Clinical Care Guideline: Couples Therapy

The term “partner(s)” is used throughout this article. Relationships come in all shapes and sizes, and the term partner here is used to reflect any number of romantic partners.

Relationship distress is a prevalent concern affecting millions of couples worldwide. Research indicates that 40-50% of first marriages end in divorce, with many more couples experiencing significant periods of relationship turmoil. Couples therapy has emerged as an evidence-based therapeutic modality that can reduce relationship distress, improve communication, enhance relationship quality, and support symptom reduction in partners with mental health conditions. 

This care guideline provides a concise overview of evidence-based best practices for effective couples therapy with adults, drawing on established therapeutic approaches and clinical research.

Assessment Considerations for Couples Therapy

When evaluating couples in therapy, consider the following key areas:

Relationship Commitment and Motivation

• Are both partners* committed to working on the relationship?
• What are each partner's goals and expectations for therapy?
• Is there mutual willingness to engage in the therapeutic process?

Safety Assessment

• Is there any history of intimate partner violence (IPV)?
• Does either partner feel unsafe in the relationship?
• Are there any current threats or concerns about physical, emotional, or psychological safety?

Substance Use

• Is there active substance abuse by either partner?
• How does substance use impact the relationship dynamics?
• Is treatment for substance abuse needed before couples work can begin?

Mental Health Considerations

• Are there individual mental health or safety concerns that need to be addressed (e.g., suicidality, self-harm, psychosis)?
• How do individual symptoms impact the relationship (communication, conflict, intimacy, parenting)?
• Would concurrent individual therapy, medication management, or higher level of care be beneficial or necessary?

Cultural Consideration

• How do each partner's cultural background and identities (e.g., race, ethnicity, immigration experience, sexual orientation, gender identity) shape their views of relationships and help-seeking?
• What gender role expectations does each partner hold, and how do these expectations influence division of labor, decision-making, and conflict?
• How do communication styles (direct vs. indirect, emotional expressiveness, conflict avoidance) reflect cultural or family-of-origin norms?
• What is the level of family or community involvement in the relationship (e.g., extended family expectations, financial ties, multigenerational households), and how does this affect boundaries and conflict?
• What religious or spiritual beliefs about marriage, commitment, separation, or divorce influence how partners view problems and potential solutions?
• How do the partners' attitudes toward seeking help (e.g., stigma, privacy concerns, mistrust of healthcare systems) affect engagement in therapy?
• Are there any language, accessibility, or technology barriers (for telehealth) that may impact participation, understanding, or alliance?

Contraindications for Couples Therapy.

Based on clinical research couples therapy may not be appropriate if:

• Active intimate partner violence is present
• Active substance abuse is occurring
• One partner has made the decision to end the relationship
• There are significant safety concerns
• Severe mental health symptoms require stabilization first
• Ongoing infidelity and unwillingness to stop

Safety Considerations:

For BOTH the primary and secondary client, documentation must be clear, specific, and thorough whenever there are concerns related to safety. 

Notes should include:

• Signs of aggression or escalating conflict and pattern & frequency of these behaviors
  • Verbal aggression (e.g., yelling, threats, insults)
  • Physical aggression (e.g., pushing, grabbing, throwing objects)
• Current, historic, or ongoing domestic violence / intimate partner violence (IPV) 
• Any disclosures of:
  • Physical violence, sexual coercion or assault, emotional, psychological, or financial abuse, coercive control, or stalking
  • Whether weapons are present or have been used or threatened
• Risk assessment: 
  • Risk to self (suicidal ideation, plans, intent, history of attempts)
  • Risk to others (homicidal ideation, threats, violent behavior)
  • Risk of continued or escalating IPV
• Safety planning if risk is present
  • Discussion of options and resources (e.g., crisis lines, shelters, legal resources, safety strategies)
  • Specific steps the client agrees to take if risk escalates
  • Any referrals provided and whether client accepted/declined
  • Any coordination with other providers, if appropriate and permitted
• Document in a blank note the secondary clients name, emergency contact, phone number, and address for emergency situations.

Documentation Considerations

When working with couples, remember that one person must be identified as the "primary patient" for insurance and documentation purposes:

• Diagnosis should be based solely on the primary client’s individual symptoms, functioning, and clinical presentation.
• Treatment goals should clearly describe how couples therapy will help reduce the primary client’s symptoms and improve functioning, with relationship changes framed as mechanisms that support the primary client’s mental health and treatment outcomes.
• Use the following table to determine the appropriate billing code:

*90846: In order to use this code, the "present at session" field in your progress note must not include the client, and the "service provided" field must be set to "family/couples therapy without the primary client present". 
*90847: To be utilized during couples sessions. 
^90837/90834: Can be utilized if doing individual sessions with identified client, not to be billed when both members of the couple are in session.

Rula-Specific Best Practices/Recommendations

Couples Therapy:
Agreement & Informed Consent

• Should be completed during the first session and clearly documented in the chart.
• Use this agreement to outline expectations, roles, confidentiality limits, and how information will be managed when a non-identified partner participates in treatment.
• It is also recommended that the identified client complete a Release of Information, but this is not required. 

Secondary Partner Intake Demographic Form

• Name, Address, Phone Number, Mental Health + Health History, Emergency Contact (Not Primary Client) should all be documented and uploaded into the patient chart for safety and contact purposes. 

Evidence-Based Approaches to Couples Therapy

Research demonstrates several effective approaches to couples therapy:

Emotionally Focused Therapy (EFT)

• Focuses on attachment bonds and emotional connection
• Helps partners identify and express underlying emotions
• Addresses negative interaction cycles

Cognitive Behavioral Couples Therapy (CBCT)

• Targets thought patterns and behavioral exchanges
• Includes communication skills training
• Addresses cognitive distortions about the relationship

Gottman Method Couples Therapy

• Based on extensive research on relationship predictors
• Focuses on building friendship, managing conflict, and creating shared meaning
• Emphasizes the "Sound Relationship House" model

Integrative Behavioral Couples Therapy (IBCT)

• Combines change-focused and acceptance-based interventions
• Helps couples understand and accept differences
• Promotes emotional intimacy through acceptance

Screening and Assessment Tools

Dyadic Adjustment Scale (DAS): A widely used measure of relationship satisfaction and adjustment that can help establish baseline functioning and track progress.

Relationship Assessment Questionnaire: Can help identify specific areas of concern and strength in the relationship.

When to Refer or Discontinue Couples Therapy

Consider referral for:

• Individual therapy when personal issues significantly impact the relationship
• Psychiatric Evaluation for medication management
• Specialized treatment for trauma, addiction, or other specific concerns
• Lack of Progress: Despite consistent effort over a reasonable period (e.g., several months or 8-12 sessions), the couple remains stuck, repeats the same arguments, or the therapeutic process feels stagnant.

Consider discontinuation when:

•  Abuse and safety concerns: Active physical or sexual abuse is a contraindication for couples therapy. 
• One partner decides to end the relationship
• Lack of engagement (i.e. consistently misses sessions or no longer committed to the process) from one or both partners
• Individual issues require primary attention
• Therapy is causing harm: if sessions consistently leave the couple feeling hopeless, angrier, or more disconnected, the current therapeutic approach may be counterproductive.

References: 

Lebow J., & Snyder, D. K. (2022). Couple therapy in the 2020s: Current status and emerging developments. Family Process, 00, 1–27. 10.1111/famp.12824

Updated May 13, 2026 18:55