Couples Therapy vs. Individual Therapy
Richard Niolon, Ph.D. 03/05

There are a number of differences between couples therapy and individual therapy, and a number of issues to consider when evaluating couples therapy research. Several are discussed briefly below:

• Who is the client?
  Is it one of the spouses? Are both spouses treated as separate clients? Or is it the relationship?
  
  
• What's the problem? (And is that really the problem?)
  He wants to stay in a dead relationship. She wants to abandon it without trying to work on it in therapy. So what is the problem, or issue on which treatment should focus? Who is responsible for the problem (or are they always both responsible)?
  
  
• What's a treatment success?
  Suppose they divorce? Is that a treatment failure? Is staying together always a success? Does it matter whether failure and success are judged from the couple's view versus the children's view? Who is responsible for the success or the failure? Can you do divorce therapy to help people part amicably? Copied from the web.
  
  
• What model do you use for treatment?
  A "couples" based model, or an "individual" based model that was based on individuals and scaled upward to account for two people? Further, how active are you? Can you empathize with one individual? Can you cut off people if their statements are hurtful to the other partner? Can you tell them not to talk about something? Is two parents working on their problem with their child "couples therapy" or family therapy? Copied from the web.
  
  
• Retention and relapse are more of an issue
  Family and couples therapy is often much more flexible. Some therapists stick with the one-hour-once-a-week model, but others, Gottman for example, does not, and will initially see couples for more than an hour, and by the end of therapy will space sessions out to perhaps one a month as a way to reduce relapse. This means that variables as simple as "number of sessions" or "average weekly minutes of therapeutic contact" are no longer simple variables a research study can track and control - they vary over the course of therapy. Copied from the web.
  
  
• True improvement vs. halted decline
  Liddle et al. (2002) report that the transition from generally distressed to generally non-distressed after treatment occurs for 35% (Jacobson et al., 1984) to 41% (Shaddish et al., 1993) of couples. Johnson & Greenberg (1994) found that 70% of couples fall in the non-distressed range after treatment, but they asked about distress regarding a specific problem as opposed to general relationship distress.
  
  The issue 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. Thus, the treatment really has only to halt the decline in order to yield significant results. Thus, a statistically significant result may not mean much (see Gollan and Jacobson's chapter in Liddle et al. 2002).
  
  
• Assessment Methods
  Methods in couple therapy are varied, and range from self-report questionnaires, observational techniques, and physiological readings, to therapist rating scales. Some don't use them, but modern therapists do. Gottman can get 90% accuracy in predicting who will be divorced in five years based on structured interviews and some questionnaires
  

• 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 and what if one says, "It's not my problem..."
• 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.
• 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. Including physiological responses often requires an additional kind of expertise that most psychologists do not have.
• 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? This asks whether 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... How do we know what works for one works for another? Copied from the web.

• Proving it Works
  Part of "proving" therapy works is by predicting something and seeing if it comes true. Non-linear events do not lend themselves to linear statistics very well. Thus, using events at Time A to prevent 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 arguing "obviously 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 engage in open conflict, while Couple #2 (based on their positive experience) allows it. So, what does open conflict help us predict about eventual problem resolution?
  
  
• Purpose of 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. Copied from the web.
  
  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.
  
  
• "Real World" Treatment
  Family therapy is in many ways much closer to "real world" therapy than treatment models used in individual therapy studies, although some question this. This is sometimes called market relevance when you start talking to insurance companies about the success of family therapy in real world settings. Multicultural couples, substance abusing partners, and infidelity are more complicated than "individual depression", and what couples therapist cares if the depression spouse has started playing intramural sports if they are still with a controlling, self-destructing, or insensitive partner?
  
  A range of therapists with different background treat a range of couples with complex combinations of stressors and problems, under real world constraints of time and resources. However, the more "real world" the treatment study is, the more removed from controlled laboratory conditions the study is likely to be as well. This makes strong and clear conclusions about the results difficult to obtain and interpret.
  
  
• Complexity
  You could go further and talk about couple therapy as a more complex therapy than individual therapy. It's one thing to sit in a quiet therapy room with an individual client who talks about the unreasonable and unkind expectations their spouse holds. It's quite another thing to sit in couple therapy and do this, and have the unreasonable and unkind spouse tell you both you are full of it.
  
  It's one thing to study "corrective emotional experiences" with the individual client and therapist, but in couple therapy, the therapist is more of a transitional object. The corrective emotional experience must come from the partner, and you need to step out of it. The client might try to pull you in with, "You are so (insert insult)! Why can you be more like Doctor Niolon?"
  
  
• Does it Work?
  Pinsoff and Wynne (2000) answer that family and/or couples therapy:

• is better than individual therapy for
• schizophrenia,
• 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,
• dementia,
• and cardiovascular risk factors
• is better than no treatment for all of the above in addition to
• obesity,
• hypertension,
• child conduct disorder,
• and 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. However, be wary of non-experts butting into this with paradoxical interventions.

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,
• and short term therapy (20 sessions and under) can produce positive results.