Is it different from Generic Supervision?
Is that Integrative Supervision or Supervision for Integrative Psychotherapy and what is Integrative Psychotherapy anyway?
There is a straightforward definition for Integrative Psychotherapy on the BACP website: “… when several distinct models of counselling and psychotherapy are used together”.
As part of the skills for health exercise in defining competencies for psychotherapy and counselling, ‘integrative’ was also defined in this way and distinguished from ‘eclectic’ by this emphasis on ‘distinct’ and prescribed models.
However, practitioners who identify as Integrative and training organisations that offer Integrative trainings are more likely to give a definition that not only includes integrating body sense, feelings, thoughts etc, but also: not being theory-led; allowing that there are many potentially useful maps, none of which fully defines the territory; reliance by the therapist on their felt sense of the client together with their own personal integration of theory, their own exploration and self-awareness to support the client to deepen their self-knowledge through experience rather than theoretically-based insight. The less the therapist is able to be aware of their own process, the more limited will be their ability to help the client explore theirs.
Fundamental to most forms of longer-term psychotherapy is the belief that it is the therapist’s ability to be with the client, to explore and affirm who they are now with compassion and respect, that allows the client to become more known to and accepting of themselves; that in turn allows for the possibility of change. If we can become aware of the instinctive responses that we have developed for trying to manage the world, then we can grow the ability to inhibit them, explore alternative responses, and choose how to be in the world afresh from moment to moment.
Common to all forms of experiential therapy is the emphasis on experiment and experience over theory-led insight; however emphasis on the therapist’s own integration of different theories through personal experience is arguably unique to Integrative psychotherapy.
Is it good enough that therapists select theories through personal integration?
We are living at an interesting moment in the evolution of psychotherapy. The combination of recent research and developments in neuroscience mean that we may really be beginning to understand how the brain develops; we are already able to image some aspects of the impact of neglect on the maturing brain and we may actually be moving towards verifying – or at least needing to update – our varied assumptions about how people adapt to their early years and how therapy achieves what it does. Simultaneously there is growing demand for objectively verifiable ‘effective’ psychotherapy.
The government’s intention to increase access to psychological therapy, the concomitant wish to provide therapy cheaply, the Department of Health’s ‘agenda for change’ aimed at increased flexibility for the employer through developing transferable skills in the work force, the consequent endeavour to define competencies for psychotherapists and the movement to regulate the professions – ostensibly for the better ‘protection of the public’ – have all contributed to this demand. In addition, contemporary culture has individuals impatient for results and less willing to suspend judgement while giving the process a chance to unfold.
Yet there is much about quantitative psychotherapy research that can be challenged. Can psychotherapy be measured like a medical treatment? Do discrete forms of psychological distress really exist in patients? Is the therapy model the biggest source of variance? Does assessing the outcome of a manualised treatment validate what is in the manual rather than the skill of the therapist? Can results from such trials be generalised? Can a ‘treatment’ be considered to be evidence-based even though all of the variables that were controlled in the original research are varied when it is delivered?
Even if evidence does support a particular treatment – such as CBT – in particular circumstances, there is also evidence to suggest that the treatment does not achieve its positive outcome in the way that the underlying model would predict; this calls into question the basic assumptions underpinning the research. (Cooper, 2008:135)
As well as there being questions with which we need to grapple, we have an ethical duty to pay attention to the implications of relevant research for our own practice. However, as suggested by Botella (Botella, 1999), perhaps the outcome of research should not be to dictate what form of therapy should be practiced with each client but to make sure that what a given therapist is doing with a given client is being helpful.
Therapists have an ongoing responsibility to challenge what they do and how they think about their work. ‘Integrative’ is not a licence for a personal potpourri but a deeply held and constantly reviewed sense of what is in the best interests of each client.
The place of supervision
Part of the role of supervision is supporting this kind of reflection and supervision itself then becomes a piece of action research, a collaborative venture where all participants – client, therapist, supervisor and supervisor’s supervisor – reflect on and feedback into the process in their own way ideally, not only into the work with one particular client, but also into the therapist’s personal development and back to the wider body of research into what makes psychotherapy work.
Supervision for integrative psychotherapy has, at its core, the task of understanding the client’s experience through the use of the therapist’s own embodied experience and the varied lenses of different theoretical frameworks that feel relevant. None of the theoretical frameworks are ‘truth’ they are devices to support creativity.
Early models of supervision assumed that the role of the supervisor was primarily educative and that the need for supervision would diminish as the practitioner became more experienced. Many current models still privilege education, as if the therapist’s model of work was static and the supervisor’s role as ‘trainer’ central, but when the therapist is the instrument, the subtlety of the work needs ongoing supervision. Much of what passes between two people in a relationship happens outside of the awareness of either of them: body language (the client’s and our own), tones of voice, choice of words, etc can pass into memory without passing through our awareness. By giving ourselves up in a safe space to a bodied reverie on the client we can recall information that we didn’t know we knew. Part of the discipline of the therapist is to make space for this kind of reverie – if possible while still in the session! – which is easier with some clients than with others. Having witnesses present to the reverie allows more echoes of the out-of-awareness communications to be gathered.
One manifestation of this out-of-awareness communication is a ‘parallel process’ in which each person in the supervisory dyad, can find themselves enacting either player in the therapeutic dyad. Providing the behaviour is identified and deconstructed it can open up new possibilities for the therapist in understanding the client’s experience in therapy and in other relationships both historic and current. If the enactment is not disentangled much useful information will be lost and, at worst, the supervisory process may become as stuck as the therapeutic process.
More worrying, and particularly pertinent to training supervision, is where a struggling supervisory relationship might get enacted in the relationship between therapist and client; if a therapist feels criticised and inadequate in supervision, the client may feel criticised or even persecuted in the therapy session. The trust necessary to explore these dynamics is crucial to the supervisory process; taking care of the supervisory relationship is essential, particularly where the supervisor has some form of managerial or assessment role.
Parallel process is born out of the ability of the supervisee to bring to supervision aspects of the client they do not know that they know, with the supervisor drawn into reciprocating behaviour. By extension, group members can also amplify aspects of the therapeutic dyad and, out of the limelight, are less likely to be drawn in and correspondingly more likely to be able to articulate what may be being experienced by the client. This can be put to good use in role-play in which co-supervisees are able to capture some elusive essence of the client that the therapist has been blind to.
One further piece of subliminal communication is the extraordinary experience of the client arriving at the next session behaving as if having been a fly-on-the-wall at the preceding supervision session. I have seen different explanations for this phenomenon ranging from the collective unconscious at work, to the notion that quantum physics, with its action at a distance, can be combined with concepts like mirror neurons for a rationale. I have also come across suggestions that the client knows that the supervisory work has been done even before entering the room, evidenced perhaps by a dream they bring. However, the recollection of the dream or the decision to bring a particular dream, or indeed the way that a particular dream is retold, could equally be a response to a perceivable change in the therapist as they open the door.
I suspect that the perception of the client being stuck is an illusion and it is generally the therapist who is stuck. Once supervision has freed the therapist’s mind, the work can flow again, the client can perceive the new acceptance in the therapist and both are free to let go of the struggle to communicate whatever it was; the indigestible has been digested. I think that in seeing as magical the fact that our feeling of ah-hah in supervision changes the client, we over-value the role that our verbal communication of our understanding plays in the process of the client.
These mysterious processes at the heart of supervision are why supervision is vital for even the most experienced practitioner and what drew me to train as a supervisor myself. They are central to the work of all relational therapists whatever the model.
Many models for supervision suffer from the shortcoming that they presume the supervisee needs to master a static repertoire of technique in which the supervisor is presumed to be expert. This runs exactly counter to my vision of integrative supervision and indeed of integrative psychotherapy where, rather than apply a technique to a client, a therapist might suggest an experiment and help the client to explore something in a new way – as a fellow traveller, not as technician/subject. That is not to say that some techniques cannot be taught but they need to be taught in such a way as to give the therapist the felt experience so that they can be properly integrated into their work and arise from the client’s experience not from the theory.
In conclusion, the prime task of integrative supervision is the creation of a safe space where the nuances of the relationship co-created by client and therapist can be explored, where the therapist’s efforts to meet the client and explore their felt experience can be mused upon, where the therapist can access information that they have gathered subliminally, recognise their blind spots, projections, assumptions, hopes and fears and gather their courage to return and make another attempt genuinely to meet the client. The therapist’s most important tools are their own human responses and one of the essential roles of supervision is to help the therapist perceive, honour and support these responses and use them for the benefit of the client.
Integrative supervision is integrative both in the sense of modelling the practice of integrative psychotherapy – ie supporting the supervisee to explore their work in all its aspects in an accepting and respectful way – and also in modelling the principal of integrative psychotherapy that all therapeutic modalities may bring something interesting to bear but need to be synthesised by the therapist before they can be taken into the work; the supervisor is not teacher but co-explorer and supervision is one part of the cycle of action research that is ethical therapy. Ethical issues, boundaries and core skills may need to be aspects of the supervisory discussion but are no different from any other aspects of that discussion. Each participant will have observations and responses about the work and, for post-qualification supervision, the supervisor’s responsibility is to be there, to be honest and to be guided by the best interests of the supervisee’s clients.
Sally Forster is an Integrative psychotherapist and supervisor working in private practice in North London. She graduated from the Minster Centre in 1998 and has since been very influenced by Formative Psychology, the work of Stanley Keleman. She studied for her Diploma in Supervision at the Gestalt Centre with Gaie Houston.
BACP: Seeking a therapist, 26th August 2011
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