Lecture: Ethics: mine, ours, theirs

There was a GASi competition this year for the most narcissistic comparison. And I won. Do you know what they said about Foulkes when he came to London’s analytic milieu?: “One of the continental males who were not very effective”. Do you know what they said about me when I came to London’s analytic milieu?: “She is a supervisor who is somewhat passive in the face of difficulties”.

A group that I supervised a couple of years ago, consisted of 4 members which had a relatively long experience of psychotherapy, but with different levels of formal psychotherapy training. They were Maja, Victor, Petra and Albertina and with their permission I am sharing our experiences now. The members of the whole group, including me as their supervisor, have had a long-term professional cooperation through working at the same clinic, but we also socialise in various non-formal contexts. After having explicitly elaborated my motivation and needs, I invited into our group those members who expressed their desire and need to have their cases supervised in previous informal discussions. The duration and frequency of supervisory sessions was agreed beforehand so the same group met regularly once a week during one year. A supervisory session lasted 90 minutes.

Vignette 1

Petra announced to her therapy group that they will continue working in the same arrangement until the beginning of summer, and will then proceed in private setting after holidays, starting in fall, meaning they will have to pay for the therapy. They were all very surprised, asking where to go, why… She shares with us the uneasy feeling of having to break this news to the group, she felt anxious and was barely able to say it aloud, overwhelmed with the feeling of apprehension. Nevertheless, she felt with all her heart that she had to make the necessary change because she was sick and tired of the hospital setting and felt that she cannot go on like this anymore.

Victor comments -indeed, it is a big change, and asks me can you do that with the group, has anyone done that?

I told them this is about the change of the setting. That therapeutic setting is very important, that Petra cannot stand its oppressiveness anymore and has to change it. It is of utmost importance that we, as therapists feel good about ourselves and the setting we work in, in order to be able to help. On the other hand, this is a very delicate situation because it looks as if Petra is using her group as her own transitional object, a group as a whole, that will help her to become independent therapist. I repeat, the way we as therapist experience the setting is extremely important, but we always have to keep in mind ethical issues of our decisions, in relation to our patients.

The same problem has returned to the supervision group after a month (vignette 2).

Vignette 2

Petra is talking about how a member from her group has told them that when she was 13 years old, she escaped through the window with her boyfriend, who is actually her husband now, they got married when she was 17, but the family has never supported her decision, and she does not see why. Another member from the group asked her is it possible that even today she cannot see how strange that was at that age? And she says – strange? No, that was that.

I told them I can spot a parallel process between what is going on in group and Petra’s decision to move the group from the clinic to private setting and the timing of her decision. That the real issue from the story about a 13 years old girl is the issue of immaturity. Her situation of changing setting was also premature, as if it was some kind of prematurus. She explicitly and firmly defended her point of view, saying everything happened exactly the way it should have. Angrily, she yells out: “I was also prematurus! I told you so, don’t you remember?”

So, as the author Murphy (2009) says: “…supervisory process is crucial to developing an ability to understand and integrate the context into further and necessary illumination of the clinical work…”

Regardless of the impact of the therapist’s personal factor on the transference to the group of patients, Vignettes 1 and 2 require additional understanding of my intervention within the context of the working environment. For years, therapists that leave the clinic and start their own private practice are looked upon as more capable, knowledgeable, independent and mature, compared to those working in the clinic. Every therapist that decided to detach himself from the institution was considered brave and fearless. I have no doubt that most professionals will reflect on the situation of change of setting, as described in the vignettes, as unethical. I regarded it the same way in the intervention, as well. But, I have to admit, deep inside, I fully understood the motivation and imperative of the group’s wider context. My internal supervisor did hear the tolerance and ambiguity in the tone of my intervention. It was profoundly shaped by the clear effects of the pressure on the favoured group and their mirrors. There are also the effects of particular “pushy, no delays” energy inside personality structure of people who are born as prematurus (that no amount of therapy can ever change, in my opinion).

Supervision did not have a managerial component. So, I had to be aware of my own role and consider where to draw the line – getting involved in informal consultation to the organisation, through the medium of the supervisees, would be taking a step too far. Thinking about where to draw the line involves a constant attention to roles and functions as well as other idiosyncratic factors. I was wondering if the anxiety of the group of patients, therapists, the whole supervision group and myself, would be lower, had I been less benevolent and firm in voicing “no”. This is the question that will never be answered. Because a difficult situation provokes anxiety, that anxiety about the correctness of the decision might continue.

Ethical decision making

The normative function of supervision derives from ethical or managerial responsibilities. The aim is to protect the client from malpractice and poor practice, to protect the reputation of the profession, and to aid the supervise in process of reflection and self-care. The first task for the supervisor is to recognize that the therapist is facing an ethical dilemma. An important skill for both therapist and supervisor is to learn to slow down and reflect, rather than give in to the pull to take urgent action. (Henderson, 2009).

In ethical decision-making we have to more or less rigorously monitor the potential for doing harm. A method for ethical problem solving proposed by Carroll (1996, in Henderson, A Different Wisdom) includes:

• Ethical sensitivity. This means that supervisor should open the question about the implication of particular supervisees behaviour in order to implement the necessary habit of creating “thoughtful delays” so that the practitioner (or supervision group) considers all aspects before taking any action;
• Formulation a moral course for action- discussing personal moral imperatives and source of conflict in supervises personal value system. In thinking about the possible outcomes, the implications for the patient should be reviewed;
• Implementing an ethical decision. Sometimes is easier not to act when one should. How to decide if inaction arises from cowardice, pragmatism or wisdom? Is there any element that prescribes action?:
• Living with the ambiguities of the decision.

While I am reviewing my interventions in vignettes 1 and 2, I have somehow respected those steps mentioned above. In thinking about areas for change with any particular supervisee, the supervisor needs to develop a sense of priorities. And that was for me the importance of the therapeutic setting. In her book “Supervision in Counselling Psychotherapy” Liz Omand thinks that the first of these is to have in mind the question of whether the supervisee has created a setting where psycho-dynamic work can take place; if there is no bounded setting it is difficult to assess the effect of other variations in the patient s reactions of behaviour. But still, my interventions were perceived by my supervisors as far too benevolent and ambiguous while approaching those delicate levels. We can see that not all psychological practitioners share the same ethics. But the supervision group was still working so this is what came in the session after some time. Petra was still working in the clinic but had moved her group to the private setting.

Vignette 3

Petra: I was in the clinic when Betty came to tell me that she wasn’t coming to the session because she had a scheduled medical exam. She gave me some pastries to take as her Christmas present for the group.

Supervisor: What a backhand, you’re paying now what you did to them, it’s as if they were copying your actions – the way you used her, now she used you back.

Petra: Yes, but she always bring pastries, and the whole group always brought them for Christmas, so many we didn’t know what to do with them.

Supervisor: Yes, that is a part of group culture. But has anyone ever asked you directly to make something, has anyone played on your ego function?

Petra: No, but they always ate the pastries, that’s how it always was. What can I do, it’s all the same thing.

Maja: No, not quite the same thing, those are two different situations.

Petra: Yes, but it turned out well, because then they started talking in the group of how emotions of aggression and love towards one and the same person can mix. They talked a lot about how it was to take care of older, sick mothers who hadn’t been particularly good mothers themselves, and they were now facing the dilemma how to make it work, because they knew they had to, but they had mixed feelings about it.

Supervisor: This way they are actually opening their relationship towards you. You were in need, you put your needs ahead of theirs by moving from the clinic to a private setting. This transfer remains unanalysed. It is very important to open a discussion about that.

Petra: Yes, but I had already given them a lot in the clinic, I think leaving the clinic setting was okay.

Supervisor: You should bear in mind that it’s not their needs we are talking about here. They left to please you. That male member told you as much – he said that you were taking it too far, it was your problem, and that wasn’t the way to do things.

Petra: What? When did he say that? I don’t remember that at all.

Supervisor: That was a situation that showed us that sometimes our patients are more mature and healthy than we are. It would do you good to show readiness to discuss that openly, that’s all we have left to do.

Albertina: It would be good to admit one’s mistakes to patients and analyse them.

Maja: Well, yes.

Petra: Yes, but they don’t want to talk about it.

Albertina: That’s because you’re not ready to talk about it.

Supervisor: At this point I have to take part of the responsibility for what is happening, I am the supervisor here and you came to work with me, with us here. It seems to me I haven’t been explicit enough. I thought you would use as good guideline my previous observations about how you were using them.

Petra: Yes, but I’ve given them so much in the clinic already, I had to do it.

Supervisor: It seems that the true understanding of the background of your decision, as well as the question of who is using whom, goes beyond the context of supervision. It would be good for you to work on that in a therapy with someone. You ought to work on ways to recognize other people’s needs and what that really means to you.

Petra: Meh. I’m really alright with all of that, everything will be okay in that group. (Intonation suggests: It’s not nearly as bad as you’re presenting it to be).

Supervisor: But no! You shouldn’t be so calm and nonchalant about it because your group is very confused about their relationship with you. They feel that you are one of those needy parents. It is as if the roles have been reversed.

We could take this session as an example of how good supervision is impossible without good therapy. Only if the supervisee has been able to work through his or her own superego and authority conflicts in the therapy group can he or she fully profit from supervision. Otherwise these unresolved conflicts will be constantly re-established in supervision, and if excessive, will make the supervisors work impossible.

But still there is also another aspect present at the same time. Eckstein (1969) differentiates between blind spots, deaf spots and dumb spots. When a supervisee hears neither the patient, nor the supervisor, that is a deaf spot. We can recognise this in the previous vignette. According to this author, such phenomena occur when there is great hostility towards authority. Bearing in mind that the conflicts within the superego are always somewhere in the relation between the analyst and the institution to which they belong, we can easily understand why there is such a strong resistance towards working through, and towards recognising the same thing within the institution.

After the session described in vignette 3, group members have told me that, during the session, almost intentionally, they waited to see what I would do about that situation. They did not explicitly say they were testing me, but that was evident.

They have told me that my series of interventions and the final message that I gave had a wow! effect for them. They also added that the gravitas and non-compromising way in which I delivered the message was very important for them.

In my group, the difficult task of judging someone work, and the imminent danger of doing it in too soft or too strict a way, was not shared by the whole group and does weigh on the supervisor’s shoulders only.

This leads to the question of how our group-analytic superego is formed, that part of our psyche which will judge our work as group conductors and either give us the feeling of being content with our work or of having made mistakes from which we can learn something. It is mainly formed in supervision, by the supervisor and by the group of supervisees.

It was not possible to share the supervisory function by the group because there were  too many disturbing mechanisms among the supervisees and their perception of the institution they all work for.  Only if the supervision group is “healthy” and not struggling all the time with its own group dynamics and with the dynamic of the institution where they work, an adequate group-analytic superego can be built (Olivieri, 1993).

We have seen that tension between the inner world and its interaction with external reality is a constant theme in supervision. A criticism often levelled by those coming from other theoretical orientations is that an analytic approach, in focusing primarily on the internal world of the patient, does not allow for a proper weight to be given to the effect of external circumstances. This is partly the reason why I am not approaching my theme only from the scope of analysing primitive levels of functioning in order to build defences against organisational anxiety. My intention is to stress some very realistic aspects of our context which have a potential to make us all crazy. Or to tolerate and cherish masochism. Or to tolerate and cherish the false-self. And diminish the reputation of the profession. And diminish self-care. And, at the end undermine ethical standards.

Vignette 4

Victor: “The setting is horrible. I cannot stand the fact there is absolutely no privacy and I have to convince both myself and my patients it makes no difference that the walls of the rooms are not soundproof. Oh, to hell with everything!’ Everything is vague, everything is annoying and frustrating and then they blame you and your character, your ignorance, your personality, as if it is not all connected to the setting you work in! I see it all clearly now, the atmosphere I work in within the hospital has everything to be blamed for! My responsibility to the patients I treat in the hospital is much smaller. I have to get away from this chaotic setting, because I don’t feel ethical, there are no criteria based on  which I choose my patients, how do I decide, who should I treat? It is a whole lot different when you are on your own in a private counselling practice.’’

As the author Omand (2009) states, which is well illustrated through vignettes in supervisions, it is useful to underline the significance of acknowledging how much organizational characteristics and changes effect work of supervisees. Supervisor must be curious and enthusiastic about the setting of learning and working of his/her supervisees, but also about all the other aspects of organizational culture they work in, because part of this experience is expressed through transference and countertransference of supervisees to the institution. This, in turn, is being carried over through parallel processes to relations towards patients and team members within the same institution.

The author Reeder (2004) tells us, as it is nicely depicted in the vignettes, that if our everyday work lacks satisfaction, it will sooner or later inevitably lead to numerous mistakes.

The provision of psychotherapy will often be dependent on political and statutory organizations for funding and therefore be subject to political policy. Both supervisor and supervisee will probably belong to several professional organizations under whose code of ethics they will practice. The balance between different norms of work  will vary from situation to situation.

The viewpoint of some authors is that a compromise needs to be found between all dimensions. Other authors state that the system of values, ethical and work norms are embodied by the training institution. They also stress that when the administrative rules of the organisation, or the wider context in which the analysis takes place, are unclear, unstable, and paradoxical, or when there is conflict and various discrepancies between the rules of the training institution and the institution in which therapy is conducted, the rules of the training institution should be followed, not vice versa.

What happened in my supervision group opens up the issue of the attitude towards authority. Bear in mind that the context in which the therapy takes place is part of the matrix of the supervision group. Within this context, there are very clearly visible situations which in many ways do not preserve the reputation of the profession.

I was passing through the waiting room of a somatic medicine department where there were about a hundred people. They had waited for their appointments for months, and now they were waiting for hours for the doctor to see them. In this context I noticed a large poster which said: “Here you make a private appointment to see the doctor in the afternoons”. Meaning, pay and you won’t have to wait. And all this in a state-funded hospital. What cynicism and what an “indecent proposal”! Indecent both for the patients and for the whole medical team that works there.

The IGA is somehow in an indecent situation in state hospitals. The training institution should embody what it considers to be good practice. That’s the relatively easy part. But the training institution does not operate in state hospitals. Group analysts and group therapists are the ones who work there. And what is happening before their eyes? Here’s what is happening: the state hospitals administrative requirements are that the therapy of psychiatric patients is conducted in groups. In a single week, there are many different groups . And it is not uncommon that the groups are conducted by “fake” therapists, those without the certificate. I have the certificate, but the hospital I work for has never ever asked me whether I am real or fake. And this is OK for the state and for the institution in which the therapy takes place. Money makes the world go round! To add insult to injury, according to current laws, you can obtain the status of a therapist without ever having attended any psychotherapy education!

Whose ethics is this? Mine, ours, theirs? In my attempts to preserve my ethics, or, to be more precise, my analytic attitude, their ethics made me feel very uneasy. The institution I work for is accredited by the state to conduct education in group analysis for the psychiatry residents. High and fancy status, isn’t it? Not quite. Running such a program means to ignore neutrality, to ignore the dual roles in which the participants and training group analysts find themselves if they work in the same clinic, to ignore the voluntary participation of both the attendees of the education and the educators. Because that’s what the state wants! This is in direct contradiction to the basic paradigm of group analysis and represents the erasure of the essential standards in education of group analysis set by EGATIN. But the state doesn’t want to know about EGATIN. The state does not want to know about the Institute. But I know and recognize EGATIN, and I know and recognise the Institute. Quite well, even. So when I uncompromisingly said that I will not and cannot ignore all these aspects and then refused to take part in running such programmes in a state institution, a serious rumour reached me that I should be dismissed.

Goethe said: “To tolerate is to insult”. Tolerance implies that there are “tolerators” and “the tolerated”, meaning a majority which tolerates a minority, or somebody in the position of power tolerating someone weaker. I leave it to the discussion groups to decide who is the tolerator and who is the tolerated in this story.

It would be helpful to introduce what Winnicott called “creative destruction”, in contrasting the pathological with the way of disintegration. Minimising and devaluing attitudes towards group therapy and its particular characteristics and needs is, according to Nitsun, part of a more fundamentally ambivalent view of groups. This ambivalence has elements of anxiety, mistrust and misunderstanding. This is a reflection of an “anti-group” attitude and the concomitant reaction within, between and towards groups.

Linking the psychotherapy or supervision group to wider social issues has particular relevance in so far as the groups themselves are a form of social group. The therapeutic group approximates to a social group. I believe the same can be said for the supervision group. These groups are “small temporary society” (Jacobs, 1989).

Optimism needs to take account of the darker, disruptive side of human behaviour, and without differentiation, there can be no integration (Agazarian, 1994).

Petra is uncompromisingly optimistic about what is going to be happening to her and her group in the future. This reaction allows us to consider “creative destruction”. It’s as if my supervision group, which is a “small temporary society” of the institution in which the supervision is taking place, turned at one point into a sort of “anti-group”, whose opinions were formed in reaction to the opinion which their institution has about therapy.

The theorists of object relationships viewed the problem of ethics as something that is very strongly connected with intersubjectivity and wider social dynamics.

When it comes to the contribution of psychoanalysis to the issues of morality and ethics, as psychotherapists, we have to bear in mind that to protect a person’s unique psychological development in every way, and to appreciate their individuality is one of our highest values. Such moral value is complex and is under a sort of attack by various social, religious, political and ideological tendencies. Norms, often rigid and repressive, are often directed against a person’s originality and creativity and can be a great obstacle to someone’s personal development. Living according to such norms, in psychoanalytical terms, paves the way to the creation of the “false self”. By conforming to such norms, the “true self” cannot be developed (Amati Sass, 1994).

I am wandering whether it could be also applied when we are talking about supervisor and supervisee relationship ? And could we perceive that all that happened in the supervision group as the unique psychological development of each member?

Conclusion

The concept of superego is helpful in understanding some of the complicated mechanisms that appear in supervision. “Superego” and “supervisor” have certain features in common. The Latin “super” means “above”. The implication is that both look from an upper position at what is happening. The supervisor is therefore often seen as a kind of  personification of the superego.

The supervisors refusal to fulfil the supervisee’s wish of declaring what is good to do is a reason for constant tension, but also a very necessary impulse for the supervisee to be his or her own judge.

Jean Arundale (2007) said  that psychodynamic supervision involves above all the transmission of internalized analytic values; it is not a matter of techniques or skills but establishing a relationship where beliefs and goals can be shared. The maturity means that supervisor doesn’t need to have all the answers, rather the reverse, that they are able to tolerate ambiguities and uncertainties while being prepared to think about the patient and supervisees and generate useful hypotheses on their situation.

In their feedback on my work, my supervisors used the word “benevolence”. The meaning of that word is: “the disposition towards doing good”. Therefore, the  opposite would be “doing something bad”, something malign. Such feedback is full of ambiguity and paradox, but it seems that, as if it were water, it carries you and guides you toward keeping your analytical attitude, perhaps more than towards questioning the ethical aspects.

Institutions generate anxiety, which may relate to the influence on group processes and the way in which the dynamics of the primary task are played out in the setting. Part of the function of supervision under these circumstances is to help the supervisee think realistically about their interaction with the organization.

Just as their supervisees will find that their boundaries are attacked at times, so supervisors have to think about their own boundaries. Thinking about organisational dynamics in supervision might be appropriate in the role of supervisor, and will allow the supervisee to take up the role of providing a psychodynamic input to difficult situations. The position of the supervisor has to be prudently equilibrated. Author Silvia Amati Sass (2018) said that “modest omnipotence” helps supervisors to accept the relativity of their “power” in this difficult work.

References

Murphey, A. (2009) The impact of the organization: the primary care context. In: Henderson, P. (ed)., Supervisor Training. Issues and Approaches. London: Karnac Books Ltd.

Hendreson, P. (2009) A Different Wisdom, London: Karnac Books Ltd.,.

Omand,L. (2009)Supervision in Couselling and Psychotherapy, Ney York, Palgrave

Eckstein, E. (1969) in:Hawkins, P. and Shohet, R. (1994) Supervision in the helping professions. An individual, group and organizational approach. Philadelphia: Open University Press.

Olivieri-Larsson, R.(1993) Superego Conflicts in Supervision, Group Analysis, Vol.26, pp 169-176.

Reeder, J. (2004) Hate and Love in Psychoanalytical institutions. New York: Other Press.

Winnicott, D. (1989) Psychoanalytic Explorations, The Winnicott Trust

Nitsun, M.  (2014) The Anti- Group: Destructive Forces in the Group and their Creative Potential, NY, Routledge

Jacobs, M. (1989) in:Nitzun, M.  (2014) The Anti- Group: Destructive Forces in the Group and their Creative Potential, NY, Routledge

Agazarien ,Y. (1994) in:Nitzun, M.  (2014) The Anti- Group: Destructive Forces in the Group and their Creative Potential, NY, Routledge

Amati Sass, S. (1994)  Etica e trans-soggetivita. Riv.di Psicoanalisi, 4, Roma: Borla.

Arundale, J. (2007) Supervising trainees: Teaching the values and teachniques of psychoanalytic psychoterapy in Petts, A. and Sharpley, B. (eds) On Supervision: Psychoanalytic  and Jungian Perspectives. London: H. Karnac.

Amati Sass, S. (2018) Reflections on the Paper Supervision of Supervision (3), Psihoterapija, Vol.31 No.2,pp 276-278

Prof. Mirjana Pernar
Clinical Psychologist
Training Group Analyst – IGA Zagreb
Ass Memb IGA London
IPA Psychoanalyst
mirjana.pernar@fzsri.uniri.hr