Psychology

The Register of Psychologists Specialising in Psychotherapists Principles and Procedure, defines supervision as the development of satisfactory and honest ways of maintaining and establishing constructive therapeutic ways with clients (2005). In all aspects of drama therapy, supervision is always connected. It is the main act of how a therapist present their work to a supervisor. Grant views supervision as the chance for clients to get the best possible help, as well as to aid the professional development of the therapist (1997). Some of the key relationship connected between drama therapy and supervision include (1) between supervisor and therapist, (2) between therapist and client, (3) between settings that offer therapy and their staff (4) and between training institutions and trainee therapists.

In drama therapy, supervision always takes place on a one-on-one basis, wherein the supervisor and supervisee meet together face to face. In addition, group drama therapy can be used, and it involves the supervisor working at the same time with other drama therapists (BADth, 2006). In all these forms of drama therapy, supervision always include regular contact, development of the process and the relationships involved.

Other literature on drama therapy supervision involved theoretical reflection on case studies of illustrative anecdotes from individuals experiences and on guidance in conducting supervision (Lahad, 2000). Therefore, the main goal of drama therapy is to achieve the therapeutic goals of symptom relief, individualpersonal growth, and emotional physical integration.

Drama therapy is often used to deal with client problems such as Vicarious Trauma, or VT. Vicarious trauma, according to Kellerman, is a secondary type of trauma that is often passed on by the client to the therapist (1992). When trauma experiences greatly impact the life of the clients, it can be recapitulated to the therapist who are supposed to help them.

According to Jones, VT is sometimes inevitable especially for the part of the therapist. However, it can be reduced and modified through the effective use of drama therapy (1996).
How does the use of drama therapy techniques in the clinical supervision process can help reduce vicarious traumatization

Supervision as a part of drama therapy is a complex long time process that is made up of different complex set of relationships. It helps in professional development of the supervisee, and is considered as emergent as there are new ideas that are being developed on daily bases. Before looking into how drama therapy can be used in the process of supervising counselors who suffer from vicarious trauma, it is important to understand supervision in all contexts.

Literature Review
In the recent past, there has been a paradigm shift in counseling supervision. There is a shift from traditional to a more intersubjective approach that is defining the modern counseling supervision.  Traditional supervision has been squarely grounded on systematic search objectivity which can be clearly reflected in authoritarian supervision style. According to Herron and Teitelbaum (2001) intersubjective supervision approach finds roots on subjectivity of reality which is encompassed in mutual dialogue experienced between the supervisor and the supervisee.   In the new intersubjetive supervision model, the aim is to support mutual definition between supervisors and supervises. On the other hand, traditional supervisory model has supervising process that is mainly defined by the supervisor which means there is no mutual agreement between supervisor and supervisee. This has impacted supervision in different ways. For example, it has been noted that under the new model, there is an increasing balance of roles between supervisor and supervisee.  This means that the current approach has put into consideration more mutual approach which is aimed at assisting the patient in the counseling process. Therefore intersubjectivity is going to improve the process of supervision.

In his work, Gregurek (2007) acknowledges supervision is an important factor in psychotherapy education. However, he is quick to point out that there are important boundaries to be maintained between supervisor and supervisee to facilitate the effectiveness of this process.  The relationship between supervisor and supervises are maintained by clear cut boundaries that are defined by style and need of both supervisor and supervisee, which recognize the difference in task of the two. Gregurek (2007) points out that supervision in psychotherapy can be described as a communicative relationship which may not be clear cut. This implies that it can take any form either with a formal supervisor or older peers working as supervisors for much young peers.  This means that the more experienced therapist can act as a supervisor to guide the young therapist and assist in meeting the standards of care. In creating the internal and external boundaries, it is important to consider supervision as a communicative interaction of supervisor and supervisee which can take any form depending on the situation at hand. The supervisor must strive to support supervisee to make him or her feel at ease bring his or her patients evaluative experiences to the supervisory process.

These sentiments are echoed by Itzhaky and Itzhaky (1996) who agrees that supervision has all to do with supervisory relationship between supervisor and supervisee. They argue that supervision comes with emotional load which need to be addressed in the supervisory relationship as a way of increasing effectiveness of the learning process.  Owing to this close relationship, it is difficult for the supervisor to keep a distance from supervision and therapy process.  There are strict boundary between supervision and therapy, thus, it is important for the supervisor to understand how to maintain this distance using the dynamic forces that operates in the supervisory space. This ensures that supervision serves its purpose of assisting supervisee in his or her work and foster professional growth.

Cary and Marques (2007) acknowledge that supervision especially in clinical settings can be considered as a medium that assist clinicians to learn multicultural practices.  This assist participant to gain cultural competency that is a prerequisite for effective counseling.  Although most supervisors are not ready to assist their supervisees to acquire cultural competency which is an important aspect of counseling, Cary and Marques (2007) stress that supervisors must rise up to this challenge and bring cultural competency conversation in the supervisory process.  Helping supervises to gain cultural competency is one of the most important factor that will assist them to gain confidence in their work.

The effective model for supervision training in drama therapy entails psychoanalytic psychotherapy and group analysis.  This model puts more emphasis on working with the unconscious. They recognize the way in which past relationship patterns are re-enacted into the present relationships. The most common employed model is that which supervision taught how to operate on different modes within the supervision process model, in what is described as developmental model.  Through experimental learning, the supervisor learns how to reconnect the past with the future such that one can engage a reflective conversation with the situation at hand and change from reflection-on-action to reflection-in-action.

In counseling process, the supervisor is supposed to make sure that the treatment is accorded to the required standards. This implies that the supervisor must recognize the balance of the contract signed with client and the therapist.  According to Rubin (1997), even considered selection of therapists cannot be considered as a way for supervisor to lessen oversight on the therapeutic process.

Supervisor has to ensure continued oversight and tolerance on the therapy work.  To ensure effective learning process for supervisors, two important aspects, including modeling and relationship are important to modulate and to shape the learning process of supervisee.  The supervisory process is cumbersome because it is a part of psychotherapy and one has to find an option between competing alternatives. The process becomes more challenging for supervisor owing to the fact that they have a double contract with both client and supervisee. Therefore it is of paramount importance to consider tension and other problems that result from the process.  In the process, there are many hurdles that supervisors have to manipulate through ranging from inexperienced therapists and ethical issues in dealing with clients.  Despite the challenges that are faced in the process, and considering both clinical and ethical point of view, supervisors have the duty of ensuring that the treatment given to patients in deed meet the set standards of professional requirements and comply with ethical requirements in the professional field.

Rubin (1997, p. 3) asserts that  it is common practice to acknowledge the potential conflict of interest involved in working with individuals where a conflict of interest is or may be present.   Therefore it is the duty of the supervisor to look or anticipate any potential conflict and therefore formulate how it will be mitigated. Therapists are likely to handle such conflict differently but most important is that they must be sensitive to ethical conflict that may arise in the process.  The training process should therefore prepare supervisors to handle such arising ethical conflicts.  This should prepare them for the complex therapeutic environment they have to work in.  There should be considerable attention paid to developmental process during learning in psychotherapy which assists supervisors to handle issues arising during practice. To ensure that supervisors develop limits of tolerance and also limits of criticism, therapist have to be trained and receive contact by supervisors while in contact with clients during in vivo training.  Their progress should be closely monitored and reports complied to understand their progress.

In their work on How does supervision teach, Cresci  (2001) argues that interpersonal model of learning is important in assisting supervisors to teach.  Cresci (2001) argues that what matters for the supervisor to teach should not be the theoretical orientation, but the manner and the personality of the supervisor. These are important considerations for the supervisor when dealing with ethical and conflict of interest issues that may arise during the process.  The personality of the supervisor assists in overcoming any issues that arise in supervisor teaching.  In her work, Cresci (2001) showed that the supervisor who made sure that the supervisee was relaxed and least anxious was regarded to the better teacher compared to those who had strict personality.

Challenges in supervision
In practice, supervisors need to understand the impact of their actions on supervisee and the client, as a facto determining the success or failure of the process. In his work on parallel process, Mothersole (1999) argues that the reaction of the supervisor to the supervisee has an effect on the relationship between the counselor and the patient. Traditional research showed that the relationship between supervisor and supervisee did not have an effect on the supervisee-client relationship but this has been overruled by current researches which show that there is parallel process between supervisor-supervisee relations and supervisee-client relationship. The fact that the impact passes down the line and affects supervisor relationship to therapeutic relationship is one of the major concern and perhaps a major challenge that supervisors have to work around.

Supervision is quite challenging especially when one has to oversee more than one counselor.  In their work on concurrent loss as a challenge in supervision, Beder et al., (1998) found out that there are a number of challenges that supervisors face when working in social environment especially for those struggling with concurrent loss.  Concurrent loses describe incidence where one has to oversee counseling clients who have loses while the supervisors are also facing similar losses.

Beder et al., (1998) discuses in details the concurrent loses like grief. They also look into the way workers react to concurrent losses and the role conflict that may arise.  When supervisors are working in such situations where they have to oversee social workers who are struggling with concurrent loss, they have to assist the social workers manage their response to the clients and at same time consider their feelings.  There is a likelihood that workers are likely to react violently and therefore Beder et al., (1998) have proposed two methods that can manage this complex situation. The two methods include use of supervisory relationship and also engaging organizational or agency culture.

Vicarious Traumatization
Vicarious traumatization, also known as secondary traumatization, is the impact of working with clients who have experienced trauma through the narration of their story about the experiences. It is called secondary because the person affected by the trauma has no direct link with the event that led to the trauma but experiences the trauma indirectly through their client (Andersen et al, 2000). A good example is the workers helping the refugees. Since the refugees have suffered major losses and life-shattering events, those working with refugee such as teachers, medical doctors, and immigration workers among others will be subject to vicarious traumatization and its impacts. In the process of supervision, this can be understood in lens of concurrent losses. This is because the supervisor would be overseeing a counselor who is already overseeing patients who have suffered traumatization. In the process, there is likelihood of the counselor getting traumatized, which means the supervisor must come up with effective ways to assist the supervisee.

Vicarious traumatization is usually a slow, cumulative process that takes place in the course of hearing many stories of loss and pain (Emunah, 1994  Axline, 1947). This makes it difficult to detect its impacts on the care givers lives. In most cases the care givers do not realize that they are suffering from vicarious traumatization until when it is too late and they have burned out. The impact of vicarious traumatization like the impacts of trauma itself is serious and can be permanent. It interferes with the care giversworkers ability to do their work effectively and this highlights the need to recognize, monitor, and minimize the effects of vicarious traumatization on workers lives (Kellermann, 1992).

Understanding Vicarious Traumatization and its Impacts
As defined above, vicarious traumatization is the experience of trauma-related stress that is often caused by working closely with trauma victims. Trauma, in definition is any experience involving serious threat personal harm or harm to others and excessive negative emotions like fear, helplessness, rage, and grief. These experiences can happen at any time of the life of individuals who have gone major losses or suffered terrible occurrences for instance in a refugee life it can occur during resettlement process or any other phase of a refugee life (Jones, 1996).

It is not possible to hear stories of tragic losses, human brutal harassments, gross injustice, and needless suffering and remain unaffected by such stories by workers who encounter human suffering on daily basis. The only way to remain unaffected is only by choosing to be numb by blocking our senses but this most often leads to ineffectiveness in service delivery and can also lead to depression and other associated problems (Jones, 1996). The fact is that we are changed by the nature of our work usually in ways we do not want. For example, a volunteer who is optimistic on himherself towards helping refugee may change drastically and become increasingly cynical and discouraged because of the unique stress emanating from hisher job (Andersen et al, 2000).

Vicarious traumatization can take various forms which are determined by an individual and the work environment.  The fact that people response to stress are different, there is no single symptom or set of signs that provide absolute evidence of vicarious traumatization or an exhaustive list showing all the signs and symptoms. Nevertheless, many of the impacts of vicarious traumatization are similar to the impacts of the trauma itself. Some of the signs and symptoms of vicarious traumatization include fatigue, depression, withdrawal from other or from activities, loss of trust, demoralization, cynicism, disillusionment, lack of sleep, loss of sense of humor, lack of emotional control and strong emotional reactions to minor occurrences, and difficulty ,making decision among other symptoms (Kellermann, 1992).

Like water flowing over a rock in a stream, on daily basis nothing seems to be happening to the rock but several years later, some parts of the rock will be worn out. Similarly, vicarious traumatization is cumulative and on a day-to-day basis, we may hardly realize that we are experiencing stress.

Eventually, the vicarious traumatization wears us down and if not dealt with, it leaves us in an exhausted position. Once in this exhausted position, we are unable to think clearly, make rational judgments, listen carefully, or even help others effectively (Jones, 1996). In addition, attributes such as cynicism, disillusionment, despair among others becomes part of our permanent identities (Carey, 1990). These are serious and damaging impacts. Fortunately, such impacts can be reduced by taking an active role of reducing such stresses that are associated with working closely with trauma survivors. The first step towards addressing vicarious traumatization is to accept that such trauma does exist and have an understanding of the contributing factors of vicarious traumatization (Sue, 1994).

Dealing with Vicarious trauma
Constructivist self development theory and other research findings have documented the importance of vicarious trauma both for personal and professional development (Trippany et al., 2004).  The increased occurrence of reality helps counselors to understand the level of their vulnerability especially when safety and security comes to be threatened which leads to loss of self control. It can affect the way in which counselors relate to their friends and family members.

As has been described, vicarious trauma has a lot of negative impact on the counseling process as it interferes with counselor s ability to deliver the expected standards of care.  Dealing with VT is important especially for supervisors.  Peer supervision is among the most effective way of dealing with VT.  Peer supervision groups act as resources for traumatic counseling. They help them to share their experience of vicarious trauma and many other traumas that they have encountered in the course of dealing with clients.  This offers social support and to some extent, it also normalizes VT experiences among counselors which alleviate the impacts of VT.  Peer supervision also helps to lower and amend cognitive distortions which assist counselors to keep a high level of objectivity.  It also assists them to reconnect together and hence provide a chance to share methods of coping and experiences (Trippany et al., 2004).

It has been documented in different studies that sharing with peers offers the most effective way of dealing with vicarious trauma.  Apart from peer supervision, education and training have also been recognized as important part of assisting counselors to deal with VT. Supervisor need to understand that training that is mainly focused on traumatology can assist counselors to alleviate the impact of VT (Trippany et al., 2004). At a personal level, counselors can deal with VT by maintaining a balance between work, play and rest. This means that they have to socialize with their friends and family members and participate in other activities as well.

Management of Vicarious Traumatization through Drama Therapy
Some researchers argue that dramatic activities do encourage a removal from the reality which is an escapist way of being, relating to others, and relating to the world. Others argue that theater and life are totally different states and if they do relate, it is only within the confines of a theater with its formal demarcation of performance and audience areas. Some argument view adult dramatization as being regressive returning to the experience of the child in play. Nevertheless, some scholars argue that drama and living are virtually connected. As Evreinov wrote  theater is a human impulse necessary to health living  (cited in Jones, 1996, p. 63). Drama therapy acknowledges that a part of this want and impulse can be employed in the maintenance of health and coping with emotional and psychological problems (De Dominico, 1988 Gil, 1994). The creation of world of fictions, play world, and the creative process itself does not need only to be seen in the perspective of an unhelpful retreat from the reality but rather be seen as an important part of living in the world. Creativity in drama therapy has a healing, life-affirming aspect. The fantasies and the artistic daydreams help in conquering the painful limits of existence. They also help in dealing with our basic conflicts (Carey, 2006).

Over the past two decades, acknowledgement of drama as a therapy has changed and this has led to the emergence of drama therapy as practiced today. These changes have two main aspects as observed by Jones that   drama therapy session can deal with primary processes involved in the client s change rather than being adjunct to other ways of working, such as psychotherapy that the root of this process is in the drama. Drama therapy is not viewed by those who support it as a psychotherapy group containing dramatic activities but rather the drama process contains the therapy itself (Jones, 1996).

Drama therapy techniques
Various elements of drama therapy combined together make drama therapy effective. These elements explain the way in which drama processes are therapeutic. These elements are not specific to any drama technique but their focus is on fundamental processes within all drama therapy. The key areas of drama and theater which are of essence to drama therapist includes the process of entry into playing as a character, entry into dramatic state, dramatic communication, relationship between the dramatic frame and real life frame, performance processes, and the audience together with the process of witnessing in theater. These drama elements are essential in developing the healing power of drama and theater and out of them there emerges series of dramatic processes which are crucial towards making drama therapy effective(Carey, 2006 Sue, 1994).

The first core drama process is dramatic projection. Wilshire in his work Role Playing and Identity describes the relationship between stage space and audience in a way that help us to see how drama projection relates to drama therapy. He observes that   the constant attractions and the needs for theater is that we see ourselves  writ large   (Wilshire, 1982 cited in Emunah, 1994, p. 37). According to this observation, seeing ourselves the way we are leads toward changing oneself according to the way we understand or see ourselves which may include a change in our perspective. In addition, as an audience, we may identify with some of characters on the stage through motivation, experience or attitude. This may also be accompanied with projection of our own motivations, feelings and experience according to the direction provided by the actor. Drama content and action witnessed by the audience can lead to a shift of their relationship with the projected feelings during or after the performance. In turn, this may affect the way the audience understand and feel about part of themselves that have been engaged with the projection (Sue, 1997). This projection and identification with the drama scene are not only to the clients that could be suffering from trauma experiences but also to the therapist who from the traditional verbal expression may be a subject to vicarious traumatization because they are actively involved as an actor or audience and also the way the client expresses his or her inner feelings through acting has lesser vicarious traumatization impacts. Though some theory such as classic Freud sees projection and identification as a defensive process, the drama therapy sees it as an important process that develops important relationship between inner emotions and external forms and presences (Weber et al, 2005 Carey, 2006).

The other core process of drama therapy is the therapeutic performance process. This process includes need identification, rehearsal, showing, and disengagement. There are two impacts within this process. The process enables the client to find expression for the material to be worked on and the working means with the material. During rehearsal and showing, client can shift their relationship to personal material by playing different role in the enactment or by directing alternative ways of the play. The focus here is to explore the content displayed by the client (Emunah, 1994). Clients and therapists may become role player or an audience member for a while. Taking these roles may be therapeutic for both the clients and the therapist for it provides an opportunity for a change in the link with the material or shift in perspective concerning the expressed material. The client and therapist involvement with the medium of drama through acting may allow them to experience their own creativity. Eventually they may be able to bring this creativity to bear upon the problem being focused within the action. This creativity may necessitate a change as the client and the therapist is able to address the problematic material from various perspectives (Sue, 1994). For instance, outside drama therapy session, a client or therapist may be stuck with a problem but they may feel capable of finding the solution through creatively engaging and experimenting new alternatives in the drama (Miller, 1994).

Empathy and distancing which are other processes within drama are often two opposing powers within theater and drama therapy. But it would be beneficial if we see both as part of any reaction that result from a dramatic phenomenon either in a theater or therapy. One may be established more strongly than the other but it is irrational to describe a response as being completely distanced or empathized. Empathy and distancing are associated to mediation and the ways in which an individual interact with others and happenings in life. Landy observes that  healthy functioning requires a balance of feeling and thought  (Landy, 1986, 98 cited in Emunah, 1994). Empathy creates a bond between the actor and the audience. It is determined by the capabilities of the audience to identify with and engage their emotions with the character. It can also be evident within the character themselves through the role they are acting with. On the other hand, distancing is where the character does not allow total transformation on the stage into the character he is acting (Miller, 1994).

Empathy development in dramatic activities is therapeutic in itself. For instance clients may have a problem of establishing relationship due to lack of abilities to empathize with other. Empathetic responses during therapy sessions encourage the client to empathize with others outside the drama therapy. On the other hand, distancing encourages participation that is more focused towards thought, reflection and perspective. This means that the client function as a reader to the material without being disengaged from the material but involved with it from a different angle (Allen, 1988). This helps the client to develop perspective on themselves or an event. The degree of response, of empathy and distancing within an action can be used as an instrument in the assessment of client s relationship with the material they present (Emunah, 1994).

Drama representation is described as the means chosen to express material within a drama session. Two particular elements common within drama practice are personification and impersonation. Personification is representing a person quality using objects dramatically. Impersonation on the other hand refers to role playing of an imaginary person (Miller, 1994). These two elements provide the client or the therapist a given focus of expression and exploration of problems and concerns. It enables the client to have a taste of what it is to be another (Emunah, 1994). This links the process of developing empathy and eventually developing the ways a client interacts with others. It can also help in the process of viewing a problematic circumstance from the point of view of another person. Participation of fictional material through personification and impersonations can develop opportunities to change and explore the concern in a new direction. This fictional world enables client explorations which the client might deny in the normal life circumstances.

Play activities which is another process in drama therapy is described as the expressive language in the therapeutic sessions. In early stages, a play usually contains games and warm up activities. A state of playfulness is developed and the client enters into a special playing state. This playful session has a link with reality. The links are exhibited by a more creative, flexible attitude towards action, impacts and held ideas. This allows the client to adopt a playful, experimenting direction towards their life encounters (Miller, 1994).  This makes play to be seen as part of an expressive continuum using specific language such object play, toys, and games among others which is seen as part of hoe the client explores material in drama therapy (Weber et al, 2005).

Conclusion
In many occasions, work in drama therapy involves a direct dramatic representation of reality for instance playing a role of real life event or an improvised experience. At other time it is indirect relationship with real life event. Many activities give a number of various types of connection simultaneously. For example, a realistic role play of relationship between a client and her mother exploring unaddressed problem may have various importance. To the client presenting material, to the other actors and audience, the relationship, may symbolize a struggle between self and personified by the mother and daughter (Miller, 1994). The process of being involved in drama activities and the potential creativity of enactment can bring transformation in a person s life. This is as result of transformation of identity the artist in the client is established within drama therapy. The development of dramatic products, the participation in dramatic process can result to a combination of thinking, feeling and creativity (Sue, 1994). This combination has a potential to transform different aspects of client s way of understanding and responding to themselves and the world. The interactions which the client forms in the drama therapy can be transformative experience. Past interactions, events and ways of addressing them cab be brought into the current drama therapy and be reworked within the drama. In supervision, effects of VT can therefore be successfully mitigated using drama therapy.