Journal of Systemic Therapies, Vol. 38, No. 1, 2019, pp.

17–29

CO-THERAPY: A COLLABORATIVE ODYSSEY

LIMOR AST
TANIA R. FLOREK
STEFANO FANFONI
Nova Southeastern University, Ft. Lauderdale, Florida

Carl Whitaker developed co-therapy from within the field of family therapy
in 1944, when he also began training students in its techniques (Smith, 1998;
Whitaker & Garfield, 1987). Practitioners of co-therapy now include clinical
supervision teams (Siddall & Bosma, 1976) and co-therapy leadership groups
(Roller & Nelson, 1991). Studies have found individual and co-therapy out-
comes equally successful, with co-therapy in some cases shown to be more
successful (Clark, Hinton, & Grames, 2016). This article discusses co-therapy
within a postmodern collaborative therapy framework (Anderson & Gehart,
2007) as applied in clinical practice and training, focusing on how therapists
can best dialogue with each other in the therapeutic setting to collaborate
effectively (Anderson, 2001). The authors demonstrate how co-therapy team
dialogue can cohesively align therapy and accommodate differing approaches
and viewpoints, while contributing to client comfort and successful outcomes.

Keywords: co-therapy, collaborative therapy, training

Co-therapy is a joint endeavor used by therapists to engage and collaborate with

clients both in the field and in academic clinical training settings. Collaboration,
properly understood, is an active process in which therapists and clients work
together to fulfill agreed upon treatment goals (Tryon & Winograd, 2011, p. 50).
Because co-therapy is not associated with a specific hypothesis or psychothera-
peutic approach, it has a flexibility that suits it to numerous therapeutic settings
(Hoffman & Laub, 2004). Over the past two decades, the use of co-therapy has
grown as a therapeutic technique in counseling families, groups, and to a lesser
degree, individual clients.
According to the literature (MacLennan, 1965; McGee & Schuman, 1970), co-
therapy as understood from a humanistic viewpoint, is for the most part a rehearsed

Address correspondence to Limor Ast, DMFT, Adjunct Faculty, Department of Family Therapy, Nova
Southeastern University, 3301 College Ave., Ft. Lauderdale, FL 33314. E-mail: alimor@nova.edu

© 2019 JST Institute LLC

17

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 18 Ast et al.

and ­persistent relationship in which the therapist holds the responsible position as
part of the relation between therapist and client (Mills & Sprenkle, 1995).
On the other hand, in co-therapy as informed by postmodern ideas, therapists
cannot ignore or exclude their involvement in the therapeutic process (Smith, 1998).
In this model, therapists reveal their thoughts, values, and beliefs as integral to the
therapeutic process. Furthermore, rather than privileging their expert knowledge,
therapists should understand their expertise and knowledge as a participatory ex-
change that develops in dialogue between people (Anderson & Gehart, 2007).
This revised understanding of knowledge requires that therapists actively engage
in the co-construction of meaning and interpretation essential to the therapeutic
development and transformation of individual or group clients.
Expanding upon the humanistic model of co-therapy, Anderson (2001) identified
the client as the expert in the therapeutic relationship. While not denying the knowl-
edge, experience, or professional skills of the therapist, they asserted the obvious:
No therapist is a blank screen, bereft of thoughts, suppositions, and partialities.
Moreover, they argued, therapists bring their identity—shaped by their personal
experience and feelings as well as their professional training and encounters—into
the treatment room. Pursuant to this, co-therapists are attuned to their values en-
suring self-awareness, respect, and appreciation for cultural diversity and beliefs.
This postmodern understanding of knowledge in co-therapy is an organic fit with
how therapists who are trained in this approach communicate with clients and one
another. As Anderson (2001) has observed, therapists and clients are interconnected
in the creation of knowledge and narratives. Furthermore, we believe therapists are
being disingenuous if they discount their participation in creating and interpreting
knowledge and meaning.

CO-THERAPY AS CONVERSATION

Co-therapy can best be understood as an engaged conversation or dialogue with

clients whether individuals, families, or groups—with a pair of cooperating thera-
pists. Moreover, research has demonstrated that when co-therapists welcome and
respect their clients, these attitudes function as a system (McGee & Schuman, 1970)
or tool that allows for in-session maneuverability and adaptability.
Anderson and Goolishian (1992) advised therapists to meet their clients with a
willingness to carefully and respectfully hear and absorb their stories (Rober, 2005).
Aman (2006) describes attending a workshop in 2003 presented by David Epston,
who offered the helpful guiding metaphor of the “therapist as a host” to describe the
“welcoming environment” (p. 4) therapists should aspire to when inviting clients
to participate in the dialogue of co-therapy counseling.
Aman (2006) also recommended that therapists use “a lot of tentative question-
ing, checking in and asking permission during therapeutic conversations” (p. 4) to

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 Co-therapy: A Collaborative Odyssey 19

create this dialogue. Understanding therapy as a gathering together or a function

of conversation requires open tone within a session.
Two questions arise: First, how do therapists form successful co-therapy relation-
ships? Second, what do these relationships look like? Whitaker and Garfield (1987)
defined an “effective co-therapy team” as one with “a mutual respect for each other”
and “the knowledge that each is different” (Clark, Hinton, & Grames, 2016, p. 161).
Within the therapeutic setting, therapists should initially think of their cooperation
as a relationship or marriage inclusive of differences. In addition, Anderson (2001)
urged therapists to work at being “public” (p. 352) with their thoughts and ideas
while providing support for each other and maintaining flexibility in the therapy
setting. The benefit of this collaborative relationship between co-therapists allows
space for an effective experience for both therapists and clients.
Anderson (2001) also suggested that therapists think about the “selves” (p. 354)
they bring into co-therapy partnerships and recommended that in doing so they con-
sider their professional training, what they know, and what they must still address.
Moreover, they should review their encounters and be open to sharing their private,
interior discussions with their therapeutic partner. The professional “self” Anderson
(2001) has described possesses a progressing personal history expressed through
regularly changing iterations of personal stories. In other words, the therapist is a
being who is getting-to-be through dialogue and narrative as he or she persistently
endeavors to comprehend the world and his or her individual selves. In this regard,
it is also important for professionals to realize that being one-half of a co-therapy
team does not mean being a professional twin or clone of the other.
In our training of co-therapists, we have found it essential to emphasize putting
trust in the process, with process understood as an ongoing dialogue. Clark et al.
(2016) suggested that a postmodern understanding of dialogue implies the two
therapists in dialogue are under no constraints to concur in any given situation.
Truth be told, differing views can demonstrate to those being counseled that flex-
ibility and alternative impressions or interpretations of the truth are accepted and
welcomed (Smith, 1998; Whitaker & Garfield, 1987).
Anderson defined the foundational concept of the collaborative-therapy partner-
ship as a “not knowing” relational position (Anderson & Goolishian, 1988; Malinen,
2004, p. 71). While trusting in this dialogic process may feel like a vulnerable position
for a counselor to bring to therapy, the trusting attitude provides many opportuni-
ties for therapists to explore and discover their concerns and those of their clients.

DEFINITION OF DIALOGUE

It is important to explain more completely what we mean by dialogue. In co-­

therapy, clients and therapists become companions in conversations with coop-
erative connections between the participants. These cooperative links are what

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 20 Ast et al.

distinguish a dialogue from a monologue. Talkers and listeners frequently ex-

change roles in these discussions with connections illuminating, shaping, and
altering each participant as they move back and forth between speaker and listener.
Thus a dialogical discussion is a two-way discussion (Anderson, 2012), a forward
and backward, a give-and-take, an in-there-together process where individuals
converse with as opposed to each other (Rober, 2005). Built in to the process is
a required openness to uncertainty.
From this position of uncertainty, whatever has been shared in counseling may
create yet another beginning for more exploration that does not necessarily match
the other therapist’s views (Saint George & Wulff, 2011). Within this frame of
inquiry, neither therapist nor client is obliged to stay on the same page.
For the co-therapists, the focus here is not to trust in what the other therapist says,
but rather to trust in the process and, more specifically, to trust that co-therapists
can use the unexpected during a session to accommodate divergent understandings
and insights. At the same time, it is equally important to place the common goal
of providing therapeutic services to the client over individual goals or agendas.

TRAINING APPLICATIONS

Research shows that clients who initially seek therapeutic services from public
counseling programs, as opposed to private practice therapy, are more likely to
continue with a new therapist if that therapist has collaborated with the primary
therapist in the client’s initial treatment (Clark, Robertson, Keen, & Cole, 2011).
For this reason, many programs that provide public counseling services use co-
therapy teams as part of their transitional treatment plan.
Traditional therapy training programs pair a more experienced therapist with a
less experienced student intern to sustain motivation and provide guidance to the
trainee (Barnard & Miller, 1987, as cited in Clark et al., 2016, p. 160). Co-therapy
training, on the other hand, matches two student intern therapists of equivalent
experience based on the assumption that the interns will bolster each other’s con-
fidence and therefore provide more effective counseling.
The reality, however, is that student interns in co-therapy training often struggle to
work together effectively, with supervisors sometimes struggling equally to convey
best co-therapy practices. Despite the prevalence of co-therapy training, research
into the best practices of this training has been limited (Clark et al., 2016) with only
a few studies evaluating co-therapy training practices (Clark et al., 2016; Hendrix,
Fournier, & Briggs, 2001; Luke & Hackney, 2007).

The Role of Supervision

Our supervisory practices are built on the assumption that supervision makes mul-
tiple contributions beyond the expectations commonly enumerated by established

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 Co-therapy: A Collaborative Odyssey 21

licensing and educational institutions. As a supervisor of student interns entering

into co-therapy training, I (Ast) focus on creating both a sustaining structure and a
climate that nurtures collaborative relationships among participants.
The obvious challenge in co-therapy training is how to create this nurturing
environment, for instance, as when a student therapist paired with a known col-
league must suddenly work with someone who is essentially a stranger. To create
a new, effective team, we take the following steps. First, we apply Aman’s guiding
metaphor of the “therapist as a host” (2006, p. 4) as discussed above. Furthermore,
we employ a concept complementary to the co-host metaphor: that of the host-guest
(Aman, 2006). Not only do therapists act as hosts who meet and greet the client as
a guest: “Therapists are simultaneously guests in their clients’ lives” (Anderson &
Gehart, 2007, p. 45). Second, by following the model of the co-therapist as a trust-
ing self, multiple voices can enter the room. Third, we practice group supervision
in the training of student interns.
As students learn to apply therapeutic practices, supervisors evaluate their per-
formance as individual therapists as well as co-therapists. Encouraging students to
view his or her partners as a co-therapist or co-host goes a long way to overcoming
the natural inclinations of each to view their partner as just another therapist in
the room. Instilling the co-host model is a first step in helping student therapists
to bond with each other. Consequently, students can see their co-therapist as an
equal partner despite differing backgrounds and experience. Another benefit to
this approach is more effective co-therapy outcomes for the client because each
therapist complements the other’s strengths and weaknesses (Hendrix et al., 2001).
According to Keith, Connell, and Whitaker (1992), in group supervision
“. . . family therapy [is] based on the spirit of mutual collaboration between the
supervisor and group members” (p. 93). In our experience, collaborative supervision
facilitates a nurturing environment that promotes equality and a mutual exchange
of ideas among group members.
At the heart of this exchange is the principle that such interactions promote
“agency” (Anderson & Gehart, 2007, p. 17) as well as an appreciation of differ-
ences among all participants. This approach also strengthens interpersonal skills
while privileging multicultural differences.
Research furthermore indicates that collaborative supervision produces valuable
outcomes for student interns and supervisors (Wilson & Rozzelle, 2005, p. 225).
Our training experience confirms this research; we have seen that collaborative
supervision contributes to a strong therapeutic alliance, empowering participants
to speak their minds in an atmosphere of compassion. Equally important, difficult
conversations can be enhanced by virtue of enhanced empathy, understanding, and
patience that co-therapy cultivates.
As part of the graduate program in Marriage and Family Therapy at our university
clinic, the training team consists of students and is supervised by a licensed faculty
member. Under supervision, master and doctoral student interns in family therapy
apply principles of co-therapy with benefits accruing to both student interns as

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 22 Ast et al.

well as clients. Woven throughout the program curriculum is a strong emphasis on

training students to become culturally sensitive. Students are invited to explore their
own biases, paying attention to social inequities with respect to issues of gender,
race, culture, class, and sexual orientation (Rambo, 2018).
The purpose of our clinical training practice is to introduce graduate students to
actual clients with the expectation that student practitioners conduct themselves
respectfully, responsibly, and professionally. All clinical training allows students
to practice therapeutic skills while discovering who they are presently as well as
developing their potential as future therapists.
As a systemic family therapy faculty supervisor in a clinical practicum, I (Ast)
consult with student intern group members in the observation room while the co-
therapists meet with their clients in the adjacent room. The two student interns
conduct sessions behind a one-way mirror while the students’ team and supervisor
watch. Recommendations from the literature on best practices advise that while in
the therapy room, student therapists attend to what their partner is saying (Clark
et al., 2016). In so doing, the one therapist can reflect on the other’s ideas and
develop new perspectives while in the session (Hendrix et al., 2001). This col-
laborative stance opens room for multiple realities.
During sessions, the student therapists will take a short recess to consult with the
team. Following the break, the therapists return to the room to relay a message or
questions based on the supervisor and team’s recommendations (Cole, Demeritt,
Shatz, & Sapoznik, 2001) in order to improve the session.
While acquiring these competencies, it is not uncommon for students to experi-
ence uneasiness the first time they actually practice therapy with clients. In addi-
tion, their uneasiness may intensify at the prospect of working with a co-therapist.
Student interns have no idea with whom they will be teamed up; that person could
be someone familiar or a stranger, someone experienced or inexperienced, someone
irritating or amiable, someone from a different background for whom English is a
second or even third language. That partner may be trained in a different therapeutic
method or lens. Our solution to these possibilities is to encourage positive human
and academic curiosity and, as discussed above, trust in the process.
As explored earlier, this stance of trust offers space for collaboration to occur
between co-therapists and makes the possibility of working with someone with
a diverse background an attractive prospect. These experiences have allowed us
to consider, explore, and discover what works for us so that we can build these
insights into our training.
Our co-therapy training practices have emerged from our ability to create an
atmosphere of comfort in the therapy room for clients without displaying any
of our own possible discomfort. Combining respectful curiosity with the desire
to respectfully listen to the client and co-therapists synchronously allowed us
to enter the therapy room with the expectation of a successful session. Further-
more, these behaviors produce a mirroring effect for the client by displaying
what productive communication and relationships may look like. Clients can

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 Co-therapy: A Collaborative Odyssey 23

take away clear models of how to communicate and work together even in the
presence of differences.

Principle of Balance
Our clinical work is firmly rooted in the straightforward proposition that therapy
sessions are collaborative conversations in which all involved coordinate to achieve
treatment goals. We believe our approaches, initially formulated through improvisa-
tional practice, constitute what we have termed a conversational organization, which is
further defined as a principle of balance in the co-therapy room. This balance requires
that both professional and student therapists incorporate, regard, and evaluate various
voices while taking care to value contrasts among them and conceivable outcomes
inherent in them. This being the case, all individuals in the session will experience
relation or the feeling of having a place, which Anderson and Gehart (2007) have
explained as a sense of welcoming interest and shared obligation. All persons in this
therapeutic meeting have a place in welcoming this communitarian relationship.
The welcoming stance is not meant to pressure those clients who may tempera-
mentally reserve or who may be reluctant participants in the therapeutic session.
No one is ever pressured to reveal themselves against their will either specifically
or indirectly. Instead, the purpose of the welcoming stance is to create an atmo-
sphere that encourages cooperative connections and an open dialogue. Welcoming
precludes specific agendas about what clients should discuss and how they should
express themselves, and it excludes any predetermined ideas of what decisions
clients should make or how they ought to live.
This being said, co-therapists still rely on their partners to ask questions that
promote opportunities to dialogue about potential topics and themes in clients’ lives.
It is nonetheless a fact that within therapy sessions, co-therapists do not always
fully understand each other’s questions or comments. Rather than being a nega-
tive situation, these instances offer openings for the trusting co-host/partner to ask
clarifying questions of his or her partner publically (i.e., within the therapy room).
In the event of a concern that a co-therapist may “mess things up” or even “take
over” the dialogue with the client, the other therapist can re-contextualize or in-
terject themselves into the conversation by way of body language or speech that
communicates their desire to contribute to the conversation. The desire to enter into
the conversation can be conveyed by eye contact or during a pause by speaking the
co-therapist’s name and saying something like, “Yes, John, you know I was curious
about that too, but it also made me think about XYZ.”
In this understanding, clients and therapists become conversational companions
as they participate in dialogical discussions and make cooperative connections. The
welcoming stance encourages and cultivates feelings of shared obligation (Rober,
2005), with the result that all participate in a communitarian relationship.
Aman (2006) summed up this process well. She urged therapists to consider
what they can do as hosts to welcome their clients, to put them at ease, and then

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 24 Ast et al.

post-session, to assess not only the quality of the greeting in regards to the client
but also the quality of the meeting.
In the following case examples, pseudonyms are used to protect participants’
anonymity.

CASE ONE

In this case, the client, John, was a young man who came to therapy to address his
frustration about the affair that his ex-wife Jill conducted for the last ten months
of their marriage. Upon discovery, he divorced her. We (Stefano and Tania), the
co-therapists, met with the couple.
During our first session, John looked at me and asked, “You, Stefano . . . As
a man, would you allow that to happen with your wife?” Rather than self-
disclosing to the client, I chose to use the client’s question to open a conversa-
tion with my co-therapist, Tania. I turned toward her and asked, “Yes. Who
would allow that to happen in his or her relationship?” Tania, who now was
also exempt from self-disclosure, moved the conversation forward by asking
the client, “What does it mean for you if a person allows [infidelity] to happen
in his or her relationship?”
As co-therapists, both Tania and I were operating from a position of a shared alli-
ance and confidence in each other. Within our collaborative relationship, I deferred
by reformulating the client’s question and addressing it to Tania; in turn Tania was
able to create the space for the client to enter the conversation by reformulating
his initial concern based on my question.

Discussion of Case One

A therapist frequently works from private judgments or speculations, impercep-
tible to others concerning a client that can affect what the therapist hears, notes,
and interprets from client’s disclosures (which include words, tone, and body lan-
guage). The result of such unvoiced thoughts and observations on the therapist’s
part can turn what should be a therapist’s quiet exchange or dialogue with a client
into a therapist-monologue dominated by private, single, or multiple unvoiced
considerations.
Rather than hoarding his or her private considerations, the therapist in co-therapy
is expected to use private considerations as a therapeutic tool by making them public.
Anderson and Goolishian (1992) found that when the therapist states or shares these
internal judgments or observations with the client, the therapist re-establishes the
integrity of his or her internal discourse. Moreover, when the co-therapist makes
these private musings public to the client, the client may discover something helpful
that can be developed within a collaborative conversation.

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 Co-therapy: A Collaborative Odyssey 25

CASE TWO

I (Stefano) am a doctoral student born and raised in Italy; English is my second

language and as such, it can sometimes present a difference and possible obstacle
in the therapeutic setting. This case demonstrates how Tania and I as co-therapists
used my misinterpretation of an English word to build shared knowledge in collab-
orative conversation with a young couple who came to us for pre-marital counseling
in order to strengthen their communication.
At some point in the session, the young woman, speaking to Tania, described
her fiancé as “the rock” of the relationship, with the metaphor of “rock” indicating
strength. When Tania asked the young woman, “What would you be then?” both
the young woman and her fiancé silently struggled to find a metaphor for her role
in the relationship.
I had mistakenly heard “rock” as “rook,” the chess piece that resembles a tower,
so I took advantage of the silence and shared the chess connection, hoping that
either Tania or the couple would find my comment relevant. With a great deal of
excitement, the young man jumped into the conversation, sharing how he loved to
play chess. He then stated, “If I am the rook, then definitely she is the queen! For
the flexibility and power of her moves as well as for how many squares she covers.”
Although Tania was less familiar with playing chess, she joined me in exploring
what their respective roles meant to them and their relationship.

Discussion of Case Two

The above exchange, based on the misinterpretation of a single word, illustrates the
sometimes unexpected benefits of making even a random private thought public
(Anderson & Gehart, 2007), even in this case where it turned out that the connec-
tion was illogically connected to what the other therapist had said. What occurred
demonstrates that sometimes any interjection may open up new avenues of important
insight (Anderson & Goolishian, 1988).
As a matter of fact, I was unsure about introducing the chess game metaphor
because, first, it would interrupt the conversation about the rock and second, it
was possible that neither the clients nor Tania were chess players. This example
shows that co-therapists do not always have to be in agreement with each other
or be on the same page in every moment of therapy for the therapeutic process to
be effective. By being open and flexible to having and sharing a different point of
view, one therapist can create an opportunity for new conversations to be created
with his or her co-therapist and the client or clients.
Therapeutic transformation is the goal of all therapy. As informed by the collab-
orative model of co-therapy, this transformation can occur within the innovative and
inventive parts of dialect, exchange, and story—as we have seen in the case above.
Sometimes it is important for the therapist to engage in some self-disclosure. With

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 26 Ast et al.

this option, the potential for transformation is as broad as the people who share
their information and stories within the flexible dialogue of co-therapy.

CASE THREE

During a session with Laura, a 30-year-old woman struggling with symptoms of

depression due to a recent death in the family, I (Stefano) was exploring the client’s
history in order to discern what was important to her.
At one point Tania, noticing a pattern of recurring stories in the client’s responses,
remarked to her, “I heard you mentioning a couple of times the importance of being
a mother. I am curious what that exactly means for you.” Without hesitating, Laura
replied, “It means everything. It’s who I am, and what my responsibilities are. . . .”
During the few moments of quiet in the room, I (Stefano) was reflecting silently
on the accuracy of Tania’s observation. Following up on Tania’s statement in order
to advance the client’s participation, I said to Tania, “That was such a great question.
I was reflecting myself on where I would learn some of the most important values
that make me who I am, and what my responsibilities are when I become a father.
In fact, I can recognize different people influencing my ideas on fatherhood and I
also remember a particular book that I read when I was 14 years old.”
As I was speaking, Laura changed her posture. Moving from the back of the couch
to its tip, she rested her elbows on her knees and joined her hands in praying position
with her fingers touching her lips. Something seemed to have awakened in her. She
eventually shared her unexpected insight, saying, “Wow. I never thought about this.
Since my mother was not around much during my childhood, I think that my grand-
mother played a big part in defining my values and expectations to be a good mother.”

Discussion of Case Three

The above case illustrates how a transforming insight can occur within the context
of one co-therapist self-disclosing information to the other that, in this case, was
in response to my partner’s cognizance of a revealing pattern of information from
the client.

DISCUSSION OF CASES

As we have seen, collaborative conversation in co-therapy often involves collective

storytelling. As Anderson (2012) observed, the varying participants in therapy tell
unique stories which can contain contending story variations. As the cases above
illustrate, the co-therapy model is well equipped to deal with narratives shared from
widely divergent viewpoints, and even incomplete narratives can lead to insights
and resolutions of differences and conflicting views.

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 Co-therapy: A Collaborative Odyssey 27

GENERAL DISCUSSION

Co-therapy allows us—co-therapists and clients—to see ourselves in process

through a collaborative dialogue. Including the co-therapist as a partner in the
exchange of information and dialogue allows differences to emerge and multiple
perspectives to enter the room.
The collaborative approach to co-therapy as described in this article strives to
facilitate an environment or setting that allows for change, growth, and development
of perspectives and insights among co-therapists and clients. It does not represent
a formal method for the implementation of co-therapy under clinical supervision.
We have learned that challenges or differences may arise between co-therapists
during a session. However, considering that our primary goal is to provide clients
with a platform to be heard and understood, the collaborative conversational ap-
proaches of co-therapy can facilitate constructive questioning, maneuverability,
and open dialogue.
Our practice-based knowledge has been acquired through practical training
rather than empirically supported research. Hence, further research will help sup-
port the use of co-therapy or co-hosting on multidimensional levels and platforms.
The systemic practices outlined in this article that do surround this process can
be of benefit to co-therapy practitioners in marriage and family therapy. While
our experience has been limited to an academic/clinical setting, we would rec-
ommend further explorations of how this approach can be effectively applied to
multiple settings. Moving forward, we plan to investigate more fully the elements
of dialogical exchange and balance that can best accommodate the presence of
multiple voices in a comfortable, open atmosphere—for the best therapeutic
client outcomes.

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