Paying for Consultation: What Are You Waiting For?

by Carol Campbell, MFT

As someone with an ongoing interest in the vitality and relevance of our profession, I am perplexed that many MFTs choose not to get regular consultation on their clinical work. According to the 2008 state CAMFT membership survey, 38% of us do not regularly get consultation on even a monthly basis, let alone more frequently.

In order to put the issue into perspective, I decided to interview some colleagues in private practice about their experiences with seeking consultation on their work. It seems there are three groups: Group A therapists occasionally ask a colleague or expert for perspective on a case they are thinking about. Group B therapists regularly seek consultation from peers. And Group C regularly pay experienced clinicians for expert consultation on their work, usually weekly.

Group A therapists would probably agree with my observation that they tend to be either highly confident, isolated, shy, and/or convinced that they can't afford consultation, either financially or time-wise. My assumption would be that they tell themselves that they do not really need consultation, or as one colleague suggested, "They think they can listen objectively — they really believe that." Or perhaps they are not convinced that objective listening is important in therapy.

Group B therapists recognize the value of having peers offer help on tough cases, so they make a point of getting together for case consultations regularly. They value the support that others in the field can provide, and in fact many times such support evolves into friendships between therapists who find themselves in the same peer consultation group. One colleague who organized a peer consultation group says, "It's really healthy to have some kind of reality check around how you are putting things into words — not just going into your own little world about how you do this."

Group B therapists also appreciate the inherent marketing value of regularly spending time with colleagues. When the time comes to make referrals, they naturally prefer to do so to colleagues whose work is known and admired. Particularly in a private practice setting, being in a peer consultation group is a business advantage because of the inherent marketing involved simply by participating in the group.

Group B therapists in peer consultation generally take turns talking about cases. Sometimes the role of presenter is assigned ahead of time. Other times whoever is most eager is given the floor. Sometimes one person dominates the sessions; other times a time limit is imposed so others can speak. This informality is valued for its tendency to reduce the presenter's anxiety, and increase the probability that eventually everyone will take advantage of the opportunity. Each person in the group is able to offer comments and suggestions about the case, thereby enriching the experience.

Group C therapists, those who pay experts for consultation, either individually or in groups, showed me a very different attitude towards the topic from those in Group A and Group B. (Full disclosure: I fall into Group C myself.) Therapists who pay for consultation had some strong opinions about what they see as the great importance of expending precious resources in order to get more than informal or peer consultation. They all said that while they also benefit from and enjoy informal consultation with peers, they see that experience as being no substitute for the quite different experience inherent in getting regular paid consultation from someone with greater expertise. They tend to get consultation on all their cases eventually, as opposed to thinking that only sometimes do they need help.

Group C therapists say they put more effort into preparation for consultation and get an order of magnitude more benefit out of it than what can be accomplished in even the best peer consultation. Group C therapists prepare written transcripts of the sessions, which they read slowly to the consultant. Line by line the consultant helps the therapist listen not only to the patient, but to how the therapist listens to herself. This listening is not about the content, but rather listening to yourself as you listen to the patient. The point is to monitor your own experience of immersing yourself into what the patient is saying, and using that information to better understand the patient's inner world. By having an actual transcript to work from, the consultant can help the therapist with questions such as: How do I feel about this person? How is this patient alike or different from other patients? What gets stirred up in me about this person? What concerns me, sticks in my mind?

Answers to these questions perhaps come with the greatest integrity when an objective third person is involved. A paid consultant has the standing to be that objective overseer. A paid consultant has less reason to pull punches or avoid saying what might be hard to hear — always a danger when it is only peers in that role. Since the therapist usually brings transcripts of the same patient for many weeks at a stretch, the depth of understanding becomes not just helpful, but profound. As a result, the quality of the therapy often improves substantially, even if it seemed to be going well in the first place. Group C therapists were adamant that having worked with it and without it, they could not think of trying to do psychotherapy without the help of a paid consultant, even if they also take part in peer consultation.

Here is my fantasy of how Group C therapists might respond to the positions of Group A or Group B therapists:

"I have been working with clients with a particular diagnosis for many years now. I know what I'm doing — I just don't need to pay someone else to be looking over my shoulder. I value the patient's privacy."

While experience with a particular client population could be presumed to be a very significant factor in establishing a good working relationship and conceptualizing a case effectively, it would be utterly foolish to presume to know what to expect with a particular individual. More importantly, there is no way one can be doing therapy under any circumstance without one's unconscious mind having an enormous impact on the work, to say nothing of the impact of the unconscious mind of the patient.

By definition if something is unconscious, there are hurdles to be leaped in order to be able to notice it. A senior therapist, who has permission to be completely objective, arguably can stand in a different place and see what is being overlooked, distorted, or misunderstood more effectively than the therapist presenting the case. The patient is the clear beneficiary from this process. No wonder the most experienced and successful clinicians tend to remain in paid consultation themselves, no matter how many years they have been practicing.

Regardless of one's approach to thinking about the patient's privacy, there is no need for any patient's identity to be shared in consultation, and every effort is taken to protect that essential premise.

"I'm a bargain hunter, and I don't like spending my hard earned money like that. Why pay for what I can get for free? I can't afford to pay someone for consultation, because I don't make that much in the first place."

As with anything else, you get what you pay for with consultation. What you get from paid consultation is qualitatively different, and generally superior, to what you get with peer consultation. With paid consultation, the therapist typically follows one case in detail over time, usually through hearing a verbatim transcript each week prepared ahead of time by the therapist. In this way the discussion can be precisely about what is happening in the sessions, not just relating stories about the client's background and life and talking about that.

The quality of one's work is tied to what you put into it. If you aren't making enough to cover the cost of good supervision, perhaps it's time to ask some tough questions. Why are you unable to attract and keep enough patients to meet your goals professionally? Nearly every person I interviewed remarked that their caseload increased as soon as they began paying for private consultation. Several people mentioned they feel confident raising their fees to reflect the added value of their work because of their outlay for consultation, and therefore they make more money now than they would otherwise.

There is no shortage of people who need therapy. There is a shortage of therapists who know how to build a practice and are then willing to suffer the challenge and stress of subjecting their work to the eyes of an expert consultant, who can often provide a remarkable boost to the quality and effectiveness of the therapy. Good consultants work with tact and empathy, and provide outstanding support through the vulnerability involved. They also share in, and add to, the joy of knowing when things are improving.

"I am more comfortable talking with peers about my work. I would be too intimidated by sharing my work with an expert or someone I don't know."

If your goal is to avoid feeling uncomfortable, then by all means seek what is familiar, but don't expect me to make referrals to you. If your goal is to be the best therapist you can be, then continuous learning is what is paramount. In order to learn, we need to suffer exposure to what it is that we do not know. Good therapists are excited by the prospect of learning. The good news is that the joy of learning something new actually makes it not a suffering experience after all.

Something has to break down (in this case our self-assuredness perhaps) before something else can come. If we want a comfortable, easy time of it, as one person said to me, there will be less learning because there is less suffering. We must bear discomfort in order to learn.

Some people I spoke with identified one source of suffering to be the inherent authority of the expert consultant that one pays. I would argue that there has to be an aspect of authority in the person you go to for consultation, and you need to recognize, suffer, and accept that. One person (the consultant) has something that the other person (the therapist) doesn't have and wants. That is the fundamental reality behind paid consultation. How seductive the urge is to dismiss the difference! From a psychoanalytic point of view, that urge has its roots in a child's resistance to acknowledging boundaries between the generations. Obviously the same process occurs between a therapist and a patient. How can we expect our patients to bear the discomfort of our authority if we avoid experiencing the same issue with a consultant?

Here's the bottom line: The best money you will ever spend as a therapist will be on paid individual consultation on your work. The next best money will be for paid group consultation. Peer consultation can be helpful, but it is no substitute for the rigors of hiring a senior therapist. Stop procrastinating — take a deep breath and make that phone call!

I would like to thank the many colleagues who shared their thoughts with me in preparing this article.

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Carol L. Campbell, MFT, is a licensed marriage and family therapist providing psychotherapy and psychoanalysis for individual adults and couples in Palo Alto, California. She has degrees from Brown University and Santa Clara University and has been licensed since 1991. Carol is a graduate of the Palo Alto Psychoanalytic Psychotherapy Training Program sponsored at Stanford by the San Francisco Center for Psychoanalysis and was a candidate at the Psychoanalytic Institute of Northern California in San Francisco from 2010-2011. She is also a clinical member of the California Association of Marriage and Family Therapists and the Northern California Society for Psychoanalytic Psychology.