When prior couples therapy failed, and I am the next therapist, it is a different situation than when someone comes to me for individual therapy after prior individual therapy failed. While many therapists helping individuals have a specific therapeutic orientation (e.g., CBT or psychodynamic), there are few couples therapists who work exclusively in one model. While I am familiar with the Gottman Method, Emotionally Focused Couples Therapy (EFCT), the Developmental Model of the Couples Institute, Family Systems Therapy, and Imago Therapy, it is rare for me to know which of those therapeutic methods the prior therapist used. Most often, the therapist wasn’t using one model, but a personalized integration of several. That is normal because couples therapy is more complex and dynamic than individual therapy and most therapists find that one treatment method won’t fit every couple or even every presenting situation with the same couple. For that reason, I utilize 3 techniques when prior couples therapy failed to make therapy with me more effective: information gathering about the past treatment, discernment about motivation to change, and treatment planning.

Information Gathering: Why Couples Therapy Failed

When I am gathering information about why prior couples therapy failed, I start by asking the couple a series of questions that might look like this:

• General questions either member of the couple may answer:
  • When was previous couples therapy?
  • How long was the treatment?
  • How regularly did you attend treatment?
• Questions I want both members of the couple to answer:
  • What did the therapist do that helped? What did the therapist do that you didn’t like?
  • What did you learn, if anything, about your role in the problems in the relationship?
  • If any technique or habit did help to improve your relationship during prior treatment are you still doing that?
  • Why did the treatment end?
  • What are you hoping will be different in treatment with me? OR What do you think would make this episode of treatment more effective for you?

These questions are designed to draw out important information including the role of treatment participation, motivation, client willingness to change, treatment method(s) used, and effectiveness of past treatment. The questions are also designed to discern what my challenges might be in helping the couple and whether those are the same or different from the challenges the prior therapist faced in helping them. It wouldn’t be uncommon for circumstances to have changed enough that the prior barriers to effective treatment are now gone or for new ones to be present.

The most common reason clients say prior couples therapy failed is that the therapist “just listened”. The couples that I see often complain that the prior therapist didn’t offer suggestions, didn’t help them regulate the emotional expression in the room, and/or didn’t give the couple tools to help them make changes outside of sessions. When I hear this complaint, I try to reassure couples that, very simply, that isn’t my style. I take an engaged and active approach by identifying the goals, stopping unproductive conversations in session, and by building tools and strategies to help the couple bridge the communication divide. If we can stop negative patterns in session, the couple can learn to stop them outside of session.

The final thing that I do to gather information is to request to speak with the prior therapist. This allows me to double-check my emerging clinical impressions with a colleague, corroborate the couple’s description of the course of therapy, and learn more clinical details about the interventions that have been tried and how effective they were. For example, does the therapist agree that prior couples therapy failed? Maybe the couple understimates the changes they made in treatment because there’s so much farther to go.

Discernment About Motivation to Change

From the questions listed above, the picture sometimes emerges that it isn’t the therapy that needs to change, but the client’s willingness to utilize it and make changes. Examples include hearing that, in prior therapy, clients received exercises and homework but didn’t try them between sessions, or hearing that changes could occur during the therapy hour but that nothing changed at home. For this reason, a part of my consent form indicates that for therapy to work, the client must be willing to do something different. When meeting with couples for the first time, I specifically review this clause to share with them that if they want something to change in the relationship, they need to identify what they are each willing to do differently.

When I share this part of my consent form with new clients, most nod and say that this sounds just fine, but on a fairly regular basis, once the therapy begins, we have to review it again. We can imagine a fairly simple illustrative situation where Stefan wants Janine to stop staying at work so late because it means they have dinner late. When Stefan brings this up with Janine in session, I will ask him what changes he is willing to make to help him meet his needs. He might then say he can’t change it on his own and that she has to change. I will gently point out to Stefan that he might need to have dinner earlier and alone if he wants it earlier, or be willing to have a good argument about it if Janine continues to not come home at the designated dinner time, maybe he could go to her office to bring dinner to her and eat it there together, or maybe he could decide that this isn’t that important of an issue after all (this list comes from applying my Five Relationship Choices while you can get by signing up for my newsletter here). Stefan’s response might be that he doesn’t want to eat early and alone, doesn’t want to argue, and would find it inconvenient or unpleasant to bring dinner to Janine and eat it with her at her work. In situations like this, I would find it very normal for Stefan to tell me why it would be more reasonable for Janine to change, or, more honestly, that he thinks she should. But if this is really important to him, Stefan only has control over himself. He may not want to change himself in order to get his need met, but it is the only change that he can choose.

Some couples would call this a communication problem between them. Yet, I would guess that Janine knows that Stefan wants her home on time because they have talked about it before. It just isn’t as important to her, and she behaves in a way that reveals that. So, I could teach Stefan to ask Janine using Nonviolent Communication (one of my common therapy interventions), but I am going to guess she already knows what he wants and how he feels. Therefore, I will guess that using a communication tool won’t solve the problem. So, the therapeutic conversation will return to the changes Stefan is willing to make.

Prior couples’ therapy often failed because the choice to change or not to was not clarified for the clients. The therapist will provide tools and methods for change but forgets to inquire deeply about the motivation for change. When I work with couples, when prior couples therapy failed, we often have a conversation about motivation to change early in the process.

Concrete Treatment Planning

Typically, in the fourth session of couples therapy, I will bring in a copy of a draft treatment plan. That treatment plan will include one or two goals that are both specific and generalizable. A sample goal would be: “The couple will reduce the frequency and intensity of arguments. Baseline: 1x/week, Intensity averages 7/10.” Then I identify what I’m going to do to help the couple achieve that goal, how we will know if the therapy is improving the situation, and how we will know that the goal is complete.

These goals often help maintain focus in therapy. From one week to the next, the presenting content might focus more on an in-law or a current financial issue, but the goals, because I write them in a generalized way, are usually still applicable. They help me hold the process-oriented thread of the conversation from one session to the next.

I regularly hear from couples that I am the only therapist they have worked with who reviewed the treatment plan with them and held the thread of the conversation from week to week. I really believe that a concrete treatment plan helps us stay clear about the work we are doing and gives me a little leverage. For example, if a client’s motivation to change wanes during treatment, I can review the treatment plan and ask what isn’t working. Is it that I’m not doing what they agreed for me to do in the therapy? Is it that the goal is no longer important? Is that the client doubts that this specific intervention will help? When I have a treatment plan agreement with the clients, it helps us hold each other accountable to beneficial change in the therapeutic work.

Conclusion: Just Because Prior Couples Therapy Failed, Doesn’t Mean It Will Again

I hope that this post makes it clear how I help couples when prior marriage therapy or couples counseling didn’t accomplish all the goals they hoped it would. I have enjoyed helping couples who have experienced a lack of progress in the past, and I have found the 3-step approach outlined above helps guide the therapy with me to a more effective conclusion than they may have experienced before. I can’t help every couple, but having an idea about how to approach challenging cases can really make a big difference.

Usually, when prior couples therapy failed, couples report that the first phone call already feels different. Give me a call, and find out for yourself.

Can Therapy Work If Prior Therapy Failed?

I recently enjoyed celebrating the successful completion of treatment with several clients for whom prior therapy failed. In this post, I describe what I do differently when a client comes to me after prior therapy failed. I divide this into two types of therapy a client might have experienced before: Cognitive Behavioral Therapy (CBT) and Psychodynamic Psychotherapy. I also discuss what I do when both CBT and Psychodynamic Therapy failed before.

What If Cognitive Behavioral Prior Therapy Failed?

Cognitive Behavioral Therapy (CBT) is the treatment of preference for many psychological disorders. The research evidence for CBT’s efficacy is very strong for many disorders, including depression. (Cuijpers et al., 2023). CBT involves gathering data on symptoms and triggers, making changes in thoughts and behaviors to reduce symptoms, and systematically overcoming those symptoms with an individually developed set of responses. Because CBT can be easily manualized for treating different disorders, it lends itself well to scientific study.

When prior therapy failed using CBT, I need to find out why. In my experience, there are three common reasons CBT treatment may have failed:

1. The client didn’t do the homework.
2. The prior therapist didn’t follow through on the homework.
3. There was a poor fit between CBT and the client’s needs.

Prior Therapy Failed Because the Client Didn’t Do the Homework

If prior therapy failed because the client didn’t do the homework, I need to find out why. Sometimes the client lacked confidence in the treatment’s effectiveness. In those cases, I help the client build confidence in CBT’s efficacy. I also identify specific fears about what it would mean if CBT didn’t work again.

For example, I reassure the client that while CBT is the preferred treatment for many disorders, other options exist if it fails. CBT is often my first choice because it is effective in a short period of time. But it is not the only path.

Sometimes the client was discouraged when the homework wasn’t 100% effective right away. Initial failures are a normal part of CBT treatment. When a tool fails, that information helps us understand which other tools may be more appropriate.

Sometimes, more personal reasons explain why the client didn’t do the homework. For example, a client might avoid eliminating anxiety if that anxiety has made them successful at work. In those cases, I determine how treatment can preserve what the client values about their symptoms while eliminating the unwanted aspects.

Prior Therapy Failed Because the Therapist Didn’t Follow Through

If prior therapy failed because the prior therapist didn’t follow through on the homework, I explain to the client that the problem isn’t CBT itself. CBT requires constant attention to data and homework. Without that follow-through, it is unlikely to be effective.

I help the client build confidence in my ability to follow that protocol. I also ensure the client understands my expectations about homework completion from the start. Not that they must do it, but that we will talk about it, even if they didn’t do it.

Prior Therapy Failed Because CBT Wasn’t the Right Treatment

If prior therapy failed due to a mismatch between CBT and the client, I figure out exactly what that mismatch is. The three most common mismatches I see are:

1. The client has a clinical inability to follow through on homework (e.g., a client with ADHD).
2. The presenting issue is not a problem but a developmental process (e.g., a midlife crisis).
3. The presenting issue is not a problem but a meaning-making challenge (e.g., grieving a death).

If a client has difficulty following through on homework, we address that challenge before trying CBT again. If the client is in a developmental process, a more psychodynamic approach may help them synthesize their history and develop their identity. If the client is in a meaning-making process, we explore past values and life meanings, identify how the current stressor challenges those meanings, and encourage the development of new ones.

What If Psychodynamic Prior Therapy Failed?

Psychodynamic Psychotherapy involves paying attention to the client’s present life, their relationship with the therapist, and their biographical history. The goal is to understand how the past shapes the present — and to use that understanding to create a new experience of self and life.

Research evidence for psychodynamic therapy’s efficacy is not as abundant as that for CBT, but meta-analytic reviews confirm its effectiveness including for depression (Driessen et al., 2015) young adults (Trotta et al., 2024). One reason it is studied less often is that it cannot be manualized as easily. There are too many variables to study it well as a treatment for a specific disorder. Yet psychodynamic psychotherapy is effective, and evidence suggests its results may be long-lasting.

When prior therapy failed using a psychodynamic approach, the most common reasons clients report are:

1. Poor fit with the therapist.
2. Too little attention to outcomes during treatment.
3. A poor fit between the presenting issue and a psychodynamic approach.

Prior Therapy Failed Because the Therapist Wasn’t a Good Fit

Psychodynamic therapy requires a strong bond between therapist and client. If prior therapy failed, I try to learn about the client’s relationship with their previous therapist. This helps me anticipate their needs and prepare for similar challenges in our work together.

Sometimes, psychodynamic therapy reaches a challenging moment for an intentional reason. For example, a therapist might invite the client to notice that, despite their fears, the therapist actually cares. This kind of moment can strain the therapy and cause the client to leave treatment prematurely.

When I suspect such a moment may have occurred in a prior episode of treatment, I talk with the client about how we would handle a similar moment between us. This preparation helps us navigate challenges that ended the prior treatment. When possible, I also try to speak with the previous therapist to gain additional context.

Prior Therapy Failed Because There Was Too Little Attention to Outcomes

Psychodynamic psychotherapy is a slow process. It can be challenging to track the broad arc of therapy and ensure the client is experiencing real change. For example, a client may come in with a relationship pattern rooted in childhood. Many sessions may focus on making conscious connections between past and present. If the therapist doesn’t attend to how the client applies those insights, the client may become frustrated by a lack of visible progress.

My collaborative treatment-planning process and regular check-ins about the client’s satisfaction help prevent this from happening again.

Prior Therapy Failed Because Psychodynamic Therapy Wasn’t the Right Treatment

When prior therapy failed due to a mismatch between the approach and the presenting need, the two most common examples I see are:

1. The client is experiencing an acute condition, like panic attacks or PTSD.
2. The client doesn’t need to understand why. They need to answer a yes-or-no question.

For acute conditions, CBT methods are more effective because they focus on building skills to reduce immediate suffering. After that suffering is relieved, insight-oriented work can be valuable.

If the client needs to answer a “whether” question — “Should I leave my spouse?” or “Should I change careers?” — these questions require attention to present values and meaning more than to past history. A psychodynamic perspective helps clients understand the origins of their behavior. But it doesn’t always focus clients on their capacity, regardless of history, to build the life they choose today.

Our individual agency to shape the future is not limitless. But it is an awesome power nonetheless. Forks in the road can paralyze us, we need a sense of clarity to cut through the enormity of the moment.

What If Both CBT and Psychodynamic Prior Therapy Failed?

When prior therapy failed using both CBT and psychodynamic approaches, I am most inclined to try an Existential-Humanistic approach. I have been alluding to this framework throughout this post without naming it.

Existential-Humanistic psychotherapy emphasizes humanistic responses to four existential truths:

• I will die.
• I am free to make my own choices — and that’s terrifying.
• I am alone. No one else is inside of me. The ongoing unfolding of my experience is unknowable to others.
• Life appears meaningless. The right answers to life’s toughest choices aren’t clear, and we’ll never know if we did it right or wrong.

In my clinical experience, when clients are grieving, existentially disoriented, or uncertain about their place in life, they often need to attend to these truths directly. Many people need to face the enormity of life and death, of suffering and evil — and only then do they find they can rest more peacefully in the present moment. Research supports the effectiveness of existential therapy for clients experiencing this kind of distress (Vos, 2023).

The picture above shows how humanism softens the hard edge of these existential truths and gives us agency to face a harsh world.

Conclusion

I don’t use Existential-Humanistic methods often because they aren’t usually the appropriate tool. However, I find the work very satisfying. My exposure to Existential-Humanistic methods has shaped how I practice CBT and psychodynamic psychotherapy.

In my experience, psychodynamic training can sometimes lead therapists to assume they know best. CBT can sometimes assume that the tools are sufficient — that if the client learns and applies the skills, they will improve. My Existential-Humanistic background brings a degree of humility to both approaches.

I may have ideas about the psychodynamic cause of a client’s relationship pattern. Whether that insight resonates with the client determines its value. I have tools to help clients overcome anxiety. It is the client’s decision whether to use them. This tends to make me less reactive when clients resist my efforts to help. In those moments of “resistance,” I pause and consider my own values and the meaning I am giving to the interaction — rather than blaming the client for what is happening.

If you liked this post, you may also be interested in When Prior Couples Therapy Failed.

If you are interested in working with a therapist who takes a different approach to help you achieve better results in your next treatment episode, please contact me.

References

Cuijpers, P., Miguel, C., Harrer, M., Plessen, C. Y., Ciharova, M., Ebert, D., & Karyotaki, E. (2023). Cognitive behavior therapy vs. control conditions, other psychotherapies, pharmacotherapies and combined treatment for depression: a comprehensive meta-analysis including 409 trials with 52,702 patients. World Psychiatry, 22(1), 105–115. https://doi.org/10.1002/wps.21069

Driessen, E., Hegelmaier, L. M., Abbass, A. A., Barber, J. P., Dekker, J. J., Van, H. L., Jansma, E. P., & Cuijpers, P. (2015). The efficacy of short-term psychodynamic psychotherapy for depression: A meta-analysis update. Clinical Psychology Review, 42, 1–15. https://doi.org/10.1016/j.cpr.2015.07.004

Trotta, A., Gerber, A. J., Rost, F., Robertson, S., Shmueli, A., & Perelberg, R. J. (2024). The efficacy of psychodynamic psychotherapy for young adults: a systematic review and meta-analysis. Frontiers in psychology, 15, 1366032. https://doi.org/10.3389/fpsyg.2024.1366032

Vos, J. (2023). Existential psychological therapies: An overview of empirical research. Pratiques Psychologiques, 29(4), 211-229. [Read an English summary]
https://doi.org/10.1016/j.prps.2023.06.001