▾ Indications for couple therapy

(Excerpted from my book, Comprehensive Couple Therapy in Practice.)

Since clients and referring individual therapists may be unsure about the optimal format for treatment, it is useful to be clear in our own minds. Usually, if the request is for help with “couple problems,” we should begin there, with conjoint sessions—just as, more generally, we should usually take a customer-oriented, problem-centered approach to any mental health problem (Lazare et al., 1972; Pinsof, 1995). If a prospective client or referring therapist is complaining of significant problems in his or her relationship—with “communication problems;” unproductive, escalating “arguments about nothing;” conflict over important issues (sex, children, money, etc.) or trouble managing life transitions—we should agree to see the couple for couple therapy.

Beginning with a conjoint couple format is preferred even though experienced therapists know that requests for certain formats or focus on certain topics can be used to direct attention away from more fundamental issues. Requests for couple therapy may serve to defend against examination of individual problems, just as requests to focus on children can conceal couple or individual problems; and, for that matter, requests for individual therapy can minimize the contributions of others by patients who prefer to blame themselves (Sander,1982). Such possibilities should be kept in mind as one does the assessment, even as starting where the couple see the problem located will usually be the best way to begin. Just as discussing an acting out teen can begin in a family therapy format, and then gradually reveal how parental discord contributes to that acting out; so beginning to work with couple maladjustment may later move to working with individual personality vulnerabilities.

For many spouses who do not see themselves as having problems, but only come because of complaints from their partners, this may be the only chance we therapists will have to reach and help them. This can be equally true of both the typical husband who comes only because of his wife’s request, and of that self-same wife who, while locating all their problems in her husband, fails to see her own contributions. When clients are uncertain about who should attend therapy, like others with a systemic orientation (Pinsof, 1995), I tend to err on the side of initially including all who seem likely to contribute to problem maintenance. With clients who indicate serious problems with their children, I usually, though not invariably, begin with the entire family. When a marital problem is mentioned, I start with both spouses. As noted above, when a spouse indicates that their main issues are with their partner, one should not agree to begin with individual meetings, for instance “to help me decide what to do.”

There are borderline situations, however, where I will sometimes see the prospective client alone for a diagnostic assessment: a person involved in an ongoing affair; a person wanting help to divorce; a person wanting to work out their own “psychological allergies,” say to anger, sadness, or anxiety or fears of self-exposure and intimacy. These may all go better in individual therapy: first since the client will be better able to be fully honest, and second because these are the staple of individual therapy. In some of these cases, I will decide that a conjoint couple format would be advantageous and I will then suggest it.

Even in situations where a prospective client has made a credible case that he or she suffers from “individual” personality issues, therapists may want to have a session or two with their partner. Such interviews with both partners present can help confirm or disconfirm the client’s (individual) diagnosis; can obtain useful information and solidify an alliance with the nonattending spouse; and will sometimes alter the format to a more expeditious course of couple therapy, or a combination of individual and couple meetings.

▾ The reluctant partner

(Excerpted from my book, Couple Therapy in Practice)

Not infrequently when I recommend couple sessions—either at the outset of therapy or during an ongoing individual treatment—I will hear that the absent partner is opposed to therapy and will not attend. In such cases, I first try to uncover the reasons for such self-protective avoidance—in the spouse, but also in the person I’m speaking with who may secretly prefer seeing me in private. So before I will agree to begin therapy with the caller alone, I coach the client on how he or she might get their partner to come in. I suggest that they discuss the issuewith their partner with an eye to uncovering that person’s negative expectations—seeing non-attendance as self-protective, rather than as simply obstinate. I list some possible reasons that their spouse might hesitate, including: shame, expense, fears of becoming angry or otherwise upset, or fears that the therapist has already sided against them. The hope is that exposing such fears may reveal some to be unrealistic. I also advise clients to tell their reluctant partners that they need only come for a few sessions, to see if they like it, and need not commit to months of treatment up front. When clients then have this discussion, the previously “reluctant spouse” often becomes willing to give therapy a try.

I also tell the spouse that should their meeting prove unpersuasive, I will reach out to their partner myself. When this is necessary, I begin with a similar exploration of negative expectations, and then appeal to two additional reasons to come—I tell the person that I could use their help in my work with their partner; and I remark that since we will be talking about the marriage, I assume that the partner “would like to have your side heard and represented, rather than having us speculate about it.”

▾ How to make an appointment

If you are interested in making an appointment call my confidential office phone number of 312-649-0570 to discuss your situation.

▾ Billing and Insurance

Fees

My current, standard fee is $300 per 45 minute session; $400 for an hour. Patients who cannot afford this can be seen at reduced rates, determined after considering ability to pay and frequency of sessions.

Bills and time of payment

I will give you a formal bill at the beginning of each month.
I ask some patients to pay me monthly (within one week of receipt of this monthly statement), while others will pay weekly at their last session of each week.

Insurance

In most cases at the present time, you just send my bill to your insurance carrier with a request for payment. If possible, insurance carriers should be instructed to remit all reimbursements to you.
Sometimes carriers will require you to complete a specific form, and sometimes there is a section on that form for me to complete.

Late payment charge and payment by credit card

There is a late payment charge of 10% on any unpaid balance more than 30 days in arrears.
I will usually forgive the first late fee charge. Bills that are two months in arrears will be charged to your credit card together with the late fees. I strongly prefer NOT to charge your credit card, since although I am set up to do this, it is a major time-waster and a big deal to do by computer.

Charges for missed appointments

I see relatively few patients, most of them for a number of years. Consequently, it is not possible for me to use cancelled time to see other patients waiting in my waiting room, say as an internist would, or to pick up new patients for a week or two while others are away working or on vacation. (This is somewhat like the situation of a landlord who cannot find a new tenant to fill in when a renter is out of town.) Rather than raising my rates so as to bill just for appointments kept—which would penalize those who attend more regularly than others—I have chosen to encourage patients to attend their appointments by charging for most missed appointments. Consequently, with the exceptions listed below, you will be billed under the following circumstances: (a) Canceling the same day. (b) Canceling in advance when not made up. (This applies only after we have settled on regular, weekly times.)

Makeup sessions

I purposely keep some open time in my schedule to allow for the inevitable shifting about of appointment times. Consequently, I can usually accommodate requests for changes. Since these are allocated on a first-come-first-served basis, it is to your advantage to schedule makeup times as soon as you know of a planned absence. Two weeks ahead will almost always be sufficient.

Generally, makeup sessions must take place during the same week as the cancellation. This is because my schedule is usually full and is planned based on an optimal number of hours which I can work per day. Shifting someone from, say, Wednesday at 9 AM to Thursday at 3 PM makes little difference to me since I will still be working about the same number of hours that week and (give or take a few) on any particular day; whereas scheduling makeup sessions for a different week while also coming at your regularly scheduled time(s) would prove too taxing and would be unfair to others since I would be less likely to function to the best of my ability.

Exceptions

You will not be charged in the following circumstances: (1) You are sick, or are required to assist a close family member who is ill or otherwise in acute need of help. (2) Some other untoward situation occurs which makes attendance impossible or unreasonable (e.g. an auto accident; major snowstorm, etc.). This does not include more mundane or commonplace "emergencies" at work or home.

Discussion

If you have any questions about any of this, please bring them up for discussion.