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And Then There Were Five . . .

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.

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