Therapy

Why Good Supervision in Psychotherapy Matters

What happens early on in training can shape the rest of your career.

Posted May 25, 2019

Sam Osherson
Source: Sam Osherson

Recently I was asked to write an introduction to a classic book on supervision, The Quiet Profession, written by Anne Alonso, a mentor of mine. Anne’s book was one of the first to take an in-depth look at what happens in psychotherapy supervision for both the supervisee and the supervisor.

“She Does Listen. That Helps.”

As I re-read the book, an army veteran I met not long ago came to mind. He struggled with PTSD after several combat tours in Afghanistan and told me of his battles to get the help he needed. The VA had failed him for years, he said, handing him drugs whenever he sought help. No one really listened. Recently, though, the small clinic in his town has come to be the only place he truly feels safe. All because of a psychiatrist he has found. Why? “Well, she still talks too much, but if I let her go on for a while, she begins to listen to me. And she does listen. That helps."

How do we help psychotherapists learn to listen better in an age when too many of us reach for psychopharmacology solutions to solve human dilemmas, and treatment is measured in short, insurance-reimbursable sessions? 

That is the challenge at the heart of Anne Alonso’s work. Anne was particularly concerned that there “always be someone to talk to,” because she understood the way that suffering is relieved when it is shared, particularly with someone who listens well. 

Parallel Processes

Anne’s special insight was that to help therapists learn to listen, we need supervisors who can listen. She identified supervision as a “blind spot” in psychotherapy training. And she realized that supervisors need to be trained as much as therapists, that good supervision requires creating a safe “holding environment” in which both therapist and supervisor can do the hard work of bearing strong feelings. This is particularly true for therapists-in-training.

After all, doing psychotherapy—being invited into the most intimate dilemmas and experiences of another person—creates anxiety for the therapist. Listening well can often be a challenge. What we hear may be disturbing to us, it may touch on our own developmental conflicts and discomforts, and we may hear problems for which we have no solution. The patient’s projections onto us—an important part of the work of therapy—may leave us questioning ourselves, rather than understanding—as Anne wrote—that the feelings are “addressed to occupant” and not truly personal comments about the therapist.

As novice therapists, or even experienced ones, we may narrow our listening or distance ourselves to protect ourselves from our own troubled feelings. 

And as supervisors, we may also struggle with the challenge of being able to listen to our supervisees and bear their anxiety—and our own.

One of Anne’s major insights was that supervision was a multiperson process that involved several players. In this regard, Anne developed an early interpersonal model of psychotherapy in which she also brought to bear her canny understanding of the underlying dynamics of organizations. In this way, Anne broadens our understanding of the supervisory process by expanding our lens to include the therapist, the patient, and the institutional setting as important components of the supervisory relationship. 

What Happens for Supervisors?

Anne’s real focus, though, was on the supervisors themselves and the complexities of the role. In her book, she bases much of her discussion on Donald Winnicott’s concept of the “good enough” parent. Anne was fond of reminding us that, “you have to make a lap for the patient.” What she meant was that the patient needs a safe place to explore the inner and outer world in order to do the work of therapy. The model for that—in therapy and supervision—is Winnicott’s notion of the “play space of mother’s lap.” 

With her typical generosity and humanity, Anne pointed out: “Just as people of a wide variety of personality types and caretaking styles can be good enough parents, so can a wide range of supervisors be good enough.” 

And what is “good enough” supervision? Anne lays out a model that involves didactic teaching, modeling the appropriate attitude toward patients, expanding the affective repertoire of the therapist, and developing the capacity to work within the transference. The latter means understanding that the therapeutic relationship is a microcosm of the patient’s life relationships and what happens between patient and therapist provides rich opportunities for learning and change. Or, as Anne used to say, “What’s outside the office is also inside the office.”

In other words, Anne developed an early model of supervision as a relational experience between therapist and supervisor. In Anne’s view, the supervisor—like the therapist—is not a blank screen, a person without qualities, but rather a participant in the process of understanding the therapist’s experience. So, she presents a developmental model discussing the experiences, and challenges, for the novice, mid-career, and late-career supervisor. Who the supervisor is—and where they are in their life—influences what happens in supervision as much as who the therapist is, or the patient.

“Don’t Just Do Something, Sit There”

I understood some of what Anne was writing about before I read her book, since I sought her out as a supervisor early in my career. I’d received my Ph.D., completed my year-long internship on the psychiatry ward of a major hospital, and was teaching at a large university in Boston, doing research on human development. I also wanted to start a private practice. 

Soon after doing so, I realized that I needed much more training. Despite rigorous graduate training, something was lacking in me. It wasn’t academic knowledge, it was emotional knowledge, the sort that involved the ability to listen and to tolerate the anxiety of not-knowing as a therapist. I needed Anne’s sort of supervision to listen more fully to both the patient and to myself, rather than to rush into action that wasn’t really rooted in what was happening between us. Or, as Anne used to advise, “Don’t just do something, sit there.”

Many of us who were supervised by Anne can remember her warmth and generosity and her well-chosen axioms. For many years, Anne was a Professor of Psychology at the Fielding Graduate University in Santa Barbara, Ca, and Director of the Center for Psychoanalytic Studies at Massachusetts General Hospital in Boston. There is now a cohort of senior clinicians around the country—psychiatrists, psychologists, and social workers—who were mentored by Anne. Therapists who were trained by Anne later took her insights about one-to-one supervision and applied them to group supervision of trainees.

Her work reminds us that the early years of graduate psychology training are crucial in the identity of a psychotherapist. We need to feel “held” ourselves as we learn to “hold” patients struggling with their own mental health. Training supervisors to be able to provide a safe space, a holding environment, for young trainees is more important than ever. Often graduate students about to begin their internships ask: What should I look for in a supervisor? One piece of advice I give is: “Pay attention to how well they listen.”

If the supervisor doesn’t listen empathically to the therapist, it’s doubly hard for the therapist to listen well to the patient.