Organizational frames – an important tool in creating the potential
space
A case study of a training program
Marie-Louise
Ögren, Ph.D., Ulrika Olsson, B. Soc. Sc.
Marie-Louise Ögren, Ph.D.
Associate professor,
Licensed Psychologist and Psychotherapist,
Department of Psychology
106 91
Phone: +46 8 16 28 79
Fax: +46 8 16 62 36
Email: mlon@psychology.su.se
Ulrika Olsson, B. Soc. Sc.
Department of Psychology
Phone: +46 732 51 94 14
Email: ulolsson@yahoo.com
Introduction
This paper illuminates the use of
organizational frames as a means of creating a good enough holding environment.
The underlying thought is that a good enough holding organization may provide a
potential space for the groups operating within the organization (Stacey,
1996).
The point of departure of a theory
concerning the experience of organizational support in working life,
”Organizational support theory” (Eisenberger, Huntington, Hutchison, &
Sowa, 1986; Shore & Shore, 1995, i Rhoades & Eisenberger, 2002), is
that employees develop a conviction about whether, and the extent to which, the
company values their input and cares about their well-being. This is done in
order to assess the company’s willingness to reward increased work and to meet
socio-emotional needs. This is called ”Perceived Organizational Support” (POS).
POS is also regarded as an assurance that the organization will be supportive
and help when the need arises so that the employee can carry out his/her work
in an effective way and be able to manage stressful situations.
Results from a study carried out by
Rhoades Shanock & Eisenberger (2006) showed that a favourable relationship
between employee and organization has repercussions downwards in the hierarchy.
This can, for example, concern subordinates or customers, depending on where in
the hierarchy the employee finds him/herself and what type of post the person
occupies. The study also shows that there is a positive association between
leaders’ and followers’ Perceived Organizational Support (POS) and performance.
It
is reasonable to suppose that supervisors and their supervisees within a training
program are affected by the organization’s frames in a similar way to employees
in working life. There is reason to assume that the prerequisite for
supervisors to be able to offer a holding learning climate for the supervisees
is that they themselves have access to an organization that offers a
professional and trustful structure that has a holding capacity (Brown &
Bourne, 1996, referred to in Hughes & Pengelly, 1997).
Frames
are of great importance in psychotherapy in order to establish “a potential and
creative space”, as well as a secure environment for the therapeutic work. The
frames of the supervision sessions are considered as most essential for an
effective learning process and good treatment for the patient. An encouraging
and holding supervision climate may be due to the institution’s organizational
capacity to contribute to a secure and holding environment for the supervision
process.
It
is reasonable to suppose that the goals and frames of psychotherapy supervision
are of crucial importance for the design of the supervision. Goals, frames and
content are influenced in turn by whether the supervision is conducted within a
formal academic program or as part of the work of a mental health care unit. The importance of the organizational structure
and organizational framework for psychotherapy supervision is discussed in the
literature (Boalt Boëthius & Ögren, 2000; 2003; Ekstein & Wallerstein,
1977; Greenhalg, 2000; Proctor & Inskipp, 2001; Proctor, 2000; Szecsödy,
1990). However, the impact of the organizational frames on psychotherapy
supervision has up until now been remarkably neglected as an area of research
and systematic evaluation.
This
study is one of the first attempts to change this state of affairs by
highlighting the organizational frames of psychotherapy supervision in advanced
level training programs in
Organizational aspects of psychotherapy supervision
The
importance of the organizational frames, with
regard to clarity and explicitness, is emphasized by several authors (Boalt
Boëthius & Ögren, 2000, 2003; Greenhalgh, 2000; Proctor & Inskipp,
2001; Proctor, 2000; Rönnestad & Reichelt, 1999; Tveiten, 2000; Watkins,
1997). Explicitness regarding the contract and frames, between the supervisor
and the responsible institution, as well as between the supervisor and the
supervisee(s) constitutes the essential basis upon which supervision work, and
therewith associated strains, can and should rest. The training institution
should, within the organizational frame, assist with a clear, bearing structure
and, amongst other things, be able to offer the supervisor an opportunity for
support, and scope for reflection about the supervision process.
Based on models of individual supervision
(Ekstein & Wallerstein, 1977; Szecsödy, 1990) as well as studies of small
groups (Aronson, 1988; Boalt Boëthius, 1983; Cooper & Gustafsson, 1985), a
framework for group supervision has been described (Boalt Boëthius, 1989; Boalt
Boëthius & Ögren, 2000, 2003). This framework enables the process in group
supervision to be described and analysed with regard to three perspectives.
These perspectives, sometimes clearly differentiated and sometimes partly
overlapping, are: the core content or the object of supervision, the
interaction between the group members and the relationship with the supervisor
as an authority, and the organizational
framework of the supervision group.
Ekstein and Wallerstein (1977) invented the concept of the
”Clinical Rhombus” to describe the complexity of intrapsychic and interpersonal
problems in the supervision situation. The model refers to the interaction
between the patient’s problems, the supervisee’s training institution and the
clinical institution.
Supervisor
Administration Patient
Figure 1. The clinical
rhombus. Ekstein & Wallerstein, 1977, p. 19.
An extension of the
concept of the Clinical Rhombus was made by Szecsödy (1990,
1994). He suggested that the interaction between patient, therapist and
supervisor is mutually influenced by each party and, moreover, influenced by
other interdependent relationships with staff, other patients, families,
administrations, organizations and society outside the institution.
Figure 2. The extended
clinical rhombus, Szecsödy, 1990, p. 10.
The current study focuses
partly upon organization and administration and partly upon supervisors. The
supervisees are also in focus, although indirectly, and this is indicated in
Figure 1 and 2.
The
learning situation of supervision in a training program
Psychotherapy supervision is a
special form of learning, in which the experienced-based and emotional
components have a dominating and prominent place. One is constantly exposed to
situations in which old ways of feeling and thinking must be reconsidered, and
in which a new state of equilibrium between knowledge and emotion must be
attained.
From a psychodynamic
perspective the emotional component is a fundamental part of a process-oriented
supervision. Unconscious levels are engaged, as a fundamental part of
psychotherapy supervision, and give rise to both insecurity and resistance, as
well as to various defensive attitudes (Boalt Boëthius & Ögren, 2000, 2003;
Szecsödy, 1990). Only in a limited respect is change a matter of a process on
an uncomplicated conscious level. The individual will also give up personality
patterns that often have powerful positive charges, or which may be essential
at an unconscious level (Szecsödy, 1986). Personal learning and growth are
therefore often associated with anxiety, which is why a secure and holding base
(organization) is needed so that learning and growth are promoted (Boalt
Boëthius & Ögren, 2003; Moxnes, 1991).
Aim and research questions
One aim of this study was to
illuminate the organizational frames of psychotherapy supervision at psychotherapy
training institutions on a postgraduate level in
How did supervision
administrators and psychotherapy supervisors, respectively, describe and
perceive:
1. The holding function
of the organization?
2. The significance
attached to the organizational frames as contributing to a potential and
creative space in the supervision process?
Method
The training institutions
The institutions involved in this
study were all university affiliated professional psychotherapy training units.
The training units offered an advanced training program at postgraduate
training level for psychotherapists. The advanced programs were part-time
programs. One to four different treatment orientations were represented at each
training unit (e.g. child and adolescent, existential, family, cognitive,
cognitive-behavioural, psychoanalytic and psychodynamic orientation). Both
funded and privately-funded training programs were represented.
The
supervisees had one or more patients in psychotherapy and participated in
supervision. The psychotherapy supervision aimed at facilitating the learning
process with regard to both the clinical work and the theoretical understanding
of this work, as well as to help the supervisee to develop her or his
professional role as a psychotherapist. The goal of the training was for the
trainees to qualify as authorized psychotherapists.
Research groups
Supervision administrators. The sample comprised 18 supervisor administrators, 10 female and 8
male, from 13 different training units. The average age of the administrator
was 60 years (ranging from 49 to 65 years). Most supervision
administrators were authorized psychotherapists/psychoanalysts, with an average
of 7 years (ranging from 1 to 18 years) experience as a supervision
administrator. Half of the respondents worked at institutions where the
supervisees or the employer paid for the training. Two of those who had
completed the questionnaire were also interviewed. In this study the person
responsible for the supervision part of the course is referred to as
supervision administrator or course leadership.
Supervisors. This
sample comprised 25 psychotherapy supervisors, 16 female and 9 male. The
average age of the female supervisors was 53 years and for male supervisors 59
years. The average experience as psychotherapy supervisor was 14 years (ranging
from 3 to 26 years). The supervisors had experience of having supervised an
average of 4 different training units (ranging from 1 to 10 training units).
The supervisors had a psychodynamic or an existential orientation.
Instruments
Data from the supervision administrators were
mainly collected via an Administrator Questionnaire (AQ). The Administrator
Questionnaire (AQ) focused on: 1) responsibility and role functions, 2)
information and communication, 3) routines and 4) the holding function of the
organization. The questionnaire consisted of open-ended questions. Two
interviews were made as a complement to the questionnaire data.
Data
from the psychotherapy supervisors were collected via a Supervisor
Questionnaire (SQ). The Supervisor Questionnaire (SQ) focused on: 1) the
significance of the organizational frames, 2) responsibility and role
functions, 3) the holding function of the organization and, 4) the impact of
the organizational frames on the learning process in supervision. The
questionnaire included open-ended questions as well as ratings on a five point
scale ranging from not very important (1) to very important (5).
Data processing
The
responses from AQ and SQ, respectively, were transcribed and independently
scrutinised by the authors. An open coding (Strauss & Corbin, 1998) was
carried out by each examiner according to the research questions. Various
possibilities for coding were tested separately and independently, and these
were later discussed and a consensus was reached resulting in a number of
themes deemed to be relevant to the issue in question. Statements were selected
via key words and were in turn sorted into the most appropriate category. The
statements were at the same time central to one of the issues being addressed
(Strauss & Corbin, 1998).
Results
The presentation of the results
follows the research questions. The presentation under the various headings is
based on data from the Administrator Questionnaire (AQ), the two Administrator
Interviews and the Supervisor Questionnaire (SQ). Under the heading for each
question with respective sub-heading the data from the supervisor
administrators is presented first, followed by data from supervisors.
The holding function of the organization
This question is divided
into the following four themes: Information and clarity, Course leadership’s
competence (only data from the supervisors’ point of view were available),
Regularity and Routines.
Information and clarity
Information to supervisors and
supervisees was often disseminated in more than one of the following ways:
personal contact, letter, email, information meetings, telephone, notes in
pigeon-holes, website, at course meetings and through assessments. One
institution described how the supervisees and the supervisors received
comprehensive written information that was distributed at the start of the
course, amongst other things, the criteria for passing the clinical component
of the course. Despite this it was not unusual that both supervisors and
supervisees later claimed that they had not received certain information.
That is the difficulty with information. What does one
have to do to see that it gets there?
The supervisors were informed and prepared in various ways for their
supervisor assignment. This could be a matter of supervisor meetings, written
instructions, that the supervisors received the course plan and all the course
components as well as regular information about schedules and changes. The
opportunity to attend a number of seminars, to receive lecture notes and used
articles as well as participate in discussions about the course’s design was
also mentioned. Other channels of information reported were further training,
joint literature studies, “acclimatization” via supervision assignments at the
basic level training and joint assessment of therapy sessions each term. That
the supervision administrator talked with the supervisor and that the
supervisor received information about the selection process was also
emphasized.
Explicit work descriptions were sought after at certain institutions, e.g. in the form of written
instructions for supervisors regarding what was expected of them. Someone
mentioned that it was an organizational frame factor of significance for
supervision and the learning process.
There was great variation between different institutions regarding views
about allocation of responsibility
between different roles. At most institutions the supervisors could have several roles, e.g. lecturer, seminar
leader, examiner, researcher, course co-ordinator and course paper supervisor.
The difficulty in having double roles, i.e. to be both supervision
administrator and supervisor was also mentioned.
Better not to be a supervisor when one is supervision
administrator. ... they are conflicting activities.
Who was
responsible for examinations concerning supervision varied. It could be the
supervision administrator, supervisor committee, the director of studies, the
supervisor or the (supervisor) staff. The supervision administrator was
often responsible on the funded training courses, whereas it was often the
supervisor on the privately-funded courses. Where the
treatment responsibility lay
also varied between the different institutions. It could lay with the
supervisor, the supervisee or both. It could also lay with the supervision
administrator, the head of department, responsible physician, the person in
charge of treatment at the institution where the treatment was carried out or
the unit’s director. In a few cases the training institution initiated a contact with the supervisee’s employer.
ALL the supervisees’
unit directors/department heads were also invited once an academic year to a
directors’ meeting at which the frames and the opportunities to conduct both
training and client work were made apparent and discussed. … However, in all
cases we have demanded a written approval from the respective director before
the supervisee starts the training course and that it is sanctioned (with or
without funding) by the management group and that the supervisee can be
provided with the opportunity to conduct treatment there.
Regularity
In most cases the responsibility for
the supervision component of the course lay with one and the same person during
a whole training course, but in some places the responsibility was shared
amongst supervision administrators. In one case it also became apparent that
the role of supervision administrator had shifted from one person to another
during the running of the course.
In most cases it was the supervision
administrator(s) who appointed and who were in
contact with the supervisors. In one case the supervisors were appointed by
the supervisees themselves with the supervision administrator. When problems
arose and to report on supervision the supervisors contacted the supervision
administrator.
The questionnaire responses showed
that the institutional support to the supervisors varied from institution to
institution. A few institutions did not offer any support, in some cases due to
economic factors. At other institutions the support to the supervisors was
well-developed.
... all supervisors were
offered an updating of the course’s content. With approximately one lecture or
study day per term they were able in “miniformat” to meet the respective
principal lecturers for the current term. They were also able to read and in
other ways come into contact with the updated literature and course content. At
the moment there is a further training course in pedagogics with one study
evening per term regarding pedagogic issues and current questions such as
gender perspective, new technical equipment at the institution, etc.
The supervisor meetings, supervision
of supervision, further training, lectures, reading articles about training
supervision, joint or more private discussions, joint assessment, access to
clinical work as well as external consultants were also issues raised as
accessible support for the supervisors.
The supervisor group is very
important, ... if a supervisor has problems, then it is of course always the
case that others have experienced something similar earlier … so it can be very
supportive and help so that it does not become so dramatic.
Frequency and regularity of the supervisor meetings varied greatly. On one course there
had not been any meetings at all, as the supervisors were spread out over a
large area geographically. Another institution mentioned two meetings in three
years and at a couple of places the meetings took place once a year. However,
it was most common that the supervisor meetings were held once or twice a term
although sometimes the meetings were held once a month or every fortnight.
The focus during the
supervisor meetings was on information to the supervisors, information about
the future, making an inventory of problems, evaluating the supervisees as well
as how the supervision process was developing. Certain institutions reported
that the focus was on what was considered to hinder and promote learning,
criteria for what the supervisees should learn, method and theory discussions
as well as current issues. At one institution group discussions were held in which
approx. 5-7 supervisors per group were given the opportunity to raise
individual questions concerning supervisees in order to hear the views of the
other supervisors in the group.
Routines
Routines for conflict management varied somewhat between the different
institutions. In some cases it was the routine to invite the supervisee (or
supervision group) to a meeting with the supervisor. A few mentioned the
possibility of bringing in an external consultant. Sometimes conflict
management resulted in a person changing supervision group or that someone
received individual supervision instead of group supervision. Close
co-operation between the supervision administrator, the course leadership, the
supervisees and the supervisors was considered to be an important factor in
preventing the development of conflicts.
… one reason that the
supervision works is the close and functioning co-operation between the
supervision administrator, the course leadership, the supervisees and the
supervisors. When problems arise extra evaluation take place in which
supervisor and supervisees are offered extra time to talk with the course
leadership or with its representative.
Routines for failing. Supervisor and evaluation meetings were emphasized by many as important
sources for identifying the risk of failing the course. However, one of the
commonest measures mentioned in this type of situation was meetings with the
supervisees. At some institutions the supervision administrator, the supervisor
and lecturer or study director were present at these meetings. At one
institution the supervisee was automatically allotted a new supervisor on
failing and could thereafter be passed or be required to receive further
supervision. In one case it was reported that the supervisee was recommended to
take a break from her/his studies. Rating of therapy sessions was also
mentioned:
Video-recordings of therapy
session are rated firstly by the supervisor concerned; a second opinion is then
given by the director and the study director.
Routine procedure regarding failing
or the risk of failing often comprised several steps:
The supervisee’s supervised
work is evaluated annually by ... . If there is a problem this is in the first
instance taken up by the supervisor who offers the supervisee support and help
to develop. If the supervisee’s supervised work cannot be approved or if the
client breaks off the treatment before the two years required to pass, the
supervisee is offered the chance to take on a new client. If the supervisee’s
work is still assessed as having shortcomings that are unacceptable there are
written routines for how this should be dealt with meticulous documentation,
meetings with and written information to the supervisee in several steps.
In several cases the supervisee was
offered extra resources, e.g. in the form of continued consultation after the
completion of the course. One respondent mentioned that this created less
financial problems if it was a case of individual supervision, where the
supervisor in all of the cases had been able to “push forward” the supervision
and therewith also the withdrawal for remuneration. In connection with group
supervision it was discussed from case to case how the extra costs could be
resolved. One respondent reported that the supervisee was responsible for the
extra cost incurred if the supervision needed to continue outside the frame of
the course. The institution tried as far as possible to prevent such situations
arising, e.g. by recommending that the supervisee did not choose clients where
the risk of dropping-out was high. It was also mentioned that if a supervisee
was failed on a privately-funded course that the course fees were not repaid.
Someone pointed out that
the lecturers/supervisors had a great responsibility in the failing process, as
it was up to them to show which criteria the supervisee had not fulfilled.
Failing somebody was considered to be a difficult process for all parties and a
couple of respondents emphasized that it meant a minor trauma or a violation
for the supervisee. The routine concerning failing was also highlighted as a
security for the supervisees:
... I have had supervisees
that have thought that they would complete term six and receive their
authorisation and whom have been told by the supervisor during the final weeks,
“I cannot pass this” and I think that is poor, because then the supervisor has
all the power and the supervisee has to accept that she/he has not passed, so
that it’s this that the lecturers/supervisors find difficult, I think that from
a students’ rights perspective then it is something good.
A couple of institutions emphasized
the importance of admission interviews in order to avoid having to fail
someone. One reason that was given for this was that it was not easy to fail
someone absolutely as the supervisee had the right to appeal against the
decision.
Routines for evaluation of the supervision’s quality varied somewhat.
At certain institutions the evaluation took place chiefly through written
assessments. In some cases the supervision was only assessed through the
supervisor or the supervisee’s supervised work. Supervisor meetings, further
training of supervisors, regular reports to the institution’s board, continuous
assessment within the supervision group and that the supervisor administrator
had a 20 minute meeting with every supervisee annually were also mentioned as
possible scenarios. At one institution work was in progress to find suitable
assessment criteria apart from the usual course assessment. In a few cases an
assessment was carried out more irregularly.
All in all there
appeared to be a certain variation between different training institutions.
Improved economic resources for supervision were sought across the board, not
least in order to be able to manage problems arising (e.g. if a client breaks
off the therapy or moves and the supervisee requires increased supervision). At
institutions where supervisors and supervisees were spread out over a large
geographical area the supervisor meetings became especially costly, which was
considered to be a major problem.
To hold supervisor meetings
during the terms. Difficult and costly to organize as the
supervisees-supervisors are spread across the country. – An organization that
saw to it, guaranteed, that the supervisors had comparable norms would have
been desirable, but not easy to achieve!
Continuous
further development of the training institution concerned was considered desirable
at the same time as its sensitivity regarding the economic frames was
highlighted.
The organization of the training
with regard to course leadership, supervision administrator and forms of
teaching were considered to be of great importance for the supervision. The
definition of the supervision task in terms of training goals, number of
supervision hours, supervisor meetings, target groups of supervisees and
patients were considered to be important parts of the organizational frame, as
well as overall goals and the training’s orientation.
An overhaul of the supervisors’
experiences of the importance of the organizational frames is evident from the
overview presented below.
Table 1. Supervisors’ ratings of the
importance of different organizational frame factors for psychotherapy
supervision in a training context
|
|
1 |
2 |
3 |
4 |
5 |
M |
|
Information
about routines concerning conflicts/failing
|
|
|
|
5 |
20 |
4.8 |
|
Support
regarding conflicts/failing |
|
1 |
|
2 |
21 |
4.6 |
|
Information
to supervisors |
|
|
2 |
6 |
17 |
4.6 |
|
Easy
access to those responsible |
|
|
2 |
14 |
9 |
4.4 |
|
Possibility
of supervision of the supervision |
|
1 |
1 |
11 |
12 |
4.4 |
|
Accordance
between information given to supervisors and supervisees |
|
|
5 |
10 |
10 |
4.2 |
|
Supervisor
meetings |
|
|
5 |
10 |
10 |
4.2 |
|
Contact
with supervisor colleagues |
|
2 |
8 |
10 |
5 |
3.7 |
|
Information
about routines for selecting group members |
3 |
3 |
14 |
6 |
2 |
3.1 |
|
Total |
3 |
7 |
37 |
74 |
107 |
4.7 |
Information about the routines
concerning conflict management and failure was considered to be most important
together with the supervision administrator’s information to the supervisors.
The accessibility of the course management as well as the possibility of
receiving support in the form of supervision of supervision were similarly
regarded as being of great importance.
Information and clarity were
throughout reported to be crucial factors for the organization’s ability to
hold the supervised client work. It was considered important for the supervisor
to have access to recurring information about current theory courses, and the
supervisees’ theoretical knowledge and performance. Clarity regarding frames
was considered important for both supervisor and supervisees in order to
promote a good climate in the supervision.
Lack of clarity from the
course leadership creates a paranoid atmosphere amongst the supervisors and
supervisees.
Concrete connections between course
plan, course leadership and lecturer/supervisor were emphasized as were clear
information channels between course leadership, supervisors and supervisees.
Clarity concerning the clinical unit’s organization and routines were also
emphasized.
Without clear frames it is not possible to conduct
meaningful psychotherapy supervision!
Clear time and space frames,
i.e. that the organization ensures that the supervision has a ”sheltered room”.
Clearly delineated areas of responsibility – who has responsibility for what.
Clear and concrete regarding finances and the scope of supervision. Clear
boundary between training/supervision/organization. That the organization
respects supervision times and, e.g. does not send people on courses. Routines
for documentation.
A clear framework concerning
supervision attendance requirements,
documentation, confidentiality as well as number of clients that the
supervisees were expected to work with was emphasized as important.
Course leadership’s competence
The course leadership’s competence
was regarded as an important organizational prerequisite for psychotherapy
supervision on a training course. A course leadership that reflected, not too
rigid, made plans and capable of laying long-term plans was considered to
promote work in the supervision. Also emphasized was the importance of
well-considered strategies for various situations that could arise for both
supervisees and supervisors.
Important that the course
leadership is competent and knows what it’s all about, preferably that they
have experience from having been in the field of supervision.
The course leadership’s
competence is important as is the course leadership’s knowledge about the
individual supervisor’s experience in order to be able to match
supervisor/supervisee/group.
Regularity
The accessibility of the course leadership was considered to be of the
greatest importance. Regular contact between course
leadership and supervisors (supervisor meetings, information, contact
opportunities with colleagues) was emphasized as important so that as
supervisor one would know who to contact in difficult situations.
The best thing is if there
is a regular contact between the supervision administrator and supervisor (supervisor
meetings, clear information, and contact with supervisor colleagues) rather
than an emergency turnout in difficult situations
Regular supervisor meetings, that were well-prepared and where the
proceedings were documented, were considered to be of the greatest importance. In
connection with supervisor meetings the course leadership ought explicitly to
initiate a discussion about what was considered to be important components and
requirements in the supervision.
Furthermore, there was value in the supervisor meetings fulfilling the
function of involving the supervisors in current development work within the
training. Supervisor meetings were considered to fulfil an important function
in enabling supervision administrator(s) and supervisor colleagues to discuss
problematic supervision situations. The importance of providing space for this
was emphasized. One prerequisite for being able to raise difficulties
concerning the supervision was considered to be that the course leadership
created the conditions for a secure atmosphere in the supervisor group. To
receive support and help from a competent and insightful course leadership was
considered to strengthen the supervisor, the supervision group and the
supervisee.
Formal and informal contact
with supervisor colleagues is important just as the supervisor meetings provide
scope for support and reflection.
Information about goals,
support in situations that are filled with conflict, ethical dilemmas,
discussion forums about supervision and in doubtful cases regarding passing of
the supervision.
The organization’s concern for competence development for lecturers and
supervisors was
perceived to be of great importance. Recurring supervisor meetings with clear
structure and content that met the supervisors’ need of discussing current
issues and at the same time had a further training purpose were considered to
be of great importance. Lectures and seminars that supported the supervision
process were of great value. Discussion of supervision cases for educational
purposes was perceived as positive as was the course leadership’s support for
research and development of the institution’s work.
Clear routines within the
organization were considered to be of fundamental importance for how one could
work in the supervision. This concerned as good as all areas, from established
frames and routines for the supervision regarding its extent, documentation,
session reports, diagnostic and therapy summary reports etc. to routines for
passing/failing and evaluation. A readiness on the organization’s part in the
form of clear routines about how to manage conflict situations and antagonisms
arising in connection with the supervision was perceived as increasing the
security for both the supervisor and the supervisee.
The organizational frames’ contribution to a potential space for
learning in the supervision process
In addressing this question organizational
frame factors are highlighted that are considered to have had/have a
promotional and inhibiting affect respectively on the learning potential of the
supervision.
Supervision
administrators
Frame conditions that promoted potential
space for learning in the supervision process
Communication
was reported to be an important factor in creating a flexible and free climate
in the supervision. This could, for example, be needed in the case of extra
supervision where the risk of being failed paralysed the supervisee, which
naturally inhibited the supervision work.
... to supervise, to be that
sort of extra resource with someone who knows that failure is in the air, then
one really has to make an effort to create a climate that is open enough to be
able to work in … here I availed myself of the organization, I brought up the
organization and how it was for her and for us and where we were.
Explicit organizational frames were mentioned as a tool that could be used to
create as promoting and creative a climate as possible for the learning process
in supervision.
Naturally one needs to have
sufficiently clear, perceptible frames so that one knows, ... what space one
has and also what possibility one has of affecting the space even more, so that
it becomes even larger. I believe that the authority vested in all who work in
the organization is very important … for example, we do not have so much in
writing [about role descriptions] but we try … orally to find ways of defining
what one is to do, so that within one’s own area, or in the small protrusions
one can find in the area, one is permitted to be creative and invent more, move
freely and have fun, feel the creativity.
A committed staff that considered the work to be enjoyable was
considered to be an important factor for creating the security needed to let
creativity flow.
One cannot expect the
supervisees to be creative if we are not. And then one must open up and let go
a little so that it can be [a little space] within the existing frames and
within all the strains that there are, if one is now talking about a specialist
training, that one can in any case test and examine and it is just such a
climate in which one is permitted to examine.
Frame conditions that inhibited potential
space for learning in the supervision process
Conflict of loyalty was emphasized as a difficulty in the role as supervision administrator.
An example was given in which a supervisee wanted to change supervisor and
raised the question with the supervision administrator. It was suggested that
the supervisee and the supervisor should talk about it. The supervisee then
wanted the supervision administrator to be at the meeting.
But then of course I am
actually a support for both supervisor and the supervisee in that situation,
like a third party so to speak, looking out for the whole training situation
but also for the supervisor who is actually an employee on this particular
training course.
Delicate situations have not always been possible to solve with the help of the existing
frames. This was illuminated with an example from a difficult conflict
concerning group supervision.
... this is a course in
which one is to think about processes and try to understand what they are … and
then we have to try and reflect over the nature of the conflicts. … What we
didn’t do then and what I have learned was that I never spoke with the parties
separately as I perceived it to be a group process and that they must try to
understand what was going on with the group … Sometimes they are such delicate
situations that the frames or the organization are no help in finding a
solution.
Supervisors
Frame conditions that promoted potential
space for learning in the supervision process
Explicitness and clarity regarding
the organizational frame factors were again perceived as completely crucial in
being able to create a favourable learning climate in supervision. Stability and clarity in the framework
must, however, be accompanied by a healthy
flexibility and support from the course administration so that each
supervision scenario can be discussed and afforded the necessary space so as to
reach an optimal solution.
The course leadership’s competence, ”wisdom”, was considered to be a valuable
contribution to a creative and favourable learning climate in the supervision.
The course leadership’s familiarity with both the supervision situation and the
difficulties that could arise as well as knowledge about the individual
supervisors inspired trust and confidence, which was reflected in the
supervision’s potential.
The course leadership’s ability to take responsibility for and hold the total training situation and the
supervision was considered to be of great importance. The course leadership’s
ability to take care of, protect and respect supervision time emphasized the
significance and potential of supervision as an important learning forum.
The course leadership’s ability to adhere to the agreed frames for supervision and client work was
perceived as crucial in creating a creative space for learning in the
supervision.
When one adhered to the
prearranged frames in connection with a supervisee developing paranoid symptoms
it made it easier for the group members to understand and for the supervisee
with problems to leave the course.
In connection with a
supervisee having particular difficulties it has been valuable to have a
dialogue with the course leadership so that it has been possible to take the
correct steps, for example, that the supervisee has received extended or
individual supervision.
The importance of the framework being so explicit that problematic
situations that arose could be resolved was expressed by many.
Scope for reflection at the supervisor meetings about current and problematic
supervision scenarios contributed to recreating a potential space for a
creative learning climate.
The training organization’s imposed recurring evaluations were considered
important for checking on current work in the supervision and for nurturing the
creative learning space.
Frame conditions that inhibited potential
space for learning in the supervision process
The supervision administrator ’s lack of knowledge was emphasized, which, for example,
could be expressed in what the course leadership expected the supervision to
contain, without this being in accord with the purpose of the supervision. The lack of fixed routines as well as
unclear communication between the course leadership, supervisor, and supervisee
was considered to contribute to splitting and acting out, which in turn reduced
the creative space in the supervision.
When there have been unclear
instructions in the course plan about how a problem student should be treated
then it has happened that a supervisee has been given too many chances with
both supervision and clients.
Lack of clarity regarding responsibility and authority for assessment was pointed to as
having an extremely inhibiting effect on the supervision. This was transmitted
as insecurity also to the supervisions in progress that were not primarily
involved in the conflict situation.
Have once experienced that
the course leadership repudiated the supervisor’s “fail” decision. For a long
time it was very difficult to work. Other supervisors didn’t see that as
supervisor one had generally lost one’s mandate to work. The only right thing
would have been if all the supervisors had left the course because of this
serious infraction of the frames.
When a “failed” supervisee
was to be assessed in a new supervision (I was supervisor 2) it turned out to
be difficult. The process became something of a formality. A further therapy
and supervision were formalities that were unable to bridge the difficulties
that the supervisee tried to conceal. The contact with the course leadership
was good, but the assignment was difficult (impossible).
One supervisee who had had a
training case at another location/institution/workplace and who did not have
the course leadership’s knowledge about routines and way of working there,
created insecurity in both the supervisee and me, which had negative
consequences for the supervisee’s way of encountering both the patient and me
as supervisor.
Furthermore, it was pointed out that
the supervision was negatively affected when the treatment organization’s
frames, where the supervisee conducted her/his client work, clashed with the
frames of the training organization, and when
this was not made clear by the course leadership.
Distance from and lack of contact with the course leadership were perceived to have an
inhibiting effect on the work in the supervision just as the lack of regular
supervisor meetings. Uncertainty about the content in the training component of the course that was
to be practised in the supervised patient work was considered to create
uncertainty in the supervision.
On one occasion when the
course plan was altered regarding the theoretical seminars I could no longer
feel certain that the supervisees received the theoretical knowledge I had
counted on. In that case it would have been important to have contact with and
give information to the supervisors.
When the supervisees were told one
thing and the supervisor another this created confusion in the supervision.
Confusion also arose when the institution had a shortage of accommodation so
that there was no continuity as to where the supervision would be held. When a course had its resources cut back
so that the number of supervision hours were suddenly reduced, confusion and
uncertainty in the supervision work also arose and creativity was
affected.
Discussion
To summarize the results, a certain
lack of uniformity could be discerned regarding the design of the organizational
frames at the various training organizations. In certain cases the
organizational framework was well thought out whereas in others it seemed to be
less well planned. Furthermore, the frames’ design was sometimes limited by
economic and/or geographical considerations. Overall the supervision
administrators showed an awareness of the frames’ importance. Among the
supervisors there was a consensus about the importance of the organizational
frames. The importance of clarity in the framework coupled with flexibility on
the part of the course leadership was emphasized throughout. The course
leadership’s competence and accessibility were also emphasized as being crucial
for a functioning supervision situation. Explicit information to all concerned
parties was also considered to be of major importance.
The results indicate that the
supervision process and supervision outcome are to a great extent affected by the administration, not least when clear criteria and
framework concerning the supervision component are lacking or when the flow of
information does not work satisfactorily. The study also shows that the
supervision situation is further complicated in the absence of a clear role and
responsibility distribution between the supervision administrator and the
supervisor, e.g. if the course leadership repudiates the supervisors “failing”
of a supervisee. Organizational structure and support to the supervision
administrators appeared to be of importance for what support the supervision
administrators could give the supervisors in relation to the supervisees.
Recurrent further training and opportunities to openly ventilate problem
situations with course leadership and with supervisor colleagues were
considered to make things easier for supervisors to create favourable learning
climates in the supervision. This is therefore in accord with the theories
concerning the ”Clinical Rhombus” (Ekstein
& Wallerstein, 1977) and ”the extended clinical rhombus” (Szecsödy, 1990, 1994), which show a high level of
interdependence between, amongst others, the supervision administrator, the
supervisor, the supervisee and the patient as well as the parties to a great
degree being affected by one another.
Supervision
entails a special form of learning in which earlier experiences, feelings and
attitudes need to be worked on and integrated with the new knowledge and
experiences that the supervisee receives through the theoretical and clinical
components of the course. This process easily awakens anxiety and the
supervisee can feel exposed in the supervision situation where his/her ability
as a therapist is assessed.
The
paradox of supervision in a training context, i.e. of the supervisee being
exposed to assessment and at the same time talking about mistakes and
difficulties, in order to be able to develop further, makes the learning
situation a complex one. A prerequisite for being able to report honestly what
is happening in the supervision appears to be that the organization utilizes the
tools it has at its disposal in order to create a potential space in
supervision. These tools consist of making the organizational frames as
explicit as possible for both the supervisor and supervisees. The goals of
supervision need to be clarified as well as the criteria for passing. To
disseminate the same information to both supervisors and supervisees was
perceived as counteracting confusion and contributed, according to the
supervisors, to an atmosphere of openness in the supervision (Holst, 2003;
Samec, 1995; Wrangsjö, 2001). The possibility to resolve conflicts and
problematic situations that could arise in connection with the supervision was
substantially greater if the organization had clear routines and a supportive
framework.
This
study has had a general focus on the organizational frames’ importance for
psychotherapy supervision. It is likely that the organizational framework
becomes even more important when supervision occurs in group format, as so many
persons and interactions within and between the supervision group(s) are involved.
Further studies need to be carried out in this area.
The
study has primarily focused upon the organizational frames’ design in advanced
level psychotherapy training programs in Sweden. As these courses lead to
authorisation, they are subjected to a meticulous, state quality control at
regular intervals. This can be a contributory factor to the fact that the
organizational frames were so well-developed and planned as this study shows
them to be.
The
results of this study are certainly limited to Swedish conditions but are in
accord with previous international research. The importance of a holding and
supportive organization for the employees (in this case the supervision
administrators and the supervisors) so that these in turn will be able to create
favourable conditions for their employees (in this case the supervisees) is
emphasized by, for example, Rhoades Shanock and Eisenberger (2006).
Supervisors’ and supervisees’ perception of the holding function of the
organization compared to their feelings of creativity and anxiety during the
supervision sessions should be examined in further
studies. Future studies also ought to focus upon the importance of the
organizational frames for supervision within the treatment organization.
Acknowledgement
Support for this research was
provided by The Swedish Research Council, 721-2002-2586 (to Marie-Louise
Ögren). We gratefully acknowledge the assistance of Professor Siv Boalt
Boëthius, Ph.D. and the ISPSO organization committee.
References
Aronson,
M. L. (1990). A group psychotherapist’s perspective on the use of supervisory
groups in training of group psychotherapists. Psychoanalysis and psychotherapy, 8 (1), 88-94.
Boalt
Boëthius, S. (1983). Autonomy, coping and
defence in small work groups. Psychological processes within and between group
members. Stockholm: Almkvist & Wiksell International.
Boalt
Boëthius, S. (1989). Analys av små grupper I ett socialpsykologiskt perspektiv.
Teorier och metoder (Theories and methods for the analysis of small groups from
a social psychological perspective). In I. Widlund (Ed.), Gruppanalytiska perspektiv (Group analytic perspectives) (pp.
72-106). Stockholm: Natur & Kultur.
Boalt Boëthius, S.
(1993). Grupphandledning och samspelsprocesser (Group supervision and
interaction processes). In D. Stiwne (Ed.), Perspektiv
på handledning (Perspectives on supervision and adjacent fields) (pp.
160-187). Stockholm: Natur och Kultur.
Boalt
Boëthius, S. Ögren, M-L. (2000). Role patterns in group supervision. The Clinical Supervisor, 19 (2), 45-69.
Boalt
Boëthius, S. & Ögren, M-L. (2003). Grupphandledning.
Den lilla gruppen som forum för lärande (Group supervision). Stockholm:
Mareld.
Brown, A. & Bourne,
I. (1996). The Social Work Supervisor. Buckingham: Open University Press.
Cooper, L. & Gustafsson,
J. (1985). Supervision in group: An application of group theory. The Clinical Supervisor, 3 (2), 7-25.
Eisenberger, R.,
Huntington, R., Hutchison, S., & Sowa, D. (1986). Perceived organizational
support. Journal of Applied Psychology,
71, 500–507.
Ekstein, R. & Wallerstein, R. S. (1977). The teaching and learning of psychotherapy. New
York: Basic Books.
Greenhalg, P. (2000). Emotional growth and learning. London and New York: Routledge.
Holst, Y. (2003). “Vad jag inte vågade säga…”
Finns det material som studenterna i sin utbildning inte berättade för sin
handledare, och i så fall, vilka skäl anges? (”What I didn’t dare to say…” Is
there material that the students in their training did not tell their
supervisor, and if so, what reasons are given?). Psykisk Hälsa, 1 74-83.
Hughes, L. &
Pengelly, P. (1997). Staff Supervision in
a Turbulent Environment. Managing Process and Task in Front-line Services.
London: Jessica Kingsley Publishers Ltd.
Moxnes, P. (1991). Vardagens ångest hos individen, gruppen, organisationen
(Everyday anxiety in the individual, the group, the organisation). Stockholm:
Natur och Kultur.
Proctor, B. (2000). Group supervision. A guide to creative
practice. London: Sage publications.
Proctor, B &
Inskipp, F. (2001). Group supervision. In J. Scaife (Ed.), Supervision in mental health professions. A practitioner’s guide
(pp. 99-121). London: Brunnder-Routledge.
Rhoades, L. & Eisenberger, R. (2002).
Perceived Organizational Support: A Review of the Literature. Journal of Applied Psychology 2002, Vol. 87,
No. 4, 698–714.
Rhoades Shanock, L. & Eisenberger, R.
(2006). When Supervisors Feel Supported: Relationships With Subordinates’
Perceived Supervisor Support, Perceived Organizational Support, and Performance. Journal of Applied Psychology 2006, Vol.
91, No. 3, 689–695.
Rönnestad, M. H. & Reichelt, S. (1999). Veiledning i psykoterapeutisk arbeid
(Supervision in psychotherapy). In M.H. Rönnestad & S. Reichelt (Eds.), Psykoterapiveiledning (Psychotherapy supervision) (pp. 13-33).
Oslo: Tano Aschehoug.
Samec, J. (1995). Shame, guilt and trauma:
Failing the psychotherapy candidate’s clinical work. The Clinical Supervisor, 13, 1-18.
Shore, L. M., &
Shore, T. H. (1995). Perceived organizational support and organizational
justice. In R. S. Cropanzano & K. M. Kacmar (Eds.), Organizational politics, justice, and support: Managing the social
climate of the workplace (pp. 149–164). Westport, CT: Quorum.
Stacey, R. D. (1996). Complexity and creativity in organizations.
San Francisco: Berrett-Koehler Publishers.
Strauss, A. &
Corbin, J. (1998). Basics of qualitative
research. Techniques and procedures for developing grounded theory. London:
Sage Publications.
Szecsödy, I. (1986).
Feed-back in psychotherapy and training. Nordisk
Psykiatrisk Tidskrift, 40, 193-200.
Szecsödy, I. (1990). The learning process in psychotherapy
supervision. Stockholm: Department of Psychiatry, Karolinska Institutet,
S:t Görans Hospital.
Szecsödy, I. (1994). Supervision – a complex tool for psychoanalytic
training. The Scandinavian Psychoanalytic
Review, 17, 119-129.
Tveiten, S. (2000). Yrkesmässig handledning – mer än ord
(Professional training – more than words). Lund: Studentlitteratur.
Watkins, E. (1997). Handbook of psychotherapy supervision.
New York: John Wiley & Sons, Inc.
Wrangsjö, B. (2001).
Dubbelbindningsaspekter av psykoterapihandledning eller öppenhetsparadoxen som
arbetskontext (Double-binding aspects of psychotherapy supervision or the
openness paradox as work context). Psykisk
Hälsa, 2, 90-107.