It is usually taught, in "therapy school," that clients or patients should not be seeing more than one therapist at the same time.
Here are some of the reasons often given for this policy:
1) seeing more than one therapist could be an inefficient use of resources
2) the multiple therapists could be "working against each other" or perhaps confusing the client or patient
3) the multiple therapists could be part of a larger process of the client being engaged in unhelpfully complex relationship entanglements
There are many case studies describing situations in which multiple therapists appeared to bring about problems.
But is there more substantial evidence, beyond case reports, about this?
To begin, why not consider other examples in life, where one might have "multiple caregivers":
1) Parents. Many people have two parents. While it is often the case that each parent provides different types of care to the child (e.g. one parent providing financial support, the other providing daily care in the home), it is more often the case, especially in the current generation, that parents share all elements of care. This is not an "inefficient use of resources," and does not lead to a higher risk of the parents "working against each other," it is just better and more enjoyable parenting!
The therapist-client/patient relationship is not the same as a parent-child relationship, but there are some similarities in most cases.
2) Friends. Many people have more than one friend. The different friends a person may have do not necessarily provide different types of "friendship experience." Some individual friends provide the exact same type of "care" as another. You might have two different friends whom you like to have personal conversations with in the same kind of way, or two other different friends who both like to go hiking with you. It often works well to have more than one friend, though of course there can be problems between them at times!
The therapist-client/patient relationship is not the same as a friendship, but there are some similarities in most cases.
3) Teachers. Many people have more than one teacher. For a given subject, there might be several different people sharing the task of teaching (for example, a professor, a TA, and a tutor). While there could sometimes be differences or contradictions between the different teachers, it is generally considered beneficial to have more than one teacher! In fact, being exposed to different teaching styles could improve learning. Even if different teachers give contradictory advice, this could often enhance a learning process, as it exposes the student to multiple viewpoints, therefore stimulating a more open-minded analysis in the intelligent student. It would be like reading two different newspapers, instead of just one, in order to better understand current events or politics.
The therapist-client/patient relationship is not the same as a teacher-student relationship, but there are some similarities in most cases.
Are there ways in which multiple therapists are already accepted as a norm?
I believe there are. In most health care systems, such as mental health teams, there are multiple people involved in an individual's care. There may be a social worker, a nurse, a "case manager," a designated "psychotherapist," and a physician or psychiatrist. While each member of this team may have particular specified roles, it is often the case that each person of the team helps most through what I might call "common factors." These "common factors" are akin to "Item 1 and Item 2" that I have described before (http://garthkroeker.blogspot.ca/2016/06/angry-birds-and-items-1-and-2.html). Such factors are the foundation of all "psychotherapy." Hence, in a stratified team setting, each member is already providing psychotherapeutic foundations. It may often be the case that the client or patient finds some particular member of the team more beneficial than any of the others, not because of the caregiver's designated role, but because this team member is attending more to Item 1 and Item 2.
In other examples, it is very common for a therapist to recommend some other health care resource. There might be regular psychotherapy sessions, but with referrals to a CBT group, a meditation group, a personal trainer, a yoga class, or a dietician. While these referrals would overtly be to allow the client or patient to pursue some other type of care which is not taking place in the current psychotherapy frame, they also inevitably lead to a fundamental duplication, once again through Item 1 and Item 2. Perhaps the yoga teacher or dietician might actually ask about the client's childhood, and offer some kind of empathic feedback! Perhaps the personal trainer might recommend some behavioural therapy exercises alongside the workout routine! This would not be unhelpful redundancy, but would rather be ways to potentially consolidate therapeutic ideas from fresh perspectives!
Are there any neurotic or biased motivations among therapists, which lead to continuing aversion to the idea of multiple therapists?
One possible bias is simply the force of tradition. It is a long-established belief that having multiple therapists is problematic. I believe there are roots in the psychoanalytic tradition; here, the theory suggests that a strong "transference" must be formed with the therapist, in order for the therapy to work properly. Having other therapists would somehow distort this transference process.
This reminds me of jealousy in a close personal relationship. The assertion from the therapist is something like, "choose me, or choose the other therapist...you can't have both!"
The thing is, jealous behaviour does not actually improve the quality of a relationship; rather, it is a sign of insecurity. Relationship quality is indeed important, but it must be built on a foundation of trust, kindness, and respect for freedom.
Here are some reasons to have a more relaxed attitude, professionally, about clients or patients having multiple therapists:
1) it is an issue of respecting the free choice of the client or patient
2) it may simply expand a circle of care, or a network of care, for vulnerable people who need or desire support
3) some therapists may have limited availability, or may frequently have absences, despite having a very good connection with a particular client or patient. It can be good to have other therapists to be involved to cover for such absences.
3) potential problems or conflicts between different therapists can be resolved through dialogue or collaboration, not simply by forbidding the possibility of having multiple therapists
4) pushing different caregivers to have more restricted roles (e.g. for psychiatrists to only have brief medication management visits) causes impairment in morale and in clinical skills among such practitioners. Psychiatrists who are only advising people about medication, while others do "psychotherapy," will become less and less attuned to Item 1 and Item 2, to the great detriment of themselves and their patients. It will strengthen the stereotype of psychiatrist as detached, medication-prescribing, and superficial.
There are indeed cases in which having multiple therapists is clearly unhelpful for the client or patient, or for the therapist or system. And, in these cases, as a professional decision, it may be beneficial to take steps to encourage the client to choose one or the other caregiver. In other cases, it may be beneficial to step back from involvement in a person's care, to allow them to focus on just one strategy at a time.
But I think such decisions should be made on a case-by-case basis, and should not be made as part of a dogmatic policy.
Friday, June 17, 2016
Thursday, June 16, 2016
The Myers-Briggs Type Indicator & its use in the workplace
Myers-Briggs personality typing is familiar to many people, and is often used in workplaces, in career counseling, and even in psychotherapy. One of the motivations is to help people understand and reflect upon their personality styles. It can help people recognize that there are a variety of different personality styles in any group, and that it is important to consider this variety respectfully, to affirm various individual strengths or talents, and to anticipate common problems. Each style is framed as bringing certain strengths or gifts to a group. But every style can be associated with certain types of problems as well. Interactions between two particular "types" can often lead to particular issues or problems; it can be useful for groups to reflect on these phenomena, in order to work towards greater harmony, enjoyment, and productivity.
There are various problems with Myers-Briggs typing, and with other forms of personality analysis, particularly when applied in a workplace setting:
Process Problems
Confidentiality & Privacy
In some group settings, personality testing is offered as an activity, in which results would be shared with the group. Immediately, there are serious concerns about confidentiality and respect for privacy. In some ways, a "personality test" is analogous to a medical test. Most of us would be uncomfortable volunteering to share our medical test results (such as a chest x-ray or urinalysis) with a group of co-workers, employers, or strangers.
Peer Pressure
While this type of activity is often respectfully introduced as voluntary, there is a strong peer pressure element. A person who would choose not to share or participate would immediately stand out as an outsider. It would not be irrational to wonder if a non-participant might be doing so because of some sort of personal difficulty, uncooperativeness, or "personality problem." Such an unhealthy dynamic is due to the activity itself, more than the dynamics of any individuals in the group.
Labeling
Also, in terms of process, the Myers-Briggs gently applies a sort of "diagnosis." The 4-letter code each person gets is actually a label. The label may be an interesting thing to reflect upon, but nevertheless it is a label, obtained from answering a small number of simple questions.
Some of the Myers-Briggs types, such as INFJ, typically occur in only 1-2% of test cohorts. If test results are shared as a group activity, with a group of 30-50 people, and with the group then dividing up according to type, then the INFJ group could be a group of just one person! This would literally "single people out," and give rise to an unnecessary experience of isolation or exclusion, rather than celebrating group togetherness or harmony.
The principle of giving people labels based on a few minutes of superficial assessment is troubling, in terms of process. It is exactly this sort of pattern that I encourage people to step away from as a practice, particularly with regard to mental health care policy. As a general principle, I like to be very reserved about diagnostic labels even after spending many hours (or even years) knowing someone; I think it is quite an egregious practice to pull out a label after a 10-minute questionnaire!
When people are given labels of any sort, particularly if such labels are sanctioned by some sort of official test, "clinical wisdom," or group approval, then it can push people into conforming to these labels. It is a form of typecasting. If you are told that you are something, you are more likely to believe that as part of your sense of self. If a teacher you trust tells you that are a talented mathematician, but not a very good writer, and shows you a questionnaire result which "proves" this, then you may be less likely to pursue an interest in writing! Of course, such feedback could be given in a way which is honest but not discouraging (e.g. "you could be a truly great writer -- but I think you need to put an extra hour of work into your writing every day this year!")
In the Myers-Briggs, the labels are generally benign, each of which laden with various positive affirmations, but the process is troubling, as it is an example of a sensitive, personal identity issue being pushed through forces of labeling and peer pressure.
Of course, the Myers-Briggs can be used simply as a tool of playful engagement in a group, almost like a "party game." It can very reasonably help a group acknowledge, respect, and admire the diversity of personal and interactional styles. And the labels can be taken with a grain of salt. None of the labels are framed in a pejorative way at all, they are all framed as style variations, which all carry different strengths or gifts that are to be respected in a group.
Yet, these process issues must be considered with great seriousness.
Validity
Personality traits of any sort occur in a continuum in the population. Generally, traits such as extroversion are normally distributed. Most people in any group will be close to the population mean on any trait. Yet the Myers-Briggs gives people a categorical label (for example "E" or "I") for these traits which are actually on a continuum. It is a literal example of "dichotomous thinking," which is considered a "cognitive distortion" in CBT theory. It would be like describing people as "tall" or "short" in a height category. Or like describing the climate of a place as "hot" or "cold." Furthermore, because of this dichotomous labeling, there is a huge statistical "fuzziness" caused by the majority of people having traits near the mean. People in the 48th percentile for extroversion would be considered an "I" while people in the 52nd percentile would be considered an "E." In reality these two people would have differences in this trait which are not statistically significant, yet they are given labels which are dichotomously opposite, in just the same way as a person with extreme introversion would be considered different from someone with extreme extroversion.
Reliability
Furthermore, because of this statistical "fuzziness," there will be limited test-retest reliability for the Myers-Briggs, particularly for those people whose scores are closest to the mean. For those people who were farther from the mean, they would not have needed to fill out a questionnaire to tell if they were introverts or extroverts! They could have just told you verbally, without any questionnaire at all!
Carl Jung
The Myers-Briggs system was based on some of Carl Jung's theories. But one of the wise themes in Carl Jung's thinking was about acknowledging contrary elements, or duality, in personality, both in the course of development through life, but even cross-sectionally in a given moment. This allows for being an "extrovert" but also having elements of "introversion" at the same time, or in different situations! Personality phenomena can be understood as much more situationally dependent than we might think. There may be elements of extroversion that can occur in particular contexts, in a particular culture, while the same person may show much more introversion in other contexts, or in another cultural milieu.
I think this basic wisdom is often missed with testing of this type. I encourage people to reflect upon all elements of their personality, and to consider how some kind of "opposing" trait is always present, and deserving of nurturance, alongside any "dominant" trait.
Money & Marketing
Test makers are earning money through administering these questionnaires, publishing books about them, leading seminars, etc. According to some estimates, it is a 500 million dollar per year industry, growing by about 10% per year. On their very "slick" website, one can enroll to take the MBTI for a fee of $49.95. The website is introduced by a compelling, poetic quotation by Carl Jung:
It is important to acknowledge the marketing agenda at hand when participating in this kind of "corporate" psychology. Just as in other areas of salesmanship and marketing, the claims made by those administering or grading the tests may be designed to please the audience sufficiently, so that people may continue buying the product. This is not necessarily unethical, it is simply commerce and free enterprise...but such economic and marketing dynamics should be left to the marketplace, and not imposed uncritically upon a work setting, particularly given the peer pressure dynamics mentioned above.
For a related discussion of this, see my other post "The Business of Psychological Questionnaires": http://garthkroeker.blogspot.ca/2015/11/the-business-of-psychological.html
Arguably, a free test could be created with similar motives, to be used in a group setting for the purposes of reflecting upon group dynamics and personality styles. Actually, no tests need be done at all! If diversity of personality styles, and respect for different approaches or attitudes is the theme of a group seminar, then this could simply be discussed together, rather than any form of testing be involved!
References
Here are some good references to look at, addressing some of these points:
http://www.indiana.edu/~jobtalk/Articles/develop/mbti.pdf
http://fortune.com/2013/05/15/have-we-all-been-duped-by-the-myers-briggs-test/
https://www.theguardian.com/science/brain-flapping/2013/mar/19/myers-briggs-test-unscientific
http://www.businessinsider.com/myers-briggs-personality-test-is-misleading-2014-6
http://signallake.com/innovation/personality.pdf
There are various problems with Myers-Briggs typing, and with other forms of personality analysis, particularly when applied in a workplace setting:
Process Problems
Confidentiality & Privacy
In some group settings, personality testing is offered as an activity, in which results would be shared with the group. Immediately, there are serious concerns about confidentiality and respect for privacy. In some ways, a "personality test" is analogous to a medical test. Most of us would be uncomfortable volunteering to share our medical test results (such as a chest x-ray or urinalysis) with a group of co-workers, employers, or strangers.
Peer Pressure
While this type of activity is often respectfully introduced as voluntary, there is a strong peer pressure element. A person who would choose not to share or participate would immediately stand out as an outsider. It would not be irrational to wonder if a non-participant might be doing so because of some sort of personal difficulty, uncooperativeness, or "personality problem." Such an unhealthy dynamic is due to the activity itself, more than the dynamics of any individuals in the group.
Labeling
Also, in terms of process, the Myers-Briggs gently applies a sort of "diagnosis." The 4-letter code each person gets is actually a label. The label may be an interesting thing to reflect upon, but nevertheless it is a label, obtained from answering a small number of simple questions.
Some of the Myers-Briggs types, such as INFJ, typically occur in only 1-2% of test cohorts. If test results are shared as a group activity, with a group of 30-50 people, and with the group then dividing up according to type, then the INFJ group could be a group of just one person! This would literally "single people out," and give rise to an unnecessary experience of isolation or exclusion, rather than celebrating group togetherness or harmony.
The principle of giving people labels based on a few minutes of superficial assessment is troubling, in terms of process. It is exactly this sort of pattern that I encourage people to step away from as a practice, particularly with regard to mental health care policy. As a general principle, I like to be very reserved about diagnostic labels even after spending many hours (or even years) knowing someone; I think it is quite an egregious practice to pull out a label after a 10-minute questionnaire!
When people are given labels of any sort, particularly if such labels are sanctioned by some sort of official test, "clinical wisdom," or group approval, then it can push people into conforming to these labels. It is a form of typecasting. If you are told that you are something, you are more likely to believe that as part of your sense of self. If a teacher you trust tells you that are a talented mathematician, but not a very good writer, and shows you a questionnaire result which "proves" this, then you may be less likely to pursue an interest in writing! Of course, such feedback could be given in a way which is honest but not discouraging (e.g. "you could be a truly great writer -- but I think you need to put an extra hour of work into your writing every day this year!")
In the Myers-Briggs, the labels are generally benign, each of which laden with various positive affirmations, but the process is troubling, as it is an example of a sensitive, personal identity issue being pushed through forces of labeling and peer pressure.
Of course, the Myers-Briggs can be used simply as a tool of playful engagement in a group, almost like a "party game." It can very reasonably help a group acknowledge, respect, and admire the diversity of personal and interactional styles. And the labels can be taken with a grain of salt. None of the labels are framed in a pejorative way at all, they are all framed as style variations, which all carry different strengths or gifts that are to be respected in a group.
Yet, these process issues must be considered with great seriousness.
Validity
Personality traits of any sort occur in a continuum in the population. Generally, traits such as extroversion are normally distributed. Most people in any group will be close to the population mean on any trait. Yet the Myers-Briggs gives people a categorical label (for example "E" or "I") for these traits which are actually on a continuum. It is a literal example of "dichotomous thinking," which is considered a "cognitive distortion" in CBT theory. It would be like describing people as "tall" or "short" in a height category. Or like describing the climate of a place as "hot" or "cold." Furthermore, because of this dichotomous labeling, there is a huge statistical "fuzziness" caused by the majority of people having traits near the mean. People in the 48th percentile for extroversion would be considered an "I" while people in the 52nd percentile would be considered an "E." In reality these two people would have differences in this trait which are not statistically significant, yet they are given labels which are dichotomously opposite, in just the same way as a person with extreme introversion would be considered different from someone with extreme extroversion.
Reliability
Furthermore, because of this statistical "fuzziness," there will be limited test-retest reliability for the Myers-Briggs, particularly for those people whose scores are closest to the mean. For those people who were farther from the mean, they would not have needed to fill out a questionnaire to tell if they were introverts or extroverts! They could have just told you verbally, without any questionnaire at all!
Carl Jung
The Myers-Briggs system was based on some of Carl Jung's theories. But one of the wise themes in Carl Jung's thinking was about acknowledging contrary elements, or duality, in personality, both in the course of development through life, but even cross-sectionally in a given moment. This allows for being an "extrovert" but also having elements of "introversion" at the same time, or in different situations! Personality phenomena can be understood as much more situationally dependent than we might think. There may be elements of extroversion that can occur in particular contexts, in a particular culture, while the same person may show much more introversion in other contexts, or in another cultural milieu.
I think this basic wisdom is often missed with testing of this type. I encourage people to reflect upon all elements of their personality, and to consider how some kind of "opposing" trait is always present, and deserving of nurturance, alongside any "dominant" trait.
Money & Marketing
Test makers are earning money through administering these questionnaires, publishing books about them, leading seminars, etc. According to some estimates, it is a 500 million dollar per year industry, growing by about 10% per year. On their very "slick" website, one can enroll to take the MBTI for a fee of $49.95. The website is introduced by a compelling, poetic quotation by Carl Jung:
It is quite masterful salesmanship to convince people that doing a brief questionnaire, then getting a very questionable 4-letter code based on the results, is actually a form of "looking into your own heart, to allow you to awake from a dream..."Your visions will become clear only when you can look into your own heart. Who looks outside, dreams; who looks inside, awakes.Carl Jung
It is important to acknowledge the marketing agenda at hand when participating in this kind of "corporate" psychology. Just as in other areas of salesmanship and marketing, the claims made by those administering or grading the tests may be designed to please the audience sufficiently, so that people may continue buying the product. This is not necessarily unethical, it is simply commerce and free enterprise...but such economic and marketing dynamics should be left to the marketplace, and not imposed uncritically upon a work setting, particularly given the peer pressure dynamics mentioned above.
For a related discussion of this, see my other post "The Business of Psychological Questionnaires": http://garthkroeker.blogspot.ca/2015/11/the-business-of-psychological.html
Arguably, a free test could be created with similar motives, to be used in a group setting for the purposes of reflecting upon group dynamics and personality styles. Actually, no tests need be done at all! If diversity of personality styles, and respect for different approaches or attitudes is the theme of a group seminar, then this could simply be discussed together, rather than any form of testing be involved!
References
Here are some good references to look at, addressing some of these points:
http://www.indiana.edu/~jobtalk/Articles/develop/mbti.pdf
http://fortune.com/2013/05/15/have-we-all-been-duped-by-the-myers-briggs-test/
https://www.theguardian.com/science/brain-flapping/2013/mar/19/myers-briggs-test-unscientific
http://www.businessinsider.com/myers-briggs-personality-test-is-misleading-2014-6
http://signallake.com/innovation/personality.pdf
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