▾ 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.

▾ When to Refer Patients in Individual Therapy to Couple Therapy

Sometimes I am asked by individual therapists or psychoanalysts to identify situations where a referral for couple therapy would be beneficial for clients they are seeing individually.

There are three typical scenarios (Nielsen, 2005):

1. The client fills the treatment hours with complaints about the spouse and no headway is being made in either the psychotherapy or the marriage. Transference work seems blocked by pressing external problems, and it is unclear how much the external impasse is due to the spouse. Spouses may appear to be opposing beneficial characterological changes obtained in the individual therapy (“I want my old wife back!”).
2. The client has an important unresolved disagreement with a spouse (whether to have children, how to handle the ones they have, how to relate to in-laws, etc.) and the individual psychotherapy has not moved things to resolution.
3. The client is improving and is considering divorce, but the therapist and client are unclear whether the spouse—usually someone with less therapy, and possibly opposed to it—would be willing to enter couple therapy in order to maintain the marriage.

What these scenarios have in common is the inability of the individual psychotherapist and client to assess or to ameliorate a specific marital impasse. Couple therapy with the absent spouse can often help.