An Individual Psychotherapeutic Approach For Couples

by Michael Hughes and Eva Ritvo

ABSTRACT
Objective: Relationship problems with a spouse or a significant other, are a major reason for seeking mental health care. Most are seen in individual treatment although conjoint psychotherapy, seeing the couple together, is generally regarded as the treatment of choice. This article presents an adaptation of individual psychotherapy for the treatment of couples: each member of the couple is seen in concurrent individual psychotherapy by separate therapists; the therapists meet collaboratively to better understand and help the couple. Methods: The literature is reviewed regarding individual psychotherapy for couple’s relational problems and for collaborative teamwork among multiple therapists.

However, we found but one article that explores individual therapy for couples, augmented by systematic collaboration between the therapists. The process of collaborative individual psychotherapy for couples is discussed, illustrated by a clinical example, with advantages and limitations considered.

Results: Collaborative individual treatment provides an opportunity to join the knowledge and techniques of individual psychotherapy with that of the field of couples and marital therapy, enhanced by the collaborative teamwork between therapists. It expands the scope of treatment options and is the treatment of choice for many couples. Practitioners of individual psychotherapy, who may be untrained or uncomfortable in treating couples conjointly, can use this approach. Conclusions: Collaborative individual treatment for couples, heretofore virtually absent from the literature, merits attention from researchers and clinicians.

INTRODUCTION
Couples therapy, sometimes called marital therapy, can be defined as treatment for the relationship of the couple. It is thought by many to consist exclusively of conjoint treatment: seeing the couple together. This conjoint procedure is used about 80% of the time by those who identify themselves as doing couples or marital therapy (1). Nevertheless, a variety of individual psychotherapies are widely employed to address ubiquitous couples relational problems, since it is estimated that a majority of adults who seek any form of mental health care have relationship difficulties as a major concern (1, 2).

This report will describe a particular use of individual psychotherapy to treat couples. Each member of the couple is seen individually by their own separate therapist. They are not seen conjointly, except perhaps during the diagnostic process. Rather, the therapists meet together and establish ongoing sessions to collaborate in the treatment of the couple. This approach has been called collaborative marital therapy (3). Two principle components will be emphasized: parallel individual psychotherapies for each member of the couple, adapted to deal with dyadic as well as individual issues, and the collaborative process between the therapists. A clinical illustration is presented.

A comprehensive overview of various marital therapies was presented by Sholevar (3). Multiple modalities were outlined and named: conjoint therapy, which treats the dyad directly; concurrent therapy, where the same therapist sees each member of the couple individually; combined marital therapy, where the same therapist treats the couple conjointly and concurrently; group therapy, where a number of couples are treated collectively; individual therapy, where one member is seen with the couple’s dyadic issues as the primary focus; and collaborative therapy. Sholevar (3), Ritvo and Glick (4), and others (5), recommend a diagnostic process to determine which approach best fits the couple. Still, clinical practice and the literature for couples therapy generally assumes a conjoint approach by one therapist, sometimes supplemented by individual sessions with one or both partners. Individual treatment is often seen by couples therapists as preparation for later conjoint work (4, 5).

Individual psychotherapy for marital problems has received attention in the marriage and couples therapy literature from various perspectives. Anecdotal reports (6, 7) have indicated that, when one member of the couple is in treatment while the other is not, the marital relationship can be harmed. However, Hunsley and Lee (8) summarized this literature and found little negative impact on marital functioning but enhanced adjustment for the couple, in some instances. Lewis (9), Bennun (10), and others (11) note that individual psychotherapy is frequently used to treat marital problems, involving one or both partners, and advocate adapting individual psychotherapy to also focus upon the relationship of the couple. Nevertheless, collaborative couples therapy – combining concurrent individual psychotherapies with consultation between the therapists – is virtually unexplored in the literature. Sholevar (3) simply defined this collaborative procedure among various approaches to marital therapy. Notwithstanding, in his recent comprehensive text, he inexplicably no longer includes collaborative treatment in his pantheon of couples therapies (1). Our search of the literature found but one reference, by a group of psychoanalysts from Chicago, that describes this process (12).

Collaborative teamwork among multiple therapists has long been standard practice in traditional child guidance clinics (13), hospital treatment teams (14), and community mental health programs (15). A patient may participate in multiple therapies or various members of a family may be in simultaneous treatment. However, ongoing collaboration among therapists is infrequent in a traditional outpatient psychotherapy practice. Some writers have described their experiences consulting with multiple therapists engaged in concurrent therapy systems (16, 17). They note the value of such collaboration and emphasize that therapists may not be aware of the extent to which they have identified with their patient’s point of view. However, our search of the literature found but one publication that addresses consultation between therapists for collaborative concurrent couples therapy (12).

PARALLEL INDIVIDUAL PSYCHOTHERAPIES
There are several ways to start the process: 1) this procedure is selected as the treatment of choice, either initially or when conjoint treatment has been unsuccessful; 2) one member is already in treatment and help for their partner is requested; 3) each member is already in individual treatment when collaboration between therapists is begun.

As collaborative treatment is undertaken the process is explained to the couple, with informed consent obtained and documented. Confidentiality is discussed in the usual way, with the caveat that information will be shared with their partner’s therapist on an ongoing basis. Each therapist will then use their own judgment about how to use this information in their work with their patient. In general, the therapist should not reveal specific personal information to their patient about their significant other. This sharing of such intimate data is best done by the couple themselves (17).

The couple’s relationship is the framework for understanding interpersonal and individual issues. Painful and repetitive interactional patterns are identified, with clarification of their detrimental circularity. However, the couple is encouraged to revisit the strengths of their relationship, what brought them together in the first place, and to attend to these with their partner. Commonalities of interests, communication in conflict free areas, and mutual activities that worked for them in the past are recalled. Positive feelings about treatment and hopes for change are mobilized to facilitate this process. While the couple works with one another to strengthen their relationship, the goal of the psychotherapies is now to shift the focus from the presenting relational conflict toward explication of individual contributions to the partnership. Each is encouraged to acknowledge and to bear their own feelings, hopes, disappointments, and subjective reality. De-escalating criticism of their partner while taking responsibility for their own feelings and perceptions is emphasized. Sharing their inner life with their therapist and subsequently with their significant other can rapidly diminish the presenting conflict and foster a sense of connectedness and well-being. Such techniques are familiar to experienced couples therapists and are readily adapted to an individual approach (5, 10).

Parallel individual psychotherapies now proceed, with the move away from the painful interpersonal crises. As each member of the couple emerges more clearly, the relationship can then be reframed more realistically. As Bennun (10) has pointed out, adaptation of individual psychotherapy to deal with the couples relational issues involves attention to the following triad: the individual, their partner, and their relationship. The couple progressively shares with one another their growing awareness of themselves. Misperceptions and projective distortions of each other can now be addressed, with clarification and consentual validation through the ongoing collaborative sessions of the therapists. Also, with the growing acceptance of one’s own vulnerabilities, each can achieve greater acceptance of the limitations and strengths of their other. Lewis (9) has addressed these issues through his perceptive definition of intimacy: the reciprocal sharing of vulnerabilities.

COLLABORATION
When collaborative treatment is undertaken, regularly scheduled sessions may be established for the therapists to meet face-to-face. Meetings should occur every three or four weeks initially, particularly when the therapists are unfamiliar with each other. Later less frequent sessions, perhaps by phone, may suffice when collaboration is proceeding well, but more often when needed. However, continuity should be maintained. Diagnoses and treatment needs for each individual are clarified. Appropriate treatment for a specific mental disorder, as through psychopharmacology and/or specialized psychotherapeutic attention, may help the particular patient as well as enable the couples’ relationship to be more amenable to psychotherapeutic benefit (5, 17). Also, to discuss with one’s significant other how one’s depressive illness or medical condition impacts them can move the couple from misunderstanding toward an opportunity to help and toward increased intimacy.

Emphasis is placed upon using the knowledge of each individual to understand and clarify relational conflicts and strengths. Historical material, characterologic traits, patterns of relationships, interests, talents, and other observations or data are shared and contrasted. Reciprocal subjective distortions for the couple’s perceptions of one another are striking features of all couples conflicts, though the degree and persistence of such distortions vary (4, 5). However our experience, as well as that of the Chicago group (12), demonstrates how easily even the most experienced psychotherapists come to share some of these perceptual distortions, as we empathize with our patients. A reasonable degree of comfort, trust, and a functional working relationship with one’s collaborating colleague fosters successfully addressing such issues. Hearing the perspective of our patient’s significant other may also help us to better understand our patients. When therapists can calibrate and recalibrate our understanding of our patients and their partners, then we can help our patients with their distortions. Transference, counter-transference, and identifications with our patients’ misperceptions all can be better understood and consentually validated by such collegial collaboration. In our experience, it is not necessary for the collaborating therapists to have similar training, theoretical understanding, or experience when mutual respect is established and differing perspectives are expected.

TERMINATION
Collaborative couples treatment ends when the couple’s relationship has improved enough and when continuing progress on their own is expected. Guidelines for termination include a mutuality of sustained understanding and acceptance, with growing intimacy and reciprocal satisfactions. Such progress in couples’ relationships will often ensue before individual psychotherapy is complete, for one or both members of the couple. Our experience has also shown that the relationship of patient and therapist can serve as a dyadic working model for what can be achieved within the couple’s relationship. In the individual psychotherapeutic dyad, the patient strives to take responsibility for and share his or her own feelings, perceptions, and vulnerabilities while the therapist strives to listen uncritically, with acceptance, support, and understanding. When the couple can assimilate this dyadic process and recreate it reciprocally with one another – sharing and accepting – then the couple can better proceed on their own (5).

CLINICAL EXAMPLE
Mrs. Z requested individual psychotherapy. Married for 16 years, she was a stay at home wife with no children. She had become involved with another man over the prior six months and her paramour advised her to seek therapy to deal with the situation. Mrs. Z was enjoying her new relationship and was planning to leave the marriage, feeling criticized, overprotected, and unappreciated by her husband. Neither Mrs. Z nor the therapist felt that conjoint couples therapy was an appropriate option at this stage. During the first few weeks of treatment, Mrs. Z separated from her husband and continued the other relationship. However, it became clear that she experienced significant shame regarding her behavior and remained attached to Mr. Z . He was unaware of the affair and repeatedly requested conjoint marital therapy to make their marriage work. Mr. Z was willing to accept a referral for individual treatment.

Collaborative individual psychotherapy then began: Mr. & Mrs. Z were each seen weekly for several years and the therapists collaborated, regularly at first and then on an as needed basis. Both therapists were aware of the affair. Mr. Z’s individual treatment revealed that he was excessively dependent upon and controlling with his wife, troubled by unresolved issues from a prior marriage, experienced a moderate depression, and suffered with a recrudescence of a significant panic disorder in response to the couple’s marital problems and impending divorce. He required medication. In the initial months, both Mr. & Mrs. Z made significant symptomatic and functional improvement. Anger was more manageable, the focus was on development of insight and personal growth, and each party became progressively able to accept responsibility for their own issues. Less blame and more mutual respect ensued within the relationship. Nevertheless, the couple proceeded to an amicable divorce. It was important for Mr. Z to date other women to re-establish his self-respect. Mrs. Z ended her other relationship but also did some dating.

About 6 months after the divorce, Mr. & Mrs. Z began dating each other. During this phase of treatment, the therapists worked with repetitive interactional patterns that had plagued the relationship, such as issues of enmeshment and control. Mr. Z was able to acknowledge and share his vulnerabilities, particularly regarding fears of abandonment and need for control, and to share his pain at being left. Mrs. Z shared her fragile sense of self-esteem and feelings of powerlessness in the marriage, while taking responsibility for her actions. Mr. Z came to an understanding of why his wife had taken such dramatic steps to regain her sense of autonomy. He also explained to her what he was learning about his panic attacks so that she could better understand and help. They began to socialize more as a couple and participate together in athletics. Positive aspects of the relationship again emerged with commonalities of interests and mutual pleasures being fostered. Consultation between therapists now indicated the likelihood of saving the marriage, with Mr. Z’s progressive clinical improvement and Mrs. Z’s growing capacity to understand and accept her husband.

One year after the divorce, Mr. & Mrs. Z began living together and subsequently remarried. During this phase, some regressions occurred. Mr. Z again became more anxious and fearful of losing Mrs. Z; issues of traumatic loss from childhood were addressed in his therapy. Mrs. Z, who had begun working, was anxious that she would lose her newfound status in the relationship and revert to her earlier subservient role. These months were trying for the couple and the therapists communicated with one another more frequently. Over time the relationship progressed, as each partner again found more pleasure together as well as in their life in general. Still, setbacks occurred as when Mrs. Z’s parents became chronically ill, absorbing much of her time and sense of autonomy while rekindling Mr. Z’s fears of abandonment.

Eventually, after three years, Mr. Z decreased his sessions to monthly and then to less often. He continues on medication which he finds quite helpful in managing anxiety and panic attacks. Mrs. Z remains in weekly therapy, now addressing the demands of caring for her aging parents. Both Mr. and Mrs. Z describe a mutually fulfilling relationship characterized by meaningful sharing of communication and intimacy, understanding and respect, and a strong friendship with a deep and lasting attachment to one another.

DISCUSSION
Collaborative couples treatment melds benefits of concurrent individual psychotherapy for each member of the couple with the perspective and understanding of the couple’s relational issues, facilitated by an ongoing collaborative process between the individual therapists. It provides a bridge to join the knowledge and techniques of the individual psychotherapies with that of the field of couples and marital therapy. The ubiquitous nature of marital and couples relational problems can be addressed through this process by a large number of therapists who practice individual psychotherapies but are untrained or uncomfortable with the conjoint couples approach. It enhances the scope of treatment options and also allows for a more prescriptive approach to treatment planning. Collaborative treatment with parallel individual psychotherapies is the treatment of choice for many couples, particularly when individual psychopathologies and treatment needs supersede or obtund a conjoint approach. Nevertheless, collaborative couples therapy is infrequently utilized and virtually absent from the literature.

The usual individual psychotherapy process is adapted to deal with the individual, their partner, and their relationship. Presenting interpersonal crises are clarified while strengths of the relationship are enhanced and parallel individual psychotherapies are established. Acknowledgement, acceptance, and responsibility for one’s individual feelings, experiences, and actions are emphasized. Intimacy is fostered for the couple through a meaningful sharing of themselves and listening to their other, as modeled and developed within the individual psychotherapy patient–therapist dyad. A sharing of vulnerabilities replaces an exchange of criticisms. Since each patient has their own therapist, competition between the couple for the therapist is avoided, an issue that may be problematic in the usual triadic construct where one therapist treats the couple, conjointly or individually.

Collaboration between therapists, through regularly scheduled sessions over time, provides opportunities to better understand both partners individually, to explore their relationship, and to attend to each partner’s contribution to the couples’ areas of conflict. Subjectively distorted perceptions by patients of their partner are often empathically shared to some degree by their therapist. A functional working relationship and mutual respect between therapists supports effective teamwork since the couple’s disagreements – conflicting perspectives and emotions – can be quite intense and are an essential focus for consideration by the therapists. These issues can be clarified and consensually validated within the collaborative process, with issues of transference and counter-transference similarly addressed. When therapists can understand and accept these differences, we are better equipped to help our patient and the couple.

The major limitation for collaborative individual treatment, in our experience, ensues when a crisis needs immediate attention. Here conjoint sessions offer an advantage. Nevertheless, collaborative treatment can attenuate crises and offer a more extended approach to both interpersonal and intrapsychic issues. Collaborative individual treatment merits further attention from clinicians and researchers, with particular emphasis on prescriptive treatment specificity.

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