An Integrative Approach to Therapy and Supervision
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An Integrative Approach to Therapy and Supervision A Practical Guide for Counsellors and Psychotherapists Mary Harris and Anne Brockbank
Jessica Kingsley Publishers London and Philadelphia
Figure 1.4 on p.33 is reproduced by permission of Taylor and Francis and Cengage Learning. Figure 3.1 on p.64 is reproduced by permission of Taylor and Francis. Figure 3.2 on p.65 is reproduced by permission of Open University Press. Figure 8.1 on p.165 is reproduced by permission of Open University Press. Figure 8.2 on p.169 is reproduced by permission of Taylor and Francis. Figure 13.1 on p.245 is reproduced by permission of Taylor and Francis and Cengage Learning. Figure 13.2 on p.250 is reproduced by permission of Taylor and Francis.
First published in 2011 by Jessica Kingsley Publishers 116 Pentonville Road London N1 9JB, UK and 400 Market Street, Suite 400 Philadelphia, PA 19106, USA www.jkp.com Copyright © Mary Harris and Anne Brockbank 2011 All rights reserved. No part of this publication may be reproduced in any material form (including photocopying or storing it in any medium by electronic means and whether or not transiently or incidentally to some other use of this publication) without the written permission of the copyright owner except in accordance with the provisions of the Copyright, Designs and Patents Act 1988 or under the terms of a licence issued by the Copyright Licensing Agency Ltd, Saffron House, 6–10 Kirby Street, London EC1N 8TS. Applications for the copyright owner’s written permission to reproduce any part of this publication should be addressed to the publisher. Warning: The doing of an unauthorised act in relation to a copyright work may result in both a civil claim for damages and criminal prosecution.
Library of Congress Cataloging in Publication Data Harris, Mary, 1947An integrative approach to therapy and supervision : a practical guide for counsellors and psychotherapists / Mary Harris and Anne Brockbank. p. ; cm. Includes bibliographical references and index. ISBN 978-1-84310-636-4 (alk. paper) 1. Psychotherapists--Supervision of. 2. Psychotherapy--Study and teaching--Supervision. I. Brockbank, Anne, 1943- II. Title. [DNLM: 1. Psychotherapy. 2. Models, Educational. 3. Models, Psychological. 4. Organization and Administration. 5. Patient Care Management. WM 420] RC480.5.H316 2011 616.89’14--dc22 2010028708 British Library Cataloguing in Publication Data A CIP catalogue record for this book is available from the British Library ISBN 9781843106364 ISBN pdf eBook 978 0 85700 498 7
This book is dedicated to Dr Kelly Suozzi and Eunice Rudman
Contents
Preface 9
PART 1: Introduction
21
1. The FIT Model
23
2. The Person-Centred Approach in Therapy and Supervision 44 3. Learning Theory in Therapy and Supervision
57
PART 2: The FIT Model Applied in Therapy
83
4. Transactional Analysis in Therapy
85
5. Gestalt in Therapy
109
6. Cognitive Behavioural Therapy
122
7. The Integrative FIT Model as a Therapeutic Approach 141
PART 3: The FIT Model in Supervision
151
8. Introducing Supervision
153
9. Using Transactional Analysis in Supervision
176
10. Using Gestalt in Supervision
192
11. Using Cognitive Behavioural Therapy in Supervision 205 12. Using the FIT Model for Individual Supervision
213
13. Using the FIT Model for Group Supervision
232
Conclusion 256
Appendix A: An example of ground rules
257
Appendix B: Supervision contract
258
Appendix C: Setting goals or objectives
261
References 263 Subject Index
267
Author Index
271
List of Figures Figure 1.1: The Single FIT
24
Figure 1.2: The Double FIT
26
Figure 1.3: The Triple FIT
27
Figure 1.4: Expressing emotion: the difficult–easy continuum
33
Figure 3.1: Single loop learning
64
Figure 3.2: Double loop learning
65
Figure 4.1: The three ego states
86
Figure 4.2: Contaminated ego states
90
Figure 4.3a: Complementary transactions
92
Figure 4.3b: Crossed transactions
92
Figure 4.4: The Drama Triangle
94
Figure 4.5: The Quinby Durable Triangle
96
Figure 5.1: Gestalt contact curve
113
Figure 8.1: Supervision matrix
165
Figure 8.2: Overview of cyclical model
169
Figure 9.1: The three ego states
177
Figure 9.2: The three ego states with subroles
179
Figure 9.3: Contaminated ego states
180
Figure 9.4: The Drama Triangle
182
Figure 9.5: The Quinby Durable triangle
184
Figure 10.1: Gestalt contact curve
196
Figure 10.2: Gestalt supervision curve
197
Figure 12.1: The Triple FIT
215
Figure 12.2: FIT diagram showing contaminated boundaries
219
Figure 13.1: Expressing emotion: the difficult–easy continuum
245
Figure 13.2: Mutual dependence of challenge and support
250
List of Tables Table 8.1: Supervision functions and domains of learning applied to the FIT model 159 Table 8.2: The seven tasks of supervision applied to the FIT model
130
Preface
This book provides a new integrative approach to psychotherapy and supervision, based on the belief that the effective model is one which addresses the whole person, and includes the three domains of human functioning, which we outline in this book as feeling (F), behaving or initiating (I), as it is called here, and thinking (T). The approach described recognises and works with these three domains and is, accordingly, called the FIT model. We start by giving an account of the theory and practice which underpin the FIT model’s approach to therapy and supervision, and then outline two of the underlying approaches: incorporating the person-centred approach and learning theory in therapy and supervision. We then describe the model and show how it can relate to the models and theory laid out in Chapters 1 to 3, illustrating how the approach can be applied in psychotherapy and supervision practice. Following this, we provide an account of key ethical and legal issues, and how to train staff to use the FIT model. We have written this book with a wide range of readers in mind. Trainee psychotherapists and supervisors will find here a discussion about the relevance of different therapeutic orientations, and we hope that these readers will find the FIT model an interesting and useful variation. Experienced therapists and supervisors, used to working within a given orientation, may discover a new approach, and practitioners should find a great deal of information about the sources, models and current practice of integrative psychotherapy and supervision in the book, as well as useful applications to their own practice. We assume in the text that the client group are seeking therapy and their counsellors or therapists are our supervisees. The contexts
9
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An Integrative Approach to Therapy and Supervision
we consider vary so that our practical examples cover a variety of sectors, including public and private sector organisations as well as health, education and therapy professions. The case material included is meant to illustrate the theories and techniques and is imaginary, rather than based on real clients. We have given our clients, supervisees and supervisors a gender in order to give life to our case studies and enable the reader to imagine the case under discussion. We have tried to assign gender equally to our case study clients and supervisees. We believe that our own life experience influences all our work so we begin this book with our own stories.
Mary’s story I began training as a psychotherapist in 1977. I received master’s and doctor’s degrees in counselling psychology from Ball State University’s Overseas Programme while living in Germany. The 1970s were heady and adventurous days in the counselling and psychotherapy field. At California’s Esalen Institute, Fritz Perls was breaking new ground by encouraging clients and therapists to work together in hot tubs and to express their feelings by speaking whenever an object or person came to mind. I remember one enthusiastic facilitator exhorting me to ‘Be the carrot!’ in whatever metaphorical soup I found myself at the time. We were encouraged to share the unexpurgated versions of our ‘inner dialogue’ to the larger world, that is, our hapless neighbours, co-workers and family members. I now cringe at the thought of the kind of ‘sharing’ I was encouraged to do with relatives and friends during that stage of my life. The ‘honest communication of feelings’ was taught via assertiveness training; I lost one job by telling a manager what I really thought of him as a person and an employer. My therapist saw this as ‘an important growth experience’ for me; I saw it as something I could have done without. To those of you who trained in the field after the 1970s, a realistic demonstration of then-current therapeutic thought and practice can be gained by viewing the film, Bob and Carol and Ted and Alice. The film’s portrayal of an encounter session and the fallout from it were accurate representations of what was taking place in the Human Potential Movement in the US at that time. During my graduate training, one
Preface 11
human sexuality course required that students attend all sessions and lectures in the nude. To the derision of my fellow graduate students, I opted to take the course at a later date, when it was taught by a more traditional, or at least more modest, lecturer; a decision I have yet to regret. Therapists were encouraging clients to explore feelings and experience themselves in ways that were vastly different from the established methods of psychoanalysis. There was little sense of appropriate boundaries, as many therapists socialised with and went on trips with clients, and physical touch was often seen as healthy and liberating. The need for boundaries and limits developed later, as therapists began to realise the damage that could and had been done to clients by what is now seen as inappropriate practice. Nonetheless, my experiences as a student trainee and as a client were invaluable. I was encouraged to explore my background and ‘hang-ups’ and gained useful insights about myself and others from the process. The academic training I received in my graduate studies was, somewhat paradoxically, extremely rigorous and demanding. I was required to learn and be able to discuss and demonstrate comprehensive psychotherapeutic theory and skills, and to take examinations about my knowledge of them. In class, I had to make presentations and participate in role-plays and personal growth sessions. The programme was ‘integrative,’ which meant that I was required to study and understand the major approaches, including psychodynamic, person-centred, existential and Gestalt, as well as cognitive and behavioural therapies. As part of the training, I was required to receive individual as well as group therapy. Over the course of my training, I worked with three different therapists because the training therapists were rotated to other countries as part of their contract with the university. As an advanced graduate student, I had to facilitate individual and group therapy while being observed and supervised by my tutors. Although the experience was terrifying, and I invariably tried to wriggle off the hook when it came to being observed, it was an invaluable learning technique. During my years of internship, I was required to submit five audiotapes of therapy sessions each week to my supervisor, who gave me detailed feedback on each of them. During later training, I was required to submit videotapes of myself working
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An Integrative Approach to Therapy and Supervision
as both an individual and group therapist, which were reviewed and critiqued by my supervisors. The experience was, again, terrifying for me, but also crucial to my learning. The feedback I was given by supervisors was remarkably thorough, insightful and detailed; one of my supervisors wrote a line-by-line critique of each of my taped sessions with clients on a weekly basis. The therapists and supervisors I had during my training were, by and large, gifted, conscientious and highly professional. As role models, they provided examples of warmth, humanity and insight, which I continue to draw on. The training group I participated in for three years was facilitated by a therapist/teacher who conducted the group in such a way that I always came away feeling both challenged and supported. I learned that a group was a place where I would always feel safe, but not always comfortable. Her challenges to group members were specific and direct, without being punitive or destructive. She embodied the right mixture of personal honesty, congruency and professionalism, and was able to move seamlessly from working with an individual group member, to discussing her own thoughts and reactions to the work. After the group therapy ended, we would spend 15 minutes processing and discussing what had taken place, which made the theory and technique come alive. Group members were able to challenge the therapist, who discussed what had taken place without becoming defensive or negative. I never had the sense that the group work and the processing overlapped and interfered with each other; the ending of the therapeutic work was so clearly delineated from the work of discussing and processing what had happened in the group. I learned to achieve closure with my feelings in group therapy sessions, and to then be able to move into my left brain to discuss and understand the right-brain work which had just taken place. The sense of choice, flexibility, genuineness and transparency in developing the FIT model derives largely from my experience in this group. As much as I learned from the positive role models provided in my training, I believe that I learned perhaps more from the less positive experiences I had of therapy as a trainee. One of my early therapists was so clearly inattentive to what I was saying that he often fell asleep during our sessions. When I finally got up the nerve to challenge him
Preface 13
about his mid-session naps, he interpreted my comment as evidence of my hostility towards him, linking it to my relationship with my father, while denying that he had fallen asleep. From him, I learned about the negative impact that a therapist can have on clients, by using interventions and interpretations to avoid what the client is saying. Another therapist was habitually late for our sessions and kept forgetting who I was. After six months of therapy with her, she continued to call me by the wrong name, and to forget what I had just said. At the end of each session, she would pat me on the back and tell me that I was ‘doing fine’. From both of these people, I gained an enhanced sense of the need to be genuine and present and to attend, in very specific ways, to what the client was saying. Similarly, some of my early supervisors seemed to lack the ability to focus on and attend to what was happening in sessions. I found it particularly unhelpful when one supervisor would use the session to lecture me about theory or technique and discount any input from me. Discussing what was going on between us in the sessions was not an option. Another supervisor was so critical and derogatory about my skills and my person that I found myself feeling nauseated before sessions with her. Whatever I might have learned from her became background to the foreground feelings of anxiety and shame that I experienced with her on a weekly basis. Neither of these experiences enhanced my skills as a supervisor or therapist in a positive direction, but were useful in teaching me how not to be in sessions. One of the questions I continue to remind myself to ask of clients and supervisees is, ‘What is it like for you to be here right now?’ and to listen closely to their answers. Fortunately, during my training I also met supervisors who were excellent, both at challenging and supporting me. They made the theories come alive and helped me to translate them into practice with my clients. They taught me to explore the deeper, underlying issues brought by the client, and encouraged, sometimes demanded, that I explore my own feelings and reactions towards clients. These supervisors were vibrant and passionate about their work and brought their energy and humanness to the sessions. Regardless of the model being discussed, they practised the person-centred values of genuineness and congruency, and encouraged me to take risks both in
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An Integrative Approach to Therapy and Supervision
supervision and, more cautiously, in my work as a therapist. I always left these supervision sessions feeling energised, which I still see as a sign that learning has taken place. Whenever I feel stagnant or bored with a client or a supervisee, I see that as I sign that I need to explore what is not being said in the room. After I completed my training, I spent five years working in, and eventually serving as director, of an agency which provided individual, group, family therapy as well as workshops on stress management, assertiveness training and communication skills. The agency provided me with a range of therapeutic experiences, as well as invaluable supervision by more experienced professionals. After leaving the agency, I spent the next seven years teaching and training psychotherapy students for Boston University’s Overseas Graduate Programme and, at the same time, began to build a private psychotherapy practice. Most of my work now involves teaching, training and supervising psychotherapists. I continue to work with a few private clients, as I believe that I need to ‘keep my ear in’. During the times I have not been seeing clients, I find that I lose the ability to function effectively as a therapist or a supervisor, because the work becomes overly theoretical. My background in counselling psychology has led me to believe that the most effective work with clients is done from an integrative and humanistic approach. In other words, clients need to be seen and treated holistically, to include attention to their feelings, behaviours and thoughts. I find it less effective to treat clients using a single approach, which deals exclusively with any one area of functioning. The core of the humanistic approach, to my way of thinking, is not in using techniques to parrot the client’s words back to them, but means that I need to respond to and respect the whole person and their subjective experience of the world. Practising this means that I give back my impression of the client’s feelings, thoughts and behaviours, and then ask them to decide where they would like the work to go at that point. I believe strongly that listening and giving the choice back to the client is necessary for effective therapy and supervision, regardless of the approach being used. When, for example, I am providing cognitive behavioural therapy (CBT) to clients, I still need to listen to them and reflect back what they are saying, to include their feelings, thoughts
Preface 15
and behaviours, and to use this information to decide, with the client, the direction of the sessions. When I fail to do this, I invariably end up addressing or trying to ‘fix’ the wrong problem. Similarly, in supervision I believe that I must take into account the supervisee as a whole person, rather than addressing part of the supervisee who is, for example, working in a setting which limits him or her to a single approach. The model that Anne Brockbank and I outline in this book involves parallel processing of the feelings, behaviours and thoughts, not just of the client, but also of supervisee, and, at times, of the supervisor. The idea of a book dedicated to explaining the FIT model came out of a conversation over coffee with Anne Brockbank, my co-author. I had known Anne for several years through mutual friends, but had never worked with her professionally. As we discussed what was to become a joint project, I began to appreciate her extensive experience in the fields of training and learning, including numerous publications, as well as the knowledge and skills requisite to the person-centred practitioner. She became interested in the model I described to her, and we decided to put our efforts together in a book about therapy and supervision. As we’ve worked on the book, I’ve come to enjoy discussing the different perspectives we have, as well as the things we have in common. As an American, my training and work with clients and supervisees has a different flavour (and a different accent), which I suspect sometimes seems alien to Anne. For her part, she continues to teach me English, and I continue to translate American for her. We have also both worked in a variety of cultural settings, rather than just our own, which has proved useful. More importantly, I have found that, although we come from different learning backgrounds, we have in common a belief in the person-centred approach in our work with others. I respect Anne’s skill, not just in ‘talking the talk’ as far as humanism goes, but also in her ability to ‘walk the walk’ as well. Whatever differences or misunderstandings have arisen during the writing of the manuscript have been easily resolved by listening and attending to the other’s viewpoint and negotiating solutions using ‘I’ messages and ‘clean language’. Sometimes the theory works!
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An Integrative Approach to Therapy and Supervision
Anne’s story I was trained as a counsellor by the Catholic Marriage Advisory Council, now Marriage Care, an organisation first created in the aftermath of the Second World War to address the increase in marriage breakdown. There was then and continues to be, no difference in the marital breakdown rate between those who are religious and those who are not. The equivalent agency, National Marriage Guidance, later renamed Relate, offered a similar service. Although the agency was, and still is, connected to the Catholic Church, in the 1980s the visionary clerics who directed it sought to modernise the approach offered to clients, at that time mostly couples. These priests were trained by Gerard Egan in Chicago, and offered aspiring counsellors a new training in the UK, based on the work and writings of Egan, who followed Carkhuff in developing Rogers’ original methods. The term counsellor was used then to describe a therapeutic process which I am now happy to describe as therapy or psychotherapy. I was recruited by invitation. This meant that parish priests in the diocese of Salford were asked to identify ‘suitable’ candidates for training. As a happily married couple with three children, actively involved in church-based activities, like parent, youth and music groups, my husband, children and I were perceived as an intact family unit. We were approached and invited to a selection meeting. The selection process was a day-long event. As candidates we were placed together in a room and invited to discuss topical or contentious issues, while two trainers observed the process. I noticed that the observers made notes when individuals offered their opinions. At various times throughout the day we were individually interviewed by the director of training, a panel of trainers and a psychologist. We noted that all the candidates were youngish (I was 37) and later discovered that no candidate over 50 was even considered. When both my husband and I were selected, we had to decide who would opt to take the training first. My husband said, ‘Why don’t you go first, and if you don’t like it we won’t bother.’ And so it was. The training was designed for working individuals, so took place at weekends over two years, using volunteer tutor/trainers. I was amazed by the person-centred stance of our trainers, who modelled all three Rogerian core conditions expertly, establishing rapport and relationship rapidly. The importance of relationship
Preface 17
soon emerged as the critical factor in a therapeutic endeavour. This echoed my discovery of how important relationships were in learning, as alongside my counsellor training I was engaged in a programme of musical education, launched by the city of Salford, known as the Suzuki method. This involved parents learning to play the instrument and, through their loving attention, passing their learning on to their child, who were as young as three or four. The children learned to play by ear, with dramatic results, and concerts were held with 300 infant learners playing tiny violins. Our training was experiential and rooted in practice, as we operated with colleagues as counsellor or client, while our trainer observed and offered feedback directly. I found this could be intensely painful as I realised that my listening left a lot to be desired! The basic Rogerian technique we were taught was strengthened by a version of what is now known as ‘clean language’, namely a restatement of what the client has said. In addition, we were given a structure to work within, the Skilled Helper model of Gerard Egan, as well as being introduced to the skills of empathy, congruence, immediacy, challenge and confrontation. Group work offered opportunities to practise these skills. The learning process was supported by ‘home groups’, those sessions at the end of a training day where participants could be cared for and their wounds soothed, again with a highly person-centred tutor/facilitator. Eventually I was allowed to work with a real client, albeit with my supervisor nearby or within telephone contact. My first supervisor had been part of the team who trained me, so she knew me well, and she used what I now see as a person-centred coaching approach to the process. Whenever I voiced a query, in response I was given a Socratic question to answer. The empathic responses of my supervisor were powerful supports for me then, as were her probing questions. Consequently, within a highly directive institution, the Catholic Church, I became part of a team of counsellors offering personcentred therapy to individuals and couples. Many non-Catholic clients sought our service as there was a shorter waiting list and our approach was at that time more modern than Relate’s. In due course I became a tutor/trainer for the agency, and again the training was covered in weekends over one calendar year. The training emphasised group dynamics, a strength which has served me well as an independent
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An Integrative Approach to Therapy and Supervision
trainer/facilitator. Indeed, these early group experiences gave me the competences I needed to launch successful academic modules at master’s level in facilitation and group dynamics. Supervision training was part of our tutor training, as all tutors for the agency acted as supervisors, and I was allocated several trainee counsellors and two ‘centres’ with up to ten experienced counsellors each. I was responsible for the in-service training of these volunteers and for monitoring the quality of therapy they were offering the public. This led to some difficult issues around professional practice, and the experience of holding my ground on ethical matters – sometimes in contention with the agency itself – was a good learning opportunity. When I relocated and left the agency, I sought a more recognised qualification and became a diplomate of South Manchester College, where I met some admirable trainers in the person-centred tradition. However, the course had an integrative stance and I was introduced to several other approaches, including transactional analysis (TA) and Gestalt, but not CBT yet. The course included live triad work with tutorial feedback, and videotaped sessions later analysed by my tutor. I experienced feeling ‘not quite good enough’, even though I was already a practising counsellor. Again the person-centred ethos ensured that whenever students were affected by feedback there was a support group where it could be processed. As part of the requirements for this British Association for Counselling and Psychotherapy (BACP) accredited diploma, I was required to submit three lengthy case studies, videotaped client sessions with analysis, an academic dissertation on my chosen orientation, 100 hours of supervised practice and 30 hours of personal therapy. This last requirement was well timed for me as I was engaged in some very dramatic life changes: leaving my first marriage, forming a business relationship with my eventual partner, dealing with the death of my parents and adjusting to a new job in London. My supervisor suggested CBT for me, and I started on a 16-week contract. After all my experience of person-centred caring I found the process cold and much too rational for my rather emotional state at the time, and I chose to end the therapy for these reasons. I then chose a psychodynamic therapist who had been recommended to me, who had a person-centred style, and this worked well for me, meeting my need to deal with all the losses I was experiencing. This relationship
Preface 19
endured for several years, far beyond the course requirement which had initiated it. My private practice developed alongside related work as locum counsellor for the Inns of Court School of Law and Brief Encounters training for solicitors and health professionals. The latter introduced me to the idea of brief person-centred therapy, which I was able to apply to the Employee Assistance Programmes work which came my way. As part of my practice I continued supervising professionals in a variety of agencies, always using the person-centred method I had learned and trusted. Much of my supervision work has been groupbased, and this has enabled me to develop as a group supervisor. My writing has extended into the fields of adult learning, particularly through facilitation, action learning, mentoring and coaching where, like therapy, the idea of reflective dialogue is so important for transformative learning.
How we collaborated It began with coffee at Mary’s when she was talking about her work and her model of supervision. I said, ‘You should write a book.’ Mary said, ‘Yeah right’, and continued talking. I said, ‘No really, you should write a book,’ and Mary said again, ‘Yeah, right.’ Finally I said, ‘Mary, let’s write a book!’ and this is where it started. I was excited by Mary’s description of her model and sensed that she was ready to present it to a wider audience. Mary was feeling hesitant, not sure she could write it by herself, or that the model deserved a wider audience. She was encouraged by my comments and appreciated my very pragmatic approach. Although I was involved in other projects, I realised that this would be a book I would very much like to be part of, and that I would be proud to collaborate with Mary. I kick-started the project by suggesting that Mary write an outline, and we fixed a meeting to put it on paper. Mary responded and liked the structured approach to the model which she might normally be using by herself. As the work proceeded, we would check out with each other how any suggestion was being received, so that both of us felt comfortable. The result is that we were both aware of giving and receiving ongoing, continual feedback. We have realised that Mary has a tendency to talk about her work when she feels unsure of herself, and I have
20
An Integrative Approach to Therapy and Supervision
a tendency to push too early for action. We devised a method of working together which reflects the model by attending to all three domains in our sessions. Discussions about the work were sometimes identified as focusing on feelings, actions or thoughts and this was made explicit. Where a strong feeling came up from one or the other, this was dealt with before continuing with the thinking activity of writing. We have developed a pattern of pausing to consider what to do next and how to do it, checking out how each prefers to work. For instance I am happy with the keyboard and Mary likes to talk through the material orally to be captured in the text. This suits my need to be in control, while accessing the creativity of talking together. For her part, Mary doesn’t enjoy typing and prefers to talk the material through. We agreed on allocated chapters and dates for presenting to each other and this pattern has carried us through to completion. So, that is the story behind the book – we hope you enjoy what follows, and find it as useful as we have done in our own practice. Readers are invited to contact us at
[email protected] or
[email protected] for questions or reactions to the book.
PART 1
Introduction
Chapter 1
The FIT Model
This chapter introduces the integrative model for enhancing psychotherapy and supervision, which we term the ‘FIT model’. The psychotherapist is referred to throughout as a therapist. The FIT model is founded upon the three domains of human functioning: Feeling (F) Initiating (or acting) (I) Thinking (T)
The FIT model developed out of a perceived need for a model of therapy and supervision which, rather than being limited to a single psychological theory and approach, utilises an holistic approach which incorporates a range of theories and issues. The model can be used by beginning and experienced therapists as well as by beginning and experienced supervisors looking for a way to expand their practice to include more than one approach in a systematic and comprehensive manner. Within our recommended person-centred approach, we propose the integrative use of ideas from three other theoretical orientations, namely transactional analysis (TA), Gestalt therapy and cognitive behavioural therapy (CBT). These approaches are summarised below. We go on to explore in more detail how each can be applied using the FIT model in both therapy and supervision in Chapters 4 to 13. The person-centred approach which underpins the model, is described in Chapter 2, and in this chapter we present a summary of the other three approaches and also map out how they relate to the FIT model.
23
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An Integrative Approach to Therapy and Supervision
The Single FIT: understanding the individual The domains addressed when using the FIT model are described as Feeling (F), Initiating (I) and Thinking (T). They are illustrated in Figure 1.1 below, the Single FIT, which depicts the three domains as they occur within an individual. Feeling (F)
Initiating (I)
Thinking (T)
Figure 1.1:The Single FIT
Explanation of the diagram
F denotes emotions, affect and feelings – material expressed in this domain of the model may be accessed using person-centred, Gestalt or TA techniques. I denotes initiating, that is, behaviours and actions initiated by the individual – this domain of the model may be accessed through TA or CBT. T denotes cognition, thoughts, beliefs and self-talk – this domain of the model may be accessed through TA, Gestalt and CBT.
The model provides a structure which encourages explicit choices by the individual in the context of therapy or supervision at every stage of the interactions. The use of transparency within the transactions reflects the person-centred belief in congruence and respect for an individual’s ability to find answers within him or herself. The listening and attending skills used throughout the process reflect Rogers’ belief that each intervention aims to achieve a deep
The FIT Model 25
understanding of the world of the individual (Rogers 1951, 1957, 1961). Instead of encouraging avoidance of difficult issues, this process fosters an organic process, that is the deeper issues emerge as and when the individual is ready and able to engage with them. The Single FIT diagram can be used by the therapist to understand how an individual client functions and views the world, which can have valuable therapeutic implications.
The Double FIT: understanding the client/therapist relationship The diagram in Figure 1.2 expands the FIT model and depicts the relationship which exists between the individual client and their therapist, who is the supervisee in this example. The insight gained by viewing the two people in relation to each other in this diagram provides useful material to be explored in supervision and also has valuable therapeutic implications. The diagram suggests that the client’s functioning in each of the three domains is seen individually as well as in relation to the therapist’s functioning. The Double FIT can give focus to the therapist’s understanding of the client’s issues and, additionally, the interplay between the issues occurring between the client and therapist. This view provides an extra dimension to the therapeutic work. The client’s feelings, thoughts and behaviours towards the therapist are manifestations and reflections of the inner world of the client and expressions of previous learning and relationships. While continuing to hold the information regarding the client’s functioning, the therapist is asked to consider his own functioning in each of the three domains, and to consider the arising interplay between the client and himself. The therapist can use the diagram to explore how his own feelings (F), behaviours (I) and beliefs (T) impact on and intersect with the client work. When this process occurs, the work in therapy becomes introspective as well as interactive. By attending to his own feelings, behaviours and thoughts regarding his work with the client, the therapist is able to gain deeper insights into both the client’s as well as his own functioning, which then informs and expands the therapeutic work. The FIT model is used to foster this process; the therapist is able to provide insights and observations to enhance their understanding of the therapeutic work.
Figure 1.2:The Double FIT
Initiating (I)
Initiating (I)
Feeling (F)
Feeling (F)
Thinking (T)
The therapist/supervisee
The client
Thinking (T)
The FIT Model 27
The Triple FIT: understanding the client/therapist/ supervisor relationship In order for the supervisor to foster the effective use of the FIT model, they need to be aware of their own functioning in each of the three domains, in order to hold and understand the interactions which occur between the client and the supervisee and between the supervisee and themselves. Figure 1.3 illustrates this relationship. Client Feeling (F)
Initiating (I)
Thinking (T)
Supervisor
Supervisee
Feeling (F)
Feeling (F)
Initiating (I)
Thinking (T)
Initiating (I)
Thinking (T)
Figure 1.3:The Triple FIT
The therapist (now the supervisee) uses supervision to examine the Single FIT, which represents the client’s functioning in the three domains, as well as the Double FIT, which represents his awareness of his own feelings, behaviours and thoughts towards the client and the interplay between the two. Both the Single FIT and Double FIT are then explored in supervision sessions. The supervision process may also include input from the supervisor’s perspective, which constitutes the third or Triple FIT.
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Figure 1.3 suggests that supervision needs to include awareness of the supervisee’s functioning as well as the client’s functioning in order for the therapy to be effective. In order to facilitate this process in supervision, the supervisor must also be aware of her own feelings, behaviours and thoughts towards the client as presented in supervision, as well as towards the supervisee. In particular, if the supervisee’s feelings (F) have been triggered by material brought by the client, supervision using this model can provide a clear framework for identifying and resolving the overlap between the supervisee’s and the client’s issues. When the supervisee has unacknowledged and unresolved feelings towards the client, he will react to the client’s feelings, behaviours and thoughts influenced by this bias. The challenge in using this model is that the supervisee is offered an opportunity to become aware of his own process and to exploring his unresolved issues, while at the same time considering the potential impact these issues can have on the client. This awareness may be in the background throughout the session or may become more in the foreground when the interactions between the supervisor and supervisee reflect dynamics occurring between them, which may impact on the work being done with the client. Throughout this process, the emphasis remains on facilitating the work with the client. Even when personal material is explored by the supervisee or expressed by the supervisor, the focus remains on deepening the supervisee’s understanding of the client’s needs and process. Supervision sessions using this model will sometimes consider the feelings, behaviours and thoughts expressed by the client towards others, as well as towards the therapist. It may also explore the supervisee’s feelings, behaviours and thoughts towards the client, and the relationship between the supervisor and supervisee as it impacts on the work being done with the client. Both the supervisor and the supervisee need to be able to process the multiple interactions at the same time, that is, to ‘parallel process’ the work occurring in the supervision and in the therapy sessions. A mental map of the various diagrams provides an awareness of the interplay taking place within each of the three individuals involved in the process and allows
The FIT Model 29
awareness of the supervisor’s and supervisee’s functioning, as well as the client’s functioning, as reported by the supervisee. Working with the FIT model, both supervisor and supervisee become increasingly adept at moving back and forth among the various domains to work with the emerging dynamics and issues.
FIT and reflective practice This section describes how the FIT model supports reflective practice in supervision. The overall approach in FIT supervision is primarily person-centred in order to offer supervisees potential learning in all three domains, but particularly the affective or emotional domain. It is our contention that this approach is the one most likely to facilitate an exploration of all three domains, as detailed earlier. Hence as part of the FIT model of supervision we recommend a dialogue which is person-centred. The supervision relationship is not a therapeutic one, but rather a learning relationship to support reflective practice. When the process of FIT supervision surfaces therapeutic material for the supervisee, then referral for therapy (quite separately from supervision) is recommended. A competent supervisor is able to identify and discuss such a referral when necessary. FIT supervision and connected knowing
In FIT supervision, the supervisor adopts a stance of ‘connected knowing’ (see Chapter 3), in which the supervisor seeks to understand the supervisee’s subjective experience and enters into a reflective dialogue. In other words, as a supervisor I do not have to necessarily agree with the stance of my supervisee, but I suspend my judgement in order to understand their stance. A supervisory relationship which nurtures connected learning is likely to stimulate the challenge of double loop learning and personcentred FIT supervision is likely to facilitate the emotional work needed for the process, as well as the actions and thoughts needed to carry out the supervisee’s learning intentions. Double loop learning is described in Chapter 3.
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FIT supervision is intentional in the sense that the supervisor is conscious of what she is doing and why. The supervisor may also wish to declare explicitly her purpose and how she intends to achieve it, to colleagues and/or supervisees. Such explicit articulation (naming that which is usually unnamed) means the supervisor can be clear about what she is doing and whether it is appropriate. The model also provides the opportunity for supervision sessions to stimulate and explore the interactions between supervisors and supervisees as well as those occurring between supervisees and their clients. In addition, it provides a framework for supervision occurring within a single session or over ongoing sessions. It is based on the process of person-centred reflective dialogue, which includes structured time, space, clear boundaries, tolerance of uncertainty and competence in dealing with emotional material. This process is known to promote a powerful learning relationship between supervisor and supervisee, with the potential for transformational learning (Brockbank and McGill 2007). While the FIT model offers intention, stance, awareness and modelling, a supervision environment which nurtures connected learning, single and double loop learning and provides for supervisees to reflect on their learning demands high level skills in their supervisors.
FIT and person-centred values The FIT model is informed by the humanistic and person-centred beliefs expressed by Carl Rogers which foster and support individual choice and human potential. We provide an introduction to a personcentred approach to therapy and supervision in Chapter 2. Here we look at how a person-centred approach can be used when using the FIT model. The well-known principles of the person-centred approach are as follows: •â•¢ Congruence: realness or genuineness, which implies some disclosure, a willingness to be real, to be and live the feelings and thoughts of the moment •â•¢ Unconditional positive regard: prizing, acceptance and trust of the learner which implies a belief that the other person is fundamentally trustworthy – this means living with uncertainty
The FIT Model 31
•â•¢ Empathy: empathic understanding which must be communicated (silent or invisible empathy is not much use). What are the implications of these principles when you are using FIT with your clients or acting as a FIT supervisor? Congruence
When using the FIT model, a therapist uses congruence in his work with clients, by openly describing his authentic reactions to the client’s experiences. As a therapist this does not mean blurting out whatever transient thoughts and feelings you are having towards your client at any given moment, but rather the expression of a pattern of feelings or experiences which you have noticed in response to your client. The process should include asking yourself first if a comment or response would be for your own benefit or for that of your client. If you believe that stating your emotional reactions would further your client’s understanding of themself, only then should you share such reactions with your client. In the same manner the person-centred supervisor is congruent for the benefit of their supervisee. What emotions might be suitable for sharing with your client or supervisee?
Traditionally seen as irrational and the part of humans associated with ‘bodily humours’, emotion has been largely ignored in Western education and hence the facility for dealing with feelings, in a learning context, has been absent from the experience of many supervisees. For supervisors who are also therapists, emotional material may be perceived as relevant only in a therapeutic context. This resistance to emotion in learning mirrors the inadequacy of emotional matters in much of the wider (Western) society (Orbach 1994). The personcentred approach allows for congruence in therapy and supervision which is characterised by authentic expression of emotion. Jourard (1971) suggests that persons who are ‘known’ by others are healthier and happier than those who are not, and in our role as supervisors we have often heard a supervisee say that being able to give voice to and express their emotions has been an important breakthrough in tackling a major issue in their client work, confirming expert findings on stress management (Cooper 1983). Emotions can
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be expressed verbally and non-verbally, and when suppressed verbally they may ‘leak’ non-verbally, in both therapy and supervision. Both can of course be expressed together as congruent behaviour. Nonverbal expression of emotion may include tone of voice, gesture and body language. How should emotion be expressed and what is its value in FIT therapy or supervision?
First, a therapist using the person-centred approach provides a model for clients of congruent expression of appropriate emotion, often voicing emotional material which the client is not aware of expressing themselves. In the same way, as a FIT supervisor you are a model for your supervisee, so that if you are comfortable with your emotions, your supervisee will dare to express theirs. Second, the motivating power of emotion is known to promote double loop learning (outlined in Chapter 3), and an ability to deal with emotional material is necessary if you seek to ‘unpack’ the blocks to learning which may emerge through reflective dialogue in supervision. To clarify where difficulties may lie, we present the difficult–easy continuum in Figure 1.4. The diagram is based on the work of Egan (1977) and indicates how awkward we find emotional expression in a variety of circumstances which occur in learning contexts like supervision (Brockbank and McGill 2006, 2007; McGill and Brockbank 2004). Those of us who have experienced a Western-style education find it easier to express negative emotion and this is borne out by our lopsided emotional vocabularies which incorporate more negative feelings than positive ones. Further, we are able to express emotions about people in their absence more easily than to their face, what we call the gossip syndrome. In order to enable reflective dialogue, discussed in Chapter 3, both therapists and supervisors are an important model of emotional expression in the here and now, so how might they express emotions appropriately? It is important that in either therapy or supervision, you take responsibility for your own emotions, being aware of your own emotional state and, if appropriate, expressing clearly and directly what it is you are feeling and why. Clients may have difficulty expressing some emotions or may express them indirectly and the FIT model
The FIT Model 33 Negative feeling
EASY About a past situation
Positive feeling Who is absent Negative feeling About the here and now Positive feeling
Expressing emotions to (or about) a person
Negative feeling About a past situation Positive feeling Who is present Negative feeling About the here and now
DIFFICULT
Positive feeling
Figure 1.4: Expressing emotion: the difficult–easy continuum Source: McGill and Brockbank (2004) The Action Learning Handbook. Abingdon: Routledge Falmer, p.138.╇ Adapted from Egan (1977) You and Me. © Wadsworth, a part of Cengage Learning, Inc. Reproduced by permission.
offers a structure for authentic expression of emotion in both therapy and supervision. For example, a therapist may find themselves feeling angry when their client is describing an abusive incident, in a calm and controlled manner, and the therapist may voice that anger for the benefit of their client. Clients often struggle to express their feelings authentically and the FIT model ensures that the feeling domain is given equal importance in therapy to the other two domains, so that a strong focus on thinking and doing does not neglect the emotional domain. In supervision, a supervisee may initially feel inferior or inadequate, while you as supervisor may feel frustrated or impatient; the first is likely to be revealed by the supervisee’s lack of eye contact and drooping body language, and the second may be leaked in your tone of voice. You may decide, in either therapy or supervision, having identified your feelings about an issue, to ‘park’ the feeling until you find the right time to raise the matter. As a supervisor you may feel impatient
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and frustrated with how your supervisee is working but you may decide that your supervisee is upset and unlikely to be receptive to your expression of frustration. You may also judge that the feelings of frustration are yours and yours alone, and not a useful contribution to the session. Whatever the emotional expression in a supervision or therapeutic session, how should the supervisor or therapist respond? Unconditional positive regard
Rogers describes unconditional positive regard as experiencing ‘a warm acceptance of each aspect of the client’s experience’ (1957, p.98). Other explanations present unconditional positive regard as an attitude, which is described as deeply valuing the other; not being deflected by the other’s behaviour; and consistent acceptance and enduring warmth towards the other (Mearns and Thorne 1988, p.59). The attitude characteristic of unconditional positive regard is enduring and consistent, and it is maintained throughout the relationship. Other descriptions include ‘non-possessive warmth’, ‘respect’, ‘affirming’, and, of course, Rogers’ unique ‘prizing’. Unconditional positive regard is powerful in therapy and supervision because it breaks into insecurities experienced by the client and the supervisee, directly undermining conditions of worth. Offering unconditional positive regard to your client or supervisee allows you as the supervisor to earn the right to be ‘let in’ behind the mask which often repels or distances others. Empathy
Rogers defines empathy as the therapist having ‘an accurate empathic understanding of the client’s awareness of his own experience’ (1957, p.99) which he describes as the ability ‘to sense the client’s private world’ as if it were her [sic] own, but without ever losing the “as if ” quality…this is empathy’ (Rogers 1957, p.99). This familiarity with the client’s world enables the therapist to move about in it freely, offering not only his understanding of what is known to the client, but also aspects of the client’s experience ‘of which the client is scarcely aware’ (1999). Other descriptions present empathy as a process where the therapist ‘lays aside her own way of experiencing and perceiving reality, preferring to sense and respond to the experiences and perceptions
The FIT Model 35
of her client’ (Mearns and Thorne 1988, p.39). Using the FIT model, you may, with care and respect for your client, enable the expression of emotions in a helpful way, using primary and, where necessary, advanced empathy (see Chapter 2). In your session, when you wish to respond to feelings with understanding you will use the skill of empathy, the genuine response to an expressed feeling (see Egan 1976 for detail). As part of the person-centred approach empathy features in the FIT model in both therapy and supervision and this is discussed in more detail in Chapters 2 and 3.
Using the person-centred approach in therapy and supervision Therapists using the person-centred approach proceed from the person-centred premises of ‘unconditional positive regard’, ‘prizing’ and ‘acceptance’ of their client, establishing trust and safety within the sessions, and the core belief in the individual’s ability and right to make his or her own decisions. Active listening and attending communicates this unconditional positive regard, and therapeutic empathy ensures that the emotional domain is addressed in therapy. In therapy and supervision, using person-centred values, the client or supervisee will be invited to proceed from a position of equality within the sessions, freely choosing what they want to explore in the session. An initial session of either therapy or supervision begins with the attitudes described above and incorporates the use of the personcentred listening and attending skills. After an initial meeting with your client or supervisee, you will more than likely have begun to form a mental image of their functioning in terms of feelings, actions and thoughts, which can be explored in subsequent sessions. As a supervisor, you begin by listening to the client material presented by the supervisee, that is, the Single FIT, and reflecting it back to them, including a summary of feelings and content. At the same time, you are listening beyond the client material presented, in order to understand your supervisee’s relation to the material being discussed, that is, the Double FIT will begin to emerge in each area of functioning. Your supervisee is encouraged to discuss what they would like the focus on, that is the feelings, actions, or thoughts
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which materialise as part of their reactions to the client within each of the three domains. As and when appropriate, the supervision session may focus on the interaction between yourself and your supervisee, as this may replicate some of the dynamics between the supervisee and their client. This is the emerging process described by the Triple FIT. In summary, the session explores the dynamics occurring between your supervisee and their client (the Double FIT), the dynamics within the supervision relationship (the Triple FIT) and the possible therapeutic approaches to be used with the client (the Single FIT). The use of the person-centred concepts and skills fosters trust within the sessions as well as a deeper understanding of the issues being explored. The use of active listening skills, which focus on and intensify feelings, and assist in clarifying content, is especially effective in initial sessions. As your supervisee becomes increasingly focused on material from the additional two domains, the use of other approaches, to include TA, Gestalt and CBT, can be successfully integrated into the sessions.
The three FIT approaches: TA, Gestalt and CBT Introducing transactional analysis (TA)
A thumbnail sketch of basic TA terms and concepts is introduced here and then expanded on in Chapter 4. Central to TA theory is the concept of the personality as composed of three parts (which are detailed in this section): the Parent, Adult and Child (Berne 1964). Within this framework, the Parent represents the part of the individual which contains rules and beliefs which are absorbed from the outside world. The Parent ego state is made up of two components, the Critical Parent, which can be judgemental, destructive and rigid, and the Nurturing Parent, which is nurturing, caring and supportive. The second personality part is known as the Child ego state, which, in its natural state, is creative and spontaneous. The subparts of the Child include the Free Child, which expresses emotions free of Critical Parent messages, the Adapted Child, who has learned to cope by becoming overly conforming to demands from the outside, and the Rebellious Child, who acts out anger and frustration towards others in aggressive and destructive ways. The third part of
The FIT Model 37
the personality is the Adult ego state, which is logical, rational, and serves as mediator or referee between the first two states. The Adult is utilised to understand the self, in the case of structural analysis, or to understand the interactions between the self and others, which is called transactional analysis. Central to TA theory is the belief that, when the individual learns to recognise the various parts of himself and their impact on him, he can then choose to free himself from negative thought and behaviour patterns, and experience life more spontaneously. In addition to learning to recognise his own and other people’s Critical Parent messages, he is encouraged to express problematic feelings and beliefs from his Adult ego state; that is, his Adult speaking for his Child (Berne 1964). Accessing the feeling, initiating and thinking domains through transactional analysis
The TA concepts described above provide the client with a clear understanding of their current functioning, primarily by using their logical, Adult voice (the ‘T’ in FIT), which also allows access to the other two domains, ‘F’ for feeling and ‘I’ for initiating or acting. In order to recognise all three domains, a basic understanding of the theory is needed and the client will need to have a clear, working understanding of TA theory and practice, so that they are able to apply it to themselves. TA theory contributes to the FIT model’s integrative approach by encouraging both client and therapist to understand their own functioning in the realms of feelings, behaviours and thoughts, and to facilitate their interactions by utilising the Adult ego state. TA is useful in encouraging awareness of and functioning in the three domains by fostering the free expression of feelings from the Child ego state, recognising and choosing more effective behaviours from the Adult ego state and encouraging the formation of healthier self-beliefs and thought patterns to replace Critical Parent messages contained within the Parent ego state. For example, your client may react powerfully to any comments which they perceive as critical, and this is affecting their therapeutic work. When exploring the Child ego state in therapy they are able to recognise their behaviour as coming from the Rebellious Child
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sub-state. In therapy your client may then be able to identify some of the sources of their reaction from childhood experiences. As a supervisor, you will strive to communicate from your Adult ego state in order to encourage your supervisee to recognise and engage with the interactions taking place between them and their clients, and in making decisions as to where and how the therapeutic work proceeds. Using Adult-to-Adult conversation focuses supervision; your supervisee’s Adult can observe whether they have focused on feelings, behaviours or thoughts, which informs their work with clients. Introducing Gestalt
The application of Gestalt concepts to the FIT model is described briefly here and expanded on in Chapter 5. The word ‘gestalt’ means, shape, form or outline in German. Gestalt theory is based on the belief that people are made up of conflicting, opposing or disowned feelings and needs (Perls 1972). The purpose of using Gestalt concepts in therapy and supervision is to help the client or supervisee to acknowledge or ‘own’ his feelings and beliefs (the ‘F’ and ‘T’ of the FIT model), which may have been swallowed whole from his environment and which he may be unaware of or have projected onto others. One of the goals of this approach is to encourage the individual to increase awareness of their own feelings and beliefs and to express them directly, in the present tense. This process facilitates change or integration of the opposing parts. When this occurs, the individual experiences resolution and integration, and the Gestalt or particular inner conflict is said to have closed. When one Gestalt closes, it recedes into the background of the individual’s awareness and creates space for another issue or Gestalt to emerge and to then become foreground. Gestalt also attends to the body, in the belief that it both holds and expresses feelings that the mind may have blocked out (Corey 1991). Gestalt techniques may focus on ‘contact’ with the self and others and ‘resistance’ which blocks genuine contact through the use of defences such as introjection, projection, retroflection, deflection and confluence.
The FIT Model 39
Accessing the feeling, initiating and thinking domains using Gestalt techniques
Using Gestalt concepts includes supporting the client in working primarily with their feelings (F), through a here-and-now process that encourages expressing feelings as if they are occurring in the present, rather than talking about or analysing them. Gestalt techniques encourage the exploration of the interactions between the therapist’s world and their client’s world, using both the initiating (I) and thinking (T) domains. For example using the empty chair technique may be used to enable a client to express their true feelings about a colleague or family member, as they may bring into awareness their feelings about these relationships. What is taking place in the therapy session may be paralleled in supervision. As a supervisor you can acknowledge both processes and dialogue with the supervisee, attending to the increased awareness, and achieve supervision which is likely to be authentic as a learning experience for both parties. For example, if your supervisee is aware that she has strong feelings towards her client which affect the way she thinks about and acts towards that client, you may ask her to put the client in an empty chair and express her feelings towards that client. By bringing her feelings into her present experience, your supervisee may begin to see that she is reacting towards her client based on her unresolved childhood experiences. By gaining awareness of the material she projects onto her client, she is then able to separate her own feelings from those of her client, and to work with her client’s material free from contamination of her own issues. Asking a supervisee to speak from her client’s position can also be useful in deepening her understanding of her client’s perspective, which can, in turn, enhance and inform future work with that client. In addition, in keeping with the Gestalt emphasis on awareness and present experience, as supervisor you will encourage your supervisee to express feelings which she is experiencing towards yourself which may replicate feelings that she may be having towards her client. This will expand her awareness of her own process and avoid projecting her own unresolved material onto her clients.
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Introducing CBT
While the person-centred, TA and Gestalt approaches focus on feelings, insights and increased self-awareness, cognitive behavioural approaches focus more on aiding the client in identifying and making changes in behaviours, cognitions and beliefs which they find problematic (Corsini and Wedding 2008). A more detailed account of cognitive and behavioural approaches, known jointly as CBT, is provided in Chapter 6. In FIT terminology, CBT attends to the realms of initiating behaviours and actions (I) and focusing on and changing thoughts, beliefs and cognitions (T). Behavioural therapists have traditionally de-emphasised feelings to focus on teaching skills to clients which enable them to alter or extinguish problematic behaviours. Although feelings have been increasingly taken into account by cognitive behavioural therapists, the focus remains on behaviours. Both behavioural and cognitive therapists have downplayed the importance of the relationship in the past and often act as teachers, guides and trainers to their clients. Current cognitive behavioural therapists, however, now recognise and place importance on the therapeutic relationship as an agent of change. They may also use techniques such as assertion training to teach clients to behave more effectively in social situations. First they explain the theory, and then they encourage clients to practise the assertive skills via role-plays within the sessions and carry out homework assignments outside the therapy sessions (Corey 1991). The use of written logs or diaries often accompanies this type of work. A range of fears and anxieties have also been successfully treated using such techniques as systematic desensitisation and deep muscle relaxation. CBT focuses on concrete issues and thought patterns, and clients are asked to listen to their negative self-talk, to identify self-defeating beliefs and to work towards developing more effective behaviours and rational self-beliefs (Corey 1991). Accessing the thinking and acting domains using CBT methods
As a therapist using CBT methods, you will be striving towards assisting your client in identifying behaviours (I) and thoughts (T) which are unhelpful in their life or work. The process aims to enable your client to learn more effective coping and thinking patterns. By
The FIT Model 41
first observing the ‘I’ and ‘T’ domains described by your client and then by exploring these two areas of functioning, your client is able to expand his understanding of cognitive and behavioural theory and techniques. The client can then explore and practise the relevant skills with you within therapy sessions. The function of the therapist dealing with the ‘I’ and ‘T’ domains is, in keeping with the CBT model, often that of teacher and trainer, helping the client to recognise patterns of behaviour and his connection with limiting beliefs. In supervision using CBT methods, if the supervisee is unaware that some of his own thoughts or behaviours towards the client may reflect the problems brought by the client to therapy, the supervisor can assist him to identify these patterns and then explore and practise appropriate interventions. The supervision sessions may explore the supervisee’s behaviours (I) and beliefs (T) operating in the therapeutic work, resulting in clearer and more effective therapeutic interventions.
Integrating TA, Gestalt and CBT in FIT supervision The FIT model integrates all three of these orientations, using them as and when they are appropriate, depending on the issues brought by the client. The limitations of each are balanced by their advantages in particular domains of learning. For example, TA enables feelings and thoughts, as well as behaviours to be explored; Gestalt explores ‘hidden’ or suppressed feelings, as well as thoughts and actions, and CBT focuses mainly on action, the ‘I’ for initiating, and the ‘T’ for thinking in FIT. The primary belief underlying the FIT model is that, in order to be effective, the therapist needs to approach the work with their client humanistically and holistically. This includes the belief that the person consists of thoughts, feelings and behaviours, and that all three of these domains must be acknowledged and addressed within a safe relationship in order to foster lasting changes. Similarly, as the therapist functions within the same three domains, these also need to be dealt with in supervision sessions within the same humanistic context. The model provides both a framework for assessment and treatment for therapeutic work and as a focus and structure for supervisory sessions. In practice, when using the FIT model in supervision, the modalities are often combined with each other to form an integrative
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approach which may be carried over into the work with clients. The application of the approaches is determined by the supervisee’s preferences, the issues under consideration, the stage of supervision, as well as the requirements of individual therapeutic settings. Clients and supervisees who are in the early stages of therapy or supervision often work best with a person-centred approach until trust in the relationship has been formed. In later stages of therapy or supervision, TA and Gestalt can be effective in dealing with deep-seated conflicts and in identifying ineffective communication patterns, while CBT can work well in dealing with issues such as fear of failure, unassertive behaviours and negative self-beliefs.
Using the FIT model in therapy The FIT model provides a framework and focus for therapy as well as for supervision sessions and offers an integrative approach which can be used in either setting. The model is used initially in therapy to identify which of the three domains clients would like to explore with their therapist. In keeping with humanistic and person-centred tenets, decisions on how to proceed and what to focus on are discussed transparently and explicitly between the therapist and client. The therapist attends to the feelings, behaviours and thought patterns that bring the client to therapy. The therapist listens for emerging patterns which suggest that the client seems to be functioning in one domain rather than others, that is he may be experiencing very strong feelings or describing problematic behaviours or thought patterns. This observation on the part of the therapist is fed back to the client using active listening skills. The client is then encouraged to decide where he would like to focus initially, on which issues and in which domain, and how he would like the work to progress. The therapist, using this integrated approach, provides very brief summaries of person-centred, TA, Gestalt and CBT, in order to give the client enough information to decide which approach and domain seems most relevant to him at that point. If the client is unable to decide, the continued use of listening and attending skills is used to elicit the focus of the session.
The FIT Model 43
Having established the initial direction of the therapy session in collaboration with the client, the therapist (now the supervisee) can use supervision sessions to enhance their understanding of the client’s issues, as well as to consider how to proceed with the therapy sessions.
Summary This chapter has presented an account of the FIT model, including the rationale and ethos which underpin it, as it applies to both therapy and supervision. It has discussed the three domains of human functioning, Feeling, Initiating and Thinking and has introduced the approaches which are used when working with each domain. It has also introduced the concepts of the Single FIT, the Double FIT and the Triple FIT, which demonstrate the inclusion of each of the three domains within the model, first with the client (Single FIT), then with the client and therapist (Double FIT), and then with the client, supervisee and the supervisor (Triple FIT).
Chapter 2
The Person-Centred Approach in Therapy and Supervision
This chapter deals with the person-centred approach which underpins the FIT model of supervision and psychotherapy (shortened to therapy and therapist for ease of reading). The person-centred approach is based on what was known as the ‘third force’ in psychotherapy. The third force, or ‘humanistic approach’, grew out of a reaction against the early schools of thought related to human learning (Goble 2004). Humanistic thought was influenced by Maslow (1968, 1969), who described basic human needs as a hierarchy which views human development as individual or unique and phenomenological, rather than age- or task-related. Within this movement, people are seen as having the innate ability to self-actualise. The approach which evolved out of humanistic philosophy is largely based on the writings of Carl Rogers. Rogers was motivated by the belief that humans have the innate ability to change and grow in healthy directions. Describing this process, Rogers stated that, ‘All individuals have within themselves the ability to guide their own lives in a manner that is both personally satisfying and socially constructive’ (1989, p.xiv).
The person-centred approach in practice The person-centred approach stresses the importance of the relationship, unconditional positive regard and the establishment of a climate of trust between the client and the therapist (Rogers 1989). In using the person-centred approach the practitioner seeks to be congruent, to assist their client in achieving congruence, to provide
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The Person-Centred Approach 45
an empathetic understanding of their world and to convey this understanding to him or her. The central technique which conveys an attitude of acceptance and understanding is ‘active listening’, which includes reflecting or restating and summarising the client’s narrative. Although Rogers was reluctant to describe his work as a set of skills, he acknowledged that by practising active listening, the therapist could attain and convey a deep level of understanding of their client’s inner world. Rogers stated that whatever intervention he made was also meant to ask ‘Is this the way it is in you? Am I catching just the colour, texture and flavour of the personal meaning you are experiencing right now?’ (Rogers 1989, p.128). The basic listening skills include a statement which reflects back the feeling/s and content of what the client or supervisee has said. The purpose of using this technique is to convey empathy and to foster trust between the therapist and client, or supervisor and supervisee. This process is based on Rogers’ three principles which are described below. These core principles are necessary for the deep and significant learning expected in therapy and supervision, as outlined in Chapter 3. Rogers maintained that ‘the facilitation of change and learning’ (1983, p.120) rests upon ‘qualities that exist in the personal relationship between the facilitator and learner’ (p.121). In using the FIT model, we assume that the therapist is acting as a facilitator of learning for their clients and that the supervisor facilitates learning for their supervisee.
What are these qualities? Rogers’ ‘non-directive approach’, as it was first known, developed as an alternative to the directive stance of then-current psychoanalytic practice. Person-centred theory respects the individual’s subjective experience and trusts that humans can move in a positive growthpromoting way given the right conditions to do so. These principles are referred to as ‘core conditions’, congruence, unconditional positive regard and empathy, which are, according to Rogers, necessary for the kind of change which leads to transformational learning (Brockbank and McGill 2007). These conditions form the basis of a learning relationship and help to create an atmosphere of trust in which the learner can move from doubtful or anxious to
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becoming congruent and confident. The learner may be a client or a supervisee. The core conditions are considered both necessary and sufficient for positive change in a therapeutic as well as a learning relationship like supervision. The Rogerian principles grew out of Rogers’ recognition that relationship feeds learning and change, and this is why we start from these principles, having established that the reflective learning sought in therapy or supervision is built on the basis of reflective dialogue in relationship with others. The characteristics of such dialogue are informed by Rogers’ principles for person-centred learning as set out in Freedom to Learn (Rogers 1983). We draw on these principles (noting that Rogers was writing prior to an awareness of gendering in texts) in the two boxes below: Some principles of person-centred learning 1. Human beings have a natural curiosity and potentiality for learning, and people learn when the subject has relevance and meaning for them. 2. Learning which involves change in self-perception is threatening and tends to be resisted, hence learning is more easily achieved when external threats are minimised and experience can be processed safely. 3. Learning is facilitated when the learner participates in the learning process and much significant learning is achieved by doing. 4. Self-initiated learning which involves the whole person, feelings as well as intellect, is most lasting and pervasive. 5. Independence, creativity and self-reliance are facilitated when self-evaluation is primary and evaluation by others is secondary. 6. The most useful learning in the modern world is learning about the process of learning, an internalisation of the experience of change. Adapted from Rogers (1983)
The principles of person-centred learning have implications for person-centred supervision or therapy and we summarise these in the box below:
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Some principles of person-centred supervision or therapy 1. The practitioner clarifies the general purposes of therapy or supervision and relies on the desire of each learner, either client or supervisee, to implement those purposes which have meaning for him. 2. The practitioner endeavours to make available the widest possible range of resources for learning and regards himself as a flexible resource. 3. The practitioner remains alert to expressions indicative of deep or strong feelings and responds to expressions of feeling and accepts both intellectual content and emotional attitudes, giving each aspect the degree of emphasis it has for the individual. 4. The practitioner, while recognising and accepting their own limitations, takes the initiative in sharing feelings, as well as thoughts, in appropriate ways. Adapted from Rogers (1983)
The principles of person-centred learning listed in the boxes above provide the basics for the practice of therapy or supervision that establishes a learning relationship within which reflective dialogue may occur, and consequently, offers learners the opportunity to achieve reflective learning. The principles are well known to personcentred therapists and apply to FIT therapy and supervision.
Congruence in therapy and supervision Congruence is defined as ‘a state of being’ (Mearns and Thorne 1988), where the practitioner is openly being herself in response to the other. She is congruent when her response shows what she genuinely feels, rather than presenting a facade. The practitioner is real and authentic, with her actual experience accurately represented by awareness of herself (Rogers 1957). This state of being was one of Rogers’ early discoveries as crucial for an effective learning relationship. This differs from the ‘history’ form of self-disclosure, which occurs
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when the practitioner shares only factual information about herself with the client or supervisee, as opposed to the ‘story’ form which includes feelings and ownership cues (Brockbank and McGill 2007). Congruence, then, is a response to the other, and relevant to that person, particularly where a pattern of feelings is emerging, or a feeling is notably striking or persistent.
Unconditional positive regard Rogers describes unconditional positive regard as experiencing ‘a warm acceptance of each aspect of the supervisee’s experience’ (Rogers 1957, p.98). Other explanations present unconditional positive regard as an attitude of acceptance and enduring warmth towards the other (Mearns and Thorne 1988) which is maintained throughout the relationship. Other descriptions include ‘nonpossessive warmth’, ‘respect’, ‘affirming’ and, of course, Rogers’ unique ‘prizing’. Unconditional positive regard is powerful in therapy because it directly undermines conditions of worth (Rogers 1951). These are the conditions in the self-concept, learnt in early life, which control affection from important others. For example, a child may learn, through parental disapproval, not to be angry.
Empathy The word empathy is of recent creation, being coined in 1904 by Vernon Lee from the German einfühlung or ‘feeling into’. The word is defined as: ‘Projection of the self into the feelings of others. It implies psychological involvement’ (Bullock and Trombley 2000). An empathic response can be experienced by the client as dramatic, as this may be the first time your client has realised an emotion of which she was previously unaware. When applying the FIT model in therapy you will use empathy routinely with your client. Primary empathy responds to feelings which have been expressed explicitly, whilst advanced empathy endeavours to ‘read between the lines’ or respond to feelings which may have been expressed obliquely. However, because learning environments tend largely to devalue feeling and emotion, some advanced empathy skills may be called for where clients or supervisees are suppressing or denying what they are clearly feeling.
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By empathy (either primary or advanced) we mean an ability to project oneself into another person’s experience while remaining unconditionally oneself. Rogers expresses it well as follows: Being empathic involves a choice on the part of the therapist to what she will pay attention to, namely the…world of the client as that individual perceives it…it assists the client in gaining a clearer understanding of, and hence a greater control over, her own world and her own behaviour. (Adapted from Rogers 1979, p.11)
In summary, empathy is an understanding of the world from the other’s point of view, his or her feelings, experience and behaviour, and the communication of that understanding in full. So feeling empathy for someone is fine, but this is not the skill of empathy-in-use. For true empathy there needs to be a communication of understanding from the therapist to the client. Egan (1976) describes a number of ways in which therapists have problems engaging in accurate empathy. We will use his terms and adapt them to the client’s learning context. For example, let us take the following statement made by the client: ‘I don’t know where I am going with this new job. I don’t see myself as academic. I’m not up to this reflective stuff.’
The client’s statement can be followed by a number of less than appropriate responses including: the cliché; the question; interpretation; inaccuracy; too soon/too late; parroting; incongruence. For instance the therapist may respond with cliché such as: ‘I hear what you’re saying’ or ‘I understand.’
This statement is of no help to the client. Such statements or clichés are more likely to convey to the client that she is not understood and that the therapist is responding in an automatic and inauthentic manner. A questioning response to our client’s statement might be: ‘Why do you think you are not academic?’
The question does not take account of the fact that our client has taken a risk in disclosing how she feels. The question does not convey
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empathic support about how and whether the therapist understands her. Interpreting the client’s words occurs when the therapist responds by trying to guess what is implied in the client’s disclosure. An example might be: ‘This academic thing is the outward problem. I bet there’s something else behind it that’s upsetting you.’
The therapist may just be plainly inaccurate with a response to the client like: ‘You feel inferior, don’t you?’
The client may be taken off-track or stop or hesitate because accurate empathy has not happened, and she may be blocked by what has been said. The therapist may be listening to his own agenda about the client rather than attending to her. Giving the client a chance to express herself gives the therapist time to sort out feelings and content. However, spontaneity is valuable and ‘interrupting’ may be necessary if the client is beginning to ramble. Care needs to be taken here in order not to convey impatience, just as in therapy the practitioner may interrupt to clarify what feelings are really being expressed and why. If the therapist merely repeats back to the client what has been said, she is parroting. The therapist needs to ‘own’ what has been said and then respond. This shows that the therapist has got ‘inside’ the client in a way that conveys accurate empathy. Egan (1976) compares parroting with a tape recording where there is little mutuality or human contact. An effective response gets to the client in a way that parroting cannot. The therapist may use language that is incongruent with the client’s. Using similar language in response to that used by the client encourages rapport, provided that the language the responding therapist uses is authentic to him. He then conveys that he is in tune with the client and this is known as ‘clean language’ (Grove 1996), a technique which is invaluable in person-centred therapy. We offer now an example of an accurate empathic response (primary) to the client’s statement about being ordinary (in our words): ‘You are feeling a bit lost about the new job – you say that you are not academic. It sounds like you’re not confident about the
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way you are working and you also seem concerned about the reflective dialogue which I’ve mentioned.’ (We have assumed here some non-verbal evidence of anxiety.)
We note that some misunderstanding about empathy exists and stress here the variety of responses which are not empathic. This is not to say they are not appropriate responses, we simply clarify what empathy is not. Empathy is not: •â•¢ giving advice •â•¢ giving an evaluation •â•¢ making a judgement •â•¢ giving an interpretation •â•¢ making a challenge •â•¢ engaging the client in a reorientation •â•¢ telling the client how you are feeling. When a client expresses a feeling it is not necessary for the therapist to treat it as a problem, go into ‘rescue’ mode or offer advice. Your solution may not be appropriate anyway and this is a key tenet of person-centred work. Understanding the client’s problem or issue is much more useful – provided the therapist communicates that understanding. That communication of understanding allows a client to move on to a discovery, in time, of their own solutions and find ways of handling them, and taking with them the knowledge of their own ability to learn and reflect. Some examples of non-empathic responses (often described as empathic) are given below: •â•¢ evaluating what the client has said, e.g. ‘Oh, dear, you mustn’t worry about the job. It’s early days.’ •â•¢ judging what the client has said, e.g. ‘Nonsense, you’ll easily get it sorted out.’ •â•¢ interpreting what the client has said, e.g. ‘You don’t like the job, do you?’
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•â•¢ challenging the client, e.g. ‘I bet you can do it if you try.’ •â•¢ reorienting the client, e.g. ‘What about your family commitments?’ Each of these responses has its place, but none of them is empathic. Empathy connects the therapist to the client and commits her to stay with the client in relationship. Empathy is a sign that the client is valuable and that their feelings will be respected in the relationship. The skill of empathy is rather rare in social interaction – few people experience it. When clients experience empathy, they recognise the power of an understanding response that builds trust, establishing the basis for a relationship within which it is safe to engage in reflective dialogue, and thus promote true reflective learning. In supervision, the supervisor, in responding to their supervisee (John) who says rather slowly and sadly that his client has cancelled their second session, might say, ‘You seem worried because your client has not come back after one session with you.’ If the supervisee agrees with the statement, he will usually say yes and/or continue speaking. If the supervisee says that he’s not so much worried as upset with his client, then the supervisor adjusts her response to reflect accurately the supervisee’s feelings about their client. In order to be effective, the statement needs to be said ‘tentatively’ to allow the supervisee to disagree (Egan 1990). By listening and adjusting to the supervisee’s words, the supervisor enables him to go deeper inside himself and begin focusing on his core concerns, which may include a fear of failure. Similarly, an awareness of ‘understating’ or ‘overstating’ the supervisee’s concerns is crucial. For example, if the supervisee says rather loudly that he has had a major argument with his manager about the number of sessions for this supervision, the supervisor may overstate by saying, ‘You’re ready to resign over this.’ Conversely, the supervisor may understate by saying, ‘You’ve had a minor disagreement with your manager and are a bit put out.’ A more accurate restatement might be, ‘You’re really angry with your manager because he has changed the agreed number of sessions without consulting you.’ The supervisee’s response lets the supervisor know if she is accurately perceiving the supervisee’s concerns or needs. The supervisor will continue rephrasing the supervisee’s words until he has understood
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them, just as a supervisor works with their supervisee to achieve understanding and connection. Of further importance when using reflecting skills is the focus on genuine feelings and specific events. Genuine feelings include anger, sadness, fear, worry, joy and excitement. If the supervisor says to the supervisee that his manager has acted hastily by stating that, ‘You feel that he has acted hastily,’ she is expressing a phoney feeling, which is actually a judgement. Using phoney feelings takes the supervisee away from his own experience and can be easily spotted by the ubiquitous use of ‘I feel that…’ which is a very popular misuse of modern language. An (advanced) empathic response could be, ‘You’re feeling angry and worried about this, as your manager seems to be changing the rules.’ By including the specific behaviour, changing the rules, with a specific and genuine feeling of anger and worry, the supervisee is encouraged to focus on his inner experience without generalising about his manager’s character.
Advanced empathy As mentioned earlier, advanced empathy differs from primary empathy in that the feelings to which we respond are not necessarily expressed explicitly. They may be revealed obliquely, through verbal or nonverbal codes. For instance, a client may be talking about his job, giving a lot of factual information quickly, in a rather anxious tone of voice. The therapist may ‘sense’ that the client is actually rather worried, and not sure what to do next. The process of empathy is the same as for primary, only in this case, because the feeling is not clearly displayed by our client, and, more important, he may be unaware of the feeling himself, then care is needed in communicating what we think we understand about his world. A tentative approach using qualifiers like ‘perhaps’, ‘it seems’, ‘I wonder if ’, and ‘it sounds like’, means that the client may dissent if they so wish. Offering advanced empathy needs care so that the client does not feel trampled on. So for advanced empathy, the definition, as given above for primary empathy is valid, with the addition of some hesitancy and caution, as the supervisor may be mistaken in her ‘sensing’. Using advanced empathy, the supervisor will, in a tentative and careful
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manner, offer an understanding of the world from the client’s point of view, her feelings, experience and behaviour, and the communication of that understanding in full. For example, in response to the client above, the therapist might say: ‘You have some concerns about the new job which we can talk about shortly. I am also wondering about how you are getting on with your new boss. It seems that you might be feeling a little confused about your role.’
Advanced empathy may lead to productive challenge in therapy. For instance, you may need to challenge your client by pointing out inconsistencies between words and facial expression; for example, ‘You say that you’re not angry about this, and yet you seem to be clenching your teeth.’ An experienced supervisor, like an experienced therapist, is well placed to ‘guess’ a lot of what is going on for their supervisee(s), and be able to offer empathy before, and possibly instead of, making judgements. Supervisees are often their own harshest judges and offering empathic understanding may provide them with a basis for tangling with their problems. Supervisors may also ‘hunch’ about their supervisee’s feelings, being prepared to be mistaken. In this case, a tentative response to John (above) may have hunched as follows: ‘You seem anxious, John. Perhaps you are remembering the last time your client didn’t come back. You seemed shocked.’
The supervisee may not agree with your hunch, and, whatever the supervisor thinks is really going on, she may prefer to return to the ‘safe’ primary, version of empathy, based on expressed feelings, by giving the following response: ‘You were asking some questions, John, and you sounded puzzled about the client. Perhaps we can explore the case together today, if that’s all right with you.’
The supervisor’s skill in summarising (based on restatement made earlier) also offers an opportunity for advanced empathy, as the sum of the supervisee’s statements may reveal a consistent feeling, like resentment or lack of confidence, and, in summary, the supervisor
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may be able to draw the threads together and tentatively comment on the overall feeling being communicated, just as a therapist does with their client. While it is important to support and unconditionally accept your supervisee, you also need to remain authentic and congruent as a model. Rather than accepting each statement made by a supervisee or client, you can accept them as a person, but not necessarily agree with everything they say or do. You might also point out an incongruence to your supervisee by stating, ‘You say you feel warm about your client, yet I sense by your tone of voice and facial expressions that you feel impatient with them.’ Criticism of the person-centred approach includes a view that the method is simplistic in that, while it is supportive, there may be a lack of challenge. Other critiques suggest that person-centred styles ignore the social and cultural context in which the supervisee lives. However, a careful reading of Rogers reveals that the subjective world of the supervisee must include their social and cultural context. The mistaken juxtaposition of ‘person-centred’ alongside ‘being nice’ or ‘unstructured’ has not helped to promote reflective learning in supervision. The need for challenging assumptions and confronting embedded suppositions is a basic requirement for reflection. The adversarial method of challenging assumptions destructively is inappropriate for reflective learning. All the evidence suggests that the supportive challenge of empathic confrontation can enable a learner to consider contradictions or new material, as well as countenancing the possibility of change that disturbs their world view (Belenky et al. 1986; Egan 1990; Rogers 1983).
Summary This chapter has briefly described the person-centred approach as the orientation which acts as a foundation to the FIT model. It is based on humanistic values and respects the core conditions for deep and significant learning by both client and supervisee. These core conditions and their use in therapy and supervision were described in detail. We have described how a person-centred approach utilising
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these core conditions facilitates the appropriate learning relationship for effective therapy and supervision. Using the FIT model in therapy and supervision has several implications. First, the client or supervisee is respected and listened to carefully. Their thoughts, feelings and perceptions are heard and valued by therapist or supervisor who attempts to grasp and understand their subjective world. Second, the relationship between therapist and client or supervisor and supervisee is paramount and egalitarian. Decisions as to the focus of the sessions are negotiated and include an awareness of each person’s perceptions, beliefs and feelings. Both parties work in an atmosphere of trust, which includes congruently sharing their deeper selves.
Chapter 3
Learning Theory in Therapy and Supervision
This chapter deals with learning in therapy and supervision, through an examination of learning theories and research. Adult learning, levels and stages of learning, single and double loop learning are discussed as well as the role of reflective dialogue in transformative reflective learning. This chapter uses ‘therapist’ to mean ‘psychotherapist’ for ease of reading and TFGs is an acronym for ‘taken for granteds’. The aim of therapy is therapeutic change and development for the client, that is, a learning experience whatever the orientation in use. Learning theory confirms many of the traditional and emerging methods used in therapy, and the learning process will reflect the principles of the particular orientation being employed. In supervision a similar process occurs. Traditionally, therapists ‘learned their trade’ through their supervisor, absorbing from the supervision process an understanding of theory and practice. This tradition, where the supervisor adopts the key focus of their own therapeutic model in preference to others, implies a philosophy of learning, often embedded in the process. Many supervisors are likely to adopt a style of supervision which they have themselves experienced, thereby perpetuating the embedded learning philosophy whatever that may be, with undeclared assumptions hidden in the process. A parallel process is likely to occur, where the implicit model is passed on to the supervisee, without the supervisor being aware of it. Many therapists focus on one aspect, for example thoughts, feelings or behaviours in their work with clients, and continue this practice in supervision by stressing the area of functioning which they favour. The supervisee picks up on the bias and uses it in their practice.
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How may the implicit or explicit approach impact on learning in therapy or supervision? In therapy the psychodynamic approach relies on childhood influences, exploration of unconscious material and interpretation. Learning in psychodynamic therapy is achieved through client realisation of the past in the context of the present. A traditional psychodynamic orientation transferred to supervision is likely to emphasise the therapist’s own responses to their client, with examination of transference, countertransference and other defence mechanisms in both the client/therapist relationship and the supervisor/supervisee relationship. The embedded learning philosophy in such an approach is likely to be didactic, with the supervisor as expert. In CBT learning relies on the idea that a change in thinking can result in changes in behaviour or feelings. Similarly, the CBT orientation transferred to supervision is likely to emphasise action and behaviour, with self-report from the supervisee mirroring the selfreport of the client. The supervision model here is likely to focus on control and monitoring and this orientation tends to de-emphasise feelings. Person-centred therapy promotes learning through a non-directive humanistic relationship, characterised by congruence, unconditional positive regard and empathy. A person-centred humanistic orientation transferred to supervision is likely to emphasise the development of the supervisee, that is how they can improve as a therapist through learning. In this book we advocate person-centred principles of learning and development as the chosen overall approach in supervision. The FIT model which we outline in Chapter 1 differs from this tradition in being integrative and holistic. Within an overall humanistic approach, it is unique in offering within the therapy or supervision process a choice, not only of focus in any given session, but also of therapeutic orientation from which the client or supervisee may draw to inform their learning: CBT, Gestalt and TA. Using the FIT model is likely to require practitioners to reflect upon their own learning philosophy in order to become aware of what is being passed on to their client or supervisee implicitly. In particular, the practitioner’s way of offering therapy or supervision will come, sometimes unconsciously, from a particular model of learning and
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development based on their understanding of how adults learn, so it is useful at this point to consider the role of learning theory and reflective practice in both therapy and supervision.
How do adults learn? There is no science or theory of learning which embraces all the activities involved in human learning. Most of what we do, think, feel and believe is learned so the field of activities is wide and varied. There is little agreement among researchers about what learning is. For example, the behavioural psychologist tends to identify learning in changed behaviour, while the cognitive psychologist seeks for change inside the learner as evidence that learning has taken place. Traditional academic learning has tended to emphasise learning as exclusively a mental process, whereas progressive approaches to learning assert that learners must also be active and learn by doing. Recent progressive ideas include emotional elements in learning and, we recommend that for deep and significant learning all three domains of learning are considered, that is, ‘feeling’, ‘acting’ and ‘thinking’, described by psychologists as ‘affect’, ‘action’ and ‘cognition’ (Brockbank and McGill 2007). For adults, research suggests that deep learning is preferable to surface learning, and is likely to be achieved by learners who take responsibility for their own learning and are motivated by their own learning ambitions (Brockbank and McGill 2007). Such learning can occur in both therapy and supervision through reflective dialogue. The social systems in which a learner is embedded will dominate learning as ‘no human thought is immune to…the influence of its social context’ (Burr 1995, p.21). The workplace or home for many clients is dominated by the prevailing discourse, which may limit how they learn by assumptions about their place in a hierarchy or system. The context for supervisees may be characterised by norms and targets, often invisible to them, for example those working in doctor’s surgeries, drop-in help centres or student centres. Reflective dialogue allows learners to create their own constructs and meanings within a social context. Most modern learning theories promote the concept of reflection as essential for deep and significant learning (Brockbank and McGill
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2007) and reflection is seen as a key element in learning from experience in such a way that the individual is affectively changed, cognitively changed or there is behavioural change. The theory underpinning our approach to learning and, in particular, reflective learning begins from the definition of reflective learning as a social process which: •â•¢ can achieve transformation as well as improvement •â•¢ is holistic, i.e. embraces all three domains of learning as above •â•¢ includes a dialogue process which is reflective. (adapted from Brockbank, McGill and Beech 2002, p.6). We discuss the difference between transformation and improvement below. Our definition indicates that there are several important factors to consider in what we know about learning. We consider some of them now.
Learning as a social process We start from the value that people are abundant in their resources. They bring their experience to learning situations. This contrasts with the rather crude view that people are ‘empty vessels’ to be filled. But learning does not occur in a vacuum. The context in which learning may happen is crucial. Learning is a social process, which will influence the degree of ‘agency’ or the personal power to change things experienced by the learner. By social process we mean the context and conditions in which learning takes place, which will influence how intentional learning situations are created and undertaken. In the case of therapy or supervision the conditions may be one-to-one or group, the context may be organisational or private and the learning process will reflect these conditions. A social constructionist stance holds that our view of reality is deeply influenced by our life experience and that ‘we create rather than discover ourselves’ (Burr 1995, p.28). We do this through engagement with others, using language in discourse.
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Your client may experience their family life as oppressive with gender role expectations which limit them. Your client or supervisee may work within one prevailing discourse and the sessions offer an alternative discourse. For example, in therapy your client may find that their gender does not necessarily imply a particular behaviour such as ‘good boy’ or ‘nice girl’. Or, the discourse in a doctor’s surgery may emphasise the medical model, methods of treatment and problemsolving, which supervision sessions do not necessarily recognise as valuable for learning. For reflective learning, the recognition that conceptual space is created through language, and that context is defined by the prevailing discourse, enables clients and supervisees to access their potential and challenge what constrains their learning.
What is the prevailing discourse? The prevailing discourse is defined as ‘a set of meanings, metaphors, representations, images, stories, statements etc. that, in some way together produce a particular version’ (Burr 1995, p.48) of events, person, or category of person. In the family, for example, how intelligent someone is judged to be may relate to their physical appearance and to how they are allowed to talk without interruption. Or the identification of a high profile medical role within the medical model may give it more status in a doctor’s surgery than from the perspective of a person-centred model of development. The operation of discourses is not power-neutral, but rather they are imbued with power relations which impact on how people are defined and whether they are granted a voice, resources and decision-making powers. These matters influence the levels of learning which can be achieved in terms of improvement or transformation.
Levels of learning: improvement and transformation When individuals learn, they may improve their performance and also transform themselves. In addition, a learner may also engage in reflecting on the learning process, that is, to learn about learning. We can identify these three levels as improvement, transformation and learning about learning.
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•â•¢ Improvement: Reflective learning will deliver improvement where clients may seek to change elements of their behaviour, for example by saying no to requests, which is a form of learning for improvement. In supervision, supervisees may process their casework by assessing and reconsidering it for improved therapeutic performance. •â•¢ Transformation: Reflective learning for transformation offers the potential for clients to alter their perception of a situation, perhaps realising that they are following expectations, and decide to challenge assumptions in the family, an example of transformational learning. In supervision, supervisees may be encouraged to move one step further and reconsider their casework in other ways, questioning and challenging existing patterns, thereby opening the door to creativity and innovation. A supervisee who sees a case in a completely different light, having identified some of their own assumptions, is an example of transformation. •â•¢ Learning about learning: The idea of a further level of reflection, which can only occur as a consequence of the first two, is reflective learning about learning. This entails the client or supervisee standing back from improvements and transformations and seeking to identify ‘how I did that’ so that this knowledge can be transferred to future situations. The review process in both therapy and supervision provides an opportunity for such learning about the learning process itself. Reflective learning at all three levels may take clients from basic changes in behaviour, through an altered appreciation of their situation, with consequent action, to a review of the process which led to their change. Reflective learning for improvement is a necessary component for a supervisee to provide a basic service to their clients. For truly professional service the supervisee should stop and reflect, critically, on their work with clients. Reflective learning for transformation occurs when supervisees are enabled to pause and reconsider the nature of what they are doing. This means more than re-examining the task in hand. It means re-examining the rationale behind what is being done.
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When such a dialogue is enabled then transformational learning can occur. Supervision may also include a review of the process itself – an example of reflecting on the learning process. What are the characteristics of these different levels of learning and how can they be achieved in therapy and supervision? This can be usefully elaborated by recourse to notions of ‘single loop learning’ and ‘double loop learning’.
Single and double loop learning The terms single and double loop learning were first used by Argyris and Schön (1996) to distinguish between learning for improving the way things are done, and learning which transforms the situation. Single loop learning, while it achieves immediate improvement, leaves underlying values and ways of seeing things unchanged. Improvement learning may involve a client’s change in behaviour but not their attitude. A supervisee may review a particular case, but is not likely to change their approach. Double loop learning is learning where assumptions about ways of seeing things are challenged and underlying values are changed (Brockbank and McGill 2007). Double loop learning, in questioning TFGs in the situation, has the potential to bring about a profound shift in attitudes by cracking their paradigms or ‘ways of seeing the world’.1 So, in the context of both therapy and supervision: In order to see how ideas different from ours exist in their own legitimate framework, it is necessary to leap out from our shell of absolute certainty and construct a whole new world based on some other person’s ideas of reality, other assumptions of truth. (Daloz 1986, p.228)
The ‘other person’ here is therapist, supervisee, co-supervisees (in group supervision) or supervisor. Single loop learning is learning for improvement, which enables progress to be made. The concept of effective single loop learning has been described graphically in a well-known diagram by Kolb (1984), where goals are set on the basis of theory, action is taken and, on the basis of this experience and reflection, a new action or plan is devised. 1
Here ‘world’ is used to denote the realities of an individual, group or organisation.
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For day-to-day learning the loop is productive and the learner gains competence and confidence, therefore this is reflective learning for improvement. The process is illustrated in Figure 3.1 below. Reflection
Experience
Revising
Testing
Figure 3.1: Single loop learning Source: Brockbank and McGill (2004) The Action Learning Handbook. Abingdon: Routledge.╇ Adapted from Kolb (1984).
What about transformation? We refer now to Peter Hawkins’ original diagram to illustrate double loop learning in Figure 3.2. The arrows in the lower circle indicate single loop learning. When the learner is offered the opportunity for reflective dialogue, assumptions or TFGs may be questioned, and the learner may swing out of the lower circle orbit and begin to traverse the upper circle in double loop learning mode, with the potential for transformational change. The option remains of returning to the single loop when appropriate, perhaps to test a new idea in the normal way, in order to achieve improvement with a new understanding. In therapy a client may experience that moment of realisation that they no longer have to act out their ‘script’ in the family where they solved all problems and fixed every difficulty, and work on how they will change their stance towards family members. A reconsideration of expectations within the family and a realisation that they are not
Learning Theory in Therapy and Supervision 65 Emergent knowing
Paradigm shift
New understanding
Reflective dialogue
Experience
Revising
Testing Figure 3.2: Double loop learning Source: Brockbank and McGill (2007) Facilitating Reflective Learning in Higher Education. ©â•‡ Adapted from Hawkins and Shohet (1989). Reproduced with the kind permission of Open University Press.╇ All rights reserved.
binding may lead to a new view of family relations and an intention to assert their right to self-definition. In supervision the supervisee may realise that their own beliefs or assumptions have influenced their approach to their client and resolve to adopt a new stance in therapeutic sessions, an example of double loop learning for the supervisee. For the individual, really effective learning is characterised by the transition from single to double loop learning which enables the learner to move beyond their existing way of working with the
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support and challenge, using reflective dialogue, of their therapist or supervisor. What is needed to enable the learner (either client or supervisee) to shoot out of the single orbit, and traverse the exciting and potentially disturbing orbit of double loop learning? If we were to pursue our analogy of orbits and trajectories the answer suggests that what is required is energy to fuel the ‘burn’ of a changed trajectory. Where is the source of this energy to come from? There is evidence that emotion supplies the required fuel for double loop learning.
Emotion in therapy and supervision The evidence suggests that ‘emotion and motivation are inherently connected’ (Giddens 1992, p.201) and that double loop learning can be triggered by strong emotion. The language used to describe such learning indicates the strong emotive content in comments like ‘passion to learn’, ‘hunger for truth’, ‘thirst for knowledge’. In addition, the process of questioning and challenging the TFGs can stimulate strong emotions, disturbance, distress and also joy and exhilaration. We are told that a certain degree of energy or excitement is necessary for learning to occur, so that a crisis may generate transformative learning. The idea that transformative learning can occur where emotional material is ignored, while favoured in many rationalist contexts, fails to appreciate the nature of the changes which take place when a meaning is transformed through reflection. What is needed for transformation of meaning is a process involving ‘a critique of assumptions…by examining their origins, nature and consequences’ (Mezirow 1994, p.223). The recommended method for such learning to occur is dialogue as ‘dialogue is central to human communication and learning.’ (p.225). The chances of such a critique being achieved without generating emotion are remote and, where emotion is denied or suppressed, transformative learning is unlikely. The traditional overemphasis on action and thinking in Western education has left a gap in our understanding of the learning process, and it is our intention within this book to propose an integrated approach that will redress the imbalance.
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How may therapy and supervision promote reflective learning? We now connect learning theory to practice through the use of reflective dialogue, the basis of effective therapy and supervision. We describe dialogue and how reflective dialogue leads to the different stages of learning. We review research which corresponds with different stages of learning and discuss how to achieve them.
Dialogue Reflective dialogue is an exchange between two people that promotes learning. Dialogue is an integral part of the supervision process. It is important to explain the particular meaning we give to dialogue and how dialogue within a learning relationship can differ from other forms of interaction. Dialogue does occur quite naturally between people. Dialogue in the form of discussion, where the speaker’s intention is to hold forth in order to convey their knowledge is unlikely to lead to some new understanding. Dialogue has been explored by Bohm (1996) who contrasts it with the word ‘discussion’. For him, discussion really means to break things up. ‘Discussion is almost like a ping-pong game, where people are batting the ideas back and forth and the object of the game is to win or to get points for yourself ’ (Bohm 1996, p.7). On the other hand, Bohm offers a definition of true dialogue as a process where ‘meaning is not static – it is flowing. And if we have the meaning being shared, then it is flowing among us’ (Bohm 1996, p.40). This is a useful point at which to introduce the notion of ‘separated’ and ‘connected’ knowing, originally set out in Belenky et al. (1986) and developed further by Goldberger et al. (1996). Separated knowing is the kind of dialogue that values the ability to pronounce or ‘report’ one’s ideas, whereas connected knowing is the kind of dialogue that relies on relationship as one enters meaningful conversations that connect one’s ideas with another (Belenky et al. 1986). Separated knowing is very similar to discussion, while connected knowing suggests the creation of that flow of meaning suggested by Bohm above. What exactly is meant by separated and connected?
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Stages of learning Belenky et al. wrote Women’s Ways of Knowing in 1986. The original research behind their book was undertaken to bring attention to the ‘missing voices of women in our understanding of how people learn’ (p.13). Prior to their work the only scheme of personal learning and development in adults was conducted by Perry (1970) who recorded the results from Harvard men only. Belenky and her colleagues argued that this represented a major failure in not examining closely women’s lives and experience. Their project was both an extension of Perry’s work and a critique of his scheme. They undertook research with a group of 135 women of different ages, ethnic and class backgrounds from urban and rural communities and with varying degrees of education. They included high school dropouts as well as women with graduate or professional qualifications. This was itself a breakthrough given that most research in this area at the time was restricted to white, middle class groups, often male. They intentionally sought a diversity of backgrounds in order ‘to see the common ground that women share, regardless of background’ (Belenky et al. 1986, p.13). Their aim, repeated ten years later, was stated thus: ‘Let us listen to the voices of diverse women to hear what they say about the varieties of female experience’ (Goldberger et al. 1996, p.4). Five learning perspectives emerged: 1. Silence: a position of not knowing in which the person feels voiceless, powerless and mindless. 2. Received knowing: a position at which knowledge and authority are construed as outside the self and invested in a powerful other from whom one is expected to learn. 3. Subjective knowing: in which knowledge is personal, private, and based on intuition and/or feeling states rather than on thought and articulated ideas that are defended with evidence. 4. Procedural knowing: the position at which techniques and procedures for acquiring, validating, and evaluating knowledge claims are developed and honoured. Within
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this sub-head they also described two modes of knowing [which are crucial for our purposes as authors]: (a) separated knowing: characterised by a distanced, sceptical and impartial stance towards that which one is trying to know. (b) connected knowing: characterised by a stance or belief and an entering into the place of the other person or the idea that one is trying to know. 5. Constructed knowing: a position at which truth is understood to be contextual and the knower is part of what is known and has a share in constructing it. In their research sample of women, constructed knowers valued multiple approaches to knowledge and insisted on bringing the self and personal commitment into the centre of the knowing process. (Goldberger et al. 1996).
To summarise the first four stages: 1. The first learning stage of silence, where learners have yet to discover their mind is a position of powerlessness. 2. The second stage of received knowing suggests the presence of a prevailing discourse, and here traditional approaches to learning can be found, as well as the learning history of many clients and supervisees. 3. The third stage of subjective knowing allows the subjective world of either client or supervisee to be recognised for the first time. 4. The fourth stage described as procedural knowledge was realised in two forms: separated and connected. Researchers found the connected mode as more typical of female conditioning, while the separated mode was more like men’s. Which seems appropriate for transformative learning in therapy and supervision?
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Separated knowing: the doubting game
The men in Perry’s (1970) research were thought to adopt a strategy entitled separated knowing. The separation strategy, known as ‘the doubting game’ is characterised by questioning and critique (Elbow 1998). Traditional learning tends to engage in separated knowledge, and features in some kinds of therapy and supervision, where enquiries are actually coded statements which may be judgements in disguise. An example of separated approach in therapy Here the process would resemble directive teaching with the therapist as expert, offering advice and interpretation, for example ‘You are reacting to your earlier experience – you must challenge your mother.’ The tradition of guidance as a form of counselling in schools and colleges would be recognisable as separated. An example of separated approach in supervision We have experienced a separated approach in supervision when our case notes were presented to be critiqued by our supervisor. The separated nature of the interaction was revealed in advice and judgement, such as: You must find out… Your client is in denial… You should… Obviously she/he needs…
Connected knowing: the believing game
Connected knowing, which can be described as the ‘believing game’ (Elbow 1998), is learned through empathy, being without judgement, and coming from an attitude of trust, and is quite the opposite of separated knowing. It is ‘the deliberate imaginative extension of one’s understanding into positions that initially feel wrong or remote’ (Belenky et al. 1986, p.121). There is no reason to suppose that connectedness is the preserve of women only and connected knowing is available to men as well as women. The principle of connectedness is essential to person-centred therapy and supervision, as they address the client and supervisee as a whole person, acknowledging their
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hopes and desires, as well as offering empathy and a mutuality of understanding. An example of connected therapy This might include statements like: You are feeling stuck with family expectations. You seem unhappy with your role in the family. You are unsure about what to do. An example of connected supervision We have also experienced connected supervision when after describing our case we were invited to describe how the clients seemed to us, how we responded to them, and how we connected with them in terms like: You seem stuck with this client – tell me how it is with her/him. You sound confused… You seem unsure what to do next…
The fifth stage: constructed knowing
Connected knowing prepares learners for their fifth and final stage of development, the adoption of constructivist approaches to knowledge. For the constructivist, ‘all knowledge is constructed, and the learner is an intimate part of the known’ (Belenky et al. 1986, p.137). Constructivist learning is characterised by empathy and connectedness, so relationship is a key ingredient in what is a completely holistic stance towards knowledge and learning. The meaning of the terms, separated knowing and connected knowing are intrinsic to an understanding of reflective learning. By going to the root of how we discourse with each other we can understand how a dialogue is an appropriate format for transformational learning and development. Separate and connected knowing
In therapy or supervision, connected knowing means the practitioner suspends judgement in an attempt to understand their client or
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supervisee’s ways of making sense of their experience. In the words of Elbow (1998) practitioners ‘play the believing game’ by using questions like: ‘What do you see? Give me the vision in your head.’ ‘That’s an experience I don’t have. Help me to understand your experience.’ (Elbow 1998, p.261)
The practitioner is seeking to understand the experience of their client or supervisee, their frame of reference, and what it means to be the ‘knower’ of that experience. In contrast, when conducting a dialogue through separate2 knowing the practitioner would relate in a different way, in Elbow’s words, ‘play the doubting game’ (Elbow 1998, p.267). This involves looking for flaws, examining statements with a critical eye and insisting on justification for every point the client or supervisee makes. With separate knowing, the dialogue is about testing the validity of propositions or statements or stories against some objective criterion and/or the person’s view of the world. With connected knowing the dialogue is about understanding what the person is saying – their experience. The mode of discourse is ‘one of allies, even advocates, of the position they are examining’ (Goldberger et al. 1996, p.208). With connected knowing there is an explicit aim to get into the world of client or supervisee. This does not mean a subjective immersion in that world. It is to try to understand where the other is coming from. The emphasis here is on the word try. It is not easy or natural. The anthropologist, Clifford Geertz (1986) is cited as follows: Comprehending that which is, in some manner or form, alien to us…without either smoothing it over with vacant murmurs of common humanity…or dismissing it as charming, lovely even, but inconsequent, it is not a natural3 capacity…upon which we can complacently rely. (Goldberger et al. 1996, p.209)
We should emphasise that getting into the other’s world through connected knowing does not mean that practitioners are uncritically accepting that world. The point is to understand their world not 2 The original term in the Belenky research was ‘separated’. In the later review of their work Goldberger et al. 1996 used the term ‘separate’. 3 In the original quotation, Geertz uses the term connatural. We take this to mean the same as natural.
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necessarily to accept it. Understanding what your client or supervisee expresses does not mean that you have to agree. Understanding (meaning comprehension and insight) needs to be distinguished from understanding (meaning agreement), and the process has been described as ‘swinging boldly into the mind’ of another. To be really heard as a learner in connected knowing terms is to be affirmed and validated and this is achieved by the practitioner ‘swinging boldly into the mind’ of their client or supervisee. Goldberger et al. (1996, p.218) suggest that by doing this, two perversions of connected knowing are prevented. The first, known in the US as the ‘Californian fuck off’, is typified by a response like: ‘Well given your background, I can see where you’re coming from’ which is a patronising and negative response. The second is a quick response like: ‘I know how you feel’ when in fact they have little idea or quite the wrong idea. Separated and connected practitioners A separated practitioner is likely to: •â•¢ seek more and more information about the client or supervisee •â•¢ interrogate for more detail •â•¢ mask statement and judgement by questioning. For example, ‘What made you ask?’ implies ‘I don’t approve’. A connected practitioner is likely to stop their client or supervisee in full flow and share their own responses to the material or offer empathy, for example: •â•¢ ‘You don’t seem confident about…’ •â•¢ ‘I’m getting a feeling of being overwhelmed…’ •â•¢ ‘You seem agitated…’
In summary, we have outlined the benefits of connected knowing. It is a procedure to enable the practitioner to enter the world of their client or supervisee in order to understand where they are coming from, and possibly to learn from it as well. We now explore how this dialogue facilitates reflection and reflective learning.
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Reflective dialogue Reflective dialogue has been identified as dialogue which ‘engages the person (who is in dialogue) at the edge of their knowledge, sense of self and the world’ (Brockbank and McGill 2007). Reflective dialogue provides the safety for the learner to voice the realities of her world, and ensures that the implications for herself and her learning are attended to. Reflective dialogue engages the learner’s realities and experience, giving space for her to consider and reconsider without haste. This form of discourse we referred to above as ‘connected knowing’ as against ‘separated knowing’ where the dialogue seeks to analyse and itemise rather than to understand and connect with the learner. In addition, connected dialogue supports the perturbation or disturbance which may occur when existing assumptions are challenged, and deals with the emotional material flowing from such challenges. The engagement with the learner at the edge of awareness, although sometimes painful and possibly difficult to maintain, may generate new learning forged from the discomfort and struggle of dialogue. This new learning emerges as the reflective learning we seek as an outcome of the supervisory or therapeutic relationship. Reflective dialogue offers opportunities for reflective learning at all three levels, described above and repeated here in the context of supervision: 1. Reflective dialogue may lead to a reconsideration of a situation and how things can be improved. In seeking reflection for improvement the supervisor will analyse and discourse with their supervisee about their case, attending to the work itself and how it was carried out. For example, the supervisee may revisit a client session and wonder if she had really listened to her client. 2. Reflective dialogue also offers the possibility of engaging at the edge of learner assumptions and beliefs, reconsidering the TFGs and this we have identified as reflective learning for transformation. For transformation, supervisors need to proceed with care, for here the relationship and trust is crucial. Examining the TFGs in casework uncovers material which may be uncomfortable and destabilising,
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so supervisors need to have skills in the emotional arena, be comfortable in it, and have a clear grasp of appropriate boundaries. For example, the supervisee may reconsider a client relationship where he has tended to make assumptions about the case like ‘he’s a beast’ and ‘she needs to leave him’ even if these are not voiced to the client. 3. Reflective dialogue, when improvement or transformation has occurred can take learning one step further, so that clients and supervisees learn about learning itself, from their experience as reflective learners. In review, clients and supervisees may choose to identify what factors enabled the realisation to emerge and the change to be implemented, that is, they reflect upon their reflective learning. Clients and supervisees can pinpoint the key elements of their learning for future reference, and this applies to supervisors too. This can be done as part of the supervision session. For example, the supervisee may review the supervision session and confirm that their listening skills can be improved (level 1) and that they are now aware of their assumptions about the client (level 2). Identifying that receiving advanced empathy and challenge from their supervisor triggered a new realisation, offers the supervisee learning about their learning. In summary, reflective dialogue in therapy may result in three levels of learning for the client, as follows: 1. In therapy, clients may reconsider their behaviour and, for example, seek to become more assertive. 2. In therapy, examining TFGs can be illuminating for clients as they realise how family expectations have limited them, and the dialogue explores how they can challenge these and change their behaviour. 3. A standard process review in therapy allows the client to learn how they have changed.
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The content of dialogue is dictated by the client or supervisee who brings material from a current issue, past events or future work, and it is likely to cover the three domains of learning: •â•¢ Feeling (F) •â•¢ Initiating (acting) (I) •â•¢ Thinking (T) We discuss in detail how these domains can be addressed in therapy and supervision using the FIT model in Chapters 7 and 12. The reflective dialogue process demands structured time, space, clear boundaries, tolerance of uncertainty and competence in dealing with emotional material for the relationship to prosper for the learner and to stimulate transformational learning. Therapy and supervision sessions provide a perfect space and time for such a reflective process.
Learning and relationship Supervision mirrors therapy in that research, repeated and replicated, shows that the orientation of a particular therapy is less important than the quality of relationship created between therapist and client (Innskipp and Proctor 1993; Sloane et al. 1975). So the learning relationship is what will make the difference in both therapy and supervision. What is meant by a learning relationship?
The significance of relationship in learning is underlined by Martin Buber (1994) who suggests that reflective learning calls for what he describes as the ‘I–Thou’ relationship in learning: a mutual, affective and respectful relationship. This is unlike the instrumental relationship, where the other is objectified for the individual’s purpose, which he identifies as the ‘I–It’ relationship (Buber 1994). Buber also claims that, ‘the learner is educated by relationships’ (1965, p.90) and that the relationship which characterises personal learning is the ‘I–Thou’ relationship, described thus: ‘Relation is mutual. My Thou affects me, as I affect thou’ (Buber 1994, p.30). So as a therapist I am affected by my client as much as they are affected by me and a parallel process occurs in supervision. Such a mutual relationship will nurture the development of reflective learning
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as it has the potential to ‘assist people to become aware of their takenfor-granted ideas about the world’ (Brookfield 1987, p.80). The unknown and unknowable outcomes of such learning relationships have enormous potential for enabling the reflective learning now sought in therapy and supervision. In summary then, the relationship required to nurture reflective learning is: •â•¢ mutual rather than one-way •â•¢ open to uncertainty •â•¢ able to accommodate the questioning of established ideas •â•¢ connected to the other by dialogue and •â•¢ recognises the reality of social and political contexts.
Requirements for reflective dialogue How can practitioners facilitate clients or supervisees to become reflective learners through reflective dialogue, and how does this differ from traditional learning methods? The requirements for reflective dialogue, discussed elsewhere are: •â•¢ intention •â•¢ awareness of process •â•¢ personal stance and •â•¢ modelling.4 Intention
Reflective dialogue does not happen accidentally; it needs to be intentional so that time and effort is allocated for it to occur. Therapy sessions and supervision sessions are intentional, that is they are planned and scheduled, so they fulfil this condition. How may the learner understand the reflective dialogue process? Awareness of process: the need for transparency
The principle of transparency provides for the practitioner making explicit the processes within the learning contract. Making process 4
See Brockbank and McGill (2007) for a full treatment.
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transparent ‘comes clean’ on the power relations which exist in the learning situation, and, in making them explicit, allow learners to adjust their stance towards it, recognising it and possibly working productively with it. The standard contract for therapeutic work is likely to have clear information about the stance the therapist will take, their orientation, their professional ethics and a complaints procedure. In supervision, where a supervisor is also a tutor this must be made explicit as there are dual roles in the relationship. An understanding of the difference between task and process is helpful here, as both are needed for learning, and the balance is the key to successful dialogue. What exactly do we mean by task and process? Task is what is to be done, while process describes how a task is undertaken. When practitioners and learners become aware of process they can then evaluate its relevance for the task in hand, and the principle of transparency makes explicit how the relationship will be conducted. Practitioners need to be aware of process, and part of their role is to enable clients and supervisees to analyse their learning process, and to review, through reflective dialogue, what has occurred between themselves and their client or supervisor. Such dialogue enables clients and supervisees to create understanding and meanings for themselves, which connect their learning to reality. An understanding of process for learners offers the possibility of grasping how their learning happens, and hence, how further learning may happen. Examples from our work follow in the box below. An example of a client and awareness of process When clients try to breach boundaries in therapy, by late arrival or missing an appointment, bringing this into therapy enables them to become aware of process, examine their behaviour and consider its implications. Many clients welcome feedback on their interpersonal style, which is part of their process that may impact on others. An example of a supervisee and awareness of process In a recent supervision session, I became aware of a parallel process effect. I was behaving almost exactly like my description of my client, stuttering and leaving sentences
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unfinished. The statement offered by my supervisor was ‘something seems to be happening to you; I haven’t heard you stutter and speak in half-sentences before’. The usual analysis followed. In the learning review (at the end of the session) I identified the intervention by my supervisor as the process which aided my learning, in this case the power of the unconscious to pick up and internalise what was occurring between my client and myself. An example of a supervisor and awareness of process At a group supervision review recently, one of us received (invited) feedback on our ‘process’ from supervisees. What had been observed by supervisees was a tendency to pose questions and, if responses did not come fast enough, supplying the answer (underlying this was the pressure of time and anxiety about time limitations). While the technique of question and answer, where the supervisor gives the answer, is a well-established method of making a subject accessible, it was not our intention to do this. It undermined our purpose, which was to enable adult learners, through Socratic questioning, to experience the process of formulating the answers for themselves. So the invisible process was usefully brought to our attention.
After feedback or reflection on process in reflective dialogue, realisation of what is happening follows, and clients or supervisees can then choose what to do about it. Although in the example above feedback destroyed my ‘innocence’ about my questioning style, it made me aware of the discrepancy between my espoused intentions and what I was actually doing. Personal stance
Personal stance influences learning by its impact on the learning context, as a practitioner’s personal stance is implicitly conveyed in his or her practice. The client or supervisee will approach the practitioner from their personal stance, interpreting what they see and hear in order to ‘place’ the practitioners. This ‘reading’ of the practitioner will influence their understanding of therapy or supervision.
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Awareness of personal stance is necessary but, as a desirable condition for reflection, we would add the articulation of it, regardless of what that stance is. For example, when a client has heard about a therapist’s stance, they may decide that this particular orientation is not for them. Many clients are unsure about different approaches in therapy and the first session may give them this information. In supervision, if a supervisor’s stance towards the supervisee’s orientation is negative her lack of enthusiasm will leak into her practice, just as a positive stance is likely to be communicated implicitly. Awareness of stance, whether positive or negative, enables a supervisor to articulate her preferred process, justify it honestly to supervisees, and, thus make ‘transparent’ some of the unseen power in the learning relationship. We recognise that this may not always be possible and simply note that the supervisor’s stance will ‘leak’ anyway, as supervisees are likely to be acute non-verbal observers. For example, one of us has experienced a supervisor who favours a psychodynamic orientation and who stated their preference at the contracting stage. This was brought into the supervision sessions overtly, providing a rich background for the person-centred therapeutic orientation in use by the supervisee. Modelling
Modelling can play a part in enabling reflective learning in therapy and supervision. We have referred to intention and process – modelling is the intentional demonstration of process. Therapist modelling is found in person-centred work where the congruence of the practitioner is a direct exemplar from which clients may learn. Supervisor modelling of dialogue is a source for supervisees to see and hear the skills they will need to engage in dialogue with each other in group supervision. As humans we tend to imitate observed behaviours, and modelling seeks to use this tendency to support learning. As learners, we ‘pick up’ the implicit process and copy it, thereby imitating behaviour rather than responding to spoken instructions, so we might as well model process intentionally. With group supervision, the possibility for reflective dialogue between supervisees has emerged. However, without the skills of dialogue, supervisees may lose the opportunities provided by such groups to engage in dialogue and achieve reflection on their
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learning. The assumption that group activity will automatically lead to skills development, particularly dialogue skills, is not borne out by experience (Assiter 1995). Supervisees, in observing person-centred behaviours in their supervisor, can model their own behaviour for effective reflective dialogue. On the other hand, a supervisor who is distant, dictatorial and unable to share the difficulties and struggles of their learning process, is likely to be copied by supervisees who, in attempting to emulate, will lose the reality of struggling to construct their own meanings. While taking account of others, they are less likely to become connected, constructivist learners, as described above. We have established that reflective learning is nurtured by the relationship between practitioner and learner. We identified the optimal learning relationship as mutual, open, challenging, contextually aware and characterised by dialogue. How can therapy and supervision create such a relationship? Chapter 2 provides an account of the person-centred approach to therapy and supervision, drawing on the work of Carl Rogers and Gerard Egan, as we recognise its potential to cultivate the learning relationship described above, and thereby promote reflective learning for clients and supervisees. Rogerian principles grew out of Rogers’ recognition that relationship feeds learning and change, which is why we start from these principles, having established that the reflective learning sought in both therapy and supervision is based on connected learning, through reflective dialogue in relationship with others. The development of Rogerian ideas by Gerard Egan has provided operational definitions of Rogers’ conditions, based on research findings (Carkhuff 1969) with detailed examples for practitioners. In particular, he identifies the failure of traditional education to develop the whole person, that is, address all three domains of learning, and he recommends an ‘intentional’ approach to training, rather than assuming that the ability comes naturally (Egan 1973). He also identifies the absence of reflexivity in training, so that incongruence between declared values and actual behaviours is unlikely to be explored (Egan 1976). Egan’s work offers a response to the criticisms levelled at Rogerian methods by some educationalists. The Rogerian approach, often incompletely understood, has been viewed as bland and ‘touchy-feely’ in facilitating learners, as it
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is believed to preclude challenge and confrontation. The conditions established by Rogers in 1957, as necessary and sufficient for personal learning and change refute this, as they included the existence of relationship and the communication of empathy, warmth and congruence. The potential for challenge in offering high level empathy from a congruent stance is recorded as being dramatic (Berenson and Mitchell 1974; Egan 1976; Mearns and Thorne 1988; Rogers 1957), and where people are properly trained in the requisite skills, there will be no possibility of the ‘soft touch’ version of the Rogerian approach, which is, unfortunately, what many have experienced in place of the real thing.
Summary Therapy and supervision have been presented in this chapter as learning relationships, and the use of person-centred approaches to learning and facilitation by practitioners has been recommended. Learning can be perceived in a variety of ways: new knowledge and understanding; a change in behaviour; or a revision of attitude, reflecting the three domains of learning feeling, action and thought as presented in the FIT model. Therapy and supervision are recognised as examples of reflective dialogue, which may result in learning at three levels through single or double loop learning. When learners dare to traverse the double loop by confronting their TFGs about their situation, they may transform their view of their work or life. The learning relationship in therapy and supervision has been described in terms of reflective dialogue, characterised by connected and constructed learning, which we maintain as essential for transformative learning outcomes. The requirements for reflective dialogue have been described here in detail, particularly the importance of intention, stance, awareness, modelling and process review. In summary, therapy or supervision may lead to learning for improvement, or it may lead to transformation, and then perhaps to learning about the learning itself.
PART 2
The FIT Model Applied in Therapy
Chapter 4
Transactional Analysis in Therapy
This chapter provides an overview of the terminology, concepts and techniques used in TA, the first of the individual approaches which inform the FIT model. The chapter discusses the use of TA in therapy and how it can be used in FIT therapy. The TA approach offers a method which accesses all three of the domains, that is, feeling, initiating and thinking. TA theories and concepts include: •â•¢ structural analysis •â•¢ transactional analysis •â•¢ feeling rackets and games •â•¢ contracting •â•¢ life positions, scripts and injunctions •â•¢ TA techniques •â•¢ the role of the TA therapist.
TA: background and theory Eric Berne conceptualised TA during the early 1960s as an alternative to the forms of psychotherapy then in use (Berne 1964). Berne, who was originally trained as a Freudian analyst, became disenchanted with some of the concepts, namely, that change could not be effected within the individual without the expert interventions of the analyst. In contrast, he proposed that humans are capable of making positive changes on their own. Berne, along with other proponents of the human potential movement, believed that people are capable of understanding their own internal processes and can consciously
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choose to make desired changes without the help of an ‘expert’. In adopting this stance, Berne was ostracised by traditional analysts who saw him as advocating a dangerous precedent (Harris 1967).
The TA theory of personality: structural analysis The part of TA theory which is called structural analysis includes Berne’s (1964) view of the personality as being composed of three distinct parts. He described these parts as the Child ego state, the Parent ego state and the Adult ego state. He proposed that it is possible to learn to recognise and distinguish between the feelings, reactions and thoughts experienced within each ego state. Berne believed that, with this awareness, comes the ability to change undesirable behaviour/s. The three ego states are shown in Figure 4.1.
Parent
Adult
Child
Figure 4.1:The three ego states The Child ego state
The first ego state to emerge is the Child, evident from birth, which comprises feelings, creativity and curiosity. The Child ego state, in its original form, consists of basic needs, wants and emotions (Berne 1964). The infant, who exists completely within the ‘Child’ for the
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first part of its life, also experiences needs for love and affection. The Child, in its uninhibited and natural state, is spontaneous, creative, playful and able to express a range of feelings directly, including joy, anger, sadness, excitement and happiness. The ‘Free Child’, or FC, as this part is sometimes called, exists until it has been adapted and socialised to inhibit curiosity, spontaneity and the direct expression of feelings. The Free Child can exist in people of any age and may be illustrated by two adult friends playing ‘catch’ in the park, with both individuals acting from their Child ego state. When a child learns from her environment that it is unacceptable to express one or more feelings, she may learn to repress one area of her functioning which may, in turn, result in the formation of additional parts of the Child known as the ‘Rebellious Child’, also known as the RC and the ‘Adapted Child’, sometimes called the AC. Both of these sub-personalities inhibit the Free Child (Harris 1967). The Rebellious Child may become aggressive and violent when confronted with limits, lashing out at any attempts to curb her behaviour. The person who consistently functions in the Rebellious Child state often experiences difficulty in forming or maintaining relationship with others, and in the work setting acts out inappropriately. A mild example of Rebellious Child behaviour is an employee who consistently drinks the last cup of coffee and fails to turn off the coffee maker or to make a new pot of coffee. A more severe version of RC behaviour is demonstrated by the person who instigates verbal or physical altercations with co-workers. Conversely, when a child internalises the message that strong feelings may not be expressed, she may react by functioning from the Adapted Child. In such cases, the child has internalised the message that her needs will only be met if she is polite and conciliatory towards others, at a cost to her own needs (Harris 1967). Because the Adapted Child state is often more acceptable in social and professional situations than the Rebellious Child, its behaviour is often rewarded and reinforced. As a result, people with a strong Adapted Child may experience depression by holding in and not expressing ‘negative’ feelings and may be seen as unassertive. The person who consistently functions from the Adapted Child may, for example, continually ask her co-workers for advice and approval.
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The Parent ego state
As children develop, they begin to incorporate messages from their environment, which interact with and influence the Child ego state, and begin to create the formation of their Parent ego state. This is the second part of the personality to come into existence (Berne 1964). The process occurs as outside influences from parents, siblings and other people are internalised. This socialisation process takes place as the Child’s curiosity is impacted on by messages coming from outside the self. As an example, a young child sees a light socket and wants to explore by sticking his finger into it. At this point, he may actually say, ‘No, No, don’t touch!’ because he has been taught to associate electricity with danger. He has begun incorporating messages from others, telling him how he ‘should’ behave (Harris 1967). Although some of the learning from the parent is necessary, such as learning to stop at traffic lights, a child may also hear external messages telling him that strong feelings, such as anger, hurt or sadness are unacceptable. He may then internalise the belief that some parts of the self are not OK, and begin to form the first sub-role of the Parent ego state, that is, the ‘Critical Parent’ or CP. When negative messages, which are sometimes called tapes, are played over and over again in the person’s mind, they can affect his feelings of confidence and self-worth. Critical Parent messages often shape the individual’s self-image; examples of this are ‘You’ll never amount to anything,’ ‘You’re just not good enough’ or ‘You can’t trust men/women.’ Such messages can form the basis of an ‘Early Life Decision’, a script which may be re-enacted throughout the individual’s adult life (Goulding and Goulding 1980). Critical Parent messages often impact on the Child ego state and are experienced by the mature adult as chronic self-hatred, depression and/or the inability to form intimate relationships. The image of a pointed finger and the use, for example, of such statements as ‘You’re lazy!’ often accompany negative messages from an internalised CP ‘tape’. While such messages originate from outside the individual, they are eventually internalised to become the voices of ‘the mother or the father in the client’s head’, which replace the voices of his or her real parents. Clients who function predominantly from their Critical Parent will experience low self-worth and may unconsciously convey these beliefs to others. One of the functions of the TA therapist is to
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increase clients’ awareness of their Critical Parent voice and its impact on their self-esteem. The second sub-role of the Parent ego state is the ‘Nurturing Parent’ or NP, which is often experienced as encouraging and supportive (Berne 1964). Nurturing Parent messages may be expressed as, ‘You’ve done a great job!’ or ‘You’re going to be a wonderful doctor/ supervisor/father/mother.’ NP messages, although often supportive, may become restrictive when the child learns that he or she must always nurture and support others, at the expense of his or her own needs. This in turn becomes the basis of Adapted Child behaviour. The NP may also nurture another person by saying, ‘You look really tired. Let me make you a cup of tea.’ It is also possible to self-nurture by saying to yourself, ‘You’re getting a cold, why don’t you stay at home, make some hot chocolate and spend the day in bed?’ People sometimes internalise the Nurturing Parent state so thoroughly that it becomes their primary driver, replacing Critical Parent messages, as well as input from their Child ego state. In this case, the person who has a strong Nurturing Parent is able to take care of others, but is often unable to express feelings such as anger or hurt, as this contradicts their role as carer for others (Stewart and Joines 1987). The Adult ego state
The third ego state, the Adult, is logical, rational and able to process information as well as identify which ego state is operating at any given time (Berne 1964). The Adult is said to begin emerging in early childhood, often at the point of learning to walk, when a child is encouraged to explore thoughts and feelings from a rational standpoint. The Adult is seen as the mediator or referee between the Parent and the Child and can negotiate compromises or solutions between the opposing messages of the two. It is also able to identify and overcome toxic CP messages and replace them with positive beliefs. The Adult is able to speak for the hurt or angry feelings of the Child. The Adult is also able to ‘re-decide’ and challenge long-held negative beliefs about the self. The Adult is then able to act with the Child and gives the Child permission to be creative and playful when it is appropriate. The Adult can also learn to curb Critical Parent messages or tapes and is able to recognise and alter their negative impact on the self and others. This process can help the individual to establish clear ego
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boundaries and to function assertively and autonomously (Harris and Harris 1995). Parent and Child contamination of the Adult
Two other aspects of structural analysis are relevant to therapy: contamination of the Adult ego state by either the Parent or the Child, as illustrated in Figure 4.2.
Parent
Adult
Child
Figure 4.2: Contaminated ego states
When the Parent ego state contaminates the Adult ego state, the individual believes that a thought pattern is logical and rational when, in fact, it stems from a bias or prejudice (Harris 1987; Harris and Harris 1995). For example, the belief that men are less emotional than women, although not borne out by statistical data, is held by many people and seen by them as rational and objective. Suggestions to the contrary may be met with disbelief. The intensity of the resistance indicates that it is emotionally driven, rather than based on rational thought. The Adult is, on the other hand, able to process information and challenges to beliefs logically and objectively and to update inaccurate beliefs. Racial prejudices and stereotyping are also examples of the Parent Contaminated Adult, an important signal for professional supervision. The Adult becomes unable to think independently and mistakes contamination for reality. The Adult may function rationally in most areas, but remain contaminated in the case of topics or situations like race or gender.
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The person whose Adult is contaminated by her Child ego state experiences all of her needs, no matter how demanding or inappropriate, as reasonable and justified (Harris 1967). The child who throws a tantrum because she wants another piece of cake is unable to access her Adult at that point in time, which might reason with her that she usually feels unwell after she has eaten too much cake. Her complete awareness is focused on getting the need met immediately. Adults who function from the Child Contaminated Adult are unable to delay gratification or recognise that the needs of others are in conflict with their own needs (Harris and Harris 1995).
Transactional analysis In addition to the TA theory of structural analysis, an understanding of transactional analysis forms a central part of TA therapy. This process involves examining the interactions between two or more individuals. The transactions between people may be described as ‘complementary’, as shown in Figure 4.3a), or ‘crossed’ as shown in Figure 4.3b). When two individuals talk disapprovingly about their colleagues having a joke, they are likely to be coming from their Critical Parent sub-states, and the transaction is complementary as they respond from their ‘target’ Parent ego states. When John tells Susan in a scolding voice that she is ‘always late’, he is probably speaking from his Critical Parent, which ‘hooks’ her Child ego state. If Susan responds by bursting into tears and leaving the room, she is probably acting from her Child ego state. This is another complementary transaction, as shown in Figure 4.3a). When two individuals talk about how to complete a task and collaborate, they are likely to be engaging in a complementary transaction between their Adult ego states. If Susan suggests to her colleague that they should ditch work and spend the day shopping in town, and her colleague agrees and gets her coat, this is a complementary transaction between their Child ego states.
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Adult–Adult transaction
Parent
Parent
Adult
Adult
Child
Child
Child–Child transaction
Parent–Child transaction
Parent
Parent
Adult
Adult
Child
Child
Figure 4.3a: Complementary transactions
Crossed transactions Parent
Adult
Child
Figure 4.3b: Crossed transactions
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When Susan suggests a meeting with John to discuss their differences, and John shouts back at her angrily saying she doesn’t deserve his time, he is probably responding from his Critical Parent ego state, and this is a crossed transaction. Susan’s communication is aiming at his Adult, but he replies from his Parent as shown in Figure 4.3b). Complementary transactions continue until one of the people concerned decides to respond from a different ego state. For example, Susan could answer John from her Adult by saying, ‘Surely I’m not always late John. That can’t be true.’ Feeling rackets
A ‘racket’ occurs when a child learns that certain feelings are acceptable, but others are not (Harris 1967). A racket is a consistent expression of one feeling which replaces the expression of all other feelings. For example, if anger cannot be expressed directly, but sadness is acceptable within the family, the child may learn to feel constantly depressed regardless of external events or circumstances. Conversely, if anger is seen as preferable to sadness or vulnerability, the individual may constantly feel angry and be unable to express or experience any other feeling/s. Once learned, the feeling racket is often generalised to other relationships outside the family. Because Feeling Rackets focus on one type of feeling/s to the exclusion of other/s, the individual is unable to express a full range of feelings (Stewart and Joines 1987). The person who interprets all events in their life through a racket which requires them to be sad, will experience any life event through that filter. Seemingly good news may, in another individual, consistently elicit anger.
Games Berne (1964) defined a game as a series of transactions that end in bad feelings for one or more of the players. It is characterised by well-defined roles and behaviours, a switch in the middle of the game and a negative pay-off, that is, bad feelings. The game ‘works’ because the interactions are taking place at two levels: the overt or spoken messages, and the covert or unspoken messages. Games provide feelings of pseudo-intimacy and reinforce negative feelings about the
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self and others. Some of TA’s games, identified by Stewart and Joines (1987), are listed below: •â•¢ Karpman Drama Triangle •â•¢ Poor me •â•¢ Yes, but •â•¢ Ain’t it awful •â•¢ If it weren’t for you •â•¢ See how hard I’ve tried •â•¢ Blemish •â•¢ Wooden leg •â•¢ Nigysob (Now I’ve got you, you son of a bitch). The Karpman (1968) Drama Triangle
This is of particular interest to therapists and supervisors, as it contains the basis for other games. Stewart and Joines (1987) believed that all games involve variations of the roles found in the Drama Triangle, albeit in simplified versions. This game involves at least three players, although it may involve larger numbers. The simple, three player version of the game is illustrated in Figure 4.4. P Persecutor no limits
R Rescuer no limits
V Victim no limits Figure 4.4:The Drama Triangle Source: Based on Karpman (1968)
The Drama Triangle consists of three players: the Persecutor, the Rescuer and the Victim. The three roles are characterised by rigid,
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unstable and unsatisfactory behaviour. The game involves a pay-off, which satisfies at least one member of the Triangle, and occurs after a switch or change in expected behaviour takes place. The Victim may become the Persecutor and/or the Persecutor may become the Rescuer. By engaging in the game, the players are able to avoid responsibility for their own actions and avoid dealing with their own issues. Their roles are described below: The Persecutor
The Persecutor’s stance is ‘It’s all your fault!’ He is blaming, critical, judgemental and overtly controlling. He often comes across as rigid and authoritarian and is driven by a sense of self-righteous anger. His behaviour keeps the Victim in a one-down or oppressed position (Karpman 1968). The Persecutor may pretend to have superior knowledge and experience and functions in the Critical Parent position. The person on the receiving end of the Persecutor’s actions often feels overtly threatened and uneasy. The pay-off for the Persecutor is to temporarily feel in control of and superior to the Victim. The Rescuer
The Rescuer’s position is ‘I can help you.’ She is most comfortable when ‘saving’ the Victim from an attack by the Persecutor. The Rescuer loves to nurture others. In alcoholic families, the Rescuer’s behaviour is often labelled as co-dependent, as it enables the alcoholic to continue drinking and protects him or her from the consequences of the addiction. The pay-off for the Rescuer is feeling superior to the Victim. By constantly rescuing others, she can also avoid dealing with her own problems and issues. Over time, the Rescuer may begin to resent always being expected to take care of others and the dependency that is created between her and the Victim. There is often collusion between the Victim and the Rescuer, which allows them to join forces against the bullying tactics of the Persecutor. This process allows a pseudo-intimacy, which only exists as long as both parties remain in their fixed dramatic positions (Karpman 1968). The Victim
The Victim’s role in the Drama Triangle is based on the pretext that he is unable to take care of himself. The Victim feels powerless and
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oppressed. The Victim learns to find people to rescue him, that is, to make decisions for him and to defend him against Persecutors. The pay-off for this position is that the Victim avoids making decisions and avoids having to learn the problem-solving skills necessary to manage independently of the Drama Triangle (Karpman 1968). The antidote to the Drama Triangle
Once clients recognise their collusion in playing the Drama Triangle, they are able to choose whether to continue their role in the triangle or to adopt healthier interactions with others. Learning how to break free from the Drama Triangle (Karpman 1968) is described in the Quinby Durable Triangle, which is represented in Figure 4.5 presented below: P Persevere with limits
R Reach out with limits
V Vulnerable with limits Figure 4.5:The Quinby Durable Triangle Source: Based on Karpman (1968)
The Quinby Durable Triangle presents an alternative to the Drama Triangle. This model centres on each player establishing clear and consistent boundaries and learning to relate to others assertively, rather than through restrictive and inauthentic roles. In order to achieve freedom from the Drama Triangle, the individual players need to make the following changes: The Persecutor
The Persecutor needs to acknowledge his need to make the Victim dependent. He needs to be willing to give up the pay-off gained in
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the form of feeling superior and powerful over others. The Persecutor can then experience more equal and authentic interactions with others (Karpman 1968). The Rescuer
The Rescuer needs to acknowledge her need to nurture others at her own expense. Giving up the need to feel superior to the Victim can result in the Rescuer learning to take better care of her own needs directly and honestly (Karpman 1968). The Victim
The Victim needs to recognise his part in being victimised and the secondary gains he derives from maintaining this role. By becoming more assertive and learning the skills necessary to manage on his own, the Victim can become independent and self-sufficient (Karpman 1968).
Examples of other TA games Stewart and Joines (1987), by suggesting that all games are variations of the Drama Triangle, assert that the roles of Persecutor, Victim and Rescuer are represented in other games, which include: Poor me
The person who consistently describes their life in terms of all the mishaps and ill-treatment that have happened to them may be playing ‘Poor me’ while presenting themself as the Victim looking for Rescuers. They get negative pay-offs from sympathetic responses from others. Their conversation usually centres around the latest disaster or catastrophe in their life. For example, the person who uses her husband, who is portrayed as the Persecutor, to elicit sympathy from friends may spend hours going over all the details of his latest ‘selfish’ behaviour, rather than seeking ways to improve or change her situation. The husband may play a different version of the same game, by regaling his friends with tales of his wife’s out-of-control spending, while he resists making positive changes in this area of his marriage. The pay-off, in both examples, is that the person is able to stay stuck in the same behaviour patterns and to avoid closeness with his or her mate (Harris 1967).
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The client who plays ‘Poor me’ may ‘hook’ his therapist into feeling sorry for him. If the therapist has a compelling need to help, that is to rescue her client, she may sympathise with his plight, rather than challenge him to empower himself. The therapist who points out what is happening between the client and herself can enable him to recognise the game and to learn to change this pattern of behaviour, both within the therapy sessions and outside the session with friends and family. Yes, but…
People who play ‘Yes, but’ initially elicit pity from listeners. The listener may then offer suggestions as to how the speaker could improve the situation. Such advice is met with comments such as, ‘Oh, I tried that, and it didn’t work.’ Eventually, friends may become frustrated with the game and withdraw from the speaker. The listener may, alternatively, become annoyed or angry with the other person and become aggressive towards him or her (Harris 1967). The ‘Yes, but’ game may also occur between the therapist and the client. If the therapist finds herself making suggestions to the client which are consistently rebuffed, she may eventually become impatient with or critical of the client. The game is ‘broken’ when either party names their feelings and discusses what is taking place between them from the Adult-to-Adult position. Ain’t it awful
In this game, two players find a common topic to complain about, whether it is their spouses, neighbours or the political party currently in power. Their conversation revolves around complaining about what is being done to them by the person/s they have put in the Persecutor role. As long as they agree that they are being victimised, their conversation can carry on forever, as it represents a complementary transaction. The players’ pay-off is that they don’t actually have to do anything about their situation and/or challenge the perceived Persecutors directly (Harris 1967). The therapist may collude with the client who is playing ‘Ain’t it awful’ by commiserating with him as he complains about the people in his life and perpetuates the belief that he is helpless. By pointing out
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the game to the client, the therapist offers him or her the possibility of recognising and abandoning the behaviour. If it weren’t for you
This game involves one person taking on the role of Victim who complains, usually to a potential Rescuer, that she has spent years sacrificing her life, career needs and so on for others. She relates all the things she has done for others such as her husband, children and other relatives, while they have selfishly and ungratefully taken advantage of her. The pay-off is that she doesn’t actually have to stand up for herself and explore, for example, her career options as long as she continues blaming others for her situation (Harris and Harris 1995). The therapist who works with clients playing ‘If it weren’t for you’ needs to assist them in recognising how they blame others for their problems and enabling them to empower themselves. When clients begin taking responsibility for their own lives, they often notice that their relationships with others improves dramatically. See how hard I’ve tried
In this game, the first player, for example, talks constantly about all the effort she has put into a project, such as making a special birthday dinner for her husband. She relates that she spent weeks shopping for his favourite foods, preparing it, and waiting for him to show up for dinner. The point of the game is that she knows he is coming back from a trip and probably won’t be able to make it back in time for the dinner. Instead of scheduling it at a later date, she sets herself up to be disappointed and let down. She then either complains to a Rescuer or upbraids her husband, thereby becoming the Persecutor. The ‘hook’ in the game is that the Victim forever tries to please others and constantly sets themself up to fail in order to elicit sympathy from others (Karpman 1968). The therapist who has a tendency towards playing this game may attempt to ‘help’ clients instead of empowering them and encouraging them to find solutions for their own problems. By recognising their own role in the game, the therapist can then assist clients in adopting new behaviours.
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Blemish
In the blemish game, one person continually finds fault with and criticises others, usually behind their backs, taking on the role of Closet Persecutor. The listener may join in the game, and the two players may continue using complementary transactions ad infinitum. The game may ‘switch’, for example, when the second player hears from a third party that player one has been criticising her behind her back. The second player may then challenge the first player with a crossed transaction or withdraw and end their relationship (Berne 1964). The therapist can give feedback to the client regarding his tendency to find fault with others, which may result in his recognising what he is doing and exploring the pay-offs he gets from this, as well as the possibility of changing this behaviour. The therapist can be fairly certain that the client also criticises her to his family and friends. She can ‘invite’ him to ‘blemish’ her directly by telling her in the session what he is dissatisfied with and then explore what it is like for him if he is able to do this. Wooden leg
The person with a ‘wooden leg’ believes that he could have been successful if only he were taller, younger, better looking, etc. In other words, his reasons for failure have nothing to do with his efforts, but are caused by something about him which is outside his control (Harris and Harris 1995). The therapist working with this client can challenge him by asking how his life would be different if he didn’t have a ‘wooden leg’ to blame for his failures. He may respond by exploring this idea or he may become angry at the therapist, which would also lead to a more honest expression of feelings towards her. Nigysob
This game, ‘Now I’ve got you, you son of a bitch’, occurs when one player has been building up resentment for the second player and waits until the ‘right’ moment to pounce on him or her for something that often seems benign (Berne 1964). For example, the therapist has been feeling annoyed with one of her clients, but has been unable to admit this to herself. Instead, she waits until the client shows up ten
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minutes late for a session, which is out of character for him, and then lambasts him for being irresponsible and narcissistic. As in the other games described above, the TA therapist’s role is to point out the game-behaviour to clients and assist them in abandoning games and becoming more honest and authentic with others (Harris and Harris 1995).
Life scripts, life positions and injunctions Berne (Harris and Harris 1995; Stewart and Joines 1987) believed that each person begins writing the story of his life at birth and that, by five years of age, he has formulated the essentials of the plot, which fall into one of the four life positions: I’m OK – You’re OK I’m not OK – You’re OK I’m OK – You’re not OK I’m not OK – You’re not OK
The first position is positive and reflects the messages the child receives from those around him; he is safe and other people will nurture him and take care of him. He feels good about himself and about other people. The second position is adopted when the child learns, through negative feedback and criticism, or abuse and neglect, that he is inadequate, but that other people are worthwhile. He has difficulty trusting himself and will often seek advice or approval from others. This is sometimes known as the ‘depressive position’. The third position is a defensive one; the child has decided that he is superior, but that other people are inferior and cannot be trusted. This is sometimes called the ‘paranoid position’. The fourth position is adopted when the child decides that he cannot trust himself or others, that no one is worthwhile. His world is bleak and hopeless. Berne believed that the life positions were linked to early experiences which became a part of each person’s life script. The ‘script’ is seen as an unconscious plan, which is ‘made in childhood, reinforced by the parents, justified by subsequent events, and
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culminating in a chosen alternative’ (Stewart and Joines 1987, p.100). The script is said to have a beginning, middle and end, and to represent the young child’s strategies as to how he can best protect himself from an often hostile and threatening world. Based on information gathered from the outside environment, he may conclude that he is powerless or helpless and continues to operate on these assumptions, without examining them, throughout his life. His decisions are based on ‘injunctions’ which influence his early life decisions. The twelve basic injunctions were described by Bob and Mary Goulding as ‘the themes that emerged again and again as the basis for people’s negative early decisions’ (Stewart and Joines 1987, p.134). The twelve themes or injunctions identified by the Gouldings (1980) include: Don’t be or don’t exist Don’t be you Don’t be a child Don’t grow up Don’t make it Don’t do anything Don’t be important Don’t belong Don’t be close Don’t be well (or sane) Don’t think Don’t feel Goulding and Goulding (1980) pointed out that these injunctions were usually stated as prohibitions, that is, ‘Don’t be…’ Part of rewriting one’s life script involves changing negative injunctions into permission-giving statements, so that ‘Don’t be…’ becomes ‘It’s OK to be…’ TA believes that, with awareness, the individual can recognise the script and negative injunctions that he has adopted and choose to move to a healthier position, so that he is OK and other people are OK.
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TA therapy in practice The TA therapist works as teacher/trainer in collaboration with the client from their respective Adult ego states. The model requires a minimal amount of teaching, so that the therapist and client are quickly able to establish a common language. The therapist is active, giving feedback to and often challenging the client. Bringing about therapeutic change often involves the use of a contract, in which the client agrees to work on specific changes in behaviour. The therapist uses structural analysis, which encourages increased awareness of the client’s ego states, and transactional analysis, which focuses on ‘crossed’ or ‘complementary’ transactions (Harris and Harris 1995). The TA therapist often uses a contract to work on the client’s awareness of his or her ego states, and may also use ‘inner child work’ to facilitate a conversation between the Child ego state and the Critical Parent. Structural analysis
The client is encouraged by the therapist to become aware of their own ego states. At this point, the Adult begins to recognise the other two ego states and is able to identify which state is in charge at any one time. The client’s Adult ego state is increasingly able to recognise and describe the Parent and Child states objectively. By acknowledging the interplay between the P and C states, the client begins to recognise internalised Critical Parent messages. Then the client can begin to make choices from the Adult ego state and to implement positive behavioural and cognitive changes and to feel better about his- or herself. Analysis of transactions
The client is asked by the therapist to explore transactions with others from the point of view of complementary or crossed transactions, as previously shown in Figures 4.3a and 4.3b. Such transactions can be explored from the therapist’s and client’s Adult ego states in the therapy sessions. The resulting awareness on the part of the client fosters positive changes in his or her interactions with others. The client is encouraged to recognise the ineffective thoughts and actions stemming from the Parent and Child and to ‘speak’ for these two states from the Adult. For example, the client might say, ‘I’m really angry
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with you right now, and I’d like to lash out, but I know that wouldn’t help the situation.’ Real play between therapist and the client, as well as homework assignments, can help to facilitate this process. Contracting
Eric Berne (1964) defined a contract as an explicit bilateral commitment to a well-defined course of action. The contract is based on TA’s belief that people can learn to exercise choice and to take responsibility for their actions. The contract makes these beliefs explicit and is defined by the involved parties agreeing to: •â•¢ the reasons for wanting to do something •â•¢ who agrees to the contract •â•¢ specific action to be taken •â•¢ dates by when action will be taken. The TA therapist often employs the use of a contract between the client and himself. The client decides which behaviours or cognitions he would like to alter and writes a contract, which describes the desired changes in behavioural terms, that is, describing which specific behaviours or aspects of himself he wants to change and when. The terms of the contract are decided by the client and formulated through a dialogue between the client and the therapist’s Adult ego state. Attention is paid to stating the contract in positive terms, rather that negative ones (Harris and Harris 1995). The contract may include real-plays or ‘homework’ assignments, which are designed to reinforce the learning. For example, the client who acknowledges that he often interrupts other people, may explore this tendency with the therapist, who has probably already noticed this pattern. The client may realplay the situation with the therapist, who then gives him feedback about his behaviour. The client may then contract to ask significant others to give him feedback when he interrupts them, as a homework assignment. Inner child work
Although TA was initially conceived as a cognitive approach, it can be used to encourage the awareness of and expression of feelings. By working with the client’s Child ego state, the therapist is able to assist
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the client in focusing on painful experiences from the past. The effect on the client is cathartic and often leads to recognising the interplay between early Critical Parent messages and resulting feelings, such as hurt, anger or rejection within the child part of himself. An extensive exploration of inner child work can be found in the writings of John Bradshaw (1991).
The role of the TA therapist The TA therapist conducts sessions from his Adult ego state, which engages all three of the client’s ego states at various times in the therapy. He is actively engaged with the client and involved in a dialogue with her. He will probably ask the client to agree to a contract to focus the work and sessions. He will give her feedback regarding her ego states and transactions with others, as he sees them. He may also suggest that she take part in role-plays which involve conversations between her Parent and Child ego states. He may give her homework assignments, asking her to listen to her Critical Parent messages and/or to write her life script (Harris 1967). The homework will then be discussed and explored in the therapy sessions.
Case study example of TA therapy The case study used to demonstrate TA in therapy presents work done with a married couple, which took place over an 18-month period. The couple, here referred to as Richard and Jeanette although those are not their real names, contacted me wanting to make an appointment for couples sessions. Jeanette phoned me initially, and the three of us arranged to meet the following week. Jeanette and Richard were in their thirties and both had demanding and stressful careers. This was the first marriage for both of them, and they had been married for two years. They had no children, but wanted to have children in the future. They were both in good health, on no medications, and had had no previous experience with therapy, either as a couple or individually. They were seeking therapy because they ‘were arguing more often and had trouble resolving differences’. She related that she was frustrated with her husband because ‘he never told her how he felt or listened to her feelings’. He said that ‘she was often critical of him’. Moreover, he wasn’t used to talking about himself and wasn’t sure what she wanted from
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An Integrative Approach to Therapy and Supervision him. They both said that they had come to therapy because they ‘loved each other and didn’t want the marriage to end’. During the initial session, I explained that I often used TA when working with couples, because it offers a focus for the sessions and could provide skills which could facilitate more effective communication between them. I gave a brief explanation of the terminology, including the definitions and roles of the three ego states, including the sub-roles of Critical Parent, Nurturing Parent, Rebellious Child and Adapted Child, as well as crossed versus complementary transactions. I gave several examples of messages from the Parent, Child and Adult, which they readily understood. They agreed to work with the TA format during the sessions.╇ At the end of the first session, we discussed a ‘contract’. In this case, they agreed to work on becoming aware of their internal messages and to identify which ego state they came from. I also suggested that they notice how they communicated with each other, in other words, through analysis of their transactions. The following week, they reported that the TA terms had been useful to them and had given them a way to defuse tension on several occasions.They both believed that, while each of them had acted and spoken from their Adult ego state, their partner had acted from either Rebellious Child or Critical Parent. This led to a discussion of how to recognise the ego states and the use of role-plays to facilitate the learning. In this case, I asked Jeanette to speak to her husband first from her Critical Parent and then from her Adult. She soon realised that the messages were identical, that is, both were critical, which helped her to understand her husband’s feelings of frustration, when, as he said, she talked down to him. Her husband also role-played messages from his Parent and his Adult, with similar results.They both agreed to work on speaking to each other from their Adult state, using it to speak for the Parent and the Child. Within this context, I discussed ‘I’ messages, and gave several examples of this, such as saying, ‘I feel annoyed when you borrow my car and return it to me with no petrol’ versus, ‘You are completely selfish and never think of anyone other than yourself.’ During the next session, they reported increased satisfaction with their communication with each other, and reported fewer arguments. They expressed a desire to learn to listen to each other ‘better’, and we spent time working on and practising active listening skills. Using both ‘I’ messages as well as active listening, they were able, over the next several months, to negotiate solutions for problems which had previously seemed
Transactional Analysis in Therapy 107 insoluble. They described an ongoing battle about where they would spend their yearly summer holiday. She liked to visit foreign cities, while he wanted to go camping or fishing. They began to realise that the argument over destinations covered up a deeper issue: they were both reluctant to give in to their partner, which they considered weak.╇After the ongoing power struggle between them was identified and discussed openly, they were able to negotiate holiday destinations successfully. During further sessions, it became apparent that, while their communication with each other had improved, they still found themselves disagreeing over such subjects as the housework and how they spent their free time. Jeanette described feeling ‘used’ because she ended up doing most of the cooking and cleaning, while Richard reported that he felt ‘resentful’ when she ‘nagged’ him to do more around the house. They were gradually able to explore and pinpoint the messages that they had each internalised as children and which were causing problems between them in the present. We explored the concept of ‘games’. She was able to recognise that she sometimes played ‘Now I’ve got you’ by erupting at Richard when he failed to follow through on a promise to her. He was able to see that he used ‘Poor me’ to reinforce his view of himself as the hardworking and unappreciated mate. They were gradually able to recognise the secondary gains or pay-offs of the games; they were both able to feel aggrieved and superior to and isolated from their partner. I began to experience discomfort during the sessions as they both tried to enlist me on their side and to agree with the other’s view of their partner. By discussing the Drama Triangle, they began to recognise that they took turns persecuting each other and were trying to enlist me to act as Rescuer. My refusal to ‘join the game’ was initially frustrating to both of them, but eventually led to more open discussions about what took place among the three of us. They were able to recognise that they played variations of the Drama Triangle with friends and relatives and began to communicate their feelings and needs more directly.
The work with this couple was primarily TA in that I used ‘contracts’, encouraged the clients to identify their own ego states (T), especially during disagreements, to analyse the transactions between each other, to become aware of the games they played (T), and to learn different ways of communicating and relating (I). They were also gradually
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able to express their feelings more openly with each other (F). I have described the work as TA, although it also included person-centred aspects, in that I used listening skills to establish trust. Moreover, the work included CBT aspects, such as teaching communication and assertiveness skills. As a TA therapist, I acted as a teacher, by explaining the terms and definitions and provided feedback, input and focus for the sessions. The work was achieved by collaborating with the clients and relating from my Adult to their Adult ego states. The couple also learned to nurture each other and became more spontaneous in their interactions with each other. In using the person-centred approach to establish a trusting relation, the work was enhanced.
Applications to the FIT model TA allows the client to explicitly choose which aspects of himself he wants to work with in the therapy sessions. By learning TA terminology, the client can communicate with the therapist from their corresponding Adult ego states to determine where and how the work should proceed. For example, if the client is experiencing feelings of sadness and depression stemming from childhood experiences, he can initiate a dialogue between his Critical Parent and his Child, which can allow him to express and work through the Child’s feelings and to recognise where they came from, that is which parental injunction. Through the use of his Adult ego state, he can understand and choose whether or not he wants to continue to let the outdated messages affect him. Gestalt techniques, described in the next chapter, work with TA in assisting clients in exploring their conflicting Parent and Child parts. TA homework assignments address the ‘T’ or thinking and the ‘I’ or initiating functions of the FIT model, as they ask the client to consider parental injunctions cognitively and to initiate, that is, to act the parts involved in the work.
Summary This chapter has described the key concepts and theories which form the basis of TA therapy. Suggestions have been made as to how therapists can utilise TA in their work with clients. A case study describing TA therapy in couples’ counselling has been presented. TA’s usefulness within the FIT model has also been discussed.
Chapter 5
Gestalt in Therapy
This chapter provides an overview of the background of Gestalt, the key theories and techniques and their applications to therapy. The Gestalt approach is primarily used to access the feeling domain (F), although its emphasis on awareness often results in changes in thought patterns (T). The relevance of the Gestalt approach to the FIT model is discussed and a case study demonstrating the use of Gestalt in therapy is included in the chapter. Some of the key concepts central to Gestalt theory and practice include: •â•¢ phenomenological and existential influences •â•¢ opposing or conflicting parts •â•¢ Gestalt’s view of unfinished business •â•¢ the contact curve •â•¢ resistance to contact •â•¢ Gestalt techniques •â•¢ Gestalt dream work •â•¢ the role of the Gestalt therapist.
Gestalt: origins and background The Gestalt approach was pioneered by Fritz Perls, who first trained as a psychiatrist in the psychoanalytic tradition in Berlin, Germany (Corey 1991). He eventually became disenchanted with the psychoanalytic approach and began formulating Gestalt therapy, which focuses on the whole person, and emphasises present versus past experience. He married Laura Perls, who played a significant role in the formulation
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of the approach, and they moved to the United States in 1946 where they formed the New York Institute for Gestalt Therapy. His work influenced the human potential movement in California, where he was active at the Esalen Institute in Big Sur. Perls was a controversial figure, who inspired respect and dislike in almost equal measures. While he was seen by followers as inspirational and charismatic, and was revered by some as a guru, others saw him as abrasive, overly confrontational and manipulative. Perls was a driving force in the Gestalt approach to therapy until his death. Since then, the practice of Gestalt therapy has become less confrontational and more supportive (Corsini and Wedding 2008).
Definition of ‘Gestalt’ The word ‘Gestalt’ is German and describes a shape, form, pattern or outline. In psychological terms, it refers to all of the parts, facets and aspects of a person, which, when combined, are greater than their sum. ‘Parts’ are often conflicting or opposing; Perls (1972) believed that we are the ‘sum of all our parts’, as opposed to fragmented pieces of the personality. The concept of wholeness features strongly in Gestalt theory, with its emphasis on valuing the whole and integrated experience of the person, the group or the environment (Sills, Fish and Lapworth 1995). For example, one part of the individual may want to stop smoking, while another part reaches for a cigarette. The person, in this case, is not made up of one of these parts or the other, but an amalgamation of both parts, which needs to be viewed together. The conflicting feelings and needs which emerge between these ‘opposing parts’ may be resolved when the opposing parts are recognised, externalised and then integrated. The individual seeks to resolve his or her internal conflicts and to ‘close’ the Gestalt created by the inner tension (Polster and Polster 1994).
Key Gestalt concepts Existential and phenomenological influences
Gestalt theory is existential and phenomenological in that it values the person’s present experience, and emphasises the ‘I–Thou’ relationship put forward by Martin Buber (1994), rather then the ‘I–It’ relationship which objectifies and depersonalises the other person.
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Gary Yontef (1993) describes Gestalt therapy as, an existential-phenomenological approach based on the premise that individuals must be understood in the context of their ongoing relationship with the environment. The initial goal is for clients to gain awareness of what they are experiencing and how they are doing it. Through this awareness, change automatically occurs. (Cited in Corey 1995, p.192)
Gestalt’s emphasis is on the individual’s present experience, known as the ‘the here and now’, with a corresponding de-emphasis on the past, characterised as ‘there and then’. Humanistic values such as personal responsibility and self-change also feature predominately in the approach. Gestalt is holistic (Polster and Polster 1994) in that the person is viewed as an amalgamation of thoughts, feelings and actions. The broad goal of psychotherapy using Gestalt methods is for the client to gain increased awareness of their subjective experience in order to expand self-understanding. This often facilitates change in perception, which results in closure of an internal conflict by integrating polarities. The Gestalt approach is often experimental and may involve the therapist suggesting experiments aimed at bringing the client into the present moment and focusing on the contact between the client and therapist. Gestalt techniques emphasise the ‘how’ rather than the ‘why’ of the client’s experience. Instead of analysing internal processes, the Gestalt approach encourages the valuing of the client’s subjective experience and learning to value his or her own frame of reference (Corey 1995). Conflicting parts
According to Perls (1972) whichever feeling or need is dominant in the moment is the primary focus of the client’s energy. The most pressing need functions as the ‘foreground,’ while the secondary need becomes ‘background’. Once the primary need is met, it ceases to be foreground and recedes to the back of the mind, allowing another need to emerge, which then becomes foreground. Closing one Gestalt or inner conflict allows another Gestalt to surface. Resolution of conflicting parts is possible when the opposing parts are recognised and integrated.
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Perls sometimes referred to the differing parts as the ‘top dog’ and ‘underdog’, and often advocated developing a dialogue between them, so that they could eventually be reconciled and integrated. This process is aimed at helping the individual to become aware of parts of the self that had been ‘disowned’, so that they could eventually be ‘reowned’, allowing the current ‘gestalt’ to close. The technique of addressing both the foreground issue, sometimes known as the ‘figure’, as presented by the client and the context or ‘ground’ in which the issue sits, is known as the ‘dialogic contact’ and is a prominent feature of Gestalt therapy. For example, the client may be experiencing conflict between feelings of anger towards one or both of his parents and the belief that he ‘should be more supportive towards them’. The client’s foreground experience, in this case feelings of guilt, needs to be addressed first. Once this issue has been dealt with, the feelings of anger which were in the background, can become foreground and be addressed. According to Perls, the person’s background experience cannot be dealt with until his current, dominant or foreground have come into his awareness and are resolved (Polster and Polster 1994). Unfinished business
Another Gestalt concept, ‘unfinished business’, is described as an aspect of the past which is impacting on the present (Perls 1972). Although Perls was against spending time in therapy exploring past events, he recognised that early experiences which still affected the client needed to be explored. For example, the client whose traumatic relationship with his mother continued to impinge on his relationships with women in the present might be asked to explore his feelings about her in the present, as if they were happening now. Although Perls disagreed with the analytical view that transference on the part of the patient and countertransference on the part of the therapist were an essential part of therapeutic work, he saw reactions on the part of the client and the therapist as projections which could be usefully explored in the sessions. The above client, who says that he has ‘unfinished business’ with his mother might be asked to tell his therapist how he feels about her. By bringing his feelings towards her into the room, he is able to explore how his past feelings affect his reactions to people in the present and to work through them in the ‘here and now’ (Sills et al. 1995).
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The Gestalt view of contact
The individual is seen as interacting with himself and his environment, which includes but is not limited to other persons (Polster and Polster 1994). Figure 5.1 outlines this process, which illustrates the individual’s initial state of equilibrium, where he is unaware of a need or desire. He may experience a feeling or sensation such as hunger, which may initially be out of his awareness. Once he has labelled the experience and it is in his awareness, he may say to himself, ‘Ah, I’m really hungry.’ He may then begin to mobilise by thinking of ways to meet the need. After he has looked in his refrigerator, he may decide to prepare food or he may consider going out to eat. Once he is acting on one of the thoughts, he is able to make contact, in this case by eating, and to experience satisfaction. Once the need has been met, he withdraws and returns to equilibrium or the resting state. Action Mobilisation
Contact
Awareness Sensation Withdrawal/equilibrium
Satisfaction
Withdrawal
Figure 5.1: Gestalt contact curve
The contact curve can be used in therapy to assist the client in understanding how he blocks or interrupts contact with himself or others. For example, the client with an eating disorder uses food to both soothe himself and to avoid contact with other people as well as himself. By asking the client to become aware of his own bodily sensations and feelings when he overeats, he is invited to come into genuine contact with himself. As he becomes increasingly aware of his own feelings, he can begin to understand how he uses food to cut himself off from his own experience, and can start to alter this pattern.
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Resistance or interruptions to contact
One of the goals of Gestalt therapy is to increase ‘contact’ with oneself and with the environment, which includes other people. When environmental conditions change, then contact elements are altered and the individual is challenged to adapt. Contact is increased by using all of the senses: seeing, touching, hearing and feeling and using them to interact with nature and with other people without losing one’s sense of individuality (Polster 1987, cited in Corey 1991). Resistance to contact takes one of five different forms (Polster and Polster 1994). These are described as follows: •â•¢ Introjection, which involves accepting others’ beliefs without critical thought. The client swallows other peoples ideas whole and sees them as his own. For example, the client may have political views which he has adopted from his parents without considering his own views about such issues. •â•¢ Projection, which takes place when the client disowns unacceptable parts of himself and assigns them elsewhere. The person who is unable to acknowledge his own anger may see the world around him as angry and hostile. For example, the client may view his wife as overly controlling, which may turn out to be a characteristic of himself. •â•¢ Retroflection, which occurs when the client turns feelings inwards that would like to express to others. For example, a client may feel a sense of failure about himself, which may reflect his attitude towards others. •â•¢ Deflection, which occurs when the individual uses humour, sarcasm or activities to distract from their own experience. The client may engage in intellectual discussions and observations in order to deflect or avoid confronting uncomfortable feelings. •â•¢ Confluence, which takes place when individuals are unaware of the boundaries between themselves and the environment. The client may have a tendency to blend in with other people, expressing their thoughts and beliefs as their own, displaying an exaggerated need to be liked and accepted and avoiding conflict at any cost.
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The Gestalt therapist may encourage the client to recognise and deal with his resistance. Perls (1972) advocated working with the resistance, rather than avoiding it. In this case, the therapist might ask the client to describe all the reasons why he ‘shouldn’t’ express feelings, as a way of going with, rather than fighting the resistance. Once the disowned feelings have been expressed and given permission to speak, they recede into the client’s ‘background’ and the next issue, becomes ‘foreground’ for the client.
Gestalt techniques Gestalt techniques which may be used by therapists are described below (Corey 1995; Polster and Polster 1994; Sills, Fish and Llapworth 1995) and include: •â•¢ the empty chair •â•¢ letting the body speak •â•¢ exaggeration •â•¢ complete reverse or doing the opposite •â•¢ ‘what’ and ‘how’ versus ‘why’ •â•¢ ‘I’ versus ‘they’ or ‘it’ •â•¢ speaking in present tense versus past tense •â•¢ talking about versus expressing feelings directly •â•¢ Gestalt dream work. The empty chair
This technique can be employed to facilitate the client’s awareness of inner conflict, that is, the opposing parts within the self. For example, the critical voice of the client’s ‘the mother inside her head’ may be ‘placed’ in one chair, while the part of her that resents the intrusion of her mother’s internal critic may be seated in the second chair. The dialogue which ensues between these two conflicting parts can foster awareness of the client’s own process and gradual resolution of the warring parts of herself.
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Body work or Letting the body speak
Body awareness may be used in Gestalt therapy to identify disowned feelings which the client may hold. ‘Letting the body speak’ includes asking the client who clenches his fist while talking about his wife to let his hand speak to her. In this manner, feelings which are out of the client’s awareness can be brought into the room and addressed. Similarly, the client who is smiling while describing a painful experience may be invited to let ‘the smile speak’ in order to experience the feelings which lie beneath the smile. Exaggeration
A person is asked to exaggerate some feeling, thought or movement in order to get in touch with the experience. For example, ‘exaggeration’ may be used when the client speaks very softly about her divorce. The therapist may ask her to say the same things in a louder voice. Asking her to repeat her words again louder and louder may allow her to begin getting in touch with the feelings she has been repressing. Repeating the sentence with more and more volume, speed or intensity serves to create congruence between the words and the feelings which the tone of voice belies. Complete reverse
This idea is based on Perls’ belief that if something is important to an individual then its opposite must also be significant. ‘Doing the opposite’ may involve asking the client to speak more slowly or more softly than they normally would and describe what happens. The intent of the exercise is paradoxical, in that it enables clients to become aware of feelings and thoughts that they may have repressed. ‘What’ and ‘how’ versus ‘why’
This technique involves encouraging the client to describe their feelings and experience subjectively and to talk about its effect on them. This can be more productive than trying to analyse their feelings, which serves to move emotions safely back into the client’s head. The therapist might ask the client to make a statement starting with, ‘I’m aware that…’
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‘I’ versus ‘they’ or ‘it’
The therapist encourages the client to speak from a personal reference point and to ‘own’ their experiences, rather than attributing them to others. The client who says, ‘It bothers me when…’ might be encouraged to say, ‘I’m bothered by…’ The client who says that her husband makes her angry might be asked to say something like, ‘I feel angry when he…’ and to then explore the difference between this statement and the previous one. Speaking in the present versus the past tense
The therapist encourages the client to speak about an event which happened in the past as if it were happening now. This aims at creating immediacy. The client who says that he felt annoyed with his boss might be asked to say, ‘I feel annoyed with her’ and then to explore his feelings in the present, rather than distancing himself from them. Expressing feelings versus talking about feelings
The therapist encourages the client to experience feelings, rather than discussing, analysing or explaining them. The use of first person, present tense statements, such as ‘Right now, I’m feeling…’ helps to facilitate the client’s awareness of their subjective experience. Gestalt dream work
Perls saw dreams as existential messages about the individual’s relationship to himself and to his environment in the current moment. Seen from this standpoint, dreams afford the person the opportunity to understand and integrate the content of the dream into his daily life. Perls saw each person, object and event in the dream as an aspect of the individual, which the person has projected out onto the environment. By recognising the part of himself that the elements of the dream represent, he will be able to reclaim lost parts of himself and integrate them into the whole person (Sills et al. 1995). In working with dreams, the Gestalt therapist may ask the client to relive the dream in the first person and in the present tense as if it were happening now. Consequently, when the client says that she was walking down a long road which had tall trees on both sides, the therapist would encourage her to say, ‘I am walking down a long road, and I see tall trees on both sides.’ The dreamer would be invited
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to speak as the road and might say something like, ‘I am a wide road and I am walked on by people every day. I’m made of small, hard stones, and I’ve been here forever.’ The road would be seen as an aspect of herself which could be explored and understood as a disowned part of herself. Similarly, the tree would be encouraged to speak and might begin by saying, ‘I’m tall and my branches reach up to the sky. My roots reach deep into the ground and keep me from moving. I offer shelter to other people, but I’m exposed to the cold and rain.’ As the work continues, the client would be asked to conduct a dialogue between the different people and objects in the dream. The client would then be encouraged to explore how each of these images represents parts of herself (Corey 1995).
The Gestalt therapist’s role The role of the Gestalt therapist is active and dynamic and emphasises the importance of the relationship between the client and himself in the here and now. The therapist is willing to express his own feelings and reactions to the client’s work and may express personal material as it relates to the client. The therapist may challenge the client when he sees inconsistencies between the client’s words and body language or facial expression. The therapist may also invite the client to take part in ‘experiments’ such as the empty chair which help to bring the client’s inner conflict into the open. The Gestalt therapist also brings an awareness of his own experience to the sessions when relevant to the client’s work. He may also give feedback to the client about his experience of what is taking place between them in the present moment (Corey 1995).
Case study example of Gestalt therapy I have chosen to describe my work with a client I have called ‘Robert’, although this was not his real name. He was 35 years old when he initially came to me, wanting to look at his relationship with his father.╇Although his father had died when Robert was ten years old, he believed that he had never properly grieved his death. He also suspected that this event continued to influence him in the present, as he reported that he was unable to establish close relationships with others and thought that the two issues might be related.
Gestalt in Therapy 119 Robert, an only child, described the relationship with his parents as ‘good’ until his father developed cancer.╇As the cancer progressed, his father became weaker and eventually bedridden. Robert’s mother devoted most of her attention to caring for her husband.╇As a result, Robert began to feel isolated and ignored within the family.╇Additionally, his mother repeatedly admonished him to be quiet, so as not to bother his father, and to help her more around the house. He was expected to stop acting like a child and to become the ‘man of the house’ once his father had died. During Robert’s initial therapy sessions, he discussed how he had resented his father’s illness, and that he felt guilty about having such ‘unreasonable feelings’. He also expressed the belief that he had somehow caused his father to become ill and that he ‘should have been able to save’ his father from dying. While able to acknowledge the illogicality of these beliefs, he continued to feel guilty and resentful towards his father. During Robert’s early therapy sessions, we focused on the beliefs and feelings he had towards his father in the present.╇ As I asked him to explore what it was like for him to describe his feelings of resentment and guilt to me, he began to cry. He told me that he was certain I must see him as ‘selfish’ and ‘wicked’ for having such feelings. This developed into an exploration of the part of himself who believed he was bad, constantly berating and criticising himself. He also identified another part of himself who felt weak and inadequate for ‘listening to’ his internal judge. This corresponded to Perls’ terms ‘top dog’ and ‘under dog,’ and led to a conversation between these two parts of himself. He began to eventually identify when his internal judge was ‘in control’, and gradually began to accept the thought that he had the right to feel angry about his childhood experiences, and even towards his father. He was then able to ‘speak’ to his father in an empty chair and to tell him how angry he had been towards him. Eventually, Robert was able to change places and to speak as his father towards his son. Robert experienced this as helpful and was gradually able to accept and integrate his feelings of anger. He was, for the first time, able to grieve the death of his father and the loss of a male role model in his life from the time he was ten years old. During the next part of therapy, Robert began to explore his relationship with his mother. He had initially described her as ‘warm, and caring, but needy’. He began to relate that, as he was unmarried, she expected him to spend every holiday with her in his childhood home.╇Although he complied with her wishes,
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Gestalt in Therapy 121 I invited him to take the therapist’s chair and to respond to Robert, the client, as he described what a worthless person he was. Speaking as the therapist, he realised that, ‘Nobody should have to live with that sort of self-abuse.’ Although the negative messages did not disappear overnight, Robert was gradually able to recognise this voice when it appeared, and, in his words, to turn the volume down on it.
Gestalt’s usefulness to the FIT model Clients who express an interest in working with the feeling domain within the FIT model find the use of Gestalt techniques particularly effective. Clients who tend to intellectualise and ‘stay in their heads’ are able to experience and work with strong feelings directly in the ‘here and now’. The empty chair technique, for example, encourages clients to acknowledge and deal with feelings more quickly than approaches which encourage them to talk about their feelings. Although Gestalt therapists typically avoid analysing or interpreting the client’s material, the approach fosters the client’s coming to his own understanding and insights regarding the meaning of his experience in therapy, thus enhancing the thinking or ‘T’ domain, in addition to the feeling or ‘F’ domain utilised in the FIT model.
Summary This chapter has discussed the theories and concepts central to Gestalt therapy. It has also presented the techniques which are used by Gestalt therapists and has included a case study representing a client experiencing Gestalt therapy. Gestalt’s usefulness within the FIT model has also been explored.
Chapter 6
Cognitive Behavioural Therapy
This chapter provides an overview of the origins and beliefs which underpin CBT and describes the major concepts and techniques used by cognitive behavioural therapists. The chapter also places CBT within the context of the FIT model, with its emphasis on the domains of behaviours (‘I’ for initiating or acting) and thoughts (‘T’ for thinking). Although CBT has traditionally de-emphasised the feeling or ‘F’ domain of the FIT model, contemporary CBT practice incorporates feelings as well as thoughts and behaviours. The chapter also provides case material demonstrating the use of CBT techniques with clients. The chapter discusses: •â•¢ the behavioural approach •â•¢ the cognitive approach •â•¢ the evolution of the CBT approach •â•¢ CBT concepts •â•¢ CBT techniques •â•¢ the role of the cognitive behavioural therapist.
Early behavioural influences on CBT The origins of CBT began in the early twentieth century with behavioural scientists Pavlov, Watson and Skinner (Corsini and Wedding 2008). It was based on learning theory, which suggested that, as all behaviour is learned, it can be unlearned and replaced with more desirable behaviours. Pavlov’s work with conditioning dogs illustrated that a dog could be taught to salivate at the sound of a bell
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by introducing food at the same time that the bell was rung. Eventually, the dog began to salivate when it heard the bell, even in the absence of food (Watson 1913). Watson and Rayner (1920) used conditioning techniques with human subjects to illustrate how behaviour could be altered by following it with a specific consequence of behaviour in the form of rewards or punishment. In his well-known Little Albert Experiment, Watson first introduced a young child to a white fuzzy toy, to which the child initially responded by laughing and smiling. Watson then gave the toy to the child and simultaneously made a loud, shrill noise whenever the child saw the toy, who then responded to the sight of the toy by crying. Thus, the child was conditioned by the noxious stimuli to react negatively to the toy. Later behavioural therapy (BT) began to emerge in the 1950s and 1960s as a departure from analysis (Goble 2004). Contributions to behavioural therapy were made by Wolpe, Bandura and Lazurus, who created treatment strategies to alleviate phobic symptoms (Bandura and Walters 1963; Wolpe and Lazurus 1969). Early behaviourists believed that changes in clients’ actions would be followed by changes in their thoughts and feelings (Corsini and Wedding 2008). Historically, behaviourists described humans in mechanistic terms and believed that people were products of both adaptive and maladaptive learned behaviours, and that since behaviour was learned, it could be unlearned. People were seen as capable of unlearning ineffective behaviours and learning appropriate behaviours through the use of reinforcement or positive learning experiences. Undesirable behaviours could be discouraged or eradicated by the use of negative learning experiences (Corsini and Wedding 2008). Current behavioural therapists still focus on specific behaviours and precise goals and methods for treatment, but view people as ‘Complex biosocial creatures with a strong tendency to pursue and establish a wide variety of goals, purposes and values’ (Ellis 2001, p.23). The mechanistic view of change, derived from experiments with animal subjects, fell short of the more complex needs and responses of humans. Changes in behaviour were often short term, and resulted in relapses to undesired behaviour. Early behavioural therapy may not have brought about long-term changes because the techniques had not addressed the emotional or cognitive issues which underlie the ineffective behaviours (Corsini and Wedding 2008). The early
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de-emphasis on the relationship between the practitioner and subject may also have hindered positive change.
The cognitive origins of CBT Cognitive approaches to therapy emerged during the mid-twentieth century. The approach is based on the idea that people create their own reality from the beliefs they have about themselves. Many of the theories and techniques used in cognitive therapy (CT) were developed by Aaron Beck and Albert Ellis during the 1960s (Corey 1991). Their early focus was on teaching clients to recognise negative thought patterns or cognitions. According to early cognitive therapists, changing the client’s automatic assumptions and negative cognitions would result in changes in the other two domains. Beck’s work with depressed clients led him to believe that clients had a repertoire of persistent, critical beliefs which maintained depression. He described these as arbitrary inference, selective abstraction, over-generalisation, magnification of negative thoughts and minimisation of positive thoughts (Beck 1975). Beck’s early work focused primarily on identifying and countering maladaptive thought patterns (Ridgway 2007). Ellis developed his approach to cognitive therapy at around the same time that Beck was developing his theories. The issue of creating change in disordered thought patterns was addressed by Ellis, who concluded that the person carries a cognitive but often distorted map of reality, which influences his view of himself, and can be altered by changing his disordered thoughts (Ellis 1996). Ellis’s original approach to treatment was called rational emotive therapy, which focused primarily on thoughts and cognitions, and to a lesser extent on behaviours. As the work of Beck and Ellis evolved, it became the basis of CBT, which increasingly includes and focuses not only thoughts and thought patterns, but also on behaviours and feelings.
The emergence of CBT as an integrated approach Although the behavioural and cognitive approaches to therapy were derived from two distinct schools of thought, the common goals of the two schools has resulted in an integrated approach to therapy, that is, CBT. As it is currently practised, CBT combines theories and
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techniques aimed at bringing about behavioural changes (‘I’ within the FIT model), such as eliminating phobic responses, and cognitive changes (the ‘T’ in FIT), such as reducing negative thought patterns, which in turn impact on clients’ feelings (the ‘F’ in FIT). CBT can be utilised by the FIT model as they both work with all three domains. The contributions of Beck and Ellis have had a major impact on current CBT practice.
CBT concepts Beck’s focus on persistent, destructive thought patterns was defined by him as negative automatic thoughts or NATs (Beck 1975; Corey 1999; Ridgway 2007). Some of the NATs identified by Beck include: I’m worthless I hate myself I’m no good I’ll never succeed I’m really weak I’m a failure Nobody will ever love me I’ll never be happy I’m helpless I always let people down I’ll always feel this lonely. Beck came to believe that distortions in thinking cause irrational emotional and behavioural consequences and were derived from generalising about past life experiences. Therefore, the individual needs to identify not only the automatic thoughts, but also the kinds of distortion that are embedded in the automatic thought (Ridgway 2007). Some of the distortions that Beck linked to automatic thoughts are described below (Leahy 2003, p.19).
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Thinking distortions
I’m a failure She thinks I’m unattractive Nothing I do works out Anyone can do this job – it doesn’t mean anything
Mislabelling Mind reading All or nothing thinking Discounting positives
Beck believed that recognising automatic thoughts and thinking distortions would not, in itself, bring about change (Leahy 2003). His work focused increasingly on assisting clients in recognising the distorted thinking, the beliefs underlying them, and then working to change the corresponding self-defeating behaviours. This approach to therapy often involves the use of Thought Record Sheets which are described in a later section of the chapter. The issue of creating change in disordered thought patterns had also been addressed by Ellis, who concluded that a person carries a cognitive but often distorted map of reality, which influences his view of himself, and can be altered by changing his view of himself. According to Ellis, people suffer from the following self-defeating beliefs: 1. It is a dire necessity for an adult human being to be loved or approved by virtually every significant other person in his community. 2. One should be thoroughly competent, adequate, and achieving in all possible respects if one is to consider oneself worthwhile. 3. Certain people are bad, wicked, or villainous and that they should be severely blamed and punished for their villainy. 4. It is easier to avoid than to face certain life difficulties and self-responsibilities. 5. It is awful and catastrophic when things are not the way one would very much like them to be.
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6. Human unhappiness is externally caused and that people have little or no ability to control their sorrows and disturbances; and 7. One’s past history is an all-important determiner of one’s present behavior and that, because something once strongly affected one’s life, it should indefinitely have a similar effect (1996, p.84).
Ellis believed that people perpetuate irrational beliefs about themselves by making the following persistent mistakes (2001): Awfulising
This involves seeing events as so terrible that nothing could possibly be worse. The consequences are too awful or dire to contemplate. Low frustration tolerance (LFT)
The perceived inability to endure discomfort or frustration. The person believes that he will fall apart and never be happy again. Depreciation
This is the tendency to belittle or deprecate oneself, the world and everyone in the world by oversimplying the complexity of oneself and one’s situation. Although some CBT techniques focus on either thoughts or feelings, many techniques focus on all three of the FIT domains. The section below introduces CBT techniques which deal with either cognitive, behavioural or combinations of the two domains, which also include a focus on feelings.
CBT techniques In the initial session the therapist usually agrees a contract with the client, which includes the changes he would like to make, how and when he will achieve them and what steps are to be taken towards meeting the goals. The cognitive behavioural therapist engages in a dialogue with her clients, explaining the concepts involved in CBT.
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When the client’s belief system is faulty or overly critical, he will experience a negative self-image and feelings of low self-worth. The therapist focuses on the client’s learning to identify, target and then work to change the negative automatic thoughts and faulty belief systems. With increased awareness, he will be able to replace the negative beliefs with positive ones, which leads to corresponding changes in feelings and behaviours. This is accomplished both during the sessions, which may include role-plays, and outside of sessions through homework assignments. Such assignments are used to foster increased awareness of negative thought patterns, to adopt more constructive behaviours, and to recognise the interplay between feelings, behaviours and thoughts. Ellis’s rational emotive behaviour therapy (REBT) provides a model which deals with thoughts, behaviours and feelings. Ellis sought to teach clients how to adapt negative criticism, or self-talk, and to create positive self-talk. The theory first developed by Ellis as rational emotive therapy (RET) later became known as REBT as it came to include more complex aspects of human functioning and the whole person (Ellis 2001). REBT theory suggests that people learn to view events through the ‘ABC’ process, which is described as: A – the activating event which takes place and triggers an outcome in the individual B – the event or A is filtered through an irrational belief system, which results in C – the consequence, which is experienced cognitively, emotionally and behaviourally as catastrophic or disastrous or unbearable. By using REBT techniques, the individual may learn to: D – dispute the irrational belief system and replace it by adopting E – effective, rational and constructive beliefs and behaviours. (Ellis 2001)
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Case example using rational emotive behaviour therapy (REBT) The REBT approach created by Ellis (2001) provides a useful example for working with a client who comes for CBT. She would, for example, be asked to write out the event that had occurred which troubled her (A in Ellis’s model). She would then be asked to identify the ‘irrational beliefs’ (B according to Ellis) and then to describe the consequence of the event and the beliefs which resulted in the consequence (C in Ellis’s model). If the client is upset because she has been passed over for a promotion at work, which forms the A or event, she may tell herself that she will never succeed in her career, that this event is absolutely awful and unbearable, and as a result (C), she will feel unhappy and depressed. Following the Ellis model, the therapist would ask her to dispute (D) her faulty beliefs and to find more rational beliefs and behaviours. She might, for example, talk to her manager to find out why she hadn’t received the promotion or she might begin to look for a position with another firm (E).
CBT techniques aimed at changing behaviours When applying CBT strategies, the therapist may encourage the client to identify undesirable behaviours, to agree specific goals, and then agree to a contract which describes the undesired patterns, and outlines the preferred changes and how they will be achieved. The contract will include short-term goals, which lead to incremental changes in behaviour. The client may be asked to keep a log of changes in behaviour, which are then reviewed with the therapist on a weekly basis until the long-term goals are met. The contract may be renegotiated on a regular basis to make it more realistic. Behavioural tasks
The purpose of behavioural experiments is to encourage the client to try out behaviours that he finds frightening and would usually try to avoid. For example, if the client fears rejection, the therapist may encourage him to ask a friend for a favour or to ask someone out on a date. Clients who ‘need’ to be perfect may be asked to complete a task which is imperfect, that is, to intentionally make mistakes. A client who is afraid of going shopping might be asked to go into a shop. By
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asking the client to try out such tasks, the therapist is encouraging him to expand his normal limits and to dispute his beliefs about himself (Trower, Casey and Dryden 1988). Relaxation and visualisation techniques
Deep muscle relaxation
Deep muscle relaxation is frequently utilised by behavioural therapists to help clients cope with stress and physical conditions such as high blood pressure. In this technique, the therapist asks the client to sit or recline comfortably and to begin relaxing by tensing the muscles in his toes and feet and then releasing the tension. The therapist may then invite the client to clench the muscle in his ankles and thighs and to release the tension again. This procedure progressively targets the client’s feet, legs, stomach, hips, chest, shoulders, arms, hand, neck and face. By this point, the client is usually feeling very relaxed and the therapist may proceed to dealing with the client’s reasons for coming to therapy. This procedure is often used in conjunction with other techniques to deal with health issues such as high blood pressure, or phobias such as agoraphobia, social phobia and phobic responses to flying, driving, dental treatment, surgery and insects or animals (Zinbarg et al. 1994). Visualisation
Imagery or visualisation techniques are used to assist the client to relax and are often combined with deep muscle relaxation procedures. The use of a special place, which the client describes as peaceful and soothing, is often introduced next to further relax the client. She will then be asked to imagine herself succeeding at the goals she has set for herself. For example, she may imagine that she sees herself successfully interviewing for a job, losing weight or feeling confident in giving a speech in public (Corey 1991). Exposure therapies
Behavioural treatment of fears and phobias include systematic desensitisation, in vivo desensitisation and flooding (Corey 1999).
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Systematic desensitisation
This approach was developed by Wolpe (1982) to treat clients who experienced extreme fear or phobic reactions in certain situations. The technique has been used successfully in the treatment of a number of fears, including fear of flying, driving in a car, public speaking, dental treatment, surgery, spiders and snakes (Corey 1991). The treatment is based on the belief that the client is not able to experience two opposing feelings at the same time, that is, that if he is in a relaxed state, he will not feel afraid of the targeted event or object. The client is initially asked to construct a hierarchy of fears relating to the target, and to arrange them in rank order, with one representing the client in a neutral state and ten representing the most fearful factor around the target. The client is then asked to relax, often through the use of deep muscle relaxation techniques, and to then imagine himself experiencing the lowest item on the hierarchy, that is, the one illiciting the least fear. If he is able to imagine this scenario twice without feeling anxious, he is then asked to move up the scale and to imagine the second most fearful scenario. If at any point he signals by moving a finger that he is feeling anxious, the therapist stops the procedure and takes him back to the last scenario where he felt safe. In this manner, he is gradually able to move up the hierarchy until he can imagine his worst fear without feeling anxious. In vivo desensitisation
This technique involves the client’s exposure to the feared object or situation in real life. The client is exposed to short, graduated exposure and can interrupt the process if he becomes too fearful. The therapist may accompany the client in such experiments or the client may be exposed to the anxiety-inducing stimuli within the safety of the therapist’s office. The client is taught relaxation procedures to assist him in coping with his anxiety, so that he gradually becomes less fearful in the presence of the object or event which arouse anxiety (Corey 1991). Flooding
Another behavioural technique used to treat anxiety involves either in vivo or imaginary exposure to the anxiety-evoking stimuli. In vivo flooding involves placing the client in the situation or with the object
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that he fears for prolonged periods of time. Prior to the exposure, he will be taught relaxation or breathing techniques to reduce his anxiety. In imaginary flooding, the client sees himself in prolonged, intense contact with the feared object or situation without actually experiencing it. This technique has proved as effective as experiencing the fearful object or situation in reality. Both techniques are successful at reducing the client’s anxiety. According to Spiegler and Guevremont (2003), both versions of flooding are the most effective treatment for anxiety disorders, although clients taking part in them need to be well briefed regarding the procedures before they agree to participate in them. Eye movement desensitisation and reprocessing (EMDR)
This technique was created by Francine Shapiro (2001) to treat posttraumatic stress in combat veterans, although it is currently used in the treatment of traumatic stress in general. The procedure involves imaginary flooding, combined with cognitive restructuring, and the use of rapid eye movements or tapping. The procedure encourages the client to experience the stressful events in their original intensity, and to then create positive outcomes or solutions to the stressful experience. The positive cognitions are reinforced so that they replace the original stressful responses to a traumatic memory.
The Assertiveness model The cognitive behavioural therapist may suggest the use of the Assertiveness model in her work with clients. The model involves teaching the differences between assertive, passive, passive aggressive and assertive behaviour. Assertive behaviour involves recognising, expressing and protecting one’s rights in a clear, direct manner, without becoming aggressive, passive or passive aggressive (Alberti and Emmons 1986). Assertiveness is defined by Bower and Bower as: the ability to express your feelings, to choose how you will act, to speak up for your rights when it is appropriate, to enhance your self-esteem, to disagree when you think it is important, and to carry out plans for modifying your own behaviour and asking
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others to change their offensive behaviour. (Bower and Bower 1991, p.4)
Assertiveness training involves learning to recognise ineffective modes of communication and replacing them with more appropriate communication skills. Ineffective and appropriate communication styles are described below. Aggressive communication
Aggressive behaviour and speech include blaming, criticising, namecalling and labelling. The aggressive communicator often speaks in a loud voice and interrupts the other person. Aggressive behaviour may temporarily bring a sense of power, but serves to alienate others in the long run. The aggressive person often feels guilty and out of control. Passive behaviour
Passive behaviours include remaining silent or apologising when criticised or attacked. The passive person often feels helpless and powerless. They are often a ‘closet’ blamer and ruminate about what the other person should have said or done. They may find their anger and resentment building up over time. At some point, this feeling may be transformed into aggression and the roles may be switched or the disagreement may escalate if both parties become more aggressive. Passive aggressive behaviour
Passive aggressive behaviour often involves the use of humour and sarcasm. This allows the person to express their feelings indirectly, thus avoiding dealing with difficult feelings and situations openly. People who express themselves in this manner, may show their anger by ‘forgetting’ to follow through on commitments or frequently arriving late for appointments. Assertive behaviour
Assertive communication is characterised by the willingness to take responsibility for one’s feelings and behaviours and to avoid blaming or attacking the other person. Assertive statements use ‘I’ messages, followed by a feeling word, and include specific events or behaviour which have taken place.
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Examples of each of the behaviours A client has been wanting to ask her manager for a pay rise for the last year. She is feeling increasingly frustrated because, although her performance evaluations rate her work as ‘excellent’, and her colleagues have received pay increases, she has not. She is afraid of her manager and decides to role-play the Assertiveness model in order to add to her self-confidence before she speaks to the person. The client plays herself and the therapist takes on the role of her manager. The client decides to practise all of the behaviours to make her more familiar with the model. Aggressive communication
Client: I deserve a rise in pay and I demand that you give it to me immediately! If you don’t, I’m going to resign. Therapist as manager: How dare you speak to me like this. You’re fired! Passive communication
Client: Uh, I was wondering if you might see your way clear to possibly giving me even a small rise in pay. Therapist as manager: (In aggressive mode) Certainly not! You know the company is losing money at the moment. You’re lucky to have a job! Assertive communication
Client: I’d like to discuss my salary with you. I’ve been here for four years and haven’t received a rise in pay. I’ve consistently received outstanding performance evaluations, and I think I’ve earned a rise. Therapist as manager: Ideally, her manager would respond by saying, ‘Yes, of course.’ She might respond by saying, ‘I’m sorry but we can’t afford it at the moment, but I will raise your salary as soon as we start showing profits again.
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The client may or may not have achieved her goal, but she will most likely feel good about herself for having communicated assertively and will probably not have lost her job.
CBT working with the ‘F’, ‘I’ and ‘T’ domains Many contemporary CBT approaches work with the client’s feelings, behaviours and thoughts rather than focusing on a single area of functioning. Towards this end, cognitive behavioural therapists often ask the clients to use a Thought Record Sheet, which monitors thoughts, feelings and behaviours. An example of such a log or diary, adapted from Greenberger and Padesky (1995) is provided below.
Thought Record Sheet 1. Situation: the client is asked to describe who she was with, what she was doing, where she was and when the undesirable behaviour occurred. 2. Feelings/moods: the client describes her feelings in one or two words and rates the intensity of the feelings from 0 to 100 per cent. 3. Automatic thoughts/images: the client is asked to describe •â•¢ what was going through her mind immediately before she started experiencing the feelings •â•¢ what the feelings said about her •â•¢ what this said about her future •â•¢ what her worst fear was •â•¢ what was the worst thing that could happen •â•¢ what memories were associated with this situation. The client is then asked to 4. circle the ‘hot’ or problematic thoughts in red and then to counter the irrational beliefs with rational evidence which supports the beliefs
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5. write out evidence disputing the ‘hot’ thoughts and to question whether the thoughts are accurate or not 6. create more balanced thoughts, which are then rated by the strength of the new belief from 0 to 100 per cent 7. rate her current mood or feeling as well as new feelings which may have arisen from 0 to 100 per cent. The client is asked to fill out the Thought Record in her own time and then to discuss it with the therapist, in order to measure change and improvement in the areas of thoughts, behaviours and feelings.
Using the Thought Record Sheet with a client The client is a young woman named Mandy who came to therapy wanting to explore her relationship with food. She was in her late twenties, not married, successfully practising as a solicitor, and related that she had ‘binged’ on food since she was six years old. Although her weight is normal, she is afraid that she will become obese in the future and also that her poor eating habits may lead to health problems, such as diabetes. Her goal for therapy is to ‘feel in control’ of her eating. After discussing the FIT model in the initial session, she decided to use CBT to work with her issues around food. I introduced the Thought Record Sheet and asked her to fill it out in relation to her last episode of binge eating while in the session with me, in order for her to understand the purpose and goals of keeping track of her thoughts in this way. In later sessions, she filled the sheets out on her own and brought them with her to the therapy sessions. An example of the Thought Record Sheet follows: 1. Situation: the client is speaking with her mother on the phone when she begins to experience a strong desire to binge on sugary foods. 2. Feelings/moods: she records that she feels angry, which she rates at 90 per cent, and helpless, which she rates at 95 per cent. 3. Automatic thoughts/images: she states that the automatic thought is that she can’t control her eating and that she is a weak person. She also states that she feels
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controlled by her mother and angry at her ‘interference’ in her life. She remembers her mother telling her what she could and couldn’t eat when she was a child, and predicting that she would grow up to be ‘fat and ugly’. She is fearful that her mother could be right, but feels unable to change her eating patterns. 4. Evidence supporting the ‘hot thoughts’: she circles the belief that she is helpless in red. The ‘factual’ evidence in this case, is that she has had these feelings and thoughts since she was very young and believes that, since she hasn’t been able to change the pattern so far, she will be stuck with it for the rest of her life. 5. Evidence disputing the ‘hot thoughts’: she remembers that she has been able to change other undesirable behaviours (she managed to stop smoking cigarettes successfully) and will probably be able to change this pattern. 6. Alternate/more balanced thoughts: she states that she is not a weak or stupid person, since she has managed to earn a master’s degree, and believes that this achievement demonstrated that she is intelligent and has the discipline to attain her goals regarding food. She rated this new belief at 50 per cent. 7. Current mood or feeling: she says that she doesn’t feel so angry, which she now rates at 40 per cent, or helpless, which she now rates at 20 per cent. By continuing to utilise the Thought Record Sheets, Mandy was slowly able to identify her negative thought patterns and began feeling less angry and helpless. She was also eventually able to become more assertive with her mother and, in her words, ‘to eat unhealthily only on very rare occasions’.
Case study example of a CBT approach The client discussed in this section is called Valerie, which is not her real name. She came to see me wanting relief from a long-standing fear of flying. She presented as a 43-year-old woman who was divorced and raising a 12-year-old daughter.
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Cognitive Behavioural Therapy 139 Over the next several sessions, we continued the desensitisation as well as two other CBT techniques. I asked her to identify the thoughts and images that came into her mind when she thought about flying, and the feelings that were evoked in her by them. She listed several thoughts, such as, ‘I just know that my plane is going to crash’ and the image of herself falling to her death. She agreed to keep a log of the thoughts and beliefs that came up in regard to flying and brought it to our session the following week. The assignment identified an additional fear; she was afraid that if she died, her daughter would have no one to take care of her. She gradually learned to recognise the negative thoughts as she experienced them and to replace them with more constructive thoughts.╇At the same time, we continued the desensitisation work until she had moved through all of the scenarios without feeling anxious. During the last session, I used a visualisation technique with Valerie.╇After relaxing her, I asked her to imagine herself on the day of the flight, feeling confident and serene, able to board the plane feeling calm, and able to experience the plane taking off without feeling anxious. By taking her through each step of her hierarchy while relaxed, she was able to imagine herself completing a flight feeling calm and relaxed. This was the last of our sessions, although I did get a phone call from her several months later to tell me that she had taken several flights since our sessions. She related that she had felt slightly nervous on take-off, but had managed to fly (without resorting to alcohol to calm her nerves) and was now able to fly without becoming anxious. In my work with Valerie, I used CBT techniques such as deep muscle relaxation, systematic desensitisation, challenges to automatic thoughts, homework assignments, thought logs and visualisation. The techniques worked well with her fear of flying. She later returned to treatment to work on her fear of public speaking, which she was able to overcome through the use of the above techniques.╇Although the CBT techniques worked well with the specific issues presented by Valerie, I was concerned that she might develop other fears as a form of ‘symptom substitution’. She was pleased with the results of the therapy and chose not to explore possible issues underlying the fears she had presented. In keeping with the underlying personcentred ethos of the FIT model, I respected her desire to end the therapy at this point.
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The role of the cognitive behavioural therapist The cognitive behavioural therapist operates as an educator, coach and role model, teaching the client techniques aimed at creating behavioural, cognitive and affective changes. The therapist focuses on information-gathering, assessment, and goal-setting, giving feedback to the client and assisting him in the formulation of strategies aimed at bringing about the desired changes. The cognitive behavioural therapist actively suggests strategies and techniques to bring about the desired changes. The therapist may engage in role-plays and rehearsal with the client, helping him practise desired behaviours. The relationship between the therapist and client, previously deemphasised, is increasingly viewed by cognitive behavioural therapists as an important component in the successful treatment of the client (Corey 1999).
The application of CBT to the FIT model Combining CBT with the FIT model gives the client explicit choice as to which area of her life she would like to work on. If she chooses to address cognitive and behavioural issues, the use of CBT techniques allow her to incorporate this work into her therapy. If working with behaviour patterns and thoughts during the sessions causes strong emotions to emerge, the client is then able to further address them. She may then choose to use either Gestalt or TA techniques, such as inner child work.
Summary This chapter has discussed the origins of cognitive and behavioural therapies and their gradual integration into the CBT approach. CBT’s usefulness in treating a range of conditions and the techniques involved in their treatment has been explored. The application of CBT techniques using the FIT model has been discussed, and case material using CBT techniques has been presented.
Chapter 7
The Integrative FIT Model as a Therapeutic Approach
The previous chapters have described the three individual approaches which underpin the FIT model and have included case studies which demonstrate their use in therapeutic practice. The models were presented as individual approaches, which can be used by themselves as stand-alone models. This chapter presents the use of the FIT model as an integrative approach and supplies a detailed case study based on the FIT model. The work with clients is discussed (in the first person) in some detail, as it is used to inform the following chapters, which connects therapy and supervision using the FIT approach. FIT therapy may include one or all of the individual approaches, depending on the client’s needs, preferences, the particular stage of therapy and the issues under consideration. This chapter describes the process which determines the direction and focus of the work with clients using the integrative FIT model. It presupposes that the clients enter into therapy willingly and have the resources to continue the sessions on an ongoing basis.
Using the FIT model in practice The model provides the framework to explore and assess the client’s issues during the initial sessions. This process is based on precepts adapted from the humanistic practice of dialoguing with the client to explore his or her issues, feelings and preferences. The relationship between the therapist and client is seen as paramount; initial sessions will be aimed at establishing rapport and trust. With this in mind, the early stages of therapy will include reflection of feeling and content, and seek to encourage the client to identify the focus, direction and approach/es to be used in future sessions. The therapist’s reflections 141
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and observations are presented tentatively (Egan 1990) to give the client time and space to explore and express his or her own feelings, concerns and needs. The FIT model is introduced to the client after trust has begun to develop. The timing of the introduction of the model varies from client to client. With some clients, trust and rapport are established quickly and easily, and the use of the model can be introduced during the first session. With others, this process takes longer. The decision as to when to introduce the model can be gleaned by asking the client directly if they would like to focus on feelings (F), behaviours (I) or thoughts (T). A basic understanding of the domains of feelings, behaviours and thoughts can be provided without resorting to lengthy theoretical discussions. This conversation is cognitive, involves both the client’s and the therapist’s Adult ego states, and usually requires some tuition or explanation of the terms and approaches. Although this represents a departure from the person-centred ethos, explaining the various concepts can be done within a short time. For example, explaining TA’s Parent ego state can be done by asking the client to identify a part or voice inside himself which is often blaming and critical. Similarly, the part of the client that feels hurt, sad or frightened represents the Child ego state. Once the client has identified his internal Parent and Child, he is ready to understand that the part of himself that recognises the other parts is, in fact, his Adult ego state, which is observing and mediating between the other two ego states. Additional approaches, such as CBT, may be briefly and concisely explained with the use of examples. Clients usually have little difficulty understanding the concepts. If a client has difficulty with the terms and concepts, the therapist uses active listening skills to explore the client’s experience at that point in the session. Asking the client what he would like to explore at that moment usually brings the focus back to the client’s current subjective experience and determines the direction of the work. Throughout the sessions, the concepts of transparency and choice are paramount. The client is invited to decide which of the three domains to focus on during the session, rather than being led or indirectly influenced by the therapist. Although the work will often take the form of a contract or agreement between client and therapist,
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it is understood that the focus is organic and emerges in response to the work, rather than static and inflexible.
Using the FIT model with Lenny An example of therapy using the FIT model is presented here in the form of a case study. I have called the client Lenny, although this is not his real name. Lenny was 37 when he came to see me in private practice to deal with ‘problems in his marriage’. He was in good physical health, had a university degree, and held a well-paid, responsible position in the computer field. He and his wife had been married for less than two years and had no children. During the first session, I concentrated on attending to and exploring his view of his world and what he wanted to get out of the sessions. He stated that, although he was satisfied with his life in general, he and his wife were experiencing difficulties in ‘talking to each other’. Using reflection of feeling and content to explore his concerns (Egan 1990), it emerged that his wife criticised him for being unable to talk about his feelings with her.╇ At her suggestion, he had come to me to ‘get in touch’ with his feelings. We spent some time exploring whether this was a reflection of his wife’s needs or his own, and what he would like to get out of the sessions for himself. I had the impression that seeing his needs as separate from hers was a new idea for him, and one that he hadn’t previously considered. As the session continued, Lenny began to tell me about his family of origin. He had come from a large, intact family, with four brothers and sisters. He described his father as quiet and stoical and his mother as the dominant and outspoken force in the family. His description of family mealtimes was vivid; his mother spoke while everyone else listened and agreed (or, as he said, pretended to agree) with her. Before he left the table, he was expected to thank her for preparing the meal and to tell her how much he had enjoyed it. When I asked him if he had always enjoyed her cooking, he seemed puzzled. He realised that he had learned to gauge his feelings by his mother’s reactions to them and was unable, at that point in his life, to say what foods he liked, much less how he felt about other matters. Interestingly, the row with his wife which had precipitated his coming to therapy centred around his reactions to her cooking.╇As a new bride, she had made great efforts to prepare romantic dinners for him. No matter what she had made, his response to her was to thank
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An Integrative Approach to Therapy and Supervision her and to leave the table. He was genuinely baffled when she expressed frustration and anger at what she saw as his lack of appreciation for the work and effort that she had put into the meal. During the first session, Lenny was able to connect the similarity between his behaviour during childhood meals and his current behaviour. He was, however, unable to ‘make sense’ of his wife’s reactions, much less to identify his own feelings. At the end of the first session, I introduced the FIT model and spent a few minutes discussing the various domains. Lenny immediately grasped the concepts and said that he wanted to learn more about his feelings (F); we agreed this as an initial goal of therapy. With this in mind, the sessions would initially centre on identifying and understanding his feelings, rather than focusing on his thoughts or behaviours. In reflecting on the first session with Lenny, I was struck by the contrasts he presented.╇Although he was tall and appeared to be physically very strong, his presentation was hesitant, and he seemed unsure of himself. He spoke in a low, soft voice, and I had to ask him to repeat himself several times in order to understand what he was saying. I had the impression that he would need time and space to express himself.With this in mind, I spent the next several sessions primarily reflecting and clarifying what he said through the use of active listening skills. He seemed to lack confidence in himself, and I thought it was especially important for him to begin to believe that I was listening to him and was truly interested in what he had to say.╇After each reflection that I made, he hesitated for what seemed like a very long time before responding to me. I found myself slowing down my pace, by waiting to react to what he said, and giving him ample time to formulate his next response. With another client, I might have had a longer discussion about therapeutic goals and talked about the different ways we could work towards his goals within the first session. With Lenny, however, I delayed this discussion in order to concentrate on the person-centred belief in the importance of building acceptance and trust and on ensuring my own understanding of his subjective experience. During our second session, Lenny described his wife’s reaction to the focus of his first therapy session. He said that she was annoyed because he had ‘spent so much time talking about his mother’ rather than about learning how to tell her how he felt.When I asked him how he had felt about the session, he replied that he had been amazed that I seemed genuinely interested in what he was saying. He was also able to identify feeling confused at what was, for him, a new experience, in other
The Integrative Fit Model as a Therapeutic Approach 145 words, being heard. He also expressed a vague sense of unease because he was ‘talking about himself’ rather than working towards meeting his wife’s needs. As the sessions continued, the work remained almost exclusively within the feeling or ‘F’ domain of the FIT model. Lenny spent most of the sessions talking about his fear of his mother and how hard he had worked to please her. Even in the present, the thought of making her angry, which he equated with disagreeing with her, made him feel nauseated. He began to realise that he had learned to blank out his own feelings to the point that he avoided thinking, much less expressing anything that might displease or anger the other person. In one of our early sessions, I asked him if he could think of something that I had said that he disagreed with.╇ After a long pause, he replied that the idea of disagreeing with me was too frightening to contemplate. I realised that I was pushing him to meet my pace, rather than encouraging him to work at his own pace and ‘downshifted’ to reflecting his experiences. He decided that he wanted to work on identifying his feelings and needs, but that he needed to work at a slower pace. In the next session, he came up with the idea of exploring which foods he liked (or disliked). This posed an interesting follow-on to the memories of his childhood mealtimes and seemed safer to him than disagreeing with me in the here and now. He decided to work on this issue by going to the grocery store and looking around at different foods to see if anything appealed to him. When he returned the second week, he reported that he had spent an hour walking around the shop looking at various foods and noticing his reactions to them. He had constantly found himself asking whether his mother or wife would ‘approve’ of a food choice, and that this had stopped him from knowing if he would like the food or not.╇As a result, he had left the shop without purchasing anything.The second week, he decided that he would go back to the grocery store, but this time he would actually buy something just because he liked it. He reported that he had taken some time to select and purchase a box of chocolate-covered cherries. The knowledge that his mother hated this particular type of chocolate had almost kept him from buying it; he had returned it to the shelf twice before he actually bought it. He had then sat in his car looking at the chocolates before ‘allowing’ himself to open the box. He had eaten one of the chocolates, decided he liked the way it tasted, and had then eaten all of them. Shortly after, he had vomited up the chocolates. I resisted my urge to interpret his reaction as
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An Integrative Approach to Therapy and Supervision one of breaking one of his mother’s rules and explored what he had got out of the experience. He decided that it had been a useful experiment, and that he could try out different foods to see if he liked them, without needing to eat everything at once. He described the experience as a useful stepping-stone towards identifying his own likes and dislikes. He realised that the experience had helped him to explore his feelings and opinions in broader areas of his life. I found it significant that, up until that point, I had worked with Lenny in what was primarily a person-centred (F) manner. He had, on his own, begun moving into another domain within our sessions. His idea of taking the work out into the real world, in other words, performing an experiment, brought the focus into the behavioural (I) domain. In discussing this with him, he recognised that he had initially needed to ‘just talk’ but that he was now ready to ‘do more than talk’. He had found a relatively non-threatening way to move forward with his work. We discussed the FIT model in more detail. I talked to Lenny again about the three different domains, and suggested that we had mainly been working on his feelings (F) until he suggested trying out new behaviours (I). We explored the usefulness of both foci, and he decided that, although he still had a lot left to look at in terms of feelings, he also wanted to continue trying out new behaviours, which he found useful in reinforcing the ‘feeling work’. I believed that Lenny could benefit from other approaches, such as Gestalt empty chair work, to access his feelings, but I also wanted to agree the work with him rather than trying to impose it on him. In discussing what might happen in Gestalt work, he decided that it was too soon for that type of approach, and that he wanted to continue with what we were doing for the time being. This decision formed the basis (or contract) for our work over the next several months; we continued to focus of feelings (F) and on behaviours (I). Lenny’s work seemed to become more intense and focused, as he went from identifying his tastes in food, to exploring feelings such as irritation and eventually anger at others. The thought that he actually felt quite angry at his mother for, as he described it, limiting and controlling his feelings, came as a shock to him. He had previously seen her as a warm and loving woman who only had his ‘best interests at heart’. Expressing his resentment towards his mother evoked strong feelings of guilt within Lenny. He spent several sessions exploring his guilt and resentment, before he decided that he had the right to feel angry towards
The Integrative Fit Model as a Therapeutic Approach 147 her. He brought up the idea of ‘wanting to do something’ with his feelings, rather than ‘just talking about them’. Reverting to the FIT model, we discussed various options, such as staying within the feeling (F) domain, but using Gestalt methods to intensify and experience feelings directly, or to explore his core beliefs and childhood messages (T) using the TA framework. Lenny decided that he wanted to understand why he felt the way he did and opted to look at his internalised beliefs. I explained the basic tenets of TA, to include the Parent, Child, and Adult ego states, as well as the possibility of learning to identify which ego state was in charge at any given time. I suggested that he could eventually be able to choose how to respond to situations from his Adult ego state. He gave himself the ‘assignment’ of listening to his conversations with other people and writing down the ego states involved. Lenny’s work at this point included a growing awareness of the ‘messages’ that influenced him in the present. Staying within the TA framework, he described core messages, such as ‘Don’t feel’, ‘Don’t think for yourself’, ‘Don’t be a man’, and ‘Don’t get close to other people’ (Harris 1967). Many of these revelations evoked strong feelings in Lenny; for the first time, he was able, not just to discuss, but to express the pain and loneliness he had felt as a child and still felt in the present. With the recognition of the beliefs which had been established in childhood and continued to affect him (T), emerged the feelings that he had buried (F).╇As a result, he eventually began to discuss his inner world with his wife, to discuss their relationship with her, and his behaviour became more assertive (I). Although Lenny was pleased that he could talk more freely with his wife and was happier with their relationship, he was still dissatisfied with his relationship with his parents, both of whom were still alive. Using the FIT model to explore ways of working on his relationship with them, we discussed the possibility of using Gestalt to continue exploring his feelings (F), focusing on his thoughts by recognising and challenging his inner beliefs and then rewriting the negative beliefs to form positive beliefs or affirmations about himself (T), or changing his behaviours and becoming more assertive with them (I). Lenny decided to continue exploring his feelings towards his parents (F) before discussing his feelings with them directly. I suggested using ‘the empty chair’ (Corsini and Wedding 2008), which he was now ready to do. He imagined his mother sitting in front of him, and began telling her how he had felt as a child. In the beginning he often talked about his feelings and told me what he would say
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An Integrative Approach to Therapy and Supervision to her, but he was eventually able to experience and express his feelings towards her directly.╇After clarifying and expressing his feelings towards his mother, he was finally able to put himself in her place without feeling threatened, and to imagine her point of view.╇ As a result, he was able to begin integrating his feelings towards her, and also able to begin recognising and accepting other parts of himself that he had seen as ‘good’ (obedient) or ‘bad’ (angry). He then moved to writing a letter to his mother, telling her how he felt about her. Because he found the thought of mailing the letter to her overwhelming, the work progressed to role-plays with her, when he imagined telling her how he felt and practising what he’d like to say to her (F) and (I). Lenny used a forthcoming visit to his parents to put into practice the work he had done in our sessions. To his surprise, he had found it fairly easy to talk to his mother about his feelings towards her and was pleased that, as a result, he felt closer to her. He was also surprised that he had found it very difficult to talk openly to his father, and returned from his visit home wanting to work on his relationship with him. He began by identifying TA’s parental injunctions (James and Jongeward 1971) which came from his father and continued to limit him in the present. This work included empty chair work telling his father how he felt towards him (F), and then led to role-playing conversations with his father (I). Lenny was eventually able to have the conversation with his father face-to-face during a later visit with his parents. Soon afterwards, Lenny decided that he had got what he needed from therapy and we worked towards ending our sessions. I saw my work with Lenny as illustrative of the FIT model in that the approach evolved over time, depending on the issues and readiness that he presented. In the beginning, he seemed to find it difficult to talk about himself, especially his feelings. By initially using the person-centred approach to establish trust and help him feel at ease, Lenny slowly began to open up.╇ As the sessions continued, he expressed the desire to ‘do more than talk in the sessions’.╇After a discussion of the choices offered by the FIT model, he decided that he chose to work within a CBT approach, looking at and changing his behaviours towards food, and expanding the choices he made around the foods he liked to eat. He then explored his cognitive beliefs (T), by looking at TA’s theory of parental injunctions.╇At every stage of our work, the focus was derived after an explicit discussion of what possible directions the work could take.╇ At each point, Lenny chose what he would like to do next.╇After identifying many of the ‘messages’ and ‘injunctions’ he had learned as a child,
The Integrative Fit Model as a Therapeutic Approach 149 Lenny decided to do Gestalt empty chair work and imagined conversations with his mother sitting opposite him. This work intensified his feelings towards his mother and gave him insights that, according to him, he would not have been able to reach if he had stayed in his ‘head’. After several sessions using the Gestalt approach, Lenny next chose to move the work forward by role-playing what he would like to say to his mother. The Gestalt empty chair work had focused on his past feelings (F) about his mother, the next stage of the therapy involved Lenny expressing himself to her in the present tense.╇As he practised a conversation with her, he realised that he had no need to tell her about all the negative feelings from the past, but did want to re-establish a relationship with her on a different basis. He practised relating to her in his Adult, establishing boundaries and limits that felt safe for him (I). He was eventually able to have the conversation with his mother in person, which led to his getting closure with his past feelings towards her, and establishing the kind of relationship he wanted with her in the present. Similarly, he was able to explore and gradually improve his relationship with his father. He reported feeling empowered by the experience of therapy, not only in terms of the outcome, but because he had been able to negotiate and decide the direction taken during our sessions.╇ At the point Lenny decided to conclude individual therapy, he told me that his wife had some issues to discuss with me, and that she would be calling me in the future to set up an appointment. It seemed that, although he now felt better about his relationship with her, she was not altogether happy with the form his personal development had taken. Looking back on my work with Lenny, I think that my own bias, which often favours working with feelings, could have had a negative impact on my work with him. I often found myself encouraging him to use Gestalt techniques, which he initially resisted. One of Lenny’s issues was his resentment of his ‘controlling’ mother; by urging him to use a particular technique, I think I ran the risk of ‘becoming’ his mother within the sessions. Fortunately, Lenny resisted my urging and continued the work in his own way, serving as a reminder to me to listen to the client and refrain from thinking I knew what was best for him.Towards this end, my own supervision was very useful in keeping me aware of my bias versus what he needed at any particular point in the sessions.
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Use of the integrative FIT model with Lenny The case study included in this chapter illustrates the use of the FIT model in practice. Lenny had come to therapy lacking trust and confidence. The FIT model provided him with choice in regard to what and how he used the sessions at every stage and also transparency, in that the choices were discussed explicitly. He was not aware of his feelings and lacked the language to express them when he initially came to therapy. The person-centred approach was initially used to establish trust and rapport and to give him the space to express his feelings. During some of the initial sessions, he made use of CBT homework assignments outside the session to address his issues with food. The therapy gradually progressed to using other approaches, including TA and Gestalt, as he worked on his relationships with his wife and later his parents.
Role of the FIT therapist The FIT therapist works from a flexible, broadly person-centred and humanistic framework and is able to listen to and respond to the client’s emerging needs, issues and feelings from a position of unconditional positive regard. The therapist needs to be able to use parallel processing to stay in touch with both the client’s experience in the moment as well as her own. From this framework, she is able to determine when and how to introduce the model’s additional approaches: TA, Gestalt and CBT. Towards this end she needs to be knowledgeable and experienced with the different approaches and be able to combine them smoothly and seamlessly as she works with clients.
Summary This chapter has demonstrated the use of the three approaches outlined in Chapters 4, 5 and 6 and described their combined use as an integrative approach using the FIT model. Suggestions have been made as to how to introduce the approach and how to use it as an assessment technique in early therapy sessions, as well as how to apply it in ongoing therapy sessions. Its usefulness in focusing and deciding the direction of the work has also been addressed. The chapter concluded with a case study demonstrating the use of the FIT model in practice.
PART 3
The FIT Model in Supervision
Chapter 8
Introducing Supervision
In this chapter we examine the historical sources of supervision, outline the basic principles of supervision, and identify the main functions and tasks of supervision, before progressing to outline the main existing models of supervision.
What is supervision? The supervision requirement for those engaged in the helping professions has been variously described as: •â•¢ support (Hawkins and Shohet 1989) •â•¢ a series of tasks (Innskipp and Proctor 1993, 1995) •â•¢ a developmental process (Bachkirova and Cox 2004; Holloway 1987; Stoltenberg and Delworth 1987) •â•¢ training (Carroll 1996b) •â•¢ a consultative process (Brown 1984; Ekstein and Wallerstein 1972) •â•¢ a reflective process (Mattinson 1975) •â•¢ a process (Hawkins and Smith 2006) •â•¢ an interpersonal interaction (Hess 1980) •â•¢ an impossible profession (Zinkin 1989) and rather grandly as •â•¢ ‘Keepers of the faith…a quiet profession’ (Alonso 1985, p.3). In this book we address supervision as a reflective learning process for adults, which was discussed in Chapter 3.
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Modern supervision The distinction between supervision and personal analysis became a subject of disagreement in the early 1930s and remains so to this day. There is a continuing debate about the tasks of supervision, that is, how much of it is teaching and how much therapy. The assumption implied in definitions of counselling supervision, especially in literature emanating from the US, is that supervision is in effect trainee supervision, which has its origins in the early practice and development of psychoanalysis. The development of consultative supervision or practitioner supervision has coincided in North America and in the UK with the emergence of counselling and psychotherapy as professions in their own right. The British Association for Counselling and Psychotherapy (BACP) insists that practitioner members are in supervision however experienced they may be, laying down an ethical framework which states that the purpose of supervision is: ‘to maintain and enhance good practice by practitioners’ as well as ‘to protect clients from poor practice’ (BACP 2001, p.6) and this applies to accomplished practitioners as well as trainees. The British Psychological Society (BPS) insists that members who practice psychotherapy should engage in continuing professional development which includes supervision: Psychologists value the continuing development and maintenance of high standards of competence in their professional work, and the importance of preserving their ability to function optimally within the recognised limits of their knowledge, skill, training, education, and experience. (BPS 2009)
The United Kingdom Council for Psychotherapy (UKCP) has a similar requirement for development which includes supervision. Supervision has developed as a profession from its origins in Freudian psychoanalysis through alternative counselling models aiming to support therapeutic work pioneered in the US for soldiers returning from World War II, to developmental or social role models from 1970 onwards. We refer to and link such models in FIT supervision. Recent recognition of the range of tasks in supervision, particularly for trainee supervision, has brought developmental models of
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supervision into mainstream practice in the UK; however, the idea of development as change is not supported by information about how supervisees change as a consequence of supervision. Acknowledgement of social role models has led to identification of functions and generic tasks in supervision which relate to the roles adopted by supervisor and supervisee, that is, counsellor/client, manager/trainee, teacher/ pupil. Because of the close tie between counselling/psychotherapy and supervision, this has meant that supervisors hand on their knowledge and skills through mirroring their own counselling or therapy orientation. This kind of counselling-bound or psychotherapybound supervision is said to use orientation-bound models (Leddick and Bernard 1980) and uses the same approach to supervision as the supervisor would use in therapy. This has tended to mask the underlying philosophy about education and learning which is therefore implicit rather than explicit. The understandable need to limit confusion and mixed messages for new trainees has favoured the same approach for both therapy and supervision. This has led to some supervision being less likely to use modern methods for adult learning. We take the view, not necessarily shared by others, that education is at the heart of supervision, and have provided a more detailed account of this in Chapter 3. We believe that the purpose of supervision is the learning and development of the supervisee and this is confirmed by Hawkins and Smith as follows: ‘Being a supervisor provides an opportunity to develop one’s educative skills in helping other practitioners to learn and develop within their work’ (Hawkins and Smith 2006, p.145).
Sources and existing models of supervision What is the purpose of supervision?
Clinical supervision has twin professional purposes, accountability and development, and these two purposes were recognised as ‘practically and conceptually interwoven’ (DHSS 1978). This interweaving acknowledged three core functions in supervision, namely supportive, managerial and educative (Kadushin 1985), and further work by Innskipp and Proctor (1993, 1995) confirmed these functions. Supervision has been described as:
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a quintessential, interpersonal interaction with the general goal that one person, the supervisor, meets with another, the supervisee, in an effort to make the latter more effective in helping people. (Hess 1980, cited in Hawkins and Shohet 1989, p.41)
or as an intensive, interpersonally focussed, one-to-one relationship in which one person is designated to facilitate the development of therapeutic competence in the other person. (Loganbill, Hardy and Delworth 1982, cited in Hawkins and Shohet 1989, p.41)
The contribution of Inskipp and Proctor provided a functional basis for supervision in the restorative, normative and formative functions, together with the developmental stages of supervision and associated supervisor interventions (Inskipp and Proctor 1993). The double matrix model of supervision, introduced by Hawkins and Shohet (1996, 2007) offered a range of foci for analysis of the supervision process, and a cyclical model of supervision has been offered by Page and Wosket (1994).
The historical sources of supervision Below we review the three sources of supervision and note their inheritance in modern supervision. The variety of declared purposes for supervision is a natural consequence of its historical roots. The three sources of supervision impact on the rationale and therefore the process of supervision in terms of their history, namely: 1. Counselling and psychotherapy: focusing primarily on exploration of the therapist’s own emotional responses to their casework. 2. Industry: focusing on control and monitoring the quality of process and action outcomes. 3. Academia: focusing on education and learning – usually with a cognitive or thinking bias. 1. Counselling and psychotherapy
The historical roots of counselling supervision lie in Freudian analysis and the training of analysts. In order to complete a training in psychoanalysis, trainees were obliged to engage in personal analysis,
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very much along the lines first found in the original Freudian circle. The rationale for this requirement was based on an understanding of how undertaking analysis is likely to trigger emotional material in the analyst as a consequence of transference and countertransference in the relationship. We can identify an early recognition of the affective, emotional or feeling domain in supervisory learning, which appears as ‘F’ for the feeling part of the FIT model. Following the Freudian model, supervision has traditionally taken the theory and practice of the counselling or psychotherapy model being used by the practitioner and simply applied them to the supervision process. Indeed, even recent commentators suggest that in supervision the supervisee may take elements of the therapeutic process as it is articulated and modelled by the supervisor, and recreate it in the counselling relationship (Holloway 1992). This transfer of counselling model to supervision has resulted in a variety of supervision models, mirroring the range of counselling approaches, for example Gestalt, person-centred, psychodynamic, rational-emotive and so on. 2. Industry
Another source for modern supervision lies in its history in the workplace. The earliest use of supervision predates the birth of therapy, as it was devised to facilitate the factory system of production, where, with the Industrial Revolution of the nineteenth century, for the first time, workers were gathered together under one roof. The factory owner/ managers perceived the need for: •â•¢ controlling activities •â•¢ assigning tasks •â•¢ measuring output •â•¢ checking times of attendance. The need to control workers as above, led to the appointment of a special group to oversee the labour process – the supervisors. They became powerful figures in the factory community and were known as ‘labour masters’, later evolving into supervisors and key figures in labour management. In modern times industrial supervisors have lost
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the power to hire, fire and fix wages, as the role has been absorbed by middle management. Within the tradition of supervision in industry, through controlling activities, assigning tasks, measuring output and checking times of attendance, we can identify the origin of how behaviour or the action domain is recognised in modern supervisory learning and appears as ‘I’ for initiating. 3.╇Academia
Academic supervision has its roots even earlier in the Greek academy where pupil philosophers learned by attending upon the masters. In the Middle Ages the first universities formed an academic community where students learned by contact with experts in one of the seven liberal arts subjects. The term supervisor did not exist then, students being attached to the ‘master’ or ‘doctor’ who was expert in the subject concerned. These titles are still enshrined in higher degrees today. The modern university offers supervision for research with students being free to take part in academic discussions with senior academics respected in their field, in order to learn from the master. The tradition within academia which has a focus on learning can be seen as fitting with the ‘T’ or thinking element of the FIT model.
Functions and tasks of supervision The three sources of supervision meet in modern approaches to the tasks of supervision. Supervision tasks arise out of the functions, identified by Innskipp and Proctor (1993, 1995) as: •â•¢ restorative (supportive) •â•¢ normative (administrative) •â•¢ formative (educative). The three functions are linked to the needs of the supervisee and relate to the three domains of learning, namely: •â•¢ affect (emotion or feeling in self and in relation to others) •â•¢ conative (acting or interacting with the world) •â•¢ cognitive (knowing or leading to knowledge).
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The FIT model of therapy and supervision outlined in Chapter 1 provides an integrative approach which encompasses these domains in which the supervisor develops: •â•¢ a willingness to receive and respond to emotional material •â•¢ self-disclosure where appropriate (restorative function – supportive need) •â•¢ a firm arrangement for contact, clear records, including a contract stating boundaries and commitment on both sides (normative function – administrative need) •â•¢ a willingness, on the part of the supervisor, to share expertise relating to therapeutic work (formative function – educative need). The categories above echo the components of the FIT model, as they address the feeling domain (F), the initiating/action domain (I) and the thinking domain (T) – as illustrated in Table 8.1 below. Table 8.1: Supervision functions and domains of learning applied to the FIT model Function
Needs of supervisee
Domain of learning
Match with FIT model
Restorative
Supportive
Affective/feeling
‘F’ for feeling
Normative
Administrative
Conative/doing
‘I’ for initiating/ action
Formative
Educative
Cognitive/knowing
‘T’ for thinking
In order to cover the three learning domains and their related functions in supervision, we suggest that the supervisor will need to attend to the seven tasks of supervision arising out of the three functions, as given below: The tasks of supervision, based on Innskipp and Proctor (1993, 1995), Carroll (1996b) and Hawkins and Shohet (1989), are shown in Table 8.2.
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Table 8.2: The seven tasks of supervision applied to the FIT model Function
Tasks
Match with FIT model
Restorative (supportive)
Relating Counselling (using counselling skills)
‘F’ for feeling
Normative (administrative)
Monitoring professional/ethical issues (can overlap with educative) Administrating, structure and organisation Consulting
‘I’ for initiating/ action
Formative (educative)
Teaching Evaluating
‘T’ for thinking
The first two, namely relating to the supervisee and using counselling skills, fulfil the restorative function (‘F’ for feeling in FIT) by giving emotional support to the supervisee, as appropriate. The supportive tasks are likely to address the restorative function and promote the personal development of the trainee. Monitoring, administration and consulting address the normative function (action or ‘I’ for initiating in FIT) so that supervisors model good organisation and sound practice. The last two, namely teaching and evaluating (knowledge or ‘T’ for thinking in FIT) provide for the formative or educative function in supervision. A description of the seven tasks are presented by Carroll (1996b) on the basis of research with supervisor/supervisee dyads. The emphasis on tasks may vary enormously and there is no agreement about, for example, what ‘teaching’ or ‘evaluation’ means in practice.
The seven tasks of supervision 1. Relating 2. Using counselling skills 3. Monitoring professional/ethical issues
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4. Administrating, structure and organisation 5. Consulting 6. Teaching and learning 7. Evaluating. Carroll’s research with counsellor supervisees (1996a) provides some insights into how the supervision tasks are addressed in the counselling context. Clearly, the emphasis on particular tasks may vary with the context and we discuss these briefly under each task heading. 1. Relating
The supervision relationship is considered by most practitioners as a key element in satisfactory supervision, and this task suggests that supervisors may need to address and work within the emotive domain. Supervisees tend to prefer supervisory relationships which are two way, and involve mutual trust and mutual respect (Page and Wosket 1994). 2. Using counselling skills
Counselling supervisors are very clear about what the supervisor’s relationship with the supervisee is not. It is not therapy. However, in order to address the emotional material triggered by the supervisee’s casework, the supervisor will need to be competent and confident in the emotional domain. In addition, many supervisors realise, in the course of their work, that referral for therapy may be appropriate for particular difficulties in the supervisee’s life. Here the skill of referral is crucial. 3. Monitoring professional/ethical issues
Supervisors are likely to consult with colleagues and be directive with their supervisees, if necessary, to fulfil this supervision task. They may need to be professionally protective, if required, and to check out with supervisees before breaching confidentiality. Thereafter, they will normally be required to act professionally to protect their supervisee and, ultimately, the client.
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4.╇ Administrating, structure and organisation
This task may be underrated in importance, and here managerial contexts are a source of learning, where traditional administrative processes provide a ‘trail’ so that external auditors may trace professional practice. The task includes record-keeping, appraisal profiles and case notes, and focuses on the practitioner’s responsibility to the agency or organisation concerned. All actions required to fulfil this supervision task need to be recorded. The key skill here is assertion and transmitting a clear message to supervisees. Supervisors who avoid the early contracting stage simply confuse their supervisees. Boundaries are a necessary condition for reflective dialogue, providing clear rules about what is to be discussed, by whom and when. Clear rules do not exist psychologically until they are articulated, so a clear statement (possibly in writing) of availability, responsibility and limits of access and so on will confirm boundaries for both parties. 5. Consulting
The most frequently used task in supervision is cited as the most productive, using psychodynamic theory to identify the potential ‘parallel process’ involved (Carroll 1996b). The six modes identified in the matrix model (Hawkins and Shohet 1996, 2007) given below, provide a rich source of material for the consultation task. Consulting refers to the supervisor’s awareness of the systems within which the supervisee is working, both the institution as well as the supervisee’s membership of social systems, for example family and friends. Many systemic difficulties can be helped through the consulting process with a skilled supervisor, as the supervisor takes the initiative and ‘consults’ with the supervisee to clarify the systems within which they are working. 6. Teaching and learning
Supervisors in counselling contexts confirm that the teaching role is not a formal one, and is dependent on the stage of development of the trainee. They also favour experiential methods and use modelling as a teaching method. This echoes the use of different facilitation modes, as described by Heron (1993), depending on the experience, confidence and maturity of the supervisee.
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To fulfil the teaching task in supervision we recommend the skills of reflective dialogue, particularly that of Socratic questioning described in Chapter 3. We recommend that supervisors begin by using the basic skills of facilitation, namely listening, responding and offering empathy, which are again described in Chapter 3. We do recognise that there will be a time and place for transmission when the relationship is healthy and mutuality is established, but suggest that this comes later, otherwise a hierarchical boundary is immediately created, which may limit the potential for dialogue and, therefore, reflective learning. 7. Evaluating
Supervisors in counselling contexts are less comfortable with this task, as evaluation may cut across their chosen philosophy. Descriptions of their unease can be seen in comments like ‘casework cop syndrome’, ‘two impossibilities’, which reflect the difficulty of dealing with power issues. The tension between creating a safe place for development and carrying out assessment is dealt with by self-evaluation and by jointly agreed criteria being increasingly adopted. Here, the skills of challenging are integral to the task, with confrontation, feedback and sometimes advanced empathy as relevant for successful evaluation and reflective dialogue. Recognition, by a trusted supervisor, of feelings of resistance may enable a supervisee to release a block, and we discuss the skills of recognising and responding to feelings in Chapter 12.
Double matrix model of supervision The double matrix model, based on Hawkins and Shohet’s (1996, 2007) Supervision in the Helping Professions, is sometimes called the ‘seven-eyed model’. Rationale for the model
Many models of supervision emphasise the developmental process at the expense of the supervision process itself while consultancy, peer supervision models, referred to as horizontal rather than vertical are free to explore the processes which occur in supervision. The double matrix model, a horizontal model, seeks to ‘turn the focus away from the context and the wider organisational issues to look more closely at the process of the supervisory relationship’ (Hawkins and Shohet 1989, p.55).
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The seven-eyed matrix model reminds supervisors to attend to all seven systems in which their supervisee is working, and analyses the supervision process in terms of the relationships between supervisor, supervisee, client and context, as shown in Figure 8.1. The figure shows how the six or seven modes do actually cover the three parts of the FIT model, as they incorporate the Double FIT and the Triple FIT, as described on pp.25–29. When practitioners are comfortable with the model they will be able to connect its parts to the matrix modes if they wish to do so. At any time in supervision there are four elements to consider: •â•¢ the supervisor •â•¢ the supervisee – a counsellor •â•¢ the client or clients •â•¢ the work context. There are two interlocking systems which connect these four elements shown in Figure 8.1 1. The supervisee matrix where the relationship between supervisee and client is reported and reflected upon in the supervision. Here the supervisory pair pay direct attention to the supervisee matrix, by reflecting together on the reported accounts given by the supervisee or supplied by others. 2. The supervision matrix where the supervisee matrix is reflected in the supervision process itself. Here the supervisory pair pay attention to the supervisee matrix through how that system is reflected in the here-and-now experience of both. Each interlocking system can be subdivided into three categories, giving six modes of supervision described below. The seventh ‘eye’ is the work context, plus any other systems within which the supervisor, supervisee or client operates. An example of the seventh eye is the situation where a supervisee is mandated by the organisation to use a CBT approach when working with clients, but prefers an integrative or humanistic approach. The FIT supervisor will use the seventh eye to address this dilemma for their supervisee.
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Supervisor Supervisor Matrix
WORK
Supervisee Matrix
Supervisee
CONTEXT
Client
Figure 8.1: Supervision matrix Source: Adapted from Hawkins and Shohet (1989) Supervision in the Helping Professions. © Reproduced with the kind permission of Open University Press.╇ All rights reserved.
The six modes of supervision
The supervisee matrix
1.1. The supervisory pair will attend to reports of the supervisee’s interaction with clients, reflecting upon events or previewing potential scenarios. An example of this would be a recounting of the supervisee’s feelings, actions and the actual or potential consequences. 1.2. The supervisory pair will explore strategies and interventions, reviewing and evaluating previous actions and considering future developments. An example of this is the analysis of a counselling/therapy session where strategies and interactions were (un)successful, so that plans can be made for a future rerun.
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1.3. Here the supervisor (mainly) will attend to what seems to be happening between the supervisee and his clients, either consciously or unconsciously, including patterns and images which have emerged from 1.1 and 1.2. The purpose is to understand better the dynamics of the supervisee’s relationships within the supervisee matrix. An example would be a discussion about the consistent difficulty which emerges with a particular client.
These three modes access the FIT domains respectively as follows: 1.1 is likely to be largely a cognitive self-report, so the material addresses ‘T’ for thinking. 1.2 reviews action and interventions, so it addresses ‘I’ for initiating or action. 1.3 attends to the feelings which occur in the supervisee matrix, so it addresses ‘F’ for feelings. The three modes correspond to the Double FIT described on p.26. The supervisor matrix
2.1. The supervisory pair in the supervision matrix attend to what the supervisee is experiencing within the supervisee matrix, particularly countertransference, the response to unconscious material from clients being projected onto the supervisee. An example of this is the annoyance felt by a supervisee who experiences a fussy client who is just like her ‘fussy’ mother.
2.2. The here-and-now process within the supervisory pair can hold up a mirror to the parallel process occurring between the supervisee and their client. The supervisor is a potentially powerful source of information about hidden dynamics between the supervisee and his clients. The supervisor may note a change in attitude or behaviour in the supervisee, like faster speech or uncharacteristic terms or style, perhaps more typical of the clients concerned, and the articulation of this may reflect the behaviour of clients, unconsciously
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‘picked up’ by the supervisee. (The supervisee ‘becomes’ their client, a phenomenon known as ‘parallel process’.)
2.3. The supervisor may experience countertransference as a consequence of unconscious projection from the supervisee and this is a valuable source of information for both. For example, the supervisor may detect in herself a feeling of impatience with her supervisee, which may be a clue to the supervisee’s own impatience with their client, which is being unconsciously conveyed to the supervisor. (The supervisor ‘becomes’ the supervisee, another example of parallel process.)
The three modes in the supervisor matrix are primarily focused on the ‘F’ for feeling domain of the FIT model; however, elements of ‘I’ for initiating and ‘T’ for thinking are likely to be encountered, so this corresponds to the Triple FIT described on pp.27–29. The seventh ‘eye’: the work context
The six modes include all the processes that occur within both the supervisee and supervisory matrices, but supervisory relationships must take account of the wider context in which the supervisor, supervisee, client, organisational, professional, ethical and social factors will all play a part. An example of the seventh eye is the situation where a supervisee is mandated by the organisation to use a CBT approach when working with clients, but prefers an integrative or humanistic approach. Such dilemmas may be addressed productively using the FIT model. Critique of the model
The model (Hawkins and Shohet 1996, 2007) can be criticised as being a ‘snapshot model’, with no perspective over time. For many supervisors the model is just too complicated and they find themselves unable to attend to six or seven modes in one supervision session. Experienced supervisors follow the model unconsciously but for new supervisors the complicated structure distracts. In addition, for many practitioners the psychodynamic language is unacceptable, meaning that transference and countertransference are not terms understood in their orientation.
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Cyclical model The cyclical model, based on Supervising the Counsellor by Page and Wosket (1994), is actually more a structure within which any model can sit. The rationale for the cyclical structure given below, echoes the argument which we will make in this book for using person-centred learning principles in supervision. The structure is not counsellingdriven or orientation-driven, apart from its humanistic credentials, like the FIT rationale. The structure allows for using a variety of different therapeutic approaches as recommended by FIT supervision. The supervisor has the responsibility to acquire educative skills to cover a variety of practitioners as in FIT supervision. Many supervisees are now using integrated or eclectic models of counselling, with no equivalent model of supervision, and this cyclical structure allows for the FIT integrated model of supervision. The cyclical structure is holographic so that it may represent the shape of an individual supervision session, and it may also represent the shape of the entire supervision cycle, over a year or more. The Page and Wosket structure provides a supervisor using the FIT model with a firm framework into which their model nests comfortably, and we recommend it. The model enables a reflective and/or critical dialogue to occur in relation to whatever work in which the helper is engaged. It lends itself to both individual and group supervision, and in both situations we are recommending a facilitative, person-centred learning approach by the supervisor, as this is likely to sustain the reflective dialogue which will lead to productive and professional work. The assumptions which underpin the cyclical model are humanistic in kind and professional in effect. For example, supervision is for the benefit of the supervisee; the relationship should be characterised by warmth, understanding and empathy; addressing emotion will enable learning in the supervisee; supervisors should reflect on their own practice. In addition, the model recognises that supervision may be exploratory, open-ended, reflective and also action-oriented, as well as acknowledging that learning in this way is exposing and challenging for the supervisee. The humanity of the supervisor is the most valuable contribution to the process for both, and the danger of mechanisation in supervision has been highlighted by Blocher:
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The possibility always exists that an immature, inadequate, and insensitive supervisor may intimidate, bully, and even damage a supervisee. No theoretical model of supervision is idiot proof and bastard resistant. When such destructive events occur in supervision it is more likely to be due to the personal inadequacies of the supervisor than to deficiencies in any wellthought through theoretical model. (Blocher 1983, p.30)
With that warning in mind, we look briefly at the five stages of our cycle: contract, focus, space, bridge and review, as outlined below, and refer readers to a more detailed treatment in Page and Wosket (1994). The model
The model has its roots in Gerard Egan’s model of helping, which can be found in The Skilled Helper (2009) and other publications (Carkhuff 1969; Egan 1976). There are five stages, as shown in Figure 8.2.
Contract
Review
Bridge
Focus
Space
Figure 8.2: Overview of cyclical model Source: Page and Wosket (1994) Supervising the Counsellor: A Cyclical Model. London: Routledge, p.36.
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1. Contract: and possibly recontracting. 2. Focus: the subject or material under consideration. 3. Space: holding the supervisee – support and challenge. 4. Bridge: the way back to the work. 5. Review: evaluation and assessment. We now discuss each stage in more detail, bearing in mind that each stage can be visited in every session, so that the contract may be checked for suitability if things have changed or if the focus alters from session to session. 1. Contract
This stage includes: •â•¢ Ground rules, e.g. who contacts who, ethics code, time keeping, etc. •â•¢ Boundaries, e.g. confidentiality, agreement regarding referral for therapy. •â•¢ Accountability, e.g. professional code of conduct with implications. •â•¢ Expectations, e.g. who is responsible for what. •â•¢ The nature of the relationship, e.g. not therapy. We offer an example of a FIT supervision contract in Appendix B, based on an adaptation from Carroll (2004). Deep learning is likely to be achieved by learners who take responsibility for their own learning, and are motivated by their own learning ambitions (Brockbank and McGill 2007). A supervision contract, which offers the possibility of the supervisee deciding on the focus of each session and the process to be employed, is an example of how this can be achieved and the FIT supervision contract fulfils this requirement exactly. Contracting or recontracting, where relevant, may occur in later sessions, but will normally feature in the first. We have established that transparency about process is a valuable facet of facilitation leading to reflective dialogue. The safety provided by firm boundaries enables a supervisee to deal with difficult issues relating to his work, for example
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clients’ DNA or ethical issues. When either party breaches boundaries then person-centred confrontation using assertive principles may be needed. Boundaries should be discussed and agreed at the beginning of the relationship and any slippage addressed without delay. Both parties should agree to refer when issues arise that are on the verge of therapeutic material. An example of ground rules agreed in one of our supervisory contracts appears in Appendix A and applies to both supervisor and supervisee. For example, time-keeping and disclosure refers to the supervisor as well as the supervisee. Every supervision relationship should begin with a contract. Supervision contracts will usually refer to a code of practice and we recommend those provided by the BACP (2001), the BPS (2009) and the UKCP (2009). Rogerian core conditions of respect, empathy and congruence are recommended to establish the supervisory relationship, and if the intention to work in such a way is voiced this will enable the relationship to inspect itself using the skill of immediacy which we discuss in Chapters 5, 11 and 12. Initial agreements should accommodate the possibility of the relationship failing and how this should be handled. 2. Focus
This stage includes: •â•¢ Supervisory material, e.g. personal response to client, fees, ethics, organisational concerns. •â•¢ Objectives, i.e. supervisee’s versus organisation’s, stated using the ‘past participle’ method, e.g. ‘achieved professional registration in one year’. •â•¢ Presentation, e.g. tape, video, drama, narrative. •â•¢ Approach, e.g. balance of questioning and listening, awareness of potential overinvolvement. •â•¢ Priorities, i.e. what the supervisee considers most urgent and important except where there are ethical or professional matters which take precedence.
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The supervisee has the right to decide the focus of the session, unless there is a serious problem which justifies the supervisor overriding the autonomy of the supervisee, and this is a key facet of the FIT model. Mnemonics for setting objectives are given in Appendix C. The choice of focus will dictate the responses of the supervisor, in deciding which domain it is appropriate to address and, therefore, which facilitative skills to use. Reflective dialogue skills needed here are patience (while the supervisee sorts out her desired focus) listening and responding, offering empathy where appropriate and, particularly, summarising what may have been presented in a spontaneous but possibly disordered fashion. Objectives should emerge from the discussion and for all supervision will need to be assented to by the supervisee. Agreeing objectives gives both parties a structure for review and evaluation later. This approach, which we advocate in this book, operates within an overall humanistic orientation and takes a non-punitive position. There is evidence that supervisors’ approaches may not always be what their supervisees want or need, for example a boundary issue where supervisors may be overintrusive and overinvolved with their supervisees. Part of the contracting may include elicitation of the supervisee’s preferences in this regard. For example, Socratic questioning (see Chapter 3), while highly effective, may put off a more reserved supervisee, who prefers to talk problems through and decide on their focus themselves. 3. Space
This stage includes: •â•¢ Collaboration, i.e. the reflective alliance formed between the supervisory pair. •â•¢ Investigation, e.g. recognition of parallel process where the supervisor may experience in parallel some of the feelings occurring in the supervisee’s own work with their client. •â•¢ Containment, e.g. when the supervision session may have generated disturbance or disorientation for the supervisee, the skilled supervisor ensures that such emotive material is contained, by acknowledging it and articulating its effects on both.
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•â•¢ Affirmation, e.g. the celebration of a supervisee’s learning and/ or struggle, a pleasant duty for supervisors which is often forgotten. As noted above, early sessions will need to attend to the relationship, using the material presented to establish rapport, and deal with feelings that are getting in the way of progress for the supervisee. Here the importance of emotional facilitation is evident and empathy will be a key skill, as the ‘F’ in the feeling domain of the FIT model. As the relationship develops and the supervisee is enabled to get to grips with their project, other tasks of supervision can be fulfilled. The space provided at this stage of the cycle will allow for containment, challenge and encouragement of the supervisee, to be creative and innovative, utilising the dialogue skills of questioning and confrontation. 4. Bridge
This stage includes: •â•¢ Consolidation, e.g. using questions and summaries which link back to the work of the session. This is the gathering together of what has gone before. Here the restatement skills of the supervisor will pay off as they will find that they are able to summarise accurately what has been discussed in the session. •â•¢ Information-giving, e.g. the preferred method for supervisors is to direct the supervisee to an appropriate source or reference. •â•¢ Goal-setting, e.g. checking out ownership of learning objectives. In addition, supervisors are likely to encourage their supervisee to articulate learning goals, which can be addressed at the review stage. •â•¢ Action planning, e.g. examining all potential ways of achieving objectives. •â•¢ Supervisee’s perspective. This is the moment to create the bridge back to the supervisee’s own work environment by checking out with them how they foresee the effect of the actions that have been agreed. For example, how will their client react to their intention to challenge him or her?
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The bridge stage of the cycle is named to indicate the link from supervision back to the actual work. Supervisors will need to question and summarise and then instigate action in this stage, action relating to the supervisee’s work. The need to record here is paramount. There are elements of both ‘T’ for thinking and ‘I’ for initiating or acting in this fourth stage of the cyclical model. 5. Review
This stage includes: •â•¢ Feedback. The focus of this feedback is the relationship itself and the exchange aims to improve the quality of the supervision relationship. The two-way mutual interaction may include dynamics in the relationship, e.g. dependency, skills used by both parties, as well as styles and approaches, such as questioning and empathy. •â•¢ Grounding. A moment of pause before moving on to evaluation, which may be silent, or comprise general comments about the session: ‘Have we covered everything you wanted to talk about?’ or ‘We seem to be spending a lot of our time on the difficulties with x – have we forgotten anything important?’ •â•¢ Evaluation. The purpose here is to consider the value of the session and note any changes that need to be made to the process, e.g. allocating a minimum length of time to particular issues. •â•¢ Assessment. An activity for supervisors who have already agreed at the outset, with their supervisees, to breach confidentiality for the purpose of conveying information to relevant parties in the organisation, e.g. the supervisee’s tutor if a trainee. •â•¢ Recontracting. This should follow evaluation. Both parties review their contract with each other, check whether it is still appropriate, revisit and renew their initial agreement. If recontracting is part of the original contract this can be done at any session, as the relationship develops, taking account of some of the changes discussed above.
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A review of the session completes the cycle and leaves the supervision pair ready to renew the process in the next session, addressing the ‘T’ for thinking part of the FIT model. As stated previously, we make the assumption that the purpose of supervision is professional learning and development, primarily for the supervisee, but not excluding the supervisor. Feedback and some evaluation are important in this stage, and the opportunity for reviewing the process of the session, but the most important part of review is the winding down of the session. The supervisor’s summary will affect this (and it should include agreed action points), as well as the supervisee’s impressions of the session (including articulation of what has been agreed). This stage is often neglected because of avoidance by both parties, unclear goals or basic time management. It is the supervisor’s responsibility to manage session timings so as to leave sufficient time for review.
Summary In this chapter we have visited the historical sources of supervision, and the three functions of supervision and how they connect with the FIT model. The chapter includes a review of two of the existing models of supervision and how they can be combined with the FIT model to address all the tasks of supervision.
Chapter 9
Using Transactional Analysis in Supervision
This chapter discusses TA, presented in Chapter 4 as a therapeutic approach, as it applies to supervision within the FIT model. As in therapy, TA supervision allows access to the feeling, initiating and thinking domains. In the case of supervision, particular attention is paid to the Adult ego state, as it is this part that processes and informs the interactions between the client, supervisee and supervisor. The chapter sets out general goals for TA supervision and then explores aspects of TA supervision in relation to major concepts and techniques. The broad goals of TA supervision include ensuring that the supervisee has an understanding of the basic theoretical models, language and techniques used in the approach. He or she needs to explore the collaborative as well as the developmental processes involved in the supervisory relationship and be able to work with both the supervisee’s transferential as well as countertransferential issues. The TA supervisor acts as gatekeeper, ensuring that ethical, professional and anti-discriminatory issues are respected both within therapy and supervision (Metanoia undated). Within this context, the chapter considers the following: •â•¢ structural analysis •â•¢ transactional analysis •â•¢ feeling rackets and games •â•¢ contracting •â•¢ life positions, scripts and injunctions •â•¢ TA techniques •â•¢ the role of the TA supervisor. 176
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Structural analysis The TA theory of personality has particular relevance for supervisors and supervisees, as it provides a framework for the supervisee to understand his client’s personality structure, as well as his own, and to apply this knowledge in the work with his clients. Structural analysis refers to Berne’s Theory of Personality (1964), which includes the Child ego state, the Parent ego state, and the Adult ego state. Berne proposed that it is possible to learn to recognise and to identify each ego state, and to understand the impact that they have on each other. The three ego states are shown in Figure 9.1.
Parent
Adult
Child
Figure 9.1: The three ego states Application to supervision
The Child ego state
By using TA terminology and concepts in supervision, the supervisor can encourage the supervisee to become more aware of his own Child ego state when it seems to be impacting on his work with clients. For example, if the supervisee describes client sessions which include an exaggerated emphasis on playfulness and jokes to the exclusion of focus on the client’s inner concerns or material, he may need to examine what his Child is avoiding in the sessions. Similarly, if the supervisee finds that he frequently self-discloses personal information
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to a client or clients, he may need to consider whether this is an effort on his part to get his own Child needs for attention and approval met. The supervisee who functions from the Adapted Child state may be unwilling to challenge clients for fear of disturbing or upsetting them. The supervisee with a strong Adapted Child may, for example, continually ask the supervisor for advice. By examining his ego states, the supervisee is able to gain insight into his own behaviour and improve his interventions with clients. The supervisee may also use his understanding of the client’s ego states to inform his work with the client. For example, if the client ‘forgets’ to pay the therapist for the session several weeks in a row, the therapist may speculate that the client is acting out, possibly from his Rebellious Child state, which may then be addressed in therapy. The Parent ego state
The Parent ego state consists of two sub-roles, the Critical Parent and the Nurturing Parent. Supervisees who have a highly developed Critical Parent are often extremely demanding of themselves in their role as therapist. They may also feel critical towards their clients and, although the critical messages will not be expressed explicitly, clients often sense the disapproval of the therapist towards them. Supervisees can explore the impact of their own Critical Parent with their supervisor. Additionally, supervisees who function predominately from their Nurturing Parent run the risk of ‘rescuing’ their clients instead of encouraging them to function independently. Many therapists find that they have somewhat overdeveloped Nurturing Parent ego states, accounting in part for their choice of career. This caring tendency may result in the supervisees preferring to focus on their clients instead of looking after themselves. TA terminology can be useful in providing a framework for the supervisee to explore such a tendency with their supervisor. The sub-roles for Parent and Child ego states are shown in Figure 9.2.
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Critical Parent
CP
NP
Adult
A
Adapted Child
AC
Nurturing Parent
FC
Free Child
Figure 9.2:The three ego states with subroles
The Adult ego state
The Adult is rational and logical and often acts as the ‘referee’ between the Parent and Child ego states (Berne 1964). The Adult ego state plays a primary role in supervision, as communication between the supervisor and the supervisee ideally takes place between their two Adult states. The supervisee is able to convey strong feelings towards clients by ‘letting his Adult speak for his Child’. Similarly, he is able to observe and recognise his own Critical Parent messages which interfere with working objectively with clients and to discuss this in supervision. The supervisee is able to obtain useful feedback from his supervisor which will increase awareness of the interplay between the client’s and his own ego states. By using their Adult ego states to communicate, the supervisee and the supervisor are able to maintain clear ego boundaries within the sessions, which also fosters the creation of clear boundaries between the supervisee and his client/s.
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Parent and Child contamination of the Adult
Two other aspects of structural analysis are particularly relevant to supervision, contamination of the Adult ego state by either the Parent ego state or the Child ego state, as illustrated in Figure 9.3.
Parent
Adult
Child
Figure 9.3: Contaminated ego states
Parent contamination of the Adult occurs in supervision when the supervisee’s Adult is unable to recognise that her beliefs about a client have been clouded by messages from her Critical Parent. The supervisee will then convey her unspoken criticism or bias to the client without being aware that she is doing so. If the supervisor colludes with the supervisee’s Contaminated Parent, they both apply this bias to their view of the client. If, however, the supervisor is able to maintain clear ego boundaries, he can challenge the supervisee from his Adult and assist her in decontaminating her Critical Parent from her Adult ego state, in order to work more effectively with clients. An example of Child contamination in supervision is a supervisee who demands extra time in a group supervision session, who consistently arrives late with inadequate reasons, and who does not pay the supervision fees on time. Another example of Child contamination would be a supervisee who reverts to their own issues (their needs) regardless of the topic being discussed. If a supervisee believes that her beliefs about clients are always correct, she may be unable to hear criticism no matter how it is offered and may
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take feedback as an attack. By maintaining his Adult ego state, the supervisor strives to help the supervisee to separate the illogical part of herself, contaminated by her Child, and to function from her Adult as she works with clients.
Transactional analysis In addition to the TA theory of structural analysis, an understanding of TA forms a central part of TA supervision. This process involves examining the interactions between the supervisee and the client or between the supervisee and the supervisor. The supervisee is encouraged to explore interactions between himself and his clients from the point of view of complementary or crossed transactions, as discussed in Chapter 4. By examining his own behaviours in relation to those of his clients from his Adult, he is able to process the events taking place between them objectively. By exploring the clients’ interactions in supervision sessions, he is able to identify when transactions are crossed or complementary, and to provide feedback to his clients from his Adult. Moreover, by listening to clients discuss their interactions with others, he can assist them in understanding their reactions to others (i.e. their transactions) from a TA framework. The supervisee can explore his own feelings towards clients with his supervisor. If, for example, he has a strong reaction to a client and recognises that the client reminds him of someone from his childhood, he can explore this in supervision. This may involve roleor real-plays, where he speaks to the client from either his Critical Parent or Child ego state. Afterwards, he can process the interactions with the supervisor, in an Adult-to-Adult discussion. The supervisee gains useful insights into himself, which can add to and enrich his work with clients. Feeling rackets as applied to supervision
A ‘racket’ occurs when a child learns that certain feelings are acceptable, but others are not (Harris 1967). A racket is a consistent expression of one feeling to the exclusion of all other feelings. Supervisees and supervisors are also susceptible to feeling rackets. If the supervisee feels sad or unhappy most of the time, he will probably convey this view of life to his clients without realising that he is doing so. As a
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result, his clients may want to please him by only describing unhappy events in their own lives. The supervisee can become aware of this by exploring it with his supervisor, and may be surprised to notice that his clients ‘suddenly’ begin expressing and exploring a wider range of emotions. Supervisees may have a feeling racket which drives them to remain happy or cheerful when working with clients, who often pick up on this stance from their therapist. Clients may, in reaction to this, avoid bringing strong feelings such as anger or sadness to the sessions. Supervisors can help supervisees to recognise such tendencies within themselves and to explore their possible impact on clients.
Games as they apply to supervision Berne’s view of games (1964) was described in Chapter 4. He described a game as a set of well-defined roles and behaviours, which include a ‘switch’ in the middle, and result in a negative pay-off, that is, bad feelings. Some of TA’s games which are relevant to supervision are described below and include: the Karpman Drama Triangle; Poor me; Yes, but; Ain’t it awful and the Nigysob game. The Karpman Drama Triangle
Understanding the Drama Triangle (Karpman 1968) is especially useful to supervisees and supervisors, as it contains the basis for other games (Stewart and Joines 1987). They believed that all other TA games involve variations of the roles found in the Drama Triangle. The simple, three-player version of the Drama Triangle is illustrated in Figure 9.4. P Persecutor no limits
R Rescuer no limits
V Victim no limits Figure 9.4:The Drama Triangle
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The Drama Triangle consists of three players: the Persecutor, the Rescuer and the Victim. Their roles are described below: The Persecutor
Within the supervision context, the supervisor may act as Persecutor to his supervisees. He may criticise their performance as therapists and undermine their belief in their ability and potential by ‘impressing’ them with his vast and superior knowledge. By exploring this tendency in his own supervision, the supervisor can learn to recognise and alter this behaviour and interact with his supervisees as equals. In therapy, either the supervisee or the client may function as the Persecutor. The client may convey to the therapist (supervisee) either directly or indirectly that she is not being helped by the therapy. The therapist (supervisee) may also convey to the client that, if only she were more clever, insightful or worked harder, the therapy would be much further along. The person on the receiving end of the Persecutor’s behaviour, whether the supervisor or the client, often feels inadequate and inferior. The supervisor can assist the supervisee in becoming aware of the implicit messages which are being exchanged between both the supervisor and the client, and encourage the supervisee to explore the transactions explicitly with his client. The Rescuer
The Rescuer needs to help other people. As the therapist or supervisor, the Rescuer is most at home when ‘saving’ the client from the Persecutors in his life and when nurturing her clients. The Rescuer may have taken on a co-dependent role if she grew up in a dysfunctional family and may have difficulty separating this childhood position from her interactions with clients. The pay-off for the Rescuer as therapist is that she feels superior to the Victim, who is the client in this case. The Rescuer therapist has found a socially acceptable way to earn her living by helping others and, at the same time, by avoiding having to deal with her own problems. The Rescuer therapist and the Victim client often collude with each other, so that the therapy continues without the client making progress, but feeling ‘safe’ with the therapist. When either supervisee or the supervisor tend to rescue others, the possibility exists that the transactions between the two will not be
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genuine. The onus, in this case, is for the supervisor to recognise this tendency in herself and to address it in either her own supervision or therapy, so that the interactions between the supervisor and supervisee are honest. The Victim
The client often takes on the role of the Victim in the Drama Triangle, with the supervisee or therapist acting as Rescuer. If the client has grown up feeling helpless and inferior, therapy may seem like the ideal setting for him to get his needs met. If the therapist or supervisee fails to convey the purpose of the sessions clearly to the client, that is, that therapy is meant to assist him in learning to empower and nurture himself, the sessions may be ineffective. The client as Victim may constantly ask for reassurance, guidance and nurturing from the therapist. If she feels comfortable as Rescuer, she may collude with the client and reinforce his belief that he cannot function independently of her. The supervisee can use supervision sessions to role-play her interactions with the supervisor, so that she gains a clearer understanding of her role in the Drama Triangle. She can then begin to separate her need to rescue from the client’s need to be rescued. The antidote to the Drama Triangle in supervision
The solution to the Drama Triangle (Karpman 1968) was introduced in Chapter 4, as the Quinby Durable Triangle, which is represented in Figure 9.5 below. P Persevere with limits
R Reach out with limits
V Vulnerable with limits Figure 9.5:The Quinby Durable Triangle
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This model is applicable to both therapy and supervision and, in both cases, focuses on the individuals involved learning to establish clear boundaries and to discuss the dishonest messages and behaviours involved in the game directly and authentically. An example of the Drama Triangle is supplied below, as it is played out within a supervision group.
Examples of the Drama Triangle in supervision The roles of Victim, Persecutor and Rescuer played out within a supervision group
Within a supervision group, the supervisor has the role of facilitator and group members act as supervisees. Ideally, the transactions are Adult to Adult and the supervisor provides feedback and information to supervisees in a direct and supportive manner. Supervisees also receive and send messages from their Adult ego states, and the group exists free from the influence of unspoken or implicit messages. Occasionally, however, hidden agendas occur in supervision groups which may replicate the Drama Triangle. For example, the supervisor may ‘scapegoat’ one of the group members by making jokes or inappropriate comments about his work. Other members of the group may respond by colluding with the supervisor and also begin to persecute the member who becomes the designated group Victim. No matter how accurate or reasonable his comments are, the supervisor and group members make dismissive comments or expressions, such as laughing or rolling their eyes when the Victim speaks. If the designated Victim confronts the persecutory behaviour, he may be ridiculed and his remarks may be taken as more proof of his lack of knowledge. Another group member may attempt to rescue the Victim; in this case, she runs the risk of becoming a Victim herself. Breaking out of this version of the Drama Triangle usually requires the supervisor to acknowledge and name the inappropriate behaviours and facilitate a discussion of the unspoken messages. Other supervisees are then encouraged to identify their part in the game, resulting in clear communication from their Adult ego states. Failing this, if several members of the group are able to confront the game assertively, the atmosphere of the group can become less toxic and more honest. The resulting insights and awareness may then be transferred to work with the supervisees’ clients.
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An example of the Drama Triangle in individual supervision
The Drama Triangle may be played out within individual supervision setting, with the client under discussion being given one role, while the supervisor and the supervisee take on the other two roles. If, for example, a client relates events which seem to show himself at the mercy of other people and events, the supervisee may react to him by taking on the role of the Persecutor or the Rescuer to the client’s Victim. If the supervisor is unable to recognise what is happening, she may try to rescue the client or persecute the supervisee. (Additional suggestions for exercises involving the Drama Triangle are found in Chapter 12.)
Other TA Games within the supervision context Poor me
Beginning supervisees may not recognise the ‘Poor me’ stance when it is presented by clients. The supervisor can assist the supervisee to become aware of the implications of the client’s statements, either through discussion or through role-play, where the supervisee takes the part of the client or the therapist, and the opposite role is taken by the supervisor. The resulting insights often enable the supervisee to continue work with the client with an enriched perspective of the interactions between them. Yes, but…
The ‘Yes, but’ game may also occur between the supervisee and the supervisor. If the supervisor finds herself making numerous suggestions to the supervisee, who says her advice does not work with this client, she may eventually become angry with the supervisee or withdraw from him. The game is ‘broken’ when either party names their feelings and discusses what is taking place between them from the Adult-toAdult position. Ain’t it awful
The supervisee may collude with the client who is playing ‘Ain’t it awful’ by commiserating with him as he complains about the people in his life and claims that he is helpless, or by attempting to ‘rescue’ the client. The supervisor either chooses to ‘name the game’ by
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pointing out to the supervisee what is happening or ‘joins the game’ by agreeing that the client’s problems are caused by other people. Nigysob
This game, ‘Now I’ve got you, you son of a bitch’, occurs when one player has been building up resentment for the second player and waits until the ‘right’ moment to pounce on him for something that often seems benign. For example, the therapist has been feeling annoyed with one of her clients, but has been unable to admit this to herself. Instead, when the client shows up ten minutes late for a session, which is out of character for him, she suggests that his behaviour is irresponsible and narcissistic. The supervisor may agree with the supervisee, rather than challenging her, and they may spend time agreeing that the client is pathological, thus avoiding the underlying issues in the supervisee’s transaction with her client. The supervisor could, on the other hand, challenge the supervisee to explore her seemingly strong reaction to the client’s behaviour in this case and encourage her to explore the feelings triggered in her by this client. Contracting
Eric Berne (1964) defined a contract as an explicit bilateral commitment to a well-defined course of action. The TA contract, based on the belief that we are responsible for our own choices and actions, is defined in more detail in Chapter 4. The contract sets out the reasons for the parties involved wanting to do something, who is agreeing to the contract, the specific actions to be taken and the dates by which they will be accomplished. Use of the contract in supervision
The TA approach to supervision may employ the use of a contract between the supervisor and supervisee. The supervisee discusses which behaviours, cognitions or ‘messages’ she would like to change with her supervisor and then writes a contract, which describes the desired changes in specific terms, as outlined above. The terms of the contract are negotiated between the supervisee and the supervisor via a dialogue between their respective Adult ego states. The contract may include real-plays or ‘homework’ assignments, which are designed to
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reinforce the learning. For example, the supervisee who acknowledges that he often interrupts his clients, may explore this tendency with the supervisor, who has probably already noticed this pattern. The supervisee may real-play his client, with the supervisor acting as the therapist who interrupts him. The supervisee may also contract to ask significant others to give him feedback when he interrupts them, as a homework assignment.
Life scripts, life positions and injunctions Berne (1964) believed that each person creates a ‘life script’ which falls in one of the four life position shown below. The four positions are discussed in relation to supervision below: I’m OK – You’re OK I’m not OK – You’re OK I’m OK – You’re not OK I’m not OK – You’re not OK I’m OK –You’re OK
This position reflects the child’s belief that he is loved and accepted by others and that the world around him is safe. As a result, he also feels good about others and about himself. In the case of a supervisee who sees herself and others as OK, she may have trouble empathising with a client who grew up in an environment that was essentially unsafe, that is, not OK. Supervisees who work with clients using TA’s script work and life positions need to be aware of their own position and life script to keep it from impinging on their work with clients. If the supervisee above role-plays the client’s position, and the supervisor takes on the role of therapist, the supervisee may be able to gain a more empathic understanding of the client’s position. I’m not OK – You’re OK
This position occurs when the individual comes to see himself as unworthy and inferior while he sees those around him as worthwhile. For example, the client who is struggling to feel good about herself (I’m not OK) will not be well served by a supervisee who sees himself as OK, but others as not OK. The unspoken message will be replicated
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in the therapy sessions until the therapist is able to acknowledge the impact of his life position on his clients. Additionally, the therapist who sees himself as not OK will often be afraid to challenge or confront his clients, as they must be OK. The supervisees in both cases can benefit their clients (and themselves) by exploring their life positions, either in supervision or in their own therapy. I’m OK – You’re not OK
This position occurs when the individual sees himself as OK, but all others as not OK. Supervisees who hold this life position will transmit a sense of their own superiority to their clients without being aware that they are doing so. The client may have his worst fears confirmed by his therapist, that he is basically unworthy. The supervisor will need to challenge the supervisee in order to realise the impact of his behaviour and often unspoken attitudes towards his clients. The use of role reversal within the supervision setting can be effective in increasing the supervisee’s self-awareness. I’m not OK – You’re not OK
The fourth position is adopted when the child decides that he cannot trust himself or others. He will feel sad and hopeless and view others from the same perspective. The supervisee who maintains this life position may probably struggle with the idea that therapy cannot help clients, which will then be conveyed to them. He needs to explore his own position in supervision as well as in therapy so its effects will not be passed on to his clients. Berne believed that the life positions were linked to and influenced the formation of each person’s life script. A list of the 12 basic negative injunctions is included in Chapter 4 and described as themes which reoccur throughout our lives. Negative injunctions begin with ‘Don’t’ and continue with messages proclaiming that we are unworthy or should not exist (Stewart and Joines 1987). Supervisees are encouraged to explore their own life positions, scripts and negative parental injunctions in therapy. Supervisees’ exploration of their negative beliefs should be continued in supervision, as and when it impacts negatively on their work with clients.
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TA techniques in supervision Supervision provides a forum for discussing interactions between others using the language of TA. This enables supervisees to gain a clear understanding of the dynamics between their clients and themselves, as well as the interactions occurring with clients in other relationships. It can also be useful for the supervisor and the supervisee to examine the interactions taking place between themselves, if the interactions seem to be replicating behaviours or patterns which are also taking place between the supervisee and clients. Attention to games and rackets is also useful to provide supervisees with an awareness of their own functioning, as well as expanding their ability to work with similar issues which arise in their clients. The TA supervisor may also use any of the other techniques employed in therapy in supervision, although the focus remains on fostering the supervisee’s work with the client. If, for example, the supervisee wants to learn more about working with life scripts, the supervisor may ask her to create her own life script and to discuss it in supervision. The supervisee’s own script work serves two functions: she can learn experientially how to use the approach with her clients and she can also examine how her own script material may be impeding the work with her clients. If large parts of unresolved material are discovered during this process, the supervisee will be asked to explore these issues in therapy. Other TA techniques, such as working with ego state positions and transactions can be explored by using role-plays in addition to discussion during supervision sessions. In this work, the discussion always ends by examining the intersection between the supervisee’s and the client’s material. The supervisee may also be asked to write a contract, in which she agrees to work on specific issues and interactions with her clients.
Role of the supervisor The TA supervisor works as teacher/trainer in collaboration with the supervisee, encouraging him or her to become aware of their respective ego states, their interactions with others and their own injunctions and script messages, both in supervision and in their work with clients. The supervisor is active, giving feedback to and sometimes challenging the supervisee to explore their ego states
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in relation to the client, as well as examining the transactions that take place between the supervisee and the client and, when relevant, between the supervisee and the supervisor. Finally, the supervisor ensures that the interactions in the sessions are conducted Adult to Adult, with both parties able to use the rational language of the Adult to describe interactions and recognise patterns which may impede the supervisee’s work with clients.
Relevance to FIT supervision The flexibility of the TA model enables all three of the FIT domains to be explored in supervision. For example, attending to the supervisee’s Child ego state allows direct access to the ‘F’ for feeling domain. This work can be understood by the Adult ego state, which, in turn, can be used to foster insights from the ‘T’ for thinking domain as to how the supervisee’s feelings may impact on the therapeutic work with clients. The insights gleaned from the Adult can then be used by the supervisee to alter his or her behaviours, utilising the ‘I’ for initiating domain, in order to improve the therapeutic work. Moreover, the Adult ego state allows an exploration of the interactions between the client’s, supervisee’s and supervisor’s various ego states and their impact on the therapeutic work, whether in the ‘F’, ‘I’ or ‘T’ domains.
Summary This chapter has provided a brief review of the beliefs and concepts central to TA. Techniques used in TA have been presented and discussed as they apply to supervision. TA’s relevance to all three of the FIT domains has also been presented. The chapter has also included examples of TA interventions used in supervision.
Chapter 10
Using Gestalt in Supervision
This chapter refers to the Gestalt concepts introduced in Chapter 5, discusses them within the context of Gestalt supervision, and then presents their application within the context of the FIT model. The chapter includes general goals for Gestalt supervision and presents case material demonstrating the theory and techniques applied to supervision. Gestalt concepts discussed in relation to supervision include: •â•¢ conflicting parts •â•¢ the Gestalt view of conflict •â•¢ resistance to contact •â•¢ Gestalt techniques •â•¢ role of the Gestalt supervisor.
Gestalt supervision Because Gestalt therapy is primarily a phenomenological and experiential approach, it follows that Gestalt supervisors make use of these concepts with supervisees. In describing Gestalt supervision in 2003, Yaro Starak states that: Supervision in Gestalt therapy practice is…broadly defined as facilitating the process of the therapist’s response-ability in working with the client or the group. Gestalt therapy supervision then is a here-and-now process that explores the contactboundary between the therapist and the client system for the purpose of enabling the therapist to become more creative and fully alive in the therapy session… The process also brings into 192
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awareness the contact-boundary between the supervisor and the supervisee. What is taking place in supervision has a parallel to what is taking place in the therapy session. Making both processes open to dialogue makes the supervisory relationship lively and more authentic as a learning experience for both parties. (Starak 2003, p.2)
Rather than placing inordinate focus on teaching specific tasks, Gestalt supervision pays attention to the relationship between the supervisor and the supervisee in the current moment and values awareness which arises from this process. In keeping with the Gestalt emphasis on ‘figure’ and ‘ground’, the process of supervision includes the supervisor’s and the supervisee’s experience of their own figure and ground as well as the context of the supervision, which constitutes its own figure-ground (Starak 2003). The skilled Gestalt supervisor must not only be a skilled therapist, but must also be able to work beyond therapy within the supervision session. The supervisor is not only required to interact with the supervisor as expert and teacher regarding the clinical material brought to the session, but must also be able to bring her own person and her experience of the person of the supervisee into the sessions. Because of the parallel processing required in this situation, the supervisor must be able to stand outside the session in progress and be able to examine the whole field. In other words, she must be able to see the trees and the forest present in the current session and its relationship to the trees and forest of the overall supervision sessions. This view of supervision challenges the supervisor and requires her to be flexible and fluid in her approach. In successfully mastering these skills, the supervisor is also able to maintain the sense of excitement central to Gestalt theory and to stay open to the emerging ground within the supervision sessions and to be able to convey this to her supervisee. In describing this process, Starak states that: Altogether, working on many levels and changing field configurations, allows for a vast variation in ways of working with people. The work is always in the present or actual situation. The dialogue can never be the same, never a routine or reduced to a mere technique. Out of the co-created explorations between the supervisor and the supervisee, can emerge a variety of possible solutions leading to new learning, growth and discovery. (Starak 2003, p.5)
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Gestalt’s holistic approach (Polster and Polster 1994) views the individual as a combination of all of their thoughts, feelings and actions; this belief applies to both the therapy as well as the supervision process. The broad goal of Gestalt supervision is aimed at the supervisee’s increased awareness of his subjective experience in order to expand self-understanding, which leads to an enhanced understanding of his work with clients. The changes which take place inside himself impact on and inform his therapeutic work with clients. Because the Gestalt approach is also experiential, it may involve the supervisor suggesting experiments aimed at bringing the supervisee into the present moment, which may focus on the contact between the supervisee/therapist and supervisor, or between the client and therapist.
Gestalt concepts The key concepts in Gestalt theory have been introduced in Chapter 5 and are discussed here as they apply to supervision. Conflicting parts
The supervisee may, for example, be working with a client who is in an abusive relationship. The client’s fears for her physical safety may constitute ‘foreground’ for her, but her need to stay in the relationship because of her family’s values regarding divorce may act as ‘background’. As the two parts of her struggle with these issues, the supervisee brings his own foreground and background to the sessions. If he believes, because of his own values, that staying in the marriage should be paramount for his client, he may ignore her foreground and focus on his own foreground in the sessions with her. According to Perls, Hefferline and Goodman (1951, cited in Polster and Polster 1994) the supervisee’s foreground concerns need to be recognised and dealt with by him before he is able to deal effectively with his client’s needs. The effective supervisor will encourage the supervisee to explore his own internal conflicts using Gestalt techniques in order to enhance the work with his client.
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Unfinished business
Another Gestalt tenet focuses on ‘unfinished business’, described as an aspect of the past which is impacting on the present (Perls 1972). The use of this concept needs careful handling in supervision as it is never a form of therapy. When issues arise in supervision which suggest a need for therapy for the supervisee, a referral process should be triggered so that the supervision remains focused on therapeutic work for the benefit of the client. However, if the client’s own unfinished business is foreground, it will need to be addressed and dealt with. For example, the supervisee may experience difficulty with some groups of clients or some issues which arise in her therapeutic work. If, for example, she has strong feelings or reactions towards either male or female clients, it is likely that she has ‘unfinished business’ with her mother or father. She may decide to do ‘chair work’ with the parent in question in order to explore the part of the past that continues to affect her work with clients in the present. If the issues are not readily resolved, then a referral to therapy is in order. The Gestalt view of contact
As introduced in Chapter 5, the individual is seen as interacting with himself and his environment, which includes but is not limited to other persons (Polster and Polster 1994). Figure 10.1 outlines this process, which depicts the supervisee beginning a therapy session in a state of equilibrium. He may begin to notice that the sun is in his eyes and find himself wanting to interrupt the session to close the curtains which are on the other side of the room. As the client is describing a painful event in her life and expressing intense feelings, he is reluctant to interrupt the session to take care of his own needs. As the sun becomes brighter, he becomes increasingly aware of his own discomfort and begins looking for a solution for his problem which will not interrupt contact with the client. At this point, the contact with the client has already been interrupted, as the sun in his eyes has become his foreground and he is barely aware of what the client is saying. The client ends the session abruptly and the supervisee is left feeling dissatisfied with himself and with the session. In supervision, he explores what has taken place and realises that, if he had attended to his own needs quickly and directly, he could have focused again on the client’s needs. In his next session with the
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client, he discusses what happened the previous week. The client is able to tell him that she felt angry with him because he was not paying attention to her, which had reminded her of all the times her father had ignored her. The client and the supervisee had been acting in tandem by failing to discuss what was taking place in the room. By increasing his awareness of his own needs and his responses to them in supervision, the supervisee was able to initiate an honest discussion with the client, who could also then explore how she often failed to meet her own needs and avoided contact with others. Action Mobilisation
Contact
Awareness Sensation Withdrawal/equilibrium
Satisfaction
Withdrawal
Figure 10.1: Gestalt contact curve
In this manner, the contact curve can be used in supervision to assist the supervisee in exploring ways that he may be blocking contact with a client. For example, the supervisee may describe one of his clients as ‘scary’ and rub his hands against his legs as he speaks about her. As he talks, the supervisor is unsure whether he is describing the client or himself in response to the client. By asking the supervisee to become aware of his own bodily sensations and feelings, he is invited to explore what he is experiencing towards the client. As his feelings come into awareness, he can begin to look at ways to separate his process and experience from his client’s and this process is shown in Figure 10.2.
Using Gestalt in Supervision 197 Discuss in supervision
Awareness
Nervous
Working with client
See client
Good session
Withdrawal
Figure 10.2: Gestalt supervision curve
Resistance or interruptions to contact
One of the goals of Gestalt is to increase ‘contact’ with oneself and with the environment, which includes other people. When environmental conditions change, then contact elements are altered and the individual is challenged to adapt. Contact is increased by using all of the senses: seeing, touching, hearing and feeling and using them to interact with nature and with other people without losing one’s sense of individuality (Polster 1987b, cited in Corey 1991). Resistance to contact takes one of five different forms: •â•¢ Introjection, which involves accepting others’ beliefs without critical thought. We swallow other peoples ideas whole and see them as our own. For example, the supervisee may hold religious or ideological views which were handed down to her in the family, church or school. •â•¢ Projection, which takes place when we disown unacceptable parts of ourselves and assign them elsewhere. The person who is unable to acknowledge anger in himself may see the world around him as angry and hostile. For example, the supervisee may view his client as overly controlling, and this may turn out to be a characteristic of himself.
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•â•¢ Retroflection, which happens when we turn feelings inwards that we would like to express to others. For example, the supervisee may feel a sense of failure about a particular client, and this may reflect their attitude to him or her. •â•¢ Deflection, which occurs when we use humour, sarcasm or activities to distract from our own experience. The supervisee may engage in intellectual discussions and observations in order to deflect or avoid confronting uncomfortable feelings. •â•¢ Confluence, which takes place when we are unaware of the boundaries between ourselves and the environment. The supervisee may have a tendency to blend in with other people, expressing their thoughts and beliefs as their own, and displays an exaggerated need to be liked and accepted and will avoid conflict at any cost. In the example presented in Figure 10.2, the supervisee may use any of the above blocks to contact in order to avoid becoming aware of his own experience. He may, for example, project his feelings of anxiety towards the client onto her. By telling himself that she is a very fearful person, his own anxiety remains out of his awareness, and hers is not dealt with. He avoids taking responsibility for his own experience and misses the opportunity to separate his own fears and concerns from those of the client, and to then work with her concerns in the therapy. The supervisee might also use deflection, that is, discussing extraneous subjects with the client, in order to avoid his own and ultimately the client’s anxiety. Supervision offers the supervisee the opportunity to sit with his own feelings, to allow them to come into his awareness, to acknowledge them, to reflect on the ways he avoids contact with himself, and to explore possible alternative reactions. This process then frees him to be in immediate and genuine contact with his client. The Gestalt supervisor may encourage the supervisee to recognise and deal with his resistance. For example, the supervisee described above may avoid or resist challenging a client. Perls (1972) advocated working with the resistance, rather than avoiding it. In this case, the supervisor might ask the supervisee to describe all the reasons that he ‘shouldn’t’ challenge the client, as a way of going with, rather than fighting the resistance. Once the disowned feelings have been
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expressed and given permission to speak, they recede into the supervisee’s background and the next issue, whether the supervisee truly needs to challenge the client, becomes foreground. The various forms of resistance can be addressed in supervision through the use of Gestalt techniques. Gestalt experiments, such as ‘letting the body speak’, ‘exaggeration’ and ‘empty chair work’ may feature in FIT supervision and are discussed below. ‘Parts work’, which compares the supervisee’s foreground and background experience, may take the form of a dialogue. When the two opposing parts or polarities are recognised, the supervisee is able to see both parts, and to work towards moving beyond the impasse or ‘stuck’ point. By using the body as a resource, the supervisee may also become aware of disowned feelings. The supervisor might point this out by saying to the supervisee, ‘You say you are not angry with the client, and yet I notice that you are rather breathless when you speak about him.’
Gestalt techniques applied to supervision With the exception of Gestalt dream work, all the Gestalt techniques introduced in Chapter 5 may be utilised in supervision. Examples of each of these techniques are given below: The empty chair
This technique can be employed to facilitate the supervisee’s awareness of their feelings and reactions in relation to their client. These reactions are what other approaches refer to as countertransference. ‘The empty chair’ is used to encourage the supervisee to sit in one chair to express one feeling and then to move to another chair to express another feeling or viewpoint. Perls often asked supervisees to put their ‘top dog’ or critical part in one chair and to put the ‘under dog’ or frightened part in another chair. Asking the supervisee to play the client and then to change roles to play themselves can enhance the supervisee’s awareness of the client’s issues. These can then be discussed in supervision in order to explore the intersection of the supervisee’s feelings versus the client’s material. Real-plays can also be ulitised to foster awareness in the supervisee of the client’s issues.
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Letting the body speak
Body awareness may be used in Gestalt supervision to identify the (possibly disowned) feelings which your supervisee may have about the client relationship. ‘Letting the body speak’ includes asking the supervisee, who is smiling through clenched teeth as she talks about the client, to let her teeth speak. Gestalt supervision also uses the therapist’s experience in the present moment as a way of recognising feelings or beliefs which are out of their awareness. Awareness exercises often begin with the sentence ‘I’m aware that…’ and continue with descriptions of whatever comes to mind in the supervisee. The exercise often shifts the supervisee from thinking about feelings in the past to experiencing them in the present. For instance, the therapist may recall how she herself felt while working with a particular client, rehearse this in supervision, and judge its appropriateness for communicating with the client. Another body awareness technique encourages the supervisee to take the role of the client and adopt their bodily posture, gestures, facial expressions and vocal style. This enables the supervisee to really experience the likely feelings of the client. Exaggeration
‘Exaggeration’ may be used with the supervisee who speaks very calmly about their frustration with the limit on sessions allowed for their clients. You may ask your supervisee to say the sentence again, only louder to exaggerate their feelings about the system and those who administer it. Repeating the sentence with more and more volume, speed or language is used to create congruence between the words and the tone of voice which carries the emotion of frustration or even anger with the situation. Complete reverse
This idea is based on Perls’ belief that if something is important to an individual then its opposite must also be significant. ‘Doing the opposite’ may involve asking your supervisee to speak more slowly or more softly than they normally would and describe what happens. The intent of the exercise is paradoxical, in that it enables supervisees to become aware of feeling and thought that they may have repressed.
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‘What’ and ‘how’ versus ‘why’
This technique involves encouraging supervisees to describe their feelings and experiences subjectively and to talk about the effect on them, rather than trying to analyse them. The supervisee might be asked to make a statement starting with, ‘I’m aware that…’ ‘I’ versus ‘they’ or ‘it’
The supervisor encourages the supervisee to speak from a personal reference point and to ‘own’ their experiences, rather than attributing them to others. The supervisor who says, ‘It bothers me when…’ might be encouraged to say, ‘I’m bothered by…’ The supervisee who says that the client makes him angry might be asked to say something like, ‘I feel angry when she…’ and to then explore how he feels rather than projecting it onto the client. Speaking in the present versus the past tense
Encouraging the supervisee to speak about an event which happened in the past as if it were happening now is aimed at creating immediacy. The supervisee who says that he felt annoyed by the client might be asked to say, ‘I feel annoyed with her’ and then to explore his feelings in the present, rather than distancing himself from them. Expressing feelings versus talking about feelings
The supervisor encourages the supervisee to experience feelings, rather than discussing, analysing or explaining them. The use of first person, present tense statements, such as ‘Right now, I’m feeling…’ helps to facilitate the supervisee’s awareness of his subjective experience.
The Gestalt supervisor’s role The Gestalt supervisor is active and dynamic and emphasises the importance of the relationship between the supervisor and supervisee in the here and now. The supervisor brings an awareness of his own experience to the sessions, which serve as background, and models the use of congruent dialogue for the supervisee. The supervisee uses the sessions to explore and express her own feelings towards clients and to explore the impact that they may have on clients. This process
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forms the foreground of the supervision sessions and encourages the supervisee to move past stuck-points in order to work more effectively with her clients. Although Gestalt theory supports the humanistic belief in unconditional acceptance of the supervisee, when using Gestalt in supervision the supervisor may often be more challenging than a person-centred supervisor. He may use his own thoughts and reactions to inform the work with supervisees, and may express his personal reactions to what they are saying. He may also suggest ‘experiments’, such as the use of the empty chair to encourage a dialogue between the supervisee’s conflicting parts. He might also point out the supervisee’s body language and ask her to exaggerate it to lead to insight, which is then used to inform work with clients. Criticism of the approach suggests that it can be experienced as overly confrontational, although it is more supportive and less directive that it was when practised by Perls. However, some critics of the approach believe that the emphasis on the here and now tends to devalue cognition and may hinder a supervisee’s rational assessment of situations.
Case study using Gestalt in supervision The supervisee in this composite case study is a therapist who is working with clients who abuse alcohol and drugs. Management supervision is in-house, and I am an external clinical supervisor. I have a strong relationship with this supervisee having worked with him during his training placement, and the relationship is now continuing as he takes up a responsible post with a drug and alcohol charity. My supervisee brings a case which is troubling him. The client reports that he is, as required, ‘clean’, meaning that he has not been using drugs or alcohol. The work begins well with a reported therapeutic connection between my supervisee and his client, with significant progress being achieved.╇ As an ex-user himself, my supervisee has begun to recognise the signs of drug use and has become suspicious that his client is using again. This would mean suspension of his treatment and, therefore, the relationship with my supervisee. So there is a dilemma between my supervisee’s wish to maintain a relationship and continue therapy with the client (the foreground or top dog), against the regulatory framework of the charity (the background or under dog).
Using Gestalt in Supervision 203 A combination of chair work, exaggeration and letting the body speak can be illustrated by this case study. First, we identified the dilemma and the ‘stuck’ feeling being experienced by my supervisee who was torn between his regard for his client, his deep respect for the progress already made, and his duty to the charity which employed him. Three chairs were employed in this exercise with one for each ‘horn’ of the dilemma and another for the relationship now at risk. My supervisee took each chair in turn, allowing himself to become the ‘part’ so that his body took on, first, the upright hopeful sense of his commitment to his client, then the drooping, rather hopeless shape of his ‘duty’, and then the bouncing up-and-down nature of the relationship. This last was the most surprising as he found a wealth of energy within the relationship chair which he didn’t realise was available. In each chair my supervisee was encouraged to exaggerate and let his body speak, so that from the first chair, he sat up straight, smiled and held his head up with real satisfaction with his client’s progress; from the second he physically folded up and became small; from the third he began to move about and then stood up and punched the air, voicing his determination to ‘deal with this’. He chose to work from the third chair and rehearsed how he would confront his client, explain his dilemma, and together they would decide on what to do.
Resolution of conflicting parts is possible when the opposing parts are recognised and integrated. The parts of the self that have been ‘disowned’ are eventually ‘reowned’, allowing the current Gestalt to close.
Relevance to FIT supervision Gestalt’s emphasis on awareness of both process and content, within the therapeutic as well as the supervisory sessions, make it well suited for use in conjunction with the FIT model. Additionally, Gestalt’s focus on feelings links it to the FIT model’s ‘F’ domain and facilitates the exploration of the client’s and the supervisee’s experience in the present moment. Gestalt’s emphasis on the relationship also provides a framework for exploration of the client’s, the supervisee’s and the supervisor’s interactions with each other via any of the techniques described above.
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Summary This chapter has presented the use of Gestalt theory and techniques in supervision. Gestalt relies on an understanding of relationships as based on Buber’s (1994) ‘I–Thou’ relation, where dialogue recognises the whole of the other, rather than the ‘I–It’ relation, which objectifies the other. This awareness can also be applied to a supervisee’s relationship with the supervisor, using Gestalt techniques which enables a dialogue which honours the supervisee’s whole person and recognises all the ‘parts’ he bring to his work. The method focuses on feelings in the present and uses the strength of the here and now to promote learning. Gestalt approaches are used in FIT supervision to address the feeling domain (F) and the thinking domain (T).
Chapter 11
using cognitive behavioural therapy in Supervision
This chapter discusses supervision within the context of CBT. Contemporary CBT addresses all three of the FIT domains, feeling, initiating and thinking, which are applied to the practice of supervision, as described in this chapter. Some of the goals and tasks included in supervision are also presented and CBT’s basic assumptions and techniques are reviewed before discussing them in relation to supervision. The chapter concludes with case study material illustrating the use of CBT in supervision.
CBT supervision’s focus on skills and process Although CBT supervision reflects its emphasis on a skills- and competency-based model, it also includes attention to the relationship between the individuals involved and the supervisee’s ability to process interactions between himself and his clients. Skills-based supervision
The skills aspects of supervision are highlighted by Helen Kennerley (2010) whose model focuses on competencies and skills. The trainee supervisor must know how to draw up contracts and goals with their supervisees, how to structure supervision sessions, how to evaluate their supervisees and how to give them feedback. In order to achieve this, the CBT supervisor must be competent and knowledgeable with all aspects of CBT and able to impart her skill and expertise to her supervisees via demonstrations and discussion. The supervisor is expected to be able to give appropriate feedback to
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the supervisee, which includes a discussion of his skills, competencies and shortcomings. The supervisor should be able to convey this information tactfully and be supportive, and to express it in specific, behavioural terms. Additionally, the CBT supervisor needs to be able to impart direct experience of various models to the supervisee by using practical assignments, such as role-plays, behavioural experiments and the completion of Thought Record Sheets as part of the supervision process. Discussions of the supervisee’s ability to present case studies also form a part of CBT supervision. The supervision process is often structured to include and reflect the practice of the CBT model (Centre for Outcomes Research and Effectiveness (CORE) 2007). Process-based aspects of supervision
Cognitive behavioural therapists are increasingly aware of the importance of the relationship as a facilitator of change (Corey 1999). This increased awareness is also reflected in the supervisory relationship, which includes asking the supervisee to talk about his feelings regarding his clients and the supervision process. This work is often done alongside skills-building in supervision. For example, the supervisee may be asked to role-play one of his clients and realise during the process that the experience has evoked rather strong feelings in himself. This will usually increase his empathetic understanding of his client. The CBT supervisor may ask him to role-play himself as the therapist with the supervisor as client. Given feedback from the supervisor, he may realise that his manner or approach may trigger strong reactions in the client; the insights gained from the experience will assist him in improving his practice.
Techniques involved in CBT supervision With its emphasis on skills as well as process, the CBT supervisor engages in a dialogue with her supervisee, discussing CBT concepts and techniques, as well as working experientially with CBT techniques. This takes place both during the sessions, via role-plays, and outside the sessions through homework assignments. When assignments take place outside the supervision session, they are processed by the supervisor and supervisee during the next session. Such assignments are used to foster increased awareness of the supervisee’s own negative
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thought patterns and to explore how these may affect his work with clients. The supervisor’s role is active, giving the supervisee feedback as to his performance as well as asking him to discuss the experience itself in terms of how he feels about his performance of the assignments and how he feels about himself in relation to the supervision process. For example, the supervisee may be asked to write out his own negative automatic thoughts (NATs) and to link them to thinking distortions. If the supervisee’s belief system is faulty or overly critical, he will experience a negative self-image and feelings of low self-worth. These beliefs will, in turn, be conveyed to his clients and will interfere with the effectiveness of his work with them. This approach focuses on identifying, targeting, and then working to change NATs. The supervisor encourages the supervisee to recognise the thoughts which lead to feelings of low self-worth and learn to systematically challenge them. With increased awareness, he will then be able to replace negative thoughts with positive ones, which leads to corresponding changes in feelings and behaviours, and to improvement in his work with clients. When using CBT in supervision, the FIT supervisor’s role is that of teacher, trainer or coach. The supervisor is typically active, making suggestions to the supervisee in order to foster change. Rather than focusing primarily on feelings or behaviours, in the ‘T’ or thinking domain, the supervisor helps the supervisee to identify negative thoughts and reactions, as well as the events that trigger them. The FIT supervisor challenges the supervisee to alter his negative thoughts and replace them with effective or constructive thoughts. Behaviours are seen as a by-product of recurring thought patterns, and the supervision will focus on behaviour changes as and when they are brought about by the supervisee’s cognitive work.
Changing negative automatic thoughts in CBT supervision The supervisee is convinced that he is unable to assist his clients as he ‘is not good enough’. The supervisor suggests that this may be seen as a belief about himself, which forms part of a wider NATs pattern, which the supervisee is asked to explore. He agrees to listen to his internal dialogue in order to identify
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The assertiveness model The FIT supervisor may wish to employ the use of assertiveness training with supervisees, who may, in turn, use it with their clients. The model, introduced in Chapter 6, involves teaching the differences between assertive, passive, passive aggressive and assertive behaviour. Assertive behaviour involves recognising, expressing and protecting one’s rights in a clear, direct manner, without becoming aggressive, passive or passive aggressive (Alberti and Emmons 1986).
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Examples of each of the behaviours
Your supervisee telephones to cancel their session five minutes before it is due to begin. Your contract states that cancellations are only accepted up to 24 hours before the session. Aggressive response: ‘Well, it’s too late. You’ll just have to pay for the session.’ Passive response: ‘Don’t worry. See you next week.’ You may feel angry or resentful, but don’t say it. Passive aggressive: ‘I don’t care. It’s your session you’re missing.’ Assertive response: ‘I’m afraid you will have to pay for this session as you did not cancel it in time.’
Use of assertive techniques in CBT supervision The supervisee, in this case, is a trainee therapist who comes to supervision feeling very dissatisfied about her work with one of her clients. She states that the client intimidates her and interrupts her constantly. One of her major concerns is that the client is unwilling to leave at the end of sessions, which often go beyond the agreed ending time. The supervisee wants to be ‘firmer’ with the client and agrees to learn assertive techniques towards this end. The supervisor explains the difference between aggressive, passive and assertive behaviours and gives examples of each.The supervisee role-plays a session with the client, demonstrating both passive as well as aggressive behaviours, and is then asked to practise assertive communication. The supervisor plays the role of the client to demonstrate possible reactions to the supervisee’s new responses and then switches roles, giving the supervisee a chance to speak as the client.╇ After several rounds of trying out different responses, the supervisee states that she feels more confident. In her next supervision session, she relates that she was able to express herself with her client more clearly, and that the sessions are now ending on time.The key behaviour in this example is discussed in detail below.
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CBT supervision including the ‘F’ domain The focus of CBT supervisors is weighted towards cognitive and behavioural patterns, reflecting the belief that people are able to affect change from within, without the help of extensive, long-term work. Increasingly, however, CBT and supervision attend to feelings as they arise during sessions. Although the supervisee’s emotions about the material brought to the supervisor are not explored in depth, they do form a part of the supervisory process. FIT supervision, while using CBT methods, includes the feeling domain, which is demonstrated in the example below.
Example of CBT approaches to FIT supervision including all three domains The supervisee has a case presentation which he is very nervous about. He relates that he ‘always’ feels very anxious when speaking in front of a group. He predicts that he will do poorly on the presentation, which represents the activating event (A) in rational emotive behaviour therapy (REBT), and that his tutor and classmates will be disappointed in his performance, which represents (B) or belief system. The supervisee is convinced that, as a consequence (C), the presentation will be a disaster and prove that he is a complete failure. The supervisor encourages him to examine the NATs underlying this belief, that is, his conviction that he ‘always’ feels nervous and anxious (globalising), and that he will do poorly with dire consequences for his counselling career (awfulising and catastrophising). In FIT supervision, exploration of the supervisee’s beliefs (B) will consider consequences (C) and conduct a reality check on them, so that the supervisee may realise that a poor presentation may not be a complete disaster. He has already witnessed several rather poor presentations by his classmates, and they have lived to tell the tale (D for disputing). So the next step is formulating some positive and effective beliefs (E).
The FIT supervisor will ask their supervisee to monitor and record their thoughts and feelings, in order to facilitate positive change. An example of such a log or diary, adapted from Greenberger and Padesky (2005) is provided below.
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Thought Record Sheet 1. Situation: the supervisee is asked to describe who they were with, what they were doing and where they were, and when the situation occurs. 2. Feelings/moods: the supervisee describes each mood in one word and rates the intensity of the feeling, from 0 to 100 per cent. 3. Automatic thoughts/images: the supervisee is asked to answer questions such as: •â•¢ What is going through my mind immediately before I started experiencing this feeling? •â•¢ What does this say about me? •â•¢ What does this say about my future? •â•¢ What am I afraid could happen? •â•¢ What is the worst thing that could happen to me? •â•¢ What memories are associated with this situation? 4. Evidence supporting the ‘hot’ thoughts from point 3 is circled in red. Supervisee writes ‘factual evidence’ to support the beliefs. 5. Evidence disputing the ‘hot’ thoughts involves the supervisee questioning whether or not the thought is completely true. 6. Alternate/more balanced thoughts are created by the supervisee, who is asked to rate the strength of the new belief from 0 to 100 per cent. 7. Current mood or feeling is rated by the supervisee, including the feelings described in point 2 as well as new feelings which may have arisen from 0 to 100 per cent. The supervisee fills out the Thought Record in his own time and then explores his answers with the supervisor, in order to create more constructive thought patterns: the D and E mentioned earlier.
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Additional CBT techniques The above scenario can also be addressed via the use of two additional CBT techniques, namely visualisation or imagery and deep muscle relaxation. For example, the supervisee who is anxious about a presentation may be asked to take an imaginary journey to the day and time of his presentation. He is encouraged to describe the scene, with his tutor and classmates watching his performance. He remains in this imaginary place while he slowly relaxes his body from the tip of his toes to the top of his head, letting go of the tension he is carrying. For this, the supervisor uses a quiet, slow voice and includes long pauses. When he is judged to be relaxed, a new idea is presented to the picture in his mind, images of his successful presentation, stepby-step, as he proceeds to deliver his talk without fear or anxiety, but feeling confident and relaxed. He can also continue the visualisation, ‘seeing’ himself as succeeding, with tutors and classmates applauding and congratulating him, and feeling good about himself.
The CBT supervisor’s role The CBT supervisor acts as instructor, trainer and role model. The supervisor is actively engaged with the supervisee, making suggestions to the supervisee as to how the work with clients can be improved. The supervision sessions are flexible, at times focusing on teaching skills and techniques, at other times practising and demonstrating the skills, and sometimes processing the feelings which are evoked in the supervisee by the sessions.
Summary This chapter has linked supervision to the CBT model and presented practical applications of the techniques with supervisees. CBT’s increasing involvement with the three domains of human functioning has also been highlighted and linked to their application to the FIT model of supervision. The chapter offered examples of how cognitive and behavioural approaches may be used in supervision based on our supervision practice.
Chapter 12
Using the FIT Model for Individual Supervision
This chapter discusses the use of the model in providing one-to-one supervision to experienced therapists as well as to trainee therapists. The model demonstrates its integrative approach, with an emphasis on the humanistic ethos, as well as dealing with the three domains of functioning: feeling (F), initiating (or acting) (I) and thinking (T). The chapter also includes the psychodynamic concepts of transference and countertransference, in that supervisees will be asked to consider the feelings they experience towards their clients, as well as the impact of their clients’ feelings towards the therapist (Corsini and Wedding 2008). The TA concept of contamination, where the feelings experienced by the supervisor and the supervisee may impact on the therapeutic work is also considered (Stewart and Joines 1987). Examples of supervision sessions illustrate how the FIT model can be used when working from three psychological approaches applied together to form an integrative approach to the therapeutic work as well as to supervision. The three different approaches used for these examples are: •â•¢ TA, which focuses on feelings, initiating and thinking •â•¢ Gestalt, which deals with feelings, initiating and thinking •â•¢ CBT, which addresses behaviours and cognitions. Also included are examples and composite case studies to illustrate how the authors use the model to provide individual supervision.
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Supervision using FIT A supervisor using the FIT model should be able to: •â•¢ acknowledge the issues, use active listening skills to identify major concerns and areas of focus for the supervisee •â•¢ introduce the FIT model, explaining and exploring applications to the supervisee’s situation, using the three domains of feeling, initiating and thinking •â•¢ use the model to explore possible therapeutic approaches with the supervisee relevant to each domain •â•¢ agree a contract, discussing the initial focus of the model, goals, targets and renegotiation process within supervision sessions •â•¢ provide a framework for exploring the supervisee’s transference and countertransference and ‘contamination’ issues •â•¢ assess progress, continuously renegotiating and recontracting as required •â•¢ use a range of supervisory skills including, active listening, restating, empathy, questioning, summarising, challenging, confronting, asserting, immediacy, transparency and role-plays. The supervisor working with the FIT model attends to the three domains within the sessions and presents this process openly to the supervisee. At this point, the supervisee will be aware that ‘F’ denotes emotions, affect and feelings, ‘I’ represents initiating, actions and behaviours and ‘T’ includes cognitions, thoughts, ideas and self-talk. The model provides a framework for structuring the supervision sessions. It also provides a focus in the sessions, by identifying the supervisee’s issues and the client’s issues as they relate to each of the domains. In addition the model may be used to consider each of the three roles under consideration in supervision, namely the supervisor, the supervisee and the client whose FIT elements may be individually addressed. This triple FIT process can be seen in Figure 12.1.
The FIT Model for Individual Supervision 215 Client Feeling (F)
Initiating (I)
Thinking (T)
Supervisor
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Feeling (F)
Feeling (F)
Initiating (I)
Thinking (T)
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Thinking (T)
Figure 12.1:The Triple FIT
Each triangle represents the FIT diagram for each of the following: •â•¢ client •â•¢ supervisee •â•¢ supervisor. This allows the model to function both interactively and introspectively. It can be applied to the current interaction during supervision between the supervisee and their supervisor. In addition, both the supervisor and supervisee bring awareness of and apply their own FIT triangle to the supervision process. The client’s triangle is described by the supervisee and then explored by the supervisor and supervisee. These insights are then used to inform the therapy sessions with the client. Hence, the sessions include three working examples of the model (even though the client is not present) as well as the overall framework of the supervision session which utilises the model. The diagram places the client foremost as the focus of the supervision session, while establishing clear boundaries between all three participants in the process. The diagram is a map of what needs to be considered in supervision and by whom. The focus for
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the session is agreed between the supervisor and the supervisee. In particular, the area of functioning, that is, feelings, action or thinking is negotiated in the session between the supervisor and supervisee, just as it would be between the client and the therapist. For example, if it appears that the supervisee’s feelings towards the client are affecting their work, then the session will focus on the supervisee’s ‘F’ domain. This may lead to an exploration of the supervisee’s countertransference issues with the client, which are then explored using the ‘T’ or thinking domain. Alternatively, if the supervisee realises that they tend to give advice to the client, then the session may focus on the supervisee’s actions, their ‘I’ domain, as well as the need to rescue clients (F). This may be useful in identifying the client’s role as a victim and the behaviours (I) which elicit this response from the therapist as well as others. Furthermore, if the supervisee and the supervisor realise that they are colluding in the session by judging or criticising the client, then the session needs to focus on their shared assumptions, their joint ‘T’, which in this case is comparable to TA’s Critical Parent voice. In such cases, contamination of the supervisor’s and supervisee’s Critical Parent states needs to be identified and disentangled.
Examples of supervision using FIT Examples are presented below which use the FIT model to address common issues in supervision. The supervision session
The supervisee is a therapist who is a master’s level trainee and comes to supervision feeling a bit overwhelmed by the various issues presented by a client. The client relates in therapy that he is having problems with his boss and may, as a result, lose his job. He says that he has lost two jobs in the past because his ‘bosses were impossible to get along with’. He also states that, because of the increased stress at work, he is having headaches, has been ‘drinking more’ and is having ‘frequent arguments’ with his wife who has told him that unless he ‘gets help’ she is considering leaving him. He is frustrated because, from his perspective, she fails to understand the nature of his ‘problem’, and that she isn’t supporting him. The client reports that
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he is willing to come to therapy to stop his wife from leaving him, but doesn’t see that he has issues to work on in the sessions. Before looking at how the supervisee might work with the client, the supervisor invites her to consider and explore her own triangle, in order to begin familiarising her with the model and to begin establishing trust. This process includes asking the supervisee to discuss her feelings (F), actions (I) and thoughts (T) in relation to the client. For example, the first question put to the supervisee is as follows: Supervisor: What are you aware of right now in terms of your feelings, actions and thoughts towards this client? Supervisee: I’m aware that I’m annoyed with him. The Supervisor responds in person-centred mode, reflecting back the supervisee’s feelings. The next question assumes the supervisee’s understanding of the model. Supervisor: Which of the three domains would you like to focus on in this session? Supervisee: I don’t like the client and then find myself feeling guilty for feeling that way towards him (F). I also find myself judging him (T) and wanting to change his behaviours (I). Supervisor: So where would you like to focus; the feeling, the judgement or the desire to change the client? Supervisee: I think that what’s getting in the way of my work with this client is my dislike of him. I believe it is keeping me from working effectively with him. Supervisor: So you’re concerned that your feelings of dislike for your client may be affecting your work with him. Are you saying that you would like to focus on your feelings in relation to this client? Supervisee: Yes, that sounds helpful. There’s something about him, about the way he speaks or maybe it’s the tone of his voice, that sounds whiny or moany. He also blames everybody else for his problems. I get annoyed with him and have trouble focusing on what he’s saying. Supervisor: Tell me more.
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Thereafter the session proceeds along the direction which is chosen by the supervisee and may include personal issues like, for example, a memory of the supervisee’s relationship with their father: Supervisee: You know, I think the problem is this client reminds me of my father – there’s a voice in my head saying he’s a bastard. He blames and uses other people just like my father did and then complains about the outcome. At this point, the supervisor offers the supervisee a range of possible methods to work with this issue, for example TA, Gestalt methods and CBT applications. In the example, the supervisee chooses to work with a TA approach in supervision.
FIT supervision in TA mode Now let us consider the supervisee’s choice as TA which includes inner child work. The supervisee is fully aware of TA terminology, for example ego states and scripts, contamination, and so on. (The work here is similar to Gestalt chair work, but has been included in this section because it uses the language of TA.) Supervisor: Are you aware of an internal dialogue in relation to this case? Supervisee: Yes, it’s my mother’s voice (Critical Parent) saying to my father, ‘You’ll never be any good; you’re irresponsible; you blame everyone else for your problems.’ My father’s voice says, ‘You don’t know how hard I work, you never try to understand me.’ Supervisor: Which voice are you identifying with? Supervisee: My mother – I guess it’s my Critical Mother’s voice controlling the session with this client. This statement indicates that the supervisee has moved into her Adult ego state. Supervisor: What is your Adult saying now? Supervisee: I’ve been judging the client and not listening to him properly because of my own Critical Parent messages which
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have been contaminating my Adult. My Adult hasn’t been present for the client. My inner child is anxious and frightened; that’s all I can focus on. Supervisor: What happens to your Child in this case? Supervisee: She feels frightened by the dialogue between her parents’ voices. Supervisor: What does that Child need? Supervisee: To feel safe – to know they won’t leave her. Supervisor: You need to hear a loving Parent saying ‘I’ll never leave you.’ The TA approach has given the supervisee an increased awareness of her inner dialogue – the critical mother and father in her head – and is able to operate from the Adult as well as looking after her own Child. Asking the Child explicitly what she needs begins the process of reparenting herself and creating her own internal Nurturing Parent. The supervisee may decide that she needs to do more work on these aspects of herself and may want to continue exploring them in her therapy.
Contaminated boundaries F Client
F I I
Supervisee
T
F T I
Supervisor
T
Figure 12.2: FIT diagram showing contaminated boundaries
For the direction and focus of the therapy session to remain clear, the therapist needs clarity regarding their own boundaries. The FIT model is useful in identifying areas of overlapping boundaries between the supervisor and supervisee, as well as between the client and therapist (supervisee). FIT takes into account the feelings, actions and thoughts
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of all three parties and can therefore reveal shared assumptions or biases. Figure 12.2 illustrates an example of three-way contamination, when boundaries are blurred between the client, the supervisee and the supervisor. This situation arises when at least two participants – between client and supervisee, supervisee and supervisor or client and supervisor – are hooked by the same issue or feeling.
Contaminated and uncontaminated supervision examples The next section provides two examples of contaminated supervision; in the first instance the supervisee’s view of the work with a client is unclear, while in the second example both the supervisee and the supervisor are contaminated by their own biases towards the client. The third example illustrates supervision that is clear or uncontaminated by the supervisee’s or the supervisor’s own material. In each of the examples provided, the client referred to is an imaginary woman, who comes to therapy seeking to improve her relationship with her husband. She relates that since her marriage eighteen months ago, her husband has become increasingly critical of her, complaining about her cooking, her housekeeping and the fact that she has gained weight since they married. She is anxious to please him and find out in therapy what she is doing wrong or indeed what’s wrong with her. Example 1: Client/supervisee contamination
Before looking at how the supervisee might work with the client, the supervisor invites the supervisee to consider and explore his own triangle, his feelings (F), actions (I) and thoughts (T) in relation to the client and, possibly, his supervisor. For instance, the first question put to the supervisee is as follows: Supervisor: What are you aware of right now in terms of your feelings, actions and thoughts? Supervisee: I’m concerned about the marriage. Her husband sounds really fed up and I think he might leave her. Supervisor: What will you do with your concerns?
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Supervisee: Well, I want to tell the client to be more understanding and nicer to her husband. The supervisor suspects that the supervisee may be overly identified with this client, which leads to the following dialogue. Supervisor: Are you aware of a feeling connected with that? Supervisee: I feel that she should consider ways to accommodate his needs. Supervisor: Could you give me a feeling word describing how you feel right now? Supervisee: Er…er… Well I’m confused – I thought I was answering your question. Supervisor: I’m not sure if you’re talking about thoughts or feelings. Is it OK with you if we focus on feelings now? Supervisee: Yes, of course. Supervisor: You said that you felt confused. Can you tell me more about feeling confused? Supervisee: Well, it seems to me that he has needs – if she can meet those needs, their relationship will improve. Supervisor: Are you saying that you think she should meet his needs? When you say that, your voice is raised and you sound perhaps a bit annoyed. Supervisee: Yes, I don’t think you understand what I’m saying. Supervisor: You’re annoyed because you think I haven’t understood you? Supervisee: Yes. Shouldn’t she be concerned about her husband’s needs? Supervisor: So you’re feeling put out with me because I don’t seem to agree. Supervisee: Yes. I am a bit frustrated. Supervisor: Me, too. Would you tell me what that’s like for you. Supervisee: Well, you seem to be on her side.
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Supervisor: You’re annoyed with me because I seem to be taking her side? I’m feeling a bit put out because you seem to be taking his side. (Having said this, the supervisor decides to ‘park’ her feelings and keep the focus on the supervisee’s reactions.) Supervisee: [silent] …Maybe I have been affected by my own problems at home. Supervisor: Ahh…so when you hear her ‘complaining’ it triggers some feelings in you? Supervisee: Yes, I think it does. The supervisee then explores his feelings of frustration towards his own wife. He has been experiencing difficulties in his own marriage and finds himself siding with the client’s husband. After expressing and clarifying his feelings, he is able to take the insights gained back to his work with the client and to hear her concerns more objectively. Example 2: Client/supervisee/supervisor contamination
The contaminated version
The therapist/supervisee is, in this case, a woman. She is seeing the same client as in Example 1 and is currently encountering the same problem with her own husband, who is critical of her. Supervisor: What are you aware of right now in terms of your feelings, actions and thoughts? Supervisee: I want her to stand up to him. Supervisor: Yes, I agree – how can we help her? Supervisee: I thought of assertiveness training. What do you think? Supervisor: Good idea! I’ve got a book on it that I can lend to you. Neither the supervisor nor the supervisee has recognised their biases and have moved into problem-solving mode (I). Neither of them is aware of their Critical Parent voices, blaming the client’s husband for the client’s unhappiness. Unexamined, this scenario could develop into a version of TA’s Drama Triangle, with the supervisor and supervisee acting as Rescuers, putting the client in the Victim role and the husband in Persecutor role. The client’s deeper issues are left unexplored, and she has not been given a choice in the decisionmaking process, for example the direction her therapy takes.
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Example 3: Uncontaminated supervision
The uncontaminated version
The case is the same as before with a client who comes to therapy saying that her husband is critical of her. Supervisor: What are you aware of right now in terms of your feelings, actions and thoughts? Supervisee: I am really annoyed with her husband (F), I want to rescue her (I) and I am aware that this is probably not a good idea (T). Supervisor: Which of those three domains would you like to focus on now? Supervisee: I am aware of feeling very angry with her husband. I’d like to work on that. Supervisor: Would you tell me more about that feeling? Supervisee: Well, it’s a kind of fury with men who behave like that. They remind me of my father, who is a lot like my husband. He’s been really critical of me lately. Supervisor: You feel very angry with men who behave like your father and your husband. Supervisee: Yes. I know this man is not my father or my husband, and I don’t want my feelings to interfere with my work with him. Supervisor: What direction would you like to go now? Towards your feelings about your father or towards your work with your client. (The supervisor is asking the supervisee to choose the domain to focus on in the session.) Supervisee: I know this stuff about my father. I’m working on it in therapy, so I want to look at how my feelings stop me from working effectively with this client. Supervisor: How do you see your feelings about your father getting in the way? Supervisee: I want to advise her to leave him before she gets hurt. Supervisor: You are afraid she will be hurt?
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Supervisee: Yes, I don’t want her to be hurt like I was. Supervisor: Where shall we go now? Some options are chair work, voicing your Critical Parent, or something else? Supervisee: I need to rehearse how I will work with her. Supervisor: Would you like to be her while I take your role? Supervisee: Yes, that sounds useful. And then, I’d like to be the therapist and have you take on her role. Supervisor: OK. In this case, the supervisee is aware of her feelings (annoyed) about the case, and her tendency to act (rescue) and her thoughts (not a good idea). The FIT model allows her to choose where to focus, and she chooses to examine her feelings towards her client’s husband. This avoids the likelihood of contamination because she articulates her feelings rather than acting on them without reflection. The supervisor is aware that she could collude with the supervisee in blaming the husband and resists joining in on the blaming. Instead, the supervisor offers the supervisee the chance to reflect on her internal process. In the event that the supervisee is unaware of a bias in at least one of the three domains, the supervisor challenges the supervisee’s bias. An example of the challenge process is given below. Supervisee: I think she needs assertiveness training. Supervisor: I have the impression that you have some strong feelings about her issues. Would you be willing to examine those? Supervisee: Er…I’m not sure. What do you mean? Supervisor: Well, you’ve said a couple of things about her husband along the lines of, ‘He should be more supportive…’ or ‘She needs to stand up to him.’ I hear a hint of Critical Parent in there. Supervisee: You could be right. Supervisor: What would your Critical Parent voice say in this instance?
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Supervisee: Oh – he’s a bastard. He doesn’t care about her. She should leave him. Supervisor: Can you identify a feeling within yourself connected with that statement? Supervisee: I guess I am angry with him. Supervisor: Tell me more. Supervisee: I’ve just realised that he reminds me of my ex-husband, and all the trauma in my life when I was going through a divorce. I want to protect my client from that experience. Supervisor: I see. Now what area would you like to focus on? Supervisee: I think I need to work on my feelings towards her a bit more. Supervisor: OK. Any thoughts about how you’d like to do that? The supervisor has challenged her supervisee to address her own issues around this case and continuously offers a transparent choice to her supervisee about where to take the session next. If the supervisor has the impression that the supervisee is unable or unwilling to identify an area of bias, the supervisee is able, through the use of ‘I’ messages, to provide stronger challenges to the supervisee. At times, the supervisor may themselves slip into strong feelings or biases about a client. A healthy supervisory relationship would allow the supervisee to then challenge the supervisor, and the supervisor would be able to acknowledge and respond to the challenge non-defensively.
FIT supervision in Gestalt mode The supervisee might opt to use Gestalt chair work in order to understand her reactions to a particular client. This would show that she is aware from the thinking (T) domain that she is experiencing strong feelings (F) towards her client and wants to explore (I) what is causing them. The work might proceed as follows: Supervisor: What are you most aware of right now? (asking the supervisee to identify the current foreground)
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Supervisee: I’d like to put my father in that chair (the ‘father’ part is foreground at this point). The supervisee moves to the other chair, herself as a child, and says: Supervisee: You are a pain – always blaming everyone and me especially for your problems. I am not here for your benefit. Grow up. I don’t blame your wife for wanting to leave you. She is living with a six-year-old child. Supervisee continues until ready to move to the opposite chair. In her father’s chair: Supervisee: You have no idea how hard I’ve worked for you. How much I’ve sacrificed for you. You are so ungrateful and you never try to understand me. This process continues until there is a shift in the dialogue which is noticed by both the supervisee and supervisor. The supervisee pauses to reflect, in her ‘T’ for thinking domain, on the two voices. At this point, the supervisee begins to integrate the two Gestalts represented by herself as a child and her father. She then says: Supervisee: You are not in charge of me any more. I am independent and I make my own decisions. I’m beginning to understand what was behind your attitude, but it’s still unacceptable and that’s your responsibility, not mine. Supervisor: What was that experience like for you? (Asking the supervisee to use her thinking domain to understand the work she has just done.) Supervisee: Illuminating. I see the client differently now – I’m not mad at him anymore. (The supervisee responds in thinking mode.) Supervisor: So what would you like to do with this now? Supervisee: I’d like to role-play working with my client. Would you be me, and I will be him? (The supervisee has moved from feeling (F) to thinking (T), and now chooses to initiate (I) the role play in order to reinforce the learning from the other two domains.)
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The Gestalt approach has facilitated the supervisee in recognising the opposing parts within herself by role-playing both parts. She is then able to stand back and become aware of their impact on her work. She can now begin to integrate the two parts which allows her to bring this awareness into her work with her client and to experience his needs and feelings as separate from her own.
FIT supervision in CBT mode Below is another example of FIT supervision, in this case, using the CBT approach. The supervisee decides to use the REBT model in looking at her work with a client. She is familiar with the model and ‘ABC’ terminology. In this case the client is a man, and the supervision might proceed as follows: Supervisor: What is the activating event (A) in working with this client? Supervisee: His whining and complaining remind me of my father. Supervisor: So you hear him ‘complaining’, and you conclude that he is like your father – he won’t take responsibility, and blames others for his problems. Supervisee: Yes, that’s right. Supervisor: So what’s the intervening belief (B) that takes you from the activating event (A) to the consequences (C)? Supervisee: Complaining about his circumstances, what he calls his rotten luck, is the activitating event (A). I confuse what he is saying with the belief (B) that he is just like my father and decide that I can’t help him, and that means that I’m useless as a therapist and a person and won’t ever be able to change, and that I’m a complete failure (C). Supervisor: As a result of your beliefs about this client, you see yourself as useless and as a complete failure? What irrational beliefs would you need to change and what would you need to replace them with?
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Supervisee: I’d need to realise (thinking domain) that this client is not my father. He is like him in some ways, but I don’t have to respond to him (initiating domain) as my father. I’m not necessarily a failure, just because I don’t feel good about my work with him (acknowledging the feeling domain). (The supervisee is now disputing his irrational beliefs (D) and seeking more constructive, effective responses (E).) Supervisor: What changes would you need to make to be more effective (E) with this client, to feel differently about yourself ? (She is asking the supervisee to begin devising strategies that would result in healthier feelings, more balanced thinking and more effective behaviours). Supervisee: I have choices now about how I perceive this client, and I can continue working on my counselling skills until I feel more confident about myself as a therapist. Supervisor: How would you like to start working towards those goals? Supervisee: I think I’d like to role-play myself as the therapist working with this client. Thereafter, the session continues with negotiation at each decision point. This ensures that the supervision stays clearly on track with the focus on either the client’s issues or the supervisee’s issues if they have an impact on her work with the client. Although the session has focused primarily on the supervisee’s beliefs (T) and behaviours (I), in keeping with the CBT approach it has given her the opportunity to express and explore her own feelings and reactions (F) as they relate to the client.
Using the FIT model in ongoing therapy and supervision The above examples have demonstrated the use of the FIT model in response to issues which occur in supervision. The next section describes the use of the model in therapy with a supervisee who is in FIT supervision. The supervisee learning from the supervision session often finds that the FIT approach will inform some of the work with her clients, regardless of her chosen orientation.
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If trainees are able to use an integrative model, they may want to introduce some of the FIT approaches to their clients. In presenting the choice to the client in such a transparent way, the client is then encouraged to begin taking responsibility for his own process of change and to work with the therapist collaboratively, rather than from a one-down position. It rarely happens that clients are unable to grasp the concepts presented above and to decide where they want to begin working. By making this decision transparent, the client is encouraged to take responsibility for his own decisions. If the therapist fails to present the choices to the client openly, they are often favouring a focus on one domain over another. For example, if the therapist responds to the client’s behaviours, she is sending out the message that therapy should focus on this area. If the therapist only reflects feelings, she is giving the client the indirect message that therapy should focus there. If the therapist believes that the client needs to explore his relationship with his father or mother in order to resolve issues with authority figures, she will influence the sessions in that direction. Clients usually find ways to resist interventions which are unpalatable to them, particularly if the decisions are made for them indirectly and without their permission. It is usually more effective (and respectful) to start where the client wants to start. The client may initially choose to work on behaviours that he finds problematic, but at some point in the sessions, he may decide that he wants to explore past relationships, which could take the work into the feeling domain. In supervision the next step might be the supervisee rehearsing the use of the model in the supervision session. This might include practising the introduction of the FIT model by asking the supervisee to role-play the client, while the supervisor takes the role of therapist. This adheres to the principle that adults learn by doing, as well as thinking and feeling. Using the FIT model, the supervisor (acting as therapist) explores with the supervisee (acting as client) which of the domains ‘F’, ‘I’ or ‘T’ seem to be causing the most distress currently, rather than making the decision for the client. The supervisor (acting as therapist) describes the manner that feelings (F) can be worked with, using Gestalt, TA and/or inner child work, along with basic descriptions of how this might be done. The supervisee (acting as client) is also asked to describe
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problematic behaviours (I) drawing on CBT approaches. In addition, the supervisee is asked to access and identify their thoughts (T) in line with CBT practice. This will give the supervisee an understanding of various ways these three domains could be worked with. Acting as client, the supervisee is then asked to decide which area of concern he would like to address initially, as described in the earlier Example 1 above. The dialogue may proceed as follows: Supervisee/client: Oh I just don’t know. I’m so upset with my wife, my job, the money…oh, just everything! Supervisor/therapist: You’re worried about losing your wife, your job and going into debt…I wonder if you could tell me which of those concerns is most important right now? (this question may need to be repeated as the supervisee behaves as his client and avoids answering the question) Supervisee/client: It’s my – I’m afraid she’s going to leave me. Supervisor/therapist: Would you like to focus on that experience? Supervisee/client: OK. What are my options? Supervisor/therapist presents several possibilities: •â•¢ You could imagine that you are talking to your wife, using Gestalt and focusing on F. •â•¢ You could stay with your fear, TA’s inner child and let that part speak, also focusing on F. •â•¢ You could explore what you would like to change about yourself, using CBT behavioural techniques. •â•¢ You could examine your thoughts about this, using CBT to explore thought patterns and cognitions. Supervisee/client: I like the idea of ‘talking’ to my wife as the client, using the empty chair, using Gestalt techniques. At some point, the supervisee is asked or decides to step out of the role of the client and process their own experience of the role-play. The supervisee often finds that the experience has given them added insight into their client’s world. It can also foster the supervisee’s insight into their own issues and gain an understanding of how
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their issues may interfere with their work with clients. This process demonstrates for the supervisee a way of using the FIT model with their client by having first-hand personal experience of it with their own responses as client.
Summary This chapter has provided examples of using the FIT model in supervision. It has included the use of the model to provide structure and focus to supervision sessions, as well as techniques and interventions linked to the model. It has also provided illustrations of the model’s use with supervisees in supervision sessions and case studies. The model works most effectively when it can be used flexibly and in its entirety; however, it can be used to good effect to focus therapy sessions which lack flexibility. In such cases, it serves to assist the supervisee/therapist’s awareness of the interactions between them and the client and to focus intentionally the work done in the sessions.
Chapter 13
Using the FIT Model for Group Supervision
The assumption up to this point is that the supervisor–supervisee relationship is one to one. It must be so at the early stage, just after training, when retaining focus is often difficult for the supervisee, and swift feedback from a supervisor can offer support and encouragement. However, FIT supervisors may like to consider the advantages of group supervision at a later stage for supervisees with some experience. What do we mean by group supervision? A supervision group will need to adopt a different approach to the supervision process as there is a need to attend to group dynamics. The need for focusing on and agreeing boundaries is part of this, and many supervisors forget this most basic skill. An effective group supervisor defines a contract and articulates boundaries clearly for group members and teaches them to respect the supervisor’s personal boundaries without damaging the relationships between supervisor and group supervisees. In this chapter, we draw on a range of psychological theories to see how group dynamics relate to group supervision. This chapter may be of interest to supervisors who would like to adopt a group method, and are curious about the way their group behaves, as well as possibly being worthwhile for supervisees as potential group members who would like to explore what is happening in terms of group dynamics.
Group psychology Our approach, while primarily humanistic in philosophy and intent, utilises ideas from the psychodynamic and existential fields, as well as behavioural and cognitive concepts.
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The psychodynamic approach to group behaviour emphasises: •â•¢ the significance of past (childhood) experience on present behaviour and feelings in the group •â•¢ the existence of unconscious feelings and motives in the group •â•¢ the potential for transference within the group and we explain what this means below. Group supervision adopts the psychodynamic principle of a ‘holding’ environment, through firmly agreed boundaries, particularly in the early stages of the group’s development (de Board 1978). In addition, supervisors will benefit from an understanding of defence mechanisms in groups, another concept from the psychodynamic field, and ‘containment’ particularly at the ‘storming’ stage (Barnes, Ernst and Hyde 1999). We discuss these psychodynamic ideas in more detail below. The existential approach confirms our social constructivist stance, discussed in Chapter 3, by emphasising the importance of relationship in learning, where members explore issues of choice, identity, isolation, freedom and responsibility. The basic assumption here is that group members create and construct their own worlds and are therefore, as intentional beings, responsible for their actions. Our approach strives to avoid ‘rescue’ or ‘blame’ and recognises the human condition of ‘angst’ or anxiety as part of living. An existential stance accepts that a group will experience an active life, what has been called the ‘performing’ stage, and will ultimately end, the mourning stage of development (Van Deurzen-Smith 1997; Yalom 1995). We explore these existential ideas in more detail below. The behavioural approach is represented in our approach by a recognition that habits and behaviours are learned and, therefore, can be unlearned by group members if they so desire. In addition, the idea of imitation and modelling is how group members develop their managerial and facilitation skills by being in the group. Our approach incorporates behavioural principles in its recognition of the power of modelling in that supervisor behaviour can be imitated by group members and skilled behaviour can be learned by imitation (Bandura and Walters 1963). We discuss how this happens in a group below.
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The cognitive approach incorporates the idea that thoughts and beliefs inform and determine our self-worth and influence our actions. According to this theory, negative thought patterns are learned and can be identified and unlearned (Ellis 2001). Our approach includes the idea that the group experience encourages members to process and identify their thought patterns and to bring beliefs about themselves and others into their awareness. With awareness, comes the possibility for change. Our approach to group supervision primarily adopts the humanistic principles of abundance in personal resources and experience, rather than deficiency of them; a belief in the human potential to grow and develop as a whole person; and a positive attitude to human endeavour in all its forms (Rowan 2001). These principles inform the structure where each group member has protected time, where the group’s resources are at their disposal, and group members work without judgement but offer challenge and support in equal measure. We discuss the way our approach uses the humanistic approach to groups in more detail below.
Learning and groups In taking a social constructionist view of learning, we assume that group members are active creators of their realities, and that these realities are deeply influenced by their life experience. The group is a learning context, which is socially constructed, in which group members are invited to ‘create rather than discover’ themselves, through engagement with others (Burr 1995, p.28). For reflective learning, the recognition that ‘the self ’ may take an infinite variety of forms, that our conceptual space is created from our language, and that our context is defined by the prevailing discourse, enables group members to access their potential and challenge what constrains their learning. The prevailing discourse is defined as ‘a group of meanings, metaphors, representations, images, stories, statements and so on that, in some way together produce a particular version’ (Burr 1995, p.48) of events, person, or class of person. Each group is likely to develop its own prevailing discourse during the life of the group. The social contructionist stance gives our approach its particular values, that is, a critical stance towards taken-for-granted knowledge,
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the potential of humans to self-develop, a resistance to objectivism and a focus on social activity. The social nature of our approach offers opportunities for group members to reflect upon their work, not only by themselves but with others. As meaning is created in relation to others, then reflection and the creation of meaning is inevitably a social process and this makes group supervision an effective learning environment for supervisees. Group working has inherent characteristics which differ markedly from traditional ways of learning like lecturing or directive training. The significance of group work for learning and development has been explored at length elsewhere (Hartley 1997; Luft 1984) and here we simply recognise that when, as supervisors, we convene a group and facilitate communication within it, group effects, known as group dynamics, affect the individuals in the group and the group as a whole. A group behaves rather like a person, with distinctive and recognisable characteristics, as well as having a significant impact on the individuals within it (Bion 1961; Egan 1977; Foulkes 1975). First, we explore the psychodynamic concepts of boundaries, a holding environment, containment and defence mechanisms, ideas borrowed from psychodynamic psychology (Bowlby 1979; Fordham 1982; Stafford-Clark 1965; Winnicott 1965). These psychodynamic concepts are well researched and form the basis of safe and effective group work in a wide range of contexts so we include them here in full. Thereafter, we identify the humanistic approach to group dynamics, including existential ideas, and we complete our exploration with a brief comment about how behaviourism and cognitive concepts play their part in group dynamics.
Psychodynamic concepts in our approach The most dramatic effect experienced by individuals in groups is feelings of fear and lack of safety, and we recognise that the degree of these feelings will vary with membership of the group, and between individuals. This effect exists in everyday social groups, though not articulated, and accounts for some of the discomfort experienced in some social situations, committee meetings and work groups. Defensive forms of behaviour in groups are usually triggered by anxieties, either anxiety triggered by being in a group or archaic anxiety with its roots
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in the past (Heron 1999). Anxiety about being in a group may take the form of ‘self-talk’ like: Will I be accepted, wanted, liked? Will I understand what’s going on? Will I be able to do what’s required? Archaic anxiety is the echo of past distress and comes from the fear of being rejected or overwhelmed. These anxieties are real for anyone who takes part in a group where all members are given voice, as in group supervision. The casual comment or joking aside may cause hurt as they can trigger damaging self-talk as described above. Taking account of this knowledge, in order to facilitate learning using a group format, the supervisor may need to accommodate the fears of group members by establishing very early an atmosphere of trust and safety, so that learners can contribute and all can benefit. The boundaries and norms in a supervision group go a long way towards providing safety for group members. At an early stage, in order to establish boundaries and norms, the group should be invited to agree on ground rules for working in a group. Why is this necessary? A ‘holding’ environment for group supervision
When a supervision group is convened, and members are offered the possibility of being congruent, it is necessary to also protect them from psychological harm. By this we do not mean nervous breakdowns or the like, but we do recognise the potential for group dynamics to trigger the hurt child in every human being (Miller 1983), and this may include the supervisor. Nitsun (1989) has compared the dynamics of early group formation with early development in infancy where the group like a newborn infant is endeavouring to integrate. The effort to ‘form’ as a group may trigger anxieties from the past. The group can be provided with a ‘good enough’ environment using the concept of ‘holding’, that is, taking care of group members, through boundaries and ground rules (Winnicott 1971). In addition, these ground rules provide what has been described as a ‘secure base’ in which group members can feel safe enough to develop themselves (Bowlby 1979). Hence when launching a supervision group the supervisor begins by discussing the model of learning she proposes, gaining agreement to it, and establishing with group members a series of ground rules for group behaviour. We are aware of a variety of versions of such guidelines and later on we list some of the items which may appear when a group is invited to contribute (usually in
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brainstorming style) to the question: ‘What conditions would you want to have in place while working in this group?’ Bion’s two groups
The nature of group dynamics was explored in depth by Bion (1961) and he established that any group operates at two levels, the basic assumption group (unconscious) and the work group (conscious). When operating in the unconscious, basic mode, group members behave as if they hold basic assumptions about the life and purpose of the group, which are quite different from the declared purpose of the work group. There are three basic assumptions which the group may adopt as follows: •â•¢ Dependency: the group believes that security lies in a powerful leader usually identified as the supervisor – and failing that the group will generate a fantasy leader. The effect of this assumption is that group members deny their own competence preferring to place all their hopes (and therefore blame) on the leader. •â•¢ Pairing: the group unconsciously shares the assumption that an ideal couple or pairing exists within the group and that this will produce a messiah who will be the group saviour. The effect of this is that group members focus on a fantasy future rather than the present and may be preocccupied with a potential romantic coupling within the group. •â•¢ Flight/fight: the shared group assumption is that the group’s survival will be achieved if its members fight or flee from someone or something. The effect of this assumption is that group members behave as if the group is being attacked by a fantasy ‘enemy’. Bion’s work, developed by others (de Board 1978) established that any group flips continuously between the basic assumption group and the work group throughout its life. Lengthy committee meetings are a mixture of both. How does Bion’s work apply to our supervision group? According to Bion, if the group remains strictly in work mode it is deprived of warmth and power, whereas if the group remains
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strictly in basic assumption mode, group members may not pursue their goals. When the group is in basic assumption mode the effect is revitalising even if it may feel catastrophic to members. Skilled supervisors often move a group into basic assumption mode in order to access its energy, by responding to expressed (but not verbalised) feelings, using primary or advanced empathy (see Chapter 2). When the emotional charge in the group is put into words by the supervisor (or indeed a group member) the group is able to access its energy, process the feelings and move on to address their task in work mode. When a group is able to function effectively in work mode, the members are able to assist each other to achieve their goals, address reality, and develop or change. The same group may operate in basic assumption mode, using its energy to defend itself from fear and anxiety, without achieving any task. The tension between the basic assumption group and the work group is believed to be essential for transformation (Barnes et al. 1999; de Board 1978). Our approach aims for the group to take energy from its basic assumption mode and pursue action within its work group mode. Our humanistic approach allows the group to move freely between both modes. For example, the speaker may find that her issue uncovers some strong feelings about her case and the group may tap into its basic assumption mode by waiting for the supervisor (their fantasy leader) to ‘rescue’ the situation. Where the emotional reality is articulated by the supervisor or group members, the group can move off into work mode as the members focus on the task in hand. We noted above the impact of group dynamics on the feelings and behaviour of those in the group, as well as the supervisor. While a full treatment of group dynamics is beyond the scope of this book, we do recognise that group members and supervisors may wish to have some idea about the unconscious forces at work in their group and we introduce the basic concepts below. The idea of a part of each person which is unconscious and inaccessible is a key concept in psychodynamic thought, and the unconscious works for the person to maintain an image of self which that person finds acceptable. Psychodynamic theory maintains that the unconscious uses defence mechanisms to keep the self-image in place, and plays its part in maintaining the psychological health of the individual.
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Defences in group supervision
The unconscious forces within a group, often called defence mechanisms, include projection, projective identification, transference, countertransference and other dynamics of group behaviour. We define these terms below. The supervisor of a supervision group does not need to ‘work with’ these dynamics as an analyst would, but she will feel more confident when she understands what is happening in a group when these unconscious forces are at work. For example, it is quite common in a group where freedom of expression is granted, for members to attack the perceived leader or authority figure. Indeed, a leaderless group will create such a figure primarily for the purpose. This is an example of Bion’s ‘dependency’ assumption above. The tendency in a supervision group for a speaker to address most of his ‘story’ to the supervisor is a sign of his identification of the supervisor as some sort of leader. A skilled supervisor will be aware of how this may affect her response, and will monitor her own response to the situation (Bion 1961; Egan 1976; Foulkes 1975). Hence, supervisors may attract aggression or adulation from group members and these feelings are part of the group dynamic. As part of a group, group members may project their own feelings onto others, especially if they are uncomfortable feelings like anger or sadness. ‘Projection is a process whereby the person defends against threatening and unacceptable feelings and impulses by acting as though these feelings and impulses only exist in other people, not in the person himself or herself ’ (McLeod 1998, p.43). For example, a group member may find themselves feeling angry about the way the speaker is being treated, while the speaker remains as cool as a cucumber! When the projection is ‘taken in’ by the other persons, i.e. they swallow what has been sent unconsciously to them, as the group member did above, and it becomes a recognisable part of self-awareness, this is called projective identification. Projective identification has been defined as a normal psychological process which is a transaction across the boundary between two people, that is, between what I am and what you are. Let us look at this idea more closely. The speaker A is projecting some feelings of anger about her colleagues onto another group member, B. A has unconsciously
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learned that angry feelings are unacceptable to have and she pushes them away from herself by ‘seeing’ them in others. This means that the speaker is not conscious that her anger is really part of her own self, having learned in the past, that being ‘good’ was being ‘not angry’. The group member B ‘takes in’ the feeling of anger unconsciously projected at him, experiences it as real, and may feel impelled to express it. Hence, what group member B is feeling in that moment is really part of the speaker A, but appears to both speaker and group member A as part of B. ‘Projective identification occurs when the person to whom the feelings and impulses are being projected is manipulated into believing that he or she actually has these feelings and impulses’ (McLeod 1998, p.43), for example, as in the group member B feeling angry above. What happens if a group member projects feelings onto the speaker? The clue to projection is the strength of feeling which the group member may have about the part of himself he perceives in the speaker, as theory suggests that this is how he really feels about himself but defends against this knowledge by projection. This is why taking back projections is incredibly illuminating. The perceived aspect of the speaker, say a lack of confidence, which the group member reacts to strongly, suggests that lack of confidence is something which clearly has importance for the group member concerned. This is why projection has been called ‘a gift in the present from the past’ (Neumann 1998). So when a group member feels strongly impatient with a speaker’s perceived weakness in dealing with her colleague, psychodynamic theory suggests that his impatience is a clue to how he himself feels about his own weakness, projected onto the speaker. If, through processing the feelings, our group member is enabled to ‘take back’ his projection and accept his own weakness, he has a chance to know himself better. We must not underestimate the fearful nature of some of our projective material – it is being sent out to another in order to lessen the pain or fear which we would experience if we ‘owned’ it properly. Hence, where projection may be identified by the supervisor or group members themselves, great care is needed if we call attention to it and we advocate a humanistic, gentle and non-jargonistic observation with no pressure on anyone to respond or recognise what is being suggested. Such an observation also releases other group members
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from ‘carrying’ the projection without making a huge fuss about it. This frees group members to deal with their own material rather than feeling weak and helpless. Another form of projection is the defence known as transference. Where feelings experienced in the past are ‘transferred’ unconsciously into present relationships, the term transference is used (Jacoby 1984). These feelings are not just memories, they are alive and can deeply affect current relationships. ‘Transference repeats and relives the love, hatred, aggression and frustration experienced as an infant in relation to his parents’ (Jacoby 1984, p.17). In addition, these feelings may not be all negative, and can take the form of undiluted admiration or hostility. The emotions and feelings involved are repetitions of the original ones (de Board 1978). Transference can be seen as an entirely normal occurrence in any relationship and may have archetypal contents (Jacoby 1984), for example the ideal father or perfect mother. If this seems a fanciful idea, the concept of projection was applied to everyday living by Ferenczi (1916) who suggested that people are continually transferring their own feelings onto other people. For instance, when a speaker focuses all her attention on the supervisor, almost ignoring group members, it may be that the speaker has ‘transferred’ feelings of undue deference onto the supervisor. Group members or the supervisor are type cast or propelled into the matching pre-prepared script, and may respond in role as if they are actually the source of the transferred feelings, and this is called countertransference. Countertransference is a particular case of projective identification, where emotions are felt in response to the projected transference feelings. Countertransference may draw on ideal archetypes just as transference does, so the group member may enjoy a sense of being god-like, the ultimate healer, the good parent, and so on in response to the speaker’s deference described above. The speaker’s transferred feelings of over-deference as above, may give rise to corresponding god-like and all-powerful feelings in the supervisor. We suggest that when supervisors begin to experience such feelings, they may call attention to what is happening by being congruent, for example, ‘I am feeling rather over-important here – I wonder why?’ The task for the supervisor or indeed group member is to disentangle what may be their own feelings from what is being
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unconsciously projected onto them by others. For instance, where the supervisor or group member feels an urge to rescue the speaker – surely not an appropriate feeling between adults – this may alert them to the possibility that the feeling is countertransference. They are feeling the urge to rescue in response to the speaker’s feelings of helplessness, transferred and projected onto others. Either group members or supervisor may choose to mention their ‘rescue’ feeling and discuss whether it is appropriate to the speaker’s situation. The supervisor needs to be aware of the effects of defences in the supervision group. As mentioned above there is no need for the supervisor to ‘work with’ any of the psychodynamic issues raised by anxiety, her awareness of them is sufficient. In our humanistic approach, when appropriate, she may use non-technical language to gently point to what is occurring in the group. For example, the supervisor may observe that the group is in flight from the task by means of distraction, as they are moving away from the speaker’s agenda, or by means of projection, as they are avoiding an uncomfortable feeling of anger or weakness by perceiving it in others. She may note that there is conflict between certain individuals in the group, and open up the issue in the process review. Alternatively, the supervisor may simply live with the unconscious projections in the group, observing that members are demonstrating dependency by waiting for a lead from the supervisor, or transference behaviours by offering the supervisor overdeference or hostility. The supervisor may deal with her own countertransference feelings of anger or irritation internally, without commenting on it. This is described as the supervisor acting as a ‘container’ for difficult or unacceptable feelings and therefore making them safe (Bion 1961).
Humanistic concepts in group supervision The supervisor can anticipate much of the group defences described earlier by declaring the humanistic values of support, trust and safety. Our approach adopts humanistic principles as it focuses on subjective experience, the individual’s view of the world and their interpretation of that world. In our approach there are no impositions or preconceptions or theoretical data. Hence, the psychodynamic ideas above are given only as background to a humanistic approach, which adopts group norms of disclosure, owning, honouring and respecting
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choice and these are the conditions identified by Carl Rogers for person-centred learning which we discussed in Chapters 1 and 2. Clearly, group members will need to understand what the humanistic style of working is, and we assume this has been established, including clarifying that responsibility for learning lies with the group member rather than the supervisor – and this can be a revealing moment for everyone. Some group members may want to be passively fed, while others are familiar with experiential group learning techniques. The brainstorming process, where all contributions are accepted should, after discussion, produce some of the following ground rules (and this list is not exhaustive): Typical ground rules for supervision group meetings: •â•¢ confidentiality, as agreed by group members •â•¢ one person at a time •â•¢ listen to others when they speak •â•¢ be honest and open •â•¢ don’t attack others •â•¢ challenge constructively •â•¢ no compulsion to speak •â•¢ feelings may be expressed •â•¢ feelings not dismissed •â•¢ awareness/acceptance of diversity •â•¢ observe time boundaries. A number of these items will require discussion to agree their meaning in any particular group and understandings may differ depending on participants and context. Taking a humanistic stance, there is no right or wrong meaning, providing the discussion conforms to the personcentred model in that persons are respected, difference is recognised and context is articulated. The group may need to get used to a different style of working to the fast-paced wordy interactions of the typical workplace or meeting. Facilitative methods seem slower at first and the group may wonder if anything is happening at all. The ground rules provide what has been
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called a ‘good enough’ holding environment for the group, and will become a ‘secure base’ from which they can develop. The supervisor’s role is to hold the boundaries agreed by the group in their ground rules even when the group is pushing against them, thereby ensuring the psychological safety of the group. Carl Rogers (1973) created the idea of an encounter group, echoing Bion’s two groups in a humanistic format. Rogers’ intent was to provide a group experience which would enable ‘normal’ people to gain insight into their own behaviour in a much more fundamental way than is possible in a social or work context. The intended outcome was for individuals to be able to relate better to others, both in groups and later in everyday life. The supervisor in such an encounter group has four functions: •â•¢ modelling self-disclosure especially emotion •â•¢ caring and support for group members •â•¢ clarifying the meaning of group dynamics •â•¢ executive responsibility for boundaries (time and space). Where individuals reported positive outcomes these were associated with a supervisor who had high ratings on caring and support, and meaning functions (Lieberman, Yalom and Miles 1973). In addition, supervisor self-disclosure offers members of the supervision group a model of behaviour, with emotional disclosure that is appropriate in depth, breadth and relevance (McGill & Brockbank 2004). The importance of boundaries in terms of beginnings and endings for a group has been confirmed in the work of Bion (1961) and Bowlby (1979), and these findings transfer to a supervision group where the objective is the learning and development of group members. The conditions required for human learning and growth were defined by Rogers (1957) as a consequence of his research into human development. The three key behaviours, known as person-centred core conditions, are congruence, empathy and unconditional positive regard, and are described in detail in Chapters 1 and 2.
The FIT Model for Group Supervision 245 Negative feeling
EASY About a past situation
Positive feeling Who is absent Negative feeling About the here and now Positive feeling
Expressing emotions to (or about) a person
Negative feeling About a past situation Positive feeling Who is present Negative feeling About the here and now Positive feeling
DIFFICULT
Figure 13.1: Expressing emotion: the difficult–easy continuum Source: McGill and Brockbank (2004), adapted from Egan (1977)
In addition, the very important core skill of empathy has been categorised by Mearns and Thorne (1988, p.42) as follows: Level 0 where the supervisor or group member has no understanding of the speaker’s expressed feeling. Level 1 where the supervisor or group member has a partial understanding of surface feelings. Level 2 where the supervisor or group member shows an understanding of expressed feeling, also known as accurate empathy (see also Egan 1990). Level 3 where the supervisor or group member shows an understanding of both surface and underlying feelings, known as additive empathy or depth reflection. (Mearns and Thorne 1988, p.42) We note that the definitions of empathy encompass all aspects of experience: doing, thinking and feeling. Where one or other is neglected the quality of empathy is likely to be reduced. In addition,
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empathic understanding must be communicated (silent or invisible empathy is not much use). Using these core conditions a humanistic approach to supervision will recognise and deal with the defences described earlier. In humanistic mode, the supervisor can help group members to unlock these defences, usually by making possible projections implicit, for example by noting that the speaker is being badly treated at work but it is the group member who is angry about it. The group can be invited to explore why this is occurring and what might change for the speaker if she were to be angry for herself. Where the supervisor is part of the defence, that is transference, where group members may project feelings of resentment or anger from the hurt child within, then the supervisor needs to resist the temptation to offer a punitive response. Similarly, the supervisor may need to resist being carried away by the undiluted admiration given by some group members and alternatively perhaps, dare to reveal the cracks! In humanistic terms, the group dynamic is dominated by feeling, and group behaviour is ruled according to ‘habeas emotum’ (Luft 1984, p.154), which is a version of the legal term ‘habeas corpus’. Habeas corpus, literally means ‘you shall have the body’, where the person is protected from illegal custody, having the right to a fair trial. Habeas emotum, refers not to physical freedom but the psychological freedom to have emotions and express them. The supervisor needs to be aware of emotion in the group as potential energy for learning or potential blocks to learning if unexpressed. An effective supervisor, taking a humanistic approach, will have the ability to observe, identify and, if appropriate, describe such dynamics in a group through process comments in simple terms, where appropriate, enabling reflection on that process by articulating it. Examples of this are calling attention to the group’s over-reliance on the supervisor, noting where group members rather than the speaker feel angry, and mentioning the tendency to ‘rescue’ in the group. Process comments, if accepted by participants, are the trigger for reflection, and may be the first time the process has been highlighted for them. We offer here a story which emphasises support and empathy from one of the authors. It is included here because it embraces the Rogers’ core conditions.
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Challenge and support I recently had an experience in a supervision group that challenged the way in which I was running the group. The group had been working together for some time and had established ground rules as a framework for agreed working together.╇When exploring the ground rules we had devoted quite a bit of time to unpicking principles such as trust and confidentiality. We had spent less time unravelling the complex concept of support and what this really meant to people in the group. At a group meeting one of the group presented a case that she was anxious about. She wanted to think about ways in which she could plan the way she would work with her client. The group asked many questions and some were aimed at challenging her to consider possible consequences of particular actions.╇At the end of the session when I asked the group to consider process issues the speaker commented that she felt quite angry that she had not felt supported by the group during her case presentation. I felt challenged as the supervisor as these comments had implications for me. I decided not to ask her more questions about why she felt unsupported but to allow her to carry on talking about the way she felt and allow there to be silences as she was doing this. When she had finished describing the way in which she felt, I, as supervisor, acknowledged her feelings and commented about how sad I was that she felt this way. I then asked the group if they would like to say anything to the speaker. No comments were given although there was a silence that conveyed how sorry people felt. I then asked the group to consider what this notion of support looked like and how we might give support in a group. The group came up with the following points: •â•¢
Support is not necessarily about saying you understand or giving loads of positive feedback to make the person feel good.
•â•¢
Support is about owning up to how you are feeling when the speaker is telling their story. So, for example, if you feel sad or anxious or frustrated it can be supportive to the speaker to share these feelings you have with them.
•â•¢
Support is about checking out with the speaker during the course of the discussion how they are feeling and what they would like from us as a group.
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Support is about paying attention to non-verbal cues and the pace of the case presentation.
Everyone engaged in this discussion and came up with a clear idea to them of what support looked like. They felt positive that they could work with this and try to put it into action. The annual review of the group occurred a few months after this event.╇All of the group members spoke about how much they had learned from this experience. The speaker commented on how she felt she had really been listened to and it would give her courage to challenge the process in the future. I learned that as an experienced supervisor there is still much learning to do, in particular the skill of reflection in action. I had to think and make decisions quite quickly in this instance. The decision I made was not to ask the speaker more in-depth questions about feeling unsupported, as she had been asked enough questions over the past hour and had already felt in the ‘hot seat’. Instead I chose to acknowledge her feelings, share how I and the rest of the group were feeling and move to using the skills within the group to learn from the experience and plan how we might look at the issue of support in the future.
The story illustrates the supervisor’s use of empathy in verbally acknowledging the feelings of the speaker; unconditional positive regard is shown by the supervisor allowing space and silence for the speaker; and congruence is present in the supervisor’s expression of her own sadness in response to what the speaker has said. All three qualities call for a high degree of emotional intelligence, in that to be genuine implies a willingness to express feelings, acceptance relies on managing competing emotions, and empathy is the key skill for handling emotional material. When a supervisor holds such attitudes group members are given ‘freedom and life and the opportunity to learn’ (Rogers 1983, p.133) and we are told that, as outcomes of the process, group members are likely to: ‘learn more and behave better when they receive high levels of understanding, caring, genuineness, than when they are given low levels of them’ (Rogers 1983, p.199). The values of our approach are undeniably drawn from the humanistic field. The emphasis is on positive outcomes, challenge as well as support, no advice, and the holistic approach to a speaker as the expert in their own casework. How do these humanist ideas link
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up with the psychodynamic principles given at the beginning of this chapter? The humanist approach recognises transference and offers empathy as a response to archaic feelings of anger or adoration. The countertransference experienced in the group usually by the supervisor can be noted by her without intervention, or can be openly articulated by her through being congruent. The projections in the group can be recognised similarly by group members’ congruence. For example, when a group member begins to feel something that does not seem to be ‘hers’ it is possible that the feeling is a projected one from another group member. For instance, if a group member finds herself feeling unaccountably angry and the speaker is talking calmly about exploitation at work, she may wonder if what she is feeling is projected from the speaker. If she can be congruent about that feeling and say she feels angry but she is not sure why, then the speaker may recognise the feeling as hers and choose to repossess the feeling. Even if the speaker chooses not to own the feeling, our group member has freed herself from the projection by her congruence. All unconscious defences are contained by a humanistic group climate which offers respect and unconditional positive regard, where the ground rules ensure that no one is attacked or over-challenged, so that fears, anxieties and perceived weakness are safely processed within the group. In addition, in order to maximise the opportunities for full reflective learning, that is, for transformation as well as improvement, the group allocates time for processing its work at the end of each session or after a particular presentation. This process review is when the group can analyse what has occurred and why.
Existential concepts in group supervision Group dynamics may also draw on some ideas from existential philosophy, and examples include the way the supervision session is structured, with time on offer to each member, which maximises the potential for individuals to take responsibility for their own client issue.
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The dedicated time for each speaker, the absence of advice-giving (ideally) and the balance of challenge and support give the speaker non-judgemental acceptance in their situation. Existential principles demand that the individual is active not passive in the way they conduct their work, being responsible for contributing to their own reality, and our approach seeks to enable this to happen. The individual group member is presumed to have freedom to choose and can therefore take responsibility for acting. The group member, as an existential human being, is presumed to be intentional, and hence self-responsible. However, existential principles require a balance of challenge together with support for the group member who seeks change and development. We illustrate this in Figure 13.2. high
RETREAT
GROWTH
STASIS
CONFIRMATION
(Challenge)
high
low (Support)
Figure 13.2: Mutual dependence of challenge and support Source: McGill and Brockbank (2004) The Action Learning Handbook. Abingdon: Routledge Falmer, p.143.
Another existential concept embedded in our approach is the idea that development is created through relationships (see Chapter 3), in particular the I–Thou relationship (Buber 1994), which has been described as follows: In an I–Thou relationship where I take my partner seriously, I owe him honesty; I can tell him how his behaviour affects me. I do not have to play the invulnerable one, I can react as a human being. (Jacoby 1984, p.86)
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The supervision group offers members the opportunity to ‘react as a human being’, express their vulnerability and collaborate with fellow members in their learning. When a speaker can admit to feeling at a loss with a client, and share this with the group, the I–Thou relationships in the group ensure that group members stay with the speaker, supporting her and encouraging her towards a resolution of her difficulty.
CBT concepts in group supervision Our approach to group supervision accepts the behavioural principle of modelling (Bandura and Walters 1963). In a group, modelled behaviour by the supervisor is picked up and imitated by group members, consciously or unconsciously. The work of Bateson (1973) explored the phenomenon of schismogenesis, the tendency for humans to imitate observed behaviours, and modelling seeks to use this tendency to support learning. The old adage, ‘don’t do as I do, do as I say’ recognises that, as learners, we ‘pick up’ the implicit process and copy it, thereby imitating behaviour rather than responding to spoken instructions, so we might as well model process intentionally. There is plenty of evidence for such effects. The power of the majority over the individual was demonstrated by the Asch (1951) research where one of the group was persuaded to change their perception about the length of a line by others disagreeing. The idea of groupthink emerged from disasters like the Bay of Pigs and Challenger (Janis 1982). On the positive side, research work in group dynamics shows that learning is enhanced by group interaction, giving dramatically better results than lectures, for instance (Chickering and Gamson 1989). The supervisor may encounter any or all of the above dynamics in the session itself, as well as in the process review. The supervisor may encourage group members to work with behaviours occurring within the group or to identify and work with behavioural patterns exhibited by clients which members present to the group. In my experience, learning is more powerful when it encompasses group members in the here and now; therefore, the example which follows is taken from a supervision group which Mary led several years ago.
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Exclusion and Inclusion The group was made up of eight trainee therapists who had been meeting as a closed group for six months. During the course of the group, I had noticed that group members were positive and encouraging towards each other, nodding and smiling when other members spoke or presented case material, with one exception. One of the women in the group was consistently ignored by other group members; her comments and presentations were met with silence and lack of eye contact.╇After Tanya (not her real name) spoke, a long silence would follow, which would only be broken by a group member making a comment about another subject, which would then be picked up on and discussed by the group. I asked the group to examine this pattern and to consider what it meant. The ensuing conversation became heated, with some group members denying that the behaviours had occurred, and other group members defending their actions because Tanya never had ‘anything of value to add to the group discussions’. Tanya was silent during the discussion; when I asked her if she would be able to comment on what was happening in the group, she shook her head and began to cry. Eventually, she began to speak and disclosed that the group members had known each other in another context, when they had taken a course together. From the beginning of their contact, she had felt ignored and excluded by the group; this behaviour had continued within the supervision group, and Tanya felt powerless to express her feelings within the group or to confront the behaviours. After the discussion, the atmosphere in the group changed. In future discussions and interactions, group members included Tanya, both in terms of eye contact and body language, as well as comments and responses from other group members directed to her. This event also led to useful discussions regarding group members’ work with clients and to the awareness that they had been conveying unspoken messages to their clients through their body language and non-verbal responses.
Although the focus in this example was primarily on group behaviours, the discussion led to other interactions within the group, some of which are described below.
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Further CBT concepts in group supervision The example given here draws on the group interaction described in the previous section, but deals with it using a cognitive approach.
Group Members’ learning After behavioural techniques had been used to identify the group interactions occurring in the above example, cognitive techniques were utilised to further the group discussion. Because of the sensitive nature of the group work in this case, I didn’t ask group members to identify their experiences using Ellis’s (2001) ABC format, but used listening and attending skills to draw out their beliefs and assumptions about the group.With this in mind, group members were asked to identify the beliefs that had influenced their behaviours towards each other. In response to this question, Tanya spoke first, stating that she had decided, during her first contact with the members of this group, that they didn’t like her, and that there was nothing she could do to change this. By exploring these thoughts, she realised that they contained core beliefs about herself, namely that she wasn’t likeable and would ‘always’ be rejected by other people. She realised that she had helped the beliefs come true in this group because of another core belief, that she was powerless to change this pattern. Stating her beliefs about herself to the group helped Tanya feel more powerful and to become more assertive in future group interactions. After Tanya had spoken, other group members began to describe the thoughts and beliefs which had influenced their behaviours in the group. Susan (not her real name) stated that, when she had first met Tanya, she had noticed that Tanya was ‘very attractive’. Susan decided that ‘someone so beautiful must be stuck-up’, and had begun to relate to Tanya based on that projection. Susan explored her beliefs about herself; she had been overweight as a child and came to decide that she was ‘ugly’ and that other people would never find her attractive.╇ As other group members began to speak, they were able to identify and to take responsibility for the beliefs which had influenced their behaviours in the group. The discussion improved the atmosphere in the group and enabled group members to use the skills gained from the experience when working with their clients’ core beliefs and negative thought patterns.
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The life of a supervision group A supervision group is both focused on self-understanding and change and also dealing with action. So does our approach have ‘stages’? For a supervision group, the ‘stages’ are embedded in the structure so that a group is ‘formed’ by initial exercises and the establishment of trust; the ‘norms’ are established by the ground rules; the group ‘performs’ within a case presentation; the group may ‘storm’ during the process review when feelings may be expressed and ‘held’ by the supervisor. So the ‘storming’ stage is contained by the structure of the supervision session and made safe by the skill of the supervisor. The stages of groups were first presented by Tuckman in 1965. A later study by Tuckman and Jensen (1977) identified the termination phase of a group – adjourning – together with some typical defence behaviours which are common to the ending of relationships, and these have been described as ‘mourning’ the ending of the group. This may occur by arrangement or by one or more members leaving the group. Group members may experience real feelings of bereavement at the ending stage and supervisors need to take account of such feelings. Supervision groups should always work to an agreed series of meetings so that members are aware when review or adjournment will occur. Each group will have its own way of ending and supervisors should enable group members to complete a satisfactory ending. Note: some group members may wish to continue in another group and then the whole process begins again.
Use of the FIT model in group supervision Group supervision provides training and learning opportunities not available in individual supervision, primarily because other group members may participate in real-plays, exercises and group-process discussions. Feedback from more than one person, that is, other group members, is an additional benefit arising in the group setting. When participating in a group which follows the FIT supervision model, members will be taught about the three domains of functioning, feelings (F), behaviours (I), and thoughts (T). Early on in the group, they will be asked to participate in exercises aimed at enabling them to identify the domains within themselves and other group members and, by extension, as they occur in their clients. Group members will
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also be asked to participate in discussions and exercises using the approaches described in the model, including humanistic, personcentred, TA, Gestalt and CBT. The group will include demonstrations of initial sessions with clients using humanistic listening skills and, at the same time, begin to identify the client’s functioning within the three domains. Supervision groups lend themselves especially well to this process as members can be asked to work in triads, acting as clients, therapists and observers to facilitate the learning. Group members will be asked to engage with the model, by practising the different therapeutic approaches with each other. They then practise combining the various approaches, using the FIT model to identify the domains with a ‘client’ and to agree a contract, which focuses their therapeutic work. Work within the FIT supervision model also includes case presentations based on client material brought by group members. Group members may be asked to role-play the client or the supervisee/ therapist or the supervisor. The practical experience is combined with group discussions, as well as experiential activities, derived from the case material. A further advantage of group supervision is provided by using the group itself as a training and learning resource. Members may be asked to explore the dynamics occurring between them. Participation in these activities increases group members self-awareness, as well as their awareness of the effect of their interactions with clients. By identifying interactions as coming from the feeling, initiating, or cognitive domain, group members become proficient at working with each domain as they arise with clients.
Summary This chapter has dealt with the characteristics of group supervision through a detailed analysis of group dynamics. Psychodynamic, existential and behavioural concepts have been discussed, as well as the humanistic approach we recommend for FIT supervision. It has also included examples, drawn from the authors’ experience as group supervisors, which demonstrate the FIT approaches used in group supervision. The chapter also includes details of the skills and activities included in a supervision group using the FIT supervision model.
Conclusion
We have written this book with the thought in mind that therapists and supervisors could benefit from a theoretical and practical approach which integrates several of the major schools of therapy currently practised. We have attempted to provide the background, theories and techniques which have informed our own integrated practice of therapy and supervision. We believe that this way of working enables practitioners to work holistically with clients and supervisees in a way that includes all three of the domains of human functioning. By systematically considering which approach to use and when, we provide a way of working with the various theories and techniques that is both flexible and creative, while still retaining an organised overall structure. Throughout the book, we have prized Carl Rogers’ belief in the healing and transformational power of the relationship. We have attempted to incorporate genuineness and congruence within ourselves and to show respect and unconditional positive regard for the people we work with, regardless of the approach in use at any one time. We hope that the model presented here is greater than the sum of the individual approaches which make it up, and that you find it useful in your practice of therapy and supervision.
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Appendix A
An example of ground rules
These are the rules by which the relationship will operate and should be part of the contract agreed between supervisor and supervisee. Examples of ground rules include who contacts who, confidentiality, duration, timing and frequency, code of ethics, cancellation and fees and recontracting. 1. Review the ground rules together 2. Limitations of confidentiality 3. Time keeping 4. Regular attendance 5. Questions for clarification are OK from either party 6. Tolerance – both have the right to disagree and have a different opinion 7. Listening to each other 8. Both parties to be prepared to disclose 9. Both parties have a choice of whether to disclose or not 10. Respecting diversity and learning from diversity 11. Supervisee to take responsibility for themselves and their learning 12. Use of ‘I’ statements in supervision sessions 13. We agree to reflect periodically on the relationship itself.
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Appendix B
Supervision contract
This is a supervision contract between…………………… and……………………from……………………until its review (or ending) on…………………… What is supervision?
We are agreed that supervision is a contracted forum used by supervisees (those being supervised) to reflect on aspects of their life and work, where they receive formal and informal feedback on that work and where they learn from their reflection how to maximise their potential. Practicalities
We will meet for……………………hours every…………………… at……………………at a time to be arranged at the end of each supervision session. Ours is a non-smoking environment and we have agreed that each of us will ensure that there are no unnecessary interruptions (mobiles, phone, people). (Add here anything about groups if group supervising, or fees, if necessary, or equipment, e.g. flip charts, overhead projectors, video, audio, etc.) Procedures
We have agreed that the following arrangements will take place in the following situations: 1. cancellation of session…………………… 2. non-attendance at supervision session…………………… 3. where there are disagreements, disputes, conflict areas between supervisor and supervisee…………………… 4. if there is need for extra supervision sessions…………………… 5. contracts with others, e.g. an organisation or a training course……………………
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6. for appeals…………………… 7. keeping of notes…………………… 8. emergencies (you are free to phone me if there is an emergency on the following number……………………). What will you (supervisee) do if I (the supervisor) am not available? Guidelines
The following guidelines/ground rules will guide our time together: 1. confidentiality (what is……………………)
we
mean
by
confidentiality
2. openness/honesty (about work done, the relationship, reports, etc.) 3. line management issues that may pertain (especially where the line manager is responsible for quality issues in the organisation) 4. gossip (any leakage of information in the systems) 5. using feedback to learn. Roles and responsibilities
We have agreed that as supervisor I will take responsibility for: •â•¢ time keeping •â•¢ managing the overall agenda of sessions •â•¢ giving feedback •â•¢ monitoring the supervision relationship •â•¢ creating a safe place •â•¢ monitor ethical and professional issues •â•¢ keeping notes of sessions •â•¢ drawing up the final reports (if needed). We have agreed that as supervisee you will be responsible for: •â•¢ preparing for the supervision session •â•¢ presenting in the supervision session •â•¢ your learning (objectives) •â•¢ applying learning from supervisor •â•¢ feedback to self and to me •â•¢ keeping notes of sessions.
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Evaluation and review
We have agreed that informal evaluation of: •â•¢ supervisee •â•¢ supervisor •â•¢ supervision will take place every sixth session. Formal evaluations will take place every year or as requested by either of us. The criteria against which evaluation of supervisees will take place may be arranged with an organisation or solely with the supervisee and will include criteria or competencies against which the supervisee wishes to be appraised, or competencies given by their organisation. Formal reports will be sent to……………………and can be viewed by…………………… They will be kept at…………………… The process for formal evaluation of supervisees (written) will be: 1. self evaluation 2. evaluation by supervisor 3. initial report by supervisor to be seen and commented on by supervisee 4. final report written by supervisor with space for comments by supervisee 5. report sent to agreed personnel (above). Renegotiation of contract
At any time either party (supervisor and/or supervisee) can initiate discussion around renegotiation of the contract or any part of it. This will be done in advance so that there is preparatory time available. Signed: …………………………………………(Supervisor) Signed: …………………………………………(Supervisee/s) Signed: …………………………………………Others (e.g. organisation or training institute)
Appendix C
Setting goals or objectives
The use of mnemonics are popular here and we explain them below: RAW R meaning Realistic A meaning Attainable W meaning Worthwhile SMART S meaning Specific M meaning Measurable A meaning Achievable R meaning Realistic T meaning Time-bounded MMM M meaning Measurable M meaning Manageable M meaning Motivational (Hay 1995)
A more thorough approach to objectives can be found in Egan’s (1990) seven-point goal-setting checklist and these state that objectives should be: 1. stated as outcomes using the ‘future perfect’ method. For instance, the statement ‘I want to lose weight’ is a description of an aim. To become a goal it needs to be phrased differently, e.g. ‘Within six months I will have lost half a stone’ the past participle being ‘lost’. So goals need to be described as something which are ‘acquired’ or ‘achieved’ or ‘decreased’, as the case may be. 2. clear and specific using the verbal techniques [we discuss in Chapter 8] to recover deep structures. For instance ‘I want to be a better negotiator’ can be made more specific by unpacking what
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‘better’ means and establishing better than what? If the goal is clear and specific it will define what better means, e.g. I will have achieved 90 per cent of my negotiating objectives this month. 3. measurable and verifiable using the clear and specific statement of the goal as above as a basis. Any defined outcome can be verified, either by counting or at least by its presence or absence, e.g. a promotion achieved or not. 4. realistic, depending on the necessary resources being available, external factors not mitigating against it, can be controlled by the supervisee, and the cost not too high. If any one of these is questionable the goal may be unrealistic. 5. substantive meaning that the goal is stretching for the supervisee but not to breaking point. An inadequate goal will be set too low for the supervisee concerned. 6. goals which are inconsistent with a supervisee’s values are unlikely to be achieved as the supervisee experiences dissonance and even distress. 7. a goal to be achieved ‘sometime’ is unlikely to see the light of day. Supervisors are responsible for persisting with the question ‘When?’ so that supervisees can set their goals in exact terms, e.g. ‘I will have qualified by the end of the year.’
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Subject Index
Note: Page numbers in italics refer to figures and tables. ABC process 128, 227–8 academic supervision 156, 158 acceptance, of client 30, 34, 35, 45, 48, 248 active listening 36, 42, 45, 142, 214 Adapted Child ego state (AC) 36, 87, 89, 178 administration supervision task 159, 162 Adult–Adult transactions 91, 92 Adult ego state contamination 90–1, 180–1, 180 and FIT model 108, 142 in supervision 179, 191 in therapy 89–90, 103–4 in therapy and supervision 37, 38 adults, learning process 59–60 advanced empathy 48, 53–5 agency, and learning 60 aggressive communication 133, 134, 209 ‘ain’t it awful’, TA game 98–9, 186–7 alcohol, in families 95 analysts counselling training 156–7 need for debate 85–6 animals, experiments with 122–3 anxiety and CBT 131–2 and group behaviour 235–6 articulation 30, 80, 166–7, 175 assertion training 40 Assertiveness model, in CBT 132–5, 208–9 automatic thoughts 124, 125–6, 135, 136–7, 211 see also negative automatic thoughts (NATs) awfulising, and CBT 127, 210
behavioural approach, to group behaviour 233 behavioural tasks, and CBT 129–30 behavioural therapy (BT) 123–4 believing game 70–1, 72 Bion’s two groups 237–8 ‘blemish’, TA game 100 body work technique, and Gestalt 116 British Association for Counselling and Psychotherapy (BACP) 154, 171 British Psychological Society (BPS) 154, 171 case studies CBT 137–9 Gestalt 202–3 TA 105–7 CBT see cognitive and behavioural approaches; cognitive behavioural therapy Child–Child transactions 91, 92 Child Contaminated Adult 91 Child ego state and contamination of Adult ego state 91, 180–1 and integrative FIT model 142 in supervision 177–8, 191 in therapy 86–7, 89, 103–4, 104–5 in therapy and supervision 36, 37 ‘clean language’ 17, 50 cliché responses 49 client/supervisee contamination 220–2 client/supervisee/supervisor contamination 222 Closet Persecutor, in TA games 100 cognitive and behavioural approaches 40–2, 58 cognitive approach, to group behaviour 234
267
cognitive behavioural therapy (CBT) Assertiveness model 132–5, 208–9 case studies 137–9, 207–8, 209, 210 concepts 125–7 emergence as an integrated approach 124–5 in group supervision 251–3 in individual supervision 227–8 influences on CBT 122–4 integrative FIT model 142, 148, 150 origins 124 role of therapist 140 in supervision 205–12 techniques 127–9, 129–32, 206–7, 212 in therapy 122–40 working with the ‘F’, ‘I’ and ‘T’ domains 135–8 cognitive therapy (CT) 124 complementary transactions 91, 92, 93, 103–4, 181 complete reverse technique, Gestalt 116, 200 conflicting parts, Gestalt 111–12, 194 confluence, Gestalt 114, 198 congruence in group supervision 244, 249 in person-centred approach 30, 31 in therapy and supervision 47–8, 55 connected knowing definition 67 and FIT supervision 29–30 and learning 69, 70–1, 71–3, 74 constructed knowing, and learning 69, 71 constructivist approach see constructed knowing, and learning consultative supervision 154
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consulting, supervision task 162 contact, Gestalt 113, 195–9 contact curve 113, 196, 196 resistance or interruptions 114–15, 197–9 supervision curve 196, 197, 198 contaminated boundaries, in individual supervision 219–22, 219 contamination, of Adult ego state 180–1, 180 contracting in CBT 127, 129 in supervision 187–8 in TA 104, 187 counselling, and supervision 155, 156–7, 161 countertransference 241–2, 249 Critical Parent ego state (CP) in supervision 178, 179, 180 in therapy 88–9, 95, 103, 105 in therapy and supervision 36, 37 crossed transactions 92, 93, 103–4 cyclical model, in supervision 168–75 deep learning 59 deep muscle relaxation, CBT 40, 130, 212 defences, in group supervision 239–42 deflection, Gestalt 114, 198 dependency, in group supervision 237 depreciation, CBT 127 depression and Adapted Child ego state (AC) 87 and Critical Parent ego state 88 and CT 124 depressive position, in TA 101 desensitisation, CBT 131, 132 dialogic contact, Gestalt 112 dialogue, reflective 67, 74–6, 77–82 diaries 40, 135, 210 difficult–easy continuum 32, 33, 245 discourse, prevailing 59, 61, 234 discussion, contrasted with dialogue 67 Double FIT 25, 26, 164, 166 double loop learning 29, 32, 63–6, 65 double matrix model, in supervision 163–7 doubting game 70, 72 dreamwork technique, Gestalt 117–18
Early Life Decisions 88 education, and supervision 155 ego states 36–7, 86–93, 86, 92, 103–5, 177 contaminated 90–1, 90 and integrative FIT model 142 in supervision 177–81, 179 emotion expressing, difficult–easy continuum 245 in person-centred approach 31–2, 32–4, 33 in therapy and supervision 66 empathy and challenge 82 and connected knowing 70–1 definitions 34–5, 48 in group supervision 238, 244, 245–8, 247–8 in person-centred approach 31, 48–53 empty chair technique, Gestalt 39, 115, 147–8, 149, 199, 225–6 encounter groups, in group supervision 244 energy 66, 111, 238, 246 Esalen Institute, Big Sur, California 110 ethical issues, supervision task 161 evaluating, supervision task 163 exaggeration technique, Gestalt 116, 200 existential approach, in group behaviour 233 existential concepts, in group supervision 249–51, 250 existential influences, Gestalt 110–11 explicit approach, impact on learning 58–9 expressing feelings versus talking about feelings technique, Gestalt 117, 201 eye-movement desensitisation and reprocessing (EMDR), CBT 132 facial expression, and advanced empathy 54 feeling (F) in CBT 40, 125, 210 and FIT models 24, 25, 28, 142, 144–9 in Gestalt 39, 109, 203, 204 in supervision 157, 160, 166, 167, 191 in TA 108 feeling rackets, in TA 93, 181–2 females, and learning 68–9 ‘figure’, Gestalt 112, 193 FIT model in CBT 140 in group supervision 232–55
in individual supervision 213–31 introduction 23 in supervision 153–75, 191, 203 in TA 108 in therapy and supervision 58–9 flight/fight, in group supervision 237 flooding, CBT 131–2 Free Child ego state (FC) 36, 87 Freudian psychoanalysis 154, 156–7 games, in TA 93–101 applied to supervision 182–8 Karpman Drama Triangle 94–6, 94, 182–4, 182 other games 97–101 Quinby Durable Triangle 96–7, 96 Gestalt accessing FIT domains 39 case studies 118–21, 202–3 concepts 110–15, 194–9, 196, 197 definition 110 in individual supervision 225–7 integration with TA and CBT 41–2 and integrative FIT model 142, 147–8, 149, 150 introduction 38 role of therapist 118–21 in supervision 192–204 techniques 115–18, 199–201 in therapy 109–21 usefulness to the FIT model 121 gossip syndrome 32 ‘ground’, Gestalt 112, 193 group psychology, in group supervision 232–4 group supervision, using the FIT model 232–55 CBT concepts 251–3 existential concepts 249–51 group psychology 232–4 humanistic concepts 242–9 learning and groups 234–5 life of a supervision group 254 psychodynamic concepts 235–42 use of FIT model 254–5 ‘habeas emotum’, in group supervision 246 ‘here and now’, Gestalt 111, 166–7 holistic approach 41–2, 111, 194, 248
homework assignments in CBT 128, 206 and integrative FIT model 147, 150 in supervision 187–8 in TA 104, 105 human potential movement 85–6, 110 humanistic approach 41–2, 44, 58, 111, 202 in group supervision 242–9 I–It relationship 76, 204 I–Thou relationship 76, 110, 204, 250–1 ‘I’ versus ‘they’ or ‘it’ technique, Gestalt 117, 201 ‘if it weren’t for you’, TA game 99 imagery techniques, CBT 130, 212 implicit approach, impact on learning 58–9 improvement, and reflective learning 62, 75 in vivo desensitisation, CBT 131 inaccurate responses 50 incorporating messages 88 individual supervision 213–31 contaminated boundaries 219–22, 219 FIT model in ongoing therapy and supervision 228–31 uncontaminated 223–5 using FIT 214–18, 215 using FIT in CBT mode 227–8 using FIT in Gestalt mode 225–7 using FIT in TA mode 218–19 industry, supervision in 157–8 influences, Gestalt 110–11 initiating (I) in CBT 40, 40–1, 125 and Double FIT 25 in Gestalt 39 and integrative FIT model 142, 146, 147, 148, 149 and Single FIT 24 in supervision 160, 166, 167, 174, 191 in TA 107, 108 injunctions, in TA 102, 188–9 innner child work, in TA 104–5 integration, of TA, Gestalt and CBT 41–2 integrative FIT model, as a therapeutic approach 141–50 case study 143–9 role of the FIT therapist 150 using the FIT model in practice 141–3, 150 intention, and reflective dialogue 77
Subject Index
269
interpreting responses 50 introjection, Gestalt 114, 197
organisation, supervision task 162 overstating 52
Karpman Drama Triangle antidote (Quinby Durable Triangle) 96–7, 96, 184–5, 184 case study 107 examples in supervision 185–6 games 94–6, 94
pairing, in group supervision 237 paradigm shifts 63, 65 parallel processing 28–9, 57, 76, 78–9, 167 paranoid position, in TA 101 Parent-Child transactions 92 Parent Contaminated Adult 90 Parent ego state and contamination of Adult ego state 90, 180 and integrative FIT model 142 in supervision 178 in therapy 88–9 in therapy and supervision 36 Parent–Parent transactions 91, 92 parental injunctions, TA 148–9 ‘parking’ feelings 33–4 parroting 50 passive aggressive behaviour, CBT 133 passive behaviour, CBT 133, 134 Pavlov’s dog 122–3 Persecutor, in TA games 94, 95, 96–7, 98, 100, 182, 183, 185, 186 person-centred approach and connected knowing 70–1 in early stages 42 in FIT supervision 23, 29, 30 in group supervision 243–4 modelling 80–1 in therapy and supervision 35–6, 44–56 person-centred values 30–5 personal responsibility, Gestalt 111 personal stance, and reflective dialogue 79–80 phenomenological influences, Gestalt 110–11 phobias, CBT 130–2 ‘poor me’, TA game 97–8, 186 practitioner supervision 154 prevailing discourse 59, 61, 234 ‘prizing’ 30, 34, 35, 48 procedural knowing learning perspective 68–9 process-based supervision, CBT 206 process, definition 78 professional issues, supervision task 161 projection, Gestalt 114, 197 in group supervision 239, 240–1, 249 projective identification, in group supervision 239–40, 241–2 psychodynamic approach in group behaviour 233, 235–42 impact on learning 58–9
leaking emotions 32, 33 learning, and groups 234–5 learning theory, in therapy and supervision 57–82 adult learning process 59–60 and emotion 66 impact of implicit and explicit approaches 58–9 levels of learning 61–3 prevailing discourse 61 reflective dialogue 67, 74–6, 77–82 reflective learning 67 and relationship 76–7 single and couble loop learning 63–6, 64, 65 stages of learning 68–73 letting the body speak technique, Gestalt 116, 200 life positions, in TA 101–2, 188–9 life scripts, in TA 101–2, 188–9 listening, active 36, 42, 45, 142, 214 Little Albert Experiment (Watson) 123 logs (written), CBT 40, 135, 210 low frustration tolerance (LFT), CBT 127 maladaptive thought patterns 124 maps, of reality 124, 126 mechanistic view of change 123 men, and learning 70 modelling, reflective dialogue 80–2 naming the unnamed 30 negative automatic thoughts (NATs) 124, 125–7, 128, 207–8, 210 negative learning experiences 123 New York Institute for Gestalt Therapy 110 ‘nigysob’, TA game 100–1, 187 non-directive approach see personcentred approach non-emphatic responses 51–2 Nurturing Parent ego state (NP) 36, 89, 178
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psychotherapists see therapists questioning responses 49–50 Quinby Durable Triangle, in TA games 96–7, 96 rational emotive behaviour therapy (REBT) 128, 129, 210, 227–8 rational emotive therapy (RET) 124, 128 real-plays 104, 181, 187, 199, 254 reality, social constructionist stance on 60 Rebellious Child ego state (RC) 36, 37–8, 87, 178 received knowing learning perspective 68, 69 referrals, to therapy 29 reflective dialogue and adult learning 59–60 definition 67 and learning 74–6 requirements 77–82 in supervision 172 reflective learning 55, 60, 61–3, 153 about learning 62, 75 in group supervision 234, 249 promotion 67 reflective practice, and FIT 29–30, 143 relating, supervision task 161 relationship, and learning 76–7 relationships, inability to form intimate 88 Rescuer, in TA games 94, 95, 97, 99, 182, 183–4, 185, 186 resistance, Gestalt 114–15 retroflection, Gestalt 114, 198 role-plays 206 safety 242 ‘see how hard I’ve tried’, TA game 99 self-beliefs, CBT 40 self-change, Gestalt 111 self-disclosure, ‘history’ form 47–8 self-hatred 88 separated knowing 67, 69, 70, 72, 73 seven-eyed model 163–7, 165 silence learning perspective 68, 69 Single FIT 24–5, 24 single loop learning 63–4, 64 skills-based supervision, CBT 205–6 social constructionists 60, 234–5 social process, learning as a 60–1 Socratic questioning 163, 172
speaking in the present versus the past tense technique, Gestalt 117, 201 ‘stages’, and life of a supervision group 254 stress management 31, 130, 132 structural analysis, in TA 86–91, 103 supervision 177–81, 177, 179, 180 subjective knowing learning perspective 68, 69 supervisee matrix, in supervision 164, 165–6, 165 supervision 153–75 cyclical model 168–75, 169 definition 153 double matrix model 163–7, 165 functions and tasks 158–63, 159, 160 historical sources 156–8 modern supervision 154–5 purpose 155–6 sources and existing models 155–8 supervisor, in TA, role 190–1 supervisor matrix, in supervision 164, 165, 166–7 support 242, 247–8, 250, 250 systematic desensitisation, CBT 40, 131
transactional analysis (TA) accessing FIT domains 37–8 case studies 105–7 games 93–101, 182–8 and individual FIT supervision 218–19 integration with Gestalt and CBT 41–2 integration with TA and Gestalt 150 introduction 36–7 role of the TA therapist 105–8 and structural analysis 177–81, 177, 179, 180 in supervision 176–91 and TA therapy 91–3 techniques 190 theory of personality 86–91 in therapy 85–108 transactions, in TA analysis 103–4 transference, Gestalt 112, 241–2 transformation, and reflective learning 62, 62–3, 64–6, 74–5 transformational learning 30 transparency, and reflective dialogue 77–9 Triple FIT 27–9, 27, 164, 167, 214–16, 215 trust 70, 142, 242 in person-centred approach 30, 44, 45–6
TA see transactional analysis taken for granteds (TFGs) 63, 64, 66, 74, 75 task, definition 78 teaching, supervision task 162–3 theory of personality, in TA structural analysis 86–91 therapists professional development 154 responses to clients 49–53 role of CBT therapist 140 role of FIT therapist 150 in TA, role 105–8 ‘there and then’, Gestalt 111 thinking (T) in CBT 40–1 and Double FIT 25 in Gestalt 39, 109, 204 and integrative FIT model 142, 147, 148 and Single FIT 24 in supervision 160, 166, 167, 174, 175, 191 in TA 107, 108 third force 44 Thought Record Sheets, CBT 126, 135–8, 211 ‘top dog’, Gestalt 112, 199 trainee supervision 154
unconditional positive regard 34, 244, 249 in person-centred approach 30, 35, 44, 48 uncontaminated individual supervision 223–5 ‘underdog’, Gestalt 112, 199 understating 52 unfinished business, Gestalt 112, 195 United Kingdom Council for Psychotherapy (UKCP) 154, 171 Victim, in TA games 94, 95–6, 97, 99, 182, 183, 184, 185, 186 visualisation, CBT 130, 212 Western education 66 and emotion 31, 32 ‘what’ and ‘how’ versus ‘why’ technique, Gestalt 116, 201 wholeness concept, Gestalt 110 women, and learning 68–9 ‘wooden leg’, TA game 100 ‘yes, but...’, TA game 98, 186
Author Index
Note: Page numbers in italics refer to figures and tables. Alberti, R. 132, 208 Alonso, A. 153 Argyris, C. 63 Asch, S.E. 251 Assiter, A. 81 Bachkirova, T. 153 Bandura, A. 123, 233, 251 Barlow, D. 130 Barnes, B. 233, 238 Bateson, G. 251 Beck, A.T. 124, 125–6 Beech, N. 60 Belenky, M.F. 55, 67, 68–9, 70, 71, 73 Berenson, B.G. 82 Bernard, J.M. 155 Berne, E. 36, 37, 85–6, 88, 89, 93, 100, 101–2, 104, 177, 179, 182, 187, 188–9 Bion, W. 235, 237–8, 239, 242, 244 Blocher, D.H. 168–9 Bohm, D. 67 Bower, G. 132–3 Bower, S. 132–3 Bowlby, J. 235, 236, 244 Bradshaw, J. 105 British Association for Counselling and Psychotherapy (BACP) 18, 154, 171 British Psychological Society (BPS) 154, 171 Brockbank, A. 30, 32, 33, 45, 48, 59, 59–60, 63, 64, 65, 74, 77, 170, 244, 245, 250 Brookfield, S. 77 Brown, A. 153 Brown, T. 130 Buber, M. 76, 110, 204, 250 Bullock, A. 48 Burr, V. 59, 60, 61, 234
Carkhuff, R.R. 81, 169, 234 Carroll, M. 153, 159, 160–1, 160, 162, 170 Casey, A. 130 Centre for Outcomes Research and Effectiveness (CORE) 206 Chickering, A. 251 Clinchy, B.M. 55, 67, 68–9, 70, 71, 72, 73 Cooper, C.L. 31 Corey, G. 38, 40, 109, 111, 114, 115, 118, 124, 125, 130, 131, 140, 197, 206 Corsini, R. 40, 110, 122, 123, 147, 213 Cox, E. 153 Cristol, A.H. 76 Daloz, L. 63 De Bord, R. 233, 237, 238, 241 Delworth, U. 153, 156 Department of Health and Social Security (DHSS) 155 Dryden, W. 130 Egan, G. 32, 33, 35, 49, 50, 52, 55, 81, 82, 142, 143, 169, 235, 239, 245, 245 Ekstein, R. 153 Elbow, P. 70, 72 Ellis, A. 123, 124, 126–7, 128–9, 234 Emmons, M. 132, 208 Ernst, S. 233, 238 Ferenczi, S. 241 Fish, S. 110, 112, 115, 117 Fordham, F. 235 Foulkes, S.H. 235, 239 Gamson, Z. 251 Geertz, C. 72 Giddens, A. 66 Goble 44, 123
271
Goldberger, N.R. 55, 67, 68–9, 70, 71, 72, 73 Goodman, P. 194 Goulding, M. 88, 102 Goulding, R. 88, 102 Greenberger, D. 135, 210 Grove, D. 50 Guevremont, D. 132 Hardy, E. 156 Harris, A. 90, 91, 99, 100, 101, 103, 104 Harris, T. 86, 87, 88, 90, 91, 93, 97, 98, 99, 100, 101, 103, 104, 105, 147, 181 Hartley, P. 235 Hawkins, P. 64, 65, 153, 155, 156, 159, 162, 163, 165, 167 Hay, J. 261 Hefferline, R. 194 Heron, J. 162, 236 Hertz, L. 130 Hess, A.K. 153, 156 Holloway, E.L. 153, 157 Hyde, K. 233, 238 Inskipp, F. 76, 153, 155, 156, 158, 159, 160 Jacoby, M. 241, 250 James, M. 148 Janis, I. 251 Jensen, M.A.C. 254 Joines, V. 89, 93, 94, 97, 101–2, 182, 189, 213 Jongeward, M. 148 Jourard, S.M. 31 Kadushin, A. 155 Karpman, S. 94–6, 94, 97, 99, 182–6, 182 Kennerley, H. 205 Kolb, D. 63, 64
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Lapworth, P. 110, 112, 115, 117 Lazarus, A. 123 Leahy, R.L. 125–6 Leddick, G.R. 155 Lee, V. 48 Lieberman, M.A. 244 Loganbill, C. 156 Luft, J. 235, 246 McGill, I. 30, 32, 33, 45, 48, 59, 59–60, 63, 64, 65, 74, 77, 170, 244, 245, 250 McLeod, J. 239, 240 Maslow, A.H. 44 Mattinson, J. 153 Mearns, D. 34, 35, 47, 48, 82, 245 Metanoia 176 Mezirow, J. 66 Miles, M.B. 244 Miller, A. 236 Mitchell, K.M. 82 Neumann, J. 240 Nitsun, M. 236 Orbach, S. 31 Padesky, C. 135, 210 Page, S. 156, 161, 168, 169, 169 Pavlov, I. 122–3 Perls, F. 10, 38, 109–10, 111–12, 115, 117, 194, 195, 198, 199, 200 Perry, W. 68, 70 Polster, E. 110, 111, 112, 113, 113, 114, 115, 194, 195 Polster, M. 110, 111, 112, 113, 113, 114, 115, 194, 195, 197 Proctor, B. 76, 153, 155, 156, 158, 159, 160 Quinby, L. 96–7, 96, 184–5, 184 Rayner, R. 123 Ridgway, I. 124, 125 Rogers, C.R. 16, 24–5, 34, 44–7, 48, 49, 55, 81–2, 243, 244, 248, 256 Rowan, J. 234 Schön, D. 63 Shapiro, F. 132 Shohet, R. 65, 153, 156, 159, 162, 163, 165, 167 Sills, C. 110, 112, 115, 117 Skinner, B.F. 122 Sloane, R.R. 76 Smith, N. 153, 155
Spiegler, M. 132 Stafford-Clark, D. 235 Staples, F.R. 76 Starak, Y. 192–3 Stewart, I. 89, 93, 94, 97, 101–2, 182, 189, 213 Stoltenberg, D. 153 Tarule, J.M. 55, 67, 68–9, 70, 71, 72, 73 Thorne, B. 34, 35, 47, 48, 82, 245 Trombley, S. 48 Trower, P. 130 Tuckman, B.W. 254 United Kingdom Council for Psychotherapy (UKCP) 154, 171 Van Deurzen-Smith, E. 233 Wallerstein, R.W. 153 Walters, R.H. 123, 233, 251 Watson, J.B. 122–3 Wedding, D. 40, 110, 122, 123, 147, 213 Whipple, K. 76 Winnicott, D.W. 235, 236 Wolpe, J. 123, 131 Wosket, V. 156, 161, 168, 169, 169 Yalom, I.D. 233, 244 Yontef, G. 111 Yorkson, N.J. 76 Zinbarg, R. 130 Zinkin, L. 153
