The Clinical Angle: Alytia Levendosky, PhD & Christopher Hopwood, PhD
An Interpersonal Approach to Clinical Supervision
Alytia A. Levendosky and Christopher J. Hopwood
Michigan State University Interpersonal Problems Clinic
Situated in the clinical psychology program at Michigan State University, a clinical science-oriented Ph.D. program, we have developed a supervision team that uses principles of the interpersonal/relational psychodynamic approach to treat patients and to supervise clinical psychology graduate students assigned to our team. Structurally, our team consists of the 2 of us as supervisors and up to 4 students, each of whom is assigned to one of us as a primary supervisor. We all meet in group supervision biweekly as well as having weekly individual supervision with the students assigned to each of us. Consistent with the clinical science approach of our training program, we focus in our team on training students to use the therapeutic relationship as a mechanism of change, based on the large and growing body of scientific evidence that the therapeutic relationship matters for treatment outcomes (e.g. Barber et al., 2009; 2014; Bennett, Parry & Ryle, 2006; Connolly et al., 1999; Constantino, Arnow, Blasey & Agras, 2005; Hoglend et al., 2006; 2011; Kurtmann & Hilsenroth, 2012; Levy, Hilsenroth, & Owen, 2015; Muran et al., 2009; Stiles et al., 1998).
Our training model is informed by Sullivan (1953) who viewed patient’s problems as involving maladaptive interpersonal patterns that recur because they worked well in important interpersonal situations during personality development and have thus become difficult to change (see Benjamin, 1993; Pincus, Lukowitsky, & Wright, 2010). We are also influenced by object relations theorists such as Winnicott (1965) and Kernberg (1967; 1987) who emphasize the importance of internal representational models of self, other and affect. Together these conceptual approaches inform our treatment goal to help patients develop more adaptive interpersonal patterns. We try to understand and modify recurring maladaptive interpersonal patterns through a focus on mentalizing rupture-repair sequences in the relationship between the patient and the therapist (Fonagy & Allison, 2014; Safran & Kraus, 2014; Safran, Muran & Eubanks-Carter, 2011).
Our approach to supervision is consistent with and parallel to our treatment approach, i.e. we frame the supervision relationship as an ongoing interpersonal situation that reflects conscious and unconscious contributions of the therapist and supervisor. Thus, consistent with contemporary relational psychodynamic supervision practice we pay attention to the here-and-now interpersonal situation in the clinical supervision because we believe that this will be a mechanism of change for the therapist’s growth (Eubanks-Carter, Muran, & Safran, 2015; Friedlander, 2015). As supervisors, we address ruptures that arise within the supervisory relationship, as well as what we observe in the treatment relationship. In order to accomplish this, we apply Sullivan’s framework of alternating between participation in and observation of the relationship to supervisory and therapeutic interactions. Balancing participation and observation is facilitated by three core qualities that we emphasize in our training as important for therapists and supervisors (see Rogers, 1957 for a similar model): authenticity (i.e. genuine participation in the relationship), empathy (i.e. understanding the other’s perspective across behavior and representations), and curiosity (i.e. wondering what is happening in the here-and-now in the relationship across the levels of behavior and representations).
Rather than solely focusing on supervision as a didactic experience, as supervisors, we engage in the relationships with the students in a way that encourages exploration of the process of supervision. In the group supervision, we inevitably experience some ruptures between ourselves as supervisors and instead of ignoring these mild disruptions in our relationship, we stay attuned to these moments and, within the context of the group, use them as opportunities to be curious about the rupture and empathically explore each of our experiences in order to repair. This exploration of the here-and-now between us as supervisors is typically the first experience of mentalizing rupture-repair cycles within the supervision and it offers an opportunity for students to witness first-hand how this can be done, without the anxiety of direct involvement. Our experience is that for many of the students we train, this is also the first experience of this kind of explicit empathic mentalization within a meaningful relationship that they have witnessed. Students who are not accustomed to the process of engaging with others in mentalizing aloud an interpersonal rupture with the person with whom it occurred, often feel uncomfortable even watching it. We try to help our students understand their affective response and share our own feelings that were involved in both the rupture and repair of our relationship. Thus, our relationship with each other as supervisors models what we intend to become a process within both the individual and group supervision, as well as within the therapeutic relationships the students are forming.
Thus, clinical supervision becomes an in vivo experience of the interpersonal situation. During supervision, we aim to be authentic, empathic, and curious and to mentalize the students, thus scaffolding their learning process as emerging therapists, and parallel to what we want them to do in the therapeutic relationship with their patients. Over the course of both individual and group supervision, interpersonal ruptures inevitably occur between the students and ourselves. By engaging (i.e. Sullivan’s idea of participation) in these relationships, we stay attuned to these ruptures and in a way that developmentally scaffolds the process, we help the students become curious about the rupture and then assist them with exploration of what was going on in the here-and-now (i.e. Sullivan’s idea of observation). This often raises significant anxiety in the students, both in individual and group supervision, however, it facilitates their knowledge of how to handle ruptures and work towards repair in meaningful relationships. As supervisors, we help to repair the ruptures in the supervisory relationship by empathically encouraging the student(s) to stay with the ruptures until the content and affect associated with the rupture is understood by all involved so that repair can occur. There is often resistance by students to staying in the rupture/repair cycle, and then we acknowledge and discuss the resistance. This cycle of acknowledging ruptures and working actively to repair them through discussing content and feelings related to them, along with the resistance to talking about this process, gives students the opportunity to experience holding all of this for themselves and the other supervision group members as they are encouraged to do with their patients in psychotherapy. As we and our students experience these rupture/repair cycles together over the course of the year, our students begin to mentalize us as their supervisors, allowing them to be more active in the repair process, again similar to what we expect will happen with patients in psychotherapy.
Ultimately, we view supervision as we view psychotherapy, i.e. as “a process of interaction, a function of two variables, the personalities of two people working together towards free spontaneous growth” (Guntrip, 1975). We hope to encourage in our students the development of the three qualities (i.e. authenticity, empathy, and curiosity) that we think are critical for clinical psychologists. We believe that these qualities underlie the capacity of the therapist to engage in participant-observation with the patient, to mentalize, and to successfully repair ruptures. If we have succeeded with our students in supervision, they will bring these three qualities to their therapeutic stance, and the relationships they develop with their patients, as well as with their supervisors, will guide them towards mutual growth. We therefore measure a number of aspects of interpersonal process in therapy and supervision, in addition to multimethod assessments of patient variables, and adjust our supervisory and therapeutic behavior based on these data. In summary, we think that our training focus on evidence-based principles of therapeutic relationship via the supervision relationship provides an in vivo model of interpersonal interaction that will lead to the therapeutic use of rupture/repair cycles and the development of therapeutic alliances, and thus better treatment outcomes.
References
Barber, J. P., Connolly, M. B., Crits-Christoph, P., Gladis, L., & Siqueland, L. (2009). Alliance predicts patients’ outcome beyond in-treatment change in symptoms. Personality Disorders: Theory, Research, and Treatment, S(1), 80-89.
Barber, J. P., Zilcha-Mano, S., Gallop, R., Barrett, M., McCarthy, K. S., & Dinger, U. (2014). The associations among improvement and alliance expectations, alliance during treatment, and treatment outcome for major depressive disorder. Psychotherapy Research, 24(3), 257-268.
Benjamin, L. S. (1993). Every psychopathology is a gift of love. Psychotherapy Research, 3, 1-24.
Bennett, D., Parry, G., & Ryle, A. (2006). Resolving threats to the therapeutic alliance in cognitive analytic therapy of borderline personality disorder: A task analysis. Psychology and Psychotherapy: Theory, Research and Practice, 79, 395-418.
Connolly, M. B., Crits-Christoph, P., Shappell, S., Barber, J. P., Luborsky, L., & Shaffer, C. (1999). The relation of transference interpretations to outcome in the early sessions of brief supportive-expressive psychotherapy. Psychotherapy Research, 9, 485-495.
Constantino, M. J., Arnow, B. A., Blasey, C., & Agras, W. S. (2005). The association between patient characteristics and the therapeutic alliance in cognitive–behavioral and interpersonal therapy for bulimia nervosa. Journal of Consulting and Clinical Psychology, 73, 203–211.
Eubanks-Carter, C., Muran, J. C., & Safran, J. D. (2015). Alliance-focused training. Psychotherapy, 52, 169–173.
Fonagy, P. & Allison, E. (2014). The role of mentalizing and epistemic trust in the therapeutic relationship. Psychotherapy, 51, 372-380.
Friedlander, M. L. (2015). Use of relational strategies to repair alliance ruptures: How responsive supervisors train responsive psychotherapists. Psychotherapy, 52, 174–179.
Guntrip, H. (1975). My experience of analysis with Fairbairn and Winnicott: How complete a result does psychoanalytic therapy achieve? International Review of Psychoanalysis, 2, 145-156.
Høglend, P., Amlo, S., Marble, A., Bøgwald, K.-P., Sørbye, Ø., Sjaastad, M. C., & Heyerdahl, O. (2006). Analysis of the patient-therapist relationship in dynamic psychotherapy: An experimental study of transference interpretations. The American Journal of Psychiatry, 163(10), 1739-1746.
Høglend, P., Hersoug, A. G., Bøgwald, K.-P., Amlo, S., Marble, A., Sørbye, Ø., . . . Crits-Christoph, P. (2011). Effects of transference work in the context of therapeutic alliance and quality of object relations. Journal of Consulting and Clinical Psychology, 79(5), 697-706.
Kernberg, O. (1967). Borderline personality organization. Journal of the American Psychoanalytic Association, 15, 641-685.
Kernberg, O. (1987) Projection and projective identification: Developmental and clinical aspects. Journal of the American Psychoanalytic Association, 35, 795-819.
Kurtmann, K. & Hilsenroth, M. J. (2012). Exploring in‐session focus on the patient–therapist relationship: Patient characteristics, process and outcome. Clinical Psychology & Psychotherapy, 19, 187-202..
Levy, S. R., Hilsenroth, M. J., & Owen, J. J. (2015). Relationship between interpretation, alliance, and outcome in psychodynamic psychotherapy: Control of therapist effects and assessment of moderator variable impact. The Journal of Nervous and Mental Disease, 203,418-424.
Muran, J. C., Safran, J. D., Gorman, B. S., Samstag, L. W., Eubanks-Carter, C., & Winston, A. (2009). The relationship of early alliance ruptures and their resolution to process and outcome in three time-limited psychotherapies for personality disorders. Psychotherapy: Theory, Research, Practice, Training, 46, 233-248.
Pincus, A.L., Lukowitsky, M.R., & Wright, A.G.C. (2010). The interpersonal nexus of personality and psychopathology. In T. Millon, R. Kreuger, & E. Simonsen (Eds.), Contemporary directions in psychopathology: Scientific foundations for DSM-V and ICD-11 (pp. 523-552). New York: Guilford.
Rogers, C.R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21, 95-103.
Safran, J. D., & Kraus, J. (2014). Alliance ruptures, impasses, and enactments: A relational perspective. Psychotherapy, 51, 381-387.
Safran, J. D., Muran, J. C., & Eubanks-Carter, C. (2011). Repairing alliance ruptures. Psychotherapy, 48(1), 80-87.
Stiles, W. B., Honos-Webb, L., & Surko, M. (1998). Responsiveness in psychotherapy. Clinical Psychology: Science and Practice, 5, 439–458.
Sullivan, H.S. (1953). The Interpersonal Theory of Psychiatry. New York, NY: Norton.
Winnicott, D. W. (1965). The Maturational Process and the Facilitating Environment: Studies in the Theory of Emotional Development. New York: International UP Inc.
Our approach to supervision is consistent with and parallel to our treatment approach, i.e. we frame the supervision relationship as an ongoing interpersonal situation that reflects conscious and unconscious contributions of the therapist and supervisor. Thus, consistent with contemporary relational psychodynamic supervision practice we pay attention to the here-and-now interpersonal situation in the clinical supervision because we believe that this will be a mechanism of change for the therapist’s growth (Eubanks-Carter, Muran, & Safran, 2015; Friedlander, 2015). As supervisors, we address ruptures that arise within the supervisory relationship, as well as what we observe in the treatment relationship. In order to accomplish this, we apply Sullivan’s framework of alternating between participation in and observation of the relationship to supervisory and therapeutic interactions. Balancing participation and observation is facilitated by three core qualities that we emphasize in our training as important for therapists and supervisors (see Rogers, 1957 for a similar model): authenticity (i.e. genuine participation in the relationship), empathy (i.e. understanding the other’s perspective across behavior and representations), and curiosity (i.e. wondering what is happening in the here-and-now in the relationship across the levels of behavior and representations).
Rather than solely focusing on supervision as a didactic experience, as supervisors, we engage in the relationships with the students in a way that encourages exploration of the process of supervision. In the group supervision, we inevitably experience some ruptures between ourselves as supervisors and instead of ignoring these mild disruptions in our relationship, we stay attuned to these moments and, within the context of the group, use them as opportunities to be curious about the rupture and empathically explore each of our experiences in order to repair. This exploration of the here-and-now between us as supervisors is typically the first experience of mentalizing rupture-repair cycles within the supervision and it offers an opportunity for students to witness first-hand how this can be done, without the anxiety of direct involvement. Our experience is that for many of the students we train, this is also the first experience of this kind of explicit empathic mentalization within a meaningful relationship that they have witnessed. Students who are not accustomed to the process of engaging with others in mentalizing aloud an interpersonal rupture with the person with whom it occurred, often feel uncomfortable even watching it. We try to help our students understand their affective response and share our own feelings that were involved in both the rupture and repair of our relationship. Thus, our relationship with each other as supervisors models what we intend to become a process within both the individual and group supervision, as well as within the therapeutic relationships the students are forming.
Thus, clinical supervision becomes an in vivo experience of the interpersonal situation. During supervision, we aim to be authentic, empathic, and curious and to mentalize the students, thus scaffolding their learning process as emerging therapists, and parallel to what we want them to do in the therapeutic relationship with their patients. Over the course of both individual and group supervision, interpersonal ruptures inevitably occur between the students and ourselves. By engaging (i.e. Sullivan’s idea of participation) in these relationships, we stay attuned to these ruptures and in a way that developmentally scaffolds the process, we help the students become curious about the rupture and then assist them with exploration of what was going on in the here-and-now (i.e. Sullivan’s idea of observation). This often raises significant anxiety in the students, both in individual and group supervision, however, it facilitates their knowledge of how to handle ruptures and work towards repair in meaningful relationships. As supervisors, we help to repair the ruptures in the supervisory relationship by empathically encouraging the student(s) to stay with the ruptures until the content and affect associated with the rupture is understood by all involved so that repair can occur. There is often resistance by students to staying in the rupture/repair cycle, and then we acknowledge and discuss the resistance. This cycle of acknowledging ruptures and working actively to repair them through discussing content and feelings related to them, along with the resistance to talking about this process, gives students the opportunity to experience holding all of this for themselves and the other supervision group members as they are encouraged to do with their patients in psychotherapy. As we and our students experience these rupture/repair cycles together over the course of the year, our students begin to mentalize us as their supervisors, allowing them to be more active in the repair process, again similar to what we expect will happen with patients in psychotherapy.
Ultimately, we view supervision as we view psychotherapy, i.e. as “a process of interaction, a function of two variables, the personalities of two people working together towards free spontaneous growth” (Guntrip, 1975). We hope to encourage in our students the development of the three qualities (i.e. authenticity, empathy, and curiosity) that we think are critical for clinical psychologists. We believe that these qualities underlie the capacity of the therapist to engage in participant-observation with the patient, to mentalize, and to successfully repair ruptures. If we have succeeded with our students in supervision, they will bring these three qualities to their therapeutic stance, and the relationships they develop with their patients, as well as with their supervisors, will guide them towards mutual growth. We therefore measure a number of aspects of interpersonal process in therapy and supervision, in addition to multimethod assessments of patient variables, and adjust our supervisory and therapeutic behavior based on these data. In summary, we think that our training focus on evidence-based principles of therapeutic relationship via the supervision relationship provides an in vivo model of interpersonal interaction that will lead to the therapeutic use of rupture/repair cycles and the development of therapeutic alliances, and thus better treatment outcomes.
References
Barber, J. P., Connolly, M. B., Crits-Christoph, P., Gladis, L., & Siqueland, L. (2009). Alliance predicts patients’ outcome beyond in-treatment change in symptoms. Personality Disorders: Theory, Research, and Treatment, S(1), 80-89.
Barber, J. P., Zilcha-Mano, S., Gallop, R., Barrett, M., McCarthy, K. S., & Dinger, U. (2014). The associations among improvement and alliance expectations, alliance during treatment, and treatment outcome for major depressive disorder. Psychotherapy Research, 24(3), 257-268.
Benjamin, L. S. (1993). Every psychopathology is a gift of love. Psychotherapy Research, 3, 1-24.
Bennett, D., Parry, G., & Ryle, A. (2006). Resolving threats to the therapeutic alliance in cognitive analytic therapy of borderline personality disorder: A task analysis. Psychology and Psychotherapy: Theory, Research and Practice, 79, 395-418.
Connolly, M. B., Crits-Christoph, P., Shappell, S., Barber, J. P., Luborsky, L., & Shaffer, C. (1999). The relation of transference interpretations to outcome in the early sessions of brief supportive-expressive psychotherapy. Psychotherapy Research, 9, 485-495.
Constantino, M. J., Arnow, B. A., Blasey, C., & Agras, W. S. (2005). The association between patient characteristics and the therapeutic alliance in cognitive–behavioral and interpersonal therapy for bulimia nervosa. Journal of Consulting and Clinical Psychology, 73, 203–211.
Eubanks-Carter, C., Muran, J. C., & Safran, J. D. (2015). Alliance-focused training. Psychotherapy, 52, 169–173.
Fonagy, P. & Allison, E. (2014). The role of mentalizing and epistemic trust in the therapeutic relationship. Psychotherapy, 51, 372-380.
Friedlander, M. L. (2015). Use of relational strategies to repair alliance ruptures: How responsive supervisors train responsive psychotherapists. Psychotherapy, 52, 174–179.
Guntrip, H. (1975). My experience of analysis with Fairbairn and Winnicott: How complete a result does psychoanalytic therapy achieve? International Review of Psychoanalysis, 2, 145-156.
Høglend, P., Amlo, S., Marble, A., Bøgwald, K.-P., Sørbye, Ø., Sjaastad, M. C., & Heyerdahl, O. (2006). Analysis of the patient-therapist relationship in dynamic psychotherapy: An experimental study of transference interpretations. The American Journal of Psychiatry, 163(10), 1739-1746.
Høglend, P., Hersoug, A. G., Bøgwald, K.-P., Amlo, S., Marble, A., Sørbye, Ø., . . . Crits-Christoph, P. (2011). Effects of transference work in the context of therapeutic alliance and quality of object relations. Journal of Consulting and Clinical Psychology, 79(5), 697-706.
Kernberg, O. (1967). Borderline personality organization. Journal of the American Psychoanalytic Association, 15, 641-685.
Kernberg, O. (1987) Projection and projective identification: Developmental and clinical aspects. Journal of the American Psychoanalytic Association, 35, 795-819.
Kurtmann, K. & Hilsenroth, M. J. (2012). Exploring in‐session focus on the patient–therapist relationship: Patient characteristics, process and outcome. Clinical Psychology & Psychotherapy, 19, 187-202..
Levy, S. R., Hilsenroth, M. J., & Owen, J. J. (2015). Relationship between interpretation, alliance, and outcome in psychodynamic psychotherapy: Control of therapist effects and assessment of moderator variable impact. The Journal of Nervous and Mental Disease, 203,418-424.
Muran, J. C., Safran, J. D., Gorman, B. S., Samstag, L. W., Eubanks-Carter, C., & Winston, A. (2009). The relationship of early alliance ruptures and their resolution to process and outcome in three time-limited psychotherapies for personality disorders. Psychotherapy: Theory, Research, Practice, Training, 46, 233-248.
Pincus, A.L., Lukowitsky, M.R., & Wright, A.G.C. (2010). The interpersonal nexus of personality and psychopathology. In T. Millon, R. Kreuger, & E. Simonsen (Eds.), Contemporary directions in psychopathology: Scientific foundations for DSM-V and ICD-11 (pp. 523-552). New York: Guilford.
Rogers, C.R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21, 95-103.
Safran, J. D., & Kraus, J. (2014). Alliance ruptures, impasses, and enactments: A relational perspective. Psychotherapy, 51, 381-387.
Safran, J. D., Muran, J. C., & Eubanks-Carter, C. (2011). Repairing alliance ruptures. Psychotherapy, 48(1), 80-87.
Stiles, W. B., Honos-Webb, L., & Surko, M. (1998). Responsiveness in psychotherapy. Clinical Psychology: Science and Practice, 5, 439–458.
Sullivan, H.S. (1953). The Interpersonal Theory of Psychiatry. New York, NY: Norton.
Winnicott, D. W. (1965). The Maturational Process and the Facilitating Environment: Studies in the Theory of Emotional Development. New York: International UP Inc.