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Fam Proc 11:1-12, 1972

Therapist Experience and "Style" as Factors in Co-therapy

DAVID G. RICE, PH.D.a
WILLIAM F. FEY, PH.D.b
JOSEPH G. KEPECS, M.D.c
aAssociate Professor, Department of Psychiatry, University of Wisconsin Medical School
bProfessor, Department of Psychiatry, University of Wisconsin Medical School
cProfessor, Department of Psychiatry, University of Wisconsin Medical School

NOTE: SEVERAL PASSAGES HAVE BEEN TRANSPOSED IN THIS ARTICLE. IT HAS BEEN REPRINTED
CORRECTLY IN VOL. 11, JUNE, 1972 AT PAGE 227
Self-descriptions of general in-therapy behavior, attitudes toward co-therapy, and ratings of co-therapy effectiveness
were collected from 25 experienced (E) and 25 inexperienced (IE) therapists who treated a total of 48 married couples in
co-therapy. Major findings were: (a) six different therapeutic "styles" emerged via factor analysis of the therapists'
self-descriptions of in-therapy behavior, (b) E and IE therapists as a group had different personal therapeutic styles and
preferences as to the style desired in a co-therapist, (c) subjectively rated effectiveness of co-therapy correlated with the
degree of comfort felt by the therapist in the relationship and the acceptance by the co-therapist, and (d) there was
evidence of a "point of diminishing returns" in satisfaction for therapists in general, which came with increasing
experience in doing co-therapy.
During the past two decades, there has been increased interest in the conjoint use of two therapists in treating
individuals, groups, couples, and families. A comprehensive survey of 40 articles published between 1950 and 19701 finds
many advocates of this procedure and relatively few detractors. Mullan and Sangiuliano (14), to cite an example, list
twenty-eight reported advantages of the use of two therapists in treatment. These center on (a) the more "valid" and
objective observation and clarification of transference and countertransference, (b) the greater likelihood of a source of
support for each therapist and for each patient, and (c) more rapid growth and knowledge of self for both the therapists and
the patients as a by-product of enhanced feedback.
Most authors have stressed the importance of the relationship between the two therapists as a key determinant in the
success of this method of therapy. In fact, critics of the method (6, 8, 17) have focused on the likelihood that two therapists
do not have the flexibility, openness, and freedom from personal difficulities that would enable them to work effectively
with one another for the patients' benefit. Gans (6) concludes that there is little or no advantage for competent therapists to
work together, although he feels the method might have some advantages for training therapists.
It is surprising that among the forty articles surveyed, there was not a single, careful, empirical study of co-therapy. In
almost all cases, the authors discuss co-therapy from a clinical viewpoint and at most cite a small number of case studies to
illustrate their points. Only three studies (7, 15, 16) report samples of co-therapy cases large enough for statistical
treatment. However, this was limited to some indication of the frequency of success of this procedure, either from the
therapists' viewpoint, or as obtained by follow-up contact with the patients. Rabin (15) was the only investigator to use a
sizeable sample of therapists (N = 38) and to employ a control procedure (the feelings of the therapist about co-therapy
versus his feelings about the use of only one therapist in treating groups). Rabin used descriptive statistics to present his
findings, rather than statistical analysis. He found general agreement among the therapists surveyed in regard to the value of
co-therapy (over regular group therapy) for groups in leading to (a) moderately more "therapeutic movement," (b)
moderately more "working through," and (c) as the preferred method when a single treatment modality is used. His sample
was made up of experienced group therapists, and this might limit the generalization of his findings to include
inexperienced therapists or to those who do not do group therapy.
Working in a different clinical area, Masters and Johnson (10) employ a co-therapy procedure with a specified
therapeutic format to treat sexual problems. Although they do not report data from a large number of therapist pairs, their
work has potential relevance for evaluating the effects of co-therapy in treating sexual problems.
In the present study, the following general predictions (stated, implied, or speculated about in previous work, but not
empirically evaluated) were among those tested, using a large number of therapist pairs who treated married couples in
four-way, conjoint co-therapy:
a. Experienced and inexperienced therapists will describe different patterns or "styles" of in-therapy behavior.

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b. Depending upon therapeutic orientation or style, therapists may choose co-therapists with styles either similar or
complementary to themselves (prediction of an interaction effect).
c. Certain factors heighten rated success of co-therapy, among them (a) felt compatibility with the co-therapist, (b) felt
approval from the co-therapist, and (c) post-therapy discussion between the therapists.

METHOD
The Department of Psychiatry at the University of Wisconsin was surveyed. Co-therapy has been a regular and popular
method of treating couples in outpatient psychotherapy at this facility since the arrival of Dr. Carl Whitaker in 1965. Each
trainee (psychiatric resident or clinical psychology "fellow") and staff member (psychologist, psychiatrist, or social worker)
who had participated in a recent co-therapy treatment experience filled out a questionnaire containing questions in regard to
(a) his therapeutic "style," (b) the "style" of his co-therapist, (c) procedural facts about the therapy meetings, (d) his feelings
about the effectiveness of the therapy, and (e) the staff and trainee members of the department he would most like to work
with. The total sample contained self-descriptions of 50 therapists and included data on 40 cases as described by both
co-therapists, plus 8 additional cases described by one of the original two therapists. Of the 40 cases in which data from
both co-therapists was available, 17 were treated by two staff members, 8 by a staff member and a trainee, and 15 by two
trainees.
Because experience has been shown to be an important variable in research on the effects of psychotherapy (3, 4, 5, 9,
13), the therapist sample was divided into 25 "experienced" (E) therapists and 25 "inexperienced" (IE) therapists. All
therapists in the E group had completed their professional training and, in addition, were actively involved in the teaching
and supervision of psychotherapy. The mean number of years of doing psychotherapy for the E therapists was 13.96 years
( = 6.89) and for the IE therapists was 3.52 years ( = 3.02), a highly significant difference between the two groups (t =
6.96, df = 48, p < .001). The mean number of couples seen in co-therapy for the E therapists was 9.96 ( = 19.47) and for
the IE therapists 7.76 ( = 9.39). A t-test indicated no significant difference between the E and IE groups on this variable.
The standard deviation for the experienced therapists reflects strong positive skewing and indicates that most of the E
therapists have not seen a large number of couples in co-therapy, although they had much more experience than the IE
therapists with other types of therapy (mostly individual psychotherapy). This is in part a by-product of the fact that
co-therapy is a recent professional innovation.
Comparisons among therapists were made via a series of self-descriptive statements, which appear in Table 1. For each
of the statements the respondent marked a scale ranging from 1 ("never") to 5 ("always"). The factorial analysis of these
self-descriptive statements in terms of therapist "styles" and comparison with the self-descriptions of one's preferred
co-therapists formed the main body of data in the study.

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Table 1
Self-description of Therapist's Behavior

RESULTS
Therapist "Styles"
The responses of all 50 therapists to the self-descriptive items in Table 1 were intercorrelated and factor analyzed, using

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a principle components-varimax rotation procedure [see Cooley and Lohnes (1)]. This yielded six principal clusters or
self-descriptive therapy factors. These six factors accounted for 57.4 per cent of the total variance in the factor matrix and
were subjectively labeled as reflecting six different therapist "styles" or orientations. Each factor is orthogonal; none
predicts any other.
The six "styles" of in-therapy behavior, the per cent of total factor variance of each, the key self-descriptive phrases
(items which "load" highly on that factor) were:
I. Blank Screen (20.5 per cent)passive, unchanging, unprovocative, anonymous, and cautious.
II. Paternal (16.8 per cent)businesslike, patient, interpretive, interested in patient's history, and impartial.
III. Transactional (16.6 per cent)"here-and-now," casual, relationship-oriented, interpretive, spontaneous.
IV. Authoritarian (16.0 per cent)theory-oriented, persistent, definite, goal-oriented, guiding, businesslike.
V. Maternal (15.9 per cent)talkative, explanatory, supportive, guiding, interpretive.
VI. Idiosyncratic (14.1 per cent)critical, unspontaneous, encourages conformity, nonprovocative, talkative.
Factor VI reflects some paradoxical features (talkative, yet nonprovocative) and is the most difficult factor to label
subjectively. It could reflect a highly individualized and developed style and, therefore, was given the label "idiosyncratic."
It may also suggest an "unusual" degree of honesty on the part of the therapist in terms of willingness to endorse
self-descriptive items that do not have socially desirable connotations (e.g. the item, "critical, disapproving"). In this sense,
the therapist whose in-therapy behavior is reflected in a high loading on Factor VI may have replied to the questionnaire
with a different response "set" than the other therapists in the sample. The use of a differential "set" may also characterize
other distinctive personality features in such a therapist that could perhaps contribute to a highly individualized style of
in-therapy behavior.

"Style" and Experience

On the basis of the above groupings, six transformed scores were obtained for each therapist, each score representing the
relative prominence of that particular factor in his style. The group mean scores (X) and standard deviations () across the
six factors for experienced and inexperienced therapists are presented in Table 2. The E therapists as a group describe
themselves as highest on the Idiosyncratic factor and lowest on the Maternal factor. The IE therapists show the opposite
pattern: highest on Maternal and lowest on Idiosyncratic. A rank order correlation () of 1.00 was obtained for the mean
scores across factors of the E and IE therapists. This difference is highly significant (p .001) and suggests that experienced
and inexperienced therapists describe themselves and their in-therapy behavior differently.
Table 2
Means (x) and Standard Deviations () for Experienced and Inexperienced Therapists on Six Factors Reflecting Therapist "Style"
Experienced
Inexperienced
(N = 25)
Factor

Label

(N = 25)

Blank screen

51.00

15.06

47.76

14.83

II

Paternal

50.52

18.38

48.48

11.53

III

Transactional

48.76

16.61

50.42

13.64

IV

Authoritarian

49.40

17.46

49.68

12.96

Maternal

46.92

13.89

52.16

16.09

VI

Idiosyncratic

51.76

15.16

45.80

13.11

Additional documentation of this difference was attempted by a repeated measures analysis of variance (2) performed on
the factor scores for all therapists. This analysis yielded no significant main effect or interaction; however, there was
significant heterogeneity of variance in the factor scores, with E therapists showing greater variability than IE therapists (F
= 2.12, df = 149,149, p < .001). The implication is that E therapists as a group have both higher and lower scores on the
different factors than the IE therapists, and this tends to cancel out any significant between group mean differences or
interactions. In an attempt to reduce variability, a square root transformation was performed. Although the degree of
heterogeneity of variance was reduced by this procedure, it remained significant (F = 1.43, df = 149,149, p < .025), and
further analysis was not undertaken. One might conclude from this finding that it reflects a more "differentiated" therapy
style for the E therapists.

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Co-therapist Preferences
Each therapist's factor scores were correlated with the mean factor scores determined from the self-descriptions of the six
individuals he chose as "the co-therapists [he] would most like to treat a couple with." This provides some tentative ideas as
to possible compatible and incompatible combinations of co-therapy "style." The following significant correlations and
trends were obtained (see Table 3):
Factor I (Blank Screen)E therapist: wants co-therapist like himself, i.e. one who describes himself as also high on
Blank Screen, (in Table 3, Factor I vs Factor I, r = .42, p < .05) and definitely doesn't want Idiosyncratic co-therapist. IE
therapist: no significant preferences; some tendency to want Maternal co-therapist.
Factor II (Paternal)E therapist: no significant preferences. IE therapist: tends not to want co-therapist like himself and
definitely doesn't want Idiosyncratic co-therapist.
Factor III (Transactional)E therapist: no significant preferences; tendency to want Authoritarian co-therapist. IE
therapist: definitely doesn't want somebody like himself and definitely wants Idiosyncratic co-therapist.
Factor IV (Authoritarian)E therapist: does not want co-therapist like himself. IE therapist: wants Maternal
co-therapist and doesn't want Idiosyncratic co-therapist.
Factor V (Maternal)E therapist: wants Idiosyncratic co-therapist. IE therapist: definitely wants co-therapist like
himself.
Factor VI (Idiosyncratic)E therapist: wants Transactional co-therapist. IE therapist: no significant preferences.
Table 3
Correlation of Experienced (E) and Inexperienced (IE) Therapist's "Style" Factor Scores with Mean "Style" Factor Scores of Those
Individuals Preferred as Co-Therapists
Preferred
Therapist Factor
Co-

II

III

IV

VI

Therapist
Factor

IE

IE

IE

IE

IE

IE

.42y

.-16

.00

-.10

-.11

-.06

-.15

-.04

-.18

-.24

-.20

-.27

II

-.21

-.07

-.13

-.35*

-.23

-.00

.07

-.04

-.22

-.04

.22

.00

III

-.24

.16

-.10

.15

.03

-.46

.17

.31

-.17

-.04

.41y

-.04

IV

.02

.25

.21

.18

.34*

-.16

-.39y

.28

.12

.22

.28

.16

-.17

.35*

-.04

.04

-.15

-.30

.00

.47z

.18

.50

.13

.04

VI

-.62

.05

.05

-.50

-.02

.56

.28

-.44y

.48y

.11

.00

.04

*p

< .10 (trend toward significance).

p < .05.
z p < .02.
p < .01.

Further analysis of co-therapist preferences was performed by comparing the mean factor scores of individuals "chosen"
as co-therapists by the E and IE therapist groups as a whole. Two of the six factors showed a highly significant
between-group difference. E therapists preferred co-therapists who described themselves as significantly higher on Factor I
(Blank Screen) and significantly lower on Factor III (Transactional) than those co-therapists chosen by IE therapists.2 The
implication is that experienced therapists as a group prefer a more "restrained" co-therapist, whereas inexperienced
therapists prefer someone who will more actively join in the task with them.
Rated effectiveness of co-therapy. For each of the 40 cases reported by the therapists, both co-therapists were asked to
answer independently the following 100-point rating scale item: "In your judgment, how effective was the therapy in this
case?" In two instances the therapist did not respond, so a total of 78 ratings was obtained. It is important to note that this
was the therapist's own subjective rating of the effectiveness of therapy and not a judgment by any external criterion. Data
were available for 15 couples treated by two experienced therapists (E-E), 8 by an experienced and inexperienced
co-therapy team (E-IE), and 16 by two inexperienced therapists (IE-IE). Mean effectiveness ratings were: E-E: X = 54.80
( = 20.88); E-IE: X = 49.44 ( = 19.49); and IE-IE: X = 56.84 ( = 18.11). An analysis of variance indicated no
significant between-groups difference. However, the ratings for the E-IE co-therapist pairs were the lowest of the three
groups, and this has implications for the hypothesis that for effective co-therapy, co-therapists should be of equal status. A
definitive answer to this important co-therapy issue awaits a study using a larger number of cases than was employed here.

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The following questionnaire items correlated significantly with the effectiveness of co-therapy, rated subjectively: For
both E and IE therapists, only the item "How comfortable were you working with this co-therapist?" was significant (E: r =
.31, < .05; IE: r = .37, = .01). One additional item: "Did you sense disapproval from your co-therapist?" was significant
for the E therapists (r = -.38, = .01) and showed a trend toward significance for the IE therapists (r = -.26, < .10). These
two items offer empirical confirmation of the importance in effective co-therapy of the relationship between the two
therapists.
For E therapists, an additional item relating to peer group popularity (how often that individual was selected as a
potential co-therapist from the group of experienced therapists) was significantly related to rated effectiveness of co-therapy
(r = .33, < .05). For IE therapists several additional items were significantly correlated with rated effectiveness:
Number of months since termination (r = -.43, < .005) ("memory is unkind").
Conflict of goals between treating "marriage" and treating individuals (r = -.40, < .01).
Frequent switch of therapist's loyalty from one spouse to another (r = -.40, < .01).
Felt discrepancy of goals with co-therapist (r = -.30, < .05). As the latter item was not significant for the E
therapists, the implication is that experienced therapists more likely choose co-therapists with similar goals or that
goal discrepancy is not as important for them in determining the effectiveness of co-therapy.
e. Felt competition with co-therapist (r = -.35, < .02).
f. Usefulness of post-therapy session talks with co-therapist (r = .38, < .01).
g. Felt candidness in post-therapy session talks (r = .44, < .005).

a.
b.
c.
d.

In summary, subjectively rated effectiveness of co-therapy was related to somewhat different variables for E and IE
co-therapists. For both, a comfortable and mutually approving relationship between the therapists was important. In
addition, IE therapists felt the need for compatible goals, a noncompetitive relationship, and candid, post-therapy session
talks.
Attitudes toward co-therapy. There were some suggestive and rather surprising findings that satisfaction from doing
co-therapy for therapists in general may reach a point of diminishing returns with increasing amounts of co-therapy done.
For E therapists, the item "Do you welcome the idea of four-way therapy?" showed a highly significant negative correlation
with number of couples seen in co-therapy (r = -.42, = .005). For IE therapists, the item "How comfortable were you
working with your co-therapist?" also showed a significant negative relationship with number of couples seen (r = -.34, =
.02).
The question "How valuable to a couple is having a co-therapist?" showed a relationship with the following two items,
significant for both E and IE therapists: (a) "Did you develop a feeling or 'transference' for the couple and regard them as a
unit?" (E: r = .31, <.05; IE: r = .32, < .05) and (b) "Did you develop a feeling that you and your therapist became a unit
or couple yourselves?" (E: r = .52, < .001; IE: r = .33, = .02). These items suggest important co-therapy parameters;
however, they reflect the therapist's attitudes and values toward co-therapy and are not significantly correlated with
subjectively rated effectiveness of co-therapy, as discussed previously.

DISCUSSION
The major statistically documented conclusions of this study are: (a) experienced and inexperienced therapists as a group
have different personal therapeutic "styles" and different preferences as to the "style" desired in a co-therapist; (b)
subjectively rated effectiveness of co-therapy is related to therapist comfortableness in the co-therapy relationship and felt
acceptance by the co-therapist; and (c) there may be a "point of diminishing returns" in co-therapy satisfaction for therapists
in general, which comes with increasing amounts of co-therapy done.
Other investigators (11, 12, 18) have attempted to measure different therapist "styles." Sundland and Barker (18) and
McNair and Lorr (12) found that experience of the therapist was not significantly related to differential technique pattern or
factor scores. The suggestive finding in the present study of a differential factor pattern for E and IE therapists would stand
in contrast to these results; however, it will be recalled that the present sample of E therapists showed a significantly greater
variability across factor scores and that this is perhaps the most meaningful differentiation between E and IE therapists. In
addition to using different questionnaires to compare therapists, both Sundland and Barker and McNair and Lorr used
therapists who had completed their training, while the IE group of the present study was composed primarily of therapists
still in training. This alone might account for the E-IE differences found here. To further elaborate the experience variable,
an attempt is currently being made to replicate our findings using a longitudinal sample of therapists, divided into a larger
number of experience levels.
A question might arise as to the differential effect of male and female co-therapists. There were six female therapists in
our sample of 50, and they were all in the IE group. Thus we did not have a large enough sample of female therapists to
evaluate adequately the effects of this variable beyond ascertaining that the "styles" of the female therapists did not
confound the overall pattern of therapist factors for the IE group. The area of sex differences of co-therapists seems an
6

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interesting one for further study.

Perhaps the most surprising finding of the study concerns the "point of diminishing returns" in co-therapy satisfaction
with increasing numbers of couples seen. The implication is that co-therapy may be the continuing "bag" for only a few
therapists. A longitudinal study of co-therapy with a large number of therapists would seem helpful in further elaborating
the question of a "point of diminishing returns" in co-therapy satisfaction.

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Reprint requests should be addressed to David G. Rice, Ph.D., Department of Psychiatry, 1300 University Avenue,
Madison, Wisconsin 53706.
1Bibliography available on request.
2Factor I: x E = 55.80, = 5.05; x IE = 50.80, = 4.45; t = 3.73, df = 48, p > .001; Factor III: x E = 43.44, = 5.82; x IE =
48.84, = 4.69; t = 3.62, df = 48, p > .001.