Friday, June 17, 2016

Seeing multiple therapists at the same time

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 (  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 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. 

1 comment:

fryer said...

I was in the process of shopping around for both a type of treatment and a practitioner for PTSD, and thought I might want to dip my toes into a couple of pools, but had a niggling sense that this "multiple therapists at the same time" thing was frowned upon, and that I'd probably be shamed for it and pressured not to do it, but I wasn't sure why or even IF that was true.

Reading online confirmed that it is, in fact, true, but the "why" was a lot less clear. First obvious thing was that it was a standard being upheld by the therapists. Clients didn't seem to be clamoring for greater restrictions on their options; in fact, they seemed more often than not to be agitated by this particular form of infantilizaton. This fact alone set off alarm bells.

The three most common answers I found as to WHY clients should be monogamous, however, differ a bit from yours. My search turned up the following: 1. that having multiple therapists interferes with necessary transference; 2. that having multiple therapists encourages the client to play them off each other; and 3. that having multiple therapists might result in multiple diagnoses that confuses the patient. Taking them in reverse order, #3 has got to be a joke. If I was denied a second medical opinion because another doctor might make another diagnosis that would be criminal. Confirming or disproving a diagnosis is the whole point of the second opinion. That this "explanation" would even be offered would seem to be an admission that psychiatric diagnoses are arbitrary at best and irrelevant at worst.

As for #2 this strikes me as no different than any other manipulative mind games a client might play, including playing the therapist against a spouse or priest or anybody else. Dealing with that sort of behavior is kind of your job, right?

And #1 first of all requires a belief that transference is good, necessary, and works. Assuming you do believe that, where is it written that feelings from previous (multiple) relationships with (multiple) people can only effectively be transferred to ONE therapist? Or at least one at a time, for therapists who don't demand a life-long commitment but do demand serial monogamy.(and I use the sexual term intentionally, because if there's one thing that pretty much everyone DOES agree on it's that sex in therapy is an ethical breach, and yet the fidelity required of the client is a kind demanded in very few non-sexual relationships)

I like how you frame the question in terms of similar relationships that do not demand non-reciprocated monogamy but still manage to work, and work well. But another angle to look at it from may be to ask what other relationships DO demand non-reciprocated monogamy, and how their power dynamics may shed light on the therapeutic relationship, and whether or not they're a good idea.

The two I can think of right off the top of my head are both notoriously exploitative: polygamy (almost always male dominated and powered by religion) and gurus/cults (again, almost always male dominated and powered by religion) This would not seem to be a crowd therapists would want to identify with.

If my yoga instructor demanded that I not take yoga classes from anybody else I would stop taking classes from HER. It smacks too much of One True Way thinking and even a kind of idolatry. And it would clearly be about honoring HER desires and preferences, not mine. That doesn't mean I MUST take yoga classes from all and sundry, only that I should be free to do so if I desire, without shaming and without pressure. In the vast majority of cases monogamy must be reciprocated to be fair, and no therapist I've ever met only takes one client at a time. I'd be more inclined to swear fealty to one therapist if she swore equal fealty to me. But since she's not going to, why should I?