Treating Relationship Distress and Psychopathology in Couples

A Cognitive-Behavioural Approach

Donald H. Baucom, Melanie S. Fischer, Sarah Corrie, Michael Worrell, Sara E. Boeding

• Publisher: Routledge
• Year: 2019
• ISBN:
  9781317234920
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

Close relationships and mental health are two key ingredients to living a meaningful, fulfilled life. These two domains are the central focus of Treating Relationship Distress and Psychopathology in Couples: A Cognitive-Behavioural Approach. As expert clinicians, trainers, and researchers in the field of cognitive-behavioural couple therapy and couple-based interventions for psychopathology, the authors offer a highly accessible volume for experienced clinicians and trainees alike.

This book details the most recent innovations in CBCT, a principle-based, flexible treatment approach for couples with a wide range of relationship concerns, circumstances, and stages of life. Based on a clear conceptual framework, readers learn how to address individual and couple functioning in an integrated, comprehensive manner and how to apply principle-based interventions that directly flow from this framework.

Treating Relationship Distress and Psychopathology in Couples was written by a team of five authors, born in four different countries and working together as a team for a number of years, providing a cohesive framework based on work in a variety of contexts. While staying close to research findings that inform treatment, they provide a text for clinicians at all levels of training and experience in working with couples.

Part I

An introduction and overview of cognitive-behavioural couple therapy

Throughout this book, we discuss committed relationships, what contributes to optimal relationship functioning, and how some relationships become distressed. Second, we emphasize how to understand individual adult psychopathology within the context of intimate relationships and how relationships and individual functioning influence each other in a reciprocal, circular manner. With this understanding in mind, we then provide a wide range of interventions for clinicians to assist couples in addressing relationship distress and individual psychopathology. In doing so, we place a primary emphasis on empirically supported intervention principles from both the cognitive-behavioural couple therapy (CBCT) and individual therapy realms. Thus, the treatments described in this book are principle driven and are not presented as a treatment manual with a given number of sessions unfolding in a set fashion. Instead, with a clear understanding of intimate relationships and adult psychopathology, the clinician develops a conceptualization and treatment plan tailored to each couple. In order to accomplish these goals, the first section of this book lays the groundwork and provides a foundation for everything that follows. First, Chapter 1 provides the rationale for why to focus professional efforts on addressing relationship distress and psychopathology in an integrated manner. In proposing that psychopathology be treated at times with a couple-based approach, we are advocating for a broadened paradigm for the field of psychotherapy, and a strong justification needs to be made for such a fundamental shift. We believe that evidence from multiple disciplines exists to justify this continued broadening and strengthening of our approaches to treating human suffering.

Chapter 2 follows and presents our overall model for how to understand healthy committed relationships from a cognitive-behavioural perspective. This model integrates two frameworks. First, our contextual framework emphases that it is crucial to understand each partner as an individual, how the two partners come together to form a couple as a unit that is more than the sum of the two individuals, and how each partner and the couple live in a broader environment. The second framework described in Chapter 2 integrates and enhances the individual cognitive-behaviour therapy (CBT) perspective by addressing how one person’s behaviours, cognitions, and emotions are impacted by the other partner’s behaviours, cognitions, and emotions, creating a reciprocal feedback loop between the two partners. Likewise, these two frameworks are integrated into the complete model, discussing how these interrelated behaviours, cognitions, and emotions between and within the two partners relate to individual, couple, and environmental factors. This model serves as the foundation for CBCT for couples presenting with relationship distress and cognitive-behavioural, couple-based interventions (CBIs) for psychopathology.

Chapter 3 discusses what implementing CBCT and CBIs actually looks like and the role of the therapist as an integral factor in optimal treatment. We believe that, along with specific intervention techniques, the therapeutic relationship and the manner in which various interventions are presented are essential elements of optimal treatment. We provide a discussion of common factors in psychotherapy that are important in treatment outcome, including treatment enhancing factors that transcend specific theoretical orientations, factors common to different CBT approaches, and factors common to couple therapy. We present this chapter before delving into specific therapeutic interventions beginning in Part II because the specific interventions must be considered within the context of these common factors. As a therapist, it is not just what you do, but how you do it. This book is about relationships and their potential to optimize quality of life; consistent with this perspective, the therapeutic relationship has great potential to assist couples, particularly when paired with empirically supported intervention principles.

Chapter 1

Introduction

When people reflect on their own and their family’s hopes and dreams, what do they see? Often they wish for a fulfilling life, happiness, good health, rewarding relationships, and opportunities to contribute to the world around them. At the end of life, people often cite these same areas of individual and interpersonal well-being as what made their lives the happiest and most fulfilling. So, the question remains, how do we get there? What leads to a full, enriching life? What makes people happy? Conversely, what factors contribute to broad dissatisfaction and even poor health?

These questions have been asked innumerable times across centuries and cultures, by people in all walks of life. Philosophers, writers, religious leaders, mental health professionals, and scientists have attempted to address this question in a multitude of ways. Although there are undoubtedly many influences, findings from several disciplines seem to converge on at least one set of factors that is vital to our well-being—the centrality of strong, caring, close relationships. Human beings are social creatures, and meaningful connections with others are essential for most people to live their lives to the fullest. This conclusion seems to surface again and again.

For example, the Harvard Study of Adult Development began in 1938 when male undergraduate students were assessed across multiple domains, including physical, psychological, and relationship well-being. That assessment has broadened and continued to the present, with some of the participants now in their 90s. Because this sample was not representative of society at large, men with lower socioeconomic status were later added to the investigation. Strikingly, a major conclusion after decades of gathering voluminous amounts of data seems surprisingly straightforward, as stated by the director of the investigation, Robert Waldinger (2015):

When we gathered together everything we knew about them at age 50, it wasn’t their middle-age cholesterol levels that predicted how they were going to grow old . . . It was how satisfied they were in their relationships. The people who were the most satisfied in their relationships at age 50 were the healthiest at age 80.

Or, as the previous director of the Harvard Study George Valliant noted, “When the study began, nobody cared about empathy or attachment. But the key to healthy aging is relationships, relationships, relationships” (Mineo, 2017).

From a very different perspective, Richard Layard, an economist at the London School of Economics, spent many years pioneering research on happiness, the economy, and other aspects of life across different countries. Although happiness is not the only goal in life, it is of paramount importance for many people and is closely related to overall life satisfaction. The associations between economic standards of living and reported quality of life are complex; clearly, poverty and living financially below what individuals experience to be a reasonable level adversely impact an individual’s well-being (Payne, Brown-Iannuzzi, & Hannay, 2017). When Layard looked beyond economic factors, he found that across cultures, genders, and walks of life, the quality of family relationships is one of the most important predictors of happiness (Layard, 2005). These findings are consistent with the Harvard study described above: Individuals who have rewarding, satisfying close relationships tend to be the happiest.

Whereas healthy relationships contribute to well-being, is the reverse true as well? Does the absence of meaningful relationships place individuals at risk for negative outcomes? Consistent with this notion, Holt-Lunstad, Smith, and Layton (2010) investigated the role of social relationships in mortality. Evaluating the findings of 148 studies, which included more than 300,000 participants in total and followed participants for an average of 7.5 years, they found a 50% increased likelihood of survival for individuals who had stronger social relationships. This finding was robust across age, sex, initial health status, and cause of death. In essence, successful relationships are about more than feeling good; they have implications for one’s very survival.

The above findings demonstrate the importance of close relationships in promoting well-being and the lack of such relationships in predicting death. Yet, relationships are not the sole factor influencing how individuals fare over their lives. It seems likely that issues which focus more explicitly on the individual would impact distress or suffering. Layard and Clark (2014) explored which factors contribute most to human suffering (note that the absence of suffering does not imply the presence of happiness and well-being). Integrating findings across countries and studies, they concluded that the greatest source of human misery is mental illness, even more so than physical illness. Consistent with this conclusion, the World Health Organization recently ranked depression as the single largest contributor to global disability (World Health Organization, 2017).

The findings across these various lines of research are striking and point to two responses to the question: “How do we live and help others live in a way that leads to the most rewarding lives possible?” First, close relationships are central in psychological and physical well-being and overall happiness, and a lack of meaningful relationships predicts a shorter life expectancy. Second, mental health is essential in order to avoid suffering. Hence, the two major foci of this book—intimate relationships and psychological well-being—are key to experiencing a full and rewarding life for most people. Furthermore, not only are these two domains important, but they also are inextricably intertwined.

The impact of relationship adjustment on individual functioning

In most cultures, a large proportion of adults form committed relationships at some point in their lives, with implications for themselves, their nuclear and extended family, and their wider community. Although marriage rates have been declining in many Western countries, marriage remains common and also has become legal for same-sex couples in an increasing number of countries. In 2018, 71.2% of adults 18 years and above in the United States were married at some point in their lives (U.S. Census Bureau, 2018a); in addition, other adults never married but were in a committed relationship. In England and Wales, 81.7% of men and 87.5% of women born in 1960 had married by the time they were 50 years old (Office for National Statistics, 2015). Thus, intimate relationships are an important aspect of the lives of most individuals, and the quality of these relationships can have wide-ranging impact on all family members.

Impact on individual partners

Strong relationships can contribute to individual well-being in a multitude of ways, largely by (a) increasing positive experiences for both partners and (b) improving individuals’ ability to cope with negative experiences, stressors, and risk factors. For example, people in satisfied relationships are more likely to have positive emotions and enjoyable experiences such as love, companionship, affection, physical and emotional intimacy, social support, and rewarding joint couple and family activities. In addition, being in a committed relationship tends to afford certain social and practical benefits, including greater financial resources and stability, shared family responsibilities, and social status.

Satisfying romantic relationships also buffer the individual against negative experiences and stressors in profound ways. While it is easy to think of practical examples of how partners might care for one another, such as taking on extra household chores when one’s partner is sick, it is also important to understand that social bonding is ingrained in human biology. That is, a person’s subjective emotional experiences, physiological responses, and behavioural reactions become interdependent with one’s partner in close relationships, which has the potential to assist the individual during difficult times (Coan, Schaefer, & Davidson, 2006; Diamond & Aspinwall, 2003; Sbarra & Hazan, 2008). The message is truly, “You don’t have to do this alone.”

The positive effects of healthy relationships are also demonstrated when one person has a psychological disorder. Many research studies and clinical observation confirm that close relationships influence the course of psychological disorders, either by helping to alleviate distress and facilitate recovery, or by contributing to the maintenance and exacerbation of symptoms (Fischer & Baucom, 2018). Across many disorders, appropriate support from a partner can be restorative and assist an individual in overcoming distressing symptoms. On the other hand, distressed relationships can serve as a broad chronic stressor on the individual. If one partner has a vulnerability to a condition such as depression, living in a chronically stressful social environment can contribute to the precipitation of a disorder or impede recovery.

However, even in satisfied relationships, well-meaning partners can inadvertently contribute to the maintenance of an individual’s disorder. Loving partners often seek to decrease the affected person’s psychological distress but do so in counterproductive ways. Termed symptom accommodation, this set of behaviours includes actions that partners may knowingly or unknowingly take to alleviate or prevent distress for the affected person in the moment, which ultimately help to maintain the disorder in the long term. For example, partners might take over roles and responsibilities or help the person avoid anxiety-provoking situations. As will be discussed at length in the current volume, accommodation takes various forms, in large part as a function of the disorder itself. Although the specific form of accommodation might vary, research on couples and families has consistently shown that accommodation to psychological symptoms is associated with more severe symptoms and poorer treatment outcomes (e.g., Boeding et al., 2013; Calvocoressi et al., 1995; Fredman, Pukay-Martin, et al., 2015; Sepulveda, Kyriacou, & Treasure, 2009). Thus, couples’ relationships have great potential to impact the course of an individual’s psychological disorder in both positive and negative ways.

Impact on children

At the family level, the impact of relationship problems appears to continue throughout the life span of children with relationally distressed or divorced parents, even for several generations. For example, children of high-conflict or divorced parents are more likely to experience internalizing and externalizing problems, academic difficulties, and low self-esteem. In addition, they are more prone to drop out of school, commit acts of juvenile delinquency, and engage in substance abuse. When these children reach adulthood, they tend to have lower socioeconomic status, relationship problems of their own, and increased divorce rates, compared to children of nondivorced parents (Amato, 2001; Hetherington & Elmore, 2004; Zimet & Jacob, 2001). Perhaps most poignantly, a follow-up study of Terman’s classic study of gifted children found that children from divorced families died on average four years earlier compared to their peers with nondivorced parents (Friedman et al., 1995). In summary, a couple’s distressed relationship or relationship termination can extend beyond themselves and impact their children in the present and for years to come, with the majority of evidence suggesting that it is relationship discord rather than divorce per se that might be the more important factor (Sbarra, Bourassa, & Manvelian, 2019).

The impact of individual functioning on relationship adjustment

As noted above, the level of relationship adjustment impacts both partners as individuals and their children. The reverse is true as well. Within a couple’s relationship, each of the two individuals influences the quality of the relationship. Being with a partner who is happy, well adjusted, skilled, flexible, and generous can be a huge asset to the other individual and to the relationship. Consistent with this perspective, Baucom and Aiken (1984) found that when both partners had strong leadership skills, were task-oriented, and were interpersonally attuned, those couples had particularly high levels of relationship satisfaction. On the other hand, individual psychological problems experienced by one person can be a major stressor for the other partner and the couple’s relationship. For example, findings confirm that when one partner is depressed, such couples have a highly elevated risk of developing subsequent relationship distress (Davila, Bradbury, Cohan, & Tochluk, 1997). This finding is not surprising because low energy and depressed mood can interfere with positive interactions between partners, decrease intimacy, and result in the redistribution of household chores. Other disorders often impact the couple’s relationship functioning in unique ways as well. Therefore, in considering how to help a couple alleviate relationship distress or optimize relationship functioning, it is important to understand how each individual’s well-being impacts the other partner and the relationship as a whole.

Treating relationship and individual distress—a dyadic perspective

Given the complex interplay between individual and relationship functioning, what is the most appropriate way to think about psychological interventions for various presenting concerns? If a couple presents with relationship distress, the couple itself often is considered to be the client, and some form of couple therapy or counselling is likely to be recommended. However, if a client presents with what traditionally has been considered to be an “individual psychological problem” such as an anxiety disorder or depression, then individual psychotherapy is often seen as the gold standard for treatment. Finally, if both individual and relationship concerns are present, the client might receive two separate forms of therapy simultaneously, employing an additive approach to addressing each concern. Thus, relationship difficulties are traditionally addressed in couple therapy and individual problems in individual therapy.

In essence, viewing adaptive and maladaptive functioning as existing solely on either a relationship level or an individual level can lead to overly simplistic conceptualizations of a client’s concerns and less than optimal treatment. A major premise of this book is that, in order to optimize treatment for a wide range of concerns, a clinician will benefit from understanding the complex interplay between relationship and individual functioning. Thus, many clients with psychological difficulties that have previously been viewed as individual problems might benefit notably from including a partner in treatment. Similarly, when assisting a couple with relationship distress, a clinician will likely have the greatest impact if they know how to integrate individual functioning into a thorough conceptualization and treatment of relationship concerns. To further contextualize individual and relationship distress, and to address other relevant factors that often maintain the distress, both demands and resources in the couple’s physical and social environment need to be attended to as well.

Hence, this book focuses on how to conduct couple-based interventions, meaning that both partners attend sessions together and both are integral to treatment. When the primary target of treatment is relationship distress, this intervention is best conceived of as couple therapy with the goal of improving the relationship. When the primary focus of treatment is one partner’s psychological concern, these interventions are termed coup...