Couples therapy for depression manual

Contents
First Joint Session 3
Introduction 3
Assessment 3
First Individual Session 4
Assessment 4
Formulation 5
Themes\Conflicts 5
Polarisation 5
Mutual Trap 6
Depression 6
Schema 6
Feedback Session 6
Techniques 6
Empathic Joining 7
Why do it 7
When to do it 7
How do it 7
Acceptance through unified detachment 7
Tolerance building 8
When to do it: 8
How to do it: 8
Notice the effects of trying to change the behaviour 8
Communication 8
When 8
How 9
Behavioural Exchange 11
Rationale for clients 11
When 11
When not to 11
Why 11
How 11
Troubleshoot 12
Stress Management 12
When 12
Why 12
How 12
Problem solving 13
Why 13
How 13
Endings 13
Why 13
When 14
How 14
Relapse prevention 14

First Joint Session

Introduction
Frame
1. Admin
a. Meet for 20 sessions
b. All sessions are recorded for supervision purposes
c. Do Not Attends and cancellations
i. Cancellations need 24 hour notice.
ii. DNAs we wait to hear from you before rebooking
d. Forms
i. Every session we need an MDS
2. Confidentiality
a. Everything you say to me is confidential except if there’s a serious risk to you or those around you. If you tell me of sexual abuse I will need to speak to someone about it
b. Unless you tell me otherwise then assume if you say something in our individual sessions I may mention this to the other.
3. Therapy
a. We treat the couple, which can treat depressive symptoms. So in some ways we’re not working with you individually but rather what goes on between you. We really need to enlist your help to observe what happens between you so we can get to understand it. I guess this will mean you’ll need to step back from your daily interactions partially to watch what happens.
b. There’s a skills element so some work outside and we might do some techniques in here
c. Topics
i. How one person affects the other, and the other person affects them
ii. Understanding the other
iii. Communication
iv. Caring for the other
v. Problem solving
d. Course of therapy
i. 4 sessions to understand the problem and formulate

Assessment
1. Current Problems
a. What are the problems you have in your relationship?
b. What is the process that happens when a problem arises in your relationship?
c. Are there any external pressures on the relationship?
2. Couples history
a. What was your relationship like to start off with?
b. What were its enjoyments\pleasures?
c. How did you act if you had problems?  How is it different to now?
3. Early part of the relationship
a. Where did you meet?
b. What was your courtship like?
c. What was your relationship like before problems began?
d. What initially attracted you to one another?
e. What parts of your relationship worked well when you were first together
f. What aspects of your relationship were you most proud of?
4. Current relationship
a. How would your relationship be different if the current problem no longer existed?
b. What’s your relationship like now when you are getting on?
5. Roles
a. What are the roles that each of you take in the relationship, how much does the other take of this role?
6. What is it about now that makes you seek treatment?

HW CSI and Individual session assessment

First Individual Session

Confidentiality:
Unless you tell me otherwise I may share information in this session in the conjoint session. Four areas for assessment
Assessment
1. Relationship history
a. What is your history of romantic relationships, have there been any patterns of the types of relationship
2. Commitment to relationship
a. How committed to the relationship are you
3. History of family or origin
a. What was your relationship like to family of upbringing
4. What are the difficulties in your relationship
5. Strengths
a. What are the strengths of your relationship
b. Are there any strengths that you have had but you now currently don’t
6. Current relationship
a. How do you contribute to the current problems
b. What changes do you need to make to improve the relationship
7. Extra marital relationships
a. Emotionally significant
b. Sex
8. How is the physical aspect of your relationship
9. Mental health history
10. Substance abuse history
11. Risk
a. What happens when there’s a really bad argument between you?
HW Reconcilable differences
Formulation
The aim of the formulation is to see where in response to a problem the problem is maintained. I do x because he’s y which results in z which makes more y.
4 parts of a formulation
1. Conflicts\Themes
2. Polarisation
3. Mutual trap
4. Depression
Themes\Conflicts
These are classes of behaviour with similar function. I would also include in here topics where there is conflict
Standard themes are
1. Closeness\distance
2. Artist\scientist
3. Control\Responsibility
a. Who has control, who has responsibility for certain domains
4. Active\Passive
Take history to understand their power of each them
Theme questions
1. What are the issues that divide you\what type of things provide conflict
2. What makes these issues\conflicts so powerful for you, have there been things in your past that could help us understand them
Polarisation
This refers to an interaction pattern that are initiated when conflict around a theme, where the more black I become the more white I see you as, and the more I think white is a deficient colour. In polarisation there can be an attempt to reduce the white but in this process you strengthen it. Thus the polarisation process refers to the attempt to eliminate differences ends up reinforcing them.
So polarisation, when there is conflict in a theme then the attempts to eliminate difference ends up reinforcing them. Polarisation also refers to the sense of I define myself at one end and you at the other end, although this is a double perceptual bias, and that your end is deficient.  Polarisation is then seeing me very black, you very white, the reason to do this is maybe to prove me right and you wrong so we accentuate both sides to create distance, in that action I then look at your side as deficient, I’m all black, you’re all white and white isn’t good enough and neither are you. The bigger the gap you believe you can make the more powerful your argument.

Polarisations questions
1. When you are in conflict around these issues what happens between you, what is the effect of this
2. How has this changed over time
Mutual Trap
The mutual trap then is the impact of the polarisation, feeling stuck, discouraged and hopeless. The effects of this is feeling trapped and resentful towards the partner and more likely to affirm your side of the polarisation
Depression
How does the depression symptoms function in the relationship? Does this produce a polarisation of sick\well?
Schema
Within formulation look for the “social” schema, beliefs etc., Others will x, it would be awful if someone y,
Feedback Session
Join the two individual sessions and use the following feedback
1. Levels of distress
2. Levels of commitment
3. Themes that divide the couple
4. Why these theme provide such a problem: including mutual coercion, vilification and polarization
5. Formulation
a. Discussion, adjustment and agreement
6. Couples strengths
7. What treatment can do/Treatment plan
a. Discussion, adjustment and agreement

Therapy can help by:
1. Improving acceptance and tolerance of each other. Tolerance is managing unpleasant feelings the other is doing something that you don’t like. Acceptance is being with that difference, not wanting to change it or escape from it, or stop it.
2. Improving communications
3. Changing behaviour, and realising the effect of depression
4. Problem solving skills to help dealing with conflict

Techniques
You need to establish empathy before you can do behavioural work like behavioural exchange and problem solving as you need a team to do BE and PS so the sequence is:
1. Build empathy/acceptance/tolerance
2. Improve communication
3. Behavioural activities
a. Behavioural exchange
b. Problem solving
Empathic Joining
Why do it
When pain is expressed as accusation and blame it then leads to pain and retaliation (marital discord)
Pain –accusation =acceptance
When to do it
When there is a no win problem, i.e. one partner wants to turn left and the other right and there is pain and blame
How do it
Stage 1
Understand each incompatible story, and what joins the stories.
Move the hard to soft feelings. Ask the other partner what it’s like for them to hear the soft feelings
Move the hard feelings to mutual soft feelings. Ask the couple what is like to realise you share some pain.
Stage 2
Having moved from one story to another, Summarise the functional components of each story=pain, anger, blame. Pain, understanding, communication, acceptance. Notice the effects of both models and how it fuels into the formulation
Stage 3
HW exercise.
1. When you notice anger or blame at partner, ask yourself what hurts for me that makes me angry
2. Think about why your partner might do the things they do, in their terms.
3. Communicate this in a form, when you do x I feel y
Different scenarios
2 active incompatible actions, you turn up late, I turn up early: this seems the most suitable for empathic joining as there are two different actions for the same scenario.  Here you can seek to understand why each choose their own way of attending the event.
1 active, 1 inactive compatible actions, I clean up you don’t: this is trickier, as person 1 cleans, person 2 doesn’t, or does less and at different times. The empathic join would be understanding the amount of cleaning that each does I guess.
Acceptance through unified detachment
Aim to get the couple to look at their relationship like scientists. To detach from their relationship and to observe its patterns.
Can we name that problem, could we put it in the chair?

Tolerance building
When to do it:
 When a struggle isn’t going to lead to greater intimacy and the behaviour isn’t likely to change
How to do it:

Understand:
Notice the effects of trying to change the behaviour
Understand why one person might like doing it and the other person doesn’t, get both to do this
Positives of behaviour, what if both partners acted the same

Treatment:
Behaviour:
Practice in session:
1. Replay the distressing behaviour
a. Rationale
i. Desensitize through repeating
ii. Increasing understanding about what each partner brings to the problem
b. Possibly stop at key points to find out what is going on
Faking it
Do it deliberately at home, notice the effects on the person that receives the action, notice the consequences of doing the action, debrief in session
1. Fake the behaviour between sessions
a. When partners have high emotions they find it hard to see the motivation of problem behaviour.
b. Partner won’t know if the behaviour is real or fake.
c. Behaviour should only last for a short period not to generate a fight
d. Partner who fakes needs to pay especial attention to how their behaviour is received
e. Only do this after you have a successful in session replay, i.e. with understanding and no escalation

Self-care:
Use self-care to look after any unpleasant effects of this behaviour, or to look after your own needs if your partner doesn’t.

Communication
When
Do it after some level of empathy, connection and tolerance and acceptance has been done
How
Introduce it as a topic. Improving communication within a couple can help how you get on. It can help reduce arguments, increase your mutual understanding and foster closeness.
Do it as an exercise.
One person speaks and practices skill 1, and the other person listens and practices skill1. Then we can build it up .

Listener skills
1. Summarising
2. Reflecting
3. Validating
4. Question asking
Speaker skills
1. Clarity in I statements
2. Clarity in requesting change
3. Conciseness
4. Editing out negative statements

Listener skills
Summarising
This helps ensure that you understand what has been said and you let the speaker know this.
Couple takes a topic that is not super-hot, and goes through this exercise which will feel a bit artificial at first.
Ask the speaker to talk for a few minutes
Ask the listener to summarise what has been said and then ask for the speaker to confirm if they summarised correctly, then debrief and see what was learnt what was difficult.
Pitfalls: it can be difficult to avoid choosing an emotionally laden area, where grievances will be aired
Why: summarising ensures that one person is listened to and that they know it, i.e. they have expressed themselves and feel heard, that can be quite powerful as if it doesn’t happen what happens, you might try to make your point quite forcefully

Reflecting (Emotional empathy)
Summarising is the basis of reflecting and this allows couples to feel closer to each other. This helps for one person to not just feel that their words have been heard, but rather what it means to them has been heard. The first step is to understand them in an emotionally attuned way.  The reflective listener shows empathy for the speaker’s position.
How to do it: on the basis of summarising then add an understanding of what the listener thinks the speaker may be feeling and why. Ask the reflector to see things from the listener’s perspective. What would it be like to experience the things the speaker is saying?
Pit falls: sometimes people will not be able to distinguish between their own feelings and those of the other

Validating (Cognitive empathy)
This can be a difficult skill as it requires a high degree of empathy.
This asks to show an appreciation of why the speaker holds the position\feels the way that they do.
You can only do this after each person’s polarised views has been validated.
You don’t need to agree with their position, but you need to be able to understand it.
The validating response needs to come from a real appreciation of the speakers position otherwise validation will appear insincere and patronising. To respond meaningfully the listener may need to ask for more information

Question asking
To be able to accurately understand what the speaker is saying may require more information, which can be achieved through question asking. Questions can be interrogations that can undermine your position, so the aim of asking questions is to explore the speaker’s perspective and not your own. Aim to enhance understanding of the other, rather than entrench misunderstanding.
Traps: point scoring and score settling
For the therapist to ask the listener whether they have heard the speaker, the context, impact, or intention of what was said can help stimulate curiosity between the partners.
Avoidance mechanisms: Many questions can be asked with no space to answer. Questions can change the topic

Speaker skills
In all speaker skills stay as specific as possible. Don’t say you never do the washing up, this can lead to arguments and is over generalised.  Rather say today you didn’t do the washing up.
Clarity in the I statements
Talk about your experience, what it’s like to be you. Avoid blaming your partner for making you feel a certain way, rather if you want to say this, let them know I feel x when you do y. This helps lessen the amount of accusations that are used in conversation you always do this and attempts to reduce generalisations.  I statements work best when affirming positive things within the relationship (?)
When you do x I feel y.
I guess the I statements allow one person to let the other person know how they are. If they get angry because they are hurt and attack the other person for this, we miss out the fact that we have been hurt that the other person might respond to with a sticking plaster, when attacked the other person will either retreat or attack back!

Clarity in requesting change
Disagreement mixed with resentment usually contains a demand for change.
How: make global complaints specific, the change should be specific and achievable.  Start small achieve then build on that.
Traps=Depression can make you think change isn’t possible, so be aware of that as a damper. Watch out for vague and global and impossible requests.

Consciousness: editing out negative statements and increasing calmness
Some partners need to reduce verbosity and repetitiveness.  This can be caused by trying to make a point from every aspect, or by chaining together complaints to make an impossible list. This can be addressed by the therapist asking them what they want to come out of this conversation.

Behavioural Exchange
Rationale for clients
When you first met you did caring things for each other that gave you pleasure? As one person gave the other person pleasure so they returned it and you created a virtuous circle. As times goes on the amount of caring things can drop and the caring things that are done are taken for granted. With this exercise we are going to change this by exchanging previous behaviours for caring ones. If we thought of your relationship as a person we are aiming to give an injection of some feel good.
When
After greater intimacy and communication
When not to
When the couple is antagonistic
Why
Increases intimacy, increases pleasure raises mood
How
Session 1: Partners are given a set of instructions to come up with some caring things they could do for the other, note it’s easier to revitalise old things rather than do new things
Session 2: Each list is gone through with each partner and the other partner doesn’t respond. Ensure each item on the list achieves the criteria. HW is for each partner to do their caring items as a gift, without expecting something will be done in return. Partner who receives it notes down when the caring item is done
Session 3: Debrief what happened, what was noticed, how this affected you as a couple, model this.  Then each partner gets to prioritise the list of the other and add one thing on and prioritise that
Session 4: Debrief what happened, what was noticed

Criteria for items on the list
1. List small things
2. List specific things
3. Undemanding things
4. Positive things (i.e. do more, rather than less of something)
5. Easily doable
6. Don’t rely on external circumstances  like good weather, or another’s availability
7. Don’t require large amount of time\energy\money
8. That can be repeated regularly
9. List things that your partner would notice
Guidelines for putting items on list
1. Choose items that would make your partner feel cared about\give them pleasure
2. It’s easier to use things you used to do that find new things

Guidelines for caring behaviours
1. Notice when one is done for you
2. When you do one, then do it as a gift, and don’t expect one back in return
Troubleshoot
One partner does nothing other partner feels disappointed annoyed.
1. Empathic joining. One hurt, one guilty.
a. Guilty
i. Goal too big, shape it
ii. Scared of getting it wrong= join of its really important to you

Stress Management
When
Needs to take place after greater intimacy and communication and there are significant stressors on the relationship.
Why
Stress is a major factor in relationship breakdown and it generalises, so stress at work, leads to stress in relationship, now we have two stresses
How
Conceptualise: Note stresses at the moment, external to the relationship and each partner, internally from the relationship, their chronicity and acuteness.  How does stress affect each partner, then how does this get played out in the relationship.  Understand existing stress management techniques
Plan: List different stress management techniques Emotional\Problem solve\Avoidance\Carrying.  List things that reduce stress generally individually or as a couple. Think of the 2 most frequent stressing factors for each on the relationship and decide which management technique would be useful, and what stress reducing activity could be generally helpful.  Decide if the technique or activity is something done individually or jointly.
Practice: When stressed about this stressor, implement strategy. If jointly the communicate need, decide time and implement.
Troubleshooting
If both partners are stressed and need the other, then schedule time for both when one can be the listener and one the speaker
Problem solving
Why
Notice when problems and working through them is one of the notable problems that the couple has, although of course that’s what brings them here, but the point is that whilst you can address many relationship difficulties in therapy, to be able to problem solve well collaboratively will enhance their future relationship as problems are part of life.

How
Take a collaborative approach
1. Explore each partners role in the problem
2. Do we fix or accept the problem
a. If it’s a perpetual problem? Then either we can tolerate\accept or do behavioural exchange to counteract.
3. Define problem clearly and only have one not a chain
a. State something positive to start off with (arguments\problem solving tend to end how they start)
b. Be SMART
c. Be Brief
d. Express feelings
e. Avoid inferences, discuss only what can be seen
f. Be neutral not negative
g. Focus on solutions
4. Look for solutions
a. Brainstorm
5. Decide on solution
a. Use pros and cons
b. Aim for mutuality and compromise in deciding which solution
6. Contract with each other to implement

Endings
Why
Ending are a perpetual part of life and can cause difficulties for people
When
2 sessions out plan for it, get homework to be done noticing what emotions, thoughts and behaviours the ending provokes.  Notice previous ways of ending.
Unplanned for ending, ask for another session and do the same as if planned.

How
Understand: Thoiughts\emotions\behaviours provoked by the ending. Notice general “ending style” from past.
Define how this ending is understood
As end, as transition, as cure, as completion?
Relapse prevention
If you came back to see me in a years’ time and the problem had returned, how would that have happened=what are the weak spots.

Clinical handbook of couples therapy

Contents
Chapter 3 Integrative Behavioural Couple Therapy 1
Theory of therapeutic change 2
Structure of IBCT 3
Role of the therapist 3
Assessment and treatment planning 4
Functional analysis 4
Case Formulation 4
Theme 4
Polarization 4
Guiding questions 4
The first conjoint interview 4
Individual Interviews 5
Feedback Session 6
Goal setting 6
Processes, techniques and strategies of IBCT 7
Acceptance through empathic joining 7
Acceptance through unified detachment 7
Tolearance building 7
Faking negative behaviour at home between sessions 8

Chapter 3 Integrative Behavioural Couple Therapy

This grew out of Tradition BCT as it was found that TBCT wasn’t working in many circumstances and what was missing was acceptance.

Acceptance isn’t resignation.

IPCT proposes that all couples will go through periods of differences and disagreements. Distress is caused by the unhelpful way couples respond to these disagreements.

Differences in the early day may have been seen as attractive.  Differences cause problems when they spring from vulnerabilities rather than preferences. These vulnerabilities may be direct, or reminders of unpleasant things.

Three destructive patterns frequently characterise couples conflict over differences

1.       Mutual coercion

2.       Vilification

3.       Polarisation

Couples deteriorate when they reduce their ability to accept, compromise and tolerate their differences.

Differences that were once attractive are sought to be changed.

Mutual coercion is where unhelpful behaviour, yelling, withdrawal, criticising, is reinforced by the other and thus kept going, as there could be intermittent reinforcing the behaviour can get more extreme.

Mutual coercion moves from a sense of my partner is different to my partner is deficient and vilification happens.

So different that is valued, difference devalued, made worse relationally then vilified and a desire is made to reform the other. Then you get polarisation where the behaviour that the partner is already proficient in becomes more accentuated and the deficiency of the other more noticed.

Happier couples confront difference with acceptance and tolerance.

Acceptance is faced with an aversive stimulus to neither, avoid escape or destroy.  For a couple it means being faced with difference and not going into a mutual coercion, vilification and polarisation.

Theory of therapeutic change

IBCT is behavioural therapy. It integrates strategies for change and strategies for acceptance. Views behaviours and change as a function of the context in which that behaviour occurs. TBCT aims to change the context through changing the agents.  IBCT focusses on the recipient of behaviour as on the agent.

So the context can change through changing the agent or the recipient of behaviour for three reason. Firstly IBCT believes there are unsolvable problems in a relationship A desires 1 from B but B won’t deliver. In this area acceptance and tolerance are the way to improve things. Secondly pressure to change may in these instance contribute to the maintenance of the problem. When the difference is accepted then a partner may not be so assertive of it. Third often the reaction to an offending behaviour is as problematic to the relationship as the original behaviour

TBCT theory is rule governed behaviour: a rule is given and then reinforced depending on the judgement of the alignment between rule and behaviour. This is arbitrary reinforcement as the rule is abstract from its environment.

IBCT theory is contingency shaped behaviour, i.e. the natural consequences of behaviour are reinforcing, so I do a nice thing to my partner, I feel good in the doing of it and they give me praise or are more intimate to me.

Rule governed behaviour takes effort, contingency shaped behaviour is natural and spontaneous.

TBCT uses rules governed behaviour, Behavioural exchange and communication and problem solving techniques. BE couples decide on behaviours that can improve their relationship in CPT learn good rules of communication, e.g. use I rather than you, summarising and paraphrasing what the other says.

Rule governed behaviour feels very different, less natural than natural contingencies. A kiss in the morning as an expression of feeling, feels quite different to following a rule to express more intimacy. Contingency shaped behaviour vs rule governed behaviour.

Functional areas are more amenable to RGB emotional goals, e.g. be more interested in me, more sex, are amenable to CSB.

IBCT aims to make changes in the couple’s natural context. So in session instead of teaching not to criticise, the therapist models validating each partners perspective. Instead of teaching to be more open, the therapist. The therapist may enquire about softer feelings, sad, hurt, lonely as opposed to the harder feelings anger, hostile

Therapist continually tries to change context not give rules.

Couple-therapist relationship essential to IBCT

Structure of IBCT

26 * 50 minute sessions

3 evaluation sessions

IBCT assumes that problems and differences are part of life, we don’t wait to terminate until all problems are resolved.

Therapy success= patterns discussing more calmly, understanding the others perspective and less distressed behaviour

Acceptance orientated sessions focus on 4 areas:

1.       Discussion of the basic differences between partners and their patterns of interaction

2.       Discussion of upcoming events that could provoke conflict

3.       Discussion of recent negative events

4.       Discussion of recent positive event

The important things to look at are relational themes.

Role of the therapist

IBCT therapists have a plan but nothing is more important than the couple’s most recent statement

Therapist as teacher, skills of communication, paraphrasing, summarising, using I

Therapist maintains the case formulation via good and compassionate listening

Therapist offering genuine empathy and understanding to each partner

Therapist as mediator

Therapist models taking a compassionate, non-confrontational validating response to each partner

Therapist highlights the function of behaviours

Therapist as historian, relating early life experiences, early couple experiences to current behaviour

Therapist uses language that hits home.

Assessment and treatment planning

4 sessions. One with each partner, one with the couple and feedback with the couple.

Functional analysis

What is the stimuli that gives rise to behaviour? What is the effect of the behaviour? The functional analysis can deal with abstracted types of behaviour so that it can apply to other situations.

Case Formulation

This comes out of the functional analysis and has three parts

1.       Theme

a.       Class of  behaviours with the same function

2.       Polarisation process

a.        

3.       Mutual trap

Theme

Standard themes:

1.       Closeness and distance, one partner seeks greater closeness the other greater distance.

2.       Control and responsibility

3.       Artist vs scientist, spontaneity vs logic and planning

When you evaluate a theme, it’s also useful to find out what in their early experience makes this theme so powerful

Polarization

When arguments come up around a theme, and the attempt is to reduce the difference. In this process of trying to reduce the difference it exaggerates this and you get polarisation. As differences are tried to be changed they become more entrenched, and seen to be intractable and as the other tries to change you and you don’t like it you dig your heels in.  One partner can’t change the other, the other partner resists change. Both partners feel trapped and hopeless.

Guiding questions

1.       How distress is this couple

2.       How committed are they to the relationship

3.       What issues divide the couple

4.       Why are these issues such a problem for them

5.       What are the strengths holding them together

6.       What can treatment do to help?

The first conjoint interview

What are the problems?

What is the process that happens when a problem arises?

Couples history=what was it like to start off with, what were the enjoyments\pleasures. How did you act if you had problems?  How is it different to now?

Early part of the relationship

Where did you meet?

What was your courtship like?

What was your relationship like before problems began

What initially attracted you to one another?

Often initial things that attracted the partner is now something that causes distress. Partners can often be attracted to opposites, things they lack, which at time can be complimentary to how they are, and at other times these opposites may clash and grate. So a relationship may benefit from the colour of emotional reactivity and the stability of being stoic, but then the stoic may grate on the emotionally reactive.
What parts of your relationship worked well when you were first together

What aspects of your relationship were you most proud of?

How would your relationship be different if the current problem no longer existed?

What’s your relationship like now when you are getting on?

Session 1 assignment

Reconcilable differences from Jacobsen and Christensen

Individual Interviews

Confidentiality: unless you tell me otherwise I may share information in this session in the conjoint session. If one partner tells the therapist something in confidence, e.g. having an affair, then the therapists asks the partner to resolve or disclose this to the other partner otherwise therapy can’t continue. I have responsibility to be honest to each partner.

Four areas for assessment

1.       Relationship history

2.       Commitment to relationship

3.       History of family or origin

4.       Relationship history

5.       Current relationship

a.       How do you contribute to the current problem

b.      What changes do you need to make to improve the relationship

6.       Extra marital relationships

a.       Emotionally significant

b.      Sexual

7.       Mental health history

8.       Substance abuse history

Keep eye out for interaction patterns, conflictual themes. Assess relational style, parents’ marriage, relationship with mum and dad.

Feedback Session

This follows directly from the original one to one 6 questions. So the therapist combines the two individual sessions and feeds back for the relationship.

So feedback

1.       Levels of distress

2.       Levels of commitment

3.       Themes that divide the couple

4.       Why these theme provide such a problem: including mutual coercion, vilification and polarization

5.       Couples strengths

6.       What treatment can do

Contra indicators

1.       Domestic abuse

a.       Battering: use of violence to subjugate or intimidate

b.      Couple therapy can be inflammatory so if low level aggression without injury use a no violence clause

2.       Extra marital affair

3.       Individual psychopathology

Assessing domestic abuse

1.       Can you describe an recent argument

2.       How do you express anger

3.       Do arguments ever get out of control

4.       Do arguments ever become physical

5.       Do arguments ever involve hitting, pushing, shoving or the use of weapons

a.       Written reports reveal more than verbal

Goal setting

Three broad goals of

1.       Understanding

2.       Acceptance

3.       Collaboration

Staying together can often put pressure on one partner to the other to change, which can maintain the couple’s distress.

Processes, techniques and strategies of IBCT

Three types of strategies

1.       Acceptance

a.       Empathic joining

b.      Unified detachment

2.       Tolerance

a.       Let go of the effort to change the other

3.       Change

a.       Behaviour exchange

b.      CPT: communication and problem solving training

Acceptance through empathic joining

Both partners are in pain and they express it through accusation and blame. This exacerbates their pain. Pain plus accusation equals marital discord, pain minus accusation equals acceptance. Empathetic joining, means in a disagreement to understand both sides in terms of their history, each in their own logic makes sense and isn’t an attack on the other.

Another strategy is to encourage soft rather than hard disclosure. Hard emotions are anger, resentment and put one in a dominant position to the other. To find this out, ask what other feelings are around apart from anger. Listen for the part of what they say that refers to the hurt that moves quickly onto anger. Sometimes express what the therapist might feel. Sometimes it can be helpful to point out mutual vulnerabilities.

Soft and hard are functional descriptions, so whilst sadness, upset generally function softly it’s not always the case, e.g. when the husband gets angry about the wife’s depression. The wife’s sadness might be making her the dominant one, the person to be looked after.

For couples to be more empathic it’s not always soft emotions that get there, softness is a function not an absolute.

Acceptance through unified detachment

Get distance from the problem by naming it, referring to it as an it with its own being. This helps deescalate blame and accusation.  This helps detached and descriptive discussions rather than emotionally laden ones.  Unified detachment can also be helped by getting the couple to look for patterns in their behaviour, or in certain incidents. To become scientists, to become psychologists

Likewise to compare and contrast incidents, give them both a history and a context. You might in this area refer to the client as the relationship and get both of the couple to help and understand. Imagine your problem is sitting in a chair. Also during between session arguments they can nominate a chair for the therapist of things they would like to say but find difficult to say to their partner.

Tolerance building

Let go of fruitless struggles to change the other. These are used where the therapist doesn’t believe the struggle offers the ability to get greater intimacy for the couple. Tolerance is focussed on behaviours which are not destructive and are not likely to change.

Pointing out positive aspects of negative behaviour

So what is a positive aspect of your partner’s negative behaviour? In the relationship does the behaviour not balance out other aspects? What happened if the partner was like you? The therapist should look at the function of behaviour not some silver lining.

Practicing negative behaviour in the therapy session

Aim here is to desensitise one partner to the others behaviour.

Faking negative behaviour at home between sessions

Do the negative behaviour only when you don’t feel like doing it.  The other partner won’t know if it’s real or faked, but after faking it for a couple of minutes both debrief to see what they noticed and what the consequences of behaviour are.

Promoting tolerance through self-care

I.e. don’t rely entirely on your partner to provide your needs but rather look to care for yourself.

Change techniques

Behavioural exchange

People are better at changing themselves than other people.  Write down a list of behaviours that would bring pleasure to the other. These behaviours should be positive, specific, behavioural and observable.  By positive this means do something that bring pleasure rather than takes away pain.  Eventually partners can ask for additions to the list of their partner.

Do this at home bring into session and read out the other partner rates the amount of pleasure this would give. Ask the couple if they would like to do any of them during the week, or put aside a specific caring day when they aim to do a few.

Communication\problem solving

Communication is about getting partners to level with feelings, edit out unnecessary negative comments and to validate one another.

Communication

Validate, levelling and editing

1.       When talking about the other, to avoid blame, always use I

2.       Avoid generalising

3.       Stay specific

4.       The listener summarises what has been said to the speakers agreement then adds their bit

Problem solving

Take a collaborative approach

1.       Accept their role in problem

2.       Define problem clearly

3.       Look for solutions

a.       Brainstorm

4.       Decide on solution

5.       Contract with each other to implement

Sequencing guidelines

Use more acceptance than tolerance and change techniques.

Start with empathic joining and unified detachment, when couples appear stuck use tolerance techniques.  End the cycle of persist and resist.

Acceptance and tolerance techniques can lead more to change techniques. Sometimes change techniques can stall in the resist and persist cycle and therefore more acceptance is needed.  If there’s strong collaboration then change interventions are more appropriate, if there isn’t collaboration then acceptance first and then tolerance.

BE is more directive, empathic joining and unified detachment teach couples new skills that can be used in their environment to change the interactions.

Empathic joining is about both partners feeling heard

Unified detachment, this can be helped by empathic joining to start off with.  It can also show a shared problem

Tolerance:

Couples therapy for depression Hewison

Contents
Chapter 1 Depression 4
What is depression? 4
What causes depression? 5
Stress triggers 7
Chapter 2 Couple therapy for depression 8
Couples and depression 8
Which comes first depression or relationship problems 8
Does being married increase the likelihood of becoming depressed 8
Are partners responsible for causing depression? 8
Depression and the parental couple 9
Can couple therapy reduce depression 9
What competencies do couple therapists need 9
Couples therapy for depression: an integrative approach 10
Chapter 3 Focussing 10
The couple as the therapists client 10
The couple as an open system 10
The history of the couple: levels of commitment 11
The geography of the couple 11
Working with older couples 13
Maintaining a balanced collaborative stance 13
Chapter 4 Beginning 13
The referrer 13
The therapist 13
The couple 14
Suitability for couple therapy 14
Which couples are unsuitable for therapy 14
Substance abuse 15
The process of assessment 16
Assessing depression 16
Assessing the relationship 16
The structure of therapy 18
Chapter 5 Formulating 18
Motivational and defence systems. 19
Chapter 6 Accepting 21
Empathic Joining 22
Building tolerance 22
Practicing the intolerable behaviour in session 23
Developing a capacity for self-care 23
Summary 23
Chapter 7 Communicating 23
Speaker skills 25
Clarity in the I statements 25
Clarity in requesting change 26
Consciousness: editing out negative statements and calmness 26
Potential barriers to communication 26
The communication wheel 27
Developing empathic communication 27
Hard and Soft emotions 27
Working with excessive expression of feeling 29
Linking emotional expression to developmental history 29
Working with cognitive distortions and changing perceptions 29
Summary 30
Chapter 8 Problem solving and changing behaviour 30
Problem solving training a two stage approach 30
Defining the problem 30
In stating a problem try to begin with something positive 31
Be specific, avoid generalisations and derogatory nouns and adjectives. 31
Express feelings 31
Be brief when defining the problem 31
Stage 2 Solving the problem 31
Both partners shoulc acknowledge their role in creating the problem 32
Discuss only one problem at a time 32
Paraphrase 32
Avoid inferences talk only about what can be observed 32
Be neutral rather than negative 32
Focus on solutions 32
Aim for mutuality and comprominse around changes in behaviour 32
Discussing the pros and cons of a solution 32
Reach agreement 33
Implement 33
The problem of perpetual problems 33
Behavioural exchange techniques 33
Caring gestures 34
Caring days 34
Companionable activities 34
Structured reciprocal behavioural exchange 35
Why BE fails 35
Helping homework to succeed 35
Chapter 9 Coping 36
Stress and the couple relationship 36
Enhancing couples coping capacities 37
Coping with Sexual problems 38
Chapter 10 Ending 39
Making an ending 39
Stopping and ending 39
Relapse prevention 39
Prevention Relapse 40
The recurrence of depression 40
Discourses on endings 40

Chapter 1 Depression

Most common presenting disorder in GP surgeries

1 in 4 women, 1 in 10 men get it during their lives.

What is depression?

Rowe: depression as being in jail with 6 gaolers

1.       No matter how good I appear to be: I am bad, worthless, useless etc.

2.       Other people must be feared, hated and envied

3.       Life is terrible death is worse

4.       Only bad things happened to me in the past only bad things will happen to me in the future.

5.       It is wrong to get angry

6.       I must never forgive anyone least alone me

Effect of depression on partner

1.       Fear of expressing feelings

2.       Frustration

Ancient Greeks depression as an excess of black bile.

19^th century, collated symptoms of depression, e.g. Kraeplin as symptoms having biological and genetic origins. Don’t listen to the patient they are insane look for the symptoms.

ICD 10: depression is 2/3=depressed mood, inability to enjoy pleasurable activity and low energy

DSM 5:  5/9 for more than 2 weeks

1.        depressed mood

2.        loss of interest in activities

3.        Thoughts of suicide

4.        Diminished ability to think

5.        Psychomotor agitation or retardation

6.       Feelings of worthless or inappropriate guilt

7.       Loss of energy

8.       Insomnia

9.       Significant weight loss

Types of depression

1.       Catatonic

2.       PND

a.       Most women get the baby blues for a few days post-partum

3.       SAD

4.       Premenstrual dysphoric disorder

Having sufficient depressive symptoms “means” you have depression, but this is an empty statement, a taxonomical statement.

People only self-report depression which we then categories by forms.

Who decides what normal is, what levels of loss of interest constitutes a problem. Love can cause problems that are above clinical thresholds.  Likewise for loss and grief they can produce likewise codable states.

To diagnose:

1.       Pathologies pain

2.       Provides a cause, and promises a treatment

3.       Provide a cause and stops the endless imaginings of cause and consequence

4.       Legitimises suffering and can start a conversation

5.       Provides a target for a drug

What causes depression?

General agreement that there is a biopsychosocial cause.

1.       Life stressors and events

a.       But not everyone gets depression

2.       Vulnerability to depression

a.       There is no depression gene

b.      Gene twin studies show genes can influence depression but not absolutely

c.       Neurotransmitters

                                                               i.      It is not clear if depletion in neurotransmitters cause depression or vice versa

d.      Hormones

                                                               i.      It is shown disturbance in the endocrine system affects depression

e.      Lack of vitamin D

3.       Psychological personality

a.       1975 neurotic temperament links with depression

b.      1983 introversion linked with depression

c.       1983 socially dependent and self-critical linked with depression

d.      Social competitiveness and rank sensitivity linked with depression

e.      Attachment difficulties can lead to avoidant learning, child turns away from the intense and unpleasant face of their mother

4.       Psychological processes

a.       See below but

                                                               i.      Bowlby insecure attachment where due to the power the parent exhibits the child blames themselves and concludes that is because there is something wrong with them. Thus any future losses can promote this pattern

                                                             ii.      Beck: distorted cognitions about loss shown in beliefs about self, world and future, learnt in early childhood make processing of loss a depressive thing.

                                                            iii.      Siegleman: a learned helpless position coming from an external overcoming event

                                                           iv.      Gilbert: disappointment borne of unfavourable comparison to others, leads to a primate defeat and withdrawal from social support or submissive to elicit investment from others

b.      Environment

                                                               i.      Social disadvantage and low status can contribute to a sense of low self-worth, hopelessness and helplessness.

                                                             ii.      That predisposing factors are being female, material or socially deprived or having adverse childhood experiences a common experience in these areas are that people are disempowered.

                                                            iii.      Increasing social inequality through income gaps, leads to bitterness towards others and shame towards self

Self as arising from interaction between animal nature and social nurture

Loss

From a Freudian point of view this involves grieving which involves anger at what is lost and sadness that it has happened. The work of mourning is about accepting the reality of the loss, managing the feelings associated with it and withdrawing the libido back from that person. Cathexis is the investment of libidinal energy.  Melancholia’s solution to the existential problem is to incorporate the lost object into the self, but this brings back the anger at being left which is then turned on the self in terms of self-criticism.

So for Freud depression is the outcome of loss where the solution to the grief, is to incorporate the lost object in the self, which then brings back the anger and then you have depression which is in part an anger at self and has loss as a theme.

Later psychoanalysis’s, the object relation school, were need driven rather than drive driven.

Bowlby humans formed relationships not simply for the meeting of biological needs, but to relieve anxiety and the regulation of emotions.

Avoidant attachment=constant rejecting by PCG resulting in self-sufficiency and the downplaying of affect

Anxious ambivalent, the PCG is inconsistently available and responsive. This promotes clingy behaviour and the up playing of affect to attract attention.

Disorganised attachment, the PCG is frightening

Insecure attachments undermine the believe in the child’s lovability and worthiness of attention.

 Experience of loss, childhood trauma, and difficulty regulating emotions of fear, rage, guilt and despair are the breeding ground for depressive episodes.

If painful experiences go unprocessed in the care giving relationship then healthy protest may stop and phobic response start? Because of the importance of the parent to the child the child may find it easier to blame themselves than risk losing the parent through blaming them.  This then set up a model for how to deal with loss, as there was loss of the PCG that the child wanted, because of their importance the child blamed themselves. Then when the lose people in the future they can blame themselves for this loss and this fuels depression. Through self-criticism and anger at self. Also through understanding the self as not worthy of the PCGs proper love... Bowlby, considered affective states created cognitive states

Beck, considered cognitive states created affective states that dysfunctional beliefs cause depression, but this isn’t the case as some depression has realistic beliefs.

Bibring, a learning theories said that the depressed ego was one that had learnt its sense of its own brokenness and ineptitude and helplessness in the face of a negative world. It learnt that it has little control over the environment and its goals are likely to be futile.  It has also learnt that three types of aspiration are likely to be thwarted the desire to be loved, the desire to be strong and the desire to be loving and good not hateful and bad.  Internal aggression in this instance is related to falling short of an ideal rather than anger at the identified with lost object.

Siegleman: theory of learned helpless where depressed client doesn’t believe they have any influence over their environment. So when humans are exposed to uncontrollable events, this carries over into other uncertain situations and they believe themselves to have little control. Sieglemna thought that depression comes from an uncontrollable external event, beck believed it to be internal attribution. Attribution theory, we infer causes rather than observe them. Attributing meaning to events produces a feeling of control over them.

Role of disappointment in depression. This can mean falling short of an ideal, or comparing yourself with others and being disappointed in that outcome.

Gilbert, drawing on ranking and social networking theory argues that we want to live in the minds of others and elicit their investment in us and to have them confer on us value, so that we can feel powerful and attractive. If through comparison someone continually comes up short then this can produce a depressive position. Where there is either primitive defeat withdrawing from others for self-protection or a submissive pattern of relating as a way to elicit investment from others.

Environment

Strongest support to the influence of the environment on depression, is the fact that predisposing factors are being female, material or socially deprived or having adverse childhood experiences A common experience in these areas are that people are disempowered.

Social disadvantage and low status can contribute to a sense of low self-worth, hopelessness and helplessness.

Current cultural influence is individualism and competition which requires comparatives and superlatives to drive it, rather than a collective responsibility. This results in social isolate plus the inherent comparison which fuels depression.

Intense emotional experiences that are shared between people allow frameworks of meaning to be created on them. This in turn allows them to be integrated into the individual.

Stress triggers

Stressful events can trigger depression.  The stress vulnerability model says that an underlying vulnerability is triggered by a stressor.

Chapter 2 Couple therapy for depression

Sick societies make for sick relationships, sick relationships make for sick individuals.

Couples and depression

Relationship problems correlates with depression. Having a confiding relationship is a protective factor against depression.

Which comes first depression or relationship problems

The strongest indication, although it is not robust is that relational difficulties precede depression. Although the conclusion drawn from research is that it is reciprocally causal.

Does being married increase the likelihood of becoming depressed

Women may carry the emotional voice for both partners.

(Depression= low status, low power to change, low power to achieve satisfaction due to being a broken machine)

Research shows that the married are happier than the unmarried. For men it seems more than depression leads to relational discord for women it’s the other way around.

Are partners responsible for causing depression?

Most episodes of depression are recurrence, and each recurrence increases the likelihood of relapse.  The stranger’s predictor of depression is having a history of depression. Depression is a recurring condition. Average age of onset of depression is mid-twenties. Average age of marriage is late twenties.

Given that depression is a recurrent condition, a life course development model is the best suited to understanding its essential nature.

Couple therapy can seem unwelcome by the non-depressed partner as they understand that the relationship and therefore they is being blamed for the depression.

Negative depressed relational pattern one partners LSE and the other partner’s frustration feed each other in a mutually reinforcing cycle of blame and guilt.

When depressed excessive reassurance seeking can take place in relationship.

A strong need for attention, emotional interdependence, fear of rejection and over sensitivity have all been associated with depression (as cause or symptom).

Depression in partners, as a psychological investment in self-confirming negative feedback.

Depression can play a part in determining the choice of partner. Children growing up in depressed families may be drawn to this quality. If I care for the depressed person I will earn the right to be cared for myself. They live vicariously through the care for their partner. Other things learnt in these families: being sick gets attention, relationship involves surrendering your competences.

An optimist is a person with a depressed friend.  Partners evoke in each other what they find most difficult to live within themselves. Is a person depressed, or is the relationship or conceivably to which partner does the depression belong.

Depression can be infectious: living with a depressed person can be depressing. There is also depression as referred pain, where it is manifest is not necessarily where its source is.

Depression and the parental couple

Whilst understanding depression as a process not as an event. A developmental understanding of depression can reduce the blame\guilt cycle when couples therapy for depression is offered. The model is that there are intra-personal difficulties that then interact with intrapersonal difficulties and the combination of the two can result in depressive symptoms.

Developmental pathways: depressed mothers emotional unavailability to a child’s distress leads the child into self-soothing, a depressed response to the mothers depression. If this is repeated this leads to emotional insecurity that can lead to depression in later years.  There are other pathways apart from this.

The parent’s relationship is a significant pathway for the child. A child evaluates their own emotional security by what is happening in the parents relationship (is it steady, will I be looked after). Children might interpret themselves as the cause of the parental conflict, which is another pathway.   Violent discord between parents as well as emotionally unavailable are pathways.

Couples therapy both represents a remedial and preventative action.

Can couple therapy reduce depression

In depressed relationships there are rules at work to govern the expression of emotion within the relationship. Patterned responses to depressive symptoms and used control to govern emotions.

Nice’s assumptions are that women are more receptive to emotional stimuli and case in the role of carer within the relationship. There are 7 million people who act as carers currently who are predominantly women.

RCTs were designed for testing drugs, where you can control the factors involved, and replicate tests. It is less clear of their use when testing relationships where you can’t isolate or control factors.

RCTs rely on controlled conditions but then need to generalise out to therapy conditions which are less controlled.  RCTs focus on outcomes rather than processes.

However process is a great influence, how the interaction between client and therapist is, has a large effect.

Behavioural exchange=do this for me and I will do that for you

Jacobson thought BE only worked with couples who were well motivated to change. `

What competencies do couple therapists need

Therapist needs to maintain a balanced relationship between both partners.  An example would be helping an enmeshed coupe with bounded communication where they talk for themselves and not for each other.

Knowing why and when to do or not to do something is important, which means a pure manual cannot guide therapy. Neither purely following a manual or pure clinical judgement leads to good outcomes.  A flexibly applied best practice guide would seem the best.

Therapy is mutually created by two active partners. How do you know how to do the right thing at the right time? Experience=shows commonly repeating pattern and theory which shows common treatments and their obstacles to these patterns.

Couples therapy for depression: an integrative approach

8 non-linear stages:

1.       Focussing

2.       Assessing

3.       Formulating

4.       Accepting

5.       Communicating

6.       Problem solving

7.       Changing behaviour

8.       Coping

9.       Ending

Chapter 3 Focussing

CTD is seen as treating those interactions between couples that maintain depression. The client is the relationship not the symptom bearer.

The couple as the therapists client

The whole is always greater than the parts, to understand one part of a system, you have to understand the other. Thus person, their history, the relationship, society... An event in one part of the system has effects throughout the rest. From a systematic perspective the ways parts are connected are more important that what is connected.  Mind, body and environment are the system.

This changed how family therapy was performed as opposed to treating someone as problematic within the family rather they become the symptom bearer performing a service for the whole family unit.

Couples hold huge emotional security for others, each member, children

Couple as the focus of interaction, i.e. so what goes on between the individuals is important

Some argue that public socio-political dramas are played out in the private theatre of relationship and what you need to do is change the public theatre.

Some argue that its individual pathology that is the3 problem so you should focus on that.

The couple as an open system

When operating as an open systems each partner brings to the relationship their history, environmental influences are felt, and there is the possibility of learning from and be supported by the relationship. However this model can overwhelm and people can draw up boundaries, and define the relationship in distinction to others.

If the boundary is drawn too tightly around the couple then influence from the external environment will not be felt, I the boundary is drawn too tightly around the individual then the interaction and dynamism will be lost between the partners,

The primary focus for therapy is the boundaries surrounding each unit as these define the interactions. In particular a sense of there being an us, which is greater than a you and me.  When the sense of us, is relatively fluid it can contain what happens between partners and what happens between the external world and each partner. If it’s not working well then events can be deadening or overwhelming.

Couple relationships therefore bound patterns of relating that regulates the emotional experiences of each partner. Do we have a depressed person or a depressed relationship? What function does the depression serve for the relationship?

In regulating emotions the couple must negotiate both the history and the geography of their situation. The history of a couple’s relationship are the things that tie them together, the geography is the pattern of interactions.

The history of the couple: levels of commitment

What is the conscious commitment to each other why did they get together, why do they stay together?

Standard external commitments maybe breadwinning and children and. internal commitments may be companionship, sex, shared values and romantic love.

What each partner expects of the other in terms of emotions and communication will be derived both consciously and unconsciously from their upbringing and life experiences.  This can be described as the internal working model: Bowlby. How relationships are for me: relationship schema beck, and object relations: Fairburn. There is then an unconscious pressure exerted to ensure conformity with this model

Partners maybe chosen on the basis of helping maintain their relational patterns, defences against anythi9ng different. If someone has grown up with an intrusive parent, they may be on their guard against it. Likewise if a person has been used to having certain emotional needs unmet, then if they feel that emotion then they will demonstrate behaviour that they have learnt from the past.

When couples run into difficulty it is most often within the unconscious ties or expectations that the answer lies.

The geography of the couple

The geography of the couple, how, when, where they interact what their expectations are, what their roles are an outcome of environmental factors, e.g. cultural values. This determines the nature of closeness\distance they want. Changes to this factor can cause disturbances.

The easier it is to predict a couple’s response to stress the more problematic their relationship might be as they have rigid patterns.

Secure attachments in others is seen in flexible care giving and care seeking and to be sensitive to which partners needs takes priority. Insecure attachment is unlikely to have this fluidity or mutuality.  Anxiety about the relationship can be seen in clingy behaviour or self-reliance.

Avoidant insecure attachment teaches people to take their upset away from the other, conceivably even away from themselves. These people are most comfortable looking after the needs of others than their own needs, although they may feel resentment about this.

Behind a dismissing exterior can lie a depressed child who has survived a history of rejection and avoids emotional connection with others?

Competitive care giving

If both partners are avoidantly insecurely attached they sometimes need to care for themselves vicariously through their partner. As neither partner will be a willing recipient of projected need, they might turn outside their relationship to do good works. They may then compete to give care to their children, with the threat of depression should they be excluded from the PCG relationship.

Competitive care seeking

Interactions where both partner seeks care from the other are likely to be competitive. They will have conflicting needs which will escalate emotions and frustration. They both have the need for the other to help them cope and have very low expectation of that need being met. Partners are more likely to be happy to express their own needs but not to look after the needs of others. These are angry rather than depressed relationships, although depression can be used as a protest.

Complementary care giving and seeking

This can work well when complementary although will make one dependent and prevent them from growing up.  The malign version is where the person giving care, seeks to produce the need for care to be given in the other.

Controlling care giving and seeking

An extreme form of avoidance\clinging, One partner coerces the other into compliance. Whatever resources a partner has to protect and assert themselves is undermined.  This may relate to disorganised attachment resulting in the victim\perpetrator pattern. These roles can switch so even though the active\passive roles remain, so suicide as a passive perpetrator action.

Analyse what goes on between partners, depression as relational, as protest.

Functions of depression

It can produce a solution to conflict, i.e. it identifies with the attacker so reduces the need to attack or be angry.

It can distract from a family loss

It can take the pain for someone: unemployed person steals the domestic role, leaving the domestic person feeling depressed

Working with older couples

Loss of paid employment bringing a loss of status and can produce enforced closeness in the relationship.

Assessing loss: both physical, psychological and functional

Helpful vs unhelpful challenging of long held beliefs, latter just results in more distress.  When would the latter be, when there is little chance of change maybe? Relating end of life experiences to the end of therapy. Endings may be powerful.

What is it that can be changed, what must be accepted or tolerated

Maintaining a balanced collaborative stance

Couples seeking help will often locate the problem in one partner. They may agree in this but often this will be the source of bitter disagreement. The upset in the relationship is likely to be destabilizing (weakens the attachment?). Thus each partner will be looking for the therapist to be on their side. This will be powerfully the case when there is a stark polarity either x or y but not both between the couple. One person’s reality excludes and challenges the other, it’s almost an existential crisis.

There are three marriages in every marriages his, hers and theirs.  The therapist needs to understand each partner’s marriage, and see the effects that it has on the other.  The therapist needs to understand both why it is that way, the fear and desire to change. 

In couples therapy the therapist needs to navigate the strong emotional whirlpool of the couple and also not hold on too much to the certainty of reason and therefore stifle any leap of faith, or change.  The therapist needs to focus on interactions both between the couple and between the couple and them.

How will the gender of the therapist affect therapy, what will be projected onto them, men are….

The relationship is critical to effective couple’s therapy.

Depression of one partner has meaning in the other person’s history, and also in their geography, i.e. how their current life and interaction is structured.

Chapter 4 Beginning

There is standardly a triangle of referral, a refer, a client and a therapist. Referrers who are made to feel weak may seek the help of experts to make them feel strong again. So you need to be aware of the client making the referrer feel powerless.

Referral information can be dressed up or down to get what the client wants.

What is the referral intended to achieve, what does each party want form it?

The referrer

Does this show support from some area, or is this a response to transgression, does the referral compound a sense of distraction, or to stigmatise and be rid of someone

The therapist

Curiosity about the referral process shows:

·         Clients motivation and how they operate   with a request for help

·         Show competing narratives in their networks.

The couple

What role has the therapist been put in: judge, healer, mediator or meddler or an irrelevance who will prove that there was nothing that could be done?

Suitability for couple therapy

Both partners need to see their relationship as something that matters and is important to them. The older the relationship before the depression started the more the depression may come out of the relationship.  Even if depression pre dates it, depression may have influenced the choice of partner p61

Which couples are unsuitable for therapy

Don’t rule out couples without depression, it can prevent it. Don’t rule out couples without distress as the non-depressed couple can need support.

Excluding aspects

1.       Self-harm

2.       Substance misuse

3.       Risk of intimate personal violence DV

Suicide

Each suicide attempt increases the risk of future attempts.

Intimate personal violence.

Intimate personal violence.   DV
Being young poor and a women, there is a high risk of DV

Taking men as the perpetrators

Women treatment=assertiveness then safety

Men treatment= take responsibility and to work on reducing it

Two male profiles that cause domestic violence

1.       Macho views about women no empathy sociopathic, criminal behaviour

a.       Lack emotional arousal due to neglect and abuse in early years

2.       LSE, emotionally dependent and jealous

a.       Highly aroused emotionally and depend on the other to help the deal with it

You then get pairings of people who both emotionally depend on the other and have LSE.

More than a third of same sex couples experience DV. BI\trans, disabled people and those with mental health difficulties are most likely to be abused.

Different types of intimate partner violence IPV

1.       Coercive violence

2.       Controlling violence

3.       Separation violence

4.       Violent resistance

5.       Situational couple violence

Conclusion DV is not always man against women. Men are predominantly the coercive and controlling violence whereas women on situational violence. Either sex instigates separation violence.

Risk

Expression of anger in the room doesn’t reflect IPV outside it. Strong feelings can be expressed with a need to express of defend oneself. This is different from hostile aggression which is related to destructive conflict.

People who have experienced abuse might be hyper vigilant towards any threat and have a greater need to control the situation than others. in order not to feel out of control themselves.

Suspicious of IPV, explore more with the couple, and then have individual sessions to establish the extent of the violence.

Coercive controlling violent couples should not be seen for conjoint therapy as it could give the perpetrator a sense of entitlement via increasing mutuality and communication of feelings. Mild situational IPV that is regretted in a couple doesn’t exclude them.

IPV witnessed by children has a powerful and damaging effect. Violence to partners correlates with violence to their children.

Assessing IPV

1.       What are the ABCs of violence

2.       Frequency

3.       Can they reflect on it or is the mood of blame

4.       Do they take responsibility of minimize what happens

5.       Do children witness, are partners violent to children  

6.       Is Substance misuse involved

Substance abuse

This will make therapy harder. There can be a reciprocal cycle between substance abuse and relational distress.                 Women in heterosexual couples may drink more to deal with relationship difficulties. Women are more likely to minimize their substance abuse.  Men are more likely to abuse alcohol\drugs and don’t conceal it. Drugs young people take them short term for excitement and to fit it, older people take them long term as palliatives.

Alcohol can be used to avoid problems. Substance abuse can be caused by and maintain depression.  To work with substance abuse in a couple you need to seek the function of the abuse, and the perspective of the other.

Alcohol affects SSRIs

The process of assessment

Assessing depression

Do an MDS. It is difficult when one partner has been diagnosed with depress, as the client is the couple and not an individual. Locating the problem in one person can lead to a polarization with one the sick the other the well. The polarisation happens through the well trying to locate the problem continually in the sick. Relationship distress leads to an increase in depressive symptoms.

Understand depression

1.       Frequency and context of episodes

2.       Did the partner know about their partner’s depression, did it affect their choice of partner? Did this lead to an implicit contract where one would care and one would be the carer.

3.       If depression happened after the start of the depression.

4.       What does each partner understand about depression, i.e. nature, cause, impact and prognosis

5.       How does depression affect each partner in the relationship

6.       What does each partner think will help the depression?

7.       How did you alleviate previous episodes of depression

Assessing the relationship

COLLATE

1.       Clarify the relationship problems

2.       Observing how they relate to each other and to the therapist

3.       Locating the different contexts relevant to their difficulties

4.       Listening for themes in the materials they bring

5.       Applying diagnostic tools

6.       Testing for suitability

7.       Enabling their participation process

Clarifying presenting problem

1.       Understand all problems

a.       What are the problems the couple are seeking treatment for

b.      What factors may be influencing these problems

c.       How distressed is each partner

d.      How committed are you to the relationship

e.      What issues divide them

f.        Why are these issues so difficult

g.       What strengths hold them together as a couple

h.      What can therapy do to help them

2.       Understand sex life

3.       Any difficulties with significant others

Observing

You can gauge the level of distress by how clients interact with each other, frozen silences or heated exchanges.  Behaviours is one indicator of how secure the client sees the relationship.  How clients behave together will give a sense of each of their roles. Who is spokesperson, carer, offender, jury...? This can help identify recurrent themes.  What feelings are stirred up in the therapist?  The therapist may experience roles that are ascribed to them of magician who can take problems away, the doctor who can soothe the pain, or the servant who is impotent to help

Locating contexts

Why present now for treatment? Disturbance in the couples systems may reflect disturbances in other systems they and each of them are involved in.

Relevant contexts are cultural and what life stage each partner is at.  Cultural background constructs the normative behaviour for each member of the couple.

External Life course. Young couples may be establishing themselves as independent from their families, but there may still be pressure, so they may not be certain what they want, or how to manage the pressure from their parents.  Has the couple just had a baby and needs to change roles? Is this a new couple one of whom needs to mourn the ending of a previous one? Is this an older couple who are facing loss of role, bodily and cognitive function?

Internal life course: This is how old or young the clients consider themselves to be irrespective of their biological age. What associations do they have with their external life occurs, e.g. becoming the parent that abused them.

So there is what’s happening the external, and what it means the internal.

Listening for themes

Themes define the roles, and organise perception, behaviours and feelings.

Themes

1.       Desire for closeness  with the fear of engulfment

2.       Quest for autonomy but the fear of isolation

Behavioural themes

1.       Attack\counter attack

2.       Attack\demand-withdrawal

3.       Mutual avoidance\withdrawal

Common language themes

1.       Closeness distance

2.       Control and responsibility

3.       You don’t love me and Its you who doesn’t love me

4.       Artist\Scientist

5.       Conventional\Unconventional

In the context of depression

1.       Needy\Needless

2.       Dependent\Independent

3.       Emotional\Unemotional

4.       Depressed\Non depressed

5.       Carer\Cared for

Themes are influenced by family history and personal biography as well as by current circumstances.

Applying Measures

Get some figures!

Testing for suitability

Coming to couples therapy can activate anxiety, through attachment issues, i.e. we are questioning the secure base. So clients may be anxious and it’s hard to listen and learn when you are feeling anxious. So the therapist needs to regulate emotion so there’s enough that the work is real and significant but not so much as it prevents engagement.

Enabling participation

Hope is fostered when they trust the therapist. Building resources by highlighting strengths and assets can be useful.

You become polarised around a theme

The structure of therapy

Session 1: Joint:

Topics: Presenting problem, strengths, weaknesses and description of the relationship. External pressures on relationship, Internal pressures on relationship.

Session 2/3: Individual

Topics own relationship history: significant relationships. Mental health history. Any concerns reluctant to voice during joint meeting

Session 4: Joint

Synthesised description of relationship, pressures on relationship at the moment, formulation. Goal for treatment, HW?

Some see individual sessions as taking away from the couple focus, i.e. what goes on between them, their interactions. Some see secrets as inevitable, some see it as preventing therapy

Individual sessions help build a WA with each partner, important as one partner can overshadow the other especially in depression.

As you assess you’re looking for themes, and within those themes polarities

Chapter 5 Formulating

The idea is that one partner’s dreams and nightmares are not their sole responsibility but rather are influenced by their partner, the thought, emotions and behaviours.

What is the function of polarisation?

What is the function of depression in the system?

A formulation is a functional description of interactions and their consequences.  It shows how the problem is self-fuelling.  The formulation shows the couples attempt to solve a problem but as a consequence makes the problem worse.

In psychodynamic terms it would how the notion of defence and anxiety, in relational terms between the notions of required relationship and avoided relationship.  The latter being associated with catastrophe.

Themes: closeness \distance

Taking blame in a relationship exerts some sense of control, where otherwise you might feel none.  Atoning for your transgressions might be preferable than trying to work out how to be assertive in a relationship as this might be linked with some unpleasant outcome.

Seeking reassurance that isn’t received confirms your fear.

Depression as keeping a partner at arm’s length.

Therapy can help by:

1.       Improving acceptance and tolerance of each other. Tolerance is managing unpleasant feelings the other is doing something that you don’t like. Acceptance is being with that difference, not wanting to change it or escape from it, or stop it.

2.       Improving communications

3.       Changing behaviour, and realising the effect of depression

4.       Problem solving skills to help dealing with conflict

Written formulations are useful to stop misremembering but aren’t helpful as they can freeze thinking and provide the right answer, as opposed to allowing the couple to think and adapt it for their purpose.

The formulation needs to be like the spine of the work, strong enough to support, but flexible enough to adapt to new information.

Polarisations= each increasing your effort to get through, which in turn pushes the gap between you ever wider. As a polarity becomes unbearable, the distance, the tension, then retreat can release this pain.

Distress tolerance seems key to quite a bit of this work.

You know, tell me therapist attitude. The therapists work is to provide the conditions in which self-healing can take place.

Motivational and defence systems.

Themes of active\passive, rational\emotional

The couple is the primary social defence against anxiety, alienation and isolation. Within it there is a need for intimacy and a tension with the fear of engulfment.  There are two things happening in a relationship the individual and the partnership, each has its own needs and they are sometimes conflicting.

Communally orientated motives include

1.       Affiliation

a.       A need to do things with people rather than as solitary activities

2.       Intimacy

a.       A need for closeness, personal disclosure

3.       Altruism

a.       A need to take care of other people’s needs even if it means personal sacrifice

4.       Succourance

a.        A need to be nurtured by others

Individually orientated motives include

1.       Autonomy to choose goals and to follow them through

2.       Power a need to exercise control over you environment

3.       Achievement, a need to increase your status

Difference in motivational profiles can cause tensions. Sometimes motivations can spring as defensive reactions to the partner’s behaviours.

Communally orientated profiles tend to have more weness, more shared activities, more flexibility in what is done. Whereas more individually orientated profiles have stricter boundaries.

Partners with large differences often choose the other as within relationship they get something in them that is lacking.

Helping someone in depression can be akin to invalidating their attempts to do it themselves.

One side of the couple fixes, the other feels, the fixer underlines the feeler through trying to fix them which the feeler resents, the feeler expresses their unpleasant feelings to work through them and the fixer resents that they are still stuck in a problem that should be fixed

It’s not that you have differences it’s the qualities you ascribe to these differences, instead of seeing your partner as different you see them as lazy, not good enough in some way. The other partner thinks they are right and the other person is wrong, both partner ends in a resentful standoff. They defend their own position and attack the other.  There can be a reframing of differences over time in the relationship.

The original unspoken contract when couples meet, when broken can generate a sense of betrayal without an obvious target.

Relationship distress is often blamed on forces that push the couple apart, i.e. differences. But it’s not the differences it’s what is made of them.

Tiny disagreements can take on a huge magnitude as they connect with a number of accumulated difficulties. 

Polarisation can be aided by the use of evaluative descriptions, good bad, or moral ones of should.

Complaints, criticisms, contempt which triggers stonewalling responses.

The mutual trap, is the impossible position where each partner feels trapped with no way out.

Sometimes insisting that the other changes merely pushes the other away.

Acceptance of difference can paradoxically create the environment where change can happen.

Chapter 6 Accepting

Unified detachment: creating distance without disconnection

Empathic joining: creating closeness without accusation

Acceptance is accepting someone is different to you without trying to change, or avoid this difference

The devil of a major detail may often lie in the detail of a trivial tiff. Conflict arises when one partner attempts to impose their preferences on the other.

BE won’t work unless there is a positive affective context, i.e. my partner deserves it. So you have to build up enough good feeling to get to this point.

The predicted consequence of behaviour can be a stimulus to that behaviour.

You always need the context in any functional analysis. The context is the situation, the mood, explicitly but also can be drawn out implicitly from the meaning that is given in functional analysis.

Acceptance orientated therapies focus on the context in which behaviour occurs.

Even the act of staying with an uncomfortable feelings rather than going into fight\flight can break a negative spiral.

Getting each partner to understand why the other might feel\think\act as they do.

3 Techniques to build acceptance in couples:

1.       Unified detachment

2.       Empathic engagement

3.       Tolerance building

Unified detachment

Creating distance without disconnection

In the heat of an argument everything provokes, everything is distressing everything seems to escalate. The same is true for depression when every engagement ends in negative thinking and making the depression worse.

Therapy needs to be a safe place, therefore distressing interchanges needed to be managed.

The idea here is then allowing the couple to stand back from what is going on. The couple need to agree on the description they come to of what is going on. A detached picture, unified detachment.  Unified detachment is to notice the interaction that are going on between the couple.

How to build unified detachment

1.       Analyse a recent distressing interaction at the process level not the emotional level

2.       Point out sequences and patterns and how they related to the formulation

3.       Help partners to see they are not their pattern

4.       Help partners to see what triggers both of them.

5.       Spot their pattern elsewhere e.g. at work

One pattern

1.       W worried and seeks reassurance

2.       M doesn’t want to talk as it could escalate, and withdraws

3.       W sees this as invalidating and withdraws as well

4.       Now have distance between each other which feels horrible

So step back from the problem in relationship. Name another couple that you can talk about, and understand it from outside.

Empathic Joining

Creating connection and avoiding confrontation.  Accusation and blame are toxic to building a feeling of togetherness.

Pain plus accusation=marital discord

Pain minus accusation =acceptance

In accusation and blame then there is hurt being expressed that the other is accused of causing. You need to see what this hurt is to start off with and see how family experiences or understanding of the relationship history has led to this.  This leads the person to feeling validated

How to encourage empathic joining

Notice where the mutual trap is and seek areas of conflict

Explore the feelings of each without alienating the other

Enable the listening partner to respond to what they have heard

Blame usually hides painful feelings

Therapist needs to balance interest between partners

Finding ways of seeing connection and sharedness

Building tolerance

This takes away blame from my partner, rather seeing them as different. Tolerance is managing what can’t be changed. Tolerance reduces threat, so reduces the need for fight or flight. Tolerance works best when change is unlikely and there is more to gain through letting go rather than struggling to get change.

How is tolerance built?

1.       Pointing out the positive aspects of negative behaviour

2.       Practising the intolerable behaviour in session

3.       Faking the intolerable behaviour at home between sessions

4.       Developing a capacity for self-care

Pointing out the positive aspects of negative behaviour

The partner’s behaviour has a positive aspect for them and potentially for the relationship. The behaviour might have been seen as positive when it was first done.

Practicing the intolerable behaviour in session

Doing it in session aims to make the actor to become more aware of the effects and the recipient more resilient to it. This needs to be set up with a clear rationale, otherwise this can cause more distress. You can only do this where all of the interaction is controlled by the couple.

Two parts:

1.       Replay the distressing behaviour

a.       Rationale

                                                               i.      Desensitize through repeating

                                                             ii.      Increasing understanding about what each partner brings to the problem

b.      Possibly stop at key points to find out what is going on

2.       Discussion after to understand what happens

3.       Fake the behaviour between sessions

a.       When partners have high emotions they find it hard to see the motivation of problem behaviour.

b.      Partner won’t know if the behaviour is real or fake.

c.       Behaviour should only last for a short period not to generate a fight

d.      Partner who fakes needs to pay especial attention to how their behaviour is received

e.      Only do this after you have a successful in session replay, i.e. with understanding and no escalation

Developing a capacity for self-care

This can help clients face the limitations of their relationship, give to themselves what their partner doesn’t. Slightly risky behaviour as this is saying my partner doesn’t I will get it elsewhere. What is is that each does for themselves that is in service of the relationship. It there is high distress in the relationship what can each partner independently do to reduce the heat.

Summary

Each partners behaviour needs to be understood in context and the context is often their culture and upbringing. Acceptance work can only happen after you get some tolerance.

Chapter 7 Communicating

Couples don’t always mean what they say!  Their communication may be true, e.g. I want to say words that hurt you as I feel hurt but they may not think the words that they say are true.

Evidence shows that communication exercises aren’t used outside of session by couples.

Communication between couples when one partner is depressed might be hard as they could be preoccupied with thoughts of uselessness and feelings of blame and guilt. The non-depressed partner may be irritated by the permanent bleakness and switched offness. The depressed person may find it hard to listen to anything that resembles a complaint or criticism which can trigger a defensive response and a breakdown in communication.  After a series of communication break downs couples may not have faith that talking is going to help!

The communication exercises may feel awkward and artificial to start off with but what they do is enable you to get greater intimacy.

Some communication skills are targeted towards the content of what is being said, some towards the connection between the speakers.

Care must be taken with the depressed person to not use communication skills as an opportunity for self-criticism.

Listener skills

1.       Summarising

2.       Reflecting

3.       Validating

4.       Question asking

Speaker skills

1.       Clarity in I statements

2.       Clarity in requesting change

3.       Conciseness

4.       Editing out negative statements

Exercise

Summarising

Couple takes a topic that is not super-hot, and goes through this exercise which will feel a bit artificial at first.

Ask the speaker to talk for a few minutes

Ask the listener to summarise what has been said and then ask for the speaker to confirm if they summarised correctly, then debrief and see what was learnt what was difficult.

Pitfalls: it can be difficult to avoid choosing an emotionally laden area, where grievances will be aired

Why: summarising ensures that one person is listen to and that they know it, i.e. they have expressed themselves and feel heard, that can be quite powerful as if it doesn’t happen what happens, you might try to make your point quite forcefully

Reflecting

Summarising is the basis of reflecting and this allows couples to feel closer to each other. This helps for one person to not just feel that their words have been heard, but rather what it means to them has been heard. The first step is to understand them in an emotionally attuned way.  The reflective listener shows empathy for the speaker’s position.

How to do it: on the basis of summarising then add an understanding of what the listener thinks the speaker may be feeling and why. Ask the reflector to see things from the listener’s perspective. What would it be like to experience the things the speaker is saying?

Pit falls: sometimes people will not be able to distinguish between their own feelings and those of the other

Validating

This can be a difficult skill as it requires a high degree of empathy.

This asks to show an appreciation of why the speaker holds the position\feels the way that they do.

You can only do this after each person’s polarised views has been validated.

You don’t need to agree with their position, but you need to be able to understand it.

The validating response needs to come from a real appreciation of the speakers position otherwise validation will appear insincere and patronising. To respond meaningfully the listener may need to ask for more information

Question asking

To be able to accurately understand what the speaker is saying may require more information, which can be achieved through question asking. Questions can be interrogations that can undermine your position, so the aim of asking questions is to explore the speaker’s perspective and not your own. Aim to enhance understanding of the other, rather than entrench misunderstanding.

Traps: point scoring and score settling

For the therapist to ask the listener whether they have heard the speaker, the context, impact, or intention of what was said can help stimulate curiosity between the partners.

Avoidance mechanisms: Many questions can be asked with no space to answer. Questions can change the topic

Speaker skills

Clarity in the I statements

This helps lessen the amount of accusations that are used in conversation you always do this and attempts to reduce generalisations.  I statements work best when affirming positive things within the relationship (?)

When you do x I feel y.

I guess the I statements allow one person to let the other person know how they are. If they get angry because they are hurt and attack the other person for this, we miss out the fact that we have been hurt that the other person might respond to with a sticking plaster, when attacked the other person will either retreat or attack back!

Clarity in requesting change

Disagreement mixed with resentment usually contains a demand for change.

How: make global complaints specific, the change should be specific and achievable.  Start small achieve then build on that.

Traps=Depression can make you think change isn’t possible, so be aware of that as a damper. Watch out for vague and global and impossible requests.

Consciousness: editing out negative statements and calmness

Some partners need to reduce verbosity and repetitiveness.  This can be caused by trying to make a point from every aspect, or by chaining together complaints to make an impossible list. This can be addressed by the therapist asking them what they want to come out of this conversation.

A speaker’s clarity, coherence and consciences is affected by how secure they are feeling.

Insecure preoccupied attachment is associated with a rambling style: You can’t put a framework around what is said, there is an ever present threat of being invaded by affective associations with other events that insert themselves into the conversations.

Insecure attachment relates to over conciseness, where the speaker may edit out much of the importance of what is being said to leave what is said hard to follow.

Conversational styles are the way of emotionally inflating or deflating the content of what is being said.  The therapist needs to reduce the too much emotional content, and spot when there is too little.

Potential barriers to communication

1.       Excursing control

2.       Acting out

3.       Make the therapist party to secrets

4.       Reverting to existing couple dynamics

5.       Using cultural differences defensively

Exercising control

Dominating the discussion or refusing to participate actively or passively. Analysing their partner, but leaving themselves out of it. Using red herrings, e.g. blaming everything on an affair, rather understanding what might lead to having an affair. Sting in the tail, where comments are followed by something belittling Also intellectualisation can be used for control as can humour on sensitive issues likewise over dramatizing.

Acting out

Refers to items that block communication, people use strategies to not communicate, e.g. mobiles, look out of window.  They may divert attention by flirting

Couple dynamic

The fit in a couple’s relationship can act as an aid to block communication, e.g. they might collude not to talk about difficult things. They may agree not to talk about anything that destabilises the balance of their relationship, e.g. through dismantling the polarisations.  

Cultural differences

Cultural, religious differences can determine what can and can’t be talked about. Likewise strongly held beliefs from childhood indicate the rules of communication.

The communication wheel

This can help with talking about troubling behaviour.  You go through each item and give a structured response.  Each partner goes through the wheel as they respond. This is not used as a communication exercise but rather to increase empathy and enhance closeness.

Promoting empathy changes the emotional context in which problematic behaviour occurs. Sometimes changing the emotional context will eradicate the problematic behaviour, sometimes it will lessen it. The emotional context being how you emotionally engage with the other in this behaviour

Developing empathic communication

As couples improve their communication more attention can be paid to the implicit as well as explicit emotions, especially when they arise out of misunderstanding of intention and motive.  The hypersensitivity and distress in relationship means that misunderstandings are more common.  Non distressed couples don’t react as strongly, as often or for as a long to misunderstandings as do distressed couples.

Emotions can be minimized, or one emotion, the bad one, hidden behind the acceptable one, e.g. anger hides upset or fear. Through either technique the emotion can be maintained as it is not assimilated, not made sense of, the hiding emotion, or behaviour is what makes sense. The feeling a bit flat, or a bit angry is acted on not what is actually going on.

Circular questioning

If you ask an individual within the couple how do you feel, you are treating the individual.  Circular questioning allows you to treat the relationship, i.e. the interactions and the differences that make the whole. Circular questions focus on interactions, the relationship (between questions, over time questions, what do you think a is feeling)

When a is depressed how do you respond?

Hard and Soft emotions

Empathic joining requires each partner to hear the others emotions.  When fired up the hard emotions can be easily expressed, but the softer emotions that are often with them aren’t. Again emotions tend to point at global expression, I hate you.

Hard emotions can conceal soft emotions.  Hard emotions are attractive as they make people feel strong, and invulnerable. Expressing hard emotions pushes people away or encourages a fight. Expressing softer feelings encourages intimacy and closeness.

Emotional distress is often linked to attachment anxieties in adults.  Secure attached couples can withstand larger emotions without losing their ability to think as they don’t think that the emotion is attachment threatening, or if it was that I’m ok and I can reattach. Secure attachment means relational distress is seen as temporary. Securely attached don’t have a one dimensional blaming of the other person, they see their part in it, the context and its temporality.

Insecure couples

Row=>Global statement you’re always x

It’s not temporary, you are a klutz and I reject you

Attack\withdraw or battle

My relationship is traumatizing, no comfort is given, either comfort is sought elsewhere or depression. No soft feelings are shown within the relationship.

The fight\flight\freeze response can be deadly in couples, this is why mutual empathy is key. Therapist needs to understand each partners emotions in terms of their wishes and desires, i.e. empathise. The emotion isn’t the problem isn’t what’s done with it, so feel scared, get angry, attack.

Amplify too quiet emotions

Dampen too loud emotions

Relate feelings to thought to be understood

One partner may think it a big deal expressing an emotion they are ashamed of, where the other partner may dismiss it. This might inflame the shame and show something of the fear the other partner has of venturing into their world.

It’s not hard emotions are bad, and soft good. Anger can get the couple to pay attention to something.  Continual fear can alienate partners and create distance.

Depression often has an overly strong expression of soft emotions.

~Evolutionary\social aspect of emotions=

Hard emotions=individualistic, self-centred behaviour designed to increase power and provide competitive edge.

Soft emotions=promote social co-operative behaviour required for attachment security

If someone often expresses an emotion, there is a tendency to increase the intensity as its affects are less.

Feelings

Hard

Soft

Flat=withdrawal, disengagement, lack of emotional involvement.

Flat feelings are often associated with depression and can make it hard for the partner to get a response.

Working with excessive expression of feeling

Sometimes the depressed client can be so involved in ruminative self-recrimination that it makes increasing understanding and empathy hard\impossible. Depression is more often associated with soft feelings but a regular expression of them makes them unpalatable and wearing.

Why do you think the emotion is over expressed?

Is this because they are not heard?

Is it because they can’t regulate their own emotions and need self-soothing?

Are they performing a role for the relationship?

Emotional containment

Keep emotion in a jar, only talk about a specific topic at therapy, or in a certain place at a certain time.

Therapist expressing the unexpressed emotions between a couples, like a parent does for a child.  Here the overwhelming nature of the unexpressed emotion lessen as it is named by another, who isn’t overwhelmed by it.

Conscious Containment

1.       Length of time to express the feeling

2.       Discuss one emotional problem at a time rather than chaining

3.       Emotional support mechanisms, things, activities, people

4.       Use tolerance techniques to make the emotions of the other bearable.

Linking emotional expression to developmental history

Some clients can’t make use of communication exercises due to early scripts, schemas etc. Therapist looks for repeating problematic patterns of relating.  Putting presenting behaviour in developmental context is useful for the partner to empathise, you then can also do this with the partner and see how they choose each other sometimes for their “weaknesses” as they get to play out things that are important to them.

Working with cognitive distortions and changing perceptions

We develop assumptions about the world which help us navigate, it’s easier to force experience into these assumptions than to change them, it’s not comfortable to change something so fundamental.

The more you screen out assumption challenges, the longer you do it, the better you become. The better you become at screening out assumption challenging then the more rigid your thoughts and emotions and behaviours become.

What are the thought patterns that is causing distress within the couple?

Difference between distresses that is warranted as it is part of life, and distress caused by a distorted reality.

Emotional distortions

1.       Because I feel angry , I think  in angry terms, and perceive in angry terms

Cognitive distortions

1.       Selective attention

2.       Attribution, who caused, what caused..

3.       Assumptions: schema, scripts

4.       Standards, the yard stick by which the relationship is measured

If you challenge ones thoughts, beware of proving the other right.

Summary

Communication problems are more often driven by emotions than lack of skill

Chapter 8 Problem solving and changing behaviour

You can only influence a problem if you are affected by it: Jung

Couples can solve problems in their life they just have difficulty in their relationship.

Problem solving training a two stage approach

Many problems are unsuited to this as:

1.       Partners may not want to solve it

2.       The desire is merely to be proven right

3.       The desire might be to get revenge

4.       The desire may be to hurt

5.       The problem is not under the couples control

6.       The problem may not be changeable

7.       The problem only has one solution e.g. want a baby

8.       The problem is perpetual

For problem solving to work there must be a range of options, to allow compromise and creative solutions that might get to a win win situation. A win lose outcome is not a success for the relationship.

Couples need to decide if they are to fight over their difficulties or solve them.  Problem solving won’t work until this happens.

Defining the problem

Couple needs to agree on the problem before starting to solve it. They need to be specific and robustly defined to stop other problems creeping in. If a solution can’t be found, then this can then be something that needs to be accepted.

There can be different interpretations between couples about the problem and the difficulties that lie underneath.  Problem solving should take up the whole session, as other difficulties can get drawn into it.

To define a problem

1.       In stating a problem, try to being with something positive

2.       Be specific, avoid generalisations and derogatory nouns and adjectives

3.       Express feelings

4.       Be brief when defining the problem

In stating a problem try to begin with something positive

Defining a problem is risky as it can bring up all the feelings associated with it.  How an argument starts defines how it will end.

Be specific, avoid generalisations and derogatory nouns and adjectives.

Vague statements can only provide vague understanding and giving a vague problem to a partner doesn’t allow them to understand it, to see if they agree, not to act on it should they want to.

Generalisations don’t work in problem solving as you can always counter with a specific instances, indeed both parties can, which is a perfect recipe for a fight.

Watch out for insults, or inflammatory remarks, invoking unchallengeable authorities, all my friends say… Use of labels tend to provoke retaliation.

Express feelings

Problems are always fuelled by feelings, if you didn’t have any about the problem, it wouldn’t be one as you wouldn’t care about it, not have the tools to deal with it.  The capacity to express feelings is generally associated with intimacy and trust.

Be brief when defining the problem

Brevity avoids chaining problems.  This can be helped by focussing on what the problem is rather than why.  Large problems need to be shaped.

Well defined problem

1.       Both partners agree on the problem

2.       Starts with something positive

3.       Is briefly defined

4.       Is specific

5.       Situations in which the problem occurs

6.       The consequences of the problem

Stage 2 Solving the problem

1.       Both partners acknowledge their role in creating the problem

2.       Only one problem should be discussed at a time

3.       Paraphrase

4.       Avoid inferences talk only about what can be observed.

5.       Be neutral rather than negative

6.       Focus on solutions

7.       Aim for mutuality and compromises when talking about changes of behaviour

8.       Discuss the pros and cons of proposed solutions

9.       Reach agreement

Both partners should acknowledge their role in creating the problem

Notice partial avoidance of responsibility, I realise I don’t x, but it’s because you don’t y. Now we were talking about x now we are talking about y. Either stick to the problem, or other partner acknowledge your part in y.

Discuss only one problem at a time

Often the discussion will remind of related issues that they will want to talk about.

Paraphrase

Paraphrase what you have heard before speaking, this reduces understanding, promotes good listening, and slows things down.

Avoid inferences talk only about what can be observed

Partners often mind read. This can change the focus from the problem to the mind read assumption.

Be neutral rather than negative

Scoring points off each other, who is better doesn’t help problem solving.

Focus on solutions

Focus on solutions not causes.  Brain storming helps even silly or impossible solutions, as it can free up the juices.

Aim for mutuality and compromise around changes in behaviour

Being together in this is one of the benefits of this approach not just the solution. Depressed partners can feel excluded, acted on which can be aggravated by the other partner taking on too much responsibility.  Change can be resisted by making unrealistic demands.  Differentiate between what is ideally wanted and what is achievable.  Small joint achievable changes promote another change. Failed over ambitious non conjoint projects leave both in the couple feeling hopeless.

Discussing the pros and cons of a solution

As you go down a brain stormed list then rule out the silly. Then ask would any solution improve the problem, if it would then put it through a pros and cons test.  Aim to work together can counteract the sense that one person is just putting obstacles in the way.  Look at pros first.  Then decide to

Remove, tweak, keep on the list until all other options have been assessed.  

Reach agreement

Agreements need to be specific. Written agreement reduce the chances of memory lapses.  Choose one solution then that will be implemented.   Establish who, where when and contingency.

Implement

As the plan is implemented then reviewing how it is going is important until the plan is finished.

The problem of perpetual problems

These can be conflicts in personality, or long held beliefs. These are not for changing but tolerating and accepting.

To work with a perpetual problem then you need a dialogue, without dialogue then you get gridlock and disengagement?

The features of a perpetual problem are:

1.       The four horsemen of the apocalypse

a.       Criticism

b.      Defensiveness

c.       Contempt

d.      Stonewalling (delay9ing or obstructing by being evasive or refusing to talk)

2.       Vilification, it’s not we are different you are deficient

3.       Each sees the other as the enemy

4.       Feeling unaccepted and criticised

5.       Entrenched positions with polarisation

6.       Fear of accepting influence

7.       Pattern of emotion disengagement.

Focus on the positive aspects of a relationship that enable you to get through the difficulties:

1.       Friendship

2.       Good times

3.       Intimacy

Behavioural exchange helps with perpetual problems, as it creates a warm container to manage difficulties. Behavioural exchange either aims at enhancing positive or decreasing negative.

Behavioural exchange techniques

This is based on the pleasurable things that used to be done are done less.  In the early days effort was put in, and good feelings resulted, now you can get unpleasant behaviours put in and no effort put in.  

Behavioural exchange=promote care and companionship

The exchange is old behaviour for new.

Behavioural exchange enhances caring gestures that enhance pleasure between couples and promote companionship. Caring gestures can be very small and relate to ordinary things.

Caring gestures

Revitalise existing ones, rather than create new ones

1.       List small things

2.       Specific

3.       Undemanding things

4.       Positive things (i.e. do more, rather than less)  

5.       Easily doable

6.       Don’t rely on external circumstances  like good weather, or another’s availability

7.       Don’t require large amount of time\energy\money

8.       That can be repeated regularly

A good exchange

1.       Becomes part of daily life

2.       Doesn’t require reciprocation

3.       Be recognised as having been done

…. that would be welcomed by your spouse.

When BE is done conditionally then this breaks down as the depressed partner isn’t as active as the non-depressed.  There can also be a score keeping, and acrimonious feelings when things go wrong. There is also the valuing, I did x which is worth 10, has only done 5, so he owes me.

Acknowledging what has been done, means you don’t take things for granted and you notice what your partner is doing to help the relationship. This can\should be a shared list.

After doing this a few times, then the other can add items to the list, following the same criteria.

Caring days

These take longer than caring gestures, and are the things   that the couple used to do, but have now got out of the habitat of doing. They provide a period of time for the couple outside of the ordinary commitments. They involve one person planning a nice thing to do for the other.

Companionable activities

Depression and distressed relationships can leave partners feeling distressed, isolated and alone. So this is to choose to do some things together.  This aims for the couple to be together in more ways that they enjoy.

Traps: stuck roles. Behavioural patterns, no planning setting up for failure.

Behavioural exchange is not an end in itself, but rather another way to increase understanding of partner by partner.

Structured reciprocal behavioural exchange

1.       Make a list of what would increase pleasure for your partner (no expectation this will be acted upon)

2.       Discuss the list at next session

a.       Set up

                                                               i.      This is therapist led, the other partner needs to not react or respond whilst this is being done.

                                                             ii.      Purpose to make sure each item on the list is clear and doable

b.      Partner one reads list

                                                               i.      Therapist clarifies and ensure they are achievable.

c.       Therapist ensures nothing is missing from the list. Hasn’t she mentioned x in session

d.      Partner two reads from their list

e.      Then homework is set for items to be done off the list and see if it’s noticed. Notice the effect on your partner.

f.        Next session review the weeks tasks

                                                               i.      Receiver speaks first

1.       What tasks did they notice

2.       Which items made them feel better about the relationship

                                                             ii.      Actor

1.       How costly to do what you did was it

                                                            iii.      Each can comment on the importance on the list of the other, and then can add items

g.       HW: do things from the list again, notice the consequences and if the partner noticed and what their reactions were.

Tasks should be more of something pleasurable and not less of something irritating.

Why BE fails

1.       Partners don’t do tasks

2.       Wrong items were chosen from the list

3.       Couple didn’t need help with this kind of interaction

4.       Therapist didn’t explain things properly

5.       Not enough acceptance is within the couple’s relationship to enable compromise, collaboration,  and accommodation of the others wishes

Helping homework to succeed

Ensure that the task isn’t assigned due to therapist frustration

Couples who are antagonistic won’t benefit from BE.

BE needs some level of empathy and communication skills, tolerance and acceptance to allow it to work.

Chapter 9 Coping

Stress is part of everyday life, dealing with it, creates a resilience. Load bearing structures need to have some tension in them to support weight. Too little stress can drain you of energy too much can paralyse you. A relationship enables stress to be managed, therefore stress within the relationship can be doubly threatening. When you add the hopelessness and helplessness of depression to a relationship, then that can lead to a sense that everyday stresses can’t be coped with.

Stress and the couple relationship

Stress causes

1.       An event

2.       Acute or chronic demands

3.       Relationships between individual and environment

Stress that affects one partner affects the other

Dyadic stress: Stress affects the couple through

1.       Same event affects both

2.       One person’s stress affects the other

3.       Stress between the partners

Three variables that determine how a couple cope with stress.

1.       Pre-existing vulnerabilities to stress

2.       The event

3.       The capacity of the couple to adapt to the stress on one partner

Stress as a	Stress that arises from causes that are
Stimulus	External\Internal
Reaction	Major\Minor
Transaction	Acute\chronic

Stress affects the relationship by

1.       Reducing meaningful time spent together

a.       Reduces bond as a couple

b.      Reduced every day intimacies

c.       Relationship isn’t seen as a comforter in the face of stress

2.       Enhancing a negative bias

3.       Reducing good communication

4.       Reducing well being

5.       Focussing on negative factors in your partner

Stress correlates with relationship break up.  Stress affects sleep, enflames illnesses, can change personalities so that people become more rigid, hostile and critical when stressed. Women can get angrier men can get more withdrawn.

As stress comes from outside and then affects the relationship it can turn from chronic into acute.

Enhancing couples coping capacities

Positive dyadic coping skills

1.       Supportive

a.       Comforting words

b.      Advice given

c.       Empathic understanding

2.       Joint

a.       Joint activities

b.      Mutual commitment

c.       Relaxing together

3.       Delegated

a.       One partner putting in requests to the other who responds to them.

Negative coping styles

1.       Hostile

a.       Disparagement, distance, mocking, sarcasm

2.       Ambivalent

a.       Support given unwillingly, or conveys ways that it is not really needed

3.       Superficial

a.       Asks how partner is then doesn’t listen. Gives support without empathic sensitivity

Start by looking at when stress has been coped with well.

3 stage coping model for dyadic stress

1.       Identify the emotional impact of stress on the stressed partner

2.       Adapt the non-stressed partners response to the stressed partner

3.       Obtain feedback and adapt the responses of the non-stressed partner

If both partners are stressed then each can take turns being speaker and responder

Exercise

1.       Purpose build emotional closeness, empathy and understanding

a.       Speaker says what is stressing them and the emotional consequences

b.      Listener summarises back what they have heard.            

2.       Listener expresses emotionally connected support

a.       Reframe situation

b.      Focus on strengths of partner

c.       Help find solutions

d.      Promoting a sense of solidarity with the partner

3.       Feedback from stressed person as to how helpful speaker has been

Exercise is then repeated but the roles are swopped and the non-stressed gives a problem and its emotional consequences.

Distinction between support that encourages and support that undermines. The latter would reinforce the sense of sick role, and incapable.

Look for connection between current stress patterns and historic ones.

Coping with Sexual problems

Depression lowers libido.  Lack of sex can be stressful for a couple and depressing in itself.  A good enough sexual relationship is the aim, that doesn’t hit the porn heights of 10 times a night, not the once you’ve been together for 2 years then it’s over. A good enough sex life has some unsatisfying encounters and some good ones.

Sexual dysfunction

1.       Interest

2.       Arousal

3.       Orgasm

Factors affecting sexual desire

Women=menstrual cycle, child birth and pregnancy

Men=age

Both=societies refusal to acknowledge older people as sexual beings.

Depression can lower your belief in your right to have pleasure.

Area of Interest	Men	Women
Interest	Impaired sexual interest	Impaired sexual interest
Arousal	Erectile dysfunction Impotence	Impaired sexual arousal, not getting wet
Orgasm	Too soon, premature ejaculation	Cant

Sex is a powerful nonverbal communication of the desire for intimacy.

Excessive politeness, or its converse hostility can inhibit sexual relationships.

As can parent\child, parent\carer relationships and not being able to shut the door and keep the kids out.

When one partner volatile and the other conciliatory, then the latte can get their own back by withholding sex.  They communicate their displeasure and exercise control in doing this.

Sexual desire\ability can be affected by various medical conditions, SSRI affects Interest, arousal and orgasm for many people.

Social homophobia can get internalised into internal homophobia.

Chapter 10 Ending

That therapy will end is just another event for the client.

Making an ending

Ending as review.  Mixed feelings as good sign, happy to finish but sad. One dimensional feelings show emotional work hasn’t been done (?). Clients need to feel some ownership of the change that has happened, otherwise it becomes lost when they finish therapy.

Sometimes one person may say directly now is not the right time to end, or indirectly with a return of symptoms. Sometimes endings can be avoided as they are found to be painful.

Client ending

Can indicate approach not right, they don’t want to work on their relationship like this, or the relationship is shot and not worth working on.

Stopping and ending

Stopping is ceasing

Ending is bring something to completion

Not everything that stops is ended and rightly so.

Relapse prevention

Ensure warning signs are spotted.

Stress is part of life, people get depressed, but this doesn’t mean to signal a disaster.

Identifying weak spots= Imagine talking to your therapist in a years’ time, and that things hadn’t been going that well, what would account for this do you think.

Therapist needing to fade out of the picture towards the end of therapy.

Issues that are thrown up at the end can be ignored, all relationships have rough edges, to engage with them might just be avoiding ending.

Prevention Relapse

Habits die hard, especially ones that say avoid discussing difficult emotions as you are having to do something a bit tough! This can mean making time for the relationship.

You can set up couple reviews to meet at 6 monthly sessions to see how things are going.

The recurrence of depression

The most reliable predictor of depression is the number of previous depressive episodes. Couples can identify triggers to depression.  Hopefully though the next one will be longer away and less intense than the last one.

Discourses on endings

Discourse	Therapeutic  relationship	Activity  in therapy
Ending as loss	Client dependent	Work through loss Mourn ending Avoid talking about ending
Ending as cure	Therapist as expert	Therapist gives client a clean bill of health Therapist redefines it as a problem of living
Ending as transition	Collaborative, client uses it to move on	Therapist Invites witnesses to clients change? Therapist questions about new knowledge and new stories of self
Ending as relief\release	Client and therapist are trapped	Therapist releases client Client frees therapist
Ending as metamorphosis	Alliance as founded in curiosity