What are the recommendations for structuring therapy sessions with a couple experiencing relationship challenges and requiring joint and individual therapy?

Structuring Therapy Sessions for Couples with Relationship Challenges

Transition immediately to couples-only therapy by discontinuing all individual sessions and requiring both partners' presence at every scheduled appointment, as this structural clarity is essential for therapeutic integrity and optimal outcomes. 1

Establishing the New Treatment Framework

Clear Communication of the Transition

• Send a brief, direct message 4-5 days before the next scheduled session reminding both partners of the upcoming couples therapy appointment with specific date and time, clearly stating that both partners must attend. 1
• Frame this transition as a clinical recommendation, not a negotiation—present it as the only ethical path forward for their treatment. 1
• The optimal structure is for you to continue as the couples therapist while each partner works with their own individual therapist for personal issues. 1

Non-Negotiable Boundaries

• Both partners must be present at every scheduled session with no exceptions. 1
• Document the new treatment structure, agreed-upon boundaries, and cancellation policy clearly in the clinical record. 1
• Provide a written summary of the plan within 24 hours of establishing these boundaries. 1

Session Structure and Frequency

Recommended Meeting Schedule

• Provide sexual or relationship counseling through several meetings using a multidisciplinary team approach where possible, as this has been shown to be beneficial for couples experiencing relationship challenges. 2
• Continue weekly sessions initially, with the option to adjust to biweekly sessions if scheduling becomes difficult. 1
• For cognitive-behavioral conjoint therapy (CBCT), plan for 19-21 sessions as this structured approach has demonstrated efficacy in reducing relationship distress. 3

Evidence-Based Therapeutic Approaches

• Utilize cognitive-behavioral therapy and social support within a psychosocial framework, as this approach is useful for couples experiencing relationship challenges. 2
• Behavioral Couple Therapy, Cognitive Behavioral Couple Therapy, Emotionally Focused Therapy, and Integrative Behavioral Couple Therapy all meet criteria as "well-established" approaches for treating couple relationship distress. 4
• Couples-based interventions are at least as effective as individual therapy across various psychological disorders, and often more effective, especially when partners are substantially involved in treatment. 5

Therapeutic Communication Strategies

The BETTER Acronym for Session Structure

The American Heart Association and ESC Council recommend using the BETTER approach to structure discussions about sensitive topics: 2

• Bring up the topic directly
• Explain concerns about quality of life impacts
• Tell patients you can guide them to resources
• Timing—consider whether this is the right moment, but reassure that issues can be discussed in the future
• Educate about potential effects on their relationship
• Record or document the assessment and interventions provided

The PLISSIT Model for Addressing Concerns

Structure interventions using these progressive stages: 2

• Permission: Give both partners permission to bring up concerns ("After relationship challenges, couples may have concerns about intimacy. What concerns do you have?")
• Limited Information: Provide basic education about common relationship patterns
• Specific Suggestions: Offer concrete behavioral strategies
• Intensive Therapy: Refer to specialists for complex or longstanding problems 2

Assessment and Monitoring

Initial and Ongoing Assessment

• Use standardized assessment instruments at baseline to establish treatment targets and measure progress. 2
• Assess for comorbid conditions such as depression or anxiety in both partners, as these significantly impact relationship functioning. 6
• Monitor therapeutic alliance routinely, as this predicts treatment outcomes. 3

Key Areas to Assess

• The couple's negative interaction cycle, which causes pain and impedes their ability to address problems—this should be an early focus. 7
• Relationship satisfaction, attachment patterns, and communication styles. 2
• Individual mental health symptoms including depression (using PHQ-9), anxiety, and any suicidal ideation. 2, 8

Integration with Individual Treatment

Coordinated Care Approach

• Collaborate with each partner's individual therapist to ensure coordinated care while maintaining appropriate boundaries. 1
• When depression or anxiety coexist with relationship distress, use a stepped-care model that prioritizes treating the individual psychiatric condition first. 8
• For moderately severe to severe depression in either partner, initiate SSRI (escitalopram 10 mg or sertraline 50 mg daily) while continuing couples therapy. 8

Common Pitfalls to Avoid

• Do not continue individual sessions with one partner while conducting couples therapy—this creates dual relationships that compromise therapeutic integrity. 1
• Avoid pathologizing normal relationship stress responses that may be culturally appropriate. 6
• Do not assume treatment failure before 6-8 weeks at therapeutic dose if medication is prescribed adjunctively. 8
• Recognize that couples lacking motivation may struggle to follow through on referrals—assess compliance biweekly or monthly until symptoms remit. 2

Documentation and Safety

Essential Documentation

• Document the treatment structure, session attendance, progress toward goals, and any safety concerns at each session. 1
• Record assessments and interventions provided, particularly regarding sensitive topics. 2

Safety Monitoring

• Assess for suicidal ideation at initial assessment, during the first 1-2 months of treatment, and at each follow-up visit. 8
• Emergency referral is necessary for any patient at risk of harm to self or others. 8
• Monitor for transitory deteriorations in functioning, acting-out behaviors, or exacerbation of conflict—these may occur during treatment. 2

Treatment Duration and Follow-Up

Expected Timeline

• Brief therapy is appropriate when there is an agreed-upon focus and termination point, typically addressing acute relationship stressors. 2
• Long-term therapy is indicated when biological or social factors are chronic, psychological difficulties are complex, or entrenched conflicts are present. 2
• Plan for follow-up assessments at 3,6,12,18, and 24 months to monitor maintenance of gains. 3