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Due 3/25/2019The ethical guidelines stipulate how helping professionals must conduct themselves when working with clients to avoid legal and ethical violations. They also include information regarding the ethical responsibility of addressing professional impairment. For example, a duty to warn refers to notifying a person or authorities if a client or student is a danger to themselves or to someone else. A duty to warn also means that if an impaired professional is unable to treat effectively and places a client or student at risk for harm, appropriate persons or authorities must be notified. For this Discussion, select one of the scenarios provided and analyze the potential for professional impairment as it relates to vicarious trauma. In addition, think about your ethical responsibility in addressing the impairment as a helping professional. Post your brief description of the scenario you selected. Then explain at least one possible impairment exhibited by the practitioner due to vicarious trauma and the impact it may have on the helping or treatment process. Then, as a helping professional, explain how you might address the impairment. Be specific and provide examples referencing your professional code of ethics. References Goren, E. (2013). Ethics, boundaries, and supervision Commentary on ‘Trauma triangles and parallel processes: Geometry and the supervisor/trainee/patient triad’. Psychoanalytic Dialogues, 23(6), 737-743. doi:10.1080/10481885.2013.851568 Knight, C. (2018). Trauma-informed supervision: Historical antecedents, current practice, and future directions. Clinical Supervisor, 37(1), 7-37. doi:10.1080/07325223.2017.1413607 Morrissette, P. J. (2004). The pain of helping: Psychological injury of helping professionals. New York, NY: Taylor & Francis. Chapter 8, “Burnout”
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Psychoanalytic Dialogues, 23:737–743, 2013
Copyright © Taylor & Francis Group, LLC
ISSN: 1048-1885 print / 1940-9222 online
DOI: 10.1080/10481885.2013.851568
Ethics, Boundaries, and Supervision. Commentary on
Trauma Triangles and Parallel Processes: Geometry and the
Supervisor/Trainee/Patient Triad
Elizabeth Goren, Ph.D.
New York, NY
The author discusses the clinical and ethical issues in enactments that are interwoven between
relational therapy and supervision as described in the case illustration. The tendency to focus on
enactments involving physical action risks obscuring attention to psychological boundary crossings
that can be equally harmful. The current maternal tilt in psychoanalysis can unwittingly lead analysts
and supervisors to avoid confrontation and analysis of hostility and aggression, thereby inhibiting
the working through of intense negative transference and countertransference. The similarities and
differences between supervision and treatment are discussed in terms of maintaining responsible
boundaries.
“Trauma Triangles and Parallel Processes: Geometry and the Supervisor/Trainee/Patient Triad”
(Castellano, this issue) is the evocative portrayal of an enactment in the therapy of a survivor of childhood abuse that was unconsciously transmitted into the therapist’s training setting
through a secondary enactment between the therapist and her supervisors. The therapist, Dana
L. Castellano, describes her senior supervisor’s behavior as abusive, and speaks of the shame
and humiliation she felt subjected to by him. Abuse is a strong word with powerful implications.
The questions I want to explore involve some of our working assumptions about abuse and our
thinking about what constitutes a boundary violation. Had the purportedly abusive supervisor’s
behavior involved physical touch, particularly of an erotic nature, there would be no doubt that a
boundary violation had been committed. But when does a way of relating constitute an expression
of abuse that should be considered professionally questionable? I highlight some of the underlying conditions, illustrated in this supervisor/trainee/patient triad, that make a conceptually sound
and genuinely motivated intervention cross the border into territory of personal violation.
Abuse suggests an acting out and aggression that violates a person’s psychic boundary and
damages one’s intactness. In this case, with the exception of the sitting on the floor, the conduct
involved in the enactments was limited to the verbal, but of course speech is action and can be
as violating as physical action. How do we determine when enough is enough? When does the
free expression of anger, disgust, disapproval, criticism, other negative affect—that is the at the
heart of the analytic approach—become so damaging to the other it should be stopped? What, if
Correspondence should be addressed to Elizabeth Goren, Ph.D., 300 Mercer Street, Suite 23L, New York, NY 10003.
E-mail: [email protected]
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GOREN
any, nonphysical relating should be specified as off limits and when? We are told that all’s well
that ends well. Dr. Castellano says that the reenactment in the third, “safer” space of supervision,
turned out to be what she needed to “develop a deeper understanding of and availability to my
patient through which true acknowledgement and a relational shift between us emerged” (p. 723).
Perhaps so. But what of those cases so compromised by dysregulated negative transference and
countertransference that the core therapeutic or supervisory contract is broken ?
BORDER CROSSINGS/NEGATIVE TRANSFERENCE AND
COUNTER-TRANSFERENCE
The boundary crossing that was publicly identified as transgressive in the therapy was made by
the therapist in her act of joining the patient on the floor. We tend to think of boundaries in this
physical way—touching a patient, “doing” something with/to a patient. Conveniently dramatic,
physical frame bending actions can be too easily targeted as the source of the problem. When they
become the central focus of analytic scrutiny, as we saw here, they can obscure analytic discovery
of the underlying issues, unwittingly fostering the further devolvement of the therapy.
On the other hand, psychologically transgressive boundary crossings, modes of verbal and
nonverbal communication, such as passive–aggressive nonresponsiveness and withdrawal, especially those that the analyst is not conscious of, may be hard for the supervisor to pick up on or
to feel free to confront. Dr. Castellano’s taking to the floor, a classifiable, and albeit potentially
problematic, boundary crossing, had been preceded by a series of less discernable, disavowed,
or dissociated negative affect and acts of aggression, likely expressed by the therapist as well
as the patient. Once on the floor, Dr. Castellano goes on to tell us she “immediately asked . . .
for permission to sit on the floor” (p. 725). However, the dirty deed was already done—post hoc
approval was what the therapist then had to obtain from her supervisors. The floor then became
the convenient symbol of all that was wrong, and a preoccupation of supervision. Should she,
shouldn’t she, followed by the desperate effort to get them both up from the floor before reaching
the twenty session boundary set by the major domo bully, the “insurance company.”
Dr. Castellano says that her decision was based on a conscious choice to “share in the intersubjective space I felt her inviting me into” and a desire to not “underscore the inherent imbalance
in the power dynamic” by remaining in her chair (p. 724). On the surface this brought positive results. The patient revealed details of her childhood traumas, drawing the therapy couple
together. However, it did not put a stop to the unaddressed verbal assaults of the patient. As when
the patient gave one of her zinger insults, calling Dr. Castellano ’s water bottle “trendy,” as her
parting shot at the end of the hour.
Dr. Castellano is quite clear about the patient’s microaggressions. She is also clear about
her supervisors’ negative countertransference, seemingly to the patient, expressed in what Dr.
Castellano felt was a dismissive diagnosis of the patient as borderline. But she appears less clear
about her own negative countertransference, which was in all likelihood hidden within plain sight
in therapeutically correct conduct, on and off the floor.
We get hints of it in her speaking of “brushing off” the patient when she was pushing at the
boundaries, and her thoughts of how sloppy, clumsy, and antifeminine the patient was. But she
does not report directly addressing these issues with the patient, or with her supervisors. Dr.
Castellano refers to trading positions in the bully/bullied dynamic, but the “miniature torments”
COMMENTARY ON TRAUMA TRIANGLES AND PARALLEL PROCESSES
739
we hear about are those inflicted by her patient. She acknowledges experiencing moments of
revulsion, like watching her patient cry in her handkerchief, but she does not discuss how her disgust and resentment were expressed and may have affected the patient. Nor do we know whether
her supervisors spoke to these issues.
Silence is as much of an action as speech, nonverbal communication as impactful as the words
spoken. I have no doubt that Dr. Castellano’s silence about her discomfort with the way the
patient was relating to her was resonant with the patient’s history. And that this silence was then
replicated in supervision, becoming a further reenactment of the family’s silence about the abuse
that the patient had endured at the hands of her brother. To what degree the patient sensed her disgust is unclear, but she surely sensed something and she seemed to be unconsciously pushing Dr.
Castellano to confront her about her provocations and be more open about the negative reactions
she may have sensed.
Meanwhile the slope was getting more slippery. Having trouble getting the patient to leave the
office at the end of the session, feeling increasingly vulnerable and violated by the patient, Dr.
Castellano ended up managing more than treating, a phenomenon we are all familiar with when
we don’t feel in sufficient control of the therapy situation, as sometimes happens when dealing
with sustained intense negative affect.
It seemed more acceptable to Dr. Castellano, and probably to her “maternal” supervisors,
to acknowledge identification with the patient as victim rather than as perpetrator. This was
expressed in Dr. Castellano’s repeated references to feelings of shame, guilt, and humiliation.
There is no mention of processing the negative transference and countertransference in supervision. Dr. Castellano acknowledges that writing the paper was a way of turning the tables and
eking revenge on her supervisors. Dr. Castellano exposes them at the same time as she, like many
abuse survivors, rationalizes their behavior by proffering the theory that the enactment in her
training turned out to be transformative for her in her work with the patient.
Professional anxiety with moralistic attitudes about frame and boundary setting led to a distracting focus on the floor as the boundary problem, thereby ignoring or insufficiently processing
the blatant negative affect and actions. The important boundary and limit setting that needed to
be established was analysis and regulation of hostility and aggression to tolerable levels.
The history of psychoanalysis is lined with innovative modifications of standard technique
to great success without sacrificing therapeutic grounding. How many of us have done similar
things to sitting on the floor, like walking outside the consulting room with a patient, or sitting
next to a patient? Frame-bending activities, whether deemed misdemeanors or creative and flexible treatment, occur much more often than we dare talk or write about. They are part of our
conflict between our shared, publicly held theories and our private professional activities. In my
experience it is not always the actual breaking of the frame that is in and of itself potentially
destructive.
The greater danger is when the actions go underground, when an analyst is unable to be open
with his colleagues, in particular with supervisors and others to whom he looks for support and
guidance. Analysts of all persuasions over the years (Chessick, 2001; Goldberg, 2005; Grand,
2003; Rangell, 1974; Slochower, 2003) have pointed to the problem of analysts’ disavowal and
dissociation of actions and feelings they feel are not consistent with their publicly held morality
or notions of acceptable feelings and conduct for an analyst, often in a matched vertical split with
the patient’s dissociation. This leaves analysts in greater need but more hesitant to seek help,
and when they do, sometimes unable to communicate what is really going on. The problem can
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be compounded by reenactments of dissociation in the supervisory interaction (Harris & Gold,
2006), which we saw here with the inability of the two “maternal” supervisors to address the
hostile acting out and negative transference/countertransference. Grand (2003) reported a similar
pattern to what happened here, where female supervisors mirrored the analyst’s avoidance of
directly addressing the hostility and aggression. The emphasis on “bounty” and empathy in the
maternal model, Grand pointed out, can obstruct confrontation and firm limit setting, especially
with female analytic dyads.
Shame, guilt, and fear of judgment about not living up to professional expectations, illustrated
in this case, can get in the way of seeking or fully utilizing supervision and consultation to understand and work through questionable actions and impulses. This leaves the analyst more isolated
and even more vulnerable to losing therapeutic grounding. Dr. Castellano had the courage to be
open with her supervisors, and for that she paid a high price, fearing not only loss of their approval
but also possible termination of her externship.
The problem with manifest bending of the frame, like sitting on the floor, is when it waylays
the therapy and supervision from seeing the underlying problems. For Dr. Castellano this was
not feeling a sense of agency, not feeling free to join the patient on the floor or not, nor free
to admit powerful negative feelings. What she needed most from her supervisors was help in
examining specific countertransference reactions and her feelings in general, about the therapy
and supervision. The cruelty of the male super-supervisor that Castellano describes, a symbol to
her of male authoritarianism gone awry, is inexcusable, and by legal and educational standards
probably out of bounds. Yet the fact remains that he was the one who directly confronted the issue
of Dr. Castellano’s pregnancy, and in so doing was able to reach her in a way that broke open the
dissociated anger that was paralyzing her.
ETHICS, BOUNDARIES, AND SUPERVISION
The border between technical merit and humane treatment, between justifiable and ethically questionable boundary crossings, is as tricky to assess in supervision as it is in the clinical situation.
After all, border crossings are the very stuff of potentially transformative opportunities in all
analytic work. But how do we determine when a particular intervention, or a lapse in judgment,
often not even identifiable until after the fact, has risen to the level of being an ethical breach, or
worse yet, that dreaded label “boundary violation”? We espouse a model of disciplined creativity,
firmness, and flexibility, or to use Hoffman’s term, “ritual and spontaneity,” but how do we know
when to bend the frame and when to hold the line?
The supervisor has the challenge and responsibility of determining when to “go personal,”
when to respect the boundary between therapy and supervision, when to be insistent didactically
or otherwise, and so on, just as the therapist must decide how far to go with a patient. When to
say something that you know will hurt a patient or supervisee, when to back off and when to hold
the line, when you need to confront something that you know will disturb the other. An accurate,
well-timed interpretation or comment can be laser delivered out of a defensive counterreaction, by
a sadistic or other hostile impulse, by an analyst or supervisor, just as by a patient or supervisee.
Even when the intervention is technically sound and genuinely motivated with the best interest of
the other in mind, the effect of our actions can be hurtful and harmful.
COMMENTARY ON TRAUMA TRIANGLES AND PARALLEL PROCESSES
741
Given the hierarchy of power in supervision and therapy, if a person in the “one down” position as Dr. Castellano refers to it, feels abused, does this mean there is sufficient cause to claim
a boundary has been violated? And what about feelings of abuse that the person in the “one up”
position may experience at the hands of the other? Professional codes of conduct can specify
only unethical conduct in a fairly delimited way. We do not have sex with patients, or otherwise
knowingly abuse or exploit our power. How do we parse the ethical from the clinical or educational function? If our primary ethical principle is “First, Do No Harm,” how do we as analysts
and supervisors determine when an experienced abuse or other clinical error rises to the level of
questionable morality? For what is right does not always feel good, and an unwillingness to make
someone feel bad can be a form of failing the other. We see this clearly with Dr Castellano’s
experience with the differing reactions of supervisors. At least one of them was not comfortable
with the floor, but she did not push it, leaving it to the super-supervisor to be the bad cop, a stand
in for the older male abuser of the patient, and indeed he played his part exceedingly well.
Dr. Castellano states that she became aware of the clinic director’s “abusive treatment” and
ethically questionable conduct only through her participation in a seminar on boundary violations
years after the incident. At what point can or should we consider conduct to rise to a level of being
ethically rather than merely technically questionable? We will never know whether the accused
abuser, the male “director,” was simply projecting or picking up something about the trainee
therapist’s own struggles in his “tongue-lashing” when he accused her of having “inappropriate
boundaries.” She felt understandably threatened by his critically questioning having accepted her
into the externship, then pointedly telling her she should “take time off” because she was “too
emotional to be rational” in her “present condition” (p. 727). As excessive and inappropriate as he
was, he was the only supervisor, at least from what we are told, to confront just how vulnerable Dr.
Castellano was feeling. Were the other supervisors being self-protective out of fear of the director
as Dr. Castellano suggests? To what extent may they also have identified with Dr. Castellano’s
vulnerability and been as avoidant of confrontation? By today’s standards raising the issue of
pregnancy put the director on shaky legal and ethical grounds. But was he crossing the boundary
of what we consider fair play for analytic inquiry?
Awareness of parallel process and the thematic resonance between supervision and therapy
has been key to relationally based supervision. It not only enhances supervisees’ understanding of
their patients and their treatments but it promotes their overall professional and personal growth.
More recently even more emphasis has been put on working with the supervisory relationship
as a didactic tool. For, as Fiscalini (1997) aptly described it, “the supervisory relationship is
a relationship about a relationship about other relationships” (p. 30). We think in terms of the
multiple roles the supervisor plays, from teacher, expert, and therapist, to mentor and quasiparent (Frawley-O’Dea, 2003; Weinstein, Winer, & Ornstein, 2009). Weinstein et al. suggested
that good supervision involves moving back and forth between various “modes of interaction,”
from a more evaluative or moral mode to a more therapeutic or modeling mode.
It’s become popular to speak about the beneficial aspects of enactments in supervision as well
as in analysis. Dr. Castellano attributes the enactment of abuse in supervision to a sudden shift
in her own self-state, from feelings of persecution to outrage, finding her agency and greater
empathy for her patient.
While the supervisory process has elements of an analytic process, it is education and training,
not therapy. It is an opportunity for the analyst to get much needed help and consultation dealing
with split-off intrapsychic states of rage, powerlessness, terror, even sadism and masochism, and
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their interpersonally enacted manifestations. But as its very name implies, super-vision involves
inherent issues of power and authority that we need to remember make it rife for abuse. This can
be based on issues that are separate from as well as those that are resonant with the treatment
and therapy relationship being supervised. Transformations, to use Levenson’s term, can go in all
directions, from supervisor to supervisee and on to patient, just as the reverse is true. Supervision
for a therapist is like being a driver at a busy intersection at rush hour. It’s the time and place where
the psychic realities and relational dynamics of patient, therapist, supervisor, and institution
converge, with everyone depending on all the other parties following the rules of the road.
Even when the clinical material pulls for expression in the supervisory interaction, it can only
happen if and when the participants are psychically prepared to respond to it. It’s all too easy
to attribute enactments to phenomena …
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