RLS Case Example
The following are two excerpts from a transcript of one remote live supervision session. The client was a 20-year-old woman who had been sexually abused as a child. She presented with daily cutting and high anxiety, including panic attacks. Although therapy had progressed well initially in reducing the client’s cutting and anxiety, it had recently become stuck in regards to the client’s inability to enjoy sexual intimacy. The psychotherapist offered remote live supervision to the client as a chance to get therapy unstuck, and the client agreed to “try it out.” At the conclusion of the session, the client expressed very high satisfaction with the session.
In the first excerpt, the client is discussing the negative self-talk she experiences about sex and other issues, which she labels as the “policeman.” The supervisor helps the psychotherapist make a more clear cognitive separation between her healthy ego and pathological superego introject.
[Note: the supervisor comments in this transcript appeared on a laptop screen sitting next to the client, in view of the psychotherapist.]
(Th):
Do you think it’s the policeman that makes things suck so much, that internal verbal abuse?
Client (Clt):
Yeah, but it’s like the policeman and me together on a united front, you know, when I feel like the two sides of me, they have to unite in order for me to treat myself a certain way, right? Most of the time I spend battling both sides, and we’ve decreased that amount of time. [“Two sides of me” indicates that the client cannot differentiate herself from her defense. The supervisor’s next comments help the supervisee address this problem.]
Sup:
Do you think the policeman is what makes things suck? [Emphasizing separation between client’s healthy ego and pathological superego]
Clt:
Yeah, in battle. And the last two months have been an increase in the police thing.
Sup:
But the policeman is not a part of you. It just masquerades as if it is you.
Th:
The thing is, the policeman is not a part of you, it just masquerades. The policeman wears a [client’s name] mask.
Clt:
I don’t understand. I feel like the policeman is a part of me.
Th:
Yeah, so this verbal abuse inside of you …
Clt:
That’s not a part of me?
Sup:
But it’s just a habit.
Th:
Well, it’s inside you, but it’s not an inherent part of you, it doesn’t have to be. It’s like if you had a scab—it’s a part of you for a little while, but you heal and it disappears. It pretends its permanent, it pretends it’s essential to you.
Clt:
[pause, thinking] … So the police are not essential?
Sup:
It has as little to do with you as a vine on a tree. [deepening cognitive separation]
Th:
Yeah, it’s like a vine on a tree. It’s attached to you, but it’s not essential.
Sup:
We have to pull this vine off the tree. [speaking to client’s will]
Th:
You don’t need the vine to live, the vine needs you.
Clt:
[thinking] That’s deep. I like that.
Th:
Just got to pull it off.
Th:
What feeling does that give you?
Clt:
I don’t know … [thinking] … I feel like you just said something really profound. It resonated in me … I feel like what we have been talking about right now … I was talking about it as if the policeman will always be a part of me.
The second excerpt takes place 47 minutes into the 75 minute session. The client had expressed rage at her mother for not protecting her from being abused 14 years previously and had visualized chopping up her mother. In this example, the supervisor uses the supervisory session to give focus to that rage and its possible meaning.
Sup:
Punishing self for 14 years for feeling this wish to chop up your mother. [Helping supervisee link client’s conscious symptoms to the specific unconscious fantasy she shared in therapy]
Th:
You’ve been punishing yourself for 14 years for your rage at your mother, the policeman’s kept you locked up for 14 years …
Sup:
Cutting yourself for wanting to chop her. [making a dynamic link clear]
Th:
You’ve been cutting yourself instead of chopping her.
Clt:
Yeah, I’ve been cutting myself, I’ve been self-sabotaging and neglecting and doing all these other fucked up things to myself.
Th:
Yeah, the policeman still has a guard on you … so if you let yourself feel your sadness, so we can get rid of the policeman.
Clt:
Is it only going to take one time?
Sup:
Depends on how willing you are to feel your feelings rather than obey the policeman.
Th:
How many times are you willing to try to get rid of the policeman?
Clt:
I’m willing to try it over and over again. I wasn’t as willing to try before.
Sup:
Doing to yourself what you wanted to do to her.
Sup:
Facing the rage toward your mother so you don’t have to turn it on self.
Th:
You did to yourself what you wanted to do to your mother.
Clt:
[nodding head] I agree.
Th:
Now you guard yourself, as if to protect her from your rage.
Clt:
[thinking, big sigh, then smiling]
Clt:
I feel really powerful right now.
Th:
You do? How do you experience your power?
Th:
You’re soothing yourself.
Clt:
I’m soothing myself, yeah.
Th:
This is the reward for getting rid of the policeman. This is what the policeman has been hiding.
Clt:
Yeah, I don’t feel anxious. I feel very, very soothed, and relaxed.
Th:
You’re facing your rage towards your mother so you don’t have to turn it towards yourself. So you don’t have to guard yourself.
Clt:
But I’m not pretending that I don’t have it, I’m not pretending with you, in here.
Th:
There isn’t this mask.
Clt:
Do I look like I’m playing around? I feel very accomplished.
Sup:
… pretended you didn’t want to chop mother, so cut self instead [pointing out self-destructive introject]
Th:
You pretended you wanted to cut yourself instead of your mother.
Clt:
Wow. [big sigh, pause]
Clt:
That resonates because you’re putting to words long-term feelings …
Clt:
So I just want to be able to give that space … that I deserve. I’m getting better at giving my feelings space.
Sup:
obviously positive feelings toward mother because you protected her hurting self
Th:
It’s obvious you had positive feelings towards your mother, because you hurt yourself to protect her….
Clt:
I don’t have very many positive feelings towards her, but I do have some.
Th:
They were strong enough to make yourself hurt yourself to protect her.
Clt:
I have a lot of pity for her; I don’t think that’s positive.
Th:
Yeah, but if it was just pity you wouldn’t have hurt yourself so much to protect her.
Th:
It looks like your positive feelings towards your mother are more guarded than your rage.
Clt:
I protect my positive feelings towards my mother more than my rage.
Sup:
… important to face complex feelings [This is a process comment, given right before the supervisor signed off. It is meant to direct the psychotherapist towards important material to cover in the remainder of the therapy session.]
Th:
It seems that you might hide your positive feelings towards your mother more than your rage.
As can be seen in this excerpt, the supervisor helps the supervisee make dynamic connections regarding how the client’s self-abusive behavior (cutting) was displaced rage at her mother. Intensive short-term dynamic psychotherapy theory states that to get the most complete symptom relief and character change, it is important for clients to accept not just their rage, but also the full range of their complex feelings towards their attachment figures, including guilt for their rage, sadness, and love (Davanloo, 1994;
Frederickson, 2013). In this excerpt, the supervisor helps the supervisee target the client’s warded off complex feelings towards her mother.
In this transcript we can see one of the benefits of RLS in action: It allows the supervisee to take a step beyond a cognitive understanding of the psychotherapy model, and instead have the actual experience of successfully applying the model with a challenging case. Although the guidance is from the supervisor, the supervisee is in control of the session, and may use his own words to interpret the supervisor’s interventions, thus showing that he is assimilating and internalizing the supervision as it is occurring. Additionally, the supervisor’s moment-to-moment guidance helps the supervisee become aware of his own countertransference (avoidance of complex feelings from his history)—an awareness that had not been achievable in traditional delay-report supervision. Previous to videoconference, the availability of live supervision was limited to the geographic location of the supervisor. Now, via videoconference, supervisors can provide this advanced training opportunity to supervisees across the globe.