7 Benefits of Concurrent Couples Therapy

Revisiting an Underappreciated Approach

7 Benefits of Concurrent Couples Therapy

Q: I was trained to meet with partners together at the start of couples therapy to avoid potential issues (like holding secrets). Is it ever okay to meet with partners separately at the start of treatment?

A: I’ve worked as a psychologist treating individuals, groups, and couples for 40 years in hospital, partial hospital, college counseling, and private office settings. In recent years, I’ve worked almost exclusively as a couples therapist and noticed that roughly half the couples I see went to other couples therapists and dropped out, often after just two or three sessions. This led me to consider how early treatment failure in couples therapy might be addressed with a different approach.

My solution has been to meet with the parties individually—a strategy psychologist James Framo described in the 1970’s as “concurrent” couples therapy. Today, there’s a strong expectation among therapists and prospective clients that couples therapy follow the more traditional “conjoint” model, meaning that therapy takes place with three people in the room. In my experience, there are advantages to starting treatment differently.

When someone calls me for couples work, I simply say I’d like to start out with some individual meetings. Not only do I receive a ready acceptance of this plan, but I also sometimes hear a sense of relief. Starting couples therapy can be intimidating. A common concern is that something unexpected will happen, that one’s partner will blindside them with complaints and criticism that they have been holding back, and indeed, sometimes this is the case. Arranging for individual sessions alleviates this concern.

I want to be able to share with the partner/spouse information and impressions I learn in the individual sessions, and I always ask permission to do so. Generally, such permission is readily granted. Sharing too many details about what I learn in an individual session may interfere with the establishment of a trusting boundary, so I am careful about this.

I am willing to keep my client’s confidences unless there is information so egregious that the other party would feel betrayed by my keeping it secret.  For example, when I hear “my spouse has poor hygiene and this is an obstacle to our physical intimacy,” I will look for a way for this to be addressed, but not necessarily immediately. On the other hand, the issue of learning about an extramarital affair in a traditionally defined marriage is a much more complicated situation.  If I learn of an ongoing affair, I will likely tell the offending party they will need to disclose this to their partner.  I may allow one or two additional individual meetings before insisting that this occur but would fear that waiting too long would destroy trust with the betrayed party.  What if the person refuses to come clean?  I would consider ending the treatment, saying that progress under such circumstances would be impossible.  Similarly with ongoing sex addiction, I typically would insist this be disclosed and addiction treatment become an ongoing part of the treatment plan.

I may share other kinds of information I have learned if I believe it will help the relationship. I can be strategic about this but never dishonest when I say, “I know things between you and your wife are tense right now, but she’s told me in our meetings that she’s never stopped loving you.” In the concurrent model, the therapist has the opportunity to manage the flow of information.  In contrast, the therapist using conjoint sessions finds more of a challenge to curtail words that are blurted out with no purpose other than to wound.

Allow me to suggest some other advantages of the concurrent model:

Meeting a therapist one-one-one for the initial session is less threatening than meeting a therapist for the first time with your partner present. In such a structure, the chance of being blindsided or shamed by one’s partner is essentially eliminated. This threat may be more acutely felt with a quieter or more introverted person who fears their partner will race ahead with a therapist and paint them in a negative light.

Concurrent sessions minimize what I call the “transparency problem”.  Some clients experience censorship in conjoint sessions, for example, when told directly or indirectly told by their partner on their way to the appointment, “be careful what you say about me or there will be a price to pay when we get home.” I am surprised so little attention is given to this phenomenon in the literature. It goes without saying that with the privacy of concurrent meetings, at least some of this threat is minimized.

The less psychologically savvy partner may benefit from concurrent sessions. In a society that reinforces gender stereotypes, women sometimes present with a level of emotionally literacy that can intimidate men (or less emotionally literate same-sex partners) in a conjoint session. Furthermore, the therapist may unconsciously find themselves preferentially engaging the more psychologically minded party, which is never helpful when trying to establish an even-handed rapport with a couple. This problem can be mitigated when therapists see clients separately. When it’s time for the less psychologically savvy partner’s session, they’re guaranteed to have the therapist’s undivided attention.

Individual sessions make it easier to conduct a diagnostic interview that can shed a light on couples’ problems. Because many diagnoses (like ADHD, substance abuse disorder, mood disorders, and autism spectrum disorders) can have a major influence on the course of couples therapy, those who practice couples therapy of any orientation need to think about diagnosis early on. The concurrent format lessens the shame of being asked personal questions about one’s psychological functioning and allows a candid discussion about a partner’s symptoms and behaviors, which can give the therapist additional information about diagnosis. It’s also important to identify personality disorders like narcissistic personality disorder and borderline personality disorder (BPD) early on, as this increases the potential for successful conjoint treatment. Depending on the condition’s severity, BPD can present management issues so significant that enlisting a co-therapist—perhaps one trained in DBT—may be necessary.

The therapist can compassionately reference character issues, limitations, or skill deficits. When a therapist can sensitively reference such issues about the partner who isn’t in the room, it can be validating to the partner in a concurrent session who lives with the emotional fallout. For example, I know Jeremy’s ADHD leads him to procrastinate. That must be hard on you. Can you tell me more what it’s like? It can also start an in-depth conversation about how to manage these flaws. This kind of potentially wounding work is more challenging in the context of a conjoint session. The language of such a discussion must never be disparaging of the partner who isn’t in the room and needs to be informed by the therapist’s compassionate understanding of the issues referenced.

The perception of favoritism is lessened. In every conjoint couples session, the therapist risks being seen as indulging in favoritism—siding with one of the parties such that their feelings or perceptions are granted more validity. This is a significant and ongoing management issue inherent in conjoint therapy. However subtle this phenomenon may be on the surface, the fantasies it produces weaken the therapeutic alliance with the partner who feels discounted. Although every couples therapist aspires to be fair-minded, complicated unconscious forces make this hard to achieve. Concurrent therapy lessens this problem because the therapist forms an alliance with each partner separately. Also, favoritism—real or perceived—is less likely to be witnessed in the initial sessions.

It may be easier to regulate partners in the event of infidelity. It goes without saying that when discovered, an affair can throw any couple into immediate crisis. Not only is the future of the relationship at stake, but for fragile individuals, there’s a risk of self-harm.  Perhaps a conjoint session is best for managing this situation, as you can observe how heated the interaction becomes. On the other hand, this may not work out with all couples. As all clinicians know, when emotions run high in a session, it is more difficult to think.  For example, the therapist might fail to curtail a brutal verbal assault, acting on an unconscious wish for the betrayer to be punished “because he/she deserves it.” If threats and destructive interactions cannot be contained in a conjoint session, concurrent sessions might be beneficial. The latter can allow the therapist to siphon off some of the most extreme emotions. Creating a sympathetic and supportive environment for the betrayed party is often helpful.

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Our professional training, traditions, and histories tend to lock us into habitual ways of practicing—some of which are so deeply ingrained we rarely stop to question them. However, we can be respectful of our training and treatment orientations and still consider new—and perhaps less habitual—ways of working, such as incorporating a concurrent couples format into our couples practice. Although couples may not expect concurrent sessions when they reach out for an initial appointment, they rarely object to giving it a try. Once rapport is established with each partner, the therapy can transition to conjoint sessions.

Joseph Delvey

Joseph Delvey, Jr., PhD, ABPP, is a board-certified clinical psychologist in private practice in Bucks County, Pennsylvania and a former faculty member of Temple University Health Sciences Center. His private practice is currently dedicated to couples work.