What practitioners actually bring to supervision

Practitioners rarely come to supervision with a technical question.

When somebody contacts me, it almost always sounds like one of these three.

I have no idea what is going on with this client, and I am doubting my own competence.

I am struggling personally and I need help now, because I have to keep working.

This client’s material is touching my own. I need help quickly so I can stay in the room with them, because they are in no position for me to withdraw.

What those three have in common

Not one of them is about a technique. All three are about the practitioner.

All three are urgent. Two of them say, in as many words, right now.

And underneath all three sits the same fear, which is almost never said out loud.

I might have to stop working.

That is not a small fear. For most of us this work is not only income. It is the thing we organised a life around, and often the place where we are most ourselves. The prospect of having to step back from it, even briefly, reaches a long way into everything else.

The kind of supervision that gets somebody through the door

There is a version of supervision built for the planned conversation. The developmental one, where you look at the next level of your practice, the patterns you keep meeting, the direction you want to set. I do a great deal of that, and it is where people actually grow.

But it is not what gets somebody through the door.

People arrive because something has landed on them that they cannot take anywhere else and cannot put down. They stay, sometimes for years, for the other thing.

I have two supervisees I began working with in March 2012. Neither arrived with a development plan. Both arrived with a version of one of those three sentences.

If you are carrying one of them today

It is not a sign that something has gone wrong with you. It is what this work does to people who take it seriously.

Nothing is too difficult or embarrassing to bring to supervision, and that includes your own personal failings. If anything, those are the ones worth bringing first.

How I work with supervisors, senior practitioners and coaches, including a single urgent consultation when something will not wait, is set out on the supervision page. There are free worksheets for practitioners, including one on countertransference, on the worksheets page.

The reaction they threw away: why practitioners bin what their bodies tell them

A supervisee and supervisor sitting together in conversation

Practitioners are trained to notice what their bodies pick up from a client. They are also, without anyone quite saying it, trained that having a reaction is a lapse. So the information arrives and gets thrown away.

Laura Joanknecht, a psychotherapist and supervisor, wrote to me this week about what she teaches her trainees: to tune into their bodies, and to notice what they’re picking up from a client before any words are exchanged.

Then she said the thing I haven’t stopped thinking about.

The hard part of the training isn’t getting them to notice. It’s getting them not to throw it away — because they’re afraid that having a reaction to a client makes them judgemental.

That isn’t a problem about perception.

We train practitioners to attend to their own responses. And at the same time, without ever quite saying it out loud, we train them that having one is a lapse. Countertransference gets taught as contamination. Judgement gets set up as the opposite of acceptance. Professionalism gets modelled, in the room, as the absence of a personal reaction.

So the information arrives — the tightening in the chest, the drop, the wish to be somewhere else, the sudden urge to protect this person — and it gets discarded at the door. Not because they didn’t feel it. Because feeling it seemed like an admission of something.

Here is why telling them it’s fine doesn’t fix it.

Shame arrives as a body state before it’s available as a thought. It isn’t a conclusion anyone reasoned their way to, so it doesn’t come apart under a better argument. Every trainee I’ve worked with agrees, intellectually, that their responses are data. They agree completely. And they still bin them.

What changes it isn’t permission. It’s having brought one, once, to someone who didn’t flinch — who took it as information rather than as something to be corrected, reassured away, or forgiven.

That’s an experience, not a piece of advice. And it’s most of what supervision is actually for.

Then there’s the half of the method that usually goes missing.

Fast is not the same as right. The empathy research has an awkward finding in it: whether a client feels understood predicts outcome better than whether the therapist read them accurately. So a practitioner trained to trust what their body reports, with no step for checking it, has been handed a very fast instrument and no way to tell when it’s wrong.

I put that to Laura, and her answer was better than my question. Slow down. See whether the information keeps returning. Pace when you share it. And take it to supervision — noting, as she did, that not every supervisor works with the body this way.

That’s the checking step. It’s also the part most likely to be skipped by practitioners who have just been liberated into taking their own responses seriously.

So: notice it. Don’t discard it. And don’t trust it either — treat it first as information about you, and only after checking, as information about them.

What did it take, for you, before you first brought one of these to a supervisor?

I didn’t realise how bad it had got: how to notice what your body is telling you

A man at a desk, one hand at his temple, the other resting on his stomach

The signal was there the whole time. What was missing was the ability to read it early enough to matter.

“I didn’t realise how bad it had got until I was ill.”

I hear that a lot. Usually from people who would describe themselves as reasonably self-aware.

Here’s the part that surprises them. It isn’t that they weren’t looking after themselves. The signal was there the whole time. What was missing was the ability to read it early enough for it to be any use.

That’s a skill in its own right, and when it’s underdeveloped it doesn’t look like “not noticing.”

It looks like fog, and a shorter fuse than usual. Headaches, gut trouble, sleep going off, appetite all over the place. Wired and tired at the same time. Empathy quietly dropping away. Finding out you were hungry, exhausted or furious only once somebody else points it out — or once your body takes the decision out of your hands.

This is the skill I’d call somatic attunement, and it sits near the beginning of the order I build these in, because most of the skills above it assume you can already tell what state you’re in.

What I train is deliberately unglamorous. Notice the signal without rushing to fix it. Put plain words to it. Find exactly where it lives. Soften around it rather than pushing it away. Make one small supportive adjustment. Ask what it’s asking for, without forcing an answer. Then take the smallest action that honours it.

Notice before fix. That order is the whole thing.

It’s both foundational and reasonably well grounded in research, and I can be specific about how.

There is a real ascending pathway carrying information from the body, terminating in one part of the insula and re-represented in another, and the anterior insula’s role in our awareness of subjective feeling is one of the better-supported findings in affective neuroscience. Putting plain words to what we’re feeling is among the better-evidenced moves in the whole field. Locating a feeling in the physical body has a meta-analysis behind it. And body-oriented approaches built explicitly around interoception have outcome evidence, including in a clinical population.

Now the uncomfortable part, which I think is the most useful thing in this article.

Researchers separate at least three things here, and they come apart. How accurately you actually detect what your body is doing. How much body awareness you report having. And whether your confidence tracks your accuracy.

Those are not the same, and a person can be high on one and low on another. Which means “I’m very in tune with my body” and “I can tell what my body is doing” are two different claims, and the first is not evidence for the second.

I’d extend that caution to my own field, including me. Most of the evidence that this kind of training works rests on people reporting more body awareness afterwards — which is a measure of what they believe, not of what they can detect. And the main objective measure researchers use is currently the subject of a live and unresolved dispute. So: real, worth doing, and not as well nailed down as the confident version of this would have you think.

What hasn’t been done is a trial of my sequence as a package against a control group. That’s a study I want to run, and until it exists I’ll keep saying so.

The question I’d ask you to sit with: when did I last notice what my body was telling me while there was still time to do something about it?

That’s a reflection question, not a validated clinical instrument, and I don’t present it as one.

If you’d rather be taken through the practice than read about it, there’s a video of me doing the whole thing with you: https://psychevita.com/vitapath

I’ll be writing about a different skill each week here, in the order I’d actually build them. All of them are designed for body-based learning. Nothing to remember, except to practise.

You can’t regulate a state you can’t feel. Which makes feeling it the first job, not the soft one.

The full practice lives here: https://psychevita.com/vitapath

Somatic Attunement is the second skill in VitaPath, the order I would build these in. It sits inside the Grow library, which is a paid membership (all content £10/month or £100/year; cancel any time; prices may vary by app/region). I’d rather tell you that now than have you find out after clicking.

For this skill, like all 48 skills, you get a short introduction, a full “do it with me” session, a brief version for everyday resets, a guided audio practice, and the written guide. They’re designed for three to ten minutes of daily practice. Practised often enough, the skill stops being something you do and becomes what you default to.

One thing worth saying about why it’s on video rather than written down. Noticing a body signal without immediately trying to fix it is much harder to get right from a description than it looks, and it feels distinctly odd the first few times you try it. Watching someone else do it, unhurried and unembarrassed, is most of the learning. That’s true of nearly everything I teach: these skills are built for the body, not for memorising. There’s nothing to remember, except to practise.

There is very little evidence that supervision improves client outcomes.

Two things done inside supervision do show up in client outcomes.

Every counsellor, psychotherapist and supervisor I know is required to have supervision. Most of us pay for it ourselves.

Here is something that surprised me when I first read it properly, and still does.

There is very little evidence that supervision improves client outcomes.

Watkins reviewed thirty years of research in 2011 and found the link thin. Not absent exactly, but nothing like what you would expect of something a whole profession mandates.

It would be easier not to say that. I supervise. I am paid to.

But I think most experienced practitioners already know it in some form. You have probably sat in supervision that met the requirement and changed nothing.

What the evidence does support is narrower, and more useful. Two things done inside supervision do show up in client outcomes: collecting structured feedback from clients, and working properly with countertransference.

It is the second one I want to say something about.

Not every model uses that second word, so to be plain about what I mean. Countertransference is the effect the client has on the practitioner, and in supervision of supervision, the effect a supervisee has on their supervisor. Attraction, or a prurient interest you would rather not have. Shock, disgust, horror. Fear, or feeling intimidated. Fascination that tips into preoccupation. Envy. Boredom. A sense of superiority, or of being the only one who could possibly help. And some of it is provoked less by what the client brings than by what they are: fame, or infamy, or extreme wealth. Everybody has a reaction to those, including the people most certain that they do not.

None of that is evidence of a defect in you. It is information about the work. It is only dangerous when there is nowhere to take it.

We tend to treat countertransference as a reaction we have and then manage. Notice it, bracket it, set it aside.

I have come to hold it differently. What our clients carry is largely procedural. It was laid down before language and it does not arrive as a story. It arrives in the room, in our bodies, before either person has words for it.

So the feeling that shows up in me while I am sitting with someone is not noise to be filtered out. It is often the first and only channel the material has.

Which makes this less a matter of management and more a matter of capacity. Three, specifically.

Whether I can register a bodily signal early enough for it to be useful, rather than finding it afterwards in my notes.

Whether I can feel and name what arrived without either discharging it into the room or sealing it off.

And whether I can tolerate what it touches. Because what client material most often finds in us is shame. A practitioner whose sense of worth depends on the session going well will act to relieve that shame rather than stay with what it is telling them.

None of that is a technique you can be taught in an afternoon. It is built, slowly, and mostly through being on the receiving end of it.

Which is, I think, the strongest argument for supervision that the evidence will actually carry. Not oversight. Not a box. Somewhere your own capacity to receive a client gets built.

Reference: Watkins, C E (2011). Does psychotherapy supervision contribute to patient outcomes? Considering 30 years of research. The Clinical Supervisor 30 (2) 235-256.

I’ve written a short self-supervision worksheet on this. Five steps to work through after a session, and a straight answer about the limit of doing it alone: https://drtonyweston.com/worksheets/

More on how I work with this, including supervision of supervision: https://drtonyweston.com/for-counsellors-and-trainees/clinical-supervision/

Why difficulty has to travel up an organisation, not down

Every organisation produces difficulty. Complaints that cannot be resolved. Decisions that harm somebody whichever way you go. Targets that do not fit the work. Illness, grief, fear, and the ordinary friction of people who have to get along. None of that is evidence of a badly run place. It is what running a place involves.

The question is not whether an organisation generates difficulty. It is where the difficulty ends up.

Containment, and its two halves

Containment is the capacity to receive something difficult, hold it, and hand it back in a form that can be used. The idea comes from Wilfred Bion, who was describing what a mother does with an infant’s distress and what an analyst does with a patient’s. It transfers to organisations more usefully than most psychoanalytic concepts do.

In an organisation it operates at two levels, and it needs both.

Structural containment is design. Whose responsibility is this, actually? What is this role expected to absorb in silence, and should it be? Unclear boundaries, moral ambiguity, conflicting demands and responsibility without limit are not personal weaknesses. They are design faults, and no amount of resilience training corrects them.

Developmental containment is personal capacity. The trained ability to stay present with fear, shame and pressure without collapsing into it and without passing it on.

Neither works alone. Good structure without capacity leaves somebody unable to use the room they have been given. Capacity without structure means a well-regulated person still ends up absorbing what the system was never designed to hold. Pressure turns into personal damage when both are missing at once.

The part that gets missed: difficulty has a direction

Here is what I have come to think matters most, and it is rarely said out loud.

When difficulty is not contained, it does not dissolve. It moves. And the default direction of travel is down.

Down is the path of least resistance, because down is where the least power is. A chief executive can pass discomfort to a director. A director can pass it to a manager. A manager can pass it to somebody on the front line. At every step it is easier to pass the discomfort on than to absorb and settle it, and at every step the person receiving the discomfort has fewer means of refusing it.

So the difficulty does not spread evenly. It concentrates, and it concentrates at the bottom of the organisation.

In a service for vulnerable people, the bottom is the client

I supervise chief executives and directors who carry responsibility for practitioners who in turn carry responsibility for vulnerable people. A child in compulsory education. A child with special needs in a specialist school. A patient on a ward. A resident in a care home. A young person in residential care. A prisoner. Somebody seeking asylum, waiting on a decision they cannot influence.

The very old, the very sick and the very young. People who, by the time the difficulty reaches them, are the least able to defend themselves against it, and the least likely to be believed if they try.

In organisations like these, the direction of travel is not an abstraction. The people at the bottom of the chain are the people the organisation exists to help, and they are there precisely because their capacity to process difficulty is already overwhelmed. That is often the reason they need the service in the first place.

So what arrives at the bottom of the chain is received by the people least equipped to hold that difficulty and most likely to act it out. The acting out is then read as the presenting problem. The organisation responds with more control. More control is more difficulty travelling down.

The organisation defeats its own purpose, and it does so while everybody in it is working hard.

A small example, told flatly

I belonged to a members’ club. Over several months one of the receptionists repeatedly refused me a towel on entry, on the grounds that my level of membership did not warrant one. On one occasion my membership card was taken from me and replaced with a lowest-tier card that locked me out of facilities I was paying for.

When I eventually got to speak to management, it turned out that through an administrative anomaly I was paying more than any other member of that club.

I tell it flatly because the interesting part is not that it was unpleasant. The interesting part is that nobody inside the system could see it. The organisation was extracting the most from the member it treated worst, and it was nobody’s decision that this should happen.

And the receptionist was not the source. They were near the bottom of that chain themselves, receiving whatever had already travelled down and had nowhere further to go. So it went sideways, into the member standing in front of them. I do not know what they were carrying and it would be wrong of me to speculate about someone I never met professionally. But the shape of it is familiar, and I have seen it in settings where the stakes were considerably higher than a towel.

Why holding difficulty is hard

Because containing costs something, and transmitting is free.

To contain is to take the difficulty in, sit with it long enough to be changed by it, and hand back something usable. That is effortful, it is uncomfortable, and nobody sees you do it. To transmit is instant and invisible: a curt email, a deadline moved without explanation, a meeting where somebody is made to feel small, a policy written in irritation. Nothing in most organisations names transmission as a failure, and nothing rewards containment as work.

Containment is also, straightforwardly, a capacity. It can be built. Most senior people have never been trained in it, because leadership development tends to teach strategy, communication and decision-making, and treats the ability to hold difficult feeling as a personality trait you either have or you do not.

Two questions

If you lead an organisation, these are the two I would start with. One is structural and one is developmental, and the answers are usually quite different.

Which decisions genuinely sit with me, and which do not?

What capacity would let me stay present with this pressure, rather than absorb it or pass it on?

If you cannot answer the first, you are carrying things that belong elsewhere and the structure needs work. If you cannot answer the second, the structure can be perfect and the difficulty will still find its way down.

What I am claiming, and what I am not

This is a clinical argument, not a research finding, and I want to be clear about the difference.

The containment concept is well established. Bion set out container and contained in the clinical context, and Isabel Menzies Lyth’s 1960 study of a general hospital nursing service showed how unprocessed anxiety in an institution gets displaced into structure and ritual rather than being metabolised. Both are theory and case study. Neither is an outcome trial.

The directional claim, that difficulty travels down by default and has to be deliberately made to travel up, is my own formulation, drawn from clinical and supervisory work rather than from a dataset. I am not aware of a body of outcome evidence demonstrating that leadership behaviour makes clinical outcomes worse for the people at the end of the chain, and I am not going to attach a number to it.

Treat it as a way of looking, not a finding. Then test it against your own organisation, which is the only place the question can actually be settled.

What this has to do with supervision

A large part of what I do with senior leaders is simply being the place the difficulty can travel up to, so that it stops with them rather than passing through them.

That is not a soft benefit and it is not a wellbeing perk. If the argument above is right, it is the point at which an organisation either serves the people it exists for or quietly works against them.

There is a free worksheet to go with this piece, What You Do With What Lands On You. Seven steps for the moment something difficult has landed on you and you have a choice about what happens next. It is on the worksheets page with the others.

More on how I work with supervisors, senior practitioners and leaders is on the supervision page. There are free worksheets for practitioners, including one on countertransference, on the worksheets page.

References

Bion, W R (1962). Learning from Experience. London: Heinemann.

Menzies, I E P (1960). A case-study in the functioning of social systems as a defence against anxiety: a report on a study of the nursing service of a general hospital. Human Relations, 13(2), 95–121.