APsaA’s Department of Psychoanalytic Education (DPE) inaugurated its Regional Educational Workshop series last September 22 in Los Angeles. This new venture, which involves yearly workshops rotating among various regions of APsaA, is an effort to bring cutting edge thinking on important educational topics to institutes and members in our different regions. In this way, we hope to promote deep and scholarly thinking about psychoanalytic education for all our institutes, faculty, candidates, and members. We also hope that having it in different regions of the country, and appealing to a broader audience than just analysts, will help local institutes in their efforts to be in the public eye and to recruit candidates.
This first regional workshop chose the subject of Supervision as its topic. It was hosted by the New Center for Psychoanalysis in Los Angeles and organized by one of their members, Sharon Blum. The excellent program and speakers succeeded in meeting all our goals. The workshop was truly regional; attendees came from as far north as Portland, Oregon, and from as far south as Tijuana, Mexico. It also brought together analysts and candidates from all the psychoanalytic institutes in LA as well as other interested mental health professionals. The audience included members of the Psychoanalytic Center of California, the Los Angeles Institute and Society for Psychoanalytic Studies, and the Institute of Contemporary Psychoanalysis as well as members of the New Center. The Oregon Psychoanalytic Center, San Diego Psychoanalytic Center, and the San Francisco Center for Psychoanalysis were also represented. All were enthusiastic about APsaA coming to their region and offering a valuable pedagogical experience.
The moderator and presenters offered a range of experience and orientations. Senior analysts and scholars like Howard Bacal, Glen Gabbard, David James Fisher, Richard Tuch and I spoke along with newly minted analysts, candidates, and students like Michele Gomes, Eliane Hary, and Kyana Barakett. This diversity of presenters and points of view spoke to our wish to examine the topic of supervision from differing perspectives including those of the supervisee as well as the supervisor. Paper presentations, interviews, and panel discussions were all used to foster dialogue among all the presenters and with the audience. Our goal was to encourage everyone present to share their thoughts, concerns, and differences rather than to have “experts” prescribe a correct approach. Feedback suggests this inclusive and inspirational approach was appreciated. In addition, it led to a very substantive discussion of the entire topic of supervision. In fact, a common reaction was dismay that the entire topic of supervision has been such an afterthought in psychoanalytic education.
The notion that supervision needs further study and thought was returned to throughout the day. A frequent question was why do we not teach supervision with the same rigor we teach candidates to analyze? It was also noted that institutes rarely evaluate TA/SA applicants for their supervisory skills. Instead, their clinical competence to analyze candidates is evaluated with the implicit assumption that such competence will generalize to their ability to supervise. The fallacies of this assumption were systematically described some of the common problems in supervision. Gabbard, for example, described four types of problematic supervisors: (1) the chatty supervisor; (2) the sleepy supervisor; (3) the supervisor with permeable boundaries; and (4) the authoritarian supervisor. These problems are so prevalent that most of the audience
could recognize some if not all from their own experiences. Such pervasive difficulties highlight the importance of teaching supervision and studying it more thoroughly.
Another aspect of supervision emphasized was its complex interactive process. Too often, this interactive nature is under-appreciated. In particular, the evaluative aspects of supervision can lead to a variety of problems with the candidate’s obtaining an optimal learning experience. Candidates can become afraid to be frank about how they are working, what they are feeling, or what they do not understand because of the inherent power imbalance in supervision. Trying to impress the supervisor can take priority over learning for candidates, who may fear exposing their fallibilities, being held back from progressing in their training, and differing with their supervisor. Some candidates may idealize their supervisor as so experienced and knowledgeable that they never make mistakes or have difficulty understanding. Supervisors with very directive or authoritarian approaches or those who make pronouncements with absolute certainty can contribute to these tendencies. It was reported that two studies on supervision found that directive or authoritarian supervisory approaches were the least helpful for candidates and could lead to a less than optimal educational outcome.
Various approaches to attenuating the anxiety of supervisees were discussed. Some advocated sharing their own experiences and difficulties in understanding and treating their patients. Others stressed the importance of the supervisor not imposing a theoretical model or “correct” approach to analyzing. Others emphasized the importance of fit between the supervisory dyad and the need for the candidate to feel safe. In this vein, the supervisor needs to have optimal responsivity to the supervisee. This requires the supervisor to be responsive to that specific supervisee with that specific patient. Characterological attributes of both partners in the dyad can also enhance or undermine fit. So can the developmental needs of the candidate at any particular point in training. Beginners often need more concrete help than advanced candidates.
The tension between whether supervision should teach or treat was also highlighted. This dialectic is complex. For example, the question of what should be taught was raised. The consensus seemed to be that teaching should emphasize helping the supervisee to better understand the patient and to think about the psychoanalytic process occurring between the patient and the candidate. Teaching theory, including theory of technique, in supervision was thought to be less helpful. Some believed the supervisor is not qualified to tell the supervisee how to analyze the particular patient whose treatment is being supervised. The supervisor is only qualified to help the supervisee see what is occurring between him and the patient because the supervisor is emotionally outside the dyad. From Bacal’s perspective, the analytic dyad is so unique and specific that prescribing technique is impossible for the supervisor.
Another complexity in this teach-or-treat dichotomy has to do with how to work with the supervisee’s countertransference. Many participants lamented the lack of help with their countertransference when supervised. Despite the more contemporary acknowledgement of the inevitability of countertransference and its value for understanding the patient, many supervisors continue to worry about how to work with it with candidates. One reason for this hesitance is the difficulty of ascertaining whether the countertransference involves projective identification from the patient versus just reflecting the candidate’s internal conflicts. These days, most authors view these factors as overlapping and not easily differentiated. Sometimes one can observe candidates identifying with their patients via an enactment with their supervisor. But causality can go in the other direction also. A supervisor’s excessive certainty in supervision can inadvertently create a candidate who comes across as excessively certain with the patient. Thus, the importance of attending to the emotional impact of supervision was stressed. It is crucial that supervisors remain open to resolving supervisory crises and stalemates.
Related closely to these issues of countertransference is the place of enactments in supervision. Enactments can occur with both the patient and with the supervisor. Various ways and motives for avoiding supervision or consultation were discussed. Two basic axioms were suggested by Gabbard. One was that the supervisee may be moving down the slippery slope to boundary violations if he or she is doing something with a patient that he or she cannot share with the supervisor. The other axiom is that the most important thing to share with a supervisor is the issue one is most reluctant to share.
Presenters also acknowledged that supervisors can enact as easily as supervisees or patients. Within institutes, for example, training analysts and supervisors with different theoretical orientations can unconsciously struggle to win the candidate’s allegiance. Boundary transgressions can easily occur in such circumstances. On the other hand, exploring and discussing such enactments before they reach this point can be quite useful in the supervisory process.
The value of consultation after graduation as part of one’s regular professional identity and continuing education was another topic of the workshop. It is an important aspect of the transition from being a candidate to being a graduate analyst. Consultation was distinguished from supervision on the basis of being non-obligatory and non-evaluative. Different arrangements for such consultation were described by Gabbard. These included group consultation, longstanding relationships between two clinicians who take turns presenting their cases, and phone consultation with an out-of-town analyst when the patient is prominent in the local community. Various resistances to such consultation and the motives for them were described. Some newly minted analysts may experience it as a sign of being weak. Some fear having their fallibilities exposed although they find rationalizations such as protecting confidentiality to avoid it. The multiplicity of excuses for avoiding it indicates the importance of the local and national educational cultures inculcating the notion that consultation should be built into our practice because, as Gabbard put it, we are all masters at self-deception.
Another fascinating part of the workshop was David James Fisher’s interview of Howard Bacal about his supervisory experiences in the British Society. Bacal was supervised by luminaries such as Winnicott, Bion, Balint, Marion Milner, and Betty Joseph. The audience and other presenters were all mesmerized by this historical perspective. In particular, his experience with Balint was interesting. The Hungarian school’s approach to supervision was brought to London by Balint. In contrast to the Eitingon-led Berlin Institute’s, as well as Vienna’s, and London’s emphasis on teaching a correct technique to candidates, the Budapest Institute and the Balints emphasized the great variability in the way analysts work. As a result, they stressed the need to emphasize the uniqueness of the practicing analyst when teaching technique. The importance of countertransference and the specificity of the analyst-analysand relationship were the primary focus of supervision. Another interesting difference was the Budapest Institute’s approach of having the first control case supervised by the candidate’s own training analyst as part of the candidate’s analytic sessions. This approach became impossible after Ernest Jones decreed that training analyses had to be kept separate from supervision in 1947. The pros and cons of this practice were discussed with the audience.
Arising out of that discussion was a spirited one about the place of evaluation in supervision. Some advocated its removal from supervision while others stressed the need to evaluate in order to teach or to weed out those who cannot do the work. Some questioned whether evaluation was useful in analytic education more generally. Running throughout that discussion was concern that such evaluation can be experienced as harsh; to the degree that it is, the candidate’s learning can be compromised. Various approaches to removing or minimizing it in supervision were suggested. One approach would be to have a candidate’s clinical competence evaluated by some other group in an institute that listens to the candidate’s process material. But some reported their institutes had found these groups could be excessively critical of the candidate, and, sometimes by inference, the supervisor. Another approach would be to pare down the supervisor’s evaluative reports to three ratings: Needs improvement, Adequate, or Honors. This suggestion involved the assumption that qualitative comments should be occurring throughout the supervision so that they were gratuitous as part of the formal evaluation.
In summary, the workshop highlighted how complex the supervisory process is. There are many facets to it, all of them deserving further study and articulation. To be sure, there is a literature on the topic. But it is tiny when compared with the vast literature on analytic technique or the content areas that comprise institute curricula. All attending were so engaged that the day had to end because we had run out of time, not because we had run out of things to say. It appears that the first DPE Regional Educational Workshop has highlighted an area the DPE and all our APsaA approved institutes will need to study further. It offers an example of one way in which the regional workshops can enhance analytic education. Everyone who attended will take home to their local institute an interest in reconsidering the multiplicity of issues in psychoanalytic supervision and its role in educating candidates. As a result, supervision of candidates will be enhanced.