Join Us

Facebook Twitter YouTube

In This Section

Recent Posts

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.
Networker Excel Clubs
Enlisting the ODD Child


Enlisting the ODD Child

How to move beyond the power struggle

By James Levine

Q: I'm a public school counselor with a fifth-grade boy diagnosed with AD/HD and ODD. At least five behavioral plans have been tried unsuccessfully. What should I do?

A: Children diagnosed with oppositional defiant disorder (ODD) inspire many myths. School personnel and even parents believe that these children enjoy frustrating others, don't care what anybody thinks about them, and are impossible to teach.

But ODD is a label for various behaviors, and it indicates nothing about why such children act as they do. Are they experiencing repeated trauma? Do they have Asperger's Syndrome and are getting more sensory stimulation than they can handle? Are they worn out and angry from living with anxiety or depression?

Harried teachers and counselors often resort to interventions without devoting enough time to learning what's driving the child to behave in this way. Once a reasonable hypothesis has been made about the cause of their actions, however, cognitive-behavioral techniques and traditional relationship-building strategies can help even the most challenging children.

Tim, 11 years old and entering the fifth grade, angered not only his teacher and principal, but many of his peers. When I observed him in the classroom, he was distractible and impulsive, continually scanning the room, calling out, and touching things and people. There was no denying the glint in his eye when the teacher sent him off to the principal's office for the umpteenth time. He seemed to get satisfaction from the uproar he caused.

His history included a lengthy record of school failure, poor self-regulatory skills (problems during transitions, with little inclination to follow rules, listen to others, stop talking when asked, or keep his anger in check), and countless disciplinary events. The school and his parents had tried many behavioral interventions, but without success. These plans were based on traditional ideas about how to intervene, incorporating a cascade of rewards and punishments with little idea about what was driving Tim's behavior and without seeking his input. The plans were imposed on him, and he found ways to defeat them. He was embroiled in an ongoing, endless power struggle.

The staff was open to trying a different approach. I recommended that the full team—everyone involved with him, including his regular and special teachers, the school counselor, and the assistant principal—schedule a time to meet together. This meeting was to explore the context of his behavior, to find patterns in when he had difficulty, and to make sense of the times when he did well. If nothing else, I wanted the team to broaden its understanding and develop a hypothesis about the reasons behind his actions.

Meeting proactively, not in response to a specific incident, proved beneficial, as the staff displayed sensitivity and compassion. We addressed the sudden disappearance of his mother, his time spent in foster care, and his need to feel in control. I didn't use the label PTSD, but what we really talked about was the trauma in his life, a concept that allowed everyone to see Tim in a new light.

I pointed out that the earlier behavioral interventions had been forced on Tim without discussion about what they were supposed to achieve (besides making him somehow "behave better"), or even how they were supposed to work. This approach had left him clueless, struggling to retain a sense of control. Therefore, I suggested that before replicating this orientation to behavioral planning, his two main fifth-grade teachers and the school counselor discuss with him the purpose of the plan, how it would work, and the specifics of its goals and rewards. Because of their antagonism toward adults in authority, children with ODD seldom receive opportunities to contribute input to their own treatment plans. My request was that he be allowed the chance to do exactly this.

Children with chronically oppositional behavior typically are unaccustomed to articulating their needs, wants, and experiences in collaborative, problem-solving ways. I often speculate about possible goals and rewards in cases when the child appears to experience the collaborative process as too intrusive or anxiety-provoking. ("How about if we try to help you with this behavior?" "Would you be interested if we provided you with time on the computer when you earn a reward?")

Tim clearly wasn't used to a collaborative approach to planning his treatment, so instead of upping the ante with a confrontation, we calmly and pleasantly invited him to take full part in the process. We asked him how he thought his treatment and reward plan should be structured. He said he wanted the plan to be easy to understand, a private arrangement between his teachers and him, and one that enabled him to receive rewards more frequently than once per week; the proposal that he wait until Friday to get his rewards made no sense to him. He was the first one during the discussion to note that he needed to do better at "listening to his teachers."

I typically try to use this type of supportive, clarifying, nonjudgmental approach to help children participate in the dialogue. The point of proceeding in this way is to allow an oppositional child to experience a sense of personal responsibility, rather than depending solely on outside control and authority. Just including Tim as a collaborator in the planning about his treatment—maybe for the first time—initiated a shift for the better. He became less defensive and more open to the idea that some of his behaviors needed to change. The process raised the possibility that issues could be talked about, rather than acted upon.

The discussion took place in short increments of time over two different days, giving him a chance to think things over and assimilate what had been talked about. The idea is to allot time to the process, to build the relationship, and to follow up on any openings to explore the child's behavior, rather than to rush into starting the actual intervention.

In consultation with Tim, we simplified the goals of the collaboratively developed plan to two: "Following directions" and "showing respect." I find that it's generally more effective to limit a plan to no more than two goals, as almost any oppositional behaviors can be encompassed by these categories and it keeps the plan from becoming unwieldy. As noted, Tim was receptive to the idea that he needed to improve on following directions. He was less inclined to acknowledge that he was disrespectful, but specific examples began to persuade him. Grudgingly, he agreed to give it a try. Again, it was an opening, a different starting point, compared with earlier, more rote approaches.

We framed the plan as a teaching tool, not a mechanism for showing him how "bad" his behavior was. Instead of receiving feedback only when he'd behaved oppositionally, the agreement was that each teacher who had him in a class would provide him with 60 to 90 seconds of behavioral feedback at the end of the class. For a boy whose life seemed to swirl around him, the predictability of this aspect of the plan would be instrumental in helping him stay with it. Another purpose of the feedback sessions was to give him a picture of what he looked like when he was on task. Teachers were initially concerned that this would be too time-consuming, but they quickly came around to the idea when they understood that children with Tim's profile tend to be more successful when the feedback is consistent and predictable, and that we'd only implement the plan for two weeks before we'd stop and evaluate it.

<< Start < Prev 1 2 Next > End >>
(Page 1 of 2)