PWP Masterclass

Introduction to Couple Therapy for Depression

1st September 2015

Dr Sabah Khan Clinical Psychologist & Couple Therapist

skhan@tccr.ac.uk Kate Thompson

Couple Psychoanalytic Psychotherapist kthompson@tccr.ac.uk

Aims

• What is Couple Therapy for Depression?

• When to refer clients for this approach

• How to “think couple” and how to work with more than one person in the room using the following core competencies: – Knowledge and understanding of the basic

principles of couple therapy

– Ability to use techniques that focus on relational aspects of depression

2

Programme • 9.30 Welcome/Introductions

• 9.45 Choice of therapy update, from Choice of Therapy PPN Workforce Board Representative, Wendy Saint, Clinical Lead, Healthy Minds, Bury

• 10.00 Film

• 10.10 Exercise -Small groups think about couple dynamic/issues > depression

• 10.25 Group feedback

• 11.00 Break

• 11.20 Overview of CTfD model

• 13.00 Lunch

• 14.00 How can you offer this therapy to clients? Identifying suitable referrals

• 14.30 How to think couple?

• 15.00 Break

• 15.20 Film

• 15.30 Working with more than one person

• 16.00 Plenary and feedback on the day

• 16.15 Choice of therapy update, from Choice of Therapy PPN Workforce Board Representative, Wendy Saint, Clinical Lead, Healthy Minds, Bury

• 16.30 End 3

Video: The Depressed Couple

David & Denise

‘The impact of unemployment on couples and the family’

TCCR

Discussion

• In small groups, think about the following:

– How does depression effect this couple?

– How do they respond to this?

– What issues contribute to depressive symptoms?

Feedback

Break

Step 2: Low Intensity Service

• Depression - Mild Moderate cCBT,

Guided Self-Help, Behavioural Activation, Exercise.

• Panic Disorder - Mild Moderate cCBT, Guided Self-Help, Pure Self Help

• GAD - Mild Moderate cCBT, Guided Self-Help, Pure Self Help, Psychoeducation Groups

• OCD - Mild Moderate Guided Self-Help

8

Step 3:

NICE Guidelines • Depression in Adults produced by NICE (2009) identified the

potential role of couple relationships in triggering, maintaining and resolving depression.

• It defined couple therapy as a time-limited, psychological intervention derived from a model of interactional processes in relationships.

• The intervention aims to help participants to identify and understand the impact of depression on both the depressed and non-depressed partner

• “The aim is to change the nature of the couple interactions so that they may develop more supportive and less conflictual relationships” (pp 207-208).

• ‘IAPT isn’t just about CBT, it’s about implementing NICE Guidelines. If NICE recommends several therapies for a condition, then patient choice should operate, because people are more likely to get better from something they have chosen.’ -David Clark

10

What comes first?

• Depression and quality of couple relationships are closely intertwined, the influence is mutual.

• Intervening to support couple relationships has been proven to be an effective and acceptable approach to treating depression.

• Benefits partners directly and next generation.

11

Relational context: Research findings

• Lack of confiding relationship is a vulnerability factor for depression in women (Brown & Harris, 1978).

• Individuals in unhappy marriages are 25x more likely to be depressed.

• Women who suffer severe relationship stressors are 6x more likely to be depressed.

• Depressed individuals in unhappy relationships recover less quickly and are more likely to relapse.

12

• A recent study of nearly 5,000 adults demonstrated that the quality of a person’s relationship with their partner predicts the likelihood of major depression disorder in the future: – 1 in 7 adults with the lowest-quality relationships were likely to develop

depression vs.

– 1 in 15 with the highest quality of relationships – more than double the risk

– Those without a partner were at no increased risk (Teo 2013).

• In fact it is estimated that 60% of those with depression attribute relationship problems as main cause for their illness (Whisman, 2001).

Relational context: Research findings

Living with depressed partner: Impact on non-depressed partner

• 54% of individuals with depressed partners had some symptoms of depression (Spangenberg and Theron, 1999).

• 40% of partners had levels of psychological distress that made them suitable for therapeutic intervention (Coyne et al, 1987).

14

Living with depressed partner: Impact on each other

• Tends to decrease cognitive and problem solving abilities of the non-depressed partner (George, 1996).

• Poor coping/high stress in non-depressed partners can cause poor emotional support to their depressed partners, aggravating depression (Spangenberg and Theron, 1999).

15

Living with a depressed partner: distressed interactions

• Relationship interactions of couples with a depressed partner are characterised by: – A higher frequency of (-) communication

behaviors e.g. blame, withdrawal, criticism, verbal aggression.

– A lower frequency of (+) communication behaviors e.g. empathy/compassion, self-disclosure, problem-solving behaviors, smiling, eye contact (Rehman et al, 2008; Sandberg et al., 2002).

16

Walking on egg-shells – Living with a depressed partner

• Non depressed partners felt anger, frustration, impatience but tend to avoid expressing it for fear of impact on their depressed partner, leaving them feeling heavily burdened and isolated.

• Non-depressed partners try to help but are fearful of doing harm.

• Couples accounts are characterised by bewilderment and struggle (Harris et al. 2006).

17

Couple Therapy for Depression (CTFD) The Model

Not a generic model of Couple Therapy

• 20 session therapy for deliver in IAPT services which focuses specifically on the treatment of depression and relapse prevention.

• Is loose enough to allow couple therapists from different modalities to focus their skills on depression.

19

Integrated approach

• Focusing

• Assessing

• Formulating

• Accepting and Tolerating

• Communicating

• Problem solving and Changing Behaviour

• Coping

• Ending & Relapse Prevention

Aims of Couple Therapy for Depression

Aims at:

a) Directly relieving the depression in the patient

b) Working on the precipitating and maintaining elements of the couple relationship that are known to have a direct effect on the incidence of depression

21

The Therapeutic Approach

• The model focuses on the relational aspects of depression and on factors that reduce stress and increase support within the couple.

22

Reduce Stress & Increase Support

• 7 Main areas – all drawn from the manualised treatments in the up-dated evidence base: – (1) Promoting Acceptance

– (2) Revising Perceptions

– (3) Managing Feelings

– (4) Improving Communication

– (5) Changing Behaviour

– (6) Solving Problems

– (7) Coping with Stress

23

Balance is at the Core of the Model

• The ability to implement couple therapy in a balanced manner that keeps the focus on the couple relationship without discounting the two individuals who comprise it.

• Seeing the ‘couple as patient’ requires a perspective that takes full account of how each partner acts on, and is acted on, by the other.

24

The Relationship is the Key

• Can add to or take away from either partner’s abilities & capacities

• Is a self-regulating system contributed to by both

• Vehicle for intimacy and sexual functioning

25

Who is the Therapy for?

• People who have a regular partner and where relationships may contribute to the development or maintenance of depression

• Or when involving the partner is considered to be of potential therapeutic benefit

26

When Might the Therapy be Unsuitable – Screening for Risk

• The couple are living apart

• The couple are actively separating

• There is the presence of

– Coercive, controlling violence

– Uncontrolled alcohol and substance misuse

– Bi-polar disorder (level of depression)

– Self Harm

Patient feedback

“The 20 sessions of counselling have been of great benefit to both of us. We have been able to use different approaches and techniques to form a better outlook on life giving us a motivation to want to change things in our lives for the better. It has helped us with the way we communicate with each other, allowing us to be more honest and open about the way we feel”

28

Lunch

How can you offer this therapy to clients?

• Both clients in the couple are feeling isolated, not understood and defensive

• Problem not located in one partner only • Communication issues = presenting problem • Rebalancing their relationship • Relationship can work as a protective factor • Behavioural –Exercises, inc homework • Results so far suggest helpful –has been shown to

have a significant impact on recovery rates nationally • National guidance recommendation for mild to

moderate depression

30

Identifying Suitable Referrals

• Do depressive symptoms feature in their presenting problems?

• Are they in a relationship?

• Screen out unsuitable couples – violence, self-harm, alcohol/substance misuse, commitment to rx, affairs.

• What to do next – after assessment – step up.

• How to ask for feedback/think about referrals made to CTfD with therapist.

31

Life Stages of a Couple

• Marriage/security

• Building a home

• Children

• Unemployment

• Death of a parent/grief/loss

• Empty nest/freedom

• Illness

• Retirement

32

How to Think Couple? (1)

Observe the interaction between the partners:

• Do they give each other space or does one dominate the interaction?

• Do they appear able to think together about things?

33

How to Think Couple? (2)

Think about your own emotional experience of the couple:

• How does it feel to be with them?

• How do they relate to you, as individuals and as a couple?

• How easy or difficult is it to keep the other partner in mind? or to keep THE RELATIONSHIP in mind?

• Can you be emotionally involved and connected with each partner AND be able to stand outside of the relationship?

34

The Therapist’s Stance

• Model good communication skills – be warmly disposed and offer positive feedback

• Listen - Be curious, interested and open • Emphasis on validation and compassion • Work to clarify understandings • Absence of confrontation – don’t get involved in the

conflict • Non-Didactic – instead model acceptance and empathy • Be alert to nuances in order to formulate • Note the couple's selective perceptions • Enable couples to see pattern(s) of difficult interaction • Utilise psycho-education • Maintain focus on the formulation

35

Jacobson & Christensen (1998) 6 Questions

1. How distressed is this couple?

2. How committed is this couple to this relationship?

3. What are the issues that divide them?

4. Why are these issues such a problem for them?

5. What are the strengths holding them together?

6. What can treatment do to help them?

The basic structure of a formulation is:

• The couple do this in this way because of that and it has this (circular) result, which is ultimately unwanted or causes more problems that lead to further maladaptive attempts to resolve things.

Tracking relational aspects

Environment

Thoughts and Perceptions

Thoughts and Perceptions

Feelings

Physical self and Motivation

Physical self and Motivation

Behaviour Behaviour Feelings

38

Tracking relational aspects

Environment

Thoughts and Perceptions

Thoughts and Perceptions

Feelings

Physical self and Motivation

Physical self and Motivation

Behaviour Behaviour Feelings

39

How do you find a Formulation?

Patterns:

–Aversive & reinforcing behaviours

–‘Stuck’ cognitions & attributions

–Defensive emotional dynamics and avoidance of pain

–Signifiers of systems of power and role

Formulation Themes

Jacobson and Christensen suggest:

• Closeness/distance

• Control/responsibility

• You don’t love me!/Yes I do! It’s you who doesn’t love me!

• Artist-/scientist

• Conventionalilty/unconventionality

We might add:

• needy/needless

• dependent/independent

• Emotional/unemotional

• depressed/non-depressed

Themes are influenced by:

• Family History

• Life experience

• Personality

• Plus the current interactions between the partners

Formulation = Backbone of the therapy

• The moment the couple accept the

Formulation the majority of the work of the therapy is done.

• Use & reuse it!

Break

Video: The Depressed Couple

Robert & Sylvia

‘The impact of unemployment on couples and the family’

TCCR

Discussion

• In small groups, think about the following:

– How does depression effect this couple?

– How do they respond to this?

– What issues contribute to depressive symptoms?

– Would they be suitable for CTfD?

Communication & Depression

• Difficulties in empathic open communication

– Depressed partner

– lack of energy / hope

– preoccupied by negative feelings

– sensitive to criticism

• Non-depressed partner

– may withdraw or ‘switch off’

Communication Wheel

• Exercise

1. Form couples

2. Negotiate who is starting first

3. First partner picks a topic and goes through the wheel. The other partner is listening, paying attention to the other talking and observing any thoughts and feelings that may come up.

4. When first partner finishes, the other partner replies using the wheel.

Competencies

• Use Exploratory Techniques

- Open – ended questions

- Extend the issue being discussed

- Use silence whilst actively and supportively listening

• Use Explanatory Techniques

- Clarify what has been said

- Provide feedback about a communication

- Reconstruct the content of a message, especially where contradictions may be embedded within it.

Blocks to Communication

COUPLE DYNAMIC

Anxious

Couple collusion

Parent/child

Critical parent (belittling)

Splitting/Projection

Victim/martyr vs aggressor

51

CULTURAL

Different languages

Different family cultures

Family scripts

Assumptions

Useful Resources

• http://philosophyforlife.org/david-clark-on-improving-access-for-psychological-therapy-iapt

• IAPT 3 year report: the 1st million patients DH Nov 2012

• Implementing NICE guidelines for psychological treatment of depression: the IAPT experience – David M Clark, Int Rev of Psychiatry, Aug 2011

• Hewison (2011) A guide to couple therapy for depression, HCPJ

http://learninghub.tccr.ac.uk/pluginfile.php/1617/mod_resource/content/1/A%20guide%20to%20CTD%20from%20HCPJ.pdf

Hewison, Clulow & Drake (2014) ‘Couple therapy for depression’ (OUP)

http://learninghub.tccr.ac.uk/pluginfile.php/1571/mod_resource/content/1/Couple%20Therapy%20for%20Depression%20book%20discount.pdf

To receive 30% discount:

978-0-19-967414-5 288 pages Paperback June 2014 £24.99 | £17.49