Choosing an operative model, such as the use of the clinical case report as training method in the supervision of clinical psychologists, first of all involves reflection on the conceptual and epistemological set-up underlying and guiding the intervention.
We owethe recognition of the historic-socio-cultural relativity of the models used to understand reality to the so-called epistemology of complexity (Vattimo & Rovatti, 1983; Pera, 1991). This recognition has focused attention on the role of the reporter/observer (Di Blasi & Lo Verso, 1998) in construing and transforming it.
The participation of the observer of the system observed has however ceased to be considered a problem for post-modern psychology, which finds its distinctive note in the interest in meaning and the way it mediates the individual-context relation (cfr. Salvatore et al., 2003). This fosters the abandonment of a criterion of a-historical, a-contextual truth and encourages debate and reflection on exactly what realities are constructed through one’s vision of the world, and what the implications are.
In this perspective, interest in the report, cutting across the applicative domains of psychology, is interest in meaning.
At the theoretical-methodological level, this is not unanimously understood. Let us give just one of the many signs of this: the different roles attributed to the context of reporting, treated at times as a mere space for data collection, other times as a semiotic context, which plays a significant role in the construction and therefore in the understanding of the fact reported.
The clinical use of the report in training clinical psychologists therefore involves a primary reflection on the nature of the data being studied, the type of reading it calls for, the kind of use, and the perspective from which to start (what use will we make of it and why?).
These considerations show what we see as the major merit of the Study days on reporting as an intervention method in clinical psychology (Rome, 16-17 May, 2008): treating reporting as a method involves the attempt to conceptualize in a psychological key what comprises the report and where it should be directed, in terms of the context in which and because of which it is carried out, apart from the contingent objects involved.
Below I will try not to take for granted the conceptual factors linking the psychodynamic perspective in its contextual, socioconstructivist version (Salvatore et al., 2003), with the interest in the process and the semiotic and dialogic context of reporting.
In order to examine this link in detail, in the first part I will give some considerations on the nature of meaning, which enable us to recognise the constructive, dialogic, contextual and contingent nature of the product and the process of reporting to someone else; in the second part I will take up some elements of clinical theory and its outcome, to enable us, in the frame of sense emerging from this dialogic exchange, to identify an object and a significant purpose of the supervision function.
Lastly, in the third part, in order to make a detailed examination of some of the methodological implications suggested by this perspective, I will present a supervision device which, in the non-referentiality of the discourse, and in the exercise of a reflective, involving function interested in the meaning that is gradually constructed in the context of the meeting, finds the two main reasons/principles in the use of the report in clinical psychology training.
Notes on a theory of the report
In other works (Venuleo & Salvatore, 2006; Venuleo, 2008), we referred to the distinction between a semantic approach and a semiotic approach to the objects of interest in psychology in the description of the difference between an interpretative model that assumes the static nature of meaning and an approach which instead acknowledges its contingent, contextual character.
Let us look at an idiographic study published in the first volume of the Yearbook of Idiographic Science to illustrate the first point of view. This is a study on the change in a young diabetic woman’s health behavior (Toise, 2008). The author wants to show the woman’s state of health, assessed with reference both to the psychic and physical aspects, and improved thanks to the practice of yoga. The author reports, as significant data, narrative fragments produced by the woman in a collaborative research setting. Thoughts and statements recorded in the context of an interview, connected to specific indicators related to her management of her diabetes, are used to show how and what has changed in the journey from dependence on insulin to independence. The data provided by the interview is therefore the semantic contents, and this is data because it is the sign of further psychic realities (self-compassion, self-perception, worldview), of those psychological components that the model of change proposed by the author sets out to describe. In this perspective, the data collected does not raise questions such as what is the woman’s representation of the interview and of her part in it? With what theory of goal does she take part in it and what is the connection with the representational contents that she chooses to describe?
The meaning of the representational contents is stable enough to justify the assumption of a space of homogeneity/agreement between the interviewee and the interviewer on the meaning of what is said (questions and answers), and the lack of comment on the context of interaction in which the contents are produced. From a complementary point of view, a semantic approach to data is based on the assumption of invariance of meaning through contexts. From this point of view, the interview, like all narrative production, is a space-time of transmission of pre-constituted meanings, pre-existing the exchange: it is therefore legitimate not to worry about making sense of the fact that what was said in that research context was said.
It is not difficult in this approach to find the epistemological model of subject-object relation adopted by classical psychology and still strongly present in research engaged in verifying the therapeutic process (Stampa & Grasso, 2006; Grasso & Stampa, 2008), as Renzo Carli underlined in opening the Study Days on Reporting (Carli, 2008). The assumption that the process and the context of knowledge-getting (the assumptions about the observer, his research goals, the social context in which knowledge is produced, exchanged, used..) are “inert” as regards the object in se, since it has a pre-existing working identity which therefore cannot be changed by the observer’s operations (Salvatore, 2003).
In relatively recent years, a growing number of authors in the psychology field (inter alias, Edwards, & Potter, 1993, Gergen, 1999; Salvatore et al., 2003, Valsiner, & Van der Veer, 2000), as well as in philosophy, semiotics and linguistics, have expressed their disaffection with a semantic approach to the understanding of signs (behaviors, discourses, techniques, procedures), suggesting that they do not intrinsically have a univocal meaning, and that this is defined in terms of the intratextual (the set of signs) and extratextual context (social purpose) in which and because of which they are produced.
In this perspective, language (and therefore also reporting) is something more than the cognitive function that implements it; it is a product and at the same time a constitutive dimension of an intrinsically intersubjective process of meaning construction (Salvatore & Venuleo, 2008a). Recently, when discussing the implications of such a perspective in relation to the definition of the objects of interest to psychology, Sergio Salvatore put forward a distinction between meaning and sense in order to reiterate the contextual contingent nature of the main data of all clinical practice (Salvatore, Ligorio, & De Franchis, 2005)1. If the meaning of a sign is stable enough, the sense (or its psychological value) is qualified according to the local, contingent, intersubjective and discursive circumstances (Wittgenstein, 1953; Harré & Gillet, 1994).
The person who listens does not confine himself to receiving and/or commenting on an already written text, but participates in the writing, interacting with the story recounted starting from his own interpretative models (Montesarchio & Venuleo, 2002). These models regulate the communicative value of the message, the meaning that will be attributed to it and the use that will be made of it in the discursive domain2.
This equates to saying that as soon as one gets out of a strictly semantic and therefore static vision of communication as the exchange of predefined and essentially unvarying meanings, reporting acquires the features of a polysemic, pragmatic-semiotic process, that cannot be constrained a priori within the meaning pathways that it allows. One discursive act may give rise to different events depending on the discursive and symbolic context in which it is produced and received.
Such a perspective involves giving up the referentiality of the discourse as a fact on which to construct one’s interpretative hypotheses (Salvatore & Scotto Di Carlo, 2005), and recognising the basic rule that what the report (the client to the psychologist, the latter to the supervisor, the interviewee to the interviewer) says or does, must be seen not as indicating a state of the world (whether it be the psychic reality of the patient or that of the psychologist recounting the case) but as the sign/significant of the semiotic context that encourages the saying and doing.
Cultural and psychodynamic psychologists have been encouraged to discuss this shared contextual epistemology (Salvatore et al., 2003; Salvatore & Zittoun, 2008). For the purposes of our discourse, it is of interest to underline that both these theoretical perspectives prompt us to go beyond technicalism, seen as the basic a-contextual idea of the psychology profession (Carli & Paniccia, 1999), in favor of a theory of the technique that takes the exploration of contexts (constraints, resources, devices for meaning construction) as the criterion guiding therapeutic practice and also training for future psychotherapists. The point is to recognise in both cases the intrinsically dialogic contextual character of the processes of meaning construction with which the client, on the one hand, and the trainee therapist on the other, organise their representation of reality (Montesarchio & Venuleo, 2006a).
On clinical theory
Clarifying the function of reporting (or of the process of reporting to someone else) in the supervision of clinical psychologists, obviously requires one to make one’s position clear not only on the theory of reporting but also on the theory of clinical work and its outcome.
The supervision model we use is part of a psychodynamic conception of the clinical process which shares with the socioconstructivist perspective the same basic postulate: the idea that relations are organisers of the cognitive sphere (Salvatore et al., 2003) and which recognises in the client’s way of asking to be listened to and of narrating, the precipitate of processes of affectively symbolizing reality (Fornari, 1976).
In this perspective, the case report presented by the psychologist-client in supervision, far from being seen as the objective description of the dynamics of an intervention, can be treated as a sign of the intersubjective context of signification that qualifies the trainee’s demand and therefore his positioning in the symbolic field that characterizes the system of activity.
The demand is seen in its clinical psychology sense (Carli, 1987; Carli & Paniccia, 2003) as the symbolic model of emotional representation of the relationship with the supervisor (or the supervising group), which brings its own emotional construction of the problem (the case) behind the request, an interpretation, a hypothesis on the way of coping with it and on the role the supervision can play in it (Salvatore & Scotto di Carlo, 2005).
The person reporting therefore proposes not only a representation of the case, but also a theory of professional action which will be reflected in the choice of what to tell and how3.
Clinical theory, in its interactionist, contextual version, has shown the regulatory role of these interpretative models4, and their mediating function as regards the client/user’s capacity for an intervention using the resources of the context of the activity they are part of. The construction of meaning is not only the product of a positioning: at the same time it is the way this positioning tries to reproduce itself in the dialectic space of discursive exchange5.
The person presenting the demand uses and interprets clinical practice based on the system of meanings, interests and purposes (more or less clear, consistent and competent) due to which and with the mediation of which he presents his demand for intervention (for therapy, or for training) (Carli, 1987).
For the psychologist in supervision, this demand however can only be produced within the cultural model that guides professional practice, and therefore suffers from the same deficit of competence that led to the request for supervision. Generating/proposing for instance an object that cannot be treated in a psychological key or at least in the general theory of the clinical intervention on which the consultation relationship is based (think of a psychologist asking how to treat his patient’s panic attack in a context of supervision which among its training goals includes the competence to analyse and elaborate demands rather than circumscribe and treat symptoms).
In this approach the supervision function cannot confine itself to the construction of hypotheses on how to deal with the case reported (assuming that there is agreement on the object to be discussed), but is primarily configured as the construction of conditions that allow the analysis to be carried out (Salvatore & Scotto Di Carlo, 2005). This leads to the interpretative models used by trainee psychologists to interpret and co-construct the relationship (with the supervisor, with the client) and on the basis of which they report the case, being treated simultaneously as the object and the goal of clinical practice (Venuleo, Salvatore, Grassi & Mossi, 2008). Supervision activity can be conceived from this point of view as the opportunity to practise the systematic surpassing of the constraints that the symbolic dimensions place on the possibility of generating new meaning.
In this direction, a fundamental methodological principle can be kept in mind. The interpretative models are themselves an event of social construction, and they develop through the time of the dialogic exchange about and through the elements of the system of activity. In this exchange the supervisor participates by proposing, encouraging, giving input, and validating premises and criteria of relating (Venuleo, Salvatore, Grassi & Mossi, 2008).
While it must be acknowledged that every participant in the supervision thinks and speaks in terms of his own interpretative universe, it is also opportune to point out that his semiotic activity of interpretation-construction of meaning is constrained/fed on by signification devices placed at his disposal by the supervision context (the contents of tasks requested, the way of presenting them, the forms of relationship offered to the trainees, the space-time organisation of work, etc). From a complementary point of view, the setting offered in supervision is not an inert frame of how the consultation relationship is configured, but it actually organises and orients it (Montesarchio & Venuleo, 2002). It is both the outcome and the mediator of the actors’ narrative practices. It is the frame of sense, in terms of which signs are interpreted, but it is also produced by means of and for the use of signs (Billig, 1996) in the discursive exchange.
It is therefore a matter of using (rather than stating) the methodological criteria of clinical action in the here and now of the training offered.
Identifying with this theoretical-methodological approach, in the following pages we will describe a methodological supervision device that uses the report to think about and propose thinking about the emotions involved in the clinical relationship (Carli, 2007). In this way no interpretative frame (normative criteria, values, feelings) will be treated as being absolute.
From the text to the relationship
The proposal emerged in a four-year group psychotherapy training school (Montesarchio & Venuleo, 2006a). For our purposes, it seems important to describe it not by starting from the clinical theory embraced by the School, but from the theory of the technique underlying the use of the group as the tool-relationship of intervention.
The hypothesis is that the exploration, the expression and the elaboration in and of the group of fantasies and expectations conveyed by the way of using the training space, can be offered as a vehicle of learning and experience of a method capable of using and valorising the relationship and the context as the criterion that orients professional practice.
The internal dynamics of this process can be described as a continuous and recursive work of constructing links between what is reported and the reporter, between the reporter and the intersubjective context (which on the one hand is constructed by its reporting, on the other contributes to constructing the report); and between what happens in the here and now of the supervision setting and what happens in the there and then of the intervention setting. This work of constructing links goes through the recognition of the reciprocal contamination between subject and object of knowledge (Borgogno, 1978).
We like to describe its ideal cognitive and relational product in terms of the socio-semiotic practice of extraneousness. By extraneousness we mean the model of symbolic relationship with the object that treats it as not immediately given or obviously re-cognisable (Montesarchio & Crotti, 1993; Paniccia, 2003).
‘Inter-visioning’…From report to report
In other works, with Gianni Montesarchio, we have talked about narration to the second, to the third and to the fourth power in the attempt to categorise the various levels of reading of the report produced on a case, and the diversity of the objects of analysis that each of these levels leads us to identify/construe (Montesarchio & Venuleo, 2006a, 2006b).
At the first level of reading of the reporting process, the object to discuss is identified as the relation of the person presenting the case with the facts of the experience (and as the interpretative categories that he proposes using). At a further level of reading, the object is identified in the context of signification co-constructed through discursive exchange by the actors involved in the case (client, reporting psychologist, colleagues, supervisor) with their different roles and powers.
Operatively, at the beginning of the session, the supervision group discusses the reporting by various colleagues of phases of interventions carried out. We call reports of cases “Narrations to the second power” to underline the constructivist approach to the data reported, the extraction of meaning from an emotional polysemic text, which would allow various explanations and various knowledge standpoints (Bion, 1965), and which it is interesting to explore not because it is the sign of the patient’s psychic or external reality, pre-existing in the eyes of the observer, but because it is a way of construing/interpreting the experience of a relationship, namely with the client but also with the supervisor.
What is offered to the group is a representation of the context, more than an object, and like the psychologist in the there and then of the intervention, the group can find a resonance with this representation, or propose to think of it.
“Narration to the third power” is the name we give to the reporting of the group that is activated on the presentation of the case, to underline a structural condition of every report, being a text open to the user’s interpretative autonomy. A report does not in itself have the criteria to organise its use. It takes shape and direction according to the professional and symbolic models of those discussing it. We therefore recognise the active role of the participants in the session in constructing the report proposed by each reporter. This role is revealed for instance by the choice of comments and questions.
The group members, like previously the person reporting with regard to his client, may take a semantic approach or a semiotic approach to the data, making an effort to orthopedically investigate the aspects seen as missing in the report or to valorise the choice of certain presences, to ascertain/clarify the meaning of what is recounted (by the psychologist or by his client) or try to give a meaning to the fact of offering and accepting a certain representational content as a problem; they may measure the closeness to a theoretical/normative reference model, giving back a collusive acting out close to an “interest in belonging”, or evaluate the attention to the demand, showing “interest in collusion” (Montesarchio & Grasso, 1993).
Giving a meaning to the event, within the conceptual coordinates we have mentioned, will,. for the participants in the group, mean capturing the emotional and therefore performative and illocutionary dimension of the demand, which is such insofar as it conveys a vision of the clinical relationship and the intersubjective relating patterns connected. Appearing as an invitation to the listener to adopt a certain vision of the problem, the supervision demand (like the client’s demand for therapy addressed to the psychologist), is a story that can be clarified only by observing (oneself) in the relationship.
Understanding this object requires the listener to consider himself part of the case being observed, an active interlocutor in a relational proposal, which prompts a specific positioning and specific construction of the object to be discussed, as well as of the questions that it is important to ask oneself in order to understand it. When faced with a detailed report of a patient’s dream, without the relationship and the context in which it was told, the group may give up the attempt to explain the dream and question itself on the meaning of that account of that dream in that kind of relationship.
The group members may offer to be a resource for the psychologist reporting the case if and when they not only agree to be part of the system that is to be analysed, but are also able to question it. What am I asked to do? Why? What have I done? Why? What kind of problem-case and solutions does this version lead us to construe? And what are the implications?
This is the movement and the object on which the group members are asked to reflect, when systematically for each case proposed, each of them is asked to bring to the next session a written report of the discussion of the case, tracing the themes, the questions, the dynamics.
The proposal of a report of a report is therefore an interpretative action that invites us to think of the fantasies and the acted out emotions and not only on the part of the colleague, but of the group itself, in narrating the management of the case. In this way, listening and the point of view elicited in the supervision group is configured as a proposed methodology for conducting the clinical interview, where the client’s demand cannot be questioned, obliterating the relationship and the cultural-organizational processes motivating it (Carli, 1987).
From a certain point, along with written reports of cases, and reports of the discussions carried out on the single reports, one of the members of the group made the commitment to bring a “report of the reports” to the following session. We call “Narration to the fourth”, this report on the group using the previous narrative levels (case reports, reporting on case reports) as a clinical case to be analysed. It is at this level that it is possible to more completely visualise and analyse the story that the participants in the session expressed and constructed through intersubjective exchange6.
The report of the reports, a group story composed through fragments of seemingly disconnected narratives, gives visibility to the recursion present in the participants’ mode of reporting cases, removing the idiosyncratic modalities running through them and rejecting the a-contextual conception of the training phase, seen as the elaboration of individualized experiences.
The trainees have experience of how the contents and emotions that they tend to treat on a personal plane can be analysed to understand the functioning, the demands, the critical points and points of growth in the supervision group (positioned in a specific organisational context) and of its way of representing the outcome, the goals, the theory of the technique of one’s professional and training identity. As a result the trainees are encouraged to consider the possibility of thinking of the cultural dimensions of the training process and of reading the context in which they appear, forming the institutional analysis under the auspices of Fornari (1976). This will make it possible to place the management of the therapeutic interview in the organisational and institutional setting where it is carried out or to use one’s interpretative competence also outside the private consulting room.
Besides being an interpretative support, supervision is also and primarily a methodological support in the analysis of cases, since the contents of knowledge about which the consultation is carried out are not discrete declarative representations (definite knowledge, information sets), tied to a specific case and difficult to transfer, but forms of organization of knowledge: representations of representations (Salvatore & Potì, 2006), designed to support on the one hand the mastery of a theory of intervention, and on the other a reflective competence, seen as the professional’s ability to accept the case and use his own subjective involvement in the consultation relationship as a resource for the intervention.
It is in the epistemological, theoretical and methodological area mentioned above that we place the clinical use of reporting and more generally the interest in a culture of educative processes open to narrations (Freda, 2004; Montesarchio & Venuleo, 2003).
This use implies a constructivist and hermeneutic vision of the clinical exchange that takes into account the emotional substance of intersubjectivity (Fornari, 1979; Gill, 1994, Schafer, 1992; Storolow, Atwood, & Brandchaft, 1994; Hoffman, 1998), as well as the idea that the outcome of knowledge and techniques of professional work is inextricably connected to the representational plane on which learning takes place (Grasso & Cordella, 2006).
The interest in reporting, which is interest in the participants’ interpretative subjectivity, ultimately invites us to recognise the regulatory, constructive role of our interpretative models as well as those of our clients in the there and then of the clinical intervention(Montesarchio & Venuleo, 2006a).
The clinical use of the report should be seen, in this perspective, as a device designed to exercise, in the setting of the meeting between supervisor and psychologist, and to promote, in the setting of the meeting between psychologist and client, the ability to activate a semipoietic, interpretative function, that generates meaning in and through the contingency of the intersubjective exchange making up the intervention.
Such a perspective in our opinion implies a semiotic approach to the report. By finding the data to analyse in meaning, it moves alongside the return to the observation field of the cultural and discursive context, for which and through which the report is constructed. The device we have described is an attempt to question it.
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* Researcher in clinical psychology. Department of Pedagogical, Psychological and Teaching Sciences - University of Salento, Italy. Top
1. Vygotsky (1934) proposed the same distinction between meaning and sense. The notion of sense we are referring to however, differs in that it contains a reference to the emotional dimension. Top
2. In the psychodynamic domain, this perspective has lead to the hypothesis that the unconscious is a process of symbolization that unfolds as a mode of discourse (Salvatore, 2004). Top
3. Suffice it to think of the different nature of the evidence that a psychologist could produce depending on whether he accepts the gnosographic conception of the diagnosis, or an interpretative-hermeneutic conception, on whether he treats the relationship as the frame or as the tool of the intervention. Top
4. Like Carli & Paniccia (1999) we call these models cultural in that they are forms of socially shared representations, rather than expressions of intrapsychic processes. Top
5. A process that can be understood by referring to the semiotic characteristics of the mind’s unconscious mode of being (Matte Blanco, 1975). For further details on this point see Salvatore & Venuleo (2008b). Top
6. It is important to stress that “narration to the fourth power” does not necessarily mean greater reflective competence than the preceding narrations. What typifies it is that as its object it takes the frame of intersubjective sense in terms of which each text/sign produced in supervision is interpreted. If we conceptualise this frame as emerging from the dialogic exchange of those sharing the system of activity, every report constitutes a “(pre-)textual syntax” that binds those that follow, making some probable, others improbable and yet others impossible. Top