Supervision and the therapeutic relationship: What does Gestalt have to offer?
Note: This is an academic literature review, written as partial fulfilment of the requirements for the degree of Master of Gestalt Therapy. It will not be everyone’s cup of tea, but here it is…
Introduction
Over the three decades since completing my initial training as a psychotherapist, my interest in psychotherapy has increasingly come to include an interest in psychotherapy supervision. While supervision commonly emphasises the supervisee’s technical skills in the specific methods of their approach to psychotherapy, my particular interest is in how supervision may enhance the therapeutic relationship. The foundations that this interest rests upon are twofold. Firstly, research indicates that a substantial percentage of positive therapy outcome can be attributed to the therapeutic relationship/alliance (Bambling & King, 2001; King, Lloyd, & Meehan, 2007; Martin, Garske, & Davis, 2000). Secondly, research indicates that the therapeutic relationship may indeed be enhanced through supervision (Bambling, King, Raue, Schweitzer, & Lambert, 2006; Crits-Christoph, et al., 2006; Kivlighan, Angelone, & Swafford, 1991). It is furthermore my belief that supervision based on Gestalt methodology may be particularly suited for enhancing the quality of the therapeutic relationship, since the relationship is at the core of Gestalt practice (Joyce & Sills, 2001; Mackewn, 1997; Yontef, 2002). This paper reviews psychotherapy literature, general and Gestalt-specific, pertaining to the connection between clinical supervision and the therapeutic relationship.
This literature review is divided into three sections. The first section presents an overview of the conceptual development of the therapeutic relationship (Bordin, 1979; L. Luborsky, 1976; Rogers, 1951). It also introduces the therapeutic relationship in Gestalt; the dialogic relationship (Buber, 1958; Jacobs, 1989; Yontef, 1993). Additionally, it discusses how the therapeutic relationship affects psychotherapy treatment outcome. The second section examines clinical supervision and its two interrelated goals; developing competence in the supervisee; and enhancing therapy outcome (Bambling, et al., 2006; Falender & Shafranske, 2004; Yontef, 1996). It discusses the role that the supervisory relationship plays in supervision (Ellis & Ladany, 1997; Falender & Shafranske, 2004; Ladany, 2002), and the impact supervisee anxiety and shame may have on the supervision process (Gard & Lewis, 2008; Kearns & Daintry, 2000; Yontef, 1996). This section also introduces the cornerstones of Gestalt supervision (Kron & Yerushalmi, 2000; Resnick & Estrup, 2000; Yontef, 1996). The third section explores how supervision can be utilised for the purpose of enhancing the therapeutic relationship. It discusses specific relationship skills that may be enhanced through supervision, and highlights how the supervision process parallels the therapy process, as well as how supervision can assist in repairing ruptures in the therapeutic relationship (Binder & Strupp, 1997; Falender & Shafranske, 2004; Safran, Muran, Stevens, & Rothman, 2008). This section also provides comments on Gestalt supervision’s attention to the therapeutic relationship from the small body of literature existing on the subject (E. K. Gold & Zahm, 2008; Resnick & Estrup, 2000; Yontef, 1997) The literature review concludes with a summary and a call for research into the utility of Gestalt supervision for enhancing of the therapeutic relationship.
The Therapeutic Relationship
Freud’s (1912) identification of the positive and the negative transference drew attention to the therapeutic relationship, and in the following decades ideas about the therapeutic component of the relationship began to emerge, which put the therapeutic relationship itself at the centre of the healing process (Bibring, 1937; Greenson, 1965; A. Horvath, 2001). One of the strongest advocates for the importance of the therapeutic relationship in the change process was Rogers (1951), who identified the facilitative therapist qualities; empathy, genuineness and unconditional positive regard for the client (Bachelor & Horvath, 1999; Goldfried & Davila, 2005; A. Horvath, 2001). In the 1970s two models involving the concept of alliance emerged. First, Luborsky’s (1976) two-stage model of the therapeutic alliance. Then, Bordin’s (1979) pantheoretical working alliance, encompassing the three elements goals, tasks and bonds. The goals, or outcomes, are the targets of the therapy. The tasks are the in-therapy procedures that lead to the accomplishment of the goals. The bonds are positive personal attachments between client and therapist, like trust, acceptance and confidence (A. Horvath & Luborsky, 1993; Summers & Barber, 2003; Wallner Samstag, 2006).
While Bordin’s working alliance model still remains the most popular in research on the therapeutic alliance (Ross, Devon, & Ward, 2008), conceptualisations of the therapeutic alliance continue to evolve, each emphasising different components of the alliance (Bachelor & Horvath, 1999). Other theories consider that the working alliance’s components of goals, tasks and bonds may not be distinct, but rather reflect one single, overarching factor (Salvio, Beutler, Wood, & Engle, 1992). It has also been proposed that the working alliance concept should be replaced with a description of the therapeutic relationship that incorporates relational concepts such as intersubjectivity and authentic relatedness as its essential elements (Wallner Samstag, 2006). Another formulation of the therapeutic relationship sees it as an integrated framework, where the working alliance is simply one of the facets, and where an equally important facet reflects the core relationship, the authentic humanness shared by client and therapist, which sometimes is referred to as the ‘real’ dimension of the therapeutic relationship (Clarkson, 2003). In Gestalt therapy this facet is reflected in the dialogic relationship.
The Dialogic Relationship in Gestalt Therapy
The theory and methodology of Gestalt therapy is systematically relational (Yontef, 2002, 2009; Yontef & Bar-Joseph, 2008), and “resonates through and through with the sense that to be is to be with” (Stawman, 2009, p. 34, emphasis in original). The relationship between client and therapist is seen as the core of Gestalt practice (Lee, 1995; Mackewn, 1997; Yontef, 1988), and anything that suits the therapist’s style, that is relevant to the therapy process, and that enhances the dialogic relationship between client and therapist is seen to further the therapeutic task (Jacobs, 1989). The term dialogic, as it is used in this context, is borrowed from Martin Buber’s (1958, 1965) existential philosophy, which identifies the meeting as taking place in a realm shared by the two people; “On the far side of the subjective, on this side of the objective, on the narrow ridge, where I and Thou meet, there is the realm of “between”” (Buber, 1965, p. 246, emphasis in original). Hence, in the dialogic meeting there is more than “I” and “You” and recognition of the difference between the two. There is also a surrendering to “the between”, i.e. to what develops and emerges out of the interaction (Yontef, 2009). In this relation-centred approach to therapy “the relationship is seen as a real experience which arises from, and has its own story, in the space subsisting between patient and therapist, not as a result of projections of transferal patterns from the patient’s past” (Spagnuolo Lobb, 2009, p. 113, emphasis in original). Hence, the Gestalt therapist works cooperatively with the client and the client’s sense of reality, and rather than maintaining an impersonal professional distance, the therapist relates as a whole person to the client as a whole person, endeavouring to meet the client as a human being, without analysing or manipulating, but being open and genuinely available to be impacted by their interactions (Joyce & Sills, 2001; Yontef, 2002; Yontef & Jacobs, 2005).
The Gestalt therapist invites the client to a dialogic relationship by embracing the dialogic principles of 1) inclusion, 2) authentic presence, 3) commitment to dialogue, and 4) living the relationship (Yontef, 1993). Inclusion can be seen as a broader form of empathy, where the therapist puts himself as fully as possible into the client’s subjective experience, while simultaneously retaining a sense of his own separate, autonomous presence (Joyce & Sills, 2001; Yontef & Bar-Joseph, 2008). Authentic presence means that the therapist is honest with the client about who he is and about what he observes, feels, thinks and experiences, to any degree that this is seen to be in the interest of the therapy process (Mackewn, 1997; Yontef, 2009). Commitment to dialogue reflects that dialogue is something that happens between two people, something that is not controlled by either one of them, but rather arises from their mutual interaction. Thus, the therapist allows ‘the between’ to control the dialogue, rather than trying to manipulate the process towards pre-conceived outcomes (Yontef, 1993; Yontef & Bar-Joseph, 2008). Living the relationship highlights that the relationship is experiential, and that dialogue is not limited to only being verbal. Other modes of dialogue, such as dancing, singing or any other relational expression can be explored in the therapy process when relevant and appropriate (Yontef, 1993).
Gestalt therapy is a collaborative endeavour, where the emphasis is on meeting the client, and where the quality of the relationship is recognises as being largely what determines the effectiveness and outcome of therapy (Fleming Crocker, 2008; Jacobs, 2009; Yontef, 2005). Yet, while Gestalt therapy clearly recognises it, this strong link between therapeutic relationship and therapy outcome is in no way exclusive to the Gestalt approach.
The Therapeutic Relationship and Therapy Outcome
The link between the therapeutic relationship and therapy outcome was recognised already by Freud (1912), who pointed out that the work with transference aims at raising to consciousness negative transference feelings and unconscious positive transference feelings, hence detaching them from the person of the analyst. The conscious, unobjectionable component of the positive transference thus remains, and “brings about the successful result in psycho-analysis as in all other remedial methods” (Freud, 1912, p. 319). As definitions and measures of the therapeutic relationship evolved, it became evident that the quality of the therapeutic relationship is a significant determinant of beneficial outcome across therapy approaches (Bachelor & Horvath, 1999; Bambling & King, 2001; Bohart & Greenberg, 1997; King, et al., 2007).
Research has consistently found that the therapeutic relationship is more important for therapy outcome than is theoretical orientation, and that the therapeutic relationship’s ability to predict outcome is independent of the type of treatment provided (A. O. Horvath & Symonds, 1991; Lambert & Ogles, 2004; Martin, et al., 2000). An extensive literature review in 1992 concluded that 30% of improvement in psychotherapy clients can be attributed to therapeutic relationship factors, such as empathy, warmth, acceptance, and encouragement of risk taking, i.e. factors which are present regardless of the therapist’s theoretical orientation. Significantly, in comparison, only 15% of improvement was attributed to ‘technique factors’, i.e. factors which are unique to the specific therapy approach (Hubble, Duncan, & Miller, 1999; Lambert, 1992). A later meta-analytic review of 79 clinical studies also found a consistent correlation between the therapeutic relationship and outcome (Martin, et al., 2000). Numerous studies have shown that successful therapists are more supportive, accepting, understanding, warm and empathic (Lambert & Ogles, 2004; Lambert & Witold, 2008). Empathy is, furthermore, itself a reliable predictor of therapy outcome, equal to the therapeutic relationship, which has been found to account for as much outcome variance as specific interventions (Bohart, Elliott, Greenberg, & Watson, 2002; L. B. Luborsky, Chandler, Auerbach, Cohen, & Bachrach, 1971; Watson, 2002). Empathy is of course also a core ingredient in the bond component of Bordin’s (1994) therapeutic alliance, and thus plays a critical role in the formation of the alliance (Angus & Kagan, 2007; Clark, 2007; Goldfried & Davila, 2005; Safran & Muran, 2000; Wampold, 2001), and recent research has shown that the bond component of the alliance can predict outcome irrespective of goals and tasks (Ross, et al., 2008).
The fact that decades of research indicate that the main curative component in psychotherapy is the nature of the therapeutic relationship, and that the relationship stands out as the strongest predictor of therapy outcome, may be one of the most important findings existing in empirical psychotherapy literature to date. Nevertheless, current understanding of the particular way in which the relationship affects outcome is incomplete and under discussion (Castonguay, Constantino, & Grosse Holtforth, 2006). It has been suggested that seeing the therapeutic relationship as a therapy factor distinct from treatment techniques, simply reflects the lack of specific theory for its effect, and that the relationship, rather than being only the basis of therapy, should perhaps be understood as being the therapy itself (Priebe & McCabe, 2008; Resnick & Estrup, 2000). Seen as a skill, technique or element of methodology, the therapeutic relationship may become subject of more attention in clinical supervision.
Clinical Supervision
The practice of clinical supervision originated in the 1920s as part of psychoanalytic training (Feltham, 2000). Early practice of supervision emphasized the authority of the supervisor, in a master-apprentice model of the supervisory relationship (Binder & Strupp, 1997). From the late 1950s the didactic approach to supervision, which focused primarily on the dynamics of the client’s behaviour, shifted toward a more experiential approach, focusing on the psychology of the supervisee (Falender & Shafranske, 2004; Frawley-O’Dea & Sarnat, 2001). In the past two decades supervision has emerged as a specialty area, and received increased attention in theory and research (Ladany & Inman, 2008; Sterner, 2009). Modern day supervision can be considered as a collaborative endeavour where supervisor and supervisee together are learning about the client, about therapy, and about themselves (Pack, 2009; Resnick & Estrup, 2000), and the supervisor-supervisee relationship is recognised as being as crucial to the process of supervision as the therapist-relationship is to the process and outcome of psychotherapy (Ellis & Ladany, 1997; Falender & Shafranske, 2004; Ladany, 2002). In this section clinical supervision is discussed in general terms and with specific emphasis on the supervisory relationship. Fundamentals of the Gestalt approach to supervision are also introduced.
Clinical supervision – enhancing professional skills for the benefit of the client
Two essential and interrelated goals that have been identified for clinical supervision are; to develop therapeutic competence in the supervisee, and to ensure the integrity of clinical services provided to the client (Bambling, et al., 2006; Falender & Shafranske, 2004; Yontef, 1996). Clinical supervision is one of the most important processes for development of professional competence in psychotherapists (Callahan, Almstrom, Swift, Borja, & Heath, 2009; Holloway & Neufeldt, 1995; Resnick & Estrup, 2000), if not “the most critical facet of the psychotherapy training endeavor” (Watkins, 1997, p. 9, emphasis in original). Supervisees see supervision as a crucial element of training, as it increases their therapeutic awareness as well as helps them develop awareness of, and ability to work with, their own feelings and reactions (Bernard & Goodyear, 1992; Safran, et al., 2008). While the development of therapeutic competence in the supervisee is certainly one of the goals of supervision, it must nevertheless be recognised that the primary goal is to enhance the value of the therapeutic process for the client (Page & Wosket, 1994). The idea is, of course, that the supervision process will alter some characteristic of the therapist, which will result in more competent delivery of psychotherapy, and subsequently lead to better outcomes for the client (Wampold & Holloway, 1997). While research into the causal connection between supervision and therapy outcome is scarce, some evidence in support of the proposition has been demonstrated (Bambling, et al., 2006; Callahan, et al., 2009; Freitas, 2002). These dual goals of supervision, developing therapist competence and optimising therapy outcome, can be accomplished in many different ways, and “there are probably as many approaches to supervision as there are supervisors” (Falender & Shafranske, 2004, p. 7). Nevertheless, one influential component obviously present in all supervision approaches is the supervisory relationship.
The supervisor-supervisee relationship is as crucial to the process of supervision as the therapist-client relationship is to the process and outcome of psychotherapy (Ellis & Ladany, 1997; Falender & Shafranske, 2004; Ladany, 2002). Similar to the therapeutic alliance, the supervisory alliance consists of goals and tasks for the supervision, and an emotional bond between supervisor and supervisee (Bordin, 1994; Ladany & Inman, 2008; Sterner, 2009). When the supervisory relationship/alliance is positive, and supervisors provide high levels of empathy, warmth, acceptance, validation, genuineness and concreteness, supervisees’ capacity to learn those same interpersonal skills, and to subsequently use them in therapy with clients, is enhanced (Bambling & King, 2000; Bernard & Goodyear, 1992; Holloway & Wampold, 1986). The supervisory relationship, furthermore, has effects on therapy outcome for clients, with effect sizes having been found to be similar to the correlation between the therapeutic relationship and therapy outcome (Bambling, et al., 2006; Reese, et al., 2009). Conversely, when there are disturbances in the supervisory relationship, supervisees are likely to experience more dissatisfaction and anxiety, which may negatively impact on supervision outcome, with consequences not only to the skills development for the supervisee, but also to the therapy outcome for the client (Bambling & King, 2000; Falender & Shafranske, 2004). It is therefore critical that supervisors continually monitor the supervisory relationship, and whenever strains emerge in the relationship, the priority in supervision should be to address those issues (Safran, et al., 2008).
In supervision, supervisees are required to examine their clinical work, including their countertransference reactions to clients, and since such examinations necessarily involves personal exposure, they may induce anxiety and shame (Falender & Shafranske, 2004). Fear of exposure as a poor clinician is one of the obstacles to successful supervision, since it may lead to reduction in recall of presented materials, supervisee defensiveness, and decreased accuracy of supervisees’ self-perceptions (J. H. Gold, 2006; Johnson, 1989). Supervisee shame, “the globalised sense of not being enough” (Yontef, 1996, p. 97), may be triggered in the supervision process, simply due to the fact that there is at least some degree of hierarchy in the relationship between supervisor and supervisee (Yontef, 1997), and may show up in the supervisee disguised as contempt, blame, envy, anger, despair or self-righteousness (Kearns & Daintry, 2000). Supervisee shame may stop the supervisee from disclosing what actually occurs in therapy, and the supervisory alliance may break down to a point where the tasks leading to achievement of the supervision goals are no longer possible to perform (Falender & Shafranske, 2004; Inman & Ladany, 2008). The supervisor can prevent supervisee anxiety and shame, by providing a compassionate supervisory style, favouring facilitation and exploration, rather than an interrogative or accusatory style, and by offering frequent praise for appropriate behaviours that the supervisee has displayed in the session (Gard & Lewis, 2008; Overholser, 2005). Supervisors can also address the supervisee’s shame by focusing attention, in an empathic and supportive manner, on the supervisee’s experience of the supervisory relationship and the transactions between supervisor and supervisee (Falender & Shafranske, 2004).
Clinical supervision in the Gestalt approach
Whilst supervision is not therapy, some of the principles of Gestalt therapy also apply to the supervisory process (Resnick & Estrup, 2000). Hence, Gestalt supervision can be seen to encompass Gestalt’s four methodological cornerstones; field theory, phenomenological focusing, experimentation, and dialogic contact (Yontef, 1996).
Field theory recognises that events such as a person’s actions cannot be understood in isolation, but only in relation to the context in which the person exists at any given moment, i.e. the field (Yontef, 2009). In supervision the two main aspects of the field are; the context in which the therapy with the client occurs; and the context of the supervision, including the supervisor’s “world views, beliefs and idiosyncratic interpretive approaches to supervision” (Kron & Yerushalmi, 2000, p. 106).
Phenomenological focusing is about working with what is observable, internally as well as externally, by means of descriptions rather than interpretations, and thus requires suspension of assumptions in order to pay attention to primary sensory data (Mackewn, 1997). In Gestalt supervision, hence, the emphasis is less on conceptualisations and explanations, and more on experiential, phenomenological awareness, and the supervisee develops as a result of expanding their awareness (Melnick & Fall, 2008; Yontef, 1997).
Experimentation refers to a process of experiential exploration, which is performed through active, behavioural or imaginative expressions, rather than merely by cognitive thinking and verbal explanations (Mackewn, 1997). It has been suggested that by taking an experiential approach to supervision blocks in therapist-functioning may be resolved, which would not be resolved by more didactic or intellectualised approaches (Yontef, 1996). Support for this view can be drawn from a recent review of 24 studies on clinical supervision, which found that supervision interventions primarily work by promoting experiential learning (Milne, Aylott, Fitzpatrick, & Ellis, 2008).
Dialogic contact has been described as “shared phenomenology” (Yontef, 2009, p. 46), a meeting between people, where neither sees the other as an object, to be analysed or manipulated, but rather as an equal to be with in relationship, and “relationship is contact over time” (Yontef & Bar-Joseph, 2008, p. 187). Supervisors who embrace dialogic contact recognise themselves as equal participants in the ongoing dialogic relationship with the supervisee, and are willing to authentically engage in clarification and exploration of the difficulties and mutual transferences that inevitably occur in the process of supervision (Kron & Yerushalmi, 2000). While “[r]ecognizing and respecting the power differential between supervisor and supervisee is critical to negotiating and maintaining an effective relationship” (Koocher, Shafranske, & Falender, 2008), dialogically oriented supervisors also openly express their needs, thoughts, and feelings, as long as this contributes to the learning process, and are not afraid of exposing their own strengths and weakness (Itzhaky & Hertzanu-Laty, 1999). Such authentic self-disclosure can help maintain equality, or horizontality, in the supervisory relationship, and thus counteract the potential for shame, which is otherwise present in a vertical, or unequal, relationship (Yontef, 1996). In the Gestalt approach to supervision, then, the supervisory relationship can be seen as a dialogic forum, where existential themes, uncertainty and complexity can be safely explored, because the dialogic relationship, by its nature, mitigates against shame (Pack, 2009).
Supervision of the therapeutic relationship
This section explores the cross-section between the previous sections; how supervision can be utilised for the purpose of enhancing the quality of the therapeutic relationship. It discusses specific relationship skills that may be enhanced through supervision, and highlights how the supervision process parallels the process that occurs in therapy, as well as how supervision can assist in repairing ruptures occurring in the therapeutic relationship.
Applying supervision to therapeutic relationship/alliance skills
In light of its importance for positive therapy outcome, it is reasonable that the therapeutic relationship is a major focus in supervision, and that frequent evaluation of relationship factors is an essential aspect of the supervision process, since it may offer valuable information about the therapy process (Falender & Shafranske, 2004; Lambert & Barley, 2001; Summers & Barber, 2003). Equally, it is reasonable to expect that when supervision does focus on the therapeutic relationship, this would also lead to an enhancement of quality of the relationship (Bambling, et al., 2006). While research investigating this expectation has been scarce (Bambling & King, 2000), a few studies exist that have produced findings in support of the proposition. A comparison between the impact of live supervision vs. supervision using videotape found that both approaches had positive effects on the therapeutic alliance (Kivlighan, et al., 1991). A study specifically focusing on fostering the therapeutic alliance found “some initial evidence that alliance-fostering therapy may successfully improve alliances” (Crits-Christoph, et al., 2006, p. 276), and a study evaluating the impact of supervision on working alliance and on symptom reduction in the treatment of major depression found that drawing supervisees’ attention to the therapeutic relationship in itself enhanced the relationship (Bambling, et al., 2006). Nevertheless, helping therapists develop the necessary skills for cultivating a positive therapeutic relationship is a complex matter.
With regard to the therapeutic relationship some therapist skills are clearly easier to develop through supervision than others. The goal and task components of the therapeutic alliance appear as more learnable and teachable than skills for developing a strong bond (Summers & Barber, 2003). The goal, task and bond components of the alliance do not, however, form independently of one another, since therapists who demonstrate warmth, understanding and positive feelings toward the client also has a better chance of establishing mutually agreed goals and tasks (Asay & Lambert, 1999). While a therapist attitude of warmth, acceptance and genuineness has proven difficult to teach as a skill, research has indicated that empathic responding skills can be taught, e.g. by combining instruction, modelling, practice and feedback (Lambert & Witold, 2008). This is of great importance, since empathy plays a critical role in the formation of the therapeutic alliance (Angus & Kagan, 2007; Clark, 2007; Safran & Muran, 2000; Wampold, 2001). Another suggestion for how empathy skills can be developed is through the use of role-play in supervision, where the supervisee gets to assume the client’s position in the therapy process (Borders & Brown, 2005; Glickauf-Hughes & Campbell, 1991; Safran, et al., 2008). It has also been suggested that “mindfulness-based methods may offer a unique set of tools in the quest to develop individuals’ capacity for empathy” (Block-Lerner, Adair, Plumb, Rhatigan, & Orsillo, 2007, p. 505), and that beginning supervision sessions with structured mindfulness exercises may lead to an increase in supervisees’ awareness of subtle feelings, thoughts and fantasies emerging in work with clients, hence providing important information about what occurs in the therapeutic relationship (Safran, et al., 2008). A small-scale study which combined role-play with mindfulness in supervision also found indications that this may be a useful avenue toward enhancing therapists’ empathy toward clients, and hence have a positive effect on the therapeutic relationship (Andersson, King, & Lalande, 2010). A somewhat less explicit opportunity for learning relationship skills furthermore exists in the supervisory relationship itself.
When the interpersonal dynamics of the therapeutic relationship stimulate and are reflected within the supervisory relationship, the supervision process becomes a parallel process to the therapy process (Aponte & Carlsen, 2009; Ekstein & Wallerstein, 1972; Glickauf-Hughes & Campbell, 1991). The concept of the parallel process originated in psychoanalytic literature, and referred to when the supervisee’s problem in supervision expresses the client’s problem in therapy (Binder & Strupp, 1997; Falender & Shafranske, 2004; Scanlon, 2000). This process also operates in the opposite direction, however, so that not only does the therapy dynamics show up in supervision, but the supervision dynamics show up in therapy as well (Binder & Strupp, 1997; Ronnestad & Ladany, 2006). Therefore, by establishing a positive supervisory alliance, the supervisor models positive alliance behaviour, which increases the probability that the supervisee will absorb those skills and apply them when working with clients (Lombardo, Milne, & Proctor, 2009; Pierce & Schauble, 1971). Conversely, when a misalliance develops in the supervisory relationship, the supervisor can provide implicit training in the skill of repairing the therapeutic relationship by constructively addressing the supervisory alliance issue (Falender & Shafranske, 2004). Hence, the suggestion to supervisors; “Do unto others as you would have them do unto others” (Ladany, Friedlander, & Nelson, 2005, p. 215). However, dealing with threats to the therapeutic relationship can be complicated, and most often requires more direct attention in supervision.
Psychotherapy consists of a complex set of interpersonal interactions between the therapist and the client, involving the individual subjectivities of both participants. Mutual reactivity and misunderstandings that may cause a rupture in the therapeutic relationship are commonplace rather than rare occurrences, and it is therefore essential that supervision helps supervisees recognise threats to the relationship and to develop skills for repairing ruptures that have occurred (Bachelor & Horvath, 1999; Falender & Shafranske, 2004). While relationship ruptures may occur in many different ways, a textbook example of its development is;
Ruptures begin when during the course of therapeutic work, the client notices some action of the therapist that confirms his or her dysfunctional or pathogenic expectations about relationships. The client reacts by either confronting or withdrawing from the therapist. This often triggers a defensive or angry reaction from the therapist, which in turn, confirms the client’s expectations. Whether the client’s initial perception was realistic or distorted, at this point, both the therapist and client are engaged in a cycle of reaction and counterreaction. (Safran, et al., 2008, p. 139)
Regardless of what the root cause and the dynamics that caused the relationship rupture may be, it is essential that supervision provides a safe place for addressing countertransference issues and other negative reactions that contribute to the rupture. Since the therapeutic relationship has a major effect on therapy outcome, failure to address relationship ruptures is likely to negatively affect therapy outcome and/or lead to precipitous terminations of treatment (Falender & Shafranske, 2004). Interestingly too, when a relationship rupture is adequately addressed and the rupture is repaired, this often leads to increased motivation and a stronger alliance (Lombardo, et al., 2009).
The initial step for resolving a relationship rupture is to investigate the therapy content and interactions that precipitated the negative reactions, so that the supervisor can help the supervisee reorient to a stance of inquiry, in order to gain some understanding of the origins of these reactions (Falender & Shafranske, 2004). Through metacommunication, that is communication about communication, the supervisor can help the supervisee analyse the communication that took place in the therapy session, and give the supervisee an opportunity to learn how perform such analysis (Safran & Muran, 2000). To be able to facilitate metacommunication together with the client, inviting the client to also share their experience of the interaction, is essential, since it has been found to be necessary for re-establishing a viable therapeutic alliance (Falender & Shafranske, 2004). Supervision furthermore plays a critical role in the development of skills, such as self-acceptance, openness to self-exploration, and capacity to engage in genuine dialogue with the client, which are needed for repairing ruptures in the therapeutic relationship (Safran, et al., 2008). It can be helpful if supervision incorporates a substantial experiential component, so that therapists may develop an awareness of their own feelings and reactions, as well as an understanding of what the client’s experience may have been of the therapy interaction, e.g. by use of role-playing and empty-chair processes (Falender & Shafranske, 2004; Safran, et al., 2008). This experiential approach is emphasised in Gestalt supervision.
Gestalt therapy supervision of the therapeutic relationship
Gestalt psychotherapy has not been well researched, and literature on Gestalt supervision, including supervision of the therapeutic relationship, is severely lacking (E. K. Gold & Zahm, 2008; Resnick & Estrup, 2000; Yontef, 1996). What can be gleaned from existing writings on Gestalt supervision, however, is the recognition that “[a] most important aspect of supervision is examining the quality of the relationship between therapist and client” (Resnick & Estrup, 2000, p. 129). Hence, in Gestalt supervision particular attention is given to the supervisee’s awareness of the present-focused contact between himself or herself and the client during therapy, and whether this contact is aligned with the dialogical principles of inclusion, authentic presence, commitment to dialogue, and living the relationship (Yontef, 1993, 1997). Gestalt supervision also pays attention to how transference issues in the therapeutic relationship are handled, yet with the emphasis on the occurrence of such issues as being a reality in the current relationship between therapist and client, rather than simply being considered as representations of past experiences, since in Gestalt therapy transference issues are seen as co-created in the interactional field where the dialogical encounter between therapist and client takes place (Joyce & Sills, 2001; Mackewn, 1997; Resnick & Estrup, 2000). With regard to ruptures in the therapeutic relationship, Gestalt’s field perspective provides implicit guidelines for the supervision process. In the relational, field oriented approach of Gestalt therapy there is an appreciation of reciprocal mutual influence, and nothing that occurs in the meeting between therapist and client is seen to arise solely in one of them, but rather to co-emerge from what goes on in the relationship between them (Jacobs, 2009; Yontef, 2009).
Conclusions
While very little research has been conducted on the relationship between supervision and psychotherapy outcome (Bambling, et al., 2006; Kavanagh, et al., 2008; Reese, et al., 2009), the impact of the therapeutic relationship on therapy outcome has been firmly established (Bambling & King, 2001; King, et al., 2007; Martin, et al., 2000). One avenue, then, that supervision can act to improve therapy outcome would be to focus the supervision process on enhancing the quality of the therapeutic relationship, since “[if] we can train therapists not to rely on their intuition but to actively and continually confirm the quality of the alliance with the client, we can expect better treatment outcomes” (A. Horvath, 2001, p. 175). The Gestalt approach to therapy and supervision strongly emphasises the dialogic relationship between therapist and client (E. K. Gold & Zahm, 2008; Pack, 2009; Yontef, 1996). Hence, it appears as a reasonable proposition that the Gestalt approach would particularly lend itself to enhancement of the therapeutic relationship. Reviewing existing literature, however, reveals that as yet very little research has been conducted into this subject (E. K. Gold & Zahm, 2008; Resnick & Estrup, 2000; Yontef, 1996). Further research is clearly needed into the effects of Gestalt supervision on the quality of the therapeutic relationship/alliance. Yet, in order for such studies to have a possible impact on the general practice of supervision, i.e. outside of the Gestalt community, it would need to also include supervisees/therapists who practise other psychotherapy approaches than Gestalt therapy. Hopefully such research is forthcoming in the near future…
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