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Key points
- There are no clear guidelines or rules for therapists considering conjoint individual and couples' therapy.
- When one therapist does both, it can create a dual relationship, triangulation and confusion for patients.
- If a therapist does conjoint individual and couples' therapy, there are important issues to consider.
- It can be appropriate and effective to do both, under limited, thoughtful circumstances.
If you ever want to watch a gathering of therapists devolve into chaos, simply lean in and say, “I think it’s absolutely fine for couples’ therapists to provide individual therapy to the members of the couple at the same time as they are doing marital therapy for the couple.” Then, sit back and watch. It’s unlikely it will turn into a brawl, but I can almost guarantee you will be entertained. This is a complex issue where therapists have strong feelings on both sides.
There aren’t super clear rules or guidelines that set rigid guardrails around this issue, which leaves it to fall back onto the therapists’ overall ethics, clinical guidelines and practice. As a result, many different therapists approach this issue differently.
The topic is a frequent area of discussion in teaching, supervision, and ethics consultation. Some schools of thought take a rigid, black-and-white approach, forbidding any conjoint individual and couples’ therapy, while other therapists feel they can manage these dynamics and navigate the potential complexities. You can read some of these discussions here, here, here, and here, for a few examples.
Is it a Dual Relationship?
In general, the issue here is that it may be a conflict and a dual role for the therapist to provide simultaneous individual psychotherapy to one or both members of a couple at the same time as they are treating the couple together. When a therapist is treating the couple, their patient is technically the dyad, the couple, meaning the therapist is focused on the overall health and success of the couple together, not the separate individuals within the dyad.
When we treat an individual, that person and their individual well-being becomes the central focus. So, when we see an individual who is in a relationship that may not be positive for them, the therapist may consider exploring whether the person should exit that relationship for their well-being. But, if the therapist is also treating the couple, this can create a conflict for the therapist. Essentially, that therapist would now have the dilemma of whether they focus on the individual well-being or ignore the individual needs and work towards the overall health of the couple.
Another issue that can frequently come up in this dynamic is that the therapist may learn during individual therapy that one of the partners has engaged in infidelity or other behaviors that jeopardize the health of the couple. In this situation, the therapist is again faced with a dilemma—do I try to protect the individual and keep this secret? Or focus on the couple and ensure that a disclosure of the boundary violations occur, so that the couple can now address it? Some therapists say flat out that “they aren’t secret keepers” and not to disclose anything to them that isn’t for the whole couple to know. Other therapists feel they can thoughtfully navigate this dynamic and hold information while moving the couple towards a healthier status.
As I supervise therapists working with couples and sexuality issues, this question comes up quite frequently, and therapists struggle to identify the safest, most ethical approaches to this dilemma.
Sometimes, geographic barriers can create a challenge. In rural areas, there simply may not be local therapists available to provide additional individual therapy outside the couples' counseling. Other times, the couples’ therapist may have a specific expertise, such as anxiety disorder treatment, that one of the individual needs, but can’t access elsewhere. Sometimes, the individuals in a couple may have disclosed highly private issues, such as their sexual interests, to the couples’ therapist and be concerned about sharing that information with another therapist, wanting to keep their work and privacy with that one therapist.
A standard practice for many couples therapists is to meet with each individual of the couple separately during the initial assessment and treatment planning process in order to get a clear idea of each individual’s approach and needs in the relationship. Sometimes, the therapist may learn that one partner is really not interested in preserving the relationship, and this then affects the therapist’s work with the relationship and turns the therapy towards helping the relationship end in the healthiest way possible. This individual assessment is not individual therapy, as the assessments are done to help the therapist help the couple, not the individuals.
Managing Triangulation and Risk
Couples’ therapists are always at risk of developing counter-productive triangulations as they work with a dyad. Some therapists may overly identify with, or ally with, one individual in the couple. They may see one partner as the victim, and the therapist’s job is to protect them from the other partner. Here, the therapist may lose sight of their focus on the overall couple’s well-being. I’ve seen this occur in many instances, where the therapist decides to tell one partner that the other partner has a personality disorder. The therapist may be well-intended, believing that this information may help the other individual know that they’re not crazy. Unfortunately, this positions the therapist in an adversarial triangle where they have now inadvertently shamed the other partner and made them feel attacked by the therapist and their partner.
I don’t believe that there is a clear, hard-and-fast, always-right answer to this dilemma. But I see therapists approach this challenging dynamic without adequately considering the complex elements at play. When this comes up in supervision and consultation, I recommend that therapists wrestle with these questions as they consider whether conjoint individual and couples’ therapy may be appropriate:
- Could conjoint individual therapy improve the health of the couple?
- What are the reasons why this should be done by the same therapist?
- Can both members of this couple keep the focus on the overall health of the couple, if we were to engage conjoint individual therapy?
- Can the therapist manage to keep a mindful focus on the couple’s well-being as they work with the individual?
- Are there any potential future conflicts or legal issues that might impact this? (For instance, possible future divorce or custody battles can create significant challenges over releases of information for records, where conjoint individual and marital therapy has occurred).
- Are there potential harms to the couple and/or individuals, and if so, can these harms be mitigated or prevented?
In general, in my approach, I discourage conjoint individual and couples’ therapy where:
- The couple is in a high level of conflict.
- Either of the individuals in the couple struggle with boundaries.
- Either of the individuals in the couple are unable to consistently and consciously consider and weigh their needs against their partners’ needs, and the needs of the couple.
- There’s past, present, or future likelihood of legal conflicts or malpractice complaints.
I have, rarely, suggested that conjoint individual and couples’ therapy may be appropriate when:
- The individual therapy is focused on helping the patient develop a specific skillset (such as communication or mindfulness) that will help the couple;
- The individual therapy is focused on treating a specific clinical issue (such as an anxiety disorder) where the individual’s improved mental health will improve the couple’s functioning;
- Brief individual therapy can serve as another assessment process, to help discern or identify issues that will help the couple. This sometimes comes up when there were issues that one partner was afraid or unable to disclose to the therapist at the beginning of therapy.
Overall, I believe it’s important for both therapists and persons in therapy to understand and think through the complex issues and dynamics that may be involved when therapy involves both couples and individual approaches. This isn’t always contraindicated, but does require thoughtful consideration of issues in order to best handle it ethically and effectively. Finally, if a therapist decides to initiate conjoint individual and couples' therapy, they should carefully discuss these issues with their patients, get their informed consent, and ensure that these discussions and consent are appropriately documented.
