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
Screening Room, More than Just Frivolity


Screening Room, More than Just Frivolity

Joel and Ethan Coen give us the antidote
to the happy ending

By Frank Pittman

More than Just Frivolity
Joel and Ethan Coen give us the antidote to the happy ending

Last year, filmmakers Joel and Ethan Coen, long the darlings of a cult audience devoted to their quirky, over-the-top output over the past 25 years, finally received mainstream acceptance and a bouquet of Oscars for No Country for Old Men.

Characteristically, it was a dark, hard-to-classify movie about the spirit of evil hovering over the deserts of the Southwest, its relentless villain deciding the fate of the other characters with a mercurial coin flip. This year, the ever-surprising Coens have shifted directions once more, whipping up Burn after Reading, an assaultive souffle of a screwball comedy designed to regularly startle us and frustrate our need for the reassuring lightness and optimism we associate with traditional comic films.

In the opening shot of Burn after Reading, the camera zooms in from outer space and comes to rest on CIA headquarters in Washington D.C., setting the tone for a film that throughout treats its characters like insignificant ants, just the way they might appear from space. The Coens don't ask us to love these ants or find them particularly endearing—just to watch with bemused detachment at the spectacle of their absurd self-absorption and foolishness as most of them are unceremoniously and gratuitously killed off.

Why do we put up with the Coens and their macabre sense of fun and existential futility? Maybe it's because they're the therapeutic counterpoise to our Hollywood-created pipedreams about prevailing over any odds stacked against us and living happily ever after. The Coens like to sprinkle their films with stink bombs of heart-stopping reality, as if they were dropping hungry ferrets into our bubble bath to make sure we snap out of the lulling fairy tales we like to tell ourselves.

Of course, at some level, comedy is usually about the precarious nature of the human condition as its heroes and heroines try to navigate the unpredictable maze of life's pitfalls. The underlying message of comedy has always been that while life is dangerous and humiliating, with a little luck, you can survive it. In Crimes and Misdemeanors, Woody Allen had Alan Alda explains it this way: "If it bends, it's funny. If it breaks, it's not funny." In most comedies, we're encouraged to embrace the main characters who stand in for us and our naive hopes of withstanding the intimidating forces of the universe arrayed against us. But in the Coen brothers' movies, there's no sunny promise of survival. As the dragon's breath gets nearer and hotter, we're never quite sure who'll escape and who won't.

The Coens have made 14 movies, mostly cast with their stock company regulars, like George Clooney, Holly Hunter, John Goodman, John Turturro, Steve Buscemi, Jon Polito, and of course, Frances McDormand, (a.k.a. Mrs. Joel Coen). Like Woody Allen, the Coens have managed to attract an illustrious roster of celebrated guest stars to their films, including Tom Hanks, Nicolas Cage, Paul Newman, Billy Bob Thornton, Tim Robbins, and Catherine Zeta-Jones. In addition to their own Oscars, their films have won Oscars for McDormand as Best Actress in Fargo and Javier Bardem as Best Supporting Actor in No Country for Old Men. Their usual cinematographer, Roger Deakins, and composer, Carter Burwell, have also won.

With varying levels of seriousness, the Coens have sought to revive the mood and look of film noir, while often giving it a comic twist. Miller's Crossing, about prohibition gangs, owes much to Dashiell Hammett. The Man Who Wasn't There, in black and white, bows to James M. Cain. Fargo, a Raymond Chandleresque murder mystery, is set in Minnesota, with McDormand as a very pregnant cop, and William Macy and Steve Buscemi as some very foolish kidnappers. Barton Fink had socialist playwright John Turturro from New York seeking the common man in California and instead discovering John Goodman, a traveling salesman carrying around a human head in his hatbox.

With a great Southern country music soundtrack, O Brother, Where Art Thou? somehow combined the dusty, poverty-stricken, chain-gang spirit of Preston Sturges's road epic, Sullivan's Travels, with Homer's Odyssey. The Big Lebowski, a convoluted takeoff on the indecipherable The Big Sleep, turned a stoned slacker, The Dude (Jeff Bridges,) and his bowling buddies (Goodman and Buscemi) into would-be detectives in search of a valise of money and a urine-stained rug.

Burn after Reading, the latest addition to the Coens' genre-bending canon, concerns the CIA, a recently fired, boozy agent (John Malkovich), who seems constantly in the grip of one kind of temper tantrum or another, and his tense, child-hating pediatrician wife, Tilda (Michael Clayton) Swinton, who's having an affair with an obsessive womanizer and exerciser played by George Clooney. Preparing to divorce her dyspeptic and newly out-of-work husband, Swinton sets the plot in motion by collecting Malkovich's financial records on a computer disc, which somehow gets left at a suburban health club, where bone-dumb trainer, Brad Pitt, finds it and comes up with the bright idea that it contains world-shattering spy secrets.

Pitt's sidekick, fellow trainer Frances McDormand, sees the "spy logs" as keys to money that'll get her the plastic surgery that'll change her life: "I've gotten all I can out of this body." When Pitt proves inept at blackmailing Malkovich, McDormand takes the disc to the Russian Embassy. Meanwhile she brushes off the lovelorn overtures of her plain, dutiful, but loving boss, Richard Jenkins, and joins the line of visitors
to Clooney's bed. Confusion swells, everyone misunderstands everyone else, and the cast graduates from divorcing or bedding one another to killing.

Even as we feel the Coens' cool and unapologetic disdain for all these characters, the film is leavened by the cast's evident delight in portraying its collection of misfits. As the sex and exercise addict who calms his nerves by going to bed with strangers and then ritualistically going for a run, Clooney plays hilariously against his own seductiveness and beauty. Equally memorable is Pitt as a severely hyperactive adult child who can't be still for a moment and has to keep all body parts—arms, legs, hands, even his dyed pompadour—in constant motion.

Ultimately the Coens are daring enough to let their characters, who are too foolish to bend, go ahead and break as they're left to their self-ordained destinies. For the brothers, there are no fairy godmothers, no superheroes flying in to save us in the nick of time. For them, life has no safety net. While seemingly indifferent to the fate of their characters, the Coens are determined that we understand that if comedy in our grim age is to be anything more than cheerful pap, it must go heavy on the vinegar and extremely light on the sugar.

Frank Pittman, M.D., is a contributing editor to the Psychotherapy Networker and is in private practice in Atlanta. Contact: fsp3md@aol.com. Letters to the Editor about this department can be e-mailed to letters@psychnetworker.org.