Basic Differences Between Couples and Individual Therapy
Some look at couple and family therapy as primarily problem-focused (or tertiary prevention), while others see it as prevention-focused (primary or secondary prevention). Thus, working with parents to help them work collaboratively to gain control of teen acting-out behavior is a problem-focused intervention for that couple. However, it is a prevention-focused intervention for his/her 10 year old sibling, as we hope the parents will not have the same problems with the sibling when s/he reaches adolescence.
To divide these approaches even further, one therapist might work with a step-family after the teen has started to act out, and use a very problem-focused, clinical intervention. Another therapist may see the parents of the step-family for brief therapy as they prepare to move into one household, and educate them about what to expect, consult with them on what their new family life should be like and how they could shape it before they are in the throes of its development, and prepare the parents for commonly seen struggles in step-family formation. This therapist is using a much more primary prevention approach (or a kind of “inoculation therapy”).
Beyond this, there are also specific couples programs to help couples remain happily partnered and good communicators, and parent programs to improve parenting during the pre-school years and prevent oppositional and aggressive behaviors (see Pinsof and Hambright’s chapter, as well as Tolan’s chapter, in Liddle et al, 2002). These are preventative but don’t actually target a specific at-risk problem.
Below are a number of questions (and answers) about couples and individual therapy.
Who is The Client?
- In individual therapy, the “client” is the individual who seeks treatment.
- In couples therapy, you might think there are two clients – the two individuals who seek therapy. However, there is still only one – the relationship. As with individual clients, you try to help them come to an understanding of what’s going on for them, how this came to be a problem, and why it has continued. For couples, you do the same, but you help them both see what’s been happening in their relationship, how it came to be and how each of them has been a factor in it, and why it has continued.
What’s “The Problem” and is That Really The Problem?
One may want to stay in what the other considers a dead relationship. The other may want to throw in the towel on what the other considers a relationship that can be saved. So what is the problem, or issue on which treatment should focus? Who is responsible for the problem (or are they always both responsible)?
- Individual therapy would focus on helping both partners make their decision to “stay or go now” while couples therapy may instead focus on helping them both see what is there in their relationship.
- If one partner has “emotionally divorced” the other already, then there may be little left to work on. However, if even the one who is ready to leave still has some hope for the relationship, it may be possible to explore that – there may be changes in the relationship that can be made to make that partner happy. John Gottman has been doing couples therapy research for almost 30 years, and found that 75% of “irreconcileable” problems can not be solved – but they can be managed so that both partners can still be happy.
What’s a Treatment Success?
Suppose they divorce? Or is staying together always a success? Does it matter whether failure and success are judged from the view of the couple, or from the whole family? Is there such a thing as “divorce therapy” to help people part amicably?
- Individual therapy can help people learn to accept things they can not control, or make decisions about how to take action to control the ones they can. That’s fine for things like illnesses, or career difficulties, or uncertainty about one’s identity.
- For relationship issues, however, couples therapy helps the partners decide on what to do. They may decide “the thrill is gone” from their marriage, but that they should stay together due to their religious beliefs, for example, or because they have young children. However, that isn’t enough to make them happy together, and it is not enough to create a happy home for their children. Individual therapy may help you decide to stay married or divorce, but it likely won’t place much focus on the other partner, or on the children. Couples therapy can help each partner decide what to do and how to do it. They may not put much stock in staying married, were it not for the children. However, a focus on how they, together, can create a happy home for the children to grow up in is something they can both agree on and make decisions about. However, when both partners do wish to divorce, and genuinely feel that would be best for them, couples therapy can help. Research does show that married couples with problems that cause “medium” levels of stress think about divorce. however, when they stay together, and five years later are asked whether staying married was a mistake, most will say “No.” That is, most couples who decided to stay together will, 5 years later, view this decision as the right one. However, with couples suffering from extrememly stressful problems, the kind that lead either to a very stressful home due to the angry and bitter fights, or to a very cold and distant homes where people do not speak to each other for days… the research supports that the children would be better off if the parents divorced, rather than continue to raise the children in that environment.
How Does Therapy Work?
Does the therapist sometimes empathize with only one of the partners? Does the therapist give advice, take sides, or tell them not to talk about something?
- In individual therapy, the work may focus on understanding one person’s “worldview” of experience of the relationship. This is to help them to know what they want and to communicate that assertively and clearly.
- In couples therapy, the work will likely focus on what both people want, and how they can communicate that… and do something about it. That may mean some negotiating and compromise, and most couple therapies do focus on communication skills in direct or indirect ways. It may also mean some “gift giving,” or agreeing to do something simply to make the other partner happier. It may also mean some “softening” or each person forgiving the other for past hurts and insensitivities, and giving them “the benefit of the doubt” or understanding why they could not do what was hoped because it frightened them, or meant giving up something they needed in the relationship. Sometimes the therapist will take one side or the other in a specific argument, but ususally only in critical issues that could mean damage to the relationship.
How often should the therapist meet with the client?
- Individual therapists have traditionally seen clients once a week for 50 minutes. This provides some stability for the client, and creates a place where the client regularly pauses in life to reflect, evaluate their progress toward their goals, and make decisions. In some ways, it is like the weekly review that productivity gurus tell us we should have, every week, to assess our work but also personal life goals and our progress toward them.
- Family and couples therapy is often much more flexible. Gottman, for example, will initially see couples for more than an hour, and by the end of therapy will space sessions out to perhaps one session a month, or one session every few months, as a way to reduce relapse into problems. He envisions a “marital clinic” in every major city where couples can seek “marital checkups.” In one sense, this is no different than going to the dentist once every four to six months for cleaning and a check-up. For research, however, this means that variables as simple as “number of sessions” or “average weekly minutes of therapeutic contact” are no longer simple variables a researcher can track and control. This means studies of the “effectiveness of treatment” sometimes have to be redesigned.
But Does Therapy Help?
- For individual therapy, there are many studies that show the effectiveness of many different models. Sometimes they show one kind of therapy is better than another for a specific problem, but more often not. More often they show most therapies can help with most all problems.
- As for couples therapy, Liddle et al. (2002) report that the transition from “distressed” to “non-distressed” after treatment occurs for 35% (Jacobson et al., 1984) to 41% (Shaddish et al., 1993) of couples. In other words, they get better, but generally only a third or so are in the “normal and happy with their relationship” range. The issue for studies of the effectiveness of therapy is that when married couples in treatment are compared to married couples on a wait-list, the couples on the wait-list decline into the “very distressed” range while they wait for therapy. Thus, the treatment really has only to halt the decline in order to yield significant results, and a statistically significant result may not mean much (see Gollan and Jacobson’s chapter in Liddle et al. 2002). However, Johnson & Greenberg (1994), however, using the Emotion Focused Therapy they developed, found musch better results. Cloutier et al. (2002) found 62% of couples were improved (less distressed) when they finished six to ten sessions of Emotion Focused Therapy. However, 77% were improved two years later, meaning they were in the “normal and happy with their relationship” range) at the end of six to ten sessions of Emotion Focused Therapy, while 64% were recovered at the two year followup. Thus, with specific couples therapy treatments shown to work, about three-fourths get better, and two-thirds are “healed” after only six to ten sessions of work.
How Do You Assess Couples’ Functioning?
Assessment Methods in couple therapy are varied, and range from self-report questionnaires, observational techniques, physiological readings… to therapist rating scales. Some therapists don’t use them, but most modern therapists do. Gottman can predict with 90% accuracy who will be divorced in five years based on structured interviews and some questionnaires. This may sound far-fetched, but he has collected long-term follow up data to prove his method works.
- Self-report questionnaires are easy to use and score, but limited in what they reveal. Further, what does it mean if two people disagree significantly in their responses? Do you average the discrepant scores? Is it “an issue” for them to discuss?
- Observational techniques are very time consuming and require great inter-rater reliability, but reveal a lot. However, the task used to observe the couple shapes the results; conflict-management-tasks pull for negative emotions and conflict, while game-playing-tasks pull for problem-solving and easy communication. Further, the observational method must be studied and proven reliable.
- Physiological readings are generally left out of individual therapy research. However, Gottman and others have tied them to general conflict resolution, dysfunctional communication patterns, and types of domestic violence with success. They also advocate using these in therapy sessions as a way to improve the process. Simple pulse monitors can help people from becoming too overwhelmed… and teach them to monitor the signs of becoming overwhelmed so they don’t need the monitors. Gottman refers to “Diffuse Physiological Arousal” as a stage of accelerated heart rate, pulse, breathing… like the “fight or flight” response you learned about in biology classes. Once a person enters this state, there is little they can do in the way of productive conversation and problem-solving.
- Therapist rating scales are a sub-type of observational techniques, which can be the best of both worlds in some ways. However, all rating scales and questionnaires share a common weakness – are they equally valid across different kinds of families? In other words, is there is bias in the measure that leads to bias in the therapist’s views (see Bray’s chapter in Liddle et al. 2002). This gets to differences between married and unmarried couples, gay and lesbian and straight couples, multicultural vs. monocultural couples… What works to help resolve a problem in one may not work so well in another. What views or behaviors or feelings reveal a key conflict in one couple may not work so well in another.
What Proof Is There That Couples Therapy Works?
This question is complex, as there are several points to consider when deciding whether a treatment works.
Part of “proving” therapy works is by predicting something and seeing if it comes true. Non-linear events do not lend themselves to statistics very well. Thus, using events at Time A to predict events at Time B may be easy to do in individual therapy. However, in couples therapy, events at Time B shape the interpretation given to events at Time A, and thus impact all future data collection (Time C).
- For example, Couple #1 sees open conflict at Time A as a bad sign, because at Time B they still had not resolved the problem, and “obviously” arguing “made matters worse.” Couple #2 sees open conflict at Time A as a good sign, since at Time B they had resolved the problem, and arguing “obviously” allowed them to “get it out in the open.”
- The next time an emotionally charged issue comes up (Time C), Couple #1 (based on their negative experience) tries not to argue at all to avoid making the problem worse, while Couple #2 (based on their positive experience) argues to get through the problem. So, what does open conflict help us predict about eventual problem resolution?
As you can see, the research is a bit tougher to interpret. The trick in this case is not to look simply at the presence or absence of arguments, but to include the couples’ beliefs and comfort with conflict. How do they communicate key needs, wants, and feelings to each other, not just in a fight but also when there is not fight? What sense do they each make of conflict, and what from their own families teaches them that? What do they put most of their focus on – weaknesses or strengths? Thus, to know if a treatment works, you have to look at the thoroughness of the studies supporting the therapy.
Family and couples therapy is in many ways much closer to “real world” therapy than treatment models used in individual therapy studies, which is sometimes called market relevance when you start talking to insurance companies about the effectiveness of family therapy. Multicultural couples, substance abusing partners, and infidelity are more complicated than individual cases of depression. While an individual therapist may find it a positive sign that their depressed client has started playing intramural sports, a couples therapist will not much care about this if the partner is still in a controlling relationship, or with an emotionally self-destructing or insensitive partner.
A range of therapists with different backgrounds treat a range of couples with complex combinations of stressors and problems, under real world constraints of time (like only a few weeks of treatment, or couples treatment as an adjunct to another kind of treatment) and resources (like insurance or funds to cover therapy costs, or access to qualified mental health care). However, the more “real world” the treatment is, the more it differs from controlled studies that test therapy types. Thus, just because a study shows that a type of therapy is effective, it doesn’t mean it is effective for all kinds of people and when offered by all kinds of therapists in all kinds of settings. Thus, to know if a treatment works, you have to look at the complexity of the cases studied.
As indicated above, some studies show a significant difference between those who get therapy, and those do don’t. However, that’s not all there is to it. For example, consider the “corrective emotional experience” with the individual client and therapist. The goal of individual therapy is for the therapist to provide some emotional healing for the client. The goal of couples therapy is for the therapist to help the two partners provide emotional healing for each other. Thus, to know if a treatment works, you have to look at whether people are “healed” when they get that therapy, and whether these gains are kept.
So… Does Couples Therapy Work?
Pinsoff and Wynne (2000) report that family/couples therapy is better than individual therapy for treatment of:
- depression in women in distressed marriages
- marital distress
- adult substance abuse
- adolescent conduct disorders and substance abuse
- anorexia in young females
- childhood autism
- aggression and non-compliance in ADHD children
- and cardiovascular risk factors
When compared to no treatment at all, family/couples therapy is better for:
- child conduct disorder
- chronic illness in childhood
Gurman and colleagues (in Garfield and Bergin) would add “medical” disorders (like eating disorders, diabetes, and asthma), anxiety, and phobias to the list of problems that benefit more from family or couples therapy than individual therapy. Gurman and colleagues offer that, generally, about two thirds of clients in any kind of family therapy get better, which is fairly similar to the numbers gained in individual therapy intervention research. They would add more specifically that:
- better gains are found when both members of a couple work on marital problems
- better gains occur when the therapist is more active in the early phases of therapy
- basic mastery of the theory and techniques by the therapist seems enough to halt deterioration, but more skill by the therapist is required for positive growth in therapy
- therapy with two therapists is just as good as therapy with one therapist
- short term therapy (20 sessions and under) can produce positive results.