Couples Therapy SOAP Note Example

In couples therapy, the note records the accounts of two people who often see the same thing differently. That is why every statement needs to be attributed to the person who makes it, and the assessment needs to describe the interaction without adopting either partner's perspective.

The example below is fictional and educational. It is not an assessment of the relationship or a risk assessment, and it does not replace professional judgement or applicable documentation requirements.

Fictional couples therapy SOAP note example

Context: Seventh joint session, systemic approach. Presenting concern: frequent arguments and growing distance since the birth of their second child. The note uses the fictional initials M. and J.

Subjective: M. reports that arguments have fallen from almost daily to two this week, both about sharing tasks in the evening. She says she feels “alone with everything” when J. stays on his phone. J. explains that he withdraws when the conversation becomes heated because “anything I say will make it worse”. Both say that on Sunday they went for a walk without the children and describe it as the best moment of the week.

Objective: They arrive together and sit at opposite ends of the sofa. When discussing how tasks are shared, M. raises her voice and J. replies in monosyllables and looks at the floor; the sequence repeats twice. When asked to describe what has just happened, both identify the pattern. J. manages to say that he feels criticised without withdrawing from the conversation.

Assessment: The demand-withdraw cycle described in the formulation persists: the more M. presses, the more J. withdraws, and the more J. withdraws, the more M. presses. Both are beginning to observe the cycle from the outside, which creates room to change it. The strain of raising two young children intensifies the pattern. Sunday's walk shows the couple's resources for connecting when demands ease.

Plan: Use the agreed signal to take a break of at least twenty minutes when they notice the cycle starting, then return to the conversation. Agree between them a concrete division of evening tasks. Keep one weekly moment without the children. At the next session, review how the break worked.

Why it is written this way

Every statement in the subjective section is attributed to the person who said it. In couples therapy, an unattributed sentence can be read as a fact or as only one partner's version.

The assessment describes a circular pattern and does not single out one person as responsible. Phrases such as “J. is not involved” or “M. is demanding” adopt one partner's view and do not help intervention.

What is observed is mainly the interaction in session. In this format, it is the most valuable information, because it shows the cycle as it happens and not only each person's account.

The initials are fictional. In your own records, decide according to your context and obligations how to identify each partner and how to organise documentation when two people take part, taking into account each person's access to the information.

The same session as a progress note

Seventh joint session. Arguments reduced to two this week, focused on evening tasks. In session the demand (M.) and withdraw (J.) cycle appears twice, and both identify it when asked. J. expresses feeling criticised without withdrawing. Walk without the children rated by both as positive. A break signal, a concrete division of evening tasks and a weekly moment without the children are agreed.

Questions to use during review

• Is each account attributed to the person who gave it?
• Does the assessment describe the interaction without taking sides?
• Are the couple's resources recorded as well as the difficulties?
• If there are signs of violence, control or fear in the relationship, does the note record how these were explored, including separately, and what was decided?
• Is it clear how information shared in individual sessions is handled?

See the SOAP notes guide and the guide to mental health progress notes. You can also see note examples with children and with adolescents, where several people are also involved.

Clara prepares an editable draft from the session and separates each participant's contributions. The clinician reviews attribution and assessment before adding it to the record. See AI clinical notes with Clara.