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Chapter 15 DEPRESSION AND ANXIETY When a member of a couple develops depression or anxiety, this has a profound effect on the relationship and members of the couple may develop interaction patterns and belief systems that maintain the anxiety or depression. It is not surprising, therefore, that there is considerable evi- dence that couples-based treatments for depression and common anxiety disorders, such as panic disorder with agoraphobia, are particularly effective (Beach, 2002; Byrne, Carr & Clarke, 2004a). A systemic model for con- ceptualising these types of problems and a systemic approach to therapy with these cases will be given in this chapter. A case example is given in Figure 15.1 and three-column formulations of problems and exceptions are given in Figure 15.2. and 15.3. The lifetime prevalence of major depression is 10–25% for women and 5–12% for men (American Psychiatric Association, 2000). Up to 15% of people with major depression commit suicide. The lifetime prevalence rates for all anxiety disorders is 10–14%, and for panic disorder with or without agoraphobia, the anxiety disorder considered in this chapter, the rate is 1.5–3.5% (American Psychiatric Association, 2000). Many people attending psychiatric services show both anxiety and depressive symptoms and often a range of other problems such as substance abuse, eating disorders and borderline personality disorder (American Psychiatric Association, 2000). DEPRESSION Major depression is a recurrent episodic condition involving: low mood; selective attention to negative features of the environment; a pessimistic belief-system; self-defeating behaviour patterns, particularly within intimate relationships; and a disturbance of sleep and appetite. Loss is often the core theme linking these clinical features: loss of an important relationship, loss of some valued attribute such as health, or loss of status, for example, through unemployment. In classifi cation systems such as the DSM-IV-TR (American Psychiatric Association, 2000) and the ICD-10 (World Health Organisation, 1992), major depression is distinguished from bipolar disorder, where there are also episodes of elation, and from dysthymia, which is a milder, non-episodic mood disorder. However, ‘double 432 FAMILY THERAPY PRACTICE WITH ADULT-FOCUSED PROBLEMS depression’, which involves persistent dysthymia coupled with episodic major depression, characterises many chronic service users, who may be referred for couples therapy. ANXIETY Anxiety is distinguished from normal fear insofar as it occurs in situations that are not construed by most people as being particularly dangerous. Figure 15.1 Case example of depression Referral. Adrian and Anne originally came to therapy because of diffi culties they were having with Aoife their teenage daughter, specifi cally the ongoing confl ict between Anne and Aoife. These diffi culties were addressed in an episode of child-focused family therapy, after which the couple contracted for a further episode of therapy addressing their marital problems. Since shortly after Aoife’s birth they had had periodic diffi culties associated with Anne’s depression. Anne, like her mother Lucy was diagnosed with major depression and had been treated periodically with antidepressant medication. Like her mother, Anne found that the mood disorder created confl ict in her marriage as well as in her relationship with her eldest child. Adrian found the mood disorder challenging to live with and coped by adopting a coldly effi cient caregiver role with respect to Anne and the children. Periodically, however, the strain of this way of managing the situation would become too much for him to cope with and he would become highly critical of Anne and verbally aggressive towards her. This would exacerbate the depression. Formulation. Three-column formulations of episodes in which the depression had a profound negative impact on the relationship and exceptional episodes where such problems were ex- pected but did not occur are given in Figures 15.2 and 15.3. Therapy. Therapy focused on helping the couple examine the problems that the complementary caregiver/invalid roles created in their marriage and specifi cally how it prevented them from meeting each other’s needs for intimacy and a more balanced distribution of power. Role- reversal exercises were used with this couple to good effect, because it helped them understand the impact of the complementary roles on their partner. The couple increased opportunities for intimacy by scheduling things they like to do together on a daily basis. They also replaced reassurance requesting and giving with the CTR routine for challenging depressive beliefs and narratives described in the chapter. TrevorMarie Anne 39y Adrian 40y John Nra 30y Frank 35y Sylvia 38y Family strengths: Adrian and Anne have prevented depression from ending their marriage for 14 years Lucy Brian 34y Amy 4y M 18 y ago Aoife 14y Nra 30y Triona 34y Depressed Aine 10y Depressed Tom 1y Rick 5y Toby 8y DEPRESSION AND ANXIETY 433 In response to stresses such as childbirth, home–work role strain, and so forth, Anne becomes depressed, irritable, silent, inactive and self-critical In response, Adrian becomes coldly efficient in caring for her and managing the children and the house In response Anne becomes more depressed Periodically, Adrian becomes angry and critical of Anne, accusing her of malingering or being intentionally irritable with him or the eldest daughter, Aoife In response, Anne becomes more depressed Later, Adrian becomes remorseful and expresses his remorse by becoming colder and more efficient in caring for Anne In response Anne feels more depressed Anne believes that she has no value and is powerless to change her situation Adrian believes he has a duty to care for Anne and the children, no matter how lonely or sad or frustrated he feels in response to Anne’s depression Adrian believes that Anne has changed forever and the wonderful woman he married and who met his needs for intimacy and companionship has been replaced by a lazy, punitive, vindictive person, but later believes that this view is a reflection of his own lack of strength and integrity Anne believes that Adrian’s criticism’s are all justified and believes she is guilty of letting him and her children down by not fulfilling her role as a wife and mother Anne may be genetically vulnerable to depression and so becomes depressed when faced with increased demands and stresses Adrian has been socialised in a family where doing one’s family duty is a central value For Adrian, the loss experience and grief associated with repeated comparisons of Anne as a depressed person and Anne as she was when he first met her make him vulnerable to grief- related anger Anne’s depressive thinking style and her family-of-origin experiences of living with a depressed mother make her vulnerable to accepting Adrian’s criticisms as valid Figure 15.2 Three-column formulation of a situation in which depression damages the relationship 434 FAMILY THERAPY PRACTICE WITH ADULT-FOCUSED PROBLEMS Within classifi cation systems such as the DSM-IV-TR (American Psy- chiatric Association, 2000) and the ICD-10 (World Health Organisation, 1992), distinctions are made between a variety of different types of anxiety disorders on the basis of the types of situations that elicit anxiety, the routines people use to avoid or modify these, and the duration of episodes of hyperarousal. For example, generalised anxiety disorder, in which many situations are viewed as threatening and chronic hyperarousal occurs, is distinguished from specifi c phobias in which individuals only fear a discreet class of situation, such as heights or confi ned spaces. One of the most debilitating anxiety disorders commonly seen in outpatient clinics, and one which we will focus on in this chapter, is In response to stress Anne becomes depressed, irritable, silent, inactive and self-critical In response Adrian expresses his sorrow and sense of loss Anne feels connected to Adrian and this makes the depression a bit more tolerable Adrian and Anne have sufficient connection to do something they both enjoy without the expectation that this will cheer Anne up for once and for all, or that it will magically relieve Adrian’s sense of sorrow In response, Anne feels a little less depressed Anne believes that she has no value and is powerless to change her situation Adrian believes that it is important to represent yourself honestly Adrian and Anne believe that doing things together will maintain their sense of being connected Anne may be genetically vulnerable to depression and so becomes depressed when faced with increased demands and stresses Adrian has been socialised in a family where being honest is a central value Both Adrian and Anne have memories of how good their relationship was initially when they did a lot of pleasurable things together and this allows them to consider the possibility that a version of this experience may be recreated Figure 15.3 Three-column formulation of an exception to a situation in which depression damages the relationship DEPRESSION AND ANXIETY 435 panic disorder with agoraphobia. With panic disorder there are recurrent unexpected panic attacks. These attacks are experienced as acute episodes of intense anxiety involving autonomic arousal and a heightened sense of being in danger. They are extremely distressing. Individuals with panic disorders come to perceive normal fl uctuations in autonomic arousal as anxiety provoking, since they may signal the onset of a panic attack. Many people with panic disorder develop secondary agoraphobia where they are frightened to venture out of the safety of their own homes in case a panic attack occurs in a public setting. The idea that the world is a dangerous or threatening place is a core belief for people with anxiety disorders. They develop constricted lifestyles and many become chronically housebound. SYSTEMIC MODEL OF ANXIETY AND DEPRESSION Single factor models of depression or anxiety, which explain these conditions in terms of genetic vulnerabilities, biological processes, early socialisation experiences, stressful life events, intrapsychic processes and belief systems, and patterns of social interaction, have made important contributions to our understanding of depression and anxiety. However, integrative models of anxiety and depression, which take account of inter- actional behaviour patterns, pessimistic or threat-oriented belief systems and both genetic and developmental vulnerabilities, offer a more com- prehensive systemic framework from which to conduct couples therapy (Beach, 2001, 2002; Byrne, et al., 2004a; Carr & McNulty, In Press, b; Craske & Zollner, 1995; Gollan, Friedman & Miller, 2002; Joiner & Coyne, 1999; Jones & Asen, 1999; Taylor, In Press). Such an integrative approach, based on the work just cited, will be presented below. It should be highlighted that most of the research on integrative systemic approaches to the conceptualisation and treatment of depression and anxiety have been based on studies of white middle-class heterosex- ual couples in which the female partner was symptomatic and the male partner was either less symptomatic or non-symptomatic. The conceptualisation given below refl ects these cultural and gender-based constraints. The conceptualisation may require modifi cation if applied in work with cases with different cultural and gender profi les. Predisposing Constitutional and Developmental Factors Both genetic and environmental factors contribute to the development of anxiety and depressive conditions. For both types of disorder, the amount of stress required to precipitate the onset of an episode of depression or anxiety is proportional to the genetic vulnerability. That is, little stress may precipitate the onset of an episode in individuals who are genetically 436 FAMILY THERAPY PRACTICE WITH ADULT-FOCUSED PROBLEMS vulnerable to the condition, whereas a great deal of stress may be neces- sary to precipitate the disorder in individuals who have no family history of anxiety or depression. For depression, early loss experiences such as unsupported separations, parental psychological absence through depression, bereavement and a depressive, pessimistic family culture may play a particularly important role in predisposing individuals to depression. For anxiety, anxious at- tachment, an inhibited temperament, excessive interpersonal sensitivity, exposure to parental anxiety and an anxiety-oriented family culture that privileges the interpretation of many environmental events as potentially hazardous may play a particularly important role in predisposing individuals to anxiety. For both depression and anxiety, negative early life experiences including abuse, neglect, multiplacement experiences, parental confl ict and family disorganisation may render youngsters vulnerable to developing either condition in adulthood. Precipitating Factors Episodes of major depression and the onset of anxiety disorders may be precipitated by stressful life events and lifecycle transitions. Loss experiences associated with the disruption of signifi cant relationships and loss experiences associated with failure to achieve valued goals, in particular, may precipitate an episode of depression in adulthood. Marital relationships may be disrupted through confl ict and criticism, infi delity and violations of trust, physical and psychological abuse and threats of separation. Other supportive peer relationships may be disrupted through developing a constricted lifestyle or moving locality. Failure to achieve valued goals and threats to autonomy may occur with work-related per- formance diffi culties or unemployment. Events that are perceived as dangerous or threatening to the individual’s security or health may precipitate the onset of an anxiety disorder. Such events include personal or family illness or injury and victimisation or serious confl ict within the marriage, wider family or the workplace. With agoraphobia in married women, one possible precipitating factor is marital confl ict arising from the woman’s unfulfi lled need for autonomy. Belief Systems Both depression and anxiety are maintained by particular types of belief systems. In depression, a preoccupation with past losses, a negative view of the self as valueless and powerless, and a pessimism and hopelessness about the future are the core themes of this belief system. With anxiety, the core theme is that of danger and threat. The world is construed as a DEPRESSION AND ANXIETY 437 dangerous place involving multiple potential threats to health, safety and security. Depressed individuals selectively monitor negative aspects of their own actions and those of others. Depressive belief systems are char- acterised by high levels of self-criticism and a belief in personal pow- erlessness where successes are attributed to chance and failure to personal weaknesses. This depressive belief system leads to a reduction in activities and an avoidance of participation in relationships that might disprove these depressive beliefs or lead to a sense of pleasure and optimism. Anxious individuals are hypervigilant for danger. They may also interpret ambiguous situations as threatening or dangerous; expect that the future will probably entail many hazards, catastrophes and dangers; expect that inconsequential events in the past will probably reap dangerous threatening consequences at some unexpected point in the future; and they may believe that minor ailments or normal visceral sensations are refl ective of inevitable serious illness. With panic disorder there is a conviction that fl uctuations in autonomic arousal refl ect the onset of full-blown anxiety attacks, which in turn are associated with a belief that death is imminent. There is also a core belief that testing out the validity of any of these beliefs will inevitably lead to more negative consequences than continuing to assume that they are true. So with panic disorder, individuals come to avoid all situations that lead to perceived fl uctuations in arousal level. Since most of these occur outside the home, the belief system leads to a constricted lifestyle. Partners of depressed and anxious individuals may develop belief systems in which they come to see their partners exclusively in terms of their problems and lose sight of other aspects of their whole personalities. Thus, non-symptomatic partners may come to construe their partners as wholly and completely depressed, anxious or incapacitated. This type of belief system give rise to excessive (and commonly futile) caregiving as described in the next section. In other instances, non-symptomatic partners may come to view their symptomatic partners as completely bad for decompensating and not fi ghting their condition, or as malingering and intentionally trying to control them by pretending to be more helpless than they are. Behaviour Patterns In marriages where one partner is depressed or anxious, the couple may become involved in destructive behaviour patterns with rigidly defi ned roles, which in turn maintain the anxiety or depression. In some instances, these behaviour patterns induce depression and other negative mood states in the initially non-symptomatic partner. 438 FAMILY THERAPY PRACTICE WITH ADULT-FOCUSED PROBLEMS In one problem-maintaining behaviour pattern, the anxious or depressed partner behaves more and more helplessly and in response the other partner engages in more and more caregiving, so that the entire relationship becomes defi ned in terms of these two rigid complementary positions. Depressed and anxious partners have diffi culty fulfi lling their routine duties at home and work, and so some of these may be taken on by the non-symptomatic partner. Depressed partners typically provide and elicit little support or sexual fulfi lment within their marriages, and in this sense non-symptomatic partners suffer a major loss of support when their partners develop depression. Depressed partners are less able to engage in effective joint problem solving and this is frustrating for their partners who may fi nd that important joint decisions are left unmade or are made unsatisfactorily. Depressed partners continually seek both reassurance and confi rmation of their negative views of themselves, a set of confl icting demands that is aversive for their partners and may lead to distancing. The development of this complementary behaviour pattern greatly compromises the couple’s capacity to meet each other’s needs for desired levels of intimacy and autonomy. (Problems in meeting these two needs were defi ned as the core issues for distressed couples in Chapter 14.) Both partners experience their need for personal power and autonomy is not being met. The anxious or depressed person believes that they are helpless to change their situation because they are intrinsically powerless or because the world is too bleak or dangerous. Caregiving partners experience themselves as trapped in an endless and futile round of caregiving where nothing they do makes their partner better and yet they feel com- pelled to continue caregiving. This frustration of their need for autonomy gives rise to anger, which neither partner may believe is appropriate to express. The symptomatic partner may believe that it would be ungrateful to criticise their partner for excessive ineffectual caregiving. Caregiving partners may believe that it would be insensitive to criticise their symptomatic partners for not recovering. However, periodically either partner may become so frustrated that t hey express their intense anger at their partner. In these instances, depressed individuals fi nd that aggression from a previously supportive partner exacerbates their depression. Subsequently, guilt for expressing aggression may lead them to return to their previous roles of apparently grateful care-receiver or apparently dutiful caregiver. This type of behaviour pattern prevents couples from meeting each other’s needs for psychological intimacy. They are only able to view each other as caregivers or receivers and unable to accept each other as people who are quite distinct from the problem and who are jointly facing the challenge of managing the anxiety or depression. Over time, this type of caregiving and receiving behaviour pattern may deteriorate into one where more frequent verbal criticism, aggression or distancing and infi delity occur. In other cases, these hostile responses DEPRESSION AND ANXIETY 439 to depression or anxiety are there from the start. Verbal and physical aggression, distancing, infi delity and threatened separation all confi rm the depressed or anxious partner’s belief system concerning the hopelessness and dangerousness of the world and so maintain the depression or anxiety. The exacerbated symptoms may elicit further aggression or distancing from the non-symptomatic partner. However, extremely depressive and helpless behaviour has been found to inhibit non-symptomatic partners’ expression of verbal or physical aggression. So in some couples, the depressed or anxious spouse learns that one way to avoid being at- tacked verbally or physically is to show extreme symptoms. This display of extreme symptoms also has a payoff for the non-symptomatic partner insofar as it inhibits aggression and so prevents the occurrence of the guilt that follows aggressive displays. Wider Social and Cultural Factors and Personal Vulnerabilities Within the wider treatment system, probably all interventions that defi ne the symptomatic person exclusively in terms of their symptoms, rather than as a person with a wide range of attributes and competen- cies needing help with managing a circumscribed problem, have the potential to maintain the couple’s destructive behaviour patterns. When couples attend a marital and family therapist for treatment of depression or panic disorder and agoraphobia, the majority have received individually-based treatment involving medication, psychotherapy or both. In many instances, within these programmes, they have come to be defi ned as their problems rather than competent people with circumscribed problems. In Chapter 14, a range of wider social and cultural factors and personal vulnerabilities which infl uence the adjustment of distressed couples were discussed. It was noted that relationship diffi culties are more common among couples who come from different cultures with differing role expectations; and from couples of lower socioeconomic status; who live in urban areas; who have married before the age of 20; and where premarital pregnancy has occurred. Outcome The average duration of a depressive episode is nine months, and half of all depressed people experience more than one episode (Carr & McNulty, In Press, b). Panic disorder with agoraphobia tends to follow a waxing and waning course (Taylor, In Press). For major depression and panic disorder with agoraphobia, approximately a third respond well to treatment; about a third show partial recovery; and about a third develop a chronically constricted lifestyle. 440 FAMILY THERAPY PRACTICE WITH ADULT-FOCUSED PROBLEMS Protective Factors At a behavioural level, a good marital relationship, good communication and problem-solving skills; a willingness to break out of complementary caregiver–care-receiver patterns or symmetrical aggressive patterns; and an openness to increasing the rate of positive interactions and level of activity within the relationship are protective factors. In terms of beliefs, symptomatic individuals who can challenge and test out their depressive and anxious belief systems are better able to develop new and useful belief systems in couples therapy. Non-symptomatic individuals who are fl exible enough to defi ne their partner as a competent individual with a circumscribed problem probably respond better to couples therapy. Individuals who are able to construe couples therapy as an opportunity for making a fresh start are more likely to benefi t from treatment. Individuals who come from families in which secure parent–child attachments were formed probably fi nd it easier to use couples therapy to resolve relationship diffi culties. With respect to sociocultural factors and personal history, similarity of cultural values and role expectations; high socioeconomic status; living in a rural area; absence of parental divorce; absence of premarital pregnancy; and marriage after the age of 30 have all been identifi ed as protective factors in long-term relationships. These factors were discussed in detail in Chapter 14. COUPLES THERAPY FOR ANXIETY AND DEPRESSION For couples in which one member has depression or panic disorder with agoraphobia, couples-based treatment, particularly behavioural marital therapy, is as effective as other treatments such as medication or individual cognitive therapy and probably more effective in cases where there are concurrent marital diffi culties (Beach, 2002; Byrne et al., 2004a). Guidelines for contracting for assessment; assessment; contracting for treatment; and treatment outlined in Chapter 14 for working with distressed couples and in Chapter 9 for family therapy may be used when working with cases of depression and anxiety. However, a number of specifi c procedures de- serve attention when working with these cases and it to these that we now turn (Beach, Sandeen & O’Leary, 1990; Craske & Zollner, 1995; Gollan et al, 2002; Jones & Asen, 1999). Contracting for Assessment Where both members of a couple voluntarily request couples therapy, contracting for assessment is a straightforward procedure. The couple may [...]... to conflict and that their marriage will deteriorate like that of her parents and grandparents and that this will ruin their child’s life John becomes increasingly irritated and occasionally argues with Maureen about her viewpoint Figure 16.2 Three-column formulation of an episode of conflict over alcohol abuse 460 FAMILY THERAPY PRACTICE WITH ADULT-FOCUSED PROBLEMS Maureen’s father and grandfather had... these instructions and listen to the tape as you do the exercises, speak in a calm relaxed quiet voice Area Exercise Hands Close your hands into fists Then allow them to open slowly Notice the change from tension to relaxation in your hands and allow this change to continue further and further still so the muscles of your hands become more and more relaxed Arms Bend your arms at the elbow and touch your... slowly…one…two…three… four…five…six and again Breath in…one…two…three and out slowly…one…two…three… four…five…six and again Breath in…one…two…three and out slowly…one…two…three… four…five…six Visualising Imagine you are lying on beautiful sandy beach and you feel the sun warm your body Make a picture in your mind of the golden sand and the warm sun As the sun warms your body you feel more and more relaxed As the... biological processes, early socialisation experiences and related personality traits, stressful life events, intrapsychic processes and belief systems, and patterns of social interaction, have Michael 8m Conor 24y Grainne 2y Michelle 27y Rita M 2 y ago Maureen 27y Mary 65 Rurai 25y Finbar 2y Shamus 65 Alcohol problem Family strengths: John and Maureen are committed to their relationship and to their... be used to help couples 4 48 FAMILY THERAPY PRACTICE WITH ADULT-FOCUSED PROBLEMS overcome the angry battles or sulky stand-offs that typically occur when they jointly try to solve a routine family problem It should be highlighted that problem solving is a slow and painstaking process, which must be approached with the expectation of cooperation Treatment of Panic Disorder and Agoraphobia Vulnerability... be Think of your hands and allow them to relax a little more Think of your arms and allow them to relax a little more Think of your shoulders s and allow them to relax a little more Think of your legs and allow them to relax a little more Think of your stomach and allow it to relax a little more Think of your face and allow it to relax a little more Breathing Breath in…one…two…three and out slowly…one…two…three…... feel more and more relaxed As the sun warms your body you feel more and more relaxed The sky is a clear, clear blue Above you, you can see a small white cloud drifting away into the distance As it drifts away you feel more and more relaxed It is drifting away and you feel more and more relaxed It is drifting away and you feel more and more relaxed As the sun warms your body you feel more and more relaxed... psychological difficulties (e.g memory loss); career and employment problems; financial difficulties; and family disintegration with consequent negative effects on the children and spouse Protective Factors At a behavioural level, a good marital relationship, good communication and problem-solving skills; a willingness to break out of complementary 464 FAMILY THERAPY PRACTICE WITH ADULT-FOCUSED PROBLEMS caregiver–care-receiver... 1993) While unilateral family therapy and other similar interventions have been shown in research studies to be effective in facilitating engagement in therapy, this approach may be at odds with the Al-Anon family groups approach, which invites family members to detach from the person with the alcohol problem and not attempt to influence their recovery (Al-Anon Family groups, 1 981 ) Psychoeducation Sober... be built into the contract, and a routine for using time-out to manage risky situations stipulated 442 FAMILY THERAPY PRACTICE WITH ADULT-FOCUSED PROBLEMS Assessment The first aim of family assessment is to construct three-column formulations, like those presented in Figures 15.2 and 15.3, of a typical problematic episode in which the anxiety or depression is at its worst and an exceptional episode . help couples 4 48 FAMILY THERAPY PRACTICE WITH ADULT-FOCUSED PROBLEMS overcome the angry battles or sulky stand-offs that typically occur when they jointly try to solve a routine family problem instances, these behaviour patterns induce depression and other negative mood states in the initially non-symptomatic partner. 4 38 FAMILY THERAPY PRACTICE WITH ADULT-FOCUSED PROBLEMS In one problem-maintaining. for treatment; and treatment outlined in Chapter 14 for working with distressed couples and in Chapter 9 for family therapy may be used when working with cases of depression and anxiety. However,

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