"Physician, do no harm" is the first principle for all professionals who work in mental health as well as in the arena of physical health. Katrina (name changed to protect her confidentiality), who is a dear friend of mine, suffered for many years with breathing and heart problems. Katrina's lung and heart doctors had worked valiantly with various medications to alleviate these problems.
Then, Katrina moved to another state. Her new physician there looked at how her body was functioning overall—and from the tests immediately diagnosed a long-standing, slow-growing colon cancer. By including in the diagnostic and treatment process the full person rather than just the area of specialty of the treating physicians, the new doctor indirectly healed the lung and heart problems as a by-product of the cancer treatment.
Similarly, in my view, the evaluation of individuals who seek therapy needs to include assessment of the couple if that individual is married, and also of the children if the primary patient is a parent. While it's certainly not a crime, individual therapy for a married person can be an inadequate model of treatment.
I recently have been treating a couple in which one spouse—let's call her Anna—had been in individual therapy treatment for several years. Anna liked her psychiatrist. He was a "nice person," she said, and talking with him was comforting. He had been truly helpful in clarifying what in her upbringing had caused her much distress.
On the other hand, however, the psychiatrist knew that his client had been having an emotional affair, and condoned it, in part because Anna's descriptions of her angry husband had created an image of a hopelessly unsympathetic spouse that had seemed to justify Anna's turning elsewhere for comfort.
The psychiatrist, meanwhile, had never met the spouse and thus had no way of coming to an independent assessment of his potential for growth—which, as it turned out, was on the extremely high end. In addition, the psychiatrist assumed his client's descriptions of her "defiant" teenagers were accurate, and commiserated with his client when she described the way her husband curried favor with the teenagers in a manner that consistently caused her to feel left out.
When Bert, Anna's husband, eventually discovered Anna's affair—which by then had become sexual as well as emotional—he, needless to say, was furious. To his credit, while Bert's first impulse was to seek an immediate divorce, after calming down enough to think over the situation, he relented and requested instead that they seek marital counseling. They found my name on the internet.
What Couple and Family Systems Therapy Can Do That Individual Therapy Cannot
To assess the couple, I first worked with them together in an initial intake session. I then saw them individually for one session each to explore the extent to which each partner was willing and able to take responsibility for making changes to their own contributions to the family's difficulties.
By the time we met again the next week to launch the couple treatment, Bert had already determined that he would never again speak angrily to his wife. Instead, he would exit any situation he might not be able to handle calmly, bring himself back to the calm zone, and then return to the dialogue. The calming process generally took him just a few minutes.
During the same week, I also met alone with Anna for a single individual therapy session. I had clarified in my first session with the couple my policy that I only work with couples who agree to end all contact with any affair partners. In her individual session, Anna announced her decision that she would gradually end contact with her affair partner in order to focus on improving her marriage relationship.
Within two weeks of further couple treatment sessions, Anna and Bert had enjoyed, for the first time in years, multiple "date nights" and a renewal of their affection at home. They also had determined that they would work together as a team to mend their full family. Their teenagers, it turned out, had been reacting to their mother's tendency to get overly controlling with them.
Now that she was working within a therapy process that included Bert's perspectives as well as her own, Anna began to see that her over-emotional ways of talking with the children had been a prime cause of their disaffection, as well as of Bert's protectiveness with them.
The psychiatrist who had worked so long with Anna in an individual treatment format had no way of gathering a broad enough database to see his client in any way other than how she presented herself, which was as a lovely, likable, and intelligent woman. Anna's many quick-tempered outbursts at home had never struck her as relevant to her marital or parenting problems, even though from my diagnostic perspective she may have been functioning in the manner of someone with a borderline personality disorder. With so little insight, Anna had been unable to share this data with her psychiatrist. Anna's hyper-emotionality showed significantly less in the calm environment of her one-on-one therapist's office, even though her hyper-sensitive amygdala reactivity, along with her husband's anger eruptions, were at the root of her family's disintegration.
The Moral of the Story
Just as people live in a full body—not just with a heart or lung that is impaired—most individuals live in the context of a family. The full family, starting with the couple, needs to be included in the assessment and eventually, in many cases, in the treatment. For a therapist to get a broad enough database to diagnose and treat effectively, it's my view that the individual therapy client's spouse is best off being part of the treatment and intervention processes.
What if the Spouse is Unwilling to Participate in Treatment?
That's a tough one. Half a loaf probably is better than none. At the same time, certain problems may not be able to be addressed unless both partners participate.
I generally encourage all new clients to bring their spouse at least to the first session. I say it's my policy. If the spouse still won't join us, I offer to phone the spouse myself, which often proves effective.
At the same time, if a married client says that they do not want their spouse in the first session, I always respect that. Usually, that request indicates that either an affair or abuse is part of the problem. Sometimes, however, it's some other issue that would have been unhelpful for the spouse to hear.
I do offer individual therapy to all married clients, but as part of an overall family system treatment program. Most couples end up with mainly couples treatment, plus occasional individual therapy sessions on an as-needed basis. To prevent sibling rivalry, I aim for symmetry of individual time. After an individual session with one partner, I generally invite the other to schedule a one-on-one session. Eventually, the children's needs must be assessed as well.
Some studies have suggested that when a therapist treats a married client in individual therapy, the odds go up that the marriage will end up in divorce. When a couple attempts to get help by hiring two separate therapists, the risk of divorce may go upward.*
*I detail this research in my book From Conflict to Resolution.