Multiple holding : A model for supervision in the context of trauma and abuse

This paper reports on a grounded theory study involving eight practitioners; four supervisees and four supervisors took part in individual interviews and two separate focus groups.The core finding of the research is that multiple holding is needed to provide adequate support for professionals working with trauma and abuse. Multiple holding is a term for the processes practitioners can use to enable them to remain working in the field of trauma and abuse and includes relational supervision, knowledge and skills and the use of resources outside the supervision relationship. The identified outside resources are: spirituality; personal therapy; collegiality; and training specific to trauma and abuse. Supervisors need to be part of a chain of holding where they in turn are held by their own supervisors, who, in turn, in an ongoing sequence, are also held in a chain of supervision and holding. Being able to choose a supervisor was found to be important to build a high level of trust in the supervisee/supervisor relationship.


Introduction
In this study two voices emerged: the supervisee and supervisor perspectives.While there are many similarities in the perspectives this paper largely reflects the needs of the supervisees.
An overview of generic supervision literature leads to the conclusion that the role of supervision is to enhance practice and maintain safety standards for practitioners in social work, psychology, psychotherapy and counselling professions (Howard, 1997, Hawkins & Shohet, 2000).Research undertaken in New Zealand on strengths-based supervision includes little in the way of commentary on the supervisee's experience in the supervision relationship (Thomas, 2005), while reports from supervisors about their private experience of the work, as opposed to their prescriptions, proscriptions and observations, are even harder to find (Rock, 1997).
Research on the supervision relationship in the context of trauma is particularly sparse.Related literature identifies issues that emerge in the supervisory relationship (Eagle, 2005;Etherington, 2000Etherington, , 2009;;Walker;2004;Knight;2005,) however, at the time of embarking on this study, the researcher could find no research that specifically explored the supervisory relationship in the context of trauma.Given the importance that professional bodies and training institutions place on clinicians receiving supervision (NZAP, 2004;NZAC, 2002;ANZASW, 2004;McGregor, 2001) it is surprising, if not alarming, that there is such a dearth of research for professionals working in the health and well-being sector who interface with trauma and abuse on a daily basis.
Social workers and counsellors in health settings support patients and their families as they face the impact of treatment, life threatening diagnoses, traumatic events and death.These professionals are directly and indirectly exposed to experiences of trauma by the nature of the work, so it is vital that professionals are aware of the potential impact and that they are supported to develop skills to cope with exposure to trauma.The supervision relationship is one of the obvious places to process working with trauma and abuse.
The following brief overview of the prevalence of reported trauma and abuse incidents in New Zealand is provided to give a context for this paper.

Background overview
In New Zealand, notifications to the government care and child protection agency Child Youth and Family (CYF) are rising.The Department of Child Youth and Family Annual Report for the year ended June 2006 reported that between 2005 and 2006 there were 66,000 care and protection notifications.Of these notifications, almost 75% required further action.This was a 25% increase in notifications for the period 2004-2005.The rate of abuse continues to rise, with New Zealand having the fifth worst status on the league table of child deaths from maltreatment in 27 wealthy countries in the OECD (Wood & Kunze, 2004).
These statistics are alarming.The health professionals who investigate reported incidents of abuse to CYF are statutory social workers working at the frontline of child abuse and trauma.A supervision process that holds these social workers, and other professionals, is crucial for their work to be effective and to be supported working in chronically stressful and demanding conditions (Hanna, 2007;Badger, Royse, & Craig, 2008).Goodyear-Smith, Lobb & Mansell (2005) found that of 647 Accident Compensation Corporation (ACC) registered treatment providers in New Zealand, three professional groups provided counselling to sexual abuse claimants: psychiatrists, psychologists and counsellors.Counsellors provided 90% of treatment to ACC sexual abuse claimants.Providers classified as counsellors will work in a range of psychotherapy and counselling training modalities.These providers, under the auspices of ACC, are working in a context of increasing interpersonal violence.An ACC case manger for sensitive claims stated '[o]n average there are 1,379 new and ongoing claims for children who have been victims of sexual abuse every year' (NZ Herald, 2007).In this background of increasing violence, core questions arise concerning effective supervision practice.

Aim of the research
The purpose of this study was to identify factors that sustain practitioners working in the context of trauma and abuse, including what makes an effective supervision relationship.

Research design and methodology
Approval for the study was granted by a recognised ethics committee that required consideration of ethics regarding participant recruitment, and issues of confidentiality and emotional safety for the participants.
The qualitative methodologies that informed the research were grounded theory and feminist research practice.Grounded theory is a qualitative methodology suited for topics not widely researched.It also encourages the researcher to use procedures that allow theoretical conceptions to emerge.In grounded theory protocol an initial literature review is not undertaken, as it may influence the researcher's direction of the research.Hence, the initial data is sought from interviews with the participants, 'from ground up' (Glaser & Strauss, 1967).As the researcher is a clinical supervisor and a psychotherapist with prior social work training, a tension during the research process was to not assume the meanings participants made of their experiences.
A fundamental connection between grounded theory and feminist research practices is to highlight and make visible the voices of the participants.The analysis of data in these methods relies on words used by the participants, described as in vivo codes, and the researcher's observations and documentation (Charmaz, 2006;Glaser & Strauss, 1967;Keddy, Sims & Stern, 1996).The emergence of the core category described in this paper was achieved by a line-by-line analysis of each interview.The process of a comparative analysis of the interviews identified sub-categories and themes.From the open coding process and axial coding -the process of putting all themes into sub categories and categories -the core category of multiple holding emerged.

Rationale for seeking participants informed by feminist principles
Feminism has had an important influence on the impact and direction of trauma therapy and social work practice (Messler Davies & Frawley, 1994;Brown, 2004;Pack, 2004;Enns, 2004;Hanna, 2007).Feminist practitioners demanded that a wide framework be applied, thus helping professionals to contextualise the social environment in which interpersonal violence is embedded.Through a feminist lens, medical explanations of trauma, such as those in the Diagnostic Statistical Manual (DSM-IV, 1994), are seen as limited and lacking an analysis of gender and power.Challenge to the application of the medical model is currently controversial in New Zealand, due to recent policy changes in the Sensitive Claims Unit of ACC, which require a psychiatric diagnosis before counselling for sexual abuse will be funded.In response to the influence of feminism, this study was also interested in researching the ways feminist principles influence the supervision relationship (Hewson, 1999).

Recruitment of participants
Letters were sent to agencies, inviting participants and explaining that taking part would involve an individual interview and a focus group discussion.Ten interviews, including two pilot interviews, were audio recorded.All the participants (see Table one) had more than 10 years' experience in social work, psychology, psychotherapy and/or counselling.Most of the participants were European Pakeha, with one who culturally identified as 'Kiwi with multiple lines of Maori and Tauiwi inheritances".Two separate focus groups, one with supervisees and one with supervisors, were facilitated by the researcher.

Core finding -multiple holding: A model for clinical supervision in the context of trauma and abuse
The conceptual map of the model (Figure 1) links the key finding of multiple holding to related secondary findings of: access to support outside the supervision relationship; relational supervision; and the supervisor's skills and knowledge.An increased sense of taking control of personal and professional life was attributed to multiple holding.

Accessing supports outside the supervision relationship
Supervisees identified that for them to continue working in the field of trauma and abuse, resources from outside the supervision relationship were required.These resources include: 1.An ongoing spiritual dimension that may include daily spiritual practice.The use of these resources led to an increased capacity to hold trauma and increased supervisees' sense of well being.A major feature expressed by both supervisors and supervisees was that the supervisor needed to demonstrate effective relational qualities in order to hold the supervision relationship.

Relational Supervision: A secure base for holding the supervision relationship in the context of trauma and abuse
As shown in Figure 1, relational supervision is a core element of multiple holding.Relational supervision is characterised by the supervisor's interpersonal qualities of warmth, acceptance, validation of the supervisee's felt experiences and being open, curious and undefended in the supervisory role.This is supported by Walker (2004) who states; Working with abuse either directly or as a supervisor demands a theoretical flexibility, theoretical and educational soundness and a relational style … a relational and collegial style is … the essence of good supervision.But in supervising trauma work it is absolutely essential (p.189).
Feeling understood and met in the supervisory relationship allowed the supervisees in this study to feel held and secure in their supervision relationship and to expose more of their practice to their supervisor and colleagues.This exposure of practice assists in developing competence.Hanna (2007) promotes the need for the supervision relationship to become a secure base for supervisees to feel held, supported and encouraged in their work, relating this to theories of attachment.
This is echoed by a supervisor taking part in this research, who has many years' experience working with trauma and abuse survivors in clinical practice as well as being a supervisor and teacher.She stated: Yeah, -like a good mother almost you know, without infantilising them.Needing to let them know that they are ok, yeah you dropped the ball.In the Winnicott sense of 'good enough'.I am here for you and I believe in you.I believe in you.I respect you and I believe in you.
In a separate interview a supervisee participant described being met by her supervisor in an inspirational way regarding her fears and distress about working with sexual abuse.
And I kept away from sexual abuse (pause).I was horrified and distressed.This was picked up of course (by supervisor) … and she treated me very gently around this and said something about, how could you get more robust?You can, and so I then determined to become robust in it and here I am working in it and loving it (laughs).And later … So her really wonderful approach to me and not saying to me -well let's face it you cannot be in this work if you can't handle this.She didn't say that.It is the inspirational.It's that being drawn upward, a kind of spiritual thing there.It was being inspired by the prospect of being able to manage this part of my life that I had been frightened [of].
The experience of this participant echoed Pack (2009) in the conceptualisation of a liminal space in supervision.The liminal space is a creative space held by the supervisor to allow change and exploration to occur 'when practitioners move to a new field of practice and are challenged to evolve their own styles and ways of working with complex issues, paralleling this movement from one culture to another' (Pack,p. 71).PAGE

Relational supervision holding the impact of vicarious trauma
McCann and Pearlman (1990) stated in their seminal study that vicarious traumatisation came about as a result of the helper's empathic engagement with the client's traumatic material, resulting in similar reactions and responses to those who present with the trauma.The ability of the supervisor to take a curious stand rather than a stance of knowing was described as relational by both supervisors and supervisees.This stance allowed the supervisors' skills and knowledge to be articulated through the unpacking of conscious and unconscious material as this participant describes: What I notice with my supervisor, she has always been aware of what is not in my consciousness.What am I not aware of that I need to be aware of and I think that is a great skill you know.
As shown in Figure one, processing vicarious trauma is an important component of relational supervision and supports the building of trust and gaining new understandings.These new understandings were linked by both supervisee and supervisor participants to increasing clinical competence and client safety.The processing of presenting issues from clinical work was frequently experienced by participants as an important lens for reflection, as was the knowledge the supervisor used to decode the supervisee's 'unconscious material', also named as transference.
In this research the initial responses from the participants who volunteered experiences of vicarious trauma emerged without being directly asked for or prompted by the researcher.For some participants this was the first time they had been asked about supervision in the context of trauma and abuse.The frequency with which vicarious trauma material arose in the research interviews, and in the subsequent focus groups, drew out the relationship between multiple holding and working with trauma and vicarious trauma.
The supervisees reported the benefits of relational supervision.They also discussed supervision relationships that were not as effective and holding.The conversations were full, engaging and lively, sometimes moving and powerful.The supervisors were clear that they supervise from a relational perspective, with passion and commitment to those they supervise and to the clients they have met through the medium of supervision.

Mediating vicarious trauma -seeking multiple holding
Supervisees stated that in order to mediate the traumatic impact of the material presented in social work and therapy settings they need additional holding, outside the supervision relationship.This includes collegial conversations discussing vicarious trauma, the impact of holding suicidal ideation of a client, and actual suicide of a client.
I reckon there should be a group of senior practitioners, experienced practitioners who are also experienced in the area of suicidality, to which you can take a client.
In a survey of 285 male and female therapists 97% of counsellors reported being fearful of a client committing suicide (Pope & Tabachnick,(1993) cited in Etherington, 2009).Given the high rate of counsellors experiencing this fear in the cited study, it is not surprising that the supervisees in this research identified the need for more support outside the supervision relationship.
In the focus group and individual interviews with both supervisees and supervisors, another aspect of holding a supervisee to ameliorate the impact of working with trauma and vicarious trauma was the influence of, and access to, spirituality and personal therapy.

The influence of spirituality and personal therapy
The importance of spirituality as a means of holding practitioners dealing with vicarious trauma is supported by research.Brady, Guy, Poelestra and Brokaw (1999) conducted a national survey of 1,000 women psychotherapists in the United States to ascertain if psychotherapists should limit clinical work with trauma survivors.The study found that 63% of respondents did not have clinical supervision for practice working with sexual abuse survivors, a startling figure similar to that in Pearlman and MacIan's (1995) study that reported that only 17% of newer therapists working with sexual abuse had clinical supervision.However the Brady et al. (1999) study found a strong correlation between working with the effects of sexual trauma and spirituality.They found that those in the study that valued spirituality were strengthened and not diminished by exposure to human cruelty: 'Practitioners who treated more abuse survivors reported a more existentially and spiritually satisfying life than those with less exposure to trauma clients' (Brady et al., 1999, p. 8).
As one participant described it: I just had it there in my office and every time that I had a sense of oh god the issues for this woman, generally it was, is just so overwhelming I looked at Tane Mahuta (god of the forest) and I'll be thinking -look this tree was there way before this person was there, way before like, there's the sense of these other things that are going on and while this is really, really huge and not to minimise that, that in the greater sort of sphere of things … As spirituality was described as fundamental to practice in trauma work, so too was the need for personal therapy.
Although the finding that personal therapy is an important element in creating a multiplicity of support in working with trauma and abuse was expected, the openness and emphasis that both supervisors and supervisees placed on personal therapy was surprising.It concurred with a study by Geller, Norcross & Orlinsky (2005) of 5,000 therapists from over 12 countries indicating that therapists who sought therapy had stated that receiving psychotherapy was helpful personally and professionally.Most of the participants in the research study being reported here were in therapy and were clear about how ongoing therapy supported their practice: It is just that I felt it so strongly in myself (referring to strong body responses).And I think that is another edge with the trauma stuff and I don't do that in the room with clients because I am well trained and I get all that stuff out with my therapist.

Chain of holding -supervisors
Supervisors discussed what held them in their work as supervisors of practitioners working with abuse and trauma.The findings were remarkably similar to the findings from the supervisees.The supervisors discussed the impact of being chosen as a supervisor, and the experience of being held themselves in their role as a supervisor.One supervisor stated that was aware there was a 'chain of holding' that held her in the work as a supervisor; she was held by her own supervisor.
Well to know that my supervisor is aware of a particularly difficult case for example.And that I may even say to my supervisee look don't do anything until I have consulted my own supervisor about that.To feel I am not alone in holding what might be quite difficult stuff.I am aware as I say (it) that (there's) a kind of chain.
Supervisors in the focus group echoed the experience of a chain of holding, a chain that included agency policies and procedures to guide practice and process.
What assists me and as I've become older and hopefully a little wiser, I used to rebel against it when I was the newer social worker, are policies and procedures.That's what really assists me and also too my theory.Things that are actually concrete I guess because when you are dealing with really intense trauma there is a lot of emotional stuff that is going on and going around and a lot of feelings.Having something concrete to hold onto and to actually help in the analysis of the situation that's what really helps me.
The supervisors want funding to be available for further training of supervisors working in the field of trauma.Suggested sources for funding were stakeholders such as ACC, in partnership with training institutes that offer supervision courses.They also emphasised the need for supervisors to be knowledgeable about the signs of vicarious trauma and of human development, including recent studies in brain development and attachment theory.A strong need that also emerged from many of the participants was for people working with trauma to be able to have easy access to colleagues and to ongoing training in the field of trauma.

Conclusion
This study relates to social workers and others working in psychology, psychotherapy and counselling settings in the trauma and abuse field who are supervised for their practice.The core finding of this research is that multiple holding is necessary for practitioners working with clients who have experienced abuse and trauma.Central to achieving this is the supervisee's ability to access supervisors who practise relational supervision as described in this paper, and to the additional supports also described.More training in supervision to equip supervisors to navigate vicarious trauma, and conscious and unconscious responses within the supervision relationship is clearly needed.
It is hoped that this study will inspire others to further explore this area of clinical supervision.
2. Personal therapy.3. Collegiality with others working with trauma issues.4. Training on trauma such as the training provided by Doctors for Sexual Abuse Care (DSAC).

Table one .
Profile of the participants.