Clinical Consultation
Dr. Klafter's Consulting Room
Approximately one-third of my professional time is devoted to consultation for psychiatrists, psychologists, psychotherapists, and other clinicians regarding diagnostic questions, impasses in psychotherapy treatment, psychopharmacologic strategy, development of advanced psychotherapy skills, and how to assess the suitability of patients for intensive psychotherapy or psychoanalysis. I also provide consultation for patients who are seeking a second opinion about diagnosis, treatment planning, or the next steps in situations where previous treatments have not produced satisfactory results.
Consultation is a normal and essential part of professional development in psychoanalysis, where it is built into training for many years alongside the analyst’s personal psychoanalytic treatment. Even after training is over, consultation remains equally important throughout one’s professional career. Even though I am frequently consulted by other therapists and psychiatrists, I continue to consult with colleagues for my own growth and development as a therapist. Psychotherapists and psychoanalysts are life-long learners, and thoughtful consultation with experienced colleagues is one of the most important ways clinicians continue to refine their work over time.
In earlier stages of the field, consultation was often referred to as supervision. I continue to use the term supervision when there is a formal hierarchical structure in place—for example, when a senior clinician supervises trainees or when a therapist is not yet licensed and works under the authority of a supervisor. In most other situations, consultation is better understood as a collaborative process between colleagues who are working together to think more carefully about complex clinical problems.
Consultation may involve a one-time diagnostic evaluation or may take place over time through ongoing discussion of clinical material, depending on the needs of the patient or referring clinician. Consultation may be helpful in the following situations:
Second-Opinion Consultations for Patients and Clinicians:
No clinician should discourage a patient from obtaining a second opinion. Patients who have questions about whether their treatment is progressing as expected may wish to meet with another clinician for consultation. There may be questions about diagnosis, modality of therapy, the therapy relationship, medications being used, or other aspects of treatment. In most cases, diagnostic or second-opinion consultations are provided while a patient continues treatment with their current clinician. Ideally, the second-opinion process is collaborative with the treating clinician and supports that treatment relationship.
Diagnostic Consultations for Patients and Clinicians
complex and difficult clinical presentations
questions about personality organization, including narcissistic and borderline states
trauma, complex trauma, and dissociation
treatment-resistant depression or anxiety
questions about the suitability of psychoanalysis or intensive psychotherapy
Psychotherapy and Psychoanalytic Consultation for Therapists and Psychoanalysts:
psychotherapy and psychoanalytic treatments that appear to have reached an impasse
deepening a psychotherapy treatment toward a psychoanalytic process
transitions from supportive or manualized therapies to psychodynamic modalities
maintaining the professional frame when professional boundaries are challenged
understanding and working with transference, countertransference, enactments, and projective identification
working with resistance
working with dreams
working with patients or families who are skeptical about the benefits of psychotherapy and mental health treatments
Psychopharmacology Consultation for Prescribers
For psychiatrists and psychiatric nurse practitioners, consultation is available regarding patients who have failed to benefit adequately from multiple medication trials, including strategic combinations of psychotropic medications for treatment-resistant disorders, and the appropriate use of tricyclic (TCA) and monoamine oxidase inhibitor (MAOI) antidepressants. I am a member of the International MAOI Expert Group.
Cultural and Identity-Related Clinical Questions
cultural, religious, political, gender, race, and sexuality-related factors that influence treatment
Professional Development Consultation for Clinicians
decisions about pursuing advanced psychotherapy or psychoanalytic training
developing a stronger psychotherapy practice
building a more financially sustainable and stable professional practice
professional burnout