424 FAMILY THERAPY PRACTICE WITH ADULT-FOCUSED PROBLEMS also opening up the possibility of an alternative systemic framing of their diffi culties. For example: I was struck by the way each of you have distinctive styles for managing situations and have discussed this with two colleagues since we last met, to obtain their expert opinions on how best to proceed. One of my colleagues was taken by ABC’s style. ABC, you have shown that your own personal style is to talk straight and say what is on your mind, so if you want DEF to know you think a job needs to be done in the house, you tell him straight and don’t beat around the bush. If he doesn’t take notice, you tell him again. That is ‘the straight talking approach’. My other colleague was impressed by your, style, DEF. You take a ‘thoughtful approach’. You think things over a great deal before saying anything. This is personal style and one that refl ects your careful approach to this relationship. I suppose the question that is raised for me is, how can the best of both styles be brought to bear on the diffi culties and distress you are both experiencing? Perhaps you have views on this you would like to air today? Externalising Problems and Building on Exceptions During the assessment stage couples are invited to construct a formula- tion of those exceptional circumstances in which an episode of confl ict or distress was expected to occur but did not. Within this formulation, a be- haviour pattern, underlying beliefs and historical or cultural factors that underpinned these are described. In treatment, couples may be invited in therapy to explore ways to recreate such exceptions and then to attempt to put this plan into action as a homework assignment. To help couples jointly work to create positive exceptions, it is useful to externalise the force that underpins the confl ict by, for example, referring to it as bad relationship habits or faulty relationship maps (White, 1995). Thus, the therapist may ask: How have you both arranged from time to time to prevent these bad relationship habits/ faulty relationship maps from infecting your relationship? If I was watching a video of these exceptional episodes, what details would I see that were different from those episodes where bad relationship habits infect your relationship? How could you use this information to arrange another situation where your relationship is uninfected by these bad habits? They may also be invited to link together all of the non-distressing non- confl ictual exceptional episodes in their relationship and construct a new narrative that frames their relationship as essentially positive with some episodes of confl ict, rather than a relationship that is basically negative with some brief positive episodes: It seems that all of these events are connected and refl ect the degree to which you really care about each other. How do you imagine this central part of your relationship will fi nd expression in the future? What will it look like? DISTRESSED COUPLES 425 Interventions that Focus on Historical and Wider Contextual Issues In couples work where responses to interventions focusing on beliefs and behaviour are ineffective, it is usually valuable to address family-of-origin issues in the way outlined in Chapter 9. In addition, two interventions that focus on historical and wider contextual issues and which are unique to couples therapy may be considered. These are: • facilitating emotive expression of attachment needs • exploring secrets. Facilitating Emotive Expression of Attachment Needs In couples where one partner’s family-of-origin experiences included in- secure attachment, this may have a negative impact on the quality of their relationship. Usually this involves one partner responding to the other in terms of the relationship map they learned from their experience of insecure attachment in childhood. That is, they respond in a hostile and angry way because they expect that their partner will not meet their at- tachment needs for safety and security. This often elicits such behaviour from their partner, and so becomes a self-fulfi lling prophecy. In such circumstances, an intervention central to emotionally-focused couples therapy is appropriate (Johnson & Denton, 2002). Couples are helped to distinguish between secondary and primary emotional responses that arise when attachment needs for safety, security and satisfaction are not met in predictable ways. Anger and resentment are secondary emotional responses. Primary emotional responses include fear, sadness, disap- pointment, emotional hurt and vulnerability. The couple’s problem may be reframed as one involving the miscommunication of primary attach- ment needs and related disappointments. Members of the couple may be invited to express their attachment needs and related primary emotional responses in full and forceful ways, but not to give vent to their second- ary emotional responses through blaming or guilt induction. When this happens, the partner listening to the emotional expression of attachment needs commonly experiences empathy and is moved to go some way to- wards meeting the other’s attachment needs. This transaction may come to replace that in which secondary emotional responses such as anger and resentment are responded to with rejection, if the therapist can facilitate its repetition in a number of sessions. Exploring Secrets In some instances, little therapeutic progress is made and the reasons for this remains obscure. When this is the case, it is worth considering that one or other member of the couple is having a secret affair. In these in- stances it is useful to ask the couple to consider the possible implications 426 FAMILY THERAPY PRACTICE WITH ADULT-FOCUSED PROBLEMS of such a hypothetical secret. Here are some useful questions to ask in such instances: It seems to me that there may be some unknown factor contributing to your distress, otherwise you would be making more progress than has occurred. I don’t know what this unknown factor is. My guess is that if one of you know what it is you think that it would be least hurtful if you kept it a secret. So please, hold on to your secret if you have one. For now, let us assume that one of you is having an affair with another person; or you’re possibly having problems with your job, or maybe with some pastime. If that were the case how would each of you handle it. Is this something you are prepared to discuss? How would you react if you found out your partner was having a relationship? If I was watching a video of the showdown when you found out about it what would I see? What would it mean for your relationship if your partner were having an affair? If you found out your partner were having an affair and you decided to end this relationship how would that pan out? What would each of you do? How would you forgive your partner? How would you expect your partner to make up for cheating (or atone for his/her infi delity)? Special Problems in Couples Therapy Three issues commonly encountered in couples therapy deserve special mention: conducting therapy with one partner in a couple; the manage- ment of domestic violence; and recovery from an episode of infi delity. One-person Marital Therapy Bennun (1997) has shown, through controlled empirical research, that unilateral marital therapy is as effective as conjoint marital therapy. He argues that, in the past, individually-based interventions for marital problems have yielded negative results because of their almost exclusive focus on individual issues and their lack of attention at a systemic level to relationship issues. One-person or unilateral marital therapy based on a systemic model of relationship diffi culties may be appropriate in cases where only one partner is available to attend treatment; where there are dependence–independence issues in the relationship; where there are problems in sustaining intimate relationships; in cases of domestic violence; where there is a major disparity between partners’ levels of self-esteem; and where one partner’s unresolved family-of-origin issues contribute signifi cantly to the couple’s problems. In Bennun’s (1997) ap- proach, therapy begins with a conjoint session. During assessment, the negative impact of partners’ diffi culties in meeting each other’s needs DISTRESSED COUPLES 427 on each partner at an intrapsychic level and on the relationship at a sys- temic level is explored. In formulating the way presenting problems have emerged and are maintained, a balance is drawn between a focus on in- dividual factors and a focus on relationship factors. Treatment targets and possible diffi culties, such as resistance and relapse, are discussed with both partners at the end of the assessment session. Following as- sessment, in unilateral marital therapy, treatment is directed at both promoting systemic change within the relationship and the psychologi- cal development of both partners as individuals, through working with one partner only. To do this the therapist invites the attending partner (usually a female) to recount the content of each session to her partner; to engage in homework assignments with her partner; and to give the therapist feedback about the impact of these events on the relationship and psychological well-being of each partner. A good argument may be made for including self-regulatory interventions described earlier in the chapter in unilateral marital therapy. Marital Violence Marital violence is associated with a wide range of variables, described in Chapter 1, but particularly with skills defi cits in anger control, com- munication and problem-solving skills and alcohol and drug abuse (Holtzworth-Munroe, Meehan, Rehman & Marshall, 2002). Only a limited number of well-controlled studies have been conducted on the effective- ness of interventions with violent marital partners and these show that court-mandated skills-training programmes are probably effective for a proportion of violent men (Davis & Taylor, 1999). Key elements of success- ful programmes include taking responsibility for the violence; challenging beliefs and cognitive distortions that justify violence; anger management training; communication and problem-solving skills training; and relapse prevention. In couples treatment, anger-management training focuses on teaching couples to: recognise anger cues; take time out when such cues are recognised; use relaxation and self-instructional methods to reduce anger-related arousal; resume interactions in a non-violent way; and use communication and problem-solving skills more effectively for confl ict resolution (Holtzworth-Munroe et al., 2002). Stith, Rosen, McCollum and Thomsen (2004) found that a multi-couple treatment programme was more effective than a single couple programme in reducing domestic violence. Male violence recidivism rates were 25% for the multi-couple group, and 43% for the individual couple group. Conjoint marital therapy is only appropriate is cases where the aggressive male commits to a no- violence contract in which he agrees to no violence while in therapy and take steps to reduce danger, such as removing weapons from the house; and/or agrees to a temporary separation; and/or engages in treatment for comorbid alcohol and drug problems. It is essential that the female partner 428 FAMILY THERAPY PRACTICE WITH ADULT-FOCUSED PROBLEMS agree a safety plan specifying what exactly she will do and where she will go if further threats of violence occur. Where a no-violence contract and a safety plan cannot be established, it is more appropriate to treat husbands in group therapy for wife batterers, which addresses the same issues as those mentioned for conjoint therapy and for the female partner to join a support group for battered wives and receive individual treatment for post-violence trauma based on evidence-based practice guidelines for post-traumatic stress disorder. Infi delity About half of all males and a quarter of all females in long-term relation- ships or marriages have affairs, and affairs are a very frequent reason for attending couples therapy (Glass, 2002). Affairs signal relationship problems and are rarely exclusively sexually motivated. Affairs fulfi l a variety of functions (Brown, 1999). Where couples continually avoid resolving confl icts within their marriage, or where one partner continu- ally sacrifi ces his or her needs to care for the other, intimacy may erode and an affair provide a way for having thwarted intimacy needs met. Other couples use affairs and intense confl ict about these to avoid in- timacy and maintain distance within the marital relationship. In other instances, sexually addicted partners use multiple brief sexual affairs to regulate negative emotional states, much as others might use drugs or alcohol. Affairs may also be used as a way of justifying the end of a marriage – so-called ‘exit affairs’. Affairs vary not only in the function they fulfi l, but also in the type and degree of involvement from brief sexual encounters to sustained long-term romantic sexual relationships. Affairs have a range of effects on those involved. Betrayed partners may develop post-traumatic symptoms, including obsessive thinking, fl ashbacks, anxiety, depression, suicidal and homicidal thoughts. Part- ners involved in affairs who believe they must give up the affair to save their marriages and protect their children may experience depression associated with the loss. Where affairs are disclosed to therapists in confi dence, there is a di- lemma about whether it is appropriate to offer couples therapy while keeping the affair a ‘secret’. Where the affair happened a long time ago, there may be little to be gained by insisting that it be disclosed within couples sessions. However, where the affair was recent or is ongoing, it is essential that the partner who has had the affair cease contact with the person with whom they have had the affair, if conjoint couples therapy is to be effective. If this cannot be agreed, because one partner is ambivalent about giving up the affair, then each of the partners may be seen in indi- vidual therapy until the affair ends. Gordon, Baucom and Snyder (2004), in a replicated case-study investi- gation of an integrative treatment for couples recovering from an affair, DISTRESSED COUPLES 429 found the 26-session programme to be effective for four out of six cou- ples. In the fi rst stage of the programme, therapists assessed the impact of the affair on couple functioning, addressed immediate crises, such as suicidality or violence, contained partners’ volatile emotions, and helped partners negotiate safe guidelines for interacting outside of therapy ses- sions. In the second stage, individual, couple and broader systemic and contextual factors that contributed to the development of the affair were explored to help the couple develop a shared understanding of how the affair occurred. In the third stage of treatment, the focus was on forgive- ness and moving on. A positive outcome from this type of intervention is more likely when both partners are strongly motivated to re-invest in their marriage; where the affair involved limited emotional involve- ment, and where the affair occurred late in the marriage and involved the male partner. SUMMARY Couples may seek therapy for a wide range of problems and in this chapter the focus was on problems that are fundamentally relational in nature. These relationship problems commonly arise from diffi culties in partners meeting each others’ needs for desired levels of intimacy and desired levels of autonomy. These diffi culties are associated with problematic behaviour patterns, which are sustained by negative belief systems and personal narratives. These behaviour patterns and belief systems may have their roots in negative family-of-origin experiences. In addition, wider contextual factors such as cultural differences or low socioeconomic status may place couples at risk for relationship problems. Therapy for couples may be conceptualised as a stage-wise process and a range of interventions targeting behaviour patterns, beliefs and histori- cal and contextual factors have been shown to be effective in alleviating relationship distress. FURTHER READING Gurman, A. & Jacobson, N. (2002). Clinical Handbook of Couple Therapy, 3rd edn. New York: Guilford. Halford, W. & Markman, H. (1997). Clinical Handbook of Marriage and Couples Interventions. New York: Wiley. Schnarch, D. (1991). Constructing the Sexual Crucible: An Integration of Sexual and Marital Therapy. New York: Norton. Leiblum, S. & Rosen, S. (2001). Principles and Practice of Sex Therapy, 3rd edn. New York: Guilford. Levine, S., Risen, C. & Althof, S. (2003). Handbook of Clinical Sexuality for Mental Health Professionals. New York: Brunner Routledge. 430 FAMILY THERAPY PRACTICE WITH ADULT-FOCUSED PROBLEMS FURTHER READING FOR CLIENTS Gottman, J. & Silver, N. (1999). The Seven Principles for Making Marriage Work. London: Weidenfeld & Nicolson. (This guide is based on years of research by Gottman.) Markman, H., Stanley, S. & Blumberg (1994). Fighting for your Marriage. San Francisco, CA: Jossey Bass. (This guide is based on a scientifi cally evaluated premarital programme.) Christensen, A. & Jacobson, N. (2002). Reconcilable Differences. New York: Guilford. Chapter 15 DEPRESSION AND ANXIETY When a member of a couple develops depression or anxiety, this has a profound effect on the relationship and members of the couple may develop interaction patterns and belief systems that maintain the anxiety or depression. It is not surprising, therefore, that there is considerable evi- dence that couples-based treatments for depression and common anxiety disorders, such as panic disorder with agoraphobia, are particularly effec- tive (Beach, 2002; Byrne, Carr & Clarke, 2004a). A systemic model for con- ceptualising these types of problems and a systemic approach to therapy with these cases will be given in this chapter. A case example is given in Figure 15.1 and three-column formulations of problems and exceptions are given in Figure 15.2. and 15.3. The lifetime prevalence of major depression is 10–25% for women and 5–12% for men (American Psychiatric Association, 2000). Up to 15% of peo- ple with major depression commit suicide. The lifetime prevalence rates for all anxiety disorders is 10–14%, and for panic disorder with or without agoraphobia, the anxiety disorder considered in this chapter, the rate is 1.5–3.5% (American Psychiatric Association, 2000). Many people attending psychiatric services show both anxiety and depressive symptoms and often a range of other problems such as substance abuse, eating disorders and borderline personality disorder (American Psychiatric Association, 2000). DEPRESSION Major depression is a recurrent episodic condition involving: low mood; selective attention to negative features of the environment; a pessimis- tic belief-system; self-defeating behaviour patterns, particularly within intimate relationships; and a disturbance of sleep and appetite. Loss is often the core theme linking these clinical features: loss of an important relationship, loss of some valued attribute such as health, or loss of status, for example, through unemployment. In classifi cation systems such as the DSM-IV-TR (American Psychiatric Association, 2000) and the ICD-10 (World Health Organisation, 1992), major depression is distinguished from bipolar disorder, where there are also episodes of elation, and from dys- thymia, which is a milder, non-episodic mood disorder. However, ‘double 432 FAMILY THERAPY PRACTICE WITH ADULT-FOCUSED PROBLEMS depression’, which involves persistent dysthymia coupled with episodic major depression, characterises many chronic service users, who may be referred for couples therapy. ANXIETY Anxiety is distinguished from normal fear insofar as it occurs in situations that are not construed by most people as being particularly dangerous. Figure 15.1 Case example of depression Referral. Adrian and Anne originally came to therapy because of diffi culties they were having with Aoife their teenage daughter, specifi cally the ongoing confl ict between Anne and Aoife. These diffi culties were addressed in an episode of child-focused family therapy, after which the couple contracted for a further episode of therapy addressing their marital problems. Since shortly after Aoife’s birth they had had periodic diffi culties associated with Anne’s depression. Anne, like her mother Lucy was diagnosed with major depression and had been treated periodi- cally with antidepressant medication. Like her mother, Anne found that the mood disorder cre- ated confl ict in her marriage as well as in her relationship with her eldest child. Adrian found the mood disorder challenging to live with and coped by adopting a coldly effi cient caregiver role with respect to Anne and the children. Periodically, however, the strain of this way of managing the situation would become too much for him to cope with and he would become highly critical of Anne and verbally aggressive towards her. This would exacerbate the depression. Formulation. Three-column formulations of episodes in which the depression had a profound negative impact on the relationship and exceptional episodes where such problems were ex- pected but did not occur are given in Figures 15.2 and 15.3. Therapy. Therapy focused on helping the couple examine the problems that the complemen- tary caregiver/invalid roles created in their marriage and specifi cally how it prevented them from meeting each other’s needs for intimacy and a more balanced distribution of power. Role- reversal exercises were used with this couple to good effect, because it helped them understand the impact of the complementary roles on their partner. The couple increased opportunities for intimacy by scheduling things they like to do together on a daily basis. They also replaced reassurance requesting and giving with the CTR routine for challenging depressive beliefs and narratives described in the chapter. TrevorMarie Anne 39y Adrian 40y John Nra 30y Frank 35y Sylvia 38y Family strengths: Adrian and Anne have prevented depression from ending their marriage for 14 years Lucy Brian 34y Amy 4y M 18 y ago Aoife 14y Nra 30y Triona 34y Depressed Aine 10y Depressed Tom 1y Rick 5y Toby 8y DEPRESSION AND ANXIETY 433 In response to stresses such as childbirth, home–work role strain, and so forth, Anne becomes depressed, irritable, silent, inactive and self-critical In response, Adrian becomes coldly efficient in caring for her and managing the children and the house In response Anne beco- mes more depressed Periodically, Adrian becomes angry and critical of Anne, accusing her of malingering or being intentionally irritable with him or the eldest daughter, Aoife In response, Anne becomes more depressed Later, Adrian becomes remorseful and expresses his remorse by becoming colder and more efficient in caring for Anne In response Anne feels more depressed Anne believes that she has no value and is powerless to change her situation Adrian believes he has a duty to care for Anne and the children, no matter how lonely or sad or frustrated he feels in response to Anne’s depression Adrian believes that Anne has changed forever and the wonderful woman he married and who met his needs for intimacy and companionship has been replaced by a lazy, punitive, vindictive person, but later believes that this view is a reflection of his own lack of strength and integrity Anne believes that Adrian’s criticism’s are all justified and believes she is guilty of letting him and her children down by not fulfilling her role as a wife and mother Anne may be genetically vulnerable to depression and so becomes depressed when faced with increased demands and stresses Adrian has been socialised in a family where doing one’s family duty is a central value For Adrian, the loss experience and grief associated with repeated comparisons of Anne as a depressed person and Anne as she was when he first met her make him vulnerable to grief- related anger Anne’s depressive thinking style and her family-of-origin experiences of living with a depressed mother make her vulnerable to accepting Adrian’s criticisms as valid Figure 15.2 Three-column formulation of a situation in which depression damages the relationship [...]...434 FAMILY THERAPY PRACTICE WITH ADULT-FOCUSED PROBLEMS Anne may be genetically vulnerable to depression and so becomes depressed when faced with increased demands and stresses Adrian has been socialised in a family where being honest is a central value Both Adrian and Anne have memories of how good their relationship was initially when they did a lot of pleasurable things together and this allows... be used to help couples 4 48 FAMILY THERAPY PRACTICE WITH ADULT-FOCUSED PROBLEMS overcome the angry battles or sulky stand-offs that typically occur when they jointly try to solve a routine family problem It should be highlighted that problem solving is a slow and painstaking process, which must be approached with the expectation of cooperation Treatment of Panic Disorder and Agoraphobia Vulnerability... these instructions and listen to the tape as you do the exercises, speak in a calm relaxed quiet voice Area Exercise Hands Close your hands into fists Then allow them to open slowly Notice the change from tension to relaxation in your hands and allow this change to continue further and further still so the muscles of your hands become more and more relaxed Arms Bend your arms at the elbow and touch your... slowly…one…two…three… four…five…six and again Breath in…one…two…three and out slowly…one…two…three… four…five…six and again Breath in…one…two…three and out slowly…one…two…three… four…five…six Visualising Imagine you are lying on beautiful sandy beach and you feel the sun warm your body Make a picture in your mind of the golden sand and the warm sun As the sun warms your body you feel more and more relaxed As the... biological processes, early socialisation experiences and related personality traits, stressful life events, intrapsychic processes and belief systems, and patterns of social interaction, have Michael 8m Conor 24y Grainne 2y Michelle 27y Rita M 2 y ago Maureen 27y Mary 65 Rurai 25y Finbar 2y Shamus 65 Alcohol problem Family strengths: John and Maureen are committed to their relationship and to their... some instances, these behaviour patterns induce depression and other negative mood states in the initially non-symptomatic partner 4 38 FAMILY THERAPY PRACTICE WITH ADULT-FOCUSED PROBLEMS In one problem-maintaining behaviour pattern, the anxious or depressed partner behaves more and more helplessly and in response the other partner engages in more and more caregiving, so that the entire relationship becomes... feel more and more relaxed As the sun warms your body you feel more and more relaxed The sky is a clear, clear blue Above you, you can see a small white cloud drifting away into the distance As it drifts away you feel more and more relaxed It is drifting away and you feel more and more relaxed It is drifting away and you feel more and more relaxed As the sun warms your body you feel more and more relaxed... be Think of your hands and allow them to relax a little more Think of your arms and allow them to relax a little more Think of your shoulders s and allow them to relax a little more Think of your legs and allow them to relax a little more Think of your stomach and allow it to relax a little more Think of your face and allow it to relax a little more Breathing Breath in…one…two…three and out slowly…one…two…three…... medication may be used to regulate sleep and appetite and increase energy levels However, for full recovery and to be equipped to manage situations where there is a risk of relapse, couples therapy is required In this sense, couple therapy can offer a fresh start, a way of beating depression and being prepared for it, if it tries to enter the couple’s life again DEPRESSION AND ANXIETY 445 Disrupting Destructive... valueless and powerless, and a pessimism and hopelessness about the future are the core themes of this belief system With anxiety, the core theme is that of danger and threat The world is construed as a DEPRESSION AND ANXIETY 437 dangerous place involving multiple potential threats to health, safety and security Depressed individuals selectively monitor negative aspects of their own actions and those . while in therapy and take steps to reduce danger, such as removing weapons from the house; and/ or agrees to a temporary separation; and/ or engages in treatment for comorbid alcohol and drug. is essential that the female partner 4 28 FAMILY THERAPY PRACTICE WITH ADULT-FOCUSED PROBLEMS agree a safety plan specifying what exactly she will do and where she will go if further threats. relationship problems. Therapy for couples may be conceptualised as a stage-wise process and a range of interventions targeting behaviour patterns, beliefs and histori- cal and contextual factors