PSYCHOSOCIAL REHABILITATION: THE SUPERVISION

By Giovanni Curcio *

*  Psychologist, supervisor of Coo.S.S.E.L Cooperative.

While work in the field of psychosocial rehabilitation in some ways different from doing couples therapy, both have in common has to work in situations emotionally strong, and it is for this reason they share the need for a supervisory model.

Let us use another example, this time the example refers to a patient hospitalized in a rehabilitation structure, which yells loudly or hits someone. In general, when patients express behaviours of such nature we confront those using principles and concepts and understanding on what is disorganised and desocialised behaviour. Mark Spivak calls this "interactional and social structure control mechanisms". If we make an attempt to answer the question, "What should we do if a patient yells loudly or hits someone?"; the answer needs to be divided into two parts:

- How do we analyse what produced the behaviours in the patient, and what, with respect to the analysis, do we need to do regarding the crisis situation.

- Do we need to confront immediately the patients’ behaviour?:

We would also need to look more closely at the symptoms, "yells loudly or hits someone", in that they express a desocialised behaviour. By doing so understanding can be gained regarding the substitutive behaviours to be applied. The conditions associated with disorganised behaviour and other aspects like behavioural conflict and behavioural frustration, that is, when patient preoccupation is directed inward towards him/herself with respect to outer reality, can foster the loss of contact with what is going on in the therapeutic environment; attempts to bring him/her back to reality can contribute to increased disorganised behaviour. Understanding the emotional excitement and situational complexity, that is, when too many stimuli interfere simultaneously and patients have trouble focalizing on figure and ground aspects, on what is important, and is indispensable for a correct analysis of the crisis situation. Without a doubt it is difficult to promote socializing interactions in those situations where behavioural disorganization is present and useless to expect to have rehabilitation success.

All of this convinces us of the importance of supervision as a guiding model in contexts where rehabilitation takes place. Supervision should not be considered solely as the acquisition of specific technical skills, but rather, as a specific personal education with particular attention directed to the fundamental dimension of "management" of the interpersonal relationship.

Supervision of the rehabilitation worker represents an important crucial variable for overall success of all rehabilitation strategies. A special context needs to be created whereby supervisor and rehabilitation worker systematically search for better worker competency and capability. At times, workers can become blocked in their personal progress rendering inefficient the rehabilitation process. It is exactly at this point where analysis of the situation becomes necessary to determine how the worker is contributing to stall rehabilitation. Not very differently from other therapeutic situations, like in couples or family therapy, the rehabilitation workers behaviour is a crucial variable that can potentially influence the patients’ behaviour in therapy.

To examine systematically the workers behaviour requires that supervisor and workers define the critical variables within the rehabilitation process that influence the workers actions and interactions. These variables can be defined as:

Rehabilitation workers’ growth and maturation is certainly a function of these variables making him/her a better person and more efficient professional. Through a direct study of these variables rehabilitation workers and supervisor are in a position to collaborate together searching for change. They can change systematically the variables referred to the workers behaviour and decide if these changes can bring about new behaviour in the rehabilitation worker and consequently changes in the patient.

As Matarazzo said (1971), "The true test... is not simply if the behaviour of the worker arrives more closely to what the supervisor believes is therapeutic, but if the patient in fact improves".

Initially the supervisory model applied with the rehabilitation workers of the Social Cooperative Coo.S.S.E.L. reflected a vertical model more than a horizontal approach.  The operators were trained to use the techniques of a specific model.   The supervisor actively assisted them in the construction of the rehabilitation interventions.   Often the supervisor participated in rehabilitation group activities and acted as an advisor of the worker on the field. The suggestions offered were very specific but no attempt was made to discuss the workers personal behaviour.  Instead, these aspects were discussed within the supervion hour at the end of the day, in the presence of all staff, (workers, coordinator, and supervisor). This gave all the opportunity to participate in the rehabilitation job analysis.

Currently, after four years, the Cooperative has shifted the supervision axis to a more horizontal approach. This presumes that the rehab workers have acquired competences and sufficient understanding, as well as demonstrated improvement in their own personal sphere in order to work more autonomously. It is presumed that they have also acquired methodological intuition in bettering their establishing interpersonal relationships, giving this task a significant value.  However, both operators and supervisor must together discuss and specify all problems common to the supervisory experience, whether these are rehabilitation or workers behavioural issues or rehabilitation setting aspects.

The supervisor’s intentions are to bring about change in the workers behaviour. However, this task is no less complex than the interventions the worker uses to bring about changes in the patients behaviour. Rehabilitation workers and supervisor need to decide on what hypotheses need to be tested. They should, first of all, work on the more probable causes of the specific problems and then on others, to determine which variables are influencing the workers behaviour. Mark Spivak has written a great deal and clearly on the pathways to chronic desocialisation through reciprocal distancing (between worker and patient), restricting the life space of the patient. A long series of negative transactions and reciprocal personal and social failures contemporarily influence patient and all significant others. This is a reciprocal process associated with interactional failure between dysfunctional persons and significant others with whom the patient interact. Each stage includes processes that can create or maintain dysfunctional behaviour and must be neutralised in the rehabilitation program if therapeutic success is to be made.

Development of social competencies lies in the socialising interactions between staff and patients, not just in learning new social skills. Therefore, undesirable behaviours in the workers can influence negatively the rehabilitation progress. The overall success of any rehabilitation project therefore, lies not only in the training of the staff but also, more immediately, in defining the relationship between worker and supervisor. Invariably communication problems within the supervisory diade can attack the rehabilitation program results. These usually are the consequences in limits of staff training and the non-definition of the bi-personal field. 

With regard to the overall model (worker-supervisor) we it find useful and helpful to define the same relationship using an evolutionary conception, that is a "developmental" concept; in particular during the first period of worker training.   This means that if the relationship is seen from a structural perspective, then when the hierarchical nature of the same relation is constantly violated, then the efficacy of both (trainer and trainee) will diminish.  In the successive stages of training the relationship can take a more egalitarian line. We would like to affirm that we grow as therapists. We cannot construct therapists, neither can we can teach psychosocial rehabilitation as a body of concepts, instruments and techniques. Like good gardeners, we activate ourselves in order to create an atmosphere that helps to grow and to learn, an atmosphere that spontaneously mixes mutual appreciation, like a garden cautiously prepared that balances a bit of sunshine with surely a bit of rain too.

In conclusion, we would like to reiterate, that the objective of supervision is to foster maturation in the rehabilitation worker so that psychosocial rehabilitation can be effected independently by the workers. For this reason rehabilitation workers need to be guided to recognise their own problems, (within and outside the rehab context) formulate reasonable hypotheses, construct testable solutions and carry-out these solutions in the rehabilitation environment. 

The Social Cooperative Coo.S.S.E.L., currently, attempts to regularly apply this model in its supervisory sessions in the programs and services that it manages.

References:

- Spivak M.: "Supervision in Psychosocial Rehabilitation. A training seminar.", Coo.S.S.E.L Cooperative – ONLUS, Reggio Calabria (1993)

- Spivak M.: "A conceptual framework for the structuring of the living of psychiatric patients in the community", in Community Mental Health Journal, 10, 1974, pp 345-350.

- Lang R.: "Psychotherapy. A Basic Text.", Jason Aronson Inc., New York (1982).