The Disordered Couple

Jon Carlson, Len Sperry, Jon Carlson, Len Sperry, Katherine Helm, Len Sperry, Katherine Helm, Jon Carlson

• Publisher: Routledge
• Year: 2019
• eBook ISBN: 9781351264020
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

The Disordered Couple, Second Edition, focuses on couples with psychiatric disorders and/or relational disorders that significantly impact their relationship, mental health, and well-being. It is the first and only book to provide mental health professionals and trainees with cutting-edge, culturally sensitive, and evidence-based clinical strategies for working effectively with disordered couples.

While maintaining its focus on disordered couples, this second edition adds several new features and considers key trends that have impacted the structure of couples and families since the original edition appeared, including the influence of social media and technology, legalization of same-sex marriage, increases in the availability of Internet pornography, and changes in societal norms regarding romantic relationships. The disorders covered reflect revisions to the DSM-5 and both psychiatric disorders and relational disorders, and the book highlights clinically relevant and culturally sensitive intervention practices for working with a wide variety of disordered couples. Chapters also include a section on specific multicultural implications for the type of couple discussed.

With proven strategies for effectively assessing, conceptualizing, and implementing treatment with disordered couples, this book is an essential reference for marital, clinical, counseling, and psychiatry professionals, as well as trainees in these areas. The Disordered Couple, Second Edition, will be of great assistance to mental health professionals in providing disordered couples with the most up-to-date, culturally sensitive, and relevant clinical care.

Part I

Treating Disordered Couples Today

1
Issues and Treatment Considerations in Couple Therapy Today

Katherine Helm

Couple Distress and Psychopathology

A review of research on the treatment of couple distress over the last decade demonstrates that couple therapy positively impacts 70% of couples receiving treatment (Lebow, Chambers, Christensen, & Johnson, 2012). These data parallel the success rates for individual therapy. Lebow et al. (2012) found that couple therapy clearly has a significant role in the treatment of several disorders, especially depression and anxiety. Couple practitioners are aware that couple distress has a negative impact on individual mental and physical health. “Evidence is beginning to accrue that couple distress is not only correlated with but also has a causal role in the generation and maintenance of individual psychopathology” (Whisman & Uebelacker, 2006, p. 146 as cited in Lebow et al., 2012; Whisman & Baucom, 2012). Whisman and Uebelacker (2006) examined correlations between marital distress and DSM-IV disorders and found that marital distress had a significant negative impact on anxiety, mood, and substance use disorders (Lebow et al., 2012).

Chronic relational distress in the couple relationship can have devastating consequences. Whisman and Baucom (2012) explored the impact relational distress has on psychopathology and found strong possibilities that a bidirectional relationship between couple discord and mental health issues exists. That is, relational discord can act as an interpersonal stressor, increasing the likelihood of a person developing mental health problems and/or mental health problems experienced by one or both members of the couple and contributing to or exacerbating relational discord. From either direction, it is clear that problems in one’s romantic relationship have a negative impact on one’s mental health. “With respect to co-occurrence between relationship discord and psychiatric symptoms, the most common disorder that has been studied is depression” (Whisman & Baucom, 2012, p. 5), and the severity of depressive symptoms is greater when individuals report lower relationship adjustment. Whisman and Baucom point to an increasing body of literature that relationship discord is associated with not only psychiatric symptoms but also psychiatric disorders; the results are highly generalizable. In large population-based samples conducted with people across the 48 contiguous United States, marital discord was associated with broad-band categories of mood, anxiety, and substance use disorders as well as with specific narrow-band diagnoses of specific disorders in DSM-IV (Whisman & Baucom, 2012).

A review of the literature finds that the association between relationship discord and psychopathology does not appear to be limited to any single disorder or class of disorders and that it may be a general risk factor for several mental health problems (Whisman & Baucom, 2012; Lebow et al., 2012). Thus, improving couple relationships could go a long way in improving one’s individual mental health issues. In fact, there is some evidence to suggest that the traditional practice of referring one partner for individual therapy when he/she has a psychological disorder may not be as effective as originally thought. Research has demonstrated that when couples have significant relationship discord, the individual with a disorder is far less likely to respond to individual therapy and pharmacological treatments (Whisman & Baucom, 2012). Additionally, couples have limited time and resources for counseling, so often couple therapists are called to do treatment with one partner for a psychological disorder within the couples counseling sessions. This approach has obvious pros and cons. One pro might be that each partner is provided psychoeducation about the disorder one partner is experiencing, which can provide both with a deeper understanding of how their relationship is impacted by a partner’s disorder. Another pro might be that the collaborative effort of the counselor and the couple in addressing one partner’s disorder could bring the couple closer together and help them to develop a mutual sense of empathy. A skilled couple therapist can help the couple both understand the impact mental health issues can have on both partners and externalize and contextualize some of the impact of the disorder. Together, the couple and therapist can work to reduce any blaming and shaming either member has about having or experiencing the effects of a psychological disorder within the couple relationship. This might serve to increase the couple’s sense of togetherness. Two of the biggest cons, in theory, are that the couple therapist may focus on one individual more than the other and the idea that the “disorder” takes away attention from working on the couple’s relational difficulties. Additionally, taking this approach might increase blaming and shaming among the couple if their relational discord does not allow the couple therapist to help establish common ground between them.

Although some of these points may be true, practitioners are aware that it is simply unrealistic at times to refer an individual due to limited financial resources and time that the couple has to give to therapy. Additionally, couple counselors understand the importance of capitalizing on the couple’s current motivation for seeking help for their relational difficulties. To further this point,

poorer marital adjustment has been demonstrated to predict increased likelihood of relapse. Individual-based treatment may be less effective for individuals with relationship problems because these treatments do not address the very problems (i.e. relationship problems) that may be contributing to the maintenance of their mental health issue. Thus ignoring relationship problems may impede treatment of individual pathology.

(Whisman & Baucom, 2012, p. 8)

Just as the disorder exists in the couple’s daily life, it exists within the couple’s counseling sessions as well, and thus separating out the individual suffering from the disorder is often unrealistic and in some cases contraindicated.

Research indicates that disordered-specific interventions should focus on creating essential changes in the couple’s relationship that will persist in the long-term and that are specific to the client’s disorder. Whisman and Baucom (2012) suggest that couple therapists can assist couples in identifying specific ways to use or modify their relationship to encourage changes the partner with the disorder needs to make in order to address specific psychological difficulties/disorders. In other words, along with utilizing certain skills the couple learns in therapy to improve their relationship, the couple themselves, working in concert with the therapist, can develop ways that their relationship can support the potential reduction of symptoms of one partner’s psychological disorder. This might involve some lifestyle changes for the couple. An example supported by the literature was in the treatment for Agoraphobia and Obsessive–Compulsive Disorder (OCD), where the partner without the disorder can participate in assisting in social experiments (for Agoraphobia) or in exposure-response prevention strategies (for OCD) (Whisman & Baucom, 2012). These partner-assisted strategies can be very helpful and go a long way in supporting the couple’s relationship and mutual skill building strategies. Lebow et al. (2012) concludes that when couples present for therapy, therapists need to assess and respond to comorbid psychotherapy that is critical to the success of overall couple treatment.

The Alliance in Couple Therapy

From the time graduate students enter counseling and psychology training programs, they are told of the importance of the therapeutic alliance between the therapist and client. Practitioners understand that without an adequate alliance, counseling will not be successful, and clients are most likely to drop out of therapy. Recent research on the alliance in couple therapy has highlighted how the alliance between couples and therapist, and individuals and therapist, differs (Knerr et al., 2012; Lebow et al., 2012). Knerr et al. (2012) found that the therapeutic alliance has been shown to predict outcomes in marital therapy, while Symonds and Horvath (2004) found a weak relation between alliance and outcome, though this correlation was much stronger when the partners agreed about the strength of the alliance (low or high). When teasing out the literature on alliance for heterosexual couples based on gender, the data are more illustrative. Symonds and Horvath (2004) found that the male partner’s alliance was more predictive of positive outcome than the female’s alliance and that when males’ alliance was greater than females’ (and when the alliance was improving over time), correlations between alliance and outcome were strong. The importance of the male alliance with the couple therapist is well documented in the literature (Knerr et al., 2012; Brown & O’Leary, 2000), and it is safe to conclude that men’s alliance with the couple therapist is a better predictor of outcome than the alliance for women. Conversely, Knobloch-Fedders, Pinsof, and Mann (2004) found that alliance did not predict changes in individual functioning but did predict 5–22% of improvement in marital distress. Knerr et al. (2012) questioned whether alliance develops in the same way when there is one client in the room vs. two and what factors are associated with variability in the development of alliance. This question is still being studied. The literature supports developing an alliance with a couple as being more complex than with an individual; the alliance for couples is more therapist-driven, while in individual therapy it is more client-driven (Knerr et al., 2012). Lebow et al. (2012) conclude that split alliances, especially when the male’s alliance is lower, present special challenges for couple therapy. Male engagement in heterosexual couple therapy may be the strongest predictor of good outcome for couple therapy. One take-away from this area of research is that couple counselors should look to continually assess alliance in both partners throughout treatment so that if the alliance is unbalanced or weak, it can be addressed early and often in treatment, which should help counseling be more successful.

Couple’s Agreement on Presenting Problems

Another area of exploration has been examining the degree to which couples agree on their presenting issues when they come to couple counseling and whether their level of agreement impacts the process and outcome of counseling. In a study investigating both brief and long-term couples counseling, Biesen and Doss (2013) determined that pretreatment agreement on relationship problems was unrelated to treatment course or outcome for longer-term integrative treatments; however, when couples received brief treatment, agreement predicted greater engagement in the therapeutic process and more positive treatment outcomes. Their findings indicate that greater agreement in a briefer therapy model meant that couples were more likely to attend the minimum number of sessions and report more clinically significant changes during therapy. The authors of this study draw some noteworthy conclusions regarding couple agreement on presenting issue. They assert that level of agreement might be associated with how severe the couple’s presenting issues are.

Different presenting problems may reflect more severe relationship distress that, like an advanced cancer, has metastasized from the original problem area to various parts of the relationship. Therefore couples who agree in their presenting problem may be seeking help for their relationship in an earlier, less severe stage of distress.

(p. 659)

This assertion supports the work of Whisman, Beach, and Snyder (2008; Whisman, Snyder, & Beach, 2009 as cited in Lebow et al., 2012) that distressed marriages may be able to be separated into two populations who seek couple counseling and that they should be treated as distinct: those that are beyond the threshold for distressed marriages with all the factors that accompany distressed marriages, including high risk for divorces; and those seeking counseling for more minor issues and for preventative purposes. Thus, early and appropriate assessment of into which category a couple may fall is warranted and likely to increase couple treatment’s overall effectiveness.

Types of Couple Therapy

A comprehensive review of couple treatments developed and refined since the first edition of this book is beyond the scope of this text. Instead, this section will focus on some of the latest developments in evidenced-based couple treatments. Individual chapters will incorporate a broader focus on some of the most current treatment approaches. Over the last decade, there has been a significant increase in the development of randomized clinical trials (RCTs) to explore the effects of certain types of couple treatment. Outcome research has increased, but there continues to be a lack of process research (Gurman, 2011). Gurman (2011) asserts that it is often the case that couple therapy research has little impact on the day-to-day practice of couple therapists, which could be due to the focus on treatment packages, use of manuals, and researchers’ tendency to ignore therapist-specific factors (i.e., factors about those who actually perform the therapy).

Several couple therapies have demonstrated effectiveness as evidenced-based treatments, including: emotion focused couple therapy (EFCT) (Johnson, 2007) and Behavioral Couple Therapy (BCT), which has three forms: Traditional Behavioral Marital Therapy (Jacobson & Margolin, 1979), Cognitive–BCT (Epstein & Baucom, 2002), and Integrative-BCT (Jacobson & Christensen, 1998). Additionally, the application of interpersonal neurobiology and the exploration of core marital interaction patterns (Gottman, 1998a, 1998b) have demonstrated effectiveness (Gurman, 2011) in multiple RCTs. Briefly, EFCT is a couple intervention that views attachment orientation and emotional ways of relating as key components of how couples perceive, interact, and feel within their couple relationship. Lebow et al. (2012) describe EFCT as incorporating a humanistic, experiential perspective that values emotion as an agent of change and applies an attachment orientation lens to adult love relationships.

Research demonstrates that key effectiveness components of the theory include the depth of emotional experiencing in sessions and the shaping of new interactions where partners are able to clearly express attachment fears and emotions and are taught to respond to one another’s emotional needs in the moment. The focus on affect regulation and developing a stable and secure emotional connection with one’s partner are other key elements. Christensen and Jacobson (2000) explore the types of behavioral treatments for couples, including Traditional Behavioral Couple Therapy (TBCT, also known as Behavioral Marital Therapy, BMT), and Integrative Behavioral Couple Therapy (IBCT). As summarized by Christensen and Jacobson, IBCT is defined as including aspects of private experience such as emotions and emphasizes concepts such as acceptance and mindfulness in addition to typical cognitive–behavioral strategies. It focuses on broad themes in partners’ concerns and puts a renewed emphasis on functional analysis of behavior, all while underscoring emotional acceptance, behavioral change, and emotional distance from problematic patterns. TBCT focuses more squarely on changing couples’ problematic behavior. Additionally, TBCT concentrates on the ratio of positive to negative interpersonal exchanges and emphasizes operant conditioning (DeLoach, 2012). “A traditional behavioral model posits that behaviors of both members of a couple are shaped, strengthened, weakened, and can be modified in therapy by consequences provided by environmental events, particularly those involving the other partner” (Baucom, Epstein, LaTaillade, & Kirby, 2008, p. 32). Lebow et al. (2012) find that the literature presents substantial evidence that couple therapy (in most cases variants of TBCT) is helpful in the treatment of disorders conceived through the lens of individual diagnosis.

It might be easy to conclude that EFT and variants of TBCT are the most effective types of evidence-based counseling; however, given that few research studies have compared multiple therapeutic approaches against one another in the same study, as well as the lack of process research for most theories, this would not be a safe conclusion. Gurman (2011) asserts that we are quite unable to answer specific questions about how therapy works but can now more assertively answer the question that it works. This might be part of the disconnect between research and practice, which is a critical area of future research in the field of couple therapy.

Family–of-Origin Issues Impacting Couples

There has been extensive research on the impact o...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Dedication
• Contents
• Acknowledgments
• List of Editors and Contributors
• Foreword
• Introduction: The Changing Landscape of Couple Therapy Today and Tomorrow
• Part I Treating Disordered Couples Today
• Part II Disordered Couples Today
• Part III Developmental Issues Impacting Couples
• Part IV Treating Disordered Couples: Retrospective and Prospective
• Index