MULTIPLE THERAPY IN PRIVATE PSYCHIATRIC PRACTICE
Authors: LEO ALEXANDER, MERRILL MOORE
Journal: American Journal of Psychiatry (1957)

This paper is based on our experiences in combining forces to treat certain of our private patients (N = 29) in individually-planned therapeutic programs, generally consisting of an integration of psychotherapy and physical-treatment procedures, one therapist devoting himself exclusively to psychotherapy, the other to physical treatments and supplementary psychotherapy as new psychodynamic constellations emerged during the treatment. On the whole, these 29 patients comprised a particularly treatment-resistant group of severe mood disorders. The fact that nevertheless 75% of them achieved either full or social recovery, a figure statistically not significantly different from that of 61% for a group of 201 unselected psychotic and borderline states treated by a single therapist with physical treatment methods and/ or psychotherapy, suggests that the particular difficulties encountered in the present group of patients were adequately met by the treament method described. We were interested to find that where the relation between referring therapist and patient was strong and positively toned, it was in no way disrupted or diminished either by any form of physical treatment (ECT, insulin coma, even lobotomy) or by the subsequent relationship with the second therapist. This became particularly striking when after some progress in physical treatment, as the patient's ego became able to assert more effective controls and defenses, the patient frequently thrust the second therapist into a sort of combined ego-superego role, attempting to impress him with an increased grasp of reality and improved mastery in many situations, all the while retaining an unchanged relationship vis a vis the first therapist, with whom the patient remained more concerned with id derivatives and inclinations. This was not due to deliberate role playing or areas of special interest on the part of the therapists but rather to a shift in the role in which the patient cast one of the therapists, usually the one carrying out the physical treatment, in response to the patient's own treatment needs arising out of the reawakening of his ego strength in response to the physical treatment. This also comes quite strikingly to the fore when one therapist alone carries the patient from psychotherapy through a series of physical treatments, thus often obscuring the fact that the original more primary way of relating to the therapist remains at all times an open avenue of additional communication; this perhaps adds particular strength and effectiveness to the multiple therapy described here. Choice of psychotherapist, following physical treatment, was left entirely to the patient, and aside from the usual influences arising from transference and countertransference factors, it was noted that patients frequently turned away from that therapist who had the better relationship with the more conflictful figures in their lives. It was as though they felt that under these circumstances the therapist could not really sympathize with their point of view, but would remain an ally of the hated or ambivalently regarded figure. Frequently, however, patients seemed able to tolerate continued combined treatment from the two therapists, deriving different but complementary benefits from each. The great flexibility of the multiple-therapy situation proved especially useful in treating cases where marital conflict was a prominent issue. Each spouse could have his own therapist, and yet there was a joint meeting and confrontation on their problems in an atmosphere often charged with an almost revivalist emotionalism and permissiveness. Not only did patients often seem to derive special benefit from the small-group emotional dynamics, but they seemed to feel that, as before a jury, they would obtain fair, impartial hearings, that their individual rights would be protected. This feeling was also evident in relatives who had become anxious and doubtful during a patient's treatment, but who were considerably reassured by being able to confer with both therapists in a roundtable discussion.