Couples Therapy and Family Therapy: How They Work

Couples therapy and family therapy are forms of psychotherapy that treat the relationship itself as the client, rather than one person in isolation. Sessions usually bring partners or family members together in the same room (or on the same video call) to talk about patterns of interaction, communication, conflict and change. A licensed clinician leads the conversation, helps each person be heard, and works with the group on goals they agree to. The approach is used for many reasons: a rough patch, a major transition, parenting disagreements, a health problem, grief, or a wish to understand each other better. It is not only for relationships in crisis, and no one has to be “bad enough” to start.

What couples therapy and family therapy actually are

Couples therapy, often called couples counseling or marriage counseling, is therapy with two people in a romantic relationship. Family therapy involves several members of a family, which may include parents and children, adult siblings, or extended family. Some are short-term and focused, others last longer; the length depends on the goals.

Therapy can be individual, couple, family or group, for children and adults, according to the American Psychiatric Association. The format is a choice about who attends, not a different kind of medicine. The clinician’s approach may draw on cognitive behavioral therapy, psychodynamic therapy, interpersonal therapy or other models. A page on the main types of therapy explains those approaches in more detail.

Who offers couples and family therapy

Marriage and family therapists (LMFTs) are licensed clinicians who train specifically in relationships and family systems. They typically hold a master’s degree, complete a state-set number of supervised hours after the degree, and pass a licensing exam. Nearly all states use the AMFTRB national exam; California gives its own exam. Requirements vary by state.

Other licensed professionals also provide couples and family therapy, including clinical social workers, professional counselors, psychologists and psychiatrists. What matters is that the person holds a current license that covers the state where the clients are located during sessions (including by video) and has experience with the kind of relationship work involved. A page on therapist credentials explains what the letters after a clinician’s name mean.

Coaching is not a licensed mental health profession. A person can ask any provider which state license they hold.

What a session looks like

A first session usually covers why the couple or family is coming, what each person hopes will change, and how the clinician works. The clinician may ask about history, daily routines, arguments, health, work and support. Goals, and how long and how often to meet, are discussed by the patient and therapist together. Sessions are typically held once every 1-2 weeks for about 30 to 50 minutes, according to psychiatry.org.

In later sessions, the clinician may:

• Ask each person to describe a recent disagreement from their own point of view.
• Point out patterns that repeat, such as one person pursuing while the other withdraws.
• Teach communication or problem-solving skills and have the couple practice them in the room.
• Give a homework exercise to try between sessions.
• Meet with one member alone for part of a session, with everyone’s agreement.

Family sessions may include a parent and a teenager, siblings, or several generations. With children, the clinician often balances the child’s needs with the parents’ role and may meet with parents separately at times.

When one person comes alone

Sometimes one partner or one family member attends alone, at least for a while. This can happen when the other person is unwilling to come, when schedules do not match, or when the clinician wants to understand one person’s perspective. A clinician should explain at the start how information shared in an individual meeting will be handled, and whether it will be brought back to the joint sessions. That arrangement is worth agreeing on in writing or at least out loud before individual meetings begin.

Confidentiality with more than one client in the room

Confidentiality works differently when a couple or family is the client. Many clinicians do not keep secrets between the people in therapy in the same way an individual therapist can, because the others are also clients; policies differ, so ask how this clinician handles it. Psychologists must discuss confidentiality at the outset, according to the APA Ethics Code, and must inform clients early about the nature and expected course of therapy, fees, involvement of third parties and the limits of confidentiality.

Confidentiality has limits. A psychologist may disclose without consent only where the law requires it or permits it for a valid purpose, such as protecting the client or others from harm. Social workers may disclose to prevent serious, foreseeable and imminent harm, and then only the minimum necessary. Mental health professionals are mandated reporters of child abuse and neglect in many states; rules vary by state. A clinician should explain these limits in plain words at the start, and each person should feel free to ask questions about them.

Safety first: abuse and danger

Couples therapy is not a safe setting for ongoing abuse. If one person is being hurt, threatened, controlled or frightened by another, safety comes first. A clinician should not push a couple to talk through violence as if it were a communication problem, and joint sessions can sometimes increase danger. In the US, anyone can call or text 988 (the 988 Suicide & Crisis Lifeline) for support, and call 911 in an emergency. A person who is not safe can also ask a clinician about local domestic violence services, or contact a hotline for guidance before deciding whether joint sessions make sense.

Insurance and couples or family therapy

Whether a health plan covers couples or family therapy depends on the plan and on how the sessions are billed. Some plans cover the sessions only when they are tied to a diagnosis, such as a mental health condition in one family member, and may not cover relationship-focused work on its own. The person to ask is the plan, not the therapist’s office alone. A clinician can explain how the sessions will be coded, and the plan can say what it covers. Medicaid benefits vary by state, and Marketplace plans cover mental health and substance use disorder services as essential health benefits, but the details of couples and family coverage still depend on the plan.

How couples and family therapy differ from group therapy

Group therapy usually brings together people who are not related, led by a clinician, and the group process itself is part of the work. Couples and family therapy brings together people who already have a relationship outside the room. A page on group therapy and support groups explains the difference between therapy groups and peer support.

What to ask a couples or family therapist

The questions worth asking are similar to those for individual therapy, with a few additions. The National Institute of Mental Health suggests asking about credentials, experience and specialty, the approach and its rationale, the goals of therapy, whether a time frame is recommended, how progress will be assessed, fees and insurance, and confidentiality and its limits. For couples or family work, also ask:

• How the clinician handles individual meetings within the therapy.
• What happens if one person wants to stop attending.
• Whether the clinician has experience with the specific issue, such as parenting, grief, illness or a major transition.
• How the clinician responds if safety concerns come up.

Rapport and trust are essential. A person should feel comfortable with the therapist. If therapy has gone on for what feels like a reasonable time without improvement, talk to the therapist; it may make sense to explore other professionals or approaches.

What goes wrong

A few common problems are worth knowing before starting.

• Waiting for a crisis. Couples and families often seek help only after a serious rupture. Earlier help is also an option, and no one has to be in crisis to start.
• Expecting the clinician to take sides. A couples or family clinician works with the relationship, not as a judge. A clinician who seems to side with one person is worth questioning.
• Keeping secrets. Individual secrets inside couples therapy can undermine the work. The clinician should explain the policy at the start, and the couple should agree to it.
• Using joint sessions when abuse is present. If there is violence, threats or fear, safety comes first, and joint sessions may not be appropriate.
• Assuming insurance will cover it. Plans may cover couples or family therapy only when it is tied to a diagnosis. Check with the plan before assuming.
• Stopping too soon or too late. If the goals are not being met, raise it with the clinician rather than quietly dropping out.

A note on crisis support

In the US, the 988 Suicide & Crisis Lifeline can be reached by calling or texting 988, or by chat. It is available 24/7, every day of the year, and conversations are free and confidential. It is for anyone who is struggling, including people worried about someone else. In a life-threatening situation, call 911 or go to the nearest emergency room.