The Textbook of Family and Couples Therapy describes the three “most common types of couples therapy”:
- Individual therapy;
- Conjoint couples therapy; and
- Combined couples therapy
In the first, a member of a couple is treated by an individual therapist, which, the textbook notes, is suitable especially for instances in which one spouse refuses to join marital therapy but a “poor choice, however, in the presence of marital disturbance and severe psychopathology…” Individual therapy for a marital problem does not give the therapist an adequately full picture of the marital interactions, nor adequate leverage to help both participants to symmetrically address their contributions to the problem. In general, because problems tend to be interactive, for one partner to make lasting changes for the better, both parties need to make changes.
In the second, “conjoint couples therapy,” both spouses are treated at the same time by a single therapist or team of co-therapists. Again, this form of treatment does not enable the therapist to see and therefore accurately diagnose the couple’s interactive patterns. Anyone can look good in individual treatment. Whole additional aspects of couples’ functioning appear once they are interacting with their partners around emotionally sensitive issues, and these are generally the issues that couples need help addressing.communicational patterns” in joint sessions. Conflict resolution treatment generally employs the third of these “most common types of couples therapy.”
As described more fully in a recent article in the Journal of Marriage and Family Therapy currently available on the website of the American Association of Marriage and Family Therapy, such combined treatment offers important benefits:
One professional is in a better position to recognize, define, and point out [and thereby ameliorate] the intrapsychic and interpersonal dimensions of the symptom-problem, to be aware of the two-way street effects of one process on the other, to know areas in either process that are being avoided and impulses that are being “acted out” rather than confronted. He [or she] is able to appreciate the subtleties of the resistances and transferences and to form an integrated concept of where the individual client and the marriage is and what the client and marriage is doing in each phase of help even though each process may be conducted according to the techniques of that particular modality…
Conversely, when a person is in individual therapy with one professional and in marriage counseling with another, the two processes may go off in opposite directions. Also, resistances may go unnoticed, the transferences may become more split or diluted, and the continuity of the person’s emotional flow and life processes may become more compartmentalized.
For these reasons, conflict resolution treatment recommends the practice of asking people being treated to take a break from any prior individual therapists if they are going to enter into treatment with a conflict resolution therapist. At the same time, the therapist explains that s/he will be available at any time for either spouse to schedule individual sessions as they feel the need. I explain that in general if I am seeing one spouse individually, I like to keep things symmetrical and work also with the other; and at the same time if this is not possible for financial or other reasons, I can be flexible. I add finally that the individual sessions may be occasional, suggested by either one of the spouses or by me, and/or may be part of an ongoing weekly pattern of treatment. For people dealing with specific difficulties—for instance, when one spouse has a borderline personality pattern or is dealing with chronic depression—as many as three sessions a week, with one couple session and one individual session for each spouse, can be ideal, finances and time permitting.
Multiple research studies have demonstrated that individual therapy for a spouse in a distressed marriage may make a couple’s conflict worse, making divorce more likely. These concerns, and their import for practice, are explained in a chapter of the 2008 Clinical Handbook of Couple Therapy, as follows:
“Because we take a systems perspective and view the couple as the client, we have found that individual therapy may interfere with our couple work. We also tell clients that research indicates that the chance of divorce is greater if clients engage in individual therapy rather than couple therapy (Bray & Jouriles 1995). Therefore, we request that partners stop individual therapy during our couple treatment. There is a greater chance of dysfunctional triangulating when another therapist is involved” (p. 504).
Conflict resolution treatment recommends this same policy, that is, flexible inclusion of individual and couple sessions within an overall couple treatment format with one therapist handling all the treatment components. The one exception to the one therapist rule for couples is for treatment of problems that lie outside the therapist’s areas of competence. Referral for additional specialized treatments such as neuropsychological exams, medication treatment, or addiction cessation would always be appropriate, provided the couple therapist and the additional treatment professional agree on a clear division of labor between the therapists.
What is essential however with a protocol that includes both individual and couple treatment formats is explicit confidentiality procedures. Conflict resolution therapists are encouraged to explain at the outset of treatment their policies with regard to confidentiality. Will information disclosed in one spouse’s individual session become the property of the couple? If so, then is it appropriate for the therapist to share individuals’ communications to the therapist with the other spouse? I believe not. Information shared by the couple in the presence of the couple of course is bounded by confidentiality vis-a-vis anyone other than the couple. Information shared with the therapist by one spouse must remain similarly bound by confidentiality to remain with the therapist.
With these principles, one spouse who may be having an affair is able to work on how to disentangle from the affair. The individual sessions enable the straying spouse to utilize the therapist’s in order to extricate from what can be a difficult situation. This option increases the likelihood of a positive marital outcome.
At the same time, if one spouse is having an affair, the therapist has a responsibility to clarify when the affair is revealed that affairs are a violation of the marriage contract. It is ethically important for a therapist to clarify to an unfaithful spouse that continuing to conduct therapy with a secret partner on the side is not an ethical endeavor or an option. However a therapist can help a partner who is engaged in an affair to settle their internal conflict, that is, to choose either to stay in the marriage or to leave it for the new partner.
I have found that this dilemma of having to hold confidential information with regards to an affair is a situation that does occur, but rarely. In most instances, holding individual spouses’ confidential information in confidence is relatively easy and greatly benefits both spouses. They can then enjoy the gains of both individual and couple treatment, with both aspects of this integrated treatment enhancing each other.
© Copyright 2010 by Susan Heitler, PhD. All Rights Reserved. Permission to publish granted to GoodTherapy.org.
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