ISSS Clinical Workshop - 2018 Clinical Supervision and Self-Injury: - - PowerPoint PPT Presentation

Clinical Supervision and Self-Injury: What can we learn from the supervisee experience?

Presenter: Karl Tooher Dublin City University (DCU )

ISSS – Clinical Workshop - 2018

21/06/2018 Karl Tooher DCU ISSS Presentation

* The research study – background et al. * Giving voice to the participants:

* What can we learn? * What matters?

* Principles arising from research and clinical work. * Time for some questions.

What I will talk about and explore

21/06/2018 Karl Tooher DCU ISSS Presentation

The study

‘Supervision and Self-Injury: Supervisee Experiences’ Dublin City University - DCU

* Researcher: Karl Tooher M.Sc. (Doctoral Candidate) * Supervisors: Dr Evelyn Gordon & Dr Rosaleen McElvaney

21/06/2018 Karl Tooher DCU ISSS Presentation

Why bother?

* The academic and clinical literature across the helping and caring professions identifies working with self-injury presentations as being particularly challenging. Reported impacts on the psychotherapist include:

* Confusion about the client’s behaviour. * Significant doubt about their ability to address the client’s needs. * Uncertainty and fear about the level of risk to the client’s well-being

• r life.

* Strong personal reactions to the client’s self-injuring, in the room and afterwards. (Fear, Anxiety, Revulsion, Disgust, Rescue, Fix)

(Favazza, 1989; Huband & Tantam, 2000; Nafisi & Stanley, 2007; Inckle, 2010; Reeves, 2010; Walsh, 2012; Schiavonea & Links, 2013; Whisenhunt et al, 2014)

21/06/2018 Karl Tooher DCU ISSS Presentation

The Gap & Study Objectives

* Studies highlight the need for relevant and effective clinical supervision when working with this client group. * However, there is a dearth of studies investigating the experience of supervision for self-injury presentations. (Hoffman & Kress, 2008) * This study will help to address these gaps:-

q To gain an insight into supervisees’ experiences of bringing the issue of client self-injury to supervision. q To identify how the supervisees respond to and evaluate supervision in this specific area of practice. q If and how clinical supervision might benefit the therapist and their work with this client population. q The form & shape such supervision may take.

21/06/2018 Karl Tooher DCU ISSS Presentation

How - Methodology

* A qualitative study - Interpretative Phenomenological Analysis (IPA).

* Phenomenology – examine ‘lived experience’. * Idiography – emphasising the ‘individual’ the ‘particular’. * Hermeneutics – theory of interpretation.

* IPA provides a position, attitude and method for gathering & analysing qualitative data. (Smith, Flowers & Larkin, 2009).

21/06/2018 Karl Tooher DCU ISSS Presentation

The participants

* Data was gathered using semi-structured one-to-one interviews - 10 participants and 11 interviews. * 8 Female and 2 Male. * Varied therapy modalities: Psychodynamic, Art Therapy, Humanistic and Integrative, CBT, Family Therapy. * Practicing and qualified psychotherapists, with minimum two years post-qualifying experience. * A history of working with clients who self-injure.

21/06/2018 Karl Tooher DCU ISSS Presentation

What is Clinical Supervision?

21/06/2018 Karl Tooher DCU ISSS Presentation

Definition Clinical Supervision

Falender and Shafranske (2004)

Clinical Supervision?

* Supervision is a distinct professional activity… * In which education and training aimed at developing science informed practice are facilitated through a collaborative interpersonal process. * It involves observation, evaluation, feedback, facilitation of supervisee self-assessment, and acquisition of knowledge and skills by instruction, modeling, and mutual problem-solving. * Building on the recognition of the strengths and talents of the supervisee, supervision encourages self-efficacy. * Supervision ensures that clinical consultation is conducted in a competent manner in which ethical standards, legal prescriptions, and professional practices are used to promote and protect the welfare of the client, the profession, and society at large.

21/06/2018 Karl Tooher DCU ISSS Presentation

What is Self-Injury?

21/06/2018 Karl Tooher DCU ISSS Presentation

Picking a term Self-Injury?

* For the study, the particular designation ‘Self-Injury’ was chosen. * It is understood as: “Self-injury, is explicated as the non-socially sanctioned purposeful damage of one’s own body tissue (probably) without suicidal intent.” (Klonsky, May, & Glenn, 2013).

21/06/2018 Karl Tooher DCU ISSS Presentation

General findings

* Participants were remarkably open and honest. * As we might expect, there were contrasting experiences. * The majority had contrasting experiences within their own history. * For the purposes of today these are organised as ranging between Unhelpful/Limiting Helpful/Enhancing

21/06/2018 Karl Tooher DCU ISSS Presentation

It’s different

* For each of the participants, they found working with clients who were self-injuring both personally and professionally challenging. * Moreover, although each of them had provided therapy on

• ther clinical issues, they reported that working with clients

who self-injured actually challenged them in ways that were quite distinct to their previous clinical experiences.

21/06/2018 Karl Tooher DCU ISSS Presentation

The unhelpful – limiting - experiences Giving voice to the participants

21/06/2018 Karl Tooher DCU ISSS Presentation

Shocked or Shaken

* A majority of the participants were left shocked and/or shaken by some of their supervisors responses.

21/06/2018 Karl Tooher DCU ISSS Presentation

Disappointed and Frustrated

* The majority of the participants had supervisory experiences which failed to meet their expectations and needs, often leaving them feeling disappointed and frustrated.

21/06/2018 Karl Tooher DCU ISSS Presentation

On my own

* Within the participants related supervisory experiences, themes of feeling isolated, abandoned, being on their

• wn…often in fear and uncertainty…are repeatedly heard.

21/06/2018 Karl Tooher DCU ISSS Presentation

Duplicity and Secrecy

* How did the participants ‘manage’ subsequent supervisory encounters...often through Duplicity and Secrecy…despite their need for support with this work, they chose to go it alone rather than revisit the difficulties they had encountered.

21/06/2018 Karl Tooher DCU ISSS Presentation

Leaving and Not Leaving

* Over half the participants left a supervisor because of their experiences…All of these had worked well with their supervisor up until bringing self-injury client presentations. * Furthermore, despite the fact that many of these experiences had happened a number of years ago, the anger or hurt was still palpable during the interview…it hadn’t been left behind.

21/06/2018 Karl Tooher DCU ISSS Presentation

The helpful – enhancing - experiences Giving voice to the participants

21/06/2018 Karl Tooher DCU ISSS Presentation

Understood and Heeded

* All of the participants spoke about other supervisory experiences of being understood - of having their deep concerns really heeded.

21/06/2018 Karl Tooher DCU ISSS Presentation

Guided and Escorted

* Helpful and enhancing supervisory experiences were reported by all of the participants…much of this happened when they were invited to actively explore…they felt guided or escorted within supervision.

21/06/2018 Karl Tooher DCU ISSS Presentation

Reassured

* All of the participants had experiences which left them feeling more reassured in themselves, their work and their supervisor.

21/06/2018 Karl Tooher DCU ISSS Presentation

Principles arising 1

* Experience matters: * How much training has the supervisor done on Self-Injury? * How much experience has a supervisor of working with clients who self-injure? * Pro-Actively: * Teaching – About Self-Injury, teaching skills. * Leading – The clinical response when necessary. * Engaging – With all the details of the clients behaviour. * Supporting – The professional and personal impacts, biases et al. * How well does the supervisor’s formal and/or informal model of supervision take account of these needs?

21/06/2018 Karl Tooher DCU ISSS Presentation

Principles arising 2

* “The map is not the territory, the word is not the thing it describes.” Alfred Korzybski - Science and Sanity, 1933 * Content Matters: Map or Territory? Both, but territory first. * Not to respond to abstract ideas of Self-Injury but to supervise what is actually happening. * Use such experiences to continue to develop our understanding of SI. * A principle I have developed and use in my teaching: * There is no such thing as Self-Injury in isolation – * “There is a person, that has a unique history, a context in which they live, who for particular reasons, self-injures.” (Tooher, 2011)

21/06/2018 Karl Tooher DCU ISSS Presentation

Principles arising 3

* Enhancing Self-Awareness: * What assumptions, ideas, explanations are informing the supervisee/supervisor – what are the implications of these? * Risk and safety or Therapy and change? Both. * ‘In Extremis’ - how do we know what can we tolerate (stomach), accept? * What’s the likely impact on supervision? * How do we conceptualise self-injury such we can better meet the functions and purposes of supervision?

21/06/2018 Karl Tooher DCU ISSS Presentation

Final thought

* Einstein: “It is the theory that decides what can be observed”

(Christakos, 2011)

* How we Conceptualise something leads us to Think, Judge, Feel and Respond to it in a more Limiting or Enhancing way... * For many people, including supervisees & supervisors, Self-Injury can be difficult to understand, this has led to the generation of many unhelpful reactions and judgements - it is worth considering that “Self-Injury is a Natural, Intimate and Complex response to Life Events and Contexts'. (Tooher, 2014)

21/06/2018 Karl Tooher DCU ISSS Presentation

Questions?

21/06/2018 Karl Tooher DCU ISSS Presentation

Email: karl.tooher2@mail.dcu.ie

* Christakos, G. (2011). Integrative problem-solving in a time of decadence. Dordrecht: Springer Science+Business Media. * Falender, C., & Shafrenske, E. P. (2008). Case book for clinical supervision: A competency based approach. Washington, DC: American Psychological Association. * Favazza, A. (1998). The coming of age of self-mutilation. The Journal Of Nervous & Mental Disease, 186(5), 259- 268. * Inckle, K. (2010). Flesh Wounds. United Kingdom: PCCS Books. * Korzybski, Alfred (1933). Science and Sanity. An Introduction to Non-Aristotelian Systems and General Semantics. The International Non-Aristotelian Library Pub. Co. pp. 747–61 * Nafisi, N., & Stanley, B. (2007). Developing and maintaining the therapeutic alliance with self-injuring

• patients. Journal Of Clinical Psychology, 63(11), 1069-1079.

* Nock, M. (2010). Self-injury. Annual Review of Clinical Psychology, 6(1), pp.339-363. * Reeves, A. (2010). Counselling suicidal clients. London: SAGE Publications. * Schiavone, F., & Links, P. (2013). Common elements for the psychotherapeutic management of patients with Self Injurious Behavior. Child Abuse & Neglect, 37(2-3), 133-138. * Walsh, B. (2012). Treating Self-Injury, Second Edition: A Practical Guide (2nd ed * Whisenhunt, J., Chang, C., Brack, G., Orr, J., Adams, L., & Paige, M. et al. (2014). Professional counselors' Conceptualizations of the relationship between suicide and self-injury. Journal Of Mental Health Counseling, 36(3), 263-282.

References

21/06/2018 Karl Tooher DCU ISSS Presentation