The analysis resulted in four superordinate themes and ten subordinate themes; presented in Table 1 below.
Consultation enabled all clinicians to develop their DBT knowledge and enhance learning in a range of different ways. The following theme highlights the learning experience in relation to model adherence and knowledge acquired from members of the consultation group.
Consultation provided a platform to both monitor and learn about the DBT model as well as assist participants in adhering to underlying DBT principles. This was partly achieved by using consultation to share resources, fine-tune DBT materials and discuss elements of the model with other members. However, the experience of learning about the model in consultation appeared initially to be an unsettling one for most participants. There was often a sense that participant anxiety was observed in and shared by fellow members in consultation.
“I remember the first consult we went to … the language in DBT is quite specific and even the language around consult and things like leader and observer and all this kind of stuff. It felt really strange.” (Deirdre).Footnote 1
There was a distinction in the interview data between experiences of founding members versus experiences of members who joined an established team. Although both expressed anxiety around the acclimatisation to the DBT model, founding members also had the added task of learning how a consultation is operationalised initially.
“I think we definitely have … come a long way with that, ‘cause I mean we started with like literally taking out the book, what are we supposed to be doing now.” (Eleanor).
For many of the participants, acclimatisation to the model was facilitated by a growing familiarity with the underlying principles of the DBT philosophy. Indeed, the consultation team’s ability to facilitate learning and confidence was aided by the regular revision of the DBT agreements, where one agreement would routinely be revisited during each session. While gaps in theoretical knowledge often existed for participants early on, many found the underlying tenets of DBT, in relation to fallibility and the essence of truth, liberating the more they learned about the agreements in consultation. The resulting effect was to reduce the pressure to always be right about the model and how the work should be completed.
“I think the assumptions about you know there being no absolute truth and we’re all fallible and everyone is doing their best but must try harder and all the rest of it… I think it kind of frees us up to make those mistakes” (Frances).
For most participants, the knowledge acquired about the model (including the various DBT skills and principles, as well as the various consultation roles) was reinforced through the active practicing of model components in consultation. Consultation was seen as a useful platform for learning when applying the DBT model to client work; in particular when discussing client issues raised by other team members.
“…if it’s not my client I’m more likely to be better able to think about the DBT principles and to think in behaviourally specific terms.” (Frances).
Consultation provided a space for clinicians to experience the aspects of the DBT model directly. This was particularly relevant to the DBT skills clinicians teach their own clients in other DBT modes i.e. individual client sessions, phone coaching and skills groups.
“Every kind of skill would come up in the consult. Again, I think a lot of emotional regulation stuff…just kind of looking at the emotion, …observing what’s driving the emotion, looking at the function of the emotion.” (Hannah).
In consultation team members often bring with them expertise related to their respective disciplines. Participants found the mix of professions in consultation extremely helpful in gaining knowledge in other relevant areas. In this respect consultation represented a useful opportunity to draw upon the expertise of other disciplines, not just in terms of member knowledge about DBT theory. For example, participants spoke of gaining knowledge around client medication, child protection information and physical injury or specific psychological learning in relation to eating disorders and addiction.
“You can kind of be with a client and you know maybe have one of their target hierarchies could be you know issues with drink or alcohol. And then you can lean towards something he [the addiction counsellor] may have said … and it can kind of shape you.” (Hannah).
Another aspect of experience transfer relates to the acquisition of knowledge from client dilemmas and issues brought to consultation. Although other clinicians might not currently be experiencing the same type of issue, listening to issues creates a type of reservoir of knowledge to draw upon at a later stage.
“… I’ll often have a situation going on even in phone coaching or… with somebody, anyway I’ll think of maybe an experience I’ve heard from somebody else in consult.” (Eleanor).
As one participant suggests “it goes in cycles”, where learning acquired from a previous consultation becomes relevant to your own work at a later stage.
Regulation of the self
This superordinate theme concerns the emotional impact of the client work experienced by participants and the role consultation plays in supporting this phenomenon. The theme examines how emotion is validated, how awareness can be developed in such circumstances and the emotional impact associated with feedback in consultation.
Participants often referred to the emotional impact of working with clients with BPD. Given the demands in terms of the learning element and the emotional impact of the client work, various emotions such as frustration, doubt and anxiety arose for different individuals in how they completed their work as DBT clinicians. Overall, consultation interaction helped most participants regulate their emotions through the validation of emotion; noting the difficulties associated with particular client issues and how this can cause stress and anxiety in how they perceive themselves and their therapeutic work.
“What was helpful in consult was that I was allowed to express the emotional experience that I was having … and … that again the team validated what was valid in that.” (Ciaran).
Participant experiences of consult also highlighted how a more directive approach was utilised to aid therapeutic self-concept. Aspects such as language and contingencies were questioned or suggested; helping to challenge therapists' viewpoints.
“‘Cause we can go down the road ‘Oh I’m absolutely useless’ … and I think the group helps to ground you and helps you to think about the language that you are using.” (Margaret).
Another aspect of therapeutic self-concept was around the choice of action selected by the clinician. Many participants found the team would often validate their choice of action, which appeared to have a regulating effect in reducing anxiety or doubt over their personal approach to the work.
“It’s very helpful as well when they say ‘Yeah that’s exactly what I’d have done as well’.” (Jennifer).
Participants mentioned structural elements of consultation and how they encouraged clinicians to reflect on their current therapeutic self-concept. This was primarily in relation to the routine questions posed at the start of consultation, which focus specifically on the clinician rather than the client. Particularly pertinent was the questioning of whether any therapists were in a state of ‘high emotion’. For most participants, this had the effect of providing space to share high emotion, as well as validating the fact that the work can be very demanding.
This theme concerns the evolution of consultation members’ viewpoints or insights and how they choose what actions to take in their DBT work. What differentiates the theme from knowledge acquisition is the interpretative quality to these insights as well as how the team input helps provide new perspectives.
Participants acknowledged how they may have the academic and technical knowledge but may still experience ‘blind spots’ during the work. This was not necessarily due to high emotion in the clinician, but rather due to a simple oversight or the large number of variables involved when working with complex clients. However, developing new insights was not simply a case of receiving suggestions from the team. Interview data highlighted that when new perspectives were brought into the participant’s awareness, they must then still decide on what action to take, sometimes employing DBT principles to do so.
“And you can take all elements and put it together rather than you know it’s not that one person is saying ‘The way that I do it is right’.” (Hannah).
Most participants did not acclimatise to the feedback process in consultation immediately. The process of feedback acclimatisation was aided by a growing familiarisation with the DBT philosophy and model underpinning the way feedback is delivered, such as the use of descriptive language rather than judgemental language when providing feedback, not treating fellow members as fragile and acknowledging the diversity of member views. However, some participants’ early experiences of feedback in consultation were particularly negative, affecting clinician confidence as well as motivation to attend consultation.
“… I was allergic to going to consult for maybe two weeks after that ...” (Jennifer).
“…you can feel like you’re getting bombarded sometimes. And also I think it feels like [to] me it can feel …you’re … being undermined” (Peter).
Above, Jennifer is referring to feedback received in consultation after providing details on a difficult client session. What made the feedback hard for her was partly due to how she was relatively new to the consultation team; that many of the people in the meeting had roughly two years more experience of DBT. For Jennifer it felt like her consultation colleagues were saying “Oh I wouldn’t have done that” or “Oh I don’t know if that was the best thing to do”. The feedback was perceived as invalidating to her, at a time where she felt she did the best she could and was looking for next steps to fix an issue rather than feedback on what she had done already.
In contrast, Peter had more experience in his particular consultation team, but as a psychologist he was used to a different type of feedback in clinical supervision. For him the feedback in his consultation meeting felt very direct and almost competitive at times. He felt when feedback in the meeting was being given it was less focused on the “relationship type stuff” that he would have in regular psychology supervision.
Often acclimatisation to how feedback is delivered in consultation led to a growing appreciation for it. Essentially, what appeared to develop for participants was an ability to focus more on the function of the feedback rather than the perceived manner it was delivered.
“But I think once I got used to it [the feedback] certainly it became a lot easier and I grew to value it.” (Frances).
This theme is evidence of participants’ experiences of some of the underlying processes that occur in the consultation team. These concern the development of a team bond over time as well as the impact membership changes have on participants’ experience of consultation.
Most interviewees were positive about the team experience; referring to a sense of comfort and support. Often it appeared that a team bond in consultation was important in developing a sense of safety and in aiding the smooth running of the meeting. Participants reported that they were more likely to learn more from the feedback process and support if they felt the relationship was strong within the team.
Often evidence of team bonding manifested itself in a sense of joviality and fun at different stages during meetings. Experiences of fun and joviality described in consultation had an important function; namely to help participants and their team manage the stresses of the work. Also, there was a shared understanding amongst participants around how only fellow consultation members fully understand the nature and demands of the work.
“Sometimes more than other times … humour is a really good I suppose way of diffusing the intensity of those experiences.” (Ciaran).
“None of the community mental health team I don’t think understand what you’re doing and that’s why the consult is really important. Because we all understand the role, the function. And we’re all working very hard.” (Niamh).
Experiences within DBT consultation were reported as being influential in developing outside support with team members. Indeed, in terms of the depth of team bond, perhaps the most potent illustration was the presence or absence of “consult outside of consult”.
“I’d ring people if like even at night-time …. like you wouldn’t really dream of doing that with other colleagues, unless I was friends with them do you know… and I think that’s all learned from consult…” (Jennifer).
All participants referred to changes in membership of the consultation team. Participants’ references to team membership changes were mainly in relation to new members joining. It also pertained to the impact of team members leaving due to promotions, changes of location and career breaks.
The reaction to new consultation team members was mixed. Some participants recognised the benefit and necessity of new clinicians joining the group in terms of new knowledge and different ways of working. However, for some other participants the difficulty with new members was their apparent impact on participants’ ability to be open in consultation, as well as the potential effect on existing team cohesiveness.
“…I noticed again when new members would join the team that people would become a little bit less comfortable again understandably. And express a little less until again built up that comfort [with] people.” (Ciaran).
Participants who joined established teams often did so along with other new members; with whom they had completed their training. Therefore, they too had their own subgroups and own level of comfort with each other prior to joining a bigger consultation team. New members could potentially identify with each other’s anxiety around how established members had more experience than them.
“…it was anxiety provoking at the start… thinking these people are more advanced than me … initially being a bit I suppose apprehensive about talking.” (Hannah).
Motivation and consistency
This theme represents the largely consistent and reliable nature of consultation and how it acts as a motivator for clinicians.
Regular and protected consultation time
Consultation acted as an anchor or milestone during the work-week, representing a place of both mental and physical refuge from the stresses and strains of work for most participants. Having a regular consultation time provided many clinicians with a greater sense of security in their clinical work.
“In terms of knowing you’re not kind of stuck with this on your own, that within the week you’re going to be back talking with your peers about it.” (Deirdre).
From a systems perspective, consultation was seen as a useful timetabled structure in the week to help buffer demands from other work sources.
“It’s great to be able to say …I won’t be in consult until Tuesday so…there’s not pressure on you to give your own sort of personal opinion or any answers to anything.” (Eleanor).
However, some participants found that time constraints during consultation were a growing issue. Firstly, four participants reported that business meetings were a significant factor in relation to consultation time infringement; how they left “very little time for … the actual full consult” (Geraldine); thus eroding the consistent nature of consultation. Secondly, the number of consultation members was a growing concern for some as the prospect of more new members joining the team created some unease around having sufficient time to discuss their clients.
There was an overwhelming consensus that consultation was a necessity in terms of motivating clinicians to work over the long-term. When asked how they would fare in the absence of consultation, each participant stated they would not feel safe in continuing; with the majority stating that they would in fact not continue to practice in its absence.
“I don’t think I could stay in DBT if consult wasn’t available… I don’t think I’d be able to survive doing it…” (Lisa).
In some cases, consultation was even perceived as a motivational reward for the hard work invested in other aspects of DBT.
“… I think the consult is a big piece of what sort of is the pay-off of that [the hard work] … if I didn’t have consult I’d feel like I’m putting a lot of my time and energy into this and I could actually go away and do my day-job…” (Deirdre).
Participants referred to how supervision helped to answer questions that were not resolved in consultation. In addition, some participants referred directly to how supervision also plays a role in supporting the continued motivation of clinicians. This was particularly relevant in relation to maintaining consistent adherence to the consultation model, helping teams to return to optimum performance levels.
“[Our supervisor] said to us … ‘Ye need to get back in gear…ye need to start … doing your consult’ you know have… your observer your chairperson you know the mindfulness. Once we went back in and started doing that it was actually very powerful.” (Lisa).