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Tough CustomersBy Rich Simon As therapists, many of us practice in two different worlds. In the first, we see polite, well-behaved, articulate clients with solid values. They engage fully in therapy, talk cogently about their problems, listen attentively to our responses, make reasonably good-faith efforts to follow our suggestions, and sooner or later get better. No wonder we genuinely like these people!

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In Consultation

Peer Supervision Groups that Work

By Eleanor Counselman

Three steps that make a difference

Q: I’d like to organize a peer supervision group, but I’ve heard their failure rate is high. What do you recommend? A: Peer supervision groups provide a welcome respite from the isolation of private practice and an informal, nonevaluative setting after years of formal supervision, particularly for young therapists. They offer valuable guidance on difficult cases and tough ethical dilemmas to therapists at any level of experience. And they’re free! However, as you note, many of them fail. In my experience, careful attention to the initial contract and the ongoing group process can make a huge difference in helping them sustain their membership and thrive. Though they’re often called peer supervision groups, it would be more accurate to call them peer consultation groups. Members don’t have direct supervisory responsibility for one another’s cases: they simply offer suggestions, which members can accept or reject. They typically have four to six members who have approximately the same level of professional experience or share a specific area of interest. Members meet on a regular, usually biweekly, basis. Group consultation, with or without a leader, offers advantages over individual consultation. It includes the possibility of multiple perspectives on the same problem and the reduction of clinicians’ shame about confusions and mistakes as they share similar stories about their struggles with difficult cases. Another benefit is peer interaction, which develops one’s professional sense of self. The hall-of-mirrors effect—seeing yourself as others see you—which is so potent in therapy groups, is a major component of the supervision group experience. Nevertheless, despite the many benefits, it’s challenging to start and maintain a consultation group, particularly if it’s a leaderless one. They can fail to thrive or suffer from “task drift,” moving them away from discussing clinical material and into a form of therapy. It can be difficult to integrate new members and maintain clarity about the group’s own process. Presenting cases in supervision in any format poses obvious risks to one’s self-esteem, and group dynamics add additional risks: issues of power, competition, exposure, and shame can lead members to drop out. It’s especially challenging to manage group dynamics in leaderless groups, as it’s usually the leader’s role to remain aware of what’s happening within the group, and without a leader in charge, shame or fear of being judged may silence members. The most successful leaderless groups seem to be those in which the group members find a balance between a focus on cognitive and emotional issues—talking about cases and about the feelings that arise when seeing clients—while consciously managing the functions that a designated leader would serve. These include protecting the group contract, setting and maintaining appropriate norms, and handling gatekeeping matters, such as bringing in new members. A crucial component of maintaining an atmosphere of group safety is regular, dependable member attendance. Without this, a group will never feel like a place to take risks. Members need to be willing to bring up concerns about irregular attendance because, just as in a therapy group, member lateness and absences can indicate issues that need exploring. Chronic irregular attendance can be demoralizing and cause a group to fail. When it comes to group safety and cohesion, Woody Allen was right: 90 percent of supervision group success is about showing up. A significant issue in any supervision group is shame and the reluctance to expose oneself. To make supervision groups feel safer, therapist David Altfeld developed a model of group consultation in which all group members simply share their emotional reactions and associations to a situation being discussed, instead of one person presenting a specific case issue and everyone else giving advice as resident “experts.” This procedure levels the playing field by not allowing members to compete for the best case analysis. It leaves room for highlighting emotional issues, countertransference reactions, and parallel process. Making everyone vulnerable in this manner avoids opportunities for excessive criticism (or its counterpart, excessive niceness) and encourages emotional sharing. Another group consultation model, developed by Irish therapist Bobby Moore, focuses only on minimal case information, such as a patient’s age, length of time in therapy, and perhaps a little demographic information. Then the presenter talks about his or her thoughts, fantasies, feelings, and associations about the patient and the therapy. Group members then share their associations. Following that, the initial presenter is invited to share any further associations. Only at this point does the presenter give the facts of the case and the clinical dilemma. Finally, the group thinks together about what’s been discussed and what it indicates about the case. For those interested in the power of the collective unconscious, this is a fascinating process to experience. To succeed, a consultation group must feel safe and useful to its members. Here are a few simple principles to follow: Clarify the group structure. The group needs to agree on the frequency and length of meetings, which is best accomplished with a predictable schedule. The group needs to agree on its task and focus: is this group for any clinical issue or just for couples, or trauma, or group therapy? How much time will the group spend on “schmoozing,” and will there be one or more than one case presented each time? What will be the presentation format? While most groups use verbal presentation, some groups are now using videoclips—which makes the discussion much livelier. Agree on membership issues. How many members will the group have, and how will new members be integrated? Once a group has formed, I believe that decisions about adding more members should be a group decision. While it may be tempting to accept a request from someone who wants to join the group, a total of six members seems to be the maximum number for each member to have enough opportunities for presentations. Attend to the group process and dynamics. While groups should build in a “schmooze” or “check-in” time, there needs to be an agreed-upon limit to the socializing, so that the group doesn’t become a therapy group or a coffee klatch. Without a leader, the members themselves must monitor the group’s procedures and raise any important issues. Some groups do this ad hoc; others schedule a regular review meeting to evaluate how things are going. Leaderless peer supervision groups can help clinicians at any stage further clinical learning and combat professional isolation. They’re likeliest to succeed when the group members have a clear working agreement, maintain regular attendance, and create an environment in which both emotional and cognitive learning occurs. Eleanor Counselman, Ed.D., is a past president of the Northeastern Society for Group Psychotherapy and an assistant professor of psychiatry at Harvard Medical School. She’s published numerous articles on psychotherapy and has a private practice in Belmont, Massachusetts.
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NP006 Couples Therapy: Today and Tomorrow

This blog focuses on discussion regarding the course, NP006 Couples Therapy: Today and Tomorrow
 
 

NP006, Couples, 3, Harville Hendrix

 

Welcome to Session 3 of Couples Therapy: Today and Tomorrow with Harville Hendrix. In this session, Hendrix, the co-developer of Imago Relationship Theory and the co-founder of Imago Relationship International, will delve into the basic principles of the Imago approach to authentic connection between couples.

Hendrix will discuss how to help the resistance to love that was founded in childhood experiences, how to help partners learn to heal wounds from each other’s childhoods, the basic skills of mirroring and empathy, and how couples can validate each other—even when they disagree.

We encourage you to use the Comment Boards as a vehicle for reflection and discussion with each other and with the presenters, to bring up any relevant thoughts or questions. What was most striking to you about this session? 


06.20.2011   Posted In: NP006 Couples Therapy: Today and Tomorrow   By Psychotherapy Networker
28
Comments
 

  • 0 avatar Lois Muir-McClain 06.23.2011 13:11
    Since I see so many attachment type problems in the adults and couples I work with, I feel that Imago Therapy can be very valuable in healing those. I like that Harville starts the first session moving toward the positive, and immediately on improving the communication rather than hearing the problems, which can quickly turn into a free-for-all.

    I also wanted to comment on how different this perspective is from Terry Real's techniques. Terry does not try to establish empathy and validation right away with both partners; he is more confrontive with the partner he sees as the "blatant" or "grandiose." I see both of these perspectives as having therapeutic value, but it is a little confusing to decide which way to go.

    Also, does Harville always start with the man validating the woman first?
    Reply
    • Not available avatar Julie 06.28.2011 11:09
      I too have trouble deciding which way to go when both options seem to have so much value. I'm not sure how one goes about figuring this out.
      Reply
    • Not available avatar Harville Hendrix 06.29.2011 14:36
      In my view, all healing and growth occurs in a safe environment, and the responsibility of the therapist is to create, facilitate and sustain safety in the session. Then defenses relax and partners can speak from their vulnerable rather than their defended place. Any transaction with the therapist or with the partner that arouses anxiety arouses defenses, and thus impedes the healing power of connection. Imago attempts to create at the beginning what hopefully will be the norm at the end.
      Reply
    • Not available avatar Harville Hendrix 07.12.2011 17:25
      Who validates first depends upon who talks first. I pay little attention to gender because in my experience the challenge of validating is not gender based but depends upon the depth of the wound, the level of anxiety and the strength of the defense. The more wounded, the more anxious and thus the more defended and thus the more difficulty "seeing" and receiving the subjectivity of another person.
      Reply
  • 0 avatar jean geffen 06.23.2011 13:12
    Excellent and helpful. Like the idea of immediate structure to avoid escalation,provide a new expeience, safety, hope. What about the patient who has trouble staying with the structure? I'm concerned about asking a patient who goes on non-stop the "magic question"- Is there more? How would you handle this without re-wounding
    patient?
    Reply
    • Not available avatar Julie 06.28.2011 11:12
      I'm am also concerned about the client who may have difficulty imagining what the other might be feeling or explaining why what they have heard makes sense.
      Reply
      • Not available avatar Harville Hendrix 06.29.2011 17:43
        In my experience, everyone has difficulty imagining what other people feel and seeing the sense they make. That is the problem of difference. So, helping partners in a relationship listen until they get it is the therapy process. IT is how one experiences themselves being heard that heals.
        Reply
    • Not available avatar Harville Hendrix 06.29.2011 17:41
      There are two ways to handle this. 1. Limit each person to talking for 5-10 minutes, the other mirrors and then responds. The receiver, after the set time, mirrors a summary, and then responds. 2) ask the receiving-listening person to raise their hand, a hand signal, when they feel on overload (they are no longer listening) and mirror back what they have heard so far. This often slows down the speaker-sender, and the mirroring often meets the need to be heard and they tend then to speak less.

      In the first comment, i did not comment on do i ask the man to validate the woman first. NO. It depends upon who takes the first turn to talk.
      Reply
  • 0 avatar James Bruni 06.23.2011 13:17
    Thank you for a fascinating discussion of your IMAGO approach to couples therapy. Two questions came to mind as I considered the foundational tools you describe as central to the dialogue: 1.Does the therapist facilitate the use of those techniques (mirroring, validation, empathy) by first demonstrating an example of their use or by deliberately guiding the direction of the response?
    2. Might "empathy" be a tool used before "validation" since,in some cases, it might be easier for someone to be able to "validate" a partner's stated need by first attempting to "empathize" those feelings that led the partner to have that need?
    Reply
    • Not available avatar Harville Hendrix 06.29.2011 17:44
      I think the sequence works better with validation first, but empathy first seems great as long as validation follows. IT is a response to both thought content and feelings that makes the difference for the depth of connection.
      Reply
  • -0.1 avatar Colleen Russell 06.23.2011 13:17
    I appreciated the emphasis on structure in the session, and I also saw similiarities in the Control Mastery Theory -- a relational, cognitive, psychodynamic theory -- researched and validated by the San Francisco Psychotherapy Research Group. I just moved from the SF Bay Area to Bend, Oregon, and I have received my reciprocity licensure. I'm excited to begin working, and will incoporate some of the Imago Theory to be sure. Thanks.
    Colleen Russell,LMFT, CGP
    Bend, Oregon
    Reply
  • Not available avatar megan nervi 06.23.2011 13:27
    This presentation was great! Very helpful! Thank you! I appreciated the emphasis on focusing on what couples want to see in their future as opposed to belabouring aspects of the partner or the marriage that have not worked. I guess my question is, how do you confront a parnter who finds this approach of mirroring and validating to be tedious or even a bit odd or unusual (perhaps a less emotionally mature client)? Obviously as a therapist, I see this as a wonderful way to communicate and can imagine it feeling very validating. I guess I can also imagine some people balking at this way of listening to one another and if so, what might that mean for the couple's ability to make lasting change? How might you intervene there? Also, what if what one partner wants is in direct opposition to what the other wants? For example, what if one is asking for more connection/touching, etc. and the other feels they need is to have more space/distance? How might you handle that in the Imago session? Thank you!
    Reply
  • Not available avatar Sandra Galgano 06.23.2011 13:41
    Thank you for such a helpful presentation. I can see myself using concepts from imago therapy and being successful with some couples who have the ability to engage in this kind of work; however there are some couples like others have mentioned in their posts that are filled with defenses or lack the emotional maturity to really engage in such a process. Or in some cases one out of the couple is able but the other is not. I would love to get both on the same page and moving in the direction of having a marriage they "dream of" as it was put in imago therapy but how would you suggest i get both on board even if they want different things? (more sex, more communication) Thank you!
    Reply
  • Not available avatar Susan 06.23.2011 14:04
    In session three with Harville Hendrix he gave a very good description of his goal for the first session. He talked about having the couple face one another and make eye contact. Is this the physical setup for all subsequent sessions?
    Thank you,
    Susan
    Reply
    • Not available avatar Harville Hendrix 07.12.2011 17:22
      Yes, we call it the Imago position=always facing each other, starting with eye contact and usually with an appreciation and then moving to concerns.
      Reply
  • 0 avatar Ann Robins 06.24.2011 00:17
    The process of beginning the first session focusing on what the clients would like their relationship to be keeps the session from becoming a continuation of the arguing the couple is doing at home.
    Reply
  • Not available avatar Lynn MIkkelsen 06.24.2011 15:23
    Thank you for sharing the background information (and your personal growth) and the basic structure of Imago therapy. My question is how do you "catch bullets" between couples who are into blaming and labeling each other, etc.? The "listening cure" seems like it would be a staple for all types of therapy. Lynn
    Reply
  • Not available avatar Evelyn Peckel 06.24.2011 17:21
    how to start therapy as you exposed when they are extremely angry and refuse to seat looking at each other.
    Reply
  • Not available avatar Tracy Krause 06.25.2011 11:36
    I like the strength-based approach to Imago therapy. I have a few questions for Dr. Hendrix.
    - I assume both partners will, before the process is complete, have an opportunity to go through their wishes for the relationship and get the responses from their partner. Is that true?
    - Does it matter which partner goes first, and, if so, how is tht determined?
    - What happens if the partner is not willing to do what is being requested as part of the dream?
    Thank you again for a thought-provoking session.
    Reply
  • Not available avatar Julie Mallory 06.25.2011 14:03
    Excellent presentation! I have not typically enjoyed couples therapy in my work mainly because I work with college students who tend to have short term relationships, and second, I'm usually seeing couples who come for sessions when one of the pair is ready to leave the marriage if the therapy doesn't perform some magic that she/he doesn't really believe exists. Consequently, it struck me as profound to hear how you're using many of the principles that also apply to treating trauma in individuals particularly how mirroring, validation and empathy are integrated to help people move from their anxiety, self absorption and emotional symbiosis. I see many applications for learning this therapy that also could apply to work with my eating disordered clients who have difficulty in many relational dyads: parent-child, intimate and forming friendships. Thank you for the clarity of your presentation and I hope to continue learning about Imago for couples.
    Reply
  • Not available avatar Jack 06.25.2011 15:01
    Hello Harville,

    I was interested to hear that you are going to focus on some educational material for couples who do not want therapy. Could you say more about your thoughts around this? It sounds like a good way to reach more people and perhaps reach them earlier in their marriages.
    Thank you,
    Jack
    Reply
  • 0 avatar susan reuter 06.27.2011 17:18
    Hi,

    I would have liked to see all the slides!!

    Thanks!!
    Reply
  • Not available avatar Samantha 06.27.2011 23:46
    Is anybody else having difficulty watching the third video session after it was first aired? This session continues to stop after the 12 minute mark and I have not been able to view the rest of the session.
    Reply
    • Not available avatar Stacy 06.28.2011 11:49
      Yes, I have not been able to watch the last 11 minutes or so of it. It keeps stopping and won't let me play it. Unfortunate, as I would have liked to see the rest.
      Reply
      • 0 avatar Psychotherapy Networker 06.29.2011 09:19
        Stacy,
        We're sorry to hear about your technical issues. I suggest viewing the comment posted to Samantha's comment above and see if that helps you as well. Please e-mail Support at support@icohere.com if you have any additional questions or issues.
        Reply
    • 0 avatar Psychotherapy Networker 06.29.2011 09:18
      Samantha,
      We’re sorry to hear that you had issues watching the last part of the presentation. I would suggest trying to watch it again, but clearing your browser’s cache and cookies first. We’ve posted instructions for how to do so on our website here: http://www.psychotherapynetworker.org/contactus/online-troubleshooting.
      When watching the presentation again, let the video download (you can tell how much is downloaded by the orange bar showing how much of the video has downloaded) by pressing “pause” and letting the video buffer until you see the orange bar go all the way across to the end. Then, you can fast forward the video until you get to the part that you weren’t able to watch. If this doesn’t work, maybe try viewing it from a different computer or using a different Internet browser.
      And as always, please feel free to email Support directly at support@icohere.com for any issues related to watching the presentation.
      Reply
  • Not available avatar jay schlechter 06.30.2011 17:37
    Elegant theory and elegant presenter. I enjoyed reviewing the imago approach. Important for anyone entering into a couple to know. Great that you are moving to communicate with a broader segment of the population! To put all that material into a one hour conversation reflects amazingly well on you and the moderator.
    Reply
  • -0.1 avatar Erika Simon 06.30.2011 22:28
    I really enjoyed learning about imago therapy and I am wondering if it has been used with couples that are dealing with an affair? The therapy focuses on what couples want to see in their marriage but when dealing with affair couples, it is more difficult to keep them within this frame of mind.
    Reply
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