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Treating the Mixed-Agenda Couple

Bill Doherty On An Approach For Unaligned Relationships

Tough Customers: Is It Them or Us?

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!

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.

You Don’t Have To Choose

Casey Truffo On Doing The Work You Love And Making It Pay

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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Clinicians Digest Nov/Dec 2008


Clinicians Digest Nov/Dec 2008

Infidelity and Disclosure

By Garry Cooper

Louisa confides to her couples therapist that she had an extramarital affair last year and asks him not to divulge this to her husband Frank. Although therapy has been progressing, Louisa's revelation troubles her therapist. Does Frank have a right to know? By not disclosing, is the therapist participating in secret-keeping and aligning himself with Louisa against Frank? Writing in the July American Journal of Family Therapy, a group of Brigham Young University researchers say that surveys of marriage and family therapists indicate that up to 96 percent of therapists would comply with the request of an unfaithful spouse.

The trio, Mark Butler, James Harper, and Ryan Seedall, suspects that most of those therapists were thinking more about the ethics of confidentiality than the principles of effective therapy. They argue, however, that if they were more concerned with good couples therapy, they'd focus instead on moving the unfaithful partner toward disclosure.

Butler, Harper, and Seedall's viewpoint mirrors the attachment perspectives of therapists like John Bowlby and Susan Johnson, who hold that affairs are corrosive, even antithetical, to intimacy. From this perspective, they insist, there's no such thing as a harmless affair. The Brigham Young trio also argues from the ethical position that each person in an intimate relationship has the right to choose the relationship's boundaries and limits, and that such choices depend upon knowing all relevant information.

They do, however, acknowledge some circumstances in which disclosing an affair might cause more harm than good. "When the affair's in the distant past," says Butler, "or one partner is terminally ill or disabled, the therapist might reasonably wrestle with a cost/benefit analysis." Similarly, if disclosure might trigger domestic violence, or one or both partners have severe psychopathology, disclosure may be too hot to handle. And when divorce is imminent, disclosure is likely to become only a punitive tool or legal fodder.

But the relationship between values, social science, and theoretical orientations is seldom as clearly delineated or cut-and-dried as we'd like. Couples therapist Esther Perel, author of Mating in Captivity, contends that views like those of Butler, Harper and Seedall are more value-laden than scientific and may create more harm than good. The role of a therapist, she insists, "isn't to advocate for disclosure." Instead, she says, therapists should help people examine why they had the affair and whether they should disclose it, and to own their choices about the affair and disclosure. She points out that the meanings of fidelity, love, and intimacy vary widely, and rather than impose their own values, therapists should help couples explore what these concepts mean to each of them.

So what should a therapist do when one person privately admits an affair? Butler, Harper, Seedall, and Perel do agree on one point: above all, therapists need to be clear with themselves about their personal values and theoretical orientations to be able to separate their own attitudes from what's best for their clients.

Deep Brain Stimulation for Depression

Despite the millions of dollars spent on research and clinical trials of promising new treatments for depression, about 10 to 20 percent of clinically depressed people suffer from treatment-resistant symptoms that no antidepressant or psychotherapy seem to alleviate. Their only option then is electro-convulsive therapy (ECT), which has devastating, albeit usually short-term, side effects on memory and affect. Sometimes even ECT fails to alleviate their depression, and when it does work, its effects can be short-lived, with the "cure" turning out to be a few years' respite before the next round of ECT.

For years, researchers have been testing three high-tech neuromodulation solutions for depression: vagus nerve stimulation, repetitive transcranial magnetic stimulation, and deep brain stimulation (see Clinician's Digest, November/December 2000, November/ December 2004, and July/August 2005). The FDA has already approved vagus nerve stimulation (VNS), in which electrodes and a pacemaker-like device are implanted in the upper chest to stimulate a nerve that runs from the brain stem to the abdomen. In repetitive transcranial magnetic stimulation (rTMS), painless electromagnetic impulses are delivered to the outside of the skull.

But a review of these treatments in the June 2008 Mt. Sinai Journal of Medicine points out that clinical trials of VNS have yielded such modest results that the FDA approval seems based more on the safety of the VNS procedure than its efficacy. As for rTMS, the review concludes that the mild improvements it causes don't seem to last. However, the results for the third treatment, deep brain stimulation (DBS), in which surgeons implant electrodes into the brain's cingulate gyrus and wire them to a small generator implanted near the collarbone, are "highly encouraging."

In the most recently published DBS study, in the September journal Biological Psychiatry, six months after the operation, 12 of 20 patients showed significant clinical progress, with 7 of the 20 improving so much they were deemed in full remission. Moreover, the positive effects lasted a year, the longest anyone has tracked DBS. Those results are even more impressive when you consider that these patients had failed to respond to a minimum of four other treatments, including ECT.

DBS has some drawbacks. It entails brain surgery, with the usual surgical risks—primarily infections on the skull—and is extremely costly. But it's already being used to treat Parkinson's Disease successfully, and it creates no memory loss. Moreover, patients undergoing DBS report that the minute the pulse generator begins, they feel as if a switch has turned off their depression.

A large clinical trial is now recruiting subjects in Chicago, Dallas, and New York City. Advanced Neuromodulation Systems, the manufacturer of the electronic device, believes this will be the final step in gaining FDA approval. If that happens, DBS is likely to become an important new treatment option. (Recruitment details of the trial are at www.BROADENstudy.com. )

PTSD Treatments and the Dodo Bird

Researchers keep hoping that head-to-head clinical trials of treatments will tell us which treatment is the best for each specific disorder. Yet way back in 1936, psychologist Saul Rosenzweig observed that head-to-head trials of responsible treatments will typically show that they all have roughly equal effects. This is Rosenzweig's so-called Dodo Bird Verdict, named after the character in Alice in Wonderland, who judged a race by declaring, "Everybody has won, so all shall have prizes."

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