Staff Perspective: From the Horse’s Mouth - What You Should Know about Consultation
One key to both learning a new approach to treatment and maintaining our existing skills involves consultation, particularly for EBPs. Don’t just take my word for it, research shows that consultation after a training workshop not only boosts providers’ subjective self-efficacy and intent to use the treatment (Ruzek et al, 2016), but also improves objective fidelity ratings as well (Webster-Stratton et al, 2014).
Fortunately, this reinforces my belief that my consultation experiences have been time well spent as I have spent a lot of time in in consultation-related activities since graduate school! To wit, I have been a consultee when new to a protocol and to the process and terrified of getting it wrong. I have been a consultant, getting to talk about my favorite subject and doing my best to keep up with the literature. I have provided consultation, formal and curbside, group and individual, in-person and via phone or video conference, in primary care and specialty settings, with interns and licensed providers, with active duty and civilians, and with psychologists, social workers psychiatric NPs and mental health technicians. Whew! With all of this I have picked up on a few things that I want to share to encourage you – the therapist -- to use and make the most of your consultation resources.
It can be scary learning something new. It takes courage to sign up for consultation. Training in a new treatment means starting at ground zero, and may bring potentially unnerving reminders of early graduate school. Even if you seek consultation in an area in which you have experience, and even if meant constructively, it in essence opens you to critique. Who wants to “start over” or feel evaluated? Let’s look at it another way instead, after all, that’s what good cognitive-behavioral therapists do. How about this alternative thought, “Who wants to continue growing their skills?” I’ve heard that children learn more comfortably because they are not afraid to try and have a few misses along the way. Even though we inevitably age, that spirit of learning and growth can continue to motivate us.
Consultants are people too, who just love to talk. Ok, ok, I am speaking for myself here (no pun intended), but I have yet to meet a consultant who does not love to answer questions. Try asking just a yes/no question and you’ll probably still get a five minute-plus response. My consultant colleagues, you know we do this! One of the values that typically drives consultants and trainers is a love of information and the desire to share that acquired knowledge. Like reading a story, we may excitedly turn the pages of a research article thinking “ooh, and then what?” As a consultee, taking advantage of this knowledge and perspective to hone your own clinical acumen means feeling free to ask plenty of questions. In turn, consultees keep consultants continually growing in turn. Questions may lead to further research or new perspectives. The best consultants get consultation themselves, and participate in a community of expertise to broaden and deepen their knowledge. You may notice a theme here, consultation promotes career-long growth for both consultees and consultants.
Is it patient reluctance or therapist reluctance to implement a treatment? Consultees often bring cases to discuss, wondering if the patient “fits” the treatment or is even ready for the treatment. Certainly, contraindications exist, such as if the patient doesn’t actually have the diagnosis for which the treatment is intended. Patients may also benefit from motivational interviewing or other strategies to enhance engagement. That said, often provider factors are the “LIMFAC” or limiting factors. Focus on basics when you consider fit: does the patient have this diagnosis, does the patient want treatment? Or does the therapist not want to try a new treatment or not feel competent delivering the treatment? Consider if questions about patient readiness come directly from the patient’s report or from your subjective perspective that may be influenced by potential discomfort with the treatment.
If the patient does not immediately improve, wait before throwing out the baby with the bath water. Lack of patient improvement is often considered one of the biggest stresses for behavioral health providers. After all, many of us joined the profession to help others. There is a balance here, on the one hand, repeatedly trying the same techniques in the face of no improvement may not only be foolhardy, but can also be unethical per APA guidelines. At the same time, switching gears to a different treatment too early could prevent enough time for an adequate dose of an intervention. Let’s first consider something that may seem basic, but in my experience, may inadvertently be overlooked. Specifically, has the patient actually done the intervention? Often patients don’t improve when they don’t fully follow treatment guidelines (surprising, I know), but are unaware that this partial adherence imparts an insufficient “dose.” A consultant can help you identify where exactly and how any non-adherence can be limiting your patient’s progress.
A two-day workshop is not enough. Learning via workshops packs so much information into a short period of time as a critical start to learning a new protocol or strategy. To insert a shameless CDP plug, we have some pretty outstanding workshops (see a list of upcoming training events at http://deploymentpsych.org/training). Provided materials then help turn the knowledge into practical skills. Yet, research shows that the relatively brief time spent in a workshop is not enough in and of itself to enable mastery of new skills (see references above as examples). Post-workshop consultation discussions have revealed this as well; it helps clinicians new to a protocol to review key points, continue to practice, and dissect real-world cases to truly internalize treatment rationale and implementation. When you take a workshop, take advantage of any consultation resources the trainers provide, preferably on a regular basis. Opportunities may be not only in person at your clinical setting, but also telephonically or through online platforms, like Zoom or Adobe Connect. The CDP offers a variety of consultation resources for providers who have taken our workshops ranging from calls to emails (see http://deploymentpsych.org/resources/consultation-services for more).
I hope that these suggestions inspire an interest in increasing your involvement in consultation. As hinted at above, I strongly believe in lifelong learning and in that light, I would still hesitate to call myself an expert. Surely what I have learned so far is just a drop in the bucket. With that in mind, don’t just take my word for it, please share your consultation experiences and suggestions!
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Diana C. Dolan, Ph.D., CBSM is a clinical psychologist serving as an evidence-based psychotherapy trainer with the Center for Deployment Psychology at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. In this capacity, she develops and presents trainings on a variety of EBPs and deployment-related topics, and provides consultation services.
References
Ruzek, J.I., Eftekhari, A., Rosen, C.S., Crowley, J.J., Kuhn, E., Foa, E.B., Hembree, E.A., & Karlin, B.E. (2016). Effects of a comprehensive training program on clinician beliefs about and intention to use Prolonged Exposure Therapy for PTSD. Psychological Trauma: Theory, Research, Practice & Policy 8(3): 348-355.
Webster-Stratton, C.H., Reid, M.J., & Marsenich, L. (2014). Improving therapist fidelity during implementation of evidence-based practices: Incredible Years program. Psychiatric Services 65(6): 789-795.
One key to both learning a new approach to treatment and maintaining our existing skills involves consultation, particularly for EBPs. Don’t just take my word for it, research shows that consultation after a training workshop not only boosts providers’ subjective self-efficacy and intent to use the treatment (Ruzek et al, 2016), but also improves objective fidelity ratings as well (Webster-Stratton et al, 2014).
Fortunately, this reinforces my belief that my consultation experiences have been time well spent as I have spent a lot of time in in consultation-related activities since graduate school! To wit, I have been a consultee when new to a protocol and to the process and terrified of getting it wrong. I have been a consultant, getting to talk about my favorite subject and doing my best to keep up with the literature. I have provided consultation, formal and curbside, group and individual, in-person and via phone or video conference, in primary care and specialty settings, with interns and licensed providers, with active duty and civilians, and with psychologists, social workers psychiatric NPs and mental health technicians. Whew! With all of this I have picked up on a few things that I want to share to encourage you – the therapist -- to use and make the most of your consultation resources.
It can be scary learning something new. It takes courage to sign up for consultation. Training in a new treatment means starting at ground zero, and may bring potentially unnerving reminders of early graduate school. Even if you seek consultation in an area in which you have experience, and even if meant constructively, it in essence opens you to critique. Who wants to “start over” or feel evaluated? Let’s look at it another way instead, after all, that’s what good cognitive-behavioral therapists do. How about this alternative thought, “Who wants to continue growing their skills?” I’ve heard that children learn more comfortably because they are not afraid to try and have a few misses along the way. Even though we inevitably age, that spirit of learning and growth can continue to motivate us.
Consultants are people too, who just love to talk. Ok, ok, I am speaking for myself here (no pun intended), but I have yet to meet a consultant who does not love to answer questions. Try asking just a yes/no question and you’ll probably still get a five minute-plus response. My consultant colleagues, you know we do this! One of the values that typically drives consultants and trainers is a love of information and the desire to share that acquired knowledge. Like reading a story, we may excitedly turn the pages of a research article thinking “ooh, and then what?” As a consultee, taking advantage of this knowledge and perspective to hone your own clinical acumen means feeling free to ask plenty of questions. In turn, consultees keep consultants continually growing in turn. Questions may lead to further research or new perspectives. The best consultants get consultation themselves, and participate in a community of expertise to broaden and deepen their knowledge. You may notice a theme here, consultation promotes career-long growth for both consultees and consultants.
Is it patient reluctance or therapist reluctance to implement a treatment? Consultees often bring cases to discuss, wondering if the patient “fits” the treatment or is even ready for the treatment. Certainly, contraindications exist, such as if the patient doesn’t actually have the diagnosis for which the treatment is intended. Patients may also benefit from motivational interviewing or other strategies to enhance engagement. That said, often provider factors are the “LIMFAC” or limiting factors. Focus on basics when you consider fit: does the patient have this diagnosis, does the patient want treatment? Or does the therapist not want to try a new treatment or not feel competent delivering the treatment? Consider if questions about patient readiness come directly from the patient’s report or from your subjective perspective that may be influenced by potential discomfort with the treatment.
If the patient does not immediately improve, wait before throwing out the baby with the bath water. Lack of patient improvement is often considered one of the biggest stresses for behavioral health providers. After all, many of us joined the profession to help others. There is a balance here, on the one hand, repeatedly trying the same techniques in the face of no improvement may not only be foolhardy, but can also be unethical per APA guidelines. At the same time, switching gears to a different treatment too early could prevent enough time for an adequate dose of an intervention. Let’s first consider something that may seem basic, but in my experience, may inadvertently be overlooked. Specifically, has the patient actually done the intervention? Often patients don’t improve when they don’t fully follow treatment guidelines (surprising, I know), but are unaware that this partial adherence imparts an insufficient “dose.” A consultant can help you identify where exactly and how any non-adherence can be limiting your patient’s progress.
A two-day workshop is not enough. Learning via workshops packs so much information into a short period of time as a critical start to learning a new protocol or strategy. To insert a shameless CDP plug, we have some pretty outstanding workshops (see a list of upcoming training events at http://deploymentpsych.org/training). Provided materials then help turn the knowledge into practical skills. Yet, research shows that the relatively brief time spent in a workshop is not enough in and of itself to enable mastery of new skills (see references above as examples). Post-workshop consultation discussions have revealed this as well; it helps clinicians new to a protocol to review key points, continue to practice, and dissect real-world cases to truly internalize treatment rationale and implementation. When you take a workshop, take advantage of any consultation resources the trainers provide, preferably on a regular basis. Opportunities may be not only in person at your clinical setting, but also telephonically or through online platforms, like Zoom or Adobe Connect. The CDP offers a variety of consultation resources for providers who have taken our workshops ranging from calls to emails (see http://deploymentpsych.org/resources/consultation-services for more).
I hope that these suggestions inspire an interest in increasing your involvement in consultation. As hinted at above, I strongly believe in lifelong learning and in that light, I would still hesitate to call myself an expert. Surely what I have learned so far is just a drop in the bucket. With that in mind, don’t just take my word for it, please share your consultation experiences and suggestions!
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Diana C. Dolan, Ph.D., CBSM is a clinical psychologist serving as an evidence-based psychotherapy trainer with the Center for Deployment Psychology at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. In this capacity, she develops and presents trainings on a variety of EBPs and deployment-related topics, and provides consultation services.
References
Ruzek, J.I., Eftekhari, A., Rosen, C.S., Crowley, J.J., Kuhn, E., Foa, E.B., Hembree, E.A., & Karlin, B.E. (2016). Effects of a comprehensive training program on clinician beliefs about and intention to use Prolonged Exposure Therapy for PTSD. Psychological Trauma: Theory, Research, Practice & Policy 8(3): 348-355.
Webster-Stratton, C.H., Reid, M.J., & Marsenich, L. (2014). Improving therapist fidelity during implementation of evidence-based practices: Incredible Years program. Psychiatric Services 65(6): 789-795.