Clinical Social Work Journal https://doi.org/10.1007/s10615-018-0662-9
ORIGINAL PAPER
The Process of Facilitating Case Formulations in Relational Clinical Supervision Brian Rasmussen1 · Faye Mishna2
© Springer Science+Business Media, LLC, part of Springer Nature 2018
Abstract This paper explores the supervisory process in relation to the ongoing challenge of developing (and re-developing) a case formulation. We adopt a relational approach to clinical practice and correspondingly to the supervisory domain. We argue that a relational approach to clinical practice firmly fits with social work values, including authenticity, mutuality and collaboration. We address typical challenges inherent in attaining and maintaining a relational formulation in the supervisory relationship. Keywords Relational supervision · Case formulation · Relational theory · Mutuality · Clinical social work
Introduction Kelsey is stuck. She begins her supervisory session by reporting that after three sessions with B. she has completed a thorough assessment yet feels overwhelmed with the complexity of the case and unsure where to start. In rapidfire succession, Kelsey recounts the enormous amount of information gathered in these sessions. The client described chronic abuse and neglect, interpersonal violence, and substance abuse. Anne, Kelsey’s supervisor, struggles to hold the information in her head, feels besieged by the sheer volume of material, and notices her own rising anxiety. Kelsey states that she thinks that B. meets the criteria for borderline personality disorder but reports, in passing, that she “doesn’t feel borderline-like” in the sessions. Confused, Kelsey presses her supervisor for concrete advice. Anne resists this demand, however, acknowledging that she too is uncertain about what to make of the material B. shared. As a relationally oriented supervisor she knows she must work * Brian Rasmussen
[email protected] 1
School of Social Work, Faculty of Health and Social Development, University of British Columbia, Okanagan Campus, Arts Building, A136, 1147 Research Road, Kelowna, BC ViV 1V7, Canada
Factor‑Inwentash Faculty of Social Work, University of Toronto, 246 Bloor Street West, Toronto, ON M5S 1V4, Canada
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collaboratively with Kelsey to make sense of the clinical material, all the while mindful of the supervisory relationship dynamics, Kelsey’s relationship with B, and the client’s relationship to the external world. It’s a tall order that will be repeated over and over. The purpose of this paper is to explore the supervisory process in relation to the ongoing challenge of developing (and re-developing) a case formulation. We adopt a relational approach to clinical practice and correspondingly to the supervisory domain. We argue, as others have previously, that a relational approach to clinical practice firmly fits with social work values, including authenticity, mutuality and collaboration. We therefore first briefly review the history of relational theory and its fit with clinical social work practice (Tosone 2004; Borden 2000; Saari 2005; Pozzuto et al. 2007). Highlighted is the major shift in thinking over the past few decades, from a so-called one-person psychology to a two-person perspective (Mitchell 2000; Aron 1996). This shift in theorizing has profound implications for our understanding of the aetiology of client problems as well as the clinical process (Goldstein et al. 2009). As we argue below, however, it can be challenging to maintain this perspective in practice or in clinical supervision. Next, we present literature on the supervisory experience from a relational perspective. While relational theory has greatly influenced psychodynamically oriented practice it has only recently received corresponding attention in the supervisory domain (Sarnat 2016). Differences between a relational approach to supervision and more traditional forms are identified. Thirdly, we
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review literature related to the challenge and importance of case formulation, with attention to relational formulations. Finally, we address typical challenges inherent in attaining and maintaining a relational formulation in the supervisory relationship.
The Relational Turn Relational Theory The relational perspective is a contemporary psychoanalytic theory, with roots in interpersonal theory, British object relations theories and self psychology (Mitchell 1988, 1993, 2000). From a relational perspective, psychological reality is understood as functioning within a “relational matrix” comprising both the interpersonal and intrapsychic realms (Mitchell 1988). Another theory on which relational theory draws is attachment theory, which considers relatedness a fundamental biological need (Bowlby 1969). According to Mitchell (1988), there is overwhelming evidence that, “the human infant does not become social through learning or conditioning, or through adaptation to reality, but that the infant is programmed to be social” (p. 24). Mitchell cites the work of Fairbairn (1952), emphasizing that because of individuals’ need for intense attachments, they will form and maintain relatedness and contact with whatever is available. The fundamental relational configuration comprises dimensions of the self, the other, and the transactional patterns that take place. Meaning, therefore, “is not provided a priori, but derives from the relational matrix” (Mitchell 1988, p. 19). According to relational theory, disturbances that occur in early relationships interfere with a person’s ensuing ability to relate (Mitchell 1988). The goal of therapy is to help the client change the way his or her relational world is structured. On the one hand, the client relates in their old patterns, attempting to connect with the therapist through the old relational pattern. At the same time, the client seeks and desires new ways of relating. As issues are explored and the relationship is repeatedly worked through, the client comes to experience the therapist in new relational ways (Ornstein and Ganzer 1997). This affective experience corresponds with the client being transformed in some way (Huang et al. 2016; Knox et al. 2012). Other frameworks that have influenced the relational perspective include feminism and postmodernism. The influence of feminism is evident in the emphasis on mutuality, egalitarianism, relationship building, validation of subjective experience, and diversity. The view of “truth” in the clinical situation as perspectival and plural to varying degrees is due to the influence of postmodernism. As Mitchell (1993) argued, “knowledge in our day is considered—can only be considered—pluralistic, not singular; contextual,
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not absolute; constructed, not uncovered; changing and dynamic, not static and eternal” (p. 44). Accordingly, the impact of the worker-client relationship on the client (Dean and Fleck-Henderson 1992; Marziali and Alexander 1991) is well demonstrated and accepted (Horvath et al. 2011).
Relational Influence on Clinical Social Work In recent decades there have been many notable contributions to relational social work practice that draw on psychodynamically oriented contemporary relational theory, consistent with the profession’s emphasis on the helping relationship. Borden (2000) provided an in-depth review of relational concepts in psychoanalytic theory and argued for its place in contemporary social work practice. Ornstein and Ganzer (1997, 2005) similarly made the case that relational theory is the model for the future of social work, as did Goldstein et al. (2009), Ganzer (2007), and Saari (2005). Noting the key features of relational social work, Tosone (2013) argued for the need to attend to a two-person psychology, the importance of mutuality, the subjective and contextual nature of truth, the role of enactments, and the attention to countertransference as a therapeutic tool. She summarized relational social work as “…the practice of using therapeutic relationships as the principal vehicle to affect change in the client’s systemic functioning, referring to the inherent interconnections of the intrapsychic, interpersonal and larger community systems” (p. 256). Consequently, relational theories have also begun to infuse clinical supervision practice, a topic that we take up next.
Relational Supervision Psychoanalytically oriented clinical supervision can be traced to Freud, dating back to 1902 and his Wednesday evening meetings (Sarnat 2016). Here, Freud held court in an authoritarian manner, insuring that members held to his doctrine. This hierarchical arrangement set the stage for the supervisor to operate as expert in all matters technical with the primary focus on the patient. Elements of this basic arrangement can be observed in many forms of traditional supervision today (Schamess 2012). In contrast to traditional forms of supervision, relational supervision, as its namesake suggests, puts the supervisory relationship at the center of consideration. Seminal leaders in this approach include Frawley-O’Dea and Sarnat (2001), and Sarnat (1992, 2016). In clinical social work several scholars have embraced and adapted this approach to supervision (Ganzer and Ornstein 2004; Miehls 2010; Ornstein and Moses 2010; Ringel 2001; Peled-Avram 2017; Yerushalmi 2012). While there is no singular view of what relational supervision entails, we will review the basic elements of this
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approach as articulated by Frawley-O’Dea and Sarnat (2001) and most recently by Sarnat (2016). Frawley-O’Dea and Sarnat (2001) contrast their model of relational supervision with the so-called classical version that is patient-centered, which views the supervisor as an expert whose didactic participation focuses primarily on the patient’s mind and the appropriate techniques. In contrast, they view the relational supervisor as an embedded participant rather than a detached expert, whose primary work attends to the full relational matrix, relational themes, and enactments. They differentiate their approach from others along three dimensions: (1) the nature of the supervisor’s authority; (2) the supervisor’s focus; and (3) the supervisor’s primary mode of participation. These dimensions are expanded upon below. First, the nature of the supervisor’s authority is fundamentally different than expert models of supervision. Frawley-O’Dea and Sarnat (2001) write, “In a relational model, the supervisor’s authority derives from her capacity to participate in, reflect upon, and process enactments, and to interpret relational themes that arise within either the therapeutic or supervisory dyads” (p. 41). While they argue that the supervisor indeed has expertise in clinical theory and practice, she does not have special knowledge with respect to the supervisee, the therapeutic relationship being examined, or the psychodynamic work. Consequently, authority is derived from a mutually co-constructed set of meanings leading to a shared view of power and authority. Nonetheless, the supervisory relationship, despite the mutually contributed subjectivities, is characterized by inherent asymmetries. Sarnat (2016) clarified: “The supervisor holds responsibility for the frame, that is, setting up the specifics of when and where the supervision will occur, and for maintaining a focus on the supervisory task, for evaluation and for ethical practice” (p. 20). Second, the shift in the nature of the material discussed in supervision means that the supervisory relationship itself is included, in addition to the client and intervention strategies. Consistent with the shift to a ‘two-person psychology’, a relational supervisor not only considers the client’s dynamics and the supervisee’s anxieties, she also opens discussion on what is happening in the supervisory relationship. Frawley-O’Dea and Sarnat (2001) explain that the relational supervisor “…sees both the patient’s conscious and unconscious expression of his psychodynamics and the supervisee’s conscious and unconscious expression of his experiences of the patient, of himself, and of the supervisor as relationally mediated phenomena embedded within the supervisory matrix” (p. 52). Sarnat (2016) adds that, consistent with contemporary views of neuroscience and cognitive science, the supervisor attends to nonsematic material that arises in the supervisory relationship, and further, assists the supervisee in learning
how to use this material. These data refer to the feelings, impressions, and non-verbal gut reactions that happen in the clinical session and the supervisory session itself. The third dimension focuses on the supervisor’s mode of participation. Here, the supervisor’s role entails a delicate balance of the “teach-treat dilemma”. Supervisees naturally reveal their own countertransference responses (knowingly and unknowingly) to their clinical practice and simultaneously experience transference reactions toward the supervisor. Keeping in mind that the ultimate goal is educational and not therapeutic, the relational supervisor can nonetheless carefully explore and co-construct the anxieties and conflicts of all participants in this matrix (Sarnat 2016). Let us consider a hypothetical example. A. is a newly minted dentist who is in therapy with B., a relatively new clinician. (A) describes near crippling anxiety, saying he feels like a fraud carrying out his new dental practice. (B) is unsure how to work with this material. B. also feels like a fraud at times, especially when feeling confused or stuck. B. anxiously takes this case to C., his supervisor, worried that he will not live up to her expectations. (C) is a wellrespected and competent supervisor. But at times, C too feels like a fraud in this role, having never taken a course or any training in clinical supervision, mostly relying on the experience of helpful past mentors. As we can imagine, there is a considerable degree of feelings of fraud floating in the air of this supervisory session. If one were to adopt a classical approach, the supervisor would likely remain focused on the client’s internal dynamics and responses to the therapist. Alternatively, a relationally focused supervisor would likely attend carefully to the process by which this material is presented, its impact on the clinician, her own subjectivity (fantasies, bodily awareness, anxieties), the supervisory relationship and the therapeutic relationship, as well as the client’s dynamics. Consequently, the exploration of supervisory material could potentially move in many different directions, and not singularly focused on the client. The supervisor might choose to disclose her own feelings of fraudulence as it emerges in the supervisory session and how she has learned to think about it and hold it in her mind. Noticing that the supervisee defends heavily against such feelings, she might gently challenge him to explore the impact of the client’s disclosure. The supervisor would also be attentive to any evidence of enactments emerging from the client-therapist or supervisory dyad. The meanings of such dynamics are mutually explored and co-created. In the end, Sarnat (2016) suggests that, “In the relational model, the supervisory relationship is understood to be more than just a carrier of knowledge and medium for collaboration; it is a formidable vehicle for growth and development” (p. 30). It is consequently important for supervisors to reflect upon, as best they can, their own resistances and defensiveness to
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the clinical material, thereby modeling for the supervisee the same. Social work scholars have also applied a relational model to theorizing the field instructor/supervisor-student relationship, recognizing that the student and supervisor mutually influence the relationship (Bogo 1993; Fox 1998; Ganzer and Ornstein 1999; Miehls 2010; Ornstein and Moses 2010). This perspective differs significantly from the traditional view whereby the supervisor’s knowledge is privileged and subsequently imparted to the supervisee (Bernard and Goodyear 2018). More interactive and less hierarchical, a relational approach “provides a model of field instruction more consistent with the values and practice of social work, where relationship and use of self are viewed as primary factors in social work outcomes” (Ganzer and Ornstein 1999, p. 232). Similarly, Schamess (2006a, b, 2012) contributed to the relational supervisory social work literature focusing his attention on transference enactments in supervision in addition to a dynamic understanding of mutuality and the bidirectional nature of supervisory action. He argues, “supervisory conversations weave together manifest and symbolic content in separate, overlapping narratives. When these narratives are viewed in relation to one another, they reveal the enduring relational templates that shape supervisees’ interactions with patients, supervisors and other significant others” (p. 408). Finally, relational theories have influenced the workings of both the student-supervisor and student-instructor relationship in social work (Ornstein and Moses 2010; Rasmussen and Mishna 2003). Indeed, it is emphasized that when the process is not optimal, it is critical that the field instructor facilitate an exploration with the student of their relationship. An important goal of such exploration is development of the student’s relationship competence (Bogo 1993). Similarly, the instructor-student relationship in the classroom has been characterized as highly influential in student social workers’ learning (Mishna and Rasmussen 2001). Corresponding with the recognition that the field instructor-student relationship influences “the student’s learning positively or negatively” (Bogo 1993), it is argued that, “the context created through classroom interaction can facilitate or inhibit students’ professional growth” (Dore 1993, p. 181). Next, we explore the need for case formulations and the role of relational perspectives in assisting clinicians in this regard.
Case Formulation Case formulation is a key but often neglected process in clinical practice, bearing an important relationship to assessment and diagnosis but synonymous with neither. While considered an important aspect of the clinical process,
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however, it should be noted that “… the results of randomized clinical trials comparing manual-driven with formulation-driven therapy are inconclusive about whether case formulation plays the essential role in psychotherapy that has been claimed for it” (Eells et al. 2011, p. 396). Such is the current state of empirical knowledge with respect to the process of developing case formulation and its relationship to psychotherapy outcomes. Nevertheless, to operate without a case formulation, however tentative and evolving, would be like building a house without a blueprint or even a concept of what the outcome might be. Eells (2007) defines case formulation as “a hypothesis about the causes, precipitants, and maintaining influences of a person’s psychological, interpersonal, and behavioural problems” (p. 4). Similarly, social work scholars Dean and Poorvu (2008) define formulations “as a focused, brief conceptualization of the client or situation based on the assessment” (p. 597). Case formulation is therefore a necessary blueprint for the intervention strategy and has an important relationship to the form of treatment offered (McWilliams 1999). For example, from a cognitive behaviour perspective, a clinician would likely identify the client’s specific cognitive distortions, worldviews, and behavioral sequences in relation to the presenting problem, and adapt the treatment strategy accordingly (Nezu et al. 2007). From a psychodynamic perspective, what remains fundamental in deriving a case formulation is articulating the dynamic interaction between the individual and their social world, incorporating hypotheses about conscious and unconscious developmental and relational antecedents (Rasmussen 2015). Accordingly, developing case formulations is a complex, multi-faceted, theory driven, artfully crafted challenge. It involves incorporating observable facts and empirically derived knowledge, along with subjective and intersubjective aspects of the treatment relationship. Astutely, Dean and Levitan Poorvu (2008) uphold that, “…we must choose the words we use in a formulation very carefully, and hold them lightly, always ready to be changed” (p. 598). Although there are many examples of case formulation, an exemplar from a psychoanalytic perspective is the work of Nancy McWilliams (1999). McWilliams first makes the case for the relationship between case formulation and psychotherapy. McWilliams argues for the value of appreciating the therapist’s subjectivity, as well as the importance of non-verbal communication, and multiple meanings of behaviour. McWilliams (1999) writes, “…when trying to come to an understanding of a complex human being and his or her complex difficulties, a therapist is silently pondering several related questions while drawing out and listening to the client” (p. 27). The areas that McWilliams advocates incorporating into a formulation include “(1) temperament and fixed attributes, (2) maturational themes, (3) defensive patterns, (4) central affects, (5) identifications, (6) relational
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schemas, (7) self-esteem regulation, and (8) pathogenic beliefs” (p. 27). Clearly, for new and even seasoned clinicians, arriving at an individualized, complex working formulation is a challenging task, therefore requiring the support of clinical supervision. Moreover, holding a social work viewpoint means expanding our formulation of the client’s problems beyond individual dynamics. Arguing that every clinical situation is unique, Dean and Poorvu (2008) contend that formulations should attend to the particular circumstances of the client and include ideas related to “… ecological, cross-cultural, psychodynamic, systemic, biological, and spiritual components” (p. 596), resting further on a social justice foundation. Likewise, Lee and Toth (2016) advocate broadening our theoretical approaches to case formulation while at the same time individualizing the process, creating a formulation that is rightfully client centred. In their words, Lee and Toth argue for formulating in a way that results in ‘developing a theory of a client’. From a relational perspective, a case formulation incorporates the kind of data noted above, while paying special attention to the nature and quality of the client’s current and past relational patterns, in addition to the nature of the therapeutic interaction. Knowing that a good deal of positive therapeutic outcomes can be attributed to the nature and quality of the therapeutic relationship, and that many problems presented by clients have their origin in care-giving relationships, understanding the causes, precipitants, and maintaining features of their presenting problems in relational terms is essential. In the next section we expand on these themes in relation to the supervisory process.
Supervisory Processes in Relational Case Formulations Ideally, relationally based practice is guided by a relationally based case formulation supported by relationally based clinical supervision. Disjunctions, inconsistencies, and incoherence in the process risk confusion for the clinician and a muddled intervention structure. It would stand to reason that theoretical coherence between these three domains sets the stage for potential successful client outcomes, although as noted above, formal research is needed to confirm this theoretical speculation (Eells et al. 2011). In this section we explore the process of assisting in the forming and reforming of case formulations and typical obstacles to this approach. We add ‘reforming’ because we believe that the boundaries between assessment, formulation, and treatment are necessarily repeatedly blurred. As Tufekcioglu and Muran (2015) argue, “… a collaboratively constructed case formulation must always be considered in the context of an evolving therapeutic relationship” (p. 469). Moreover, because it is in the supervisory
relationship that these formulations are mutually developed, shifts and changes in this relationship can potentially alter the formulation. In providing clinical supervision and consultation our experience has led us to observe that there are two kinds of cases frequently brought to supervision. First, a case is presented because the presenting problem(s) are complex, multifaceted, and perplexing, perhaps extending beyond the supervisee’s level or sense of competence. The supervisee is in effect saying, “I’m not sure what is going on and I’m not sure where to start, please help”. Such was the example at the outset of this paper. Secondly, supervisees are inclined (consciously and unconsciously) to present case material that reflects some of their own unresolved dynamics and/or an over-identification with some aspect of the clinical story (Schamess 2006a, b). Here, the supervisee is saying something like, “this client reminds me of myself at 17” or “my countertransference is so strong with respect to… this or that”. The supervisee may also be unwittingly participating in an enactment with this treatment. Of course, these scenarios are not necessarily mutually exclusive, but nonetheless we will examine both separately for the sake of clarity. It is completely understandable that supervisees tend to present difficult and complex cases. This is what supervision is for! In this scenario it is typical that a great deal of material is presented, sometimes in a disconnected way, perhaps parallel to the way it emerged in the clinical consulting room. While the assessment may have been thorough and a diagnosis or diagnoses known, often a case formulation is wanting. At this point in the process the supervisor may feel pressure (internal or external) to do something. She may feel pressure to fill in the gaps or precipitously propose a clinical formulation. Very often the supervisor, if she is honest with both herself and the supervisee, is also confused, overwhelmed, and suspended in a state of ‘not knowing’ (Schamess 2013). Nonetheless, she may feel compelled to operate from an expert position. Drawing her authority from more extensive clinical expertise she may respond to the pressure by offering a formulation, providing advice, and suggesting specific interventions. Such a process relies on general knowledge of diagnostic categories, evidence based approaches known to be effective according to randomized controlled trials, and well-utilized monolithic case formulations (Persons and Tompkins 2007). However valuable the supervisor’s experience and the empirical evidence, she cannot know (from the outset), what is going on with this specific client which is affected by the specific relationship with this therapist. Sarnat writes, “Just as relational model supervisors discourage supervisees from pretending to false competencies, we refrain from assuming false expertise ourselves. When we acknowledge our limitation as supervisors, we model for supervisees accepting and working with their own limitations as clinicians” (2016, p. 30). Operating from
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a relational perspective requires a strong capacity to tolerate not knowing. Not knowing is challenging for supervisors and supervisees alike. The state of not knowing is anxiety producing and antithetical to our sense of self as effective helpers. In effect, to not know is to be a helpless participant in this context. But Taylor and White (2005) suggest “that practitioners need to be realistic about assessment and decision making and to see it in all its complexity and uncertainty” (p. 950). Accordingly, they argue for a therapeutic stance of ‘respectful uncertainty’. In step with this thinking, we contend that for a relational supervisor to be effective she must be able to tolerate and model the capacity to manage uncertainty. She may say, “I too am not sure what to make of all this material. Let’s work together to make some sense of it”. These kinds of statements model humility and mutuality. Her options in moving forward must be guided by an understanding of the supervisory relational matrix that includes the therapist-client relationship, the client’s external relationships, and the supervisory relationship. Importantly, holding a stance of not knowing provides the clinician with a model for how to be in a session with the client. As Schamess (2013) proposes, “When therapists can tolerate the feelings of inadequacy that accompany ‘not knowing’, they open themselves to encountering unexpected, enlightening aspects of patients’ inner lives, and also unexpected aspects of their own” (p. 230). Notwithstanding the importance of modelling ‘not knowing’, a formulation, however tentative, is needed to inform the treatment process, and the supervisor bears responsibility in guiding this process. Let’s return to the vignette at the outset of the paper. Listening for relational themes, the supervisor picks up on the supervisee’s statement “she doesn’t feel borderline-like in the sessions”. This statement, made in passing, holds considerable relational weight and confusion for the supervisee. Curious about this statement the supervisor asks Kelsey how she feels toward the client in the session. Beyond feeling somewhat overwhelmed in the session, she reports surprise at how much she likes this client. It is this surprise that the supervisor keys in on (and not whether the client has met all the criteria for BPD). Knowing that every therapeutic relationship is unique, the relational supervisor seeks to explore how this particular relationship is being established and how it is unfolding. A relational formulation continually incorporates the evolving and ever changing relational dynamics. At this moment in time Kelsey also expresses a fear, based on her work with others similarly diagnosed, that “soon the other shoe is going to drop”. Her supervisor says, “I guess we’ll have to wait and see, but in the meantime let’s see if we can understand what the client needs from you now”. Interestingly, while Eells et al. (2011) have noted that little research has been conducted on the content and process
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of arriving at a case formulation, and indeed its relationship to clinical outcomes, research does exist to suggest that expert clinicians formulate cases differently than novice therapists. They distinguish between forward and backward styles of reasoning. Backward reasoning, characteristic of novices, is marked by “the generation of problem solutions on the basis of a hypothesis for which supporting data are then sought” (p. 386). For instance, a novice therapist might arrive at a formulation based on what he or she knows about a diagnostic category and the associated behavioral characteristics. On the other hand, experienced therapists who employ more forward thinking draw inferences based on descriptive data at hand, arriving at more integrated, individualized, and complex formulations (Eells et al. 2011). In the above example, the supervisee may be operating more from a ‘backwards reasoning’ perspective, drawing heavily on what she has known about working with someone labelled BPD and its accompanying diagnostic criteria. In addition to resisting the pressure to ‘know’ before one has explored relational data, the anxieties of both supervisor and supervisee, in our experience, may result in collapsing the relational frame back to a ‘one-person model’. In this instance it is natural for the discussion to shift toward an exclusive focus on the client, and efforts to arrive at a tentative formulation will accordingly only include ideas particular to the individual seeking help. Missing from the formulation are the subjectivities of the supervisee and supervisor, including what Sarnat (2016) refers to as the nonsematic experiences. Sarnat adds that such awareness is particularly important when working with trauma survivors and those experiencing dissociative states. Staying with the example above, the supervisee reports experiencing concurrent feelings of positive attraction toward the client and dread for what may lie ahead. These states are largely unformulated ‘gut feelings’. They are based on relatively little formal information from the client but nonetheless are important to understand. Shifting attention exclusively back on the client could be a defensive manoeuvre within the supervisory relationship, perhaps to avoid the ‘not knowing’ states, and a return to the safety of assessing the client. The second kind of case frequently brought forward is one about which the supervisee acknowledges some troubling countertransference or an over-identification with some aspect of the clinical situation. It is understandable that this scenario is brought to supervision as the subjectivity of the supervisee needs to be explored in relation to the formulation. It should be emphasized however, that all treatments involve countertransference and some degree of identification or lack thereof. Supervision can be helpful in holding a conversation in a trusting non-judgemental manner that purposefully explores these feelings in relation to understanding the client. In the example below, Sandy, an experienced clinician, attempts to determine the motivation
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and capacity for change with a mandated client, both important elements of a case formulation (McWilliams 1999). Sandy is a 47 year-old divorced white woman who has been a clinical social worker for 20 years. She is down to earth and relates well with a wide range of clients. She is having trouble imagining the possibilities for change with her new client Jack, however, who is in the midst of a protracted custody battle. A judge had ordered joint counselling rather than continued litigation. In the three assessment hours spent with Jack she struggles to empathize with him and as she states, “his litany of complaints.” Sandy has met with Jack’s ex-wife Emma, whom she finds “patient and reasonable.” Sandy assesses the situation as one in which Jack’s argumentative and arrogant style offers little hope for therapeutic progress. Although wanting to be helpful, the supervisee wonders whether she should just close the file and let the Judge know that they are not amenable to treatment. The supervisor privately contemplates this action, considering it to be a reasonable course of action but hears a tone of nagging doubt in the supervisee’s voice as she ponders giving up on this client. The supervisor invites her to reflect further on her countertransference, while trying to contain his own feelings of hopelessness. Sandy says “well, I’ve seen this before with other cases, and frankly it looks a lot like my own divorce”. The supervisee shares a bit more about her own divorce 5 years previously, noting that this man behaves similarly to her ex-partner. Sandy laments, “eventually I had to give up on my ex”. As the supervisory conversation unfolds, Sandy considers the possibility that her own painful experience of attempting to co-parent after separating was influencing the way she was formulating the case and assessing Jack’s capacity for change. In this case example, the supervisor must tread carefully within the so-called “treat-teach” situation (Frawley-O’Dea and Sarnat 2001; Ganzer and Ornstein 2004; Ornstein and Moses 2010; Sarnat 2016). The challenge from a relational supervisory perspective is how to hold a conversation about powerful emotions and their multiple origins without responding as the supervisor’s therapist. Ornstein and Moses (2010) write that in these situations “...what is indicated is a careful, tactful and respectful investigation of the interpersonal world of all the participants…” (p. 108). This may involve self-disclosure on the supervisor’s part about his subjective state as he listens to the clinical material. In this example, the supervisor acknowledged a feeling of wanting to give up on this case and move on to another. Perhaps this state reflected the supervisee’s conflicted wish to exit the therapeutic relationship, or maybe it had something to do with the supervisor’s psychology—or both. Regardless, it was important to acknowledge these feelings in the midst of sorting out whether meaningful change could occur for Jack. Assessing and formulating something as important as a person’s motivation and capacity for change cannot be
disconnected from the observer’s own dynamics and the interaction of the various participants. When we remove our own subjectivity from the process of formulating a case we contribute to the illusion that we are objectively describing and making sense of a thing rather than a complex person and his or her relationships.
Conclusion In this paper we have sought to explore the process of working toward a case formulation from a relational perspective. We have emphasized process over content in keeping with the essence of relationally informed clinical supervision. This is not to minimize the importance of arriving at a stated formulation, however firmly or tentatively held, but rather to speak to the nature and quality of the supervisory relationship in facilitating this method. While there is no consensus of what specifically constitutes relational supervision, we have underscored characteristics illustrative of this approach when assisting in developing case formulations. Some of the features central to this conceptualization include the mutual efforts to explore the various realms of the client’s relational patterns, along with the client-therapist and superviseesupervisor relationship. The process is flexible, reciprocal, tentative, humble, evolving, subjective, intersubjective, and incorporative of various sources of data. Moreover, the process is respectful of the uniqueness of the client and accordingly the distinctiveness of the parallel therapeutic and supervision relationships. For clinical social work practice to continue moving toward a relational approach in case formulation and practice it is reasoned that the accompanying clinical supervision correspondingly match this sensibility.
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