1	Supervision of TFP Frank Yeomans, MD, PhD Pamela Foelsch, PhD
2	Structure of Supervision Parallel to Treatment Contract for Therapy Supervision vs. “Intervision” Role of leader Role of consensus Centrality of videotapes of sessions (role play is a possible alternative)
3	Setting Up a Supervision Group Initial Training Number? (2 – 5 minimum) Expert Assistance, minimum of every six months, with consultation as needed Dutch example Quebec example
4	Functions of Supervision To Guide and Reinforce Learning To Provide Support To Identify Negative Therapeutic Interactions To Increase Awareness of Countertransferance To Intervene When Necessary (these functions overlap)
5	Issues Related to Supervision Therapist Qualities Needed for TFP Capacity to move beyond “just” the Strategies Ability to enter into Patient’s Internal World Ability/willingness to discuss own emotional responses openly in the group A “participant-observer” stance Aspects of Therapy that lead to Change Cognition plus affect A real, though unique, relationship with the pt.
6	Inclusion/Exclusion Criteria -I Basic Training in Psychotherapy Some experience of personal therapy An interest in the work – some therapists are put off by working with primitive, unconscious, primary process material A basic level of psychological stability Capacity to tolerate strong affect & combine affective & cognitive understanding
7	Inclusion/Exclusion Criteria - II Therapist Limitations Lack of psychological mindedness and comfort with unconscious processes Difficulty maintaining boundaries Always wanting give more Getting seduced, or punished, or both Rigidity withdrawing from the relationship When to call it quits
8	Functions of Supervision I Learning II Support III Monitoring
9	Aspects of Learning in Supervision-I Help reading the “3 channels” of communication (e.g., stopping the video to observe) Repeatedly refocusing the therapist on the “here and now” interaction Help the therapist see the “broad strokes” Helping with the many “judgment call” moments Help therapist move between affective & cognitive experience
10	Aspects of Learning in Supervision-II Encourage therapists to intervene now/not hesitate (increase speed) Pull therapists out of the projective identifications Focus on subtle threat to continuation of treatment (the “drop out” issue) Train with two cases (compare & contrast) Matching Patient “Types” with Therapist characteristics Avoidant/Dismissive behaviorally “acting out”/unresolved
11	Aspects of Learning in Supervision - III In general, supervision helps therapists who have learned the model to develop a flexibility within the model, to follow the spirit of the model without being dogmatically tied to the “letter of the law”.
12	Aspects of Support in Supervision To help “withstand” intense transferences Provide outside Reflective Functioning To help the therapist accept how important he or she is to the patient Help therapist hold the frame when tempted to deviate, and be flexible when indicated
13	Monitoring Countertransference - I Helps therapist avoid stalemates and enactments Probably helps decrease drop-out rate… Develops skill at identifying object relationship dyads (and oscillations) If a therapist has consistent difficulties, the supervision group may suggest: A period of more intense individual supervision Referral to psychotherapy (supervision should not become psychotherapy).
14	Monitoring Countertransference - II Be mindful of therapists who tend to: Be rigidly logical and cannot empathically regress (obsessive issues) Have the capacity to regress but not to resonate empathically with the deeper aspects of an other (narcissistic issues) Are so prone to empathic regression that they cannot keep an observing distance (histrionic issues) Therapists with aggressive and narcissistic issues (can be a threat to the group)
15	Key Supervisory Questions - I What is the non-verbal communication? What is the therapist feeling at a given moment? (particularly when the supervisor is having a “parallel process” reaction) This can help address therapist resistances (e.g., not feeling anger, fear, sympathy, arousal, etc. when it may be elicited from the material) What is the object relationship dyad?
16	Key Supervisory Questions - II The supervision group is not so interested in criticizing the therapist for what he/she did wrong or missed as in asking the questions: “How can we understand what happened in this interaction?”, and “In light of this understanding, what should the therapist do in the next session?”
17	Common Questions and Reactions from New Groups Is this patient borderline? This patient is too psychotic, sociopathic, perverse, “sick” to treat (…with TFP) In working with the countertransference, should I reveal what I feel to the patient? Disclosure: When, What, & For what purpose? How to judge therapist discretion vs. resistance to intervening Am I “doing enough” if I “only understand?”
18	“When can I stop Supervision?”- I Ideally, continuing a supervision is desirable as long as one is treating borderline patients Even the most experienced therapists can get caught up in transference-countertransference patterns that they are not aware of Most participants find it a continued source of enrichment and gratification
19	“When Can I Stop Supervision?” - II In reality, some therapists cannot continue or choose not to continue. Even in these cases, supervision must be available for times when the therapist feels stuck or at risk. An objective evaluation of competency is needed.
20	Complications of Supervision In TFP, there is often no “one right way” to deal with a particular situation Nevertheless, the most serious wrong way is when the therapist consistently avoids/deflects the transference Different therapists have different comfort levels with the intensity of the affects that emerge in the therapy (role of level of experience)
21	Example of complication How much of a break in the frame/contract is too much? (flexibility vs. rigidity in TFP) We try to continue the therapy if it is “in the transference”, i.e. if we feel we can interpret the break, with some result Example of internet intrusion
22	Second Example Superviser saying “You really want to get rid of that patient, don’t you?” reminded the therapist he could stop, freed him from the feeling of being enslaved, that he realized came from the patient’s internal world. This helped the therapist avoid enacting the opposite representation: the abandoner.
23	Observations from Supervision - I Most therapists begin listening to the content at the expense of the other two channels of communication Most therapists begin enacting supportive measures to avoid accepting the (inevitable) negative transference Therapists tend to become more supportive during a “crisis” (on the contrary, it is critical to go “in depth”) Therapists tend to confuse technical neutrality with lack of affect
24	Observations from Supervision - II Therapists with aggressive and narcissistic issues can be a threat to the group In-depth prior psychoanalytic or psychodynamic training is not essential Experienced analysts can have a hard time with some aspects of TFP: Accepting modification of psychoanalytic frame The level of therapist activity The focus on the here-and-now interaction Accepting (experiencing) the level of affect in the room