Psychotherapy 2015, Vol. 52, No. 2, 153–157
© 2014 American Psychological Association 0033-3204/15/$12.00 http://dx.doi.org/10.1037/a0038085
Supervisory Process From a Supportive–Expressive Relational Psychodynamic Approach Marc J. Diener and Vicky Mesrie
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Long Island University—Post Substantial theoretical and empirical focus has been placed on detailing the processes that therapists use in psychotherapy. Relatively limited investigation, however, has been conducted into the utility of the various techniques and processes that supervisors use in facilitating the development of trainee competence to conduct psychotherapy. The present article explores 2 sets of supervisory techniques/processes that can be used to assist novice therapists in the development of clinical skills from a supportive– expressive (Luborsky, 1984) relational (Greenberg & Mitchell, 1983) psychodynamic approach: (a) providing systematic and structured training in interpretation, and (b) facilitating trainee use of countertransference. We detail the theoretical underpinnings and research findings for each supervisory process, followed by presentation of vignettes illustrating supervisor–supervisee interactions that demonstrate the use of these processes. Keywords: psychodynamic psychotherapy, supervision, supervisory process, relational psychotherapy, supportive– expressive psychotherapy
theory of psychoanalytic session process and how to intervene accordingly, and (d) helping trainees recognize and use their countertransference. In terms of the first two components, Kernberg (2010) argued that supervision requires an honest and critical evaluation of supervisee performance while providing explicit feedback. The third component involves articulating not only concrete recommendations for how to respond to the patient, but also presenting the theoretical background for these recommendations. Finally, Kernberg (2010) enjoined supervisors to engage in countertransference analysis with trainees. This analysis involves discussion of how the patient’s transference affected trainee countertransference while balancing analysis of a trainee’s subjective reactions with respect for the trainee’s privacy. Diener and Pierson (2013) provided a brief overview of the theoretical, clinical, and empirical foundations for several therapeutic techniques and clinical processes from a supportive– expressive (Luborsky, 1984) relational (Greenberg & Mitchell, 1983) psychodynamic approach. In the present article, drawing from the same theoretical and clinical approach, we outline two key supervisory techniques and processes: (a) providing systematic and structured training in interpretation, and (b) facilitating trainee use of countertransference. We selected these two processes based on the importance ascribed to them by contemporary theorists, as well as some preliminary research support for their utility. We detail the theoretical and empirical support for these processes in their respective sections below. From a research standpoint, the question that is most crucial for trying to develop guidelines for supervision is to what extent does supervision positively influence patient outcomes. Limited empirical research, however, exists that addresses this important question (Watkins, 2011). In his review of 30 years of research, Watkins (2011) identified only 18 total studies that examined the impact of psychotherapy supervision on patient outcomes.
Theorists and researchers have provided a rich literature illustrating the clinical applications of—and evidence for—techniques and processes used by therapists to promote beneficial patient outcomes. Guidance for clinical supervisors for use in training therapists, by contrast, has received relatively less attention. In his model for assessing psychoanalytic trainee competencies, Tuckett (2005) pointed to the importance of maintaining a participant-observational frame. Training therapists to achieve these competencies involves attending to their abilities to listen to, observe, and reflect on the emotional experiences of the patient and the therapist, or, in other words, the management of countertransference. Another set of trainee competencies involves case conceptualization. To address these competencies, supervisors should help trainees recognize the transference and countertransference, and then conceptualize these therapeutic processes in a way that is consistent with a particular psychodynamic theory. A third set of competencies includes formulating and executing psychodynamic interventions. To assist trainees in the development of these competencies, supervisors monitor the interventions used by the therapists for coherence, as well as for consistency with the previously mentioned trainees’ participant-observational stance and conceptualization of therapeutic change. Kernberg (2010) outlined several key components in psychoanalytic supervision, including (a) the integration of teaching with explicit attention to the supervisor’s evaluative role, (b) engaging supervisees in an honest and collegial manner, (c) providing a clear
This article was published Online First November 3, 2014. Marc J. Diener and Vicky Mesrie, Clinical Psychology Doctoral Program, Department of Psychology, Long Island University—Post. Correspondence concerning this article should be addressed to Marc J. Diener, Clinical Psychology Doctoral Program, Department of Psychology, Long Island University—Post, 720 Northern Boulevard, Lodge B, Room 214, Brookville, NY 11548. E-mail: [email protected] 153
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
154
DIENER AND MESRIE
In fact, Watkins (2011) maintained that seven of these studies, that is, almost 40%, were incorrectly classified by previous authors, and that these studies did not actually investigate the impact of supervision on therapy outcome. Of the remaining 11 studies he reviewed, Watkins (2011) identified only three studies (Bambling, King, Raue, Schweitzer, & Lambert, 2006; Bradshaw, Butterworth, & Mairs, 2007; White & Winstanley, 2010) that did not suffer from significant methodological limitations. These latter three studies identified by Watkins (2011), however, did not investigate psychodynamic therapy. In the remainder of this article, therefore, we primarily review only studies of the role of supervision on therapist adherence or competence in psychodynamic therapy, with the exception of Sandell (1985) and Bein et al. (2000). Sandell (1985) studied nine therapists who received on-the-job training in Mann’s time-limited dynamic therapy, and who treated a total of 20 patients in an outpatient psychiatric clinic in Sweden. Some of these therapy cases were presented in supervision, whereas others were not. The supervision consisted of a onceweekly peer discussion (see also Watkins, 2011) of one case at a time, attended by three to four therapists, one of whom served as an informal group leader. Patient outcomes were rated by judges on the basis of a number of variables (e.g., symptom improvement, resolution of basic conflict), and these ratings were completed by judges who reviewed case summaries. Although results of a subsample of the participants (n ⫽ 17) demonstrated a negative correlation between whether or not patient cases had been presented in supervision and patient outcome (r ⫽ ⫺.31), this correlation was not statistically significant (p ⬎ .10). Using path analysis, the relation between supervision and outcome yielded a coefficient of ⫺.43. The methodology used in Sandell’s (1985) study, however, suffered from significant external validity threats (Sandell, 1985; Watkins, 2011). Trained professional supervision was not provided (Watkins, 2011); instead, the supervisory experience consisted of “supervision in groups with no formal or clear supervisorship and with relatively scarce time available for each patient and session (Sandell, 1985, p. 107),” substantially hindering this study’s ability to test the importance of formal supervision under the real-world conditions in which most trainees operate. Bein et al. (2000), as part of the Vanderbilt II study, examined the outcomes of patients treated by eight psychiatrists and eight psychologists who had no prior training in brief dynamic therapy. These clinicians each treated four patients; two patients were treated prior to receiving one year of training in time-limited dynamic psychotherapy (TLDP), and two were treated after receiving this training, yielding a total sample size of 64. Bein et al. (2000) compared the termination and 1-year follow-up outcomes for patients treated before the training with those treated after the training. Of the nine outcome variables compared between these groups at termination, only a single one yielded a statistically significant finding, with one additional variable demonstrating marginal significance. Even these findings, however, were in the opposite of the predicted direction, that is, patients treated prior to the TLDP training had higher mean outcome scores than patients treated after the training. In their analyses of the 1-year follow-up data, Bein et al. (2000) found two outcome variables that had significantly higher scores for the posttraining cohort than the pretraining cohort, as well as
one additional variable that demonstrated a trend in the same direction. Although the results of the study as a whole did not support the hypothesis that training would yield superior patient outcomes, data on therapist adherence to the TLDP model indicated that only 28% of the treated cases were judged to have achieved a minimal level of TLDP skill. Bein et al. (2000) argued that a training consisting of didactic presentations, reading the manual, and treatment of a training case with small group supervision was unable to facilitate a sufficient level of therapist skill in the treatment model.
Systematic and Structured Training in Interpretation Theory Interpretation constitutes an essential and defining component of psychodynamic treatment (Greenson, 1967). Interpretation refers to a class of interventions that help patients recognize and understand psychological processes that take place outside of their conscious awareness (Greenson, 1967; Malan, 1979). These interventions are often classified as falling at the expressive end of a supportive– expressive continuum of psychodynamic techniques, and they include clarification, confrontation, and interpretation proper (Gabbard, 2000). Clarification refers to reformulation of patients’ communication when they experience difficulty in articulating something (Gabbard, 2000). Moving farther along the expressive continuum, confrontation does not—as the term may seem to imply—involve communication of a hostile nature. Instead, confrontation refers to addressing patient denial, avoidance, or minimization of uncomfortable material. Finally, interpretation proper refers to the most expressive technique in this set of interventions, and it involves therapist statements that connect patients’ conscious thoughts, feelings, and behaviors to their unconscious meanings or origins. Tuckett (2005) detailed a number of strategies that supervisors can use to facilitate trainee development in the use of interpretation. These strategies include (a) providing feedback regarding the degree to which the supervisee’s timing and execution fits the patient’s current emotional capacity to tolerate the interpretation; (b) discussing whether the interpretation appropriately balances elicitation of intellectual and emotional insight; (c) highlighting the degree to which the interpretation fits the specific psychodynamic theory of therapeutic change, while providing examples to illustrate the supervisor’s recommendations; and (d) providing examples of transference interpretations that demonstrate more effective alternatives to the interpretation offered by the supervisee. Psychodynamic treatment manuals (Luborsky, 1984; Strupp & Binder, 1984) provide useful operational definitions of dynamic interventions, including interpretation, as well as guidelines for when and how to apply them. Although using these manuals does not guarantee that supervisees will skillfully execute dynamic interventions, such training can provide well-articulated explanations for the basic components of psychodynamic techniques in a systematic and clear manner (Binder, 1999).
Research In an earlier analysis of the Vanderbilt II study—with the same patient sample as the previously discussed Bein et al. (2000)
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
SUPERVISION IN SE RELATIONAL THERAPY
study—Henry, Strupp, Butler, Schacht, and Binder (1993) investigated therapists who received TLDP training, and who each treated two patients prior to receiving the training and two patients after receiving the training. Results indicated significantly higher ratings for treatments conducted after TLDP training relative to those conducted beforehand on four out of five items that measured adherence to interpretive techniques (e.g., “Therapist links recurrent behaviors or interpersonal conflict to patient-therapist transactions”). Standardized mean difference effect sizes (ESs) comparing the two groups ranged from 0.80 to 2.0.1 Hilsenroth, DeFife, Blagys, and Ackerman (2006) studied the adherence to psychodynamic–interpersonal (PI) technique of 15 graduate clinicians who received structured supervision in shortterm psychodynamic psychotherapy. The authors investigated within-case changes in trainees’ PI adherence in the early (3rd session) and later (9th session) sessions of their first two patients, as well as between-case changes by comparing therapists’ PI adherence between their first and second cases. Results indicated a significant increase in overall adherence to PI technique when comparing the early sessions to the later sessions, t(29) ⫽ 3.5, p ⫽ .001, d ⫽ 0.65. In terms of specific techniques, results indicated that adherence to the technique “therapist suggests alternative ways to understand experiences or events not previously recognized by the patient” used by therapists for their first two cases significantly increased between Sessions 3 and 9, t(29) ⫽ 3.5, p ⫽ .001, d ⫽ 0.68, as did adherence to the techniques “therapist identifies recurrent patterns in patient’s actions, feelings, and experiences,” t(29) ⫽ 2.1, p ⫽ .04, d ⫽ 0.40, and “therapist links the patient’s current feelings or perceptions to experiences of the past,” t(29) ⫽ 2.0, p ⫽ .05, d ⫽ 0.39.
Vignette During supervision, a trainee discussed an incident that occurred with a 40-year-old male patient (“Mr. A.”)2 who struggled with difficulties in developing close and rewarding relationships. The treatment was based on the Core Conflictual Relationship Theme (CCRT) method for supportive– expressive dynamic therapy (Luborsky, 1984), which involves identifying and exploring recurrent interpersonal patterns. These patterns consist of a wish (i.e., what the patient desires in a relationship), a response of other (i.e., how the patient anticipates or expects others to respond to the wish), and a response of self (i.e., what the patient feels and how s/he behaves when there is a conflict between the wish and response of other). Trainee:
Mr. A. left a voice message for me. He said that he was really upset and that he needed to speak to me. I got the message at 9 p.m. the night before our session, so I didn’t call him before he and I met the next day.
Supervisor: How did that go? Trainee:
He got very irritated, and he told me that I really don’t understand him, that I was only interested in him because he’s a training case and it helps me learn how to do therapy.
Supervisor: Let’s see if we can make sense of what happened here in the context of what we’ve learned
155
about Mr. A. so far. If we use the CCRT framework, what do you think is his wish? Trainee:
Maybe that I will drop everything to take care of him, to show him how much I am attuned to his emotional needs.
Supervisor: Just like he’s wanted his friends and parents to do! What about the response of other? Trainee:
He experiences the fact that I didn’t call him back as evidence that I don’t really care about him, that I am really using him for my own needs.
Supervisor: Right, so even though it was reasonable for you to wait until the next day and not call him back so late at night, he saw that as you rejecting him and as a reflection of your “real” feelings about him. And what about his response of self? Trainee:
Well, he became angry and pretty critical of me, accusing me of things he’s felt that others do to him.
Supervisor: Good, so his experience of you was framed by his earlier relationships, and he views your actions as entirely consistent with how others have treated him in the past. That’s another example of a transference reaction that we’ve talked about before. What you want to do is flesh out with him each of the CCRT components, one at a time, and begin to make links from this pattern with you to his other relationships, including his relationship with his parents. The more that he can realize how his past relationships, current relationships, and the transference relationship line up in similar ways, the more likely it is that he can begin to change his reflexive, automatic ways of relating to others. In this example, the supervisor used the CCRT approach to help the trainee recognize the patient’s experience of the transference relationship. Using the clearly operationalized method of the CCRT, the supervisor worked with the trainee to outline the patient’s repetitive, problematic relationship patterns and to develop interpretations to further the therapeutic work. In addition, the vignette illustrates how supervisors’ theory of technique can enhance trainees’ ability to generalize from specific recommendations offered in particular circumstances. 1 We refer to these data specifically as “standardized mean difference effect sizes” to distinguish them from data presented by other studies discussed below in the form of d. In the present study, effect size data were calculated by first obtaining the mean difference in scores between the two cohorts and then dividing it by the standard deviation of the pretraining cohort only. The other studies discussed below, which use the effect size d, however, used a pooled standard deviation for the denominator. 2 Throughout this article, all vignettes consist of fictitious, composite, or modified examples of actual therapist–patient and supervisor–supervisee interactions. In all cases, identifying information has been removed to protect confidentiality.
DIENER AND MESRIE
156
Facilitating Trainee Use of Countertransference
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Theory Psychoanalytic theorists originally defined countertransference as the therapist’s own transference, that is, the therapist’s psychological response to the patient that derives from the therapist’s past, and which represents both a distortion of the patient’s actions as well as an impediment to treatment (Betan, Heim, Conklin, & Westen, 2005; Gabbard, 2001). Over time, however, new theoretical approaches to countertransference emerged, which defined countertransference as the therapist’s response to the patient— both conscious and unconscious (Betan et al., 2005)—that derives from a combination of the therapist’s internal representations as well as feelings induced by the patient (Gabbard, 2001). As a result, countertransference became recognized as an important source of clinical information about the patient’s internal representations (Gabbard, 2001). As noted above, Tuckett (2005) considered the ability to maintain a “participant-observational frame” to be a key psychodynamic competency, and one which supervision is designed to facilitate. Maintaining this frame refers to the therapist’s capacity to manage the countertransference, or “to become aware of his perceptions inside his own mind, as inside the minds of patients . . . to achieve a particular quality of mental participation and observation” (Tuckett, 2005, p. 38). To help trainees develop this capacity, supervisors can draw from a number of the recommendations offered by Tuckett (2005). These include identifying instances in which the trainee is able to reflect on the therapeutic process rather than “act in,” helping the trainee recognize the impact of interventions on both the patient and therapist, and discussing ways of recognizing and reflecting on therapist “mistakes” without becoming defensive.
Hayes, Gelso, and Hummel (2011) conducted a meta-analysis that synthesized research on several aspects of countertransference.3 One aspect included the relation between countertransference management and therapy outcome. Results indicated a large positive effect size that was statistically significant, r ⫽ .56, p ⬍ .001, demonstrating that more effective countertransference management was associated with better therapy outcomes. These studies by Gelso and colleagues (Gelso et al., 2002; Hayes et al., 2011) did not examine the impact of supervision on therapist use of countertransference, but instead they focused on the relation between countertransference management and outcome. We nevertheless included these studies in our discussion because the results of these studies suggest the importance of countertransference management for patient outcomes, and therefore point to the potential significance of addressing therapist countertransference in supervision.
Vignette In the following vignette, the supervisor and trainee discuss an interaction that the trainee had with his patient during a recent session. Trainee:
Supervisor: Wow, it does sound like he caught you offguard. What was going on for you when he said that? Trainee:
Research In the Vanderbilt II study discussed earlier, Henry et al. (1993) compared the use of TLDP technique by clinicians conducting treatments both before and after receiving TLDP training. Results indicated that ratings for the item “Therapist uses own reactions to some aspect of patient’s behavior to clarify communications/guide exploration of possible distortions in patient’s perceptions” were significantly higher for treatments conducted after TLDP training (ES ⫽ 1.48). Caution, however, is warranted in interpreting these results given findings that suggested some increase in negative therapist attitude/behavior, as well as lack of demonstrably better outcomes in the posttraining cases compared with the pretraining ones (data from two variables, in fact, suggested that pretraining cases may have had better outcomes). Gelso, Latts, Gomez, and Fassinger (2002) studied the relation between countertransference management by 32 counseling trainees and psychotherapy outcome. Results indicated that the overall score on a measure of trainee countertransference management measure (that included items such as “reflects deeply on how his or her feelings relate to clients’ feelings;” Gelso et al., 2002, p. 865) demonstrated significant positive correlations with both counselor-rated outcome, r ⫽ .42, p ⬍ .01, and supervisor-rated outcome, r ⫽ .36, p ⬍ .05. These findings suggest that therapists with greater skill at managing their countertransference tended to have better outcomes with their patients.
This was a really rough session. My patient jumped right into how disappointed and upset he was with me. He said that based on how I responded to him in the session before, he thinks I really don’t care about his needs.
I felt like I really don’t know what I’m doing in our treatment. I’ve just started to gain some tentative confidence in my therapeutic skills, and now he has me really questioning that.
Supervisor: So in your work with your other patients, you’ve not really had this experience where you feel so challenged and doubtful of your ability? Trainee:
No, not really. I felt that way at the beginning of this year, but it’s more reflective of my selfdoubt rather than anything my patients have said.
Supervisor: That’s a really important observation you just made. There’s something specific that this patient is doing which seems to make you feel devalued as a therapist. That tells us that there may be an enactment going on here, that the dynamic he has pulled you into is one in which he becomes critical of your work as a therapist, which then has you feeling unsure about your therapeutic skills. Trainee:
Hmm, that could be. What does it mean?
3 Note that this meta-analysis did not include the Gelso et al. (2002) study discussed above.
SUPERVISION IN SE RELATIONAL THERAPY
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Supervisor: Good question. It might give us a glimpse into how he is with other important people in his life. He reaches out to them when he feels that he is in crisis, but then he becomes hostile and critical when they try to help him. His strong desire to connect with others becomes thwarted when he begins to experience others in ways that are very familiar to him from the past. He then responds in the only way that he knows how to protect himself, by creating distance between himself and others, while feeling dejected and lonely as a result. In this vignette, the supervisor works with the trainee to reflect on his emotional response to the interaction with his patient. Using this information, the supervisor and trainee formulated an understanding of the ways in which the patient creates an interpersonal pattern that deprives him of the relational experiences for which he wishes, and that he does so by eliciting the very emotional response from the therapist that he experiences from significant others in his life.
Conclusion In this article, we presented two key supervisory techniques and processes used in a supportive– expressive relational psychodynamic model: (a) providing systematic and structured training in interpretation, and (b) facilitating trainee use of countertransference. We provided an overview of theoretical considerations for these supervisory techniques. Research findings reviewed in this article, although not without their limitations, offer some empirical support for the importance of these techniques and processes, suggesting useful ways in which these processes can be used, as well as future directions for their elaboration and modification.
References Bambling, M., King, R., Raue, P., Schweitzer, R., & Lambert, W. (2006). Clinical supervision: Its influence on client-rated working alliance and client symptom reduction in the brief treatment of major depression. Psychotherapy Research, 16, 317–331. doi:10.1080/ 10503300500268524 Bein, E., Anderson, T., Strupp, H. H., Henry, W. P., Schacht, T. E., Binder, J. L., & Butler, S. F. (2000). The effects of training in Time-Limited Dynamic Psychotherapy: Changes in therapeutic outcome. Psychotherapy Research, 10, 119 –132. doi:10.1080/713663669 Betan, E., Heim, A., Conklin, C., & Westen, D. (2005). Countertransference phenomena and personality pathology in clinical practice: An empirical investigation. The American Journal of Psychiatry, 162, 890 – 898. doi:10.1176/appi.ajp.162.5.890 Binder, J. L. (1999). Issues in teaching and learning time-limited psychodynamic psychotherapy. Clinical Psychology Review, 19, 705–719. doi:10.1016/S0272-7358(98)00078-6 Bradshaw, T., Butterworth, A., & Mairs, H. (2007). Does structured clinical supervision during psychosocial intervention education enhance outcome for mental health nurses and the service users they work with?
157
Journal of Psychiatric and Mental Health Nursing, 14, 4 –12. doi: 10.1111/j.1365-2850.2007.01021.x Diener, M. J., & Pierson, M. M. (2013). Technique and therapeutic process from a supportive-expressive relational psychodynamic approach. Psychotherapy (Chic), 50, 424 – 427. doi:10.1037/a0032404 Gabbard, G. O. (2000). Psychodynamic psychiatry in clinical practice (3rd ed.). Arlington, VA: American Psychiatric Publishing, Inc. Gabbard, G. O. (2001). A contemporary psychoanalytic model of countertransference. Journal of Clinical Psychology, 57, 983–991. Retrieved from http://onlinelibrary.wiley.com/journal/10.1002/(ISSN)1097-4679. doi:10.1002/jclp.1065 Gelso, C. J., Latts, M. G., Gomez, M. J., & Fassinger, R. E. (2002). Countertransference management and therapy outcome: An initial evaluation. Journal of Clinical Psychology, 58, 861– 867. doi:10.1002/jclp .2010 Greenberg, J. R., & Mitchell, S. A. (1983). Object relations in psychoanalytic theory. Cambridge, MA: Harvard University Press. Greenson, R. R. (1967). The technique and practice of psychoanalysis (Vol. 1). Madison, CT: International Universities Press. Hayes, J. A., Gelso, C. J., & Hummel, A. M. (2011). Managing countertransference. Psychotherapy (Chic), 48, 88 –97. doi:10.1037/a0022182 Henry, W. P., Strupp, H. H., Butler, S. F., Schacht, T. E., & Binder, J. L. (1993). Effects of training in time-limited dynamic psychotherapy: Changes in therapist behavior. Journal of Consulting and Clinical Psychology, 61, 434 – 440. doi:10.1037/0022-006X.61.3.434 Hilsenroth, M., DeFife, J., Blagys, M., & Ackerman, S. (2006). Effects of training in short-term psychodynamic psychotherapy: Changes in graduate clinician technique. Psychotherapy Research, 16, 293–305. doi: 10.1080/10503300500264887 Kernberg, O. F. (2010). Psychoanalytic supervision: The supervisor’s tasks. The Psychoanalytic Quarterly, 79, 603– 627. doi:10.1002/j.21674086.2010.tb00459.x Luborsky, L. (1984). Principles of psychoanalytic psychotherapy: A manual for supportive/expressive treatment. New York, NY: Basic Books. Malan, D. H. (1979). Individual psychotherapy and the science of psychodynamics. London: Butterworths. Sandell, R. (1985). Influence of supervision, therapist’s competence, and patient’s ego level on the effects of time-limited psychotherapy. Psychotherapy and Psychosomatics, 44, 103–109. doi:10.1159/000287900 Strupp, H. H., & Binder, J. (1984). Psychotherapy in a new key. New York, NY: Basic Books. Tuckett, D. (2005). Does anything go? Towards a framework for the more transparent assessment of psychoanalytic competence. The International Journal of Psychoanalysis, 86, 31– 49. doi:10.1516/R2U5-XJ37-7DFJDD18 Watkins, C. E. (2011). Does Psychotherapy supervision contribute to patient outcomes? Considering thirty years of research. The Clinical Supervisor, 30, 235–256. doi:10.1080/07325223.2011.619417 White, E., & Winstanley, J. (2010). A randomised controlled trial of clinical supervision: Selected findings from a novel Australian attempt to establish the evidence base for causal relationships with quality of care and patient outcomes, as an informed contribution to mental health nursing practice development. Journal of Research in Nursing, 15, 151–167. doi:10.1177/1744987109357816
Received April 7, 2014 Revision received August 21, 2014 Accepted August 30, 2014 䡲
© 2014 American Psychological Association 0033-3204/15/$12.00 http://dx.doi.org/10.1037/a0038085
Supervisory Process From a Supportive–Expressive Relational Psychodynamic Approach Marc J. Diener and Vicky Mesrie
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Long Island University—Post Substantial theoretical and empirical focus has been placed on detailing the processes that therapists use in psychotherapy. Relatively limited investigation, however, has been conducted into the utility of the various techniques and processes that supervisors use in facilitating the development of trainee competence to conduct psychotherapy. The present article explores 2 sets of supervisory techniques/processes that can be used to assist novice therapists in the development of clinical skills from a supportive– expressive (Luborsky, 1984) relational (Greenberg & Mitchell, 1983) psychodynamic approach: (a) providing systematic and structured training in interpretation, and (b) facilitating trainee use of countertransference. We detail the theoretical underpinnings and research findings for each supervisory process, followed by presentation of vignettes illustrating supervisor–supervisee interactions that demonstrate the use of these processes. Keywords: psychodynamic psychotherapy, supervision, supervisory process, relational psychotherapy, supportive– expressive psychotherapy
theory of psychoanalytic session process and how to intervene accordingly, and (d) helping trainees recognize and use their countertransference. In terms of the first two components, Kernberg (2010) argued that supervision requires an honest and critical evaluation of supervisee performance while providing explicit feedback. The third component involves articulating not only concrete recommendations for how to respond to the patient, but also presenting the theoretical background for these recommendations. Finally, Kernberg (2010) enjoined supervisors to engage in countertransference analysis with trainees. This analysis involves discussion of how the patient’s transference affected trainee countertransference while balancing analysis of a trainee’s subjective reactions with respect for the trainee’s privacy. Diener and Pierson (2013) provided a brief overview of the theoretical, clinical, and empirical foundations for several therapeutic techniques and clinical processes from a supportive– expressive (Luborsky, 1984) relational (Greenberg & Mitchell, 1983) psychodynamic approach. In the present article, drawing from the same theoretical and clinical approach, we outline two key supervisory techniques and processes: (a) providing systematic and structured training in interpretation, and (b) facilitating trainee use of countertransference. We selected these two processes based on the importance ascribed to them by contemporary theorists, as well as some preliminary research support for their utility. We detail the theoretical and empirical support for these processes in their respective sections below. From a research standpoint, the question that is most crucial for trying to develop guidelines for supervision is to what extent does supervision positively influence patient outcomes. Limited empirical research, however, exists that addresses this important question (Watkins, 2011). In his review of 30 years of research, Watkins (2011) identified only 18 total studies that examined the impact of psychotherapy supervision on patient outcomes.
Theorists and researchers have provided a rich literature illustrating the clinical applications of—and evidence for—techniques and processes used by therapists to promote beneficial patient outcomes. Guidance for clinical supervisors for use in training therapists, by contrast, has received relatively less attention. In his model for assessing psychoanalytic trainee competencies, Tuckett (2005) pointed to the importance of maintaining a participant-observational frame. Training therapists to achieve these competencies involves attending to their abilities to listen to, observe, and reflect on the emotional experiences of the patient and the therapist, or, in other words, the management of countertransference. Another set of trainee competencies involves case conceptualization. To address these competencies, supervisors should help trainees recognize the transference and countertransference, and then conceptualize these therapeutic processes in a way that is consistent with a particular psychodynamic theory. A third set of competencies includes formulating and executing psychodynamic interventions. To assist trainees in the development of these competencies, supervisors monitor the interventions used by the therapists for coherence, as well as for consistency with the previously mentioned trainees’ participant-observational stance and conceptualization of therapeutic change. Kernberg (2010) outlined several key components in psychoanalytic supervision, including (a) the integration of teaching with explicit attention to the supervisor’s evaluative role, (b) engaging supervisees in an honest and collegial manner, (c) providing a clear
This article was published Online First November 3, 2014. Marc J. Diener and Vicky Mesrie, Clinical Psychology Doctoral Program, Department of Psychology, Long Island University—Post. Correspondence concerning this article should be addressed to Marc J. Diener, Clinical Psychology Doctoral Program, Department of Psychology, Long Island University—Post, 720 Northern Boulevard, Lodge B, Room 214, Brookville, NY 11548. E-mail: [email protected] 153
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
154
DIENER AND MESRIE
In fact, Watkins (2011) maintained that seven of these studies, that is, almost 40%, were incorrectly classified by previous authors, and that these studies did not actually investigate the impact of supervision on therapy outcome. Of the remaining 11 studies he reviewed, Watkins (2011) identified only three studies (Bambling, King, Raue, Schweitzer, & Lambert, 2006; Bradshaw, Butterworth, & Mairs, 2007; White & Winstanley, 2010) that did not suffer from significant methodological limitations. These latter three studies identified by Watkins (2011), however, did not investigate psychodynamic therapy. In the remainder of this article, therefore, we primarily review only studies of the role of supervision on therapist adherence or competence in psychodynamic therapy, with the exception of Sandell (1985) and Bein et al. (2000). Sandell (1985) studied nine therapists who received on-the-job training in Mann’s time-limited dynamic therapy, and who treated a total of 20 patients in an outpatient psychiatric clinic in Sweden. Some of these therapy cases were presented in supervision, whereas others were not. The supervision consisted of a onceweekly peer discussion (see also Watkins, 2011) of one case at a time, attended by three to four therapists, one of whom served as an informal group leader. Patient outcomes were rated by judges on the basis of a number of variables (e.g., symptom improvement, resolution of basic conflict), and these ratings were completed by judges who reviewed case summaries. Although results of a subsample of the participants (n ⫽ 17) demonstrated a negative correlation between whether or not patient cases had been presented in supervision and patient outcome (r ⫽ ⫺.31), this correlation was not statistically significant (p ⬎ .10). Using path analysis, the relation between supervision and outcome yielded a coefficient of ⫺.43. The methodology used in Sandell’s (1985) study, however, suffered from significant external validity threats (Sandell, 1985; Watkins, 2011). Trained professional supervision was not provided (Watkins, 2011); instead, the supervisory experience consisted of “supervision in groups with no formal or clear supervisorship and with relatively scarce time available for each patient and session (Sandell, 1985, p. 107),” substantially hindering this study’s ability to test the importance of formal supervision under the real-world conditions in which most trainees operate. Bein et al. (2000), as part of the Vanderbilt II study, examined the outcomes of patients treated by eight psychiatrists and eight psychologists who had no prior training in brief dynamic therapy. These clinicians each treated four patients; two patients were treated prior to receiving one year of training in time-limited dynamic psychotherapy (TLDP), and two were treated after receiving this training, yielding a total sample size of 64. Bein et al. (2000) compared the termination and 1-year follow-up outcomes for patients treated before the training with those treated after the training. Of the nine outcome variables compared between these groups at termination, only a single one yielded a statistically significant finding, with one additional variable demonstrating marginal significance. Even these findings, however, were in the opposite of the predicted direction, that is, patients treated prior to the TLDP training had higher mean outcome scores than patients treated after the training. In their analyses of the 1-year follow-up data, Bein et al. (2000) found two outcome variables that had significantly higher scores for the posttraining cohort than the pretraining cohort, as well as
one additional variable that demonstrated a trend in the same direction. Although the results of the study as a whole did not support the hypothesis that training would yield superior patient outcomes, data on therapist adherence to the TLDP model indicated that only 28% of the treated cases were judged to have achieved a minimal level of TLDP skill. Bein et al. (2000) argued that a training consisting of didactic presentations, reading the manual, and treatment of a training case with small group supervision was unable to facilitate a sufficient level of therapist skill in the treatment model.
Systematic and Structured Training in Interpretation Theory Interpretation constitutes an essential and defining component of psychodynamic treatment (Greenson, 1967). Interpretation refers to a class of interventions that help patients recognize and understand psychological processes that take place outside of their conscious awareness (Greenson, 1967; Malan, 1979). These interventions are often classified as falling at the expressive end of a supportive– expressive continuum of psychodynamic techniques, and they include clarification, confrontation, and interpretation proper (Gabbard, 2000). Clarification refers to reformulation of patients’ communication when they experience difficulty in articulating something (Gabbard, 2000). Moving farther along the expressive continuum, confrontation does not—as the term may seem to imply—involve communication of a hostile nature. Instead, confrontation refers to addressing patient denial, avoidance, or minimization of uncomfortable material. Finally, interpretation proper refers to the most expressive technique in this set of interventions, and it involves therapist statements that connect patients’ conscious thoughts, feelings, and behaviors to their unconscious meanings or origins. Tuckett (2005) detailed a number of strategies that supervisors can use to facilitate trainee development in the use of interpretation. These strategies include (a) providing feedback regarding the degree to which the supervisee’s timing and execution fits the patient’s current emotional capacity to tolerate the interpretation; (b) discussing whether the interpretation appropriately balances elicitation of intellectual and emotional insight; (c) highlighting the degree to which the interpretation fits the specific psychodynamic theory of therapeutic change, while providing examples to illustrate the supervisor’s recommendations; and (d) providing examples of transference interpretations that demonstrate more effective alternatives to the interpretation offered by the supervisee. Psychodynamic treatment manuals (Luborsky, 1984; Strupp & Binder, 1984) provide useful operational definitions of dynamic interventions, including interpretation, as well as guidelines for when and how to apply them. Although using these manuals does not guarantee that supervisees will skillfully execute dynamic interventions, such training can provide well-articulated explanations for the basic components of psychodynamic techniques in a systematic and clear manner (Binder, 1999).
Research In an earlier analysis of the Vanderbilt II study—with the same patient sample as the previously discussed Bein et al. (2000)
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
SUPERVISION IN SE RELATIONAL THERAPY
study—Henry, Strupp, Butler, Schacht, and Binder (1993) investigated therapists who received TLDP training, and who each treated two patients prior to receiving the training and two patients after receiving the training. Results indicated significantly higher ratings for treatments conducted after TLDP training relative to those conducted beforehand on four out of five items that measured adherence to interpretive techniques (e.g., “Therapist links recurrent behaviors or interpersonal conflict to patient-therapist transactions”). Standardized mean difference effect sizes (ESs) comparing the two groups ranged from 0.80 to 2.0.1 Hilsenroth, DeFife, Blagys, and Ackerman (2006) studied the adherence to psychodynamic–interpersonal (PI) technique of 15 graduate clinicians who received structured supervision in shortterm psychodynamic psychotherapy. The authors investigated within-case changes in trainees’ PI adherence in the early (3rd session) and later (9th session) sessions of their first two patients, as well as between-case changes by comparing therapists’ PI adherence between their first and second cases. Results indicated a significant increase in overall adherence to PI technique when comparing the early sessions to the later sessions, t(29) ⫽ 3.5, p ⫽ .001, d ⫽ 0.65. In terms of specific techniques, results indicated that adherence to the technique “therapist suggests alternative ways to understand experiences or events not previously recognized by the patient” used by therapists for their first two cases significantly increased between Sessions 3 and 9, t(29) ⫽ 3.5, p ⫽ .001, d ⫽ 0.68, as did adherence to the techniques “therapist identifies recurrent patterns in patient’s actions, feelings, and experiences,” t(29) ⫽ 2.1, p ⫽ .04, d ⫽ 0.40, and “therapist links the patient’s current feelings or perceptions to experiences of the past,” t(29) ⫽ 2.0, p ⫽ .05, d ⫽ 0.39.
Vignette During supervision, a trainee discussed an incident that occurred with a 40-year-old male patient (“Mr. A.”)2 who struggled with difficulties in developing close and rewarding relationships. The treatment was based on the Core Conflictual Relationship Theme (CCRT) method for supportive– expressive dynamic therapy (Luborsky, 1984), which involves identifying and exploring recurrent interpersonal patterns. These patterns consist of a wish (i.e., what the patient desires in a relationship), a response of other (i.e., how the patient anticipates or expects others to respond to the wish), and a response of self (i.e., what the patient feels and how s/he behaves when there is a conflict between the wish and response of other). Trainee:
Mr. A. left a voice message for me. He said that he was really upset and that he needed to speak to me. I got the message at 9 p.m. the night before our session, so I didn’t call him before he and I met the next day.
Supervisor: How did that go? Trainee:
He got very irritated, and he told me that I really don’t understand him, that I was only interested in him because he’s a training case and it helps me learn how to do therapy.
Supervisor: Let’s see if we can make sense of what happened here in the context of what we’ve learned
155
about Mr. A. so far. If we use the CCRT framework, what do you think is his wish? Trainee:
Maybe that I will drop everything to take care of him, to show him how much I am attuned to his emotional needs.
Supervisor: Just like he’s wanted his friends and parents to do! What about the response of other? Trainee:
He experiences the fact that I didn’t call him back as evidence that I don’t really care about him, that I am really using him for my own needs.
Supervisor: Right, so even though it was reasonable for you to wait until the next day and not call him back so late at night, he saw that as you rejecting him and as a reflection of your “real” feelings about him. And what about his response of self? Trainee:
Well, he became angry and pretty critical of me, accusing me of things he’s felt that others do to him.
Supervisor: Good, so his experience of you was framed by his earlier relationships, and he views your actions as entirely consistent with how others have treated him in the past. That’s another example of a transference reaction that we’ve talked about before. What you want to do is flesh out with him each of the CCRT components, one at a time, and begin to make links from this pattern with you to his other relationships, including his relationship with his parents. The more that he can realize how his past relationships, current relationships, and the transference relationship line up in similar ways, the more likely it is that he can begin to change his reflexive, automatic ways of relating to others. In this example, the supervisor used the CCRT approach to help the trainee recognize the patient’s experience of the transference relationship. Using the clearly operationalized method of the CCRT, the supervisor worked with the trainee to outline the patient’s repetitive, problematic relationship patterns and to develop interpretations to further the therapeutic work. In addition, the vignette illustrates how supervisors’ theory of technique can enhance trainees’ ability to generalize from specific recommendations offered in particular circumstances. 1 We refer to these data specifically as “standardized mean difference effect sizes” to distinguish them from data presented by other studies discussed below in the form of d. In the present study, effect size data were calculated by first obtaining the mean difference in scores between the two cohorts and then dividing it by the standard deviation of the pretraining cohort only. The other studies discussed below, which use the effect size d, however, used a pooled standard deviation for the denominator. 2 Throughout this article, all vignettes consist of fictitious, composite, or modified examples of actual therapist–patient and supervisor–supervisee interactions. In all cases, identifying information has been removed to protect confidentiality.
DIENER AND MESRIE
156
Facilitating Trainee Use of Countertransference
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Theory Psychoanalytic theorists originally defined countertransference as the therapist’s own transference, that is, the therapist’s psychological response to the patient that derives from the therapist’s past, and which represents both a distortion of the patient’s actions as well as an impediment to treatment (Betan, Heim, Conklin, & Westen, 2005; Gabbard, 2001). Over time, however, new theoretical approaches to countertransference emerged, which defined countertransference as the therapist’s response to the patient— both conscious and unconscious (Betan et al., 2005)—that derives from a combination of the therapist’s internal representations as well as feelings induced by the patient (Gabbard, 2001). As a result, countertransference became recognized as an important source of clinical information about the patient’s internal representations (Gabbard, 2001). As noted above, Tuckett (2005) considered the ability to maintain a “participant-observational frame” to be a key psychodynamic competency, and one which supervision is designed to facilitate. Maintaining this frame refers to the therapist’s capacity to manage the countertransference, or “to become aware of his perceptions inside his own mind, as inside the minds of patients . . . to achieve a particular quality of mental participation and observation” (Tuckett, 2005, p. 38). To help trainees develop this capacity, supervisors can draw from a number of the recommendations offered by Tuckett (2005). These include identifying instances in which the trainee is able to reflect on the therapeutic process rather than “act in,” helping the trainee recognize the impact of interventions on both the patient and therapist, and discussing ways of recognizing and reflecting on therapist “mistakes” without becoming defensive.
Hayes, Gelso, and Hummel (2011) conducted a meta-analysis that synthesized research on several aspects of countertransference.3 One aspect included the relation between countertransference management and therapy outcome. Results indicated a large positive effect size that was statistically significant, r ⫽ .56, p ⬍ .001, demonstrating that more effective countertransference management was associated with better therapy outcomes. These studies by Gelso and colleagues (Gelso et al., 2002; Hayes et al., 2011) did not examine the impact of supervision on therapist use of countertransference, but instead they focused on the relation between countertransference management and outcome. We nevertheless included these studies in our discussion because the results of these studies suggest the importance of countertransference management for patient outcomes, and therefore point to the potential significance of addressing therapist countertransference in supervision.
Vignette In the following vignette, the supervisor and trainee discuss an interaction that the trainee had with his patient during a recent session. Trainee:
Supervisor: Wow, it does sound like he caught you offguard. What was going on for you when he said that? Trainee:
Research In the Vanderbilt II study discussed earlier, Henry et al. (1993) compared the use of TLDP technique by clinicians conducting treatments both before and after receiving TLDP training. Results indicated that ratings for the item “Therapist uses own reactions to some aspect of patient’s behavior to clarify communications/guide exploration of possible distortions in patient’s perceptions” were significantly higher for treatments conducted after TLDP training (ES ⫽ 1.48). Caution, however, is warranted in interpreting these results given findings that suggested some increase in negative therapist attitude/behavior, as well as lack of demonstrably better outcomes in the posttraining cases compared with the pretraining ones (data from two variables, in fact, suggested that pretraining cases may have had better outcomes). Gelso, Latts, Gomez, and Fassinger (2002) studied the relation between countertransference management by 32 counseling trainees and psychotherapy outcome. Results indicated that the overall score on a measure of trainee countertransference management measure (that included items such as “reflects deeply on how his or her feelings relate to clients’ feelings;” Gelso et al., 2002, p. 865) demonstrated significant positive correlations with both counselor-rated outcome, r ⫽ .42, p ⬍ .01, and supervisor-rated outcome, r ⫽ .36, p ⬍ .05. These findings suggest that therapists with greater skill at managing their countertransference tended to have better outcomes with their patients.
This was a really rough session. My patient jumped right into how disappointed and upset he was with me. He said that based on how I responded to him in the session before, he thinks I really don’t care about his needs.
I felt like I really don’t know what I’m doing in our treatment. I’ve just started to gain some tentative confidence in my therapeutic skills, and now he has me really questioning that.
Supervisor: So in your work with your other patients, you’ve not really had this experience where you feel so challenged and doubtful of your ability? Trainee:
No, not really. I felt that way at the beginning of this year, but it’s more reflective of my selfdoubt rather than anything my patients have said.
Supervisor: That’s a really important observation you just made. There’s something specific that this patient is doing which seems to make you feel devalued as a therapist. That tells us that there may be an enactment going on here, that the dynamic he has pulled you into is one in which he becomes critical of your work as a therapist, which then has you feeling unsure about your therapeutic skills. Trainee:
Hmm, that could be. What does it mean?
3 Note that this meta-analysis did not include the Gelso et al. (2002) study discussed above.
SUPERVISION IN SE RELATIONAL THERAPY
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Supervisor: Good question. It might give us a glimpse into how he is with other important people in his life. He reaches out to them when he feels that he is in crisis, but then he becomes hostile and critical when they try to help him. His strong desire to connect with others becomes thwarted when he begins to experience others in ways that are very familiar to him from the past. He then responds in the only way that he knows how to protect himself, by creating distance between himself and others, while feeling dejected and lonely as a result. In this vignette, the supervisor works with the trainee to reflect on his emotional response to the interaction with his patient. Using this information, the supervisor and trainee formulated an understanding of the ways in which the patient creates an interpersonal pattern that deprives him of the relational experiences for which he wishes, and that he does so by eliciting the very emotional response from the therapist that he experiences from significant others in his life.
Conclusion In this article, we presented two key supervisory techniques and processes used in a supportive– expressive relational psychodynamic model: (a) providing systematic and structured training in interpretation, and (b) facilitating trainee use of countertransference. We provided an overview of theoretical considerations for these supervisory techniques. Research findings reviewed in this article, although not without their limitations, offer some empirical support for the importance of these techniques and processes, suggesting useful ways in which these processes can be used, as well as future directions for their elaboration and modification.
References Bambling, M., King, R., Raue, P., Schweitzer, R., & Lambert, W. (2006). Clinical supervision: Its influence on client-rated working alliance and client symptom reduction in the brief treatment of major depression. Psychotherapy Research, 16, 317–331. doi:10.1080/ 10503300500268524 Bein, E., Anderson, T., Strupp, H. H., Henry, W. P., Schacht, T. E., Binder, J. L., & Butler, S. F. (2000). The effects of training in Time-Limited Dynamic Psychotherapy: Changes in therapeutic outcome. Psychotherapy Research, 10, 119 –132. doi:10.1080/713663669 Betan, E., Heim, A., Conklin, C., & Westen, D. (2005). Countertransference phenomena and personality pathology in clinical practice: An empirical investigation. The American Journal of Psychiatry, 162, 890 – 898. doi:10.1176/appi.ajp.162.5.890 Binder, J. L. (1999). Issues in teaching and learning time-limited psychodynamic psychotherapy. Clinical Psychology Review, 19, 705–719. doi:10.1016/S0272-7358(98)00078-6 Bradshaw, T., Butterworth, A., & Mairs, H. (2007). Does structured clinical supervision during psychosocial intervention education enhance outcome for mental health nurses and the service users they work with?
157
Journal of Psychiatric and Mental Health Nursing, 14, 4 –12. doi: 10.1111/j.1365-2850.2007.01021.x Diener, M. J., & Pierson, M. M. (2013). Technique and therapeutic process from a supportive-expressive relational psychodynamic approach. Psychotherapy (Chic), 50, 424 – 427. doi:10.1037/a0032404 Gabbard, G. O. (2000). Psychodynamic psychiatry in clinical practice (3rd ed.). Arlington, VA: American Psychiatric Publishing, Inc. Gabbard, G. O. (2001). A contemporary psychoanalytic model of countertransference. Journal of Clinical Psychology, 57, 983–991. Retrieved from http://onlinelibrary.wiley.com/journal/10.1002/(ISSN)1097-4679. doi:10.1002/jclp.1065 Gelso, C. J., Latts, M. G., Gomez, M. J., & Fassinger, R. E. (2002). Countertransference management and therapy outcome: An initial evaluation. Journal of Clinical Psychology, 58, 861– 867. doi:10.1002/jclp .2010 Greenberg, J. R., & Mitchell, S. A. (1983). Object relations in psychoanalytic theory. Cambridge, MA: Harvard University Press. Greenson, R. R. (1967). The technique and practice of psychoanalysis (Vol. 1). Madison, CT: International Universities Press. Hayes, J. A., Gelso, C. J., & Hummel, A. M. (2011). Managing countertransference. Psychotherapy (Chic), 48, 88 –97. doi:10.1037/a0022182 Henry, W. P., Strupp, H. H., Butler, S. F., Schacht, T. E., & Binder, J. L. (1993). Effects of training in time-limited dynamic psychotherapy: Changes in therapist behavior. Journal of Consulting and Clinical Psychology, 61, 434 – 440. doi:10.1037/0022-006X.61.3.434 Hilsenroth, M., DeFife, J., Blagys, M., & Ackerman, S. (2006). Effects of training in short-term psychodynamic psychotherapy: Changes in graduate clinician technique. Psychotherapy Research, 16, 293–305. doi: 10.1080/10503300500264887 Kernberg, O. F. (2010). Psychoanalytic supervision: The supervisor’s tasks. The Psychoanalytic Quarterly, 79, 603– 627. doi:10.1002/j.21674086.2010.tb00459.x Luborsky, L. (1984). Principles of psychoanalytic psychotherapy: A manual for supportive/expressive treatment. New York, NY: Basic Books. Malan, D. H. (1979). Individual psychotherapy and the science of psychodynamics. London: Butterworths. Sandell, R. (1985). Influence of supervision, therapist’s competence, and patient’s ego level on the effects of time-limited psychotherapy. Psychotherapy and Psychosomatics, 44, 103–109. doi:10.1159/000287900 Strupp, H. H., & Binder, J. (1984). Psychotherapy in a new key. New York, NY: Basic Books. Tuckett, D. (2005). Does anything go? Towards a framework for the more transparent assessment of psychoanalytic competence. The International Journal of Psychoanalysis, 86, 31– 49. doi:10.1516/R2U5-XJ37-7DFJDD18 Watkins, C. E. (2011). Does Psychotherapy supervision contribute to patient outcomes? Considering thirty years of research. The Clinical Supervisor, 30, 235–256. doi:10.1080/07325223.2011.619417 White, E., & Winstanley, J. (2010). A randomised controlled trial of clinical supervision: Selected findings from a novel Australian attempt to establish the evidence base for causal relationships with quality of care and patient outcomes, as an informed contribution to mental health nursing practice development. Journal of Research in Nursing, 15, 151–167. doi:10.1177/1744987109357816
Received April 7, 2014 Revision received August 21, 2014 Accepted August 30, 2014 䡲
