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Tough Customers: Is It Them or Us?
By 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! Does This Kid Need Medication? with Ron Taffel
Meds: Myths and Realities: NP0035 – Session 3
Do you feel like you could be a more effective therapist with your younger clients? Do you find it hard to determine when interventions--psychological and pharmacological--might be needed? Join Ron Taffel and learn to identify key diagnostic signs that indicate medications could be helpful when dealing with depression, anxiety, AD/HD, and affective disorders. After the session, please let us know what you think. If you ever have any technical questions or issues, please feel free to email support@psychotherapynetworker.org.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.
| Fantasy in Couples Therapy |
Fantasy in Couples TherapyIs encouraging sexual fantasies playing with fire?By Tammy Nelson Couples who are satisfied with their sex lives are happier than those who aren't, and are likelier to stay together. They describe their relationships as connected, intimate, safe, fun, and affectionate. Conversely, as I've found over 20 years of practice, partners who aren't having good sex are usually more dissatisfied with their relationships overall—more frustrated with each other, more discouraged about their joint future, and likelier to split. Many therapists assume that if they help couples improve their relationships, the improvement will naturally lead to a rewarding erotic life. But what if helping couples create a satisfying erotic life is the key to increasing their feelings of companionship and mutual connection, not the other way around? The age-old question is: how can couples maintain a strong, vital sex life over many years without having boredom undermine eroticism? Sexual boredom often results from the assumption by each partner that there's no longer anything new to discover about the other, or about their sex life together. I've found that a therapist can alleviate such sexual ennui by helping each partner reveal previously undisclosed erotic fantasies. This apparently simple step can lead to new ways of seeing and experiencing the partner and the self. In a short time, it can have an invigorating erotic impact. Sheila and Johan were both in their early fifties. They were physically active, with no psychiatric histories, and had been in therapy for three months. Johan reported that he felt bored in the marriage and was thinking of straying. "I crave adventure," he said. "I've been thinking of having an affair, just to do something different." Sheila reported that she felt distant from Johan and that they'd drifted apart. They rarely shared meals anymore, often worked late into the night in their separate home offices, and sometimes didn't even spend much time together on weekends. Sheila complained that she no longer felt Johan was interested in her, and wondered whether he still found her attractive. They hadn't been physically affectionate for many months, rarely holding hands or touching casually, and seemed to be living parallel lives. She feared they were on the verge of separating. In addition to hearing about their general marital unhappiness, I took a history of their sex life together, asking if they enjoyed their sex, whether each had orgasms, and if they knew their partner's sexual fantasies. Johan thought he knew exactly what Sheila liked and didn't like in bed. This was comforting to him and helped him feel confident that he could please her, yet it led to a high level of sexual boredom. He felt her needs were predictable and that they didn't venture far from the things that had been "working" over the years. Sheila longed for the times when Johan had been excited and turned on by her, describing what they had now as "maintenance" sex. They each knew how to touch each other, but they'd been doing it the same way for so long that it felt as though they were stuck in a rut. Neither Johan nor Sheila said anything about feeling an intimate connection during sex. At this point, many therapists might focus on helping the couple get along better in their day-to-day connection by teaching them what might be called "companionship skills," including better ways of communicating, resolving conflicts, changing behaviors, and, when appropriate, becoming more effective parents. Clearly, these skills determine how well we coexist with our partner, and, theoretically, once the nonsexual relationship is back on track, the sexual connection should follow. But I thought we should focus on how Sheila and Johan could create connection and add adventure and excitement to their sex life while keeping their relationship safe. It's been my experience that unless couples are satisfied with feeling like nonsexual roommates (and I have yet to see such a couple), they won't connect in a deeply intimate and meaningful way unless their erotic relationship improves. As I've suggested, sexuality is the fuel that fires feelings of connection and intimacy. The erotic aspect of a relationship includes all the partners' needs for intimacy, erotic release, sensual contact, touch, affection, attention, and physical and emotional connection. When the erotic side works, couples feel less conflict, negotiate their needs more fluidly, and feel deeper connection and commitment to each other. By contrast, sexual dissatisfaction can itself cause conflict, tension, and stress. Desire discrepancy, sexual dysfunction, affairs, sex addiction, and other sex-related issues may be underlying many of the "companionship" issues that present for treatment in a couple. Deciding which couples are appropriate for this fantasy-evoking approach is determined by assessing their capacity for empathy in the early sessions. Part of this determination comes from seeing how the couple presents in the initial stages of therapy, and how they respond to questions about their sex life. Some couples visibly relax in the session when the topic of their sexual relationship is raised. They sink into their chairs, move closer to each other, making more eye contact, and engage each other more. Other couples seem to freeze up. Simple assessment questions can include "How is your sex life currently? How many times per month are you having sex? When you do have sex, how satisfying is the experience? Do you both have orgasms? What's your vision of how your erotic life might look differently if you could make changes together?" Such questions will trigger a response in the couple ranging from resentment and conflict to a more in-depth exploration of a shared passionate relationship. To help clients feel more connected within their relationships, therapists must become more comfortable talking about sex in their sessions, providing a model for their clients to follow in engaging in more open and frank discussions, in the office or at home. Even more important, clients need to be encouraged to explore and discuss fantasies as a way of opening a dialogue and focusing on the erotic. Before having a couple share their fantasies, it's important to explain how they can validate each other's experience. When one partner talks about his or her vision of an ideal erotic sex life, the listener should simply mirror back what the experience sounds like, and acknowledge that this is their partner's experience, even if he or she doesn't understand it, or experiences it differently. When a partner can see that the other can have his own personal response to the erotic experience, and listen without judgment or defensiveness, the couple is ready to move into a dialogue about erotic fantasies. |
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