Working with Couples Where One Partner Has A Severe Anxiety Disorder

When you apply the Developmental Model in your work with couples, sometimes you will encounter issues that add an extra layer of complexity. Examples of this include addiction or severe depression. An even more common example is when one partner struggles with a severe anxiety disorder.

This month let’s look at some ways to begin a session when you encounter a couple with a very anxious partner.

When one partner is extremely anxious, the process of defining what belongs to each partner can be frustrating and quite confusing. You will notice that if you are trying to encapsulate each person’s issues, the anxious partner will continue to circle back to anxious thoughts he or she has.

You may start to question what type of therapy makes sense. Are you able to do effective couples work? What is possible? How do you disrupt patterns that you know are keeping the relationship stuck?

First, assess whether the anxious partner has been properly diagnosed, and if the client is getting direct help with their patterns of managing anxiety.

If there is an individual therapist or a psychiatrist managing medication, can you collaborate with them? How do they view successful anxiety management for this client? Do they understand the work you will be doing with the couple and why? Will they support you when you ask your client to attend to issues that are part of healthy couples development?

If so, one of your first challenges will be explaining and keeping your couple focused on early differentiation work at a level they can tolerate. Even at this point in the pandemic, many couples are spending more time at home together and there are multiple opportunities to strengthen their differentiation. It requires skill and practice to learn how to do so without overwhelming the anxious partner.

You can start by providing solid education. An anxious partner often perceives all anxiety as bad anxiety. He or she may not be able to see the possibility that growth comes from anxiety and discomfort. This is a pathway you can illuminate for them.

Describe the Four Ways Anxiety Keeps Couples Stuck and Inhibits Growth

  1. One partner is anxious, and they respond to their anxiety by collapsing easily, giving themselves up and merging with the other person in order to mitigate some of their anxiety. This results in underlying tension, anger, and martyr behavior.
  2. One partner feels anxious about a particular wish or desire and does not feel entitled to their own wishes/desires. Instead they describe their anxiety as a joint problem. This makes it hard to know what part of the anxiety sits with the person who’s raising an issue versus what part if any might belong to the other partner. Any risk that would be required to pursue an individual desire is then stifled and growth stops.
  3. A partner who is anxious and uncomfortable dominates the relationship with their anxiety, getting the other partner to merge with them and give themselves up. The anxious partner may have dominated choices the couple has made for years. This results in secondary gain and the spouse tiptoeing around out of fear of increasing the anxiety even more. Over time, this results in the couple having fewer choices and a smaller life.
  4. The anxious partner becomes increasingly passive. They take little responsibility for managing their own anxious thoughts. Instead, while their passivity persists the other spouse will over-function. This may start as a loving gesture, but as it continues resentment builds. Both partners lose the ability to know when a legitimate threat exists and when anxiety can be endured, leading to growth for both partners.

How to Structure Sessions When Anxiety Is Present

When I’m working with a couple where I recognize these types of dynamics, and one partner  presents an issue, I often ask myself several questions to help me figure out how to structure that session:

  1. Is the issue that’s being presented a typical problem that a couple would have and that makes sense for them to be working on together? In our work, I want them to bring up some things that are normal, real, and would be part of any couple doing early differentiation work. So, do we have that kind of problem today in what is being tentatively raised? Some examples might be developing household routines, talking about money and budgets, managing time apart and time together.
  2. Or, alternatively, is the issue that’s being presented carrying an underlying message of unhelpful symbiosis? Is what’s being presented designed to get the other one to go along with something that will inhibit their growth?
  3. A third option exists. The couple is engaged in healthy dialogue about real and challenging decisions. Real growth is already occurring in what the couple is telling you. They just don’t recognize their own growth. Here, you will champion their growth. You will support the couple by describing that they’re doing something new and different – something that’s good, and healthy, something that will change their dynamics and contribute to their growth.

Differentiation is both an internal process and an interpersonal process. The interpersonal part is where it gets especially messy and challenging with anxious partners. For them, anxiety has always signaled a threat! They don’t have experience tolerating tension and creating the space to handle real issues and real challenges.

Beginning differentiation may mean you describe that they each want something different and nothing is wrong with having different desires. In fact recognizing differences is a first step in healthy couples development. Instead of avoiding these emotions and these differentiation moments, you will be helping them tolerate discomfort for long-term growth.

Because you’re working on disentangling a lot of ongoing enmeshment, it will take time for each partner to develop the emotional capacity to do this without you. It doesn’t come easily. It doesn’t come naturally. They may spiral into confusion or uncertainty. It will take an enormous amount of structure, lots of repetition, and lots of reinforcement to disrupt their symbiotic patterns.

But you remember, differentiation matters. Anxiety is not always a negative threat signal. It’s the territory where couples learn how to build a solid sense of self as well as long-term intimacy and connection, so their relationship flourish and grows.

Please comment below. Are you seeing anxious partners facing differentiation issues during quarantine and shelter in place? What issues are you seeing these partners tackle?

Have something to say?

Notify of

Inline Feedbacks
View all comments
Janet Dagenhart
Janet Dagenhart

Excellent reading. I lead a men’s addiction recovery group weekly and anxiety management as it relates to family structures and relapse is certainly a topic I address. These guys are in a four month in house recovery program. The last 21 years of my career was in hospice work. Every family had various levels of anxiety addressing dying.


Very helpful and interesting to see these specific ways that anxiety can interfere with differentiation! Thanks!

Marie O’Neill
Marie O’Neill

I am so looking forward to this. Especially challenging when the person with anxiety refuses to take meds or see another
clinician to work more extensively with the pre existing anxiety
before an affair that brought them in …. I’m looking forward to this session very much .

Elany Mueller
Elany Mueller

This is super helpful for me right now. I’m seeing a couple where she has Panic D/O and he is struggling with alcoholism. There was an awesome moment during an I-I when she was speaking about all of her anxieties and I simply directed her to talk about her feelings. In an instant she became calm and focused in a way I had not seen happen before. She was beginning to self-define, maybe for the first time in this marriage. Her husband was deeply affected by her vulnerability and probably tuned in to her in a way that he hasn’t been able to before. An awesome growth moment!


Yes, yes, yes. All of this is extremely helpful in picking apart the dynamics in the couple relationship AND remembering that the overlay of COVD19 anxiety, whether conscious or existential is SO important. I am seeing both individuals and couples in therapy who are underestimating the impact of the global impact and anxiety that dealing with COVID19 is having. It is not an excuse or singular explanation, however it absolutely has a major impact on pre-existing issues – quite a revelatory energy. Thank you!

Elaine Wells
Elaine Wells

The couple is my partner and me. I think we are handling pretty well our different perceptions of the COVID threat and how much caution we should take. We agree that COVID is deadly & on the rise, & that our ages (75 & 78) put us at higher risk. He feels anxious when he goes out, and is perfectly happy to sequester himself at his home. I am much more social, but have followed CDC guidelines, & gone along with his requests: that I not go into restaurants or homes, & not let friends or clients come into my home or office. Now his anxiety is 11/10 & he wishes that I would NOT go into any store. I find online shopping extremely frustrating, and going to the grocery store 1ce/week during “elder hour” is the highlight of my week (sad I know – but how can you “get a life” during COVID?). He is coming to see me every 3rd night (as usual) in spite of his anxiety. When he stayed away for 6 weeks in Spring, I had to do a lot of rational self talk to deal with my slightly insecure attachment (which was exacerbated when my husband of 23 years suddenly left me & later ended his life 12 years ago due to bipolar disorder). We really love each other & enjoy being together. So when he stays an extra night at his house, I sometimes decide to detach emotionally, which makes me feel more autonomous, but feels like to down side of being so close when he is with me. My question: how can I maintain a more consistent sense of attachment instead of riding this emotional roller coaster of intimacy and detachment?


Wow, this was clarifying and validating. I hadn’t thought of using anxiety as a signal for differential growth. I did however, learn to frame the anxious spouses influence in the marriage and the family system as a “powerful” force. Meanwhile, helping the spouse to see that when the power overwhelms her, it’s actually an invitation to notice the difference in her behavior and extreme mood changes in mood (to help identify distress). I now see that I need to create further clarity to help the client see when anxiety is functioning to help or to hurt and ways that they experience the cycle when it hurts. Thanks again!

Dilyara Fatkhullina
Dilyara Fatkhullina

Sometimes it seems like the right information comes at the right time, thank you Ellyn for the wonderful post, I’m just working with a person (male) who has a lot of anxiety and relationship problems. Every time I started a session, I had a thought: where to start to intervene: relationships vs anxiety. The couple is at the stage of symbiosis-differentiation, it is the husband who asked for a help. He seems to be passive, very anxious, feels guilty, and the wife often attacks, they live separately, because he works for a month away from home and then stays at home for a month. I seems clear that one problem stemmed from the other, and that without any substantial help to differentiate, it would be difficult to solve this difficult task.


Thank you! The three points you describe are already being helpful as I read them. I do get confused! There is no quarantine now, but post issues. Specially with couples with babies and young children.

Ann-Mari Farsund Lilleløkken
Ann-Mari Farsund Lilleløkken

Great read. Do you have any structured recommendations on how to deal with men who perceive themselves as dominant when it is part of their ego defence strategy for characteristic stereotype male behaviour that is situated in a specific culture and time (in terms of their age that is situated in expected norms for male behaviours in 60s/70s/80s or 90s upbringing)? Anxiety as provoked by a perceived identity threat in therapy sessions in response to self-perceived expected characteristic male stereotyped behaviour based on culture that is then projected in therapy session? Paternal caregiver projecting anxiety on to maternal caregiver as a personal strategy for managing perceived identity threats rather than tackling his own narcissism? How to manage senior male caregivers perceived identity threat as he’s coming to terms with his own anxiety and narcissism, and as he is developing his understanding that it is intrapersonal rather than continuing to project his issues on to the therapist or others in the therapy session? More specifically, would you guys as experts at the couples institute advise for these male caregivers to go to individual therapy as well as couples therapy? Many thanks, AM

Andre Lampa
Andre Lampa

Thanks Ellyn for this. I find anxiety, diagnosed or not, is a feature of so many cases.

Some attachment theorists seem to suggest that all anxiety is at root about attachment, and while I think that’s worth looking at, I don’t find that to always be the answer. The pandemic provides some good examples of issues that may or may not be relational to start with, but there are often plenty more to do with normal household functioning that on face might be inconsequential.

I try to find the outlines or boundaries at play, i.e. Who does the anxiety belong to? Who is trying to share it, and who is refusing to accept it as a burden? What is the desired outcome of sharing, behavioral change? or some more fundamental way of connecting? I.e., do they have a functional or relational view of the problem? This can lead nicely into the concepts of differentiation, but also attachment needs. Pete said recently that people want what they don’t need, and need what they don’t want, so I try to focus on where each partner may find their growth.

I gently try to find out whether the individual thinks of their anxiety as adaptive (protective, ego-syntonic, rewarding through secondary gains, etc.) or whether they are interested in overcoming it in at least some ways or instances. When it’s blended with mistrust from infidelity, or Covid-related precautions, this gets especially tricky. 

Ann-Mari and others, I’m NOT a representative of the Couples Institute, but I’ve completed Level 1. I’m setting up an online peer consultation group where we can talk about some couple cases in some depth. If you are a couples therapist already skilled in the Developmental Model and want to participate, google me and send me an email.

maureen hope
maureen hope

Dear Ellen, thank you for this timely piece of article. i do work with couples of differentiation and this information has given me the tool or solution to some of their questions hope

Dr. Ellyn Bader

Dr. Ellyn Bader is Co-Founder & Director of The Couples Institute and creator of The Developmental Model of Couples Therapy. Ellyn is widely recognized as an expert in couples therapy, and since 2006 she has led innovative online training programs for therapists. Professionals from around the world connect with her through internet, conference calls and blog discussions to study couples therapy. Ellyn’s first book, "In Quest of the Mythical Mate," won the Clark Vincent Award by the California Association of Marriage & Family Therapists for its outstanding contribution to the field of marital therapy and is now in its 18th printing. She has been featured on over 50 radio and television programs including "The Today Show" and "CBS Early Morning News," and she has been quoted in many publications including "The New York Times," "The Oprah Magazine" and "Cosmopolitan."

Read Other Popular Articles

Here are the Zoom Details to Join the Call Live:

One tap mobile :

US: +16465588656, 82302466709# or +16469313860, 82302466709#

Telephone (US):

+1 301 715 8592
+1 312 626 6799
+1 346 248 7799
+1 646 558 8656
+1 669 900 6833
+1 253 215 8782

Webinar ID: 82302466709

International numbers available

We will send out an email reminder on the day of the call.
There will be a replay available within 24 hours.

Learn from a pioneer and leader in couples therapy training as she shares exactly what to say in difficult therapy sessions.
We respect your privacy.
We won't sell or rent your infomation to 3rd party marketers.
Msg & data rates may apply for text messages.