic technique but restricts the depth and longitudinal nature of the discussion.
From a psychodynamic perspective any patient/therapist pair undertake a complex process involving both conscious as well as unconscious forces in both participants. Social, cultural and reality factors add to the complexity of the interactions at cognitive, emotional, interpersonal and therapeutically responsive levels. Because the supervisor is somewhat removed from the immediate clinical interaction, the supervisor can assist the therapist in establishing a formulation of the core conflicts – both conscious and unconscious – presented by the patient. This includes an assessment of the patient’s strengths and liabilities, defenses, and choice of goals for the therapy. The supervisor can also suggest areas of incomplete information for deeper exploration.
The psychodynamic supervisor helps the supervisee recognize the differences between the patient’s manifest vs. latent communications and when and how to respond to them based on the overall treatment strategy. This includes helping the supervisee identify the patient’s transferences, as well as the therapist’s countertransferences. This is significant whether the treatment strategy is primarily insight directed or supportive.
The supervision process must also consider the evolving relationship between supervisee and supervisor which also includes conscious and unconscious transference- countertransference elements. The supervisee must feel the situation is safe, that there is a teaching-learning alliance so that he/she can openly reveal the undistorted elements of the therapy interaction, including thoughts, feelings, and mistakes. The supervisor must give prompt feedback, both positive comments and constructive criticism where appropriate, but must avoid information overload and unrealistic expectations so as to interact in ways to maintain the supervisee’s self-esteem.
Supervisory consultation is also appropriate when an experienced therapist encounters a case where the therapy appears to be in a stalemate or when countertransference forces prevent the therapist from optimal function. The consulting supervisor, who is free from the immediate pressures of the case, may be in a position to recognize factors in the therapeutic interaction that permit the therapist to adopt a new perspective on the treatment. Even a very experienced therapist will encounter cases where consultation helps clarify a difficult therapeutic impasse.
The late Paul A. Dewald, MD, served as the St. Louis Psychoanalytic Institute’s Director, training and supervising analyst, and lifetime Board member. He was a clinical professor of psychiatry, St. Louis University School of Medicine.
Supervision, whether individual or in small groups, is an integral part of all the St. Louis Psychoanalytic Institute’s training programs: Adult and Child Analytic Training and Advanced Psychodynamic Psychotherapy Program (APP). Faculty members, on a private basis, also arrange for supervision with practitioners from the community, either individually or in small groups.