Couples therapy notes

Couples therapy notes are a necessity for many therapists but like relationships they’re not always easy. They take work. 

Here is what you need to know about creating couples therapy notes.

Couples therapy notes vs. individual (and group) therapy notes

Sometimes, couples have serious troubles that require professional assistance and couples therapy is an effective way to help solve many problems that partners encounter. 

But couples therapy is a much different experience for the therapist than individual therapy. You are getting two points of view instead of just one. And much of the time, those perspectives differ wildly. 

Similar to group therapy, the therapist is as interested in the interaction between the couple as they are in the content of what they are saying. Unlike group therapy, however, you are dealing with the couple as a unit rather than a bunch of individuals who don’t know each other outside of treatment. 

While it is very helpful for a therapist to get both sides of a story, it does present some complications in writing couples therapy notes. For instance, something seemingly as simple as naming the identified client can be a difficult undertaking. Let’s take a closer look at what needs to be included in a couples therapy note.

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What to include in a couples therapy note

Client and session information

This section sounds straightforward but can be tricky. Certain items, such as the date, time, and duration of the session are easily determined. The difficulty lies in choosing what client information to include.

The therapist has a few options when deciding who to name as the identified client. 

• The first option is to name one member of the couple as the client in your couples therapy note and refer to the other person without using identifying information. 

• The second option is to have both members of the couple as individual clients with two separate charts. 

• The third option is to lump them together as one unit, identifying both as a client but with one chart. 

The choice is partly the personal preference of the therapist but is also affected by whether the couple is using insurance and whether they are in a committed relationship. Insurance companies often don’t cover couples therapy as a treatment modality, so the therapist must identify one member of the couple as the client and call it family therapy. In those cases, you won’t want to explicitly name both members of the couple as clients in a therapy note. 

Further, if a couple isn’t in a committed relationship, or is struggling with staying together, they may not want both of their names and information in the same note due to confidentiality issues. The easiest situation for a therapist is if the couple is committed and isn’t using insurance. In those cases, the therapist can usually handle the client’s information as they prefer.

Themes

This section talks about what topics were discussed in the session and how they relate to progress on the couple’s objectives. It concentrates on content rather than process. This part of the note answers the question, “How is the couple doing towards meeting their treatment goals?”

Interventions

It is recommended that one part of the couples therapy note focuses on the therapist’s interventions in a particular session. This will highlight what techniques the therapist used and whether or not they appeared to be effective. If you are using a GIRP or BIRP note format, for instance, this is already built into the structure of the note.

Observations

This part of the couples therapy note includes the objective and subjective impressions of the couple’s interactions. This section of couples therapy notes is just as important as the content of what is being discussed. There may be nothing more valuable than seeing the couple’s dynamics play out right in front of you.

Observing the couple in action gives you a window into their everyday life.

Plan

The last part of a couples therapy note involves what is going to happen next. For example, when is the next session, and what is the plan for therapy going forward? Almost all types of couples therapists give homework as a way to promote progress and that is noted in this section as well.

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Therapist tips for writing couples therapy notes

Confidentiality

Earlier, we discussed the choices a therapist faces as to who will be the identified client in a couples therapy note. Whoever it is, the therapist must tell both members of the couple how they are handling their notes and get their consent. This will prevent any surprises later if there are insurance problems or if another professional wants to see the notes. The confidentiality of both members of the couple must be preserved, even if only one of them is the identified client.

Don’t take sides

When you are hearing two sides of a story, there is a natural inclination to lean toward one person or the other. The therapist must remain the voice of objectivity so they don’t alienate either member of the couple. This is also true in the notes, where the therapist must try to refrain from biased judgments.

Seeing one client

At times, a therapist might want to see one member of a couple without the other. This might be for assessment purposes or at the request of the client. The decision to meet with only one member of the couple is up to the therapist’s discretion. Some therapists refuse to do it because it threatens their objectivity and injects potential bias into the therapy. 

If the therapist does see only one client, they need to let the other member of the couple know that this is occurring and give them the same opportunity. The therapy note needs to make clear that only one person is being seen and it will be treated more like an individual progress note. 

If the person being seen is not the identified client, and the couple has been using insurance, the individual may have to pay out-of-pocket for that session or use their own insurance and open up a separate file.

Incorporate theory

Couples therapy is based upon particular theoretical orientations. The most popular theories are emotionally focused couples therapy and the Gottman method. Your notes should make clear what type of therapy you are practicing by referring to specific interventions or terminology associated with that theory. 

For example, your notes might mention “the four horsemen” when employing the Gottman method. Discussing theory lets you (and your client) know what you have attempted as an intervention and allows other professionals to see what has been done so they can treat your client accordingly.

• The Couples Psychotherapy Progress Notes Planner, 2nd Edition, is an excellent resource for everything you need to know about couples notes. It comes complete with numerous templates and examples to make writing couples’ progress notes a breeze.

Couples therapy is a supportive resource for managing the ups and downs of relationships. However, writing notes for couples counseling has some unique features that can make it a complicated task. 

By keeping in mind several suggestions, therapists can create effective couples therapy notes without spending too much valuable time.