Reflections on the peer supervision process

About five months ago the head psychiatrist at the clinic where I work approached me about starting a peer supervision group for the Interns and Externs training there. He wanted to construct a space where they could present and discuss their cases, receive feedback from their peers and also raise any issues that they were having in the clinic. As a 5th year psychology Intern, I was the most senior training clinician (it feels as much as an oxymoron as it sounds) and we agreed that it would be my responsibility for creating this space. Our initial discussions outlined the goals of the group, that it would be voluntary, confidential, open to all the trainees, run for twelve weeks, and that each week a different clinician would present a case for discussion.

However, we were less clear when defining my role and exactly how I would create the space for this to occur. We contrasted the pros and cons of the traditional group supervisor role to the supervisor as a group facilitator. While the former provided more in the way of structure and boundaries we were concerned about it feeling like a therapy group or clinical rounds. Indeed, having established collegial and friendly relationships with the clinicians it was important to be clear that the supervision group was not a therapy group. Alternatively, the latter appeared to engender more space for open discussion but provided less structure and clarity around roles. After going back and forth over the differences, we agreed to use a facilitator model. In this model, I was responsible for bringing the group to a beginning and an end, ensuring that there was a presenter each week, and generally facilitating discussion. We also decided that I would not present my own cases and that I would generally try to allow others to answer questions so that they would not be directed at me. Having established the framework, we ended our conversation with the psychiatrist sounding the ominous and prophetic warning that he had never participated in a successful peer supervision group.

As the group started and began to meet weekly, some of the outlined aspects worked well. Notably, some members appeared to benefit from presenting cases and being given an open forum to ask questions. Furthermore, clinicians felt they could discuss issues they had in the clinic in a confidential area. However, as predicted by the psychiatrist, for the large part the group did not feel like it ever took off. Attendance was spotty from the second week onwards, robust discussions were sparse, and much of the group process seemed to go through me.

Succinctly, the group never seemed to take ownership over itself. While there are likely many reasons and contributing factors for this, reflecting back over the course of the group I am struck by how much my own role influenced the development of the group. Specifically, I believe that I failed to commit to the role of group facilitator. Instead, I moved back and forth between supervisor and facilitator and by not being consistent limited the group’s growth. In hindsight (which is not always 20/20) this is not surprising and seems to me a product of the ambiguity inherent in peer supervision groups, and my own ambivalence towards authority.

There are two important differences to peer supervision groups and other forms of groups, including regular supervision groups, therapy groups, and even support groups. The first is that in peer groups, the members either already know each other, or will at some point through their interactions come to know each other. Thus, unlike other groups, where members maintain little contact with each other outside of the group, in a peer supervision group they frequently interact outside of the group. Secondly, in other groups, the supervisor or leader is typically a more experienced clinician, whose role and position is defined, however in peer groups all members are expected to contribute equally.

The result of these differences is that the boundaries established in other groups to ensure safety are less pronounced and more ambiguous, meaning that the peer supervision group members themselves have to establish trust amongst each other. Although this may seem easy, it is as I learned actually a complicated process requiring a lot of faith and an ability to tolerate vulnerability. Without a supervisor to orientate around (more on that in a minute), group members are asked to establish trust through the act of discussing cases with their peers. This is potentially frightening, case discussions reveal aspects of us as therapists or individuals that we may not be aware of. Doing so in an ambiguous setting, with colleagues we trust, but perhaps not entirely, is daunting, difficult, and anxiety provoking for even I imagine experienced clinicians. Compounding these obstacles, is that many of the trainees were just starting to gain clinical experience and may have felt vulnerable and out of place discussing their experiences with others. It is not that the members did not explicitly trust each other, as much as the valence of the group pulled them away from easily building trust with each other.

One of the ways of lessening anxiety – or countering this valence – is for the supervisor to take an active role in running supervision, establishing boundaries regarding member interaction and a consistent structure for the group to follow each week. In doing so, individuals come to know what is expected of them less through their interactions with each other, than with the supervisor, who acts as an anchor for them to orientate around. Two of the most likely configurations are that either supervisee’s develop trust in the supervisor and it expands towards the other members, or alternatively, they develop trust in each other and perhaps later the supervisor. In either case, the supervisor’s role is defined by stability and consistency.

Notably, while trust can develop amongst all the parties, the power differential of supervisor and supervisee remains. Peer supervision offers the opportunity for a greater balance of power. Each individual can temporarily step into different roles, each taking turns at supervising, facilitating, being supervised, etc. In other words, by giving up the traditional role of supervisee (or group member) and managing the anxiety that comes with it, other interpersonal relationships are possible.

However, not only does the supervisee have to give up their role, but the supervisor as well. Indeed, while I thought that I was ready to do this, in retrospect it proved more difficult than I anticipated. In trying to establish the space for peer supervision I was also (although likely unaware of it at the time) moving away from my own basis of security. In this sense, much as I was asking the supervisee’s to handle anxiety by giving up their role, I was also asking myself to deal with anxiety of not having a clear role either. This process seemed to entail an interesting paradox whereby in order to give up authority I first had to use it.

Broadly speaking, initiating a group already entails a certain relationship between supervisor and supervisee’s (initiator and initiates), although as already described the aim of this group was to move that relationship into the background and place peer relationships in the foreground. In order to accomplish this, I originally thought it would be enough to describe the aims, goals, rules, etc. However, as described earlier, this did not work – and indeed, may have likely contributed to increased anxiety and ambiguity in the group. Looking back, I now wonder if it would have been more effective to use the authority present from initiating the group, being senior, etc to attempt and remove that authority. While I am not entirely certain of the form that this process would take what seems clear is the need to act, as an authority to communicate that there is no authority. In other words, by actively placing my trust in the group (only something the supervisor/authority can do) I would have more fully taken the role of facilitator.

Of course, this is easier said then done, particularly in a peer setting. Indeed, early in the group, the question of authority was raised and despite my wish to move away from these traditional group issues, by spreading authority around I found myself more often then not responding from a place as the supervisor. While this involved using authority it was in the form of maintaining a more conventional relationship. Instead, I wonder what it would have been like to use my authority to let it go. By constraining the extent to which I would reply (perhaps less as supervisor and more as a peer?) would that have facilitated a more effective peer group experience?

I believe that my difficulties doing this, reflects some of my own ambivalence to authority and hesitancy to fully embrace a facilitator role. Indeed, much like supervisee’s look to quell their anxiety through the supervisor, I was doing the same. Retreating into roles makes managing anxiety easier but also limits some of the opportunities for novel experiencing. In this respect, my movement between facilitator and supervisor limited the extent to which I committed to either and thus the extent to which a genuine peer interaction could develop.

For me, anxiety around authority stems from the possibility of overly constraining self and other. Accordingly, my response is to make space by either reluctantly (or inconsistently) accepting authority or alternatively challenging it. Although at times effective and important it can also be confusing and prevent roles and novelty from becoming fully developed. Instead I find it necessary to remind myself that authority much like other roles can be taken up, released, and modified, and that constraint enables action, which of course modifies constraint. Being more flexible at doing so may allow for more productive peer supervision groups!