Within the couple psychotherapy literature there is very little written about how the illness of one or both partners emerges and is treated in the consulting room. This paper redresses this situation by drawing on clinical experience and research findings to develop a conceptual framework to identify how illness is experienced by those with serious illnesses and to locate these findings within a psycho‐dynamic couple context. Narrative research has explored how individuals talk about illness and Frank's (2009; The Wounded Storyteller: Body, Illness and Ethics) restitution narrative, chaos narrative and quest narrative are described and illustrated. In addition, the phenomenological research of Toombs (1987; Journal of Medicine and Philosophy 12: 219–40) identifies five major existential challenges that seriously ill people have to manage – the loss of wholeness, the loss of certainty, the loss of control, the loss of freedom to act and the loss of the familiar world. The work of Frank and Toombs focuses on the experience of individuals and does not account for a couple dimension. This paper cites research and clinical examples of couple functioning to show that these illness‐related experiences are often part of a shared couple interaction and elements in a couple's mutual defence and projective system.