Reflective group supervision: psychotherapists and child health centre nurses in collaboration

ABSTRACT

Postpartum depression affects every sixth mother, and emotional distress in infants is also common. The need for parent-infant consultations and psychotherapies probably greatly exceeds the number of families who in fact receive qualified help. Nurses at child health centres are the first professionals to meet distressed families. Their readiness to help them is clouded by conflicting professional attitudes, patients’ expectations, and uncertainties of how to handle patient-nurse interactions. Nurses may experience clinical impasses that need attention. Reflective group supervision can be a valuable remedy, and a method for educating nurses in daily practice. The method is illustrated by a vignette, and a review of the nursing and psychoanalytic literature. Nurses often address problems with anger, guilt, and anxiety of uncertainty, which may block their understanding of the families’ emotional entanglements. Supervision combines the supervisor’s psychodynamic competence and the nurses’ experiences, to inspire self-reflection on difficult cases. It should be provided regularly with management support, and the supervisor should preferably be a psychotherapist experienced in child and adult work. The therapist can work simultaneously as a consultant clinician at the centre, thus increasing the opportunities for families to receive adequate help.

KEYWORDS:

• Clinical supervision
• infant health care
• nursing
• parent-infant psychotherapy
• reflective supervision

Background

This paper discusses reflective group supervision (Fenichel, 1992; Weatherston et al., 2009), in which psychotherapists supervise nurses¹ working in infant health care. It is written mainly for psychotherapists with an interest in supervision. To also support nurses working in this field, I will argue why such supervision is essential for detecting families with perinatal distress and helping them appropriately. The paper will introduce reflective group supervision based on psychoanalytic and attachment theory, and illustrate how it helps nurses comprehend and handle emotional reactions to these families. It will also suggest that in such supervision a psychotherapist, preferably with experience of working both with adults and children, can use his/her experience to advance skills and deepen insights in the nursing team, as to how perinatal distress manifests and can be approached.

My professional background is in adult and child psychoanalysis, as well as psychotherapy with families with toddlers and infants in Stockholm. I collaborate with nurses as a consultant psychiatrist at a child health centre. These are nation-wide subsidised units in Sweden offering families with infants and pre-schoolers developmental check-ups, advice, and inoculations. Nurses are trained to detect parental depression and infant distress. At such a centre, I set up a model where I saw families once a week – from one-time consultations to lengthier parent-infant psychotherapies (Baradon et al., 2016; Salomonsson, 2014). I soon realised that group supervision was decisive for inspiring the nurses to detect and address families with perinatal distress. This combinatory model is described in a monograph (Salomonsson, 2018).

When I suggested reflective supervision at the centre, I noted a paradox. Nurses felt it was helpful and agreed on its importance, yet they claimed that supervision ‘took time from the patients’. I sensed this must have to do with their attitudes to supervision and decided to investigate that topic.

Supervision in the nursing tradition

Many nursing studies confirm the value of supervision, as when an experienced nurse supervises students or young nurses (Cutcliffe et al., 2011; Holm et al., 1998; Hyrkäs et al., 2006). They teach the nurse a clinical method after which she is expected to master it. However, since emotional problems in clinical interactions tend to re-occur in new forms throughout a nurse’s career, they cannot be evaded by once learning a certain method. Something else needs to be added, namely, and as I will argue presently, continuous supervision.

Another observation is that nursing publications rarely detail the supervision process with mental health nurses (Arvidsson et al., 2001), nursing students (Holm et al., 1998; Lindgren et al., 2005), hospital nurses (Bégat et al., 2005), or nurses in health care (Hyrkäs et al., 2006). These studies’ methods differ from reflective supervision and will henceforth be called clinical supervision (Anonymous Author, 2019). Yet, clarifying the latter term is hard since its practice is varied (Lyth, 2000). Cutcliffe et al. (2011) delineate two versions; one is ‘an opportunity for a more experienced nurse to monitor, educate and support a less experienced nurse in how to “do” technical skills’ (Cutcliffe et al., 2011, p. 39). In the second version, clinical supervision should ‘help and support nurses reflect on their dilemmas, difficulties and successes, and to explore how they reacted to, solved or achieved them’ (Cutcliffe et al., 2011). Here, the task is to help supervisees become more skilled and reflective practitioners. As Cutcliffe et al. (2011) argue, this difference is seldom spelled out in the literature. Reflective supervision resembles – but is not identical to – their second version which, however, is less anchored in a consistent psychological theory. Furthermore, it aims more to provide collegial support and identity building than to promote the supervisee’s insight as to his/her intra- and inter-personal difficulties.

Arvidsson et al. (2001) ask why supervision is not ‘an integral part of nursing education and nurses’ skills development’ (p. 170). Building on my experiences at the child health centre, I would ask why it is not integrated in everyday nursing. We know that, though the prevalence and negative effects of postnatal depression are well-known, far from all distressed families with infants are detected and receive adequate help. Interviews in a randomised controlled trial (Salomonsson & Sandell, 2011) of mother-infant psychotherapy showed that many depressed mothers had remained under the radar at the centres. One explanation was their low self-esteem (Liss et al., 2013) and guilt, shame, and anger conflicts (Blum, 2007), which blocked them from revealing their troubles to the nurse (Lutz et al., 2009). Another obstacle was that nurses felt insecure when detecting parents’ anxieties and were uncomfortable and afraid of causing harm if they addressed them – and then uninformed as to what to do next.

These observations led me to institute supervision groups with nurses at my centre, and at postgraduate courses for nurses. In psychotherapy training, individual supervision has a long tradition in helping us deal with our job’s technical and emotional difficulties. When setting up supervision groups, I integrated psychodynamic and attachment perspectives by authors in the U.S. (Eaves Simpson et al., 2018; Emde, 2009; Fenichel & Eggbeer, 1991; O’Rourke, 2011), the U.K. (Allan, 2011; Fabricius, 1991; Rafferty, 2000), and Scandinavia (Salomonsson, 2019).

In these groups, the nurses appreciated venting emotional challenges, feeling that it diminished their stress and helped then learn to cope with demanding clinical situations. This concurred with studies of reflective supervision (Frosch et al., 2019; Larrieu & Dickson, 2009; Shea et al., 2016). In contrast, their managers and executives, often nurses themselves, vacillated in supporting such supervision. When the workload increased, or funding decreased, they were thinned out or abolished. Alternatively, one no longer demanded that the supervisor should be a licenced psychotherapist with supervision training. Supervision was thus not treated as an axiomatic high-quality method for continuous clinical quality improvement.

In our times of evidence-based practice, one might object that ‘there is no convincing evidence of effectiveness and [there is] a lack of agreement over the nature of clinical supervision’ (Pollock et al., 2017). In my response, given the difficulties in measuring the effectiveness and performance of various supervision methods, it is imperative first of all to detail their respective theory and practice. After presenting a supervision session, the paper expounds and discusses theory and practice, and investigates the usefulness of the method for the nursing profession. It also discusses what a psychotherapist may learn about these nurses’ working conditions, and how they interact with the families’ difficulties in addressing their distress.

A supervision session

The following text was transcribed immediately after the supervision session ended. Pamela is an experienced nurse at the Centre. She and six colleagues participate in regular bi-weekly group supervision. I begin by asking who has a case they would like to discuss. Pamela is the only one today:

Pamela: I’m seeing a young mother who can’t decide on breastfeeding or the bottle. The baby is four months old and doesn’t gain weight. It’s worrying! I tell her, ‘You must decide: either you breastfeed or give it up and bottle feed!’ The mum responds, ‘OK, I will breastfeed, but it’s such BIG work’.

There is a slightly caricaturish quality in Pamela’s description of the ‘nonchalant and uninvolved’ mother. Her colleagues agree with this. I usually ask about the participants’ reactions before I summarise and offer my ideas. But Pamela is frustrated, so I step in.

Supervisor: What do you feel, and what do you think the mother feels about you Pamela?

She bypasses my question and I ask the group to reflect on the dialogues between Pamela and mother, and Pamela and me.

Samantha and Beatrice: This sounds like a teenager and her mother! Pamela, are you annoyed?

Pamela surprised: I never told her I’m annoyed … but I did think, ‘Shape up, girl!’

Evidently, Pamela assumes the mother never noticed Pamela’s affect.

Marcia: The mother is irresponsible, like a teenager, blaming all the trouble on someone else! And then Pamela becomes a real hag with her.

Supervisor: What did you think about your mothers in your teens?

Everybody sighs: Adolescence wasn’t my favourite period …

Supervisor: Responsibility, isn’t that a major theme in adolescence? A girl claims that her mother’s ideas are corny about boys, the pill, drugs but she does expect her mother to assume responsibility.

Pamela: No, I don’t agree. I did not show this mother my vexation! Besides, I didn’t grasp the mother-teenager-theme that you guys brought up!

Supervisor: Did you feel we criticised you?

Pamela: No, I’m just trying to grasp what you guys think!

Supervisor: What if you asked the mother, ‘I wonder why we get stuck in this dialogue, you and me. You ask me about breastfeeding, I respond, I give you advice, and I say it’s your choice, but then you do something else.’

Pamela, after a long pause, says: NOW REALLY, let’s take it from the start, WE CAN’T GO ON LIKE THIS!

I startle.

Pamela: You think I’m silly?

Supervisor: No! I identified with ‘your’ mother and felt, ‘Now you care for me!’

Pamela, moved and pensive, says: I thought of talking to her that way but …

Beatrice: Yeah, you could tell her you’ve been thinking why it’s so hard for her.

Jenny: Once, I quarrelled with my son about a party. He wanted to go, but I thought it was risky. Finally, he admitted that I cared for him. Then we could talk without squabbling.

Psychodynamic interpretation of the session

Pamela complains that the mother pleads for and rejects her help. She does not notice that she, too, appeals for and rejects the group’s help. When I ask the group to reflect on the dialogues between Pamela and mother, and Pamela and me, my hunch is that we are facing a parallel process whereby a similar contradictory interaction occurs in the two dyadic sets. The phenomenon was first described in psychotherapy supervisions (Searles, 1955) and has also been noted among infant health care professionals (Flowers & Burgeson, 2015; Shea et al., 2016). As long as the group did not observe this process, Pamela’s colleagues were stuck in confirming that the mother was impossible. Similarly, as long as Pamela did not see the mother’s conflicting messages, she felt trapped in a double bind (Bateson et al., 1956) of two contrasting injunctions: to help the mother quit/continue breastfeeding. Double bind often occurs in schizophrenic families and in borderline patients, but Pamela’s quandary shows that similar phenomena can appear when well-functioning individuals get into tense relationships.

Pamela’s two colleagues suggested the mother-teenager metaphor. Like in psychotherapy, where metaphors and imagery can make room for new meanings (Civitarese & Ferro, 2013; Kirshner, 2015; Norman, 1989; Ogden, 1997; Reider, 1972; Salomonsson, 2022), they tend to emerge spontaneously in supervision sessions to illuminate the nurse-patient relationship. To exemplify, the teenager imagery helped Pamela see her relationship with the mother from a new and less threatening angle.

As seen in the vignette, a professional’s feelings of stupidity, anger, boredom etc. can reveal much about the patient’s struggles. Of course, unresolved personal conflicts and difficulties may also interfere with those of the client, as noted by Julia Fabricius (1995, p. 26), a therapist working in supervision with nurses. The supervisor needs to handle such influences with care. Pamela’s comment that she had not verbalised her vexation may point to an expeditious view on how her non-verbal communication could impact the mother. As supervisor, I refrained from approaching such personal issues. In my view, a supervisor needs to gauge when such personal issues can be discussed to advance the supervisee’s job, or when it approaches personal psychotherapy – which reflective supervision should not be.

In addition, another factor may have prohibited Pamela from being straightforward with the mother; her professional ethos seemed to urge her to subdue her vexation with the patient. Thomas (2008), nurse and researcher, when focusing on nurses’ feelings about their patients, penetrated their problems with aggression and explained them on many levels; the caring structure tends to suppress such emotions; relations with colleagues might scare the nurse from being angry or displaying it; and, last but not least, personal factors may interfere.

Pamela strove to hold her patient in ‘unconditional positive regard’ (Eaves Simpson et al., 2018, p. 482). However, this did not help her when she noticed the clash between the mother’s and her own attitude to breastfeeding. Pamela then suppressed her vexation, which stilted their interchange. In supervision, the teenager metaphor emerged, which helped Pamela view her position as comparable to that of her colleagues. This encouraged her to voice her fears of appearing silly and then to exclaim, ‘Let’s take it from the start’. She was now calling for clarity in how to perceive the clinical problem and improve their relationship. Pamela could observe, from the outside as it were, herself and the mother in interaction.

Emotional obstacles in nursing

Some periods or conditions in life can imply an increase in emotional challenges, for example, when we enter a new phase of maturation, like adolescence or ageing, or when we choose a profession like psychotherapy or nursing. Psychotherapists’ emotional challenges have been dealt with extensively in the literature. Nurses’ dilemmas have been covered in the nursing literature as well but, in my view, they deserve more attention from psychotherapists who work in medical settings. This is because we can provide deeper and more coherent interpretations of the unconscious conflicts that interfere with nurses’ daily work.

Thomas (2008) objects to ‘the societal characterization of nurses as self-sacrificing and subservient’ (Thomas, 2008, p. ix). The prototype is Florence Nightingale, who became a national hero as the gentle ‘lady with the lamp’ after the Crimean war. Thomas reminds us that the epithet was lopsided. Nightingale was in fact a strong and resolute person with easy access to anger. In her own words, the view of the self-sacrificing nurse ‘would do just as well for a porter. It might even do for a horse’ (Thomas, 2008). Thomas has written extensively about how anger surfaces and is managed by nurses. Since I have seen this emotion frequently displayed in supervision, I will start with it as I discuss some emotions that influence nurses’ satisfaction, creativity, and perspicacity in their daily work, and thus contribute to frozen clinical situations.

Anger

If a nurse pursues an ethos not to be angry with a suffering patient, but nevertheless gets angry, one outcome may be surface acting (Hochschild, 2015). That author’s example is flight attendants who, in their training and daily work, are subjected to ‘emotional labour – the managing of hearts for the company good’ (Hochschild, 2015, p. 329). Training teaches them to smile, but when complaining passengers turn into ‘irates’, a secret epithet among attendants, problems arise. They keep smiling, no matter how the passengers behave. This results in surface acting, ‘the putting on of an outward appearance’ (Hochschild, 2015, p. 334). If this becomes part of one’s daily milieu, it ‘will penetrate deeper and deeper in what we used to think of as a private, psychological, sacred part of a person’s self and soul’ (Hochschild, 2015, p. 333).

One example of surface acting may have been Pamela’s outwardly friendly attitude towards the mother while thinking ‘Shape up, girl’. The nurse thought the mother never noticed her vexation, which in an intersubjective interpretation seems unlikely. The mother appeared subservient and sulky, and I assume that one contribution was her intuition that Pamela was angry with her. This illustrates that surface acting is not conducive to a more open and sincere dialogue.

Pamela’s behaviour can also be interpreted as representing ‘emotional dissonance’ (Abraham, 1999). The term originally referred to a person-role conflict when one’s ‘expressed emotions conform with organizational norms but clash with true feelings’ (Abraham, 1999, p. 442). I also use the term when our expressed emotions conform with our norms but clash with our true feelings, that is, in cases of intrapsychic conflict. Brotheridge and Grandey (2002), in a study of antecedents to burnout among professionals in ‘people work’, found that nurses and childcare workers ‘may be intrinsically motivated to be genuine and truly care about their patients/clients’ (Abraham, 1999, p. 31). This is true, but two counterforces need attention; one is external demands from the management to work hard and efficiently, and the other is internal self-imposed appeals to be ‘the lady with the lamp’. Unfortunately, this can end with the nurse treating patients as objects or being angry, cynical, or annoyed with them. Even if the professional seriously makes a good-faith effort of ‘deep acting’, that is, ‘controlling internal thoughts and feelings to meet the mandated display rules’ (Abraham, 1999, p. 22), her dissonance can affect job satisfaction, anger management, and end in a burnout condition (Bakker & Heuven, 2006; Yang & Chang, 2008). To conclude, there are many good reasons to help the supervised nurse reach emotional consonance.

Readers versed in psychoanalytic literature may compare surface acting and emotional dissonance to Winnicott’s ‘False Self’ (Winnicott, 1960). This is true if we speak of its less malignant manifestation, as ‘represented by the whole organization of the polite and mannered social attitude, a ‘not wearing the heart on the sleeve’ (Winnicott, 1960, p. 142). Thus, when we dampen outward manifestations of our emotions, we gain a ‘place in society which can never be attained or maintained by the True Self alone’ (Winnicott, 1960). It is interesting that nurses at the centre meet children whose struggle to establish a ‘True Self’ has just begun. This challenges nurses to be authentic, and dare see signs in baby or parent that run counter to the parent’s ‘official version’. This is another argument that it is never too early to help a distressed family.

Guilt

When anger runs counter to one’s ethos this often leads to guilt feelings. They can be adaptive when they urge us to assume responsibility for our actions, as Severinsson (2003) suggests in a paper on moral stress in nurses. As psychotherapists we know, however, that unconscious guilt can be a source of distress (Blatt, 1998), and may stifle efforts at helping those who suffer. Duarte and Pinto-Gouveia (2017) investigated how demands of empathy in nurses, combined with a propensity to ‘pathogenic guilt’, could compromise well-being and lead to burnout. When empathy is untarnished by such guilt, nurses’ ‘compassion fatigue’, that is, being desensitised of patients’ needs, is low. They can empathise with many patients without being brusque or crass. But, when guilt increases and interferes with empathy, compassion fatigue and eventually burnout may ensue. This can be harmful to patient and nurse alike. These findings make it important to highlight guilt in supervision.

At the child health centre, nurses mainly address three kinds of guilt: 1) They fear neglecting infant diseases and malformations, though this is uncommon in my view; 2) More commonly, they feel critical of the family without being fully aware of it. Instead, they feel blameworthy in a diffuse way; 3) They feel guilty about bringing up psychological distress that they discern in a parent or a baby.

To exemplify diffuse guilt, one nurse in a qualitative interview study of infant health care nurses (Kornaros et al., 2018) felt distressed when screening mothers for postpartum depression. When she discussed results with the mother, she felt she must have something to offer but, as she said, ‘we nurses don’t have any therapeutic education … we have built on experience, quite simply, and if you don’t have that … ’.

The third point will be exemplified from another session I supervised. Nurse Tanya said, ‘I’d like to tell a sad mother that I’m concerned about her. But if I told her, would I harm her?’ Tanya feared that being sincere with the mother would be detrimental. Nurses I have supervised often feel that, even though they are taught to bring up postnatal distress with the mother, they trespass on the therapist’s role if they broach such a topic. Sometimes, nurses explain this reticence as their lack of knowledge about the deeper causes of the mother’s anxiety. Yet, it is also possible that guilt of trespassing on ‘forbidden ground’ may lie behind such reticence.

Anxiety of uncertainty

Beyond any possible guilt, Tanya’s doubts of telling the mother might reflect another emotional roadblock; her fear of not knowing the ‘right’ answer or explanation. I got this idea when Tanya continued, ‘What if I’m WRONG? Maybe mother and baby feel great! I’d make a fool of myself!’ We know from Kant (1781/1996/1996) that we cannot know the ‘real’ world, the thing in itself or noumenon. Instead, we interpret our perceptions according to preconceived categories and concepts. Still, we often continue groping for what we hope is ‘the real Truth’; we pose questions, suggest examinations, and consult textbooks to combat our uncertainty. Maybe, we do it especially with psychological issues since we can never be certain about another person’s experience.

As psychotherapists, we are trained to refrain from giving rapid answers or suggestions to the patient, and to tolerate ambiguous interchanges and emotional challenges by using our negative capability (Bion, 1970). This is a huge challenge in the medical professions, where students are taught to know which explanation or treatment to suggest to distraught patients (Boudreau & Fuks, 2015). They are less trained to wait for a new comment that might reveal more of the patient’s worries. Even less encouraged is the ability to remain in a state of unknowing, and to wait and see what comes up in themselves.

In other fields, negative capability is more encouraged, as illustrated in papers on psychotherapy (Civitarese, 2019), organisational psychology (French, 2001) and supervision (Yerushalmi, 2019). The latter author claims that understanding negative capability ‘might liberate supervisees from the need to respond impulsively and facilitate internal processes of metabolizing patients’ experiences’ (Yerushalmi, 2019, p. 290, italics added).

When Tanya feared that her intuition about the mother’s depression was wrong, her negative capability came under strain. One advantage of group supervision is that the supervisee may find herself not alone in her fears. This happened to Tanya when her colleagues revealed similar dilemmas:

Karen: I know I’m wrong sometimes! But what if I address a mother’s distress and she starts sobbing? What should I do?

Andrea: Maybe she’s got postnatal depression?

Fran: In such cases I blab about baby food, though, I know it’s beside the point!

The quartet struggled with anxieties of uncertainty; Tanya feared being wrong, Karen was anxious about what to do with a crying mother, Andrea reached for a diagnosis, and Fran addressed food issues instead of the mother’s distress. Their comments showed that negative capability can be challenged from many angles. Together, the colleagues’ remarks helped Karen metabolise her experience of the mother’s distress rather than act ‘impulsively’.

Kornaros et al. (2018) apply Aristotelian concepts described by Ross (1999) to discern various components of medical practise. Techne refers to practical skills and episteme to their underlying logic, whereas phronesis implies judgement and practical wisdom, not the least in human encounters. In the interview study (Kornaros et al., 2018), infant nurses tended to overlook their phronesis and grope for techne (like Karen: ‘I don’t know what to do’) or episteme-oriented terms (Andrea: ‘postnatal depression’). Phronesis is therefore related to negative capability, that is, of not being certain about everything but having the composure of bearing one’s anxiety of uncertainty.

The development of reflective supervision

Reflective supervision (Fenichel & Eggbeer, 1991) was introduced to infant health workers by mental health professionals who were concerned about the staff’s complex workload, and the scant possibilities to reflect on it. The argument for emphasising supervision for infant care professionals is to do with ‘the vulnerability of the infant, the importance of nonverbal communication and the need to understand the meaning of interactional patterns’ (Anonymous Author, 2019, p. 6). Reflective supervision is often performed in groups where the supervisee is ‘exposed to the wide range of personal responses from other group members’ (O’Rourke, 2011, p. 170). This enables a ‘shared exploration of the emotional content of infant and family work as expressed in relationships between parents and infants, parents and practitioners, and supervisors and practitioners’ (Weatherston et al., 2010, p. 23).

Parent-infant work may also revive a nurse’s less integrated emotional challenges. Supervision may reveal that she receives a family in a way that reflects her own conflicted past relationships (Emde, 2009, p. 667). Supervision can then inspire her to become curious of herself, with the aim of improving her reflective functioning, affect regulation, and mentalizing capacity (Fonagy et al., 2002). Reflective functioning is illustrated by Pamela’s comment, ‘I thought of talking to the mother that way but … ’ Her improved affect regulation was evidenced when she became less annoyed with the mother. Mentalization was shown in Pamela’s increased understanding of the mother’s point of view.

In the United Kingdom, a slightly different supervision tradition developed in the 1990s. It focused on uncovering unconscious forces in the nurse, especially those emanating from infantile layers of her personality and counteracting her intentions of helping the patient. One member of this Tavistock Clinic Consulting to Institutions Workshop (Menzies-Lyth, 1990), investigated nurses’ work behaviour and attitudes. She suggested they often defended against anxieties that emerged due to their close work with patients. These psychotherapists, some of whom were also nurses, set up supervision groups that probed into nurses’ distress at death, suffering, helplessness, disillusion, ire; in short, ‘the emotional bombardment which the nurse receives’ (Fabricius, 1995, p. 18).

Theoretical considerations on the reflective supervision process

This section applies psychodynamic concepts to clarify the supervisory process and how it relates to parents’ worries. The concepts pertain to classical (A. Freud, 1937; S. Freud, 1923) and object-relations (Bion, 1970) theories.

Projective identification

A family member may unconsciously evoke or ‘push’ distress into the nurse and expect her to identify with it. Such projective identification has two purposes; the person seeks to relieve themselves from anguish and communicate it to the nurse (Grotstein, 1999; Sandler, 1993). The concept thus covers both intrapsychic and interpersonal processes. To exemplify with Pamela’s mother patient, she vacillated on breastfeeding while unconsciously ‘exporting’ her anguish and responsibility to Pamela. The nurse received it and responded by unconsciously turning into a sender in a projective counteridentification (Grinberg, 1979), as when she backfired to the mother by thinking, ‘Shape up, girl’. The mother’s internal ping pong game (to breastfeed or not) had now turned into a nurse-patient duel. In supervision, it continued between Pamela and colleagues, until the mother-teenager metaphor emerged.

Intra-group dissent

This phenomenon can occur in supervision sessions when some nurses take up an opinionated position towards the family while others emphasise its mirror image. Some side with a mother against her ‘terrible husband’, while others empathise with him against his ‘submissive wife’. Such positioning arises from splitting mechanisms, in which contrasting views on a difficult case become projected onto different nurses who, unwittingly, counter-identify with these projections. The group can settle on basic assumptions (Bion, 1961) or rigid thought patterns. Initially, they may induce feelings of security (Gould, 1997), but most often they will turn into obstructing optimal work.

To exemplify, as long as the nurses thought Pamela’s vexation with the ‘hopeless’ mother was justified, they enacted a game of ‘us-against-the mother’ and further insightful work was forestalled. They were approaching a basic assumption about the mother’s shortcomings and Pamela’s blameless efforts – until the comment by two nurses that Pamela’s narrative sounded like a teenager and her mother. This imagery inspired them to think differently, and the group turned into a work-group.

When splitting tendencies emerge, the supervisor needs to address the group. Publications on reflective supervision emphasise that support from group members ‘can have a soothing effect and restore affect regulation’ (Emde, 2009, p. 667). This is true but, as I emphasise, only to the extent that support does not cover up basic assumption functioning. The responsibility of detecting the difference rests on the supervisor. Here, I have found countertransference to be an invaluable source, a topic that will now be briefly approached.

Countertransference

Any clinical encounter can release powerful emotions. Freud (1910) discovered that unconscious emotional involvement with the patient could stifle therapy progress. He saw this as perilous whereas, as is common knowledge among psychotherapists nowadays, we are more curious about what happens inside themselves in their work. We tend to view countertransference (Hinshelwood, 1999) as a vital source of information of how we and the patient unconsciously affect each other (Gabbard, 2001; Tsiantis et al., 1996). This applies to supervisory experiences too.

One example is when I startled after Pamela had exclaimed, ‘we can’t go on like this!’ I interpreted this to indicate that I identified with her mother patient. Now I felt that she really cared for me/mother. The startle was thus my embodied response of the mother’s and (by displacement my own) relief that someone now was standing at the helm of the clinical interchange. Indeed, countertransference may be quite intense in supervision, which makes it all the more important to uphold a stance that will be approached in the next paragraph; that of the frame.

The frame

To handle emotions among group members, the supervisor should contain them within a frame (Rafferty, 2000). I do not only use the term to refer to explicit ingredients such as time, place, and continuity of sessions. I also include more implicit elements; the supervisor’s ‘particular stance, his manner, approach, etc.’ (Spruiell, 1983, p. 9). The frame thus represents ‘a symbolic boundary between the external world and the inner (the analytic room) where another form of reality reigns’ (Künstlicher, 1996). In brief, it is a way of thinking inwards without acting outwards. Furthermore, the frame implies the supervisor’s maintenance of abstinence, that is, discretion regarding personal quandaries and finally, upholding neutrality; to avoid forcing one’s ideals onto the patient/supervisee (S. Freud, 1919, p. 164).

To compare with the nursing literature, it has also highlighted the need of structure and climate in group supervision (Lindgren et al., 2005). Structure comprises ‘voluntariness, continuity, confidentiality, responsibility and willingness to self-development’ (p. 823). Climate factors cover ‘genuineness, acceptance, empathy, support and challenge’ (Lindgren et al., 2005, p. 823). Bégat et al. (2005) state that ‘systematic supervision structure helps the nurses to reflect, analyse, solve problems, plan actions and learn for future practice’ (p. 223).

The psychoanalytic frame concept adds to the quotes from the nursing literature that the therapist – and here, the supervisor – must also contain anxiety (Bion, 1970). The aim is both to support the supervisee and inspire her to uncover stifling unconscious attitudes and emotions. An additional advantage is that by upholding the frame, the supervisor indirectly inspires the supervised nurse to maintain the frame with her own parents/patients. She thus personifies to the parent(s) a more resolute way of scaffolding the baby’s anxiety than has been possible for the distressed parent. The supervisor’s conduct can thus, stepwise, indirectly and positively, influence the family.

Technical recommendations for reflective supervision

This is a summary of the technique in reflective supervision.

• To forestall unrest in the group, changing supervisor should be avoided, whereas changing locality and participants is unavoidable in health care settings. Any frame changes should be clarified and talked about. The number of participants should be kept to 5 – 7 nurses.

• Confidentiality about patient material and the group’s dialogue is mandatory.

• Reflective supervision focuses on job-related emotional reactions but not on working conditions, payrolls, organisation, or management issues. Personnel groups should be separated from it, and the two should not have the same leader.

• The supervisor may well work simultaneously at the centre as a consultant or a therapist. The prerequisite is that he or she maintains an internal frame, where one separates the two roles. For example, one must not speak of one’s therapy cases in supervision sessions. The advantage of a combined supervisor/therapist post is that nurses become acquainted with the therapist, which creates a climate of familiarity and trust. In the end, this is beneficial for the families.

• Management support of supervision is an essential part of the frame since it gives professional legitimacy to the activity.

When I work with reflective supervision, I start the session by asking who has a case to discuss. The time for each presenter is estimated, and one nurse starts relating her case, after which I invite participants to submit associations in due order. A debate between presenter and colleagues should be avoided. Instead, I ask participants to toss up ideas ‘in the air’ while the presenter listens. I end by summarising the comments and adding my own thoughts. Then I ask the presenter how she felt about the discussion. As seen in Pamela’s case, this pattern is not followed slavishly, but the general aim remains: to encourage reflection on emotional patterns in the nurse-patient relationship. In Aristotelian terms, it is more to do with inspiring phronesis than teaching techne.

Discussion

I have already approached many theoretical and practical aspects of supervision. The following discussion focuses on psychological supervision as a method of continuous education for medical professionals, especially nurses. Infant health care nurses are known to be interested in, and relatively accurate in, evaluating parent-infant interactions (Elmer et al., 2019). They want to help distressed families but feel obstructed due to their ‘perceived lack of competency’ (Jones et al., 2012, p. 216). Other nurses are hesitant or hold negative attitudes towards handling perinatal problems. Even very experienced nurses can feel entangled and powerless with some distressed families (Kornaros et al., 2018).

It is sometimes claimed by nurses, management, and faculty that supervision should be reserved for the novice, whereas experienced colleagues would not need supervision anymore. This position is highly arguable. Experienced nurses can, via their long experience, inspire the younger supervision group members. Every psychotherapist knows the continuous risk of missing blind spots in one’s involvement with other people. Supervision can help us observe and handle them and is therefore needed as an unceasing and regular educational element in psychotherapeutic practice. I will start from this position and veer into two other questions; if supervision is the best method of helping the professional and if other methods than reflective supervision could do a better job.

The word ‘education’ has two Latin roots (Bass & Good, 2004). Educare means to train or to mould, while educere means to lead out. The verbs illustrate two complementary but non-identical views on education. Educare implies to instruct, as when we teach a child to bike or a nurse to inject, and then expect them to learn and remember. It implies ‘the preservation and passing down of knowledge’ (Bass & Good, 2004, p. 162) that already exists. Educere, in contrast, covers education as when we are ‘preparing a new generation for the changes that are to come – readying them to create solutions to problems yet unknown’ (Bass & Good, 2004).

Those who claim that supervision is redundant in daily practice since the nurse already had courses in psychology and patient care in her training, probably rely on the educare definition. True, once we learn to inject, the procedure or techne and its underlying logic or episteme remain essentially the same – and we are expected to remember and practice it henceforth. Things are very different when nurses encounter patients with unique backgrounds, mindsets, symptoms etc. It goes without saying that nurses are individuals as well. Pamela needed to find her solution to the frustrating situation. In Aristotelian terms, supervision brought out her phronesis. Up till now, Pamela had found it hard to use the tempered wisdom and reflection covered by phronesis. Supervision introduced an educere approach to detecting her new approach to the mother.

One can also argue for continuous supervision from another perspective. As individuals, we are also subject to lifelong processes of change. A young nurse student does not struggle with the same unconscious fears and inclinations that she will tackle ten or forty years later. Who knows if young nurse Pamela might have been struggling with similar issues fifteen years ago as her mother patient did now? And who knows if this unconscious recognition made Pamela sensitive to such issues today? This suggests that various unconscious conflicts and entanglements emerge during different life phases. In our unconscious, we are never fully learned and thus, we need supervision continuously.

Once we admit that nurses’ contacts with patients elicit emotional burdens, and we also claim that we have found tenable arguments for continuously assisting them, we may ask if, specifically, supervision is the best method. One might object that if a nurse has a problematic relation with her patient, personal psychotherapy would be appropriate. Yet, we can raise a counterargument from the psychoanalytic tradition. Psychotherapy students are indeed required to have personal therapy to learn more about their character issues and blind spots obstructing clinical progress. However, supervision is regarded as equally important in their training to acquaint them with challenges in therapy sessions. This argument can also be applied to supervision with nurses.

Another question is if other techniques are more or less efficient than reflective supervision. The question parallels the debate ‘which psychotherapy method is most efficient’, where the brief answer is that it depends on personal factors in patient and therapist and how they match. The same goes for supervision. No one can claim that reflective supervision is superior to other methods, only that it is geared towards enabling troublesome facets in the clinical interaction to surface. If this is what the team is looking for, it is well-suited. Its framework sets boundaries, which helps the presenter to be outspoken. Secondly, the group members submit their own associations to the material rather than suggest to the presenter what to do. Less experienced nurses, however, may feel that such abstention provokes anxiety and therefore may demand instructions and recommendations. If so, a more paedagogical method, such as traditional clinical supervision, might be appropriate for them to learn skills and build up professional identity.

To sum up, when it comes to handling emotional interferences in clinical work, a combination of nurse and psychodynamic competencies, as in the presented method, can make daily clinical work more profound and enriching. The supervisor must uphold the frame and discern intra-group interactions that obstruct insight into the nurse’s and the patient’s problems. To handle such hindering phenomena (Enyedy et al., 2003), the supervisor should have adequate education. The nursing literature contains little about this requirement (Lyth, 2000), whereas the psychotherapy field has a long tradition of it. My combined experience as a psychotherapist and a supervisor of nurses makes me argue for a collaboration between nurses and psychotherapists who also work as supervisors, preferably at the same unit. The aim is to inspire nurses to develop a deeper understanding of their emotional issues with a family, thus helping parents and babies to develop in a more positive direction.

Acknowledgments

I wish to thank the nurses in the supervision group for providing me with many valuable insights, and for giving their consent to publish the account in its present, de-identified form. All names in the paper were changed, and no data enabling identification of any participant are included. My thanks also go to the Bertil Wennborg Foundation for invaluable support.

Disclosure statement

No potential conflict of interest was reported by the author.

Additional information

Funding

The work was supported by the Bertil Wennborg Foundation.

Notes on contributors

Björn Salomonsson

Björn Salomonsson is a member of the Swedish psychoanalytical association, Stockholm, working in private practice and at the Mama Mia child health centre. He is an associate professor at the department of women’s and children’s health, at the Karolinska institute. His research and publications focus on psychoanalytical parent-infant therapies (theory, practice, and quantitative outcomes), child analysis and the ‘weaving thoughts’ presentation method. His books and texts have been published in English (by Routledge) and in other languages.

Notes

1. The paper proceeds from experiences at a child health centre, where all nurses are female. I have therefore thought it cumbersome to write ‘he or she’ and have mostly resorted to ‘she’. However, the paper’s conclusions apply to nurses of any gender.