Combining individual psychotherapy and couple therapy - part 3
One or more therapists
This is part three 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
Chapter 1 of this article looked at how individual psychotherapy can impact on the partners of those in treatment and suggested that psychotherapists should maintain an awareness of this potential along with an openness to adjusting the therapy format if necessary. Chapter 2 then explored how the therapy format can be altered to include the partner if the need arises.
If the therapist and client agree to include the partner in the therapy process, and the partner agrees to attend, the next decision is who should conduct the treatment? The choices are that either one therapist does all the work with both partners, or a referral is made to a colleague. Each approach warrants different considerations. If one therapist conducts both therapies, then confidentiality becomes the pressing issue. If two or more therapists become involved in the treatment, the main concern is how the therapists will collaborate and integrate the different treatments.
One therapist
Some common pitfalls noted by Lundell and Mann (1966) regarding multiple therapists attempting to work together are: hierarchical problems, differences in viewpoint, differences in skill level, assessment differences, communication difficulties, and each therapist taking on the role of advocate for their own patient. Therefore, whilst separate therapists for separate therapies are preferred by some, others believe that both partners being seen simultaneously by the same therapist is preferable in order to overcome some of these potential obstacles. Oberndorf (1938) says that as long as the therapist “is able to maintain a position of analytic neutrality, and impassivity, a difficulty is avoided which may arise when each member is being analysed by a different [therapist]” (p. 474).
Confidentiality
One of the most difficult problems that can arise when partners are seen separately by the same therapist is when one of them shares certain facts with the therapist that are not yet known to the other. There are few guidelines to help the therapist in these situations and differences in handling this matter vary. Whilst some therapists will maintain a secret shared by one partner, others will refuse to have any contact without both partners present so as to avoid this dilemma entirely (Mann & Lundell, 1977). The following section will discuss three approaches to the challenge of managing confidentiality amongst couples: secrets will not be kept, secrets will be kept, and the therapist will use their discretion.
All information is shared
In this approach the therapist treats all information as if it is common knowledge between partners and is open that they will not keep secrets and that anything that is said in private will be treated as if it was said in the couple sessions. Whilst this stance initially appears to simplify the therapist's task in terms of managing confidentiality, the major disadvantage is that if one partner does have a secret that would affect the relationship, there is a strong possibility that they will not reveal this information. Thus, the therapy will proceed on the assumption that no secrets exist even if one partner or the therapist suspects otherwise. The partner with the secret is forced to lie in order to conceal their information which means that they will have little opportunity to explore their options and choices related to the undisclosed material (Weeks, Gambescia, & Jenkins, 2003). With this stance the therapist has inadvertently created a format in which there is no safe environment for personal disclosures, and subsequently, no space for exploration of personal issues affecting the relationship (Margolin, 1982). Therefore, whilst this approach absolves the therapist of the responsibility of keeping or disclosing a secret, the likelihood of a halt in the therapy exists and a failure of the therapeutic goal is probable (Weeks et al., 2003) .
All information is kept confidential
This position implies that the therapist treats all information as confidential. So, if during an individual session with one partner a secret is disclosed, the therapist maintains confidentiality and does not share the information. The immediate problem with this scenario is that the therapist is forced into colluding with the partner holding the secret, which then excludes the other partner. Inevitably therapeutic progress will suffer leaving the therapy and the therapist ineffective.
Furthermore, if the therapist has been protecting the secret and the betrayed partner finds out then it is likely that they will experience increased emotional trauma through being deceived not only by their partner, but also by the therapist. Additionally, if this dilemma is left unattended it also raises the possibility that the therapist might either consciously or unconsciously find a way to end the treatment due to their personal discomfort or inexperience around how to manage the secret information. (Weeks et al., 2003).
The therapist's discretion
In this approach the therapist can choose to keep information confidential in the short term with the understanding that the partner holding the secret must accept responsibility and aim to either disclose or take a stance that alleviates the secret - for example, ending an affair. If the client remains unwilling to be accountable for their actions then the therapist can make the unilateral decision to terminate the couple therapy without any need to provide a specific reason to the couple. Obviously this action on the part of the therapist would raise suspicion in the partner who is not privy to the secret. Nevertheless, through taking this stance the therapist is upholding an ethical position of refusing to collude with the partner who is holding a secret but still providing them with options to explore which direction they would like to take, within the short-term safety of individual sessions (Weeks et al., 2003).
Weeks et al. (2003) emphasize that when the therapist agrees not to divulge secret information, they do so with the understanding that the client will be held accountable for their behaviour. A clear deadline is given within which the secret must be either resolved or revealed and if this is not done then the couple sessions are terminated. The therapist will then need to provide ongoing individual sessions in order to provide the withholding partner a place in which to explore and understand their situation and to make a decision about how to proceed.
Confidentiality when the therapy format changes
Margolin (1982) raises the important issue of how confidentiality should be managed when the format of the therapy changes; for example, when individual therapy becomes couple therapy. What should the therapist do with information that was obtained during the course of the individual therapy?
One simple option, she says, is to ask the client if information that is already known can be used in the couple sessions should the therapist feel it necessary. However, if the client declines then that information must be kept confidential which then forces the therapist into a secret holding collusion. And even if the client has permitted that any information can be shared, this agreement would have been reached after the client disclosed private information which means that they may have thought differently about had they known this in advance.
Clear policy in place from the start
Despite the differences in how confidentiality can be approached, there is unanimous agreement that the therapist must have a clear policy on how confidentiality will be handled when working with partners and this policy must be clearly understood by all parties at the onset of the therapy (Margolin, 1982). Bass and Quimby (2006) emphasise the importance of having a carefully constructed confidentiality agreement in place before the therapist agrees to treat clients individually in the context of couple sessions and they go to the extent of providing clients with a printed copy of their policy at the first session. Weeks et al. (2003) point out that the therapist's confidentiality stance should be clearly explained regardless of the presenting problem because influential secrets are not always apparent in the initial sessions or in the early phases of therapy, and may not appear relevant until much later.
On a final note about confidentiality following a change in the format, Margolin (1982) points out that if the client has previously experienced individual therapy then it is likely that they will presume confidentiality between themselves and the therapist. If the policy of the therapist is that they do not keep confidences when working with couples then it is imperative that they inform both partners at the onset of the couple therapy of therapy.
Multiple therapists
As previously noted, some authors believe that if an individual therapy is already established then it impractical to try to convert it into a couple therapy because primary loyalties between the therapist and the initial client make it difficult to build an effective working alliance with the partner who joins later. These authors advise that a referral should be made to another therapist who can begin the therapy with an equal relationship with both partners.
Splitting
Whilst beneficial in some regards, multiple therapists working with the same client is not without obstacles. One of the concerns raised is the potential that this format provides for splitting. For example, if the individual therapist is providing an empathic and supportive role but the couple therapist is taking a more challenging stance, it could become easy for the client to cast their therapists as the good one and the bad one. Thus, the need for containment within this therapeutic matrix becomes pressing. Some therapists may be reluctant to make referrals to another therapist because of this risk and depending on the pathology of the individual, the risk of splitting might be a contraindication for a simultaneous therapy (Burch & Jenkins, 1999). Heitler (2001) goes as far as asking her clients to take a break from any other therapies whilst working with her in order to reduce the risk of this type of complication.
Just as clients may split their transference between the therapists, the therapists themselves may face a similar struggle in their feelings towards their own client, the partner who is being treated elsewhere, and the other therapist. Burch and Jenkins (1999) use the metaphor of a stepfamily to describe the complex transferential dynamics that may arise in this scenario:
Stepfamilies contain more than one parental system, with differing values, standards, and perspectives. They inevitably have somewhat different understandings of the family situation and different expectations. Likewise, two therapists working with the same person bring different values and perspectives, different organising principles, and work from somewhat different concerns and conclusions. (p233)
Thus, the individual therapist will always lack some degree of investment in the other therapist's client - the stepchild. They will have a greater investment in their own client and it quickly becomes easier to problematize the other than their own (Burch & Jenkins, 1999).
Collaboration
In many concurrent psychotherapies it may be unnecessary for the therapists to communicate with each other because higher functioning patients are able to integrate the specific components from the different therapies without any additional assistance (Graller et al., 2001). However, when patients are more disturbed, communication between therapists will often be helpful and necessary (Maltas, 1998). This highlights perhaps the biggest struggle when multiple therapists have clients in common: collaboration. If separate therapies are sought then the immediate problem becomes how to integrate the two in order to understand and relate the therapies to the dynamics of the initial struggle (Ackerman, 1958).
Advantages of collaboration
The advantages of collegial collaboration are plentiful. Perhaps the most significant benefit is that it allows several therapists to bring in their combined creative power in order to better their understanding of both the individuals and the relationship dynamics of the clients. When a therapist anticipates a discussion with another colleague it encourages them to review the transference and countertransference themes which in itself improves understanding (Graller et al., 2001). Also, when a colleague sees a client in a different therapy context, their additional experience of the client can be helpful in gauging one’s own experience of that person (Donovan, 2003).
Another advantage is that successful collaboration can ultimately reduce the pressure on the therapist. When we feel part of a larger team, it becomes easier to focus on the work at hand. Collaborative work is also invigorating. Sometimes some of the stress that a therapist experiences arises from the isolation in which the work is done. Therefore, working in collaboration with other therapists can ease the loneliness which in turn helps clear the way for an increased vitality to enter the therapeutic work (Graller et al., 2001).
Collaboration is not only about similar thinking but can also be about differences, as both of these can be helpful in informing the therapist’s opinions. For example, differences of opinion can aid critical thinking and offer useful challenges that might allow for an expansion of thinking. Agreements, of course, can strengthen the therapist’s conviction about being on the right track (Graller et al., 2001).
Risk factors of collaboration
Whilst collaboration can be helpful it can also pose problems and should not be undertaken without proper consideration. When therapists decide whether or not collaborate with their colleagues the primary concern must always be around the impact that this might have on the therapeutic process. The principal danger of collaboration is that the therapeutic alliance might become damaged. For instance, if the patient has experienced trauma or psychological intrusion that has violated their boundaries, an explicit consultation with the other therapist may feel too threatening or overwhelming. It is also possible that information learnt from the other therapist could be premature or even disruptive to the therapists’ development of an empathic connection with a particularly fragile patient (Burch & Jenkins, 1999). If sensitive information is injudiciously shared the patient may be left feeling betrayed. Therefore, it is imperative that the therapist request approval from the client before any communication between therapists occurs, as this will allow the client to state if there is any specific information that they would prefer to keep private (Graller et al., 2001).
Timing of the collaboration
The stage of therapy at which collaboration occurs can have a significant impact on its usefulness. Graller et al. (2001) say that when outside consultation is sought to help with a stalemate or a crisis it is less helpful than when a full collaboration is being conducted from the beginning of the therapy. If collaboration is implemented at the onset of the treatment then both therapists will have a better understanding of their own transference and countertransferential responses, in addition to the data about their clients. However, if collaboration is sought simply when a problem arises, the conversation between the therapists is more likely to focus on factual information. This could mean that the underlying dynamics will be less visible between the therapists because the lack of any previous communication has prevented the development of a collaborative alliance.
Therapist fear of collaboration
Graller et al. (2001) raise the point that when therapists discuss and share with their peers their way of working, there is a real as well as imagined risk of criticism or judgment from colleagues. They consider anxieties experienced by the therapist to be the most significant impediments to collegial collaboration. Maltas (1998) voices some common concerns arising in the therapist when faced with the prospect of discussing work with a peer:
Do you call the other therapists, and if so what happens when they prefer not to talk to you? Do you accept “no” for an answer, and do you handle it differently if you know and respect the other therapist? What is the proper role for the patient in integrating the work occurring in the different domains? Do we ask about the other therapy or wait to see if they bring it up? Do we bring in information from the other therapist, especially if it conflicts with what the patient is telling us? (p339).
Though these anxieties are common, Graller et al. (2001) mention that they can be partially eased if the therapist is able to anticipate the benefit of consultation. For example, if the therapist is able to reveal to a colleague their unfavourable fantasies about their client’s partner it may provide a rich resource of information and be valuable in unlocking impasses. As summed up by Burch and Jenkins (1999): “The interactive effect of two therapies brings in a new dimension - an affirmation of one therapist's perceptions or a challenge to them - which may move each forward” (p. 250).
Collaboration difficulties
Despite the advantages that collaboration can provide, putting it into practice is not always smooth sailing. Maltas (1998) describes an experience that occurred when she attempted to communicate with the two individual therapists who were simultaneously treating her couple. “Neither therapist showed much interest in my views about the partner he or she had never met, and they did not seem to consider that the unknown partner might be other than described by the patient” (p. 345). Inevitably what developed was a split in each therapist’s view of the others, which created mistrust between them.
Brody (1961) points out that it is unrealistic to assume that communication between therapists will be without problems. Maltas (1998) agrees and says “when different clinicians look at the same clinical situation from different vantage points, and through the lenses shaped by different theoretical orientations and personal experiences, conflicting views can be expected” (p350). Furthermore, on top of the concern of differing views sits the practical hurdle of two therapists in private practice, with busy diaries, trying to coordinate time to talk (Brody, 1961). Ackerman (1958) states that integrating the two separate therapies is very difficult and extremely rare, and often lip service is paid to the concept but in reality it does not happen.
It is not only with strangers that communication problems can occur. Maltas (1998) describes a collaborative effort with colleagues with whom she has a long and good relationship, and even within this ‘dream team’ she acknowledges the difficulties that inevitably arose. However, the difference was that with her colleagues they were able to persevere and discuss these differences and to use them as valuable information in understanding their clients. She concludes that split transferences are to be expected and should be used as meaningful communications for the therapists in the same way that transference is used within individual therapy.
Summary
Chapter 1 suggested that individual psychotherapy can have a significant impact on the client’s partner and in order to maintain ethical practice psychotherapists should hold an awareness of this impact and initiate appropriate clinical interventions should the need arise. Chapter 2 looked at the different options available for conducting simultaneous therapies. Chapter 3 explored the next step in this course of treatment by considering two approaches to conducting the simultaneous therapies; the first option is for one therapist to do all aspects of the work, i.e., doing both the individual and the couple work in separate sessions. The other approach discussed is for multiple therapists to attend to each of the separate formats.
If one therapist does all the work then caution and planning needs to be given as to how confidentiality will be managed. The biggest challenge is how to guard against becoming entangled in an ethical bind if information is shared by one partner that the other does not know, whilst at the same time allowing both clients to explore all of their concerns freely. Three confidentiality stances have been discussed: no secrets will be kept, all secrets will be kept, and secrets will be kept short-term with the understanding that they must be shared or resolved by an agreed time.
If multiple therapists attend to different therapies, the concern then becomes how to integrate these separate formats. Discussion has been given to potential problems facing therapists who work collaboratively and recommendations given to when and how collaboration should occur.
Conclusion
This article has explored how psychotherapists can transition from individual to couple psychotherapy, or a combination of both, when client’s partners warrant inclusion in the treatment. The nature of the literature read for this article is not empirical research, but expert opinion. Therefore, the outcome is not a series of established proofs, but rather a collection of useful clinical considerations for the therapist. Based on these clinical considerations this paper has followed a path beginning with why the therapist might consider changing the therapy to include the client’s partner, through to how this change in the treatment can be conducted and put into practice.
First, the article discussed possible unfavourable reactions from partners following changes made by their spouse during individual therapy which might indicate a need for adjusting the treatment. Ethical arguments were raised suggesting that therapists are obliged to attend to the client’s partner when they are impacted on by the individual psychotherapy. Next, practical considerations were considered regarding how the partner could be attended to should problems arise, with a focus on when and how to include them in the therapy and possible formats that this inclusive therapy could take. Treatment formats considered include changing from individual to couple therapy, as well as introducing a simultaneous individual therapy for the partner or a simultaneous couple therapy for both partners. Finally, two options for conducting the new therapy arrangement were discussed. One option is for the same therapist to attend to both treatments, and the alternative is to involve another therapist(s) to work with the other format. Considerations for each of these options were explored, including managing confidentiality and therapist collaboration.
If a client enters individual psychotherapy and they are in an intimate relationship, the therapist has an ethical obligation to consider the client’s partner and any impact that the treatment might have on them. This is congruent with the New Zealand Association of Psychotherapists Code of Ethics which states that psychotherapists must do no harm; detriment to the client’s relationship must certainly fall within this category. Thus, the therapist should discuss with the client early in the therapy the possible side effects of individual treatment so that both the therapist and the client can hold this awareness in mind and be vigilant for any undesirable consequences. If problems do arise then appropriate action can be taken.
Failure to acknowledge the impact of individual psychotherapy on the client’s partner runs the risk of undesirable reactions from the spouse as well as the possibility of new problems emerging in the client’s relationship. Whilst some might argue that any negative impact is either unavoidable or simply a reconciliation with the truth, as shown in this paper, there are various considerations that can be held in mind by the therapist to reduce this risk or to accommodate some of the problems that might arise. Therapists need to be aware of their own preferences and biases when making decisions about clients in relationships so as to avoid unwittingly dismissing the partner’s problems without proper consideration.
References
Ackerman, N. W. (1958). The psychodynamics of family life. New York, NY: Basic Books.
Bass, B. A., & Quimby, J. L. (2006). Addressing secrets in couples counseling: An alternative approach to informed consent. The Family Journal, 14(1), 77.
Brody, S. (1961). Simultaneous psychotherapy of married couples: Preliminary observations. Psychoanalytic Review, 48(4), 94-107.
Burch, B., & Jenkins, C. (1999). The interactive potential between individual therapy and couple therapy: An intersubjective paradigm. Contemporary Psychoanalysis, 35(2), 229-252.
Donovan, J. M. (2003). Short-term object relations couples therapy: The five-step model. New York, NY: Brunner-Routledge.
Graller, J., Nielsen, A., Garber, B., Glusberg Davison, L., Gable, L., & Seidenberg, H. (2001). Concurrent therapies: A model for collaboration between psychoanalysts and other therapists. Journal of the American Psychoanalytic Association, 49(2), 587.
Heitler, S. (2001). Combined individual/marital therapy: A conflict resolution framework and ethical considerations. Journal of Psychotherapy Integration, 11(3), 349-383.
Lundell, F. W., & Mann, A. M. (1966). Conjoint psychotherapy of marital pairs. Canadian Medical Association Journal, 94(11), 542.
Maltas, C. (1998). Concurrent therapies when therapists don't concur. Journal of Clinical Psychoanalysis, 7, 337-355.
Mann, A. M., & Lundell, F. W. (1977). Further experience in conjoint psychotherapy of marital pairs. Canadian Medical Association Journal, 116(7), 772 - 774.
Margolin, G. (1982). Ethical and legal considerations in marital and family therapy. American Psychologist, 37(7), 788-801.
Oberndorf, C. P. (1938). Psychoanalysis of married couples. Psychoanalytic Review, 25(4), 453-475.
Weeks, G., Gambescia, N., & Jenkins, R. E. (2003). Treating infidelity: Therapeutic dilemmas and effective strategies. West Sussex, England: John Wiley & Sons.