The Three Times I Won't Treat a Couple
I love working with couples. I reserve my best time slots for them. I prioritize couples when I can't squeeze anyone else in. As I write this, I am marketing my practice toward couples.
I also charge a lot to treat couples. It's hard work, highly specialized, and I believe I have a particular gift for it. I have seen couples make more progress with me in one or two sessions than they did in years of trying to talk things through at home. $200 is a bargain for the transformations I've seen after single sessions, and the unquantifiable improvement in quality of life when one is finally talking freely, laughing, and having sex with their spouse again.
So for many reasons, couples are my most prized customers.
And yet, I won't treat every couple.
I want to see rapid progress for my couples. I want them to be done with me in a few months! After all, who needs a couples therapist when you've got a loving partner and a happy home life? It's immensely gratifying for me, and although I need my couples to be patient in order for our work to transpire effectively, I do want them to get what they are paying for, fast.
I won't see that progress if a relationship is too far gone, headed downhill, or toxic. At some point, I have an obligation to tell a couple if I don't believe I can help them, or if I don't believe the relationship should be saved. Of course, if they would like to use my help to separate or peacefully negotiate parenting issues, I am happy to help with that, on certain terms.
Beyond that, there are certain conditions I refuse to work with in a couple. Here are my three screening criteria, and the reasons for each.
1. Intimate partner violence
Physical violence; verbal threats of physical violence; posturing so as to suggest danger of violence; throwing or breaking objects; punching walls; reckless driving; cornering, trapping, barring one's exit, or hiding objects one needs in order to leave; stealing; inflicting harm upon or threatening to harm oneself, a child, animal, relative, friend, or any other life form - these are all unacceptable and dangerous domestic violence behaviors for which there is no excuse. (No, your own trauma history is not an excuse.) Abundant evidence suggests that when violence in any of these forms is present, it is likely to get worse.
It would be a dangerous slippery slope to behave in such a way as to imply that one person's abuse problem is a relational problem. Abusers often say that the person they abused "made" them do it, or indicate they would stop abusing if only the other person would stop or start (fill in the blank). This, of course, can be used to control victims. It can also tempt inexperienced therapists, or other people trying to help for that matter, into trying to help both people change their behaviors that "trigger" one another: "She nagged him, so he threw a glass against the wall? Oh, well then we better help her learn to stop nagging." No! To treat an abusive relationship this way is to indulge the abuser's skewed viewpoint and validate the false and dangerous premise that there is ever an excuse for violence. The violence needs to stop 100%, no matter what. As a therapist, I refuse to perpetuate the idea that there is anything a victim should be working on doing differently in this situation except getting out of there! An abuser's choice to express their feelings in inappropriate ways is 100% not the victim's fault.
Once someone has learned to fear that their partner might resort to violence and control, they are no longer in the relationship freely, a necessary component of participation in couples counseling: both partners have to want to be there, and have genuine motives for our work together. But the victim is now in the relationship through coercion and intimidation. They are no longer free to speak their mind without fear of negative repercussions. Their motives and chosen actions may be driven by the need to placate their partner and thus prevent further violence.
If a couple came to me in this situation, I would aim to refer the abuser to treatment for perpetrators of domestic violence, and to safety plan with the victim. Depending on the victim's situation, it may indeed be appropriate to help her - at least temporarily - to indeed placate her partner. For as long as she needs to stay in a given situation, it may be the best course of action to behave in such a way as to minimize the likelihood that her abuser will act out. However, minimizing conflict in this way is a very different matter from the aims of conflict reduction in couples therapy.
Abusers isolate their victims, hide what's going on and often attempt to charm their network into seeing them benevolently. Couples counselors pose a threat to abusers, that the victim will be seen and supported, that the abuse will be called out and the abuser confronted. So any abuser somehow brought to couples counseling will be desperate to prevent this from happening, and may all the more daftly manipulate the therapist into joining in a way that reinforces the abuse patterns. They may use therapy to reinforce their power and control, and back up their hurtful words against their victim.
If an abuser is unsuccessful in charming the therapist and suspects that he has been found out, he will become power-hungry and enraged, and more likely to take out his narcissistic injury on his victim. He may also twist around and weaponize the therapist's or his partner's words from the therapy session. Thus, what happens after a therapy session may be worse than what happened before.
For all these reasons, I make every attempt to avoid finding myself in a situation where I am working with a couple and discover that abuse has occurred.
2. Substance abuse
The line that distinguishes substance use from abuse is fine and can vary from person to person. That being said, when it is clear that a person's relationship with alcohol, cannabis, or any other substance has reached a level that interferes in their day-to-day life, health, or primary relationship, that needs to be examined. For the purposes of this article, I will call that addiction.
My issue with treating a couple where one partner has an untreated addiction is similar to one of my issues about working with DV cases: I do not wish to contribute to the sense that there is any excuse for the behavior. A person with an addiction who repeatedly says they are "trying" to change will always have some kind of reason that they haven't quit yet, or have relapsed. "I'm trying to stop drinking, but I had a really hard day at work." "I'm trying to stop drinking, but that guy on the highway was being such an asshole." "I'm trying to stop drinking, but Jim invited me over for a beer, and I haven't seen him in a while." This can go on for years until the person with the problem decides to cultivate an internal locus of control. My question is this: if a hard day at work, mean guy on the freeway, or friend, are all reasons to drink despite an intention not to, how the heck are you supposed to handle the exponentially greater stress of a fight with your partner? I am not saying there is never a place in life for a drink or two, or for that matter, an edible (we do live in Oregon, after all). But for people who have consistently demonstrated a pattern of being unable to use in moderation without causing harm to their lives, health, and relationships, the self-delusion needs to stop before the healing can start. A person with an addiction needs to be willing to take full responsibility for their addiction, seek appropriate support, make a commitment to stop, and hopefully regain the trust of their loved ones over time through demonstrating consistently trustworthy behavior. Only when they are able to make a commitment to not drink, regardless of what stressors life throws at them, can they participate meaningfully in a relationship without on some level blaming their partner for their own behavior.
We need to be able to show up soberly to our difficult moments with our partners. We need to be able to regulate our nervous systems, both alone and together. Addictions interfere with that. Addiction is strongly correlated with self-medicating childhood trauma and insecure attachment. To be healthy in relationships, we need to work with our partner and other supports to resolve how trauma is impacting us. We need to learn to create a more secure attachment with our partner, and to turn toward our partner to soothe us in times of distress. We simply cannot do that if a substance is taking their place.
For these reasons, I attempt to screen for addiction prior to agreeing to working with a couple. Should I find myself working with a couple and observe that an addiction is prevalent, I would refer the addicted partner(s) for addiction treatment, and possibly the other for codependency treatment.
3. Suicidal ideation
In other articles this is described as "severe mental illness," but I think that phrase and the reasoning behind it can be confusing, so I am using a clear symptom description in my own attempt to approach the issue. It is not appropriate to do couples counseling when one partner has current suicidal ideation.
As we have already discussed, we don't want to feed into the idea that there's ever a time for abuse, and we don't want to feed into the idea that there's ever a time for addiction; similarly, we don't want to feed into the belief that there's ever a time for suicide. If the idea behind couples therapy is that addressing the problems in the relationship will help one person stop feeling suicidal, that's risky: what happens if couples therapy doesn't work out? We want to help the suicidal person get enough support and recover their mental health enough that they are protected from the risk of suicide even if things don't go as they would hope in their primary relationship. A person at risk of suicide needs individual therapy and comprehensive mental health care, which might also include group therapy, medication, intensive outpatient, or even inpatient, treatment, depending on severity. Of course, their loved ones can and often should be involved in their care, for support and education. However, there is a difference between family therapy in which I might bring in family members to help the wellbeing of the "identified patient," or IP, and true couples counseling, in which I treat the couple as a unit, and not necessarily the particular mental health of one individual. In family therapy focused on treating one member with a severe mental illness, I may need to be sensitive to the limits of the IP in terms of their ability to tolerate distress; we don't want to make things worse. In couples therapy, on the other hand, both partners need to have enough of a degree of emotional stability to be able to take some emotional risks together and tolerate discomfort without a threat being posed to anyone's safety.
I hope that this article has been helpful for you. If you and your loved one need help and no one in the relationship is at risk of violence, suicide, or addiction, you can view my rates for couples therapy, read about why I don't bill insurance for couples, or contact me for a free consultation. (Oregon residents only.)
