Yaliu He, Ph.D
Madigan Family Postdoctoral Clinical Research Fellow
The Family Institute at Northwestern University
Newswise — When couples are dissatisfied in their relationship, couple therapy, in which both members of the couple participate in the treatment, has become one of the most widely practiced interventions. The effectiveness of couple therapy in improving couple relationships has been demonstrated by several studies (Shadish Baldwin, 2003). For example, in their systematic review, Lebow, Chambers, Christensen, and Johnson (2012) summarized research findings indicating that couple therapy improves relationship satisfaction for 71% of participating couples at the end of treatment, while distressed couples who received no treatment made no improvement (Shadish Baldwin, 2003, 2005; Baucom, Hahlweg, & Kuschel, 2003).
While couple therapy is significantly more effective than individual therapy in addressing relationship distress (Barbato & Avanzo, 2008), many people who seek help for couple-related issues are treated in individual therapy. There are several reasons for this. Individuals may be reluctant to invite their partners into treatment because they don’t think their partners are willing to engage in couple therapy, or their partners may refuse to participate even if invited. Therapists may decide that individual therapy is a better option than couple therapy when the partner demonstrates cognitive impairment, substance abuse, or domestic violence. Individual therapy may be the only treatment format offered in some clinical organizations or specific geographic areas (Gurman & Burton,2014). Finally, some therapists only conduct individual therapy because they have not been trained in couple therapy approaches.
Because a large number of people with relationship concerns are treated in individual therapy, this article is designed to provide tips and suggestions for clinicians who treat couple-related problems with only one partner participating in the treatment. Moreover, given that a large number of individuals turn to at least one confidant within their social network before they seek professional help, this article will also provide ideas for lay helpers in their efforts to assist friends and family members suffering from couple relationship problems.
Potential pitfalls in treating couples’ issues in individual therapy
Three major concerns have been raised about treating couple problems in individual therapy (Gurman & Burton,2014). First, therapists cannot accurately understand the interaction pattern of the couple without direct observation of the two together. Because therapists do not have a chance to observe the couple’s dynamics, their treatment conceptualization may be biased via being drawn into individuals’ one-sided story about a relationship that often depicts their partners in a negative light. For example, therapists may make the mistake of asking leading questions – such as “Why do you still stay in the relationship if you have suffered a lot?” and “Why do you think she wants to control you?” – which implies that the partner is the problem. In this way, relationships may be potentially undermined by therapists who consistently attribute negative motives to the partner. This is because when therapists reinforce the individual’s negative views about the relationship, he or she may feel temporarily understood and affirmed, but this can lead to despair quickly because he or she cannot change the partner within the context of therapy.
Second, therapists cannot directly apply interaction-oriented interventions when the partner is absent. For example, therapists who are unable to intervene with both members of the couple directly may miss the opportunity to activate each partner’s vulnerabilities (Scheinkman & Finshbane, 2004), promote adaptive communication styles, and discuss the potential mismatch in their cognitive views, which are critical change mechanisms related to improvement in relationship quality.
A third potential pitfall related to treating relationship problems in individual therapy is that when individuals ascribe the problem as either their partner’s fault or their own mistake, they cannot take shared responsibility for the relationship problems between them (Gurman, 2008). For example, individuals who state that their partners are not willing to come to couple therapy may believe that “the only problem is me” and “I need to get myself fixed.” This assumption – that they are the sole problem – may lead them to self-criticism and depression.
Tips for Therapists: Couple Sensitive Individual Therapy (CSI)
Given the above concerns related to treating couple problems in individual therapy, it is not surprising that, compared to individual therapy, couple therapy is more effective in treating relationship distress (Barbato & Avanzo, 2008). However, is it still possible to effectively treat couple problems within individual therapy? William Doherty, a professor at University of Minnesota, has developed a clinical protocol called Couple Sensitive Individual Therapy (CSI; Doherty, 2015) that provides clinical strategies to address the concerns raised by Gurman and Burton (2014). CSI is defined as individual psychotherapy that is aware of how therapy affects the client’s intimate partner and the couple relationship (Doherty, 2015).
Doherty (2015) identified two master strategies in CSI therapy: “aligning with the client’s therapeutic goals, not with the person against someone” and “helping the client learn to manage self during relationship difficulties.” He emphasized that therapists should validate the individual’s painful feelings rather than his or beliefs about the partner. For example, a therapist can say “This sounds very painful for you,” rather than “I understand how hurt you were when your wife didn’t trust you.” In some cases, individuals’ report of their relationship problems may not reflect reality well because they may ignore their own contributions to the problem. In this situation, the therapist should paraphrase the individual’s perspective in a neutral way, such as “you think she doesn’t trust you,” which avoids suggesting that what the individual says about his or her partner is true.
When the therapeutic alliance is established, therapists can start to explore both the individual’s contribution and the partner’s contribution to their relationship conflicts. For example, therapists may ask “What do you do when your husband gets angry?” and “What can you do to change the way you two interact during stressful situations?” Helping individuals realize what they need to change, and helping them take responsibility for making those changes, is a goal shared by all individual therapists, regardless of their theoretical orientation. Additionally, a CSI therapist guides the individual to better understand where his or her partner is coming from by speculating about the partner’s vulnerable feelings underlying his or her behavior. However, the partner’s unacceptable behavior (e.g., domestic violence) can never be justified (Doherty, 2015).
It may also be helpful to invite a client’s partner to come to therapy for one session (Doherty, 2015). The purpose of meeting the partner is not to turn the individual therapy into couple therapy; instead, it allows the therapist to better understand the partner’s perspective and observe the couple’s interactions. A joint session also helps the therapist build a shared understanding with the partner, given that the therapeutic alliance between the therapist and other family members is important for treatment outcome (Pinsof, Zinbarg, & Knobloch-Fedders, 2008).
Although within a single meeting the therapist does not have much opportunity to intervene with the couple, the information gathered by observing the couple’s interactions and hearing the partners’ perspectives helps prevent any blind spots or biases the therapist may develop. This helps the individual therapist better understand relationship issues due to the opportunity to directly observe the couple dynamics within the joint session.
Tips for Confidants: The Marital First Responders Program
Before seeking psychotherapy, individuals often confide in others within their social network about their relationship concerns. A recent survey of a national sample of 1,000 U.S. adults between the ages of 25 to 70 found that 62.6% of participants confided in someone about their relationship problems, and 65.7% of participants had someone confide in them within the past year (Lind Deal, Doherty, & Harris, 2016). Individuals were most likely to confide in their female friends (32.9%), male friends (16.6%), siblings (8%), and coworkers (7.9%). As described by Lind Deal et al. (2016), specific problems discussed included growing apart (67%), not able to talk together (66.3%), not enough attention (63%), how their spouse handles money (60%), and considering divorce (57.9%). Research has drawn inconclusive findings about the benefits of using an outsider confiding relationship in an effort to improve marital quality. For example, Crane et al. (1984) found that wives who shared their marital conflicts with confidants were more likely to decide to get divorced. Widmer, Kellerhals, and Levy (2004) found that a third party could negatively affect the marital relationship by magnifying the confider’s complaints. In contrast, other studies have obtained opposite findings, reporting that a confiding relationship is associated with positive relationship outcomes (Helms, Crouter, & McHale, 2003) and lower likelihood of depression (Osborn et al., 2003).
Similar to the common pitfalls which occur when couple-level problems are addressed in individual therapy, several risks to the relationship exist when an individual confides relationship problems to a third person. For example, a friend or family member may side with the confider and reinforce negative views of the partner. The confidant may be biased by the one-sided judgments shared by the individual, and may want to show support by completely agreeing with him or her even though the confidant may never meet the partner. After the conversation, the confider may believe that separation is the best option because his or her negative views of the partner were validated or reinforced. Finally, tension between the confider and the confidant may arise because the individual still wants to maintain the relationship, despite sharing complaints about his or her partner.
Give these concerns, a community educational program called Marital First Responders was developed by William Doherty (2014) to train lay helpers/confidants to respond appropriately to people’s relationship concerns. Guidelines include being non-judgmental, engaging as an active listener without giving too much advice, and refraining from criticizing the partner. When a relationship crisis occurs and an individual reaches out to a friend, family member, or coworker for support, some common errors made by the support person include changing the topic, rushing to reassure, asking too many questions, and offering a perspective too soon (Doherty, 2014).
The confidant is encouraged to listen for feelings, show empathy, affirm the strengths of the confider, and offer one’s own perspective only if asked. It may be beneficial to ask the confider to consider his or her partner’s feelings and motivations underlying his or her reactions and behaviors. For example, “Have you thought about how he felt?” or “Why do you think she got so angry in that situation?” When the relationship problems seem serious, it may be useful to suggest professional help by saying something like, “Do you think talking to a counselor may help?” Because not everyone who experiences relationship problems are able or willing to go to psychotherapy, learning how to provide support without expressing judgment about the partner and/or the relationship is critically important.
Promoting individuals’ autonomy and helping them make informed decisions about their life is one of the crucial tasks in psychotherapy. It is not valid to suggest that clinicians and lay helpers should try all means possible to preserve a relationship while compromising individuals’ self-development and personal needs. Instead, it is important to raise awareness regarding how individual therapists’ or lay confidants’ reactions may affect the relationship decisions of those who seek support.
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Doherty, W. (2014, November 7). Marital First Responders [Video File]. Retrieved from https://www.youtube.com/watch?v=PY3mzxhi VA0
Doherty, W. (2015, October 9). CSI (Couple Sensitive Individual) Therapy: How to Avoid Colluding with Your Clients [Video File]. Retrieved from https://mncamh.umn.edu/clinical-training/webinars/csi-couple-sensitive-individual-therapy-how-avoid-colluding-your-clients
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Yaliu He, Ph.D., is the Madigan Family Postdoctoral Clinical Research Fellow at The Family Institute at Northwestern University. Dr. He earned a master’s degree in Applied Psychology from Tsinghua University, Beijing, and a Ph.D. in Family Social Science from the University of Minnesota, Twin Cities. Dr. He has a rigorous research agenda on understanding the effects of involving clients to be active participants in the design of their treatment. She uses the Integrative Systemic Therapy approach to treat individuals, couples and families. She has received training in Emotionally Focused Couple Therapy, Gottman Method Couples Therapy, Emotion Focused Individual Therapy, and Attachment-based Family Therapy.