The magic of parallel process (and the clinical rhombus)

יום ראשון כ"ו בכסלו תשס"ז

For those of us who have gotten involved in teaching people to perform pastoral care, one of the most amazing things we first learn about is parallel process. In its simplest form, this is when a student chaplain is describing a patient visit and you realize all of a sudden that the student is acting just like the patient acted with the student!! Sometimes, the student will (completely unaware, mind you) be speaking in almost exactly the same way – in the same language -- as the patient spoke with the student.

This parallel process is extremely helpful in supervising students. First, it gives the supervisor great insight into what are the important personal and pastoral issues that the student is now working through for his or herself (you just have to look at what the student is saying about the patient’s issues to learn about the student’s issues). Second, it gives you great insight into what is happening with the patient (just observe the way the student is acting to learn about the patient).

When I first heard about parallel process, I didn’t believe it – why would it happen, I asked myself? But then, once I started looking for it, I saw it all over the place. So, I started to believe that parallel process existed, but I still had no understanding at all about why it existed. That is, it became just a sort of wonderful magic to me.

On Thursday, I went to a presentation that helped me start to better understand parallel process. The presentation was on an article about the clinical rhombus (The clinical rhombus revisited: learning through resistance and change). The clinical rhombus (see diagram below) was articulated by Ekstein and Wallerstein in their (see their 1972 book, The Teaching and Learning of Psychotherapy).

The rhombus helps illustrate the dynamics of various three-party relationships in the supervisory process, especially the dynamic between the supervisor, the student/chaplain and the patient. What it graphically illustrates is that the student sits in the middle of this interaction, and that it is the student who is the party in common that allows parallel process to happen.

In his book, The Supervision of Pastoral Care, David Steere, gives an excellent explanation of how parallel process can happen:

[S]upervisees unconsciously identify with their patients and involuntarily behave in such a manner as to elicit in the supervisor the same emotions the supervisees experienced while working with their patients. (Steere, 46-7)

I bolded the word ‘identify’ above to illustrate the theoretical understanding behind how this works. Identification – along with the related, projection -- is a psychological concept that emerges out of a Freud’s work. It is identification and projection the make parallel process work.

Steere says that the parallel process may even be a way the student unconsciously seeks help from the supervisor with things that he or she cannot consciously articulate:

[Parallel process is the student’s] unconscious attempts to show the kind of behavior the patient is exhibiting with which the [student/chaplain] needs the most assistance. What cannot be conveyed
verbally the [student] acts out with the supervisor, assuming the client’s tone, manner, and behavior while reporting the case. (Steere, 47)

Put another way, the student is so overwhelmed by the difficulties he or she had in trying to care for the patient, that the student can’t put these issues into words (especially the parts that had to do with non-verbal behavior). So, the student (again, unconsciously, mind you) sets up a kind of role play with the supervisor: the student takes the patient’s role, while the supervisor is forced to take the chaplain’s role (which the student found so difficult and overwhelming in the actual interaction with the patient).

It was also helpful to me to realize, in rereading Steere, that Ekstein and Wallerstein had borrowed some of their terminology from social work. This was especially helpful to me in building my understanding of how and why learning to accept pastoral care is one of the most important elements of learning how to give pastoral care:

Since supervision in social casework teaches a helping process, it must become a helping process itself, so workers can experience what they are learning to use with their clients. . . . An intimate relationship exists between one’s ability to be helped and one’s capacity to become a helper. As students overcome their own difficulties in receiving help through supervision, they are able to give help to their clients. What social workers described as problems in helping and being helped, Ekstein and Wallerstein discussed as learning problems and problems about learning. (Steere 49; some emphasis mine)

If you look at the diagram above, you will see Ekstein and Wallerstein’s terms learning problems and problems about learning. I’ve always (and still!) find these terms clumsy and non-intuitive (which makes it hard to remember what they mean!). I’ve put the original social work terms in parenthesis; I think they’re much more intuitive and that there’s nothing about them (other than tradition!) that makes them inappropriate for use in pastoral care.

The clinical rhombus helps illustrate how the problems in being helped come up in the relationship between the supervisor and the student, whereas the problems in helping come up between the patient and the student. The parallel process is when the student acts out those problems in helping with the supervisor. In effect, this turns the problems in helping also into a problem in being helped. And, thus, if the supervisor can aid the student in addressing the problems in being helped then the problem in helping is addressed, too!! This is the magic of why learning to accept pastoral care helps one learn to give pastoral care.