Anxiety Disorders and Family Therapy

The role of family therapy in anxiety disorders is controversial. Empirical data exist only in relation to agoraphobia and obsessive compulsive disorders. Experienced clinicians, generally working with complex cases, regard marital and family conflict as central to many cases, which require a family approach for optimal therapy. In contrast, research workers generally regard marital and family factors as irrelevant to treatment. This is because complex cases are usually excluded from empirical research. This leaves mainly uncomplicated cases without significant family conflicts, for which a family approach is rarely necessary. Techniques for treating anxiety disorders in a marital/family setting are outlined.     

ENGAGING THE NON-ATTENDING SPOUSE IN MARITAL THERAPY THROUGH THE USE OF THERAPIST-INITIATED WRITTEN COMMUNICATION

There is currently rather widespread acceptance among clinicians that conjoint marital therapy is the preferred format for treating marital difficulties. However, more often than not, it seems that the marital referral or inquiry for therapy stems from the efforts of one spouse, with the other spouse remaining uninvolved or resistant. Consequently, engaging the non-attending spouse in therapy is an important issue for professionals working with married couples.     

Antecedents and consequences of negative marital stressors

Many couples seeking therapy report the occurrence of severe, negative marital stressors (e.g., infidelity, threats of marital dissolution). In addition, existing research has demonstrated that these marital stressors precipitate Major Depressive Episodes and psychological symptoms. This longitudinal study examines the antecedents and consequences of negative marital stressors to help clinicians and researchers develop interventions that might prevent these stressors and their outcomes. Forty-one women completed a semistructured interview and measures of marital discord and depressive symptoms within one month after experiencing a marital stressor (baseline) and at a 16-month follow up. The results indicate that baseline marital discorded contributes to the occurrence of additional marital stressors during the follow-up period. Although baseline depressive symptoms do not predict additional marital stressors, depressive symptoms along with marital discord predict future depressive symptoms. Finally, baseline marital discord and additional marital stressors contribute to future marital dissolution. Clinical and research implications are discussed.     

TREATMENT OF MARITAL CONFLICT AND PREVENTION OF DIVORCE

This paper provides a review of previous literature reviews on the effectiveness of marital therapy and evaluates the long-term efficacy of couples therapy in preventing marital separation and divorce. There is general agreement that marital therapy can be effective in reducing marital conflict and promoting marital satisfaction, at least in the short term. Research examining the long-term efficacy of couples therapy for the prevention of marital separation and divorce is sparse but promising with respect to its effectiveness in promoting marital stability. Predictors of successful marital therapy outcomes, the clinical significance of marital therapy outcomes, and the cost effectiveness of marital therapy are also discussed.     

Implementation of Behavioral Marital Therapy

Implementing behavioral marital therapy is discussed with emphasis on the techniques of problem-solving, communications training, behavioral contracting, and homework assignments. The therapist's intervention style and the aspects of treatment which aid in generalization and maintenance of therapeutic gains are also described, and a typical treatment session is outlined.     

TOWARD AN OBJECT-RELATIONS APPROACH IN PSYCHOANALYTIC MARITAL THERAPY*

The purpose of this paper is to describe the features which distinguish psychoanalytic marital therapy from other forms of marital therapy, to describe briefly how important classical psychoanalytic concepts can be applied to marital therapy, to present in somewhat greater detail the author's view of how object-relations theories and, particularly, the work of three authors, Fairbairn, Kohut and Gilligan, can be applied to psychoanalytic marital therapy, and finally, to indicate certain directions for further study.     

Analysis of projective identification: An object-relations approach to marital treatment

Projective identification is an important construct to both analytic and family therapy practice approaches. It is an especially useful concept in marital therapy, and can be used as the foundation for assessment and intervention. This paper provides an overview of projective identification and an illustration of its use in marital treatment.     

Marital Therapy,EMDR, Herman's Model of Recovery from Trauma The Journey of One Woman and Her Family

Judith Herman (1992, page 183) delineates a three stage model of recovery from trauma: 1) Safety, 2) Remembrance and Mourning, 3) Reconnection. She criticises current treatment methods for their failure to make a difference in the “constrictive symptoms of numbing and social withdrawal … and marital, social and work problems do not necessarily improve”. Family therapy has been criticised often for insufficient focus on emotion and general sensations. This case analysis will illustrate how these shortcomings can be successfully addressed with the use of marital counselling and EMDR. The use of multiple treatment approaches contributed to one client's resolution of recent trauma due to a car accident, of past crises due to marital infidelity and early childhood abuse, with significant changes for her in her current family as well as in her family of origin. Theoretical implications for “family therapy” are raised.     

LEAVING THE CONSULTING ROOM TO PROVOKE ENACTMENT IN MARITAL THERAPY*

Enactment of emotionally intense, intimate behaviors is often important in marital therapy. But clients' concerns for privacy and their dependence on the therapist as a facilitator of communication can deter them from exhibiting such behavior in the therapist's presence. By walking out of the consulting room, the therapist can stimulate the enactment that would have been inhibited otherwise. Three case examples illustrate the technique. Specific points of procedure are considered, and the technique's limitations and risks are noted.     

The Case for Insurance Reimbursement of Couple Therapy

A case is made for why it may now be in the best interest of insurance companies to reimburse for marital therapy to treat marital distress. Relevant literature is reviewed with a considerable focus on the reasons that insurance companies would benefit from reimbursing marital therapy – the high costs of marital distress, the growing link between marital distress and a host of related physical and mental health problems, as well as the availability of empirically supported treatments for marital distress. This is followed by a focus on the major reasons insurance companies cite for not reimbursing marital therapy, along with a discussion of advances in several growing bodies of research to address these concerns. Main arguments include the direct medical offset costs of couple and family therapy (including for high utilizers of health insurance), and the fact that insurance companies already find it cost effective to reimburse for prevention of other health and psychological problems. This is followed by implications for practitioners and researchers.     

Secondary Trauma: A Team Approach

Bearing witness to trauma stories can evoke in clinicians the confusion and emotional turmoil their clients experience, known as secondary trauma. Given the complexities of trauma work, practitioners need help to clarify issues and feel more effective. The terror attacks of September 11, 2001 further compound the task, as therapists may themselves be feeling the impact of those events. Presented here is a team model for structured case discussion which can help workers identify and deal with their reactions to both client trauma stories and their own experiences. The model is explained and illustrated with examples, and the process by which it was piloted and evaluated is discussed.     

Treatment of narcissistic and borderline disorders in marital therapy: Suggestions toward an enhanced therapeutic approach

This paper examines a psychodynamic model of marital therapy that has been found to be useful when one or both partners suffer from disorders of the self. The theories of Heinz Kohut and recent self psychologists give insight into ways of understanding and treating each partner's narcissistic vulnerabilities. Some specific aspects of borderline and narcissistic disorders are described and discussed within the context of a marital relationship. This method of marital therapy not only helps couples to learn how to be selfobjects for each other, but also may facilitate rebuilding of damaged structures of the self. A case example is provided along with a discussion of why certain specific therapeutic interventions were made.I have no hesitation in claiming that there is no mature love in which the love object is not also a selfobject. Or, to put this depth-psychological formulation into a psychosocial context: There is no love relationship without mutual, self-esteem enhancing, mirroring and idealization (Kohut, 1977, p. 122).     

Affirmative Practice and Alternative Sexual Orientations: Helping Clients Navigate the Coming Out Process

Those who differ from the dominant heterosexual ideal of exclusively other-sex attraction and intimacy encounter unique challenges, such as the coming out process, during which individuals with alternative sexual orientations must explore, define, and disclose their orientations in a way straight individuals need not. This article focuses on how clinicians can aid clients throughout the coming out process in a way that affirms the full range of sexual orientations. Following an overview of alternative sexual orientations and models of the coming out process, a case example is used to illustrate how clinicians can help clients address three challenges of coming out: overcoming internalized biases; clarifying their sexual orientation and identity; and making decisions about disclosure.     

SEX ROLE CONSIDERATIONS AND BEHAVIORAL MARITAL THERAPY: EQUAL DOES NOT MEAN IDENTICAL*

Despite the egalitarian position espoused in behavioral marital therapy, little attention has been paid to sex role issues and female-male differences. This paper explores advantages and disadvantages of behavioral marital therapy vis à vis the treatment of women and men. Features of behavioral marital therapy implicated as important in the consideration of sex role issues include underlying assumptions of egalitarianism, assumptions of external causality, and orientation toward action, as well as specific procedures such as goal setting, behavioral exchange and training in communication and problem-solving skills. Each of these features is evaluated with respect to clinical considerations as well as to research findings on female-male differences in marriage. The paper concludes with recommendations as to how behavioral marital therapy could become more sensitive to sex role issues.     

A BLUEPRINT FOR INCREASING THE RELEVANCE OF FAMILY THERAPY RESEARCH

Family therapy research and psychotherapy research in general have been criticized for their lack of relevance to clinical practice. This paper presents a fivestage model that family therapy researchers can follow to increase the relevance of their work for clinicians and other consumers of family therapy research. Using lessons derived from private industry, the research model is based on a marketing and developmental perspective.     

Predicting Change in Marital Satisfaction Throughout Emotionally Focused Couple Therapy

Emotionally focused couple therapy (EFT) is an empirically validated approach to couple therapy that uses attachment theory to understand the needs and emotions of romantic partners. EFT is recognized as one of the most effective approaches to couple therapy, but to guide therapists in their use of EFT, a theoretically based model to predict change is needed. This study tested such a model by recruiting 32 couples, and 14 therapists who provided approximately 21 sessions of EFT. Couples completed self‐report measures of marital satisfaction, attachment security, relationship trust, and emotional control at pre‐ and posttherapy and after each therapy session. Results of hierarchical linear modeling suggested that individuals higher on self‐report attachment anxiety and higher levels of emotional control had greater change in marital satisfaction across EFT sessions. Assessing attachment security at the start of therapy will inform therapists of the emotion regulating strategies used by couples and may help couples achieve positive outcomes from EFT.     

Transitional Relationships After Divorce

This article focuses on the exploration in therapy of different transitional realtionships following divorce. During the adjustment period after divorce, the individual is often left without sufficient means of self-definition. The individual has difficulty measuring movement within and seeks out others who (a) help close past marital issues and (b) crystallize these emerging qualities of the individual. By helping the client define him/herself within the context of his/her relationships, by helping him/her to remove projections attached to others, a foundation for new identity can be laid. The use of fantasy and projective techniques is discussed, and case examples are provided.     

SEXUAL ATTARACTION AND ROMANTIC LOVE: FORGOTTEN VARIABLES IN MARITAL THERAPY*

The purpose of this paper is to address the lack of attention in the mariage therapy literature ot romantic love and sexual attraction. Although mot coupples marry because of romantic love and tent to divorce when they “fall out of love,” few guidelines are available to therapists concerning how to deal with love as an issue in therapy. In contrast to models of marriage therapy which focus on rational skill devlopment, the model presented here is based on the assumption that marriage problems are emotional in nature and that the success of marital theapists is dependent upon skill in addressing emotional states. Based on recent findings in neurobioloy, this model contends that the affective dimension of love is precognitive and similar to the attchment between infant and parnent. By providing nonverbal and precognitive experience whithin therapy that can alter the emotional pattern of couples, therapists can increase the likelihood of a successful outcome.     

ONE COUPLE,THREE THERAPISTS: THERAPEUTIC OVERDOSE OR COLLUSION BREAKER?

The use of multiple therapists for one case is sometimes an unnecessary overdose of therapy. This paper discusses those couples in which each has reached a plateau in his/her individual therapy and they are referred for concurrent marital therapy to break the impasse. Projective identification is the major defense used by these couples. The author suggests a time-limited, issue-focused approach lasting 2–6 months. The more severe the pathology, the shorter the marital therapy should be.