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O R I G I N A L P A P E R

Teaching the Use of Self Through the Process of Clinical Supervision

John P. McTighe

Published online: 29 September 2010

� Springer Science+Business Media, LLC 2010

Abstract In their efforts to learn the skills involved in the

use of self, clinical social work supervisees are faced with

the daunting task of integrating information coming not

only from the patient but also from their own complex set

of responses. The clinical supervisor serves a key role in

guiding the trainee through this process. Grounded in

contemporary psychodynamic theory, this paper discusses

an approach to helping the supervisor model the use of self

in the context of the supervisory relationship. A supervi-

sory case example is used to illustrate.

Keywords Use of self � Clinical supervision � Countertransference � Psychodynamic theory

Among the greatest challenges for the novice clinical social

worker is the process of learning to incorporate and make

sense of the myriad information that is communicated and

received throughout the course of even a single psycho-

therapy session. At a time in training when the student’s

emerging sense of professional identity is often quite

fragile (Gill 2001), the task of sorting out the internal

responses evoked by the patient from those emerging from

one’s own history, all while attempting to conceptualize

case material through the lens of one’s increasing font of

academic knowledge, can seem insurmountable. Beginning

therapists are learning to sort out the complex implications

of issues such as race, gender, and perceived socio-eco-

nomic status (both of the clinician and the patient). They

are dealing with their responses to the material that the

patient is presenting, especially when this material is

experienced as taboo or otherwise provocative (e.g. issues

of abuse). At the same time, they are learning to attend to

the many levels of conscious and unconscious communi-

cation that are occurring throughout the treatment. Making

therapeutic use of this material by means of well-conceived

and well-crafted interventions can thus seem a Herculean

task well beyond the grasp of the trainee. It falls in large

measure to the clinical supervisor to accompany the neo-

phyte therapist in the process of growth, discovery, and

integration.

Grounded in contemporary psychodynamic theory, this

paper will explore processes by which the supervisor can

assist social work supervisees in incorporating the use of

self into their practice. In addition to surveying briefly the

history of the concepts of countertransference and use of

self as well as their perceived role in therapeutic treatment

since the time of Freud, it will consider the skills that we

seek to develop in supervisees, and the role of the super-

visor as teacher and model of use of self. In particular, it

will consider ways in which the supervisor can model a

stance of non-judgmental, reflective attention to one’s

internal responses in the clinical situation, and make use of

these as a tool for understanding and intervening with

patients. Existing models for educating trainees about the

use of self will be reviewed. A detailed supervisory case

example will be used to illustrate.

Historical Perspectives on Countertransference

and the Use of Self

Beginning with Freud, much attention has been paid to the

phenomenon of countertransference and its impact on the

J. P. McTighe (&) Department of Counseling, Health & Wellness, William

Paterson University of New Jersey, 300 Pompton Road,

Wayne, NJ 07470, USA

e-mail: [email protected]

123

Clin Soc Work J (2011) 39:301–307

DOI 10.1007/s10615-010-0304-3

clinical situation. Freud (1910) first described counter-

transference as ‘‘a result of the patient’s influence on his

[i.e. the analyst’s] unconscious feelings’’ (p. 144). Later,

Freud (1912) used the image of the telephone to describe

the nature of communication between the analyst and

analysand, encouraging the analyst to be receptive to the

patient’s transmittal of unconscious material. Thus, it fell

to the analyst to do all in his or her power to eliminate

interference with this process. The classical tradition, then,

encouraged awareness of the complex set of personal

reactions and responses to the patient known as counter-

transference with a view to decreasing its influence in the

therapeutic situation and facilitating the neutral stance of

the therapist (Edwards and Bess 1998; Jacobs 1991; Racker

1988/1957; Thompson 1988/1956).

Beginning in the 1940s a shift was noticed in the way in

which countertransference was viewed (Thompson 1988/

1956). This shift involved a reconsideration of the nature

and therapeutic value of countertransference. Increasingly,

these internal responses came to be seen as a potentially

valuable tool that the clinician might use to advance the

clinical work with the patient. In his writing, for example,

Tauber (1988/1954)) notes that an analyst may be so

concerned with avoiding the possible impingement of

countertransference that he or she may not be able to attend

fully to the contents of the material that the patient is

presenting. To remedy this, Tauber encourages the con-

servative and responsible use of the countertransference

material as long as the analyst is willing to take responsi-

bility for the effects of doing so in the treatment and not to

react with defensiveness. In this way, he suggests, issues of

resistance may be more easily worked through.

For her part, Thompson (1988/1956) adds that the ana-

lyst should be open to the patient pointing out what may be

blind spots in the analyst’s personality, and calls upon the

analyst to respond in a non-defensive manner, thus

encouraging the analyst’s naturalness and spontaneity. She

draws attention to the notion that the whole person of the

analyst and the whole person of the patient exert a mutual

influence upon each other.

In decades since, the emergence of the relational,

interpersonal, and self-psychological traditions has con-

tributed further to our understanding of the meaning and

role of countertransference in psychotherapy. In these

views, the internal experience of the therapist is seen less

as a hindrance and more as an integral part of the thera-

peutic process. This inner dynamic serves not only to help

the therapist understand the unconscious communication of

the patient, but also to craft interventions that utilize and

build upon the therapeutic relationship. It is this relation-

ship and the interface of the subjectivities of therapist and

patient that is seen as central to the helping, healing process

(Brown and Miller 2002). The whole self thus becomes the

instrument or tool of the therapist (Thompson 1988/1956).

In this view, not only is it undesirable to eliminate the

impact of the clinician’s subjectivity from treatment, it is

downright impossible (Lewis 1991). This has important

implications for the supervisory relationship as a key place

where beginning clinicians learn to make use of their self in

their work.

Cultivating the Supervisee’s Use of Self Through

Supervision

Various methods have been proposed for teaching the use

of self to students of psychotherapy. Edwards and Bess

(1998) focus their attention on the central importance of

self-awareness on the part of the therapist as a way of

integrating personal and professional selves (Reupert 2007,

2008). To this end they advocate a three-pronged approach

to the exploration of the self. First, they suggest, the

therapist must make an inventory of the self. This includes

a self-examination of personality traits that contribute to

her identity as a therapist. They encourage reflection on

questions such as what one enjoys about being a therapist

and a consideration of the role that this plays in the ther-

apeutic work. Secondly, they call for the development of

self-knowledge. This especially concerns beliefs and atti-

tudes on the part of the therapist about the nature of life’s

problems and how they are best solved. Finally, the authors

point to the need for an acceptance of risks to the self. That

is to say, therapists must remain open to self-discovery

with all the challenges that accompany it. Only in this way,

they suggest, can therapists hope to understand their

patients better.

For his part, Lewis (1991) has developed a modular

training program for therapists that includes one section

devoted the development of use of self. This module

contains various elements. Lewis begins with the consid-

eration of the impact the therapist makes upon a patient by

virtue of factors such as appearance, size, movement,

posture, office setting, among others. Furthermore, he

suggests that students will benefit from as much insight as

possible into their interpersonal style and how this impacts

others. Thirdly, growth in the use of self demands attention

to the therapist’s developing feelings (including sexual

feelings) about the patient. Finally, Lewis utilizes an

exercise in which trainees discuss and elaborate fantasies

about themselves and their patient as a way of uncovering

underlying countertransference.

Glickauf-Hughes (1997) describes a model of supervi-

sion in which supervisees are taught in both didactic and

experiential ways how to manage patients’ use of primitive

defenses such as splitting, projection and projective iden-

tification and their impact on the clinical situation. Citing

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the work of Bion (1962) on containment, Glickauf-Hughes

notes that therapy provides a new opportunity for patients

to have their difficult feelings and behaviors effectively

contained thereby allowing for the possibility of an inter-

personal dynamic with the therapist that is different from

the one to which they have become accustomed. In order

for this kind of containment to occur, therapists must be

able to acknowledge, sit with, and wonder about their

experience of a range of affective states that are often

difficult to tolerate, particularly in the clinical context.

Examples of such states might include anger, shame,

incompetence, boredom, and sexual arousal.

These considerations highlight in a particular way the

issue of personal psychotherapy as an element of training

in clinical practice. Personal psychotherapy has long been

considered to be of great benefit to the developing psy-

chotherapist, not only to prevent unresolved personal issues

from adversely affecting the treatment as discussed previ-

ously, but in fact to free up areas of the therapist’s per-

sonality for greater use in the therapeutic relationship

(Thompson 1988/1956; Wolstein 1988/1959). Edwards and

Bess (1998) suggest that personal psychotherapy affords

the student the opportunity to have a therapist who may be

a model for practice, provides a first-hand understanding of

the therapeutic process, and facilitates the integration of

one’s personality with one’s professional learning. In

keeping with the perspective presented here, personal

psychotherapy can provide new clinicians with a safe space

in which to grow in comfort with the exploration of a wide

range of emotional experiences as they deepen their self-

awareness.

Still, the narcissistic vulnerability to which new thera-

pists are subject can make the practice of attending to the

many internal and external aspects of treatment seem

extremely daunting. Psychotherapy trainees of any disci-

pline who are trying on an unfamiliar role are commonly

preoccupied with issues of competence such as following

the rules, doing things correctly and well, understanding

the patient’s presenting problem, and using effective

techniques and interventions. Thus, they may find it quite

difficult to listen deeply to their internal responses in the

ways that have been suggested. An example serves to

illustrate.

Ms. K was a second year social work student placed in

an outpatient mental health clinic. Eager to learn, she

nonetheless expressed normal doubts about her ability

since she had never before conducted individual psycho-

therapy with patients. She felt full of questions on issues

ranging from the initial orchestration of the formalities of a

session to the complex work of assessment, diagnosis, and

intervention. Her supervisor, while providing needed

answers to her task-oriented questions, reassured her that

he would be there to support her, and encouraged her to be

patient with herself and to allow the process to unfold. In

this way he attempted to shore up her vulnerable sense of

self as a student and emerging professional.

As Ms. K began treating her first patients, her supervisor

noted that her process recordings were peppered with self-

recriminations about the ‘‘badness’’ of her reactions to her

patients. Statements such as, ‘‘I’m feeling like I want to

take care of the patient, and I know that is really bad,’’

were common. The supervisor asked her what she believed

was bad about her feelings. Ms. K. stated that she believed

she had to maintain a neutral and distant stance in order to

help her patients. The supervisor clarified that this belief

was grounded in a particular theoretical system and sug-

gested that her countertransference might in fact be helpful

in her work. He encouraged Ms. K to suspend judgment of

her reactions and suggested an observation of the material

that emerged both from the patient and herself, taking all of

this as information that would help her to understand her

patient better. This would serve as a framework for the

interpretation of future countertransference reactions.

Bion (1970) exhorted the analyst to come to the session

without memory, desire, or understanding. Trained in east-

ern traditions of philosophy, Bion believed that such a stance

created the condition for the possibility of openness on the

part of the therapist. If the supervisee can be encouraged to

begin from a stance of non-judgment, both of the patient and

of herself, the kind of observation and active wondering that

the use of self demands may be facilitated. Having thus

cleared away much of the static that can result from

expectable initial self-consciousness and doubt, the student

can be guided to consider and make use of her self experience

in a more integrated way with the patient and to translate this

experience into effective interventions.

The Supervisor as a Model of the Use of Self

As already noted, the task of guiding the beginning clinical

social worker in the development of the use of self falls

largely to the clinical supervisor. What, then, are the attitudes

and tasks that this requires of the supervisor? Like the novice

or experienced therapist, the supervisor may be encouraged

to follow the advice of Bion (1970) by approaching the work

of supervision without memory, desire, or understanding.

Thus, while the supervisee is being encouraged to attend not

only to the accuracy of assessment, understandings, inter-

pretations and other interventions, but also to the role of

countertransference in the weaving of the therapeutic rela-

tionship, so too must the supervisor attend not only to the

work of teaching (i.e. the transmittal of information)

and skill development, but to the impact of counter-

transference reactions on the supervisory relationship itself

(Kindler 1998).

Clin Soc Work J (2011) 39:301–307 303

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Furthermore, several authors discuss the mutual interac-

tion or influence of the supervisor, the supervisee, and the

patient in the context of supervision. Here too, the supervisor

serves as a model for the use of self. Strean (2000), for

example, notes that attention to one’s own countertransfer-

ence with the supervisee can be useful in working through

difficulties in the student’s clinical work inasmuch as these

difficulties often get unconsciously enacted in the supervi-

sory relationship. He recommends judicious suspension of

the anonymity of the supervisor so as to facilitate the

student’s work. The student is likewise assisted in the

development of the use of self when the supervisor acts as a

model in this way. For example, Knox et al. (2008) found that

supervisors’ self-disclosure of their reactions to supervisees’

patients helped normalize supervisees’ feelings, served as a

teaching tool, and strengthened the alliance between super-

visor and supervisee.

In her method of teaching students to deal with patients’

use of primitive defenses, Glickauf-Hughes (1997) notes

that due to their primitive nature and the complexity of

dealing with them, such defenses may be enacted by

students in the supervisory relationship. This may serve as

an unconscious way of communicating to the supervisor

what is happening in the treatment (Bromberg 1982).

Furthermore, this parallel process offers the supervisee the

opportunity to experience the containment of these difficult

dynamics by the supervisor. Other examples of students’

manifestation of their efforts to manage patient’s primitive

defenses might include rejecting the supervisor’s attempts

to help, feeling dejected because of a patient’s devaluation

of them, expressing intense anger towards the patient, and

wishing to terminate the therapy precipitously. Glickauf-

Hughes recommends a variety of techniques for dealing

with this including various combinations of teaching,

clarification, modeling, and role playing.

Kindler (1998) discusses supervision from a self-psy-

chological perspective. Borrowing from Fosshage’s (1995)

thinking regarding the analyst’s experience of listening

from a variety of positions, Kindler applies this construct to

the supervisory relationship. In addition to her stance as

supervisor, she may also take the position of the supervisee

as well as the patient. Furthermore, the supervisor may

listen from the perspective of empathy (e.g. from the

patient’s perspective) or from an other-centered perspec-

tive (e.g. as someone in relationship to the patient). By

taking this stance, the supervisor may more effectively

listen and understand not only the patient’s internal pro-

cess, but the dynamic process between the supervisee and

the patient. This facilitates not only the treatment but the

development of the supervisee as well. Confirmation of this

development may be seen in the supervisee’s increased

capacity for self-righting, the expansion of self-awareness,

and symbolic reorganization.

Kindler goes on to emphasize the importance of the

supervisor’s empathic listening to the supervisee, even if

this seems to preempt the discussion of patient material.

This activity is viewed as not only modeling the process of

self-psychologically-oriented treatment, but also serving

self-cohesion and vitality functions for the supervisee thus

enabling her to focus more adeptly on the subjectivity of

the patient. Likewise, consistent with a self-psychological

orientation, he recommends a close and non-defensive

attention to the supervisee’s experience of the supervisor to

promote feelings of safety and the growth of the supervi-

sory relationship.

From a related school of thought, Brown and Miller

(2002) add an intersubjective nuance to the discussion by

viewing the supervisory process as a triadic intersubjective

matrix. While akin to Fosshage’s (1995) notion of multiple

perspectives, Brown and Miller see the supervisory rela-

tionship as the ‘‘point of interaction’’ (p. 814) of three

unconscious processes. By viewing the supervisory expe-

rience as a ‘‘space for listening’’ the authors seek to attend

to the unconscious communication between supervisor,

supervisee, and patient. Such a perspective does not come

without its perils, according to the authors. Attending to the

confluence of unconscious processes in this way runs the

risk of blurring the line between supervision and the

supervisee’s personal treatment—a hazard not uncom-

monly encountered in the supervisory relationship. Like-

wise, supervision in this vein depends upon the willingness

of both supervisor and supervisee to foster an atmosphere

of self-disclosure in which material such as dreams as well

as their personal reactions in the process are laid bare. The

authors acknowledge that this may be difficult especially

for the beginning student who is in a more vulnerable

position.

Calling upon Mitchell’s (1998) notion of the relational

matrix, Ganzer (2007) applies a relational perspective to

the structure of supervision. She states that a relationally

oriented supervision is built not on the hierarchical stance

of the supervisor vis a vis the supervisee, but on the mutual

influence of the supervisor, the supervisee and the patient.

This relational matrix, she suggests, is constructed from the

intrapsychic, interpersonal, environmental, and organiza-

tional characteristics of all those involved.

Clinical Example

Ms. K brought the case of Victoria to supervision. Ms. K

had begun treatment with Victoria approximately 4 weeks

earlier. A single woman in her early twenties, Victoria was

accompanied to the clinic by her mother and the two began

to describe issues of poor self-esteem, a history of learning

difficulties, social awkwardness, irritability, and loneliness.

304 Clin Soc Work J (2011) 39:301–307

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Her mother reported frustration with Victoria, stating that

she just wanted her to get married, and stop being such a

problem. Significantly overweight, Victoria reported a

great deal of self-consciousness about her appearance and

detailed her envy of her reportedly beautiful and popular

sisters. She had never been in a romantic relationship, and

though she longed for this experience she stated that she

did not know how she would ever find a man who would

love her. She stated that she felt verbally abused by her

father and brother who called her names and related trau-

matic incidents of verbal abuse by teachers when she was

in grade school. She noted that these experiences continued

to disturb her.

Though Victoria stated that she wanted therapy, Ms. K

reported that she experienced her as apathetic and com-

plaining during the sessions and wondered what to make of

this. Ms. K went on to explore further with her supervisor

an incident with Victoria that had occurred the day before

supervision. Victoria had arrived for her session over two

hours late. When Ms. K was informed by the receptionist

that Victoria had arrived she was surprised, having sup-

posed that Victoria would not come at all. She informed the

secretary that she would be down shortly to speak with

Victoria. Ms. K came to the supervisor’s office for advice

on how to proceed. While she had availability in her

schedule she did not know if she should see Victoria. She

stated that she had learned in Social Work Practice class to

reinforce the importance of coming on time to session, and

she was concerned about the possibility of encouraging the

behavior of arriving late. While acknowledging this,

the supervisor reminded Ms. K that it was still unclear

why Victoria had come late. Together they decided that,

when she went to speak with Victoria, Ms. K would inquire

about the reason for the lateness and assess whether or not

Victoria was in any kind of crisis. If Victoria was in crisis,

she would be seen. If she simply had not come on time,

Ms. K would reschedule the session.

Ms. K told the supervisor that when she went down-

stairs, she greeted Victoria in a friendly manner. She noted

that Victoria did not appear to be in any distress. Ms. K

called Victoria to the side and quietly noted that she was

two hours late for her appointment. Ms. K asked Victoria if

she was alright and assessed her for any sign of crisis.

When Victoria stated that everything was fine Ms. K told

her that they would need to reschedule the appointment. At

that, Victoria began to yell loudly at Ms. K, asking her why

she hadn’t said so in the first place. Ms. K felt confused and

asked what Victoria meant. Victoria responded in the same

loud tone that Ms. K should have just told the secretary that

she was not going to see her instead of making her sit there

and wait. When Ms. K replied that she wanted to come

down and speak with Victoria personally, Victoria yelled

that all Ms. K was doing was wasting Victoria’s time. With

that she stormed out of the clinic as other patients looked

on from a nearby waiting area. No follow up appointment

was made. Ms. K stated that she was unsure what to do

next.

When the supervisor asked Ms. K how she felt about what

had transpired she reported confusion and anger. The con-

fusion, she said, related to her sense that Victoria’s outburst

had come out of nowhere. The anger related to her embar-

rassment at having been yelled at in view of the receptionist

and patients in the waiting room. Furthermore, she admitted

that, in her anger, she felt ‘‘turned off’’ to the idea of working

with Victoria and somewhat pleased at the prospect of not

seeing her again. The supervisor validated Ms. K’s reactions

both verbally and non-verbally, empathizing with both how

confusing and embarrassing it must have been for her. He

then asked Ms. K if she felt able to sit with those feelings and

her memory of the interaction. Perhaps she and the super-

visor could wonder about this together. What else did she

think and feel about her exchange with Victoria? What else

might have been going on?

As she processed her experience with the supervisor,

Ms. K stated that it seemed like Victoria was telling her she

was a bad therapist and was therefore rejecting her by

storming out of the clinic. She spoke about feeling

embarrassed and thought that she had perhaps not handled

the situation well. Maybe this was why Victoria was

leaving treatment. For his part, the supervisor was aware of

having another feeling about the interaction between Ms. K

and Victoria. He shared with Ms. K his sense of irritation.

Victoria seemed not to have taken into account the value of

Ms. K’s time, he said, but then proceeded to accuse Ms. K

of wasting her time. This led Ms. K to identify more with

her own sense of irritation, which she had initially named

but then abandoned to focus on her sense of embarrassment

and inadequacy. The supervisor interpreted these latter

feelings as understandable and likely related to her inse-

curity as a beginner, and added that they may in fact cloud

some of her deeper reactions. The supervisor further noted

that, if properly contained and dealt with, difficult count-

ertransferential reactions, like irritation, can sometimes be

a great source of insight and can open new pathways for

therapeutic progress.

As they continued the supervisory session, the supervi-

sor encouraged Ms. K to sit with and be curious about her

own sense of irritation or annoyance. This led Ms. K to

make a number of associations to Victoria’s mother and to

descriptions of the dynamics between the two as well as

to Victoria’s home life in general. The supervisor asked

Ms. K to describe these. What emerged was a pattern of

unstable, shifting affects in Victoria’s relationships that

evoked in her the very sense of emptiness and inadequacy

she sought to remedy through therapy. As the supervisory

dialogue continued, and the supervisor further modeled a

Clin Soc Work J (2011) 39:301–307 305

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wondering stance, Ms. K grew more comfortable articu-

lating and exploring her feelings and associations to what

transpired with Victoria the day before. Having shared his

sense of irritation, the supervisor facilitated Ms. K’s

identification and acceptance of her own anger, as well as

her desire to end her therapeutic relationship with Victo-

ria—not an easy thing for a new supervisee to admit to her

supervisor.

However, this in turn helped Ms. K identify on an

experiential as well as intellectual level a pattern whereby

Victoria thwarted the development of healthy relationships.

The supervisor encouraged Ms. K to think more deeply

about the origins and implications of this pattern. Ms. K

began to see that this aspect of Victoria’s interpersonal

behavior was born of repeated experiences of traumatic

rejection that led to a narcissistically depleted self. In a

self-protective but interpersonally frustrating way, Victoria

evoked the very rejection she feared. However, she did so

in such a manner as to walk away with some sense of

control. At this point Ms. K said she was aware of expe-

riencing even more empathy for Victoria and felt free to

reach out genuinely to Victoria while allowing her the

freedom to leave treatment if she chose to. With a mini-

mum of effort, Ms. K was able to reconnect with Victoria

and her treatment continued. Ms. K’s increased under-

standing of and empathy for Victoria helped her not only to

facilitate the repair of their relationship but to form a strong

working alliance with her. Together, they began to examine

the dynamics of Victoria’s relationships and how they

could be improved.

This clinical and supervisory experience helped Ms. K

to grow in a number of ways. On a procedural level, she

gained a clearer understanding of the way in which patient

lateness was handled in the mental health clinic to which

she was assigned. Furthermore, she benefitted from the

experience of working through a conflictual encounter with

her patient. Perhaps most significantly, however, she grew

in her ability to explore her affective response to her

patient and to wonder about the nature and meaning of that

response. Further development of this skill will contribute

to her growing confidence and effectiveness as a clinician.

Conclusion

The development of the use of self demands cooperative

effort on the part of both the social work supervisee and the

clinical supervisor. For the supervisee, this means the fos-

tering of self-awareness with its attendant risks, the will-

ingness to explore countertransferential experiences on all

levels, the capacity for insight, and the ability to tolerate

uncertainty and to suspend judgment both of the self and the

patient in order to listen with evenly suspended attention. For

the supervisor, this means the ability to model self-awareness

and the vulnerability that comes with the appropriate sharing

of one’s feelings and thoughts, and the ability to listen

carefully and non-judgmentally not only to one’s own

countertransference, but to the experiences of the patient and

supervisee alike. Having assisted the supervisee in the

identification and exploration of his or her experience of the

patient, the supervisor is then able to help the supervisee

translate that insight into clinically useful interventions that

will advance the treatment. In this way, the supervisor is in a

unique position to assist in the integration of the new clini-

cian’s personal and professional identities, and the honing of

the finest of therapeutic instruments—the supervisee’s very

self.

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Author Biography

John P. McTighe is Associate Director of Counseling, Health & Wellness at William Paterson University. He holds a M.S.W. and

Ph.D. in Clinical Social Work from New York University. He is an

adjunct assistant professor of Pastoral Counseling at Fordham

University and maintains a private practice in northern New Jersey.

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