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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.
| Freud Revisited - Again |
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How could a man who was so wrong be such a shaper of modern thought? By Richard Handler Sigmund Freud: Inventor of the Modern Mind How to Read Freud How to Read Jung All the major publishing houses are now producing not just biographies, but biographical essays: short books, with only the crucial stuff in them, often written by well-known writers. These include the series Brief Lives and Penguin Lives, among others, as well as the graphic novel-like series, "Introducing," in which illustrations of Sigmund Freud or Carl Jung or Ludwig Wittgenstein utter their thoughts in comic-book bubbles, as if they were just coming up with them. What's good about these "potted biographies" is that they turn lives into a good story and tell you why these people are important—like good feature-magazine articles between book covers, with narrative and analysis interwoven. There's an honorable tradition of such essaying, as the editors of the latest series addition, Eminent Lives (published by HarperCollins) remind us. The notion of brief biographies goes back to Plutarch, Ben Johnson, and Lytton Strachey's Eminent Victorians. On the back page, the HarperCollins editors promote their new works as "perfect for an age short on time." One of the latest from the Eminent Lives series is Peter Kramer's Sigmund Freud: Inventor of the Modern Mind. Kramer, if you recall, is a psychiatrist and the author of Listening to Prozac and Beyond Depression (also reviewed in the Networker). He presents Freud as an imposing, impossible character. He analyzes Freud's core ideas and asks one crucial, fascinating question: how could Sigmund Freud, a man who was so wrong about so many things, be so massively important and become, as the subtitle says, the "Inventor of the Modern Mind"? Freud is often cited as a seminal figure because he "discovered" the unconscious, a vast, mysterious, subterranean territory filled with startling psychic energies and impulses. He didn't. Even Freud, imperious and arrogant as he was, never claimed that. He gave that honor to philosophers, artists, and the creators of classical mythology and drama. Kramer notes that in Freud's day, the unconscious was even a subject of idle speculation within the salons of Vienna. Freud is also credited with originating the "talking cure" that many readers of this magazine practice. He didn't. Even in the middle of the 19th century, other doctors were treating their patients with talk, though not many. Freud's early work with mentors like Joseph Breuer focused on hysterical patients—people with symptoms with no seeming neurological, medical basis. Hypnosis was tried; so were cocaine and other narcotics and medications. But often all Freud and others could do was talk and listen. For a man who became famous for the talking cure, Freud wasn't a great listener. Here's how Kramer succinctly judges his personality: "He was a poor judge of character, socially awkward, anxious, obsessive, self-justifying, overly reliant on reasoning and shockingly unempathetic [emphasis added]. . . . He applied his theories stubbornly and then declared victory, in the office and in print. Throughout, he was a mythmaker on his own behalf." Freud was a lousy therapist. He cured none of his patients (even if he said he did). Unlike the image of the analyst as a mute, nondirective figure, he repeatedly gave his patients advice. He told one patient whom he should marry. Because Freud was more interested in theory than in individuals, his advice was often ill-considered (and self-serving), sometimes with terrible consequences. At least one suicide resulted. Modern-day supervisors reading this account would never have let Sigmund Freud graduate from their clinical programs. Almost none of Freud's theories remain intact. His great claim to fame was his theory of infantile sexuality, which Alfred Adler and Carl Jung disliked (they were ultimately banished or left Freud's inner circle). Even contemporary psychoanalysts now know that infantile sexuality (as Freud construed it) doesn't make much sense. No evidence for it exists. It seemed to be a figment of his own imagination. Even the great man himself knew his theory presented practical and theoretical problems. So he constantly amended his own corpus—one of his great strengths. Kramer writes that Freud "had about him something of the hypomanic executive, spewing forth ideas and editing them spottily." He presented speculations and then "defended them as facts." Freud constructed a theory of mind with instinctual drives (the id) battling the superego (society and conscience), moderated by the ego. The result was neurotic complexes, which could only be relieved by aimless, free association while lying on a therapist's couch. Even Freud knew that his treatment model was deficient because his patients resisted getting better. So he conceived his theory of the pleasure principle (Eros) battling the death instinct (Thanatos), which led him to the chilly notion that the purpose of life was death—hardly a welcomed prognosis for any suffering patient. But maybe it isn't surprising for a man who was temperamentally glum and whose life spanned the butchery of World War I followed by the new barbarism of Nazism. Freud safely left Vienna with his family in 1938, but his four sisters were murdered by the Nazis. He became the Great Pessimist, anxiously worrying how his theories—infantile sexuality, mechanical mind schema, pleasure principle, death instinct—would be regarded in the future. For many historians and critics he's prized not for his science but for his literary accomplishments. A sad conclusion because Freud believed to the end that he was a scientist. Yet the question remains: why is Freud considered a giant? Kramer tries to provide an answer, but he isn't entirely convincing, partly because he sees so many of the man's flaws. Kramer's provisional answer to his own question is that Freud may not have invented the talking cure, but he consolidated it. Even psychologists who disregard him must give him his due. He was personally imposing and, in Kramer's phrase, a "force of nature." Thought is carved by great elemental forces, like water and wind on the surface of the planet. Freud had this about him: his ideas were a raw storm that blew across our culture. And he had the literary gifts to etch his thought into our consciousness. On a more practical level, says Kramer, psychologists owe Freud two great contributions. First, the idea that human beings desire fulfillment—they aren't content to be simply miserable (this he shared with almost every philosopher of note). The second, more specific and useful contribution to therapy is the theory of transference. When patients present themselves to a therapist, the relationship they forge is part of the talking cure. Though Freud insisted on the correctness of his theory of Oedipal and sexual conflicts, it was the bond between patient and therapist that was ultimately crucial. Relationship is at the heart of all therapy—even "third wave" cognitive therapists realize that therapy will die if it's just a workbook exercise. Dynamic therapists, coaches, and counselors of all stripes owe the recognition of this to that great, sour man, Freud, who had no friends (only "study companions" and acolytes), and whom few people ever liked. Freud's impact in America has been greater than in Europe. Americans (whom he thought crude and uncultured) were notoriously constrained by their Puritan past and Freud helped them to embrace a newfound sexual liberation. As for being the "inventor of the modern mind," that may be true on this continent, but not in Japan, India, or China—or among a billion-plus Muslims. The term modern mind recalls the great New Yorker cartoon showing the U.S. being comprised of New York City, a few slivers of the Midwest and a slice of California. Finally, there remains Freud's great edifice, the unconscious. Kramer doesn't make a big fuss over it because he's a psychiatrist for whom the unconscious has been eclipsed by neuroscience and pharmacology. At best, psychologists give credence to what some call the subconscious, which has been popularized in Malcolm Gladwell's Blink. This hidden aspect of the mind is more like a great processing computer that beeps at you from time to time. The therapeutic school it most resembles is Gestalt, where images and feelings rise to the surface and overtake each other in order of importance. But for others, the unconscious in its Freudian sense remains a potent force. Granta Books' How to Read Freud and How to Read Jung aren't written by psychologists, but by literary critics Josh Cohen and David Tacey, respectively. For Cohen, the Freud's unconscious is a deep, dark sea: by definition, not immediately accessible. It operates by subterfuge and disguise, in dreams, slips of the tongue, and neurotic symptoms. These writers note that for years Freud and Jung's ideas of the unconscious have carried great force with many cultural critics. Respect the power of the unconscious, says Cohen. His reading of Freud is a subtle and slippery enterprise, though—all in all, it could be more lucid. Tacey's How to Read Jung is a clearer retelling of the importance of a man who still has impact for therapists. Jung's unconscious is a real place, the domain of energies which cohere into "archetypes." It's much more hopeful than Freud's dungeon—which is why it still has cachet for psychologists and healers. Freud thought life was tough, and you should grit your teeth and bear it. Instinctual release only leads to chaos (Americans don't like to believe this, even if they must). But Jung believed in "individuation": the health of a balanced psyche. Tacey gives a better account of Jung's ideas in 128 pages than Deirdre Bair's overly detailed Jung: A Biography does in 900. That's the value and convenience of the publishing industry's venture into "brief lives"—when it works. Richard Handler is a radio producer with the Canadian Broadcasting Corporation in Toronto, Canada. Contact: rhandler@ |
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