What Clinicians Can Learn When They See the Same Patient Differently

James Tobin, Ph.D.

When clinicians—such as individual and couples therapists, psychiatrists, or other treating professionals—consult with one another about a shared patient, they may discover that they have come to know that person quite differently. This essay explores how those differences can become a valuable source of clinical understanding.

Key Points

• Clinicians treating the same patient may encounter meaningfully different aspects of that person’s psychological functioning.
• These discrepancies need not be resolved; the patient between therapists refers to what may become knowable when clinicians investigate their different observations.
• Effective consultation begins with observation before interpretation, asking what each clinician sees and under what relational conditions it occurs.
• Observational humility allows therapists to trust their own clinical experience while remaining open to what another treatment relationship has made visible.
• At its best, consultation can generate an understanding of the patient that neither clinician could have developed alone.

A familiar consultation begins with a simple request: Would you have a few minutes to talk about our shared patient?

The request is ordinary. A patient may be working with an individual therapist while also participating in couples or family therapy, receiving psychiatric care, or seeing another clinician for a specific therapeutic purpose. With appropriate consent, clinicians communicate to exchange relevant information, clarify roles, coordinate interventions, and avoid working at cross-purposes.

Yet these conversations sometimes produce a peculiar experience. The other therapist begins describing the patient—and for a moment, we scarcely recognize the person being described.

An individual therapist may know someone as vulnerable, reflective, and burdened by shame. A couples therapist may encounter the same person as controlling, emotionally unavailable, or unable to recognize the impact of his behavior on a partner. A family therapist may observe dependency, rigidity, loyalty conflicts, or struggles over authority that barely appear in individual treatment. A psychiatrist may encounter yet another organization of the patient’s experience around symptoms, functioning, and the meaning of medication.

The natural impulse is to explain the discrepancy. Perhaps the clinicians have different theoretical orientations. Perhaps one has information the other lacks. Perhaps the patient presents differently to different people. Perhaps one therapist has been idealized, another devalued. Perhaps countertransference, splitting, or enactment is involved.

Any of these explanations may be correct.

But another possibility deserves more attention: the therapists may be encountering different organizations of the patient’s psychological life because they participate in different relationships with the patient.

If so, the discrepancy between therapists is not necessarily a problem to eliminate. It may be clinical information.

There May Be No Single Patient to Discover

Psychological functioning does not emerge independently of relational context. Our capacities for reflection, dependency, aggression, reciprocity, shame, self-protection, and recognition of another person’s subjectivity change according to the relationships in which we find ourselves.

This is hardly a radical proposition in contemporary psychoanalytic thinking. Relational and intersubjective traditions have long challenged the image of the therapist as a detached observer discovering an independently constituted psychological reality. Clinical understanding develops through participation. What becomes observable is shaped, in part, by the relationship in which the observation occurs (Aron, 1996; Hoffman, 1998; Orange, 2009).

The implications become particularly interesting when the same patient participates in more than one treatment.

Individual psychotherapy creates certain relational conditions. The patient has the therapist’s sustained attention. Private experience, fantasy, shame, dependency, internal conflict, and vulnerability may become especially available for exploration.

Couples therapy creates very different conditions. Now the patient must negotiate attachment threat, frustration, reciprocity, competing subjectivities, accountability, and the immediate consequences of his or her behavior on another person. Capacities that appear relatively stable in individual treatment may become much less available under these conditions.

Family treatment creates still another environment, making visible patterns involving hierarchy, loyalty, role, differentiation, and intergenerational organization.

None of this means that one setting reveals the authentic patient while another reveals only a defensive distortion.

Instead, we might think of treatment relationships as distinct observational environments. Each creates conditions under which particular dimensions of psychological life become especially visible, while other dimensions remain less accessible.

A patient may therefore be genuinely vulnerable in one relationship and genuinely coercive in another. Someone capable of considerable psychological reflection in individual therapy may lose that capacity when a partner expresses anger or disappointment. A person who seems self-sufficient in one context may become intensely dependent in another.

These are not necessarily competing versions of the person. They may be contextually organized versions of the same person. The clinical question then changes. Rather than asking, Which therapist is seeing the patient correctly?, we can ask: What can we learn about the patient from the fact that each of us is seeing something different?

The Patient Between Therapists

I use the phrase the patient between therapists to describe what becomes available for inquiry when clinicians examine the relationship between their differing observations.

The phrase does not refer to a more accurate patient hidden behind the separate treatments. Nor does it imply that clinicians should combine their formulations into a single, supposedly comprehensive picture. The patient between therapists is relational rather than composite. It becomes visible through the discrepancy itself.

Why does this patient seem so different in these two relationships? What does each treatment permit, evoke, constrain, or expose? What capacities remain available in one setting but disappear in another? What can one therapist know precisely because of the position that therapist occupies—and what might that same position make difficult to see?

Consider a relatively common configuration.

An individual therapist has repeatedly encountered a patient’s shame, fear of abandonment, and profound sensitivity to criticism. The therapist has come to understand withdrawal as protection against humiliation and anticipated rejection.

The couples therapist encounters something different. When the patient’s partner expresses hurt, the patient becomes silent, defensive, explanatory, or counteraccusatory. From within the couple, withdrawal looks less like private suffering and more like a failure to remain emotionally available when another person needs recognition.

It is easy for these accounts to become competitors. The individual therapist may worry that the couples therapist is insufficiently attuned to the patient’s vulnerability. The couples therapist may worry that the individual therapist’s emphasis on vulnerability minimizes the patient’s interpersonal impact.

But suppose both observations are clinically important.

Consultation might reveal that shame is not simply something the patient feels after conflict. Shame may be part of the mechanism through which the patient loses the capacity to remain psychologically present to another person. The partner’s expression of hurt evokes shame; shame precipitates withdrawal or self-protection; withdrawal leaves the partner feeling increasingly unseen; the partner escalates efforts to obtain recognition; and the increased interpersonal pressure generates still more shame and withdrawal.

Neither therapist necessarily sees this entire sequence from within a single treatment. It becomes visible between them.

When Consultation Develops a Psychology of Its Own

There is another complication.

Therapists do not arrive at consultation as neutral observers comparing notes. Each clinician’s formulation has developed through sustained participation in a treatment relationship. Our understandings carry histories of concern, frustration, protectiveness, uncertainty, hope, disappointment, identification, and responsibility.

Questioning a formulation can therefore feel different from questioning an abstract hypothesis. This is why consultation itself can become a psychological field.

Psychoanalytic traditions concerning parallel process, projective identification, split treatment, and the analytic third have long drawn attention to the ways psychological experience can become organized across relationships rather than simply communicated through words (Busch & Gould, 1993; Kahn, 1991; Mendelsohn, 2012; Ogden, 1994). In concurrent treatments, the relationship between therapists may consequently acquire psychological significance of its own (Weinberg & Ditroi, 2007).

I think of this as the consultation field: the relational space created when two clinicians bring their separately developed experiences of a patient into contact.

Agreement can emerge in this field. So can surprise, skepticism, protectiveness, irritation, relief, or the conviction that the other therapist has somehow failed to understand something essential.

These reactions should not automatically be interpreted as enactments of the patient’s dynamics. Therapists disagree for ordinary reasons. We have different theories, different information, different responsibilities, and sometimes simply different clinical judgments.

But the reactions should not always be dismissed as professional noise either.

Sometimes the most interesting question becomes not only What are we saying about this patient? but What is happening to our capacity to think together as we try to understand this patient?

A consultation in which two thoughtful clinicians become unusually polarized, defensive, or certain may deserve attention. Not because this proves that the patient has somehow “caused” the polarization, but because something psychologically interesting may be occurring as their different experiences encounter one another.

From Observation to Advocacy

There is a subtle movement that can occur during consultation. I think of it as an advocacy gradient.

At one end, a therapist describes what has been observed: This is what repeatedly happens in my sessions. Observation gradually becomes formulation: This is how I have come to understand what happens. Formulation acquires coherence and conviction. Eventually the therapist may find himself in a somewhat different position: This is what the patient is really like.

At that point, consultation can shift from inquiry toward advocacy.

The individual therapist begins protecting the patient’s vulnerability from what feels like excessive emphasis on accountability. The couples therapist begins protecting the partner’s experience from what feels like excessive emphasis on vulnerability. Each clinician may have a legitimate concern. Yet each may become increasingly invested in persuading the other of what the other has failed to see.

Difference becomes division.

Psychoanalytic language can sometimes make this worse rather than better. It is tempting to explain disagreement immediately through splitting, projective identification, countertransference, or parallel process. Yet interpreting every discrepancy as enactment simply privileges another formulation before the observations themselves have been adequately examined.

Several possibilities need to remain open simultaneously.

One therapist may be mistaken. The clinicians may be interpreting similar phenomena differently. Each may be encountering psychological functioning that is genuinely more visible within one treatment. Something from the patient’s relational world may also be entering the consultation and organizing the therapists’ positions.

These possibilities are not mutually exclusive. A useful consultation therefore asks two questions at once: What might we be reproducing? and What might each of us actually be seeing?

A Different Way to Consult

If differences between therapists can contain information, consultation needs to preserve those differences long enough to examine them.

This begins with the frame.

Patient authorization is essential, but authorization does not mean that everything disclosed in one therapy should automatically be transmitted into another. Clinicians still need a defined clinical purpose, attention to confidentiality, and judgment about what information is necessary to share. Consultation should enlarge understanding without turning separate treatments into one merged treatment. Within those boundaries, I have found several principles particularly useful.

Begin with observation rather than diagnosis

Instead of beginning with He is narcissistic, She cannot mentalize, or He is defended against dependency, begin closer to experience.

What repeatedly happens in your sessions?

When does it happen?

What seems to precede it?

What changes in the patient’s affect, reflective capacity, self-experience, or ability to recognize another person?

What continues to surprise you?

Observation is never entirely free of interpretation. But beginning close to experience makes it less likely that consultation will immediately become a contest between explanatory systems.

Compare contexts, not simply conclusions

Once each therapist has described what occurs, ask where the observations converge and where they diverge.

What does one clinician repeatedly encounter that the other rarely sees?

Under what relational conditions does the patient become more reflective, more defended, more dependent, more dismissive, more emotionally available, or more withdrawn?

The purpose is not to determine which treatment is producing the truer version of the patient. It is to understand what each relational context makes possible.

Preserve the treatment frames

An individual therapist should not attempt to reproduce couples therapy inside individual treatment. A couples therapist should not become the patient’s second individual therapist. Different treatments have different purposes and responsibilities.

But preserving treatment frames does not require preserving formulations unchanged.

After consultation, the individual therapist in the earlier example might become more attentive to subtle moments in which shame interrupts the patient’s capacity to recognize another person’s experience. The couples therapist might become more sensitive to moments when apparent indifference is actually accompanied by a rapid collapse into shame and psychic withdrawal.

Neither clinician has adopted the other’s formulation. Each has acquired an altered field of attention. That may be one of the most useful outcomes consultation can produce.

Observational Humility

The stance required for this kind of work is more demanding than collegiality or open-mindedness. I call it observational humility: the capacity to take one’s clinical observations seriously while recognizing that every therapeutic relationship provides both access to psychological life and limits on what can be known from within it.

Observational humility is not relativism. It does not require clinicians to distrust their perceptions, surrender clinical judgment, or assume that competing formulations are equally valid.

A therapist’s observations have authority precisely because they have developed through sustained participation in a relationship. But that authority is situated.

The same therapeutic relationship that allows us to know certain dimensions of a patient’s experience intimately may make other dimensions comparatively difficult to see.

Every clinical observation is therefore both an achievement and a limitation: something we have become capable of seeing, seen from a position that cannot reveal everything.

This becomes most difficult when another therapist describes a patient we barely recognize.

Our first impulse may be explanatory. Perhaps the other therapist has been idealized. Perhaps a defensive organization has been activated. Perhaps the clinician has misunderstood the patient. Perhaps something obvious to us has simply been missed.

Any of those possibilities may eventually prove correct. Observational humility asks us to delay that conclusion long enough to entertain a more unsettling possibility: What has this therapist been able to see that I could not have seen from where I stand?

That question does not diminish clinical authority. It places authority in context. It also asks something psychologically difficult of therapists: to remain educable.

Consultation as a Form of Clinical Knowing

Much consultation appropriately remains practical. Clinicians exchange information, discuss risk, clarify roles, coordinate interventions, or make sure simultaneous treatments are not undermining one another.

But consultation can sometimes do something more.

Therapists can compare what each has actually encountered. The discrepancy between their observations becomes an object of thought. Another clinician’s experience may then begin to reorganize the meaning of one’s own observations.

At its most generative, dialogue produces an understanding that neither therapist could readily have formulated from within a single treatment relationship. This is what I mean by collaborative clinical knowing.

Its defining feature is not consensus. It is transformation. The individual therapist does not simply learn what happens in couples therapy, and the couples therapist does not simply acquire information from the individual treatment. Instead, the relationship between their observations changes what each becomes capable of noticing. The difference is subtle but consequential.

Consultation is no longer merely the transmission of knowledge from one clinician to another. It becomes a method through which clinical knowledge itself can change.

The Value of Not Knowing the Whole Patient

Clinical work inevitably gives us a partial view.

A therapist may know a patient deeply—sometimes over many years—and still know that person from within the particular relationship in which that knowledge developed. Another therapist may encounter something strikingly different.

Our temptation is often to decide which account is closer to the truth.

Sometimes that judgment is necessary. Therapists can misunderstand patients. Important clinical realities can be minimized. Harmful behavior can be obscured by formulations that explain too much. Consultation should never become an excuse for abandoning clinical judgment.

But neither should difference automatically be treated as error.

Sometimes two clinicians are seeing different aspects of a psychological organization that changes with relational conditions. Sometimes the difference between their observations tells us something neither observation could tell us alone.

The challenge is to make that difference available for thought without requiring its premature resolution.

At its best, consultation allows us to remain faithful to what our own treatment has taught us while becoming susceptible to what another treatment has made visible. The patient between therapists emerges in that space—not as a final, definitive, or more complete version of the patient, but as an invitation to examine the limits of what can be known from within any single clinical relationship.

What consultation makes possible, then, may not be a more complete view of the patient.

It may be something more useful: a more complex understanding of how the patient becomes knowable across relationships.

Frequently Asked Questions

What does “the patient between therapists” mean?

It refers to what clinicians may learn when they compare their different experiences of a shared patient. Rather than assuming that one clinician has the more accurate view, the differences themselves can become a source of clinical understanding.

Why might two therapists experience the same patient so differently?

Different treatment relationships create different psychological conditions. A patient may show considerable vulnerability and self-reflection in individual therapy while becoming defensive, withdrawn, or less able to consider another person’s experience during couples or family therapy.

Does this mean that both therapists are always equally correct?

No. Clinicians can misunderstand patients, overlook important information, or reach different clinical judgments. The point is to avoid deciding too quickly that a discrepancy must mean one therapist is right and the other is wrong.

What should therapists focus on when consulting about a shared patient?

It can be useful to begin with what each clinician actually observes rather than immediately comparing diagnoses or interpretations: What happens in each treatment? When does it happen? What seems to evoke it? Where do the therapists’ observations converge, and where do they differ?

What is “observational humility”?

Observational humility means taking one’s own clinical experience seriously while recognizing that every treatment relationship both reveals and limits what can be known about a patient. Another clinician may be seeing something that is difficult to see from within one’s own therapeutic relationship.

What can good consultation ultimately accomplish?

At its best, consultation does more than exchange information or coordinate treatment. It can help both clinicians understand the patient differently, sometimes generating an understanding that neither therapist could have developed from within one treatment relationship alone.

Disclaimer

The clinical observations and examples discussed in this article are drawn from themes that commonly emerge in psychotherapy and from the author’s broader clinical experience. They are not intended to describe any particular patient, couple, or course of treatment. Where clinical situations are referenced, identifying details have been omitted, altered, or combined in order to protect confidentiality. Any resemblance to a specific individual or couple should not be understood as a description of an actual patient or therapeutic relationship.

This article is intended for educational and informational purposes and should not be considered a substitute for psychotherapy, psychological assessment, or other individualized professional care.

About the Author

James Tobin, Ph.D. is a clinical psychologist in private practice in Irvine, California. His work is informed by contemporary psychoanalytic, relational, and attachment perspectives, with particular interests in the therapeutic relationship, couples and family dynamics, psychological development, and the processes through which clinical understanding emerges between patient and therapist.

Dr. Tobin received his undergraduate degree from Harvard University, an M.F.A. in creative writing from Indiana University, and a Ph.D. in clinical psychology from The Catholic University of America. He completed postdoctoral training at Massachusetts General Hospital/Harvard Medical School, where he subsequently served as a staff psychologist and Clinical Instructor in Psychology at Harvard Medical School. He has more than two decades of clinical experience working with adults, couples, families, and young adults. His writing explores psychological ideas at the intersection of clinical practice, psychoanalytic theory, relationships, and contemporary life.

Selected References

Aron, L. (1996). A meeting of minds: Mutuality in psychoanalysis. Analytic Press.

Busch, F. N., & Gould, E. (1993). Treatment by a psychotherapist and a psychopharmacologist: Transference and countertransference issues. Hospital & Community Psychiatry, 44(8), 772–774.

Hoffman, I. Z. (1998). Ritual and spontaneity in the psychoanalytic process: A dialectical-constructivist view. Analytic Press.

Kahn, D. A. (1991). Medication consultation and split treatment during psychotherapy. Journal of the American Academy of Psychoanalysis, 19(1), 84–98.

Mendelsohn, R. (2012). Parallel process and projective identification in psychoanalytic supervision. The Psychoanalytic Review, 99(3), 297–314.

Ogden, T. H. (1994). The analytic third: Working with intersubjective clinical facts. The International Journal of Psycho-Analysis, 75(1), 3–19.

Orange, D. M. (2009). Intersubjective systems theory: A fallibilist’s journey. Annals of the New York Academy of Sciences, 1159(1), 237–248.

Orange, D. M. (2017). From fallibilism to clinical humility. Psychoanalytic Inquiry, 37(6), 425–428.

Weinberg, H., & Ditroi, A. (2007). Concurrent therapy, countertransference, and the analytic third. Group, 31(1–2), 47–62.