Need Essay, Please

INDIVIDUAL THERAPY FOR COUPLE PROBLEMS:

PERSPECTIVES AND PITFALLS

Alan S. Gurman The Family Institute at Northwestern University and

University of Wisconsin-Madison

Mark Burton Independent Practice

Despite the demonstrated eﬃcacy of conjoint couple therapy, many clients seeking help for

couple problems ultimately ﬁnd themselves in individual therapy for these concerns. Individ-

ual therapy for couple problems (ITCP) may evolve from a partner’s refusal of conjoint

therapy or from the treatment format preferences of either the client or therapist. Having

acknowledged the role of partner refusals, we oﬀer some perspectives about the idiosyncratic

personal factors and professional background factors that may lead therapists to provide

ITCP and discuss the signiﬁcant pitfalls in its practice. We emphasize ﬁve central areas of

concern in the ongoing practice of ITCP: structural constraints on change; therapist side-

taking and the therapeutic alliance; inaccurate assessments based on individual client

reports; therapeutic focus; and ethical issues relevant to both attending and nonattending

partners. We conclude by urging that this very important but largely neglected topic be paid

greater attention in psychotherapy research, training and continuing education.

My wife says I never listen to her …or something like that.

— Anonymous

A recent study of expert psychotherapists’ predictions about future practices in psychotherapy

(Norcross, Pfund, & Prochaska, 2013) reveals couple therapy to be the therapy format likely to

achieve the most growth in the next decade, surpassing individual, group, and family treatment.

This ﬁnding is all the more interesting in that few of the experts polled were themselves couple (or

family) therapists. Clearly, couple therapy has ﬂourished in the last decade, growing increasingly

independent of the ﬁeld of family therapy from which it partially sprang (Gurman & Fraenkel,

2002). Widely read omnibus family therapy journals now often highlight special issues devoted to

advances in couple therapy, and couple therapy has evolved to include more than a dozen theoreti-

cally coherent and inﬂuential models of conjoint treatment (Gurman, 2008a). Additionally, couple

therapy’s eﬃcacy has been well established in the treatment for both general couple conﬂict and a

number of “individual” psychological disorders such as depression, posttraumatic stress disorder,

and alcoholism (Lebow, Chambers, Christensen, & Johnson, 2012).

Considering the evidence of couple therapy’s viability and versatility, it is not surprising that

the conjoint format has become the community standard for treating couple conﬂict. Yet individ-

ual therapy is the format in which many clients seeking help for relational problems ultimately ﬁnd

themselves, paralleling a good many self-deﬁned “family” therapists’ recent movement away from

working with whole families (Breunlin & Jacobson, 2014; Minuchin, 1998). We are unaware of any

Alan S. Gurman, PhD, was a Clinical Professor of Psychology and a member of the Teaching Faculty/MSMFT

Program, The Family Institute at Northwestern University, Evanston, IL, and a Clinical Professor of Psychology,

Clinical Psychology Doctoral Program, University of Wisconsin, Madison, WI. Regrettably, Dr. Gurman passed

away in September of 2013. Mark Burton, PsyD, is in independent practice in Portland, OR, specializing in couples

therapy, and coaches individuals within organizations on communication, conﬂict and emotional intelligence.

Authorship is equal.

Address correspondence to Mark Burton, 7505 SW Beveland St., Ste. 201, Portland, Oregon 97223; E-mail:

[email protected]

470 JOURNAL OF MARITAL AND FAMILY THERAPY October 2014

Journal of Marital and Family Therapy doi: 10.1111/jmft.12061October 2014, Vol. 40, No. 4, 470–483 published data on the prevalence of individual therapy for couple problems (ITCP) among either

couple and family therapists or therapists in other mental health professions. The two largest

national surveys to date (Doherty & Simmons, 1996; Northey, 2002) of the practice patterns of

Clinical Members of the American Association for Marriage and Family Therapy (AAMFT) do

not present data that allow us to determine with conﬁdence what portion of cases with primary

“couple diﬃculties” are treated conjointly versus individually. Nonetheless, the practice appears to

be very common, in that, among all treatment formats, including individual adult, individual child

or adolescent, couple, family, and group therapy (Northey, 2002), almost half of marriage and

family therapists’ caseloads are comprised of adults seen in individual therapy, even while couple

diﬃculties account for almost 60% of the most common or second most common presenting prob-

lems in their practices.

Individual therapy for couple problems (ITCP) may eventuate from a client’s request to be

seen alone, a partner’s refusal to participate, a therapist’s recommendation, or a collaborative deci-

sion between the client and the therapist. ITCP may be selected due to factors such as a partner’s

cognitive impairment or substance abuse that is signiﬁcant enough to preclude meaningful engage-

ment in conjoint therapy or from an insuﬃcient level of emotional and physical safety in the rela-

tionship. Additionally, the therapist may suggest ITCP as an appropriate format ﬁtting the scope

of his

1individually oriented clinical practice or as the only format allowed by third-party adminis-

trative forces (Hoyt & Gurman, 2012).

Considering the prevalence of ITCP and the various reasons that it occurs, it is unfortunate

that its potential beneﬁts and limitations are rarely discussed in the literature of couple or individ-

ual therapy. Moreover, randomized clinical trials of conjoint couple versus individual therapy are

almost nonexistent, and commentators on the empirical status of ITCP have diﬀered considerably

in their assessments. For example, a comprehensive review of research relevant to ITCP appearing

more than twenty-ﬁve years ago was largely discouraging of the practice (Gurman, Kniskern &

Pinsof, 1986). The most recent review of ITCP (Bennun, 1997) was published more than a decade

ago and, by contrast, was encouraging of ITCP, based on anecdote and the results of only one con-

trolled study of ITCP (Bennun, 1985).

Our purpose is to examine the concerns regarding ITCP that have appeared over time and to

add some new perspectives in light of more recent research in related areas. We aim to promote

renewed attention to ITCP and to encourage empirical analysis of its beneﬁts, limitations, and

potential mechanisms of change. In a subsequent publication, we will discuss approaches to ITCP

that we believe hold promise of avoiding the pitfalls discussed here and oﬀer suggestions for

improving psychotherapy training in this realm of clinical practice.

We want to emphasize our view that, due to the strong support for the eﬃcacy of couple

therapy and the minimal research evaluation of ITCP to date, conjoint couple therapy should be

considered the current treatment of choice for couple problems. A clinical decision to exclude one

of the partners from treatment should result only from thorough consideration of the unique and

speciﬁc needs of the particular client.

Mapping the Territory

Various circumstances can warrant meeting with individuals seeking help for couple problems,

some of which are beyond the scope of what we consider ITCP. We are not addressing occasional

sessions with individual partners who are being treated conjointly, including initial individual

assessment sessions; ongoing individual sessions held concurrently with ongoing conjoint sessions

provided by the same therapist; individual sessions held with a partner to obtain information

about a primary client’s behavior, symptoms or progress; brief intermittent conversations between

a client and her

1therapist about her marriage in the course of individual psychotherapy that is not

primarily focused on couple concerns, nor individual therapy addressing individual goals using a

family systems perspective. Our focus is on therapy that is primarily individual in format and

addresses goals that are primarily relevant to the couple relationship.

This article will be structured in three parts. After a brief consideration of partner-generated

refusals of conjoint therapy, we consider what we see as the most salient factors in therapists’

deciding to treat relational problems in individual therapy. We then identify the most recurrent

and potentially problematic issues that are likely to arise in the practice of ITCP. Because we

October 2014JOURNAL OF MARITAL AND FAMILY THERAPY471 believe that the practice concerns we raise are relevant to all theoretical approaches to ITCP, we

make few references to extant inﬂuential models of working in this format.

PARTNER-GENERATED REFUSALS OF CONJOINT THERAPY

There are several common reasons given by clients for their partners’ treatment refusals. Part-

ner A may attribute B’s refusal to that partner’s negative assumptions about or experiences in ther-

apy (e.g., “I just know him

1…he’d never go to therapy”; “He had a bad experience with that other

therapist we saw”). Partner A may attribute the refusal to B’s assertion that A is responsible for

the problem and/or should be the primary agent of change(e.g., “She said, ‘I don’t thinkwe’vegot

a problem…if you think we do, thenyougo see a therapist’”). Alternatively, A may request to be

seen alone because of her own belief that she is the source of the couple’s problems and/or the opti-

mal source of their remediation (e.g., “I think the problem with us isme”; “I think it’smychild-

hood stuﬀ that’s damaging our marriage”). Lastly, A may be struggling with concerns that would

reasonably warrant conjoint therapy, but believe they are currently and solely amenable to individ-

ual therapy. Examples include aﬀairs or uncertain commitment to the relationship.

While any of these examples of A’s reasons for seeking ITCP could reﬂect that partner’s accu-

rate perception and good judgment, the therapist must remain circumspect in listening to such

reports from A without B’s input. Reasons for this will become clear as we later discuss potential

pitfalls in practicing ITCP. We suggest that it is essential that the therapist seek to understand the

meaning of such reports and the potential for false attributions. For example, attributions about B

may be based on either simple misunderstandings of B’s intentions or an overreaction to B’s

ambivalence, or alternatively, may be a manifestation of A’s own ambivalence about B’s participa-

tion in therapy. Similarly, attributing the source of couple problems primarily to oneself (“I think

the problem isme”) can reﬂect either A’s accurate assessment or A’s avoidance, whether conscious

or unconscious, of direct engagement with B over their shared diﬃculties. It is essential to consider

the dynamics of A’s preference for the individual format early in therapy because the way in which

they are understood and discussed can materially inﬂuence the choice of treatment format and the

subsequent therapy process. Partner A’s potential over-responsibility for her relationship,

misperceptions of her mate’s willingness to participate, and avoidance of couple conﬂict can each

intensify common problematic patterns that occur in ongoing ITCP, which we consider later in this

article.

THE THERAPIST’S DECISION TO PROVIDE INDIVIDUAL THERAPY

FOR COUPLE PROBLEMS

One of family therapy’s undisputed pioneers, Carl Whitaker, often perceptively quipped,

“The indications for family [and couple] therapy are in the therapist”. We agree with Whitaker that

while partner refusals of attendance certainly often occur, the therapist is most often the central

ﬁgure and force inﬂuencing whether treatment proceeds individually or conjointly. In this section,

we will identify factors that we believe motivate therapists to oﬀer ITCP. One factor derives from

idiosyncratic personal aspects of working with couples, the other from professional background

and training experiences. Our conclusions are drawn from client disclosures, therapist consulta-

tions and from our experience as teachers and supervisors.

It is important to consider that iatrogenic impacts of poorly executed ITCP occur in the con-

text of a paucity of literature on ITCP and related gaps in the training of most therapists. We do

not mean to imply that errors are willful, negligent, or deliberately self-serving. Our aim is to

improve clinical decision-making and outcomes by heightening well-meaning and competent ther-

apists’ awareness of ITCP’s potential pitfalls.

Idiosyncratic Personal Factors

Beyond the general structural and theoretical diﬀerences between all couple therapies and

individual therapy (Gurman, 2001), a number of speciﬁc aspects of practicing couple therapy may

bias therapists toward favoring the individual format. First, and perhaps foremost, couple therapy

generally requires the therapist to actively guide and structure the conversation, more so than in

472JOURNAL OF MARITAL AND FAMILY THERAPYOctober 2014 most individual therapy. One often hears dissatisﬁed former couple therapy clients complain that

their therapist “Just sat there and listened to us and told us to talk to each other.” Indeed, the fail-

ure of the therapist to provide suﬃcient structuring in the opening phase of conjoint therapy is a

predictor of early client dropout (Gurman & Kniskern, 1978a) and is associated in ongoing ther-

apy with deterioration (Gurman & Kniskern, 1978b; Doherty, 2002). Structuring can take many

forms, for example, directing and focusing the overall conversation, interrupting one partner’s

speaking to facilitate empathic connections, providing psychoeducational perspectives to detoxify

aspects of the couple’s interaction, blocking one partner’s hurtful commentary about the other

partner to maintain an atmosphere of emotional safety, providing methods or strategies to facili-

tate in-session aﬀective downregulation, and so on. In couple therapy, therapist passivity is poison-

ous. Some therapists, although clearly competent in individual therapy, nonetheless have diﬃculty

reliably demonstrating the active leadership so essential to couple therapy. For some, it is a matter

of what has become customary in their predominantly individually oriented practice, while for

others, the kind of active style so often needed in couple therapy may be uncomfortable or in other

ways simply not a good “ﬁt”. A less active style, resulting from either habit or preference, may

predispose therapists to embrace the use of individual therapy for couples’ issues when conjoint

treatment is needed.

Some therapists steer away from conjoint therapy when they begin to realize that their rela-

tional role in couple therapy is quite diﬀerent in a way that is less personally satisfying than in indi-

vidual therapy. There is a certain ineﬀable intimacy that often occurs in individual therapy,

particularly in more exploratory, experiential, and supportive modes of practice. Such therapist–

client intimacy is realized less often in couple therapy. And there is good reason for that. In couple

therapy, while therapist–partner alliances must be rebalanced and repaired often, the therapist–

partner relationships are not the central mechanism through which change occurs. Rather, it is the

healing power of the relationship between the client partners themselves, facilitated by the thera-

pist, that sets conjoint therapy apart from individual therapy (Gurman, 2001; Christensen, 2010).

For therapists who prefer the kind of intimacy common to individual therapy, the practice of

couple therapy may simply be experienced as too distancing, witnessing, and consultative.

In addition, for either of two reasons, some therapists prefer to avoid the aﬀective intensity of

couple conﬂict, which often is higher than the intensity of emotional experience in individual treat-

ment. First, a couple’s aﬀective dysregulation may trigger an untoward degree of negative emo-

tional arousal in the therapist himself, for any number of personal reasons. Secondly, he may have

diﬃculty containing such emotion, staying centered on the experiences of his clients or using the

emotion as a barometer of his clients’ experience. In either such circumstance, he may ﬁnd his help-

fulness to the couple is signiﬁcantly and frustratingly impeded. Experiences of this sort, especially

those that occur in unsuccessful courses of conjoint therapy early in one’s training, can quickly

deter neophyte therapists from working conjointly and draw them toward the more comfortable

ITCP. This risk must be counterbalanced by sophisticated supervision provided by clinicians

experienced in the complexities of both couple conﬂict and the practice of ITCP.

Therapists who can work comfortably and eﬀectively with the emotional intensity of couple

therapy, yet are unfamiliar with the uncertain eﬃcacy of ITCP, may consider ITCP inherently

“simpler” to practice and therefore preferable to practice. For example, there is no need to deal

with such “annoyances” as communications from Partner B, and there are fewer administrative

complications when billing individual therapy to an insurance provider. Moreover, in providing

ITCP, there is no need to become beleaguered by the inherent complexity of conjoint therapy.

Most of this complexity centers on aspects of treatment that are routinely addressed in-depth in

the training of couple and family therapists in both AAMFT—accredited programs (Nelson et al.,

2007) and specialized couple and family psychology (Stanton & Welsh, 2011) programs, yet over-

looked in the vast majority of individual therapy-oriented graduate and professional programs.

Training and Background Factors

The overwhelming majority of professionally trained psychotherapists primarily receive

coursework and supervision in the practice of individual therapy. For example, very few doctoral-

level psychologists receive signiﬁcant exposure to the theory and/or practice of couple

therapy. The rigorous standards that have been developed for training in the clinical psychology

October 2014JOURNAL OF MARITAL AND FAMILY THERAPY473 subspecialization of family psychology (Kaslow, Celano, & Stanton, 2005) vastly exceed what

ordinarily is required or even available in general clinical or counseling psychology programs.

Although a large majority of clinical psychologists regularly practice couple therapy (Norcross,

Karpiak, & Santoro, 2005), systematic couple therapy training is rarely oﬀered during predoctoral

clinical internships in either ﬁeld (Association of Psychology Postdoctoral & Internship Centers,

2013). Similarly, even in highly regarded training programs in child psychiatry, fellows in child

psychiatry regularly lack suﬃcient opportunity to develop proﬁciency in such practices (Rait,

2012). Nor is family systems and couple therapy training widely available for residents in general

adult psychiatry (Berman & Heru, 2005). In essence, no mental health specialty group, including

even students in marital and family therapy (MFT) training programs, is universally required by

national training standards to have even one course speciﬁcally on couple therapy, although in

practice most MFT programs do require one and few oﬀer two. Furthermore, direct clinical expe-

rience with couples is not required anywhere for licensure as a mental health professional, even for

licensure as a marital and family therapist. This widespread insuﬃciency of training in couple ther-

apy was succinctly described by Doherty (2002), “…most therapists learn couples therapy after

they get licensed, through workshops and by trial and error. Most specialize in individual therapy,

and work with couples on the side. Most have never had anyone observe or critique their couples

work” (pp. 26).

Many therapists who provide ITCP do so without an organized treatment plan that is sensi-

tive to the complexities of conjoint couple therapy. For example, one of us once attended a couple

therapy conference at which the approximately three hundred attendees were asked by one of the

speakers whether they had a systematic plan for how they conducted initial clinical assessments

with couples, to which only about a dozen responded aﬃrmatively.

Practicing conjoint couple therapy can be richly rewarding, but it is arguably the most chal-

lenging form of therapy. Therapists trained primarily and often exclusively in individual models of

psychotherapy, based in linear rather than circular thinking, understandably ﬁnd it diﬃcult, at

times even perplexing, to identify and adhere to a systemically grounded schema for organizing

case formulations and treatment planning (such as Scheinkman & Fishbane, 2004; vulnerability

cycle model or the integrative problem-centered metaframeworks approach of Breunlin, Pinsof,

Russell, & Lebow, 2011). Yet such models are necessary to map the complex, multiple patterns of

couples’ interactions operating concurrently at multiple levels (Scheinkman & Fishbane, 2004) and

inﬂuenced by a potentially enormous range of controlling factors (Breunlin et al., 2011). More-

over, therapists trained and experienced in individual therapy often have diﬃculty perceiving and

retaining multiple and often literally competing, partner perspectives about their diﬃculties and

their overall relationship. They also have diﬃculty ﬁnding the “experiential we” in the circularity

of the couple’s relationship. They ﬁnd it challenging, as Stanton and Welsh (2012, p.15) put the

matter, to “see the system”. Faced with such diﬃculty, they may inappropriately favor an individ-

ual format when presented with relationship complaints during an assessment or in the context of

an ongoing diagnosis-focused individual therapy. Upon initiating ITCP, they may lack the neces-

sary skills to conceptualize and address the relationship problems, and worse yet, might blame

them on the absent partner.

Moreover, one often hears of graduate-level professionals with extensive education and train-

ing in couple therapy treating couple problems in individual therapy without speciﬁc training in

how this should be carried out. Even when therapists have been trained to practice psychotherapy

from a systemic perspective, they may not be adequately exposed to the subtleties and complexities

of ITCP. For example, the AAMFT created a task force to deﬁne core competencies for the prac-

tice of couple and family therapy (Nelson et al., 2007). There are several competency domains

within which it would certainly be appropriate to address the considerable challenges of providing

ITCP that are discussed below, for example, Domain 1/Admission to Treatment: “Understand the

risks and beneﬁts of individual, marital, couple, family, and group psychotherapy;” “Determine

who should attend therapy and in what conﬁguration”; Domain 3/Treatment Planning and Case

Management: “Know which models, modalities, and/or techniques are most eﬀective for present-

ing problems”; Domain 5/Legal Issues, Ethics, and Standards: “Recognize ethical dilemmas in

practice setting”. Unfortunately, nothing is identiﬁed in that comprehensive delineation of compe-

tencies that explicitly requires training programs to provide either didactic instruction about or

474JOURNAL OF MARITAL AND FAMILY THERAPYOctober 2014 clinical supervision of ITCP, and so, exposure to such matters about this complex, common, and

potentially iatrogenic clinical practice is likely to be highly variable. Of course, adequate attention

is even less likely to be paid to these issues in therapy training programs that are less consistently

organized within a systemic perspective.

Finally, we are concerned that therapists who lack adequate training in couple assessment,

ITCP assessment, and treatment of both kinds, are likely to falter when facing decisions about

whether to oﬀer ITCP, refer out for conjoint treatment, refer out while providing concurrent indi-

vidual treatment, and so on. Therapists in this group may be inclined to agree too quickly with the

contraindications to conjoint therapy oﬀered by Bennun (1997), “competitive and hostile” couples,

couples with “fears of dependency”, partners “with low self-esteem,” or a “history of diﬃculty in

sustaining two-person relationships “ (pp. 467). While this list may have merit at certain levels of

intensity, for example, when volatility means that the couple cannot speak to each other for ﬁve

minutes without one or the other storming out of the therapist’s oﬃce, the uncertain eﬃcacy of

ITCP does not warrant a liberal interpretation of such contraindications. If oﬀers of ITCP are

made by therapists who do not have signiﬁcant training and supervision in couple therapy, many

of the very couples most in need of working together will be treated using a nonvalidated format

for therapy that can be ineﬀective and even damaging. We believe that any therapist advising an

individual client, even as a secondary focus of therapy, about couple issues should be educated and

current about the nature of couple relationships (e.g., Gottman, 2011), approaches to couple treat-

ment (e.g., Gurman, 2008a), and the risks involved when a partner is absent from treatment by

either choice or circumstance.

POTENTIAL PITFALLS IN THE PRACTICE OF ITCP

In addition to idiosyncratic therapist factors inﬂuencing the oﬀering of ITCP when conjoint

therapy seems indicated, there appear to us to be ﬁve central areas of concern in the ongoing prac-

tice of ITCP. They include (a) constraining change, (b) therapist side-taking and the working alli-

ance, (c) inaccurate assessments based on individual client reports, (d) establishing, maintaining

and changing the therapeutic focus, and (e) ethical considerations.

Some therapists who are well trained in systems-sensitive approaches may be surprised that

we raise such concerns, especially if they practice independently and do not interact with therapists

who are not systemically trained. They also might assume that such concerns arise solely from sto-

ries heard secondhand from therapists’ clients or from colleagues. We do not believe that every

reader is vulnerable to the concerns we put forth, but endeavor to address a range of concerns that

have arisen out of our discussions in various professional contexts.

Constraining Change

ITCP seems to be characterized by two particularly worrisome and related structural attri-

butes, the therapist’s inability to directly observe the couple, and the therapist’s inability to directly

apply interactionally oriented interventions. At the most elemental level, ITCP by deﬁnition does

not allow for the therapist’s direct experience of the relationship between partners. Indeed, it is this

opportunity to observe, experience, and interact with relationshipsin vivothat, since its infancy,

has set couple and family therapy apart from extant individual therapies. It is the creation of an

artiﬁcial yet highly facilitative therapeutic environment, one closely approximating the natural

environment and often marked by important change-oriented enactments (Simon, 2008) that

empowers such a wide range of couple treatment approaches and promotes generalization of ther-

apeutic eﬀects outside the consultation room (Gurman, 2001). The impossibility of the ITCP ther-

apist’s direct observation of couple interactions limits her opportunity to help establish treatment

goals ﬁtted to the subtle ways in which intimate partners activate each other’s vulnerabilities (Sche-

inkman & Fishbane, 2004). ITCP also limits the therapist’s opportunity to address diﬀerences in

partners’ views of their central diﬃculties, diﬀerences which aﬀect the outcome of conjoint treat-

ment (Biesen & Doss, 2013) and are often quite salient in ITCP. In addition, the therapist’s inabil-

ity to assess therapeutic progress directly may blind her to the strengths of both partners and their

relationship.

October 2014JOURNAL OF MARITAL AND FAMILY THERAPY475 The most telling structural limitation imposed by ITCP is that it impedes application of princi-

ples of therapeutic action central to the process of enduring improvement in couples’ relationships.

To date, very little couple therapy research addresses what is ultimately the most important

question about any method of psychotherapy, “Howdoes change occur?” (Gurman, 2011;

Christensen, 2010). It is not clear whether there are a ﬁnite number of universally relevant change

principles that operate across the various approaches to couple therapy (Christensen, 2010) and/or

whether diﬀerent methods draw upon diﬀerent principles of change (Gurman, 2011) or for which

couples particular principles are most salient.

Even without such universal principles or related method-speciﬁc change mechanisms having

been identiﬁed empirically, we may reasonably posit the likely operation of several such processes.

While some of these processes are merely very diﬃcult to activate in the practice of ITCP, others

appear to be nearly impossible to activate in ITCP. In addition to common factors (Sprenkle,

Davis, & Lebow, 2009) that provide a foundation for change, these putative principles include (a)

the inculcation of partners’ systemic awareness of the circularity and contextual embeddedness of

their conﬂicts (Scheinkman & Fishbane, 2004) which may help the identiﬁcation of central prob-

lematic themes; (b) the establishment of the premise that partners have shared responsibility for

bringing about change (Gurman, 2008b); (c) improved mutual acceptance of one’s partner, often

facilitated by the expression of unacknowledged or unexpressed emotions (Johnson, 2004); (d) the

interrupting of maladaptive conﬂict-maintaining interactions, allowing for new adaptive sequences

(Pinsof, Breunlin, Russell, & Lebow, 2011), and the potential for more secure attachment (John-

son, 2004); (e)when needed, reﬁnement of communication and problem-solving skills (Christensen,

2010), and (f) normalizing couple conﬂict via psychoeducation about intimate relational function-

ing (Gottman, 2011). The limitation ITCP may place on the application of such change principles

is aptly summarized by structural family therapist Simon (2008), who understatedly observed, “…

one couple member cannot experience the other diﬀerently if that person is not in the therapy room

with him or her” (pp. 328).

ITCP’s structure may also impose limits on the likely rate of change, thus distorting treatment

expectations. Relationship changes that occur initially may be falsely encouraging to both client

and therapist, considering that with ITCP, the therapist’s inability to directly access the relation-

ship means that there is less opportunity to build support and reinforcement outside the consulting

room for the client’s changes. This makes the client’s new behavior particularly vulnerable to

extinction, to erosion within the system’s current homeostasis, or worse, to sabotage by the part-

ner. As ITCP may be diﬀerentially eﬀective for partners who are highly motivated, psychologically

ﬂexible, and doggedly persistent, it is important for the therapist to be cautious in estimating,

based on single cases, ITCP’s potential for success with a wider variety of individuals.

Therapist Side-taking and the Working Alliance

Bordin’s (1979) inﬂuential tripartite model of the working therapeutic alliance, brought into

the couple and family therapy world by Pinsof (1995; Pinsof and Catherall 2007), includes goals

(“Where are we going?”), tasks (“How do we get there?”), and bonds. We will comment below on

ITCP goal and task formulation and focus here on bonds. When a psychotherapist meets with an

individual, he must be able to grasp her experiential frame of reference in order to build the bond

between them, that is, the aﬀective sense of connection, mutual liking, and caring. The client wants

to, and needs to, feel both understood and accepted.

Given that probably a vast majority of clients attribute a good deal of responsibility for their

couple problems to their partners, the therapist’s empathic stance toward his ITCP client can yield

unexpected and undesirable consequences. Speciﬁcally, an empathic response to the client’s suﬀer-

ing may be experienced by the client not only as emotionally supportive, but also as supporting his

perspective on the source of his couple concerns. It is commonplace to hear ITCP clients’ reports

that their new therapists “agree” with them about which partner is most blameworthy, even when

their therapists have not expressed such a position and may not even hold it. Unfortunately, it also

commonplace to hear of therapists, insuﬃciently trained to think systemically, who actually

express such a view. Sometimes this takes the form of diagnosing, either conﬁdently or specula-

tively, the partner whom the therapist has never met. Sometimes the therapist asks “leading ques-

tions” about why the client stays in the relationship despite his suﬀering, etc., implying that this

476JOURNAL OF MARITAL AND FAMILY THERAPYOctober 2014 must reﬂect pathology on his part, as anyone else would see that the relationship is not worth sav-

ing. Such untoward therapist positions may implicitly encourage divorce or at least fail to foster

change within the couple relationship and possibly worsen the couple’s problems by reinforcing

the attending partner’s polarized position.

The therapist’s eﬀort to establish a working therapeutic alliance and caution about challeng-

ing the client’s position about her relationship can result in the therapist’s induction into the per-

ceptive set of the client and run the risk of fostering the client’s idealization of her therapist. This is

often alluded to when the attending partner tells her therapist, “Well, at leastyouunderstand

me.”As Hurvitz (1967) observed more than four decades ago, “…her interpretation of the thera-

pist’s interest becomes the model of her expectations of her husband” (pp. 39). The wife’s ITCP

experience “oﬀers her a permissive setting within which she disparages her husband with impunity

and thereby reinforces her negative attitudes toward him” (pp. 40). This process is easily bolstered

and buttressed by biased perception, selective attention, and highly fallible memory fragments.

Inaccurate Assessments Based on Individual Client Reports

Many couples come to treatment wanting to address communication (Doss, Simpson, &

Christensen, 2004), but ITCP therapists can make inferences about couples’ communication only

from clients’ reports. Many individual therapists do not understand how much a client’s depiction

of spousal interactions can be distorted by the inherent inaccuracies of couples’ communication

itself, as well as by other factors. The accuracy of reporting and comprehension in ITCP can be

impacted by a number of speciﬁc distortions including, to name a few, correspondence bias (Gil-

bert & Malone, 1995), attitude polarization (Jacobson & Christensen, 1996), marital sentiment

override (Hawkins, Carrere, & Gottman, 2002), perceived punctuation of events (Watzlawick,

Bavelas, & Jackson, 1967), mood congruency eﬀects (Pereg & Mikulincer, 2004), conﬁrmation bias

(Hergovich, Schott, & Burger, 2010), and confabulation (Johnson, 2006). This list reﬂects factors

that are known to aﬀect normal perception and does not begin to address additional clinical con-

cerns such as transference and projection. Some of these errors aﬀect the client’s perception of the

partner, some aﬀect the client’s understanding of the partner’s communication, some aﬀect the cli-

ent’s memory of the absent partner, and some aﬀect the ITCP therapist’s ability to accurately

interpret the client’s report. Because clients seek therapy at a time of conﬂict and distress, it is most

common that these distortions create a negative bias in reporting. Not only can such bias sway the

therapist’s allegiance toward the attending partner, but it also can more broadly impact assessment

and intervention by providing a generally inaccurate view of the couple’s relationship. To illustrate

this point, we will describe several examples of common distortions.

Attitude polarization is one of the interactional phenomena that can distort partners’ views of

one another and subsequent reporting to therapists. For example, a diﬀerence in communication

style on a volatile—avoidant continuum can easily create polarization in a couple. The avoidant

partner perceives the volatile partner as “out of his mind,” while the volatile partner perceives the

avoidant partner as a “cold ﬁsh.” In an attempt to get a meaningful response, the volatile partner

begins to escalate the intensity of communication, while the avoidant partner withdraws even fur-

ther to avoid the din. Seeing such a couple together, one might discover that their styles are not

very dissimilar from what is common in the general population. The partners have developed

polarized perceptions of each other resulting from the escalation of an otherwise small initial dif-

ference. In ITCP, the client’s characterization of the partner will make it diﬃcult to discern to what

degree the client’s complaint results from an individual trait or from an entrenched interaction

pattern.

Distorted reports about the couple relationship can also result from inherent limits in commu-

nication. Each message between partners involves several layers of translation and potential distor-

tion, from the sender’s thoughts to expressed language, from language expressed to language

heard, and from language heard to the listener’s interpretation of meaning. This is humorously

characterized by Robert McCloskey as “I know that you believe you understand what you think I

said, but I’m not sure you realize that what you heard is not what I meant.” In ITCP, when the cli-

ent relays a report of a conversation that occurred with the partner, these layers of translation and

potential distortion that have already occurred between partners are repeated yet a second time

between client and therapist. In couple therapy, the therapist actually observes the communication

October 2014JOURNAL OF MARITAL AND FAMILY THERAPY477 between partners and has the opportunity to more directly analyze potential misunderstandings,

as well as habitual patterns of misunderstanding.

Another signiﬁcant problem with client reports in ITCP involves the risk of distorted

memories. ITCP clients often describe partners’ comments that were made during conﬂict and seek

support or perspective from the therapist. This also occurs in couple therapy, but in that context, it

is common for partners to express markedly diﬀerent memories of the conﬂict. Some of this is

attributable to the problems with communication noted above, but some of the diﬃculty stems

from limitations in memory that have become better understood in the last decade due to research

on eyewitness memory. For example, it has been found that memory is subject to distortion partic-

ularly when the original event included high emotional arousal and verbal or auditory stimuli, both

of which are characteristics of typical couple conﬂict. In fact, in guidelines for understanding mem-

ory in legal settings, the British Psychological Society (2008) oﬀered the following regarding mem-

ory of “spoken utterances:” “In controlled experiments in the laboratory and in ﬁeld studies of

actual witness memories it has been found that such recall is simply not possible. What is recalled

of this nature is invariably wrong” (pp. 1).

Memories and judgments made while reﬂecting on remembered events tend to be mood-

congruent, such that negative emotions facilitate recall of more negative events and also promote

harsher judgments (Pereg & Mikulincer, 2004). Additionally, there is evidence that general mem-

ory recall is made worse by even simple query regarding emotions, query typical of the individual

therapy context (Johnson, 2006). Demonstrating the degree to which partners’ memories can be

contradictory for even relatively simple events, it was discovered (Jacobson & Christensen, 1996,

p.164) that partners using a daily checklist of shared activities had only 70% agreement on the

item, “We took a shower together,” and only 60% agreement on, “We had sexual intercourse.”

(To be fair, the researchers acknowledged that the item did not specify with whom!)

Distortions in assessment of the couple relationship can also occur in ITCP due to additional

factors in the direct interaction between client and therapist. Once a client in ITCP begins to share

perceptions of the absent partner with the therapist, conﬁrmation bias also can begin to aﬀect cli-

ent and therapist perceptions of the partner and relationship. Similar to the ways in which physi-

cians, having formed an initial diagnosis, can overlook critical diagnostic factors (Groopman,

2007), the client and therapist may be inclined to accentuate initial negative appraisals of the part-

ner and/or relationship by unconsciously accumulating conﬁrming data and neglecting essential

positive facts that now seem random or irrelevant.

The potential for distortion at various levels of communication between the partners and

within the client–therapist dyad is well reﬂected in a comment from John Gottman (personal com-

munication, 2013) that, “Most communication is the correction of miscommunication”. It is

important to remember that in ITCP there is one critical witness perpetually absent during the pro-

cess of correction.

Drift and Shift: Establishing, Maintaining and Changing the Therapeutic Focus

Many psychotherapy experiences involve modiﬁcations of initial treatment goals as clients

and therapists reﬁne their understanding of the problems at hand. Nonetheless, the establishment

of a clear, if evolving, therapeutic focus is a hallmark of all models of couple therapy (Gurman,

2008a).With the current emphasis in healthcare delivery systems on therapeutic brevity (Gurman,

2001), the clarity of treatment goals is made all the more important. We have often observed that

when therapists practice ITCP, there is a strong tendency towardtherapeutic drift, that is, a drift

away from clients’ primary relationship goals, or a drift, either conscious or inadvertent, between

various goals that lack a consistent assignment of priority. We believe that the paucity of literature

and training addressing ITCP is an important contextual factor in the occurrence of such drift.

Therapists lacking clarity about or conﬁdence in a relevant guiding model have diﬃculty maintain-

ing focus in treatment. Therapists trained in individual models may experience additional diﬃculty

focusing on relationship goals in ITCP and may drift toward addressing individual diagnoses or

concerns.

Drift is usually signaled by one or more of three emergent processes, which can be described

as supportive, entropic, and client-focused. First, the therapist may be suﬃciently inducted

into the attending partner’s perspective on his relationship and his nonattending partner that

478JOURNAL OF MARITAL AND FAMILY THERAPYOctober 2014 interventions become almost entirely supportive. Empathizing with the distressed client is accom-

panied by little eﬀort to introduce novel ideas about the couple’s diﬃculties or to experiment with

new ways of interacting with the nonattending partner. Such a drifting therapist role is more likely

when the client is very dependent on the therapist, perhaps lacking adequate social support in

everyday life. Resignation about the possibilities for change may reign.

A second form of drift comes with the environmental stress, subjective distress, and the variety

of concerns presented by most clients seeking therapy. These factors constitute an entropic force

that can easily overwhelm a therapy endeavor that lacks established eﬃcacy, a supportive litera-

ture and available training. Consequently, vacillation occurs between the client’s couple concerns

and any number of non-couple-centered topics which, while of genuine interest to the client (e.g.,

current work stress, ﬁnancial worries) likewise oﬀer little potential to eﬀect change in the realm of

the client’s primary relationship. The ITCP may slide seemingly aimlessly into conversations about

the past, whether about the client’s individual past or the couple’s past, with much ambiguity

about how such conversations are relevant to the client’s presenting problem. When ITCP lacks

clarity about the causal links between the individual and couple domains, or fails to focus on goals

long enough to assess progress, comforting, and seemingly meaningful conversations that avail

very little may ensue.

The third form of therapeutic drift, toward an excessive focus on the individual client, is espe-

cially concerning. Here, drift is manifest in the client’s assumption of an excessive degree of respon-

sibility for the couple’s problems, the converse of when client and therapist inadvertently collude

to fault an absent partner. Recognition of one’s own role in couple conﬂict is usually fundamental

to change and is to be valued. Conversations leaning this way are not inherently unproductive or

harmful. Rather, they are more likely to be detrimental to the client when the therapist is not suﬃ-

ciently grounded in a clear and relevant method such as McGoldrick and Carter’s (2001) Bowen

Family Systems Therapy-based approach to “coaching” one person in the context of the couple

system. The usefulness of such approaches lies in their focus on the role and experience of the

attending partner in the circular and bilateral nature of couple conﬂicts. Clients in such individual

therapies can “become observers of their roles and behavior in their (family)” and are trained to

“become researchers of (family) patterns” (pp. 282). While self-awareness is fostered, “other-

awareness” is also central to the therapeutic focus. Absent some systemic aspect of an ITCP

approach, imbalanced attributions of blame for couple conﬂicts and responsibility for their repair

may fall disproportionately on the shoulders of the individual client, and most commonly this

means on the shoulders of women (Doss et al., 2004).

In addition to drift, ITCP may also involvetherapeutic shift,a disruptive change in treatment

formulation or format. The shift is sometimes presaged by a therapist becoming pessimistic about

the amount of change that appears likely by continuing the individual work. At other times, the

therapist may have been initially withholding his more relational perspective on the couple’s prob-

lems, fearing that it might not be well received by the attending partner. In either circumstance, the

therapist, having avoided introducing a contextual or systemic view, may now suggest inviting the

nonattending partner to join the therapy for ongoing participation. While his new assessment of a

treatment direction may be perfectly warranted on conceptual grounds, the attending partner may

experience the change as a painful abandonment and betrayal. Especially when ITCP has been

ongoing, the strategic and ethical complexities of such a shift are many and the working alliance

with the attending partner may be signiﬁcantly tested.

Ethical Issues and “Participating Nonparticipants”

Although there is substantial empirical evidence of the eﬃcacy of conjoint couple therapy, as

suggested earlier, there are no controlled outcome studies of ITCP among either the approaches

most often discussed in the couple therapy literature, that is, Bowen Family Systems Therapy

(McGoldrick & Carter, 2001), solution-focused therapy (Berg, 1988; Nelson, 2002), and psychody-

namic therapy (Jenkins & Asen, 1992).

This empirical state of aﬀairs raises important ethical issues. The ultimate outcome risk of pro-

viding ITCP, of course, is that clients will not receive the best empirically supported treatment for

their diﬃculties. As described earlier, there are also several process risks that may harm either the

couple’s relationship or the attending partner: (a) The absence of the second partner may result in

October 2014JOURNAL OF MARITAL AND FAMILY THERAPY479 inaccurate assessment and misguided interventions; (b) although well-intentioned, the therapist’s

expressions of empathy may reinforce the client’s corrosive polarization about the couple’s

problems; (c) the therapist may unwittingly model an idealized relationship standard that is

unreasonably diﬃcult to emulate in everyday intimate relationship life; and (d) the client may expe-

rience excessive responsibility for aﬀecting change in the relationship, and a heightened sense of

ineﬃcacy when change does not occur.

In addition to the unintended process and outcome risks that may accrue to the attending

partner, concerns may also be raised about the potential eﬀects of ITCP on the nonattending part-

ner. The ITCP therapist has no legal responsibility to the nonattending partner, who by deﬁnition,

is not the client of record and typically has never even met the therapist. Nevertheless, the therapist

should consider his ethical obligation to monitor and mitigate potential harm to the nonattending

partner resulting from changes that the client makes under the therapist’s guidance. The nonat-

tending partner’s emotional welfare is inextricably bound up with the client, usually in ways that

are possible to understand and anticipate. Although the second partner may never appear for ther-

apy, one might argue that she is truly a “participating nonparticipant”, or what Breunlin et al.

(2011) refer to as a member of the “indirect client system”, to whom the therapist should show

some degree of responsibility in terms of therapy’s impact.

While the therapist may have an ethical obligation to consider therapy’s downstream impacts

on the client’s partner, it is quite a diﬀerent thing to intentionally design such impacts. It is our

belief that the more ITCP intentionally focuses on aﬀecting the relationship or absent partner, and

the more it does so in the context of health care, the more it risks harm to the absent partner and,

in addition, risks allegations of harm, regardless of actual outcome. Interventions aimed at the

partner’s attitudes or behaviors risk harm because of the therapist’s limited and secondhand

understanding of the partner’s relationship needs, which may easily diﬀer from those of the client

(Doss et al., 2004). Doing so in the context of health carries the same risk, but is more clearly con-

demnable as remote diagnosis and/or treatment without consent. Opinions vary widely about the

therapist’s responsibility to seek consent from an absent partner, ranging from the opinion that

involvement of the partner is wholly subject to the attending client’s right to self-determination

(Kaslow, 1986) to the opinion that treatment should not proceed without the absent partner’s edu-

cation about the risks of ITCP and that partner’s written consent for the client to be treated indi-

vidually (Wilcoxon, 1986). Involving a partner belatedly or intermittently in ITCP raises other

ethical issues, for example, the role of the partner as a client or collateral participant, the choice of

referral to a couple therapist versus change of treatment format with the individual therapist (Patt-

erson, 2009) and the informed consent requirements inherent in both decisions.

The therapist’s personal values are another important factor to consider relative to the issues

of potential harm and informed consent, particularly because clients in ITCP so often experience

some degree of ambivalence about commitment to the absent partner. It is impossible for the ther-

apist to intervene with a couple’s system without personal values coming into play (Margolin,

1982). In the case of marriage, the therapist’s values pertaining to personal growth or social

responsibility may signiﬁcantly aﬀect the degree of focus on an ambivalent client’s commitment to

the absent spouse (Doherty, 2011). It is important for the therapist not only to be aware of such

personal leanings, but also to collaborate in such a way that the client understands how biases

might aﬀect the perceived range of choices.

Lastly, there are two noteworthy ethical considerations regarding the relationship between the

client, therapist and healthcare insurer when ITCP is provided. Whether treatment occurs in an

individual or conjoint format, it is our experience that, without exception, insurers will only cover

psychotherapy that is intended to address an individual’s diagnosed health condition. If insurance

reimbursement is pursued for ITCP sessions, it is important that the treatment addresses relation-

ship factors aﬀecting the client’s health status or addresses relationship functioning that is

adversely impacted by the client’s mental health condition. As our healthcare system is currently

designed, to seek reimbursement for relationship enhancement that is not related to health status is

unethical. Documentation of health-related intervention is also essential to prevent an insurance

audit from requiring retroactive repayments for which the client is unprepared.

Considering that ITCP is not yet empirically supported, while couple therapy has established

eﬃcacy on a par with individual therapy (Gurman, 2011) for the treatment for several common

480JOURNAL OF MARITAL AND FAMILY THERAPYOctober 2014 psychological disorders (Lebow et al., 2012), we consider it unethical for insurers to provide bene-

ﬁts for the treatment for mental health disorders while excluding conjoint therapy as a covered

treatment modality. Doing so, particularly in cases for which couple problems hold a clear and

causal role in maintaining the member’s compromised health status (Hoyt & Gurman, 2012), limits

treatment options to ITCP, a currently untested treatment modality.

CONCLUSION

Our understanding of the eﬃcacy of ITCP is both stale and murky. In the last decade and half,

advances in psychological research and psychotherapy that are relevant to ITCP warrant renewed

attention to this common practice. Given the frequency with which ITCP is both requested and

provided, we believe that our understanding of ITCP should evolve at the same pace as conjoint

therapy and any specialty area of individual therapy. While we hope to have elucidated some of

the pitfalls of ITCP, our primary objective was the stimulation of new research and clinical writ-

ings on this very important but largely neglected topic and especially its careful consideration in

training contexts. This article was motivated by a belief in the potential of ITCP to ultimately

become a valuable treatment approach when conducted with greater awareness of its limitations

and subtle complexities.

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NOTE

1Footnote. Throughout this article, we use the gendered pronouns “she” and “he” randomly,

except where meaning or exposition requires one rather than the other.

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