On being skilled and deskilled as a psychotherapy supervisor.

Those of us who take pride in supervising psychotherapy have a huge investment in keeping the flame of our profession alive and in successfully mentoring new generations of clinicians. To the extent that we succeed, we meet our professional ego ideals. We teach, cajole, inspire, and shape our students toward our own standard of professional excellence. If we are really lucky, we learn new things and grow in the process. By the same token, when we fail, the cut is deep and the challenge to our sense of competence is profound. The goal of this Grand Rounds is to explore the clinical process in supervision and to offer examples of clinical supervision that illustrate successful and failed instances in that process. Emerging ideas about intersubjectivity lead us to a renewed awareness of the influence the two parties have on one another. So if I as a supervisor am skilled, that depends to some extent on my student's participation in making me skillful and on my own part in increasing his or her level of clinical competence. By the same token, if I am deskilled (meaning that my skills are not proving adequate to this particular supervision), I suspect we are both participating in that sorry state, to our mutual detriment, to say nothing of the patient whose well-being ideally remains central to our concern. If measuring a successful therapy is an elusive goal, measuring a successful supervision is even more elusive. More poignantly, we remain in the dark about how the work can go awry so quickly when it does—or, for that matter, how to fix it. My own definition of an optimal psychotherapy supervision is one in which the supervisor is focused primarily on the clinical and professional development of the supervisee. Thus, the supervisor is always perched on the border between teaching the student and therapeutically addressing the implicit developmental impediments to the student's learning. The supervisor, in effect, must listen with a clinician's ear and speak with a teacher's mouth. To do less is to avoid the power in the supervisory situation. Although my context in writing this is the supervision of psychoanalytic psychotherapy, I believe that many of the same principles apply across the range of theories. Currently, we may be guided to some extent by new developments in intersubjective theory,1–3 which insist that all parties to the field are influencing and influenced by any processes and changes that occur in the clinical situation. From this perspective, the more overly interested I become in guiding the patient's therapy without appearing to do so, the less effective I become as a supervisor, and the more I have to note a potential resistance to the process either in the student or in myself. At the other extreme, the more I find myself feeling like an analyst of the student rather than like a supervisor, the more attention I must focus on the shared transference and countertransference between my student and myself rather than on the student's clinical work. After all, the goal of all this is to provide optimal clinical care to the patient, whose best interest is easily subordinated in the supervisory confusion. When supervision goes well, the experience is valued highly by both parties to the interaction. A supervision at impasse, however, is painful and anxiety-laden, and there are few guidelines for clearly setting forth a curative path. I am aware that my use of the words “cure” and “healing” in this context may make some of my colleagues uncomfortable, since those words imply a more clinical and less educative function. But this is just my point—that the clinical and the didactic are inextricably linked in the supervisory encounter. At the point of impasse, supervisors usually feel disabled. The tools available to use in the hour with a patient are not necessarily appropriate or helpful in the supervisory hour. From the point of view of the supervisee, it is difficult to imagine emerging from a serious impasse with a supervisor without feeling doubts and shame about one's work and, for that matter, without questioning one's competence and identity as a clinician.