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.