Clinical Social Work JournalVol. 29, No. 2, Summer 2001

IN THE SHADOW OF DEATH: RELATIONALPARADIGMS IN CLINICAL SUPERVISION

Shoshana Ringel

ABSTRACT: The process of clinical supervision is a complex undertaking thatis influenced by multiple factors, including the personalities and characteristics ofthe supervisory dyad, developmental considerations, social attitudes, ecologicalfactors and the parallel process. The supervisory interchange becomes even moredifficult and complex when it occurs in the context of HIV and AIDS relatedpractice, which introduces the reality of untimely death accompanied by grief andloss. In this paper, I will review the literature in regards to developmental aspectsof the supervisory relationship, transference and countertransference paradigmsand the parallel process. These particular issues will be framed within a relationalperspective and the ways it shapes the supervisory process. The focus of thispaper will be clinical work with clients diagnosed with HIV and AIDS and theimpact of death and dying on the supervisory paradigm. The literature review willbe elaborated on through a clinical vignette followed by an extended discussion.

KEY WORDS: supervision; parallel process; AIDS; death and dying; relationaltheory.

INTRODUCTION

The supervisory relationship contains many rich and complex facetsand intricate interpersonal dynamics that may trigger unresolved issuesfor both the supervisor and supervisee. As will be illustrated in the follow-ing literature review, a relational model of supervision that has emergedmore recently maintains that the view of the supervisor as an expert anda knower who imparts knowledge to her supervisee may no longer berelevant. In this relational model, knowledge and understanding emergefrom the supervisee/supervisor reciprocal engagements and from theircollaborative efforts to interpret the meanings of the supervisee/supervi-

171 2001 Human Sciences Press, Inc.

172

CLINICAL SOCIAL WORK JOURNAL

sor interactive process as it relates to supervisee/client narratives. Ratherthan viewing the student as developmentally immature, or as a novicewho is there only to learn from their supervisor’s knowledge and expertise,both student and supervisor contribute their insights and utilize the su-pervisory relationship to further mutual learning and growth. In therelational model, the supervisor and student’s willingness to work throughsupervisory conflicts with mutual honesty and openness and to admitmistakes can serve as a model for the student’s working through of thera-peutic conflicts with their own clients.

When supervising in the context of death and dying, existential issuessuch as the meaning of one’s life, the fear of death, and survivor’s guiltbecome part of the matrix of the supervisory process, adding additionallayers of complexity to the transference-countertransference dynamicsbetween supervisee and supervisor. Fear, anger, guilt, denial, grief, andburnout are some of the underlying affects for both, contributing to aheightened intensity of the supervisory engagement. Supervision in thecontext of field instruction presents somewhat different challenges thana purely clinical supervisory relationship in that it is not contained withinthe supervisory hour itself, but rather includes everyday interactionsbetween student and supervisor. These create opportunities for both toobserve and note personal and relational aspects of each other that maybe excluded otherwise. These mundane interactions may contribute todemystifying and “informalizing” the supervisory relationship and conse-quently add to the difficulty of maintaining coherent professional bound-aries. It can also contribute to the development of fantasized or idealizedaspects of the relationship.

In the following paper, I will present a literature review that ad-dresses transference and countertransference paradigms and the parallelprocess within the context of HIV and AIDS related clinical practice.These domains will be elaborated through a short vignette describing thiswriter’s supervisory engagement with a second year social work internaround a particular incident. The vignette will be followed by a discussion.

TRANSFERENCE-COUNTERTRANSFERENCE PARADIGMS

Several authors discuss parent-child transference dynamics and theirimpact on the supervisory relationship. Watkins (1992), for example, sug-gests that in most developmental models of supervision autonomy vs.dependency are crucial issues with which the supervisee must grapple. Hemaintains that separation-individuation issues play out in the supervisoryprocess with supervisees who attempt to establish their own professionalidentity away from the supervisor. Itzhaky and Sztern (1999) believe,however, that these developmental dynamics can interfere with the profes-

173

SHOSHANA RINGEL

sional boundaries of the supervisory relationship. They warn of the possi-bility that “supervision of young workers may slip into a parent-childmode” that “may intrude” on the supervision process. Clearly, however,there are times when these transference dynamics, occurring of coursewithin appropriate professional boundaries, may be useful for the supervi-sory dyad to reflect upon in order to gain further insights that woulddeepen and enrich both the supervisory process and the student’s under-standing of and empathy for their client.

Some transference and countertransference paradigms may poten-tially contribute to the power differentials between supervisor and super-visee. These include the student’s anxiety, dependency needs, idealizationof the supervisor, and desire to identify with her. The supervisor, onthe other hand, may experience envy of the supervisee, anxiety that thesupervisee’s work will reflect negatively on the supervisor, over-identifica-tion or an attitude of “omniscience” (Tosone, 1997 p. 20). A multidimen-sional, relational perspective of the transference dynamic may include thesupervisory dyad’s own personal characteristics or their organizationalsettings as well as relevant treatment issues between the client and thesupervisee. This inclusive, ecological view of the supervisory relationshipis supported by Salvendy (1993), who suggests that in addition to thesupervisor/supervisee dynamics, the organization and the client are im-portant in the relational paradigm of supervision and need to be takeninto consideration as integral aspects of the interaction. Research findingssuggest that for most supervisees, the supervisor’s perceived empathy,caring, and active engagement were more important than their knowledgeor expertise, suggesting that the affective quality of the supervisory work-ing alliance is a significant aspect of the learning process for the student(Kadushin, 1992). In a relational model, the transference-countertransfer-ence paradigms between student and supervisor and their mutual work-ing-through is an important aspect of the supervisory relationship.

THE USE OF PARALLEL PROCESS AND THE RELATIONAL VIEW

Searles (1955) was the first to address the parallel process, which hecalled the “reflective process.” In this view, the supervisory process canat times reflect the dynamics of the patient-therapist relationship andcan contribute to the understanding of “blind spots” and impasses. Tosone(1997) defines the parallel process as an instance “when a supervisor, forunconscious and subjective reasons, is predisposed to enact a given rolewith a supervisee” (p. 29). Fiscalini (1987) views the parallel processas a chain reaction that can connect “interpersonal situations that aredynamically similar” (p. 29). Similarly, McCue and Lane (1995) note thatthe parallel process is an “unconscious repetition of a conflict within

174

CLINICAL SOCIAL WORK JOURNAL

two similar interpersonal settings” (p. 13), i.e., the supervisory and thetherapeutic, and therefore view it as a multidirectional process.

Some writers maintain that the parallel process is inevitable (Jarmon,1990, Wolkenfeld, 1990), and a recent study (Raichelson, Herron Primave-ral & Ramirez, 1997) found that most of the clinicians surveyed believedthat the parallel process tends to occur in psychodynamic supervision.Some of the shared dynamics in both the clinical and the supervisoryrelationships that have been mentioned are shared narcissistic vulnerabil-ities (Gediman & Wolkenfeld, 1980), shared concerns over authority anddependency (Grey & Fiscalini, 1987), and dissociated affective experiences(Frawley-O’dea, 1997). More current writings, however, have questionedthis unilateral perspective of the supervisory relationship and point tothe multiplicity of factors that need to be taken into consideration inorder to understand its complex dynamics. Current relational writings,for example, discourage the belief in “objectivity” and “neutrality” or theability of therapists and supervisors to make observations outside of thesupervisory relationship itself, with the supervisor as the supposedly most“self-aware” party (Miller & Twomey, 1999). Other writers appear toquestion the use of parallel process or its appropriateness to every encoun-ter when it does not necessarily contribute to the deepening of the thera-peutic engagement (Fosshage, 1997, Hirsch, 1997). This view is sharedby Rosbrow (1997) who objects to the supervisor becoming the “omniscientinterpreter/therapist, while the supervisee is in the position of the un-knowing patient” (p. 217). Sarnat (1992) further suggests that the adop-tion of a two-person approach to the supervisory process can help withthe working through of relational conflicts that can serve as a model tothe supervisee when working with her clients.

As Ganzer and Ornstein (1999) note, this two-person model of supervi-sion fits well with social work’s ecological perspective, where each partof the system influences all of the others. The relational, social construc-tionist perspective, by challenging the hierarchical view of the supervisoras the “expert” is also aligned with social work’s strength perspective,wherein the narrative and the expertise of the client (and the supervisee)become important components in the process (Saleeby, 1992). In this view,the supervisor and the supervisee should engage in an open dialogue andeach has something important to teach the other (Rock. 1997, p. 116 inGanzer & Ornstein, p. 234)

SUPERVISION IN THE CONTEXT OF DEATH AND DYING

As noted previously, there is a rich body of literature concerningdiverse aspects of the supervisory process. However, the dimensions ofclinical supervision in the context of death and dying appear to be an

175

SHOSHANA RINGEL

area on which little has been written thus far. This gap in the literaturemay reflect our cultural discomfort with the process of death and itspotential implications for the supervisory process.

Social work practice with clients who are diagnosed with HIV andAIDS (especially prior to the use of Protease Inhibitors, which turnedAIDS into a manageable chronic illness in the mid-1990’s) has presentedunique issues for both the student and the supervisor. Some countertrans-ference reactions that have been documented in relation to practice withdying patients are survivor’s guilt, fear, anger, grief, denial, burn out,and isolation (Goldfinger, 1990). Social work practice with clients whohave a terminal illness can also trigger unresolved feelings of grief andloss for both the supervisee and supervisor. These feelings will intensifythe student’s “performance anxiety” and dependency needs around theirrole transition and new professional identity, and inevitably color thesupervisory dynamics.

Some of the complex issues that may arise during supervision willreflect the clinical process with terminally ill clients. Dunkel and Hatfield(1986) discuss countertransference issues for the clinician working withclients diagnosed with HIV or AIDS, such as fear of the unknown, fearof contagion, fear of dying, denial of helplessness, over-identification,anger, and the need for omnipotence. Farber (1994) notes the therapist’shelplessness in working with patients diagnosed with HIV and AIDS. Hesuggests that this work can cause severe psychological distress for theclinician, including nightmares, irritability, and exhaustion (classic PTSDsymptoms). Farber defines helplessness as the experience of powerless-ness, impotence, and defenselessness stemming from feeling a lack ofcontrol to change the situation and suggests that the clinician’s self-doubtmake it difficult for her to offer effective treatment and to develop accurateempathy toward the client. The clinician’s sense of futility, frustration,anger, and denial seem to be common reactions, as she internalizes theclient’s own sense of helplessness and hopelessness. Gabriel (1992) notesthis process of identification with the client typically occurs during theclinician’s mourning process and is often complicated by multiple losses.This array of complex feelings and attitudes toward death will inevitablyemerge during the supervisory process as well.

The experience of eminent death raises existential issues for boththe client and the therapist (such as the meaning of life and death) andsocial issues that can motivate them to question their own spiritual atti-tudes and belief systems. These existential and social dimensions inevita-bly become a part of the transference-countertransference dimensions ofthe supervisory relationship as well. Van Wormer (1990) addresses socialattitudes in Western cultures toward death, such as denial and escapethrough medical jargon, which make it even more difficult to explore anddiscuss death and dying during the supervisory process. American social

176

CLINICAL SOCIAL WORK JOURNAL

attitudes toward death and dying are implicit in the frequent denial andavoidance of looking at or discussing illness and death, and these social/cultural attitudes may cause added loneliness and isolation for the super-visee. These countertransference dynamics and social attitudes towardsdeath further contribute to making social work practice with dying cli-ents—and consequently the supervisory process itself—complex, difficult,and challenging for both the supervisor and the novice practitioner.

As discussed previously, working with people who are dying of AIDScan trigger many intense feelings in the clinician, such as survivor’s guilt,isolation, anger, and helplessness. In addition to dealing with the realityof loss and death, clients diagnosed with HIV and AIDS tend to be youngand to suffer marginalization and ostracism because of their ethnicity,sexual orientation, socio-economic status, or involvement with illicitdrugs. Their marginalized status can serve to intensify further the clini-cian’s countertransference reactions of fear, guilt, and anger. Inevitably,this array of complicated feelings becomes part of the matrix of the super-visory process and at times may become re-enacted in dramatic waysbetween student and supervisor. The following vignette will illustratehow some of these transference-countertransference paradigms evolvedbetween this writer and her social work student/supervisee in the contextof clinical practice with clients with HIV and AIDS.

CASE VIGNETTE

I worked as a clinical social worker in an urban hospital’s AIDS center formany years. One of my roles was to provide clinical supervision to MSW studentsin their final year of social work school. I looked forward to this supervisory roleas a respite from my own difficult, draining, and frequently tragic and frustratingwork. Supervising students offered me an opportunity to engage in an endeavorthat, unlike my clinical work with my terminally ill clients, promised more hopefuland satisfying outcomes.

Karen, a second year MSW student, had been my supervisee for the past fewmonths, and I thought that I had gotten to know her well. She appeared to bemature, experienced, and clearly committed to her work with her clients. She andI were close in age, so that a mutual identification and idealization took placebetween us, a process that was undeniably pleasant for me. Karen saw me as amentor, a teacher, and a role model she could identify with, and I perceived her tobe someone who, like me, possessed an extensive life experience, was emotionallymature and was someone whom I could relate to as a colleague rather than as anovice. As if to prove that my confidence in her was well deserved, Karen quicklymoved to engage her clients in the therapeutic process. She also set up supportgroups and reached out to other staff members on our team early on in herinternship. She proved to be particularly successful in engaging substance-abus-ing, difficult, and resistant clients. On the face of it, she appeared confident,secure, and at ease with herself and with her work. As I saw it, my role wasto help Karen develop her clinical skills and integrate relevant theoretical and

177

SHOSHANA RINGEL

conceptual frameworks with her clinical experience and examine her countertrans-ference dynamics in order to understand how these might influence or interferewith her clinical work. I enjoyed my role a great deal because I saw that Karenwas developing good listening skills, demonstrating keen insight, examiningboundaries issues, and beginning to tie her experiential knowledge with the theo-retical frameworks that she was learning in school.

One day, however, Karen came to my office, extremely upset, and closed thedoor. She stated that she had her own agenda today and then described how afew days ago she had witnessed a client’s death for the first time in her life. Wediscussed the traumatic impact that this event had on her, including her ownidentification with the client, her grief, and her shock and outrage at what sheperceived to be the callousness, disrespect, and disinterest of nurses and physi-cians, and of the hospital system in general. She expressed her anger at theintrusiveness and disrespect that she observed, up to and throughout the momentof her client’s death. She continued to elaborate on her own fear of death and herdeep identification with her client, an isolated African American man withoutfamily or significant others to mourn his death. Karen then turned to me withtears in her eyes and expressed her anger and disappointment with me as well.I was not available enough to support her emotionally in doing this difficult andoften devastating work. Further, I did not come to visit her in her office and neverwalked with her after the weekly case conferences, leaving her to walk alone. Shewanted me to be more protective of her. She was tired of proving to me howindependent and self-sufficient she was. She felt vulnerable, helpless, and scared,and she wanted me to know it.

I was at loss for words and completely taken aback. This was a part of KarenI had not seen before. I recognized that perhaps I had encouraged Karen to expressher competence and independence far too quickly. Further, I realized that perhapsI did not really want to see the needier and more emotionally vulnerable part ofKaren, as it evoked in me intolerable feelings of guilt and helplessness. Karen’sexpectations of me, her anger, fear, and frustration and my own helplessnessand unconscious denial of her needs seemed to reflect some of the transference-countertransference paradigms that typically develop between clients and clini-cians in this context. For these clients, isolation, marginalization, helplessness,rage, and multiple losses were familiar experiences, experiences that are ex-tremely difficult for a seasoned clinician, let alone a student, to witness andcontain.

DISCUSSION

An environment where loss and multiple deaths are ongoing realitiesinevitably triggers intense feelings of sadness, rage, helplessness, andfear in the clinician. Consequently, an inexperienced student’s unresolvedconflicts around loss, grief, and abandonment can easily be re-enactedthrough transference-countertransference interactions within the super-visory relationship. The student’s dependency needs and her desire tolook up to and to idealize her supervisor may become exacerbated as heranxiety and fear of death intensifies. But as Karen discovered, I had notprotected her and she consequently became deeply disappointed in me.As a consequence of her disillusionment and recognition of my human

178

CLINICAL SOCIAL WORK JOURNAL

flaws, Karen was able to express her own doubts, despair, and vulnerabil-ity. In addition, I became more aware in recognizing how my own counter-transference reactions to AIDS related practice, such as burnout, helpless-ness, and denial of death played into our mutual exclusion of importantpersonal dimensions from the supervisory process.

Subsequently, Karen became more aware of her need to maintain afacade of strength, determined cheerfulness, and independence in orderto please and impress me, as well as her clients, with her professionalcompetence. I, on the other hand, realized that it had been easier andmore pleasant for me to connect with this part of her and to deny hergrief, dependency, and rage, which had evoked similar uncomfortablefeelings within me. Ultimately, we were able to use this experience todeepen our work together. Karen realized that some of her clients weregrappling with similar issues. Later, she reported that she recognizedwhen some of them seemed reluctant to burden her with their needs andto express their own fear and helplessness.

In conclusion, this case vignette demonstrates some of the complextransference-countertransference dynamics that were raised in the litera-ture review in relation to supervision in the context of HIV and AIDS. Ina relational framework, both the supervisor and the supervisee contributetheir experiences and characteristics to the supervisory process and tothe mutual enactments that occur throughout. Consequently, in this view,both student and supervisor collaborate in the process of insight andknowledge building that takes place. The vignette further illustrates theimplications of the parallel process and how it may become salient to thestudent’s learning process. As previously discussed, a student-supervisorrelationship in the face of death can trigger complex transference-counter-transference paradigms for both that need to be carefully worked through.The supervisor’s role, therefore, is to examine, reflect on, and gain insightinto their own affective reactions, so as to enable them to help the studentgain better understanding into their complex array of feelings. If unexam-ined, the supervisory relationship could potentially be anchored in mutualcollusion, idealization, and denial of the reality of death. Consequently,an important task of the supervisor in this context is to develop self-awareness and constant self-observation and reflection, as well as helpingthe student face and examine her own feelings and attitudes towarddeath. In addition, it is important to facilitate the interpersonal processesbetween student and supervisor as they occur and to explore the ways inwhich these may bear on the student’s interactions with their clients.

REFERENCES

Alonso, A. (1985). The quiet profession: Supervisors of psychotherapy. New York: McMillan.Dunkel, J. & Hatfield, S. (1986). Countertransference issues in working with persons with

AIDS. Social Work, March–April, 114–117.

179

SHOSHANA RINGEL

Farber, E. (1994). Psychotherapy with HIV and AIDS patients: The phenomenon of helpless-ness in therapists. Psychotherapy, 31(4), Winter, 715–723.

Fiscalini, J. (1985). On supervisory parataxis and dialogue. Contemporary Psychoanalysis,21, 591–607.

Fosshage, J. (1997). Toward a model of psychoanalytic supervision from a self-psychological/intersubjective perspective. In M. H. Rock (Ed.), Psychodynamic supervision: Perspec-tives of the supervisor and the supervisee, pp.189–210. Northvale, NJ: Jason Aronson.

Frawley-O’dea, M. (1997a). Supervision amidst abuse: The supervisee’s perspective. In M.H.Rock (Ed.), Psychodynamic supervision: Perspectives of the supervisor and the supervisee,pp. 315–335. Northvale, NJ: Jason Aronson.

Gabriel, M. (1992). Anniversary reactions: Trauma revisited. Clinical Social Work Journal,20(2), Summer, 179–191.

Ganzer, C. & Ornstein, E. (1999). Beyond parallel process: Relational perspectives on fieldinstruction. Clinical Social Work Journal, 27(3), 231–246.

Gediman, H. & Wolkenfeld, F. (1990). The parallelism phenomenon in psychoanalysis: Itsreconsideration as a triadic system. Psychoanalytic Quarterly, 49, 234–255.

Goldfinger, S. M. (1990). Psychiatric aspects of AIDS and HIV infection. New Directions forMental Health Services, 48, 5–20.

Grey, A., & Fiscalini, J. (1987). Parallel process as transference-countertransference interac-tion. Psychoanalytic Psychology, 41–144.

Hirsch, I. (1997). Supervision amidst abuse: The supervisor’s perspective. In M.H. Rock(Ed.), Psychodynamic supervision: Perspective of the supervisor and the supervisee,pp.339–357. Northvale, NJ: Jason Aronson.

Itzhaky, H. & Sztern, L. (1999). The take over of parent-child dynamics in a supervisoryrelationship: Identifying the role transformation. Clinical Social Work Journal, 27(3),Fall, 247–258.

Jarmon, H. (1990). The supervisory experience: An object relations perspective. Psychother-apy, 27, 195–201.

Kadushin (1992). What’s wrong what’s right with social work supervision. The ClinicalSupervisor, 10(1), 3–19.

McCue, R. & Lane, R. (1995). Parallel process and perspective: Understanding, detectingand intervening. Psychotherapy in Private Practice, 14, 13–32.

Miller, L. & Twomey, J. (1999). A parallel without a process. Contemporary Psychoanalysis,35(4), 557–580.

Raichelson, S. H., Herron, W. G., Primavera, L.H., & Ramirez, S. M. (1997). Incidence andeffects of parallel process in psychotherapy supervision. The Clinical Supervisor, 15,37–48.

Rock, H.M. (1997). Effective supervision. In H.M. Rock (Ed.), Psychodynamic supervision,pp. 107–132. Northvale, NJ, Jason Aronson.

Saleeby, S. (1992). The strengths perspective in social work practice. New York: Longman.Salvendy, J. (1993). Control and power in supervision. International Journal of Group

Psychotherapy, 43(3), 363–377.Searles, H. (1955). The informational value of the supervisor’s emotional experiences. Psychi-

atry, 18: 135–146.Tosone, C. (1997). Countertransference and clinical social work supervision: Contributions

and considerations. The Clinical Supervisor, 16(2), 17–33.Van Wormer, K. (199). Private practice with the terminally ill. Journal of Independent

Social Work, 5(1), 23–37.Watkins, E. (1992). Psychotherapy, supervision and the separation-individuation process.

The Clinical Supervisor, 10(1), 111–121.Wolkenfeld, F. (1990). The parallel process phenomenon revisited: Some additional thoughts

about the supervisory process. In R.C. Lane (Ed.), Psychoanalytic approaches to supervi-sion, pp. 95–112, New York: Brunner/Mazel.

Shoshana Ringel, Ph.D.Assistant ProfessorUniversity of Western MichiganSchool of Social WorkKalamazoo, MI 49008