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Chapter: Essentials of Psychiatry: Couples Therapy

Indications for Couples Therapy

The process of choosing a type of therapy is complex and re-search is just beginning to develop guidelines for such decisions.

Indications for Couples Therapy


The process of choosing a type of therapy is complex and re-search is just beginning to develop guidelines for such decisions. The therapist must most often base his or her judgment on clini-cal intuition, general clinical opinion, and the wishes and judg-ments of the people involved.



Marital Versus Individual Therapy


One of the most common questions for clinicians who are profi-cient in both therapies is regarding the decision about type and timing of therapy. The basic theoretical premise of couple/fam-ily therapy is that many problems are purely relational, that indi-vidual symptoms in one person can be viewed as interpersonal in terms of etiology or problem maintenance, and that they can be changed by altering the system. The basic principle of individual therapy is that problems or symptoms develop because of the biochemistry or dynamics of the individual, and that change oc-curs in the individual (either behaviorally or because of cognitive understanding of the problems) in the presence of an intense and exclusive relationship with the therapist. In truth, for many people, both forms of therapy may be useful or necessary. Self-knowledge does not always help the person understand the com-plex family system and how one’s behavior affects and is affected by family members. In addition, family therapy does not allow for intense exploration of psychodynamic issues. Individual ther-apy also does not allow the clinician to see how the problems of other family members may also be affecting the system.


Since people tend to pick partners at similar stages of differentiation, it is not unusual for people with psychological difficulties to have spouses with similar or complementary but equally severe problems. In addition to the need to evaluate the partner, it must be recognized that such couples create problems maintaining systems that need to be addressed directly. Children in such families often suffer either from genetically based similar illnesses (such as depression) or symptoms as a result of dealing with parental problems. These are often best treated with family therapy, but this does not rule out special time just for the child. For many people, both types of therapy are helpful, allowing for increased pleasure with the partner and also a context for per-sonal and private growth.


The choice of timing of therapy is always of interest. If the person is highly symptomatic and has a problem which is usu-ally amenable to medications, it is often helpful to begin medica-tion and family therapy first, in order to reduce the symptoms and educate the family, as well as to eliminate family sources of stress.


In general, one tries to deal with the most acute problems first. If it is possible in terms of timing and finances, it is easily possible to do individual and couples therapy at the same time. It is often recommended that the therapies be conducted by differ-ent therapists, however, in this strategy it is imperative that the therapists remain in contact to avoid splitting or conflicting treat-ment. Others, including therapists on occasion, have treated both the couple and one member of the couple individually, although this can present some additional challenges to the therapist to re-main neutral and unbiased. The therapist’s criteria depend more on the characteristics of the couple and how they function than on the particular diagnosis or problem area. The bias of the couple or individual must also be taken into account.


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