Navigating the "identified patient" in couples therapy requires a clear clinical framework. Unlike individual therapy, the "client" is the relationship itself. This article outlines how to manage the complexities of documentation, billing, and the ethical "triangles" that can arise.
Note: Always consult your state licensing board and professional liability insurance for specific regulations regarding "Secrets Policies" and medical record releases in your area.
1. Balancing Individual Sessions within a Couple's Dynamic
While the couple is the focus, brief individual "breakout" sessions can sometimes be clinically useful to explore history or personal barriers.
- Goal Orientation: Best practice is for individual sessions to be utilized specifically to assist the couple in meeting their shared goals.
- Avoiding Dual Relationships: If individual sessions deviate into long-term personal work unrelated to the relationship, you risk creating a dual relationship that can compromise the couple's treatment.
2. Billing and Documenting Individual Time
How you bill depends on which member of the unit you are meeting with:
- Meeting with the Non-Identified Client (Partner): Utilize CPT code 90846 (Family/Couples psychotherapy without the patient present). This is used when the partner is present to discuss the relationship dynamic, but the "identified patient" is absent.
- Meeting with the Identified Client: Individual sessions held with the primary identified client can be billed using standard individual codes such as 90834 or 90837.
- Documentation: Always document how the individual session's content relates back to the couple's shared treatment plan. Also, be sure to clearly document who is present at the session.
3. Transitioning Between Individual and Couples Therapy
A common pitfall is "flipping" roles (e.g., seeing an individual client, then adding their partner later).
- The Risk: This often leads to the new partner feeling like an "outsider" or the therapist being biased by months of one-sided history.
- The Protocol: It is generally a best practice to refer out for couples therapy if you are already seeing one person individually. If you must transition, have a robust "informed consent" discussion about the shift in the therapeutic alliance.
4. Ending Couples Therapy: Sticking with One Individual
When a couple separates or ends therapy, they may ask if one of them can continue with you individually.
- Ethical Consideration: This can create a conflict of interest, particularly in legal proceedings or divorce cases.
- Recommendation: The most ethical path is to provide three referrals to both parties for individual work. If you choose to keep one person, the other partner should ideally provide written consent acknowledging they understand you are no longer their therapist.
5. Policies on Confidentiality (Secrets)
Practitioners must decide how to handle information shared in private that has not been shared with the partner.
- Clinical Judgment: As a private practice practitioner, you are able to determine your own best practice. You may choose to utilize a "No Secrets" policy or a "Limited Secrets" policy.
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Rula Policy: Rula does not currently have a blanket policy. However, we encourage providers to:
- Remain steadfast in their own chosen policies.
- Clearly communicate these policies to clients at the onset of treatment.
- Document that communication thoroughly in your clinical notes.
6. Managing Bias and Perceived Bias
In the "room of three," the therapist must remain a neutral facilitator.
- Bias: Actual favoritism toward one partner’s perspective.
- Perceived Bias: When a partner feels ganged up on, even if the therapist is being objective.
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Mitigation: * Track your "talk time" for each partner.
- Avoid using "I agree with..." language.
- Reflect back feelings to both sides: "I hear that you feel neglected, and I also hear that you feel overwhelmed by the pressure to perform."
7. Ethical Boundaries and Documentation
Your notes are legal documents that can be subpoenaed. Best practice is to write notes with the consideration that they may be read aloud in a court hearing. Please see our other documentation best practices help center article surrounding couples.
- Who Owns the Record?: In many jurisdictions, both partners must sign a release to share records.
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Documentation Concerns: Avoid taking sides in the text (e.g., "The husband's volume increased and he used a firm tone" vs. "The husband was aggressive").
- Clearly document any "secrets" disclosed and how they were handled according to your specific policy.
- Always note the presence (or absence) of both parties at every session.
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