1. PEER CONSULTATION GROUPS AND TREATMENT TEAMS:
Strategies for an Effective Dynamic
How many people here are in private practice?
How many work for a treatment center?
Any that do both?
Other settings or types of work represented?
A little about my background:
currently private practice started my own consultation group
previously Clinical Director at Oliver-Pyatt Centers in South Miami
worked on a multi-disciplinary treatment team at the University of California - Davis

2. Our Structure Today Why This Topic is Important
Models of Peer Consultation
Group Dynamics
Strategies for Effectiveness
Scenarios and Discussion
In the spirit of creating more effective professional groups, be it treatment center treatment teams that are already formed (i.e. there’s no membership interview) or whether you’re looking to create your own opportunity for consultation in your professional community, I’d like to start us off by setting and example and using today as one model since we are a group of professionals and we will be consulting with one another to some degree.
So, in this particular model we have here today, there’s is a designated leader for the next two hours (that’s me). However, my style is pretty casual. I don’t mind being interrupted for questions or discussions. I don’t claim to have all the answers, so I’m happy to hear from others if they have a different perspective. One thing that I do ask of you as our facilitator is to be mindful of stepping up or stepping down and what I mean by that is that if you tend to be a talker, take note of how much talking you may be doing during our two hours together and maybe catch yourself and “step down” to make room for others. If you are someone who does not tend to ask questions or share as much, then I want to encourage you to “step-up” today and take some risks, get your questions answered or share your insights.
I ask that we all talk to each other with respect, knowing that we can have a different opinion or perspective and still have a meaningful dialogue, because what works for you might not work for your neighbor.
Starting with peer consultation groups first, I want those of you who work in treatment teams (and I’m thinking primarily of treatment center type treatment teams where you don’t pick who is in the group) to still consider how the peer consultation group slides have application to your workplace setting and more specifically to any consistent treatment team meetings, staff meetings, set that you may have on a regular basis. Then we will be talking specifically about treatment team dynamics and strategies for making those work groups more effective. What do I mean by effective? Meaningful use of time together, collegial spirit.

3. Legal and Ethical Issues in Non-Hierarchial Professional Relationships
Consultation groups can offer their opinions, but licensed healthcare professionals retain control over all their decisions and have the option of following, modifying, or ignoring the recommendations of their peers.
Literally, the term “peer consultation” is redundant because consultants are peers, at least in the sense of having the same legal authority. Consultants have no legal authority to direct the professional activities or usurp the clinical judgment of their peers.
Knapp, Gottlieb & Handelsman (2017)
Although the APA Ethics Code does not mandate reporting of substandard conduct on the part of a consultee, we nonetheless urge consultants to take actions to remediate or at least mitigate potential harm to patients. When consultants learn of incompetent behavior, we suggest that they clarify the expected standards of good professional performance.  Such complex situations may require special interpersonal skills, including helping consultees reflect on their professional behaviors. This often means being highly tactful when delivering negative feedback. However, tactfulness is subservient to the goal of promoting good standards of conduct.

4. Self-Reflection, Self-Assessment & Self-Care
These three benchmarks of competence are woven through the peer consultation group and the treatment team group experience. (Falender & Shafranske, 2012)
“Supershinks” (Miller, Hubble & Duncan, 2007)
Proactively seek feedback
Thoughtfully reflect
Use tools to establish a baseline of clinical performance
Engage in forethought about the next step in development
Reflect on the the means to improve in the next session
If self-reflection and self-assessment have been identified as essential components of competence.
Metacompetence - the ability to assess what one knows and what one does not know
To me best articulated as a skillset that involves self-assessment and impacts self-care.

5. Reflective Practice (Moon, 2008)
Reflective practice as a set of abilities or skills
Reflective practice and criticality
Reflective practice as a state of mind
Reflective practice as an orientation to problem solving
Reflective practice, intuition and emotion
Consider the form of reflective practice in which you typically engage and the form of reflective practice that is primarily promoted in your professional groups (peer consultation/supervision; treatment teams)
Focuses on specific competencies or behaviors, such as the ability for self-awareness or an activity such as journaling about an event.
2. Focuses on looking back in a critical way at what has happened and using the resulting knowledge to tackle new situations (Experiential Learning Cycle, Kolb 1984)
3. Characterized as a gentle process of noticing and being concerned, similar to applications of mindfulness, increasing awareness of subtle feelings, thoughts and fantasies that emerge when working
4. Similar to criticality, such a conscious process aims to identify problematic issues and consider solutions
5. Outcomes of reflection in this form turn into “being in the zone”; knowledge or skills that one uses in a given therapeutic moment with little conscious deliberation, performing complex actions or responses without deliberateness of a beginner; working from the gut

6. Definition of Peer Consultation
“a process of peers consulting with peers in a non- hierarchical fashion This involves the practice of fully qualified and often highly experienced practitioners working collaboratively to access and share information, discuss opinions, receive support, monitor best practice and obtain rigorous evaluation of their own professional activities within a professional context.”
-Australian Psychological Society (2008)
Let’s differentiate that from Treatment Teams which might have a hierarchy if it’s within a treatment center or other organization; any time there’s job evaluation in the mix it makes things trickier. Not unreasonable, but just something to be aware of.

7. Types of Peer Consultation Groups
Case Focused
Process Focused
Dual Focused
Practice Management
Continuing Education/Psychoeducational Groups
For those of you who are looking at this through the treatment team lens, I’m guessing a large percentage of your professional time is case centered. Is there an opportunity or time for process centered support to explore the dynamics that are felt and enacted between the team and a challenging client or family?
These top three are really what I have in mind as I talk today, because they’re the most common forms of peer consultation groups.
1. Case focused - there’s a great consultation model from DBT consultation groups which always starts with the group asking if anyone has any urgent

8. Four Conditions of Peer Consultation Groups
Organization of the group
Open or closed
Homogenous or heterogenous clinicians
Size
Schedule (How frequently do you meet or is it “as needed”?)
Group processes
Conduct of peer support
Review of group’s functioning
Is the group always open to new members? How do new members join?
Are the group members brought together by a common treatment population, theoretical orientation, diagnostic presentation or is the group diverse in their clinical work?
Range of experience? Diverse or prefer early career group of clinicians or seasoned clinicians?
How many clinicians are too many clinicians?

9. Counselman & Weber Model (2004)
Tasks of leadership …
Adherence to contract …
Gate-keeping …
Boundary management …
Working with resistance …
are all shared by members.

10. DBT Consultation Group Model
Led by a rotating leader
Starts with a 5-minute mindfulness meditation
Any latecomer does a chain analysis
Develop the agenda
How urgent is your client consultation?
(on a scale from 1-3 or 1-5)
Marsha M. Linehan, Ph.D., ABPP ( )
Abbreviated version
This particular structure helps avoid “Task Drift” (Hunt & Issacharoff, 1975)
Even though there isn’t one consistent leader there is a leader.
Pretty solid structure for treatment teams which may have more time constraints and demand for collaboration in decision making.

11. Nancy McWilliams Psychoanalyst
“My four private [consultation] groups consist of seven licensed therapists who meet regularly for 90 minutes to talk about cases. One group meets
weekly, one three times a month, and two every other week. Membership is fairly stable. The
oldest group formed in 1978 and still contains an original member. The newest began in 1997 as
a seminar on personality organization for practitioners and became an ongoing group when
several participants wanted to continue meeting and learning.”
Aims
The chief purpose of a supervision group is to increase the therapeutic skills of members.
It offers fringe benefits in friendship, networking, comparing notes on professional issues, and
learning for its own sake. It provides a rare kind of sanctuary, a place where therapists–who
suffer self-conscious concern about their impact on others to a greater extent than any other
professionals I know–can let their hair down, laugh, compare experiences, and find
consolation.
In contrast to my own experience of being with a direct and challenging group leader, my groups seem to appeal to
many people without much psychodynamic background; frequently, members join to add that
perspective to their professional repertoire. They have not signed up to bare their souls and would
probably feel invaded and exposed if I were to probe into their dynamics.
In the GSAPP setting, where participants are burdened with the status of students
under constant evaluation, there seems to be a greater need for me to address dynamic issues
such as competition for my approval, insider/outsider themes (often presenting as old
member/new member issues), and inhibitions about giving me negative feedback. At the same
time, these groups are particularly hungry for content.

12. Acceptance & Commitment Therapy Consultation Group Model
Time
1st hour - announcements, business items, and questions
2nd hour - experiential, role-play
Roles Defined
Group Leader (Keeps group on schedule. Can use bell to unobtrusively signal transitions)
Opening Exercise Leader (Begins group)
Process Monitor (Observes that the group remains ACT-focused, and gently brings to the group’s attention the it is not)
Skills Builder (This individual practices an ACT skill in the second half and receives feedback)
Assistant to Skills Builder (Available if he/she feels stuck)
Case Presenter (Presents case in service of the Skills Builder’s learning)
Hexaflex Monitor (Notes ACT processes during Skill Builder’s experiential work)
Roles rotate, so before the meeting wraps up, roles are assigned for the next meeting

13. Strategies for More Effective Peer Consultation Groups
Interviews/Pre-Group Meeting with Individuals
Group Contract When Beginning or Adding Members
Designated Leader
Consider Fee for Leader: increase investment from everyone and reduces potential resentment from the person with leadership responsibilities
Rating Scales for Group Feedback on Consultation Experience
These have some benefit that they can potentially screen out people who aren’t a good fit for the dynamic/skill/vulnerability that you might be looking for and/or for the current dynamic if the group already has history and is looking to add new members.
Would facilities with treatment teams benefit from supporting peer consultation (in-house or otherwise)
-Some possible resistance: Don’t want outside clinicians knowing of tx, concerns about confidentiality, propriety knowledge

14. Interpersonal At Play Defensiveness Insecurity/Lack of Trust
Take up too much space
Not stepping up/Risk Avoidant
Lateness/Inconsistent Attendance
Step-Up/Step Down as an initial guideline that’s talked about
Example GP non-licensed, limited contribution
Have a conversation as a group and revisit from time to time: How are we going to navigate dynamics like this when they show up? Facilitate inclusive that we’re all vulnerable to feeling and demonstrating these and it opens the door to naming potential difficulties and how this group will acknowledge it for increased effectiveness.
Story of S & L

15. Individual Reflection
1. If you were in a professional group, what would make you reluctant to participate at times?
2. Cultural factors sometimes count for lack of participation by group members. If there is no leader, what would likely be your action/inaction in that situation, if someone else is noticeably quiet from your perspective?
3. How can you challenge peers in a caring way, without increasing their defensiveness?
4. How do you distinguish support that is helpful verses support that is a form of defense?
5. If you tend to be a talker, what clues you in to step-down and allow more space for others?
Adapted from Corey, Corey & Corey (2010, 8th Ed)
Pick an imaginary group if you don’t have a current experience in mind
We’re noticing what’s impacting us to step-down from being active, present, fully engaged.
Crucial Conversations - Resource on delicate conversations and navigating defensiveness

16. Symptoms That You Might Have An Ineffective Professional Group
1. Apathy coming from multiple people
Missing meetings
Chronic lateness
Chronic lack of energy when together
2. Using group less and less for professional development and more and more for socializing
3. Defensiveness and withholding vulnerability in cases is common across members
Apathy can show up as missing meetings, chronic lateness or chronic lack of energy when together
A good group is going to have a social element, but look at the balance. This may be a symptom that it’s “easier” to socialize. There may be a lack of trust and willingness to be vulnerable with each other.
It could also mean that the group as a whole needs more self-care in the sense that maybe members are all lacking a social life.

17. Check-In Questions for Your Professional Group
1. What has surprised you, positively or negatively, about this group?
2. Is our group what we each professionally need?
3. Everyone name two high points and two low points of being in this group.
4. Is there anything we want to work on altering or changing?
5. Is there safety and trust in this group? How can we increase those feelings?
6. Is it difficult to take risks here sometimes?
7. What do you want to walk away with from our time together that you’re not walking away with?
This is basically just to get a meaningful dialogue started. There’s no magic to these specific questions.
Really interesting in workplace settings!

18. Scenario 1
You host a peer consultation group at your office and were the one to get the ball rolling with finding people to join. Everyone relies on you to be the organizer, although that wasn’t really your initial intention and you have vocalized this before to the group, but no one really stepped-up or had an alternative idea. Even though you have a great time connecting and consulting with the group, you get tired of rallying everyone together to figure out schedules and to make it all happen.
What would you do you do? What do you see as your alternatives?

19. Scenario 2
You work at a treatment center and meet weekly with the multi-disciplinary team, who are all psychologically minded. You have a good working dynamic, but there never seems to be enough time to talk about everything and everyone seems stressed with the demand that goes with this level of care. Your supervisors are open to new ideas.
What might you suggest or uniquely bring to the table, in efforts to make more efficient and meaningful use of this weekly case consultation meeting?

20. Questions or
Additional Scenarios

21. LET’S CONNECT! Social Media
Website: drkarinlawson.com
Social Media
LinkedIn: linkedin.com/drkarinlawson
Facebook: facebook.com/drkarinlawson

22. References
Australian Psychological Society (APS). (2008). APS peer consultation network guidelines. Retrieved February 1, 2018, from
Counselman, E.F. & Weber, R.L. (2004). Organizing and maintaining peer supervision groups. International Journal of Group Psychotherapy, 54,
Corey, M.S., Corey, G. & Corey, C. (2010). Groups: Process and Practice. Belmont, CA: Brooks/Cole.
Hunt, W., & Issacharoff, A. (1975). History and analysis of a leaderless group of professional therapists. American Journal of Psychiatry, 132,
Knapp, S., Gottlieb, M.C. and Handelsman, M.M. (2017, Spring). Some Ethical Considerations in Paid Peer Consultations in Health Care. Journal of Health Service Psychology
Linehan, M.M. (2008). DBT Consultation Team Format. Retrieved February 5, 2018, from
format_and_tasks_2006_v2.pdf

23. References Continued
McWilliams, N. (2004). Some Observations About Supervision/Consultation Groups. Retrieved February 10, 2018, from
Miller, S., Hubble, M., & Duncan, B. (2007, November-December). Supershrinks: What’s the secret of their success? Psychotherapy Networker. Retrieved from
Moon, J.A. (2008). Reflection in learning and professional development: Theory and practice. New York, NY: RoutledgeFalmer.
Nobler, H. (1980). A peer group for therapists: Successful experience in sharing. International Journal of Group Psychotherapy, 30,
Shafranske, E.P. & Falender, C.A. (2008). Supervision addressing personal factors and countertransference. In C.A. Falender & E.P. Shafranske (Eds.), Casebook for clinical supervision: A competency-based approach (pp ). Washington, DC: American Psychological Association.