On Internal Supervision

I recently read Patrick Casement’s excellent book, On Learning From the Patient. Highly recommended for clinicians, and for anyone curious about how a sensitive, skillful psychoanalyst works. Casement is rigorous without being academic or tedious—which can’t always be said of analysts who write about the work.

A core theme of the book is what Casement calls “internal supervision.” He shows us what he means by inviting the reader to observe his process with patients. For example, a patient indirectly describes feeling a kind of suicidal despair; Casement lets the patient know he’s aware of this communication. So far so good, and the man responds well. But then Casement seeks to reassure the man by offering an extra session. His internal supervisor notices that he’s likely offering more help than is asked for, or needed; perhaps led by his own anxiety rather than any need of the patient. Subsequently, Casement learns that the patient felt some resentment and concern because Casement’s offer made him worry he was less stable and competent to care for himself than he had thought.

Developing an internal supervisor involves cultivating an observing mind that isn’t identified with what’s happening between therapist and patient in the moment-to-moment engagement of the session. The internal supervisor is thus able to monitor the process, even as another part of us is in it. Thus the internal supervisor functions much like the observing mind in Buddhism, which notices the stream of passing thoughts, feelings, and sensations without identifying with them. Alluding to Winnicott’s notion of ‘transitional objects,’ Casement calls on therapists to develop a “transitional presence” which makes them available to the patient as needed—actively interpreting in one moment, say, while receding into a witnessing role in the next.

As I read Casement’s book, I found this ideal internal supervisor intimidatingly thoughtful! They exercise foresight in relation to what may be encountered in a session, hindsight in relation to what happened or was missed by the analyst during the session, and insight regarding what’s happening during session. Casement reminds us of how much attention can be brought to our work with patients. I say, patients, but much of what he says can be applied to the quality of attention we hope to give our children, friends, and partners.

In a previous note offering advice to aspiring therapists, I said that paying for ongoing supervision is the single best investment a therapist can make. One reason is that it’s actually an investment in our internal supervisor, because we develop one partly by internalizing our experiences with an external supervisor. For example, for many years I took weekly classes from a great yoga teacher. Even now, over 10 years since the last class, when I’m practicing yoga I can hear Eric’s voice (in a Liverpool accent!) reminding me of this or that nuance in a pose.

With practice the expectation is that we develop our own distinctive way of working and supervising ourselves. But how good that internal supervisor becomes depends first on having good external supervision, and second on attentive practice. Similarly, part of what patients can learn from a therapist is to develop their own internal supervisor—their own capacity to observe their thoughts, feelings, and actions with a little more perspective and skill, and often a lot more compassion for themselves, than they had when first they came to therapy.

Casement’s internal supervisor notices all manner of things, from mistakes and missed opportunities to details of the patient’s communications, conscious and unconscious. The book is titled On Learning from the Patient, but what struck me is how much Casement is learning from himself as therapist, by giving careful ongoing attention to whatever crosses his mind before, during, and between sessions with his patients—trusting as he does that there’s potential value in it all.