Combining individual psychotherapy and couple therapy - part 1

Should therapists consider the client’s partner in individual counselling and psychotherapy?

This is part one of a three part article. The content is adapted from a paper written by Jon Hay and Stephen Appel PhD entitled "From one person to two person psychotherapy: considerations and practicalities for including the partner in the treatment". The original article can be downloaded from the AUT University library website.

Introduction

The first chapter in this three part article explores various views suggesting that if a client is in a relationship then the impact of individual psychotherapy on their partner should be a consideration throughout treatment. As will be seen, the first point raised suggests a bias in the literature to either an individual or a couple approach to therapy, but little mention to working with a blend of the two. Next, new problems that might arise in a client’s romantic relationship when they are in the process of individual therapy are considered, followed by a look at ways that significant others could resist or sabotage their partner’s therapy if they do not appreciate or understand the changes that are taking place. Finally, some ethical arguments are raised which suggest that psychotherapists should not ignore the impact that psychotherapy has on their client’s relationships.

A dichotomy in the literature

"Every cobbler thinks leather is the only thing." (Mills, 2000, p. 19).

There is a dichotomy in the psychodynamic literature: that psychotherapy involves either an individual or a couple therapy approach to treatment - one or the other. Whilst some couple therapy writers give occasional note to the usefulness of individual sessions within the couple therapy format (e.g., Johnson, 2004; Scharff & Scharff, 1997) any mention given is usually brief. However, that amount appears generous when compared to the scarcity with which individual therapists mention meeting the couple.

Phillips (1983) says that many psychotherapists lean towards the classical approach which involves only meeting with and treating the individual. He warns that focusing on an exclusively individual format overlooks the important point that “any form of therapy is an intervention in a system of interpersonal relationships” (p. 11). When an individual is having psychotherapy their treatment affects their significant other regardless of whether the therapist thinks this way or not. Heitler (2001) suggests that focusing exclusively on the individual is overly simplistic and is likely to inadvertently harm some patients. She says: “Emotional health is based on the complex paradoxical reality that people need both individual happiness and relationship success. Oversimplification of treatment to address just one dimension risks harming the other” (p. 380).

Whilst many psychotherapists work with both individuals and couples, a widespread view is that they must decide to treat only one partner or only the couple (Weeks & Treat, 2001). This dualism has little impact when the client’s needs are straightforward; for example, individual therapy to help long-standing depression, or couple therapy to help with relationship conflict.

However, as we shall see in the following chapters, sometimes effective treatment may warrant a shift from one format to the other or a combination of both, and subsequently, an either/or approach may not be the best fit. For example, what happens when a client requests individual psychotherapy that seems fitting initially, but as they begin to describe their problem their partner figures prominently in their struggle? Or what happens when individual therapy is underway but as the treatment progresses, change in the client impacts problematically on their partner? In other words, when the need arises, how can we transition from individual therapy to couple therapy, or work with both approaches simultaneously?

An individual therapy bias

Psychodynamic therapists commonly assume that for deep change to occur, individual therapy is the only context that really facilitates this (Burch & Jenkins, 1999). Whilst this may sometimes be true, couple therapy, others argue, can enable change which cannot be achieved in individual work. “The often fierce and fastpaced interactional field of [couple] therapy is rich in occasions of intimate encounters, providing certain opportunities lacking in individual psychotherapy” (p. 243).

However, psychotherapists who prefer not to work with couples or who are not trained in couple therapy may have a bias for individual psychotherapy making them more likely to assume individual therapy as default and failing to consider whether alternative treatment formats could be more helpful (Zeitner, 2003). Hurvitz (1967) describes how this bias, if unacknowledged, might manifest itself in practice; he depicts a common scenario in which the individual therapist alludes to the fact that in order to obtain greater psychological well-being, a subsequent disturbance in the client’s relationships may be either a necessary sacrifice, or simply a reconciliation with the truth.

Another widespread notion voiced by Zeitner (2003) is that any characterological or interpersonal problems experienced by the client will inevitably manifest themselves within the individual therapy, either by disclosure or through observance of the transference. This view, he argues, fails to consider the importance of the intersubjective aspect of all human relationships.

Kottler and Carlson (2003) stress the importance of having a sense of flexibility and a pluralistic approach to psychotherapy rather than simply relying on a rigid format. They say that a failure in therapy happens when the therapist reaches the limit of one model and then is unable to reach for another.

Individual therapy that leads to new problems in the couple

The following two sections will look at some common scenarios that may warrant consideration for change in the therapy format. The first of these is when personal changes in individual therapy lead to problems in the client’s relationship with their partner.

Coyne (1976) and Graziano and Fink (1973) both note how individual therapy impacts on the client’s psychosocial environment, often placing unwanted changes and demands on significant others. This runs the risk of producing new conflicts or aggravating and compounding old difficulties. Therefore, whilst the common assumption is that individual psychotherapy is for the benefit of all, there is frequent mention in the literature around the potential of a negative impact resulting from changes that are unwelcome by the patient’s partner (e.g. Colson, Lewis, & Horwitz, 1985; Kohl, 1962; Moran, 1954; Zeitner, 2003).

Observations of this type are nothing new. Freud (1920) noted the frequency in which he encountered his female clients suffering marital difficulties subsequent to their treatment:

[I]t constantly happens that a husband instructs the physician as follows: “My wife suffers from nerves, and for that reason gets on badly with me; please cure her, so that we may lead a happy married life again.” But often enough it turns out that such a request is impossible to fulfil - that is to say, the physician cannot bring about the result for which the husband sought the treatment. As soon as the wife is freed from her neurotic inhibitions she sets about getting a separation, for her neurosis was the sole condition under which the marriage could be maintained (p. 150).

However, whilst many authors describe their own observations of new problems arising following individual therapy, researchers have reported mixed findings. For example, Pomerantz and Seely (2000) conducted a study in which they asked 473 undergraduates to envision their partner as having individual psychotherapy and then answered questions describing their distress to specific scenarios. Overall the study found that participants felt some distress at simply imagining having a partner in therapy, with the most distressing responses occurring when clients refused to discuss their therapy, and when partners were unaware of the reason for their partner’s therapy. Similarly, Gurman and Kniskern (1978) carried out a meta-analysis in which they analysed over 200 reports and studies that examined relationship deterioration during family or marital therapy. They found that negative therapeutic effects were twice as likely when the patient was seen in individual therapy rather than in a format that included both partners.

On the other hand, Hunsley and Lee (1995) conducted a meta-study of 20 independent clinical samples which looked at the impact that individual therapy has on relationships and they conclude that there are less negative consequences than some early studies indicated. They suggest that perhaps the increased number of female therapists contributes to this decrease in partner difficulties. In the past, clients of therapy have often been female and therapists were usually male which was likely to have invited inadvertent negative comparisons between the nurturing therapeutic relationship and troubles at home. Hunsley and Lee say that treatment with a same-sex therapist can reduce this risk. They also say that contemporary therapists may be more likely to encourage their clients to explore what they can do towards improving their happiness at home rather than simply complaining about their spouse. Hunsley and Lee conclude that whilst individual therapy often causes disruption to the relationship, this disturbance is usually temporary and there is no conclusive evidence to the long-term negative impact on the patient's relationship.

However, a critique of Hunsley and Lee’s findings is that psychotherapists cannot reliably predict whether a therapy will be long-term. Therefore, even though Hunsley and Lee conclude that disruption is often temporary, if the therapist does not attend to the partner in some way, they will be left to make a judgment call on whether or not the client will remain in therapy long enough, or whether the client’s relationship is strong enough, to withstand any problems that may have developed during the course of the treatment.

Nevertheless, we must not overlook the fact that client’s partners are often pleased with the outcome of their spouses’ individual treatment and they commonly find that it benefits themselves as well as their relationship (Lefebvre & Hunsley, 1994). Thus, holding in mind that individual treatment aims to be advantageous, Hunsley and Lee suggest that therapists discuss with married clients both the positive and negative impacts that individual treatment may have on their marital relationship and in doing so make it clear to the client the options of both individual and couple treatment.

In short, any therapy that has an impact on an individual will subsequently have an impact on their partner. As Garfield (2004) points out, “problems may occur in individual therapy when the therapist is unaware of the impact of the therapeutic alliance on the patient's relationships outside therapy” (p. 460). Therefore, if the individual therapist recognises that they have activated a disturbance in the client's relationship with their partner, Garfield suggests that this is the time for the therapist to encourage a consultation for couple therapy.

Resistance or sabotage by the partner

When the therapist does not give appropriate attention to the spouse's role in the client's difficulties, Hurvitz (1967) says the spouse may be resistant to any change that the client attempts to bring about and may try to sabotage the therapy in conscious or unconscious ways. For example, Kohl (1962) conducted a 10 year study in which he observed marital partners who were not included in the therapy exhibiting various types of reaction to their partners improvement; these ranged from resentment or suspicion of the therapist or the therapy, recurrence of addictive behaviours such as alcoholism, threats of divorce, through to threats or attempts of suicide. Ackerman (1958) also describes commonly observing one partner improving as the other gets worse, or one partner maturing as the other becomes more depressed.

Similarly, Pollak (1965) and Mittelmann (1944) point out that consideration should be given to the client's spouse, stating that change in one spouse is not always appreciated by their partner. If the partner does not welcome the changes in their previously familiar environment it is possible that they will be resistant to any change or may sabotage the therapy in some way.

Brody (1961) refers to a comment made by Freud about “the family poking their noses into the scene of the operation”. Brody responds by saying that the meddling of spouses signifies an attempt to get help for themselves and goes on to say that the barrier which is created by individual psychotherapy could make intrusion the only method by which the isolated spouse can “knock on the door of the partner’s analysis” (p.98).

However, these pathological reactions are often predictable, says Kohl (1962), and if a scenario such as this develops then the marital partner should be included in the therapy as early as possible. He says that the therapist's ability to effectively manage the conscious and unconscious hostility of the marital partner has a direct impact on the success or failure of the patient treatment. If and when to consider including the partner in the therapy is, of course, a judgement call. Zeitner (2003) describes a common scenario when after spending time in individual therapy and making significant changes the client complains to the therapist that their “spouse is still reacting to him or her as if he were controlling, helpless, stubborn, or whatever other characteristic might have been the focus of struggle. It is often at this point that the analyst and sometimes the patient, too, become aware of the presence of interlocking pathology which will less likely improve without couple therapy” (p. 350).

Likewise, Carveth and Hartman (2002) write that when the patient has been in individual therapy for some time and begins to notice that their partner is not only not changing with them but they are actually sabotaging any healthy progress, it may be time for the therapist to consider including the partner in the treatment. Kohl (1962) notes that inclusion of the marital partner is indicated when they react to the patient's obvious progress either by a resistance to their partners improvement, or by the development of clinical illness. He says that in these cases it is often clear that the well-being of one partner has a direct relation to the illness of the other and he found that it was not uncommon for the marital partner seeking treatment to actually be the less sick one in the relationship. Indeed, it may be that the partner who seeks treatment may not be the sicker one, and this may be one of the reasons that partners react badly to improvement in the other (Berger & Berger, 1979).

A common opinion amongst individual therapists, says Brody (1961) is that “in prolonged treatment with one individual, the idea has been expressed that if one member, the presumed 'sicker one' got 'straightened out,' the family difficulties would be automatically cleared up” (p. 97). This idea is unrealistic, he explains, because the real problem is still being ignored. He goes on to say that “the untreated partner may be treatment-rejecting precisely because he is afflicted with an even more severe disturbance than the treatment-accepting partner”. In other words, the client who arrives at the therapist’s office for treatment may not be the only one with a problem, and if treated in isolation, the other’s problems, as well as the impact of individual treatment of the partner, are being overlooked.

Ethical reasons for considering the partner

In addition to the practical considerations discussed so far, there are also ethical reasons for considering the partner. Sider and Clements (1982) say that what is good for the individual may not always be good for the couple and they suggest that individual therapists tend to overlook the ethics of considering the partner and avoid it in a variety of ways. For example, the individual therapist might maintain that there is no conflict between their therapeutic loyalty to the good of the individual and the good of the relationship that they are part. The assumption is that the good of one, in the long run, works for the good of the other. Another common justification they describe is that the therapist's sole interest is in achieving the goals of the therapy which have been defined by the participants of the therapy; the therapist is simply an agent of the process and has no interest in the outcome.

During the initial assessment for individual therapy, many therapists will routinely communicate to the client their qualifications, perhaps discuss the procedure and goals of therapy, and maybe establish a therapeutic contract of sorts. However, fully informing the client of the possible side-effects of therapy is often glanced over during this initial interview (Hare-Mustin, Marecek, Kaplan, & Liss-Levinson, 1979). What is being overlooked is that clients often enter into therapy believing that the process will enhance their relationship with their partner and whilst this may often be true, as mentioned previously there is the possibility that therapy may well harm it (Hurvitz, 1967).

Indeed, “is it ethical to offer married individuals assessment and treatment that does not include the spouse?” asks Heitler (2001, p. 349). Her rationale is that if therapy is started with one individual and not their partner, it introduces the likelihood that an asymmetrical alliance will be developed with one spouse, jeopardising the ability to work with both partners later if the need arises. In line with this, Lefebvre and Hunsley (1994) suggest that partners of clients in therapy should be included in discussion about the possible impact therapy can have on a relationship and that both partners are made aware that any impact to their relationship could be positive or negative.

Phillips (1983) says that in order to practice ethically, therapists need to develop and hold a clear premise of what constitutes appropriate concern for their clients overall wellbeing. If necessary they should broaden this view so that it includes the patient’s wider socio-psychological environment and not simply be confined to resolving unconscious conflict in the individual. “Realistic expectations of the potential benefits and costs of entering treatment should be fostered from the beginning, and include sufficient information regarding possible, albeit unintended, negative side-effects” (p. 10).

Whilst the views expressed so far have all leant towards an ethical obligation to inform the client of the potential outcomes of therapy at the onset, a critique of this is that real life practicalities may not always make this possible; for example, if the client presents in crisis. However, whilst the practicalities of attending to the client’s immediate concerns may make these explanations unwelcome or even unhelpful, Phillips (1983) maintains that “therapists must accept the ethical obligation to continually examine the effects of their interventions on the lives of the clients they serve” (p. 12). Therefore, if practical matters make the timing of this conversation inappropriate, then once the crisis is over the ethical conversation should be initiated by the therapist if the client intends to continue therapy. Phillips goes on to say that “just as the physician is obligated to inform the patient of the possible side-effects of a particular drug, and the lawyer is obligated to provide information regarding the possible gains and losses involved in legal action, the psychotherapist incurs a similar responsibility” (p. 10).

Summary

This chapter has discussed how psychodynamic literature commonly focuses on either individual or couple therapy with little written regarding transitioning or combining the two. This dichotomy flows into clinical practice leaving many therapists feeling as if they need to choose one format or the other. An individual therapy bias has been suggested and discussion given to understanding how this bias could be harmful to the client if not recognised. If the limits of individual therapy are overlooked by the clinician then an individual format may be chosen as default, even when it might not be the best course of action. If indiscriminately applied without consideration of the client’s relationship, individual therapy runs the risk of the spouse being resistant to any change made in their partner and the possibility of new problems arising. This would then force the therapist to decide either to include the partner in the therapy in some way or trust that these problems will be attended to appropriately in due course within the context of the individual therapy. Finally, ethical arguments have been raised that suggest an obligation to the therapist to attend to the client’s relationship appropriately and also to fully inform the client at the onset of therapy that their treatment may have an impact on their relationship.

The next chapter in this article looks at choosing and changing the therapy format.

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