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Fam Proc 11:13-15, 1972

COMMENTARY BY CARL A. WHITAKER, M.D.

A LONGITUDINAL VIEW OF THERAPY STYLES WHERE N = 1
Dr. Rice and his colleagues have presented a fascinating set of data on co-therapy. The discovery that the more
co-therapy, the less desirable it seems to the therapist and that the comfort with one's co-therapist decreases with the
number of couples treated seems to me a honeymoon phenomenon. The samples of therapists used in this study should be
labeled "experienced" or "inexperienced" in doing co-therapy, not experienced or inexperienced in doing therapy. Just as
the first fight in a new marriage is devastating, I assume for therapists who are beginning to use co-therapy the first fight
with the co-therapist seems devastating. Certainly the stress between co-therapists is much more disturbing and personal as
feedback for the therapist than fighting with a patient. Furthermore, the battle between the co-therapists often results in a
collusion between one therapist and patient against the other therapist or even a collusion between the couple in treatment
and one therapist against the other therapist. This threatens not only one's therapeutic comfort, but also one's personal
security. To further expand on this idea, if a co-therapy setting is like father, mother, and children, then in fantasy when
mother is away, father and the children have a peaceful life. In reality, only when the children (patient) split mother and
father (co-therapists), do things become chaotic. Even the choice of co-therapist, like the choice of marital partner, depends
upon who is available, who is complementary to the therapist and with whom one identifies. Therefore, the choice is not a
free one but is closely related to the situation.
The personal style of the therapist is, of course, conditioned by many factors. His own character structure would be the
most fundamental, but his previous training and experience would also be an important factor. Forty years ago one
psychiatric clinician devastated his audience with a photograph of himself as an adolescent in which he looked like the
classical introvert and then showed a picture of himself at his current 55-year-old stage in which he was obviously an
extrovert. Maybe we should place psychotherapy style in the same time-framework; then we could see different styles at
different periods in the therapist's life. With this as a background, let me sketch my own style development from a time
perspective.
Beginning as a psychiatrist in 1938, I had a very limited experience in adult psychiatry and moved directly into learning
play therapy with young children. My style of observing and participating with small children during those years from
1940-1944 was basically the "blank screen" pattern. I think of it as my pornographic period. My impotence as a therapist
made it safer to watch and listen and to respond only to prove I was present and to prevent the patient from discovering
how little I knew. The years 1944-1947 I would consider my "maternal" phase. I was working with high motivation and
under high pressure at the Oak Ridge Atomic Energy Project living the basic "doctor model" while seeing twenty patients
back-to-back on a half-hour schedule. My early religious training also reinforced my total acceptance facade, and my
"Jewish mother" guilt made me concerned if patients did not feel tied to me; I actually fed most patients with a baby bottle
as though to develop my own breast feeding competence. By 1948 I was becoming more willing to tell the patient where it
was at and would now designate myself an "authoritarian" with cognitive dominance. While working in a medical school
ghetto hospital in Atlanta, Georgia, I became comfortable with taking charge and insisting on what was curative for each
patient. I became more personally secure and mature from my own personal psychotherapy episodes, and I would now
consider my 1950-1960 work as "paternal" in style. I was authoritative, yet kindly, and as I moved into private practice
from the ghetto teaching situation at Grady Hospital, I became more considerate of the middle-class patient and more apt to
be responsive to the patient and the situation. This included the frequent use of a co-therapist or consultant.
From 1960-1965 my psychotherapy looks from this distance to be mainly "transactional." My security in private practice
made it easier to be existentially related to the patient and to my equally experienced co-therapist, and the process of
psychotherapy took place in the dyadic or triadic relationship rather than in the patient.
Beginning in 1965 it seems more and more clear that my style was a mixture of all of the previous stylistic patterns. I
was personally looser because of my five personal therapy experiences. I was freer to be myself, less duty-laden, less
mission-oriented, more personal, more open in my free associations, less anxious to please the patient, more willing to
confront him or join forces with him, as the situation moved me. I was free to just be, to mother, to father, to interact or to
be authoritative, as I felt inclined. I made less effort to maintain some kind of model, was less and less concerned with
trying to satisfy either an image I wanted the patient to see or an image of him that I was projecting upon him.
Superimposed upon this rather free wheeling guess as to how styles change over time is the fact that I began doing
co-therapy in 1945 with Dr. John Warkentin and that for twenty years massive feedback was a part of my daily living. By
1948 the feedback included Dr. Malone and the other five members of our fulltime teaching staff, who in 1955 became a
private practice group. Multiple therapy was not an occasional modality, but a constant process. From 1955 to 1965 every
patient in the clinic was seen by a co-therapy team for at least a second interview, and in any difficult treatment situation
multiple therapy was continued intermittently or throughout the entire treatment.

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In summary, then, the style of therapy may be influenced by many factorsthe character of the therapist and the
character of his work situation are two significant ones. The value of co-therapy as judged by experienced or inexperienced
therapists should not be confused with the value of co-therapy to a therapist who has used it over many years rather than
one who is just beginning. The most fundamental thing about co-therapy is that it challenges the person of the therapist, not
just his style. The authors seem to have invented a system for evaluating style and the satisfaction of co-therapy. I hope they
will undertake a follow-up of the present data to evaluate changing styles and patterns of co-therapists over time, as well as
push on to a systematic investigation of the outcome of co-therapy as contrasted with therapy of a couple by a single
therapist.