THE

THERAPIST IN BEHAVIORAL AND

MULTIMODAL THERAPY

Allen Fay, M.D. Arnold A. Lazarus, Ph.D.

 e-Book 2016 International Psychotherapy Institute

From Psychotherapy with Psychotherapists edited by Florence Kaslow

All Rights Reserved

Created in the United States of America

Copyright © 1984 by Florence Kaslow

 Table of Contents
THE THERAPIST IN BEHAVIORAL AND MULTIMODAL THERAPY

EDITOR’S COMMENTARY THE CLARITY AND DEFINITIVENESS OF

MULTIMODAL THERAPY

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 CONTRIBUTORS
Allen Fay, M.D., is in the Department of Psychiatry, Mount Sinai School of Medicine, City
University of New York.

Arnold A. Lazarus, Ph.D., is a professor in the Graduate School of Applied and Professional
Psychology, Rutgers-The State University of New Jersey, New Brunswick.

Florence W. Kaslow, Ph.D., is in independent practice as a therapist and consultant in West Palm
Beach, Florida. She is Director of the Florida Couples Family Institute and an
adjunct professor in the Department of Psychiatry at Duke University Medical
School, Durham, North Carolina.

Psychotherapy with Psychotherapists 5

 THE THERAPIST IN BEHAVIORAL AND
MULTIMODAL THERAPY
Allen Fay, M.D. Arnold A. Lazarus, Ph.D.

Starting from a traditional psychoanalytic perspective, we gradually shifted

our orientations in a more behavioral direction and subsequently evolved a

multimodal approach to assessment and treatment (Lazarus, 1981; Fay &

Lazarus, 1981). It is not the purpose of this chapter to discuss in detail the

practice of behavior therapy or multimodal therapy; the purpose is rather to

indicate what might be distinctive about therapy with professionals,

particularly from a behavioral or multimodal perspective. For readers

unacquainted with behavior therapy, we define it as:

1. A philosophy that stresses learning as a major factor in the development

and/or alleviation of a large proportion of dysfunctional
behaviors, thought patterns, and feeling states, and

2. A set of techniques basically derived from and utilizing learning

principles.

A close relationship to scientific methodology has been an intrinsic

part of behavior therapy since its inception. The approach is essentially

direct and problem focused.

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 The fundamental assumptions and distinguishing features of

multimodal therapy have been summarized as follows (Lazarus & Fay, in

press):

1. Psychological disorders represent some combination of biological

determinants and learning factors.

2. Abnormal behavior that is a product of learning factors is acquired and

maintained according to the same principles as normal behavior.

3. Dysfunctions attributable to faulty or inadequate learning, and even

many disturbances with strong biological inputs, may be
alleviated by the application of techniques derived from learning
principles.

4. Presenting problems are viewed as real problems, and are investigated

on their own merits, rather than being regarded as symptoms of
some underlying problem or process.

5. The focus is on the present rather than on remote antecedents or

unconscious processes. Immediate antecedents and current
factors maintaining behavior are emphasized.

6. Assessment involves investigation of all areas of behavioral, cognitive,

and interpersonal functioning to discover dysfunctions or deficits
that are not immediately presented.

7. Simple behavioral descriptions are preferred to diagnostic labels.

8. Though recognizing that therapy, to some extent, involves transmission

Psychotherapy with Psychotherapists 7

 of values, behavior therapists minimize value statements. Rather
than behavior being labeled as good or bad, its consequences are
specified.

9. The therapist is active and interactive, often assuming the role of

teacher and serving as a model.

10. The locus of resistance is primarily in the therapy and the therapist
rather than in the patient.

11. Emphasis is on self-management. Patients are taught specific self-

management techniques so that the likelihood of autonomous
functioning in problem areas is maximized and dependency on
the therapist is reduced. Assigned homework is an essential part
of the behavioral approach.

12. Involvement of the identified patient's social network is desirable and

often necessary. It permits the therapist to structure an optimal
reinforcement environment and to resolve interpersonal
conflicts through such approaches as communication training
and contracting. (For details of specific behavioral techniques,
see Bellack & Hersen, 1977; Goldfried & Davison, 1976; Rimm &
Masters, 1979; Wilson & O'Leary, 1980.)

The multimodal approach is broader and deeper than traditional

behavior therapy. In addition to overt behavioral responses, it delves into

affective processes, sensory reactions, images, cognitions, and the subjective

nuances of interpersonal relationships. There is significant overlap between

behavioral and multimodal theories and techniques (Wilson, 1982), but

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there are also important points of departure (Lazarus, 1981, 1983). In most
instances, when colleagues have sought our counsel, they were drawn to us
partly for what we represent, as well as for what we oppose—

psychodynamic psychotherapy (Lazarus & Fay, 1982; Fay & Lazarus, 1982).

In a much misquoted paper, Lazarus (1971a) observed that many

behavior therapists were apt to seek treatment from nonbehavioral

practitioners. This was not because these therapists had little confidence in

behavioral techniques and considered psychoanalysis or Gestalt therapy or

any other nonbehavioral system superior. Rather, since traditional behavior

therapy has little to offer the person who functions well (i.e., is not phobic,
obsessive-compulsive, unassertive, sexually dysfunctional, depressed, obese,

or beset by maladaptive habits), it is logical to consult nonbehavioral

clinicians when the object is to attain insight, to explore the "collective

unconscious," to experience existential encounters, to enjoy an excursion in

guided imagery, and so forth.

Our colleagues—psychiatrists, clinical psychologists, psychiatric social

workers, counselors, and other mental health workers—have usually

consulted us only after receiving more traditional therapy without success.

The majority were self-referred, having read our writings or having attended
lectures, seminars, or workshops that we presented. Their range of

problems has covered the gamut from organic disorders, through substance

Psychotherapy with Psychotherapists 9

abuse, schizophrenia, and major affective disorders, to anxiety, psycho-
sexual dysfunctions, and family relationship issues. Rarely have we had the

experience of treating a colleague who simply wished to get in touch with his

or her feelings, or understand his or her dreams. In terms of DSM-III

nomenclature, the most benign subsets were comprised of colleagues with

"adjustment disorders with work or academic inhibition," with specific

"marital problems," and with "other specified family circumstances."

The vulnerability of mental health professionals to psychological-

psychiatric ills is well documented and the high suicide rate among

psychiatrists well publicized (Freeman, 1967; Rich & Pitts, 1980). Still the

idea persists in the public mind, and even among professionals, that

therapists have, or at least should have, a high level of psychological

wellness. This attitude tends to make it difficult for some therapists to seek

assistance, and it may complicate therapy as well.

During the first year of psychiatric residence one of us (A.F.) recalls

how anxiety-producing it was when on several occasions a psychiatrist was

admitted to our inpatient service. Although a senior attending psychiatrist

was usually the principal therapist, a resident was involved as well, and on
occasion a resident was the therapist. How does one talk to such a patient?

How does a tyro talk to a seasoned clinician, let alone be therapeutic?

Fortunately, the therapist-patients were usually not as forbidding as the

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residents had anticipated. Admittedly, this situation is somewhat unusual in
that therapists generally seek help from equally or, often, more experienced

therapists than themselves.

Another trauma occurred when a fellow resident had a psychotic

episode. Twenty years ago it was de rigeur for residents to be in

psychoanalysis, and somehow if you were accepted for treatment by a

training analyst at a major institute, it seemed to offer some kind of

assurance that psychosis was not in your future. Being in psychotherapy as

opposed to analysis was a mark of inferiority. Behavior therapy was not

even accorded the status of heresy; it was simply superficial nonsense. As

time passed, it became more apparent that therapists were as vulnerable as

anyone else to psychiatric disability, and possibly more so. In fact it became
clear that some enter our field seemingly in search of help, whereas others

do so in an attempt to demonstrate that they are not disturbed.

In our first year of training, a junior staff psychiatrist made the

astounding statement that he never saw a patient whose symptom he did

not have himself to some degree (Fay, 1978). What seemed like a shocking

and inappropriate revelation of gross psychopathology was seen

subsequently as one of the central truths in the practice of psychological

therapy. What this young psychiatrist meant was that most individuals, at
some time or another, have irrational fears, depressive ideation,

Psychotherapy with Psychotherapists 11

superstitious ruminations, compulsions, thoughts of suicide, and paranoid
notions. One of the senior supervisors, who was a faculty member of an

analytic institute, commented that when candidates came for a training

analysis, one of the most important aspects of the therapy was to convince
them that they were neurotic and not simply satisfying a perfunctory

requirement.

In most essential respects, our therapy is identical for professionals

and nonprofessionals. Assessment procedures are no different, the technical

armamentarium is basically the same, and relationship factors are crucial to

both. But there are significant differences although we cannot generalize

about therapy with "therapists." Therapists have different theoretical

orientations and styles in their practices, and they have different

expectations and beliefs about therapy for themselves. Some therapist-

patients (we refer to them as t-ps for convenience) are absolutely committed

to therapy as a way of life and seem totally comfortable consulting a

colleague. Others are embarrassed and feel less worthy as a result of their

excursion into therapy. Still others who had therapy or psychoanalysis

earlier in life feel that it is a defeat to seek help again.

Initially, our major thrust of therapy is usually in the cognitive sphere;

there are certain basic beliefs and attitudes that require examination and
modification. For example, we regard the idea that therapists are, or should

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be, better than their clients as highly dysfunctional (Lazarus & Fay, 1975).
The basic difference between therapists and nontherapists is not pathology,

neither the fact nor even the degree; the basic difference is training and

experience in their vocational area. Consider the following dialogue between

Fay (A.F.) and a 41-year-old female T-P:

T-P: Yesterday I saw a patient who was so much like me, it was scary. It's really a joke,
the blind leading the blind.

A.F.: Who's more appropriate?

T-P: Who? A normal person.

A.F.: What's a "normal person"?

T-P: You know.

A.F.: You mean someone well-adjusted who sailed through the best schools without a
care, someone with a great marriage, fabulous sex life, two normal children who
never had a problem, makes $200,000 a year, someone who is never anxious and
never depressed and never has self-doubts? Is that what you mean?

T-P: Yeah, something like that.

A.F.: I'd be terrified to see someone like that. I don't think I could learn anything—or
relate to such a person.

T-P: But I'm a far cry from that.

A.F.: Tell me, how many patients have you destroyed with your problems?

T-P: (Laughs) I hope not too many.

Psychotherapy with Psychotherapists 13

 A.F.: Do you know what to do for this patient who is so similar to you?

T-P: I think so.

A.F.: Are you interested in helping her?

T-P: Sure!

A.F.: Does she seem to trust you?

T-P: I guess so.

A.F.: Are your problems bothering her?

T-P: Not that I know. Actually, when I told her how devastated I was when Bill left me,
she was relieved.

A.F.: (Paradoxically) Well, then, it seems that you have all the ingredients of a terrible
therapist.

T-P: (Laughs)

A.F.: Apart from the fact that you're not quite as dilapidated as you think, did it ever
occur to you that mental health might not be the most important quality in a good
therapist? You know, Freud was a complete fruitcake.

The type of problem and the intensity of symptoms certainly may be a

factor in a therapist's ability to conduct a practice. For example, one must be

able to tolerate criticism from patients and be reasonably comfortable when

discussing sex. Depression in a therapist may make it more difficult to

communicate than would a circumscribed phobia or hypochondriasis. On

the other hand, the latter symptoms might preclude the behavioral

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technique of in vivo exposure with participant modeling (i.e., the therapist
takes the patient into the feared situation and demonstrates exposure or

contamination exercises).

Among the unique relationship factors with T-Ps is the fact that more

experienced therapists who work with less experienced T-Ps are not only

communicating messages about problem solving but are also transmitting

therapeutic skills. A large segment of our T-P population has consisted of

graduate students in psychology. Here we are often seen as teachers as well

as therapists, especially by those students in programs with a cognitive-

behavioral orientation. A subset of this group consists of students who have

been in our classes.

Another significant feature of our relationship with T-Ps is that we will

sometimes refer a patient to our T-P. Although some might think that this
would complicate the "transference," even orthodox analysts have engaged

in this practice since Freud's time. In fact, many years ago one of us (A.F.)

was treating a patient jointly with his analyst, an orthodox Freudian on the
faculty of the New York Psychoanalytic Institute. Referring patients to T-Ps

might create problems if you are known to engage in it with some T-Ps and

not others. More than one of our T-Ps has said "If you didn't think I was too

sick, you would have referred a patient to me" or "You wouldn't send me a

patient, would you, and take the risk that I would louse it up?"

Psychotherapy with Psychotherapists 15

 Sometimes the converse occurs, that is, our T-P refers a patient to us,

either someone he or she is having difficulty with or perhaps a relative or

friend.

A couple of T-Ps have asked us to arrange our schedules so as to avoid

waiting-room encounters. We can recall two occasions over the years when
patients showed up at the wrong times. In one case it was assumed that the

T-P's session was a conference between colleagues, and in the other case it

was not mentioned. As an aside, it is obvious that many professional

psychotherapists who seek personal psychotherapy are even more sensitive

than "ordinary patients" about matters of confidentiality. Some of our

psychoanalytically oriented confreres particularly have been concerned that

nobody should discover that they sought our professional counsel.

Behaviorally oriented T-Ps will often know the techniques we suggest,

so that the major task is to get them to implement what they already know;

whereas with nonprofessionals we must explain the basic approach as well

as describe and illustrate the techniques.

In our experience, one of the most essential factors in therapy is

therapist self-disclosure. It is particularly important with T-Ps, because we

are even more likely to be role models for such patients. As mentioned
earlier, behavior therapy rests on learning principles and the techniques

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derived therefrom, and modeling is one of the major mechanisms of learning
(Bandura, 1969). It is a tenet of social learning theory that the closer the

resemblance between the subject and model, the easier it is for learning to

occur. T-Ps are sometimes encouraged to be more disclosing to their own

patients for the dual reason that it is often beneficial to themselves and their
patients. Although there is some controversy in this area, coping models are

probably more effective than mastery models, so that telling patients about

our great successes in life and our sterling achievements will not be as
effective as discussions about our own struggles with some of the issues

with which they are dealing. We disclose our own symptoms, limitations,

and life problems, not compulsively but selectively, when we feel it would

serve a constructive purpose for the patient.

There is a tendency for many patients to put therapists in a one-up

position; T-Ps may do this also, even while trying to convince us of their

adequacy. It is critical for the therapists of professionals not to feel

competitive, or act in a competitive way, or derive satisfaction from the

plight of their colleagues, or feel superior to them.

Two patients expressed concern that we would steal their ideas and

publish them. Trust may be even more important when working with T-Ps
than with others, since betrayal can have professional as well as personal

repercussions.

Psychotherapy with Psychotherapists 17

 Some feel that professionals in therapy know too much and that their

expertise fosters "resistance." We have discussed the concept of resistance as

rationalization elsewhere (Lazarus & Fay, 1982; Fay & Lazarus, 1982). Some

years ago, a very scholarly confrere was told by his world-renowned analyst

that if he continued reading the analytic literature his therapy could not

continue. In behavior therapy, as a rule, the more you know, the better it is.

Although in some instances this attitude may foster intellectual discussions

about therapy, it also makes it easier to discuss basic issues and implement

techniques. Frequently, a therapy session is a combination of therapy and

supervision. In fact, we believe that supervision is often part of the therapy,

since discussions about therapy and specific issues in case management can
be personally helpful. In general, supervision may be therapeutic, provided

the supervisor has the appropriate personality and style. T-Ps may feel

better and develop greater self-confidence and self-esteem by improving

their technical competence.

One patient reported that work inhibition was one of her major
problems. She mentioned that she had been thinking about writing a book,

but had procrastinated for several years. We talked about her most

important and interesting topic for a while, and then she was asked to mail
an outline to us before the next session, which she did. This occurred at the

same time that one of us was working on a book. He commented that his way
of writing was to take a week off several times during the year and devote it

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to fulltime writing. The patient thought that was a good idea and called a

couple of days later to say that she would be taking the following week off.

At the end of the period she came in with about 45 pages of typed material.

We sometimes make specific content suggestions and even edit the writings
of some of our patients. Occasionally we have asked a patient to do the same

for us.

Sometimes therapists feel that it is a sign of weakness to be in therapy

more than other patients do. Analytically oriented individuals are

particularly harsh with themselves, making negative judgments about their

behavior and labeling themselves immature, narcissistic, infantile,

regressed, or acting out. The following dialogue between a 36-year-old

clinical psychologist (C.P.) and Lazarus (A.A.L.) illustrates this point:

C.P.: I'm so damn immature and controlling. So needy.

A.A.L.: Can you give me some examples?

C.P.: All right, let's talk about the set-up at work. When I joined the hospital, the
Adolescent Unit was losing money. So I was put in charge, and within six to seven
months they were out of the red and showing a nice profit. Well, the chairman
never said anything about it, and I kept waiting to see if he would say, "Nice
work!" or something like that, some acknowledgment. Now, why the hell do I
need his approval? I should be more mature and secure instead of looking for
strokes from Big Daddy. Why do I have to suckle the breast?

A.A.L.: I don't see anything wrong with a desire for recognition and reward for one's
efforts. Why is that a symptom of immaturity?

Psychotherapy with Psychotherapists 19

 C.P.: Well, when he said nothing to me about the—if I say so myself—fantastic job I had
done, I got pissed and asked for a raise. It's the same theme—give to me, nurture
me, stroke me. I see the patients exploiting, controlling, manipulating all the time,
but I'm no different. I'm just as regressive and immature.

A.A.L.: So in your book, a mature individual wouldn't desire rewards or recognition?

C.P.: Self-satisfaction should suffice. I know I did a hell of a good job. I pulled them out of
a hole. I feel good about that. So why be so hung up on whether or not others
applaud or appreciate my efforts or achievements? It's this damn dependency.

A.A.L.: You seem to put negative labels on everything. Self-satisfaction is sweetened by

acknowledgment and reward from others.

C.P.: Yes, but wait till you hear the rest of it. My request for a raise was turned down.
Well, when I learned this bit of information I was really down.

A.A.L.: Depressed?

C.P.: You bet! I just sulked around the place all day, behaving exactly like any of the
adolescents on the ward.

A.A.L.: Weren't you angry? Didn't you feel that you deserved the raise?

C.P.: Who can figure out who deserves what? The point is that if the chairman would
have noticed or praised my efforts, I wouldn't have asked for the raise—it was
only when he didn't give me the strokes that I asked for the money.

A.A.L.: Would you rather have received the strokes or the money?

C.P.: My immediate impulse was to say "both"! That's what I mean about being needy.

A.A.L.: Are you implying that if you had received both lavish praise and a raise, you still
would have felt deprived or shortchanged?

C.P.: Well, when people start gushing, I question their hidden agendas.

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 A.A.L.: Let me rephrase the question. If you had received both acknowledgment for your
achievements and a salary increment, would you still complain that you wished
for more?

C.P.: No, that would be great, but my point is why be so put out when it's not
forthcoming?

A.A.L.: I think you have unrealistic expectations for yourself. Moreover, your
psychological orientation leads you to fall back on global pejorative labels when
your idealistic standards are compromised. Self-reward can go only so far, and
when appreciation from significant others is not forthcoming, I maintain that
there is nothing pathological in feeling let down. What also strikes me about your
account is that you made no assertive responses. You did not approach the
chairman and ask him if he was aware of the fact that your efforts had changed
the ward from veritable bankruptcy to one of financial profit.

C.P.: But that would be so controlling!

C.P.'s deprecatory talents seemed unlimited. He was able to pull "primitive impulse
gratifications" out of thin air the way magicians pull cards, coins, and rabbits from
hats. The outcome was inevitable self-condemnation. (The corollary is that such a
therapist might be apt to engender guilt and self-belittlement in his clients.)

Whereas many of our psychoanalytically oriented patients tended to

dwell on putative complexes and would often allude to intrapsychic

dynamics (thereby retarding the course of therapy), the same tendencies,

but with different words, were prevalent in other nonbehaviorally trained

clinicians. For example, those with a systems orientation tended to perceive

double-binds, hidden agendas, sabotaging maneuvers, and various

triangulations and collusions. It was often impossible to detect precise

behavioral referents for these inferred constructs. We are not denying that

Psychotherapy with Psychotherapists 21

nonconscious processes may determine certain behaviors, that defensive
reactions may lead to various perceptual distortions, and that some
communication patterns are governed by manipulative ploys and unhealthy

collusions. Our point is that many of our colleague-patients tended to

perceive pathologies in themselves that appeared to have no basis in fact.

Psychiatrists or other physicians, when treated by a clinical

psychologist (or any nonmedical therapist), sometimes present barriers

pertaining to the medical hegemony. Psychiatrists wield more power and

authority than psychologists, and it is not uncommon for physicians to "pull

rank" when treatment issues prove threatening. One of us (A.A.L.) was

treating a psychiatrist who manifested persecutory trends, a distinct

loosening of associations, and signs of inappropriate affect. The advisability

of consulting another psychiatrist to determine if psychotropic medication

might be indicated was tactfully broached. The following dialogue

(reconstructed from memory) ensued:

client: What gives you the right to talk about drugs to me? Do you like to play doctor with
all your patients? I've a good mind to have your license revoked. Let me remind
you that I majored in psychology at college, after which I went to medical school,
and then I went through a residency in psychiatry. And you have the gall to come
on to me like some wise and seasoned physician when you know nothing about
medicine! If I needed medicine, I sure as hell would be able to recognize it before
you would.

A.A.L.: It's difficult to be objective with oneself. As you know, the right medication can
often potentiate important behavioral changes.

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 client: I can prescribe my own medication. I don't need you to tell me about that.

A.A.L.: I'd be happier if you were willing to give over that responsibility to another
psychiatrist. It's like a dentist refusing to see a colleague and insisting on filling
his own teeth.

In the foregoing excerpt many issues other than the medical versus

nonmedical emphasis are present, among which the client's anxieties and

unwillingness to recognize the extent of his own limitations are perhaps

uppermost.

When working with a thirty-four-year-old psychiatrist who referred

himself for the treatment of "anxiety-hysteria," Lazarus (1971b), during the

second interview, asked him to project himself into the following scene:

“Imagine that you and I are on a deserted island for six months with two
beautiful women, one of whom will be attracted and responsive only to you,

whereas the other will be turned on only by me, so there is no risk of

rejection or any need for competition." The following dialogue shows how

productive this fantasy test can be, both diagnostically and therapeutically:

pt: Oh, God! The four of us will be there for six months?

A.A.L.: Uh huh.

pt: Ummmm, uh. Gee! Well, I will obviously be in charge of our physical well-being, you
know. I'll obviously be the doctor.

A.A.L.: That's taken care of. I mean it's a magic island, and we are all going to be well and
healthy for the entire period. We won't require your medical services, just you as

Psychotherapy with Psychotherapists 23

 a human being.

pt: Well, somebody has to be in charge of the place. We won't let the women take over, so
obviously you and I will have to compete for leadership.

A.A.L.: Why? I mean, why can't we just all be together as four human beings—sharing,
experiencing, confiding, relating? Why must someone be in charge?

pt: I just know you'll tell me what and what not to do. And I'll kick you in the balls.

A.A.L.: Would requests or suggestions be tantamount to telling you what to do?

pt: I can be awful touchy. But let's face it. Even though you have ruled out competition
between us and the women, I might still feel that your woman was closer and
more loving to you than mine was to me. This would cause friction between my
uh . . . girl and myself, uh . . . and also lead to jealousy and resentment toward you.

A.A.L.: It sounds as if you are just determined to look for trouble and to find deficiencies
in yourself. You set yourself up so that everything becomes a competition.
Couldn't you just enjoy your relationship and not even notice if I was a little
closer or perhaps a little more distant from my woman? Obviously, if there was a
big difference, if my woman was much more loving and attentive to me than
yours was to you . . .

pt: How much is "much more"? Look, frankly, I'd be afraid that I wouldn't be as adequate
sexually as you would be.

A.A.L In what way?

pt: Well, in real life, my wife has only slept with me, so she has no means of comparison.
But maybe the girl on the island has had many lovers, and I wouldn't measure up.

As the dialogue continued, the focus of therapy centered on his anxiety,

extreme competitiveness, and sexual insecurity. The course of therapy was

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surprisingly smooth, although from time to time his competitive proclivities

intruded into the therapeutic relationship, calling for frank yet tactful

management. Whenever he felt threatened, he tended to fall back on his M.D.

degree.

We have seen many couples in marital therapy where one or both

partners were mental health professionals. It is our clinical impression that

when both were therapists, with few exceptions, marriage therapy was more

easily conducted than with nonprofessionals. On the other hand, where one

party was a therapist, couples therapy tended to prove more difficult. One of
the most prevalent tactics in the latter instance was the use of jargon by the

T-P against the partner. This called for considerable clinical skill in

recognizing the professional credentials of the T-P and simultaneously

supporting the nonprofessional partner against unfair onslaughts.

Some of the most challenging treatment situations arose when

multimodal assessment dictated the need for family retraining and where

one or more family members were themselves professional therapists. The

family setting tended to bring competitive strivings into the open. In some
instances, the therapist family member was inclined to demonstrate for his

or her family that he or she was "the best therapist in the room." In other

families, the primary allegiance of a sibling, or especially a child of the

therapist family member, led to combative tactics whenever we made

Psychotherapy with Psychotherapists 25

observations or suggestions. When recommending homework exercises to
enhance communication in one family, the eleven-year-old son of the T-P (a

prominent psychotherapist) said: "I don't have to listen to you. My dad

knows more than you do!"

A few colleagues have consulted us to confirm their allegiance to the

safe confines of the couch. They labeled our educational orientation as

"mechanistic" and retreated to the introspectionistic realms of

psychoanalysis. We have found this especially frustrating when we felt fairly

certain that if only the T-P would be willing to modify certain behaviors,

positive benefits would accrue. In many instances, this apparent "resistance"

proved to be a function of the T-P's a priori belief that all overt behavior is

an insignificant part of a more basic unconscious conflict. Elsewhere

(Lazarus & Fay, 1975) we have emphasized that "many people waste

inordinate amounts of time struggling to change by delving into their early

life, by analyzing their dreams, by reading ponderous tomes, and through

philosophical reflections about the meaning of life. Life is too short and that

struggle too long."

Behavior therapy and especially multimodal therapy are freer from the
taboos and proscriptions that typify some approaches to psychotherapy. For

example, when one of us had just started analysis, he grew tense at the sight
of his analyst sitting a few rows away at a professional meeting, because he

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did not know whether he would be greeted cordially or viewed as
complicating the transference. We are generally delighted to see T-Ps at

meetings and sometimes exchange information about interesting

conferences and workshops either of us may not have heard about. At times,
T-Ps attend presentations where we are the speakers.

Modern behavior therapy and multimodal therapy are, above all,

humanistic endeavors. Theodore Kheel, the well-known labor negotiator,

said that "some people think in terms of problems and some in terms of

solutions." Our treatment orientation is essentially one of problem solving,

and no matter who the client or patient turns out to be, we do our best to

ensure that he or she will acquire a more adaptive repertoire of coping skills.

References

Bandura, A. Principles of behavior modification. New York: Holt, Rinehart & Winston, 1969.

Bellack, A. S., & Hersen, M. Behavior modification: An introductory textbook. Baltimore: Williams
& Wilkins, 1977.

Fay, A. Making things better by making them worse. New York: Hawthorn Books, 1978.

Fay, A., & Lazarus, A. A. Multimodal therapy and the problems of depression. In J. F. Clarkin & H.
I. Glazer (Eds.), Depression: Behavioral and directive intervention strategies. New
York: Garland, 1981.

Fay, A., & Lazarus, A. A. Psychoanalytic resistance and behavioral nonresponsiveness: A

dialectical impasse. In P. L. Wachtel (Ed.), Resistance: Psychodynamic and
behavioral approaches. New York: Plenum, 1982.

Psychotherapy with Psychotherapists 27

Freeman, W. Psychiatrists who kill themselves: A study in suicide. American Journal of
Psychiatry, 1967, 124, 846-847.

Goldfried, M. R., & Davison, G. C. Clinical behavior therapy. New York: Holt, Rinehart & Winston,
1976.

Lazarus, A. A. Where do behavior therapists take their troubles? Psychological Reports, 1971a,
28, 349-350.

Lazarus, A. A. Behavior therapy and beyond. New York: McGraw-Hill, 1971b.

Lazarus, A. A. The practice of multimodal therapy. New York: McGraw-Hill, 1981.

Lazarus, A. A. Multimodal therapy. In R. J. Corsini (Ed.), Current psychotherapies. (3rd ed.) Itasca,
Illinois: Peacock, 1983.

Lazarus, A. A., & Fay, A. I can if I want to. New York: Warner Books, 1975.

Lazarus, A. A., & Fay, A. Resistance or rationalization? A cognitive-behavioral perspective. In P.

L. Wachtel (Ed.), Resistance: Psychodynamic and behavioral approaches. New York:
Plenum, 1982.

Lazarus, A. A., & Fay, A. Behavior therapy. American Psychiatric Association Commission on
Psychiatric Therapies (in press).

Rich, C. L., & Pitts, F. N. Suicide by psychiatrists: A study of medical specialists among 18,730
consecutive physician deaths during a 5-year period, 1967-72. Journal of Clinical
Psychiatry, 1980, 41, 261-263.

Rimm, D. C., & Masters, J. C. Behavior therapy: Techniques and empirical findings. (2nd ed.). New
York: Academic Press, 1979.

Wilson, G. T. Clinical issues and strategies in the practice of behavior therapy. In C. M. Franks, G.
T. Wilson, P. C. Kendall, & K. D. Brownell, Annual review of behavior therapy. Vol. 8.
New York: Guilford, 1982.

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Wilson, G. T., & O'Leary, K. D. Principles of behavior therapy. Englewood Cliffs, N.J.: Prentice-Hall,
1980.

Psychotherapy with Psychotherapists 29

 EDITOR’S COMMENTARY
THE CLARITY AND DEFINITIVENESS OF
MULTIMODAL THERAPY
Florence Kaslow, Ph.D.

Fay and Lazarus succeed in elucidating with great specificity some often-

murky areas. Like N. Kaslow and Friedman (Chapter 3), they deal with a

client population that includes a subset of graduate students. Although their

trainee populations were drawn from somewhat different geographic areas

and although they discuss different treatment approaches (mainly

psychodynamic and behavioral/multimodal), both pairs of authors indicate

that the students may well receive from some clinicians therapy that
includes a component of supervision. This marks quite a departure from a

purist stance of a clear demarcation between these two functions.

In this chapter, Fay and Lazarus highlight how often the therapist

becomes the prototypical "role model" of how therapy is done—and even,

perhaps, how it should be done. Training and training issues may become

intertwined with treatment and treatment issues; thus a complex tapestry

emerges as these roles overlap. When the patient/trainee is also a student in

the therapist's classes, apparently a not uncommon happening in small

communities with a shortage of fine therapists who are not also on the
faculty of the graduate or medical school, great caution must be exercised in

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keeping their roles and functions separate but integrated. For example, how
does the therapist's knowledge of a student's deep deprivation impinge

upon how he or she grades the student in a course? Does the patient as

student exploit the sympathy of the therapist as professor? Does the

therapist's power cross roles and intimidate the student in some subtle ways

or inhibit his or her self-disclosures?

Given the therapist/professor's multidimensional influence, the

process of selecting graduate students and faculty becomes compelling.

Well-designed research to determine the impact of this multiplicity of roles

on the student's therapy and training certainly seems crucial if we are to

derive answers to these important questions.

Several additional aspects of the material presented by Fay and

Lazarus initially seem unusual, yet on further consideration are probably not

so atypical. They indicate that they sometimes refer potential patients to

their own patients who are therapists, implying that they have confidence in
their competence. Certainly this may give a boost to the latter's self-esteem,

yet one wonders if it also heightens feelings of dependency and

competitiveness. They also indicate that they sometimes edit patients'

writings and have collegial relationships with patient/therapists at

professional conferences.

Psychotherapy with Psychotherapists 31

 Given that in analytic circles, analyst and analysand are cautioned that

contact outside of the analytic hour will impede the transference and is

definitely contraindicated (see Chapter 2), this work by Fay and Lazarus

serves to highlight the diversity of ideas about what is tenable, feasible, and

appropriate in the field.

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