Couples and family therapy consists of four stages.
Stage 1: Planning
Who to invite: Decision needs to be made regarding who to invite and involve in the therapy. Network analysis helps in deciding “the minimum sufficient network” required for the assessment. It may include the client, any person who is legally responsible for the client, primary support individuals, etc.
Planning an agenda: To decide what to ask to elicit the information required to understand the problem and its occurrence.
Stage 2: Assessment
Contract: Setting clear expectations from the process of assessment and a mutual agreement on the terms.
Managing engagement challenges: Refusal to participate in the assessment, non-attendance, and receiving inaccurate referral information are some of the challenges.
Completing the assessment and formulation: Once the contract is established, interviewing each individual and using questionnaires and rating scales wherever required to understand the presenting problem.
Alliance building: Building a working alliance is the priority and base for further interventions.
Formulation and feedback: Formulation of the presenting problem and the client’s agreement on the formulation is required to move to the treatment.
Stage 3: Treatment
Setting goals and contracting for treatment: Mutually setting clear, measurable, and realistic short-term and long-term goals to guide the flow of the therapy.
Participating in treatment: Beginning interventions to reduce problem behaviors, developing new belief systems, and working toward the goals decided.
Managing resistance: Non-compliant clients, transference, etc. may lead to resistance toward therapy. Understanding the resistance and managing it is a crucial step.
Stage 4: Disengagement
Fading out sessions: Once the change starts to reflect, increasing the gap between the sessions is recommended for the client to gain confidence in his/her ability to manage difficulties without professional help.
Discussing permanence and the change process: If improvement is visible, the client’s beliefs about the permanence of the change are established.
Relapse management: Discuss and foresee the types of situations in which relapse may occur and how to manage them.
Framing disengagement as an episode in a relationship: Not ending the relationship completely, the therapist may plan follow-up sessions, teletherapy sessions, or a couple of sessions on request.
Re-contracting: If the contract for one issue is ended, there may arise a need to immediately establish another contract for other issues faced in the family.
Ethical Issues
Defining the client: In individual therapy, the therapist is clear on who is the client and works for the best interest of the client. However, in couples and family therapy, what is in the best interest of one member may not support the welfare of the other. Zygmond and Boorehm (1989) suggested that to resolve this issue, “choosing interventions that benefit the family and, at the same time, minimize any harmful outcomes” is the best decision.
Informed consent: Given the dilemma of defining the client, another issue that comes up is informed consent. It becomes very difficult to gain informed consent from all the family members.
Competency to practice: The therapist must be competent enough to take up couples and family therapy. Constantly maintaining competence through education, training, supervised clinical experience, etc. is an obligation of the therapist.
Confidentiality: At times, family secrets pose a great confidentiality threat to the therapy. There may be individual secrets that are kept from the rest of the family, internal family secrets that are known to a few of the family members but withheld from the rest, and shared secrets that are known to the family but withheld from the outsiders (Karpel, 1980).
Ethical guidelines vs. family values: Working in a multicultural context, there may be clashes between whether to follow ethical guidelines that may not be culturally accepted by the client; in such cases, choose a more culturally appropriate action while violating their organizational values.
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