Therapy with couples, deciding on the structure and format

In this first of a two-part discussion of therapy with couples, I will explain some of the options for arranging the structure of the couples therapy. The second part of the discussion will delve into the process of working with couples in therapy. I will explore some thoughts about why couples therapy works and sometimes why it doesn’t work.

The structure of working with couples in therapy depends on three issues the couple must decide up front. Does the couple want to use insurance or pay out of pocket? Do they want to designate one of them or the couple as the “client?” Does one of them want to see me for individual issues in addition to the relationship issues they want to resolve in therapy?

My role as a Licensed Marriage and Family Therapist also plays a part in the structure of couples therapy. Consider the difference between a “counselor” and a “therapist.” You might never have thought about the difference, but in my mind there is one, and it is important. For nearly 15 years, I was a lawyer. Another word for lawyer is “counselor at law.” This meant that I not only represented clients in court, but frequently gave my clients legal advice. I advised them about their options, telling them what I thought they should do to address, pursue and resolve their legal problems. As a general rule, I never do this as a therapist. I do not give advice to therapy clients, whether they are individuals, couples or families. I am not a marriage and family counselor. I am a Marriage and Family Therapist. The reason I do not give advice is simple: the likelihood and the stakes for me being wrong are too high. As an attorney, I had no issue giving legal advice because I could fairly easily obtain a sufficiently complete picture of the situation (the facts and evidence) and research the legal options that surrounded a client’s legal issue. So, when I gave them options, I had a pretty good idea that my advice was sound, and pretty likely accurate (but no guarantees). In therapy, working with people’s emotions, mental states, life histories, family histories, relationship interactions, and countless other variables, I just never know enough to think I am in a position to tell them what I think they should do. Maybe more importantly, even if I were able to really “put myself in their situation,” what if I am wrong? Suppose I tell a client I think they should stay in a relationship, move across the country with their partner, and then it ends up being the worst decision that person has ever made in their lives, and they regret it for the next two or four decades? Yikes. I do not give advice to therapy clients about how to live their lives because I do not have to live with that advice if it is wrong, they do.

I bring this up in the context of couples therapy because it so often comes up in this context. Couples often come to therapy because one or both of them are thinking about ending the relationship. Naturally, they will sometimes ask if I think they should stay in the relationship, end the relationship, or insist on conditions (like a timeline for making a decision about whether and when to get married, have children, etc.). This issue is so prevalent for Marriage and Family Therapists, our licensing board specifically mentions it in our professional ethics. “A therapist must respect the right of a client to make decisions and must help the client understand the consequences of the decisions. A therapist must advise a client that a decision on marital status is the responsibility of the client.” When I am asked this question, I give them some version of the previous paragraph to explain why I don’t give advice, why I don’t tell clients what they should do with their lives, including their relationships. I also tell them I firmly believe everyone is fully capable of making good decisions for themselves, and they are in the best position to make decisions that could have deep and lasting effects on them for years. Sometimes, people just need help asking the best questions to come up with the right answers for themselves. That’s where I come in, by helping people focus on the best (and sometimes very difficult) questions, so they can sort through the often very confusing, complex, and difficult issues to make the most appropriate decisions based on what is important to them. In fact, the only time (very rare) I am willing to tell a client what I think they should do in their lives is when the client, someone else they know, or particularly when children, are in danger. If a person is in a physically abusive relationship, I am plenty willing to tell them to get out, and will (and have) helped them find the resources they need to exit safely.

Couples come into therapy in two ways. They decide they want to go to therapy as a couple right from the beginning. They agree they have important issues they have been unable to resolve on their own and would benefit from the facilitation and insights of someone else (me). Or one of them comes to therapy to address individual issues and somewhere along the lines that client decides it would be helpful to their own mental health to also resolve issues they are having in a primary relationship. I am fine with and completely open to either approach. However, if I am seeing an individual client who then wants me to see their partner with them for couples therapy, I restrict my willingness to change the designation of who is the client.

For instance, Let’s say I am seeing a woman named Dawn as an individual in therapy. Dawn is in a heterosexual relationship. She wants to bring her fiancé Doug to do couples therapy that will help her accomplish the goals we were working on her individual therapy. We can do that, and even add some relationship goals Dawn and Doug both come up with after he starts to come to therapy. Here the thing, though: I am not willing to make Doug my client, even if that’s what Dawn and Doug both want (as might happen if Dawn and Doug agree she has worked through her individual issues, but Doug has not). The reason is pretty straightforward, but Dawn might not have considered it: what happens if somewhere down the road, Dawn wants to come back to see me for individual therapy? Can I see both Dawn and Doug separately for individual issues, and also see them together for couples issues? Some therapists are willing to do this. I am not. I think it would be too confusing for me. I also think it would invite some problems with trust. Dawn would wonder what Doug was telling me, and Doug would wonder what Dawn was telling me. See what I mean? Now, to throw another wrench into it, what if I agreed to see both as individuals, and then they broke up, and they were embroiled in a protracted legal dispute over finances or custody? Too complicated for everyone, don’t you think? Maybe some therapists are able to do this, and that is fine, but I don’t think I can, so I don’t. Besides, there are plenty of therapists around for Doug to find his own therapist. He doesn’t need to see me. Dawn is already seeing me.

So, let’s say I am seeing Dawn as my individual therapy client. She has a mental health diagnosis of moderate depression. She brings Doug, hoping that improving their relationship will help her improve her struggle with depression. This makes sense. And it often is helpful to do some couples work in addition to individual work. Dawn is still my client. Doug is not my client. He is primarily there to help Dawn. Hopefully Doug will derive some benefit from improving his relationship with Dawn and by helping her in her struggle with depression. In this situation, if I see Dawn alone, what she tells me is confidential, so Doug is not entitled to know what we talk about, unless Dawn wants to discuss it with Doug. I might also see Doug alone on a few occasions to make it easier for him to open up. What he says though, is not confidential—he is not my client. Dawn is likely to respect his request to keep it private with me, but if she asks me to tell her what he talked about, I don’t have a choice. Dawn is my client. Even though I am not likely to just blithely blurt out to Dawn everything Doug tells me, I can’t guarantee she isn’t going to want to know. I avoid this kind of issue as best I can by reminding Doug that he is not my client, so if he doesn’t want Dawn to know something, it is best he not tell me.

If instead Dawn and Doug had come to me together to work on relationship issues, and neither wanted to be my individual client, then it is up to me to decide what I think the other person would benefit from knowing what I was told during an individual session, unless they both agree ahead of time that they do not want to know what the other one says. Again, I make this clear up front. If later, one of them tells me something that they really do not want the other person to know (which they can do because they are both my clients and therefore they are both entitled to confidentiality), I might decide not to continue therapy if the issue is likely to prevent success in therapy or it puts me in the position of feeling like I am hiding something important the other person would expect to know if I knew. Let’s say Dawn tells me she is having an affair and plans to continue it while we work on the relationship. I would not tell Doug about the affair (due to confidentiality), but would probably discontinue therapy if Dawn didn’t want to tell Doug or stop the affair pretty quickly. I could imagine Doug being rightfully hurt and ticked off if he later discovered she’d been having the affair and I had known about it for some time and continued to do therapy as if there was nothing going on.

As you can see, the structure of couples therapy can be pretty complicated. Not all therapists handle it the same way, and there does seem to be pretty wide latitude in terms of what is acceptable practice in working with couples. These are just some of my methods for addressing the more common issues that come up when trying to decide how to proceed with a couple in therapy.  My main goal is always to do what I can to make sure my client is benefitting from therapy, whomever we decide is “the client” (one of the individuals or the couple itself).  I also want to make sure that I can create as much trust as possible, so I try to make things very clear right away about how I handle confidentiality, and that I do not see it as my role to tell people what to do with their lives (I don’t give advice), except when someone’s safety is involved.  Once these issues are discussed and understood, the couple is ready to make a decision on how they want to structure couples therapy, and then we can focus on helping meet their relationship goals, which will be the topic of part 2 of this exploration of how couples’ therapy works (with me anyway).

Copyright 2013, Michael Kinzer. Blog entries and other materials available on Jupiter Center’s website are only intended to stimulate thoughts and conversations and to supplement therapy work with Jupiter Center clients already in therapy. If you or someone you know suffers from a mental illness, you are strongly encouraged to seek help from a mental health professional. For further information about this blog, or Jupiter Center, contact Michael Kinzer at 612-701-0064 or michael(at)jupitercenter.com.