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Systemic Couple Therapy and Depression

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Based on a research project which demonstrated the effectiveness of systemic therapy, this book can be used as the basis of a training programme in systemic couple therapy, as a phase in the treatment of depression. It describes in explicit detail the range of techniques used and can therefore also inform the next generation of research studies, which will be greatly facilitated by this work.

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CHAPTER ONE. The London Depression Intervention Trial: design and findings

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The London Depression Intervention Trial (LDIT: Leff et al., in press) was set up in 1991 to compare the effectiveness of antidepressant drugs, individual cognitive behaviour therapy (CBT), and systemic couple therapy. Patients diagnosed as “depressed” by psychiatrists were randomly assigned to one of these three treatment modalities. However, the CBT arm of the trial had to be stopped at an early stage because the drop-out rate was so high (8 out of the first 11 cases). The final comparison, therefore, was between drug therapy and systemic couple therapy and involved 88 subjects who met the research criteria and were taken into treatment.

One of the major findings was that depressed people seen in systemic couple therapy did significantly better than those treated with CBT or antidepressant medication. It was because of these encouraging results for couple therapy that we decided to write this book.

Background of the study

All research projects have their own histories. They come to life in specific contexts, for specific reasons. Julian Leff, professor of psychiatry and an internationally known researcher, has been involved for many years in furthering the understanding and clinical usefulness of the concept of Expressed Emotion (EE) in research on families and persons diagnosed as suffering from schizophrenia (Leff, Kuipers, Berkowitz, Eberleinfries, & Sturgeon, 1982). There has been some research support for the hypothesis that EE might be relevant in working with depressed patients and their key relatives. This led to the setting up of the LDIT to determine whether intervening with a family member or partner might have beneficial effects on the designated patient’s depressive symptoms if the partner’s EE was reduced.

 

CHAPTER TWO. The therapy manual

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A requirement of the research project was that each treatment modality had to provide a protocol describing its approach. Eia Asen had already started this process during the pilot phase, and both authors then continued to struggle with several more versions. We found the writing of such a protocol difficult partly because of our distaste for pinning down our practice in what seemed a rigid and prescriptive format—psychotherapy is, after all, an art as well as a set of techniques—but also because the two of us orient ourselves at somewhat different ends of the systemic spectrum. Thus Elsa Jones could be described as being placed somewhere in the “post-Milan” group, strongly influenced by feminist and social constructionist ideas (Jones, 1993), whereas Eia Asen occupies a position that draws on a number of different approaches, from structural to strategic to post-Milan therapies (Asen, 1997). Thus the final working document stated that “each therapist is likely to use most of these techniques during the course of therapy with each couple” but some techniques were very unlikely to be used, at least in their pure form, by both therapists. Additionally, experienced therapists are unlikely to be working in a way that reflects a pure model, since, after a significant period as a practitioner, one’s style becomes personal and influenced by a continuous learning process from colleagues, clients, and one’s own life.

 

CHAPTER THREE. Working with depression, I

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Els a Jones

I attempt in this chapter to discuss, by means of clinical examples, some of the ways in which I worked with couples in the study. I look at what I think worked, what I found difficult, where I struggled and failed to help the clients, and what I learned in the process. Clients gave permission for material from the work with them to be used for the research programme, and, where relevant, I renegotiated this permission after the completion of the work; nevertheless, I would like to stress my hope that my treatment of their therapy, and your reading of it, can be done with respect for their privacy, and with gratitude to them for the opportunity to enhance our professional understanding. Pseudonyms are used, biographical and therapeutic accounts are condensed, and identifying details are altered.

The material in this chapter is organized around certain themes and patterns that seem to me central to this work, using detailed examples from the work with one couple and short illustrative anecdotes from other case material. Other themes will be elaborated in chapter five. As pointed out in chapters one and two, the work done with these couples does not constitute a newly invented model of psychotherapy; it is systemic couples therapy done in the context of a comparative research programme.

 

CHAPTER FOUR. Working with depression, II

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Eia Asen

Rosie M. is a 31-year-old white working-class woman with 25 years’ worth of experiences with psychiatric services. As a 6-year-old child, she was referred by her GP to the local child-guidance clinic because of being “very low, crying all the time, miserable and no friends”. She was seen over a period of six months on altogether eight occasions, first with her mother, then by herself, and once with her step-father. Some improvements were reported. At the age of 8, she was re-referred, this time by the school. The teachers reported her to be “low, isolated, without friends”. She was assessed and tested by a child psychologist, and this was followed by some school-based work. Rosie also received six sessions of individual counselling. At the age of 10, another referral was made, this time by her parents, because of “depression”. Individual child psychotherapy was offered, and after some wait Rosie attended once-weekly for one year. Rosie was 13 when her parents contacted the (re-named) Child and Family Consultation Service. They described her as “depressed and very difficult to manage at home”. Family therapy was offered, but Rosie dropped out after the second session. Eight months later she was admitted to the local hospital after taking a paracetamol overdose. The visiting child psychiatrist made the diagnosis of “clinical depression” and put her on antidepressants. Two months later, Rosie took a second overdose, this time using the prescribed medication. The medical response was swift and predictable: Rosie was put on a new brand of antidepressants, and these were meant to be kept by her mother and dispensed each day. Only six weeks later, Rosie had taken another overdose, paracetamol on this occasion, and this led to her being admitted to an adolescent unit. Once there, she had a fairly turbulent time; she started cutting herself and refused to see her parents throughout her stay. Nine months later, now nearly 16, Rosie was discharged. She did not return to school but went to live in a squat. She made dubious friends and started taking drugs. Her medical notes show that she took three further overdoses between the ages of 16 and 18 but that she was not given any specific treatments. She had a six-week in-patient admission at the age of 18, followed by three further in-patient admissions between the ages of 18 and 26. The recorded diagnoses varied from “depressive illness” to “schizoaffective disorder” to “personality disorder”. Since then, she had seen different psychiatrists on numerous occasions, with a whole range of antidepressants prescribed.

 

CHAPTER FIVE. Themes and variations

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While participating in the study, both during the period of direct work with couples and subsequently when we were given access to the results, we found ourselves struck by a number of themes that seemed of particular significance in working with this client group under these particular circumstances. Some of these themes will, of course, be of general interest in all systemic work, or in all couples work; some are perhaps more relevant to the particular context of this work. We discuss in this chapter the themes that proved of relevance to both of us here; other themes are taken up in the individual clinical chapters (chapters three and four). Some of the themes are clinically significant, while others relate more to the experience, for clinicians, of being researched.

Working on the engagement of partners

Working in a public context marked as “psychiatric” invites referrals different to those that one would receive in, for example, a private setting that in its official description contains the word “Family Therapy”, “Systemic Consultation”, or such like. This, of course, very much affects the responses to any such referrals. Whilst in a public psychiatric setting some of the referrers wish their patients (this is what they are actually called) to have family or couple therapy in addition to other forms of treatment, at least half of these patients turn up for their first appointment by themselves. The reasons for this are manifold: poor preparation for this type of work by referrers, a wish to retain “patient” status, fears of subjecting oneself to this unknown “new” therapy, and so forth, Working in such a setting has taught me to work with whoever turns up and to respect the power of the “illness”, the diagnosis, and the construction of the presenting person as “patient”. This implies that the therapist should behave as if any other family member were a potential resource to help the treatment of the patient—hence the term “partner-assisted” or “family-assisted” therapy, or, more medically oriented, “treatment”. I therefore felt familiar with the referral process and the problem definitions of the depressed patients—or, more correctly, individuals diagnosed by psychiatrists as suffering from clinical depression and individuals who went along with receiving such a label. I knew that a major part of the initial work had to involve recruiting the partner and keep him or her in treatment. Hence, almost all of my initial sessions focused on the symptoms of depression, respecting the partner as a potential informant and helper—with the result that none of the partners (and designated patients) dropped out. Use was made of telephone contact with individuals and their partners if they had missed appointments.

 

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