I’ve just completed presentations on consultation for therapists at the annual conferences of three professional associations: The National Association of Social Workers- Illinois Chapter, the Illinois Psychological Association, and the Illinois Counseling Association. Each presentation was organized around a lecture/slide show about consultation, and included a live demonstration in which I provided consultation to a volunteer therapist consultee. Each presentation also had its own emphasis: more information about consultation, and psychodynamic and cognitive-behavioral concepts, for the NASW-IL; less focus on consultation in general, in order to allow for an additional focus on trauma-informed consultation, for IPA; and less focus on consultation in general, in order to allow time for participants to practice peer consultation with one another, at ICA. Each of the programs went well, based on participant engagement, comments, and the feedback I’ve received. In this post, I’ll cover some of the consultation presentation, with the caveat that the live demonstration is what makes it really, well, come alive.
There is an infinite amount of learning about how to do therapy that mental health professionals can explore and accomplish after achieving licensure. Consultation is a key way for working therapists to inform and refine our therapeutic awareness, perceptions and skills.
Consultation is not supervision, which has specific legal meaning in licensure law for each profession. In supervision, the supervisor, or program for which the supervisor works, is clinically and legally responsible for the supervisee’s work. The supervisor is a professional gatekeeper who is responsible for evaluating the supervisee’s qualification to enter the field. Supervisees cannot select their supervisors at will, and may have to work with supervisors whose therapeutic styles, methodological preferences, and theoretical commitments are not a good match for their own talents, skills or interests. Nor can supervisors select supervisees; they may have to work with supervisees in whom they have little confidence, or about whose talents and abilities they may have doubts, due to program commitments. And supervisees have to work under supervision for a legally designated number of hours in order to be eligible for licensure.
Consultation, on the other hand, is a relationship between independently licensed professionals, which aims at informing and refining the consultee’s therapeutic awareness, perceptions and skills. It confers no formal certification and is entirely at will. Consultees can select any consultant they’d like to work with who will work with them (and with online consultation, their consultant can be anywhere in the world). Frequency of meeting is up to the consultant-consultee pair; weekly, every other week, every third or four week, etc. There is no required amount of time for consultation; it continues until either or both parties decide to stop. Basically, we select people to consult with from whom we can learn.
There are different types of consultation. Mentoring consultation is a teacher-and-learner relationship, in which the consultee works with a consultant from whom the consultee has something to learn. In peer consultation, colleagues consult on an equal basis for mutual benefit. Either mentoring consultation or peer consultation can take place on a 1:1 or group basis, and either form of consultation can be time-limited or ongoing.
In addition to types of consultation, there are styles of consultation. The length of time the consultee prepares to present a case can vary from none (a completely spontaneous presentation) to some (some forethought, review of therapy notes, making some notes to present from), to extensive (preparation involving hours of writing and pages of text). The length of time after the consultee begins presenting the case, before the consultant (or, in a group, consultants) begin to engage by asking questions or making comments, can vary from a few minutes to half an hour or more. Some consultation is strictly within a particular theoretical model, while other consultation uses any model of mind, and of how therapy works, that helps to make sense of the cases and experiences which consultee and consultant are discussing. The amount of coherence expected in the consultee’s presentation of the case can also vary. My preference is not to expect too much coherence, because that risks the consultee and consultant trying to make the therapy fit a particular theoretical model. I prefer to allow coherence to emerge in the discussion of the experience of the therapist, the experience of the client, and the experience of the therapist-client pair.
What do consultants and consultees talk about? We talk about the client’s situation, history and experience, past and present, outside the therapy office. We also talk about the client’s experience, feelings and behavior in the therapy office, and the therapist’s experience of being with, and working with, the client. We talk about how the therapist understands the client, and her therapeutic relationship with the client, and about areas where the therapist feels confused or stuck; and ways the consultant might see the therapy that the consultee is describing.
We also talk about the “frame” of the therapeutic relationship, which means the therapeutic, economic and professional roles and responsibilities of the client and therapist to themselves and each other in their work together. This includes such areas as late arrival, extending sessions, missed payments, missed sessions, control of the focus of the conversation, etc. We talk about the therapeutic agreement or contract, meaning the goal(s) or purpose(s) of therapy, and whether they are clear, achievable, and agreed by client and therapist. A lot of therapy takes place in a kind of preliminary phase, where the goals and purposes of therapy are, at best, implicit and emerging. Clarifying goals itself can be a therapeutic process.
From psychoanalytic culture comes the idea that there are two levels of therapy. The first is where the client receives the attention, respect, caring, concern, presence and empathic support of the therapist. These are all necessary ingredients of the therapeutic relationship, and that can often be as far as the therapy goes. The second is where the therapy is providing that support and also making it possible for the client to work on her- or himself. This means that the client is looking at his own issues outside the room, in life outside of therapy, as well as inside the room, in the therapeutic relationship. Some analysts call these two levels the supportive relationship and the analytic relationship. I’ve referred to them as the supportive relationship and the working relationship, in order to make headroom for work, with and on the self, that may include, and also extend beyond, the traditional mental models of psychoanalysis. Consultation can help therapists establish the first level, and then co-create bridges, with their clients, to the second.
Since consultation is so valuable, why isn’t it more widely known, recommended and practiced? Part of the explanation lies in the fragmentation of the world of psychotherapy, in which people in different therapeutic cultures keep pretty much in their own silos. Psychoanalytic culture does feature what it still calls supervision, even after licensure and certification. But that culture tends to be wrapped up within itself, and affords few points of entry for mainstream therapists who don’t wish to steep themselves in its theories, terminology, or fealty to Freud or other iconic figures. Jonathan Shedler, a leading psychodynamic researcher and practitioner, commented that he had learned, from teaching therapy to beginners, that if he couldn’t explain what he meant to them in ways they could understand in the context of the therapy they were doing, that meant he didn’t understand it well enough. “If you’re only talking to other people steeped in the same history and traditions, you operate on the assumption that you both understand what you are talking about. I thought I understood (basic psychodynamic concepts) until I had to explain them to someone who wasn’t steeped in that tradition, and I floundered with it” (personal communication). He emphasized that it’s up to consultants to “bridge the gap” between what they know and what their consultees need to learn.
Cognitive-behavioral therapy, on the other hand, has tended to be narrowly focused on specific conditions and treatments, allowing little space for the complexity of human experience involved in the exploration of relationships, identity and meaning. Nor has it tended to recognize the potential wellspring of learning that can be harvested from the complexity of the client-therapist relationship itself. That is beginning to change with the development of hybrid treatments like Dialectical Behavioral Therapy and Acceptance and Commitment Therapy, but a narrow focus on problems and goals tends to be characteristic, as does the role of the therapist as director rather than collaborative guide in the work. What’s needed is a general practice of consultation beyond therapeutic silos, by consultants who can add value to consultees without requiring them to spend years acquiring a new culture–most of which will be irrelevant to them–or to trim and package their work with clients to fit within a silo’s theoretical framework.
Therapy cultivates reflection: the client’s reflection on himself, the therapist’s reflection on the client, and both client’s and therapist’s reflection on their therapeutic relationship. Consultation adds another dimension of reflection, in which the consultant helps the therapist reflect on herself. her client, and their work together. The therapist “polishes the mirror” for the client, and the consultant “polishes the mirror” for the therapist.