Making Consultation Groups Work
Too often, consultation groups--the main venues for discussing our craft and getting feedback--reinforce clinical inertia by focusing on the limitations of our clients and not on our own limitations as therapists. Our colleagues take our side just as physicians do when a patient crashes: you did all you could, given the patient's issues. Sometimes, of course, this is true; not everyone is a good candidate for what we offer, and we can't unilaterally control the outcome of therapy. But faulting the client should be way down on the list of explanations when therapy doesn't go well. Most carpenters wouldn't blame the wood if a wall collapsed. Our own insight and skill should be where we look first.
Partly, the problem is that we don't give our consultants and colleagues enough details about our therapeutic conversations. Early in my career, I recall a therapist in case consultations saying from time to time that a client was triggering his "competency issues," a revelation we all honored as a vulnerable self-of-the-therapist disclosure and not a revealing comment about his real competency. Looking back, I think his competency issues were real: he wasn't good yet at the craft of therapy, especially with difficult clients. He paced too much with clients and didn't lead them well enough. He was a good listener, but often ended sessions without giving clients somewhere to go. If he were a singer, his range was too narrowly in the middle--not enough high notes and low notes to have a strong effect on his clients. I hope he went on to improve his craft, but we certainly didn't help him much.
Given clinical inertia and the tricks that confidence plays on us, how can we push ourselves to improve our craft? The best place to start is with our pressure points--areas of practice that we find stressful or unsatisfying, where our System 1 skills aren't working well enough, but neither are our familiar rationalizations. A pressure point might be a mode of therapy; couples therapy is notably hard and unsatisfying for many therapists. It might be a type of client problem; one of my pressure points is borderline personality disorder in couples therapy. Or it might be a challenge across modalities and client problems, as when clients express frustration or disappointment with our work. One indication that it's a pressure point is finding ourselves involved in what my colleague C. J. Peek calls "clumsy conversations," moments when the words don't come easily, our confidence waivers, and we're off our game.
What we lack are venues for turning our fumbles into greater expertise. Psychologist and author Daniel Kahneman asserts, "true intuitive expertise is learned from prolonged experience, with good feedback on mistakes." While we get plenty of prolonged experience if we practice long enough, we usually don't get enough specific, honest feedback on our work to improve our craft. After all, most of us practice alone, nearly invisible to our peers. For the most part, our colleagues know only what we tell them about what happens in our sessions, and what they can intuit from how we describe what went on.
Most therapists learn new approaches to treatment in workshops, and, while workshops may show off the presenter's skills, they don't necessarily enhance the skills of passive participants. I try to counter this passivity by asking participants to become more active--write down what they'd do and say in a particular clinical moment in a taped session or role play. Then we parse the advantages and disadvantages of potential moves the participants have suggested. We get to learn from mistakes without anyone's being harmed.
Of course, some therapists go beyond workshops to formal externships in a therapy model. These learning opportunities are better if they involve direct feedback on role plays and taped sessions, but model-based trainers sometimes just assume that trainees come with a good set of basic microskills common across models. I recall a training tape in which a psychologist learning Emotionally Focused Therapy (EFT) showed a couples video session to Sue Johnson and an audience. When the couple ignored him and flared at each other, it was clear that the therapist lacked the skill of preventing escalation. He was attempting a higher-level skill in empathic connection without an important microskill in couples therapy. Sue Johnson then coached him on the craft of preventing escalation before going on to demonstrate the special skills of EFT. Feedback on tapes of sessions like this can help therapists learn both basic and advanced skills. But even after advanced training and credentialing, these therapists are at risk of plateauing again if they don't find settings for ongoing feedback.
Other than intensive externships, where can we get feedback to improve our skills in therapeutic conversation? One approach I've been using is to ask colleagues in case consultation and other conversations what specifically they do and say in situations that lead me to have clumsy conversations or just a vague sense that there may be a better way. Here are my tips for doing this kind of craft consultation: don't ask for a case consultation, or you'll get lost in the details of the case, and bring up a challenge that cuts across cases.Then ask for actual words your colleagues use when they deal with it.
I asked my case consultation group what they say to clients who are considering walking out of a marriage because they don't feel "in love" with their spouse anymore. Before long, I had actual words and phrases from five seasoned therapists, along with their reasoning behind the words. I told them what I generally say in these situations and how clients sometimes respond. Then my colleagues helped with the next level in these conversations, for example, how to respond when the client says, "Yeah, other therapists have told me the same thing, that loving feelings can follow if I change my behavior, but it feels fake."
Another time, I asked my colleagues how they open sessions of therapy. Do they begin the same way with each client, or do they vary it? Do they let the client start, or do they begin themselves? And what words do they use? We talk so little in our field about things so basic to our work. We have no recognized range of session-opening practices that we can examine for advantages and downsides with different kinds of clients. Carried over into the medical field, this would be like a situation in which every surgeon decided on his or her own where to make the initial incision for a common procedure--surely there must be some better and worse places to start!
Another approach to making case consultation more useful for continued craft learning is to ask for role plays on clumsy moments with actual clients. Identify the conversational exchange that makes you feel stuck and play it out, requesting feedback on how you're handling it. Then invite colleagues to play your role as the therapist, with you being the client, and observe their language, intonation, and nonverbals. It's one thing to hear the feedback, "I think you may be pushing too hard; I'd be curious with the client about what's keeping her stuck." It's another thing to see your colleagues demonstrate how to do that. One of my colleagues gave me elegant words for an intervention with a client who's no longer progressing: "We all have in us a pull toward change and a pull toward stability--toward keeping things the way they are. We've been working on the change part for a while; maybe we should talk about the stability part now."
What if your case consultation group isn't up for this way of working? The culture of many groups is pretty much set on putting out clinical fires, rather than promoting clinical improvement. Maybe a subset of your consultation group would be willing to meet at other times to try a new approach. But we need new kinds of groups: developmental communities of practice. They wouldn't be for help with specific cases, at least directly, but for learning to improve our craft by pooling the best practices of the group and searching out other practices from experts and admired colleagues.
These groups could gather face-to-face, online, or through phone bridges. Every group member would identify pressure points, clumsy conversations, and areas of curiosity about whether his or her current practices could use refurbishing. Although clinical models and strategies could be part of the conversation, the norm would be that everything gets driven down to the level of specific exchanges with clients.
Every session would involve a tape or a role play, not just general discussion. Expert tapes would be watched not mainly for demonstrating clinical models, but for the conversational craft that cuts across models and therapeutic styles. Someone would take notes to accumulate the lessons coming from the group. If these developmental communities of practice were linked in a larger network, there could a web repository of collective challenges and lessons. The vision would be that therapists would get better, not just more confident, with experience.