And Then There Were Five . . .

"There are only four of us in the family," Mr Johnson sighed. "But we have five therapists-how can that be?" He looked at me plaintively. It was true. And I was responsible for all the referrals. Each referral to a new caregiver had been carefully thought out with regard to necessity and function. But the case did seem top-heavy with team members. The Johnson family embraced the treatment plan but felt overwhelmed by the number of appointments, office locations, and therapists they had to meet with each week.

In thinking about Mr Johnson's question, I have begun to reevaluate how many "hats" I can wear when I treat a disturbed child in a distressed and troubled family. How much can I alone offer before asking the family to see additional therapists? I first faced this issue during residency training.

Jack's story

While still a psychiatry resident, I was assigned the treatment of an older teenaged boy named Jack. Jack suffered from a mood disorder and obsessive-compulsive disorder (OCD). His parents were volatile and on the cusp of divorce. After an evaluation, I offered him psychotherapy and medication. As part of a comprehensive treatment plan for Jack, I also met with his parents to help them with their own unhappiness and provide parenting guidance.

One of my supervisors suggested that I share the care of this complicated family. The supervisor felt that family therapy might help. Quite honestly, I was overwhelmed by taking care of every member of this family. I felt relieved and believed that adding another therapist was an appropriate intervention. Soon thereafter, my colleague, Dr James, joined the case.

. . . and then there were two.

Within months of the start of Jack's treatment, Dr James and I decided that a course of adjunctive cognitive behavioral therapy (CBT) would help Jack with his OCD symptoms. The OCD experts that we consulted agreed with this recommendation. Jack began CBT with Dr Ruhe, a psychologist who specialized in treatment of this disorder.

. . . and then there were three.

After a year of therapy, Jack's parents decided that family work and parenting guidance were insufficient to address their marital problems. They were desperate to salvage their marriage. They requested a referral to a couples therapist. My colleagues and I agreed. We carefully chose a marriage counselor who matched well with the parents and with the rest of the team.

. . . and then there were four.

As a trainee, I was expected to become fully capable in the biologic treatment of my patients. A new supervisor for Jack's case wondered whether I should be the person both giving medication to Jack and discussing the meaning of his need for medication. This supervisor, who used an analytic model, did not think that Jack would be free to discuss all of his feelings about the medicine if I was the prescriber. I referred Jack to a psychopharmacologist.

. . . and then there were five.

The multipronged approach

In the past few years, I've begun to see multiple family members in individual therapy. Often this begins in the context of a child treatment case. Janet was a wiry, tall, blonde nine-year-old. She was referred to me for failure in school that was leading to low self-esteem and feelings of hopelessness. It was impossible for Janet to read a book and then recount the main idea of the story. Her neurocognitive style left her bogged down in details. To put it simply, in all areas of life, Janet couldn't see the forest for the trees. Janet's parents, Dan and June, were schoolteachers, who thought that they were in a good position to help their daughter with her schoolwork. Unfortunately, Janet wanted no part of their supervisory or tutorial help.

I started Janet's treatment with an individual child psychotherapy model. I met with her once a week and with her parents twice a month. Janet and I played and we talked about her life at school and at home. She spent much of our time together drawing pictures, which she immediately scribbled over because they just weren't good enough.

She enjoyed board games, but became despondent when she didn't win. Janet's psychotherapy was rich with material that we could make use of to help her feel better about herself. I met with her parents to help them understand their daughter's learning style. Despite being fully trained teachers, they were not sophisticated about learning disabilities. I also tried to help them with the pain they experienced when Janet rejected their help.

Soon Janet's mother, June, asked me to treat her individually to help deal with her sorrows around her aging and critically ill mother. I tried to refer her to a colleague, but June insisted that she couldn't bear to get to know another therapist when both her mother and daughter were in crisis. Dan also wanted her to be in my care. "We trust you," he calmly explained. Ultimately, I did take on June's care, feeling I could effectively serve them all.

On another occasion, I had the experience of seeing two siblings in individual work over the same period. Austin was four years old when he came to me for an evaluation of his activity level. Austin was like a ball in motion. He didn't stop running, jumping, or jiggling during our time together. I concluded that Austin needed medication for hyperactivity associated with attentional issues and that he was not a candidate for psychotherapy. I agreed to be Austin's psychopharmacologist, and within months, I was approached by his parents to evaluate Chloe, his seven-year-old sister. Chloe had fears about separation from her parents that became more intense at bedtime. Chloe would moan, "Mommy, daddy, mommy, daddy . . . ," every night until she virtually passed out from exhaustion. Her parents wanted me simultaneously to be Austin's psychopharmacologist and, during a separate appointment hour, see Chloe for psychotherapy. I agreed to this arrangement. It worked well for several years until Austin started to have issues he wanted to tell someone about-and that someone, he told his parents, was me. His parents asked me to do psychotherapy with both children in separate sessions. With some regret, I refused. Austin and I liked each other and he felt that I had provided him with medications that helped him stay in control. He often referred to me as the "focus lady." But now, Austin wanted the kind of time with me that his sister was having.

I pictured an imaginary situation in which Austin and Chloe discussed my feedback about their most recent fight, which each had reported to me in their individual sessions. Austin: "But she said that you were a pest to have as a sister. . . ." Chloe: "No, she was sorry that you made me feel awful because you're a mean brother. . . ." In my imagination, my attempts to be empathic with both of them would be used as "missiles" in further fights, and I would lose my credibility with both siblings.

In the end, I referred Austin to a trusted colleague for both his therapy and his medications. We agreed that he would stop back from time to time to let me know how things were going in his life.

Guiding principles

Here are my guiding questions with regard to a single therapist caring for multiple family members:

• Does it make clinical sense to render care to more than 1 family member, given the spectrum of problems at hand?

• Will each person's developmental, emotional, neurocognitive, and interpersonal needs be met if I am the sole clinician?

• Can I maintain each patient's privacy in this kind of treatment structure?

• As in the Rashomon tale, will I be able to keep the flood of information clear if I am hearing the "facts" from multiple sources?

• Will the individual members of the family be able to bear the feelings associated with sharing their physician?

• If I need to see multiple members of a family at separate times, does this mean a different modality of treatment is indicated? For instance, is family therapy really the indicated treatment?

• By sparing the family the extra work of going to multiple therapists, am I removing a burden or, in fact, giving in to entitlements that should be understood?

• Am I missing a self-centered motive for keeping all of the therapy in my own practice? It does help fill my practice hours-of course, this is an unacceptable reason for treating multiple family members all by myself.

If the answers to all of these questions are clinically sound, then and only then will I embark on this multipronged treatment.

For the most part, I only treat one individual member per family. My training in residency indicated that this was the proper way to conduct a treatment. And I am very comfortable with this model of care. But after 25 years of working with children and their families, I have come to realize that there may be other paths to help an entire family arrive at good health.

Back to Jack

Mulling over the end of my patient Jack's multitherapist story is quite illuminating. In fact, I may have to rethink this whole mystery of the appropriate numbers of therapists per family.

At the end of the second year of therapy, Jack's OCD symptoms worsened despite CBT and medication. This led to a brief hospitalization to reassess his entire outpatient care, including his diagnosis, medications, and treatment modalities. A new set of "eyes" were available to consult. His hospitalization could have fostered regression and dependence; instead, it gave Jack's entire outpatient team a chance to think about our respective roles and the reasons for his failure to get better. The inpatient attending physician, Dr Grune, consulted on the case. He thought that there were too many therapists involved. After long discussions with Jack, Dr Grune explained that Jack believed he needed so many caregivers because he was terribly ill-no one person was strong enough to bear all of Jack's troubles. According to Dr Grune, Jack had come a long way toward healthy functioning since the beginning of his outpatient treatment, but he recommended that the team be disbanded and that treatment be terminated for a time to give Jack a chance to consolidate his gains and become more confident about his capacities to function independently.

. . . and then there were none.

(Apologies to Agatha Christie.)

Dr Helper is a psychiatrist in private practice in Newton, Mass. She has written previously about managed care, the diagnostic assessment of children, the therapeutic space, and the developmental aspects of treehouses. All names used in this column are fictional.