Staff Voices: The Clash Between the Ideal and the Realities of Consultation

Staff Voices: The Clash Between the Ideal and the Realities of Consultation

Kelly Chrestman, Ph.D.

I recently had the privilege of working with my colleagues, Dr. David Riggs and Dr. Paula Dominici, to deliver a workshop for experienced PE therapists who are taking their skills and knowledge to the next level by becoming consultants. If you know Dave and Paula, then you are aware that the workshop was well-organized, data-driven, thorough, and extremely clinically relevant. It was a beautiful thing.

So why was I there? What could I add? I asked Paula for some guidance, because frankly she and Dave are the A-team. I wondered what I could bring to the table that wasn’t already being thoroughly and expertly covered. Paula told me to bring my day-to-day experiences, doing consultation in the field, with the smart, busy, mission–focused clinicians that I speak with and consult with every day.

OK. My part was to bring the chaos. That is, to discuss the real-life monkey wrenches that clinical work, or consultation, or any other real-life, real-people activity brings to our neat and logical plans. The question I needed to address was this: knowing what the ideal consultation situation is, how can we be effective (Effective with a capital E, trying my best to channel Marsha Linehan here), when the ideal circumstances are not only elusive, but often impossible.

As a result, the workshop was partly about consultation logistics, partly about advanced PE skills, and partly about herding cats…that are on fire…and afraid of water.

Now before I am accused of disrespect, for comparing consultees to tortured cats, let me clarify: I like cats. I never, ever torture them (except for an occasional flashlight on the wall trick). Even more so, I really admire and respect the people who consult with me, both at CDP and in the field. The goofy metaphor is more a response to circumstances in the field, than to the incredibly selfless and dedicated people who provide the services.

The circumstances are thus - they/we are in the midst of a massive culture change toward evidence-based practice in the world of mental health care. EBPs aside, mental health care resources, i.e., the number of available therapists, are not keeping pace with the number of clients who need care. Finally, though evidence-based treatment holds a lot of promise, change of this magnitude is a messy and lengthy process. We, as a culture, aren’t just painting the façade, we are knocking down walls and installing new structural supports, plumbing, and wiring …(I can’t help it. It’s a metaphor addiction.)

Dave and Paula know all this, which is why they included me in the workshop. I bring the mess. And the goofy metaphors. There are those who believe that consultation can only be effective if it is provided under ideal circumstances, and that to do less is to risk the mission and dilute the effectiveness of EBPs. While I agree that the ideal is best (I will address what some versions of the “ideal” look like in future posts), I am a firm believer in blooming where you are planted…or making lemonade out of lemons…or not sacrificing the good in the service of the perfect…you get the idea.

For me consultation, not unlike clinical work, or teaching, or raising kids, it is not always a neat, linear, and predictable process, as much as we would like it to be. It sometimes feels like you are chasing people around; dedicated, hard-working, talented people who have way too much work to do, and not enough hours to do it in. And the “solution” you are offering them is to spend MORE of their scarce time with you, doing stuff that is sometimes difficult, often unfamiliar, and that feels fraught with (mostly unjustified) fear. It’s a pretty hard sell.

So as we oriented the new consultants in the workshop, we definitely outlined the ideal situation – and we encouraged them to shoot for that at all times – but we also made it clear that other realities are possible, and probably pretty likely. When reality happens, they can and should focus on the present moment, and remember that they can be Effective, with a capital E, in each moment.

We don’t want them to lose sight of the mission of making evidence-based psychotherapy available to all the people who need it. If consultants are prepared to work with each situation as it is, ideal or not, then there is a better chance that an over-scheduled, under-appreciated therapist is going to continue to use EBPs. Even better, that therapist might feel motivated to come for consultation again, because they felt supported, enriched, and appreciated by their interaction with the consultant, and, as a result the mission is incrementally advanced.

Besides, there is more than one way to skin a cat…*

*see previous disclaimer about cat cruelty.

Dr. Kelly Chrestman is the Lead for Online Consultation Services at the Center for Deployment Psychology.