Therapy in LA

Spring 2006
GOOD OR BAD - MORE THAN ONE FAMILY MEMBER SEEING THE SAME THERAPIST?
By Malcolm Miller, Ph.D.

Wouldn't it be great if this question could be answered with a simple "Yes" or "No"!
Unfortunately, although this is an extremely important question, there is no easy answer. However, the following description of benefits and cautions, with explanations and real case examples, is offered here with the hope that this information will help you to clarify your thinking in case the need to make this decision ever arises.

First, let me be clear that I am not referring to the family members involved in couple, parent-child, or family therapy sessions. Clearly these forms of therapy can be very valuable, but they are beyond the scope of this article. This discussion centers on whether different forms of therapy should occur with the same therapist with members of the same family (or nonmarried partners). For example, should a therapist seeing the husband in individual therapy be treating the husband and wife in couple therapy? Should the same therapist be seeing a parent and child in their own individual therapies? Your therapist can offer helpful insights, but therapists have different professional/personal biases about this issue. Therefore you and the other family members, in consultation with the therapist, need to examine deeply your own thoughts and feelings about yourself, the needs of other members of your family, and your sense of the capabilities of the particular therapist for multiple therapies. Some of these points may be complicated, especially if you have not been in therapy before. Feel free to copy this article and bring it to your therapist for discussion if this issue arises. I will begin with the points in favor.

Points in Favor

Less repetition and confusion. Having the same therapist means that history, current circumstances, etc. do not need to be repeated, reducing the number of sessions and thus the cost of therapy. Also, if there are inconsistencies among family members, these will be more quickly and clearly noted when the therapist is the same person. Many times, when I have met a particular family member, he or she was quite different from the person described by the other family member.
There is greater congruity. Therapists have different theoretical orientations, styles, and personalities. Although these differences can be valuable, in combination they may lead to contradictions. For example, let us say one therapist seeing a member of the family is strictly psychodynamic and the other is strictly behavioral. The family members, incorporating what they have learned, may be coming from very different perspectives, and therefore, be confused and unsure of how best to work out difficulties. Another example would be one therapist recommending subtlety while the other is recommending being more direct. Again at home, miscommunication, frustration and confusion can occur. If there are family sessions and individual sessions related to parent/child issues, one therapist could come from a more "tough love" perspective and the other from a more "give and take" perspective, also resulting in confusion and frustration. Seeing only one therapist prevents these situations from occurring. Furthermore, although the therapist is committed to the needs of whomever (s)he is meeting with at the time, the overall treatment can fit more like a mosaic, with the same therapist, than a combination of pieces from different puzzles, as can occur with multiple therapists. For example, there have been times when I have seen a husband and wife individually to focus on their individual issues in addition to couple sessions. Each felt that, although I was assisting one at a time, I was attuned to their desire that solutions ultimately needed to be congruent and in the interest of both.
There can be greater trust. If the first client in treatment trusts the capability of the therapist, (s)he will be more trusting of the competency of the therapist meeting later with another family member. Similarly if a member of the family has liked the work the therapist did with another member of the family, (s)he may feel less fearful going to the same therapist. A specific example involved my seeing a husband who was having difficulties with career issues. The wife felt positive about the assistance I had provided him, and she wanted me to help with issues she had with her mother and felt confident in my abilities. Later they both returned to me for assistance with their relationship.

Although it would be simpler if we left it here with savings of time and money and the other important points, there are some very serious cautions that need to be evaluated. A critical factor that enabled the above therapies to be successful was the fact that the clients and I thoroughly explored the cautions discussed below. There also have been many situations where my recommendation was that different therapists would ultimately be in the best interests of the clients.

Points Against

Trust--questioning whether the therapist has the client's interests in the forefront. In successful therapy clients need to feel assured that the therapist has their needs as primary. Clients have different levels of trust and security. Some clients are quite apprehensive that, if the therapist is meeting with another member of the family, the therapist will be biased or be incorrectly influenced in favor of the other client. In this situation, the client's significant trust concerns will likely lead to a recommendation for separate therapists. It is important to note, my trustworthiness as a therapist is not the issue; it is the client's sense of trust. This supersedes all the advantages of seeing the same therapist. Also, when there is a significant history of rivalry or mistrust in a client's past or present, I will likely recommend separate therapists. Additionally, adolescents, if the therapist is meeting with the parents also, may be concerned that the therapist will be guided by the parents' needs and perceptions. I am often surprised that for many adolescents this is really not a concern. If this is a significant concern, though, it must be honored and different therapists for the adolescent and parents are best.
Confidentiality concerns--worry that private information will be revealed, even by honest mistake, with another member of the family. For example, a client may discuss a trauma (s)he experienced as a child. The client is not yet ready to discuss this with (her)his partner and may be afraid the therapist might inadvertently share this information in the couple session. Also the child or adolescent may be hesitant to be completely open with the therapist, out of fear that the therapist will share information with the parent. This goes beyond the legal limits of confidentiality where a therapist must disclose to responsible others when there is or has been child abuse or when someone is in imminent danger to themselves or others. As an important aside, when clients reveal confidential information to a therapist seeing more than one member of a family, the diligent therapist will note this in (her)his case notes and review this frequently. Again, if this is a significant concern, it must be honored and different therapists are best. This concern is also true when the therapist is seeing a child or adolescent but updating the parents on the therapy. I always review with children and adolescents the limits of confidentiality, and when there is something important to be shared with a parent, I review this with them ahead of time and encourage them to be the ones to share the information, with me there for support.
Differences in personalities and style. All therapists and clients are not necessarily good matches. A therapist who is very good with one member of a family may not be with another. Also some therapists are better with one mode of therapy, such as individual, and another therapist may have more skills working with families, etc.
Blurring of Issues-- it is critical that the therapy be focused on the objectives for that therapy. Often it is hard to focus on oneself, and it is much easier to focus on another member of the family or family issues. Sometimes discussion of other members help the individual therapy, but often it is a diversion. This can occur even when the therapist is seeing only one member of the family, but it is easier to slip into when the therapist is seeing members of the family in different combinations. Both the therapist and the client need to diligently maintain the focus of the particular therapy; and if this cannot be done successfully, it is best to have different therapists for individual and couple treatment, etc.
Problems in therapeutic neutrality. This is a very critical and tricky issue that can potentially compromise the therapy. A couple of examples will clarify this point. If the therapist is seeing both the couple and one or more members of that couple individually, the therapist needs to be able to express or interpret what is best for the client. In couple therapy, the client is the couple; in individual therapy, the client is that particular individual. Sometimes what is best for the individual may not be in the best interest of the continuing couple relationship and vice-versa. For example, let us say the chosen goals of couple therapy are to work out differences and continue the relationship. In the individual therapy, it becomes clear to the therapist that this relationship may be harmful to the client, repeating issues from the past that are destructive to the individual. The therapist needs to feel (s)he can explore this issue in the individual therapy to best meet the needs of (her)his client--in this instance the individual. This may very well be in conflict with the goals of the couple therapy, and the therapist needs to be honest in both therapies, not try to do an artificial juggling act. On the positive side, if the therapist is accurate in this, it would be good to change the couple therapy goal to assessing whether their remaining together will be best in the long run. If the relationship is not best for both members of the family, it will eventually become clear and lead to a separation or divorce, or, cause both a tremendous amount of grief over the years. On the rare occasions where this has arisen and where both clients are not in agreement with the concerns I have raised, I have had to recommend that they seek an alternative couple therapist. It is best if this possibility can be avoided at the beginning of treatment. I therefore recommend to new couple clients that we have dual goals of assessing whether the issues can indeed be worked out to meet both of these needs, and, if they can, to work on ways to achieve this.
The therapist keeping secrets. Although this issue relates to the last point on therapist neutrality, it deserves its own section. This concerns the therapist being placed or placing (her)himself in the position of keeping a critical relationship issue a secret from the other member of the family in treatment. An example of this would be a client revealing an ongoing affair in individual therapy and not wanting it raised in couple therapy. If the therapist were to agree to this, it would clearly compromise the therapist's neutrality in couple therapy, since (s)he is colluding in keeping a secret from the partner. This would break the implicit trust with the other partner. Another example would be the parents in couple sessions discussing their decision to divorce and not wanting the children to be informed in the family sessions. This would be a betrayal of the children, since their expectation is that there will be honesty in the family sessions. This is different from the parents questioning whether to get a divorce and not wanting this discussed in family sessions until a decision is made.

Apparent easy solutions to such dilemmas would be:

to tell clients at the beginning of therapy that the therapist will not keep secrets from individual therapy that directly relate to the couple therapy, or
to simply have different therapists.

Regarding the former, I, like all conscientious therapists, always raise the issue of secrets when I am seeing clients in couple or family therapy, whether or not I am seeing one or more in individual therapy. In spite of this caution, I remember one case where an individual client shared a critical relationship secret and forbade me to reveal it and would not reveal it (her)himself. I was forced then to end the couple sessions, since I could not ethically continue the couple therapy while knowing such a secret. The same complications with secrets can occur when one is only seeing the couple or family. One member could ask to see the therapist for a minute or call the therapist on the phone, say "I wanted you to know this", "I am not willing to share this with my spouse", "I do not give you permission to share this." Again the couple therapy needs to end at this point. Responsible therapists try their best to avoid this from the beginning by discussing in depth with clients the harm of relational secrets to the couple therapy and the critical importance of the therapist being able to maintain neutrality to best help them. The latter solution of having different therapists is also problematic. If we use the example of the affair, which is being discussed in individual therapy, the couple therapy is still compromised, since there is still a breakdown in honesty and trust. The only difference here is that the couple therapist is unaware of this also, in addition to the spouse. Unless the client is getting assistance in individual therapy to end the affair and not repeat it, the real work in couple therapy, to improve trust and solidify the relationship, is sabotaged. Also, it is as true in relationships as it is in politics, secrets usually have a way of becoming exposed.

Final Thought

As I stated in my opening paragraph, there are no easy answers to this question of single versus multiple therapists. I hope that this article has raised your awareness and understanding of this issue. I encourage you to discuss your questions, should they arise, in therapy to help avoid the potential pitfalls.

Dr. Miller is Chief Psychologist at the Airport Marina Counseling Service. He is a member of the Independent Psychotherapy Network.

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