Indications and contraindications

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If there is a relationship problem identified by either the couple or their advisers, and the couple are willing to discuss and work on it, then in most cases they are suitable for behavioural-systems couple therapy. The breadth of the therapeutic approach, the fact that the behavioural techniques are of proven efficacy (see below), and the fact that the systemic interventions are suitable for those with more psychiatric symptoms or similar problem behaviours, all give the therapy a wide range of positive indications.

The nature of the problem

Clearly those with relationship problems such as arguments and tensions are highly suitable for couple therapy. Another related indication is those relationships in which one partner (who might be attending a counsellor or psychiatrist alone) spends much time complaining about the absent partner's behaviour. A third indication is where the health of one partner suffers following the other partner's individual therapy.

Many problems with sexual function would be suitable for couple therapy, including those couples where there is a disparity in sexual desire, or those where one partner has a specific phobia for sex. In some such cases there is also a need for individual therapy, especially where one partner is the survivor of earlier childhood sexual abuse.

Many people with depression or anxiety, especially those where there is also poor self-esteem, may be suitable for couple therapy. This depends on whether the patient, his or her partner or the therapist feels that there are aspects of the problem that are exacerbated by the relationship. Where jealousy is present the problem usually affects the non-jealous partner to a greater or lesser extent, and here it would almost always be useful to have at least a few conjoint sessions with the couple.

Some problems are perhaps less amenable to couple work, and among these are, for example, phobias which seem unconnected with home life in any way, and post-traumatic stress reactions where the event happened away from the partner. Some alcoholic and drug-addicted patients have so much of their existence involved with the addiction that they are not available emotionally to do couple work, and the work would at that stage be wasted on them. Similarly, those with an acute psychosis would, at the time they are acutely ill, be unavailable to this kind of therapy, and should not be offered it. However, in both cases, when the acute crisis is over and the addiction or psychosis is under control, it would be very appropriate to offer them some kind of couple therapy, even if this had limited aims and expectations.

Degree of connection with the relationship

Some problems in individuals have been in existence long before they entered the present relationship. If this is the case, the therapist should consider whether it is best to embark on couple therapy or whether individual therapy would be better. However, even when there seems no causal connection with the relationship, the effect on the partner of the problem may be such as to warrant at least one or two couple sessions.

Availability and willingness for joint therapy

If the partner of a patient is unavailable or unwilling to attend for therapy, it may be appropriate to let the situation be, and not offer treatment. In some immigrant couples, for example, there are cultural reasons given for a wife not attending therapy, and we usually have to respect these. However, in both situations it is sometimes right to put some pressure on the absent partner to attend, because the reasons for non-attendance may be relevant to the couple problems we are trying to treat.

Is the relationship continuing?

If the person who is asking for therapy is going through a divorce or equivalent breakup of a relationship, it may not be appropriate or possible to treat both partners. However, in some cases there is good work to be done in arranging a more satisfactory breakup, in terms of domicile and care of any children. This 'mediation' work is increasingly being done, and many of the processes are similar to those of couple therapy.

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