Avoid the trap of narcissistic co-narcissistic relationships in supervision

Supervision is a term that often causes much debate within counselling and psychotherapy circles. It was once considered to be something you ‘got landed with’ by virtue of being the most experienced practitioner within an organisation.  Implicit in this view was that therapy should be conducted in a right way and, therefore, not in a wrong way, and that supervision should be arranged and facilitated by the most senior and most experienced therapist, regardless of their competence, knowledge base, attitude or management skill.  This hierarchical view of supervision is possibly reflected in working practices within organisational settings where managers are worried of things going wrong and being the subject of a claim or complaint. The NHS is a case in point whereby supervision is more likely to be for those further down the food chain. Consultants in the NHS are not routinely offered clinical supervision as part of their working arrangements. Whilst some might engage in loose forms of reflective practice listening with their colleagues there is no formal supervision arrangements, certainly not as psychotherapists would understand it.

Some therapists see supervision as a box filling exercise, and something which they are required to undertake, whilst others view it as an opportunity to merge with the person who they like and respect. I recall from my training days when certain trainees would choose their personal private supervisor on the basis that they were similar in outlook and where there was a great deal of deference and admiration. In such cases I was left wondering about the motivations of such individuals in their choice of supervisor.

Clients can also have differing views on how supervision could be defined and what the process entails although they rarely show much interest. When they do they sometimes wonder if their personal material will be discussed with a stranger and consequently if their privacy and confidentiality could be compromised and can, as a result, be defensive about the thought that the therapist is engaging in such a process.

So, how is clinical supervision defined by professional accrediting bodies?

The UKCP defines supervision as a reflective and evaluative process conducted within an articulated working relationship between a qualified or trainee psychotherapeutic practitioner and an appropriately knowledgeable supervisor. The BACP Ethical framework says the following: ‘A specialised form of mentoring provided for practitioners responsible for undertaking challenging work with people. Supervision is provided to ensure standards, enhance quality, advance learning, stimulate creativity, and support the sustainability and resilience of the work being undertaken.’ In Hawkins and Smith 2006 Professor Hawkins defined supervision as: “The process by which a Coach with the help of a Supervisor, can attend to understanding better both the Client system and themselves as part of the Client / Coach system, and by so doing transform their work and develop their craft.”

Clinical supervision is different to consultative supervision and informal reflective practice. Consultative supervision and reflective practice can potentially take place with anyone whereas clinical supervision might typically take place with another therapist who is appropriately qualified, and usually accredited (although a lot of supervision training is not associated with a formal accrediting body). Supervision is now a core component of continuing professional accreditation (cpd) and, indeed, is now viewed as a discipline in its own right with its own training route.

Supervisors should not follow outdated rulebooks

Supervision is not personal therapy. However, it would be naïve to think that the therapist’s personal material is not also relevant within the discussions in a supervision session. I recall from my training days a strict demarcation enforced by some supervisors between what was considered appropriate for the content of clinical supervision and what was considered personal material. I felt at the time that this demarcation to be a bit mechanical, as if the supervisor was following an outdated rulebook. It was almost like the supervisee could not refer in any way to any personal material possibly triggered by client material.  Such material was considered to be something that should be taken to personal therapy.  This approach, I feel, can be potentially shaming for the supervisee. It is my view that a good supervision session allows for a wide ranging airing of views and should not be restricted to strict mechanical ways of working. Supervisees should, of course, remain open-minded and inquisitive about other options when presented with a view about ways of working in supervision but should also avoid the temptation to hand their authority and accreditation away to others.

I wonder if the work of David Rennie on deference in the client therapist relationship could also be usefully applied to the supervisee–supervisor relationship. Indeed, I often muse if the word supervision almost unconsciously sets up the potential for a narcissist co-narcissist relationship. The supervisee can potentially be approaching the supervisor in the child ego state rather than entering into an adult to adult form of communication or as one professional to another.

Themes of control, management, hierarchy and power are often associated with the term supervision, particularly in periods of formal training. This ethos of deference is probably not that surprising since trainees need the supervisor to effectively approve them during periods of continuous assessment. However, the good trainees will be the ones who form their own opinions and learn to trust their own intuition rather than deferring to another.

Putting supervisors on pedestals is dangerous

Liking your supervisor is perhaps not an all together bad idea but putting them on pedestals is dangerous, as this is when narcissistic co-narcissistic relationships can take hold. The co-narcissist part of the relationship has the potential for an ego driven supervisor to feel boosted when in receipt of such admiration. When this happens the supervisor can fill the role of being a know-it-all.

A more mature approach to supervision might be to view the process as one professional exchanging unconscious material with another in an open-minded pursuit of different perspectives. In such an open-minded approach it can perhaps be useful to flirt with your hypothesis but not to marry it.

Parallel processing might result when the supervisor and supervisee re-enact in their relationship something that the client is not expressing. This form of projective identification might feel uncomfortable for the supervisee, and might not feel enjoyable, but could ultimately prove very useful for understanding the client better. An example of this might be a client who presents with historical shame and the therapist starts to connect with their own shame with the supervisor. This might be what Margaret Rioch referred to when she wrote about increased self-awareness for both parties. Feeling discomfort might actually be where the crux of the work might be residing rather than the apparent comfort zone when seeking to merge with the supervisor. Working in this way would be difficult if one party has been put on a pedestal by the other.

Role reversal can be useful, as the Gestaltist author Yontef suggests in the Handbook of Psychotherapy Supervision (Watkins, 1997 p158), in the exploration of counter-transference and gaining a different perspective. This can potentially involve the therapist playing the role of their client and acting in an ‘as if’ capacity. The therapist can act as if they are the client in the supervision setting and this way of working can be transformative in helping to realise unconscious material. This way of working might be difficult in a narcissist co-narcissist relationship.

Supervision should be like going on retreat

Rather than supervision, I prefer the terms ‘all vision’ or even ‘independent consultation’ as a process whereby the therapist can explore client material with a professional colleague. Supervisees should not feel like they need to justify their interventions with clients, or have to ponder too long as to whether they are ‘doing it right’. I don’t believe that the supervision consultation should be about right and wrong ways of working but for the exercise to have value it can offer the opportunity for the therapist to gain access to their own blind spots in their unconscious material and to consider other ways of working. Approaching the process in this manner will help protect against the risks associated with the creation of a narcissist co-narcissist relationship.

I like how Lady Diana Whitmore refers to supervision as akin to going on retreat where the therapist can explore client material in an uncensored way. This approach is very different to the tick box exercise when the therapist is required to fulfil professional accreditation and licensing requirements or to satisfy organisational demands. Supervisees attend sessions to stop and listen and to open their awareness. However, for the process to be effective it needs to be a two way process. The supervisor is providing the space for retreat, the holding for retreat and the transpersonal context for retreat, not sharing their own frustrations with their working day or the state of the profession.  I like what Houston says (1995, p95) that the supervisor takes the supervisee forward at the right pace toward self-confidence based on reality and toward abundant motivations.   This is when supervision is a containing and an enabling process rather than an educational or even neccessarily a therapeutic process.

See also

Hawkins and Shohet devised the 7 eyed model of supervision. See my interview with Robin Shohet. 

The 7 eyed model of supervision is:

Eye 1: Focus on the Client
Eye 2: Focus on Interventions
Eye 3: Focus on Client-Therapist Relationship
Eye 4: Focus on Therapist’s Process
Eye 5: Focus on Therapist-Supervisor Relationship
Eye 6: Focus on Supervisor’s Process
Eye 7: Focus on Wider Context

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Are fidget spinners a useful learning tool?

Have you heard of fidget spinners?  If not, you might be surprised to hear then that they top the lists of the best-selling toys on Amazon UK.  They are the latest craze amongst school children and are being hailed as a learning tool to help kids suffering from inattentive states of mind.

Today I was interviewed on Sky News about the latest craze of fidget spinners and the potential benefits for kids using the devices. See the link to the interview here http://news.sky.com/video/fidget-spinners-the-issues-debated-10881551 The central issue, it seems to me,  is whether these devices can be effective stress management tools in addition to being an aid to learning for kids suffering with the negative aspects of attention deficit hyperactivity disorder (ADHD), or whether they are distracting and could cause problematical behaviour in themselves.

The marketers claim that the devices can be an aid to learning for those suffering from ADHD in the classroom as well as potentially relieving the symptoms of ADHD itself, autism and even post-traumatic stress disorder (PTSD). These are big claims.

However, there are no clinical research findings to support these views, at this stage of their usage. At best what could be said is that there might be anecdotal evidence to suggest that these devices may help inattentive kids to concentrate on their learning. However, it would be inaccurate to suggest that these devices support the learning capacity of such kids, particularly those suffering with symptoms associated with ADHD.

These spinner devices are visually distracting which could be their major drawback. Some of the devices have lights on them which could make them further distracting in addition to the whirr sounds. This could potentially act as a mitigating factor against their usefulness as a learning tool. Other fidget devices, which don’t have the visual distractions, could possibly be better gadgets as an aid to learning for kids suffering from inattention. Indeed, good old stress balls (with no visual distractions) would be more effective as an aid to learning for inattentive kids.

Riding a stationary bike whist reading would offer the potential for small and non-distracting motor movements. Fidget Spinners,however, don’t require gross body movement, which is needed for increasing the activity of the frontal and prefrontal parts of the brain that are responsible for sustaining attention.

Problem behaviour, as with any dependence on any gadget, is when negative consequences begin to occur in other aspects of the user’s life or when they act as barriers to communication.  Addiction is the search for emotional satisfaction. It is worth asking what happens to the emotional regulation and mood when the device is not available. The key is that kids are taught how to use these devices appropriately so that they do not prove to be distracting to their learning but can be used in a constructive way.

If you are a parent and worried about your child potentially having ADHD it could be worth a consultation with your GP who will be able to direct you to the appropriate support services. See the NICE guidelines for more information on support for ADHD.

See also

My son is addicted to computer games

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Chemsex partygoers and improving access to psychological services

I often wonder how the whole field of counselling and psychotherapy could help to better address the needs of those who are essentially most in need of psychological support. Men, for instance, who suffer from depression often present as angry individuals but the anger is often hiding the pain of depression. Depression in men is so often difficult to identify as it can be accompanied by displays of angry behaviour in social situations. Men, in effect, can more easily end up in prison than in a therapist’s room.

The stigma for men surrounding not only drug use but also gay sex can act as a barrier for individuals who really need help accessing psychological support services. The drug-fuelled party lifestyle associated with chemsex can destabilise the mental health of those already suffering from pre-existing mental health problems. These issues will be presenting more and more in the coming years in counselling rooms with the advances in mobile telephony and hookup apps. But a prevalent culture of silence, secrecy and stigma in the chemsex world can keep individuals isolated from accessing services. Chemsex users perhaps need to be reassured, more than any other client group, that they will be understood, and not judged, if they do end up presenting for help.

Therapy can offer people a vital place of safety to unravel their story so that greater insight can be obtained for problem behaviour. It can be common for attachment issues to get played out in all forms of addiction, as well as past traumas and previous psychological wounding.  Therapists need to be even more aware of their need to make personal connection with the presenting issues with such clients. An abstinence based approach might not always be appropriate for them, at least initially, as the thought of complete abstinence might make them run away. Harm reduction and psycho education could be useful areas to cover as well as the principles and ethos of motivational interviewing. These clients are often in a contemplative mode when assessing the options about their future intentions. Chemsex users are familiar with high adrenaline excitement as a means of mood regulation and will be easily frightened about slowing down and getting in touch with difficult personal material that might threaten their equilibrium.

Chemsex parties offer excitement and the apparent lure of social connection. However, for those vulnerable to psychological wounding the lifestyle can be a dangerous playground and chronic feelings of aloneness can persist. Addiction can be viewed as a search for emotional satisfaction, as a place of safety, balance and comfort. If the connection in the consulting room is robust the underlying psychological issues will get played out in a safe environment through projections and transferences.

To read more about chemsex and what is involved see my article: When the chemsex parties stop being fun

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The drama triangle and asking for your needs

I believe that transformation in psychotherapy is when insight is achieved into one’s historical ways of operating in the world, that are not serving well, and personal qualities are harnessed to bring about change and a different way of behaving with other individuals. Therapists from different modalities will often seek to accuntuate the theoretical differences between each other and point to their own particular (and unique) training but ultimately, however, I believe we are all behaviourists. After all, we are all trying to help our clients to bring about changes in their behaviour so that they can enjoy more effective relationships – whether that is in their personal, family or business lives.

Stephen Karpman, a student of Berne’s Transactional Analysis, coined the term ‘drama triangle’ when he outlined the roles of persecutor, rescuer and victim. My latest article is on the drama triangle and asking for your needs so that you can avoid the victim role.

For more information and background on the drama triangle see this video below:

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Men are at greater risk of physical illness from chronic anxiety

ecnpA major research study from the European College of Neuropsychopharmacology (ECNP) and the University of Cambridge reported on its findings earlier this week. The study involved tracking over 16000 Britons over a period of 15 years and found that men who suffered from anxiety were more at risk of dying from cancer as those men who don’t suffer from anxiety. It also found that the correlation held true regardless of other risk factors to cancer such as the levels of alcohol consumption, smoking and the rate of physical activity. There were a few standout points from the study. One of which was that the association was not shared by women.

Why are men more likely to suffer greater physical risk from chronic anxiety?

The results of this new study lend another piece of evidence that links chronic fretfulness to  sickness and death in males. However, the evidence still leave doubts over why this should be. An obvious, and perhaps lazy, explanation might be that men tend to smoke and drink more alcohol and don’t look after themselves as well as women. However, after researchers compensated for those factors, the strong association remained.

There are other studies that could add weight to the recent study to show the greater risk of physical illness from chronic anxiety (thanks to a Times2 article on the subject by John Naish).

A Finnish study in 2014, that tracked middle aged men for over 23 years, found that men who scored highly for anxiety were more vulnerable to the risk of death from all causes, not just from cancer.

A recent University of Edinburgh study found that those with ‘subclinical’ depression or anxiety had a 29 per cent increased risk of dying from heart disease and stroke over a decade than those who did not. ‘Subclinical’ is a term used to define a scenario whereby sufferers thought it unworthy of medical attention. It must be said that Dr Tom Russ, who led the study, is not saying that anxiety actually causes illness. His point is that the results of the study may show an association but the proof for causation might not be present. For instance, it could be that individuals with undiagnosed cancers suffer from pains that cause anxiety, although that doesn’t appear to explain it fully.

men-and-anxietyIt could be that chronic anxiety in men causes physical reactions that ignite the body’s defences, thereby sparking long-term inflammation that in turn may cause a wide range of illnesses such as cancer. For example, psychiatrists at the VU University Medical Center in Amsterdam reported that  men who develop anxiety disorders in adult life show significantly raised levels of inflammatory chemicals in their bloodstream, such as C-reactive protein (CRP), a phenomenon not occurring with women. CRP is not in itself necessarily harmful, as it can play a very useful role in the immune system such as protecting against the threat of infections, but can be dangerous if they persist at chronic levels. In particular, they are linked to a raised risk of developing cancers, heart disease and even diabetes. The production of CRP can also occur from sleep disturbance associated with anxiety.

Furthermore, psychiatrists at the Emory University School of Medicine reported that chronically raised levels of inflammatory chemicals can cause the brain’s centres, that initiate our fight-or-flight response, to become overactive (an area of our brain called the hypothalamus).

gut-fear“Gut fear”, that wrenching physical symptom of anxiety when your body is telling you to watch out because there is danger ahead, seems to have a physical affect on the brain. Evidence points to how inflamed stomachs damage our mental states, through neurological links such as the vagus nerve, which links our gut and brain, and by changing the balance of the billions of bacteria that thrive in our guts. For a full explanation on the physical symptoms of anxiety see the Anxiety UK website.

Scientists at the University of Exeter found that when people with depression, a common result of chronic anxiety, were given drugs to block the effect of their bodies’ inflammatory chemicals, their symptoms were mildly alleviated.

Such evidence clearly demonstrates the need for men to take seriously the deadly impact of anxiety.  Therapy can be a lifesaver for men but they invariably only attend when things are at a crisis point in their lives. We all need to address why men find it so difficult to reach out for support and there are no easy answers.

For more information on what works for the treatment of anxiety see my most recent article on Manxiety: The Importance of Men addressing their anxiety.

See also:

The acute mental health needs of men
Engage with the power of imagination to ease anxiety
Help your brain to reduce anxiety
Self discipline exercises that will ease your anxiety
Anxiety UK – for information on symptoms

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Making better decisions

making better decisionsI always find it interesting when people not trained in psychology adopt tools, techniques and insights from the field and start to practice them in their particular area. Sports coaches are increasingly using psychological insights to improve elite performance in individual and teams sports.  Another area is the investment sector to boost one’s ability to improve upon their decision making. Michael J. Mauboussin, an investment strategist, has written a well researched book entitled ‘Think Twice – Harnessing the Power of Counter Intuition’ and has produced an interesting set of statistics, case studies and self-help tips to help improve the way we make decisions.

The power of intuition was an influential theme running through my psychotherapy training.  But, intriguingly, whilst Mauboussin encourages us to trust our intuition in the decision making process, he also cautions against overly relying upon it.

We all make poor decisions in all aspects of our lives from time to time. Even the people with the finest brainpower regularly make mistakes. The 2008 financial crisis is a classic example of that. Nobody embarks upon their day with the intent of making poor decisions. Poor decisions can emanate from cognitive biases and a failure to spot when we are acting from a blind spot. So, how might a person prevent new distortions from arising and bring more awareness to their distorted thinking?

The business of decision making can be highly complex. However, by instigating a few simple, yet counterintuitive habits, we can position ourselves to make better decisions.  See my article on Counselling Directory for some ideas to help improve your capacity to make better decisions more often.

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To-do lists and how to help your brain run more efficiently

listsI have often wondered whether the compiling of to-do lists merely fuel our anxiety or help to ease our worry in an era of information overload. If you are anything like me you might fret about the unfinished tasks on a list rather than rejoice about the accomplishment of the tasks that you do manage to finish. There is no doubt that it feels good to tick a task as completed but what about the ones that get left as unfinished at the end of the day? It is interesting what Daniel Levitin, author of The Organized Mind, has been saying about how we can help our brains run more efficiently by devising categories within lists so that we are more productive. Apparently, our brains can only hold between four to seven pieces of information at any one time. This is when lists, containing categories of tasks, can help to offload a lot of the difficult work of the brain into the environment. Index cards, with short lists, can be very useful when making presentations or preparing for exams.

Andy Murray motivational speechThe current Wimbledon tennis champion Andy Murray was once a little bit wayward with the disclosure of his list in the form of motivational tips. A journalist at the Rotterdam Open in 2015 snapped a list of his motivational tips courtside (see picture, opposite) which contained some of the following:

  • be good to yourself
  • try your best
  • be proactive during points
  • focus on each point and the process
  • try to be the one dictating
  • stay low on passes and use your legs.

Sir Richard Branson once said “I live by to-do lists” but the key, for him, was to actually do them.  So, can lists help to make your brain run more efficiently for you and are you curious about the possibility of boosting your levels of productivity? Why not give it a try. What’s the worst that can happen?

Learning to cope with having unfinished tasks on your to-do list at the end of the day might be your biggest challenge. For more information on lists see my article: How to organise your brain more efficiently

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Existentialism and integral studies

Existential thinkingIncorporating existential thinking into an integrative approach to psychotherapeutic practice has always been a huge influence for me.  An existential approach may have its limitations but there are a number of ideas within the approach, not that the approach is always coherent and uniform, that can be of enormous benefit when seeking to view the whole person in therapy. Take, for example, the ‘ultimate concerns’ or also known as the givens in life; inevitability of death, isolation/aloneness, freedom/responsibility and a search for meaning. It can be beneficial to view life struggles and associated psychological stress from the framework of how we relate to these concerns.  Do we, for example, engage in addictive behaviour as attempts at making connection and forging meaning in our lives? Do we stay in unhealthy relationships to avoid the fear of aloneness? Do we stay busy to avoid the anxiety associated with these concerns? Have we reconciled ourselves to the inevitability of our own physical demise?

Sometimes these questions are forced upon us, such as at times of great distress due to health matters, but it need not be that way. Once we begin to align ourselves to the challenges presented by the ultimate concerns we can achieve a new freedom in the present moment. New energy is found to live more meaningfully today. This is what it means to be truly present. An old sage once said that it is crucial to avoid the danger of getting to the day of your death only to realise that you have never lived.

See also my latest article on aligning to the four givens in life as a way of setting yourself free.

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How to avoid the victim role and enjoy better relations

Karpman drama triangle

Steven B. Karpman, M.D. – 

Do you regularly find yourself blaming others for your plot in life? Do you often feel helpless and powerless in your dealings with other people? Do you struggle to make decisions and enjoy pleasurable experiences in life? If these questions resonate with you then you may be triggering the victim mentality when dealing with other people.

The “Karpman drama triangle” is a useful tool in bringing awareness to how humans relate to each other and can be attributed to Dr Stephen Karpman, a student of Eric Berne’s Transactional Analysis. Berne was a Canadian psychiatrist and was the author of The Games People Play. Karpman borrowed heavily from Berne and used triangles to map conflicted or drama-intense relationships and involves three people unconsciously playing out three roles that mirror their attitudes and behaviour. Whereas Berne used the parent/adult/child triangle Karpman used persecutor/victim/rescuer. Karpman referred to them as being the three aspects, or faces of drama.

Rescuers tend to find victims, as victims are seeking saviours. Co-dependent relationships involve one person enabling another’s laziness, addiction, recklessness, emotional immaturity or irresponsibility. Persecutors will blame the victims and criticise the enabling behaviour of rescuers.

A way of seeking to “escape” the Drama Triangle is to firstly bringing more awareness to how you operate in the world. The target is to function as an “adult” and not participate in the game. Once you gain greater  insight into the way you operate in the world you can free up negative psychic energy. There is a fresh flow of vitality and positive energy when you realise that that there are other, more positive, ways of behaving. The dynamic of your relationships can change for the better.

For more information see my article:  How to avoid the victim role and enjoy better relations

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Better understand your attraction to the bad boy

The term bad boy could be seen as a cultural archetype and in the movies James Dean’s 17-year-old character Jim Stark in Rebel Without a Cause would be a bad boy archetype.  A modern Jungian perspective would view an archetype as a primitive mental image inherited from our earliest human ancestors, and is present in the collective unconscious. For Jungians, the collective unconscious is a universal datum. Everyone is endowed with this psychic archetype from birth. It is innate and, therefore, cannot be acquired by conscious effort.

Think of an archetype as the best example of a specific category and Superman as the archetype of a superhero. To discover why you might be attracted to the bad boy read my latest article: better understand your attraction to the bad boy

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