DETERMINACIÓN DEL CONTENIDO DE CENIZAS

Eighteen patients presenting to an NHS walk-in community mental health centre were selected and fourteen were successfully treated by brief psychotherapy contracts by members of the multiprofessional team: there was significant therapeutic improvement on measures of symptoms, problems, depression, social adjustment and hostility. The patients obtained a therapeutic experience in which they felt liked, understood and free to communicate verbally with their therapists about their

problems. There was only moderate agreement on themes of the session and main problem of the session, suggesting that any disagreement or conflict that existed was covert, the issues being confined to areas of joint understanding and positive feeling.

There was evidence that work in the transference, thought to be vital for therapeutic change in brief therapy by numerous workers including Malan (1978), Sifneous (1978), Mann (1976) and Davanloo (1980), did occur in this sample of therapeutic work.

Although the arousal of emotion is often linked with therapeutic change (Davenloo, 1980; Mann, 1972), this study revealed that the experienced level of emotion in the sessions as rated by the patients was not high, between slight and moderate, suggesting that uncovering or abreactive techniques were not being used.

Supervision Effect

It appears that the levels of warmth, empathy and positive regard basic to the Rogerian (1957) counselling climate found at the centre, as indicated by the post­ session questionnaires, were not affected by the supervision group. Supervision did not produce a difference in how much the patient understood him or herself, in feeling understood by the therapist, in understanding what the therapist said, in liking or feeling liked by the therapist, in freedom to speak or amount of speech, or in emotional level. Nor did it affect the

therapist's rating of his or her understanding of the patient, of feeling the patient understood what the therapist said, of increased understanding over the previous session, of liking or feeling liked by the patient, or of the amount of talk by the patient. There were no differences between the supervision conditions for agreement between therapist and patient on focus or main problem of the session. It is a common finding in psychotherapy research that therapists and patients do not necessarily agree on sessional events and topics, even in effective psychotherapy (Begley & Lieberman, 1970; Llewelyn, 1982).

It was expected that the supervised therapists would produce higher scores in the relationship areas that were emphasized in the supervision group, an indication that learning was taking place similar to the results found by Maguire et al (1984). This was borne out in that significantly more comment occurred in the sessions conducted by supervised therapists on the patient/therapist relation, feelings toward the therapist, working with the transference as the main treatment approach, comment on verbal resistance and termination. There were no differences between the groups on sessions in which there was an emphasis on the relationship with the therapist, rated by both therapist and patient, nor on sessions in which transference links were made with the patient's life, a technique stressed by Malan (1978). These findings

indicate that supervision input promoted to some degree an increased use of the therapeutic relationship as a treatment tool, which was a focus of the supervision group. However, the sample was small and the effects due to therapists and patients were not accounted for. Nevertheless, the findings by Sundland & Garfield (1974) and Vickers (1974), discussed in the Introduction section of this chapter, that the influence of supervision is minimal was brought into question, not in regard to theoretical orientation, which was not tested, but in the clinical application of concepts tested by post-session report. Casement (1985) discusses how learning from supervision takes place as an internalization of both the supervisor and the processes discussed in the supervision group.

The patients of supervised therapists had significant improvement at outcome over the patients of unsupervised therapists on three measures: rating of severity of main problem, the GHQ, and the amount of hostility. Although the Global SAS score did not indicate a group difference, three SAS sub-scores for Social & Leisure, Performance and Feelings showed significantly greater improvement of unsupervised treatment over supervised. These results, indicating a differential effect of supervision on the treatment outcome, are difficult to explain fully within existing theories of supervision. However, it might be speculated that therapists without supervision stressed and

encouraged social functioning and conducted therapy more along the lines of a social visit to the patient's home, resulting in improved functioning in areas of social behaviour and feeling. The supervised therapists, with input from the group that focused on discussion of the patient's dilemma and an emphasis on the issues of transference, resistance and termination, it may be argued, affected the outcome of problem reduction, overall distress as measured by the GHQ, and reduction of hostility. That hostility is reduced by transference work, found to be at higher levels in the supervised group of therapists, is a basic psychoanalytic tenet originally put forward by Freud (1915) and developed by many later theorists including those of the brief therapy models. Malan (1978), Mann

(1973) and Sifneos (1979).

Although the level of depression decreased significantly in the treated group as a whole, there was not a difference between patients of supervised and unsupervised therapists, suggesting the possibilities that all the therapists incorporated techniques that reduced depression, or that Rogerian or non-specific effects of the therapeutic contact were helpful in reducing depression and improving morale. A psychodynamic approach that tests effects of supervision would require specific training in issues around separation and loss (Freud, 1915), not a feature in the present study.

interactions in the sessions was increased to some degree by means of supervision. There was also a demonstration of supervision affect on outcome, however, the quasi- experimental design and uncontrolled therapist variables in this study preclude any conclusions about whether it was supervision that actually produced the differences. A further study, with an experimental design and a more rigorous supervision condition, would advance the investigation of supervision effect and its impact on therapy sessions and patient outcome. The next chapter will report this further investigation.