Best Practices for Co-Therapy

Dr. Anna Lynn Schooley is my guest on the blog this week. She is explaining best practices for conducting co-therapy that she's gathered over her years of practice.  The information in this post will be particularly helpful for clinical supervisors, professors, and managers in settings that accept interns and students. 

View my video interview with Dr. Schooley, or read the summary, below.

What has been your journey with doing co-therapy?

The beginning

Well, it stretches all the way back to my doctoral studies, and the practicums we did. We would go in [to the therapy room] in pairs.

The struggle

My first several experiences were not so great, because I couldn't think fast enough. So, my co-therapist was always doing all the talking. That inspired me to really work at being able to craft questions, and many of the things that we've talked about together on the blog.

The benefits

Over time, I began to really appreciate the benefit of co-therapy. Particularly in a job that I had locally where we only had six weeks. The program grant gave you only six weeks to work with the family. These were families where a child had been hospitalized for suicidal ideation, or other self-harming things. The child would come home, and we'd have six weeks. We could meet as often as we wanted during those six weeks.

Almost the whole [clinical] team were all marriage and family therapy doctoral students from the same school, so we all talked the same talk. And, there weren't many cases to fill all of our caseloads, so we did a lot of co-therapy in order to get out there and do the work.

[From those experiences,] I developed some practices that I talk about all the time. Then, when I became a teacher of practicum, I would always have students in their master's practicum go [into the therapy room] in pairs, for a number of reasons. One, is so they could be in the room. There's a big difference between being in the room with clients and being behind the mirror, or reading about [therapy].

Best Practices for Co-Therapy

Pre-Sessioning

Pre-session, so that co-therapists are on the same page. Pre-sessioning allows them to have an intention for the session, agree to a theoretical model, and have a game plan, in general.

I would often ask questions like:

• What would blow you guys out of the water?

• What would be so shocking that you wouldn't know what to do?

Let's brainstorm. 

They would say things like, "Well, what if they start arguing in front of us?" So, we'd strategize:

• How would you manage that?

• What do you anticipate?

• What is your theory of what's going on--your theory of the problem? 

For these reasons, pre-sessioning is critical.

Strategies for the therapy room

Tag team

One starts speaking, while the other would be writing questions, and perhaps nodding occasionally, or making validating and summarizing statements. 

Then, when number one (i.e. the one who was speaking) runs out (because this always happens with master's students; they can't think of a question), number two is ready. They're ready, because they've been writing questions, and they can jump in with those questions.

So, you can kind of tag-team.

Preparation and sharing air time

Split the joining tasks

Before you go into the room, you decide which member of the couple each therapist will focus on with joining.  For example: Ili, you're going to join with the husband, and I'm going to join with the wife.

It's very specific who we're each validating, empathizing, and summarizing. If you start asking questions of the husband, it's my job to ask the follow-up questions of the wife. In the same vein with the wife, so that we're like two advocates.

Reflecting teams
Now the cool thing about that is that, at times, you can do a reflecting team, where the two therapists turn to each other and talk about what's going on. In one instance, the co-therapist and I actually fought with each other (on purpose!). We would fight about what was going on, and then we would turn back to the couple and say, "Where are we going wrong?, or "How are we getting it right?" So, you can do all these cool things to split up tasks, by being the advocate.

The five therapists example

In another article I read, they talked about having five therapists interacting on a continuum from most pessimistic to most optimistic, and everything in between.  Adapting the concept to two therapists, you could cover all the solution talk, and I would cover all the problem.

This is also good for Prochaska's stages of change; particularly the second stage--contemplation. It's also helpful with "fence jumpers" (Green & Flemons, 2004).-- people who go back and forth between, "I really have to change, but it's really super hard." (Side note: This also relates to visitors and complainants).

So, if we split it up that you're always validating "But it's really, really hard," and I'm always validating, "But yeah, things have to change," we're, again, splitting up the work. You're always doing problem, and I'm always doing solution, or some other kind of way that we split up the work.

The outcome

The outcome we found is that with two of us splitting up the work this way, we actually made twice as much progress.

Ili:  I would think that there are also less barriers for that individual, because you're validating everything the client is feeling.

If you're an individual therapist there's less stuff that slips through the cracks.  

Also for the client, they don't have to carry the conflict.

Absolutely.

Yeah, so the idea of splitting up the work kind of figuring out--What are the dichotomies that are present with the couple?

Perhaps one advocating for divorce, one advocating for staying together.

Then, the real magic is that in the next session, the therapists switch.
 

Yes, because you don't want to get that idea engrained. You don't want them to have the idea that she's on my side and he's on your side. Yeah, that they can't hang on to that.

Best settings and circumstances for co-therapy

I get it that co-therapy therapy is tough, because you know, who's gonna do the billing, and how do you split the fee?

Co-therapy is great in an academic settings. It's great with what I'm doing right now, because I really don't worry about the money. I'm really doing it just to keep my "hand in." It's also great for training purposes--being able to be a backup a new therapist, so that when they go up, the more seasoned therapist can do a prompt, or do a reflecting team.

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Let's Chat

Let me know, in the comments  below:

• What's one thing you are taking away from this article?

• What's your experience with co-therapy?

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