Combining individual psychotherapy and couple therapy - part 2
Choosing and changing the therapy format
This is part two 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 previous chapter suggested that individual psychotherapy can have a significant impact on the partners of those who are in treatment and that in order to practice ethically, psychotherapists need to maintain an awareness of this impact and initiate the appropriate action should the need arise. It has not been suggested that all individual therapists should convert to couple therapists, and the importance of an individual psychotherapy treatment is not being minimised. As Mann and Lundell (1977) point out, when couple therapy methods are applied overzealously without proper assessment of individual needs, they too can have a significant detrimental effect on the therapeutic outcome. What is being suggested is that when a client comes for individual therapy who is in an intimate relationship, then in a sense it is already couple therapy whether the partner is physically present or not.
The following chapter will bring together some views and suggestions from therapists who have included client’s partners in various ways. The therapy formats considered range from the partner attending one or more sessions of the individual therapy, through to changing the format from an individual therapy to a couple approach. This chapter looks at factors that can guide therapists when deciding on a format near the start of the process as well as converting the format of an already established individual therapy.
Consumer model
A clearly articulated criteria for deciding whether to opt for individual versus couple therapy has yet to be written and changing or extending the initially requested format carries many considerations (Maya, James, & Steven, 2003). For instance, who should decide on which format to undertake: should the therapist simply accommodate the client’s wishes or might professional opinion take precedence?
Gabbard (1994) considers things such as: What is the patient asking for? Does one client come to the office looking for therapy or are there in fact two clients? During the initial meeting with an individual, do they focus on their own problem or a shared problem with their partner? Does the individual consider their problem as having an internal origin or an external one?
In an ideal scenario, Zeitner (2003) says the therapist will conduct an in-depth assessment and then after discussion with the client reach a consensus over which is the best course of treatment for the presenting problem. McWilliams has a similar view and says that therapists should typically respect the client’s wishes in the first instance and then revise the initial decision over time, in collaboration with the client (personal communication, 20th May, 2010).
In the absence of reliable research, it is clinical wisdom that becomes most helpful in choosing between an individual or couple format. The following section will bring together expert opinions regarding indicators for both approaches. First, some general indicators that suggest proceeding with an individual format are outlined below.
Indications for individual therapy
Maya, James and Steven (2003) point out the obvious and state that individual interventions are indicated when one spouse is unable or unwilling to attend therapy. Corcoran (2004) adds that an individual format is indicated if: the client is suicidal, if the individual sees their depression as arising before any relationship problems or as unrelated to their relationship, when the client wants to attend to many personal issues, when there is a lack of commitment to their relationship, if the partner is having an affair, or if marital violence is present. Johnson and her colleagues (1999) also say that when ongoing abuse is present then an individual format takes precedence. Johnson refers abusive partners to either group therapy or separate individual therapy to help them deal with their abusive behaviour and couple therapy is only offered when the abusive individual has completed their therapy and their partner no longer feels at risk.
Halford and Bouma (1997) say that couples therapy is unlikely to be helpful if either partner is experiencing an acute psychotic episode or if they abuse alcohol to the extent that it inhibits any effective engagement in therapy. Likewise, if somebody is severely depressed and is subsequently unable to engage effectively then individual treatment is likely to be more helpful before any couple work is considered.
If the relationship is ending because of separation or divorce, Crowe and Ridley (1990) say this may be an indication for only seeing one partner. Often that partner will come for help because they are going through the equivalent of bereavement and the therapy may centre on initially helping them mourn the loss of their relationship.
A final note comes from Johnson (2005) who says that when an individual has experienced trauma then individual therapy should be the preferred choice at the onset and couple therapy can be considered to attend to any interpersonal trauma symptoms once the acute individual symptoms have been addressed.
Indications for couple therapy
The following opinions discuss when it may be helpful to suggest a couple format instead of, or as well as, continuing with an individual therapy.
Problems relating specifically to arguments and relationship tension appear to be an obvious starting point for considering couple therapy, say Crowe and Ridley (1990). Another consideration they point out is when a client in individual therapy spends much of the session complaining about their partner's behaviour. Couple therapy might also be indicated when one partner experiences an increase in stress as a result of the improvement of their partner from their own individual therapy.
Crowe and Ridley (1990) also suggest couple therapy when an individual’s problem directly affects their relationship. For example, a wife who has a phobia with sex might believe that the problem is all hers and certainly individual therapy will likely be of benefit to her. However, her problem may also generate frustration for her husband and as a result, his frustration may well impact on her phobia. Thus, couple therapy could allow both partners to explore the part that each of them may be playing in terms of maintaining the problem.
If the primary difficulty seems to be related to an inability to cope with the marital relationship - despite the individual's adequate functioning in other social settings - then Mann and Lundell (1977) say that treatment involving both partners may be a preferable format. Corcoran (2004) mentions that if an individual suffers depression and they perceive their symptoms as being caused by their relationship problems then couple therapy is indicated. Likewise, Maya and colleagues (2003) note that couple therapy should be considered when a client believes that their relationship is playing a primary role in their symptoms. Finally, Brody (1988) points out that if couple therapy is being considered, it is important that each partner is capable of forming and maintaining an alliance with both the therapist and their partner.
Meeting the partner at the start of therapy
The attendance of partners needs careful consideration and meeting them during the onset of therapy has different implications than meeting them later in the treatment. As will be seen in the following section, many authors appear strong advocates for the usefulness of meeting the significant other near the start regardless of which therapy format they plan to undertake.
Even if the therapist does not wish or believe it necessary to pursue couple therapy, it can be helpful to have at least one session in which the partners are seen together, suggest Mann and Lundell (1977). They believe that this introduces another dimension into therapy, and also helps in reducing observer error. Berger and Berger (1979) believe the therapist can have a more truthful experience of the client when they meet both partners together. They say that it is not uncommon to discover that each partner behaves quite differently when seen alone than when seen with their partner.
Maltas (1998), reflects on her own experience and says that “after more than 20 years of practising individual and couple therapy I am still shocked at the difference between my image of a partner, developed in the course of an individual therapy, and the person who walks into my office claiming to be that partner” (p. 348). Yalom (2003), too, says “never have I regretted interviewing some significant figure in the life of my patients” (p. 211). He makes the point that whenever a patient describes to him their significant other he creates a mental image in his mind of that person, often overlooking or forgetting that the information he is being given is highly skewed by the patient's subjective bias of their partner. Yalom believes that when he meets the significant other he is able to see more fully into the life of his patient. He notes that because he meets the significant other in the unusual setting of a therapeutic session their behaviour and manner will be influenced by the rather odd context. Nevertheless, Yalom believes that the “image of the face and person of the other permits… a richer encounter with [the] patient” (p. 211).
Meeting the partner is not without risk however. In keeping with the views that have already been mentioned, Vaglum et al. (1994) concur with the usefulness of interviewing the spouse when the therapy commences in order to help the therapist better understand the new patient. However, they warn that this interview not only impacts on the patient, but also on the spouse. For example, rather than ease any negative transference that the partner may have, it may actually increase their feelings of discomfort, perhaps increasing envy, as they see first-hand the closeness and intimacy that their partner has or will develop with the therapist. They say that if the therapist gets any indication that this is occurring then it is important that they make efforts to address it directly.
However, is it a good thing that the therapist becomes privy to information through means other than by disclosure from the client, ask Carveth and Hantman (2002)? They point out that therapists of a post-modern view might state that this type of fact-finding is irrelevant to the therapeutic task . However, they believe that exposure to information about the client (from those who are in relationship with him or her) can help the therapist guard against potential identifications ranging from “twinship experiences or mergers..., to projective counteridentification, all the way to outright folie-a-deux” (p.35).
So, many authors agree that meeting the partner can be helpful when a client is in a serious intimate relationship even if couple therapy is not part of the treatment plan (Carveth & Hantman, 2002). Furthermore, meeting the partner at the start of the therapy opens up possibilities of including them later on should the need arise.
Getting the partner to attend
So far we have looked at reasons for considering the partner and reasons why it may or may not be helpful to include them in the therapy. Using the information discussed one is able to begin building a picture of when it might be helpful to include them. If client and therapist agree to the partner attending one or more sessions, the next consideration is how to get the significant other to attend.
The reluctant partner
Odell and Campbell (1998) discuss the common problem of an individual who states a desire to include their partner in therapy but declares that they will not attend. How do you get the other person into the therapist’s office? Initially the client should be asked if they have actually invited their partner to come to therapy. Odell and Campbell say that in their experience it is common that the individual client is assuming that their partner is reluctant but they have often not actually asked him or her if they would be prepared to come to couple therapy. They suggest that at times all it takes is an encouraging partner in order to get the spouse to attend therapy as well.
Sometimes, however, the invitation is refused. Odell and Campbell point out that it is important to determine why the invitation was declined. It might be that the reluctant partner has had an undesirable therapeutic encounter before. They suggest that the therapist (after obtaining permission) contact the reluctant partner directly. During this contact, the therapist can address things such as a realistic representation of themselves as a therapist, the client's pride, and also perhaps appealing to the spouse's sense of duty.
Sometimes one partner is unwilling to attend because they are having an affair with somebody else. Or perhaps the couple are having an affair with each other and one or both are also involved in another relationship that has not ended. Crowe and Ridley (1990) say that an ongoing affair is not always a complete block to therapy. However, if the involved partner does attend sessions it is likely that the divided loyalty and strong ambivalence will make therapy very difficult.
Who should invite the partner?
There are opposing views around who should take responsibility for encouraging the partner to attend the therapy. Forrest (1969) takes the position that when it is apparent that the marital partner is directly involved in the presenting issue then the therapist must work hard to motivate and involve the one who did not seek therapeutic services. Similarly, Crowe and Ridley (1990) suggest the therapist make efforts to involve the other partner or contact them directly - especially if communication has been via the partner in treatment - in case they had been misrepresented by the attending client due to their wish to avoid couple therapy.
Framo (1992), on the other hand, says that it is not appropriate for the therapist to get directly involved with inviting other family members to attend therapy. He says that any efforts made directly by the therapist will likely just strengthen any resistance and that inviting others is the responsibility of the client. This will be demonstrated in the subsequent example.
Caution about including the partner
A study was conducted by Halford et al. (1997) aimed at assisting women who reported problematic drinking in their partners. During the programme a number of the participants discussed how they feared assault by their partner if it were discovered that they were seeking assistance. This example highlights the fact that even when the partner is part of the problem there are still occasions when trying to include them may be ill advised. Sometimes, simply informing one partner that the other is in therapy can pose problems.
Even when the therapist strongly believes that including the partner will be helpful, the clients’ wishes must be respected. Mann and Lundell (1977) share a sobering account of an overzealous attempt to include the partner:
A 38-year-old woman who was being treated for depression had many vindictive complaints about her husband's lack of understanding and other faults. The therapist, thinking it would be sound to see the couple together, attempted to overcome the patient's steadfast refusal to agree to conjoint therapy. Eventually an appointment was arranged. The husband appeared punctually; the wife was not present. After a telephone call, the wife joined her husband and therapist in the office 20 minutes late. The therapist attempted without success to discuss the material the wife had presented at earlier sessions. After 15 minutes, the wife said that she had ‘had enough’ and stalked out of the office. She later telephoned to tell the therapist that he would not be bothered with her again, and that she had told him therapy would not work; she then took an overdose of a drug and had to be admitted to hospital. The overdosage seemed an obvious attempt to avenge herself on the therapist for what she perceived as a devastating humiliation. This patient was delivering a serious message, despite the non-lethality of her overdose; never again have we been this insistent or forceful in arranging conjoint sessions. (p. 116)
Getting the partner to attend clearly extends beyond simple logistics. As well as understanding when it can be helpful, it should not be overlooked that sometimes it could be harmful.
The partner refuses
Even when indicators suggest that it would be wise to include the significant other, the reality is that some people will not attend therapy with their partner under any conditions. In these situations the therapist must work with whatever they have access to. Sometimes this will be enough to bring about change and sometimes it may not (Odell & Campbell, 1998).
Crowe and Ridley (1990) believe that it is possible to provide couple therapy even when only one partner attends the sessions simply because the non-attending partners can be affected by any changes that the attending partner makes. They go on to talk about including the non-attending partner by, for example, the attending one taking home instructions for homework exercises. However, they note that this would only apply to those who are unable to attend for genuine practical reasons and not to those who are simply unwilling to get involved.
Converting an established individual therapy to a couple therapy
Introducing the partner when an individual therapy is already established warrants different considerations to meeting them at the start. A therapeutic alliance will already have been established with the initial client and injudicious introduction of the partner risks damaging it.
Not all therapists believe that the partner can be successfully introduced. Gabbard (1994), for example, believes that if the individual process is well established then it is rare that it can be converted into a successful couple therapy. He highlights the obvious fact that the partner who was brought in later on will feel the therapist's primary loyalty to the other partner and subsequently is rarely able to form an effective working alliance with the therapist. Gabbard suggests that the best solution in this scenario is to refer the couple to a separate couple therapist whilst continuing with the original individual therapy.
Yalom (2003) also believes that when the therapist already has a primary loyalty to one member of the partnership then they are not able to treat the couple. He says that if the therapist attempts couple therapy when they already have a wealth of confidential information from one partner, the therapist will inevitably become involved in a withholding parallel process with the other. Yalom, too, suggests that couple therapy should subsequently be conducted by another therapist who will have a balanced allegiance with both partners from the beginning.
However, if the risk factors are understood and carefully considered, many authors agree that introducing the partner into an established therapy is a worthwhile, albeit challenging task. Weeks et al. (2003), for example, say that when the individual has been in therapy for a long time it runs the risk of becoming counterproductive because loyalties will have been established with one individual which if threatened can have a detrimental effect on the therapeutic alliance. Wilke (1984) adds that when the partner joins the therapy (and then later leaves) it disrupts the individual process for some time. Nevertheless, he believes that the necessity and the outcome of directly dealing with the relationship concern in the conjoint format is extremely profitable and achievable. Therefore, if the therapist does decide to change to couple therapy having worked long-term with the individual, precautions can be taken with the individual client that involve educating them about what they might be able to expect or feel when the other partner is present.
For example, the long-term client could be warned that they may experience feelings of loss or perhaps even feelings of being judged. The therapist needs to explain that they will attempt to be balanced between both individuals but because the long-term client is likely to feel a sense of loyalty towards the therapist, when this is perceived with the spouse it may be felt as a betrayal (Weeks et al., 2003).
Those with severe narcissistic wounds might feel disappointed if they believe that somebody else in the session got more attention than they did, notes Framo (1992). He suggests that these types of clients need special preparation for joint sessions and an explanation that both parties will be attended to by the therapist. Framo says that it may be necessary for the therapist to keep interaction between partners at a minimum and encourage more direct and empathic communication between the therapist and each client.
Carveth and Hantman (2002) note that care is needed when introducing the partner into therapy. “The analyst who takes on as a new patient the spouse of the acting-out [client] will find that, at every turn, both members of the couple will unconsciously thwart the treatment” (p. 38). They say that whilst the more self-aware client may recognise their feelings and be able to verbalise to the therapist any concerns they might have, the more emotionally retarded client may be completely unaware of any discomfort that they may be experiencing. These clients may act out in destructive ways as the unbearable anxiety increases in response to the therapist having a relationship with the client's significant other.
It might be helpful, suggest Weeks and Treat (2001), to see the partner who is joining the therapy for several individual sessions before commencing a joint session. This will allow the therapist to show some empathy for the perspective of the spouse, which may lessen the degree to which they might feel like a guest at their partner's therapy, or already threatened by their perception of an existing alliance. They also suggest that it might be helpful if the transition from individual therapy to couple therapy is initially done on a provisional basis and if it becomes counterproductive then other alternatives can be explored and possibly pursued. They point out that it is crucial to explore with the spouse who is joining the therapy the possibility of feeling aligned against or ganged up on and an agreement made that they will voice this immediately should it occur. Hurvitz (1967) adds that if a couple format is being adopted to attend to a newly emerged problem, the partner’s feelings toward the therapist should also be explored, as the therapist may be perceived as playing a significant role in the arisen relationship difficulty.
Simultaneous individual therapies
There are times when the partner may be part of the problem but changing to a couple therapy may not be preferable. For example, Ackerman (1958) says that if both partners are locked in a pathological conflict then separate therapies may be the best way forward.
However, “involving the isolated, non-participating partner in simultaneous psychotherapy may pave the way for such a couple to secure separate treatment”, cautions Brody (1961), and “this may represent a continuing pattern of pursuing their separate ways and perpetuating their unhappiness” (p. 98). Heitler (2001), warns that a format in which two separate individual therapists each see one partner creates the dual relationship most likely to eventuate in separation or divorce. She says that this arrangement is most helpful for a couple who are already clear that they want to separate and warns that it is ill-advised for any couple who want to save their marriage.
Ackerman (1958) says that if separate individual therapies are planned then treatment must begin with adequate emotional preparation and clarification of the interpersonal level of disturbance, in order to lay an effective foundation for communication between the two therapists as the treatment progresses. (Further discussion on communication between therapists is given in chapter 3).
Individual / couple therapy continuum
The variations for mixing individual and couple therapy formats are broad (P. R. Brody, 1988). One end of the continuum represents a purely individual based therapy where the therapist will only meet with the individual throughout the treatment and the other end of the continuum is a purely couple-based format where the therapist always meets with both partners together. Moving in from the individual end we approach an area that can be described as partner supported individual therapy where the focus is on individual treatment but the partner may attend some sessions as required. Moving in from the couple end of the continuum is couple therapy with some individual sessions as required. As these two ends of the continuum approach the middle we find an area consisting of individual therapy and couple therapy running simultaneously (Zeitner, 2003).
Mixing the formats
Which format to apply when varies between therapists. Brody (1988) presents a model of psychotherapy where both partners are seen together for conjoint weekly therapy, and each individual is also seen separately for biweekly individual therapy. He points out that this format is aimed primarily at high functioning couples.
However, high functioning is not a prerequisite held by Heitler (2001). She uses a variable format when working with couples where both partners have long-standing patterns of borderline, narcissistic, depressive, or paranoid functioning. She describes a format of three sessions a week; one couple session and one individual session with each partner. Heitler points out that whilst this form of comprehensive treatment can help couples such as these to live emotionally satisfying lives, it does take a significant investment of time and money.
A variable format is also suggested by Berger and Berger (1979) for clients who have more serious disorders. They say that if one partner is diagnosed as having a “serious character neurosis” then they may suggest individual treatment on a regular basis whilst the partner is seen monthly (sometimes weekly) for couple sessions.
Greenbaum (1983) refers to using a primarily individual format and then using conjoint sessions irregularly, as the need arises throughout the individual process. These joint sessions would usually occur “during periods of crisis from which the patients are unable to extricate themselves” (p. 289). However, Harwood (2004) warns that therapists should only consider including a flexible couple therapy as part of the individual treatment when the therapeutic bond with the individual is strong enough to withstand disruption and repair.
At the other end of the continuum, individual sessions within a couple format are commonly mentioned in the literature (e.g. Johnson, 2004; Lundell & Mann, 1966; Scharff & Scharff, 1997) and are used almost routinely by some therapists for reasons ranging from allowing time for individual assessment through to exploring suspected secrets that may be hindering the couple work.
Summary
Chapter 1 asked why psychotherapists might consider changing from an individual to a couple therapy format. Chapter 2 looked at the next step and explored some views and opinions on how therapists might choose which format to follow and how to implement this. General indicators have been suggested that may help guide in choosing between individual or couple formats, and views have been explored that encourage meeting the partner at the onset of therapy, regardless of whether an individual or a couple format will be pursued. Inviting the partner to therapy is not a task to be taken lightly, and cautions and considerations regarding including the partner in the process have been raised.
Next, the possibility of converting an established individual therapy into a couple therapy was discussed. Views differ on this, in that some therapists believe that a referral should be made to another therapist to begin anew - with equal loyalties to both partners - whilst others believe that with appropriate understanding and preparation, an individual therapy can be successfully changed to a couple therapy format and still be conducted by the same therapist. Finally, conducting a simultaneous therapy to run alongside the initial individual therapy and the variations available within this approach have been explored.
As well as the points already raised, there are countless other factors to consider such as the social and cultural context, the severity of the initial problem, the seriousness of the relationship with the partner, and whether or not there are children involved. The list is endless and ultimately therapists are left to rely on clinical wisdom. However, as Ackerman (1958) points out, the clinician needs to make a decision about treatment early on, despite the fact that at this stage he or she has inadequate knowledge with which to predict with any real confidence the outcome or effect of the therapy on each partner.
The next chapter looks at practicalities and considerations when one therapist versus multiple therapists conduct the new therapy format.
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