This article was first published in Psychoanalytic Social Work Vol 23(1) in 2016. It was presented in a shorter version in Durban, South Africa at the 2014 World Council of Psychotherapy conference.
Abstract
Transference-Love in supervision remains a relatively unexplored subject in psychotherapy. This paper describes and analyze an incident of the supervision of a student whose dress-code raised a question regarding the existence of transference-love. The role of the institution in maintaining a protective envelope will be shown to be significant in the satisfactory resolution of what appeared to have been an impasse (Aron, 2006). In addition, multi-cultural and gender issues will be examined to illustrate the complexity of the subject.
Keywords: supervision, transference-love, sexual abuse, gender, institution, impasse
Introduction
The significance of supervision in the therapeutic professions is undisputed. It is thought that without it, the practice of therapy is at best inadequate and at worst unethical. Therapists, especially those who are at the beginning of their careers, need supervision both as a learning arena as well as a place where they can endeavor to guarantee the best possible treatment for their patients. As I will show in this paper, supervision is also a place where institutional and multi-cultural issues come to the front as tacit players in the therapeutic process. Without good-enough supervision, the patient, as well as the therapist, are in danger of being subjected to compulsive repetition of pathological patterns.
The significance of supervision
There are many different supervision styles that one can refer to when trying to analyze their goals, theoretical assumptions and clinical implications (Semrad 1969, Wolberg 1977, Wallerstein 1981, Caligor et al. 1984, Lane 1985, Mann 1994, Berman 2000, Sher 2003, Howard, 2007). For the purpose of this paper, I will briefly describe some key aspects which are relevant to the case study.
From a clinical point of view, supervision’s main thrust can be described as placing the stress upon intensive exploration of the way the supervisee is conducting the therapeutic relationship in view of the patient’s symptoms, needs and pathological status. Often, specific characteristics of the supervisee and patient are explored within the transferences and counter-transference paradigm. Less often, aspects of transference between the supervisor and the supervisee are also explored. This, as I later will demonstrate, creates a rather complex multi-dimensional therapeutic and supervisory structure that needs to be contained. Often, the mind of the supervisor and of the supervisee are not sufficient as containers and an additional containment is needed in order to prevent acting-out. The underlying assumption is that a supervisory process would lead to a better therapeutic process and thus the patient benefits.
Pertinent to this assumption and to the case study I am describing, are Searles’ (1955) observations that the supervisee's behavior and feelings in supervision are often a reflection of an event which was happening in the therapist-patient relationship and, ultimately, in the patient’s history and psyche. The alternation of roles, from therapist to supervisee, makes the situation particularly difficult and leads to identification with the defensive behaviors, enactments, and negative therapeutic reactions of the patient, which are repeated during supervision. The term “parallel process” is often used in this context, denoting the connection between the supervisee\therapist's issues in supervision and the patient's issues in psychotherapy (Doehrman 1976; Caligor 1984). Overlooking its impact can lead to adverse consequences for supervision and therapy. Transference and countertransference issues emanating from both interactions intermingle and blend, and the supervisee is involved in what appears to be an unresolved situation (an impasse). An unconscious need to re-enact an unresolved issue during the supervision session is formed, where the therapist\supervisee plays the role of the patient and the supervisor that of the therapist (Caligor 1984). Parallel re-enactments take place due to the overall identifications involved in the unconscious current underlying the therapy and supervision. Thus, the supervisor’s tendency to identify with the supervisee internal objects might interact with the patient’s tendency to identify with the therapist\supervisee’s internal objects. A complex and multi-layered matrix of conscious and unconscious links are ever evolving within the live relationships between the people involved (Berman, 2000). In addition to the intersubjective perspective Berman offers, which throws light upon the complexity of the situation, authors such as Lloyd-Owen (1997) offer a specialized perspective on the particular and potent content that might be projected, and introjected, within particular settings. Describing numerous examples of mental health workers who work with disturbed patients in agencies such as probation services, she puts an emphasis on the severity and impact of unconscious work in the area of primitive emotional development where enactments can take place. Once noticed and acknowledged, such enactments can be verbalized and be transformed to a transitional area wherein the impasse can be remembered, resolved and worked through.
Supervision is also a pedagogic practice. The supervisor is perceived as the teacher and guide of the supervisee and most of the interactions between them are focused upon knowledge being passed from the supervisor to the supervisee. A strong emphasis is placed upon on the authority of the supervisor, and can be criticized as too hierarchical. It also tends to relate to the supervisee as helpless and weak and thus infantilizing the process. Critics of such an approach would call for a more humanistic approach where the supervisor is an equal contributor to the supervision dyad. This will allow a mutually recognizing space for learning and growth, allowing the exploration of the supervisee\therapist's and supervisor’s feelings of countertransference which form the living material of psychotherapy (Grinberg 1970, 1984, Benjamin, 1988, Goldberg 1990, Karon 1990). This can be perceived to be blurring the distinction between therapy and supervision, and is criticized for abandoning ethical and critical aspects of the learning process. There is a danger that the supervisory relationship will be used as a clearing ground, where the supervisor relieves the supervisee of the guilt and shame often felt, and thus impedes an important aspect of the learning process.
The Institution
The involvement and the overall presence of the institution wherein the supervision takes place, might intensify the complexity of the identifications in the patient-therapist\supervisee-supervisor triad. The objectives and rules of the institution are present within the therapeutic and supervisory relationships, verbally and non-verbally, consciously and unconsciously, and their impact needs to be acknowledged to monitor transference onto the setting (Luber, 1991).
The presence of the agency is detected mostly by its boundaries and demands upon the individuals operating within it (Goffman, 1961). It tends to identify individuals as members of groups that keep strict boundaries governing their areas of interaction. Anything, or anyone, that crosses or threatens the boundaries, in a concrete or metaphoric way, as often happens in the supervisory triad, is observed, evaluated and is acted-upon in a manner consistent with the institution’s overt and covert policies. Each shift that one of those individual makes, may cause a disturbance to be dealt with in the appropriate manner, by mechanisms of assimilation or expulsion.
A degree of identification with the agency and its policies is desired for the workers to be able to work to fulfil its aims. When the institution is creative and flexible in its structure, this increases the workers’ self-confidence. The success of an institution depends to a large extent on its ability to contain the anxiety of its members within the overt and covert policies and boundaries. As I will demonstrate later on, when one of those policies, and in this example the dress code of the workers, becomes contentious, the institution is “called in” into the triad and becomes an active participant.
Case study
The clinical illustration that I will describe, involved a student, M.[2] in her third and final year of her postgraduate studies of psychotherapy who was supervised by me in my capacity as a fully trained psychotherapist and clinical social worker. She was on placement in a special-needs primary school in a major city in Israel where she practiced play therapy with children.
M. was doing well in her placement, after some initial difficulty, and the staff of the school, including the counsellor and the educational psychologist, were pleased both with her reports of play therapy and with her consultations with them. She seemed to be reasonably enjoying her placement, though at times she seemed to be downcast and was preoccupied with something she did not share. Most of the time, I thought the supervision was going well, though I did experience a sense of M. not sharing all she could regarding her work. Was it an impasse, I wondered, or was it a matter of her gaining more confidence in her work and needing more reassurance and containment before she could dare to be more open?
Sometime after the placement was underway, she arrived to school wearing a very short miniskirt, which was unusual in relation to how all other women dressed in that school. I noticed it straight away and felt puzzled by it. At first, I did not know what to do about it, even though it was commented upon by other staff members as being perhaps an inappropriate way for a student to dress. I felt stuck. I firmly believed that it was her right as a woman to dress as she pleased and that my reaction was my own responsibility and had to be understood and contained as part of my own self-analysis. I found myself being distracted by it to the extent that my full attention was not always on the material she presented. I felt shame. After a few more times when M. appeared wearing the same or very similar mini-skirts, I discussed it with a female colleague who was sympathetic and supportive enough to reassure me that no boundaries were crossed and advised me to wait it out. Was she trying to seduce you? Asked the colleague. She confirmed that M.’s dress was in discord with the general ambiance of the school. She also agreed that making an issue out of it could be perceived to be an act of oppression against M. and could be interpreted as an aggressive male act of cultural domination. It was an impasse. What was I to do? Was I being seduced? Was I inviting such an act on account of something I did? Was it a case of transference-love in supervision, and if so, what did it represent?
A couple of weeks later, the director of the local Social Services department visited the school and was introduced to the school's staff, therapists and students. The visit itself proceeded well but a couple of days later, I received a phone call from her. The director approached the subject of what was and what was not appropriate as a formal dress code in the school. She asked me to consider the possibility that M.'s choice of dress was perhaps a statement, perhaps partially unconscious, either regarding the placement as a whole, or regarding the supervisory relationship between a male supervisor and a female student.
Personal vs. Political
I found myself considering her remark within two different but related fields: the first one was the inter-personal nature of the supervisory relationship, touching upon issues of authority in clinical work as well as on issues of transference and counter-transference. The second one was concerning cultural assumptions and power-relation. In other words, was the dilemma a clinical one, resulting from an incident of acting-out within the supervisory transference, or whether it was a political one, resulting from gender, national and cultural difference? With time, as I will now demonstrate, I came to see that it was both.
The school was situated in a major Israeli city. The pupils and teaching staff came from a variety of cultural and religious backgrounds. There were Moslems, Christian and Jewish pupils and teachers with a strong majority of the Jewish population, in accordance to the demographic mix of the area and the country. The school was secular and liberal and respectful of all three religions. The pupils in the school were of normal intelligence but all exhibited various behavioral problems, either due to conditions diagnosed by DSM-IV as ADHD, Oppositional Disorder and Conduct Disorder. Most of the children came from low socio-economic backgrounds and from a variety of cultural, ethnic and national backgrounds. Some were placed within foster families and some were living in residential homes, having been removed from their parents’ care due to neglect or abuse. The school staff was diverse and included, as well as an educational staff, many therapists from different backgrounds, who provided the children with a variety of individual and group therapeutic interventions, ranging from weekly individual sessions to daily group therapy meetings. The educational and therapeutic staff groups met on a regular basis and held consultations regarding the needed therapy for each of the children. Regular assessments and supervision meetings were held to ensure that the therapeutic interventions were effective.
I am an Israeli Jew and M. is an Arab Christian. This is not an unusual situation in many mixed Israeli cities and towns. As the Jewish and Arab communities often live within very close proximity to each other, often in the same neighborhoods, schools in those areas would provide for both Jews and Arabs, and naturally the staff would be of a similar mix. The scope of this paper does not allow for a deeper explorations of the complexities, challenges and difficulties that arise on a regular basis in this mutli-cultural and multi-national country. Lately, the complexity of the situation is further deepened due to the existence of a growing population of African immigrants and refugees who move into the inner city areas. The political climate in Israel ever since its proclamation in 1948, and even before, has been dominated by unrest and is still far from reaching a status where one could assume peaceful co-existence at all times. Still, there are many examples where Jewish and Arab professionals co-exist in an atmosphere of mutual respect and recognition, and the particular school described here is one of them. I think of myself as being aware of the inherent complexities being a member of the Jewish majority in the state of Israel, especially when placed in a position of relative authority as one is in a supervision setting. I was also aware that my relative ease in thinking about the national and cultural differences could be partly attributed to my belonging to the majority group and that M.’s point of view and general disposition could well be different. On top of that, I was also aware that it might not be as easy for her to fully acknowledge and express her sense of discomfort due to the national and cultural difference. This made the issue very complex. Nevertheless, as far as the school’s overt policies were concerned, ample room was given during the staff meetings for such delicate issues to be addressed.
Even though the supervision was going on relatively well at the time described, it did not start like that. M.’s initial request for this placement was to work with adults in a mental health setting. Due to various circumstances, this was not possible and she was placed in the school. When I first met her, she complained about this and was very resentful towards the University for not granting her request.
We dedicated a part of the first supervision sessions to the real professional challenges she was facing. It was becoming clearer that some of her reluctance to the placement in that school was also to do with her lack of confidence in her ability to work well with children. It was clear that regarding academic requirements and previous experience, she did have sufficient ability for the placement. She was meant to undertake at least one course of play therapy as well as participating in group activities and staff meetings. It was not a workload considered too harsh for students.
On my part, I did have my residual doubts as to whether it was always safe and wise to let young students work with close proximity with children who were often very hurt children. Past experience had shown my fear to be unfounded, and previous placements went very well. When M. expressed her displeasure from even being there, I had to be careful and listen to her and not let my own bias overshadow the situation at hand. My assessment at the time was that as a student, she should be able to adjust herself to the situation and accept the placement as it was. I conveyed that to her clearly but was also empathic to her difficulty.
During the following weeks, after the induction period was over and M. became more familiar with the setting of the school, she began to fulfil her assignments. This she did very well and I found myself even surprised as to how quickly she had adjusted herself, considering how upset she was previously.
The Personal is Political
Focusing on the “easier” overt option that dealing with the dress code offered me, I had to check with the institution’s administration whether such a dress code indeed existed. I soon discovered that indeed there was no written institutional rule detailing the acceptable dress code. Supervision is an administrative practice designed to improve services to clients through the development of the worker or the student's skills in the employment of institution-structured goals (Levy, 1973). Thus, I had the responsibility to make sure that the student will employ her developing skills to the benefit of the institution's clients. I had to ask whether M.'s personal ethical behavior, i.e. her code of dress, was interfering with her developments of skills in general and in particular her skills of working with children at the school. It was not enough to pass a judgment upon her dress as such (the action itself) but to consider the maxim of the action (the action in context).
The question of authority in a supervision relationship between an Israeli Jew and an Arab Christian is a political issue. Being part of a minority places one in a subjectively more vulnerable position. I could not rule out the possibility that she felt unsafe in the school due to that. It was possible that she was keeping her true political sentiments to herself. Was her dress a signifier of a deeper sentiment she dare not express openly? I had seen her talking and behaving freely and openly with other colleagues, both Jews and Arabs, and got the impression that she felt at ease in the liberal atmosphere of the school. Could it be that M. was acting-out in the transference? If so, what was being thus acted-out rather than remembered?
I felt somewhat anxious before the next supervision meeting began with all these questions circling in my mind. I thought that my anxiety must signify that this was not just a clear cut issue of boundaries and authority. If that was the case and M. was just a student who needed to be made aware of the gender and cultural implications of her dress choice, I would not have felt such anxiety. I felt paralyzed by the thought and the session came to an end without the issue of her dress, nor the sensations it aroused, having been addressed. The impasse remained intact.
Transference-Love
When I did eventually approach the issue during our next session, we were able to work through this carefully. I suggested to M. that her dress was indicative of a thought or a feeling that perhaps even she was not fully aware of, and suggested that we talked about this. Luckily, after her initial embarrassment, she welcomed this intervention. I was relieved that she did not feel too admonished, even though I did share with her that it was the Social Services director’s intervention that made me realize something was not being discussed. What follows is the narrative we both were able to piece together during the following sessions which led to the good-enough resolution of the impasse.
M. had found herself in a placement she did not want to be. Her wish for a specific placement was frustrated by the decision taken by the university. She felt powerless and hard-done by. She felt that her genuine interest and ability went unrecognized and even ignored by the institution, represented by the university's tutors and supervisors. Nevertheless, her actual experience during the first few days at the school was fulfilling. She found herself actually enjoying what she was learning. Still, she had a lingering feeling that it could have been better. She said that when she had first met me, she was impressed by my welcoming smile. She soon learnt to acknowledge our work together as beneficial and found the sessions very helpful. More than that, she even liked me, a little bit more than she had allowed herself to admit. To her friends, she spoke of a good-looking Jewish psychotherapist who was very knowledgeable. She masked her own interest by suggested to her friends that she thought I fancied her, even though I showed no sign of it. She felt embarrassed by it but also not able to ignore her sensations. She knew what transference-love was, she had studied it, and felt awkward about it. Was it really a case of transference-love?
Before answering that and describing how the impasse was finally resolved, I would like to briefly explore some theoretical dimensions of transference-love. Beginning with Freud’s seminal paper (1915), the issue of transference-love has remained a thorny one. Despite the sense that the discussion of the issue was already ”over-due” in 1915, not much has been written about until the 90’s, when a number of intersubjective psychoanalytic authors have begun exploring the subject with more rigor and candor (Davies, 1994, Hirsch, 1994, Bollas, 1994, Bologoni, 1994, Gabbard, 2006, de Massi, 2012). The scope of this paper is not sufficient to do justice with the enormity and complexity of the subject, but it is possible to outline two general views of the phenomenon (Person, Hagelin & Fonagy, 1993). The first view tends to conceptualize the appearance of transference-love as indicating resistance due to the imminent sense of danger of exposing some repressed material, usually relating to infantile sexual issues. According to such an approach, the therapist needs to address the resistance as he would any other form of resistance in order to allow the therapy to continue unhindered. The second, somewhat more sophisticated view, tends to view the appearance of transference-love as an almost inevitable occurrence within the therapeutic relationship, indicating a “affectionate transference” which facilitated an intimate evocation of deep layers of emotional development. Therefore the guarded exploration of the transference-counter transference issues, will lead towards a break-through of the therapeutic impasse, allowing the patient to gain a greater sense of personal freedom in the expression and fulfilment of their capacity for adult love. Thus, exploring transference-love within the therapeutic boundaries allows the patient to remember repressed areas of infantile love rather than to act out them as transgressions. The same, of course, can be said concerning the therapist himself (Stern, 1993). All views warn against any breach of the therapeutic boundaries, a breach that was a part of Freud’s initial motivation in writing his paper back in 1915, having been a witness to the Jung’s and Ferenczi’s illicit affairs with their patients (Canestri, 1993).
So, if indeed the impasse was as a result of an unresolved conflict, what was it that was being acted-out rather than remembered? To answer that, I shall now describe the third part of the supervisory triad, M.’s client.
The child who was chosen to work with was an 11 years old girl, B. who lived with foster parents after having been removed from her parents' care after being sexually abused by her step-father five years earlier, when she was six years old. B.’s mother suffered from chronic schizophrenia and as she was often in hospital, was found to be unable to care for her daughter. The abuse involved the step-father exposing the girl to pornographic materials on the internet and suggesting to her that he showed her "how it was being done". B. told her previous schoolteacher about his suggestions, and social services intervened, finding a household on the brink of collapse. B. was removed from her parents’ care and placed with a foster home.
B. had been in intensive psychotherapy in previous years and M.'s objective in meeting her was to help her further develop her social skills. It had been noticed that she had a tendency to be over-dominant with her friends. The short-term focused sessions with M. were intended to give her some room for ventilation in order to assess whether she needed to return to intensive psychotherapy. M. found B. to be a likeable and talkative girl and formed a warm connection with very quickly. The knowledge of her abuse was intimidating. Working on her sessions reports in our supervision sessions, we were forming the opinion that B. was presenting over-dominance in her interactions with her peers as a natural part of her character and that it was anticipated that M. would be able to help her with that during the short-term course of their meetings.
During that time, M. had a frightening dream from which she awoke with a start. The dream showed a young boy being chased down a long corridor by male figures who seemed to want to drag him into a box. In the following session, she told me about the dream, as I had instructed her to monitor closely her dreams which may shed light upon the unconscious communication between her and B. This was done to help her to develop her skills of working with unconscious communications. M. only shared that dream in supervision with some reluctance, as she was ashamed of it. She felt it would be too revealing. She rationalized that as a way of maintaining her sense of autonomy in the supervision. It was then she began wearing a mini-skirt.
Discussion
M.'s dress choice was an instance of acting-out within the supervisory relationship. It was a junction where two unconscious links met and formed what Spero (2014) termed “a nodal point.” It formed both a political choice and a personal one. Until revealed and resolved, M.’s sense of frustration in supervision and in therapy was given expression through an instance of transference-love. Until discussed, it posed the potential danger of violating boundaries. Those boundaries had been violated by B.’s step-father and it was that violation that formed the driving force behind the impasse.
B. has suffered sexual injury which was she brought up both verbally and in her play during her therapy sessions. M. had formed a good therapeutic alliance with B. and felt attuned to her. That meant she was also receptive to unconscious communication. When discussing her dream, she could see that it contained a reference to a projected part of B.’s undigested injured psyche. It was a piece of her psyche that perhaps demonstrates Bollas’ (1987) term “the unthought known.” M. reception of that projected unconscious item indicated the good rapport she has established with B. The dream itself had not been interpreted and worked-out by her, and remained an undigested and painful psychic item. It was passed on, since at that time it lacked a contained envelope which could defuse it. The sexual nature of the occurrence linked up in her with her own conflict, which got played out in the supervisory relationship with me. Due to the level of unresolved tension that existed in the supervisory dyad, that bit of raw, unconscious material erupted through the acting out of her behavior in the form of dressing inappropriately.
It was the institution’s presence in, the figure of the Social Services director, who was able to alert the players to the danger involved. That figure was absent, due to illness, in B.'s case and left her exposed to sexual abuse. In the supervisory triad, it was the good-enough parent who intervened in the silent but potent drama that was developing and transformed what could have been an acting-out into a memory which could be acknowledged and worked out.
All these insights were discussed and worked-through during the following supervision sessions, as well as in a meeting I held with the Social Services director. Despite the initial embarrassment that was experienced both by M. and myself, we were eventually able to marvel together at the wonders of the unconscious. The placement continued, as did M.’s work with B. During the supervision sessions, we were able to use the insights gained to further develop our understanding of the triadic situation in its complexity. Once she became aware of her unconscious motivation for wearing her mini-skirt, M. could see that wearing a mini-skirt when working with a sexually abused child was not an act she should have done. Even without resolving totally the question as to whether a therapist should wear revealing items clothes when working in therapy, doing so with a sexually abused child certainly called for trouble.
An After Thought
What is the truth of this incident? Is there one single truth?
The central aim of supervision, apart from being a learning process, often mutual, is for the supervisor to understand his supervisee and form a working alliance, so that transference, counter-transference and resistance are dealt with in such a way that all parties benefit from it, and especially the patient.
When that happens under the gaze of an institution, it is pertinent that the supervisor is aware of the multi-dimensional issues that are involved in his working relationship with the supervisee, including multicultural issues and transference issues. The triadic form of the supervision relationship is based on personal relationships which are naturally subjected to numerous factors that affect them.
The involvement of an institution in supervision can be inhibitory but also beneficial. It is my opinion that the institution, as was shown in this case, can be seen as facilitating a better understanding of the supervision practice and illuminate unconscious aspects. That insight is vital for the learning which is and must always be the driving force in psychotherapy.
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