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Nancy McWilliams, "Psychoanalytic Supervision" (Guilford Publications, 2021)
00:59:06
An interview with Nancy McWilliams
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Jacob Goldberg
Hello everybody.
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Marshall Poe
This is Marshall Po. I'm the founder of the New Books Network, and if you're listening to this podcast on the New Books Network, I bet you like to read. I know that I do. That's why I founded the New Books Network. So as readers, we need to know what to read. And I have a podcast to recommend for you. That being the Proofread podcast. Do you have a goal to read more this year? How about a goal to read more of what you love and less of what you don't? The Proofread podcast is here to help you. Hosted by Casey and Tyler, two English professors and avid readers with busy lives, Proofread helps you decide what books are worth spending your precious time on and what books aren't. They have 15 minute episodes that give you everything you need to know about a book to decide if you should read it or skip it. They offer a brief synopsis, there's fun and witty commentary, and there are no spoilers and no sponsored reviews. Life's too short to read a bad book, so subscribe to the Proofread podcast today. And by the way, there's a new season coming soon. Extra value meals are back. That means 10 tender, juicy McNuggets and medium fries and a drink are just.
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- [01:45]
Marshall Poe
Welcome to the New Books Network.
- [01:49]
Jacob Goldberg
Hi, and welcome back to New Books in Psychoanalysis. My name is Jacob Goldberg, your host and today I am thoroughly excited to be speaking with Dr. Nancy McWilliams about her latest book, Psychoanalytic Supervision, published by Guilford in 2021. Nancy McWilliams is a giant within the field of psychoanalysis, shaping our understanding of subjects as varied as case formulation, diagnosis and personality. She is also a key figure in the greater world of mental health care, where she has become a kind of diplomatic, deftly translating psychoanalytic concepts for the wider public and defending psychoanalysis against charges of quoting, unquote, ineffectiveness. As the back flap of her book says, she is, and I'm just reading here, a teacher in the Graduate School of Applied and Professional Psychology at Rutgers and in private practice in New Jersey. Additionally, she is author of such books as Psychoanalytic Diagnosis, Psychoanalytic Case Formulation, and Psychoanalytic Psychotherapy, as well as being co editor of the Psychodynamic Diagnostic Manual. Nancy is past President of Division 39 and currently serves on the Board of Psychoanalytic Psychology. Her affiliations include the center for Psychotherapy and Psychoanalysis of New Jersey, and she serves on the Board of Trustees at the Austin Riggs Center. Nancy has been honored with the Deaver Award, the Goethe Scholarship Rosalie White Award, and the Laughlin Distinguished Teacher Award, the Hans H. Schupp Award, and the International Leadership and Scholarship awards of Division 39. Nancy is also an honorary member of the American Psychoanalytic association, the Moscow Psychoanalytic Society, the Inter Institute for Psychoanalytic Psychotherapy of Turin, and the Warsaw Scientific association for Psychodynamic Psychotherapy. Her work has been translated into 20 languages. Nancy, welcome to New Books in Psychoanalysis.
- [03:41]
Nancy McWilliams
Thank you. Thank you. I am a just recently retired from active teaching at Rutgers, although I'm very connected with them, and B maybe not still an honorary member of the Moscow Psychoanalytic Society because I have been very vocal about what the Ukrainians need to defend themselves against the Russian invasion. And to a great extent, I don't know if this is true of analysts in Russia, but to a great extent Russians are believing that somehow Ukraine provoked this and that the Russians are trying to save the Ukrainians so they would not understand why I am on the wrong side of this from their perspective. So I have no idea if they still want me or not.
- [04:27]
Jacob Goldberg
But the theme of ethics is perhaps something we'll get into in our chat today. I'm so excited to be speaking with you, not least because as far as I know, we've never had an episode on this podcast about supervision. And for me it seems like a great opportunity to be able to speak with you about this because supervision is in and of itself a fascinating subject. And also it's a, it's a, it's, it's a central feature of life in psychoanalyst, perhaps because it's so behind the scenes in some sense, tends to get short shrift. So, you know, the general way we like to begin interviews on this channel is just, you know, what inspired you to write this book? What were your motivations insofar as we can know them? And yeah, like what's your relationship with supervision?
- [05:20]
Nancy McWilliams
Well, I have been a supervisor. Since I think people started coming to me for consultation in about 1973 when I was working in a mental health center. So it's been a long run. It's been 50 years of being in this role. That's part of it. But. But the honest answer is I had not intended to write another textbook. But Covid happened, and all my trips to teach in various interesting places got canceled. I had time on my hands. I thought, gee, maybe work on another writing project. And my friend Malin Fors from Norway said, why don't you write a book on supervision? And the idea sort of grew in my mind. And it sort of was a perfect storm of influences. Because just about a year before that, I'd been asked to co author a book on supervision by the American Psychological Association. But they wanted to frame the supervisory process as teaching skills in a kind of hierarchical order. This is a bit sarcastic, but as if. First you teach empathic listening, and then you teach sensitive questioning. And then you teach naming defenses, and then you teach interpreting defenses. Almost as if they were comparing it implicitly to an athletic skill that's kind of layered like that, or a musical skill. And I reflected a lot on the supervision that was so important to me coming up and. And to the feedback I get from my supervisees. And it's never about teaching skills. Not that we don't teach skills in supervision, but that's not the total nature of the process. That it's so much more a process of personal growth that, like therapy, a more experienced person is helping you to accomplish. It's a kind of professional growth. When you interview people in the psychoanalytic community. And you ask them what were the most important influences on your work, they they inevitably say, number one, their personal analysis, but number two, their supervision and only number three, their coursework. Supervisors have a great deal of power. You're right. We don't have nearly the literature about supervision that we have about psychotherapy. And we also don't have nearly the amount of research on supervision that we do Avalon Psychotherapy. So it occurred to me, you know, a lot of places are now asking to have courses on supervision. And there's not a huge literature out there. Certainly there wasn't an integrative psychoanalytic book. There were some very good psychoanalytic books about coming from a particular perspective. Like, there's a couple of good books on relational supervision and a couple of good books on classical supervision and so on. But I wanted to do something more integrative. And the idea grew on me. And it Just sort of slowly wrote itself, because I've been thinking about supervision, of course, for 50 years.
- [08:57]
Jacob Goldberg
There's so much there. I think the first question, you know, one of the most characteristic features of your style as a writer, as a thinker, as a teacher is taking these huge shibboleths and kind of like unpacking them and looking at them from the ground up. And so I have a bit of a naive question, if I can ask, which is just why is supervision important?
- [09:25]
Nancy McWilliams
Because especially when we all start out, we feel like we're going to make all kinds of mistakes. We feel the responsibility of the job, that patients are depending on us to know what we're doing. And none of us feel, when we're starting out like we know what we're doing. Every person is unique and different. And, you know, we get training in general styles of psychotherapy, but any patient is going to throw you off whatever, you know, supervisory algorithm you got trained in, because they're going to be unique. And if you have a more experienced person, you can bounce your experience off and they have more experience than you and can generalize about what you're dealing with and some possibilities for intervention that would move the process along, it's immensely helpful. It can be kind of a holding environment for the therapist who otherwise feels really out there alone.
- [10:35]
Jacob Goldberg
While I was reading your book, you in fact even insighted this line at one point that, you know, like the. The patient isn't cured by free association. The patient is in fact cured when he or she can free associate. And one of the. Like the. Maybe it's a bit pithy or axiomatic, but something that came to mind as I was reading and as we're speaking now, thinking of it again, is that, sure, it may be true that the patient is cured when he or she can free associate, but the analyst can only do the work of curing, so to speak, if they can free associate. And I don't mean that only in the sense of the analyst has freedom of mind in the consulting room, but in addition, kind of as you were alluding to in your response at the beginning of our interview, the analyst also can be a bit of a free agent with regard to all the theoretical orientations so freely associate more or less to their historical influences and also just more or less the theoretical orientation of the patient. So I don't know exactly if there's a question there, but maybe you're hearing something or want to respond to something in that.
- [11:51]
Nancy McWilliams
Well, it's interesting. It's not that free association isn't a part of the process that moves people forward. But patients find it hard to associate really freely because they find themselves running into obstacles. They run into resistances. And in psychoanalysis, the concept of resistance isn't that I don't want to do what you want me to do. It's I want to do something, and I run into an internal resistance against it. I may project that onto you. I may be able to deal with it in the relationship. I mean, the therapist can say something like, I notice, like, every time you start talking about your mother, you abruptly change the subject. That would be, you know, one way that a person is associating freely. And then something cuts them off from where they seem to be going. And the quote that you gave is that we're not really able to associate completely freely until we've had all those obstacles removed in the psychotherapy process. We've worked out what's happening between us and another person, and we're free. And we have our full capacity for what Ogden called reverie, or Freud called evenly hovering attention. And it's a process. The patient, I think, feels more in a difficult spot in terms of bearing their soul to a complete stranger than the therapist does in the dyad. But the therapist can run into certain kinds of internal resistances, too. Some things are very painful to hear, or they're disturbing because they involve criticism of the therapist or any one of a number of other reasons. And that's why we need somebody to help us keep our own reverie relatively free and be able to sit with any kind of affect, any kind of content, and use it to understand the person, rather than getting reactive or defensive or shutting down somehow dissociating, deciding the patient's hopeless, or any of the other ways that we can deal with our own limitations of hanging in there with really painful, difficult, often traumatic, ugly, sometimes very hostile process.
- [14:31]
Jacob Goldberg
This is reminding me of early in the book when you're just trying to kind of approach a definition of what psychoanalytic supervision looks like. You call it, in a very beautiful turn of phrase, an intimate education. And you also, almost in the same breath, or maybe it's in response to this, you call it impossible, kind of referring to Freud's three impossible professions. And I'm wondering if you could, yeah, just speak to our listeners. I'm also fascinated by, you know, just these three facets, so to speak, of supervision, its intimacy, its educational value, and also a bit kind of, you know, glibly, it's. It's impossibility.
- [15:16]
Nancy McWilliams
Yeah. Learning is hard And I think supervision in psychotherapy confronts therapists with a difficult situation. Therapists tend to be fairly self critical people. They tend to be very responsible people. They get attracted to the profession because they're trying to do good and they fear any part of themselves that might do harm. So to expose your work to somebody that you have fantasies is going to see every mistake, every, every piece of damage, every naive reaction you had to the patient, or every way in which you were ignorant. That's really hard on people. And that's why in the supervision literature, and this is according to a very lovely article by Charles Watkins, we've moved from the teaching of technique to the building of a supervisory relationship and put the emphasis much more on the relationship. Very much the way we have with psychotherapy over the course of time realized that it's not the brand name of the treatment that's important, it's the relationship between the therapist and the patient and the personalities of both parties to the relationship. So I think supervision, you want it to be intimate, but it's hard, it's just very hard for people to, to really say to somebody else who they. Especially if they're still in a situation where the supervisor has evaluative power over them to move on. In the institute or in the graduate program, it's very hard for them to say everything they said and did because they are so afraid that they're going to be criticized for it. And the empirical literature is only beginning to study what supervisees tell them. And supervisees, in some of the recent research on what it's like for them, acknowledged often keeping secrets from supervisor. So the first principle of good supervision, I suppose is making the person safe enough to try to tell you what they really said and did. And it's not nearly as easy as you think it would be. Some programs, of course, try to get around this by having people filmed or by having supervisors watching through a one way mirror. But eventually you want to get to the point where somebody feels okay doing this as an independent professional that can report to another, more experienced person and get help with any areas that they felt were difficult.
- [18:19]
Jacob Goldberg
Yeah, I'm reminded of, I can't remember which chapter it was on. It could have been on the personality matchup between supervisor and supervisee. But you say a penchant towards secrecy is the enemy of clinical maturation. But sometimes, as you're alluding to, there are actually in fact, there are structures that in some ways they don't incentivize, but they make it harder just by their nature to Just communicate in a more open, transparent way.
- [18:51]
Nancy McWilliams
Yes. And let's not forget that some supervisors aren't the greatest. And that many supervisees might have a very good reason not to bring up something. For example, as I read the empirical literature about supervisees saying they don't always tell the whole story, often they're very sensitive to the narcissistic equilibrium of the supervisor. They don't want to tell the supervisor that some technique the supervisor is really wedded to isn't going to work or didn't work. They're very aware of the ways in which supervisors may be defended, and they may not be wrong.
- [19:39]
Jacob Goldberg
We've been circling around, and you've been alluding to one of the major themes in the book, which for me was like. It was so exciting and provocative to read about, which is this. This tension in the history of psychoanalysis between the status of the supervisor as the teacher or the treater. And I'm curious if you could maybe deconstruct that binary a bit, but also explain to our listeners, to me, how you see the difference. I mean, I don't mean this so kind of playfully, but what's the difference between, you know, a patient and a supervisee? And what's the difference between a psychotherapist and a supervisor, knowing all the while that some psychotherapists are supervisors as well? But what, what. What to you, kind of distinguishes those, the two relationships?
- [20:35]
Nancy McWilliams
Well, in psychotherapy, the therapist is not in any way structurally judging the patient. The patient may feel like they are. But in supervision, especially if you're still, you know, going for a credential. And many people distinguish between supervision, which is that situation, and consultation where the supervisor doesn't have legal responsibility for evaluating the supervising. But if you are in supervision, you are being judged. So that's one difference. Another difference is that the boundaries are different. In psychotherapy, you want to be very careful about boundaries. In supervision, you have to be very observant of some boundaries. But you also are talking to a younger colleague who is going to become somebody that you might refer to or go out to lunch with or work on committees with. And that's not your expectation. When you're treating most patients. You're not expecting them after the therapy is over to be your friend, your colleague, to shift from. Most therapists want to keep the door open for further therapy and stay in the role of therapists. And I think psychoanalysts feel more strongly about this than people of other theoretical orientations. Because of our work with the powerful machinery of the transference. We really understand how you don't ever completely leave that position with a patient where you encouraged the full elaboration of a transference reaction. It's not that supervisees don't have transferences. I had really powerful transferences to my supervisor, but they are addressed a somewhat different way. The supervisor doesn't simply say, so say more about that. What does that remind you of? You know, whatever's going on between you in the service of understanding whatever patient you're presenting. So they may look at, oh, so you're hoping, you know, you're trying. You're idealizing me right now. And I noticed that that's what the patient is doing with you. So say more about what it feels like to be in an idealizing state. You want somebody to know what they're doing right. And that would be a defense against the fact that even the best supervisor is going to make some mistakes. So you work with it, but you work with it educatively and cognitively more than you would in therapy. And therapy you want it to fully elaborate at an affective level. So supervision is. It involves a heavier dose of education and evaluation. And the boundaries may be quite different. You might have somebody in supervision and have them in a class and go out to lunch with them because they are younger colleagues. People differ on exactly where they draw those lines. But if you did those things with a patient, you'd be interfering with the possibility of the patient elaborating their fantasy about what it would be like to go out to lunch with you or be your colleague and so forth. It's a very fraught question in the literature because different supervisors approach supervision differently. And I had supervisors who were all over the map on this. And they were good at what they did. And as long as their boundaries were clear and they had integrity, I went with it. One of my supervisors, Arthur Robbins, was very experiential in his form of supervision. And it was very hard to distinguish that from psychotherapy. My other major supervisor in my analytic training was Stanley Moldowski, who was much more apparently boundaried in the role of teaching classical technique. But I learned a lot from both of them. And I think both of those relationships were actually therapeutic. If you have a very good supervisor, you have a therapeutic response. You. You learn something at a pretty deep level. But that doesn't mean the person was setting out to give you therapy. It's just that really good supervision helps you develop mentally in a kind of comparable way to with therapy. Helping you developmentally does that Muddy it up or make it clear?
- [25:47]
Jacob Goldberg
No, it's. I mean, by muddying it is kind of making it clearer in the strange, paradoxical sense. I want to pick up on something you said. This kind of. This good supervision. There's so much, you know, like, especially with, like, you know, the. The interventions of the relational school, with analysis now becoming more about, you know, developing one's own authentic voice in that. In. In a way that makes. That makes the task of becoming an analyst and training so much more exciting, but also so much more fraught with challenges because you're really. There's almost an injunction to be. To be your original self, which is a great injunction, but it also can be. It can be a hard standard to achieve. And I found myself thinking, you know, again, because of this dearth of literature and supervision, how does. Not just pragmatically, but. But also just kind of personally, how does one really grow into the role of supervisor?
- [26:48]
Nancy McWilliams
As I look at my own evolution, I come from a whole family of teachers, so I probably did this more prematurely than some people. You know, I was one of those people who was a camp counselor for years, always teaching something and then teaching 40 years in a graduate program, too. So it was fairly painless as a developmental experience for me. What made me increasingly confident in it was the same thing that made me increasingly competent. Confident as a therapist. As a therapist, you get much more confident when you see the evidence that your patient is really doing better. And you don't have that for a while, but as you get it, you get more and more confident as a supervisor, you get, first of all, the appreciation of the supervisee who then tells you that put into practice what you recommended and it moved the therapy along. You get enough of that, you start feeling good. And even more important, you see the evidence in the patient that the patient is doing better because of your intervention with the therapist. And again, that's cumulative. So that eventually you got to keep your humility in all this because you can be, you know, wrong, like in anything. But your confidence builds.
- [28:27]
Jacob Goldberg
Yeah.
- [28:29]
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- [28:59]
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- [29:05]
Nancy McWilliams
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- [29:08]
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- [29:10]
Jacob Goldberg
We're all in for a very big Christmas treat.
- [29:12]
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- [29:31]
Jacob Goldberg
I'm hoping we can. Throughout the book, you know, like, there were so many exciting moments where you were either offering a clinical vignette or just like, offering like kind of a recommendation for a potential situation. And I'm wondering if we can get like a quite concrete, like, what is, what is the consulting room in a supervisory relationship look like? What, what are you, what are you listening for? What's happening? I know that you mentioned in the book that sometimes different supervisors have different requests of their consultants or their mentees to bring either a transcript or to bring a, a video. You mentioned that you just like to hear the kind of spontaneous associations of the, of the supervisee. But yeah, what, what? I don't know. Again, there's a, there's a, there's not. So there's a kind of a lack in the cultural imagination about what supervision might look like. So I'm trying to get a sense of, you could, if you could paint a picture for us, what supervision looks like.
- [30:31]
Nancy McWilliams
Well, it partly differs depending on, you know, the, the level of background of a supervisee. You know, for example, very experienced people might want to go deeply into their countertransference, and relatively inexperienced people might want to know something like, how do I end the session with this person who keeps falling, bursting into tears at one minute before the end of this session and makes me feel like a bully if I say our time is up? The role changes depending on the level of experience of the supervisee. But in general, with supervisees, I tell them the way that I think I work best is if you first of all tell me something about whatever problem you're running into with the patient so that I can orient toward the problem you're trying to solve. And then tell me background of the therapy. How long have you seen the patient? Give me their basic demographics, what's the history of the problem? Give me A nutshell version of their personal history, what their major caregivers were like, any traumatic experiences or things in their history that were particularly important. And then tell me something about how the therapy is going, how you find yourself feeling with the person. And, and that is enough of an orientation for people to start, you know, talking. Well, this is a 27 year old cisgender white female who came for an eating disorder that she developed three years ago. She's, you know, and, and then they're off and, and running. And I listen not to just to the words, but to the music, like to the body language of the presenter, to the tone in which the presenter is, is talking about this person, to my own affective reactions. For example, I heard a presentation earlier this week where a man had been very successful. He'd always been competing with his father and trying to get his father's approval. And he, he built a whole building and named it after his father. And his father came in and said, I've built much better buildings than this. There's only two or three rooms. And the guy was, of course devastated, but then changed the name of the building. And I remember thinking, yes, you go, you know, I was so cheered by the fact that this guy wasn't gonna put up with being devalued by his father and still masochistically be acting like he's so cooler than sliced bread or whatever metaphor you want to put. Anyway, I was very interested in my own identification with the patient's developing capacity to set a limit on this very coercive parent who had been so critical all through his life. And it was my own affect that helped me find my way into affecting the patient that the therapist had to pay attention to because it was going to come into the therapy. The therapist had had this sense that there was some hostility coming up, and I, we were able to reframe the hostility as something that was positive. And yeah, this guy became critical of him in the treatment. Not only would it be his way of showing him what the father did to him all his life, which would be one of the communications, but also that he might think about it as this patient's getting braver. He's able to talk to a male authority figure as if he doesn't think that he's cooler than sliced bread. So I'm always struck by how much it's my own affect, my own imagery, songs I notice going through my head that might give me some clue to a theme that I should pay attention to. And I should say here that I Think everyone's experience is that unless you have a very manipulative or untalented therapist under supervision with you, which is extremely rare because people go into this field with big hearts and a lot of intelligence. But unless you have a really troubled supervisee, supervision is much less difficult than psychotherapy. You're hearing things from one remove and they're clearer to you. You're not in the soup the same way the therapist is. So even though it's a role of great responsibility, it's actually an easier role and then being the therapist.
- [36:05]
Jacob Goldberg
So my thought, my thought. Oh, sorry. Did I. Am I hearing feedback or was that okay? I'm. I'm curious if, you know, you, you mentioned like these, these kind of, these reveries that you might have in the session. And I'm curious, like, what, what, what's your stance or what's your perspective that, like the, the consensus in the field. If you could, if you could come to one about disclosures from the supervisor to the supervisee, like, would you, for example, I know it depends on the style, but would you, Would you tell the supervisee, perhaps the song that you're hearing?
- [36:45]
Nancy McWilliams
That's one place where I notice in myself the boundaries are very different. I wouldn't disclose something about my personal fantasy life, countertransference to a patient without thinking it through extremely carefully. But with supervisees, I do it all the time because it's data and I'm not trying to develop a transference in them. And if they're troubled by it, they can tell me how they're feeling in response. They're not in the same sort of vulnerable position. They are in a vulnerable position, but not the same kind of vulnerable position as someone who's in psychotherapy. So, yeah, I disclose a lot. I talk about, oh, this reminds me of a patient I made a terrible mistake with. Describe what went wrong, because people can learn as much from that as they can from times when you've done something and it worked out well then. And supervisees need to identify with the person who acknowledges that we all make mistakes and have to do a lot of repair in this process. It's impossible to fully understand another person. And we're going to. This is one of the things the relational movement has been very explicit about, that rupture and repair is critical to the whole psychotherapy process. And it's so much easier when you're a supervisor. If you hurt your supervised D's feeling, chances are they'll say, well, that sucks. That feel lousy. And then you can look at what's going on.
- [38:31]
Marshall Poe
And.
- [38:34]
Jacob Goldberg
You mentioned earlier that in some ways supervising is, is, is. It's not as freighted with certain, like, emotional baggage as, as a psychotherapy. And in that sense it's, you know, it seems a bit lighter in tone and, and just an easier, maybe an easier hour than a certain more challenging, challenging hour. Play, more room for play. How about. Are there. What are some of the challenges, like the, the bigger challenges of, of supervision that come to mind for you?
- [39:10]
Nancy McWilliams
The worst ones is if you're supervising somebody who's patient, you're afraid might kill themselves because it's possible to help them reduce that probability, but not fully. And it's such a devastating experience that. That's a terrible burden to feel like I may not be able to protect this therapist from the absolute worst outcome of any therapist. That's a hard one. But I would say the hardest one is the very occasional situation where you have somebody that really shouldn't be a therapist. You know, maybe they're very smart, but they, they don't have the intuitive and emotional skills somehow, like only in 40 years. I can only think of like two or three people that went through our program at Rutgers that did not have the talent to be a therapist. They tended to be people that we took because they had extraordinary scores on their GREs and nothing but a four point average all through and so forth. And they were really brilliant, but they couldn't sit with another person and make that person feel safe and comfortable and like they wanted to tell them their steward. And if you're in that role as a supervisor, especially if you're having to report to a department, then you have to deal with a supervisee about your worries, about their limitations, and then they hate you. But you, you are responsible. Because we are the gatekeepers. The supervisors in programs like that are the gatekeepers. And we don't want to inflict troubled people on mental patients, on people suffering with psychopathology. I did have many, many years ago. There was one student in a different program that I taught in who, who was profoundly manipulative and who also believed that every. He was a heterosexual guy and every attractive heterosexual female patient, he was sure she had an erotic transference to him. And he would start talking about sex and how do you feel about me? And weren't you excited to come today? And it was creepy. It was creepy. And fortunately we were able to counsel him out of the program because I think he was a danger. But it's very difficult. I mean, he was rationalizing. Well, didn't Freud say that everything was about sex? And all the people who don't like what I'm doing, they're just not open to what I'm open to. Interestingly, it was only the attractive female patients that all had these erotic transferences to him. The unattractive ones didn't seem to have these erotic transferences. So that was awful. It's awful to start having to keep a kind of record of your concern because you're going to try to counsel somebody out of a program and then they're going to sue, and then you have to make the case of why you had to protect the public. It just changes everything from what's usually a very supportive, egalitarian, welcome to the field, and let me see how I can make it as painless as possible for you to get better and better at this crazy profession. That's usually a joy, but when it's not, it's, it's, it's pretty tough.
- [43:19]
Jacob Goldberg
I'm, I'm really struck by what you were saying earlier with regard to the, the suicidal patient. I'm, I'm wondering like in the, in the tragic event that, that, that, that comes to pass, in fact, what happens to the supervisory relationship? Obviously, the, the, the, the, the material for the session, for every supervisory session is the ongoing therapeutic work with the patient. But if the patient sadly takes their life, what happens then to the supervisor relationship?
- [43:54]
Nancy McWilliams
Well, in my own experience, most people who hire me or even people who were assigned to me who have had that happen to them, have talked to me about other patients as well. So it's not as if this is their only person. And my experience is they don't blame me for it. They're afraid that I blame them, that I think that they did something wrong. And I just try to be as supportive as possible. I remember the first time I was concerned about this. It was when I was in training and a close friend of mine lost a patient to suicide. And I was talking to my supervisor about, I said, I feel so bad for him. I don't see what. That he did anything wrong. My supervisor said, have you ever had a patient suicide? And I said, no. And he said, you will. And I, it reframed everything for me. Oh, this is a field in which that's an occupational hazard and nobody's good enough, not ever, to have a suicide, especially if you're working with people with substance use disorders, post traumatic histories, or really severe depressive problems, or they're impulsive. So at any rate, what I end up Working with the supervisee on is how to deal in the aftermath of suicide. Their attorneys are going to tell them admit nothing, but it's terrible advice psychologically because what they have to do, if the family consult, you know, gets in touch with them is to say, I'm so sorry, I did my best, I'm feeling terrible about this. What can I do to help? And they don't get sued if they do that. If they join the family and grieve with the family, they don't run into all the secondary negative consequences. They still have to deal. Jane Tillman and Eric Plaikin at Austin Riggs have done a lot of studies of what it does to therapists to have suicide. And it's ugly. It's really a terrible thing. We all go into this field hoping to save people and when we fail, it's awful. So I can't remember a supervisory relationship where a patient suicided and the therapist decided to fire me. It's more they felt an increased need for processing of what had happened to them.
- [46:42]
Jacob Goldberg
You touched on something, you know, that was a major theme in the book. You were speaking now kind of about the ethics of, of supervision. And I'm, this was, this was new to me and I just. Could you generally introduce that, that theme and like what, what are the ways in which not just, you know, the, the, the moral responsibilities that, that the supervisor has toward the therapist and the therapist has towards the patient, but also just, you know, societally. Can you speak about, you know, ethical quandaries in the, in supervision?
- [47:24]
Nancy McWilliams
Well, I think any ethical quandary worth its salt is one that's very hard to resolve just by following certain clear rules because most of them are trade offs where if you do this, it'll be positive in this way and negative in that way. If you do that, it'll be positive in this way and negative in that way. Let me talk about a particular situation. Supervisees go to supervisors a lot for ethical advice. They often need help with things like when to call your malpractice insurance person and ask about risk management for this patient, when to get another consultation, when to refer a patient on, and again, there aren't really clear rules for that. But here's an example. I was working with a guy in South America, I tell this story in the book who is working with a young woman who was brought up by a single mother. And the story is that her father was, you know, some guy that her mother had a one night stand with. The mother doesn't even know who the father is. And they live in a fairly distant community from the one where the father impregnated the mother. And my supervisee is from that community, but doesn't give it much thought. And then as the therapy moves on, like two years into the therapy, if I'm remembering this right, and the patient is talking about her curiosity about her father. And you know, when this patient walked into his office, the supervisee had this sudden sense of liking her and realized she resembled an old friend of his. And she thought, that's probably why I like her. But she mentioned, in the context of her curiosity about her paternity, she mentioned that a few years back she had gone for a particular course of study in a very esoteric subject in another country, I think it was Japan. The therapist had this sudden brain flash of having gotten drunk one night with an old friend who told him that he had had a one night stand with a woman who had a daughter who later on hit him up for money to support a very esoteric program in Japan in a particular area. And my supervisee realized this is the father of my patient. Okay, now he can't know that 100% sure, but he was pretty sure. What's his ethical responsibility should he fallen? I mean, if he's, if the, if the patient wants to work with him about how to find her father, which hasn't happened yet, but might, he's going to feel like he's being dishonest if he's not saying what he knows. On the other hand, if he's saying what he knows, what is going to be the impact on this young woman, on her mother? He also has an obligation to his friend because his friend made him promise never to tell anybody about this event. So he has a promise that he would be breaking to the friend. And he and I really struggled with this. It's terrible to have information about a patient that the patient doesn't have. I think most therapists have suffered this in some situation. Like you learn that somebody in your community is having an affair with the husband of a patient of yours, and you realize the patient has no idea of this and that information is really burdensome to you. Generally we don't share it, but it's hard to listen with the same, you know, openness when, when we think we know what's going on. Anyway, I, I just elaborated in the chapter, what were the pros and cons of disclosing and not disclosing? The therapist and I eventually decided, since he couldn't be 100% confident that this was the father, probably he should keep his mouth shut for a while because one of the problems of disclosing anything is you can't undisclose it. If you just. If you decide not to disclose, you can always change your mind later. And he. I talked to him fairly recently and he, he said she's not talking about her paternity in recent sessions. Of course, they could be unconsciously colluding that out of the session. Who knows? But at any rate, that's the kind of. There's nothing in a rule book about what you do when, when you're working with a. A fatherless patient who's told that the father essentially doesn't exist. And then you find out that not only does he, but he's a good friend of yours. Those kinds of things happen to therapists all the time. And we have to have somebody that we talk to about how to use judgment in the situation. And I think many supervisees have the idea that there's a right way to do things, and that's often not true. There are better and worse ways. If anything ever does come to a legal challenge, judges are interested in whether you thought through what you did. They don't expect you to have been perfect, but they expect you to have thought about the different options and to have reasons for what you didn't do. And you can teach supervisees how to keep records that will protect the them. So that moves into risk management, away from ethics per se, but also, you know, how to struggle with the fact that many ethical questions aren't so easy.
- [53:44]
Jacob Goldberg
Yeah. When I read that vignette in the textbook, I was kind of blown away. And one of the themes you're bringing up here is what happens when the. The frame is kind of challenged by external information. And I'm feeling a bit of myself to be a bit sad now because we're reaching the end of our time together today in our frame. And I would really love to continue speaking, but we're going to need to wrap up soon. So I'm wondering if, you know, if there's anything we missed that you would like to speak about in the book or if there's any projects you're currently working on or any things you're just generally thinking about or wanting to engage with that you want to speak to our audience about. The floor is really yours.
- [54:39]
Nancy McWilliams
Oh, thank you. I guess where my mind is going is when I started writing the book, I started telling people I was working on supervision, and colleagues would often spontaneously offer to me stories of their own. Supervision and most of them were positive. But almost everybody also had a horror story. And the gist of them tended to be the person in supervision was working with the patient. The supervisor had a very dogmatic idea about what the supervisee should do. The supervisee intuitively knew that was not going to work. But after all, this is the supervisor. They put the advice to use and lost the patient. I heard several stories like that and I give one in the book. So I think the implication of that is for supervisors, the supervisee is the one in the room with the patient. Most supervisees are people with decent intuition. Don't get so sure you know better than somebody who's in the room with the patient. And always supply your recommendations with a certain amount of tentativeness and with room for the patient, for the supervisee to argue with you and to feel safe enough to do that. So I think I've thought a lot about the psychology of supervision. There's a certain degree to which people get across purposes. Supervisors tend to feel, I want to have something to give here. The person should leave knowing more than they came in with. But if the supervisor is feeling not so much like I need more information, but God, I hope I didn't screw up totally. If what the supervisee needs is, yeah, you did pretty well, is basic validation of their okayness. A supervisor goes too quickly to trying to give something to them may be taken in by the supervisee as oh, I thought I did okay, but they're saying there was something else I should do, so I'm not good enough yet. So this cross purpose thing, the narcissism of both parties is fueled by somewhat different things. So that's something to be quite sensitive to as a supervisor. Just stay in touch with where the self esteem of your supervisee is rather than your own sense that your own self esteem requires you to be adding something to what they know. I guess those are the main things that come to my mind that we haven't had a chance to talk through. But I'd say that I really enjoyed writing this book more than my other books. I don't know why. Maybe it's just I had so much more to look back on and there's so many interesting questions about how people learn. I mean, that's just, that's a question in psychotherapy too. How do we take in new information?
- [57:56]
Jacob Goldberg
Well, I, I want to just wrap up by saying thank you so much for, you know, joining us on the podcast today. This is really a pleasure get to get to speak with you. Your work has made a really profound influence on the way I think about psychotherapy. So and I can I I can speak for, you know, friends and just random people I've gotten to come to pass by with. It's really you've left a very meaningful and significant mark on me and others. I know. So I'm so happy we had you today, Nancy.
- [58:29]
Nancy McWilliams
Oh, thank you. This has been fun for me, too. I appreciate your asking me to do this.
- [58:34]
Jacob Goldberg
Yeah. Well, so just for and I should say for our listeners, please go out and buy this book. It's spectacular. And. Yeah. Today my guest has been Nancy McWilliams. We've been speaking about psychoanalytic supervision. And we'll see you next time. Thanks so much. Bye. Now.