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Chapter: Essentials of Psychiatry: Couples Therapy

Couples Therapy: Effectiveness and Efficacy, Dropouts, Ethical Issues, Boundaries

Effectiveness and Efficacy of Couples Therapy, The Conflicting Interests of Family Members,

Effectiveness and Efficacy of Couples Therapy


There are two major sources for reviews of efficacy of couples therapy. Shadish and coworkers (1995) summarized 163 rand-omized studies, 62 marital and 101 family therapy. Pinsof and Wynne (1995) in a commentary have summarized the data. These studies point to the following general conclusions:


·   Family treatment is more effective than no treatment. This conclusion is manifest in studies that contrast family and mar-ital treatment to no-treatment control groups. Roughly 67% of marital cases and 70% of family cases improve. The outcome may be slightly better if the identified patient is a child or an adolescent than if he or she is an adult. These findings were statistically significant. No one therapy method was demon-strated clearly to be better than another.


·    The deterioration rate (i.e., the percentage of patients who be-come worse or experience negative effects of therapy) is esti-mated at about 10% – lower than for individual therapy. Pinsof and Wynne (1995) believe the rate is lower than 5 to 10% and describe family therapy as not harmful.


·   In several areas evidence indicates that family treatment is the preferred intervention strategy. In other areas family therapy and individual therapy were tied – often in situations in which the identified patient had a significant Axis I problem (Shadish et al., 1995). These treatments of choice are of great impor-tance for practitioners and students.




The dropout rate in the early stage of couple or family therapy is relatively high. In one study, about 30% of all the families or couples referred for family treatment failed to appear for the first session (defected) and another 30% terminated in the first three sessions, leaving about 40% who continued (Shapiro and Budman, 1973). The main reason families gave for termina-tion was a lack of activity on the part of the therapist, whereas defectors in general had a “change of heart”, and denied that a problem existed. The issue usually is that no matter how bad a situation was, it was preferable to what might happen if a couple changed their behaviors. The motivation of the husband appeared to play a crucial role: the more motivated he was, the more likely the family was to continue treatment. The idea that a dropout is “denying a problem” may or may not be true. Be-cause the process of entering therapy is frightening for many people and because the therapist must meet the needs of sev-eral people, it is unsurprising that the process of engagement is rocky.


Ethical Issues in Couples Therapy


The fundamental ethical dilemmas inherent in psychotherapy: confidentiality, limits of control, duty to warn/reporting of abuse and therapist–patient boundaries become more complex when the treatment involves more than one person. The couple’s thera-pist has an ethical responsibility to everyone in the family. In some cases, individual needs and system needs may be in con-flict. For example, a husband may wish to conceal a brief episode of unprotected sex with another woman, while his wife is better protected, for health reasons as well as psychological reasons, if she knows about it. A wife’s wish to be divorced from a psychiat-rically ill and demanding husband may conflict with his need for her care. Such clinical situations provide a set of ethical dilem-mas for the therapist. The therapist must be clear that his/her job in most cases (such as impending divorce) is to help the partners sort out their values, obligations and options rather than making a decision for them. In some cases, however (such as the report-ing of child abuse), the ethical decision must be the therapist’s. And in some cases the therapist faces difficult gray areas which must be decided on a case-by-case basis. The therapist also has certain unalterable ethical obligations such as not engaging in “dual relationships” (see later) with patients or exploiting them for their own benefit.


While the operative concept is “first do no harm”, the is-sues of how one defines harm, and who will or will not be harmed by a certain action, are complex and difficult questions, espe-cially when treating a couple or family.


The Conflicting Interests of Family Members


It is not unusual for the interests of each member of the couple to conflict at some point. Boszormenyi-Nagy and Spark (1973) years ago emphasized the contractual obligations and account-ability between persons in the multigenerations of a family. Relational ethics are concerned with the balance of equitable fairness between people. To gauge the balance of fairness in the here-and-now, and across time and generations, each member must consider both his/her own interests and the interests of each of their partners. The basic issue is one of equitability, that is, everyone is entitled to have his or her welfare and interests con-sidered in a way that is fair to the related interests of other family members.


There may be times when it is difficult to decide whether a therapeutic action or suggestion may be helpful for one indi-vidual, but not helpful or even temporarily harmful to the other individual. In their concern for the healthy functioning of the sys-tem as a whole, therapists may inadvertently ignore what is best for one individual. An ethical issue is how the decision is made. Should it be the therapist’s concern alone or should it be shared with the couple? How much information should they be given on the pros and cons of modalities? The authors’ bias is to negotiate and give the couple all the relevant information so that they can make the most informed decision possible (for further discussion, see also Hare-Mustin et al., 1979; Hare-Mustin, 1980).





The issue of boundaries and dual relationships is a critical one in all forms of psychotherapy. Because couples therapy involves more than one patient in the consulting room, there is less like-lihood of inappropriate sexual contact between therapist and patient. However, there have been cases in which a therapist, working with a couple, began an affair with one of the spouses, either during couple’s therapy or after the couple separated. The American Association of Marital and Family Therapy (AAMFT) Code of Ethics (1998) has a very sensible code of ethics making clear the inappropriateness of this kind of behavior.


Other confusing issues may arise because the issues that couples face are the same as issues therapists face in their own lives, making it very likely that at some point countertransfer-ence issues may become ethical ones. For example, seeing a couple going through a separation at the same time one is going through the early stages of one’s own divorce is an extremely difficult thing to do, and the likelihood of remaining neutral to both parties is not great. While it is obviously impossible for a therapist to stop treating patients while going through a divorce, he or she could certainly choose not to accept a new patient whose situation is very similar to their own or who reminds them of their departing spouse. Issues of “confidentiality” and “boundaries” are issues mentioned in the AAMFT Code of Ethics (1998). Three of these have special relevance to couples therapists:


·   Marriage and family therapists are aware of their influential position with respect to clients, and they avoid exploiting the trust and dependency of such persons. Therapists, therefore, make every effort to avoid dual relationships with clients that could impair professional judgment or increase the risk of exploitation. When a dual relationship cannot be avoided, therapists take appropriate professional precautions to ensure judgment is not impaired and no exploitation occurs. Exam-ples of such dual relationships include, but are not limited to business or close personal relationships with clients. Sexual intimacy with clients is prohibited. Sexual intimacy with former clients for 2 years following the termination of therapy is prohibited.


·   Marriage and family therapists respect the right of clients to make decisions and help them understand the consequences of these decisions. Therapists clearly advise a client that a deci-sion on marital status is the responsibility of the client.


·   Marriage and family therapists have unique confidentiality concerns because the client in a therapeutic relationship may be more than one person. Therapists respect and guard confi-dences of each individual client.


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